*Purpose: Leukopenia post-orthotopic liver transplant (OLT) is associated with an increased incidence of infection and mortality. Prior to OLT, leukopenia may suggest innate immunosuppression and pose a potential risk of infection and medication intolerance post-OLT. We sought to describe post-transplant outcomes of patients presenting with leukopenia at the time of OLT.

*Methods: This is a single-center retrospective study of patients who received an OLT between 1/2016-7/2017. Leukopenia was defined as a white blood cell count (WBC) of ≤ 3 x 10⁹/L. Exclusion criteria were multi-organ transplant, death within 24 hours post-OLT, or receipt of belatacept. Maintenance immunosuppression consisted of tacrolimus (target trough level of 6-8 ng/mL), mycophenolate mofetil (MMF) total daily dose of 1 g, and a steroid taper.

*Results: Of the 232 included patients, 25 (11%) were leukopenic at time of OLT. Baseline characteristics are shown in Table 1. WBC increased early post-OLT likely from steroids, yet remained between 3.5-4.2 x 10⁹/L from 30-365 days post-OLT (Figure 1). Overall, there was an 88% incidence of a composite of culture positive or culture negative empirically treated infection, however the incidence of culture positive infection alone was 44%. Of the 7 patients with biopsy proven acute rejection (BPAR) at 1 year, BPAR preceded infection in 5 and infection preceded BPAR by 1 day in 2 cases. MMF doses were similar to our protocol (Figure 2) and 28% of patients had an interruption of MMF therapy within 90 days post-OLT. Of the 7 patients with BPAR, 1 had an interruption of MMF therapy prior to BPAR. Pneumocystis jirovecii and cytomegalovirus prophylactic therapy was held in 32% and 12% of patients, respectively. One year patient survival was 92%.

*Conclusions: Despite leukopenia at the time of OLT, patients can be successfully transplanted. Although there was a high rate of infection, BPAR preceded infection in most patients who rejected and overall 1-year survival was acceptable. Early rejection can be seen in this population, necessitating judicious immunosuppressant dose reductions in the face of hematologic tolerability.

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