*Purpose: Controversy remains on the role of rabbit anti-thymocyte globulin (rATG) induction for calcineurin inhibitor (CNI) delay after liver transplantation (LT). We examined the effect of rATG with and without CNI delay on outcomes after LT.

*Methods: We analyzed primary LT recipients from 01/2016 to 06/2020. Combined LT and cardiothoracic transplant were excluded. Analysis was performed based on rATG receipt and CNI initiation ≥ 3 days post-LT. Infection was assessed by provider notes, medications, and lab results. Rejection was defined as biopsy-proven or clinically diagnosed by lab values.

*Results: Of 528 eligible patients, 110 received rATG and 418 did not. RATG group was younger, had higher MELD-Na scores, and had more females. Renal function was not different at baseline or at 1 year. Patients receiving rATG had significantly higher rates of bacterial infection (50%, vs 26%, p<0.001). However, survival and rejection rates were not different at 1 year. We examined a subset of patients that had CNI delay ≥ 3 days post-transplant. In this subset, those that received rATG had worse renal function over a year (p<0.001).

*Conclusions: Use of rATG was not associated with improved patient/graft survival but resulted in more bacterial infections. In the setting of CNI delay, use of rATG resulted in significantly worse renal function. The use of rATG in renal preservation strategies above and beyond CNI delay needs to be reconsidered.

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