Introduction Acute kidney injury (AKI) complicates up to 25% of patients undergoing orthotopic heart transplant (OHT) and can be exacerbated by the introduction of calcineurin inhibition (CNI). Induction with rabbit anti-thymocyte globulin (ATG) can provide immunosuppression to prevent early rejection until CNI therapy is introduced. However, current data regarding ATG use to allow delayed CNI initiation is limited. Hypothesis ATG induction with delayed initiation of tacrolimus as a renal sparing strategy will result in less renal failure without a significant increase in infection and rejection. Methods From January 2014 to December 2019, 143 patients underwent OHT. Dual organ transplantation, those requiring ATG for non-renal sparing reasons, and patients without 1 -year follow-up were excluded. Using standard statistical analysis, we compared in-hospital and post discharge outcomes at 1, 6, and 12 months between patients with and without ATG administration. Results ATG was given to 26/71 (36.6%) patients as a renal sparing strategy. Compared to the no ATG group, the ATG group had higher pre-transplant creatinine (1.5 vs 1.2 mg/dL, p=0.001) and lower glomerular filtration rate (GFR) (58.6 vs 76.4 ml/min, p=0.002), but no other significant differences in baseline characteristics. Tacrolimus was started later in the ATG group (3.6 vs 0.9 days, p=0.0001). The ATG group had lower GFR at 1 month (64.1 vs 82.5 ml/min, p = 0.009) and 6 months (44.2 vs 58.1 ml/min, p= 0.028) with a non-significant difference at 1 year (50.1 vs 62.4 ml/min, p=0.08). The ATG group was more likely to require renal replacement therapy (RRT) during the index admission (34.6 vs 4.4%, p=0.01). This difference persisted at discharge (19.2% vs 2.2%, p= 0.022) and 1 year (15.4% vs 0%, p= 0.015). No significant difference between the two groups in the rate of worsening chronic kidney disease at 1, 6 and 12 months. Freedom from readmission for infection was lower in the ATG group (53.8 % vs 80%, p= 0.03). There were no significant differences in in-hospital (p=1.00), 1 year mortality (p=0.19), and 1 year freedom from rejection (p=0.80) between groups. Conclusions ATG use as a renal sparing strategy in OHT recipients with renal dysfunction at baseline was associated with a high rate of early RRT but overall change in renal function over one year was similar. Freedom from readmission for infection was lower in the ATG group and freedom from rejection was equal in both groups. Thus, it appears in this retrospective analysis, that a strategy of induction therapy for renal sparing was not beneficial and increased the risk of infection.