*Purpose: As many as 30% of liver transplant candidates have renal insufficiency requiring a combined liver and kidney transplantation. The prolonged and complex simultaneous liver-kidney transplant, with its inherent blood loss and transfusion, hypotension and administration of vasopressors, coagulopathy and reperfusion injury are sought to be associated with high rate (21%-80%) of delayed kidney graft function (DGF), as well as lower graft survival. To overcome this adverse outcome, we introduced a novel approach for the management of combined liver-kidney transplant by staging the two procedures and delaying the kidney transplant for several hours following the completion of the liver transplantation, allowing patients resuscitation and stabilization. With this study we present our initial experience of staged approach to liver-kidney transplant with the primary outcome being delayed graft function rate and graft survival.

*Methods: 24 consecutive patients who underwent staged liver-kidney transplant at Swedish Medical Center between 2013 and 2018 were followed. Patient demographics and perioperative outcomes were collected and analyzed. Data are presented as median (mean ± SD). In all cases both organs were procured from the same donor and all kidneys were placed on hypothermic pulsatile machine perfusion until transplant. Following liver transplant patients were resuscitated in the intensive care unit.

*Results: Majority of recipients were man (71%), age of 55 (54 ± 10) and BMI of 30.5 (30 ± 6). Fourteen patients (58%) had alcoholic cirrhosis with MELD of 35.5 (35 ± 5) and 71% required RRT prior to transplant. Twenty donors (83%) suffered brain death (DBD), age of 30.5 (31 ± 11) with KDPI of 15% (21±17). Time interval between liver to kidney reperfusion was 20 hours (20 ± 4) with kidney cold ischemia time of 24 hours (26 ± 7.5). Only two patients (8%) experienced delayed graft function requiring post-operative renal replacement therapy. With a follow-up of 30 months (27 ± 19), patient survival was 92% with liver and otherwise kidney allograft survival of 100%.

*Conclusions: Our staged procedure approach for simultaneous liver-kidney transplant is associated with improved kidney function and rate of DGF as well as patient and graft survival

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