*Purpose: Survival benefits have been shown with primary simultaneous liver kidney (SLK) transplantation as well as kidney after primary liver transplant when patients develop kidney failure after liver transplantation. Little is known about patient and graft survival following secondary liver transplantation alone versus SLK. Understanding if the benefit of SLK persists in secondary transplants would allow for an improved algorithm regarding kidney allocation for liver re-transplantation with kidney failure.

*Methods: The SRTR database was queried for all liver transplant patients that underwent liver re-transplantation. We excluded patients with prior to OLT, transplants other than SLK or KAL. Only recipients listed on the kidney transplant list at the time of their second liver transplant were included. A total of 772 primary liver with secondary SLK and 137 primary liver with secondary liver transplant recipients were identified. The groups were further stratified by LDRI (<1.6 and >1.6) and KDPI (≤35%, 35-85% and ≥85%) for secondary SLK. Survival distributions were evaluated with Kaplan-Meier curves and long-rank test to 10 years post transplantation.

*Results: Overall 1, 5, 10- year patient survival was statically significantly greater after SLK (79%, 68%, 56%) compared to liver alone (54%, 47%, 41%, p<0.0001). Similarly graft survival was greater for SLK group at 1, 5, 10 years (78%, 50%, 25%) compared to liver alone (53%, 40%, 27%, p<0.0391). Graft survival was greater in the SLK group when stratified by LDRI (p=0.0389), while patient survival was not found to be statistically significant (p=0.4690). Stratification by LDRI revealed superior patient and graft survival for SLK compared to liver alone LDRI<1.6 (p<0.0284 and p<0.0134) and LDRI >1.6 (p<0.0001, P<0.0007) respectively. To evaluate the impact of KDPI we divided the SLK and liver alone cohorts by LDRI <1.6 and >1.6 and further stratified by KDPI <35%, 35-85% and >85%. SLK with LDRI <1.6 showed a greater patient and graft survival for those recipients with lower KDPI (p=0.0284 and p=0.0134 respectively). Similarly SLK with LDRI >1.6 when stratified by KDPI showed a proportional improvement of patient and graft survival with lower KDPI (p=0.0013 and p=0.0126, respectively).

*Conclusions: Our study revealed superior patient and graft survival with secondary SLK compared to liver alone in patients who meet criteria for a renal transplant. This suggests a synergistic effect between the quality of the liver and kidney allografts that affect both patient and graft survival. These findings demonstrate the importance of thoughtful organ allocation in this patient population.

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