*Purpose: Simultaneous kidney and heart transplants (SKHT) are employed for patients with both end-stage heart failure and severely impaired kidney function. Renal outcomes in such recipients have been described, albeit in single-center cohorts. In addition, very little is known about SKHT and their outcomes among pediatric patients. We analyzed the United Network for Organ Sharing (UNOS) dataset comprising of 1706 simultaneous kidney-heart transplant recipients.

*Methods: This is a retrospective cohort analysis of simultaneous kidney-heart transplant recipients in the UNOS cohort who received their transplants between October 1987 and December 2018. We compared the incidence and risk factors of renal allograft loss in SKHT recipients with failed renal allograft and those with a functioning renal allograft at 3-year follow-up. Post-hoc analysis was done to analyze the risk factors in pediatric age group and to assess the outcomes following SKHT. The Student t-test or Kruskal Wallis tests were used to compare continuous variables, and the Chi-2 test for categorical variables between groups. Cox regression hazard model was used to study the factors associated with graft failure.

*Results: A total of 1706 SKHT recipients were included in the analysis. Of these, 1608 (94.3%) had functioning renal allografts and 98 (5.7%) had failed kidney graft over 3 years of follow up. Compared to the group with functioning renal allograft, recipients with failed renal allografts were more likely to have high-risk CMV status, expanded-criteria donor, delayed graft function and higher creatinine at discharge. Use of tacrolimus at the time of discharge was higher in group with functioning renal allograft. Similarly, pediatric patients were more likely to have high serum creatinine at discharge, higher non-preemptive transplant and higher rate of delayed graft function. Renal graft failure occurred due to primary failure in 16%, chronic rejection in 12%, acute rejection in 11%, cardiorenal in 8%, infections in 7% and other causes in the rest. While in pediatric population, 41.6% graft losses were due to chronic rejection and median graft survival time was 906 [206-2226] days.

*Conclusions: The number of simultaneous kidney-heart transplants has been gradually increasing in the United States over the past two decades. Single-center studies have previously described renal outcomes in SKHT recipients at their respective centers. Our study describing the factors associated with renal graft loss in SKHT recipients in the UNOS database is the largest till date.

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