*Purpose: Criteria for listing for Simultaneous Liver and Kidney (SLK) transplant changed on August 10, 2017. These changes were implemented to standardize the criteria for SLK and provide for a “Safety Net” (SN) kidney transplant option for liver transplant alone candidates who had low GFR or dialysis dependence after liver transplant. We compared the outcomes of SLK and SN to historical controls.

*Methods: Using the SRTR database, we compared a cohort of 549 SLK and 78 SN transplants on or after August 11, 2019 to a historical control cohort of 1226 SLK and 38 Kidney after Liver (KAL) from 1^st January 2004 to 1^st January 2015. A buffer from 1^st January 2015 to 11^th August 2019 was chosen as listing behaviors that may have changed in anticipation of the rollout of the new policy. KAL transplants were restricted to deceased donor kidney transplants that occurred 60 – 365 days after liver transplant to mirror current SN policy.

*Results: Kaplan Meier (KM) curves for patient survival, liver and kidney survival are shown in Figures 1, 2 and 3. There were no significant differences before and after the policy change, despite the increase in the MELD score after the change. Table 1 shows the characteristics of the cohort. The significant differences were increase in white recipients 83.6% compared to 79.9% (p=0.014); an increase in cold ischemic time from 6 hours (4.71; 7.60) compared to 5.75 hours (4.65; 7.1) (p=0.025); donor age was lower 31.8 (23.6; 45) compared to 34.5 (25.6; 46.3) (p=0.007); an increase MELD after policy change with p<0.001 for trend. We compared SN to historical deceased donor kidney after liver transplant with cohort characteristics listed in Table 2. MELD at liver transplant was significantly higher in the SN cohort p<0.001 for trend. There were three deaths in the SN cohort and none in the historical control group (p=0.10). There were no graft failures in either group in the follow up period. There were no significant differences in rejection at six months with 5.9% in the SN cohort and 10% in control (p=0.66). eGFR at six months was 53.5 ml/min/1.73 m² in the SN group and 58.4 ml/min/1.73 m² (p=0.42).

*Conclusions: Policy changes governing listing for SLK have resulted in no significant changes in patient or graft survival. SN kidney outcomes are similar to historical controls for eGFR, rejection at six months as well as patient and graft survival.

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