*Purpose: The long-term pediatric outcomes of simultaneous liver-kidney (SLK) transplantation and sequential liver and kidney transplantation, liver after kidney (LAK) and kidney after liver (KAL), remain to be further investigated.

*Methods: The UNOS database was queried for sequential and simultaneous liver and kidney transplants in pediatric (age<18yrs) recipients between 1988 and 2018. Multivisceral listings and retransplants were excluded. SLK transplants were defined as occurring ≤1 day apart. LAK and KAL were each defined as occurring >1 day apart. Patient survival was calculated from time of first transplant and graft survival was calculated since receipt of the second organ. Kaplan-Meier survival analysis compared SLK, LAK, and KAL, and log-rank tests were used to determine statistical significance. ANOVA and chi-square tests were used for univariate analyses.

*Results: Our study included 265 SLK, 42 LAK, 82 KAL pediatric transplant recipients. There was a significant patient survival benefit for KAL relative to SLK and LAK, with KAL resulting in a patient survival probability of 86% relative to 73% for SLK and 56% for LAK at 17 years post-transplant (p<0.0001, Figure 1). When adjusted for 16 covariates, including demographic factors and total time on waiting lists, KAL no longer displayed a significant survival benefit relative to SLK (p<0.77). For kidney graft survival, beginning at 4.5 years post-transplant, there was a significant (p<0.044) survival benefit for SLK relative to KAL and LAK. At 17 years post-transplant, SLK had the greatest kidney graft survival (59%) benefit relative to KAL (36%) and LAK (26%) (p<0.003). For liver graft survival, there was a significant survival benefit for KAL relative to SLK and LAK at all times (p<0.0001). At 16 years post-transplant, KAL showed a 75% survival probability, SLK showed a 56% survival probability, and LAK showed a 46% survival probability. Table 1: Patient Demographics and Clinical Indicators

Figure 1

*Conclusions: LAK has the worst outcomes, likely due to recurrent cholangitis or portal hypertension in patients who are already immunosuppressed after kidney transplant. Therefore, SLK should be considered.

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