*Purpose: Patients with cirrhosis often develop chronic hypotension, which contributes to kidney dysfunction. Midodrine can improve hemodynamics and renal perfusion in these hypotensive patients. There is evidence that midodrine use prior to kidney transplant (KT) is associated with worse renal allograft outcomes. However, the impact of pre-transplant midodrine on renal allograft outcomes after simultaneous liver-kidney transplant (SLKT) is unknown. We aimed to evaluate whether the need for pre-transplant midodrine resulted in worse outcomes for SLKT patients.

*Methods: We conducted a retrospective study of all adult SLKTs performed at a single academic transplant center from 2/1/02 to 6/30/19. Demographic and transplant-related clinical data were collected until date of last follow up or death. Descriptive statistics were tested using a Wilcoxon rank sum or Fisher exact test.

*Results: From 2/1/02 to 6/30/19, our institution performed 64 SLKTs (43 on no midodrine prior to transplant, 17 on midodrine alone and 4 on IV vasopressor). Patients on midodrine were significantly older (61.5 vs 52.6, p=0.001), and more commonly had hepatic encephalopathy and hepatorenal syndrome. No differences were noted in gender, BMI or medical comorbidities (HTN, DM, CAD) between the groups. In the midodrine group, 9 (53%) were on midodrine for >3 months; 9 (53%) were taking between 10-30mg/day and 7 (41%) were taking >30mg/day. The midodrine cohort had significantly lower blood pressures (SBP 110 vs 133; p=0.007) and higher MELD-Na scores at listing (30 vs 25; p=0.002) and at transplant (31 vs 26; p=0.003). There were no differences in donor demographics or transplant parameters such as CIT, WIT, PRA, KDPI, or immunosuppression. There were no significant differences in estimated GFR at post-transplant discharge or at 1 year, irrespective of the use of pre-transplant HD. Furthermore, there were no significant differences in hospital length of stay, need for post-transplant HD, midodrine use at discharge, development of renal dysfunction in follow up, and number of hospitalizations in the first 6 months or mortality (Table 1).

*Conclusions: In our single center cohort, the need for pre-transplant midodrine did not negatively impact outcomes in the first year after SLKT, in contrast to KT alone. Multi-center confirmation of these results would be desirable.

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