*Purpose: The utilization of SLKT in the United States is rising in the MELD era. We aimed to understand the contemporary changes in characteristics and outcomes of SLKT recipients at 6 large geographically diverse liver transplant centers in the US—we hypothesized that the emergence of NASH and aging of the LT population would affect SLKT outcomes.

*Methods: SLKT recipients between 2002 – 2017 at any of the 6 centers in 6 different UNOS regions this study were retrospectively enrolled in the US Multicenter SLKT Consortium. Time-related trends in recipient characteristics 1 year post-SLKT outcomes were evaluated with non-parametric methods and Kaplan-Meier analysis.

*Results: 572 patients were enrolled, median age 58 years, 36% female, 63% Caucasian, 33% HCV, 41% diabetic, 52% hypertensive, 41% with sustained AKI as their kidney transplant indication. There were significant changes in the characteristics of patients undergoing SLKT between 2002 and 2017, as the 2017 recipients were older (59 v. 52 years, p<0.001); more likely to have CKD as opposed to sustained AKI (71% v. 17%, p<0.001); more likely to have coronary artery disease (21% v. 11%, p=0.002) and less likely to have HCV (11% v. 39%, p<0.001). Our cohort had a median follow up of 5.3 (2.4 - 9.2) years and there were 188 (33%) post-SLKT deaths. 41 (7%) died within 1 year and 1-year mortality significantly decreased over time (11% in 2002 to 4% in 2017, p<0.001). This occurred despite an increase in the % of patients with delayed kidney graft function (DGF, 6% in 2002 to 43% in 2017, p<0.001). The rates of 1-year mortality ranged from 1 - 21% by center, p = 0.001. Overall, factors associated with 1-year post-SLKT mortality in multivariable analysis included: HD at listing (HR 2.0, 95CI 1.0 - 3.9); transplant year (HR 0.9 per year from 2002 to 2017, 95CI 0.8 - 0.9), DGF (HR 3.0, 95CI 1.5 - 5.8) and national donor as compared to local (HR 2.9, 95CI 1.0 - 8.5), adjusting for center.

*Conclusions: In this large contemporary cohort of SLKT recipients, along with the increased utilization of SLKT, there have been significant changes in the demographics of SLKT recipients – including older patients with CKD, as opposed to sustained AKI. Despite these trends, there was a marked improvement in early SLKT outcomes over the study period, with those on HD at listing, with imported organs and with DGF having the highest risk of mortality. Our data support ongoing surveillance of SLKT trends and outcomes to inform the optimization of this life-saving therapy.

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