*Purpose: Progressive decline in renal function is common among patients with end-stage liver disease. Liver transplant (LT) candidates can often develop severely impaired renal function which prompts the consideration of simultaneous liver kidney transplantation (SLKT). In 2017, the United Network for Organ Sharing (UNOS) recommended SLKT in patients with GFR <30 ml/min after being <60 ml/min for at least 90 days. This study aims to assess the post-LT renal recovery in patients who met UNOS criteria for SLKT, yet received liver alone.

*Methods: We performed a retrospective records review of adult patients who underwent LT between 1/1/2009 to 12/31/2018 at a North American Center. Liver only recipients whose last GFR before LT was <30 ml/min after being <60 ml/min for more than 90 days were included. Demographic, clinical, and laboratory data were collected. Partial recovery was defined as post-LT GFR increase to 30-60 ml/min and full recovery was defined as increase to >60 ml/min.

*Results: Of 800 patients who underwent LT during the observation period, 123 patients had GFR <30 ml/min pre-LT and of them only 34 had GFR <60 ml/min preceding LT by 90 days or longer. Median age was 63 years. Females constituted 59% of the cohort. Following liver transplant, 20 patients (59%) had partial recovery and 10 patients (29%) had full recovery within a median of 6 and 61 days, respectively. Among baseline characteristics including comorbidities, abnormal radiologic appearance of the kidneys pre-LT, reflective of chronic disease, was the only predictor of lack of recovery (p=0.03). All initial immunosuppressive regimens were tacrolimus-based. On last follow up after a median of 4.8 years, 15 patients (44%) still had GFR >30 ml/min while 19 (56%) patients were on dialysis, awaiting kidney transplant, or received kidney transplant. Patients with pre-LT unrecovered AKI or HRS had the highest likelihood of recovery on last follow up (OR 4.7, p=0.03).

*Conclusions: LT candidates who meet UNOS criteria for SLKT yet undergo LT only still have a remarkably high chance for post LT renal recovery, approaching 90% on short-term. A large proportion of patients can sustain recovery long-term. The use of the 2 to 12 month Safety Net for kidney transplant post-LT is an important consideration for those with potentially recoverable renal dysfunction pre-LT as opposed to SLKT.

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