*Purpose: The liver is unique in that it is considered an immunologically tolerant organ against graft destruction by antibodies. Simultaneous liver-kidney transplantation (SLKT) are often performed under the assumption that the liver confers an immunologic protection to a kidney allograft. This study evaluated outcomes on pre-SLKT allosensitization in highly sensitized recipients.

*Methods: This single-center, retrospective study assessed SLKT recipients between January 2016 – June 2019. We defined high sensitization as panel reactive antibody (PRA) levels greater than 50%. Pre-existing and de novo donor specific antibodies (DSA) were trended 15 months post-transplant. Rejection rates, serum creatinine and patient survival within the first year post-transplant were assessed. Human leukocyte antigen testing was performed via single antigen beads with a 2,000 mean fluorescence intensity (MFI) cut-off for positivity. No desensitizing strategies occurred pre- or post-SLKT.

*Results: Ten SLKT patients were highly sensitized and included in the analysis. A 71% class I and 56% class II average reduction in PRA was observed from baseline to 1-year post-transplant. Four patients had pre-existing DSAs, all of which cleared by three months post-SLKT. Five patients had de novo DSA formation, three of which had clearance and two with persistent DSAs. No biopsy-proven kidney rejections and 2 (20%) acute cellular liver rejections occurred. Graft and patient survival was 100% 1-year post-SLK.

*Conclusions: SLKT in highly sensitized recipients does not result in post-transplant kidney rejection at 1 year. Despite rejection in 20% of the liver allografts, no grafts were lost. A liver allograft may confer a protective benefit to a kidney allograft in sensitized SLKT recipients.

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