*Purpose: End stage kidney disease (ESKD) in liver transplant (LT) candidates is associated with worse survival. We sought to identify the predictors of ESKD in LT patients and the financial impact of the different kidney allocation timing.

*Methods: All adult LT recipients with eGFR <60 at the time of listing who received their first solid organ transplant between 2016-2019 were included. Using SRTR data merged with the Vizient Clinical Data Base, generalized linear modelling was performed to identify trends associated with gender, age, race, pre-transplant GFR, and transplant timing (simultaneous liver-kidney transplant (SLK) vs liver transplant alone (LTA) and kidney after liver transplant (KAL)) and cost for index transplant admission and first year post-transplant. Logistic regression was then used to determine likelihood of receiving SLK vs LTA or KAL.

*Results: 14,815 LTs were identified (Table 1). When compared to the White patients, Black patients are twice as likely to receive SLK as opposed to LTA (OR 1.99, 95^th%CI 1.50-2.64). Patients with GFR ≤30 were 77 times as likely than those with GFR >30 to receive SLK compared to LTA (OR 76.92, 95^th%CI 50.00-111.11). Index admission and one-year costs were higher for Asian patients, those with pre-transplant GFR ≤30, and those receiving SLK or KAL (Table 2). Cost gap increased for SLK and KAL patients between index admission and first year total, but paradoxically narrowed in patients with pre-transplant GFR ≤30.

*Conclusions: Black LT patients are twice as likely to receive a simultaneous kidney when compared to their White peers. Given the racial disparities in the burden of kidney disease and additional risk for kidney disease post LT, it is noteworthy that KAL was lower in Black LT recipients. This is concerning for access remaining inequitable. More work is needed to understand factors affecting allocation of SLK and KAL. SLK costs are higher during the index admission, presumed to be associated with the addition of the kidney transplant. We are exploring whether the additional cost of KAL over SLK remains or dissipates over a 3-year horizon.

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