*Purpose: The 2017 combined liver-kidney allocation modification provided early access to kidney transplantation (KT) for liver transplant (LT) recipients with severe post-LT kidney dysfunction. Although this policy intended to mitigate the risk of persistent kidney dysfunction for LT candidates not meeting criteria for combined LT/KT, real-world access to this “safety-net” is poorly understood.

*Methods: Single-center LT recipient data from a single-center was extracted from August 10, 2017-December 31, 2020 to retrospectively identify LT recipients meeting safety-net criteria under the revised allocation system. Multi-organ recipients were excluded. Post-LT estimated glomerular filtration rate (eGFR) during the safety-net window (60-365 days post-LT) was calculated for all LT recipients without using race in the calculation. LT recipients eligible for safety-net KT listing (eGFR<20 60-365 days post-LT) were assessed for KT evaluation, listing, and transplant status. Outcomes included binary measures of referral for kidney evaluation, initiating kidney evaluation, achieving KT waitlist status, receiving KT, dialysis status, and mortality.

*Results: A total of 465 LTs were performed during the study period. 106 of LT recipients (22.8%) had an eGFR<20 during the designated safety-net window period. Of these eligible patients, 28 (26.4%) were referred for KT, 24 (22.6%) of whom proceeded to evaluation. Only 15 (14.2%) LT patients were waitlisted for safety-net KT, and just 3 (2.8%) of overall at-risk post-LT patients successfully achieved KT. Seventy-four (69.8%) of the priority KT eligible patients required dialysis during the safety-net period; and 21(19.8%) of these patients died.

*Conclusions: Although a large portion of LT recipients potentially qualified for a safety-net KT, the evaluation and listing process represented a significant barrier to KT access. Factors associated with this inadequate access likely included pre-LT disease severity, post-LT complications, and failure to progress nutritionally and functionally post-LT while compromised by persistent kidney dysfunction. Persistent dialysis requirement during the safety-net period was associated with high post-LT mortality. Although recent studies report positive outcomes in LT patients successfully listed for safety-net KT, future studies should examine the broader issue of access to KT listing in this high-risk group of LT recipients.

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