Identification of which liver transplant candidates with severe kidney injury can have full recovery of renal function after liver only transplant is difficult. Avoiding unnecessary simultaneous liver-kidney (SLK) transplant can optimize use of scarce kidney grafts. Incorrect predictions of spontaneous renal recovery after liver transplant alone (LTA) can lead to increased morbidity and mortality after a missed opportunity for SLK. METHODS: In a retrospective study of all adult LTAs performed from 2002-2012 at our liver and kidney transplant center, we identified recipients with severe sub-acute kidney injury (defined as: serum creatinine < 2 mg/dL within 3 months before a LTA and subsequent serum creatinine≥2 mg/dL or renal replacement therapy (RRT)). Severity of kidney injury was assessed by AKIN class and RIFLE class. We used logistic regression models with the outcome of renal recovery (defined as: serum creatinine <2 mg/dL, not on RRT, and not listed for kidney after liver transplant (KAL)) at 2 years after LTA. RESULTS: Of 42 LTA recipients, 28 (67%) had renal recovery and 14 did not. The median (IQR) warm ischemic time (minutes) in recipients that with and without renal recovery after LTA was 31 (27-46) and 39 (34-49), p=0.011, respectively. At the time of LTA, the number in AKIN class 0/1/2/3 was 1/5/5/31 and the number in RIFLE class 0/1/2/3/4 was 4/2/4/30/2. AKIN and RILFE were not associated with renal recovery after LTA (p>0.05). Adjusting for severity of sub-acute kidney injury with either AKIN or RIFLE, increasing warm ischemic time was associated with lack of renal recovery, HR 1.08 (1.01-1.17, p=0.031) and HR 1.09 (1.01-1.18, p=0.020), respectively. For each minute of increased warm ischemic time, there was an 8% to 9% increase in the risk of lack of renal recovery after LTA. The association of increasing warm ischemic time with lack of renal recovery remained statistically significant (p<0.05) in separate models adjusting AKIN or RIFLE and for the following factors individually: recipient diabetes, hypertension, proteinuria, hematuria, hepatorenal syndrome, calcineurin inhibitor at discharge, cold ischemic time and donor age. CONCLUSIONS: In liver transplant candidates with severe sub-acute renal injury, operative measures to minimize warm ischemic time may improve renal recovery, avoid renal replacement therapy and the need for subsequent kidney transplant.

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