Purpose: Patients requiring combined liver and kidney transplantation (LK) are at risk for worse outcomes because of severity of illness and complexity of the procedure. Delayed function of the renal graft can result from hypotension and pressor use related to the liver transplant procedure (LT). Delayed transplantation of the kidney graft may allow post-LT stabilization of hemodynamics and coagulopathy, as well as decompression of varices. This study is a retrospective analysis of delayed and simultaneous kidney transplant in LK patients.

Methods: There were 95 LKs performed between 2002 and 2012 at a single center. All kidneys underwent continuous hypothermic pulsatile perfusion until transplant, 70 with simultaneous (at time of LT) and 25 with delayed implantation (performed at a later time as a second operation). The median MELD score was 26. In each case, the kidney was transplanted through a separate standard kidney transplant incision in the left pelvis. All patients received continuous venovenous hemodialysis during the LT. Outcomes included early renal graft function and graft and patient survival.

Results: Recipient, donor and transplant characteristics were comparable in both groups. Mean liver cold ischemia time was less than 7 hours in both groups, while kidney cold ischemia time was 9.9 ± 2.7 (range 5-19) and 37.0 ± 9.3 (range 20-53) hours, for the simultaneous and delayed groups (p<0.001), respectively. The two study groups did not differ significantly for dialysis in the first 7 days, nor for urine output in the first 24 hours. There was a higher likelihood of creatinine decrease in the first 24 hours for the delayed group (p=0.03). GFR was higher for the delayed group at 6- and 12-months (73 vs 67 (6 months) and 73 vs 64 (12 months)), but this did not reach statistical significance. Graft and patient survival at 90-days and 1-year was equivalent. Three year Cox regression survival for the kidney graft was equivalent (82% at 3-years).

Conclusions: In LK patients, kidney transplant can be safely delayed up to 2-days post-LT with outcomes comparable to simultaneous transplantation. Delayed implantation of the kidney post LT allows (i) time for stabilization of the patient and (ii) creates flexibility for the management of patients and personnel at a high-volume transplant center.

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