*Purpose: Simultaneous heart kidney transplantation (SHKT) is increasing in frequency; however there is a lack of consensus regarding patient selection criteria for this life saving procedure. Frailty as measured by the mFI-5 frailty index is a new method for quantifying patient characteristics as they relate to adverse surgical outcomes. Frailty variables defined within this index fall short in their applicability to the transplant field. For patients undergoing SHKT, symptom-based variables are inherently alleviated by transplantation itself, rendering the score unusable for long term outcomes. Here, we sought to find donor and recipient variables that could be used to predict outcomes after SHKT

*Methods: Using the United Network for Organ Sharing (UNOS) database, data from patients with a SHKT from 2006 – 2018 was analyzed. A total of 1061 patients were included in this study. Recipient and donor characteristics were studied and mFI-5 Frailty index was calculated for all patients. Additional variables included were pre-transplant dialysis status, functional status, kidney donor profile index (KDPI), donor age, recipient age, and time on weight list. The primary outcome was overall patient survival. Results were analyzed using Kaplan Meier survival analysis, univariate and multivariate Cox Regression analysis.

*Results: A total of 1061 consecutive SHKT were analyzed. The mean age was 54 years. 80% of these were male. The average time on the wait list was 198 days. The mean mFI5 score was 2.93 with a standard deviation of 0.735. Using Kaplan Meier survival analysis, five variables were predictive of improved overall patient survival. These variables were recipient age, Time on the wait list, pre-transplant dialysis status (p <0.001), functional status (p <0.001), as well as donor age (p= 0.011). These variables maintain their significance for predicting patient survival when combined (p<0.001). While KDPI(p <0.001) and time on weight list (p = 0.031) were found to be significant as isolated variables, they were no longer significant when in combination.

*Conclusions: Pre-transplant dialysis and poor recipient functional status predict poor overall survival after SHKT. These variables in combination with donor age can be used to build an index to predict patient survival post SHKT. This new scoring tool for SHKT candidates will help more informed and precise decision making and maximize equity and utility in Heart and Kidney allocation.

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