*Purpose: Simultaneous heart kidney transplant (SHK) is increasingly common and unregulated. We sought to understand variation in patient selection for SHK at the center level.

*Methods: Data for adult heart transplant recipients and candidates since 2003 were obtained from the UNOS STAR file. Variability in center practice was assessed for all centers performing at least one SHK per year in the study period. Variability in the proportion of dialysis dependent (DD) patients undergoing SHK was determined. Variability in estimated glomerular filtration rate (eGFR) at transplant among non-dialysis dependent (NDD) SHK recipients was examined, including in relationship to center volume and waitlist mortality. Center level effects on the probability of SHK among non-DD patients were investigated by multivariable logistic regression controlling for age, transplant year, eGFR, ventricular assist device usage, and diabetes status.

*Results: A total 33,463 transplant recipients and 20,390 waitlist registrants were included. There was a high degree of variability in the proportion of DD patients who underwent SHK at the center level (Range 25-82%, Figure 1A). The median eGFR of NDD patients undergoing SHK at the time of transplant varied widely both between (Range 19-56 mL/min/1.73m²) and within centers (Figure 1B). There was no relationship between eGFR at transplant of SHK recipients and either center volume (p=0.448) or waitlist mortality (p=0.156). The odds of receiving SHK among NDD recipients varied widely by center with the odds ratio of the most to least SHK permissive center being 35.0 (95% CI 11.5-106.3). When examining the marginal probability of SHK, we noted that it decreased with increasing eGFR but was different between centers (Figure 2).

*Conclusions: There is wide variation in patient selection for SHK both within and between centers. This variation may present an opportunity to improve allocation of kidneys for these dual organ transplants.

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