*Purpose: Patients undergoing kidney transplant (KTA) often have risk factors for liver disease including viral hepatitis and non-alcoholic fatty liver disease (NAFLD). Recent European Association for the Study of the Liver (EASL) and Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend kidney transplant alone in patients with cirrhosis without portal hypertension. However, there is limited data on long term outcomes, especially in patients without hepatitis C (HCV). We hypothesized that compensated cirrhosis patients are still at risk for liver related complications after KTA.

*Methods: We performed a multi-center study (Baylor University Medical Center at Dallas, Baylor Scott & White All Saints Medical Center, Keck Hospital of University of Southern California, and University of Washington) to assess clinical outcomes in cirrhosis patients undergoing KTA. Clinical outcomes included liver decompensation, hepatocellular carcinoma (HCC), and death. Baseline patient characteristics and outcomes were evaluated over a 5-year period post-KTA.

*Results: Across the four centers, 30 KTA recipients were identified to have cirrhosis before or after transplant between 1999-2019. The median age of the patient population was 57 years (IQR 48.5-61.5). 14 of the patients carried a diagnosis of cirrhosis prior to KTA, while 16 were diagnosed after-KTA. Cirrhosis etiologies included HCV (33.3%), alcohol-related liver disease (10%), and NAFLD (26.7%). In total, 6 patients had portal hypertension and grade 1 esophageal varices, with 4 of these patients having been identified prior to transplantation. Early liver decompensation as a result of kidney alone transplant was rare. Within the first year post-KTA, only one patient developed ascites and progressed to CP class B, requiring a liver transplant. 2 patients developed ascites 3-years post-KTA, while 3 patients developed ascites 5-years post-KTA. However, 2 patients developed HCC 1-year post-KTA, and one patient developed HCC 5 years post-KTA. One patient died at the 1-year time point, no patients died at the 3-year time point, and two died at the 5-year time point.

*Conclusions: Diagnosis of cirrhosis is common after KTA and may be related to inadequate workup for NAFLD. KTA in compensated cirrhosis is feasible. However, complications of portal hypertension, re-transplantation, liver cancer and death were observed in 40% unique patients within 5 years after KTA. Continued vigilance and surveillance is needed, especially after introduction of recent guidance by relevant professional societies. This is especially important given the increasing burden of NAFLD in patients being evaluated for kidney transplantation.

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