Background: The Model for End-Stage Liver Disease (MELD) system prioritizes liver allocation to patients in renal failure, increasing the number of simultaneous liver-kidney transplants (SLK). Identifying predictors of post-transplant futility (90-day or in-hospital mortality) and renal recovery could maximize utilization of these scarce resources.

Methods: Analysis of adult LT recipients on pre-transplant RRT from July 2004 to September 2012 at a single-institution using 33 recipient, donor, and operative variables. Multivariate logistic regression was used to identify predictors of futility and dialysis dependence at 3-months.

Results: Of 1546 LT recipients, 529 were on RRT (34%). The mean MELD score was 38. Compared to patients undergoing LT alone (LTA, n=407), SLK (n=94) patients were significantly older and more obese, diabetic, and hypertensive, but less likely hospitalized, on continuous RRT, ventilator-dependent, or on vasopressors. Despite kidney transplantation, 21% of SLK recipients were dialysis-dependent at 3-months, compared to 43% of LTA recipients (P<0.001). Of all futile LTs (n=94, 19%), only 4 patients (4%) became dialysis-independent prior to their death. Futile LT accounted for 43% and 75% of failures to achieve dialysis independence in LTA and SLK, respectively. Multivariate predictors of futility included coagulopathy requiring abdominal packing, pre-transplant length of RRT, mechanical ventilation, recipient and donor age, and hyperlipidemia. In non-futile patients, multivariate predictors of dialysis dependence included non-fulminant etiology, LTA, emergent intraoperative RRT, pre-transplant RRT > 7 days, metabolic syndrome, pre-transplant stay, and gender (Table).

Conclusions: We report the largest single-institution experience of LT in patients on pre-transplant RRT. We identified important predictors of post-LT futility and renal recovery that may help to guide the allocation of kidneys in these challenging LT recipients.

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