Background: Combined liver-kidney transplantation (CLKT) in children is uncommon. Reports on outcomes are scarce and usually on small cohorts.

Methods: Using the North-American Scientific Registry of Transplant Recipients (SRTR), data were analyzed on 135 primary pediatric CLKT performed from October 1987 to February 2011. Pre-transplant recipient medical condition (RMC) was defined as one of the following: “at home”, “ward patient”, or “patient in the ICU”. Univariate analyses were performed using pre-transplant and post-transplant recipient and donor characteristics to identify predictors of graft and patient survival.

Results: Patient survival was 85.1%, 79.1% and 74.7% at 1, 5 and 10 years, respectively. Liver graft survival was 85.1%, 84.1% and 82.5%, and kidney graft survival was 90.2%, 85.3% and 75.9% (as graft loss owing to patient death was censored, graft survival can exceed patient survival). Factors that influenced both 1-year and 5-year patient survival were: primary liver diagnosis (p=0.02) and primary kidney diagnosis (p=0.01), RMC (p=0.01), pre-transplant weight Z-score (wZ) (p=0.01) and donor/recipient weight-ratio (DRWR) (p=0.02). Additionally, 5-year patient survival was also determined by liver graft survival (p=0.003) and liver-kidney graft survival (p=0.006). Liver graft survival at 2 months and 1 year was influenced by liver graft warm ischemia time (p=0.01 and p=0.05). In addition, RMC further influenced 1-year liver graft survival (p=0.03). 2-month kidney graft survival was influenced by wZ (p=0.02) and post-transplantation first week dialysis (p=0.01). Infection was the most frequent cause of death (6/30 patients).

Conclusions: Pediatric CLKT offers excellent patient and graft survival. Pre-transplant diagnosis, wZ and liver graft survival were strong determinants of long-term patient survival. Several factors contributing to patient outcomes may be modifiable: wZ by focusing on pre-transplant nutrition; RMC at the time of transplant by moving forward time of listing; and post-transplant death owing to infection by decreasing immunosuppression. Reducing liver warm ischemia time might improve liver graft survival and thus patient survival.

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