Background: Data on patient and liver kidney graft survival following combined liver kidney (CLK) transplantation remain conflicting. Aim: To compare outcomes after CLK transplantation to patients receiving only liver but listed for kidney also. Methods and Results: UNOS data used to select first deceased donor adult liver transplants with or without kidney during 1994 and 2011. Of 79,160 transplants, 4930 were CLK (441 kidney after liver [KAL], 770 liver after kidney [LAK], 3719 simultaneous liver kidney [SLK]) and 74,230 liver alone (2065 listed for kidney [LALK]). During 1994-2011, CLK proportion of all transplants increased from 3.2% to 9.5% and LALK decreased from 4.8% to 1.6%. Compared to LALK, patients with CLK transplants were a) older (52±9 vs. 49±10 yrs.); b) more likely to have higher MELD (29±9 vs. 24±12), renal insufficiency (RI), creatinine> 2 mg/dl (85% vs. 33%) and diabetes (33% vs. 28%); c) more likely on dialysis (65% vs. 17%) and in MELD era (78% vs. 53%). Once listed for kidney, predictors of receiving CLK were RI, dialysis, MELD era transplants. Hispanic race had 19% less likely to receive CLK compared to other races. Comparing 5 yr. survival for LALK to KAL, LAK, and SLK showed lower survival for LALK for liver graft (67% vs. 68%, 74%, and 71%; Log Rank P=0.0002) and similar for patient (77% vs. 76%, 74% and 77%; P=0.1). Other predictors were black race, on ventilator, dialysis, and RI. Kidney graft 5 yr. survival was lower for LAK compared to KAL and SLK (54% vs. 67% and 69%, P<0.0001). Amongst LAK transplants, 5 yr. outcomes were poor for patient and kidney graft if liver received >30 d after kidney (N=203) compared to ≤ 30 d (N=567): 67% vs. 77%; P=0.01 and 50% vs. 67%; P=0.0001). For KAL transplants, patient survival was poor for kidney received within 30 days after liver (N=383) compared to >30 days (N=83): 73% vs. 92%; P=0.0001. LALK was a predictor for liver graft loss [1.32 (1.11-1.45)] and patient mortality [1.6 (1.3-2)]. Other predictors were being on ventilator, dialysis, RI, black race, and male gender. Conclusions: Proportion of CLK transplantation is increasing in the US. Guidelines are needed for patient selection to list for CLK transplantation balancing at optimizing use of kidneys and achieving good post transplant outcomes.

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