Chronic kidney disease (CKD) is increasingly common among liver transplant candidates, driven by shifts in liver disease epidemiology and rising rates of concurrent renal dysfunction [1, 2]. In the United States, alcohol-associated liver disease and metabolic dysfunction–associated steatohepatitis (MASH) have emerged as the leading indications for liver transplantation [3], both of which are strongly associated with CKD [2, 4]. This evolving landscape necessitates more nuanced decisions regarding organ allocation, particularly in balancing the use of simultaneous liver–kidney transplantation (SLK) versus kidney-alone transplantation (KAT).

In patients with compensated cirrhosis, early SLK listing practices were shaped by concerns that kidney transplantation alone could precipitate hepatic decompensation, leading to conservative strategies that favored dual-organ allocation [5–7]. This caution remains evident in the kidney transplant community, where hesitancy persists in offering KAT to patients with compensated cirrhosis, even when synthetic liver function appears preserved [8, 9]. Central concerns include the risk of post-transplant liver decompensation, progression to end-stage liver disease, and inadequate assessment of portal hypertension or ongoing hepatic injury [10].

In the United States, candidates are considered for simultaneous liver–kidney transplantation (SLK) only after meeting accepted indications for liver transplantation while also satisfying kidney-specific eligibility criteria established by the Organ Procurement and Transplantation Network (OPTN). Current OPTN policy defines SLK eligibility primarily by the severity and duration of kidney dysfunction, including prolonged dialysis dependence or sustained reductions in estimated glomerular filtration rate (eGFR), rather than by standardized measures of liver disease reversibility [11, 12].

While these criteria improved consistency in SLK allocation, they do not directly address the dynamic nature of liver disease or changes in transplant candidacy over time. Consequently, transplant decision-making often shifts to the kidney transplant community when candidates initially listed for SLK reach a point where liver transplantation is no longer pursued yet continue to require kidney transplantation. In this setting, uncertainty remains regarding the safety of proceeding with kidney-alone transplantation (KAT), particularly in the absence of standardized measures of hepatic stability or objective assessment of portal hypertension. Consequently, centers may vary in their willingness to proceed with KAT. Although several single-center studies suggest that KAT may be feasible in carefully selected patients, long-term outcomes in this unique population remain poorly characterized [13–15].

Recently, our group examined national waitlist outcomes among more than 15,000 candidates listed for SLK transplantation using the SRTR. That study demonstrated that kidney-alone transplantation following SLK listing is uncommon, occurring in approximately 1%–1.5% of candidates, while approximately 15% were removed from the waitlist because transplantation was no longer considered necessary. These findings highlight the dynamic nature of transplant candidacy and suggest that a small but clinically important subgroup of candidates may ultimately proceed with kidney-alone transplantation. However, the long-term post-transplant outcomes of these recipients remain unknown [16].

This study leverages national SRTR data to evaluate outcomes in recipients who were initially listed for SLK but ultimately received KAT following liver waitlist delisting. By comparing these recipients with matched kidney-alone transplant recipients without liver disease, we characterize patient and graft survival, evaluate the subsequent need for liver transplantation, and provide evidence to inform transplant decision-making in this uncommon but clinically important population.

In this national registry analysis, we evaluated outcomes of kidney-alone transplantation among recipients who were initially listed for SLK but ultimately underwent kidney-alone transplantation after liver transplantation was no longer pursued. These findings demonstrate that graft and patient survival in this administratively defined cohort are comparable to those of demographically matched primary KAT recipients. Across death-censored graft survival and overall graft survival, neither Kaplan–Meier analyses nor multivariable Cox models revealed significant differences between groups. While unadjusted Kaplan–Meier curves demonstrated lower patient survival in RLD-KAT recipients, this difference was attenuated and no longer statistically significant after multivariable adjustment. These findings suggest that kidney-alone transplantation may be an appropriate strategy in carefully selected prior SLK candidates following liver waitlist delisting.

The separation observed in the unadjusted Kaplan–Meier survival curve likely reflects baseline differences between groups. Adjustment for clinically relevant variables attenuated the mortality signal, suggesting that the crude survival difference was driven by measured confounders rather than an independent effect of prior liver-kidney listing status. Given the modest sample size and the inherent selection of recipients in whom liver transplantations was no longer considered necessary, these findings should not be interpreted as demonstrating equivalence but rather as supportive of acceptable outcomes in a selected cohort.

The findings of this study align with real-world clinical practice within transplant hepatology and transplant surgery. Liver transplant teams may opt to discontinue pursuit of liver transplantation when hepatic recovery is sufficient, especially when synthetic function improves, portal hypertension stabilizes, MELD components normalize, or patients respond to interventions such as alcohol abstinence, antiviral therapy, or medical optimization [18–21]. In our cohort, 65.2% of recipients were removed from the liver waitlist because of documented clinical improvement. Although the SRTR does not capture the specific clinical factors underlying these decisions, our findings demonstrate that recipients who ultimately underwent kidney-alone transplantation after liver transplantation was no longer pursued had long-term outcomes comparable to standard KAT recipients. Notably, these outcomes were observed despite the RLD-KAT group having longer pre-transplant dialysis duration and a lower proportion of living donors (Table 1). Future work should aim to establish objective criteria, such as estimation of portal hypertension, fibrosis regression markers or biochemical recovery thresholds, that can better identify individuals who can safely transition from SLK consideration to KAT.

Recent work by Schmidt et al. further supports the concept of dynamic liver transplant candidacy. In a national SRTR analysis of more than 15,000 SLK-listed candidates, prior TIPS placement was associated with significantly lower one-year mortality and a 29% reduction in adjusted mortality overall [16]. These findings emphasize the importance of considering the evolving trajectory of hepatic candidacy, when determining whether SLK or KAT is the more appropriate strategy. Our results add a valuable post-transplant perspective to this evolving paradigm. Among carefully selected SLK candidate in whom liver transplantation was not pursued, long-term outcomes were comparable to those observed among matched KAT recipients. A notable finding is the durability of this treatment strategy. Only six patients (3.7%) in the RLD-KAT cohort required subsequent liver transplantation, four liver alone transplants and two SLK, suggesting that progression to liver transplantation after KAT was uncommon. Together, these findings support a more individualized approach to SLK vs. KAT decision-making. Transplant nephrologists and surgeons should consider KAT in carefully selected prior SLK candidates, as this approach appears both clinically safe and resource efficient.

Several smaller single center studies have demonstrated that kidney transplantation alone can be safe and effective in patients with well-compensated cirrhosis [13–15, 22]. For example, Nathani et al. reported favorable post-KAT outcomes in cirrhotic patients with preserved hepatic function in a single center study including 32 patients, with 19% of cirrhotic patients presenting with hepatic decompensation post KAT. In a multicenter retrospective study including 34 patients with compensated cirrhosis, Dodge et al. demonstrated that kidney transplantation alone is feasible and associated with a five-year post-KTA incidence of hepatic decompensation of 23.5%, consistent with the natural history of disease progression in cirrhosis [23–25]. Our data complement and extend these findings by providing a national, matched cohort analysis with long-term follow-up. However, caution is warranted when generalizing our findings to all patients with compensated cirrhosis, as the RLD-KAT cohort represents a highly selected group of prior SLK candidates, and unmeasured factors such as degree of portal hypertension, presence of ascites, fibrosis, alcohol abstinence, or virologic control likely contributed to the outcomes.

A specific population warranting mention is patients with autosomal dominant polycystic kidney disease and coexisting polycystic liver disease. These individuals often present with massive hepatomegaly and progressive renal failure, and may be considered for SLK primarily to address symptom burden due to space constraints such as anorexia and abdominal distention, potentially leading to cachexia [26]. Hepatic synthetic function in this population is typically preserved, and liver disease rarely progresses to decompensation [27]. Our findings suggest that when renal dysfunction dominates the clinical picture, KAT may be an appropriate option even in patients previously listed for SLK, particularly with appropriate preoperative imaging and multidisciplinary planning (Supplementary Figure 1). Although our study was not designed specifically to evaluate this subgroup, these observations support careful patient selection and individualized decision-making regarding SLK versus KAT in polycystic liver disease.

The importance of this clinical question is likely to increase as the epidemiology and treatment of chronic liver disease continue to evolve. Alcohol-associated liver disease and MASH have become the leading indications for liver transplantation [3] and an increasing number of patients may experience meaningful improvement in liver function following sustained alcohol abstinence [18], antiviral therapy for chronic viral hepatitis [19, 20], optimization of portal hypertension [21], and emerging disease-modifying therapies for metabolic liver disease [28, 29]. As transplant candidacy becomes increasingly dynamic, multidisciplinary reassessment of both liver and kidney transplant needs will be key. Future studies should focus on developing objective clinical criteria incorporating portal hypertension, liver synthetic function, and disease trajectory to better identify candidates who may safely transition from SLK consideration to kidney-alone transplantation.

Nevertheless, several limitations merit acknowledgement. First, the SRTR lacks detailed clinical granularity regarding liver disease recovery. Importantly, the exposure of interest in this study is administrative rather than physiologic. “Recompensation” in this analysis reflects transplant center listing decisions and liver waitlist status recorded within the SRTR rather than direct measures of portal hypertension, fibrosis regression, ascites history, abstinence durability, or virologic control. Furthermore, liver waitlist removal and documented reasons for removal were used to characterize the clinical pathway preceding kidney transplantation, rather than to ascertain cohort eligibility. Consequently, variability in transplant center practices regarding waitlist management may have influenced cohort characterization without affecting cohort ascertainment. As such, this study evaluates outcomes in candidates deemed stable enough that liver transplantation was not pursued, rather than the biologic reversal of cirrhosis. The findings, therefore, reflect selection practices and center-level decision-making as much as liver disease trajectory. Second, although we identified recipients who were initially listed for SLK and ultimately underwent kidney-alone transplantation, the SRTR database does not capture individuals who were referred for liver transplant evaluation but never listed. As a result, an important segment of patients with early or improving liver function is not represented. Third, despite matching and multivariable adjustments, unmeasured confounding remains possible, particularly given the extensive clinical selection and transplant center decision-making inherent to the RLD-KAT cohort. Additionally, because the SRTR does not capture the clinical rationale underlying initial SLK listing decisions, we cannot determine whether some candidates were listed conservatively before the trajectory of their liver disease became fully apparent. As disease-modifying therapies for alcohol-associated liver disease, viral hepatitis, and MASH continue to evolve, liver transplant candidacy may become increasingly dynamic, further emphasizing the need for objective criteria to identify candidates who can safely undergo kidney-alone transplantation.

Despite these limitations, the study provides valuable insights into the durability and outcomes of kidney-alone transplantation in carefully selected prior SLK candidates after liver transplantation was no longer pursued.

Kidney-alone transplantation in carefully selected candidates previously listed for SLK in whom liver transplantation was no longer pursued is associated with acceptable graft and patient survival and a low incidence of subsequent liver transplantation. These findings support careful individualized consideration of KAT over SLK in appropriately selected patients but should not be extrapolated to all patients with compensated cirrhosis or used to redefine SLK eligibility criteria. Rather, they provide reassurance regarding outcomes in this administratively defined, highly selected population.