What are the listing criteria for a combined liver and kidney transplant in patients with end-stage liver and kidney disease, such as cirrhosis and nephropathy, with impaired renal function (Glomerular Filtration Rate (GFR) < 30 mL/min) and a high Model for End-Stage Liver Disease (MELD) score?

Combined Liver-Kidney Transplant Listing Criteria

Combined liver-kidney transplantation should be listed for patients with cirrhosis who meet specific renal dysfunction thresholds: eGFR/creatinine clearance <30 mL/min, dialysis for end-stage renal disease, or sustained acute kidney injury with GFR <25 mL/min and/or hemodialysis for at least 6 weeks. 1

Primary Listing Criteria for Chronic Kidney Disease

For patients with cirrhosis and chronic kidney disease, the 2024 EASL guidelines provide the most current framework 1:

• eGFR/creatinine clearance <30 mL/min at the time of registration qualifies for combined transplantation 1
• Active dialysis for end-stage renal disease is an absolute indication 1
• The underlying diagnosis must be confirmed by a transplant nephrologist as CKD with measured or calculated GFR ≤60 mL/min for >3 months 1

Listing Criteria for Sustained Acute Kidney Injury

For patients with cirrhosis-associated sustained AKI, more stringent criteria apply 1:

• GFR <25 mL/min for at least 6 weeks (documented by weekly measurements) 1
• Hemodialysis for at least 6 weeks 1
• Any combination of the above two criteria for 6 weeks 1
• Regular hemodialysis without specific duration requirement also qualifies 1

Special Metabolic Disease Indications

Certain metabolic diseases warrant combined transplantation regardless of GFR thresholds 1:

• Primary hyperoxaluria 1
• Atypical hemolytic uremic syndrome (aHUS) from mutations in complement factor H or I 1
• Familial nonneuropathic systemic amyloidosis 1
• Methylmalonic aciduria 1

Sequential vs. Simultaneous Transplantation

When reversibility of renal dysfunction is uncertain, both approaches are acceptable 1:

• Simultaneous liver-kidney transplantation is recommended for sustained AKI meeting the 6-week criteria 1
• Sequential transplantation (liver first, kidney later if needed) may be considered when CKD reversibility is uncertain 1
• The UNOS "safety net" policy allows priority kidney access for liver-alone recipients who develop renal failure post-transplant 1

Critical Pitfalls to Avoid

Do not list for kidney transplant alone in patients with compensated cirrhosis unless clinically significant portal hypertension has been definitively excluded 1. Portal hypertension significantly worsens outcomes after isolated kidney transplantation, and these patients require hepatology evaluation with specific studies to rule out portal hypertension 1.

Avoid premature listing for combined transplant in patients with potentially reversible AKI 1. The 6-week threshold for AKI exists specifically to differentiate hepatorenal syndrome (which may reverse after liver transplant alone) from intrinsic renal disease requiring kidney transplantation 1, 2.

Documentation Requirements

The transplant program must document 1:

• Nephrologist confirmation of the underlying renal diagnosis
• Serial GFR measurements demonstrating sustained dysfunction
• Dialysis records if applicable
• Evidence that renal dysfunction has persisted for the required duration (3 months for CKD, 6 weeks for AKI)

High MELD Score Considerations

While high MELD scores reflect both hepatic and renal dysfunction, the MELD score itself is not a criterion for combined transplantation 1. The specific renal function thresholds (GFR <30 mL/min for CKD or <25 mL/min for AKI) must be met independently 1. However, patients meeting combined transplant criteria typically have elevated MELD scores due to the creatinine component, which appropriately prioritizes them for organ allocation 1.