![]() From 2002 to 2013, the percentage of simultaneous liver-kidney (SLK) transplants among all liver transplantations has nearly doubled, increasing from 4.2% to 8.1% ( Figure 1). Because an estimation of a candidate’s renal function using serum creatinine as a surrogate marker is included, implementation of the MELD scoring system shifted donor liver prioritization to transplant candidates with renal dysfunction. 5 The three variables comprising MELD – serum creatinine, the international normalized ratio (INR), and total bilirubin – encompass the major manifestations of decompensated end-stage liver disease (ESLD), including renal dysfunction, coagulopathy, and cholestasis, respectively. This system has been highly effective in reducing mortality on the liver transplant wait-list. 1 In response to this recommendation, the United Network for Organ Sharing (UNOS) implemented a new liver allocation system in February 2002 that was based on the Model for End-Stage Liver Disease (MELD) score, a laboratory-based metric that accurately predicts 90-day risk of death. These practices prompted an Institute of Medicine report 2 recommending that liver allocation be based solely on objective predictors of mortality. In the late 1990s, the controversy surrounding prioritization of candidates for liver transplantation centered around the use of waiting time, that is not associated with mortality, 1 as well as subjective factors that could be manipulated to assign priority to liver transplant candidates. The growing deficit in liver donor supply relative to demand has raised the issue of liver allocation to the forefront of debate in the field of liver transplantation. We conclude by discussing potential improvements to current practices including the use of the MELD-sodium score, alternatives to creatinine and creatinine-based equation for estimating renal function and the use of intraoperative renal replacement therapy during liver transplantation. We then discuss pitfalls to the current practices of liver transplantation in patients with renal dysfunction. In this review, we discuss current practices in liver transplantation in patients with renal dysfunction focusing briefly on the decision to perform simultaneous liver-kidney (SLK) transplantation. ![]() As the MELD score is driven in part by serum creatinine as a marker of renal function, the prevalence of renal dysfunction and failure in patients with end-stage liver disease (ESLD) at the time of listing and at transplantation has steadily risen. In February 2002, the United Network for Organ Sharing implemented a system for prioritizing candidates for liver transplantation that was based on the risk of 90-day mortality as determined by the Model for End-Stage Liver Disease (MELD) score. ![]()
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