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Background Kidney transplantation has been advocated as a therapeutic option in lung recipients who develop end-stage renal disease ( ESRD). This analysis outlines patterns of allograft survival following kidney transplantation in previous lung recipients ( KAL). Methods Data from the UNOS lung and kidney transplantation registries (1987-2013) were cross-linked to identify lung recipients who were subsequently listed for and/or underwent kidney transplantation. Time-dependent Cox models compared the survival rates in KAL patients with those waitlisted for renal transplantation who never received kidneys. Survival analyses compared outcomes between KAL patients and risk-matched recipients of primary, kidney-only transplantation with no history of lung transplantation ( KTx). Results A total of 270 lung recipients subsequently underwent kidney transplantation ( KAL). Regression models demonstrated a lower risk of post-listing mortality for KAL patients compared with 346 lung recipients on the kidney waitlist who never received kidneys ( P<.05). Comparisons between matched KAL and KTx patients demonstrated significantly increased risk of death and graft loss ( P<.05), but not death-censored graft loss, for KAL patients ( P = .86). Conclusions KAL patients enjoy a significant survival benefit compared with waitlisted lung recipients who do not receive kidneys. However, KAL patients do poorly compared with KTx patients. Decisions about KAL transplantation must be made on a case-by-case basis considering patient and donor factors. [ABSTRACT FROM AUTHOR]