OBJECTIVES: Despite significant improvements in survival and quality of life (QoL) of liver transplant (LTx) recipients, patients remain at risk from complications related to disease recurrence and long-term use of immunosuppressant (IS). The objective was to assess cost, survival, and QoL outcomes of LTx recipients and the impact of renal dysfunction on LTx outcomes. METHODS: A de novo cohort Markov model was developed to predict long-term outcomes post LTx along two independent pathways: 1) liver-related (acute rejection, hepatocellular carcinoma, hepatitis C (HCV) recurrence, graft loss), 2) kidney-related (chronic kidney disease, dialysis, renal transplantation) and death. All patients, stratified by liver diagnosis, entered the model at time of LTx and followed both pathways, allowing for multiple combinations of liver and kidney health states. Costs and utilities were assigned to each health renal and liver state. Renal complications costs and utility decrements were added to those accrued in the liver pathway. The lifetime model used an annual cycle length except for the 1st year post LTx (quarterly). Choice of immunosuppressant strategy could impact the risk of acute rejection, change in renal function and HCV fibrosis progression. A 3% discount rate was applied to costs and outcomes. RESULTS: On average, life expectancy post LTx was 13.3 years with 10.2 QALYs. Lifetime cost of managing post LTx recipients was USD 550,000 (excluding LTx procedure): >50% was related to IS regimen, monitoring and adverse events; around 40% to renal complications and 2-7% to liver complications. Patients developing renal dysfunction lost 5.2 life-years and 1.5 QALYs. CONCLUSIONS: To our knowledge, this is the first Markov model simulating lifetime costs and outcomes post-LTx and the impact of change in renal function on patient survival. A health care intervention that could improve or maintain renal function would have significant impact on survival and costs.