Abstract Background and Aims The number of patients listed and receiving simultaneous heart-kidney transplantation (SHKT) has significantly increased in the last decade. This is likely due to the increased knowledge that SHKT is associated with a significant survival benefit in patients with heart failure with chronic kidney disease (CKD), compared to isolated heart transplant and sequential heart and kidney transplantation. Recent analysis of large data bases has shown a survival benefit in SHKT even in older patients and beyond dialysis dependent patients. However, this benefit is only proven for irreversible CKD which is often difficult to prove in patients with severe heart failure. Our center has the largest experience in SHKT in Portugal, and our aim is to report our experience with a total of 8 recipients and their outcomes after 10 years of follow up. Method We performed a retrospective analysis of all the patients submitted to SHKT in Coimbra University Hospital Center from 1 January 2009 to 31 December 2019. Data was collected using the clinical and laboratorial registries from our database. Follow up at December 2019 varied between 6 months to 10 years (median 5,5 years). Results A total of 8 patients received SHKT between 1 January 2009 and 31 December 2019. Only one patient was female and the mean age at transplant was 58.88 ± 9.7 years. The etiology of heart failure was dilated cardiomyopathy (N=4, 50%), severe valvular disease (N=2, 25%), ischemic cardiomyopathy (N=1, 12,5%) and one patient had familiar amyloidosis (N=1, 12,5%). Regarding CKD, the majority of the patients had type 2 cardiorenal syndrome (N=5, 62,5%), one patient had calcineurin toxicity due to previous liver transplantation, one patient had autosomal dominant polycystic disease, and in one patient the etiology remained unknown. Half of the patients were on chronic hemodialysis program for more than 3 months, and the remaining were preemptive. Regarding post-transplant results, average hospitalization was 19 days. Seven patients (87,5%) had immediate cardiac graft function (mean LVEF 70 ± 5.8% and mean PSAP 22.25 ± 5.6 mmHg). One patient had acute cardiac and subsequent renal graft dysfunction and died during hospitalization. Regarding renal graft outcomes, besides the patient that died, another patient had primary renal graft dysfunction due to renal artery thrombosis and one patient presented late graft function. The remaining five patients had immediate graft function and presented normal kidney graft function at follow up. Regarding complications, neoplasia was reported in two patients (one with sarcoma and the other with prostatic cancer), and there were twenty-five episodes of infection, present in all patients. Mortality at follow up was 37% (N=3). One of these, described above, died during hospitalization twenty-two days after transplant, and the other two died 4 and 5 years later due to a cardiovascular event and sarcoma, respectively. At follow up in 2019 five patients present stable kidney graft, good cardiac function and no recent complications. Conclusion In selected patients with co-existing heart and kidney failure, combined heart and kidney transplantation might be the best approach and appears to be associated with better graft and patient survival. Despite having a small number of cases, our center has the biggest experience in SHKT in Portugal and our results are very satisfying. A multidisciplinary approach between Nephrology, Cardiology and Cardiothoracic Surgery is fundamental and in the next decades it is expected an increase in SHKT number.