*Purpose: To inform future organ distribution policy.

*Methods: We determined access to deceased donor transplantation, transplant survival, the duration of additional renal replacement therapy needed within ten years after transplantation, and the survival benefit of transplantation in patients with a history of first transplant failure (n= 27,459) and transplant naïve, incident ESRD patients (n= 1,426,677) between 1995-2014 in the United States.

*Results: Few patients in either group (14.8% and 13.7%) underwent transplantation within ten years of requiring renal replacement therapy, but the likelihood of transplantation was higher in patients with transplant failure, HR =1.16 [95% CI: 1.12-1.20, p < 0.001]. Among transplant recipients, second transplant recipients had a higher likelihood of death censored transplant failure (HR = 1.44 [95% CI: 1.34 - 1.54, p < 0.001]), but were not a higher risk for death with transplant function (HR = 0.90 [95% CI: 0.80 - 1.01, p = 0.07]). The mean duration of additional renal replacement therapy required within ten years after transplantation was greater in second transplant recipients (9.4 versus 2.4 months). Despite inferior transplant outcomes, patients with transplant failure derived a greater survival benefit from transplantation compared to treatment with dialysis (HR = 0.32 [95% CI: 0.29 - 0.35, p < 0.001]) than did incident ESRD patients (HR = 0.40 [95% CI: 0.39 - 0.41, p < 0.001]).

*Conclusions: The findings support equal allocation of organs to patients with previous transplant failure and the need for dedicated strategies to improve outcomes in these patients.

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