*Purpose: Re-transplantation may be associated with management dilemmas including repeat allocation of limited kidney allografts to same individuals in the face of an increasing waiting list. These individuals are often sensitized and present post-transplant challenges with immunosuppression and rejections. There are also technical challenges of implanting in positions already utilized by previous failed transplants. Could transplant nephrectomy to create space for the subsequent transplant cause increased sensitization?

*Methods: This study retrospectively analyses 71 third and 9 fourth transplants out of 3300 adult transplants carried out between 1998 and 2017 in a single transplant unit. Outcomes were evaluated and comparisons made between standard extra-peritoneal and intra-peritoneal routes of implantation; and sensitisation with and without prior allograft nephrectomy.

*Results: Overall patient survival at 1 and 5 years were 98.8% and 96.1% respectively while graft survival at 1 and 5 years were 92.0% and 70.6% respectively. Delayed graft function at 21% was similar in both third and fourth transplants. Acute rejection occurred in 15% of the third transplants and none in fourth transplant group. 50% of the rejection episodes were antibody mediated rejection. 33 out of 80 patients developed perioperative complications, majority of which (75%) occurred in the extra-peritoneal route of implantation. Previous nephrectomy of failed allografts prior to third and fourth transplant did not make any significant difference on patient or graft survival rates. Antibody mediated rejection, though not statistically significant, was found to be higher in those who had prior allograft nephrectomy. Sensitization increased with successive re-transplants and not necessarily post graft nephrectomy.

*Conclusions: Third and fourth kidney transplants have acceptable outcomes and are therefore justified. Standard extraperitoneal kidney implantation predisposes to higher peri-operative complication rates. Sensitization does not necessarily occur as a result of transplant nephrectomy but rather as a result of exposure to increasing number of mismatched HLA antigens in successive re-transplants.

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