*Purpose: The only effective therapeutic strategy for irreversible liver graft failure is re-transplantation. The impact of liver and kidney quality in secondary SLK (sSLK) survival outcomes is not well understood. This study evaluates and compares primary SLK (pSLK) and sSLK patient and graft survival with respect to liver donor risk index (LDRI) and kidney donor profile index (KDPI).

*Methods: The SRTR database 2000-2017 was queried for pSLK and sSLK recipients with prior primary liver transplantation or SLK. Both cohorts were stratified according to LDRI (≤1.1, 1.1-1.6, >1.6) and KDPI (≤20%, 20-85%, >85%). Kaplan-Meier analysis and log-rank test were used to compare survival distributions on respective cohorts.

*Results: There were 6236 SLK patients that met criteria: 5481 pSLK and 755 sSLK. The groups were demographically distinct in age (55.7±9 vs. 50.7±12, p<0.01), ethnicity (15% vs. 18% African-American, p<0.01) and MELD score (29±0.1 vs. 32±0.3, p<0.01), respectively for pSLK and sSLK. The 3-, 5- and 10-year patient survival rates were 83%, 78% and 64% for pSLK, and 73%, 68% and 55% for sSLK (p<0.01). Survival rates for liver and kidney were superior for sSLK (p<0.01 for both). A reduction in patient and liver graft survival were observed proportional to increases in LDRI scores for pSLK and sSLK (p<0.01 for both). Lower KDPI scores provided pSLK recipients with superior patient and kidney graft survival (p<0.01 for both). In contrast, sSLK patient survival rates with KDPI ≤20% and 20-85% were not significantly different (p=0.60), yet both were superior to KDPI >85% (p=0.03 and p=0.045, respectively). For kidney graft survival in sSLK, only the group with KDPI ≤20% had superior graft survival over KDPI >85% (p<0.01). To evaluate the impact of KDPI in patients with similar LDRI, we divided pSLK and sSLK cohorts by LDRI and stratified by KDPI. KDPI did not have a significant impact on survival in sSLK patients with LDRI <1.6, whereas pSLK patients with LDRI <1.6 did show a reduction in survival per KDPI increment (p<0.01).

*Conclusions: SSLK provides excellent survival outcomes by extending the life expectancy of liver transplant recipients with irreversible graft failure. Similarly to pSLK, better patient and graft survival are observed in patients with superior liver allograft quality. Lower KDPI scores improve patient survival in sSLK recipients, but better graft survival are only observed in those with KDPI ≤20%. As we aim to maximize utility of limited resources, the importance of liver and kidney allograft quality should not be underestimated when allocating organs for sSLK.

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