*Purpose: Success of transplantation is not limited to initial receipt of a donor organ. Many patients experience graft loss within their lifetime and the benefits of expedited kidney transplantation extend to patients with a prior transplant despite relatively increased risk of graft failure. Factors associated with access to repeat transplantation may be unique and certain barriers to care may be attenuated given patients’ experience with the transplant process and prior qualification as a viable candidate.

*Methods: We examined the incidence, risk factors, secular changes and center-level variation of preemptive re-listing or transplant (PRLT) for kidney transplant recipients in the United States with a graft failure (not due to death) using SRTR data from 1998-2018(n=53,739).

*Results: The incidence of PRLT was 13% over the study period (lower than preemptive rates at initial listing – 15%), increasing from 1998(4.5%) to 2009(15.0%) and slightly decreasing to 2018(11.9%). Limited to patients who were eventually re-listed within 5 years of graft failure, the proportion of PRLT was 22%.Significantly lower rates of PRLT were evident among patients that were African American and Hispanic, obese, publicly insured, diabetic, longer dialysis time prior to initial transplant, older, shorter graft survival, longer distance to the transplant center and residing in more distressed communities. There was pronounced variation in PRLT by initial transplant center, median=12%, 10^th percentile=5%, 90^th percentile=20% (adjusted ratios displayed on Figure).

*Conclusions: Cumulatively, results indicate that despite a recognized population with prior access to transplantation, rates of PRLT remains modest. Moreover, there are pronounced clinical, social and center-level sources of variation suggesting opportunities to understand and attenuate barriers to preemptive care. Navigation of care to receive a timely re-transplant remains a critical challenge for the transplant population and has important implications for managing patients with a failing graft.

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