Introduction: For patients who have lost their first renal graft, a second kidney transplant is widely accepted as the next best therapeutic option (due to similar graft survival rates). This study investigates patient and graft outcomes following 3^rd, 4^th and 5^th renal transplants.

Methods: We reviewed all transplants performed between 2000 and 2014 at our Unit. 1^st and 2^nd transplants (Group 1) were grouped together and compared with 3^rd, 4^th and 5^th transplants (Group 2).

Results: There were 2951 renal transplants during the study period. 2895 were 1^st and 2^nd transplants (median age 44, IQR 21) and 56 (1.9%) were 3^rd, 4^th and 5^th transplants (median age 43, IQR 17.75).

1150 (39.7%) recipients in Group 1 were female versus 28 (50%) in Group 2. Also 1379 (47.6%) donors in Group 1 were DBD, 427(14.7%) DCD and the rest from living donors. There were 27 (48.2%) DBD, 2 (3.6%) DCD and 27 (48.2%) living donors in Group 2.

The 1-, 3-, 5- and 10 year patient survival for Group 1 was 97.5, 95.7, 93.8 and 89.3% where as the graft survival for the same period was 94.7, 90.8, 83.3 and 32.3%. The 1-, 3-, 5- and 10 year patient survival for Group 2 was 96.3% 94.1% 94.1% and 87.4% where as the graft survival for the same period was 82.6% 80.2% 76.7% and 57.8% (p-values=0.811 and 0.854 respectively).

In 43 cases out of 49 (87.8%) where the information was available, at least one of the previous grafts was removed at some point. Moreover, in 21 out of 45 cases (46.7%), the common iliac artery was used for the new arterial anastomosis. In 8 out of 47 cases (17.0%) the new transplant was performed intraperitoneally.

Conclusions: Despite the surgical challenges associated with re-transplantation, performing a 3^rd, 4^th or 5^th kidney transplant is feasible with comparable results in terms of short and long term patient and graft survival compared to patients who had their 1^st and 2^nd transplant.

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