Background: The size of the kidney wait list as well as the waiting time is increasing in the US. Given the current shortage of renal allografts, the utility of a kidney transplant among individuals with 2 prior kidney transplants is unknown. Therefore we sought to determine the survival benefit of a third kidney transplant (3KT).

Methods: Multivariable Cox regression models were created to determine characteristics associated with 3KT outcomes and the survival benefit of 3KT among recipients wait listed and transplanted within the United States between 1995 and 2009.

Results: 4,334 patients were wait listed for a 3KT and 2,492 patients received a 3KT. In a multivariate analysis, controlling for both donor and recipient variables, 3KT demonstrated an overall patient survival benefit compared to the wait list (HR-0.379, CI=0.302-0.475 p<0.001) for those awaiting their first, second or third kidney transplants (Figure 1). However, the time to benefit did not accrue until 8-months post transplant. Additionally, we found that the duration of second graft survival was predictive of third graft survival, where second graft survival beyond 5 years is associated with superior 3KT graft survival (Figure 2). Graft loss in 30 days or less did not indicate a worse 3KT graft survival.

Conclusion: 3KT achieves a survival benefit over remaining on the wait list and should be pursued in the appropriate candidates. Second transplant graft survival beyond 5 years is associated with superior 3KT graft survival.

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