title: Long-term outcomes after third liver transplant.
abstract: OBJECTIVE
  Orthotopic liver transplant is the treatment of choice for patients with end-stage liver disease. Patients with first graft failure requiring liver retransplant are commonly seen at most liver transplant centers. However, patients with a second graft failure requiring a third graft are uncommon. Liver retransplant in this setting has only been pursued at a few large transplant centers.
  
  
  METHODS
  This is a retrospective analysis of the long-term outcomes of recipients who underwent 3 or more orthotopic liver transplants. Between February 1998 and August 2009, 24 patients had 3 or more orthotopic liver transplants at the Mayo Clinic in Florida.
  
  
  RESULTS
  Mean patient survival was 103.8 months for the study cohort. Actuarial patient survival after the last orthotopic liver transplant in -1, -5, and -10 years was 60%, 40%, 33%. Patients were transplanted with lower donor risk index score grafts in each subsequent orthotopic liver transplant. Patients who had a graft with a donor risk index score > 1.6 at the time of the third orthotopic liver transplant had significantly lower survival rate compared with those with grafts with a donor risk index score ≤ 1.6.
  
  
  CONCLUSIONS
  Multiple liver retransplants offer acceptable patient survival. Each transplant program must decide whether to do multiple orthotopic liver transplants based on the program's transplant volume and outcomes to help this subgroup of patients. The concerns of potentially decreasing access to first time orthotopic liver transplant candidates should also be weighed in the decision to move forward.
authors.affiliation: Department of Transplantation, Mayo Clinic Florida, Jacksonville, FL 32224, USA. taner.burcin@mayo.edu
authors.forename: C Burcin
authors.initials: CB
authors.lastname: Taner
authors.forename: Deniz
authors.initials: D
authors.lastname: Balci
authors.forename: Darrin L
authors.initials: DL
authors.lastname: Willingham
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Keaveny
authors.forename: Barry G
authors.initials: BG
authors.lastname: Rosser
authors.forename: Juan M
authors.initials: JM
authors.lastname: Canabal
authors.forename: Timothy S J
authors.initials: TS
authors.lastname: Shine
authors.forename: Denise M
authors.initials: DM
authors.lastname: Harnois
authors.forename: David J
authors.initials: DJ
authors.lastname: Kramer
authors.forename: Justin H
authors.initials: JH
authors.lastname: Nguyen
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005431:Florida; D006801:Humans; D053208:Kaplan-Meier Estimate; D008107:Liver Diseases / Q000175:diagnosis* / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation / Q000401:mortality*; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011788:Quality of Life; D019233:Retreatment; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome