title: Outcomes of adult liver re-transplant patients in the model for end-stage liver disease era: is it time to reconsider its indications?
abstract: OBJECTIVE
  To better understand the outcomes and utility of liver re-transplantation in non-hepatitis C patients, we sought to identify predictors that impact post-transplant patient and graft survival comparing primary liver transplant patients to those receiving subsequent allografts.
  
  
  METHODS
  We conducted a retrospective cohort analysis using the United Network for Organ Sharing database from February 2002 through December 2012, including non-hepatitis C infected adults (18 yr and older) who underwent primary and repeat liver transplantation. Patient and graft survival were compared between the two groups using the Kaplan-Meier estimator. Cox proportional hazards models were constructed to evaluate variables associated with both patient and graft survival.
  
  
  RESULTS
  We identified 33 176 primary transplant recipients and 2710 re-transplants. Re-transplantation patients were more likely to be on dialysis prior to transplant (18% vs. 10%), hospitalized (26% vs. 16%), in the intensive care unit (ICU) (34% vs. 13%), on a ventilator (17% vs. 3%), and had higher model for end-stage liver disease (MELD) score (27 vs. 21). Re-transplants also received livers with a lower donor risk index (DRI) (1.57 vs. 1.64). We estimated an adjusted hazard ratio (HR) of 1.7 for patient survival (95% CI: 1.56-1.84) and 1.61 (95% CI: 1.5-1.73) for graft survival.
  
  
  CONCLUSIONS
  Liver re-transplantation in non-hepatitis C patients, although life saving, has significantly inferior patient and graft survival compared to primary liver transplantation. Higher quality grafts are used inefficiently in a sicker patient population, suggesting that a more optimal strategy may include restricting their use to patients who obtain a longer term benefit.
authors.affiliation: Department of Surgery, Division of Transplantation, University of Washington, Seattle, WA, USA.
authors.forename: Martin I
authors.initials: MI
authors.lastname: Montenovo
authors.forename: Ryan N
authors.initials: RN
authors.lastname: Hansen
authors.forename: André A S
authors.initials: AA
authors.lastname: Dick
mesh_terms: D000293:Adolescent; D000328:Adult; D058625:End Stage Liver Disease / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006085:Graft Survival; D006801:Humans; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011379:Prognosis; D012086:Reoperation; D012189:Retrospective Studies; D015996:Survival Rate; D055815:Young Adult
keywords: adults; liver re-transplantation; patient and graft survival