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Key Points 1. Retransplantation (re-LT) for hepatitis C virus (HCV) recurrence is controversial. Although re-LT accounts for 10% of all liver transplants (LTs), the number of patients requiring re-LT is expected to grow as primary LT recipients survive long enough to develop graft failure from recurrent disease. 2. Utility, as applied to the medical ethics of transplantation, refers to allocating organs to those individuals who will make the best use of them. The utility function (U) of liver transplantation is represented by the product of outcome (O ‫؍‬ 1-year survival with LT) times emergency (E ‫؍‬ 3-month mortality without LT), i.e., U ‫؍‬ O ؋ E. H epatitis C virus (HCV)-related liver disease is currently the leading indication for liver transplantation (LT) throughout the world. Infection of the allograft after LT is universal. Fibrosis develops at a faster rate in the allograft than in the native liver and allograft cirrhosis may develop in 20% to 40% at 5 years, compared to 3% to 20% at 20 years in non-LT patients. 1 -3 The development of allograft cirrhosis is associated with a 40% decompensation rate within 1 year compared with 3 to 5% in non-LT patients with cirrhosis. 2,4 Half of these patients do not survive an additional year. 4 Treatment of recurrent HCV after LT has proven difficult due to toxicity and limited effect on outcome. 5,6 For many patients with allograft failure, the only chance of long-term survival is derived from retransplantation (re-LT).Re-LT for HCV accounts for about 40% of re-LTs performed annually in the United States. 7,8 Re-LT for HCV might be expected to increase in the future, as more patients are transplanted for HCV and develop allograft failure from HCV recurrence. However, re-LT in HCV-positive patients has been associated with poorer outcome compared to non-HCV diagnoses. 7,9 Regardless of the indication, re-LT is controversial due to issues of poor outcome, cost, and resource utilization. 10 Numerous factors have been identified as influencing survival following re-LT (Table 1). Despite these data, a recent survey revealed that a minority of transplant centers feel that a model for end-stage liver disease (MELD) score over 30 should be an exclusion criterion for patients being considered for re-LT for recurrent HCV. 23 The aim of our study was to develop a model to determine what MELD score is associated with the greatest utility in re-LT for recurrent HCV. We hypothesized that the MELD score associated with maximal utility for re-LT due to recurrent HCV would be lower than the MELD score associated with maximal utility for primary LT due to HCV cirrhosis.

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