The Evolution of Redo Liver Transplantation Over 35 years

Abstract

Objective: Despite the durability of liver transplantation (LT), graft failure affects up to 40% of LT recipients. We examined liver retransplantation (ReLT) over 35-years at a single center. Methods: All adult, ReLTs from 1984-2021 were analyzed. Comparisons were made between ReLTs in the pre- vs. post- model for end-stage liver disease (MELD) eras and between ReLTs and primary-LTs in the modern era. Multivariate analysis was used for prognostic modeling. Results: 654 ReLTs were performed in 590 recipients. There were 372 pre-MELD ReLTs and 282 post-MELD ReLTs. 89% of ReLT recipients had one previous LT, while 11% had ≥2. Primary non-function was the most common indication in the pre-MELD era (33%) vs. recurrent disease (24%) in the post-MELD era. Post-MELD ReLT recipients were older (53 vs. 48, P=0.001), had higher MELD scores (35 vs. 31, P=0.01), and more comorbidities. However, post-MELD ReLT patients had superior 1-, 5-, and 10-year survival compared to pre-MELD ReLT (75%, 60%, and 43% vs. 53%, 43%, and 35% respectively, P<0.001) and lower in-hospital mortality and rejection rates. Notably, in the post-MELD era, MELD score did not affect survival. We identified the following risk factors for early mortality (≤12 months): coronary artery disease, obesity, ventilatory support, older recipient age, longer pre-ReLT hospital stay. Conclusion: This represents the largest single center ReLT report to date. Despite increased acuity and complexity of ReLT patients, post-MELD era outcomes have improved. With careful patient selection, these results support the efficacy and survival benefit of ReLT in an acuity-based allocation environment.