End-Stage Renal Disease (ESRD) represents a significant public health challenge worldwide, contributing to considerable morbidity and mortality rates. The global prevalence of ESRD continues to rise in parallel with increasing rates of diabetes mellitus, hypertension, and aging populations [1]. Renal Replacement Therapy (RRT) is vital for patients with ESRD, with kidney transplantation emerging as the preferred treatment modality due to its association with improved survival rates, enhanced quality of life and reduced healthcare costs compared to long-term dialysis [2]-[6].

While Living DONOR kidney Transplantation (LDKT) offers optimal graft survival and patient outcomes [7], it remains inaccessible to many due to limitations in donor availability, medical contraindications among potential donors, and sociocultural or psychological barriers [8]. This donor shortfall has intensified the demand for Deceased Donor Kidney Transplantation (DDKT), which plays a crucial role in bridging the gap between organ supply and the growing transplant waiting list. DDKT not only expands transplant opportunities but also provides an essential avenue for patients with no suitable living donors [9], particularly in regions with a high prevalence of ESRD.

Patients with failed primary kidney grafts, especially those who previously received living-related donor kidneys, represent a unique and clinically challenging cohort. These individuals frequently face immunological sensitization, vascular complications and deteriorating health, making subsequent transplantation more complex [10]. For such candidates, DDKT as a re-transplant offers renewed hope for long-term renal function and survival, though data on its outcomes remain limited and variable across centers.

The challenges associated with DDKT as a kidney re-transplant are multifaceted. These patients often have heightened immunological risk due to sensitization from prior transplantation, more complex surgical histories and greater comorbidity burdens. The decision to proceed with a re-transplant—especially after the loss of a graft from a living related donor, often perceived as the best initial option—brings significant emotional and clinical weight for patients and providers alike. Importantly, recent international studies demonstrate that with careful patient selection and optimized immunosuppression protocols, outcomes for second DDKT can approach those of primary transplants, offering renewed hope for long-term renal function and patient survival [10]-[12]. Therefore, documenting and understanding successful outcomes in this setting is not only vital for guiding clinical management but also provides optimism for patients facing the daunting prospect of a re-transplant, reinforcing the value of DDKT as a lifesaving intervention.

Recognizing this gap, our study aims to review the graft and patient-associated outcomes of DDKT performed as a re-transplant over a ten-year period at a tertiary care center. By evaluating clinical parameters, graft survival, metabolic complications, and patient mortality, this analysis seeks to inform clinical practice and optimize management strategies for this high-risk, underserved population.

This study aims to evaluate the graft and patient-associated outcomes for DDKT performed as re-transplants over ten years follow-up at a tertiary care center.

The study includes data from 21 recipients and 21 donors. The recipients have a mean age of 41.00 years (SD = 13.03), with 38.1% being male. The mean BMI for recipients is 24.79 (SD = 5.80). Among the recipients, 9.5% have undergone a preemptive renal transplant, and 19.0% use a different RRT modality. The average duration of RRT is 5.26 years (SD = 5.50). Additionally, 33.3% of recipients have diabetes mellitus (DM), and 85.7% have Hypertension (HTN).

For the donor group, the mean age is 37.48 years (SD = 10.44), and 85.7% are male. Among donors, 14.3% have DM and 14.3% have HTN. The mean baseline creatinine level is 156.00 (SD = 104.81). In terms of surgical decisions, 81.0% of cases involve SDC. Acute Kidney Injury (AKI) is present in 57.1% of donors, and 42.9% have an infection requiring antibiotics (Table 1).

Table 1. Recipient & donor characteristics.

The analysis reveals trends in recipient and donor characteristics, with key findings indicating higher prevalence rates of HTN in recipients and a substantial percentage of donors with AKI.

Table 2. Preoperative factors.

The analysis of preoperative factors (Table 2) reveals that the mean cold ischemia time was 12.90 hours (SD = 4.81) and the mean anastomosis time was 43.76 minutes (SD = 7.80). Intraoperative hypotension occurred in 42.9% of the cases. Additionally, 19.0% of patients required Hemodialysis (HD) within the first 7 days post-operation. These results highlight the critical preoperative conditions encountered during the study.

Table 3. Longitudinal analysis of creatinine and (tacrolimus) FK levels in recipients.

The mean creatinine levels decrease from 117.25 µmol/L (SD = 41.04) at 1 month to 104.00 µmol/L (SD = 45.07) at 5 years (Table 3). The mean creatinine at last follow-up with minimum follow-up of one year and maximum follow-up of plus 10 years was 103.81 umol/l (SD = 37.23). FK levels show an initial increase, peaking at 1 month with a mean of 10.61 ng/mL (SD = 3.80), then stabilizing over time to 6.45 ng/mL (SD = 1.30) at 5 years. The data suggest a trend of stabilization in both creatinine and FK levels in recipients over the observed period.

Table 4. Factors associated with graft loss.

Table 4 examines factors associated with graft loss in our study population, among whom 9.5% experienced graft loss. The mean age of recipients without graft loss is 42.1 years, compared to 31.0 years in those with graft loss, though this difference is not statistically significant (p = 0.264).

The type of Renal Replacement Therapy (RRT) modality shows no significant association with graft loss, as both groups predominantly used Hemodialysis (HD). However, the mean duration of RRT is longer in the graft loss group (12.0 years) compared to those without graft loss (4.5 years), approaching significance (p = 0.066).

Donor characteristics such as Diabetes Mellitus (DM) and Acute Kidney Injury (AKI) do not show a significant relationship with graft loss. However, all recipients with graft loss had donors with Hypertension (HTN), though this was not statistically significant (p = 1.000).

Cold ischemia time and anastomosis time are similar between groups, indicating no significant impact on graft loss. However, intraoperative hypotension is more frequent in the graft loss group (100% vs. 36.8%), although not statistically significant (p = 0.171).

A significant finding is that all patients with graft loss required hemodialysis within the first 7 days post-operation, contrasting with only 10.5% in the non-graft loss group (p = 0.029), suggesting early post-operative dialysis is associated with graft loss.

Table 5. Factors associated with graft rejection.

Table 5 explores the factors associated with graft rejection in a cohort of 21 patients, where 14.3% experienced graft rejection. The mean age of recipients experiencing rejection is higher (48.7 years) compared to those without rejection (39.7 years), though not statistically significant (p = 0.282).

The modality of Renal Replacement Therapy (RRT) does not show a significant association with graft rejection, with the majority using Hemodialysis (HD). The mean years on RRT are similar between groups (p = 0.951).

Donor characteristics such as Diabetes Mellitus (DM) and Acute Kidney Injury (AKI) do not significantly impact graft rejection, although all cases of rejection occurred in recipients with donors who had AKI (p = 0.229). Hypertension (HTN) is present in all recipients with graft rejection, but not significantly associated (p = 1.000).

Cold ischemia time and anastomosis time minutes are similar between groups, indicating no significant impact on graft rejection. Intraoperative hypotension is more frequent in the non-rejection group (50.0%), though not significant (p = 0.229).

The initial need for hemodialysis within the first 7 days post-operation does not differ significantly between groups (p = 1.000), suggesting it is not a predictor of graft rejection in this cohort.

Table 6. Factors associated with mortality in patients.

Table 6 analyzes factors associated with mortality among 21 patients, with 9.5% experiencing mortality. The mean age of recipients who died is younger (26.0 years) compared to those who survived (42.6 years), with a p-value of 0.087, indicating a trend without statistical significance.

Renal Replacement Therapy (RRT) modality shows no significant association with mortality, as all deceased patients were on Hemodialysis (HD). The average duration of RRT is longer in patients who died (8.5 years) than those who survived (4.9 years), although this is not statistically significant (p = 0.395).

Donor characteristics such as Diabetes Mellitus (DM) and Acute Kidney Injury (AKI) do not show a significant impact on mortality, though all deceased patients had donors with AKI. Hypertension (HTN) in recipients is not significantly associated with mortality (p = 1.000). Cold ischemia and anastomosis times are similar between groups, with no significant differences. Intraoperative hypotension and early post-operative dialysis within the first 7 days also do not show significant associations with mortality, with p-values of 1.000 and 0.352, respectively. Overall, the analysis suggests no single factor shows a statistically significant association with mortality, though trends in younger recipient age and longer RRT duration warrant further investigation.

This ten-year retrospective analysis evaluated the outcomes of Deceased Donor Kidney Transplantation (DDKT) as a second or third re-transplant in a clinically complex cohort. Our findings demonstrate relatively favorable patient and graft survival, with low rates of rejection and acceptable metabolic complication rates, even among recipients with substantial comorbidities and a history of prior graft failure. Notably, the incidence of Delayed Graft Function (DGF), early post-transplant dialysis and metabolic complications such as Post-Transplant Diabetes Mellitus (PTDM) and Post-Transplant Hypertension (PTHTN) was consistent with, or even favorable compared to existing literature on high-risk transplant populations. The study’s significance lies in its focus on a population—recipients with previous graft failure, often from living related donors—for whom optimal management strategies and outcome expectations remain insufficiently defined.

Comparison with international studies highlights that our observed graft and patient survival rates align well with global reports on second kidney transplantation using deceased donor organs. For instance, a study by Gumber et al. [10] reported a five-year graft survival of approximately 80% in second deceased donor transplants, closely mirroring our outcomes. Likewise, Miles et al. [13] and Yahyazadeh et al. [14] have shown that, despite increased immunological risk and surgical complexity, second DDKT recipients can achieve long-term graft function and survival rates comparable to primary transplant recipients, especially when careful patient selection and optimized perioperative management are employed. Additional analyses underscore the pivotal role of standardized immunosuppression protocols and meticulous perioperative care in reducing rejection and improving outcomes in sensitized or high-risk recipients. Reports by Girerd et al. [11] and Franco et al. [12] emphasize that individualized immunosuppression and vigilant post-transplant monitoring significantly contribute to improved graft longevity and recipient survival. Furthermore, a systematic review by Tonelli et al. [3] supports the assertion that transplantation, even for repeat recipients, confers better survival and quality of life compared to remaining on dialysis, underscoring the value of pursuing DDKT when living donor options are exhausted. Recent population-based studies from Europe and North America further reinforce these findings. For example, Sandal et al. [15] analyzed a large US cohort and found that second and third kidney transplants from deceased donors remain associated with substantial survival benefits, despite slightly higher rates of early complications. Similarly, a Norwegian registry-based study by Heldal et al. [16] concluded that there was no difference in outcomes in elderly recipients of DDKT as first or second transplant. Access to repeat transplantation, including DDKT, is critical for maximizing the lifetime benefit of renal replacement therapy and outcomes continue to improve with advancements in immunological risk stratification and organ allocation policies. A broader literature review reveals a growing consensus that DDKT is an effective and often necessary intervention for patients with failed previous grafts, particularly in health systems with limited living donor availability or where sociocultural factors impede living donation. The observed stability in renal function and manageable rates of complications reinforce the notion that DDKT can and should be offered to suitable candidates, even as a repeat procedure, provided that individualized perioperative care and immunological risk management are rigorously applied.

Despite valuable insights, our study has limitations. The small sample size (n = 21) does not stop us from gaining an insight into studied outcomes and their potential association with clinical, immunological and demographic factors but restricts the statistical power to detect significant associations. We did not have the opportunity to perform protocol biopsies due to a lack of consent from the patient which might underdiagnose subclinical graft rejection. Being a single-center study, results may not be generalizable to diverse populations with varying immunosuppressive practices. Finally, retrospective data collection introduces potential selection bias and accuracy issues in data collection. There is also a concern about missing out important clinical events due to possible follow-up of patient for clinical diagnosis or treatment outside our institution.

Our study provides encouraging evidence supporting the use of deceased donor kidney transplantation as a second or third transplant in patients with prior graft failure. With meticulous perioperative management and standardized immunosuppression, favorable patient and graft survival can be achieved, even in this high-risk group. Our findings support the expansion of DDKT programs to address the donor organ gap and offer renewed hope to patients who have exhausted primary transplantation options. Further large-scale, prospective studies are warranted to confirm these findings, refine recipient selection, and optimize clinical protocols for this challenging but increasingly prevalent clinical scenario.

Dr. Bilal contributed to the study design. Dr. Bilal, Dr Lujain, Dr Saima and Dr Wahaj were involved in the writing of article. Data analysis was done by Dr Nadeem and Ms Lama Hefni. Dr Bushra, Dr Bilal and Dr Lujain contributed to the organization of the MS Excel sheet. Dr Wahaj and Dr Saima Faisal were responsible for proof reading, formatting and editing the article according to publication guidelines. Dr Wael Habhab and Dr Najla oversaw work supervision and coordination. Dr Bilal is the corresponding author.

This retrospective study was conducted in accordance with the ethical standards of the KFSHRC Institutional Review Board and adhered to the principles outlined in the Declaration of Helsinki (as revised in 2013). The study protocol was reviewed and approved by the ethics committee.

Given the retrospective nature of the study and the use of de-identified data from ESRD patients, the requirement for informed consent was waived by the IRB.

All patient details have been anonymized to ensure confidentiality in accordance with ethical guidelines and the Declaration of Helsinki.

All the available data is mentioned in the primary manuscript or the supporting material.

We utilized Paper Pal services for grammatical correction and editing before submission.

We would like to acknowledge Ms. Lama Hefni who was of key importance in the administrative journey of this research.