Outcomes of pediatric liver retransplantation candidates in the modern era: Strategies are needed to avoid waitlist mortality in the United States.

Pediatric liver retransplantation (rLT) has historically shown poorer outcomes compared to primary liver transplantation (pLT). Comprehensive studies assessing outcomes for pediatric rLT candidates under the modern allocation policy are lacking. OPTN data from January 1, 2010, to December 31, 2022 were obtained; exclusion criteria included candidates ≥18years of age and those listed or transplanted for multiple organs. 7645 children met the inclusion criteria: 7162 pLT and 483 rLT candidates. The rLT candidates, despite a shorter median waitlist time to transplant (6.5 d vs. 54 d for pLT), had significantly higher waitlist dropout rates and worse post-transplant outcomes. Vascular complications were the most common reason for primary graft failure (PGR). The small size of the recipient was a significant risk factor. Among those retransplanted, the timing of relisting was significantly associated with outcomes, with those relisted within 30days from the pLT demonstrating considerably worse outcomes. Our findings emphasize the importance of a center's surgical expertise in performing transplants on small recipients to minimize post-operative complications leading to PGF. Once relisted, the timing of suitable organ availability was vital. The opportunity for technical variant grafts is crucial to capture every potential transplant opportunity could ultimately decide between life and death.