The third and fourth renal transplant; technically challenging, but still a valid option.

At present, first and second kidney transplantation have established surgical techniques with few variations between surgeons. They also are considered the best renal replacement therapy for patients with end stage renal disease. Both offer better quality of life and longer survival compared to dialysis. However the third and fourth transplants are significantly more complex. Patients are often highly sensitized, comorbid with limited surgical options due to the previous operations, immunosuppression and long periods on dialysis. There is an incorrect belief that third and fourth retransplantation will not offer any advantage to this cohort of patients and considered to be poor utilization of the limited supply of organs. Recent work demonstrated that third and fourth transplantation offers a survival advantage however it slightly inferior to first and second transplantation, but still there is no established technique. In spite of the surgical challenge, the main cause of graft loss in this cohort of patient is immune mediated rather than the surgical complications. In this review article, we describe various techniques used in transplanting these surgically, immunologically and medically challenging patients demonstrating the effect of surgical complications on the outcome.