Pediatric liver retransplantation (rLT) has historically shown poorer outcomes compared to primary liver transplantation (pLT). Comprehensive studies assessing outcomes for pediatric candidates for rLT under the modern allocation policy are lacking. Organ Procurement and Transplantation Network data from January 1, 2010, to December 31, 2022, were obtained
exclusion criteria included candidates ≥18 years of age and those listed or transplanted for multiple organs. A total of 7645 children met the inclusion criteria, including 7162 candidates for pLT and 483 candidates for rLT. The candidates for rLT, despite a shorter median waitlist time to transplant (6.5 vs. 54 d for pLT), had significantly higher waitlist dropout rates and worse posttransplant outcomes. Vascular complications were the most common reason for primary graft failure. 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 30 days 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 postoperative complications leading to primary graft failure. Once relisted, the timing of suitable organ availability was vital. The opportunity for technical variant grafts is crucial to capture every potential transplant opportunity that could ultimately decide between life and death.