**6. Conclusions**

In conclusion, a living donor kidney has the greatest impact on improving graft and recipient survival in patients with multiple kidney transplants. We recommend early work up of recipients with failing grafts to achieve pre-emptive transplantation and minimise time on dialysis, and early pursuit of a living donor option for these individuals.

In our view, it is fundamental to consider that not only recipients' factors but also donors' characteristics are strongly related to short- and long-term results after kidney transplantation and that the higher the risk represented by the recipient, as in the case of the repeated kidney transplant population, the more likely stress and damage in the immediate and longer follow up will occur, therefore potentially irreversibly compromising the graft.

Living donor kidneys represent an undervalued resource significantly impacting the transplant outcome for higher-risk candidates, where a standard donor is instead more likely to be a ffected by the recipient status.

**Author Contributions:** M.I.B.: study conception; writing the original manuscript and revision; data analysis; A.E.C.: study conception; data collection; manuscript revision; J.A.M.: study conception, data collection and analysis; manuscript revision. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was supported by the Northern Ireland Kidney Research Fund (NIKRF).

**Conflicts of Interest:** The authors declare no conflict of interest with relevance to the present study.
