Steroid Withdrawal Versus Maintenance in Simultaneous Pancreas-Kidney Transplantation: Long-Term Outcomes in a...

Simultaneous pancreas and kidney (SPK) transplants using steroid-free regimens are a frequently used immunosuppressive strategy in low immunologic risk recipients. The long-term effect on recipient outcomes remains incompletely understood.

We analyzed post-transplant outcomes in 307 SPK recipients from a single center, comparing early steroid withdrawal (after completion of Thymoglobulin) with maintenance steroids. Steroid withdrawal was primarily utilized in low immunologic risk patients.

In total, 170 SPK recipients underwent steroid withdrawal, and 137 received maintenance steroids. The withdrawal group had a lower cPRA and included fewer Black recipients. Biopsy-proven rejection rates (kidney, pancreas, or both) were similar between groups (26% vs. 29%, p = 0.523), with worse kidney/pancreas graft survival among those with rejection. Rejection occurred earliest in recipients rejecting both the kidney and pancreas, followed by those rejecting the kidney alone, and then those rejecting the pancreas. Multivariate analysis showed that kidney and pancreas survival were strongly interdependent. Kidney rejection was the primary predictor of graft survival. The steroid regimen was not independently associated with survival of either organ. Obesity at follow-up was associated with an increased risk of pancreas graft failure.

In this single-center cohort, steroid withdrawal was safe in appropriately selected SPK recipients, with rejection-not the steroid regimen-driving long-term graft outcomes.