*Purpose: Delayed graft function (DGF) is a common complication associated with significant untoward effects in kidney-alone transplantation. The incidence and outcomes following kidney delayed graft function (K-DGF) among patients undergoing simultaneous pancreas-kidney transplantation (SPK) are less certain.

*Methods: We analyzed SPK recipients transplanted at our center between 01/1994 and 12/2017 who had post-transplant DGF. Patients not yet on dialysis (pre-emptive SPK transplants) or early kidney graft failure due to thrombosis were excluded. Risk factors for K-DGF and its association with pancreas and kidney graft failure were outcomes of interest.

*Results: A total of 632 recipients fulfilled the selection criteria, including 69 with DGF (DGF+) and 563 without (DGF-). Multivariate analyses showed a significantly higher rate of DGF in recipients of organs from older donors (HR:1.44, 95% 1.13-1.82, p=0.003) and after donation after circulatory death (DCD) (HR:6.38, 95% 3.38-12.04, p<0.001). Other baseline donor and recipient characteristics were similar between DGF+ and DGF- recipients. K-DGF was associated with pancreas graft failure in bivariate analysis (Figure 1A; p=0.004). Multivariate analyses confirmed K-DGF (HR: 1.53, 95% CI, 1.01-2.32, p=0.04) as a risk for pancreas graft loss, as well as older donors (HR: 1.22, 95% CI, 1.12-1.43, p<0.001), and Africcan American recipients (HR: 2.52, 95% CI, 1.21-5.23). Analyses of the number and timing of post-transplant pancreas graft losses showed there were 39 graft failures within 90 days of transplant, of which 9 occured in the DGF+ group ( 58.0/100 person yrs) vs 30 in the DGF- group (22.3/100 person yrs; p=0.02). The causes of early pancreas graft losses in the DGF group [thrombosis (n=3), leak (n=3), bleeding (n=2), rejection (n=1)], were no different than the DGF- group. Interestingly, the rates pancreas graft loss after 90 days were not statistically significantly different between the two groups. In addition, DGF was not associated with kidney graft failure (Figure 1B).

*Conclusions: In this single-center, retrospective analysis of SPK transplantation, we found K-DGF to be a significant risk factor for pancreas graft failure but not kidney graft failure. The major risk period is early (<90 days) post-transplant. Further analyses are needed to more clearly discern the mechanisms underlying the early risk of pancreas graft losses but appears associated with organs from older donors.

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