*Purpose: The optimal induction strategy in pancreas transplantation has not been elucidated. Available evidence supports use of both basiliximab and lymphocyte depleting agents. Rabbit anti-thymocyte globulin (rATG) is associated with more infusion-related concerns such as cytokine-release syndrome, hypotension, and tachycardia, but is associated with lower rates of rejection. There is no available literature to date that describes the combined use of both agents. This study explores outcomes of traditional basiliximab induction compared to a single intraoperative dose of basiliximab to avoid adverse hemodynamic events followed by reduced dose rATG.

*Methods: This is a single-center retrospective study of 24 adult simultaneous kidney-pancreas or pancreas alone transplants from January 2017 to December 2019. Historically, induction at our center was basiliximab 20mg on post-operative day 0 (POD0) and POD4. In 2018, the induction protocol was revised to single dose basiliximab POD0 followed by rATG for a total dose of 4.5mg/kg. Triple maintenance immunosuppression for all patients consisted of tacrolimus, mycophenolate mofetil (MMF), and prednisone.

*Results: Seventeen patients received basiliximab alone, and 7 patients received the combination protocol of basiliximab + rATG. Baseline patient characteristics were similar between both groups (Figure 1). Mean tacrolimus trough levels were similar between groups and all patients received corticosteroids. MMF starting dose for all patients was 2g/day, with the average dose decreased to 1g/day by 12 months due to gastrointestinal side effects or bone marrow suppression. This maintenance immunosuppression was similar between groups. At 1 year, there was no difference in patient or pancreas graft survival (Figure 2). Biopsy proven acute kidney rejection (BPAR) incidence was 6% in basiliximab and 14% in the basiliximab + rATG induction group. Despite increased immunosuppression, postoperative complications and infections were not increased in the basiliximab + rATG group. Only patients who received basiliximab alone induction developed CMV viremia (n=3); however, there was more CMV seronegative mismatch within this group.

*Conclusions: In this single-center study, overall outcomes of patients who underwent pancreas transplantation using two different induction regimens (basiliximab vs. basiliximab + rATG) are comparable with no increased infections in the dual induction group.

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