*Purpose: The utility of dd-cfDNA in patients undergoing pancreas transplantation has not been well studied. Pancreatic rejection remains a major clinical concern. Early identification of allograft injury is imperative to optimize treatment. Here, we describe dd-cfDNA levels in pancreas transplant(PTx) recipients in the setting of clinical stability and immunological events.

*Methods: PTx recipients were monitored longitudinally with dd-cfDNA at the discretion of the treating physician. dd-cfDNA was collected with standard of care testing including serum creatinine, amylase, lipase and DSA. Pancreatic graft dysfunction was defined by at least 2-fold elevation in serum amylase/lipase or dysregulated glucose control. The reference population was defined by stable allograft function in the absence of immunological or clinical events. Immunological events were defined as clinically suspected allograft rejection or subtherapeutic immunosuppression.

*Results: A total of 1 PAK and 15 SPK patients were monitored longitudinally with dd-cfDNA. Patient demographics are shown in Table 1. 12 patients met criteria for the stable reference population with a median dd-cfDNA level of 0.22% (IQR 0.12-0.36%, n=248). There was a trend towards increased variability in dd-cfDNA levels in the first 2 months post-transplant, after which there was no significant difference in dd-cfDNA by time (Fig. 1A). 4 patients developed 6 independent immunological events, associated with a significantly increased median dd-cfDNA level of 1.15% (IQR 0.15 – 1.85%) compared to 0.22% in the reference population (p=0.03, Fig 1B).

*Conclusions: In stable PTx recipients, dd-cfDNA levels remain low post-transplant and reflects the reference ranges validated in kidney transplant alone. Early variability in dd-cfDNA levels may be explained by recovery from ischemia reperfusion injury. Significant increases in dd-cfDNA were associated with immunological events including clinically suspected allograft rejection, highlighting its utility in longitudinal graft surveillance.

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