*Purpose: Because of the higher immunological risk associated with pancreas compared to kidney transplantation, many have assumed that T depleting induction is required for pancreas recipients. However, limited data exists on relative outcomes with T depletion versus IL-2 receptor (IL2R) blockade in pancreas transplantation.

*Methods: We analyzed the records of all patients who underwent simultaneous pancreas- kidney (SPK) or pancreas transplant alone (PTA) at our institution between 01/01/2011 and 12/31/2019. We compared T-cell depletion to IL2R blockade for patient and pancreas allograft survival, rejection, and infectious complications.

*Results: Of 417 pancreas transplant recipients, 291 received induction with a T-depleting agent and 126 received induction with an IL2R blocker. The mean follow-up post-transplant was 5.3 ± 3 years. No difference was detected in pancreas allograft death censored (p=0.7) or uncensored (p=0.5) survival. CMV and bacterial infections were significantly more common in the patients who received T-cell depleting agents for induction (21% vs 11%, p=0.03; 34% vs 23%, p=0.04, respectively). On multivariate analysis, history of pancreas rejection (HR=3.80, p<0.0001; 95% Cl 2.28 to 6.33) and history of previously failed pancreas allograft (HR=2.10, p=0.02; 95% Cl 1.11 to 3.97) were associated with increased risk of pancreas allograft loss, but choice of induction was not (HR=0.78, p=0.37; 95% Cl 0.45 to 1.33). Further, on multivariate analysis, CMV infection (HR=1.78, p=0.01; 95% Cl 1.11 to 2.87) was associated with increased risk of pancreas allograft rejection, but choice of induction was not (HR=0.84, p=0.46; 95% Cl 0.54 to 1.32). Similarly, further analyses showed bacterial infection was associated with increased risk of patient death (HR=2.94, p=0.04; 95% Cl 1.03 to 8.32) but choice of induction was not (HR= 0.94 p=0.91; 95% Cl 0.32 to 2.71).

*Conclusions: In appropriately selected patients, patient and pancreas allograft survival were not different between the patients who received induction with T-depleting agents versus IL2R blockade. However, bacterial and CMV infection rates were higher in patients who received a T-cell depleting agent for induction. We suggest that IL-2 receptor blockade may be a reasonable choice of induction for pancreas transplant recipients at low immunological risk.

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