*Purpose: We present the case of a 20 year old female with history of autoimmune hepatitis diagnosed in 2014, treated with tacrolimus, and insulin dependent diabetes mellitus (IDDM), diagnosed in 2017, presenting with diabetic ketoacidosis (DKA). IDDM was suspected secondary to autoimmune insulitis vs. CNi induced beta cell toxicity. Despite detectable c-peptide at diagnosis, the patient suffered with recurrent DKA requiring hospitalization and remained insulin dependent. From 2017-2018 she was treated with multiple daily injections (MDI) insulin with poor control. In 2019, continuous glucose monitoring (CGM) was added without significant improvement (Fig 1A). She developed insulin resistance requiring >1 unit/kg/day of insulin with worsening cirrhosis. Hepatic encephalopathy and early satiety complicated adherence to MDI therapy. She was evaluated and listed for simultaneous liver and pancreas transplantation (SLiPT); however, recurrent admissions for DKA and deconditioning were barriers to transplantation.

*Methods: In May 2021, insulin therapy was advanced from MDI to hybrid closed loop (HCL).

*Results: After 2 months, the patient’s monthly time in glycemic target range, defined as 70 to 180mg/dL, improved from 27% on MDI to 47% on the HCL (Fig 1B, Table 1). With improved glucose control, she achieved acceptable functional status and successfully underwent en-bloc SLiPT in August 2021. She had immediate graft function of both organs and achieved insulin independence with time in target at 94% during the first 14 days after discharge (Fig 1C, Table 1).

*Conclusions: We present a comparison of CGM data for this patient on MDI + CGM therapy, HCL insulin pump therapy, followed finally by post-pancreas transplantation, which highlights the use of advanced diabetic therapies as a means to optimize patients at high risk of deterioration from poorly controlled diabetes while awaiting transplantation. These therapies for insulin delivery should be considered complimentary rather than competing with islet replacement therapies.

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