Graft survival following pancreas transplant alone (PTA) is inferior to other pancreas transplants. Steroid elimination is appealing, but a two drug maintenance strategy may be inadequate. Additionally, although not enough to qualify for kidney Tx, recipients tend to have diabetic nephropathy and do not tolerate nephrotoxic medications. A three drug maintenance strategy permits more immunosuppression as well as an opportunity to use lower doses of the individual medications. For the last decade, we have used a three drug maintenance regimen for all PTAs. Methods: Induction consisted of five doses of rATG (1 mg/kg/dose). As of Oct 2007, a single dose of rituximab (150 mg/m2) was added on POD 1. Steroids were exclusively used as premedication for rATG. Maintenance consisted of tacrolimus (target trough 6-8 ng/ml), sirolimus (target trough 3-6 ng/ml) and mycophenolate mofetil (500 mg po bid). Results: From 2004 to 2014, 131 PTA were performed. Graft loss at 7 and 90 days were 5% and 6% and one year patient and graft survival were 97% and 90%. The Incidence of rejection was 5% and infection was 43% (CMV 11%). Comparing induction without (27%, median f/u102 months) to with (73%, median f/u 47 months) Rituximab, there was no significant difference in recipient demographics, although there were significantly more female donors (p=0.02) and donors had a higher BMI (p=0.05) in the rituximab group. There was no significant difference in 7 or 90 day graft loss, 1 year patient or graft survival or in the rate of rejection or infection.

Conclusion: Rabbit antithymocyte globulin induction and steroid withdrawal followed by a three drug immunosuppression regimen is an excellent strategy for pancreas transplant alone recipients. Preliminary results using rituximab as a component of induction appear promising.

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