Introduction: Simultaneous pancreas-kidney transplant (SPKT) recipients are a relatively homogeneous population that are considered high immunological risk because of younger age, presumed autoimmune etiology of diabetes, erratic drug absorption due to gastroparesis, and inherent immunogenicity of the pancreas graft. At present, <30% of SPKT in the US undergo early steroid withdrawal (ESW) and <20% are performed with portal-enteric drainage or alemtuzumab (Alem) induction. The study purpose was to analyze our outcomes in primary SPKT recipients undergoing intent-to-treat portal-enteric drainage and Alem induction with tacrolimus (TAC)/mycophenolate (MP) maintenance therapy ± ESW. Methods: From 2005-2016, 120 primary SPKTs (107 portal-enteric drainage) were performed. All patients (pts) received single dose Alem (30 mg intra-operative) with TAC/MP ± steroids. ESW was performed unless pts were African-Americans (AA) <40 years old (n=22), sensitized with a panel reactive antibody >20% (n=12) or experienced kidney delayed graft function (n=4). Results: The study group included 85 Caucasian, 32 AA, and 3 other pts; 25 pts had pre-transplant C-peptide levels ≥2.0 ng/ml, suggesting a type 2 diabetes phenotype. Mean follow-up was 5 years. Overall pt, kidney and pancreas (insulin independence) graft survival rates were 90%, 79%, and 75%, respectively, and did not differ by ethnicity, pre-transplant C-peptide status, or in pts with ESW. ESW was attempted in 86 (72%) pts; 45 (52%) remain steroid-free. There were no significant differences between 1-year and overall rates of acute rejection (AR) in ESW (26%, 34%) versus non-ESW (n=34; 38%, 50%) pts. Death with functioning graft and AR/chronic rejection were the most common causes of kidney and pancreas graft loss. Most AR episodes were heralded by dose reduction in either TAC or MP because of infection or specific drug toxicities. Most pts could not tolerate full/therapeutic doses of TAC and MP, with 16 pts (13%) unable to tolerate either drug. Conclusion: Although ESW is feasible and durable in about half of appropriately selected SPKT pts, one must carefully weigh the benefits and risks of such a strategy, given that rates of AR are high and most diabetic pts cannot tolerate full doses of TAC and MP.

CITATION INFORMATION: Harriman D., Farney A., Rogers J., Orlando G., Reeves-Daniel A., Gautreaux M., Doares W., Kaczmorski S., Stratta R. Experience with Alemtuzumab Induction with Tacrolimus/Mycophenolate +/- Steroids in Simultaneous Pancreas-Kidney Transplant Recipients with Portal-Enteric Drainage Am J Transplant. 2017;17 (suppl 3).

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