*Purpose: Diabetic patients with renal failure may list for kidney-alone (KI) or kidney-pancreas (KP) transplantation. The benefits of KP vs KI for diabetic patients are controversial. Multiorgan transplants including KP receive high waitlist priority, and the OPTN is evaluating changes to waitlist priority for KP patients. We evaluated temporal trends, center practices, access-to-transplant, and waitlist mortality in diabetic patients listed for KI or KP.

*Methods: Using SRTR data 2000-2019, we modeled time-to-transplant and waitlist mortality in adult, diabetic KP vs KI patients, using Cox regression with inverse-probability weighting to account for confounding.

*Results: Of 49,382 type-1 diabetic (DM-1) waitlist registrants, 45.6% listed for KP; of 144,004 DM-2 registrants, 1.9% (N=2,671) listed for KP. Between 2000-2019, KP listing declined from 52.7% to 42.7% for DM-1 registrants and from 3.9% to 1.8% for DM-2. Center-level rates of KP listing ranged from 0%-78.5% for DM1 registrants and 0-18.8% for DM2; the top 27 KP centers performed half of all KP transplants. Among DM-1 registrants, median time to KT was 1.2y for KP vs 5.4y for KI (wHR=_3.1 3.2 _3.4, p<0.001). Risk of waitlist mortality was comparable among KT and KI registrants (p=0.2), but accounting for competing risk of DDKT, waitlist mortality was sharply reduced for KP registrants (10-year cumulative survival 81.8% vs 71.7%, Figure 1). Similar patterns were observed for DM-2 (Figure 2).

*Conclusions: DM-1 and DM-2 patients listed for KP have substantially reduced waitlist mortality due to faster time-to-transplant, which mostly benefits a few centers. Centers should aggressively pursue KP listing when appropriate. Policymakers should reevaluate KP priority.

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