*Purpose: There are limited data comparing outcomes with different induction agents in pancreas transplantation. In this study, we compare T-cell depletion to IL-2 receptor (IL2R) blockade for patient and pancreas allograft survival, rejection, and infectious complications.

*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 12/31/2017. We found no statistically significant differences between anti-thymocyte globulin and alemtuzumab recipients in patient survival, graft survival, rejection or infection, so the two groups were combined for further analysis. In addition, there were no significant differences between SPK and PTA recipients in the impact of T-depletion versus IL2R blockade on outcomes, so the two groups were combined for further analysis.

*Results: Of 317 pancreas transplant recipients, 191 received induction with a T-depleting agent (139 with anti-thymocyte globulin and 52 with alemtuzumab), and 126 received induction with an IL2R blocker (basiliximab). The mean follow-up post-transplant was 5.2 ± 2.4 years. There were a total of 12 (4%) patient deaths, 6 (3%) in the T-depletion group, and 6 (5%) in the IL2R blockade group. Similarly, there were a total of 33 (17%) death censored pancreas graft failures in T-cell depleting group and 22 (17.4%) with IL2R blockade (p=0.9). No difference was detected in patient (p=0.3) or pancreas allograft (p=0.8) survival between the two groups. Also, no statistically significant difference was found in pancreas allograft rejection between the two groups (48 vs. 43; p=0.2). Bacterial and CMV infections were significantly more common in the patients who received T-cell depleting agents for induction (p=0.001, p=0.01, respectively). On multivariate analysis, history of pancreas rejection (HR=3.47, p=0.0002; 95% Cl 2.02 to 5.93) and history of previously failed pancreas allograft (HR=2.0, p=0.01; 95% Cl 1.18 to 4.46) were associated with increased risk of pancreas allograft loss, but choice of induction was not (HR=0.76, p=0.31; 95% Cl 0.45 to 1.28). Further, on multivariate analysis, HLA-mismatching (HR=1.17, p=0.08; 95% Cl 0.98 to 1.39) and CMV infection after transplant (HR=2.3, p=0.0005; 95% Cl 1.45 to 3.80) were associated with increased risk of pancreas allograft rejection, but choice of induction was not (HR=0.77, p=0.22; 95% Cl 0.73 to 1.10). Similarly, further analyses showed CMV infection was associated with increased risk of patient death (HR=3.84, p=0.03; 95% Cl 1.11 to 13.21) but choice of induction was not not (HR= 0.88, p=0.8; 95% Cl 0.27 to 2.81).

*Conclusions: 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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