*Purpose: Steroid avoidance in kidney transplantation has been proven non-inferior. Data on steroid avoidance in simultaneous pancreas-kidney (SPK) is scant.

*Methods: We utilized the Scientific Registry of Transplant Recipients (SRTR) between 2000 and 2020 we studied all primary crossmatch negative SPK recipients (N=6011) who received anti-thymocyte globulin for induction and were discharged alive on tacrolimus and mycophenolate with or without steroid maintenance. Recipients were grouped according to steroid use into two groups: steroid maintenance (n=4477) and steroid avoidance (n=1534). Kaplan-Meier curves with generated for Recipient and allografts survival according to steroid maintenance censored at 10 years (Figure 1). Predictors for recipient and grafts survival were examined using Cox proportional Hazards. Models were adjusted for recipient age, BMI, ethnicity, diabetes type, HLA-antigen mismatches, transplant era, steroid maintenance, preemptive transplantation, and PDRI with the transplant center included as a random effect.

*Results: Steroid avoidance has gained popularity over the years, accounting for nearly a third of the studied cohort. One-year acute rejection rates by steroid avoidance were comparable for kidney (8.5 vs. 8.9%, P= 0.7), however pancreas rejection was less observed in the steroid avoidance group (8.1 vs. 10.1%. P=0.05). Compared to steroid maintenance steroid avoidance did not influence recipient (_LLCI, aHR, _ULCI) (_0.94, 1.14,_1.37), kidney (0.98, 1.19, 1.46), or pancreas graft survival (0.80, 0.99, 1.23).

*Conclusions: Steroid avoidance is associated with similar patient, graft, and immunologic outcomes when compared with steroid maintenance in SPK transplants who receive anti-thymocyte globulin induction.

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