*Purpose: Patients with type 1 diabetes with end stage renal failure are indicated for SPK, but if the family requests a renal donation and living renal transplantation prior to pancreatic transplantation, can transplant surgeons recommend that preceding solo-kidney transplantation be carried out?

*Methods: To examine the effectiveness of preceding solo-kidney transplantation for type 1 diabetes with end stage renal failure, a comparative retrospective analysis was made between SPK (n=269) and PAK (n=43) groups which underwent surgery from 2000 to 2017.

*Results: 1. Is the waiting period prolonged for pancreas transplantation if kidney transplantation is preceded? The median waiting period was SPK: 1962 days and PAK:756 days, showing no statistically significant difference ( p=0.064) but having a shorter tendency in PAK. 2. After PAK, does renal function deteriorate? Among 43 cases of PAK who had undergone surgery one year prior, s-Cre values before surgery and one year after surgery were compared. It was found that s-Cre one year after surgery had statistically significantly increased (p=0.022). However, the median sCre had slightly increased from 1.18 mg/dl before surgery to 1.21 mg/dl one year after surgery, which is not considered clinically problematic.

3. Is pancreatic graft survival the same with SPK? 1, and 5-year pancreatic graft survival after SPK was 87.8% and 83.8%, respectively, and 88.2%, and 50.4% after PAK. Pancreatic graft survival for longer terms after PAK substantially declined, indicating significantly lesser survival (p<0.001). Graft loss occurred due to rejection among 10/17 cases (58.8%) after PAK, indicating significantly higher occurrence of pancreatic graft loss due to rejection compared to SPK (p=0.01). However, in PAK using rATG for induction, rejection occurred as a complication among 3/19 cases (15.8%), indicating a lower tendency compared to that occurring among cases in which rATG was not used (11/24 cases, 45.8%). Moreover, while 5-year pancreatic graft survival was 31.3% after PAK not using rATG, it was revealed that survival of 83.1% could be maintained in cases of rATG induction (p=0.032).

4. Can the prognosis be improved by a preceding kidney transplantation? From the registered data of the Japan Organ Transplant Network, the life prognosis of patients waiting for SPK and PAK was compared. 1 and 5-year survival of patients waiting for SPK was 98.4% and 88.0%, respectively, while that of patients waiting for PAK was 100% and 96.6%, with the life prognosis of patients waiting for PAK significantly better than those waiting for SPK (p=0.029).

*Conclusions: PAK has a higher occurrence of pancreatic graft loss due to graft rejection compared to SPK, however, it was suggested that induction therapy using rATG could reduce the incidence of complicated graft rejection and improve pancreatic graft survival. In addition, the life prognosis was significantly better in patients waiting for PAK than those waiting for SPK, suggesting that we should recommend preceding kidney transplantation for those with type 1 diabetes with end stage renal failure, if a donor is available, with induction therapy using rATG desirable for subsequent pancreas transplantations.

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