*Purpose: Simultaneous pancreas-kidney transplantation (SPK) improves survival in type I diabetic patients with end stage renal disease (ESRD). Corticosteroids have traditionally been an integral component of maintenance immunosuppression but are associated with significant side effects. We hypothesize that a phenotype of SPK recipients exists in whom early steroid withdrawal (ESW) is practical and does not compromise graft or patient survival.

*Methods: Patients who underwent SPK between 1998 and 2017 were identified from our institutional database. Information was available for patient and donor demographics. Univariate and multivariable cox proportional hazards models were used to investigate the association between patient survival and factors of interest. Data were analyzed using intent-to-treat analysis.

*Results: We identified 275 SPK of whom 148 (121 treated, 27 intent-to-treat) were classified as ESW. ESW patients were younger (36 vs 40, p=<0.001), higher BMI (24.5 vs 23.4, p=0.022), greater HLA mismatch (4.5 vs 4.1, p=<0.001), more likely to experience postop reoperation (26 % vs 14% p=0.018) and more commonly received SPK from black donors (38% vs 18%, p=<0.001) than non-ESW patients. In multivariable cox proportional hazard intent-to-treat analysis, we observed no association between pancreas graft loss and ESW (p=0.600). In multivariable analysis of overall patient survival, early ESW regimen exhibited a significant survival benefit [HR (95% CI): 0.33 (0.13-0.83), p=0.019]. There was no significant interaction between race and ESW for either graft loss or patient survival.

*Conclusions: Compared to a steroid-based maintenance immunosuppression regimen, ESW after SPK was associated with improved patient survival and similar pancreas survival. ESW should be considered in select SPK recipients.

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