*Purpose: A successful pancreas transplant provides patients with brittle diabetes the opportunity of good long-term metabolic control. While initially more and more retransplants were performed, the number of pancreas retransplants decreased by 75% between 2004/05 and 2018/19. This may be due to the technically demanding procedure and the suboptimal outcome in certain subgroups. We analyzed outcome of pancreas retransplants over the past 15 years.

*Methods: All 1368 pancreas retransplants performed between 1/1/2004 and 12/31/2019 were included. Comprehensive univariate and multivariable models were developed to describe outcome and potential risk factors for retransplant graft outcome. To describe the impact on long term graft function in the primary graft an artificial cut point of 5 years was chosen.

*Results: Between 1/1/2004 and 12/31/2019 1025 pancreas retransplants were performed (66% rePAK, 15% rePTA and 19% reSPK). The decrease in numbers was mainly due to the smaller number of rePAK. Of the primary failed transplants, the majority (58%) were SPK. Over the years, the rate of patients who lost their primary graft for immunological reason increased from 52% to 58%. This was due to the increased better long term function after primary transplant. The median time of pancreas graft function in this primary pancreas grafts increased from 49 mos to 87mos. The longest failed primary pancreas functioned for over 25 years before being retransplanted. Pancreata that failed for early technical reasons were retransplanted early as well as pancreata that functioned > 5 years. Pancreata that failed early due to immunological reasons showed the longest time between failure and retransplant.

*Conclusions: With careful patient and donor selection pancreas retransplants in all 3 recipient categories can be successful. Only primary pancreas transplants that failed due to early acute rejection carried a significantly higher (early) risk for retransplant failure. The use of depleting induction therapy and the standard maintenance protocol of tacrolimus and MMF further decreased the risk of retransplant failure loss.

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