Early surgical complications influence outcomes following simultaneous pancreas-kidney transplantation (SPKT).  The study purpose was to analyze longitudinally our 20-year experience in SPKT with an emphasis on changes in practice that improved outcomes in the most recent era.  

Methods:  Single center retrospective review of all SPKTs performed from 11/1/01 - 8/12/20 including 216 with portal- and 39 with systemic-enteric drainage.  Early relaparotomy was defined as occurring within 3 months of SPKT.  Patients were stratified into 2 sequential eras: Era 1 (E1): 11/1/2001 – 12/31/2010; Era 2 (E2) 1/1/2011 - 8/12/20) based on changes in practice that occurred pursuant to reducing donor age and pancreas cold ischemia time (CIT), and changing antibody induction from rATG to alemtuzumab.  

Results: 255 consecutive SPKTs were analyzed (E1, n=126; E2, n=129).  E1 patients received organs from older donors (mean E1 28.1 vs. E2 23.7 years) with longer pancreas CITs (mean E1 16.8 vs. E2 13.4 hours, both p<0.05).  E2 had more non-Caucasians (24.2% E1 vs 37.8% E2, p=0.03) and more E2 patients received alemtuzumab induction (61.2% E1 vs 96.7% E2, p<0.0001).  E1 patients had higher early relaparotomy (E1 44.4% vs. E2 21.7%, p=0.0002), pancreas thrombosis (E1 7.9% vs E2 3.1%, p=0.11) and allograft pancreatectomy (E1 9.5% vs E2 3.9%, p=0.08) rates.  In the most recent 90 consecutive cases, early relaparotomy and thrombosis rates were reduced to 14.4% and 2.2%, respectively.  E1 patients underwent portal venous drainage more frequently (E1 92.9% vs. E2 76.7%, p=0.0004) but pancreas venous drainage did not influence relaparotomy, thrombosis, or allograft pancreatectomy rates.  The one-year pancreas graft survival rate was higher in E2 (85.7% E1 vs 94.6% E2, p=0.02).  In the univariate Cox regression analysis of death-censored pancreas graft survival, alemtuzumab induction and E2 were both associated with improved pancreas graft survival while longer pancreas CIT was associated with inferior pancreas graft survival.  Only alemtuzumab induction had a significant (protective) effect on pancreas graft survival in the multivariate model. In the logistic regression analyses for early relaparotomy, longer dialysis duration, recipient BMI >30 kg/m², and longer pancreas CIT each increased the risk of relaparotomy whereas alemtuzumab induction and E2 were associated with a lower risk of relaparotomy in the univariate model.  In the multivariate model, however, only longer dialysis duration, longer pancreas CIT, and E2 remained significant variables affecting the risk of early relaparotomy.  Actual 5-year patient survival (89.7% E1 vs 95% E2), kidney (75.4% E1 vs 83.8% E2), and pancreas graft survival (68.3% E1 vs 77.5% E2, all p≤0.20) rates were all slightly higher in E2.  

Conclusions:  In our longitudinal experience, maximizing donor quality (younger donors), minimizing pancreas CIT, and alemtuzumab induction are paramount for improving outcomes following SPKT in E2.