Beyond Survival: Factors Driving Textbook Outcome After Simultaneous Pancreas–Kidney Transplantation—A Retrospective Analysis

<b>Background:</b> Simultaneous pancreas-kidney transplantation (SPK) is the standard treatment for selected patients with type 1 diabetes mellitus and end-stage renal disease. Textbook Outcome (TO), a composite of perioperative and long-term quality indicators, provides a benchmark for optimal results. This study analyzed factors associated with failure to achieve TO after SPK. <b>Methods:</b> We retrospectively analyzed 119 SPK recipients (1980-2022). TO was defined according to IQTIG criteria: (i) patient survival ≥ 3 years, (ii) insulin independence at discharge, (iii) kidney function at discharge (GFR ≥ 20 mL/min), (iv) insulin-free survival ≥ 3 years, and (v) sustained kidney function ≥ 3 years. Predictors of TO failure were identified by logistic regression. Long-term survival was assessed by Kaplan-Meier analysis. <b>Results:</b> Ninety-two patients were eligible for TO assessment; 52% achieved TO. Compared with TO patients, non-TO patients had older donors (median 30 vs. 25.5 years, <i>p</i> = 0.017), older recipients (44 vs. 39 years, <i>p</i> = 0.012), longer kidney cold ischemia time (CIT; 13.0 vs. 9.7 h, <i>p</i> = 0.005), and more pancreatic complications (<i>p</i> = 0.009). In multivariate analysis, donor age (OR 1.050, <i>p</i> = 0.030) and kidney CIT (OR 1.180, <i>p</i> = 0.029) independently predicted TO failure. Cut-offs were donor age ≤ 37 years and kidney CIT ≤ 11.5 h. Patients achieving TO had significantly better long-term survival (15 years, <i>p</i> = 0.0077). <b>Conclusions:</b> Younger donor age and shorter kidney CIT independently predict TO achievement, which is associated with superior long-term survival. Optimized donor selection and perioperative management may improve SPK outcomes.