Intestinal obstruction (IO) is an important but underexplored complication following simultaneous pancreas‐kidney transplantation (SPKT) and is associated with considerable morbidity and both clinical and economic burdens. This study aimed to quantify the incidence of IO, identify significant predictors, and evaluate its impact on graft outcomes and patient survival.

This single‐center cohort study (January 2016 and February 2025) was conducted at The Second Affiliated Hospital, Guangzhou Medical University. Perioperative parameters, including demographic characteristics, surgical variables, and laboratory findings over time, were analyzed. Univariate and multivariable logistic regression with Firth's penalization (in view of the number of events being limited to 20) were performed to identify significant predictors of clinical outcomes. Survival was evaluated using the Kaplan‐Meier method, with intergroup comparisons using the log‐rank test.

There were 264 SPKT recipients during the study period. The overall incidence of postoperative IO was 7.6% (20/264). Multivariable Firth's penalized logistic regression identified preoperative diabetic gastroenteropathy (odds ratio [OR] = 4.04, 95% confidence interval [CI]: 1.46–11.19, p = 0.007), operation time > 8 h (OR = 4.24, 95% CI: 1.46–12.26, p = 0.008), and postoperative hypoalbuminemia (OR = 3.25, 95% CI: 1.13–9.32, p = 0.028) as significant independent predictors of risk. Conservative management (e.g., bowel rest, decompression, laxatives) was successful in 90% (18/20) of cases, with only 10% requiring surgical intervention. Kaplan–Meier analysis revealed no significant difference in long‐term survival between patients with and without IO (p = 0.370), with comparable 1‐year, 3‐year, and 5‐year survival rates.

The findings of this observational cohort study underscore the importance of preoperative optimization and vigilant postoperative monitoring in high‐risk SPKT recipients. IO occurred in a subset of SPKT recipients and was significantly associated with diabetic gastroenteropathy, a prolonged operation time, and postoperative hypoalbuminemia. However, IO was amenable to nonoperative management and showed no significant association with long‐term mortality or graft loss. These findings should be interpreted as hypothesis‐generating, given the limited number of events, and warrant validation in larger cohorts.