In this review summarizes studies addressing a critical and long-overlooked vulnerability in simultaneous pancreas-kidney transplantation (SPKT): Perioperative metabolic instability during the transition from graft ischemia to endocrine recovery after reperfusion. Despite the central role of glycemia in pancreatic graft viability, intraoperative glucose management has remained largely empirical, reactive, and inconsistently standardized across transplant centres. The authors propose a structured