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New oral anticoagulants like direct thrombin inhibitors are an attractive alternative to vitamin K antagonists as anticoagulation therapy and can be used in heparin induced thrombocytopenia. They are convenient in low risk surgery, as there is no need for bridging with heparins. Patients who need urgent major surgery are at similar risk as on warfarin therapy, which however is multifold higher than in elective procedures. Due to their elimination profile, these drugs are generally contraindicated in patients with severe renal insufficiency. Pancreas transplantation is associated with high risk of bleeding and substantial risk of graft thrombosis on the other hand. There are no recommendations on anticoagulation therapy in high risk patients on kidney-pancreas waiting list who cannot be given heparins.We describe a case of simultaneous pancreas-kidney transplantation in a patient with heparin-induced thrombocytopenia on dabigatran treatment.We conclude, that despite high risk, pancreas transplantation in a patient with HIT can be safely done on NOAC therapy, but an access to idarucizumab should be assured.