Pancreas and Islet Transplantation for Patients With Diabetes
During an initial visit earlier this year with a 55-year-old woman who had a 31-year history of type 1 diabetes, the patient told me that an islet cell transplant would be needed as soon as possible. The woman had minimal complications and had done extremely well with her diabetes. Asked why there was such a rush and why she should have a transplant, she told me that it would be the only way she could normalize her life. She explained that this is so because she needs to care for both her mother and her granddaughter (her daughter is a single mother who works two jobs). Furthermore, she was so busy with her volunteer activities that it only made sense that she should have this procedure so that she could "get on with" her life. Suffice it to say, I didn't know quite how to respond.
The report of the Edmonton Protocol and the successful islet cell transplant experience earlier this year1 was certainly headline news and hopefully will lead to even more exciting results during the next few years. In the meantime, all health care providers must have accurate information to relate to patients and their families when questions about islet cell or pancreas transplants arise. For this reason, we are reprinting on the following pages the American Diabetes Association's technical review on this topic.2
As the story of my patient illustrates and as is often the case, patients can frequently misunderstand the stage of development of a publicized advance in the field of medicine. Whereas everyone has reason to be excited about the possibility of islet cell transplantation, much more work is required before this can be considered a routine procedure.
Even if we find out that this transplant is reproducible and transplant centers all over the world begin islet cell infusions, we face a serious pancreas shortage. This is not a new problem for anyone familiar with organ transplantation, and it is simply magnified when one considers there may be close to 1 million people with type 1 diabetes in the United States alone.
Despite the fact that no one yet knows how many islets will be required for a successful islet cell transplant, it is clear from the number of people involved that not everyone will be able to be "cured" even if the research continues to be successful. It is for this reason that there was so much excitement with the report of a pancreatic -cell line that could potentially provide an unlimited supply of islets.3 Unfortunately, it will likely be years before this preliminary work replaces the use of human islet tissue.
Assuming for a moment that the Canadian experience continues to be successful, our next mission as clinicians will be to encourage all eligible people to become organ donors. For primary care physicians, this would include patients and their families who do not have diabetes or, for that matter, any other conditions requiring transplantation.
In addition to this technical review, there are some excellent websites with accurate, up-to-date information. The Edmonton group can be accessed at www.afdr.ab.ca. The address for the Diabetes Research Institute is www.drinet.org. The American Diabetes Association's address is www.diabetes.org.
1Shapiro AMJ, Lakey JRT, Ryan EA, Korbutt GS, Toth E, Warnock GL, Kneteman NM, Rajotte RV: Islet transplantation in seven patients with type 1 diabetes mellitus using a glucocorticoid-free immunosuppressive regimen. N Engl J Med 343:230-38, 2000.
2Robertson RP, Davis C, Larsen J, Stratta R, Sutherland DER: Pancreas and islet transplantation for patients with diabetes (Technical Review). Diabetes Care 23:112-16, 2000.
3Halvorson T, Beattie GM, Lopez A, Itkin-Ansari P, Loy M, Hayek A, Levine F: In vivo glucose-responsive insulin secretion from a human pancreatic -cell line. Diabetes 49 (Suppl. 1):A32, 2000.
Irl B. Hirsch, MD, is an associate professor of medicine and medical director of the Diabetes Care Center at the University of Washington School of Medicine in Seattle. He is editor-in-chief of Clinical Diabetes.
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