From Arlington Heights, Illinois, USA:
My nephew has Type 1 diabetes and has been insulin dependent since age 5. (He is now age 19.) He has been well controlled and has had very few "reactions" with his insulin doses remaining fairly unvaried over the years. A friend has told me about a pancreatic transplant that her cousin had this year at the University of Nebraska that has eliminated the need for insulin injections. Are these transplants occuring more frequently? Are they successful? Is it difficult to become a candidate and what are the requirements?
The primary objectives of both pancreas and islet cell transplantation are to normalize metabolic control in the absence of severe episodes of hypoglycemia and to prevent, halt, or reverse the chronic complications of diabetes. Normalization of HbA1c without added risks (e.g., severe hypoglycemia, infections and cancer) should be considered a primary endpoint of transplantation in diabetes, rather than independence from exogenous insulin injections. Nevertheless, freedom from the daily requirements of glucose monitoring and insulin injections is the most desired immediate effect that patients with Type 1 diabetes would like to see associated with a transplant procedure.
The advantage of whole-organ pancreas transplantation is essentially that the procedure generally results in an insulin-independent state with normalization of glycosylated hemoglobin levels. The penalties for normal glucose homeostasis are the operative and post-operative risks of the organ transplant procedure and the need for life-long immunosuppression of the recipients with the well known complications associated to chronic immunosuppressive therapy (increased infections, risk of cancer and organ toxicity).
The advantage of islet cell transplantation is the ease of the procedure, which virtually eliminates operative risks and post-operative morbidity. However, islet transplantation has achieved complete insulin independence in the minority of the recipients and the results are generally reported as "functioning" islet transplants, referring to post-transplant C-peptide secretion in previously C-peptide negative recipients and decreased insulin requirements compared to pre-transplant levels.
Both procedures are currently justified in patients already requiring another organ transplant, such as a kidney, or in recipients of a previous kidney graft, since these patients already are treated with chronic immunosuppression. In addition, other categories of patients who could benefit from biologic replacement of the pancreatic endocrine function are subjects with hyperlabile diabetes, hypoglycemic unawareness, or extreme difficulty in obtaining metabolic control. In these cases, it is essential to carefully assess risks and benefits for each individual patient. The potential advantages of the procedure selected should be weighed against the risks of the immunosuppressive strategy as well as the operative procedure that will be utilized in the specific case.
In the United States, the large majority of pancreas transplants are simultaneous kidney-pancreas transplants (over 85%), while pancreas after kidney transplant procedures account for only 10% and pancreas transplants alone are still a rare event, totalling 2% of the overall whole organ transplant procedures. The total number of pancreas transplants performed in the U.S. has increased over the last several years, reaching 1,045 in 1997.
The overall graft functional survival for pancreas transplantation in the United States was 76% at one year, and 61% at five years. The best results have been obtained in simultaneous kidney-pancreas procedures, while the poorest results were obtained in pancreas transplants alone (performed without an associated kidney transplant).
Original posting 2 Jan 1999
Posted to Research: Cure
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