Weighing up the transplant options
In his new module for EASD e-Learning, Professor Eelco de Koning considers the various options available for restoring normal glucose regulation by replacing insulin-producing cells – whether through islets or whole pancreas transplantation.
Eelco de Koning, Professor of Diabetology at Leiden University Medical Center, The Netherlands, is in no doubt about the challenges posed by diabetes self-management. “We should all realise that the insulin-producing cell is the perfect closed-loop system,” he says. “It measures glucose continuously. It provides the right signals to the secretory part of the insulin-producing cell, providing exactly the amount of insulin that is needed. The insulin will have its effect on glucose uptake, especially in muscle and fat tissue. And the lowering of glucose by increased glucose uptake will be detected by the glucose sensor. In our treatment of patients with severe beta cell failure, we try to mimic this sensory function and the secretory function of the cell as well as possible. But it is impossible to achieve a perfect mimicry of this. And therefore, chronic hyperglycaemia will always exist, even with the advanced hybrid closed-loop systems that are currently available. So the only real solution for completely normal glucose regulation without risk of hypoglycaemia is replacement of the insulin-producing cells. But how do we do that?”
This last point is the central question addressed by Eelco’s module. Several transplantation options are now available, including islet transplants, simultaneous pancreas-kidney transplants and pancreas transplantation alone. All carry risks – not least the necessity for immunosuppressive treatment for as long as the transplant endures. Whole pancreas options carry additional surgical risk, including bleeds, leaks and fistulas. Islet grafts will likely require more than one infusion of islets due to the high rate of beta cell mass-loss involved. All are constrained by availability of donor tissues.
Weighed against these are the benefits in terms of glycaemic control, risk of diabetes complications, long-term survival and quality of life. Of huge significance for many transplant recipients is the associated relief from hypoglycaemia – a benefit Eelco is keen to highlight, and spoke passionately to in his podcast on ‘The patient who changed the way I think about diabetes’. He describes the case of a middle-aged woman whose life had been seriously disrupted by repeated episodes of severe hypoglycaemia and loss of hypo awareness. “When we performed an islet transplantation it really transformed her life. She still needed a little bit of long-acting insulin, but still her life changed in a way that she was able to go out again, to go shopping, to interact with her friends, to have a social life. This example showed me what the impact of type 1 diabetes can be on patients that have to live with type 1 diabetes every minute of their life. And it also showed me the power of islet replacement therapy, the enormous impact that can have in a positive way on the lives of patients with type 1 diabetes.”
Eelco’s module ‘Pancreas and islet transplantation’ launches this week on the EASD e-Learning platform.
Don’t miss ‘Hypo impact’, Eelco’s contribution to our series The patient who changed the way I think about diabetes’, available on Horizons.
Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.