I WRITE in response to recent coverage about pancreas transplantation.
Insulin dependent diabetes is very intrusive into one's lifestyle and requires a great deal of self discipline. It involves reasonably strict adherence to a diet, frequent self monitoring of blood glucose by finger prick and between two and four injections of insulin daily. The hazard of hypoglycaemia (low blood sugar) is an ever present threat to those who do not recognise the warning symptoms, with the potential for loss of consciousness. The fear of long term complications (blindness, kidney failure and severe circulatory problems) is also ever present. Such complications can be avoided, but this requires increasing self discipline and compliance with treatment.
It is perfectly understandable therefore that when a new form of treatment such as pancreas transplantation comes along with the potential to remove these burdens, there is a great deal of optimism - and anxiety.
Following whole organ transplantation, it is necessary for the recipient of the organ to remain indefinitely on drugs which suppress the recipient's immune system in order to prevent rejection of the donor organ. These drugs are far from innocuous and are potentially toxic to the kidneys, liver and bone marrow and can lead to the development of various cancers in time. However, in the case of kidney, heart and liver transplantation, the benefit of these lifesaving procedures far outweighs the risks in lifelong immuno suppression.
Since diabetes is perhaps the commonest cause of renal failure which will ultimately lead to kidney transplantation, the potential for combined kidney and pancreas transplantation becomes a reality. The rationale is that a pancreas may as well be transplanted into such an individual since that individual will already be on immuno suppressive drugs to prevent rejection of the transplanted kidney. This philosophy has universal acceptance as being ethically sound and thus combined pancreas/kidney transplantation in insulin dependent diabetes is an accepted form of treatment.
However, the subject of pancreas only transplantation is more controversial, partly due to the risks of the surgical procedure, partly due to the failure rate of the transplanted pancreas and partly due to the potential toxicity of long term immuno suppressive treatment.
Thus the risk/benefit ratio of a pancreas only transplant is much less favourable, particularly when an adequate, albeit inconvenient alternative - insulin - exists.
Thus, the major patient organisations such as the American Diabetes Association and the British Diabetes Association do not recommend pancreas alone transplantation as standard treatment in the vast majority of individuals with insulin dependent diabetes.
So, who can benefit from the pancreas alone transplantation? As with many surgical procedures, the indication should be a failure of adequate and expert medical treatment with insulin. This may be manifested as an inexorable progression of life threatening, or quality of life threatening complications which cannot be averted or treated by adequate medical therapy. Intractable and recurrent hypoglycaemia is also sometimes quoted as a potential indication. In fact, recurrent hypoglycaemia can be almost virtually abolished by use of modern multiple daily injection regimes and adequate patient education.
There may remain a small number of patients who are unwilling or unable to comply with standard treatment and who are manifesting advancing complications or intractable hypoglycaemia. Many of these are unable to comply because of such problems as intractable vomiting, eating disorders or other psychological problems. There may be a case for pancreas alone transplantation in such individuals but the issues are complex.
Furthermore, new technologies such as a fully automated implantable insulin pump will inevitably be coming on line in the future.
Therefore, the decision to refer patients for pancreas alone transplantation should be made by a consultant with a particular and specific interest in diabetes mellitus.
NONE of this is meant to denigrate the transplantation team at Beaumont Hospital who are to be congratulated on achieving outstanding results with their combined kidney/pancreas transplant pool of patients. The two pancreas alone transplants performed there were both exceptional cases. The first case was referred to Beaumont for the procedure by myself.
I would suggest that individuals who wish to learn more about this should discuss it with their doctor. They should also be reassured that they can be considered for surgery if they fulfil these extraordinarily strict criteria wherever they live in the country and whichever clinic they attend.