Pancreas transplants: Are they a cure for diabetes?
Pancreas transplants: Are they a cure for diabetes?
Patients face a lifetime of immunosuppressants
More than 10,000 pancreas transplants have been performed worldwide since the procedure was first performed in 1966, three-quarters of them in the United States. And while a successful pancreas transplant rids the patient of diabetes, opinions vary whether a pancreas transplant should be performed before complications of diabetes set in and make a kidney transplant necessary as well.
One surgeon notes since more donor pancreases are available than are used, clinicians should think more about doing transplants early in the disease process. At what point should a physician advise a transplant?
Diabetes Management found two transplant surgeons with vastly differing viewpoints:
David Sutherland, MD, a pioneer in transplant surgery, is a staunch advocate of early and wide-spread use of pancreas transplants for diabetic patients before the cascade of complications starts. "Why would you wait? Why not do it before complications set in?" asks Sutherland, a professor of surgery at the University of Minne-sota in Minneapolis and the director of the Dia-betes Institute for Immunity and Transplantation, also in Minneapolis.
He argues that there is a relative abundance of pancreases available for transplant because virtually their only use is for diabetics. "Most of my patients are very unhappy with the burden of managing their diabetes Just think of more than 3,000 fingersticks a year and 2,000 needlesticks a year — that alone is a very unpleasant business. The relative side effects of a lifetime of immunosuppressant therapy (including possible renal failure, tremors, and hirsutism) are minor compared to that."
And he explodes the myth that poor control is the sole cause of complications in Type 1 and Type 2 diabetes. "Even at an HBA1c of 7.0, you’ll get 20% of the patients with retinopathy, neuropathy, and renal failure," he says.
Practically all of the patients on the University of Minnesota’s pancreas transplant list will get their pancreas transplants, Sutherland says, because the procedure is so underutilized. "There are 30,000 new cases of Type 1 diabetes a year, and there are about 5,000 pancreases available."
Yet, he points out, only about 1,100 pancreas transplants are performed each year, perhaps because doctors and patients aren’t aware of the benefits of the procedure. "If a diabetic patient wants a pancreas transplant, he should get it."
Another view
At the core of the controversy is the lifelong course of immunosuppressants to prevent rejection and the unpleasant side effects of the therapy.
Transplant surgeon Christopher Shackleton, MD, associate director of the multi-organ transplant center at Cedars-Sinai Medical Center in Los Angeles, says he’s in favor of a pancreas transplant only if a diabetic patient needs a kidney transplant and will need to be on immunosuppressants in any case.
"A pancreas transplant is a quality of life-enhancing procedure," he says. It’s purpose is to restore near normal intermediary metabolism, have some beneficial effects against complications, and reduce the chance of the recurrence of renal failure.
Shackleton says he simply doesn’t think it’s worth the risk of complications to transplant a pancreas alone and only considers a simultaneous kidney-pancreas transplant after carefully evaluating the level of risk. Beyond risks of a major surgery such as transplantation, the greatest risk with a pancreas transplant is a failure of the graft, which forces the patient to once again rely on the old defective pancreas.
[Contact David Sutherland at (612) 625-7600 and Christopher Shackleton at (310) 855-2641.]
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