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. 2001 Apr 7;322(7290):861.

Could fewer islet cells be transplanted in type 1 diabetes?

Insulin independence should be dominant force in islet transplantation

James Shapiro 1,2,3, Edmond Ryan 1,2,3, Garth L Warnock 1,2,3, Norman M Kneteman 1,2,3, Jonathan Lakey 1,2,3, Gregory S Korbutt 1,2,3, Ray V Rajotte 1,2,3
PMCID: PMC1120020  PMID: 11290632

Editor—Waugh is correct in saying that demand for islet transplantation will exceed supply and the ratio of risk to benefit should be balanced for the individual patient.1 Balancing the societal benefit of cost and utility hinges more on the definition of success. Accepting glucose stability rather than insulin independence has been discussed among our group but in the first instance we believe that freedom from insulin should be the goal. Unfortunately, the fact that few patients given islet transplants during the past two decades have become insulin independent has affected advances in the discipline. If we lower the goal posts now, when outcomes of islet transplantation have been radically transformed, this could delay advances further.

Transplantation of islets is beginning to emerge as an alternative treatment to transplantation of the whole pancreas in highly selected patients with type 1 diabetes. The risks associated with chronic long term immunosuppression are much less readily accepted by patients if freedom from insulin is not the predominant goal. Rather than accept second best, intensive research to expand the quantity of transplantable islet mass, coupled with anti-inflammatory strategies designed to promote the engraftment and long term survival of islets after implantation, will in time provide similar success with single donors. The goal posts of islet transplantation should not be lowered in favour of a subtherapeutic implant mass, at least until these avenues have been explored.

References

BMJ. 2001 Apr 7;322(7290):861.

Author's reply

Norman Waugh 1

Editor—I welcome the comments from Shapiro et al and wish them well with the research into harvesting outlined in their second paragraph. Better retrieval of islet cells would, however, not remove the question of best possible use. The cells could still be used for individually optimal use for one patient (insulin independence), or perhaps to provide less good results (good control but continuing injections) for two.

There are several research questions.

Firstly, what do people with type 1 diabetes think? Would they prefer one person to have insulin independence, or two to have good control but still need injections?

Secondly, what dose of islet cells is needed for very good control—and hence what options are available with one donor?

Thirdly, we need an economic study taking into account all costs and benefits, including quality of life impacts of insulin injections and immunosuppressant medications, good control of diabetes with reduction of both short and long term complications, and adverse effects of immunosuppression. Some of these questions may be unnecessary if islet cells can be grown in vitro, as envisaged in a review by Serup et al.1-1

References

  • 1-1.Serup P, Madsen OD, Mandrup-Poulsen T. Islet and stem cell transplantation for treating diabetes. BMJ. 2001;322:29–32. doi: 10.1136/bmj.322.7277.29. . (6 January.) [DOI] [PMC free article] [PubMed] [Google Scholar]

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