Response to Comment on: Robertson (2010) Islet Transplantation a Decade Later and Strategies for Filling a Half-Full Glass. Diabetes;59:1285–1291

Among the several opinions expressed by Cravedi, Remuzzi, and Remuzzi (1) in their commentary about my Perspectives in Diabetes article in the June issue of Diabetes (2), none resonates more with me than the one pointing out the need for controlled trials of pancreas and islet transplantation. My personal opinions are that the procedure of simultaneous pancreas and kidney transplantation has certainly earned its stripes as an efficacious treatment for appropriately chosen patients with type 1 diabetes, and that islet transplantation continues to be a valuable and promising procedure that needs much more development. A side note is that autoislet transplantation for a nondiabetic patient with chronic, unrelentingly painful pancreatitis who needs a pancreatectomy is clearly highly successful, but this procedure somehow is vastly underutilized. The challenge is to settle on a suitable design for controlled trials. Surgeons rightly argue that one cannot simply randomize patients to transplant or not transplant groups. Patients come to surgeons seeking a cure, not a randomized study. Nonetheless, I can imagine and have long championed (albeit unsuccessfully) initiating a protocol involving a comparison of clinical outcomes in a cohort of medically managed patients who do not want transplantation with a carefully matched cohort that wants and qualifies for transplantation according to American Diabetes Association (ADA) guidelines. The key words, of course, are “carefully matched.” For believers in transplantation, it seems very possible that preemptive organ transplantation in the long run will be less expensive and will have better clinical outcomes for patients doomed to irresolvable, unacceptable levels of hyperglycemia and severe complications despite optimal medical management. Yes, such a trial would be very expensive. But if nothing else, if the appropriate cost arithmetic were done, testing this hypothesis should be attractive not only to insurance companies but also to pharmaceutical companies that specialize in the provision of immunosuppressive drugs. Such an analysis would require thinking about long-term, not short-term, gains. This is especially true for insurance companies who need to embrace the truth that poorly controlled diabetic patients require increasingly more costly medical service as they age over many years. If all parties involved would just take on this challenge, I believe everyone will win—third-party payers, pharmaceutical companies, clinical researchers, increasingly understaffed medical care systems, and most importantly, diabetic patients with uncontrollable hyperglycemia.