DRWF Research Manager Dr Eleanor Kennedy reports from the International Pancreas and Islet Transplantation Association Congress, in Lyon, France. Day 2
The second day of the conference dawns bright and sunny but, by 8am, hundreds of us are packed into the main conference hall to enjoy a plenary session entitled “Hypes and Hopes of the Artificial Pancreas”.
This technology has been rumbling away in the type 1 world for several years now and studies and real world evidence have proven that the artificial pancreas improves quality of life, reduces diabetes management distress, leads to greater treatment satisfaction, reduces fear of hypoglycaemia and improves sleep patterns. But, in some studies using the Medtronic 670G, a significant percentage of participants have discontinued the “auto” mode of the device citing calibration issues, sensor durability or adhesion, skin irritation and alarm fatigue as some of the reasons so there is still much that can be improved. And very powerful testimony from the mother of a daughter diagnosed at 8 years old resonated with the audience as she strived to find a robust, user-friendly and non-scary system that would help improve her daughter’s quality of life.
Trials using this technology are still ongoing though and Professor Pierre-Yves Benhamou from the Centre Hospitalier Universitaire in Grenoble introduced the audience to the STABILOT trial of patients at high risk of severe hypoglycaemia. This study is a randomised, prospective, medico-economic nationwide investigation across France looking at islet cell transplantation in patients with severely unstable type 1 diabetes. The study design is that the 30 patients included in the trial either received an immediate islet transplantation or had a delayed islet transplant following 12 months of sensor-augmented pump therapy. All the recruits in the trial have now received their islet transplants but we’ll just have to watch this space – the results of the STABILOT trial will not be announced at the next IPITA conference in 2021!
Dr Pratik Choudhary from King’s College, London reminds us that, whilst we have come a long way. From once- or twice-daily insulin injections coupled to lab-based urine or blood testing to new paradigms where patients are encouraged to do multiple daily injections of insulin or can be offered insulin pumps and continuous blood glucose monitoring which allow people simply to glance at their glucose level, a situation increasingly termed “sugar surfing”. And, now, with hybrid closed loop and full closed loop technologies moving towards limited calibrations, is the dream of the artificial pancreas actually a real-time, global reality?
Well, yes and no!
It appears that, with increasing technology, there are clearly benefits but Dr Choudhary explains that good glycaemic control does not universally appear to be one of them! In several studies, HbA1c levels have become worse and there was much subsequent discussion about the burden of technology which may actually be discouraging people by overloading them with data. He suggests that, for some patients, on a case-by-case basis, it may be better to skip the first line of structured, hypoglycaemia-specific education, and the second and third lines of treatment of insulin pump and sensor-augmented pump therapy with low glucose suspend and move straight to islet cell transplantation.
But islet cell transplantation still comes with its own risks – life-long immunosuppression along with the occasional reports of infection, kidney damage etc. So, what or, more importantly, who, should determine the choice of therapy? Is the main problem for the patient hypos or poor control or the complications of diabetes or, perhaps, there are psychological or emotional issues? Importantly, the perception of risk and personal attitudes to risk should be thoroughly assessed. Until we have a large supply of islets that can be transplanted without immunosuppression, technology can achieve adequate protection from hypoglycaemia with the full knowledge that the existing technology is not fool-proof. But, at the end of the day, the choice is the patient’s to make.
However, the next session I attend is given by the current President of IPITA, Professor Thierry Berney from the University of Geneva and he states that, although there are still issues with both whole pancreas and islet cell transplant, more research needs to be carried out to investigate where islets could be cited upon transplant in order to circumvent this need for immunosuppression that is required for both whole pancreas transplant and islet cell transplant into the liver, the site most frequently used for this kind of transplant. These sites include underneath the kidney capsule and a number of subcutaneous sites.
And I finish my second day at the conference, listening to some new research to assess changes in biomedical outcomes and psychosocial status following islet transplantation. In a UK-based project, several questionnaires were given to the people about to undergo an islet transplant and then the same questionnaires re-administered at 6-monthly periods post-transplant until there was confirmed graft failure. These questionnaires included the so-called Gold Score which has just one item – “Do you always know when your hypos are commencing?”, the HFS-11, which has over 30 questions relating to fear of hypoglycaemia and the DQOL, which assesses diabetes-specific quality of life.
Post-transplant, biomedical parameters improved and there was less fear of hypoglycaemia and an overall improvement in the diabetes-specific quality of life. However, anxiety symptoms persisted post-transplant so the conclusion was that psychosocial support and follow-up is warranted post-transplant despite ongoing graft function and clinically relevant biomedical and psychosocial benefits.
Another day draws to a close and, as I stroll the short walk through the hot and humid late afternoon sunshine back to my hotel, I can’t help but be impressed by the diversity of research being presented. Everything from surgical procedures to the psychological outcomes of transplantation, all being covered by researchers representing hundreds of different institutes, universities and hospitals in dozens of different countries and all to ensure that, going forward, the lives of people living with diabetes are improved. And that has to be applauded!