THE PATIENT
When I was four, I collapsed at home and was rushed to hospital. I was semi-conscious and the doctor immediately realised what was wrong — I had type 1 diabetes.
He gave me an insulin injection and my condition quickly improved.
Looking back, I’d been suffering from all the classic signs: urinating all the time, a burning thirst and I had lost weight. My pancreas wasn’t producing any of the hormone insulin so my blood sugar levels had risen dangerously high.
From then on, I needed a daily injection of insulin and had to avoid eating too many carbohydrates.
Susan Dawson, from St Andrews, has had an islet transplant to treat her type 1 diabetes, last year
Like all diabetics who take insulin or glucose-lowering medication, I sometimes had hypoglycemia, or ‘hypo’, attacks, when my blood sugar level became too low because I’d had too much insulin for the amount of food I’d eaten or exercise I’d taken.
When I was younger, I would often feel strange — wobbly and sweaty. I could ward off an attack as it came on by eating something sugary.
But the longer I lived with diabetes, the less I noticed the warning signs. Even when I was having double vision — a sign of a full-on hypo — I had lost the awareness that I needed sugar urgently. This can be dangerous and I had to surrender my driving licence.
It put a lot of responsibility on others. My husband, John, had to make sure someone was always around on our farm.
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In 2008, I had an insulin pump fitted into my side to give me the hormone when my body needed it. I also wore a sensor on my skin that signalled to me if my blood sugar level was too high or too low. But even that didn’t always work.
Four years ago, the diabetic team at Victoria Hospital in Kirkcaldy mentioned islet cell transplantation to me.
This involves having islet cells, which produce insulin in the pancreas, extracted from an organ donor and injected into my liver. Though these cells are normally found in the pancreas, they can do the same job quite easily in the liver and the advantage, I was told, is that the liver is much easier to access.
I’d need less insulin, my blood sugar would be steadier and I’d recognise signs of a hypo again.
‘Four years ago, the team at Victoria Hospital in Kirkcaldy mentioned islet cell transplantation,’ Susan says
‘After ten days, I could tell the new cells were working because I needed half my usual insulin’, she added
I was referred to John Casey, a transplant surgeon at the Royal Infirmary of Edinburgh, and was put on the waiting list. After 18 months, in October 2014, the call came saying there was a suitable donor.
On the drive to the hospital I felt excited. When I arrived, I had checks to ensure I didn’t have antibodies to the potential donor and that my liver was working as it should.
The next morning, I was given immunosuppressants an hour before the transplant and a local anaesthetic in the right side of my chest. The cells were injected via a tube directly into my liver.
I was a little sore where the injection had gone in and I had to lie on my right side for four hours afterwards in case there was bleeding in my liver, but thankfully a scan the next day showed it was fine.
I spent 24 hours in intensive care while my blood sugar levels were monitored before going home.
After ten days, I could tell the new cells were working because I needed half my usual insulin.
There aren’t enough islet cells in one pancreas, so in April 2015, I had my second transplant.
My insulin is about a third of what it was before and, crucially, I’m not worrying about having a hypo.
Previously my daughter, Clare, couldn’t have left me with my 15-month-old grandson, Andrew, in case I fell into a coma, but now that’s very unlikely. And I’m about to run the Edinburgh Marathon.
The transplant has transformed my life and my family’s lives, too.
THE SURGEON
JOHN CASEY is a consultant transplant surgeon at the Royal Infirmary of Edinburgh and lead clinician for Scotland’s islet transplantation programme.
Type 1 diabetes affects more than 300,000 people in the UK. It is an autoimmune disease where the body’s immune system attacks the cells that produce insulin — the hormone needed to move glucose out of the blood and into the body’s cells to be used as energy.
For many years, the only way to treat it was through insulin shots. Now, growing numbers of patients have an insulin pump fitted, which regulates levels of the hormone.
But in the past decade, there has been another option. It involves the transplant of islet cells, which produce insulin.
For years, the only way to treat diabetes was through insulin shots. Now, patients have an insulin pump fitted, which regulates levels of the hormone
These cells are extracted from the pancreas of a deceased organ donor. The donor and recipient need only the same blood group to be a match.
Since 2008 in England and a year later in Scotland, the NHS has funded this treatment. In the UK, we do about 30 to 40 transplants each year.
We offer the islet transplant only to people with a particular complication: those who are unaware when they are becoming hypoglycemic. It’s thought to be partly due to nerve damage caused by diabetes.
The risk is that the patient will have a seizure and go into a coma, which can make it difficult to have a job and care for children.
But if we give these patients an islet transplant, it will immediately reverse this problem within a few weeks. As their blood sugar level control could be almost perfect again, they might not need insulin at all.
However, we need at least two donor organs to help one diabetic patient. That’s because to extract the donor cells, technicians use an enzyme to digest the pancreas, but it can also digest the islets.
We can normally extract only 30 to 50 per cent of the islets intact. Once extracted, they are put in a fluid.
During the procedure, we give the patient local anaesthetic before inserting a cannula (a tube) into the vein that leads to the liver and delivering 200ml of the fluid.
It takes about 20 minutes for the islets (we use 300,000 to 500,000 cells) to infuse into the liver.
We are looking at using what is left of the pancreas after the initial extraction to grow more islet cells in a laboratory. The project is being run by a firm called Cell and Gene Therapy Catapult with Aberdeen University.
It could be a game-changer for diabetic patients. It means someone like Susan would not have to wait until a donor became available — we could give her a much bigger total dose in one single transplant, and top-up cells if necessary.
The new development could mean a child with type 1 diabetes wouldn’t ever have to take insulin, and could avoid the health dangers that may face people with diabetes, such as strokes, heart attacks, kidney failure and blindness.
This technology has also been used on mice with type 2 diabetes, so it might have potential for this form of the disease, too.
WHAT ARE THE RISKS?
– The main risk is infection due to the patient’s immune system being suppressed.
– If anti-rejection medication does not work effectively, the transplant could fail.
– There is evidence of a slightly higher chance of cancers for islet transplant patients.
– It is common for the transplanted cells to become less effective over time.
– ‘This procedure provides a life-saving treatment for people with insulin-dependent diabetes who are suffering dangerously low glucose levels leading to collapse without warning,’ says James Shaw, professor of regenerative medicine for diabetes at Newcastle University.
‘Successful conversion of more of the donor pancreas into insulin-producing cells in the lab could significantly enhance this treatment — delivering long-term freedom from insulin injections.’