Question index:
Questions received during this symposium have been paraphrased
and the answers submitted by the panelists are presented.

Why is a kidney transplant only a "temporary solution?"
What is the news about pancreatic islet cell transplant and xenotransplantation?
Is it too late for these new advances to benefit established diabetics?
Could a live donor give up part of his pancreas?

Dr. Friedman's answers
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Why is a kidney transplant only a "temporary solution?"
Dr. Friedman:
Even the fact that you ask that question shows that there is much reason for you to understand more than you do about kidney transplant. For example, up until a short time ago, the mean or average survival of a kidney transplant from a cadaver, a dead person, was 7.5 years. It is now up to 10 years. So if you are 30 years and everything goes perfectly and you get your kidney transplant, then by the current statistics half will be lost by the time you are 40, and you are going to need another one. That is not bad. It doesn't mean the surgeon has done anything other than an excellent job. It is the state of the art. That is what I meant by that. A kidney transplant is not forever. If you get a living related donor kidney, the picture is brighter. It may even be as long as 20 years, though those statistics are just being developed now. Whatever the statistics are, you have to know them so that you don't get depressed and feel that you have been uniquely signaled out as the victim when your kidney fails.

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What is the news about pancreatic islet cell transplant and xenotransplantation?
Dr. Friedman:
This is another Canadian victory from Edmonton, Alberta, where they are doing pancreatic islet cell transplants. They have 14 out of 14 successes in giving the portion of the islet, the portion of the pancreas, that corrects diabetes and cures it without any need for long-term steroids, the drugs that make it difficult. Fourteen people with Type 1 diabetes in Canada no longer have diabetes, and there are 10 centers in the United States that are copying this procedure. In the Albert Einstein College of Medicine, the cell that makes insulin, the beta cell, is being grown by Michael Brownlee and associates by the bathtub-full. We will overcome the shortage of pancreases for islet transplant.

Lastly, the good news is that we are taking pigs, who are very close immunologically to humans, and putting human genes into the pigs, hoping to have an unlimited supply of kidney donor organs so that rather than wait... the wait in New York is four to five years for a cadaver kidney--I don't know what it is in Toronto. But rather than have to wait that long because there is a shortage of organs, we probably will be able to have an unlimited supply of acceptable humanized pig organs, solving the problems of repeated and initial kidney transplants.

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Is it too late for these new advances to benefit established diabetics?
Dr. Friedman:
Up until a short while ago, I would have taught my medical students just what you said--that the kidneys cannot regenerate and that the damage is irreversible in diabetes. Then in 1999, scientists from the University of Minnesota reported in The New England Journal of Medicine a series of biopsies of Type 1 diabetic people. They did biopsies of their kidneys, immediately, after 5 years, and 10 years after they got a pancreas transplant. And what they showed was something I said didn't occur and couldn't occur--the reversal of diabetic nephropathy 10 years after they got a pancreas, their own kidneys, had the disappearance of diabetic changes.

What is going to happen to you 10 years after you get the pig islet or 10 years after you get human pancreas or 10 years after you get Brownlee beta cells? I don't know, but there is every reason for optimism, every reason to reject the fact that we know it all, that the picture is clear and that it is hopeless. I am suggesting that by staying on the mainstream of a patient organization, knowing what is happening and trying to get on the early list of people who get the latest advances, the story may be quite good.

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Could a live donor give up part of his pancreas?
Dr. Friedman:
This has been a question explored intensively by the University of Minnesota group. They started it first with identical twins. They did a portion of the pancreas from a non-diabetic twin to the diabetic twin with kidney failure, along with a kidney. It worked, but two things happened. The pancreas transplant in the recipient was attacked by the same disease that destroyed the initial pancreas, so they had to start giving immunosuppressive drugs to protect the pancreas.

The second series of experiments was parent to child. These are being evaluated now, and I don't think I can give you a summative answer. A couple of the pancreas donors developed Type 2 diabetes. Remember, Type 1--too little insulin; Type 2--a little unclear, inadequate amounts of insulin to handle the metabolic load. But a couple of the pancreas donors have developed Type 2 diabetes.

Do I think that you can give up a portion of your pancreas? Probably yes if you are in the hands of an expert like David Southerland at the University of Minnesota. Beyond that, I am unaware of success. Again, I would suggest to you that there really is cause for optimism that things are going to get better in the very near term.