Combined liver and pancreas transplantation in two children with cystic fibrosis-First experience in Australia and New Zealand

Cystic fibrosis related diabetes (CFRD) prognosis

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Poor nutritional status and decreased lean body mass.

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Decline in pulmonary function.

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Increased mortality from lung disease.

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Microvascular complications.

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Macrovascular complications (not currently a significant complication but this may change with modulators).

Cystic fibrosis related diabetes (CFRD) occurs in at least 40–50% of adults with CF. With other forms of diabetes, microvascular and macrovascular disease are the major causes of morbidity and mortality. Macrovascular disease is rare in CF. While microvascular disease does occur in this population, there are CF-specific diabetes complications that have a more important impact on prognosis. The additional diagnosis of diabetes in CF is associated with decreased lung function, poor nutritional status, and an overall increase in mortality from lung disease. These negative findings start even before the clinical diagnosis of CFRD, during the period when patients experience abnormal glucose tolerance related to insulin insufficiency. The main mechanisms by which CFRD negatively affects prognosis are thought to be a combination of 1) protein catabolism, decreased lean body mass and undernutrition resulting from insulin insufficiency, and 2) an increased pro-inflammatory and pro-infectious state related to intermittent hyperglycemia. With the introduction of CFTR modulators, the care of CF patients has been revolutionized and many aspects of CF health such as BMI and lung function are improving. The impact of these drugs on the adverse prognosis related to the diagnosis of diabetes in CF, as well as the potential to delay or prevent onset of CFRD remain to be determined.

Islet Transplantation in Children

PURPOSE OF REVIEW

Transplantation of the islets of Langerhans or the pancreas aims to restore blood sugar control. We review both forms of transplantation in children.

RECENT FINDINGS

Allogenic islet transplantation typically in to the liver via the portal vein may be a potential alternative to pancreas transplantation in the future. Autologous islet transplantation after total pancreatectomy is effective for debilitating symptoms of recurrent and chronic pancreatitis. Chronic pancreatitis in children is most often related to genetic mutations but is otherwise similar to adults with eventual exocrine and endocrine failure. Removal of the pancreas ameliorates pain, and islet transplantation preserves endocrine function to the extent allowed by the damage sustained by the pancreas from chronic inflammation. Despite the complexity of the operative procedure, the outcome of total pancreatectomy and autologous islet transplantation in children has been excellent including quality of life.

Cystic fibrosis - an example of personalized and precision medicine

Cystic fibrosis (CF) is a severe, monogenic, autosomal recessive disease caused by mutations in the CFTR (cystic fibrosis transmembrane regulator) gene, where disturbed chloride and bicarbonate transportation in epithelial cells results in a multiorgan disease with primarily pulmonary infections and pancreatic insufficiency. In 1968, the Copenhagen CF Center was established, and centralized care of CF patients with monthly control was introduced. Close monitoring and treatment of Pseudomonas lung infection as well as segregation of patients with different infection status improved the clinical outcome as well as survival. Prophylactic basic treatment as well as infection treatments follow specific algorithms. A variety of comorbidities have all along the pulmonary infection control necessitated personalized care, adjusted to the patients' phenotype. With the introduction of CFTR modulators, the treatment has shifted from prophylactic, symptomatic type toward a new era of precision medicine targeting the basic defect according to the patients' CFTR genotype. Future directions will focus on further improvement of the CFTR modulators and gene therapy, as well as modifier genes and CF phenotype.