Establishing a national program of islet transplantation in Australia

We read with interest the opinion piece by Ricordi and Japour in STAT (August 27, 2019). It is interesting that the development of an appropriate funding pathway for islet transplantation seems to have stalled in the US, when in fact it was the early multicentre trials originating from the US and Canada that were the major stimulus for the procedure elsewhere. In Australia, islet transplantation for severe hypoglycaemia and metabolic instability has been funded via the National Funded Centres (NFC) program since 2012. The NFC program was established by the Australian Health Ministers Advisory Council (AHMAC) to provide access for Australian patients to high cost, low volume procedures that are of such a complexity that it is impractical for them to exist in every large public hospital. The high regulatory burden and expertise required for islet isolation and the limitation of suitable islet donors meant that it was not cost-effective to have an isolation centre in each state and a ‘hub and spoke’ model similar to that developed in the UK was established. Two isolation centres, based in Melbourne and Sydney were established along with 3 transplanting centres in Adelaide, Melbourne and Sydney. Clinical efficacy was confirmed by the Australian multicentre trial with the primary outcomes of prevention of hypoglycaemia, reduction in insulin requirements and HBA1c less than 7%. The primary end point was achieved in 87% of recipients [1]. Complications were largely procedure associated and there was no mortality. Although trial numbers were small, the findings were in line with overseas experience, including several multicentre studies from North America [2, 3]. The current program provides a national service, an essential requirement for all NFC applications. The cost of the procedure including travel to treatment centres, islet isolation, inpatient care and immunosuppression are covered by the NFC funding. Cost may fall as cost of immunosuppression drops and with future innovation in islet isolation. Potential recipients are assessed against standard criteria by consortium participants. All patients are place on a single national list. Donor-recipient matching, and donor pancreas allocation criteria are developed by a standing committee of the Transplantation Society of Australia and New Zealand. Currently, donor pancreases for whole pancreas transplantation take precedence over islet transplantation. However, the success of islet transplantation has meant that