Fresh human islet transplantation to replace pancreatic endocrine function in type 1 diabetic patients. Report of six cases

The aim of this study was to evaluate the feasibility of islet allografts in patients with type 1 diabetes mellitus. Six patients received human islets from either one or two donors via the portal vein, after (n = 4) or simultaneously with (n = 2) a kidney graft. The patients with functioning kidney grafts (nos. 1-4) were already on triple immunosuppressive therapy (cyclosporine A, azathioprine, prednisone). Prednisone was increased to 60 mg/day for 15 days after the islet transplant in patient 1. Patients 2-4 and the patients who underwent a simultaneous kidney-islets graft (nos. 5, 6) also received antilymphocyte globulin. Intravenous insulin was given for the first 15 days to maintain blood glucose concentrations within the normal range. Patient 1 rejected the islets within 15 days of islet transplantation. In patient 2, a 25% reduction in insulin requirement was observed and 12 months after transplantation post-prandial serum C-peptide was 1.5 ng/ml. In patient 3, the insulin requirement decreased from 40 to 8 units/day with a post-prandial serum C-peptide of 4.1 ng/ml 12 months after islet transplantation. In patient 4 the post-prandial secretion of C-peptide increased to 6.4 ng/ml. Six months after the islet infusion, insulin therapy was discontinued and HbA1c, 24-h metabolic profile and oral glucose tolerance test remained within the normal range. He had remained off insulin for 5 months until recently, when foot gangrene paralleled a worsening of post-prandial glycaemic control. Twelve months after transplantation he is receiving 8 units insulin/day.(ABSTRACT TRUNCATED AT 250 WORDS)

Prednisone administration in recent onset type I diabetes

The aim of our study was to investigate the efficacy of prednisone to preserve pancreatic beta-cell function in patients with recent-onset Type I diabetes mellitus (IDDM). Twenty-five patients with IDDM, aged 24 +/- 6 years, entered the trial within 8 weeks of the onset of diabetes. They were allocated, according to a single blind randomized protocol, to one of the following treatments: (A) prednisone (15 mg/day), (B) indomethacin (100 mg/day), (C) placebo. All treatments lasted 8 months and all patients achieved satisfactory metabolic control with a multi-injection regimen (three injections/day) within a few weeks, and maintained it throughout the entire period of observation. Only minor side effects were observed in the prednisone-treated patients. A lower insulin requirement was observed in the prednisone group than in other patients at 12 months (0.33 +/- 0.11 vs 0.57 +/- 0.06 U/kg/day, P less than 0.05), 18 months (0.34 +/- 0.11 vs 0.64 +/- 0.06, P less than 0.05) and 24 months (0.38 +/- 0.10 vs 0.63 +/- 0.05, P less than 0.05). Endogenous insulin release, evaluated as urinary C-peptide, was higher in the prednisone group than in other patients at 3, 6, 9, 12, 18 and 24 months (P less than 0.05). ANOVA confirmed differences among the three groups. Our study indicates that prednisone administration, at low doses and for a long period of time, effectively restored endogenous insulin release in IDDM patients.

Reduction of insulin resistance by combined kidney-pancreas transplantation in type 1 (insulin-dependent) diabetic patients

To evaluate the effect of combined kidney and pancreas transplantation on insulin action and glucose metabolism, 15 Type 1 (insulin-dependent) diabetic patients who were undergoing combined kidney-pancreas transplantation were studied before transplantation by means of the euglycaemic hyperinsulinaemic clamp technique combined with 3-3H-glucose infusion and indirect calorimetry. Nine of the original 15 patients were studied again after four months and six after 12 months, successful combined kidney-pancreas transplantation with the same experimental protocol. Nine volunteers formed the group of normal subjects. Combined kidney-pancreas transplantation normalised hepatic glucose production and reduced peripheral insulin resistance in Type 1 diabetic uraemic patients, despite chronic immunosuppressive therapy. To further evaluate the hypothesis that residual insulin resistance was due to chronic steroid therapy. 11 additional subjects with chronic uveitis (six of whom were treated with only prednisone, and five treated only with cyclosporin) underwent the same protocol demonstrating a normal hepatic glucose production. The insulin-stimulated peripheral glucose uptake was reduced in the prednisone-treated group, but normal in cyclosporin-treated subjects. Four additional diabetic patients with a kidney transplant were also studied. They showed a peripheral insulin sensitivity intermediate between diabetic uraemic patients and patients after combined transplant. We conclude that short-term (one year) combined kidney-pancreas transplantation improves glucose metabolism by restoring normal rates of hepatic glucose production and reducing peripheral insulin resistance; chronic steroid therapy is the major determinant of residual reduced insulin action. Both kidney and pancreas substitution play a role in reducing peripheral insulin resistance.

[MR (1.5 T) in the evaluation of pancreas transplant rejection]

Graft rejection is the major cause of graft loss following pancreatic transplantation. Early detection of the rejection process is of great importance towards planning effective treatment when transplant recipients present with aspecific clinical findings suggesting rejection. Up to date, the demonstration of pancreatic transplant rejection has been attempted with nuclear medicine and sonography (US). The authors studied high-field (1.5 T) MR potentials in pancreatic transplantation and rejection and correlated MR findings with clinical and laboratory data. Eleven MR scans were obtained from 4 patients with suspected pancreatic graft rejection, and 9 MR images from 4 patients with normal pancreatic allografts. Qualitative image evaluation showed the pancreatic tissue of the patients diagnosed with rejection to be hypointense on T1-weighted scans and highly hyperintense on T2-weighted scans, as compared to normal grafts. Quantitative data were obtained by comparing the signal intensity of pancreatic grafts to that of the nearby muscle. On both T1- and T2-weighted images, pancreatic tissue/muscle signal-intensity ratios were significantly different, in rejecting transplants, from those of normal allografts (p less than 0.001). Our qualitative and quantitative findings suggest the use of MR imaging as a reliable means of detecting pancreatic graft rejection.

Impairment of lymphocyte suppressive system in recent onset insulin-dependent diabetes mellitus. Correlation with blood glucose and serum insulin levels

In a previous study, we observed an impairment of the theophylline-induced suppressive system in recent onset IDDM patients, and demonstrated also a correlation with metabolic derangement. The aim of this study was to better investigate the relationship between theophylline sensitivity (ThS) and blood glucose/plasma insulin levels in recent onset IDDM patients subjected to preprogrammed variations by an insulin/glucose clamp with artificial pancreas. Eight patients were studied within 8 weeks from the onset of IDDM. ThS was evaluated as the ability of theophylline to inhibit blastogenic response of peripheral blood lymphocytes (PBL) to Concanavalin A (ConA), after 120 min preincubation of the cells. All patients were connected to an artificial pancreas. Through i.v. continuous insulin infusion (0.02 U/kg/h) and/or i.v. continuous glucose and saline infusion, the following experimental conditions, lasting at least 1h, were obtained: T1: relative euglycemia and normal insulinemia; T2: relative euglycemia and hyperinsulinemia; T3: hyperglycemia and normal insulinemia; T4: hyperglycemia and hyperinsulinemia. ThS was maintained in 6/8 patients at T1 and in 8/8 patients at T4. ThS was lost in 4/8 patients at T2 and T3. These data suggest that the loss of ThS induced by hyperglycemia can be corrected by hyperinsulinemia, and that it is maintained when euglycemia is accompanied by hypoinsulinemia. It is lost when these two parameters lose their interrelationship.

Islet cell autoimmunity in type I diabetic patients after HLA-mismatched pancreas transplantation

The aim of this study was to investigate a possible reenhancement of islet cell autoimmunity in type I (insulin-dependent) diabetic patients who received HLA-mismatched pancreas transplants from cadaveric donors and who underwent generalized immunosuppression. Circulating islet cell antibodies (ICA) and complement-fixing ICAs (CF-ICAs) have been tested at 1, 2, 3, 6, and 12 mo and at least once a year posttransplantation in 23 recipients of 25 transplants (22 simultaneous with kidney, 2 retransplants, 1 isolated; 23 segmental neoprene injected, 2 whole with enteric drainage). Patients were aged 35.3 +/- 1.9 yr with a duration of diabetes of 20.6 +/- 1.1 yr. Immunosuppression consisted of double or triple association of azathioprine, cyclosporin, and prednisone with or without temporary antilymphocyte globulins. The number of HLA-A and HLA-B compatibilities was none in 8 patients, one in 12 patients, two in 4 patients, and three in 1 patient. The mean follow-up was 4.0 +/- 0.4 yr/patient (range 0.4-7.2). ICAs were positive pretransplantation in 2 of 25 patients and reappeared 1-42 mo posttransplantation in another 7. In 6 patients, CF-ICAs were also positive. In 7 of 9 ICA+ patients the pancreas transplant failed; in 1 patient this occurred 4 mo before ICA reappearance, and in 6 patients it occurred 2-35 mo after the first detection of ICAs. Pancreas-transplant failure was significantly associated with the positivity for ICAs (P less than .05) and particularly for CF-ICAs (P less than .005). ICA positivity was transitory in 4 patients (2-27 mo) and persistent in the remaining 5 (up to 61 mo).(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical experience in pancreas transplantation in Lyon: long-term survival of duct injected pancreatic grafts

Ninety-seven pancreatic grafts in 92 insulin-dependent diabetic patients were performed during the last 11 years. Eighty-three of these grafts were carried out after neoprene duct injection, the other patients underwent pancreato-duodenal transplantation. In 80 cases, a double pancreas and kidney graft was performed. Five different immunosuppressive protocols were subsequently applied. Actuarial survival of patients and pancreata was 75.1% and 47%, after one year and 54.6% and 22.1%, respectively, 4 years after transplantation. Slightly better results were observed in double pancreas and kidney transplantation. The survival of both patients and pancreas improved when the most recent immunosuppressive protocols including cyclosporin A and only small doses of steroids were applied. The main causes of loss of the pancreatic graft were rejection, vascular thrombosis and death of the patient with functioning organ. Metabolic studies showed good insulin secretion with normal or impaired glucose tolerance as well as good short and half-term glycemic control. Whole pancreas grafts with enteric diversion yielded prompter and higher insulin secretion but the incidence of surgical complications was increased. In comparison to the data recorded at 6 months after pancreas transplantation, 5 patients of our series with still functioning organ showed an equally satisfactory and unchanged glycemic control after more than 4 years from surgery. In these patients, the previously high insulinemic values decreased to normal levels. However, 3 of these patients showed a decrease in post-prandial peaks as confirmed also by OGTT. However, mean blood glucose level was not altered. In our series the suppression of exocrine pancreatic secretion by neoprene duct injection did not appear to represent a relevant cause of decrease in endocrine function. The results obtained do not yet allow us to draw definite conclusions as to the efficacy of pancreas transplantation in the treatment of degenerative complications in diabetic patients.

Effects of arginine and arginine plus somatostatin infusion on insulin release in diabetic patients submitted to pancreas allotransplantation

The present study was aimed at evaluating the role of the Autonomic Nervous System (ANS) in the insulin (IRI) response to arginine in humans. Nine patients who were recipients of simultaneous segmental pancreatic and renal grafts (6 receiving steroids and azathioprine as immuno suppression therapy, 3 treated with Cyclosporine A), 3 non-diabetic patients with kidney grafts (receiving steroid and azathioprine) and 10 normal subjects were studied. Arginine induced a clear IRI release in all subjects with no significant difference among the groups. Somatostatin (SRIF) inhibited IRI release to a similar degree in all subjects. Since the transplanted pancreas is completely denervated, these data suggest that the integrity of the ANS is not essential to the IRI response to arginine, nor for the inhibitory effect of SRIF on IRI release.

Impairment of lymphocyte-suppressive system in recent-onset insulin-dependent diabetes mellitus. Correlation with metabolic control

Impairment of suppressor-cell activity may be important in the pathogenesis and maintenance of insulin-dependent diabetes mellitus (IDDM). In 23 recent-onset IDDM patients, lymphocyte sensitivity in vitro to theophylline was tested both in basal conditions and after improvement of metabolic control. This pharmacologic agent is mainly effective on a lymphocytic subpopulation with phenotypic and functional suppressive features. Peripheral blood lymphocytes from IDDM patients showed a loss of theophylline sensitivity, identified as inhibition of both E-rosette formation and blastogenic response to polyclonal mitogens concanavalin A (ConA) and phytohemagglutinin (PHA). An inverse relationship was demonstrated between the theophylline-induced suppression of ConA blastogenic response and blood glucose and glycosylated hemoglobin levels (P less than .01). Metabolic control seemed to be important even in relation to lymphocyte subpopulation distribution. In IDDM patients we found a significant (P less than .05) reduction of OKT4+ lymphocytes that is correlated with blood glucose and glycosylated hemoglobin levels (P less than .01). The improvement of metabolic control led to recovery of theophylline sensitivity. We suggest a deficiency in a suppressive system that could be involved in IDDM onset and the possible role of metabolic control in the impairment of some immunologic functions reported with this pathologic condition.

Effects of oral administration of maltitol on plasma glucose, plasma sorbitol, and serum insulin levels in man

The present study was aimed to investigate the metabolic effects of acute and chronic oral administration of maltitol (4-O-i-D-glucopyranosyl-D-glucitol), a hypocaloric sweetener obtained from maltose by catalytic hydrogenation. Fifty grams of maltitol induced a increase lower glycemic and insulinemic than the same dose of glucose or sucrose. No variations of plasma glucose and serum insulin levels were observed after 180 min. A slight increase of plasma maltitol was observed 45 min after maltitol. The chronic administration of maltitol (10 g 3 X daily for 5 days) induced no variations of glycemia or insulinemia when compared with the same dose of sucrose. Plasma sorbitol levels were slightly higher after maltitol than after sucrose. Low amounts of maltitol were detected in the urine and feces.

Metabolic control of type I (insulin dependent) diabetes after pancreas transplantation

A study was conducted of the circadian hormonal and metabolic patterns of 10 type I (insulin dependent) uraemic diabetic patients after pancreas and renal transplantation. A single 24 hour profile was obtained in each patient following as closely as possible his or her normal daily routine two to 15 months after transplantation. None of the patients were using insulin at the time of the study. Compared with a group of six normal subjects the transplant recipients had mildly raised blood glucose concentrations, hyperinsulinaemia between meals and at night, delayed postprandial insulin peaks, mild hyperketonaemia, and normal blood lactate and plasma glucagon concentrations. The findings showed that successful pancreas transplantation results in disappearance of the need for insulin and return to normal or near normal of the metabolic abnormalities of diabetes. The minor differences observed in comparison with normal hormonal and metabolic homoeostasis were probably due to intrinsic (reduced islet mass, denervation, peripheral hormone delivery) and environmental (immunosuppression, relatively impaired renal function) factors.

Thirty months' experience with cyclosporin in human pancreatic transplantation

Between September 1978 and December 1983, 33 simultaneous kidney plus pancreatic transplantations were performed in Type 1 (insulin-dependent) diabetic patients with uraemia at the Herriot Hospital, Lyon. In eight patients grafted before June 1981, immunosuppressive treatment consisted of azathioprine, steroids and a temporary course with anti-lymphocyte globulins (protocol A). Since June 1981, the immunosuppressive treatment has consisted of cyclosporin administered according to two protocols: from the day of transplantation with temporary anti-lymphocyte globulins with or without steroids (protocol B, seven patients), or after an initial course with protocol A, with or without steroids (protocol C, 18 patients). Only slight differences in patient and pancreatic graft survival between the three protocols were observed at 3, 6 and 12 months, while an improved survival rate for both patients and pancreatic grafts was observed in protocols B and C at 2 years. Moreover the incidence of pancreatic rejection as a cause of loss of pancreatic function seemed to be reduced under protocols B and C.

Renal glucose transport after kidney transplantation

Tubular maximal transport of glucose (TmG), plasma glucose threshold ( PGT ) and fractional maximal tubular reabsorption (TmG/GFR) were measured in fourteen kidney-grafted patients. Seven patients showed decreased PGT and normal or decreased TmG/GFR (type A or B renal glycosuria (RG) ), whereas seven other patients showed normal values. No difference was found between the two groups with respect to parameters of renal function and to clinical parameters characterizing kidney transplantation. The only difference observed between the two groups was the rate of decrease of plasma creatinine levels during the 1st week after transplantation: it was faster in the group without renal glycosuria. No difference was seen between the two groups of patients with respect to the number of rejection episodes occurred over the first 12 months.

Study of hypoglycemic patients by the glucose clamp technique using the artificial pancreas

Using the artificial pancreas, blood glucose levels were maintained at 80 mg/dl in nine hypoglycemic patients (four with histologically proven insulinomas and five with nontumoral hypoglycemia) and in four normal subjects during a 24-h fast. The amount of glucose used, serum insulin levels, and glucose clearance were higher in patients with nontumoral hypoglycemia than in normal subjects and highest in the patients with an insulinoma. Surgical or pharmacological treatment resulted in normalization of all parameters. In contrast to the 72-h fast, the 24-h glucose clamp technique allowed the study of hypoglycemic patients without inducing hazardous hypoglycemia.