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Diabetes Mellitus: New Challenges and Innovative Therapies. NEW STRATEGIES TO ADVANCE PRE/DIABETES CARE: INTEGRATIVE APPROACH BY PPPM 2013; 3. [PMCID: PMC7120768 DOI: 10.1007/978-94-007-5971-8_3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Diabetes is a common chronic disease affecting an estimated 285 million adults worldwide. The rising incidence of diabetes, metabolic syndrome, and subsequent vascular diseases is a major public health problem in industrialized countries. This chapter summarizes current pharmacological approaches to treat diabetes mellitus and focuses on novel therapies for diabetes mellitus that are under development. There is great potential for developing a new generation of therapeutics that offer better control of diabetes, its co-morbidities and its complications. Preclinical results are discussed for new approaches including AMPK activation, the FGF21 target, cell therapy approaches, adiponectin mimetics and novel insulin formulations. Gene-based therapies are among the most promising emerging alternatives to conventional treatments. Therapies based on gene silencing using vector systems to deliver interference RNA to cells (i.e. against VEGF in diabetic retinopathy) are also a promising therapeutic option for the treatment of several diabetic complications. In conclusion, treatment of diabetes faces now a new era that is characterized by a variety of innovative therapeutic approaches that will improve quality of life in the near future.
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Hematti P, Kim J, Stein AP, Kaufman D. Potential role of mesenchymal stromal cells in pancreatic islet transplantation. Transplant Rev (Orlando) 2013; 27:21-9. [PMID: 23290684 DOI: 10.1016/j.trre.2012.11.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 11/09/2012] [Indexed: 12/11/2022]
Abstract
Pancreatic islet transplantation is an attractive option for treatment of type 1 diabetes mellitus but maintaining long term islet function remains challenging. Mesenchymal stromal cells (MSCs), derived from bone marrow or other sources, are being extensively investigated in the clinical setting for their immunomodulatory and tissue regenerative properties. Indeed, MSCs have been already tested in some feasibility studies in the context of islet transplantation. MSCs could be utilized to improve engraftment of pancreatic islets by suppressing inflammatory damage and immune mediated rejection. In addition to their immunomodulatory effects, MSCs are known to provide a supportive microenvironmental niche by secreting paracrine factors and depositing extracellular matrix. These properties could be used for in vivo co-transplantation to improve islet engraftment, or for in vitro co-culture to prime freshly isolated islets prior to implantation. Further, tissue specific pancreatic islet derived MSCs may open new opportunities for its use in islet transplantation as those cells might be more physiological to pancreatic islets.
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Affiliation(s)
- Peiman Hematti
- Department of Medicine, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, WI, USA.
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154
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Tavakoli M, Mitu-Pretorian M, Petropoulos IN, Fadavi H, Asghar O, Alam U, Ponirakis G, Jeziorska M, Marshall A, Efron N, Boulton AJ, Augustine T, Malik RA. Corneal confocal microscopy detects early nerve regeneration in diabetic neuropathy after simultaneous pancreas and kidney transplantation. Diabetes 2013; 62:254-60. [PMID: 23002037 PMCID: PMC3526062 DOI: 10.2337/db12-0574] [Citation(s) in RCA: 199] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diabetic neuropathy is associated with increased morbidity and mortality. To date, limited data in subjects with impaired glucose tolerance and diabetes demonstrate nerve fiber repair after intervention. This may reflect a lack of efficacy of the interventions but may also reflect difficulty of the tests currently deployed to adequately assess nerve fiber repair, particularly in short-term studies. Corneal confocal microscopy (CCM) represents a novel noninvasive means to quantify nerve fiber damage and repair. Fifteen type 1 diabetic patients undergoing simultaneous pancreas-kidney transplantation (SPK) underwent detailed assessment of neurologic deficits, quantitative sensory testing (QST), electrophysiology, skin biopsy, corneal sensitivity, and CCM at baseline and at 6 and 12 months after successful SPK. At baseline, diabetic patients had a significant neuropathy compared with control subjects. After successful SPK there was no significant change in neurologic impairment, neurophysiology, QST, corneal sensitivity, and intraepidermal nerve fiber density (IENFD). However, CCM demonstrated significant improvements in corneal nerve fiber density, branch density, and length at 12 months. Normalization of glycemia after SPK shows no significant improvement in neuropathy assessed by the neurologic deficits, QST, electrophysiology, and IENFD. However, CCM shows a significant improvement in nerve morphology, providing a novel noninvasive means to establish early nerve repair that is missed by currently advocated assessment techniques.
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Affiliation(s)
- Mitra Tavakoli
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Maria Mitu-Pretorian
- Transplantation Unit, Manchester Royal Infirmary, Central Manchester University Hospitals Foundation Trust, Manchester, U.K
| | - Ioannis N. Petropoulos
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Hassan Fadavi
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Omar Asghar
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Uazman Alam
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Georgios Ponirakis
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Maria Jeziorska
- Tissue Injury and Repair Group, School of Medicine, The University of Manchester, U.K
| | - Andy Marshall
- Department of Clinical Neurophysiology, Manchester Royal Infirmary, Central Manchester University Hospitals Foundation Trust, U.K.; and
| | - Nathan Efron
- Institute of Health and Biomedical Innovation and School of Optometry and Vision Science, Queensland University of Technology, Brisbane, Australia
| | - Andrew J. Boulton
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Titus Augustine
- Transplantation Unit, Manchester Royal Infirmary, Central Manchester University Hospitals Foundation Trust, Manchester, U.K
| | - Rayaz A. Malik
- Division of Cardiovascular Medicine, University of Manchester and Wellcome Trust Clinical Research Facility, Manchester, U.K
- Corresponding author: Rayaz A. Malik,
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155
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Tavakoli A, Liong S. Pancreatic transplant in diabetes. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 771:420-37. [PMID: 23393694 DOI: 10.1007/978-1-4614-5441-0_30] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Whole organ pancreas transplantation is increasingly being performed for the treatment of diabetes mellitus. To date, over 32,000 pancreas transplants have been performed worldwide. The procedure is associated with significant mortality and morbidity in early transplant period. However, the successful pancreas transplantation has the potential to render patients insulin-independent and halt the progression of complications of diabetes, thereby improving both quality of life and patient survival.
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Affiliation(s)
- Afshin Tavakoli
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester, UK.
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156
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Liu BL, Liu SQ, Cao XK. Basic research and clinical application of islet transplantation: Current status and future prospects. Shijie Huaren Xiaohua Zazhi 2012; 20:3186-3190. [DOI: 10.11569/wcjd.v20.i33.3186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Type 1 diabetes mellitus is a chronic autoimmune disease. Although treatment with insulin is effective in most patients with type 1 diabetes mellitus, it can result in severe hypoglycemia which can be even deadly in some patients. Beta cell replacement, which can be achieved by whole pancreas transplantation or isolated islet cell transplantation, is usually used to restore physiologic glucose homeostasis. Compared with pancreas transplantation, islet transplantation has certain advantages. However, there was not a great breakthrough in islet transplantation until 2000 when the Edmonton protocol was published. However, some investigators believe that progressive graft loss and lack of reproducibility are fatal flaws of the Edmonton protocol. Thus, the protocol needs some improvements. In this article, we briefly describe the Edmonton protocol and its improvements and review the current status and future prospects of islet transplantation.
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157
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158
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Vandermeer FQ, Manning MA, Frazier AA, Wong-You-Cheong JJ. Imaging of whole-organ pancreas transplants. Radiographics 2012; 32:411-35. [PMID: 22411940 DOI: 10.1148/rg.322115144] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Whole pancreas transplantation is an established treatment for selected patients with diabetic nephropathy or poorly controlled diabetes. Surgical techniques vary and have evolved over the past 4 decades. Imaging evaluation of the whole-pancreas transplant should begin with an understanding of the most commonly used surgical techniques and the spectrum of postoperative complications. Ultrasonography (US) should be the first-line modality in evaluating the pancreas allograft and vasculature. Computed tomography (CT) is useful in the assessment of extra-allograft processes, particularly in ruling out abscess formation or evaluating suspected bowel complications. Magnetic resonance (MR) imaging is reserved for cases in which complete evaluation with US or CT is not possible. MR angiography can help provide an accurate assessment of vascular abnormalities. The radiologist must be familiar with the spectrum of surgical techniques and the normal postoperative imaging appearances of the whole-pancreas transplant so as to be able to recognize abnormal postoperative findings. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.322115144/-/DC1.
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Affiliation(s)
- Fauzia Q Vandermeer
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201, USA.
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159
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Abstract
The immobilization of cells into polymeric scaffolds releasing therapeutic factors, such as alginate microcapsules, has been widely employed as a drug-delivery system for numerous diseases for many years. As a result of the potential benefits stem cells offer, during recent decades, this type of cell has gained the attention of the scientific community in the field of cell microencapsulation technology and has opened many perspectives. Stem cells represent an ideal tool for cell immobilization and so does alginate as a biomaterial of choice in the elaboration of these biomimetic scaffolds, offering us the possibility of benefiting from both disciplines in a synergistic way. This review intends to give an overview of the many possibilities and the current situation of immobilized stem cells in alginate bioscaffolds, showing the diverse therapeutic applications they can already be employed in; not only drug-delivery systems, but also tissue engineering platforms.
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160
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Fishman B, Segev H, Kopper O, Nissenbaum J, Schulman M, Benvenisty N, Itskovitz-Eldor J, Kitsberg D. Targeting Pancreatic Progenitor Cells in Human Embryonic Stem Cell Differentiation for the Identification of Novel Cell Surface Markers. Stem Cell Rev Rep 2012; 8:792-802. [DOI: 10.1007/s12015-012-9363-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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161
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[Prophylaxis of cytomegalovirus infection in pancreatic transplantation]. Enferm Infecc Microbiol Clin 2012; 29 Suppl 6:56-9. [PMID: 22541925 DOI: 10.1016/s0213-005x(11)70060-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pancreatic transplantation carries a higher risk of cytomegalovirus (CMV) infection than renal transplantation alone. The management of CMV disease in pancreatic transplantation depends on the risk indicated by the donor's and recipient's serological profiles (CMV IgG) and the use of antibodies as immunosuppressive therapy (especially thymoglobulin). Most clinical guidelines recommend the use of prophylaxis in preference to preemptive therapy in both donor (D)+/recipient (R)- and D+/R+ pancreatic transplantations. In combinations with highest risk (D+/R-), prophylaxis with valganciclovir 900mg per day for 3 to 6 months is recommended, adjusted to renal funtion. In D+/R+ combinations, if antibody therapy was used in the transplant or in rejection, valgancioclovir prophylaxis is also recommended for 1 to 3 months. When prophylaxis is finished, in both cases, viral load determination (quantitative polymerase chain reaction of CMV) or antigenemia should be carried out for the first year. In D-/R-combinations, preemptive therapy can be considered with determinations of viral load or antigenemia at each follow-up visit during the first year. Once prophylaxis has been suspended, special attention should be paid to the development of delayed CMV disease.
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162
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Long-Term (5 Years) Efficacy and Safety of Pancreas Transplantation Alone in Type 1 Diabetic Patients. Transplantation 2012; 93:842-6. [DOI: 10.1097/tp.0b013e318247a782] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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163
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Richter A, Lerner SM, Schröppel B. Curing diabetes with transplantation? ACTA ACUST UNITED AC 2012; 79:267-75. [PMID: 22499497 DOI: 10.1002/msj.21304] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Type 1 diabetes affects >1 million people in the United States, where it accounts for up to 10% of all diabetes cases. Glycemic control via the use of exogenous insulin injections in diabetic patients is incomplete, resulting in multiple long-term complications such as retinopathy, neuropathy, vasculopathy, and nephropathy. The goal of beta-cell replacement by whole-pancreas or islet transplantation is to achieve long-term insulin independence, and the proposed benefits are improved quality of life, prevention of recurrent diabetic nephropathy, stabilization or improvement in secondary complications, and improved mortality. No other regimen of insulin delivery can achieve this level of physiologic regulation.
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Affiliation(s)
- Anja Richter
- Nephrology Division, Mount Sinai School of Medicine, New York, NY, USA
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164
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Thomas MP, Wilson CH, Nayar M, Manas DM, Walker M, Shaw J, White SA. Endoscopic Botulinum Toxin Injection for the Treatment of Diabetic Gastropathy in Pancreas and Islet-cell Transplant Patients. EXP CLIN TRANSPLANT 2012; 10:168-71. [DOI: 10.6002/ect.2011.0109] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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165
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Bratton CF, Hamid A, Selby JB, Baliga PK. Case report: gastrointestinal hemorrhage caused by a pancreas transplant arteriovenous fistula with large psuedoanuerysm 9 years after transplantation. Transplant Proc 2012; 43:4039-43. [PMID: 22172898 DOI: 10.1016/j.transproceed.2011.09.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 09/16/2011] [Indexed: 02/07/2023]
Abstract
Reported cases of arteriovenous fistulae in transplant recipients are uncommon. We present a case of an arteriovenous fistula associated with a large pseudoaneurysm in the root of the small bowel mesentery of a pancreas transplant. Uniquely, in our case, the arteriovenous fistula presented with an episode of gastrointestinal (GI) hemorrhage 9 years postoperatively. Radiographic imaging including coronal computed tomography angiogram and conventional angiogram demonstrated an arteriovenous fistula in the patient's pancreas transplant between the distal superior mesenteric artery (SMA) and superior mesenteric vein (SMV) with 6 cm aneurysmal dilatation. The tremendous flow in the fistula in the root of the graft small intestine mesentery led to graft duodenal mucosal congestion and lower GI hemorrhage. After successful embolization of the SMA-SMV fistula and pseudoaneurysm using interventional radiographic techniques, the arteriovenous fistula remained thrombosed. The patient had no further episodes of GI bleeding and her endoscopic evaluation was otherwise negative. The presence of arteriovenous fistulae and pseudoaneurysms in pancreas transplant recipients is uncommon, but has been previously documented. This case is further distinguished from previous reports by the notable 9-year interval between transplantation and the onset of hemorrhage. Historically, symptomatic vascular malformations have been associated with significant patient morbidity and mortality. Successful patient management involves timely and accurate diagnosis and intervention.
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Affiliation(s)
- C F Bratton
- Department of Surgery, Division of Transplant, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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166
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Enteroscopic biopsies in the management of pancreas transplants: a proof of concept study for a novel monitoring tool. Transplantation 2012; 93:207-13. [PMID: 22134369 DOI: 10.1097/tp.0b013e31823cf953] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although percutaneous biopsies are considered to be the gold standard in diagnosing pancreas graft rejection, they are not performed routinely because of their association with severe complications. On the other hand, correct diagnosis of rejection is essential but may be difficult in cases of enteric drainage, particularly in patients with a pancreas transplant alone or a pancreas after kidney transplant. METHODS Pancreas recipients who underwent enteroscopy between May 2005 and September 2009 were included in this retrospective analysis. Biopsies were graded 0 to 4 for interstitial and vascular changes. RESULTS During the study period a total of 65 simultaneous pancreas-kidney transplants, 13 pancreas after kidney transplants and 4 pancreas transplants alone were performed. Sixty-three patients underwent a single enteroscopy, 10 had two, and 6 had three or more. Indications were protocol graft monitoring (n=73), graft dysfunction (n=17), enteric hemorrhage (n=9), or other (n=3). The duodenal segment was accessed in 76 instances (75%) with abnormal findings in 23. A total of 69 biopsies were obtained and revealed normal mucosa in 49 cases (71%). Histology showed signs of acute rejection in 11 cases. The upper gastrointestinal tract was also assessed, and, in 13 cases, additional pathologies were identified including gastroduodenitis (n=10), gastric/duodenal ulcer (n=2), and hemorrhagic esophagitis (n=1). No procedure-related complication occurred. CONCLUSIONS This series of enteroscopies demonstrates that the duodenal segment of a pancreatic graft is accessible using our implant technique, and thus permitting biopsies to be obtained and endoscopic interventions to be performed.
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167
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Abstract
SPK transplant is the definitive treatment of type 1 diabetes combined with end-stage renal disease. Long-term graft function can lead to improvement in diabetes-related complications and, in patients younger than 50 years, can lead to improved overall survival. PAK transplant and PA transplant do not result in similar improvements in patient survival, but with appropriate patient selection, they can improve quality of life by rendering patients insulin-free. Pancreas transplant is associated with more surgical complications and higher perioperative morbidity and mortality than KTA. Therefore, careful donor and recipient selection along with meticulous surgical technique are mandatory for optimal outcomes.
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Affiliation(s)
- Kiran K Dhanireddy
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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168
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Finger EB, Radosevich DM, Bland BJ, Dunn TB, Chinnakotla S, Sutherland DER, Pruett TL, Kandaswamy R. Comparison of recipient outcomes following transplant from local versus imported pancreas donors. Am J Transplant 2012; 12:447-57. [PMID: 22070451 DOI: 10.1111/j.1600-6143.2011.03828.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The shortage of deceased donor organs for solid organ transplantation continues to be an ongoing dilemma. One approach to increase the number of pancreas transplants is to share organs between procurement regions. To assess for the effects of organ importation, we reviewed the outcomes of 1014 patients undergoing deceased donor pancreas transplant at a single center. We performed univariate and multivariate analyses of the association of donor, recipient and surgical characteristics with patient outcomes. Organ importation had no effect on graft or recipient survival for recipients of solitary pancreas transplants. Similarly, there was no effect on technical failure rate, graft survival or long-term patient survival for simultaneous kidney-pancreas (SPK) recipients. In contrast, there was a significant and independent increased risk of death in the first year in SPK recipients of imported organs. SPK recipients had longer hospitalizations and increased hospital costs. This increased medical complexity may make these patients more susceptible to short-term complications resulting from the longer preservation times of import transplants. These findings support the continued use of organ sharing to reduce transplant wait times but highlight the importance of strategies to reduce organ preservation times.
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Affiliation(s)
- E B Finger
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
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169
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Chou FC, Huang SH, Sytwu HK. Genetically engineered islets and alternative sources of insulin-producing cells for treating autoimmune diabetes: quo vadis? Int J Endocrinol 2012; 2012:296485. [PMID: 22690214 PMCID: PMC3368364 DOI: 10.1155/2012/296485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Accepted: 03/29/2012] [Indexed: 01/29/2023] Open
Abstract
Islet transplantation is a promising therapy for patients with type 1 diabetes that can provide moment-to-moment metabolic control of glucose and allow them to achieve insulin independence. However, two major problems need to be overcome: (1) detrimental immune responses, including inflammation induced by the islet isolation/transplantation procedure, recurrence autoimmunity, and allorejection, can cause graft loss and (2) inadequate numbers of organ donors. Several gene therapy approaches and pharmaceutical treatments have been demonstrated to prolong the survival of pancreatic islet grafts in animal models; however, the clinical applications need to be investigated further. In addition, for an alternative source of pancreatic β-cell replacement therapy, the ex vivo generation of insulin-secreting cells from diverse origins of stem/progenitor cells has become an attractive option in regenerative medicine. This paper focuses on the genetic manipulation of islets during transplantation therapy and summarizes current strategies to obtain functional insulin-secreting cells from stem/progenitor cells.
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Affiliation(s)
- Feng-Cheng Chou
- Department and Graduate Institute of Microbiology and Immunology, National Defense Medical Center, Neihu, Taipei 114, Taiwan
| | - Shing-Hwa Huang
- Department of General Surgery, Tri-Service General Hospital, Taipei 114, Taiwan
| | - Huey-Kang Sytwu
- Department and Graduate Institute of Microbiology and Immunology, National Defense Medical Center, Neihu, Taipei 114, Taiwan
- *Huey-Kang Sytwu:
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170
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Schnitzbauer AA, Woeste G, Ulrich F, Bechstein WO. Indikationen und Komplikationen bei Multiorgantransplantationen. VISZERALMEDIZIN 2012. [DOI: 10.1159/000343766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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171
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Godfrey KJ, Mathew B, Bulman JC, Shah O, Clement S, Gallicano GI. Stem cell-based treatments for Type 1 diabetes mellitus: bone marrow, embryonic, hepatic, pancreatic and induced pluripotent stem cells. Diabet Med 2012; 29:14-23. [PMID: 21883442 DOI: 10.1111/j.1464-5491.2011.03433.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Type 1 diabetes mellitus--characterized by the permanent destruction of insulin-secreting β-cells--is responsive to cell-based treatments that replace lost β-cell populations. The current gold standard of pancreas transplantation provides only temporary independence from exogenous insulin and is fraught with complications, including increased mortality. Stem cells offer a number of theoretical advantages over current therapies. Our review will focus on the development of treatments involving tissue stem cells from bone marrow, liver and pancreatic cells, as well as the potential use of embryonic and induced pluripotent stem cells for Type 1 diabetes therapy. While the body of research involving stem cells is at once promising and inconsistent, bone marrow-derived mesenchymal stem cell transplantation seems to offer the most compelling evidence of efficacy. These cells have been demonstrated to increase endogenous insulin production, while partially mitigating the autoimmune destruction of newly formed β-cells. However, recently successful experiments involving induced pluripotent stem cells could quickly move them into the foreground of therapeutic research. We address the limitations encountered by present research and look toward the future of stem cell treatments for Type 1 diabetes.
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Affiliation(s)
- K J Godfrey
- Georgetown University School of Medicine, Georgetown University Medical Center, Washington, DC 20057, USA
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172
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Cantarovich D, De Amicis S, Akl A, Devys A, Vistoli F, Karam G, Soulillou JP. Posttransplant donor-specific anti-HLA antibodies negatively impact pancreas transplantation outcome. Am J Transplant 2011; 11:2737-46. [PMID: 21906255 DOI: 10.1111/j.1600-6143.2011.03729.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
During a 9-year follow-up, 167 consecutive pancreas transplant recipients (152 simultaneous pancreas-kidney [SPK]) were followed for the detection of posttransplant anti-HLA antibodies. Forty patients (24%) developed anti-HLA antibodies, 26 (65%) had donor-specific antibodies (DSA; 61% anticlass 2) and 14 (35%) non-DSA (78.6% anticlass 1). More rejection episodes were observed in patients with positive anti-HLA antibodies than in patients without antibodies (42.5% vs. 11%; p = 0.001), with the highest incidence observed in DSA patients (53.8%). More severe rejections (according to rescue therapy) were observed in DSA patients compared to non-DSA (p < 0.05) or to negative patients (p < 0.001). Contrasting with the kidney, pancreas graft survival did not differ between patients with or without anti-HLA antibodies. On the contrary, pancreas and kidney survivals were significantly lower in DSA positive patients (75% for both organs) as compared to non-DSA positive patients (100% for pancreas and 92% for kidney) or to HLA-negative patients (91% for pancreas and 89% for kidney). Nontechnical pancreas and kidney graft failures were significantly higher in positive than in negative anti-HLA patients (32.5% vs. 11%; p < 0.01). Occurrence of posttransplant DSA was an independent risk factor for both pancreas and kidney survival (HR 3.2; p = 0.039) in diabetic transplant recipients.
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Affiliation(s)
- D Cantarovich
- Institut de Transplantation et de Recherche en Transplantation, Nantes University Hospital, Nantes, France.
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173
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Aranda-Narváez JM, Pérez-Daga JA, Cabello-Díaz M, Blanco-Reina F, Santoyo-Santoyo J. [Renal-pancreas transplant: prognosis of the pancreas after technical failure of the kidney]. Cir Esp 2011; 90:672-4. [PMID: 22113074 DOI: 10.1016/j.ciresp.2011.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 07/01/2011] [Indexed: 10/15/2022]
Affiliation(s)
- José Manuel Aranda-Narváez
- Unidad de Gestión Clínicade Cirugía General, Digestiva y Trasplante, Hospital Regional Universitario Carlos Haya, Málaga, España.
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174
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Scalea JR, Cooper M. Surgical strategies for type II diabetes. Transplant Rev (Orlando) 2011; 26:177-82. [PMID: 22115951 DOI: 10.1016/j.trre.2011.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 07/05/2011] [Indexed: 02/06/2023]
Abstract
Diabetes mellitus type II (or type 2 diabetes; DM2) has multiple definitions but is generally considered to be a disease marked by insulin resistance and loss of β cell function that develops in adulthood. Today, greater than 90% of patients with diabetes have DM2. When uncontrolled, DM2 may result in comorbidities such as cardiovascular disease, retinopathy, neuropathy, immune system dysfunction, and renal failure. Classically, treatment of type 2 diabetes has included dietary and lifestyle changes. Even with behavior modification and oral hypoglycemics, many patients are unable to maintain glycemic control. With a growing understanding of the hormonal signals involved in the pathogenesis of type 2 diabetes, there has been a shift in the therapeutic approach to this growing epidemic. Bariatric surgery has been shown to decrease the progression and potentially reverse the effects of diabetes in 80% to 90% of patients. In addition, bariatric operations are associated with sustained weight loss in contrast to nonsurgical options. The antidiabetic effect of bariatric operations is likely due to the improvement in the hormonal dysregulation associated with the development of diabetes. Many patients with diabetes, however, have irreparably damaged insulin production capabilities as well. In addition, it is well recognized that transplantation may be required for patients with severe loss of islet cell function. Surgery for type 2 diabetes, via bariatric procedures and transplantation, has become an important treatment modality for patients with advanced disease.
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Affiliation(s)
- Joseph R Scalea
- Division of Transplantation, Department of Surgery, University of Maryland, Baltimore, MD, USA.
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175
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García-Gil FA, Albendea CD, Escartín J, Lampreave F, Fuentes-Broto L, Roselló-Catafau J, López-Pingarrón L, Reiter RJ, Alvarez-Alegret R, García JJ. Melatonin prolongs graft survival of pancreas allotransplants in pigs. J Pineal Res 2011; 51:445-53. [PMID: 21718360 DOI: 10.1111/j.1600-079x.2011.00908.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Oxidative stress is involved in ischemia-reperfusion injury and allograft rejection after transplantation. We studied two well-known antioxidants, melatonin and ascorbic acid (AA), in relation to the survival of a pancreas transplantation model without immunosuppression. Forty-eight Landrace pigs were divided into three groups (n = 16 each; eight donors and eight recipients) that received melatonin, AA, or no antioxidant therapy (controls). Melatonin and AA were administered (10 mg/kg body weight) intravenously to donors and recipients during surgery and on postoperative days 1-7. The molecules were also added (5 mm) to a University of Wisconsin preservation solution during organ cold storage. Melatonin significantly delayed acute rejection and prolonged allograft survival (25.1 ± 7.7 days) compared with the controls (8.1 ± 0.8 days, P = 0.013) and the AA group (9.4 ± 1.6 days, P = 0.049). Melatonin reduced indicators of oxidative stress, malondialdehyde, and 4-hydroxyalkenals, in pancreatic samples collected during procurement, cold ischemia, and reperfusion. Melatonin also reduced serum pig-major acute-phase protein/inter-α-trypsin inhibitor heavy chain 4 (pMAP/ITIH(4)) in the early post-transplantation period. AA only partially reduced oxidative damage 30 min postreperfusion and failed to prevent pMAP/ITIH(4) elevations. These findings suggested that melatonin may be a useful therapeutic tool for organ transplantation.
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176
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Improving islet engraftment by gene therapy. J Transplant 2011; 2011:594851. [PMID: 22132301 PMCID: PMC3202131 DOI: 10.1155/2011/594851] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 08/22/2011] [Indexed: 11/18/2022] Open
Abstract
Islet cell transplantation is currently the only feasible long-term treatment option for patients with type 1 diabetes. However, the majority of transplanted islets experience damage and apoptosis during the isolation process, a blood-mediated inflammatory microenvironment in the portal vein upon islet infusion, hypoxia induced by the low oxygenated milieu, and poor-revascularization-mediated lack of nutrients, and impaired hormone modulation in the local transplanted site. Strategies using genetic modification methods through overexpression or silencing of those proteins involved in promoting new formation of blood vessels or inhibition of apoptosis may overcome these hurdles and improve islet engraftment outcomes.
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177
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Chatzizacharias NA, Vaidya A, Sinha S, Smith R, Jones G, Sharples E, Friend PJ. Renal function in type 1 diabetics one year after successful pancreas transplantation. Clin Transplant 2011; 25:E509-15. [PMID: 21999782 DOI: 10.1111/j.1399-0012.2011.01458.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The effect of pancreas transplantation on renal function remains a matter of debate. The purpose of this retrospective, single-unit study is a preliminary analysis of renal function one yr after pancreas transplant (pancreas alone [PTA] or pancreas after kidney [PAK]). Fifty-nine patients were included. Serum creatinine and estimated glomerular filtration rate (eGFR) levels were compared three, six, and 12 months post-transplantation for the whole sample and separately for PTA and PAK and high (>45 mL/min/1.73 m(2)) and low (≤45 mL/min/1.73 m(2)) pre-transplant eGFR subgroups. Overall, eGFR did not change significantly (p = 0.228) at the end of the first year post-transplant, with patients of low initial eGFR presenting a more prominent trend toward stable or improved levels. In the PAK subgroup, eGFR was significantly improved (p = 0.035). High eGFR subgroup demonstrated no significant deterioration in renal function, while patients with low initial eGFR had significantly higher levels 3 (p = 0.012) and six months (p = 0.009) post-transplant. Our study shows that renal function did not deteriorate significantly one yr after pancreas transplant (PTA or PAK), even in patients with substantial pre-existing renal dysfunction. Evaluation at a wider scale and identification of risk factors for potential deterioration are challenges for future research.
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Abstract
INTRODUCTION A large proportion of clinical islet transplant recipients fail to initially achieve or sustain meaningful independence from exogenous insulin use. We hypothesized that immediate allograft injury is a key constraint on independence from exogenous insulin use. METHODS Standard human leukocyte antigen genotyping was reviewed to identify nonshared polymorphisms between 21 prospectively recruited islet transplant recipients from a single institution and their respective donors. Human leukocyte antigen polymorphism-specific quantitative polymerase chain reaction was used to quantify donor DNA shed into blood by injured islets from serial sera acquired over the first 10 days postprocedure and examined for correlation with achievement of insulin independence. RESULTS Nearly fourfold higher serum concentrations of donor DNA were detected in subjects whose grafts failed to generate insulin independence. The median for the average area under the curve in recipients who did and did not achieve insulin independence was 12 (range, 1-61) and 45 (range, 14-255) donor genome equivalents (gEq)-day/mL (p=0.03), respectively. CONCLUSIONS These findings represent the first direct testing of allograft injury in humans undergoing islet cell transplantation. Injury to donor islets very soon after transplantation may represent an important barrier to achieving insulin independence other than adaptive immune responses targeting allografts at later times. In addition, soluble donor DNA merits further development as a quantifiable biomarker to evaluate new interventions aimed at mitigating immediate islet injury.
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179
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Chatzizacharias NA, Vaidya A, Sinha S, Sharples E, Smith R, Jones G, Brockmann J, Friend PJ. Risk analysis for deterioration of renal function after pancreas alone transplant. Clin Transplant 2011; 26:387-92. [PMID: 21980989 DOI: 10.1111/j.1399-0012.2011.01534.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The risk of progression to renal replacement after pancreas transplant alone (PTA) is a concern in patients with pre-transplant estimated glomerular filtration rate (eGFR) < 70 mL/min/1.73 m(2). This is a retrospective, single-center risk analysis of potential factors affecting renal function after PTA. Twenty-four patients, transplanted over a three-yr period, with functioning pancreatic grafts at the study's end point were included. High tacrolimus levels (> 12 mg/dL) at six months post-transplant was the only independent risk factor identifying a substantial decline in native renal function by Cox regression analysis (HR = 14.300, CI = 1.271-160.907, p = 0.031). The presence of severe pre-transplant proteinuria (urine Pr/Cr ≥ 100 mg/mmol) marginally failed to reach significance (p = 0.056). Low eGFR levels alone (≤ 45 and ≤ 40 mL/min/1.73 m(2)) at the time of transplant did not correlate with substantial decline in renal function. Our data suggest that PTA is a justifiable therapy for patients with hypoglycemia unawareness or other life-threatening diabetic complications, even in those with borderline renal function, provided that they do not suffer from severe proteinuria and appropriate monitoring and tailoring of immunosuppression is ensured.
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180
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Burke GW, Vendrame F, Pileggi A, Ciancio G, Reijonen H, Pugliese A. Recurrence of autoimmunity following pancreas transplantation. Curr Diab Rep 2011; 11:413-9. [PMID: 21660419 PMCID: PMC4018301 DOI: 10.1007/s11892-011-0206-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pancreas transplantation is a therapeutic option for patients with type 1 diabetes. Advances in immunosuppression have reduced immunologic failures, and these are usually categorized as chronic rejection. Yet studies in our cohort of pancreas transplant recipients identified several patients in whom chronic islet autoimmunity led to recurrent diabetes, despite immunosuppression that prevented rejection. Recurrent diabetes in our cohort is as frequent as chronic rejection, and thus is a significant cause of immunologic graft failure. Our studies demonstrated islet autoimmunity by the presence of autoantibodies and autoreactive T cells, which mediated ß-cell destruction in a transplantation model. Biopsy of the transplanted pancreas revealed variable degrees of ß-cell loss, with or without insulitis, in the absence of pancreas and kidney transplant rejection. Additional research is needed to better understand recurrent disease and to identify new treatment regimens that can suppress autoimmunity, as in our experience this is not effectively inhibited by conventional immunosuppression.
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Affiliation(s)
- George W. Burke
- Department of Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, 1801 NW 9th Avenue, Miami FL 33136, Tel. 305-355-5000 Fax 305-355-5134
| | - Francesco Vendrame
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, 1450 NW 10th Avenue, Miami, FL 33136 USA, Tel. 305-243-5353 Fax 305-243-4404
| | - Antonello Pileggi
- Diabetes Research Institute and Department of Surgery, Leonard Miller School of Medicine, 1450 NW 10th Avenue, Miami, FL 33136 USA, Tel. 305-243-2924 Fax 305-243-4404
| | - Gaetano Ciancio
- Departments of Urology and Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, 1801 NW 9th Avenue, Miami FL 33136, Tel. 305-355-5000 Fax 305-355-5134
| | - Helena Reijonen
- Benaroya Research Institute, 1201 Ninth Avenue, Seattle, WA 98101, Tel. 206-223-8813 Fax 206-223-7638
| | - Alberto Pugliese
- Diabetes Research Institute, Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, and Department of Microbiology and Immunology, Leonard Miller School of Medicine, 1450 NW 10th Avenue, Miami, FL 33136 USA, Tel. 305-243-5348 Fax 305-243-4404
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181
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Banga N, Hadjianastassiou VG, Mamode N, Calder F, Olsburgh J, Drage M, Sammartino C, Koffman G, Taylor J. Outcome of surgical complications following simultaneous pancreas-kidney transplantation. Nephrol Dial Transplant 2011; 27:1658-63. [PMID: 21903603 DOI: 10.1093/ndt/gfr502] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Simultaneous pancreas-kidney (SPK) transplantation carries a higher risk of surgical complications than kidney transplantation alone. We aimed to establish the incidence of surgical complications after SPK transplantation and determine the effect on graft and patient survival. METHODS Outcomes of all SPK transplants performed at our centre were compared between patients who experienced a surgical complication (SC group) and those who did not (NSC group). RESULTS Our centre performed 193 SPK transplants in a 15-year period; 44 patients (23%) experienced a surgical complication. One-year and 5-year pancreatic graft survival was 89 and 80%, respectively; this was lower in the SC group. There was no significant difference in patient or kidney graft survival between the SC and NSC groups at 5 years (92 and 83%, respectively.) CONCLUSION Surgical complications following SPK transplantation can cause significant morbidity and adversely affect pancreas graft survival, but do not affect long-term kidney or patient survival.
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Affiliation(s)
- Neal Banga
- Department of Transplantation, Guys and St Thomas’ NHS Foundation Trust, London, UK
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182
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Liong SY, Dixon RE, Chalmers N, Tavakoli A, Augustine T, O'Shea S. Complications following pancreatic transplantations: imaging features. ACTA ACUST UNITED AC 2011; 36:206-14. [PMID: 20563577 DOI: 10.1007/s00261-010-9632-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Whole organ vascularized pancreatic transplant is a recognized treatment for diabetes and is increasingly being performed worldwide. The procedure itself is complex and is associated with significant mortality and morbidity. Despite improvements in surgical techniques, postoperative complications of pancreatic transplantation are still common and include graft rejection, pancreatitis, peripancreatic fluid collections, exocrine leaks, vascular thrombosis, and hemorrhage. In this pictorial essay, we review clinical presentation and imaging features of these complications. We also briefly discuss technique and complications of islet cell transplants.
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Affiliation(s)
- S Y Liong
- Department of Clinical Radiology, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
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183
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Boggi U, Vistoli F, Amorese G, Giannarelli R, Coppelli A, Mariotti R, Rondinini L, Barsotti M, Piaggesi A, Tedeschi A, Signori S, De Lio N, Occhipinti M, Mangione E, Cantarovich D, Del Prato S, Mosca F, Marchetti P. Results of pancreas transplantation alone with special attention to native kidney function and proteinuria in type 1 diabetes patients. Rev Diabet Stud 2011; 8:259-67. [PMID: 22189549 DOI: 10.1900/rds.2011.8.259] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
We report on our single-center experience with pancreas transplantation alone (PTA) in 71 patients with type 1 diabetes, and a 4-year follow-up. Portal insulin delivery was used in 73.2% of cases and enteric drainage of exocrine secretion in 100%. Immunosuppression consisted of basiliximab (76%), or thymoglobulin (24%), followed by mycophenolate mofetil, tacrolimus, and low-dose steroids. Actuarial patient and pancreas survival at 4 years were 98.4% and 76.7%, respectively. Relaparatomy was needed in 18.3% of patients. Restored endogenous insulin secretion resulted in sustained normalization of fasting plasma glucose levels and HbA1c concentration in all technically successful transplantations. Protenuria (24-hour) improved significantly after PTA. Renal function declined only in recipients with pretransplant glomerular filtration rate (GFR) greater than 90 ml/min, possibly as a result of correction of hyperfiltration following normalization of glucose metabolism. Further improvements were recorded in several cardiovascular risk factors, retinopathy, and neuropathy. We conclude that PTA was an effective and reasonably safe procedure in this single-center experience.
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Affiliation(s)
- Ugo Boggi
- Division of General and Transplant Surgery in Uremic and Diabetic Patients, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy.
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184
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Hume PS, Anseth KS. Polymerizable superoxide dismutase mimetic protects cells encapsulated in poly(ethylene glycol) hydrogels from reactive oxygen species-mediated damage. J Biomed Mater Res A 2011; 99:29-37. [PMID: 21793194 DOI: 10.1002/jbm.a.33160] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 05/01/2011] [Accepted: 05/06/2011] [Indexed: 01/18/2023]
Abstract
A polymerizable superoxide dismutase mimetic (SODm) was incorporated into poly(ethylene glycol) (PEG) hydrogels to protect encapsulated cells from superoxide-mediated damage. Superoxide and other small reactive oxygen species (ROS) can cause oxidative damage to donor tissue encapsulated within size exclusion barrier materials. To enzymatically breakdown ROS within biomaterial cell encapsulation systems, Mn(III) Tetrakis[1-(3-acryloxy-propyl)-4-pyridyl] porphyrin (MnTTPyP-acryl), a polymerizable manganese metalloporphyrin SOD mimetic, was photopolymerized with PEG diacrylate (PEGDA) to create functional gels. In unmodified PEG hydrogels, a significant reduction in metabolic activity was observed when encapsulated Min6 β-cells were challenged with chemically generated superoxide. Cells encapsulated within MnTPPyP-co-PEG hydrogels, however, demonstrated greatly improved metabolic activity following various superoxide challenges. Further, cells were encapsulated and cultured for 10 days within MnTPPyP-co-PEG hydrogels and challenged with superoxide on days 4, 6, and 8. At the conclusion of this study, cells in blank PEG hydrogels had no observable metabolic activity but when encapsulated in MnTPPyP-functionalized hydrogels, cells retained 60 ± 5% of the metabolic activity compared to untreated controls.
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Affiliation(s)
- Patrick S Hume
- Department of Chemical and Biological Engineering, University of Colorado, 424 UCB, Boulder, Colorado 80309, USA
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185
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Sanchez EQ, Melton LB, Chinnakotla S, Levy MF, Fischbach BV, Goldstein R, Klintmalm GB. Whole-organ pancreas transplantation at Baylor Regional Transplant Institute: a chance to cure diabetes. Proc (Bayl Univ Med Cent) 2011; 23:3-6. [PMID: 20157494 DOI: 10.1080/08998280.2010.11928569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The success of pancreas transplantation has improved over the past several decades with advancements in surgical technique, immunosuppressive medicines, and immunologic testing. We retrospectively reviewed our experience with pancreas transplantation from 1995 to 2008. At the Baylor Regional Transplant Program, 151 pancreas transplants were performed in 147 patients: 135 were simultaneous pancreas-kidney transplants, 10 were pancreas transplants after kidney transplants, and 6 were pancreas transplants alone. Follow-up information was available for 138 patients. The 1-year acute cellular rejection rate was 31.6%; the 30-day surgical reexploration rate was 10%; and the technical failure rate was 5.3%. Five-year pancreas graft survival rates were 67% for simultaneous pancreas and kidney transplants and 50% for pancreas transplants after kidney transplants. These outcomes exceed expected results as calculated by the Scientific Registry of Transplant Recipients. In addition, the median time to transplant was 3.8 months, compared with a US median of 14.1 months. Pancreas transplantation is currently the closest thing to a cure for diabetes and should be given as an option for diabetic patients with or without end-stage renal disease.
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Affiliation(s)
- Edmund Q Sanchez
- Baylor Regional Transplant Institute (Sanchez, Chinnakotla, Levy, Goldstein, Klintmalm), Dallas and Fort Worth, Texas; the Division of Nephrology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas (Melton); and the Division of Nephrology, Department of Internal Medicine, Baylor All Saints Medical Center, Fort Worth, Texas (Fischbach)
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186
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Koyama S, Tomimatsu T, Kanagawa T, Daimon E, Kimura T, Kuroda A, Tanemura M, Doki Y, Ito T. Successful pregnancy after simultaneous pancreas-kidney transplantation from a brain-dead donor: the first case report in Japan. J Obstet Gynaecol Res 2011; 37:1711-6. [PMID: 21676071 DOI: 10.1111/j.1447-0756.2011.01560.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Simultaneous pancreas-kidney transplantation is a revolutionary medical procedure to cure diabetes mellitus and its complications in one step. For women with type 1 diabetes mellitus and end-stage renal disease, this procedure not only treats their disease but may also allow them to have children. Worldwide, 77 pregnancies from 43 pancreas-kidney recipients have been reported. Here, we present the first case report of successful pregnancy after simultaneous pancreas-kidney transplantation from a brain-dead donor in Japan. She conceived spontaneously 32 months after transplantation. Her pregnancy course was favorable except for mild rejection of the grafted pancreas and development of gestational diabetes. She delivered a 2882-g healthy infant in October 2010. Pregnancy after simultaneous pancreas-kidney transplantation is discussed.
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Affiliation(s)
- Shinsuke Koyama
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka, Japan.
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187
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Hume PS, Bowman CN, Anseth KS. Functionalized PEG hydrogels through reactive dip-coating for the formation of immunoactive barriers. Biomaterials 2011; 32:6204-12. [PMID: 21658759 DOI: 10.1016/j.biomaterials.2011.04.049] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 04/20/2011] [Indexed: 12/11/2022]
Abstract
Influencing the host immune system via implantable cell-delivery devices has the potential to reduce inflammation at the transplant site and increase the likelihood of tissue acceptance. Towards this goal, an enzymatically-initiated, dip-coating technique is adapted to fabricate conformal hydrogel layers and to create immunoactive polymer coatings on cell-laden poly(ethylene glycol) (PEG) hydrogels. Glucose oxidase (GOx)-initiated dip coatings enable the rapid formation of uniform, PEG-based coatings on the surfaces of PEG hydrogels, with thicknesses up to 500 μm where the thickness is proportional to the reaction time. Biofunctional coatings were fabricated by thiolating biomolecules that were subsequently covalently incorporated into the coating layer via thiol-acrylate copolymerization. The presence of these proteins was verified via fluorescent confocal microscopy and a modified ELISA, which indicated IgG concentrations as high as 13 ± 1 ng/coated cm² were achievable. Anti-Fas antibody, known to induce T cell apoptosis, was incorporated into coatings, with or without the addition of ICAM-1 to promote T cell interaction with the functionalized coating. Jurkat T cells were seeded atop functionalized coatings and the induction of apoptosis was measured as an indicator of coating bioactivity. After 48 h of interaction with the functionalized coatings, 61 ± 9% of all cells were either apoptotic or dead, compared to only 18 ± 5% of T cells on non-functionalized coatings. Finally, the cytocompatibility of the surface-initiated GOx coating process was confirmed by modifying gels with either encapsulated β-cells or 3T3 fibroblasts within a gel that contained a PEG methacrylate coating.
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Affiliation(s)
- Patrick S Hume
- Department of Chemical and Biological Engineering, University of Colorado, 424 UCB, Boulder, CO 80309, USA
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188
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Zhang SH, Wu HY, Zhu L. Current status of pancreas transplantation. Shijie Huaren Xiaohua Zazhi 2011; 19:1651-1658. [DOI: 10.11569/wcjd.v19.i16.1651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pancreas transplantation has emerged as the treatment of choice for patients with end-stage diabetes mellitus. Over the last four decades, many improvements have been made in the surgical techniques and immunosuppressive regimens, which contributed to increased number of indications and improved allograft survival. Pancreas transplantation can be justified on the basis that patients replace daily injections of insulin with an improved quality of life but at the expense of a major surgical procedure with a relatively higher complication rate, and lifelong immunosuppression. Therefore, efforts to develop more minimally invasive techniques for endocrine replacement therapy such as islet transplantation have been in progress. This article summarizes the current understanding of pancreas transplantation-associated indications, donor selection, surgical techniques, immunosuppression, and rejection.
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189
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Gruessner AC. 2011 update on pancreas transplantation: comprehensive trend analysis of 25,000 cases followed up over the course of twenty-four years at the International Pancreas Transplant Registry (IPTR). Rev Diabet Stud 2011; 8:6-16. [PMID: 21720668 DOI: 10.1900/rds.2011.8.6] [Citation(s) in RCA: 215] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
AIM This study aimed to analyze the outcome of pancreas and pancreas-kidney transplantations based on the comprehensive follow-up data reported to the International Pancreas Transplant Registry (IPTR). METHODS As of December 2010, more than 35,000 pancreas transplantations have been reported to the IPTR: more than 24,000 transplantations in the US and more than 12,000 outside the US. Cases with follow-up information until March 2011 were included in the analysis. RESULTS Pancreas transplantations in diabetic patients were divided into 3 categories: those performed simultaneously with a kidney (SPK) (75%), those given after a previous kidney transplantation (PAK) (18%), and pancreas transplantation alone (PTA) (7%). The total number of pancreas transplantations steadily increased until 2004 but has since declined. The largest decrease was seen in PAK, which decreased by 50% from 2004 through 2010. Comparatively, the number of SPK decreased by 7% during this time. Era analysis of US transplantations between 1987 and 2010 showed changes in recipient and donor characteristics. Recipient age at transplantation increased significantly as well as transplantations in type 2 diabetes patients. The trend over time was towards tighter donor criteria. There was a concentration on younger donors, preferable trauma victims, with short preservation time. Surgical techniques for the drainage of the pancreatic duct changed over time, too. Now enteric drainage is the predominantly used technique in combination with systemic drainage of the venous effluent of the pancreas graft. Immunosuppressive protocols developed towards antibody induction therapy with tacrolimus and MMF as maintenance therapy. The rate of transplantations with steroid avoidance increased over time in all 3 categories. These changes have led to improved patient and graft survival. Patient survival now reaches over 95% at one year post-transplant and over 83% after 5 years. The best graft survival was found in SPK with 86% pancreas and 93% kidney graft function at one year. PAK pancreas graft function reached 80%, and PTA pancreas graft function reached 78% at one year. In all 3 categories, early technical graft loss rates decreased significantly to 8-9%. Likewise, the 1-year immunological graft loss rate also decreased: in SPK, the immunological 1-year graft loss rate was 1.8%, in PAK 3.7%, and in PTA 6.0%. CONCLUSIONS Patient survival and graft function improved significantly over the course of 24 years of pancreas transplantation in all 3 categories. With further reduction in surgical complications and improvements in immunosuppressive protocols, pancreas transplantation offers excellent outcomes for patients with labile diabetes.
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Affiliation(s)
- Angelika C Gruessner
- Division of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin, Tucson AZ 85724, USA.
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Yamamoto S, Tufveson G, Wahlberg J, Berne C, Wadström J, Biglarnia AR. Factors influencing outcome of simultaneous kidney and pancreas transplantation: a 23-year single-center clinical experience. Transplant Proc 2011; 42:4197-201. [PMID: 21168663 DOI: 10.1016/j.transproceed.2010.09.076] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 09/20/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Simultaneous kidney and pancreas transplantation (SKPT) has become an effective treatment for patients who have diabetes mellitus type I with advanced nephropathy. This study assesses the progress of the SKPT program at Uppsala University Hospital, Sweden, and evaluates prognostic factors for graft survival. MATERIALS AND METHODS Between February 1986 and September 2009, we performed 113 SKPT. The immunosuppression protocols changed over time and are defined as era 1, cyclosporine (CyA), atzathioprine (AZA) and steroids (C/A/S); era 2, C/A/S with antithymocyte globulin (ATG) induction (C/A/S/A); era 3, CyA, mycophenolate mofetic (MMF), steroids and ATG induction (C/M/S/A); era 4, tacrolimus (TAC), MMF, steroid, and ATG induction (T/M/S/A) and era 5, TAC, MMF, steroids and basiliximab induction (T/M/S/B). We analyzed donor/recipient/operative and postoperative variables to assess their influence on pancreas graft and patient survivals. RESULTS The overall 1-, 5-, and 10-year patient survivals were 95.5%, 84.1%, and 65.5%, respectively. The 1-, 5-, and 10-year overall pancreas graft survivals were 77.6%, 58.4%, and 48.4%. The 1-, 5-, and 10-year pancreas graft survivals in SKPT patients transplanted between October 1997 and September 2009. (T/M/S/A and T/M/S/B; eras 4 and 5) were 95.3%, 72.7%, and 63.1%, respectively, which was significantly better than those of patients transplanted between February 1986 and September 1997 (era, 1 through 3) (P < 0.01, P < 0.0001, respectively). The quadruple regimen with TAC and MMF (eras 4 and 5) decreased the incidence of acute rejection episodes compared with eras 1 through 3 (P < 0.0001). Basiliximab induction (T/M/S/B; era 5) reduced the CMV infection rate compared with eras 1 through 4 (P < 0.01). Multivariate analysis revealed that donor age (younger than 40 years), immunosuppressive regimen with TAC and MMF (eras 4 and 5), and absence of acute rejection episodes independently affected pancreas graft survival. CONCLUSIONS We demonstrate a superiority of the quadruple protocol with T/M/S/B for graft and patient survival with a decreased incidence of CMV infection after SKPT.
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Affiliation(s)
- S Yamamoto
- Division of Transplantation and Liver Surgery, Department of Surgery, Uppsala University Hospital, Uppsala, Sweden.
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191
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Lackner C, Offner F, Nizze H. [Small intestine, pancreas and islet cell transplantation]. DER PATHOLOGE 2011; 32:135-43. [PMID: 21442442 DOI: 10.1007/s00292-010-1410-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The past decade has seen substantial improvements in patient and graft survival after intestinal transplantation. This improvement has been achieved by advances in donor and recipient selection, patient management, immunosuppression and surgical techniques. Intestinal transplantation is therefore considered a therapeutic option in the treatment of short bowel syndrome. Mile stones include the development of the calcineurin inhibitor Tacrolimus for immunosuppression as well as induction therapy using immune modulating substances like interleukin-2 receptor antagonists and antilymphocyte preparations. In addition to improvements in immunosuppression, antimicrobial prophylaxis and diagnosis of rejection, advances in surgical techniques have been crucial to achieving increased graft survival. Pancreas transplantation, generally with simultaneous kidney transplantation, is now available as a treatment option for patients with labile diabetes mellitus (usually type 1). Allogeneic islet transplantation was developed in the 1990s as a minimally invasive alternative to pancreas transplantation. Pancreatic islets are isolated enzymatically from the donor pancreas, in most cases infused into the portal vein and thus engrafted into the liver. Currently, technical and medical problems as well as high costs prevent the application of islet transplantation as a therapeutic option for a larger number of patients with diabetes mellitus.
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Affiliation(s)
- C Lackner
- Institut für Pathologie, Medizinische Universität Graz, Auenbruggerplatz 25, 8010, Graz, Österreich.
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192
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Pugliese A, Reijonen HK, Nepom J, Burke GW. Recurrence of autoimmunity in pancreas transplant patients: research update. ACTA ACUST UNITED AC 2011; 1:229-238. [PMID: 21927622 DOI: 10.2217/dmt.10.21] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Type 1 diabetes is an autoimmune disorder leading to loss of pancreatic β-cells and insulin secretion, followed by insulin dependence. Islet and whole pancreas transplantation restore insulin secretion. Pancreas transplantation is often performed together with a kidney transplant in patients with end-stage renal disease. With improved immunosuppression, immunological failures of whole pancreas grafts have become less frequent and are usually categorized as chronic rejection. However, growing evidence indicates that chronic islet autoimmunity may eventually lead to recurrent diabetes, despite immunosuppression to prevent rejection. Thus, islet autoimmunity should be included in the diagnostic work-up of graft failure and ideally should be routinely assessed pretransplant and on follow-up in Type 1 diabetes recipients of pancreas and islet cell transplants. There is a need to develop new treatment regimens that can control autoimmunity, as this may not be effectively suppressed by conventional immunosuppression.
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Affiliation(s)
- Alberto Pugliese
- Diabetes Research Institute, University of Miami Miller School of Medicine, 1450 NW 10th Avenue, Miami, FL 33136, USA
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193
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Opara EC, Mirmalek-Sani SH, Khanna O, Moya ML, Brey EM. Design of a bioartificial pancreas(+). J Investig Med 2011; 58:831-7. [PMID: 20683347 DOI: 10.231/jim.0b013e3181ed3807] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION In type 1 diabetes, the β-cells that secrete insulin have been destroyed such that daily exogenous insulin administration is required for the control of blood glucose in individuals with the disease. After the development of reliable techniques for the isolation of islets from the human pancreas, islet transplantation has emerged as a therapeutic option, albeit for only a few selected patients largely because there are not enough islets for the millions of patients requiring the treatment, and there is also the need to use immunosuppressive drugs to prevent transplant rejection. In 1980, the concept of islet immunoisolation by microencapsulation was introduced as a technique to overcome these 2 major barriers to islet transplantation. Microencapsulation of islets and transplantation in the peritoneal cavity was then described as a bioartificial pancreas. However, it is difficult to retrieve encapsulated islets transplanted in the peritoneal cavity, thus making it difficult to meet all the criteria for a bioartificial pancreas. A new design of a bioartificial pancreas comprising islets co-encapsulated with angiogenic protein in permselective multilayer alginate-poly-L-ornithine-alginate microcapsules and transplanted in an omentum pouch is described in this paper. MATERIALS AND METHODS The multilayer alginate-poly-L-ornithine-alginate microcapsules are made with ultrapure alginate using poly-L-ornithine as a semipermeable membrane separating the 2 alginate layers. The inner alginate layer is used to encapsulate the islets, and the outer layer is used to encapsulate angiogenic protein, which would induce neovascularization around the graft within the omentum pouch. RESULTS In in vitro studies, we found that both the wild-type and the heparin-binding growth-associated molecule (HBGAM)-fibroblast growth factor-1 chimera can be encapsulated and released in a controlled and sustained manner from the outer alginate layer with a mean diameter in the range of 113 to 164 µm when 1.25% high guluronic acid alginate is used to formulate this outer layer. DISCUSSION We are currently performing in vivo experiments to determine the ability of angiogenic proteins released from this outer layer to induce neovascularization around the grafts in the omentum pouch. We will subsequently examine the effect of co-encapsulation of islets with angiogenic protein on blood glucose control in diabetic animals. It is hoped that addition of tissue engineering to encapsulated islet transplantation will result in long-term survival of the islets and their ability to control blood glucose in type 1 diabetes without the necessity to use risky immunosuppressive drugs to prevent transplant rejection.
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Affiliation(s)
- Emmanuel C Opara
- Institute for Regenerative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
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194
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Mauricio MC, Cesar RV. Pancreas Transplant Salvage by Proximal Loop Ileostomy and Distal Ileostotomy Tube for Duodenal Stump Leak after Enteric Conversion. ACTA ACUST UNITED AC 2011. [DOI: 10.4236/ss.2011.21001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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195
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Abstract
Diabetes mellitus is generally treated with oral diabetic drugs and/or insulin. However, the morbidity and mortality associated with this condition increases over time, even in patients receiving intensive insulin treatment, and this is largely attributable to diabetic complications or the insulin therapy itself. Pancreas transplantation in humans was first conducted in 1966, since when there has been much debate regarding the legitimacy of this procedure. Technical refinements and the development of better immunosuppressants and better postoperative care have brought about marked improvements in patient and graft survival and a reduction in postoperative morbidity. Consequently, pancreas transplantation has become the curative treatment modality for diabetes, particularly for type I diabetes. An overview of pancreas transplantation is provided herein, covering the history of pancreas transplantation, indications for transplantation, cadaveric and living donors, surgical techniques, immunosuppressants, and outcome following pancreas transplantation. The impact of successful pancreas transplantation on the complications of diabetes will also be reviewed briefly.
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Affiliation(s)
- Duck Jong Han
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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196
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Schenker P, Vonend O, Krüger B, Klein T, Michalski S, Wunsch A, Krämer BK, Viebahn R. Long-term results of pancreas transplantation in patients older than 50 years. Transpl Int 2010; 24:136-42. [DOI: 10.1111/j.1432-2277.2010.01172.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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197
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Hirshberg B. The cardinal features of recurrent autoimmunity in simultaneous pancreas-kidney transplant recipients. Curr Diab Rep 2010; 10:321-2. [PMID: 20640940 DOI: 10.1007/s11892-010-0134-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Boaz Hirshberg
- Clinical Research, AstraZeneca Pharmaceuticals, 1800 Concord Pike, Wilmington, DE 19850-5437, USA.
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198
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Heilman RL, Mazur MJ, Reddy KS. Immunosuppression in simultaneous pancreas-kidney transplantation: progress to date. Drugs 2010; 70:793-804. [PMID: 20426494 DOI: 10.2165/11535430-000000000-00000] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Simultaneous pancreas-kidney transplantation (SPKT) is the treatment of choice for patients with end-stage renal failure due to type 1 diabetes mellitus. With advances in surgical techniques and immunosuppression management, outcomes have improved, with current 1- and 10-year pancreas graft survival rates of 86% and 53%, respectively. Induction therapy with either alemtuzumab or rabbit antithymocyte globulin (rATG) in combination with a calcineurin inhibitor (CNI) and mycophenolate mofetil (MMF) or sirolimus appears to be safe and effective in the setting of rapid steroid withdrawal (RSW), with excellent graft survival and low rejection rates. There are no large randomized trials between alemtuzumab and rATG to determine whether one is better than the other. Anti-interleukin (IL)-2 receptor antibody induction and no induction in combination with a CNI, MMF or sirolimus, and prednisone have demonstrated excellent graft survival rates but are associated with a higher incidence of acute rejection. The efficacy of anti-IL-2 receptor antibodies or no induction in the setting of RSW is unproven. Both of the CNIs, ciclosporin and tacrolimus, are effective in preventing acute rejection in SPKT recipients; however, pancreas allograft survival may be better with tacrolimus. MMF is more effective than azathioprine in preventing acute rejection. Sirolimus appears to be effective in preventing acute rejection, but the combination of sirolimus with a CNI may accentuate the nephrotoxicity of the CNI. RSW with induction therapy is safe and effective in SPKT recipients, but longer follow-up data on outcomes are needed. Recent analysis of registry data shows that most transplant centres are using an induction agent followed by a combination of tacrolimus, MMF and corticosteroids in SPKT recipients.
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Affiliation(s)
- Raymond L Heilman
- Department of Medicine, Mayo Clinic Arizona, Phoenix, Arizona 85054, USA.
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199
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Reddy K, Devarapalli Y, Mazur M, Hamawi K, Chakkera H, Moss A, Mekeel K, Post D, Heilman R, Mulligan D. Alemtuzumab with Rapid Steroid Taper in Simultaneous Kidney and Pancreas Transplantation: Comparison to Induction with Antithymocyte Globulin. Transplant Proc 2010; 42:2006-8. [DOI: 10.1016/j.transproceed.2010.05.090] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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200
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Kim JH. Transplantation Options in Type 1 Diabetes with End Stage Renal Disease. KOREAN JOURNAL OF TRANSPLANTATION 2010. [DOI: 10.4285/jkstn.2010.24.2.69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jae Hyeon Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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