1
|
Lega IC, Yale JF, Chadha A, Paty B, Roscoe R, Snider M, Steier J, Bajaj HS, Barnes T, Gilbert J, Honshorst K, Kim J, Lewis J, MacDonald B, MacKay D, Mansell K, Senior P, Rabi D, Sherifali D. Hypoglycemia in Adults. Can J Diabetes 2023; 47:548-559. [PMID: 37821214 DOI: 10.1016/j.jcjd.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
|
2
|
Dmitriev IV, Severina AS, Zhuravel NS, Yevloyeva MI, Salimkhanov RK, Shchelykalina SP, Bezunov EA, Shamkhalova MS, Semenova JF, Klimontov VV, Shestakova MV. Continuous Glucose Monitoring in Patients Following Simultaneous Pancreas-Kidney Transplantation: Time in Range and Glucose Variability. Diagnostics (Basel) 2023; 13:diagnostics13091606. [PMID: 37174997 PMCID: PMC10177867 DOI: 10.3390/diagnostics13091606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Simultaneous pancreas-kidney transplantation (SPKT) can improve long-term patient survival and restore endogenous insulin secretion in recipients with type 1 diabetes (T1D). There are currently few data on glucose fluctuations assessed by continuous glucose monitoring (CGM) after SPKT. Aim: to evaluate CGM-derived time in range (TIR) and glucose variability (GV) in patients with T1D and functioning pancreatic grafts after SPKT. Fifty-four CGM recordings from 43 patients, 15 men and 28 women, aged 34 (31; 39) years were analyzed. Time since SKPT was up to 1 year (group 1, n = 13), from 1 to 5 years (group 2, n = 15), and from 5 to 12 years (group 3, n = 26). TIR (3.9-10 mmol/L), Time Above Range (TAR), Time Below Range (TBR), and GV parameters were estimated. There were no differences in mean glucose (5.5 [5.1; 6.2], 5.9 [5.4; 6.2], and 5.9 [5.6; 6.7] mmol/L), TIR (97.6 [92.8-99.1], 97.2 [93.2; 99.1], and 97.5 [93.4; 99]%); TAR (0, 1.8 [1.3; 3.7], and 2.5 [2; 5]%), TBR (5 [3.3; 12.7], 4.1 [2.2; 10.1], and 3.5 [1.3; 6.5]%) and GV parameters between three groups (all p > 0.05). Thus, recipients with functioning pancreatic grafts demonstrate remarkably high TIR and low GV after SPKT.
Collapse
Affiliation(s)
- Ilya V Dmitriev
- Sklifosovsky Research Institute for Emergency Medicine, 129090 Moscow, Russia
| | | | - Nikita S Zhuravel
- Sklifosovsky Research Institute for Emergency Medicine, 129090 Moscow, Russia
| | | | | | - Svetlana P Shchelykalina
- Department of Medical Cybernetics and Computer Science MBF Pirogov Russian National Research Medical University (RNRMU), 117997 Moscow, Russia
| | - Evgeniy A Bezunov
- FSBI "Central Clinical Hospital with Polyclinic" of the Presidential Department of the Russian Federation, 121359 Moscow, Russia
| | | | - Julia F Semenova
- Research Institute of Clinical and Experimental Lymphology-Branch of the Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences (RICEL-Branch of IC&G SB RAS), 630060 Novosibirsk, Russia
| | - Vadim V Klimontov
- Research Institute of Clinical and Experimental Lymphology-Branch of the Institute of Cytology and Genetics, Siberian Branch of Russian Academy of Sciences (RICEL-Branch of IC&G SB RAS), 630060 Novosibirsk, Russia
| | | |
Collapse
|
3
|
Vieira IH, Barros LM, Baptista CF, Melo M, Rodrigues DM, Paiva IM. Hypoglycemia unawareness in type 1 diabetes patients using intermittent continuous glucose monitoring: Identification of risk factors and glycemic patterns. Diabetes Metab Syndr 2022; 16:102525. [PMID: 35660933 DOI: 10.1016/j.dsx.2022.102525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 05/03/2022] [Accepted: 05/22/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hypoglycemia unawareness designates failure to detect eminent hypoglycemia. Clarke's questionnaire is one of the most used systems to evaluate this problem. AIMS To relate Clarke's questionnaire (QQ) results with continuous glucose monitoring data. METHODS Application of the questionnaire in a sample of type 1 diabetes mellitus (T1DM) patients using intermittent continuous glucose monitoring (iCGM). RESULTS 111 T1DM patients were evaluated, 56.8% female, mean age 35.0 ± 12.4 years and mean disease duration 18.8 ± 10.5 years. According to CQ, 13.5% had unawareness, 76.6% awareness and 9.9% indeterminate awareness to hypoglycemia. Those with unawareness had longer disease duration (25.1 ± 10.4 vs 18.2 ± 10.3 for awareness and 14.9 ± 9.9 for indeterminate awareness, p = 0.047), more time below range (10.3 ± 4.9% vs 6.3 ± 5.1 and 6.3 ± 4.8; p = 0.009) and higher mean duration of hypoglycemia (131.7 ± 38.6 vs 116.6 ± 49.6 and 131.7 ± 38.6; p = 0.008). In multivariate analysis, mean duration of hypoglycemia was an independent predictor of CQ results. In a receiver operating curve (AUC 0.746; p = 0.004) a mean duration of hypoglycemia ≥106.5 min showed 84.6% sensitivity/64.4% specificity for unawareness. CONCLUSIONS Our sample had a significative prevalence of hypoglycemia unawareness which increased with longer diabetes duration. iCGM data can be indicative of this problem, with a mean hypoglycemia duration ≥106.5 min being suggestive, albeit unspecific.
Collapse
Affiliation(s)
- Inês H Vieira
- Coimbra Hospital and University Centre, Praceta Professor Mota Pinto, 3004-561, Coimbra, Portugal.
| | - Luísa M Barros
- Coimbra Hospital and University Centre, Praceta Professor Mota Pinto, 3004-561, Coimbra, Portugal
| | - Carla F Baptista
- Coimbra Hospital and University Centre, Praceta Professor Mota Pinto, 3004-561, Coimbra, Portugal
| | - Miguel Melo
- Coimbra Hospital and University Centre, Praceta Professor Mota Pinto, 3004-561, Coimbra, Portugal; Faculty of Medicine of the University of Coimbra Polo das Ciências da Saúde Azinhaga de Santa Comba, 3000-354, Coimbra, Portugal; Institute of Pathology and Immunology of the University of Porto Rua Júlio, Amaral de Carvalho 45, 4200-135, Porto, Portugal
| | - Dírcea M Rodrigues
- Coimbra Hospital and University Centre, Praceta Professor Mota Pinto, 3004-561, Coimbra, Portugal; Faculty of Medicine of the University of Coimbra Polo das Ciências da Saúde Azinhaga de Santa Comba, 3000-354, Coimbra, Portugal
| | - Isabel M Paiva
- Coimbra Hospital and University Centre, Praceta Professor Mota Pinto, 3004-561, Coimbra, Portugal
| |
Collapse
|
4
|
Flatt AJS, Greenbaum CJ, Shaw JAM, Rickels MR. Pancreatic islet reserve in type 1 diabetes. Ann N Y Acad Sci 2021; 1495:40-54. [PMID: 33550589 DOI: 10.1111/nyas.14572] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/18/2021] [Accepted: 01/21/2021] [Indexed: 12/22/2022]
Abstract
Type 1 diabetes (T1D) is a chronic autoimmune disease characterized by pancreatic islet β cell loss and dysfunction resulting in insulin deficiency and hyperglycemia. During a presymptomatic phase of established β cell autoimmunity, β cell loss may first be evident through assessment of β cell secretory capacity, a measure of functional β cell mass. Reduction in pancreatic islet β cell reserve eventually manifests as impaired first-phase insulin response to glucose and abnormal glucose tolerance, which progresses until the functional capacity for β cell secretion can no longer meet the demand for insulin to control glycemia. A functional β cell mass of ∼25% of normal may be required to avoid symptomatic T1D but is already associated with dysregulated glucagon secretion. With symptomatic T1D, stimulated C-peptide levels >0.60 ng/mL (0.200 pmol/mL) indicate the presence of clinically meaningful residual β cell function for contributing to glycemic control, although even higher residual C-peptide appears necessary for evidencing glucose-dependent islet β and α cell function that may contribute to maintaining (near)normal glycemia. β cell replacement by islet transplantation can restore a physiologic reserve capacity for insulin secretion, confirming thresholds for functional β cell mass required for independence from insulin therapy.
Collapse
Affiliation(s)
- Anneliese J S Flatt
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Carla J Greenbaum
- Diabetes Program and Center for Interventional Immunology, Benaroya Research Institute, Seattle, Washington
| | - James A M Shaw
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Michael R Rickels
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.,Institute for Diabetes, Obesity and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
5
|
Narayanan S, Bhutiani N, Adamson DT, Jones CM. Pancreatectomy, Islet Cell Transplantation, and Nutrition Considerations. Nutr Clin Pract 2020; 36:385-397. [PMID: 33002260 DOI: 10.1002/ncp.10578] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pancreatic islet transplantation is a reliable approach for treating insulin-deficient diabetes. This established β-cell replacement approach has shown considerable improvements in the last 2 decades. It has helped achieve metabolic homeostasis and safe outcomes for a subset of patients with type 1 diabetes and severe pancreatitis. Nutrition support, until recently, was considered as a secondary factor, merely identified as a means of providing all the necessary nutrients for such patients. However, new literature suggests that several factors, such as the route, timing, quantity, and composition of all the nutrients administered, have key disease-altering properties and are vital during the perioperative management of such patients. This review will highlight the benefits of performing the clinical islet transplantation on a subgroup of patients with type 1 diabetes and pancreatitis and summarize new data that identify the pivotal role of nutrition support as a critical intervention in their management.
Collapse
Affiliation(s)
- Siddharth Narayanan
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Neal Bhutiani
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Dylan T Adamson
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Christopher M Jones
- Division of Transplantation, Hiram C. Polk Jr. MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| |
Collapse
|
6
|
Flatt AJS, Bennett D, Counter C, Brown AL, White SA, Shaw JAM. β-Cell and renal transplantation options for diabetes. Diabet Med 2020; 37:580-592. [PMID: 31705689 DOI: 10.1111/dme.14177] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2019] [Indexed: 12/16/2022]
Abstract
Despite major advances in structured education, insulin delivery and glucose monitoring, diabetes self-management remains an unremitting challenge. Insulin therapy is inextricably linked to risk of dangerous hypoglycaemia and sustained hyperglycaemia remains a leading cause of renal failure. This review sets out to demystify transplantation for diabetes multidisciplinary teams, facilitating consideration and incorporation within holistic overall person-centred management. Deceased and living donor kidney, whole pancreas and isolated islet transplant procedures, indications and potential benefits are described, in addition to outcomes within the integrated UK transplant programme.
Collapse
Affiliation(s)
- A J S Flatt
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - D Bennett
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - C Counter
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - A L Brown
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - S A White
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - J A M Shaw
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| |
Collapse
|
7
|
Coentro JQ, De Pieri A, Gaspar D, Tsiapalis D, Zeugolis DI, Bayon Y. Translational Research Symposium-collaborative efforts as driving forces of healthcare innovation. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2019; 30:133. [PMID: 31792698 DOI: 10.1007/s10856-019-6339-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 11/16/2019] [Indexed: 06/10/2023]
Abstract
The 5th Translational Research Symposium was organised at the annual meeting of the European Society for Biomaterials 2018, Maastricht, the Netherlands, with emphasis on the future of emerging and smart technologies for healthcare in Europe. Invited speakers from academia and industry highlighted the vision and expectations of healthcare in Europe beyond 2020 and the perspectives of innovation stakeholders, such as small and medium enterprises, large companies and Universities. The aim of the present article is to summarise and explain the main statements made during the symposium, with particular attention on the need to identify unmet clinical needs and their efficient translation into healthcare solutions through active collaborations between all the participants involved in the value chain.
Collapse
Affiliation(s)
- João Q Coentro
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), National University of Galway Ireland (NUI Galway), Galway, Ireland
- Science Foundation Ireland (SFI) Centre for Research in Medical Devices (CÚRAM), National University of Galway Ireland (NUI Galway), Galway, Ireland
| | - Andrea De Pieri
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), National University of Galway Ireland (NUI Galway), Galway, Ireland
- Science Foundation Ireland (SFI) Centre for Research in Medical Devices (CÚRAM), National University of Galway Ireland (NUI Galway), Galway, Ireland
- Proxy Biomedical, Spiddal, Galway, Ireland
| | - Diana Gaspar
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), National University of Galway Ireland (NUI Galway), Galway, Ireland
- Science Foundation Ireland (SFI) Centre for Research in Medical Devices (CÚRAM), National University of Galway Ireland (NUI Galway), Galway, Ireland
| | - Dimitrios Tsiapalis
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), National University of Galway Ireland (NUI Galway), Galway, Ireland
- Science Foundation Ireland (SFI) Centre for Research in Medical Devices (CÚRAM), National University of Galway Ireland (NUI Galway), Galway, Ireland
| | - Dimitrios I Zeugolis
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), National University of Galway Ireland (NUI Galway), Galway, Ireland
- Science Foundation Ireland (SFI) Centre for Research in Medical Devices (CÚRAM), National University of Galway Ireland (NUI Galway), Galway, Ireland
| | - Yves Bayon
- Medtronic, Sofradim Production, Trevoux, France.
| |
Collapse
|
8
|
Rickels MR. Hypoglycemia-associated autonomic failure, counterregulatory responses, and therapeutic options in type 1 diabetes. Ann N Y Acad Sci 2019; 1454:68-79. [PMID: 31389033 DOI: 10.1111/nyas.14214] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/06/2019] [Accepted: 07/19/2019] [Indexed: 12/12/2022]
Abstract
Hypoglycemia remains a major barrier to the achievement of target levels of glycemic control for most individuals with insulin-dependent type 1 diabetes (T1D). Both the loss of β cells and an accompanying defect in the α cell response to hypoglycemia predispose patients with T1D to the development of low blood glucose. Increased glucose variability, exposure to hypoglycemia, and impaired awareness of hypoglycemia all contribute to increased risk of experiencing severe hypoglycemia, which is explained by progressive impairment in epinephrine secretion and autonomic symptom generation in response to hypoglycemia leading to defective glucose counterregulation and hypoglycemia unawareness that characterize hypoglycemia-associated autonomic failure (HAAF). Interruption of HAAF requires interfering with the mechanisms of brain adaptation to low blood glucose that affect central glucose sensing and the autonomic response to hypoglycemia, or avoidance of hypoglycemia that may allow for eventual recovery of counterregulatory and autonomic symptom responses. Strategies for hypoglycemia avoidance that include continuous glucose monitoring may reduce, but do not eliminate, clinically significant hypoglycemia, with ongoing counterregulatory defects and impaired awareness of hypoglycemia. Complete avoidance of hypoglycemia can be achieved following pancreatic islet transplantation and allows for the restoration of counterregulatory and autonomic symptom responses that evidences the potential for reversing HAAF in T1D.
Collapse
Affiliation(s)
- Michael R Rickels
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.,Institute for Diabetes, Obesity and Metabolism, the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
9
|
Rickels MR. Stem Cell-Derived Islets: Next Steps for Histologic and Functional Assessment During Development as a Cellular Therapy for the Treatment of Diabetes. Diabetes 2019; 68:901-903. [PMID: 31010882 PMCID: PMC6477905 DOI: 10.2337/dbi18-0054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Michael R Rickels
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, and Institute for Diabetes, Obesity & Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| |
Collapse
|
10
|
Huang Y, Mei J, Yu Y, Ding Y, Xia W, Yue T, Chen W, Zhou M, Yang Y. Comparative Decellularization and Recellularization of Normal Versus Streptozotocin‐Induced Diabetes Mellitus Rat Pancreas. Artif Organs 2018; 43:399-412. [PMID: 30182423 DOI: 10.1111/aor.13353] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 08/25/2018] [Accepted: 08/28/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Ying‐Bao Huang
- Department of Radiology The First Affiliated Hospital of Wenzhou Medical University Wenzhou China
| | - Jin Mei
- Anatomy Department Wenzhou Medical University Wenzhou China
- Institute of Bioscaffold Transplantation and Immunology Wenzhou Medical University Wenzhou China
- Institute of Neuroscience Wenzhou Medical University Wenzhou China
| | - Yaling Yu
- Department of Orthopedic Surgery Shanghai Jiao Tong University Affiliated Sixth People’s Hospital Shanghai China
| | - Yuqiang Ding
- Institute of Neuroscience Wenzhou Medical University Wenzhou China
| | - Weizhi Xia
- Department of Radiology The Second Affiliated Hospital of Wenzhou Medical University Wenzhou China
| | - Ting Yue
- Department of Radiology The First Affiliated Hospital of Wenzhou Medical University Wenzhou China
| | - Weijian Chen
- Department of Radiology The First Affiliated Hospital of Wenzhou Medical University Wenzhou China
| | - Meng‐Tao Zhou
- Department of Surgery The First Affiliated Hospital of Wenzhou Medical University Wenzhou China
| | - Yun‐Jun Yang
- Department of Radiology The First Affiliated Hospital of Wenzhou Medical University Wenzhou China
| |
Collapse
|
11
|
|
12
|
Abstract
PURPOSE OF REVIEW New treatment strategies are needed for patients with type 1 diabetes (T1D). Closed loop insulin delivery and beta-cell replacement therapy are promising new strategies. This review aims to give an insight in the most relevant literature on this topic and to compare the two radically different treatment modalities. RECENT FINDINGS Multiple clinical studies have been performed with closed loop insulin delivery devices and have shown an improvement in overall glycemic control and time spent in hypoglycemia. Beta-cell transplantation has been shown to normalize or greatly improve glycemic control in T1D, but the donor organ shortage and the necessity to use immunosuppressive agents are major drawbacks. Donor organ shortage may be solved by the utilization of stem cell-derived beta cells, which has shown great promise in animal models and are now tested in clinical studies. Immunosuppression may be avoided by encapsulation. Closed loop insulin delivery devices are promising treatment strategies and are likely to be used in clinical practice in the short term. But this approach will always suffer from delays in glucose measurement and insulin action preventing it from normalizing glycemic control. In the long term, stem cell-derived beta cell transplantation may be able to achieve this, but wide implementation in clinical practice is still far away.
Collapse
Affiliation(s)
- Michiel F. Nijhoff
- Department of Medicine, Division of Nephrology and Transplantation, Division of Endocrinology and Metabolism, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, the Netherlands
| | - Eelco J. P. de Koning
- Department of Medicine, Division of Nephrology and Transplantation, Division of Endocrinology and Metabolism, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, the Netherlands
| |
Collapse
|
13
|
Abstract
β cell replacement with either pancreas or islet transplantation has progressed immensely over the last decades with current 1- and 5-year insulin independence rates of approximately 85% and 50%, respectively. Recent advances are largely attributed to improvements in immunosuppressive regimen, donor selection, and surgical technique. However, both strategies are compromised by a scarce donor source. Xenotransplantation offers a potential solution by providing a theoretically unlimited supply of islets, but clinical application has been limited by concerns for a potent immune response against xenogeneic tissue. β cell clusters derived from embryonic or induced pluripotent stem cells represent another promising unlimited source of insulin producing cells, but clinical application is pending further advances in the function of the β cell like clusters. Exciting developments and rapid progress in all areas of β cell replacement prompted a lively debate by members of the young investigator committee of the International Pancreas and Islet Transplant Association at the 15th International Pancreas and Islet Transplant Association Congress in Melbourne and at the 26th international congress of The Transplant Society in Hong Kong. This international group of young investigators debated which modality of β cell replacement would predominate the landscape in 10 years, and their arguments are summarized here.
Collapse
|
14
|
Bottino R, Knoll MF, Knoll CA, Bertera S, Trucco MM. The Future of Islet Transplantation Is Now. Front Med (Lausanne) 2018; 5:202. [PMID: 30057900 PMCID: PMC6053495 DOI: 10.3389/fmed.2018.00202] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 06/25/2018] [Indexed: 12/15/2022] Open
Abstract
Milestones in the history of diabetes therapy include the discovery of insulin and successful methods of beta cell replacement including whole pancreas and islet cell transplantation options. While pancreas transplantation remains the gold standard for patients who have difficulty controlling their symptoms with exogenous insulin, islet allotransplantation is now able to provide similar results with some advantages that make it an attractive potential alternative. The Edmonton Protocol, which incorporated a large dose of islets from multiple donors with steroid-free immunosuppression helped to establish the modern era of islet transplantation almost 20 years ago. While islet allotransplantation is recognized around the world as a powerful clinical therapy for type 1 diabetes it is not yet recognized by the Federal Drug Administration of the United States. Large-scale clinical trials administered by the Clinical Islet Transplantation Consortium have recently demonstrated that the well-regulated manufacture of a human islet product transplanted into patients with difficult to control type 1 diabetes and with a history of severe hyperglycemic episodes can safely and efficaciously maintain glycemic balance and eliminate the most severe complications associated with diabetes. The results of these clinical trials have established a strong basis for licensure of clinical islet allotransplantation in the US. Recognition by the Federal Drug Administration would likely lead to third party reimbursement for islet allotransplantation as a therapeutic option in the United States and would make the treatment available to many more patients. The high costs of rampant diabetes justify the expense of the treatment, which is in-line with the costs of clinical pancreas transplantation. While much enthusiasm and hope is raised toward the development and optimization of stem cell therapy, the islet transplantation community should push toward licensure, if that means broader access of this procedure to patients who may benefit from it. Even as we prepare to take the first steps in that direction, we must acknowledge the new challenges that a shift from the experimental to clinical will bring. Clinical islet allotransplantation in the United States would be a game-changing event in the treatment of type 1 diabetes and also generate enthusiasm for continued research.
Collapse
Affiliation(s)
- Rita Bottino
- Institute of Cellular Therapeutics, Allegheny Health Network Research Institute, Allegheny Health Network, Pittsburgh, PA, United States
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, United States
- College of Medicine, Drexel University, Philadelphia, PA, United States
| | - Michael F. Knoll
- Institute of Cellular Therapeutics, Allegheny Health Network Research Institute, Allegheny Health Network, Pittsburgh, PA, United States
| | - Carmela A. Knoll
- Institute of Cellular Therapeutics, Allegheny Health Network Research Institute, Allegheny Health Network, Pittsburgh, PA, United States
| | - Suzanne Bertera
- Institute of Cellular Therapeutics, Allegheny Health Network Research Institute, Allegheny Health Network, Pittsburgh, PA, United States
| | - Massimo M. Trucco
- Institute of Cellular Therapeutics, Allegheny Health Network Research Institute, Allegheny Health Network, Pittsburgh, PA, United States
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, United States
- College of Medicine, Drexel University, Philadelphia, PA, United States
| |
Collapse
|
15
|
Transcutaneously refillable, 3D-printed biopolymeric encapsulation system for the transplantation of endocrine cells. Biomaterials 2018; 177:125-138. [PMID: 29886385 DOI: 10.1016/j.biomaterials.2018.05.047] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/17/2018] [Accepted: 05/27/2018] [Indexed: 12/17/2022]
Abstract
Autologous cell transplantation holds enormous promise to restore organ and tissue functions in the treatment of various pathologies including endocrine, cardiovascular, and neurological diseases among others. Even though immune rejection is circumvented with autologous transplantation, clinical adoption remains limited due to poor cell retention and survival. Cell transplant success requires homing to vascularized environment, cell engraftment and importantly, maintenance of inherent cell function. To address this need, we developed a three dimensional (3D) printed cell encapsulation device created with polylactic acid (PLA), termed neovascularized implantable cell homing and encapsulation (NICHE). In this paper, we present the development and systematic evaluation of the NICHE in vitro, and the in vivo validation with encapsulated testosterone-secreting Leydig cells in Rag1-/- castrated mice. Enhanced subcutaneous vascularization of NICHE via platelet-rich plasma (PRP) hydrogel coating and filling was demonstrated in vivo via a chorioallantoic membrane (CAM) assay as well as in mice. After establishment of a pre-vascularized bed within the NICHE, transcutaneously transplanted Leydig cells, maintained viability and robust testosterone secretion for the duration of the study. Immunohistochemical analysis revealed extensive Leydig cell colonization in the NICHE. Furthermore, transplanted cells achieved physiologic testosterone levels in castrated mice. The promising results provide a proof of concept for the NICHE as a viable platform technology for autologous cell transplantation for the treatment of a variety of diseases.
Collapse
|
16
|
Murai N, Ohtaki H, Watanabe J, Xu Z, Sasaki S, Yagura K, Shioda S, Nagasaka S, Honda K, Izumizaki M. Intrapancreatic injection of human bone marrow-derived mesenchymal stem/stromal cells alleviates hyperglycemia and modulates the macrophage state in streptozotocin-induced type 1 diabetic mice. PLoS One 2017; 12:e0186637. [PMID: 29073149 PMCID: PMC5657972 DOI: 10.1371/journal.pone.0186637] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 10/04/2017] [Indexed: 12/11/2022] Open
Abstract
Type 1 diabetes mellitus is a progressive disease caused by the destruction of pancreatic β-cells, resulting in insulin dependency and hyperglycemia. While transplanted bone marrow-derived mesenchymal stem/stromal cells (BMMSCs) have been explored as an alternative therapeutic approach for diseases, the choice of delivery route may be a critical factor determining their sustainability. This study evaluated the effects of intrapancreatic and intravenous injection of human BMMSCs (hBMMSCs) in streptozotocin (STZ)-induced type 1 diabetic mouse model. C57/BL6 mice were intraperitoneally injected with 115 mg/kg STZ on day 0. hBMMSCs (1 × 106 cells) or vehicle were injected into the pancreas or jugular vein on day 7. Intrapancreatic, but not intravenous, hBMMSC injection significantly reduced blood glucose levels on day 28 compared with vehicle injection by the same route. This glucose-lowering effect was not induced by intrapancreatic injection of human fibroblasts as the xenograft control. Intrapancreatically injected fluorescence-labeled hBMMSCs were observed in the intra- and extra-lobular spaces of the pancreas, and intravenously injected cells were in the lung region, although the number of cells mostly decreased within 2 weeks of injection. For hBMMSCs injected twice into the pancreatic region on days 7 and 28, the injected mice had further reduced blood glucose to borderline diabetic levels on day 56. Animals injected with hBMMSCs twice exhibited increases in the plasma insulin level, number and size of islets, insulin-positive proportion of the total pancreas area, and intensity of insulin staining compared with vehicle-injected animals. We found a decrease of Iba1-positive cells in islets and an increase of CD206-positive cells in both the endocrine and exocrine pancreas. The hBMMSC injection also reduced the number of CD40-positive cells merged with glucagon immunoreactions in the islets. These results suggest that intrapancreatic injection may be a better delivery route of hBMMSCs for the treatment of type 1 diabetes mellitus.
Collapse
Affiliation(s)
- Norimitsu Murai
- Department of Physiology, Showa University School of Medicine, Tokyo, Japan
- Department of Anatomy, Showa University School of Medicine, Tokyo, Japan
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Hirokazu Ohtaki
- Department of Anatomy, Showa University School of Medicine, Tokyo, Japan
| | - Jun Watanabe
- Department of Anatomy, Showa University School of Medicine, Tokyo, Japan
- Center for Biotechnology, Showa University, Tokyo, Japan
| | - Zhifang Xu
- Department of Anatomy, Showa University School of Medicine, Tokyo, Japan
| | - Shun Sasaki
- Department of Anatomy, Showa University School of Medicine, Tokyo, Japan
| | - Kazumichi Yagura
- Department of Anatomy, Showa University School of Medicine, Tokyo, Japan
| | - Seiji Shioda
- Peptide Drug Innovation, Global Research Center for Innovative Life Science, Hoshi University School of Pharmacy and Pharmaceutical Sciences, Tokyo, Japan
| | - Shoichiro Nagasaka
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Kazuho Honda
- Department of Anatomy, Showa University School of Medicine, Tokyo, Japan
| | - Masahiko Izumizaki
- Department of Physiology, Showa University School of Medicine, Tokyo, Japan
- * E-mail:
| |
Collapse
|
17
|
Voglová B, Zahradnická M, Girman P, Kríž J, Berková Z, Koblas T, Vávrová E, Németová L, Kosinová L, Habart D, Fábryová E, Dovolilová E, Leontovyc I, Neškudla T, Peregrin J, Kovác J, Lipár K, Kocík M, Marada T, Svoboda J, Saudek F. Benefits of Islet Transplantation as an Alternative to Pancreas Transplantation: Retrospective Study of More Than 10 Ten Years of Experience in a Single Center. Rev Diabet Stud 2017. [PMID: 28632818 DOI: 10.1900/rds.2017.14.10] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Pancreas transplantation (PTx) represents the method of choice in type 1 diabetic patients with conservatively intractable hypoglycemia unawareness syndrome. In 2005, the Institute for Clinical and Experimental Medicine (IKEM) launched a program to investigate the safety potential of islet transplantation (ITx) in comparison to PTx. AIM This study aims to compare the results of PTx and ITx regarding severe hypoglycemia elimination, metabolic control, and complication rate. METHODS We analyzed the results of 30 patients undergoing ITx and 49 patients treated with PTx. All patients were C-peptide-negative and suffered from hypoglycemia unawareness syndrome. Patients in the ITx group received a mean number of 12,349 (6,387-15,331) IEQ/kg/person administered percutaneously into the portal vein under local anesthesia and radiological control. The islet number was reached by 1-3 applications, as needed. In both groups, we evaluated glycated hemoglobin, insulin dose, fasting and stimulated C-peptide, frequency of severe hypoglycemia, and complications. We used the Mann Whitney test, Wilcoxon signed-rank test, and paired t-test for analysis. We also individually assessed the ITx outcomes for each patient according to recently suggested criteria established at the EPITA meeting in Igls. RESULTS Most of the recipients showed a significant improvement in metabolic control one and two years after ITx, with a significant decrease in HbA1c, significant elevation of fasting and stimulated C-peptide, and a markedly significant reduction in insulin dose and the frequency of severe hypoglycemia. Seventeen percent of ITx recipients were temporarily insulin-independent. The results in the PTx group were comparable to those in the ITx group, with 73% graft survival and insulin independence in year 1, 68% 2 years and 55% 5 years after transplantation. There was a higher rate of complications related to the procedure in the PTx group. Severe hypoglycemia was eliminated in the majority of both ITx and PTx recipients. CONCLUSION This report proves the successful initiation of pancreatic islet transplantation in a center with a well-established PTx program. ITx has been shown to be the method of choice for hypoglycemia unawareness syndrome, and may be considered for application in clinical practice if conservative options are exhausted.
Collapse
Affiliation(s)
- Barbora Voglová
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Martina Zahradnická
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Peter Girman
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jan Kríž
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Zuzana Berková
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Tomáš Koblas
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ema Vávrová
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Lenka Németová
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Lucie Kosinová
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - David Habart
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Eva Fábryová
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Eva Dovolilová
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ivan Leontovyc
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Tomáš Neškudla
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jan Peregrin
- Department of Diagnostic and Interventional Radiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jozef Kovác
- Department of Diagnostic and Interventional Radiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Kvetoslav Lipár
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Matej Kocík
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Tomáš Marada
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jirí Svoboda
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - František Saudek
- Department of Diabetes, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| |
Collapse
|
18
|
Tatum JA, Meneveau MO, Brayman KL. Single-donor islet transplantation in type 1 diabetes: patient selection and special considerations. Diabetes Metab Syndr Obes 2017; 10:73-78. [PMID: 28280376 PMCID: PMC5338842 DOI: 10.2147/dmso.s105692] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Type 1 diabetes mellitus is an autoimmune disorder of the endocrine pancreas that currently affects millions of people in the United States. Although the disease can be managed with exogenous insulin administration, the ultimate cure for the condition lies in restoring a patient's ability to produce their own insulin. Islet cell allotransplantation provides a means of endogenous insulin production. Though far from perfected, islet transplants are now a proven treatment for type 1 diabetics. However, proper patient selection is critical for achieving optimal outcomes. Given the shortage of transplantable organs, selecting appropriate candidates for whom the procedure will be of greatest benefit is essential. Although many of those who receive islets do not retain insulin independence, grafts do play a significant role in preventing hypoglycemic episodes that can be quite detrimental to quality of life and potentially fatal. Additionally, islet transplant requires lifelong immunosuppression. Antibodies, both preformed and following islet infusion, may play important roles in graft outcomes. Finally, no procedure is without inherent risk and islet transfusions can have serious consequences for recipients' livers in the form of both vascular and metabolic complications. Therefore, patient-specific factors that should be taken into account before islet transplantation include aims of therapy, sensitization, and potential increased risk for hepatic and portal-venous sequelae.
Collapse
Affiliation(s)
- Jacob A Tatum
- Department of Surgery, Division of Transplantation, The University of Virginia Health System, Charlottesville, VA, USA
| | - Max O Meneveau
- Department of Surgery, Division of Transplantation, The University of Virginia Health System, Charlottesville, VA, USA
| | - Kenneth L Brayman
- Department of Surgery, Division of Transplantation, The University of Virginia Health System, Charlottesville, VA, USA
- Correspondence: Kenneth L Brayman, Department of Surgery, University of Virginia Health System, 1215 Lee Street, Charlottesville, VA 22908, USA, Tel +1 434 924 9370, Fax +1 434 924 5539, Email
| |
Collapse
|
19
|
Lauria MW, Ribeiro-Oliveira A. Diabetes and other endocrine-metabolic abnormalities in the long-term follow-up of pancreas transplantation. Clin Diabetes Endocrinol 2016; 2:14. [PMID: 28702248 PMCID: PMC5471933 DOI: 10.1186/s40842-016-0032-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 07/03/2016] [Indexed: 12/12/2022] Open
Abstract
Pancreas transplantation (PTX) has been demonstrated to restore long-term glucose homeostasis beyond what can be achieved by intensive insulin therapy or islet transplants. Moreover, PTX has been shown to decrease the progression of the chronic complications of diabetes. However, PTX patients require chronic use of immunosuppressive drugs with potential side effects. The long-term follow-up of PTX patients demands special care regarding metabolic deviations, infectious complications, and chronic rejection. Diabetes and other endocrine metabolic abnormalities following transplantation are common and can increase morbidity and mortality. Previous recipient-related and donor-related factors, as well as other aspects inherent to the transplant, act together in the pathogenesis of those abnormalities. Early recognition of these disturbances is the key to timely treatment; however, adequate tools to achieve this goal are often lacking. In a way, the type of PTX procedure, whether simultaneous pancreas kidney or not, seems to differentially influence the evolution of endocrine and metabolic abnormalities. Further studies are needed to define the best approach for PTX patients. This review will focus on the most common endocrine metabolic disorders seen in the long-term management of PTX: diabetes mellitus, hyperlipidemia, and bone loss. The authors here cover each one of these endocrine topics by showing the evaluation as well as proper management in the follow-up after PTX.
Collapse
Affiliation(s)
- Marcio W Lauria
- Department of Internal Medicine (Endocrinology section and Transplantation unit), Federal University of Minas Gerais, Rua Alfredo Balena, 190, 30130-100 Belo Horizonte, MG Brazil
| | - Antonio Ribeiro-Oliveira
- Department of Internal Medicine (Endocrinology section and Transplantation unit), Federal University of Minas Gerais, Rua Alfredo Balena, 190, 30130-100 Belo Horizonte, MG Brazil
| |
Collapse
|
20
|
Redfield RR, Rickels MR, Naji A, Odorico JS. Pancreas Transplantation in the Modern Era. Gastroenterol Clin North Am 2016; 45:145-66. [PMID: 26895686 DOI: 10.1016/j.gtc.2015.10.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The field of pancreas transplantation has evolved from an experimental procedure in the 1980s to become a routine transplant in the modern era. With short- and long-term outcomes continuing to improve and the significant mortality, quality-of-life, and end-organ disease benefits, pancreas transplantation should be offered to more patients. In this article, we review current indications, patient selection, surgical considerations, complications, and outcomes in the modern era of pancreas transplantation.
Collapse
Affiliation(s)
- Robert R Redfield
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Clinical Science Cntr-H4/772, Madison, WI 53792, USA.
| | - Michael R Rickels
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, 2-134 Smilow Center for Translational Research, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Ali Naji
- Division of Transplantation, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104-4283, USA
| | - Jon S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Clinical Science Cntr-H4/772, Madison, WI 53792, USA
| |
Collapse
|
21
|
Bonaventura A, Montecucco F, Dallegri F. Update on strategies limiting iatrogenic hypoglycemia. Endocr Connect 2015; 4:R37-45. [PMID: 26099256 PMCID: PMC4512278 DOI: 10.1530/ec-15-0044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/19/2015] [Indexed: 12/17/2022]
Abstract
The prevalence of type 2 diabetes mellitus (T2DM) is increasing all over the world. Targeting good glycemic control is fundamental to avoid the complications of diabetes linked to hyperglycemia. This narrative review is based on material searched for and obtained via PubMed up to April 2015. The search terms we used were: 'hypoglycemia, diabetes, complications' in combination with 'iatrogenic, treatment, symptoms.' Serious complications might occur from an inappropriate treatment of hyperglycemia. The most frequent complication is iatrogenic hypoglycemia that is often associated with autonomic and neuroglycopenic symptoms. Furthermore, hypoglycemia causes acute cardiovascular effects, which may explain some of the typical symptoms: ischemia, QT prolongation, and arrhythmia. With regards to the latter, the night represents a dangerous period because of the major increase in arrhythmias and the prolonged period of hypoglycemia; indeed, sleep has been shown to blunt the sympatho-adrenal response to hypoglycemia. Two main strategies have been implemented to reduce these effects: monitoring blood glucose values and individualized HbA1c goals. Several drugs for the treatment of T2DM are currently available and different combinations have been recommended to achieve individualized glycemic targets, considering age, comorbidities, disease duration, and life expectancy. In conclusion, according to international guidelines, hypoglycemia-avoiding therapy must reach an individualized glycemic goal, which is the lowest HbA1c not causing severe hypoglycemia and preserving awareness of hypoglycemia.
Collapse
Affiliation(s)
- Aldo Bonaventura
- Department of Internal MedicineFirst Clinic of Internal Medicine, University of Genoa School of Medicine, IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, ItalyDivision of CardiologyFoundation for Medical Researches, Department of Medical Specialties, University of Geneva, Geneva, SwitzerlandDivision of Laboratory MedicineDepartment of Genetics and Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, Avenue de la Roseraie 64, 1205 Geneva, Switzerland
| | - Fabrizio Montecucco
- Department of Internal MedicineFirst Clinic of Internal Medicine, University of Genoa School of Medicine, IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, ItalyDivision of CardiologyFoundation for Medical Researches, Department of Medical Specialties, University of Geneva, Geneva, SwitzerlandDivision of Laboratory MedicineDepartment of Genetics and Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, Avenue de la Roseraie 64, 1205 Geneva, Switzerland Department of Internal MedicineFirst Clinic of Internal Medicine, University of Genoa School of Medicine, IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, ItalyDivision of CardiologyFoundation for Medical Researches, Department of Medical Specialties, University of Geneva, Geneva, SwitzerlandDivision of Laboratory MedicineDepartment of Genetics and Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, Avenue de la Roseraie 64, 1205 Geneva, Switzerland Department of Internal MedicineFirst Clinic of Internal Medicine, University of Genoa School of Medicine, IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, ItalyDivision of CardiologyFoundation for Medical Researches, Department of Medical Specialties, University of Geneva, Geneva, SwitzerlandDivision of Laboratory MedicineDepartment of Genetics and Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, Avenue de la Roseraie 64, 1205 Geneva, Switzerland
| | - Franco Dallegri
- Department of Internal MedicineFirst Clinic of Internal Medicine, University of Genoa School of Medicine, IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, ItalyDivision of CardiologyFoundation for Medical Researches, Department of Medical Specialties, University of Geneva, Geneva, SwitzerlandDivision of Laboratory MedicineDepartment of Genetics and Laboratory Medicine, Geneva University Hospitals, 4 rue Gabrielle-Perret-Gentil, Avenue de la Roseraie 64, 1205 Geneva, Switzerland
| |
Collapse
|
22
|
Najjar M, Manzoli V, Abreu M, Villa C, Martino MM, Molano RD, Torrente Y, Pileggi A, Inverardi L, Ricordi C, Hubbell JA, Tomei AA. Fibrin gels engineered with pro-angiogenic growth factors promote engraftment of pancreatic islets in extrahepatic sites in mice. Biotechnol Bioeng 2015; 112:1916-26. [PMID: 25786390 DOI: 10.1002/bit.25589] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 01/21/2015] [Accepted: 03/09/2015] [Indexed: 01/08/2023]
Abstract
With a view toward reduction of graft loss, we explored pancreatic islet transplantation within fibrin matrices rendered pro-angiogenic by incorporation of minimal doses of vascular endothelial growth factor-A165 and platelet-derived growth factor-BB presented complexed to a fibrin-bound integrin-binding fibronectin domain. Engineered matrices allowed for extended release of pro-angiogenic factors and for their synergistic signaling with extracellular matrix-binding domains in the post-transplant period. Aprotinin addition delayed matrix degradation and prolonged pro-angiogenic factor availability within the graft. Both subcutaneous (SC) and epididymal fat pad (EFP) sites were evaluated. We show that in the SC site, diabetes reversal in mice transplanted with 1,000 IEQ of syngeneic islets was not observed for islets transplanted alone, while engineered matrices resulted in a diabetes median reversal time (MDRT) of 38 days. In the EFP site, the MDRT with 250 IEQ of syngeneic islets within the engineered matrices was 24 days versus 86 days for islets transplanted alone. Improved function of engineered grafts was associated with enhanced and earlier (by day 7) angiogenesis. Our findings show that by engineering the transplant site to promote prompt re-vascularization, engraftment and long-term function of islet grafts can be improved in relevant extrahepatic sites.
Collapse
Affiliation(s)
- Mejdi Najjar
- Diabetes Research Institute, University of Miami Miller School of Medicine, 1450 NW 10th Avenue, Miami, Florida
| | - Vita Manzoli
- Diabetes Research Institute, University of Miami Miller School of Medicine, 1450 NW 10th Avenue, Miami, Florida.,Department of Electronics, Information and Bioengineering, Politecnico di Milano, Italy
| | - Maria Abreu
- Diabetes Research Institute, University of Miami Miller School of Medicine, 1450 NW 10th Avenue, Miami, Florida
| | - Chiara Villa
- Diabetes Research Institute, University of Miami Miller School of Medicine, 1450 NW 10th Avenue, Miami, Florida.,Department of Pathophysiology and Transplantation, Universitá degli Studi di Milano, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy
| | - Mikaël M Martino
- Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - R Damaris Molano
- Diabetes Research Institute, University of Miami Miller School of Medicine, 1450 NW 10th Avenue, Miami, Florida
| | - Yvan Torrente
- Diabetes Research Institute, University of Miami Miller School of Medicine, 1450 NW 10th Avenue, Miami, Florida.,Department of Pathophysiology and Transplantation, Universitá degli Studi di Milano, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Italy
| | - Antonello Pileggi
- Diabetes Research Institute, University of Miami Miller School of Medicine, 1450 NW 10th Avenue, Miami, Florida.,Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida.,Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, Florida.,Department of Biomedical Engineering, University of Miami, Miami, Florida
| | - Luca Inverardi
- Diabetes Research Institute, University of Miami Miller School of Medicine, 1450 NW 10th Avenue, Miami, Florida.,Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, Florida.,Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Camillo Ricordi
- Diabetes Research Institute, University of Miami Miller School of Medicine, 1450 NW 10th Avenue, Miami, Florida.,Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida.,Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, Florida.,Department of Biomedical Engineering, University of Miami, Miami, Florida.,Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Jeffrey A Hubbell
- Diabetes Research Institute, University of Miami Miller School of Medicine, 1450 NW 10th Avenue, Miami, Florida.,Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland.,Institute for Molecular Engineering, University of Chicago, Illinois
| | - Alice A Tomei
- Diabetes Research Institute, University of Miami Miller School of Medicine, 1450 NW 10th Avenue, Miami, Florida. .,Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida. .,Department of Biomedical Engineering, University of Miami, Miami, Florida.
| |
Collapse
|
23
|
Pugliese A, Yang M, Kusmarteva I, Heiple T, Vendrame F, Wasserfall C, Rowe P, Moraski JM, Ball S, Jebson L, Schatz DA, Gianani R, Burke GW, Nierras C, Staeva T, Kaddis JS, Campbell-Thompson M, Atkinson MA. The Juvenile Diabetes Research Foundation Network for Pancreatic Organ Donors with Diabetes (nPOD) Program: goals, operational model and emerging findings. Pediatr Diabetes 2014; 15:1-9. [PMID: 24325575 PMCID: PMC4282794 DOI: 10.1111/pedi.12097] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 09/30/2013] [Accepted: 10/23/2013] [Indexed: 12/17/2022] Open
Abstract
nPOD actively promotes a multidisciplinary and unbiased approach toward a better understanding of T1D and identify novel therapeutic targets, through its focus on the study of human samples. Unique to this effort is the coordination of collaborative efforts and real-time data sharing. Studies supported by nPOD are providing direct evidence that human T1D isa complex and heterogeneous disease, in which a multitude of pathogenic factors may be operational and may contribute to the onset of the disease. Importantly, the concept that beta cell destruction is almost completed and that the autoimmune process is almost extinguished soon after diagnosis is being challenged. nPOD investigators are exploring the hypothesis that beta cell dysfunction may also be a significant cause of hyperglycemia, at least around the time of diagnosis, and are uncovering novel molecules and pathways that are linked to the pathogenesis and etiology of human T1D. The validation of therapeutic targets is also a key component of this effort, with recent and future findings providing new strategic direction for clinical trials.
Collapse
Affiliation(s)
- Alberto Pugliese
- Diabetes Research Institute, University of Miami Miller School of MedicineMiami, FL, USA,Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, University of Miami Miller School of MedicineMiami, FL, USA,Department of Immunology and Microbiology, University of Miami Miller School of MedicineMiami, FL, USA
| | - Mingder Yang
- Department of Pathology, Immunology, and Laboratory Medicine, The University of Florida College of MedicineGainesville, FL, USA
| | - Irina Kusmarteva
- Department of Pathology, Immunology, and Laboratory Medicine, The University of Florida College of MedicineGainesville, FL, USA
| | - Tiffany Heiple
- Department of Pathology, Immunology, and Laboratory Medicine, The University of Florida College of MedicineGainesville, FL, USA
| | - Francesco Vendrame
- Diabetes Research Institute, University of Miami Miller School of MedicineMiami, FL, USA
| | - Clive Wasserfall
- Department of Pathology, Immunology, and Laboratory Medicine, The University of Florida College of MedicineGainesville, FL, USA
| | - Patrick Rowe
- Department of Pathology, Immunology, and Laboratory Medicine, The University of Florida College of MedicineGainesville, FL, USA
| | - Jayne M Moraski
- Department of Pathology, Immunology, and Laboratory Medicine, The University of Florida College of MedicineGainesville, FL, USA
| | - Suzanne Ball
- Department of Pathology, Immunology, and Laboratory Medicine, The University of Florida College of MedicineGainesville, FL, USA
| | - Les Jebson
- Department of Pathology, Immunology, and Laboratory Medicine, The University of Florida College of MedicineGainesville, FL, USA
| | - Desmond A Schatz
- Department of Pediatrics, The University of Florida College of MedicineGainesville, FL, USA
| | | | - George W Burke
- Department of Surgery, University of Miami Miller School of MedicineMiami, FL, USA
| | | | | | - John S Kaddis
- Department of Information Sciences, City of Hope National Medical CenterDuarte, CA, USA
| | - Martha Campbell-Thompson
- Department of Pathology, Immunology, and Laboratory Medicine, The University of Florida College of MedicineGainesville, FL, USA
| | - Mark A Atkinson
- Department of Pathology, Immunology, and Laboratory Medicine, The University of Florida College of MedicineGainesville, FL, USA,Department of Pediatrics, The University of Florida College of MedicineGainesville, FL, USA
| |
Collapse
|
24
|
Elkhafif NM, Borot S, Morel P, Demuylder-Mischler S, Giovannoni L, Toso C, Bosco D, Berney T. Endocrine secretory reserve and proinsulin processing in recipients of islet of langerhans versus whole pancreas transplants. Diabetes Care 2013; 36:3726-31. [PMID: 24041681 PMCID: PMC3816861 DOI: 10.2337/dc12-2710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE β-Cells have demonstrated altered proinsulin processing after islet transplantation. We compare β-cell metabolic responses and proinsulin processing in pancreas and islet transplant recipients with respect to healthy control subjects. RESEARCH DESIGN AND METHODS We studied 15 islet and 32 pancreas transplant recipients. Islet subjects were subdivided into insulin-requiring (IR-ISL, n = 6) and insulin-independent (II-ISL, n = 9) groups. Ten healthy subjects served as control subjects. Subjects were administered an intravenous arginine stimulation test, and insulin, C-peptide, total proinsulin, intact proinsulin, and proinsulin fragment levels were determined from serum samples. Acute insulin response (AIR) and proinsulin processing rates were calculated. RESULTS We found that basal insulin and C-peptide levels were higher in the pancreas group than in all other groups. II-ISL patients had basal insulin and C-peptide levels similar to healthy control subjects. The IR-ISL group had significantly lower AIRs than all other groups. Basal processing rates were higher in the pancreas and II-ISL groups than in healthy control subjects and the IR-ISL group. After arginine stimulation, all groups had elevated processing rates, with the exception of the IR-ISL group. CONCLUSIONS Our data suggest that II-ISL transplant recipients can maintain basal metabolic parameters similar to healthy control subjects at the cost of a higher rate of proinsulin processing. IR-ISL transplant recipients, on the other hand, demonstrate both lower insulin response and lower basal rates of proinsulin processing even after arginine stimulation.
Collapse
|
25
|
Abstract
For many patients with type 1 diabetes mellitus and selected patients with type 2 diabetes mellitus, a successful pancreas transplant is the only definitive long-term treatment that both restores euglycaemia without the risk of severe hypoglycaemia and prevents, halts or reverses secondary complications. These benefits come at the cost of major surgery and lifelong immunosuppression. Nevertheless, pancreas transplants are safe and effective, with patient survival rates currently >95% at 1 year and >88% at 5 years; graft survival rates are almost 85% at 1 year and >60% at 5 years. The estimated half-life of a pancreas graft is now 7-14 years. The improvements in graft survival are attributable to considerable reductions in technical failures and in immunologic graft losses. Pancreas recipients have reduced mortality compared with waiting candidates or patients with diabetes mellitus who undergo a kidney transplant alone. Pancreas transplants should be more frequently offered to nonuraemic patients with brittle diabetes mellitus to prevent the development of secondary diabetic complications and to avoid the need for a kidney transplant. Although the results of islet transplantation have also improved, islet recipients rarely maintain long-term insulin independence despite the use of multiple organ donor pancreases. Pancreas transplants and islet transplants should be considered complementary, not mutually exclusive, procedures that are chosen on the basis of the individual patient's surgical risk.
Collapse
Affiliation(s)
- Rainer W G Gruessner
- Department of Surgery, University of Arizona, 1501 N. Campbell Avenue, Room 4410, PO Box 245066, Tucson, AZ 85724, USA. rgruessner@ surgery.arizona.edu
| | | |
Collapse
|
26
|
Rickels MR, Liu C, Shlansky-Goldberg RD, Soleimanpour SA, Vivek K, Kamoun M, Min Z, Markmann E, Palangian M, Dalton-Bakes C, Fuller C, Chiou AJ, Barker CF, Luning Prak ET, Naji A. Improvement in β-cell secretory capacity after human islet transplantation according to the CIT07 protocol. Diabetes 2013; 62:2890-7. [PMID: 23630300 PMCID: PMC3717864 DOI: 10.2337/db12-1802] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 04/24/2013] [Indexed: 12/15/2022]
Abstract
The Clinical Islet Transplantation 07 (CIT07) protocol uses antithymocyte globulin and etanercept induction, islet culture, heparinization, and intensive insulin therapy with the same low-dose tacrolimus and sirolimus maintenance immunosuppression as in the Edmonton protocol. To determine whether CIT07 improves engrafted islet β-cell mass, our center measured β-cell secretory capacity from glucose-potentiated arginine tests at days 75 and 365 after transplantation and compared those results with the results previously achieved by our group using the Edmonton protocol and normal subjects. All subjects were insulin free, with CIT07 subjects receiving fewer islet equivalents from a median of one donor compared with two donors for Edmonton protocol subjects. The acute insulin response to glucose-potentiated arginine (AIRpot) was greater in the CIT07 protocol than in the Edmonton protocol and was less in both cohorts than in normal subjects, with similar findings for C-peptide. The CIT07 subjects who completed reassessment at day 365 exhibited increasing AIRpot by trend relative to that of day 75. These data indicate that engrafted islet β-cell mass is markedly improved with the CIT07 protocol, especially given more frequent use of single islet donors. Although several peritransplant differences may have each contributed to this improvement, the lack of deterioration in β-cell secretory capacity over time in the CIT07 protocol suggests that low-dose tacrolimus and sirolimus are not toxic to islets.
Collapse
Affiliation(s)
- Michael R Rickels
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Languren G, Montiel T, Julio-Amilpas A, Massieu L. Neuronal damage and cognitive impairment associated with hypoglycemia: An integrated view. Neurochem Int 2013; 63:331-43. [PMID: 23876631 DOI: 10.1016/j.neuint.2013.06.018] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 06/28/2013] [Accepted: 06/30/2013] [Indexed: 01/01/2023]
Abstract
The aim of the present review is to offer a current perspective about the consequences of hypoglycemia and its impact on the diabetic disorder due to the increasing incidence of diabetes around the world. The main consequence of insulin treatment in type 1 diabetic patients is the occurrence of repetitive periods of hypoglycemia and even episodes of severe hypoglycemia leading to coma. In the latter, selective neuronal death is observed in brain vulnerable regions both in humans and animal models, such as the cortex and the hippocampus. Cognitive damage subsequent to hypoglycemic coma has been associated with neuronal death in the hippocampus. The mechanisms implicated in selective damage are not completely understood but many factors have been identified including excitotoxicity, oxidative stress, zinc release, PARP-1 activation and mitochondrial dysfunction. Importantly, the diabetic condition aggravates neuronal damage and cognitive failure induced by hypoglycemia. In the absence of coma prolonged and severe hypoglycemia leads to increased oxidative stress and discrete neuronal death mainly in the cerebral cortex. The mechanisms responsible for cell damage in this condition are still unknown. Recurrent moderate hypoglycemia is far more common in diabetic patients than severe hypoglycemia and currently important efforts are being done in order to elucidate the relationship between cognitive deficits and recurrent hypoglycemia in diabetics. Human studies suggest impaired performance mainly in memory and attention tasks in healthy and diabetic individuals under the hypoglycemic condition. Only scarce neuronal death has been observed under moderate repetitive hypoglycemia but studies suggest that impaired hippocampal synaptic function might be one of the causes of cognitive failure. Recent studies have also implicated altered mitochondrial function and mitochondrial oxidative stress.
Collapse
Affiliation(s)
- Gabriela Languren
- Departamento de Neuropatología Molecular, División de Neurociencias, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, CP 04510, AP 70-253, México, D.F., Mexico
| | | | | | | |
Collapse
|
28
|
Gene expression changes in rat pancreas transplant model after long-term cold storage of the graft in perfluorohexyloctane. Transplant Proc 2013; 45:1729-33. [PMID: 23769033 DOI: 10.1016/j.transproceed.2012.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 11/19/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND Perfluorohexyloctane (PFH) is a promising storage solution that has been successfully used for pancreas preservation before islet isolation. This hyperoxygen carrier has been designed to prevent ischemic injury to the pancreas graft during cold storage. In our storage, we aimed to evaluate the impact of this solution on long-term cold storage in a rat whole pancreas transplantation model. METHOD Brown-Norway rats were used for syngeneic heterotopic pancreas transplantation. The procured organs were cold-stored for 18 hours in preoxygenated PFH (PFH group; n = 8) or in the University of Wisconsin solution (UW group; n = 8), or were transplanted immediately in the control group (n = 8). Two hours after reperfusion, we obtained blood and pancreas tissue samples for biochemistry and gene analyses (real-time polymerase chain reaction). RESULTS A significant difference between the UW and PFH group was observed in the tumor necrosis factor (TNF)β and endothelin 1 genes, which was overexpressed more than twofold in the UW group. In the blood samples, the UW group compared with the PFH group showed significantly higher levels of pancreatic amylase and lipase (94.2 ± 25.2 vs 67.7 ± 13.4 μkat/L and 5.5 ± 2.8 vs 3 ± 0.7 μkat/L, respectively; P < .05). CONCLUSION We found significantly lower expression levels of the endothelin 1 and TNFβ genes and lower concentrations of pancreatic amylase and lipase in the PFH group. All these findings suggest lower rate of ischemic reperfusion injury in the PFH group. These findings may result in better post-transplant outcomes after long-term cold storage in PFH compared with the UW solution. Further research in this area is required.
Collapse
|
29
|
Ten Years' Evaluation of Diet, Anthropometry, and Physical Exercise Adherence After Islet Allotransplantation. Transplant Proc 2013; 45:2025-8. [DOI: 10.1016/j.transproceed.2013.01.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 01/15/2013] [Indexed: 12/29/2022]
|
30
|
Reno CM, Litvin M, Clark AL, Fisher SJ. Defective counterregulation and hypoglycemia unawareness in diabetes: mechanisms and emerging treatments. Endocrinol Metab Clin North Am 2013; 42:15-38. [PMID: 23391237 PMCID: PMC3568263 DOI: 10.1016/j.ecl.2012.11.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
For people with diabetes, hypoglycemia remains the limiting factor in achieving glycemic control. This article reviews recent advances in how the brain senses and responds to hypoglycemia. Novel mechanisms by which individuals with insulin-treated diabetes develop hypoglycemia unawareness and impaired counterregulatory responses are outlined. Prevention strategies for reducing the incidence of hypoglycemia are discussed.
Collapse
Affiliation(s)
- Candace M. Reno
- Division of Endocrinology, Metabolism, & Lipid Research, Department of Medicine, Washington University, St. Louis, MO
| | - Marina Litvin
- Division of Endocrinology, Metabolism, & Lipid Research, Department of Medicine, Washington University, St. Louis, MO
| | - Amy L. Clark
- Division of Endocrinology and Diabetes, Department of Pediatrics, Washington University, St. Louis, MO
| | - Simon J. Fisher
- Division of Endocrinology, Metabolism, & Lipid Research, Department of Medicine, Washington University, St. Louis, MO
- Department of Cell Biology and Physiology, Washington University, St. Louis, MO
| |
Collapse
|