Rehabilitation of adaptive immunity and regeneration of beta cells

Teplizumab: type 1 diabetes mellitus preventable?

Type 1 diabetes mellitus (T1DM) is an autoimmune condition driven by T lymphocytes that specifically declines the function of beta cells of pancreas. Immunological treatments aim to stop this decline in β-cell function thus preventing TIDM. Although TIDM occur at any age, it is one of the most common chronic disorders in children. T1DM accounts for 5 to 10% of all cases of diabetes amounting 21-42 million affected persons. Teplizumab is a novel drug recently approved by the US FDA for the treatment of T1DM. This drug reduces abnormal glucose tolerance who are at high risk for developing T1DM and have antibodies suggesting an immunological attack on their pancreas. A 14-day infusion of the drug prevents T cells' attack of the insulin-producing cells of the pancreas. Adverse events due to teplizumab reported so far mild and of limited duration. This review gives an overview of the preclinical and clinical research on teplizumab for their role in new-onset T1DM.

Teplizumab therapy for type 1 diabetes

IMPORTANCE OF THE FIELD

Type 1 diabetes mellitus (T1D) is a T-cell mediated autoimmune disease with selective destruction of beta cells. Immunological interventions are directed at arresting the loss of beta-cell function with the promise that this will make it easier for patients to control their glucose levels.

AREAS COVERED IN THIS REVIEW

This review provides a summary of the preclinical and clinical research published between 1992 and 2009 using teplizumab and other anti-CD3 antibodies to arrest the loss of beta-cell function in new onset T1D. Data from animal and human studies on the probable mechanism of action of teplizumab are also reviewed.

WHAT THE READER WILL GAIN

A broad perspective on the use of teplizumab in inducing disease specific tolerance.

TAKE HOME MESSAGE

In Phase I/II randomized control trials, in patients with new onset T1D, teplizumab slowed the rate of loss of beta-cell function over 2 years of follow-up. Treated patients had better glycemic control and lower insulin requirements. Adverse events so far are mild and of limited duration. Phase III clinical trials are underway to confirm these results and to determine if two courses of drug have greater efficacy in arresting loss of beta-cell function.

B7-H4 transfection prolongs beta-cell graft survival

B7-H4, a recently discovered member of B7 family, can negatively regulate T cell responses. However, it is not clear whether B7-H4 negatively function in cell transplantation. In this study we investigated the immunosuppressive effect of B7-H4 on beta-cell transplantation. An insulinoma cell line, NIT-1, transfected with B7-H4 (B7-H4-NIT) was established, and transplanted to diabetic C57BL/6 mice by intraperitoneal injection. Proliferation assay of splenocytes in vitro showed that B7-H4-NIT suppressed alloreactive T cell activation. The proportion of IFN-gamma-producing cells in recipient spleen was significantly reduced and the number of Treg cells was upregulated in B7-H4-NIT group compared to the control, EGFP-NIT. The expression of mRNA coding IFN-gamma was lower but that of IL-4 was higher in B7-H4-NIT transplanted recipients than in the control animals. The results of ELISA also revealed the same trends. Diabetic mice reached normalglycemic quickly and gained weight after transplantation of B7-H4-NIT. More importantly, the survival time for recipients transplanted with B7-H4-NIT cells was significantly longer than that with EGFP-NIT cells. These results indicate that B7-H4 transfection prolongs beta-cell graft survival.

On the use of general control samples for genome-wide association studies: genetic matching highlights causal variants

Resources being amassed for genome-wide association (GWA) studies include "control databases" genotyped with a large-scale SNP array. How to use these databases effectively is an open question. We develop a method to match, by genetic ancestry, controls to affected individuals (cases). The impact of this method, especially for heterogeneous human populations, is to reduce the false-positive rate, inflate other spuriously small p values, and have little impact on the p values associated with true positive loci. Thus, it highlights true positives by downplaying false positives. We perform a GWA by matching Americans with type 1 diabetes (T1D) to controls from Germany. Despite the complex study design, these analyses identify numerous loci known to confer risk for T1D.

Mesenchymal stem cells cooperate with bone marrow cells in therapy of diabetes

Several recent studies have suggested that the adult bone marrow harbors cells that can influence beta-cell regeneration in diabetic animals. Other reports, however, have contradicted these findings. To address this issue, we used an animal model of type 1 diabetes in which the disease was induced with streptozotocin in mice. Freshly prepared sex-mismatched bone marrow cells (BMCs) and syngeneic or allogeneic mesenchymal stem cells (MSCs) were concomitantly administrated into sublethally irradiated diabetic mice. Blood glucose and serum insulin concentrations rapidly returned to normal levels, accompanied by efficient tissue regeneration after a single injection of a mixture of 10(6) BMCs per 10(5) MSCs. Neither BMC nor MSC transplantation was effective alone. Successful treatment of diabetic animals was not due to the reconstitution of the damaged islet cells from the transplant, since no donor-derived beta-cells were found in the recovered animals, indicating a graft-initiated endogenous repair process. Moreover, MSC injection caused the disappearance of beta-cell-specific T lymphocytes from diabetic pancreas. Therefore, we suggest that two aspects of this successful treatment regimen operate in parallel and synergistically in our model. First, BMCs and MSCs induce the regeneration of recipient-derived pancreatic insulin-secreting cells. Second, MSCs inhibit T-cell-mediated immune responses against newly formed beta-cells, which, in turn, are able to survive in this altered immunological milieu. Thus, the application of this therapy in human patients suffering from diabetes and/or other tissue destructive autoimmune diseases may be feasible.

Stem cell-based therapy for the treatment of Type 1 diabetes mellitus

Diabetes mellitus is the most common metabolic disorder, which occurs in two forms: Type 1 diabetes (juvenile or insulin-dependent diabetes mellitus) and Type 2 diabetes (adult or noninsulin-dependent diabetes mellitus). Type 1 diabetes mellitus is a T-cell-mediated, organ-specific autoimmune disorder, in which the body's own immune system attacks beta-cells and damages them sufficiently resulting in reduced insulin production. To overcome autoimmunity, immunosuppressive therapy, gene therapy, islet cell regeneration or encapsulation of islet cells offer dramatic treatment solutions. At present, efforts for finding ways to replace damaged insulin-secreting beta-cells by implanting new cells is an active field of research. Various therapeutic strategies are under investigation and stem cell-based therapy with the combination of other treatments offers exciting possibilities for the development of treatment for such diseases. In the current review, we focus on stem cells and their potential clinical applications and summarize the recent progress in this field.

Commentary: engineering of tissue healing and regeneration

Regenerative medicine aims to restore homeostasis of diseased tissues and organs. With time, engineered replacement tissue constructs will play an increasingly important role in achieving this goal. Equally important, however, will be the ability to resolve disease-associated inflammation and to optimize tissue regenerative capacity by specifically patterning the host tissue microenvironment. The tools of bioengineering are uniquely suited to meet these challenges. Here, the candidate molecular and cellular targets for manipulating the host's inflammatory environment and tissue regenerative capacity are briefly discussed within the context of current and emerging bioengineering strategies. The objective is to draw the attention of basic scientists and engineers to the importance of regulating inflammation in achieving the goals of tissue engineering and regenerative medicine.

Stem/Progenitor cell sources of insulin-producing cells for the treatment of diabetes

Patients with diabetes experience decreased insulin secretion that is linked to a significant reduction in the number of islet cells. Reversal of diabetes can be achieved through islet transplantation, but the scarcity of donor islets severely hinders wide application of this therapeutic modality. Toward that end, embryonic stem cells, adult tissue-residing progenitor cells, and regenerating native beta-cells may serve as sources of islet cell surrogates. Insulin-producing cells generated from stem or progenitor cells display subsets of native beta-cell attributes, indicating the need for further development of methods for differentiation to completely functional beta-cells. Pharmacological approaches aiming at stimulating the in vivo/ex vivo regeneration of beta-cells have also been proposed as a way of augmenting islet cell mass. We review the current state of the generation of insulin-producing cells from different sources with emphasis on embryonic stem cells and adult progenitor cells. Challenges for the clinical use of these sources are also discussed.