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Saito R, Inagaki A, Nakamura Y, Imura T, Kanai N, Mitsugashira H, Endo Kumata Y, Katano T, Suzuki S, Tokodai K, Kamei T, Unno M, Watanabe K, Tabata Y, Goto M. A Gelatin Hydrogel Nonwoven Fabric Combined With Adipose Tissue-Derived Stem Cells Enhances Subcutaneous Islet Engraftment. Cell Transplant 2024; 33:9636897241251621. [PMID: 38756050 PMCID: PMC11102670 DOI: 10.1177/09636897241251621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/09/2024] [Accepted: 04/12/2024] [Indexed: 05/18/2024] Open
Abstract
Subcutaneous islet transplantation is a promising treatment for severe diabetes; however, poor engraftment hinders its prevalence. We previously revealed that a gelatin hydrogel nonwoven fabric (GHNF) markedly improved subcutaneous islet engraftment. We herein investigated whether the addition of adipose tissue-derived stem cells (ADSCs) to GHNF affected the outcome. A silicone spacer sandwiched between two GHNFs with (AG group) or without (GHNF group) ADSCs, or a silicone spacer alone (Silicone group) was implanted into the subcutaneous space of healthy mice at 6 weeks before transplantation, then diabetes was induced 7 days before transplantation. Syngeneic islets were transplanted into the pretreated space. Intraportal transplantation (IPO group) was also performed to compare the transplant efficiency. Blood glucose, intraperitoneal glucose tolerance, immunohistochemistry, and inflammatory mediators were evaluated. The results in the subcutaneous transplantation were compared using the Silicone group as a control. The results of the IPO group were also compared with those of the AG group. The AG group showed significantly better blood glucose changes than the Silicone and the IPO groups. The cure rate of AG group (72.7%) was the highest among the groups (GHNF; 40.0%, IPO; 40.0%, Silicone; 0%). The number of vWF-positive vessels in the subcutaneous space of the AG group was significantly higher than that in other groups before transplantation (P < 0.01). Lectin angiography also showed that the same results (P < 0.05). According to the results of the ADSCs tracing, ADSCs did not exist at the transplant site (6 weeks after implantation). The positive rates for laminin and collagen III constructed around the transplanted islets did not differ among groups. Inflammatory mediators were higher in the Silicone group, followed by the AG and GHNF groups. Pretreatment using bioabsorbable scaffolds combined with ADSCs enhanced neovascularization in subcutaneous space, and subcutaneous islet transplantation using GHNF with ADSCs was superior to intraportal islet transplantation.
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Affiliation(s)
- Ryusuke Saito
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Akiko Inagaki
- Division of Transplantation and Regenerative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Takehiro Imura
- Division of Transplantation and Regenerative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Norifumi Kanai
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Mitsugashira
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yukiko Endo Kumata
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takumi Katano
- Division of Transplantation and Regenerative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shoki Suzuki
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuaki Tokodai
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kimiko Watanabe
- Division of Transplantation and Regenerative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiko Tabata
- Plastic and Reconstructive Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masafumi Goto
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Transplantation and Regenerative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Kanai N, Inagaki A, Nakamura Y, Imura T, Mitsugashira H, Saito R, Miyagi S, Watanabe K, Kamei T, Unno M, Tabata Y, Goto M. A gelatin hydrogel nonwoven fabric improves outcomes of subcutaneous islet transplantation. Sci Rep 2023; 13:11968. [PMID: 37488155 PMCID: PMC10366205 DOI: 10.1038/s41598-023-39212-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 07/21/2023] [Indexed: 07/26/2023] Open
Abstract
Subcutaneous islet transplantation is a promising treatment for severe diabetes; however, poor engraftment hinders its prevalence. We previously reported that a recombinant peptide (RCP) enhances subcutaneous islet engraftment. However, it is impractical for clinical use because RCP must be removed when transplanting islets. We herein investigated whether a novel bioabsorbable gelatin hydrogel nonwoven fabric (GHNF) could improve subcutaneous islet engraftment. A silicon spacer with or without GHNF was implanted into the subcutaneous space of diabetic mice. Syngeneic islets were transplanted into the pretreated space or intraportally (Ipo group). Blood glucose, intraperitoneal glucose tolerance, immunohistochemistry, CT angiography and gene expression were evaluated. The cure rate and glucose tolerance of the GHNF group were significantly better than in the control and Ipo groups (p < 0.01, p < 0.05, respectively). In the GHNF group, a limited increase of vWF-positive vessels was detected in the islet capsule, whereas laminin (p < 0.05), collagen III and IV were considerably enhanced. TaqMan arrays revealed a significant upregulation of 19 target genes (including insulin-like growth factor-2) in the pretreated space. GHNF markedly improved the subcutaneous islet transplantation outcomes, likely due to ECM compensation and protection of islet function by various growth factors, rather than enhanced neovascularization.
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Affiliation(s)
- Norifumi Kanai
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-0872, Japan
| | - Akiko Inagaki
- Division of Transplantation and Regenerative Medicine, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Graduate School of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, 983-8536, Japan
| | - Takehiro Imura
- Division of Transplantation and Regenerative Medicine, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan
| | - Hiroaki Mitsugashira
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-0872, Japan
| | - Ryusuke Saito
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-0872, Japan
| | - Shigehito Miyagi
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-0872, Japan
| | - Kimiko Watanabe
- Division of Transplantation and Regenerative Medicine, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-0872, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-0872, Japan
| | - Yasuhiko Tabata
- Laboratory of Biomaterials, Department of Regeneration Science and Engineering, Institute for Life and Medical Sciences (LiMe), Kyoto University, Kyoto, 606-8507, Japan
| | - Masafumi Goto
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, 980-0872, Japan.
- Division of Transplantation and Regenerative Medicine, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan.
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Saito R, Inagaki A, Nakamura Y, Imura T, Kanai N, Mitsugashira H, Endo Y, Katano T, Suzuki S, Tokodai K, Kamei T, Unno M, Watanabe K, Tabata Y, Goto M. Ideal Duration of Pretreatment Using a Gelatin Hydrogel Nonwoven Fabric Prior to Subcutaneous Islet Transplantation. Cell Transplant 2023; 32:9636897231186063. [PMID: 37466120 PMCID: PMC10363859 DOI: 10.1177/09636897231186063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/05/2023] [Accepted: 06/19/2023] [Indexed: 07/20/2023] Open
Abstract
Subcutaneous islet transplantation is a promising treatment for severe diabetes; however, poor engraftment hinders its prevalence. We previously revealed that a gelatin hydrogel nonwoven fabric (GHNF) markedly improved subcutaneous islet engraftment in comparison with intraportal islet transplantation. We herein investigated whether the duration of pretreatment using GHNF affected the outcome of subcutaneous islet transplantation. A silicone spacer with GHNF was implanted into the subcutaneous space of healthy mice at 2, 4, 6, or 8 weeks before transplantation, and then diabetes was induced 7 days before transplantation. Syngeneic islets were transplanted into the pretreated space. Blood glucose, intraperitoneal glucose tolerance, immunohistochemistry, inflammatory mediators, and gene expression were evaluated. The 6-week group showed significantly better blood glucose changes than the other groups (P < 0.05). The cure rate of the 6-week group (60.0%) was the highest among the groups (2-week = 0%, 4-week = 50.0%, 8-week = 15.4%). The number of von Willebrand factor (vWF)-positive vessels in the 6-week group was significantly higher than in the other groups at pre-islet and post-islet transplantation (P < 0.01 [vs 2-and 4-week groups] and P < 0.05 [vs all other groups], respectively). Notably, this beneficial effect was also observed when GHNF was implanted into diabetic mice injected with streptozotocin 7 days before GHNF implantation. The positive rates for laminin, collagen III, and collagen IV increased as the duration of pretreatment became longer and were significantly higher in the 8-week group (P < 0.01). Inflammatory mediators, including interleukin (IL)-1b, granulocyte colony-stimulating factor (G-CSF), and interferon (IFN)-γ, were gradually downregulated according to the duration of GHNF pretreatment and re-elevated in the 8-week group. Taken together, the duration of GHNF pretreatment apparently had an impact on the outcomes of subcutaneous islet transplantation, and 6 weeks appeared to be the ideal duration. Islet graft revascularization, extracellular matrix compensation of the islet capsule, and the inflammatory status at the subcutaneous space would be crucial factors for successful subcutaneous islet transplantation.
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Affiliation(s)
- Ryusuke Saito
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Akiko Inagaki
- Division of Transplantation and Regenerative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Graduate School of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Takehiro Imura
- Division of Transplantation and Regenerative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Norifumi Kanai
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Mitsugashira
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yukiko Endo
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takumi Katano
- Division of Transplantation and Regenerative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shoki Suzuki
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuaki Tokodai
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kimiko Watanabe
- Division of Transplantation and Regenerative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiko Tabata
- Laboratory of Biomaterials, Department of Regeneration Science and Engineering, Institute for Life and Medical Sciences (LiMe), Kyoto University, Kyoto, Japan
| | - Masafumi Goto
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
- Division of Transplantation and Regenerative Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Development of a novel method for measuring tissue oxygen pressure to improve the hypoxic condition in subcutaneous islet transplantation. Sci Rep 2022; 12:14731. [PMID: 36042259 PMCID: PMC9427780 DOI: 10.1038/s41598-022-19189-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/25/2022] [Indexed: 11/08/2022] Open
Abstract
Subcutaneous tissue is a promising site for islet transplantation, but poor engraftment, due to hypoxia and low vascularity, hinders its prevalence. However, oxygen partial pressure (pO2) of the subcutaneous space (SC) and other sites were reported to be equivalent in several previous reports. This contradiction may be based on accidental puncture to the indwelling micro-vessels in target tissues. We therefore developed a novel optical sensor system, instead of a conventional Clark-type needle probe, for measuring tissue pO2 and found that pO2 of the SC was extremely low in comparison to other sites. To verify the utility of this method, we transplanted syngeneic rat islets subcutaneously into diabetic recipients under several oxygenation conditions using an oxygen delivery device, then performed pO2 measurement, glucose tolerance, and immunohistochemistry. The optical sensor system was validated by correlating the pO2 values with the transplanted islet function. Interestingly, this novel technique revealed that islet viability estimated by ATP/DNA assay reduced to less than 75% by hypoxic condition at the SC, indicating that islet engraftment may substantially improve if the pO2 levels reach those of the renal subcapsular space. Further refinements for a hypoxic condition using the present technique may contribute to improving the efficiency of subcutaneous islet transplantation.
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Clinical Islet Transplantation Covered by Health Insurance in Japan. J Clin Med 2022; 11:jcm11143977. [PMID: 35887740 PMCID: PMC9321768 DOI: 10.3390/jcm11143977] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 07/05/2022] [Indexed: 12/04/2022] Open
Abstract
Pancreatic islet transplantation is a treatment option for patients with type 1 diabetes mellitus and has been performed in various countries [1–5]. [...]
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Ito T, Kenmochi T, Kurihara K, Aida N. The History of Clinical Islet Transplantation in Japan. J Clin Med 2022; 11:jcm11061645. [PMID: 35329971 PMCID: PMC8953643 DOI: 10.3390/jcm11061645] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 01/01/2023] Open
Abstract
Islet transplantation shows the promise of being capable of relieving glucose instability and improving QOL of patients with type 1 diabetes that cannot be controlled due to severe hypoglycemia unawareness. In Japan, following the first human islet isolation from a donor after cardiac death in 2003 and the first clinical islet transplantation in 2004, islet transplantation was performed for the improvement of type 1 diabetes as a single-center trial in several centers. Although it was discontinued due to the possibility of contamination of collagenase by bovine brain component in 2007, the phase II clinical trial of islet transplantation started using ATG induction and a TNF-α inhibition protocol in 2012. The primary endpoints of this trial were the proportion of patients with HbA1c < 7.4% and freedom from severe hypoglycemic events at one year after the first islet cell infusion. In an interim analysis, this endpoint was achieved in 75% of cases. In April 2020, clinical islet transplantation was finally covered by health insurance in Japan, thanks to these outcomes. We herein introduce more than 20 years of history of clinical islet transplantation in Japan.
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Affiliation(s)
- Taihei Ito
- Correspondence: ; Tel.: +81-562-93-2000; Fax: +81-562-93-7060
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De Paep DL, Van Hulle F, Ling Z, Vanhoeij M, Pirenne J, Keymeulen B, Pipeleers D, Jacobs-Tulleneers-Thevissen D. Lower beta cell yield from donor pancreases after controlled circulatory death prevented by shortening acirculatory warm ischemia time and by using IGL-1 cold preservation solution. PLoS One 2021; 16:e0251055. [PMID: 33939760 PMCID: PMC8092795 DOI: 10.1371/journal.pone.0251055] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/19/2021] [Indexed: 02/07/2023] Open
Abstract
Organs from donors after controlled circulatory death (DCD III) exhibit a higher risk for graft dysfunction due to an initial period of warm ischemia. This procurement condition can also affect the yield of beta cells in islet isolates from donor pancreases, and hence their use for transplantation. The present study uses data collected and generated by our Beta Cell Bank to compare the number of beta cells in isolates from DCD III (n = 141) with that from donors after brain death (DBD, n = 609), before and after culture, and examines the influence of donor and procurement variables. Beta cell number per DCD III-organ was significantly lower (58 x 106 versus 84 x 106 beta cells per DBD-organ; p < 0.001) but their purity (24% insulin positive cells) and insulin content (17 μg / 106 beta cells in DCD III-organs versus 19 μg / 106 beta cells in DBD-organs) were similar. Beta cell number correlated negatively with duration of acirculatory warm ischemia time above 10 min; for shorter acirculatory warm ischemia time, DCD III-organs did not exhibit a lower beta cell yield (74 x 106 beta cells). Use of Institut Georges Lopez-1 cold preservation solution instead of University of Wisconsin solution or histidine-tryptophan-ketoglutarate also protected against the loss in beta cell yield from DCD III-organs (86 x 106 for IGL-1 versus 54 x 106 and 65 x 106 beta cells respectively, p = 0.042). Multivariate analysis indicates that both limitation of acirculatory warm ischemia time and use of IGL-1 prevent the reduced beta cell yield in islet cell isolates from DCD III-organs.
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Affiliation(s)
- Diedert L. De Paep
- Diabetes Research Center, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Diabetes Clinic, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
- Department of Surgery, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Freya Van Hulle
- Diabetes Research Center, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Diabetes Clinic, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Zhidong Ling
- Diabetes Research Center, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Diabetes Clinic, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Marian Vanhoeij
- Department of Surgery, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Jacques Pirenne
- Department of Abdominal Transplantation and Transplantation Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Bart Keymeulen
- Diabetes Research Center, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Diabetes Clinic, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Daniel Pipeleers
- Diabetes Research Center, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Diabetes Clinic, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Daniel Jacobs-Tulleneers-Thevissen
- Diabetes Research Center, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Diabetes Clinic, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
- Department of Surgery, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
- * E-mail:
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Nakamura T, Fujikura J, Anazawa T, Ito R, Ogura M, Okajima H, Uemoto S, Inagaki N. Long-term outcome of islet transplantation on insulin-dependent diabetes mellitus: An observational cohort study. J Diabetes Investig 2020; 11:363-372. [PMID: 31390159 PMCID: PMC7078128 DOI: 10.1111/jdi.13128] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 07/17/2019] [Accepted: 07/29/2019] [Indexed: 12/13/2022] Open
Abstract
AIMS/INTRODUCTION To investigate the long-term efficacy and safety of islet transplantation (ITx) compared with multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). MATERIALS AND METHODS Among 619 patients diagnosed as insulin-dependent diabetes mellitus or type 1 diabetes at Kyoto University, Kyoto, Japan, seven patients were selected as the ITx group and 26 age-matched patients with no endogenous insulin secretion were selected as the MDI/CSII group. Hemoglobin A1c, aspartate aminotransferase/alanine aminotransferase (AST/ALT) and creatinine were assessed retrospectively at 1, 2, 5 and 10 years for both groups; serum C-peptide immunoreactivity was assessed for the ITx group. Major clinical events were also assessed. RESULTS Hemoglobin A1c improvement in ITx was significant at 1 year (8.4% [7.8-9.9%] at baseline to 7.1% [6.3-7.4%] in ITx vs 8.2% [7.4-9.8%] at baseline to 8.1% [7.3-9.5%] in MDI/CSII, P < 0.01 between groups), and was maintained at 2 years (7.4% [6.3-8.2%] vs 8.4% [7.4-9.6%], P = 0.11). The increase of stimulated C-peptide immunoreactivity was significant at 1 year (0.57 ng/mL [0.26-0.99 ng/mL], P < 0.05 from baseline) and 2 years (0.43 ng/mL [0.19-0.67 ng/mL], P < 0.05), although it became insignificant thereafter. There was no significant difference in AST/ALT or creatinine at 10 years, although a transient AST/ALT elevation was observed in ITx. In regard to clinical events, the occurrence of severe hypoglycemia was 14% vs 31% (relative risk 0.46, P = 0.64), that of infectious disease was 43% vs 12% (relative risk 3.71, P = 0.09) and digestive symptoms was 43% vs 7.7% (relative risk 5.57, P = 0.05) in ITx vs MDI/CSII, respectively. No patient died in either group. CONCLUSIONS The present findings showed that ITx was considered to contribute to the reduction of hypoglycemia and better glycemic control with tolerable, but attention-requiring, risks over a period of 10 years compared with MDI/CSII.
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Affiliation(s)
- Toshihiro Nakamura
- Department of Diabetes, Endocrinology and NutritionGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Junji Fujikura
- Department of Diabetes, Endocrinology and NutritionGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Takayuki Anazawa
- Division of Hepato‐Biliary‐Pancreatic Surgery and TransplantationGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Ryo Ito
- Department of Diabetes, Endocrinology and NutritionGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Masahito Ogura
- Department of Diabetes, Endocrinology and NutritionGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Hideaki Okajima
- Division of Hepato‐Biliary‐Pancreatic Surgery and TransplantationGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Shinji Uemoto
- Division of Hepato‐Biliary‐Pancreatic Surgery and TransplantationGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and NutritionGraduate School of MedicineKyoto UniversityKyotoJapan
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The Effects of Using Pancreases Obtained from Brain-Dead Donors for Clinical Islet Transplantation in Japan. J Clin Med 2019; 8:jcm8091430. [PMID: 31510059 PMCID: PMC6780198 DOI: 10.3390/jcm8091430] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/03/2019] [Accepted: 09/05/2019] [Indexed: 01/09/2023] Open
Abstract
Background: The pool of brain-dead donors (BDDs) was increased with the revision to the relevant law in 2010, and islet transplantation from BDDs was started in 2013. The present study assessed the influence of using pancreases from BDDs on islet transplantation in Japan. Methods: The donor information registered with the secretariat of islet transplants from 2012 was reviewed, and the results of 86 clinical islet isolations performed in Japan between 2003 and 2018 with non-heart-beating donors (NHBDs) (n = 71) and BDDs (n = 15) were investigated. Results: The number of cases for which donor information was registered with the secretariat of islet transplants increased to 1.84 cases/month from 2013 to 2018 in comparison to 1.44/month in 2012, when only NHBDs were used. The median pancreatic islet yield was 275,550 IEQ (Islet equivalents) in the NHBD group but 362,700 in the BDD group, which amounted to a statistically significant difference (p = 0.02). As a result, 38/71 cases (53.5%) were achieved successful islet isolation (>5000 IEQ per recipient weight (kg)) was achieved in 38/71 cases (53.5%) in the NHBD group, and 12/15 cases (80.0%) in the BDD group; thus, the rate of successful islet transplantation was higher in the BDD group. Conclusion: The use of pancreases from BDDs has increased the overall number of cases for which donor information is registered with the secretariat of islet transplants and has improved the performance of islet isolation, thereby increasing the probability of successfully achieving islet transplantation.
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Päth G, Perakakis N, Mantzoros CS, Seufert J. Stem cells in the treatment of diabetes mellitus - Focus on mesenchymal stem cells. Metabolism 2019; 90:1-15. [PMID: 30342065 DOI: 10.1016/j.metabol.2018.10.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/25/2018] [Accepted: 10/14/2018] [Indexed: 12/14/2022]
Abstract
Diabetes mellitus type 1 and type 2 have become a global epidemic with dramatically increasing incidences. Poorly controlled diabetes is associated with severe life-threatening complications. Beside traditional treatment with insulin and oral anti-diabetic drugs, clinicians try to improve patient's care by cell therapies using embryonic stem cells (ESC), induced pluripotent stem cells (iPSC) and adult mesenchymal stem cells (MSC). ESC display a virtually unlimited plasticity, including the differentiation into insulin producing β-cells, but they raise ethical concerns and bear, like iPSC, the risk of tumours. IPSC may further inherit somatic mutations and remaining somatic transcriptional memory upon incomplete re-programming, but allow the generation of patient/disease-specific cell lines. MSC avoid such issues but have not been successfully differentiated into β-cells. Instead, MSC and their pericyte phenotypes outside the bone marrow have been recognized to secrete numerous immunomodulatory and tissue regenerative factors. On this account, the term 'medicinal signaling cells' has been proposed to define the new conception of a 'drug store' for injured tissues and to stay with the MSC nomenclature. This review presents the biological background and the resulting clinical potential and limitations of ESC, iPSC and MSC, and summarizes the current status quo of cell therapeutic concepts and trials.
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Affiliation(s)
- Günter Päth
- Division of Endocrinology and Diabetology, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
| | - Nikolaos Perakakis
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Christos S Mantzoros
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jochen Seufert
- Division of Endocrinology and Diabetology, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
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Zhu H, Zhang X, He Y, Yu L, Lü Y, Pan K, Wang B, Chen G. [Research progress on the donor cell sources of pancreatic islet transplantation for treatment of diabetes mellitus]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:104-111. [PMID: 29806374 PMCID: PMC8414200 DOI: 10.7507/1002-1892.201707049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 12/13/2017] [Indexed: 11/03/2022]
Abstract
Objective To summarize the research progress on the source and selection of donor cells in the field of islet replacement therapy for diabetes mellitus. Methods Domestic and abroad literature concerning islet replacement therapy for diabetes mellitus, as well as donor source and donor selection was reviewed and analyzed thoroughly. Results The shortage of donor supply is still a major obstacle for the widely clinical application of pancreatic islet transplantation (PIT). Currently, in addition to the progress on the allogeneic/autologous donor islet supply, some remarkable achievements have been also attained in the application of xenogeneic islet (from pig donor), as well as islet like cells derived from stem cells and islet cell line, potentially enlarging the source of implantable cells. Conclusion Adequate and suitable donor cell supply is an essential prerequisite for widely clinical application of PIT therapy for type 1 diabetes mellitus (T1DM). Further perfection of organ donation system, together with development of immune-tolerance induction, gene and bioengineering technology etc. will possibly solve the problem of donor cell shortage and provide a basis for clinical application of cellular replacement therapy for T1DM.
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Affiliation(s)
- Haitao Zhu
- Department of Pediatrics (No. 3 Ward), Northwest Women's and Children's Hospital, Xi'an Shaanxi, 710061, P.R.China;Department of Hepatobiliary Surgery, the First Affiliated Hospital, Medical School of Xi'an Jiaotong University, Xi'an Shaanxi, 710061, P.R.China
| | - Xiaoge Zhang
- Department of Pediatrics (No. 3 Ward), Northwest Women's and Children's Hospital, Xi'an Shaanxi, 710061, P.R.China
| | - Yayi He
- Department of Endocrinology, the First Affiliated Hospital, Medical School of Xi'an Jiaotong University, Xi'an Shaanxi, 710061, P.R.China
| | - Liang Yu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital, Medical School of Xi'an Jiaotong University, Xi'an Shaanxi, 710061, P.R.China
| | - Yi Lü
- Department of Hepatobiliary Surgery, the First Affiliated Hospital, Medical School of Xi'an Jiaotong University, Xi'an Shaanxi, 710061, P.R.China;Research Institute of Advanced Surgical Technology and Engineering, Xi'an Jiaotong University, Xi'an Shaanxi, 710061, P.R.China
| | - Kaili Pan
- Department of Pediatrics (No. 2 Ward), Northwest Women's and Children's Hospital, Xi'an Shaanxi, 710061, P.R.China
| | - Bo Wang
- Department of Hepatobiliary Surgery, the First Affiliated Hospital, Medical School of Xi'an Jiaotong University, Xi'an Shaanxi, 710061, P.R.China;Department of Endocrinology, the First Affiliated Hospital, Medical School of Xi'an Jiaotong University, Xi'an Shaanxi, 710061,
| | - Guoqiang Chen
- Department of Pediatrics (No. 3 Ward), Northwest Women's and Children's Hospital, Xi'an Shaanxi, 710061,
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Kieffer TJ, Woltjen K, Osafune K, Yabe D, Inagaki N. Beta-cell replacement strategies for diabetes. J Diabetes Investig 2017; 9:457-463. [PMID: 28984038 PMCID: PMC5934267 DOI: 10.1111/jdi.12758] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 09/29/2017] [Accepted: 09/29/2017] [Indexed: 12/25/2022] Open
Abstract
Diabetes is characterized by elevated levels of blood glucose as a result of insufficient production of insulin from loss or dysfunction of pancreatic islet β-cells. Here, we review several approaches to replacing β-cells that were recently discussed at a symposium held in Kyoto, Japan. Transplant of donor human islets can effectively treat diabetes and eliminate the need for insulin injections, supporting research aimed at identifying abundant supplies of cells. Studies showing the feasibility of producing mouse islets in rats support the concept of generating pigs with human pancreas that can serve as donors of human islets, although scientific and ethical challenges remain. Alternatively, in vitro differentiation of both human embryonic stem cells and induced pluripotent stem cells is being actively pursued as an islet cell source, and embryonic stem cell-derived pancreatic progenitor cells are now in clinical trials in North America in patients with diabetes. Macro-encapsulation devices are being used to contain and protect the cells from immune attack, and alternate strategies of immune-isolation are being pursued, such as islets contained within long microfibers. Recent advancements in genetic engineering tools offer exciting opportunities to broaden therapeutic strategies and to probe the genetic involvement in β-cell failure that contributes to diabetes. Personalized medicine might eventually become a possibility with genetically edited patient-induced pluripotent stem cells, and the development of simplified robust differentiation protocols that ideally become standardized and automated. Additional efforts to develop a safe and effective β-cell replacement strategy to treat diabetes are warranted.
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Affiliation(s)
- Timothy J Kieffer
- Department of Cellular & Physiological SciencesLife Sciences InstituteUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Center for iPS Cell Research and Application (CiRA)Kyoto UniversityKyotoJapan
| | - Knut Woltjen
- Center for iPS Cell Research and Application (CiRA)Kyoto UniversityKyotoJapan
- Hakubi Center for Advanced ResearchKyoto UniversityKyotoJapan
| | - Kenji Osafune
- Department of Cellular & Physiological SciencesLife Sciences InstituteUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Daisuke Yabe
- Department of Diabetes, Endocrinology and NutritionGraduate School of MedicineKyoto UniversityKyotoJapan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and NutritionGraduate School of MedicineKyoto UniversityKyotoJapan
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13
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Suzuki Y, Kenjo A, Togano T, Yamamoto N, Ohto H, Kume H. Infectious diseases in solid organ transplant recipients: Analysis of autopsied cases in Japan. J Infect Chemother 2017. [PMID: 28647177 DOI: 10.1016/j.jiac.2017.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND With the improvements in immunosuppressive agents and graft survival, infections such as mycoses have become major complications after solid organ transplantation (SOT). METHODS Our group has continuously updated an epidemiological database of visceral mycoses (VM) among autopsy cases in Japan since 1989. Data on infectious agents and clinical information were complied using similar procedures. RESULTS Among the all autopsied cases studied, 356 undergone SOT. Of these, 214 (60.1%) suffered from one or more types of infections, including 51 (14.3%) with VM. Thus, the incidence of VM was higher in SOT recipients than in non-transplanted cases (P < 0.0001). Aspergillus spp. (Asp) was the most predominant agent and Candida spp. was second. Specifically, among SOT recipients, Asp was the most predominant in liver and lung transplant recipients. Among the 217 autopsied liver transplants cases, the incidence of VM was highest in those with fulminant hepatitis (FH, P = 0.01). The incidence of cytomegalovirus infection tended to be higher in cases with mycosis (P = 0.06). Multivariate logistic regression analysis identified FH (odds ratio, 3.61, 95% confidence interval 1.34-9.75; P = 0.03) as an independent risk factor for mycosis in liver transplant recipients. CONCLUSION This epidemiological analysis of autopsied cases provides a strong incentive to intensify efforts to diagnose and treat post-SOT infectious diseases.
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Affiliation(s)
- Yuhko Suzuki
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Fukushima, Japan.
| | - Akira Kenjo
- Department of Regenerative Surgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Tomiteru Togano
- Department of Hematology, National Center for Global Health and Medicine, Shinjyuku, Tokyo, Japan
| | - Natsuo Yamamoto
- Department of Infection Control, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Hitoshi Ohto
- Department of Blood Transfusion and Transplantation Immunology, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Hikaru Kume
- Department of Pathology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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14
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Bruni A, Pepper AR, Gala-Lopez B, Pawlick R, Abualhassan N, Crapo JD, Piganelli JD, Shapiro AMJ. A novel redox-active metalloporphyrin reduces reactive oxygen species and inflammatory markers but does not improve marginal mass engraftment in a murine donation after circulatory death islet transplantation model. Islets 2016; 8:e1190058. [PMID: 27220256 PMCID: PMC4987021 DOI: 10.1080/19382014.2016.1190058] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Islet transplantation is a highly effective treatment for stabilizing glycemic control for select patients with type-1 diabetes. Despite improvements to clinical transplantation, single-donor transplant success has been hard to achieve routinely, necessitating increasing demands on viable organ availability. Donation after circulatory death (DCD) may be an alternative option to increase organ availability however, these organs tend to be more compromised. The use of metalloporphyrin anti-inflammatory and antioxidant (MnP) compounds previously demonstrated improved in vivo islet function in preclinical islet transplantation. However, the administration of MnP (BMX-001) in a DCD islet isolation and transplantation model has yet to be established. In this study, murine donors were subjected to a 15-min warm ischemic (WI) period prior to isolation and culture with or without MnP. Subsequent to one-hour culture, islets were assessed for in vitro viability and in vivo function. A 15-minute WI period significantly reduced islet yield, regardless of MnP-treatment relative to yields from standard isolation. MnP-treated islets did not improve islet viability compared to DCD islets alone. MnP-treatment did significantly reduce the presence of extracellular reactive oxygen species (ROS) (p < 0 .05). Marginal, syngeneic islets (200 islets) transplanted under the renal capsule exhibited similar in vivo outcomes regardless of WI or MnP-treatment. DCD islet grafts harvested 7 d post-transplant exhibited sustained TNF-α and IL-10, while MnP-treated islet-bearing grafts demonstrated reduced IL-10 levels. Taken together, 15-minute WI in murine islet isolation significantly impairs islet yield. DCD islets do indeed demonstrate in vivo function, though MnP therapy was unable to improve viability and engraftment outcomes.
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Affiliation(s)
- Antonio Bruni
- Clinical Islet Transplant Program, Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Andrew R. Pepper
- Clinical Islet Transplant Program, Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Boris Gala-Lopez
- Clinical Islet Transplant Program, Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Rena Pawlick
- Clinical Islet Transplant Program, Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Nasser Abualhassan
- Clinical Islet Transplant Program, Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - James D. Crapo
- Department of Medicine, National Jewish Health, Denver, CO, USA, and BioMimetix JV, LLC, Englewood, CO, USA
| | - Jon D. Piganelli
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- BioMimetix JV, LLC, Englewood, CO, USA
| | - A. M. James Shapiro
- Clinical Islet Transplant Program, Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- CONTACT A.M. James Shapiro, MD, PhD, Professor, Director of Clinical Islet and Living Donor Liver Transplant Programs, Canada Research Chair in Transplantation Surgery and Regenerative MedicineClinical Islet Transplant Program, University of Alberta, 2000 College Plaza, 8215-112th St, Edmonton T6G 2C8, Alberta, Canada
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15
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Andres A, Kin T, O'Gorman D, Livingstone S, Bigam D, Kneteman N, Senior P, Shapiro AMJ. Clinical islet isolation and transplantation outcomes with deceased cardiac death donors are similar to neurological determination of death donors. Transpl Int 2016; 29:34-40. [PMID: 26264982 DOI: 10.1111/tri.12650] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 06/12/2015] [Accepted: 08/02/2015] [Indexed: 02/05/2023]
Abstract
In islet transplantation, deceased cardiac death (DCD) donation has been identified as a potential extended source. There are currently no studies comparing outcomes between these categories, and our goal was to compare islet isolation success rates and transplantation outcomes between DCD and neurological determination of death (NDD) donors. Islet isolations from 15 DCD and 418 NDD were performed in our centre between September 2008 and September 2014. Donor variables, islet yields, metabolic function of isolated isled and insulin requirements at 1-month post-transplant were compared. Compared to NDD, pancreata from DCD were more often procured locally and donors required less vasopressive support (P < 0.001 and P = 0.023, respectively), but the other variables were similar between groups. Pre- and postpurification islet yields were similar between NDD and DCD (576 vs. 608 × 10(3) islet equivalent, P = 0.628 and 386 vs. 379, P = 0.881, respectively). The metabolic function was similar between NDD and DCD, as well as the mean decrease in insulin requirement at 1-month post-transplantation (NDD: 64.82%; DCD: 60.17% reduction, P = 0.517). These results support the broader use of DCD pancreata for islet isolation. A much larger DCD islet experience will be required to truly determine noninferiority of both short- and long-term outcomes.
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Affiliation(s)
- Axel Andres
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - Tatsuya Kin
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - Doug O'Gorman
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - Scott Livingstone
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - David Bigam
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - Norman Kneteman
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - Peter Senior
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
| | - A M James Shapiro
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
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Dietrich I, Crescenzi A, Chaib E, D'Albuquerque LAC. Trophic effects of adipose derived stem cells on Langerhans islets viability--Review. Transplant Rev (Orlando) 2015; 29:121-6. [PMID: 26002997 DOI: 10.1016/j.trre.2015.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 04/14/2015] [Accepted: 04/30/2015] [Indexed: 12/18/2022]
Abstract
Langerhans islets transplantation has been proposed to provide an endogenous source of insulin in Type I diabetes. However, the hypoxic stress and the receptor's immune reaction suffered by the implants cause them to fail in sustaining the insulin production along the time. Experimental studies have shown that adipose derived stem cells (ADSCs) can secrete cytokines that activate free radical scavengers, antioxidants and chaperone heat/shock proteins leading to reduction of apoptosis in damaged tissues. Therefore, using the PubMed database, we reviewed the experimental studies that investigated the trophic effects of ADSCs on Langerhans islets viability, in vitro and in vivo, from 2009 to 2014. We excluded articles that investigated the effects of other types of mesenchymal stem cells on β-cell survival as well articles that worked in the differentiation of ADSCs into insulin producing cells. The analysis of the experiments revealed that exposure of islets to ADSCs in vitro, even for a short period of time, can enhance islet cell viability and function. In vivo studies also corroborated the trophic effects of ADSCs leading to the improvement of islet function and reduction of the number of the islets required for controlling the receptor's glucose levels. This review can contribute to guide future experiments looking for a long term diabetes treatment employing ADSC trophic effects for the enhancement of transplanted Langerhans islet viability and functioning.
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Affiliation(s)
- Isa Dietrich
- Department of Gastroenterology, Liver and Pancreas Transplantation-Surgery Unit, São Paulo University Medical School, São Paulo 05403090 Brazil.
| | - Alessandra Crescenzi
- Department of Gastroenterology, Liver and Pancreas Transplantation-Surgery Unit, São Paulo University Medical School, São Paulo 05403090 Brazil
| | - Elezar Chaib
- Department of Gastroenterology, Liver and Pancreas Transplantation-Surgery Unit, São Paulo University Medical School, São Paulo 05403090 Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- Department of Gastroenterology, Liver and Pancreas Transplantation-Surgery Unit, São Paulo University Medical School, São Paulo 05403090 Brazil
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