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Rodriguez-Diaz R, Tamayo A, Hara M, Caicedo A. The Local Paracrine Actions of the Pancreatic α-Cell. Diabetes 2020; 69:550-558. [PMID: 31882565 PMCID: PMC7085245 DOI: 10.2337/dbi19-0002] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 12/16/2019] [Indexed: 12/13/2022]
Abstract
Secretion of glucagon from the pancreatic α-cells is conventionally seen as the first and most important defense against hypoglycemia. Recent findings, however, show that α-cell signals stimulate insulin secretion from the neighboring β-cell. This article focuses on these seemingly counterintuitive local actions of α-cells and describes how they impact islet biology and glucose metabolism. It is mostly based on studies published in the last decade on the physiology of α-cells in human islets and incorporates results from rodents where appropriate. As this and the accompanying articles show, the emerging picture of α-cell function is one of increased complexity that needs to be considered when developing new therapies aimed at promoting islet function in the context of diabetes.
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Affiliation(s)
- Rayner Rodriguez-Diaz
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Alejandro Tamayo
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Manami Hara
- Department of Medicine, University of Chicago, Chicago, IL
| | - Alejandro Caicedo
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
- Department of Physiology and Biophysics, University of Miami Miller School of Medicine, Miami, FL
- Program in Neuroscience, University of Miami Miller School of Medicine, Miami, FL
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2
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Rodriguez-Diaz R, Caicedo A. Novel approaches to studying the role of innervation in the biology of pancreatic islets. Endocrinol Metab Clin North Am 2013; 42:39-56. [PMID: 23391238 PMCID: PMC3576136 DOI: 10.1016/j.ecl.2012.11.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The autonomic nervous system helps regulate glucose homeostasis by acting on pancreatic islets of Langerhans. Despite decades of research on the innervation of the pancreatic islet, the mechanisms used by the autonomic nervous input to influence islet cell biology have not been elucidated. This article discusses how these barriers can be overcome to study the role of the autonomic innervation of the pancreatic islet in glucose metabolism. It describes recent advances in microscopy and novel approaches to studying the effects of nervous input that may help clarify how autonomic axons regulate islet biology.
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Affiliation(s)
- Rayner Rodriguez-Diaz
- Diabetes Research Institute, Miller School of Medicine, University of Miami, FL 33136
| | - Alejandro Caicedo
- Diabetes Research Institute, Miller School of Medicine, University of Miami, FL 33136
- Department of Medicine, Miller School of Medicine, University of Miami, FL 33136
- Department of Physiology and Biophysics, Miller School of Medicine, University of Miami, FL 33136
- Program in Neuroscience, Miller School of Medicine, University of Miami, FL 33136
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Rodriguez-Diaz R, Abdulreda MH, Formoso AL, Gans I, Ricordi C, Berggren PO, Caicedo A. Innervation patterns of autonomic axons in the human endocrine pancreas. Cell Metab 2011; 14:45-54. [PMID: 21723503 PMCID: PMC3135265 DOI: 10.1016/j.cmet.2011.05.008] [Citation(s) in RCA: 242] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Revised: 03/30/2011] [Accepted: 05/05/2011] [Indexed: 11/18/2022]
Abstract
The autonomic nervous system regulates hormone secretion from the endocrine pancreas, the islets of Langerhans, thus impacting glucose metabolism. The parasympathetic and sympathetic nerves innervate the pancreatic islet, but the precise innervation patterns are unknown, particularly in human. Here we demonstrate that the innervation of human islets is different from that of mouse islets and does not conform to existing models of autonomic control of islet function. By visualizing axons in three dimensions and quantifying axonal densities and contacts within pancreatic islets, we found that, unlike mouse endocrine cells, human endocrine cells are sparsely contacted by autonomic axons. Few parasympathetic cholinergic axons penetrate the human islet, and the invading sympathetic fibers preferentially innervate smooth muscle cells of blood vessels located within the islet. Thus, rather than modulating endocrine cell function directly, sympathetic nerves may regulate hormone secretion in human islets by controlling local blood flow or by acting on islet regions located downstream.
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Affiliation(s)
- Rayner Rodriguez-Diaz
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
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4
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Alpha cells secrete acetylcholine as a non-neuronal paracrine signal priming beta cell function in humans. Nat Med 2011; 17:888-92. [PMID: 21685896 PMCID: PMC3132226 DOI: 10.1038/nm.2371] [Citation(s) in RCA: 227] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 04/05/2011] [Indexed: 01/02/2023]
Abstract
Acetylcholine is a neurotransmitter that plays a major role in the function of the insulin secreting pancreatic beta cell1,2. Parasympathetic innervation of the endocrine pancreas, the islets of Langerhans, has been shown to provide cholinergic input to the beta cell in several species1,3,4, but the role of autonomic innervation in human beta cell function is at present unclear. Here we show that, in contrast to mouse islets, cholinergic innervation of human islets is sparse. Instead, we find that the alpha cells of the human islet provide paracrine cholinergic input to surrounding endocrine cells. Human alpha cells express the vesicular acetylcholine transporter and release acetylcholine when stimulated with kainate or a lowering in glucose concentration. Acetylcholine secretion by alpha cells in turn sensitizes the beta cell response to increases in glucose concentration. Our results demonstrate that in human islets acetylcholine is a paracrine signal that primes the beta cell to respond optimally to subsequent increases in glucose concentration. We anticipate these results to revise models about neural input and cholinergic signaling in the endocrine pancreas. Cholinergic signaling within the islet represents a potential therapeutic target in diabetes5, highlighting the relevance of this advance to future drug development.
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Petruzzo P, Badet L, Lefrançois N, Berthillot C, Dorel SB, Martin X, Laville M. Metabolic consequences of pancreatic systemic or portal venous drainage in simultaneous pancreas-kidney transplant recipients. Diabet Med 2006; 23:654-9. [PMID: 16759308 DOI: 10.1111/j.1464-5491.2006.01891.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIMS The aim was to investigate pancreatic B-cell function and insulin sensitivity in simultaneous pancreas-kidney (SPK) recipients with systemic or portal venous drained pancreas allograft using simple and easy tests. METHODS The study included 44 patients with Type 1 diabetes and end-stage renal disease who had undergone SPK transplantation: 20 recipients received a pancreas allograft with systemic venous drainage (S-SPK) and 24 with portal venous drainage (P-SPK). We studied only recipients with functioning grafts, with normal serum glucose, HbA(1c) and serum creatinine values, on a stable drug regimen. The subjects were studied at 6, 12, 24, 36, 48 and 60 months after transplantation. Insulin sensitivity and B-cell function indices were derived from blood samples and oral glucose tolerance tests. RESULTS All patients from both groups had normal fasting glucose, body mass index and HbA(1c) values by selection. The homeostatic model (HOMA) beta-cell index was significantly lower in P-SPK recipients at several points of the follow-up. HOMA-IR was significantly higher in S-SPK recipients at 6 and 24 months after transplantation and was positively correlated with fasting insulin values, but never exceeded 3.2. There was no significant difference in QUICKI index values between the two groups. Although all patients from both groups always had normal glucose tolerance, the area under the insulin curve was higher in the S-SPK group. Cholesterol, low-density lipoprotein-cholesterol and triglycerides were higher in the P-SPK group. CONCLUSIONS The results suggest sustained long-term endocrine function in both groups and show that portal venous drainage does not offer major metabolic advantages.
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Affiliation(s)
- P Petruzzo
- Department of Surgery, University of Cagliari, Cagliari, Italy.
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La Rocca E, Fiorina P, di Carlo V, Astorri E, Rossetti C, Lucignani G, Fazio F, Giudici D, Cristallo M, Bianchi G, Pozza G, Secchi A. Cardiovascular outcomes after kidney-pancreas and kidney-alone transplantation. Kidney Int 2001; 60:1964-71. [PMID: 11703616 DOI: 10.1046/j.1523-1755.2001.00008.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND This study retrospectively assessed, with an intention-to-treat analysis, the effect of kidney-pancreas transplantation (KP) on survival and cardiovascular outcome in type 1 diabetic uremic patients. METHODS A total of 351 uremic type 1 diabetic patients were enrolled on a waiting list for KP: 130 underwent KP transplantation, 25 underwent kidney transplantation alone (KA), whereas 196 patients remained on dialysis (WL). The three populations had similar cardiovascular conditions. Actuarial survival rates and causes of death were recorded over a period of seven years. Finally, 23 KP and 13 KA patients underwent left radionuclide ventriculography, during a follow-up of four years. RESULTS In the entire group of 351 patients the seven-year survival rate was 77.4% for KP, 56.0% for KA and 39.6% for WL (KP vs. WL, P = 0.01). Cardiovascular death rate was 7.6% in KP, 20.0% in KA and 16.1% in WL (KP versus WL, P = 0.03; KP vs. KA, P = 0.16). In the subsample studied with radionuclide ventriculography, left ventricular ejection fraction improved in KP, but did not in KA, with significant differences between groups at two and four years. At four years only the KP patients presented normal values of diastolic parameters, including the peak filling rate, time-to-peak filling rate, and peak filling rate/peak ejection rate ratio. Glycated hemoglobin was negatively associated with the ejection fraction, peak filling rate and peak filling rate/peak ejection rate ratio, and positively associated with the time-to-peak filling rate. CONCLUSIONS Normalization of blood glucose metabolism and improvement of blood pressure control obtained with KP transplant is associated with positive effects on survival, cardiovascular death rate, and left ventricular function.
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Affiliation(s)
- E La Rocca
- Department of Internal Medicine, San Raffaele Scientific Institute, Universitá Vita e Salute, Via Olgettina 60, 20132 Milan, Italy
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La Rocca E, Fiorina P, Astorri E, Rossetti C, Lucignani G, Fazio F, Giudici D, Castoldi R, Bianchi G, Di Carlo V, Pozza G, Secchi A. Patient survival and cardiovascular events after kidney-pancreas transplantation: comparison with kidney transplantation alone in uremic IDDM patients. Cell Transplant 2000; 9:929-32. [PMID: 11202580 DOI: 10.1177/096368970000900621] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In diabetic patients cardiovascular morbidity and mortality is still a major problem. Our aim was to study the effect of kidney-pancreas transplantation on survival, cardiovascular events, and causes of death in diabetic type 1 uremic patients. Three hundred and thirty-three uremic IDDM patients were enrolled in our waiting list for kidney-pancreas transplantation: 107 underwent kidney-pancreas transplantation (KP), 34 underwent kidney transplantation alone (KA), whereas 192 patients remained on dialysis (WL). Actuarial survival and causes of death were recorded over a period of 7 years. Seven-year survival rate was 75% for the KP group, 63% for the KA group, and 37% for the WL group (p = 0.001). Cardiovascular death rate was 9.8% in the KP group, 17.6% in the KA group, and 18.1% in the WL group (KP vs. WL, p = 0.05). Rate of acute myocardial infarction in the KP group was lower than in the KA group (2.4% vs. 17.6%, p = 0.005) as well as rate of acute pulmonary edema (0.8% vs. 23.5%, p = 0.0001) and rate of hypertensive patients at 1 (40.9% vs. 85.0%, p = 0.0001) and at 2 years (57.6% vs. 80%, p = 0.03). Kidney-pancreas transplant helped to obtain euglycemia with positive effects on survival and cardiovascular events.
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Affiliation(s)
- E La Rocca
- Department of Internal Medicine, San Raffaele Scientific Institute, Milano, Italy
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8
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Nauck MA, Pfeffer F, Erb M, Müller T, Benz S, Schmiegel W, Hopt U. Does glucagon stimulation predict oral glucose tolerance in patients after simultaneous pancreas-kidney transplantation? Transplantation 2000; 70:545-7. [PMID: 10949203 DOI: 10.1097/00007890-200008150-00027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Exogenous glucagon rapidly stimulates insulin secretion. This test has been used to estimate insulin secretory capacity, which may predict oral glucose tolerance in patients after pancreas transplantation. METHODS In 32 pancreas-kidney transplant recipients, in 10 nondiabetic kidney transplant recipients, and in 9 healthy control subjects, a glucagon stimulation test (1 mg i.v.) and a 75-g oral glucose tolerance test were performed with determination of glucose, insulin, and C-peptide profiles. RESULTS Of 16 pancreas transplant recipients with the lowest insulin responses after glucagon, 7 had an impaired oral glucose tolerance, in contrast to 1 of 16 with high insulin responses (P=0.037). A low insulin response after glucagon was associated with significantly lower 120-min glucose concentrations (P=0.043) and a lower integrated incremental insulin response after oral glucose (P=0.006). CONCLUSIONS In pancreas-kidney transplant recipients, a low insulin response after intravenous glucagon predicts a reduced insulin response after oral glucose and an impaired oral glucose tolerance. This simple test may be helpful in the follow-up of pancreas transplant recipients.
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Affiliation(s)
- M A Nauck
- Department of Medicine, Ruhr-University Bochum, Knappschafts-Krankenhaus, Germany
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9
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Malighetti ME, Berra C, Secchi A, Pozza G, Di Carlo V, Luzi L. Persistence of anomalies in the growth hormone-releasing hormone-stimulated growth hormone response in diabetic-uremic patients after combined kidney-pancreas transplantation. Transplantation 2000; 69:1965-8. [PMID: 10830243 DOI: 10.1097/00007890-200005150-00041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Increased circulating growth hormone (GH) levels and aberrant response to different stimuli characterize both type 1 diabetes mellitus and chronic uremia and are associated with severe retinal, kidney and heart complications. Combined kidney and pancreas transplantation is a therapy that restores the endogenous, closed-loop, insulin secretion in diabetes and cure uremia. To evaluate if combined transplantation can restore a normal secretion and response of GH to growth hormone releasing hormone (GH-RH), we studied four groups of subjects: (1) seven type 1 diabetic patients with end-stage renal failure who had received pancreas and kidney transplantation (KPTx); (2) six diabetic uremic subjects, candidates for combined transplantation (IDDUP); (3) nine patients with chronic uveitis on immunosuppressive therapy comparable to pancreas recipients, six of whom treated only with prednisone (UVEST), while three (4) were treated with both prednisone and cyclosporin (UVESTCY). All subjects underwent a GH-RH test (50 microg intravenously, i.v., at 13:00 h). Serum insulin levels were significantly higher in IDDUP compared to UVEST (P=0.05) both at baseline and post GH-RH stimulus, while were similar to KPTx (P=0.2) and UVESTCY (P=0.7). In contrast, plasma free fatty acids were similar in all groups. In IDDUP baseline plasma glycerol was higher than in KPTx (P=0.04) and UVEST (P=0.02) and similar to UVESTCY (P=0.36); glycerol concentration did not change after GH-RH (P=0.08). Before and after GH-RH, serum GH levels tended to be higher in IDDUP (P=0.5) and KPTx (P=0.2) compared to UVEST and UVESTCY. Our results indicate that: 1) kidney-pancreas transplantation does not normalize the GH response to GH-RH; 2) GH abnormalities are not due either to the chronic immunosuppressive therapy or to the insulin effect on GH release; 3) GH abnormalities are probably secondary to functional and/or organic complications of the hypothalamus and/or pituitary as a sequela of diabetes mellitus.
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Affiliation(s)
- M E Malighetti
- Department of Medicine and Surgery, San Raphael Scientific Institute, University of Milan, Italy
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10
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Abstract
AIMS This review examines the status of vascularized pancreas transplantation as a treatment for Type 1 diabetes mellitus (DM). METHODS The world literature, with a particular emphasis on data from the International Pancreas Transplant Registry (IPTR), is reviewed and interpreted particularly for clinical indications and outcome. RESULTS Over 9000 cases of vascularized pancreas transplant (VPT) have been registered, with insulin dependence approaching 82% at 1 year with 94% patient survival. The majority of transplants are simultaneous pancreas and kidney (SPK) transplants, with far fewer pancreas after kidney (PAK) or pancreas transplants alone (PTA). The success rates differ between the procedures but are generally improving as technical advances, improvements in immunosupression and greater experience are gained. The most obvious advantage is an improved quality of life (QoL) but there are risks associated with the procedure and with the immunosuppression. There is some evidence coming to light of a very slow beneficial effect on microvascular complications. CONCLUSIONS VPT is an attractive option to offer Type 1 DM patients who need or already have a renal allograft. Patients have to decide between the increased surgical risk and the risks of long-term immunosuppression and the benefits of improved QoL. In the absense of end-stage renal failure (ESRF) there is no justification for PTA, except where the diabetes itself poses a greater risk to life than the transplantation procedure.
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Affiliation(s)
- S A White
- Department of Surgery, University of Leicester, Leicester General Hospital, UK
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Babazono T, Teraoka S, Tomonaga O, Iwamoto Y, Omori Y. Circulating proinsulin levels in insulin-dependent diabetic patients after whole pancreas-kidney transplantation. Metabolism 1998; 47:1325-30. [PMID: 9826207 DOI: 10.1016/s0026-0495(98)90299-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Disproportional hyperproinsulinemia is a sensitive marker for beta-cell dysfunction. The objective of this study was to assess the proinsulin profile in persons with insulin-dependent diabetes mellitus (IDDM) after pancreas-kidney transplantation. We determined serum insulin, C-peptide, and proinsulin concentrations during an oral glucose challenge in five pancreas-kidney transplant recipients, nine nondiabetic kidney transplant recipients, and 17 normal subjects. Basal proinsulin concentrations were significantly increased in pancreas-kidney recipients (geometric mean [+/-1 SE range], 6.0 [5.5 to 6.4] pmol/L) and kidney recipients (6.4 [5.4 to 7.5] pmol/L) compared with the normal subjects (2.8 [2.5 to 3.2] pmol/L). Integrated proinsulin concentrations during the oral glucose load were also higher in pancreas-kidney recipients (1.4 [1.1 to 1.8] nmol/L x min) and kidney recipients (1.5 [1.2 to 2.0] nmol/L x min) versus normal subjects (0.8 [0.7 to 0.9] nmol/L x min). There was no difference in basal or integrated proinsulin concentrations between the two transplant groups. Even after adjustment for the glomerular filtration rate (GFR), basal and incremental proinsulin concentrations continued to be higher in the transplant groups than in the normal subjects. Proinsulin to C-peptide molar ratios both before and after the glucose load were similar in the three groups. From these findings, we conclude that pancreas-kidney transplantation provokes proportional hyperproinsulinemia, which is closely associated with its reduced clearance in the kidneys.
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Affiliation(s)
- T Babazono
- Department of Medicine, Diabetes Center, Tokyo Women's Medical College, Japan
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Secchi A, Martinenghi S, Castoldi R, Giudici D, Di Carlo V, Pozza G. Effects of pancreas transplantation on quality of life in type I diabetic patients undergoing kidney transplantation. Transplant Proc 1998; 30:339-42. [PMID: 9532068 DOI: 10.1016/s0041-1345(97)01296-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- A Secchi
- Department of Internal Medicine, Scientific Institute San Raffaele, University of Milan, Italy
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Pfeffer F, Nauck MA, Benz S, Gwodzinski A, Erb M, Hopt UT. Prediction of glucose tolerance with glucagon stimulation in pancreas transplanted patients. Transplant Proc 1997; 29:3122-3. [PMID: 9365692 DOI: 10.1016/s0041-1345(97)00808-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- F Pfeffer
- Department of Surgery, University of Rostock, Germany
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Pfeffer F, Nauck MA, Benz S, Gwodzinski A, Zink R, Büsing M, Becker HD, Hopt UT. Determinants of a normal (versus impaired) oral glucose tolerance after combined pancreas-kidney transplantation in IDDM patients. Diabetologia 1996; 39:462-8. [PMID: 8777996 DOI: 10.1007/bf00400678] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
After successful pancreas transplantation, insulin-dependent diabetic patients are characterized by a normal or at worst impaired oral glucose tolerance (World Health Organisation criteria). It is not known which pathophysiological mechanisms cause the difference between normal and impaired oral glucose tolerance. Therefore, we studied 41 patients after successful combined pancreas-kidney transplantation using stimulation in the fasting state with oral glucose (75 g), intravenous glucose (0.33 g/kg) and glucagon bolus injection (1 mg i.v.). Glucose (glucose oxidase), insulin and C-peptide (immunoassay) were measured. Repeated-measures analysis of variance and multiple regression analysis were used to analyse the results which showed: 28 patients had a normal, and 13 patients had an impaired oral glucose tolerance. Impaired oral glucose tolerance was associated with a greatly reduced early phase insulin secretory response (insulin p < 0.0001; C-peptide p = 0.037). Age (p = 0.65), body mass index (p = 0.94), immunosuppressive therapy (cyclosporin A p = 0.84; predniso(lo)ne p = 0.91; azathioprine p = 0.60) and additional clinical parameters were not different. Reduced insulin secretory responses in patients with impaired oral glucose tolerance were also found with intravenous glucose or glucagon stimulations. Exocrine secretion (alpha-amylase in 24-h urine collections) also demonstrated reduced pancreatic function in these patients (-46%; p = 0.04). Multiple regression analysis showed a significant correlation of 120-min glucose with ischaemia time (p = 0.003) and the number of HLA-DR mismatches (p = 0.026), but not with HLA-AB-mismatches (p = 0.084). In conclusion, the pathophysiological basis of impaired oral glucose tolerance after pancreas transplantation is a reduced insulin secretory capacity. Transplant damage is most likely caused by perioperative influences (ischaemia) and by the extent of rejection damage related, for example, to DR-mis-matches.
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Affiliation(s)
- F Pfeffer
- Department of Surgery, University of Rostock, Germany
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15
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Secchi A, Caldara R, Caumo A, Monti LD, Bonfatti D, Di Carlo V, Pozza G. Cephalic-phase insulin and glucagon release in normal subjects and in patients receiving pancreas transplantation. Metabolism 1995; 44:1153-8. [PMID: 7666788 DOI: 10.1016/0026-0495(95)90008-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The aim of the study was to evaluate whether the cephalic phase of insulin release is still present in patients submitted to simultaneous kidney and pancreas transplantation. Subjects were five kidney-pancreas-transplanted patients (group P) and five control (group C). The experimental protocol lasted 30 minutes, and blood samples were collected at 1-minute intervals. After a 20-minute period of steady-state fasting (premeal period), subjects received a palatable standard meal (pizza). Samples were collected over the subsequent 10 minutes (meal period). No evidence of an increase in serum free insulin, serum C-peptide, and plasma glucagon during food ingestion was observed in group P whereas the test was effective in eliciting cephalic-phase insulin and glucagon release in group C. Gastric inhibitory polypeptide and somatostatin did not show any variation during the test in both groups. In conclusion, the absence of cephalic-phase insulin and glucagon release in group P could be explained by denervation of the grafted pancreas. This early alteration could contribute to the impairment in glucose tolerance frequently observed in successfully pancreas-transplanted patients.
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Affiliation(s)
- A Secchi
- Department of Internal Medicine, San Raffaele Scientific Institute, Milan, Italy
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16
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La Rocca E, Secchi A, Parlavecchia M, Bonfatti D, Ragogna F, Di Carlo V, Pozza G, Ruotolo G. Lipoprotein profile after combined kidney-pancreas transplantation in insulin dependent diabetes mellitus. Transpl Int 1995; 8:190-5. [PMID: 7626178 DOI: 10.1007/bf00336536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
In order to evaluate the effect of a combined kidney-pancreas (KP) transplantation in insulin-dependent diabetes mellitus (IDDM) patients on the lipid and lipoprotein profile, 15 KP patients were compared with 11 kidney (K)--transplanted IDDM patients, 19 IDDM patients on hemodialysis (HD), and 15 nondiabetic control subjects. Cholesterol, triglycerides, apo AI, and apo B were measured in total plasma and in VLDL, LDL, and HDL of all participants. VLDL cholesterol, VLDL-triglycerides, and VLDL-apo B were significantly lower in KP patients, but not in K patients, than in HD patients. In addition, patients in the K, but not in the KP, group showed high levels of apo B in LDL and an increased triglyceride/apo B ratio in VLDL, compared with patients in the HD group. The percentage of apo AI associated with HDL was significantly higher in both transplanted groups than in the HD group. However, compared with a nondiabetic control population, an increase in VLDL particles and in triglyceride content in LDL and HDL still persisted following combined KP transplantation. Insulin resistance (probably due to steroid therapy) associated with high peripheral and potentially low hepatic insulin levels (due to the systemic drainage of the transplanted pancreas) could be the main causes of the remaining lipoprotein abnormalities.
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Affiliation(s)
- E La Rocca
- Department of Medicine, Scientific Institute H San Raffaele, Milan, Italy
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17
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Rocca EL, Secchi A, Parlavecchia M, Bonfatti D, Ragogna F, Carlo VD, Pozza G, Ruotolo G. Lipoprotein profile after combined kidneypancreas transplantation in insulindependent diabetes mellitus. Transpl Int 1995. [DOI: 10.1111/j.1432-2277.1995.tb01502.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Battezzati A, Luzi L, Perseghin G, Bianchi E, Spotti D, Secchi A, Vergani S, Di Carlo V, Pozza G. Persistence of counter-regulatory abnormalities in insulin-dependent diabetes mellitus after pancreas transplantation. Eur J Clin Invest 1994; 24:751-8. [PMID: 7890013 DOI: 10.1111/j.1365-2362.1994.tb01072.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Conventional insulin therapy does not correct the counter-regulatory abnormalities of insulin-dependent diabetes mellitus. Pancreas transplantation is an alternative therapy that restores the endogenous insulin secretion in diabetes. In this study, the effects of segmental pancreas transplantation on counter-regulation to mild hypoglycaemia were evaluated. Glucose kinetics and the counter-regulatory hormonal responses were assessed in eight insulin-dependent diabetics with end-stage renal failure who had received pancreas and kidney transplantation 1 year previously, seven diabetic uraemic subjects (candidates for combined transplantation), five patients with chronic uveitis on immunosuppressive therapy comparable to pancreas recipients and 10 normal subjects. Insulin (0.3 mU kg-1 min-1) was infused for 2 h to induce mild hypoglycaemia (plasma glucose 3.2-3.5 mmol l-1) and exogenous glucose was infused as required to prevent any glucose decrease below 3.1 mmol l-1. After transplantation, two of eight recipients had hypoglycaemic episodes reported in their medical records. During the study, hepatic glucose production was rapidly suppressed in the controls and in the patients on immunosuppression (-80 +/- 7 and -54 +/- 7%, P < 0.001 vs. basal), and rebounded to the baseline values within 1 h (-3 +/- 1 and -6 +/- 2%, P = NS vs. basal). The transplant recipients had similar suppression in the first hour (-88 +/- 8%, P < 0.001 vs. basal), but the suppression persisted in the second hour (-69 +/- 11%, P < 0.001 vs. basal) indicating a lack of glucose counter-regulatory response.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- A Battezzati
- Department of Internal Medicine, Istituto Scientifico San Raffaele, Università di Milano, Italy
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19
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Zehrer CL, Gross CR. Patient perceptions of benefits and concerns following pancreas transplantation. DIABETES EDUCATOR 1994; 20:216-20. [PMID: 7851236 DOI: 10.1177/014572179402000307] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The purpose of this study was to assess patient perceptions of the impact of pancreas transplantation on various aspects of life, as well as perceptions of the benefits of and concerns with the procedure. All surviving adult patients who had received a pancreas transplant at a midwestern hospital and were at least 1 year posttransplant at the time of the study (N = 138) were sent a self-report questionnaire that included demographic data, questions about life satisfaction, quality of life, symptoms, and health impact. Patients with pancreas graft function reported less pain with healthcare treatment, fewer episodes of feeling physically ill, fewer dietary restrictions, less interference with family life, fewer health limitations in interpersonal relationships and leisure activities, and feeling good about themselves compared with those without graft function. A majority of patients with functioning grafts cited the following benefits: freedom from insulin reactions, normal blood sugars, freedom from insulin injections, freedom from a specialized diet, decreased chance of amputation, feeling better physically, more feelings of hope for the future, and more freedom and control over life. Major concerns posttransplant included side effects and the expense of immunosuppressive medications.
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20
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Christiansen E, Andersen HB, Rasmussen K, Christensen NJ, Olgaard K, Kirkegaard P, Tronier B, Vølund A, Damsbo P, Burcharth F. Pancreatic beta-cell function and glucose metabolism in human segmental pancreas and kidney transplantation. THE AMERICAN JOURNAL OF PHYSIOLOGY 1993; 264:E441-9. [PMID: 8460692 DOI: 10.1152/ajpendo.1993.264.3.e441] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
beta-Cell function and glucose metabolism were studied in eight insulin-dependent diabetic recipients of combined segmental pancreas and kidney transplant with peripheral insulin delivery (Px), in eight nondiabetic kidney-transplant individuals (Kx), and in eight normal subjects (Ns) after three consecutive mixed meals. All subjects had normal fasting plasma glucose, but increased basal levels of C-peptide were demonstrated in the transplant groups (P < 0.05 relative to Ns). Postprandial hyperglycemia was increased 14% in Kx and 32% in Px (P < 0.05), whereas compared with Ns postprandial C-peptide levels were increased three- and twofold, respectively, in Kx and Px (P < 0.05). Compared with Ns basal insulin secretion rate (combined model) was increased 2-fold in Kx and 1.4-fold in Px (P < 0.05). Maximal insulin secretion rate was reduced 25% in Px compared with Kx (P < 0.05) but not different from that of Ns (P NS). Also, maximal insulin secretion rate occurred later in Px than in controls (Tmax: Px 50 min, Kx 30 min, and Ns 32 min; P < 0.05). The total integrated insulin secretion was increased 1.4-fold in Px compared with Ns (P < 0.05) but decreased 1.4-fold compared with Kx (P < 0.05). Fasting and postprandial proinsulin-to-C-peptide molar ratios were inappropriately increased in Px compared with Kx and Ns. Basal hepatic glucose production was increased 43% in Px and 33% in Kx compared with Ns (P < 0.05). Postprandial total systemic glucose appearance was similar in all three groups, whereas peripheral glucose disposal was 15% reduced in Px (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- E Christiansen
- Department of Internal Medicine, Herlev Hospital, University of Copenhagen, Denmark
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21
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Nauck MA, Büsing M, Orskov C, Siegel EG, Talartschik J, Baartz A, Baartz T, Hölzer H, Hopt UT, Ebert R. Basal and nutrient-stimulated pancreatic and gastrointestinal hormone concentrations in type-1-diabetic patients after successful combined pancreas and kidney transplantation. THE CLINICAL INVESTIGATOR 1992; 70:40-8. [PMID: 1600330 DOI: 10.1007/bf00422937] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The secretion of pancreatic and gastrointestinal hormones in the basal state and after nutrient stimuli (50 g glucose, 50 g protein, or 30 g triglyceride administered on separate occasions) was assessed in ten previously type-1-diabetic patients after successful combined kidney and pancreas transplantation (systemic venous drainage). Fasting values were compared to matched non-diabetic kidney-transplanted patients and related to kidney function (endogenous creatinine clearance) and to the type and dosage of immunosuppressive medication. In the fasting state, only IR insulin concentrations were higher in pancreas-kidney-transplanted patients (by 88%; P = 0.001) than in the kidney graft recipients. There were significant inverse correlations of plasma C-peptide, GIP, and gastrin immunoreactivity to endogenous creatinine clearance (kidney function). In response to nutrients, insulin secretion (IR insulin, C-peptide) was significantly stimulated by glucose, and - to a lesser degree - also by protein. Pancreatic glucagon was suppressed by glucose and stimulated by protein ingestion. GIP was raised after glucose and triglyceride more than after protein (P = 0.0003). GLP-1 immunoreactivity was stimulated by all nutrients, with a tendency towards higher responses to protein and fat (P = 0.06). Gastrin was mainly raised by protein. In conclusion, the overall pattern of pancreatic and gastrointestinal hormone release is normal in patients after combined pancreas-kidney-transplantation, but there are some peculiarities due to (a) systemic venous drainage of the pancreas graft (elevated fasting IR insulin) and (b) impaired kidney function (negative correlation of fasting plasma values to endogenous creatinine clearance for C-peptide, GIP, and gastrin).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M A Nauck
- Abteilung Gastroenterologie und Endokrinologie, Georg-August-Universität, Göttingen
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22
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Homan M, Nicholson CP, Katz H, Perkins J, Haymond M, Jensen M, Butler P, Rizza R. Effects of chronic systemic insulin delivery on insulin action in dogs. Diabetologia 1991; 34:702-8. [PMID: 1959702 DOI: 10.1007/bf00401514] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The metabolic consequences of the prolonged systemic insulin delivery associated with human pancreas transplantation have not been precisely defined. To determine if systemic insulin delivery in the absence of immunosuppressive agents results in alterations in hepatic or extrahepatic insulin action, three groups of dogs were studied 2 months after either a sham operation or after their pancreatic venous drainage was severed and anastomosed to the inferior vena cava or portal vein (sham, peripheral and portal groups, respectively). The pattern of venous drainage was documented by measuring vena cava and portal insulin concentrations before and after glucose injection. Systemic insulin concentrations were higher (p less than 0.05) in the peripheral group than in the portal group both following a 14-h fast and after intravenous glucose. During a hyperinsulinaemic euglycaemic clamp (1 mU.kg-1.min-1), glucose utilization (measured using [6(3)H]glucose) was slightly lower (p = 0.07) in the peripheral than in the portal group. Hepatic glucose release was equal in all groups. Carbon dioxide incorporation into glucose (an estimate of gluconeogenesis) was higher in the portal than peripheral group in the fasted state but not during insulin infusion. Plasma concentrations and flux rates of fatty acids and amino acids did not differ between groups. We conclude that chronic systemic insulin delivery results in a) systemic but not portal hyperinsulinaemia, b) a minimal impairment in insulin-stimulated glucose uptake, without altering insulin-induced suppression of hepatic glucose release, and c) no effect on fatty acid or amino acid turnover.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M Homan
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
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23
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Abstract
The quality of life outcome of 131 pancreas transplant recipients who were 1 to 11 years post-transplant were studied. Patients with a functioning pancreas graft (n = 65) described their current quality of life and rated their health significantly more favourably than those with non-functioning grafts (n = 66). For example, of those patients with a functioning pancreas graft, 68% expressed overall satisfaction with their life, 89% felt healthier since their transplant, and 78% reported that they could care for themselves and their routine daily activities. In contrast, of those patients without a functioning graft, only 48% expressed overall satisfaction with life (p less than 0.01), only 25% felt healthier since their transplant (p less than 0.001), and only 56% indicated they could care for themselves and their daily activities (p less than 0.001). Regardless of graft function, the majority of patients were comfortable with their decision to have the transplant, and most of the patients with pancreas graft function reported that they would have another transplant if their graft failed. While successful pancreas transplantation may not elevate all diabetic patients to the level of health and function of the general population, these patients report a significantly better quality of life than do those patients who remain diabetic.
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Affiliation(s)
- C L Zehrer
- Department of Nursing Services, University of Minnesota, Minneapolis
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24
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Secchi A, Martinenghi S, Caldara R, La Rocca E, Di Carlo V, Pozza G. First peak insulin release after intravenous glucose and arginine is maintained for up to 3 years after segmental pancreas transplantation. Diabetologia 1991; 34 Suppl 1:S53-6. [PMID: 1936696 DOI: 10.1007/bf00587620] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In this study we have investigated blood glucose and serum free insulin response to glucose and to arginine orally or intravenously, 3 months and 3 years after a successful segmental, neoprene-injected, pancreas transplantation. Serum insulin responses to different secretagogues were normal 3 months after transplantation; they remained normal up to 3 years after transplantation.
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Affiliation(s)
- A Secchi
- Department of Internal Medicine, Istituto Scientifico San Raffaele, Milan, Italy
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25
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Secchi A, Di Carlo V, Martinenghi S, La Rocca E, Caldara R, Spotti D, Slaviero G, Staudacher C, Ferrari G, Pozza G. Effect of pancreas transplantation on life expectancy, kidney function and quality of life in uraemic type 1 (insulin-dependent) diabetic patients. Diabetologia 1991; 34 Suppl 1:S141-4. [PMID: 1936682 DOI: 10.1007/bf00587642] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The aim of our study was to evaluate the effects of haemodialysis, kidney transplantation and simultaneous kidney and pancreas transplantation on survival of diabetic subjects and on kidney function. 40 Type 1 (insulin-dependent) diabetic patients received a kidney transplantation: in 31 cases the kidney was transplanted simultaneously to a pancreas graft from the same donor (KP group), while in 9 cases the pancreas was not available (K group). 44 uraemic Type 1 (insulin-dependent) diabetic patients on dialysis and in waiting list for kidney transplantation, constituted the control group (HD group). Patient survival rate 1, 3 and 5 years following transplantation was better in KP group (93%, 89%, 89%, respectively) and in K group (88%, 88%, 73%, respectively) and in HD group (88%, 62%, 51%, respectively). Kidney graft survival at 1, 3 and 5 years post-transplant was better in KP group (93%, 72%, 72%, respectively) than in K group (76%, 61%, 31%, respectively). 1 year after transplantation, patients of the KP group who had lost the pancreas for technical reasons (thrombosis) were included in the K group so as to evaluate the effect of the transplanted pancreas on long-term patient and kidney survival. Patient survival rate in the KP group (17 patients) at 2 and 4 years was 100%, while at the same intervals it was 78% in the K group (13 patients). Kidney graft function rate at 2 and 4 years was 93% in the KP group (17 grafts) and 54% and 27% respectively in the K group (14 grafts).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- A Secchi
- Department of Internal Medicine, Istituto Scientifico San Raffaele, Milan, Italy
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26
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Barr JD, Cornett G, Parish ES, Freedlender AE, Flanagan TL, Kaiser DL, Hanks JB. Glipizide treatment of pancreas autotransplantation: effects on alterations in glucose-insulin relationships. Endocr Res 1991; 17:367-81. [PMID: 1811986 DOI: 10.1080/07435809109106814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pancreas transplantation has been proven effective in supplying an endogenous insulin supply in diabetics. However, alterations in glucose metabolism after transplantation suggest a possible "insensitivity" to its action in the periphery. We hypothesized that sulfonylurea treatment of canines who had received segmental pancreas autotransplants would correct these alterations by altering peripheral insulin sensitivity. Glipizide therapy (5 mg p.o. b.i.d.) did appear, in fact, to enhance basal insulin sensitivity by lowering fasting glucose (100 +/- 3 to 81 +/- 11 mg/dl pre-treatment to post-treatment) while not affecting basal insulin levels. However, glipizide therapy was associated with decreased insulin response to challenge by either oral glucose (2 gm/kg) or sustained intravenous hyperglycemia (150 mg/dl above basal). We conclude that our model of pancreas autotransplantation documents alterations in glucose metabolism which are devoid of the effect of immunosuppression. Glipizide treatment appears to affect fasting sensitivity to insulin, but results in a decrement of insulin response to oral or intravenous glucose challenge.
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Affiliation(s)
- J D Barr
- Department of Surgery, University of Virginia Health Sciences Center, Charlottesville
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27
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Diem P, Redmon JB, Abid M, Moran A, Sutherland DE, Halter JB, Robertson RP. Glucagon, catecholamine and pancreatic polypeptide secretion in type I diabetic recipients of pancreas allografts. J Clin Invest 1990; 86:2008-13. [PMID: 2254456 PMCID: PMC329838 DOI: 10.1172/jci114936] [Citation(s) in RCA: 103] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Successful pancreas transplantation in type I diabetic patients restores normal fasting glucose levels and biphasic insulin responses to glucose. However, virtually no data from pancreas recipients are available relative to other islet hormonal responses or hormonal counterregulation of hypoglycemia. Consequently, glucose, glucagon, catecholamine, and pancreatic polypeptide responses to insulin-induced hypoglycemia and to stimulation with arginine and secretin were examined in 38 diabetic pancreas recipients, 54 type I diabetic nonrecipients, and 26 nondiabetic normal control subjects. Glucose recovery after insulin-induced hypoglycemia in pancreas recipients was significantly improved. Basal glucagon levels were significantly higher in recipients compared with nonrecipients and normal subjects. Glucagon responses to insulin-induced hypoglycemia were significantly greater in the pancreas recipients compared with nonrecipients and similar to that observed in control subjects. Glucagon responses to intravenous arginine were significantly greater in pancreas recipients than that observed in both the nonrecipients and normal subjects. No differences were observed in epinephrine responses during insulin-induced hypoglycemia. No differences in pancreatic polypeptide responses to hypoglycemia were observed when comparing the recipient and nonrecipient groups, both of which were less than that observed in the control subjects. Our data demonstrate significant improvement in glucose recovery after hypoglycemia which was associated with improved glucagon secretion in type I diabetic recipients of pancreas transplantation.
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Affiliation(s)
- P Diem
- Department of Medicine, University of Minnesota, Minneapolis
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28
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Luzi L, Secchi A, Facchini F, Battezzati A, Staudacher C, Spotti D, Castoldi R, Ferrari G, Di Carlo V, Pozza G. Reduction of insulin resistance by combined kidney-pancreas transplantation in type 1 (insulin-dependent) diabetic patients. Diabetologia 1990; 33:549-56. [PMID: 2253832 DOI: 10.1007/bf00404143] [Citation(s) in RCA: 81] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To evaluate the effect of combined kidney and pancreas transplantation on insulin action and glucose metabolism, 15 Type 1 (insulin-dependent) diabetic patients who were undergoing combined kidney-pancreas transplantation were studied before transplantation by means of the euglycaemic hyperinsulinaemic clamp technique combined with 3-3H-glucose infusion and indirect calorimetry. Nine of the original 15 patients were studied again after four months and six after 12 months, successful combined kidney-pancreas transplantation with the same experimental protocol. Nine volunteers formed the group of normal subjects. Combined kidney-pancreas transplantation normalised hepatic glucose production and reduced peripheral insulin resistance in Type 1 diabetic uraemic patients, despite chronic immunosuppressive therapy. To further evaluate the hypothesis that residual insulin resistance was due to chronic steroid therapy. 11 additional subjects with chronic uveitis (six of whom were treated with only prednisone, and five treated only with cyclosporin) underwent the same protocol demonstrating a normal hepatic glucose production. The insulin-stimulated peripheral glucose uptake was reduced in the prednisone-treated group, but normal in cyclosporin-treated subjects. Four additional diabetic patients with a kidney transplant were also studied. They showed a peripheral insulin sensitivity intermediate between diabetic uraemic patients and patients after combined transplant. We conclude that short-term (one year) combined kidney-pancreas transplantation improves glucose metabolism by restoring normal rates of hepatic glucose production and reducing peripheral insulin resistance; chronic steroid therapy is the major determinant of residual reduced insulin action. Both kidney and pancreas substitution play a role in reducing peripheral insulin resistance.
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Affiliation(s)
- L Luzi
- Department of Internal Medicine, Istituto Scientifico San Raffaele, University of Milan, Italy
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29
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Landgraf R, Nusser J, Scheuer R, Fiedler A, Scheider A, Meyer-Schwickerath E, Müller-Felber W, Illner WD, Abendroth D, Land W. Metabolic control and effect on secondary complications of diabetes mellitus by pancreatic transplantation. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1989; 3:865-76. [PMID: 2701725 DOI: 10.1016/0950-3528(89)90038-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
After successful pancreatic transplantation blood glucose can be normalized without exogenous insulin, although oral and intravenous glucose tolerance remains impaired in 10-45% of the patients. There is no significant deterioration of glucose control with time in most patients. Since most recipients of pancreatic grafts have far advanced secondary diabetic lesions and the observation time after grafting is rather short, the effects of pancreatic transplantation on these complications are difficult to interpret. However, the development of diabetic nephropathy can be prevented, skin microcirculation improves significantly, while autonomic and peripheral neuropathy and diabetic retinopathy remain stable or improve slightly in most patients. But these ameliorations may be in part due to elimination of uraemia, since in almost all patients combined pancreas/kidney transplantations were performed. It is concluded that pancreas grafting probably has to be performed much earlier in the course of diabetes, although the improvement in the quality of life is striking even in the end-stage diabetics studied so far.
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30
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Pozza G, Di Carlo V. Pancreas transplantation in diabetic patients. ACTA DIABETOLOGICA LATINA 1989; 26:57-68. [PMID: 2501961 DOI: 10.1007/bf02581197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
After a brief historical background on pancreas transplantation in the treatment of diabetes mellitus, this review deals with the major surgical, pharmacological and functional aspects of this approach. In the Authors' opinion pancreas transplantation should be proposed only when the end-stage renal failure (ESRF), due to diabetic nephropathy, needs kidney transplantation. By using injection of polymers (mainly neoprene) into the pancreatic ducts, or urinary diversion of pancreatic juice and appropriate immunosuppressive therapy (cyclosporin, corticosteroids and azathioprine), dramatic advantages have been achieved in the last years, so that a satisfactory segmental or total pancreas graft survival on one hand, and the early graft rejection recognition on the other have been presently obtained. A prompt and good functional activity of pancreas graft has also been demonstrated by the Authors in successfully transplanted patients. As far as chronic diabetic complications are concerned, no conclusive results have been reported up to now; it is noteworthy, however, that pancreas transplantation may preserve the transplanted kidney from a relapse of diabetic nephropathy. The combined pancreas-kidney transplantation may actually be considered as a correct solution to the problem of diabetic patients with ESRF. Moreover, careful selection of patients, appropriate surgical technique and experienced immunosuppressive treatment are the major prerequisites to achieve a satisfactory improvement of diabetic status in addition to that of renal failure.
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Affiliation(s)
- G Pozza
- Cattedra di Clinica Medica Generale e Terapia Medica, Università degli Studi
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31
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Abstract
The number of pancreas transplants being performed and the success rate have continued to increase. Most pancreas transplants have been placed in diabetic recipients of kidney transplants, but application to nonuremic, non-kidney transplant recipients without end-stage disease is increasing. Drainage of pancreatic graft duct into the bladder allows exocrine function to be assessed directly and has led to earlier diagnosis and treatment of rejection episodes. The improvement in graft survival rates has been associated with the use of cyclosporine in combination with other immunosuppressants. The effect that establishment of a euglycemic state by successful pancreas transplantation has on the specific complications of diabetes is just beginning to be discerned but appears to be favorable if the transplant is performed sufficiently early in the course of the disease.
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Affiliation(s)
- D E Sutherland
- Department of Surgery, University of Minnesota Hospitals, Minneapolis 55455
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32
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Pfeiffer EF. On the way to the automated (blood) glucose regulation in diabetes: the dark past, the grey present and the rosy future. XII Congress of the International Diabetes Federation, Madrid, 22-28 September 1985. Diabetologia 1987; 30:51-65. [PMID: 3552826 DOI: 10.1007/bf00274572] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The development of the artificial pancreas represents an important step forward in modern diabetology. The practical and theoretical findings obtained by its application to Type 1 (insulin-dependent) diabetic patients has given new insights into modes of insulin secretion, pathophysiology of diabetes mellitus, and new forms of treatment, i.e. the development of portable insulin pumps and intensified conventional insulin therapy. All of these therapies provided better results than conventional insulin administration. However, there is no doubt that the restoration of normoglycaemia in a real sense is obtainable only by an implantable artificial pancreas or pancreas transplantation. The development of the implantable artificial pancreas, on the other hand, is dependent upon the development of a reliably working permanently implantable glucose sensor. The first attempts in that direction have opened new vistas as to the differences between blood and interstitial tissue glucose measurements, displaying different modes of regulation under normal and pathologic conditions. A number of barriers have to be overcome until the final goal has been attained: to obtain, by automated blood glucose control, narrow glycaemic fluctuations of the normal subject, and to prevent, hopefully, relentless diabetic complications.
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