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Nemati M, Hosseinzadeh Z, Nemati F, Koohpeyma F. Improvement effects of transplanting pancreatic islet that previously incubated with biomaterials on the diabetic nephropathy in STZ- diabetic rats. BMC Nephrol 2024; 25:156. [PMID: 38724923 PMCID: PMC11080158 DOI: 10.1186/s12882-024-03572-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 04/05/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Islet transplantation is an effective treatment for diabetes or even its complications. Aim of this study is to investigate efficacy of biomaterial treated islet transplantation on treating diabetic nephropathy. METHODS Male rats were randomly divided into 6 groups; Control, diabetic control, diabetic transplanted with untreated islets, with platelet rich plasma treated islets, with pancreatic islets homogenate treated islets, or with these biomaterials combination treated islets. Islets cultured with biomaterials and transplanted to diabetic rats. After 60 days, biochemical, oxidative stress, and stereological parameters were assessed. RESULTS Serum albumin and BUN concentration, decreased and increased respectively, Oxidative stress of kidney impaired, kidney weight, volume of kidney, cortex, medulla, glomerulus, proximal and distal tubules, collecting ducts, vessels, inflammatory, necrotic and fibrotic tissue in diabetic group increased compared to control group (p < 0.001). In treated groups, especially pancreatic islets homogenate treated islets transplanting animals, there was significant changes in kidney weight, and volume of kidney, proximal and distal tubules, Henle's loop and collecting ducts compared with diabetic group (p = 0.013 to p < 0.001). Combination treated islets animals showed significant increase in vessel volume compared to diabetic group (p < 0.001). Necrotic and fibrotic tissue significantly decreased in islets treated than untreated islet animals, it was higher in pancreatic islets homogenate, and combination treated islets groups (p = 0.001). CONCLUSIONS Biomaterials treated islets transplanting could improve diabetic nephropathy. Improvement of oxidative stress followed by controlling glucose level, and effects of growth factors presenting in biomaterials can be considered as capable underlying mechanism of ameliorating inflammatory, necrotic and fibrotic tissue volume.
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Affiliation(s)
- Marzieh Nemati
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Zahra Hosseinzadeh
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Nemati
- School of Dentistry, Shiraz University of Medical Science, Shiraz, Iran
| | - Farhad Koohpeyma
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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2
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Caldara R, Tomajer V, Monti P, Sordi V, Citro A, Chimienti R, Gremizzi C, Catarinella D, Tentori S, Paloschi V, Melzi R, Mercalli A, Nano R, Magistretti P, Partelli S, Piemonti L. Allo Beta Cell transplantation: specific features, unanswered questions, and immunological challenge. Front Immunol 2023; 14:1323439. [PMID: 38077372 PMCID: PMC10701551 DOI: 10.3389/fimmu.2023.1323439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
Type 1 diabetes (T1D) presents a persistent medical challenge, demanding innovative strategies for sustained glycemic control and enhanced patient well-being. Beta cells are specialized cells in the pancreas that produce insulin, a hormone that regulates blood sugar levels. When beta cells are damaged or destroyed, insulin production decreases, which leads to T1D. Allo Beta Cell Transplantation has emerged as a promising therapeutic avenue, with the goal of reinstating glucose regulation and insulin production in T1D patients. However, the path to success in this approach is fraught with complex immunological hurdles that demand rigorous exploration and resolution for enduring therapeutic efficacy. This exploration focuses on the distinct immunological characteristics inherent to Allo Beta Cell Transplantation. An understanding of these unique challenges is pivotal for the development of effective therapeutic interventions. The critical role of glucose regulation and insulin in immune activation is emphasized, with an emphasis on the intricate interplay between beta cells and immune cells. The transplantation site, particularly the liver, is examined in depth, highlighting its relevance in the context of complex immunological issues. Scrutiny extends to recipient and donor matching, including the utilization of multiple islet donors, while also considering the potential risk of autoimmune recurrence. Moreover, unanswered questions and persistent gaps in knowledge within the field are identified. These include the absence of robust evidence supporting immunosuppression treatments, the need for reliable methods to assess rejection and treatment protocols, the lack of validated biomarkers for monitoring beta cell loss, and the imperative need for improved beta cell imaging techniques. In addition, attention is drawn to emerging directions and transformative strategies in the field. This encompasses alternative immunosuppressive regimens and calcineurin-free immunoprotocols, as well as a reevaluation of induction therapy and recipient preconditioning methods. Innovative approaches targeting autoimmune recurrence, such as CAR Tregs and TCR Tregs, are explored, along with the potential of stem stealth cells, tissue engineering, and encapsulation to overcome the risk of graft rejection. In summary, this review provides a comprehensive overview of the inherent immunological obstacles associated with Allo Beta Cell Transplantation. It offers valuable insights into emerging strategies and directions that hold great promise for advancing the field and ultimately improving outcomes for individuals living with diabetes.
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Affiliation(s)
- Rossana Caldara
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Valentina Tomajer
- Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Paolo Monti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Valeria Sordi
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Antonio Citro
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Raniero Chimienti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Chiara Gremizzi
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Davide Catarinella
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Stefano Tentori
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Vera Paloschi
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Raffella Melzi
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessia Mercalli
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Rita Nano
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Paola Magistretti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Stefano Partelli
- Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Lorenzo Piemonti
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
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3
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Sordi V, Monaco L, Piemonti L. Cell Therapy for Type 1 Diabetes: From Islet Transplantation to Stem Cells. Horm Res Paediatr 2022; 96:658-669. [PMID: 36041412 DOI: 10.1159/000526618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 08/08/2022] [Indexed: 11/19/2022] Open
Abstract
The field of cell therapy of type 1 diabetes is a particularly interesting example in the scenario of regenerative medicine. In fact, β-cell replacement has its roots in the experience of islet transplantation, which began 40 years ago and is currently a rapidly accelerating field, with several ongoing clinical trials using β cells derived from stem cells. Type 1 diabetes is particularly suitable for cell therapy as it is a disease due to the deficiency of only one cell type, the insulin-producing β cell, and this endocrine cell does not need to be positioned inside the pancreas to perform its function. On the other hand, the presence of a double immunological barrier, the allogeneic one and the autoimmune one, makes the protection of β cells from rejection a major challenge. Until today, islet transplantation has taught us a lot, pioneering immunosuppressive therapies, graft encapsulation, tissue engineering, and test of different implant sites and has stimulated a great variety of studies on β-cell function. This review starts from islet transplantation, presenting its current indications and the latest published trials, to arrive at the prospects of stem cell therapy, presenting the latest innovations in the field.
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Affiliation(s)
- Valeria Sordi
- Diabetes Research Institute, San Raffaele Hospital, Milan, Italy,
| | - Laura Monaco
- Diabetes Research Institute, San Raffaele Hospital, Milan, Italy
| | - Lorenzo Piemonti
- Diabetes Research Institute, San Raffaele Hospital, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Piemonti L. Felix dies natalis, insulin… ceterum autem censeo "beta is better". Acta Diabetol 2021; 58:1287-1306. [PMID: 34027619 DOI: 10.1007/s00592-021-01737-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/06/2021] [Indexed: 12/12/2022]
Abstract
One hundred years after its discovery, insulin remains the life-saving therapy for many patients with diabetes. It has been a 100-years-old success story thanks to the fact that insulin therapy has continuously integrated the knowledge developed over a century. In 1982, insulin becomes the first therapeutic protein to be produced using recombinant DNA technology. The first "mini" insulin pump and the first insulin pen become available in 1983 and 1985, respectively. In 1996, the first generation of insulin analogues were produced. In 1999, the first continuous glucose-monitoring device for reading interstitial glucose was approved by the FDA. In 2010s, the ultra-long action insulins were introduced. An equally exciting story developed in parallel. In 1966. Kelly et al. performed the first clinical pancreas transplant at the University of Minnesota, and now it is a well-established clinical option. First successful islet transplantations in humans were obtained in the late 1980s and 1990s. Their ability to consistently re-establish the endogenous insulin secretion was obtained in 2000s. More recently, the possibility to generate large numbers of functional human β cells from pluripotent stem cells was demonstrated, and the first clinical trial using stem cell-derived insulin producing cell was started in 2014. This year, the discovery of this life-saving hormone turns 100 years. This provides a unique opportunity not only to celebrate this extraordinary success story, but also to reflect on the limits of insulin therapy and renew the commitment of the scientific community to an insulin free world for our patients.
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Affiliation(s)
- Lorenzo Piemonti
- San Raffaele Diabetes Research Institute, San Raffaele Scientific Institute, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
- Università Vita-Salute San Raffaele, Milan, Italy.
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5
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Xiao S, Yang Y, Liu YT, Zhu J. Liraglutide Regulates the Kidney and Liver in Diabetic Nephropathy Rats through the miR-34a/SIRT1 Pathway. J Diabetes Res 2021; 2021:8873956. [PMID: 33880382 PMCID: PMC8046563 DOI: 10.1155/2021/8873956] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 02/25/2021] [Accepted: 03/23/2021] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To explore the regulatory effects of liraglutide on the kidney and liver through the miR-34a/SIRT1 pathway with related factors in diabetic nephropathy (DN) rats. METHODS DN rats were randomly divided into two groups (n = 10) and were injected with liraglutide or normal saline twice a day. The 24-hour urine microalbumin content and biochemical index levels were measured. qRT-PCR was performed to detect the expression of miR-34a in the kidney and liver tissues. The levels of SIRT1, HIF-1a, Egr-1, and TGF-β1 in kidney and liver tissues were determined using qRT-PCR, western blot, and immunohistochemistry. Electron microscopy and HE staining were used to observe the ultrastructure and pathological changes. RESULTS Liraglutide treatment in DN rats decreased blood glucose, 24-hour urine microalbumin, TC, TG, LDL-C, UA, Cr, UREA, ALT, and AST levels and increased the level of HDL-C (P < 0.05). Compared with the control group, the miR-34a levels were significantly decreased in kidney and liver tissues followed by liraglutide treatment (P < 0.05). The levels of SIRT1 in the liraglutide group are significantly higher than those in the control group with the kidney and liver tissues (P < 0.05). Conversely, the contents of HIF-1a, Egr-1, and TGF-β1 were significantly lower in the liraglutide group than in the control group (P < 0.05). Electron microscopy showed that the kidney of the liraglutide-treated group exhibited minor broadening of the mesangial areas, fewer deposits, and a well-organized foot process. HE staining revealed that the kidney of the liraglutide-treated rats had a more regular morphology of the glomerulus and Bowman sac cavity and lighter tubular edema. Additionally, the liraglutide-treated DN rats had a clear hepatic structure, a lower degree of steatosis, and mild inflammatory cell infiltration. CONCLUSION Liraglutide, through its effect on the miR-34a/SIRT1 pathway, may have a protective role in the kidney and liver of DN rats.
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Affiliation(s)
- Shan Xiao
- Department of Endocrinology, People's Hospital of Shenzhen Baoan District, The Second School of Clinical Medicine, Southern Medical University, The Second Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Ye Yang
- Department of No. 1 Cadres, The Second Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Yue-Tong Liu
- Department of Ultrasonic ECG, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Jun Zhu
- Department of Endocrinology, People's Hospital of Shenzhen Baoan District, The Second School of Clinical Medicine, Southern Medical University, The Second Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
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Naficy S, Dehghani F, Chew YV, Hawthorne WJ, Le TYL. Engineering a Porous Hydrogel-Based Device for Cell Transplantation. ACS APPLIED BIO MATERIALS 2020; 3:1986-1994. [DOI: 10.1021/acsabm.9b01144] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Sina Naficy
- School of Chemical and Biomolecular Engineering, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Fariba Dehghani
- School of Chemical and Biomolecular Engineering, The University of Sydney, Sydney, New South Wales 2006, Australia
| | - Yi Vee Chew
- Westmead Institute for Medical Research, The University of Sydney, Westmead Hospital, Westmead, New South Wales 2145, Australia
| | - Wayne J. Hawthorne
- Westmead Institute for Medical Research, The University of Sydney, Westmead Hospital, Westmead, New South Wales 2145, Australia
| | - Thi Yen Loan Le
- School of Chemical and Biomolecular Engineering, The University of Sydney, Sydney, New South Wales 2006, Australia
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Citro A, Pellegrini S, Dugnani E, Eulberg D, Klussmann S, Piemonti L. CCL2/MCP-1 and CXCL12/SDF-1 blockade by L-aptamers improve pancreatic islet engraftment and survival in mouse. Am J Transplant 2019; 19:3131-3138. [PMID: 31267721 DOI: 10.1111/ajt.15518] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/06/2019] [Accepted: 06/24/2019] [Indexed: 01/25/2023]
Abstract
The blockade of pro-inflammatory mediators is a successful approach to improve the engraftment after islet transplantation. L-aptamers are chemically synthesized, nonimmunogenic bio-stable oligonucleotides that bind and inhibit target molecules conceptually similar to antibodies. We aimed to evaluate if blockade-aptamer-based inhibitors of C-C Motif Chemokine Ligand 2/monocyte chemoattractant protein-1 (CCL2/MCP-1) and C-X-C Motif Chemokine Ligand 12/stromal cell-derived factor-1 (CXCL12/SDF-1) are able to favor islet survival in mouse models for islet transplantation and for type 1 diabetes. We evaluated the efficacy of the CCL2-specific mNOX-E36 and the CXCL12-specific NOX-A12 on islet survival in a syngeneic mouse model of intraportal islet transplantation and in a multiple low doses of streptozotocin (MLD-STZ) diabetes induction model. Moreover, we characterized intrahepatic infiltrated leukocytes by flow cytometry before and 3 days after islet infusion in presence or absence of these inhibitors. The administration for 14 days of mNOX-E36 and NOX-A12 significantly improved islet engraftment, either compound alone or in combination. Intrahepatic islet transplantation recruited CD45+ leucocytes and more specifically CD45+/CD11b+ mono/macrophages; mNOX-E36 and NOX-A12 treatments significantly decreased the recruitment of inflammatory monocytes, CD11b+ /Ly6Chigh /CCR2+ and CD11b+ /Ly6Chigh /CXCR4+ cells, respectively. Additionally, both L-aptamers significantly attenuated diabetes progression in the MLD-STZ model. In conclusion, CCL2/MCP-1 and CXCL12/SDF-1 blockade by L-aptamers is an efficient strategy to improve islet engraftment and survival.
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Affiliation(s)
- Antonio Citro
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Silvia Pellegrini
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Erica Dugnani
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Sven Klussmann
- NOXXON Pharma AG, Berlin, Germany.,Aptarion Biotech AG, Berlin, Germany
| | - Lorenzo Piemonti
- San Raffaele Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
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8
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Abstract
PURPOSE OF REVIEW In patients with type 1 diabetes with extreme glycemic variability, the restoration of pancreas endocrine function is potentially and completely achieved with islets of Langerhans (tissue derived from whole organ) or pancreas (whole organ) transplantation. The aim of our review is to report on the latest studies and to highlight the benefits and risks of the two procedures, providing clearer, more selective, evidence-based clinical indications that also consider the impact on the degenerative complications of diabetes as a potential benefit. RECENT FINDINGS Clinical experience in this field has been dynamic over the last three decades, and has been characterized by the development of more standardized protocols and a clearer definition of clinical outcome. On the contrary, the recommendations thus far are not well delineated and tend to overlap, and the past ADA position statement for pancreas transplant alone has also been applied to islet transplant alone, without differentiation. Both outcome-driven and non-outcome-driven criteria are considered in the conclusions, in an attempt to streamline indications for islet-alone or pancreas-alone transplantation.
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Affiliation(s)
- Paola Maffi
- Diabetes Research Institute - Internal Medicine and Transplant Unit, IRCCS Scientific Institute Ospedale San Raffaele, Milan, Italy.
| | - Antonio Secchi
- Internal Medicine and Transplant Unit, Vita-Salute San Raffaele University, Milan, Italy
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9
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Anti-Inflammatory Strategies in Intrahepatic Islet Transplantation: A Comparative Study in Preclinical Models. Transplantation 2018; 102:240-248. [PMID: 28902069 DOI: 10.1097/tp.0000000000001925] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The identification of pathway(s) playing a pivotal role in peritransplant detrimental inflammatory events represents the crucial step toward a better management and outcome of pancreatic islet transplanted patients. Recently, we selected the CXCR1/2 inhibition as a relevant strategy in enhancing pancreatic islet survival after transplantation. METHODS Here, the most clinically used anti-inflammatory compounds (IL1-receptor antagonist, steroids, and TNF-α inhibitor) alone or in combination with a CXCR1/2 inhibitor were evaluated in their ability to improve engraftment or delay graft rejection. To rule out bias related to transplantation site, we used well-established preclinical syngeneic (250 C57BL/6 equivalent islets in C57BL/6) and allogeneic (400 Balb/c equivalent islets in C57BL6) intrahepatic islet transplantation platforms. RESULTS In mice, we confirmed that targeting the CXCR1/2 pathway is crucial in preserving islet function and improving engraftment. In the allogeneic setting, CXCR1/2 inhibitor alone could reduce the overall recruitment of transplant-induced leukocytes and significantly prolong the time to graft rejection both as a single agent and in combination with immunosuppression. No other anti-inflammatory compounds tested (IL1-receptor antagonist, steroids, and TNF-α inhibitor) alone or in combination with CXCR1/2 inhibitor improve islet engraftment and significantly delay graft rejection in the presence of MMF + FK-506 immunosuppressive treatment. CONCLUSIONS These findings indicate that only the CXCR1/2-mediated axis plays a crucial role in controlling the islet damage and should be a target for intervention to improve the efficiency of islet transplantation.
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Lablanche S, Vantyghem MC, Kessler L, Wojtusciszyn A, Borot S, Thivolet C, Girerd S, Bosco D, Bosson JL, Colin C, Tetaz R, Logerot S, Kerr-Conte J, Renard E, Penfornis A, Morelon E, Buron F, Skaare K, Grguric G, Camillo-Brault C, Egelhofer H, Benomar K, Badet L, Berney T, Pattou F, Benhamou PY. Islet transplantation versus insulin therapy in patients with type 1 diabetes with severe hypoglycaemia or poorly controlled glycaemia after kidney transplantation (TRIMECO): a multicentre, randomised controlled trial. Lancet Diabetes Endocrinol 2018; 6:527-537. [PMID: 29776895 DOI: 10.1016/s2213-8587(18)30078-0] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/28/2018] [Accepted: 02/28/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Islet transplantation is indicated for patients with type 1 diabetes with severe hypoglycaemia or after kidney transplantation. We did a randomised trial to assess the efficacy and safety of islet transplantation compared with insulin therapy in these patients. METHODS In this multicentre, open-label, randomised controlled trial, we randomly assigned (1:1) patients with type 1 diabetes at 15 university hospitals to receive immediate islet transplantation or intensive insulin therapy (followed by delayed islet transplantation). Eligible patients were aged 18-65 years and had severe hypoglycaemia or hypoglycaemia unawareness, or kidney grafts with poor glycaemic control. We used computer-generated randomisation, stratified by centre and type of patient. Islet recipients were scheduled to receive 11 000 islet equivalents per kg bodyweight in one to three infusions. The primary outcome was proportion of patients with a modified β-score (in which an overall score of 0 was not allocated when stimulated C-peptide was negative) of 6 or higher at 6 months after first islet infusion in the immediate transplantation group or 6 months after randomisation in the insulin group. The primary analysis included all patients who received the allocated intervention; safety was assessed in all patients who received islet infusions. This trial is registered with ClinicalTrials.gov, number NCT01148680, and is completed. FINDINGS Between July 8, 2010, and July 29, 2013, 50 patients were randomly assigned to immediate islet transplantation (n=26) or insulin treatment (n=24), of whom three (one in the immediate islet transplantation group and two in the insulin therapy group) did not receive the allocated intervention. Median follow-up was 184 days (IQR 181-186) in the immediate transplantation group and 185 days (172-201) in the insulin therapy group. At 6 months, 16 (64% [95% CI 43-82]) of 25 patients in the immediate islet transplantation group had a modified β-score of 6 or higher versus none (0% [0-15]) of the 22 patients in the insulin group (p<0·0001). At 12 months after first infusion, bleeding complications had occurred in four (7% [2-18]) of 55 infusions, and a decrease in median glomerular filtration rate from 90·5 mL/min (IQR 76·6-94·0) to 71·8 mL/min (59·0-89·0) was observed in islet recipients who had not previously received a kidney graft and from 63·0 mL/min (55·0-71·0) to 57·0 mL/min (45·5-65·1) in islet recipients who had previously received a kidney graft. INTERPRETATION For the indications assessed in this study, islet transplantation effectively improves metabolic outcomes. Although studies with longer-term follow-up are needed, islet transplantation seems to be a valid option for patients with severe, unstable type 1 diabetes who are not responding to intensive medical treatments. However, immunosuppression can affect kidney function, necessitating careful selection of patients. FUNDING Programme Hospitalier de Recherche Clinique grant from the French Government.
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Affiliation(s)
- Sandrine Lablanche
- Department of Endocrinology, Diabetes, and Nutrition, Grenoble Alpes University, Grenoble, France; Inserm U1055, Laboratory of Fundamental and Applied Bioenergetics Grenoble, Grenoble, France.
| | - Marie-Christine Vantyghem
- Department of Endocrinology, Diabetes, and Nutrition, C Huriez Hospital, Lille University Hospital, Lille, France; Inserm 1190, European Genomic Institute for Diabetes, Lille, France
| | - Laurence Kessler
- Hôpitaux Universitaires de Strasbourg, Service d'Endocrinologie Diabète et Maladies Métaboliques, and Equipe d'Accueil 7293, Fédération de Médecine Translationnelle de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Anne Wojtusciszyn
- Department of Endocrinology, Diabetes, and Nutrition, Montpellier University Hospital, Montpellier, France; Laboratory of Cell Therapy of Diabetes, Institute of Functional Genomics, Mixed Research Unit, French National Center for Scientific Research 5203, Inserm U1191, University of Montpellier, Montpellier, France
| | - Sophie Borot
- Centre Hospitalier Universitaire Jean Minjoz, Service d'Endocrinologie-Métabolisme et Diabétologie-Nutrition, Besançon, France
| | - Charles Thivolet
- Service d'Endocrinologie Diabète Nutrition, Hospices Civils de Lyon, Groupement Hospitalier Centre, Université de Lyon, Lyon, France
| | - Sophie Girerd
- Service de Néphrologie, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Domenico Bosco
- Department of Surgery, Islet Isolation, and Transplantation, Geneva University Hospitals, Geneva, Switzerland
| | - Jean-Luc Bosson
- French National Center for Scientific Research, Grenoble Alpes University, Grenoble, France; Department of Public Health, Grenoble Alpes University, Grenoble, France; Laboratoire des Techniques de l'Ingénierie Médicale et de la Complexité-Informatique, Mathématiques et Applications de Grenoble, Grenoble, France
| | - Cyrille Colin
- Pôle de Santé Publique Service Evaluation Economique en Santé, Hospices Civils de Lyon, Groupement Hospitalier Centre, Université de Lyon, Lyon, France; F-69003, EA 7425 Health Services and Performance Research, Public Health Service and Health Economic Evaluation, Claude Bernard University Lyon 1, Lyon, France
| | - Rachel Tetaz
- Department of Nephrology, Grenoble Alpes University, Grenoble, France
| | - Sophie Logerot
- Department of Clinical Trial Surveillance, Direction of Clinical Research and Innovation, Grenoble Alpes University, Grenoble, France
| | - Julie Kerr-Conte
- Department of Endocrinology, Diabetes, and Nutrition, C Huriez Hospital, Lille University Hospital, Lille, France; Inserm 1190, European Genomic Institute for Diabetes, Lille, France
| | - Eric Renard
- Department of Endocrinology, Diabetes, and Nutrition, Montpellier University Hospital, Montpellier, France; Laboratory of Cell Therapy of Diabetes, Institute of Functional Genomics, Mixed Research Unit, French National Center for Scientific Research 5203, Inserm U1191, University of Montpellier, Montpellier, France
| | - Alfred Penfornis
- Department of Diabetes, Sud-Francilien Hospital, Corbeil-Essonnes, France; Université Paris-Sud, Orsay, France
| | - Emmanuel Morelon
- Service de Transplantation, Néphrologie et Immunologie Clinique, Hospices Civils de Lyon, Groupement Hospitalier Centre, Université de Lyon, Lyon, France
| | - Fanny Buron
- Service de Transplantation, Néphrologie et Immunologie Clinique, Hospices Civils de Lyon, Groupement Hospitalier Centre, Université de Lyon, Lyon, France
| | - Kristina Skaare
- French National Center for Scientific Research, Grenoble Alpes University, Grenoble, France; Department of Public Health, Grenoble Alpes University, Grenoble, France; Laboratoire des Techniques de l'Ingénierie Médicale et de la Complexité-Informatique, Mathématiques et Applications de Grenoble, Grenoble, France
| | - Gwen Grguric
- Pôle de Santé Publique Service Evaluation Economique en Santé, Hospices Civils de Lyon, Groupement Hospitalier Centre, Université de Lyon, Lyon, France; F-69003, EA 7425 Health Services and Performance Research, Public Health Service and Health Economic Evaluation, Claude Bernard University Lyon 1, Lyon, France
| | - Coralie Camillo-Brault
- Pôle de Santé Publique Service Evaluation Economique en Santé, Hospices Civils de Lyon, Groupement Hospitalier Centre, Université de Lyon, Lyon, France; F-69003, EA 7425 Health Services and Performance Research, Public Health Service and Health Economic Evaluation, Claude Bernard University Lyon 1, Lyon, France
| | - Harald Egelhofer
- Cellular Therapy Unit, National Blood Service Rhône-Alpes, Grenoble University Hospital, Grenoble Alpes University, Grenoble, France
| | - Kanza Benomar
- Department of Endocrinology, Diabetes, and Nutrition, C Huriez Hospital, Lille University Hospital, Lille, France; Inserm 1190, European Genomic Institute for Diabetes, Lille, France
| | - Lionel Badet
- Service d'Urologie et de Chirurgie de la Transplantation, Hospices Civils de Lyon, Groupement Hospitalier Centre, Université de Lyon, Lyon, France
| | - Thierry Berney
- Department of Surgery, Islet Isolation, and Transplantation, Geneva University Hospitals, Geneva, Switzerland
| | - François Pattou
- Department of Endocrinology, Diabetes, and Nutrition, C Huriez Hospital, Lille University Hospital, Lille, France; Inserm 1190, European Genomic Institute for Diabetes, Lille, France
| | - Pierre-Yves Benhamou
- Department of Endocrinology, Diabetes, and Nutrition, Grenoble Alpes University, Grenoble, France; Inserm U1055, Laboratory of Fundamental and Applied Bioenergetics Grenoble, Grenoble, France
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11
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Zhu H, Li W, Liu Z, Li W, Chen N, Lu L, Zhang W, Wang Z, Wang B, Pan K, Zhang X, Chen G. Selection of Implantation Sites for Transplantation of Encapsulated Pancreatic Islets. TISSUE ENGINEERING PART B-REVIEWS 2018; 24:191-214. [PMID: 29048258 DOI: 10.1089/ten.teb.2017.0311] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreatic islet transplantation has been validated as a valuable therapy for type 1 diabetes mellitus patients with exhausted insulin treatment. However, this therapy remains limited by the shortage of donor and the requirement of lifelong immunosuppression. Islet encapsulation, as an available bioartificial pancreas (BAP), represents a promising approach to enable protecting islet grafts without or with minimal immunosuppression and possibly expanding the donor pool. To develop a clinically implantable BAP, some key aspects need to be taken into account: encapsulation material, capsule design, and implant site. Among them, the implant site exerts an important influence on the engraftment, stability, and biocompatibility of implanted BAP. Currently, an optimal site for encapsulated islet transplantation may include sufficient capacity to host large graft volumes, portal drainage, ease of access using safe and reproducible procedure, adequate blood/oxygen supply, minimal immune/inflammatory reaction, pliable for noninvasive imaging and biopsy, and potential of local microenvironment manipulation or bioengineering. Varying degrees of success have been confirmed with the utilization of liver or extrahepatic sites in an experimental or preclinical setting. However, the ideal implant site remains to be further engineered or selected for the widespread application of encapsulated islet transplantation.
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Affiliation(s)
- Haitao Zhu
- 1 Department of Pediatrics (No. 3 Ward), Northwest Women's and Children's Hospital , Xi'an, China .,2 Department of Hepatobiliary Surgery, the First Affiliated Hospital, Medical School of Xi'an Jiaotong University , Xi'an, China
| | - Wenjing Li
- 1 Department of Pediatrics (No. 3 Ward), Northwest Women's and Children's Hospital , Xi'an, China
| | - Zhongwei Liu
- 3 Department of Cardiology, Shaanxi Provincial People's Hospital , Xi'an, China
| | - Wenliang Li
- 1 Department of Pediatrics (No. 3 Ward), Northwest Women's and Children's Hospital , Xi'an, China
| | - Niuniu Chen
- 1 Department of Pediatrics (No. 3 Ward), Northwest Women's and Children's Hospital , Xi'an, China
| | - Linlin Lu
- 1 Department of Pediatrics (No. 3 Ward), Northwest Women's and Children's Hospital , Xi'an, China
| | - Wei Zhang
- 1 Department of Pediatrics (No. 3 Ward), Northwest Women's and Children's Hospital , Xi'an, China
| | - Zhen Wang
- 1 Department of Pediatrics (No. 3 Ward), Northwest Women's and Children's Hospital , Xi'an, China
| | - Bo Wang
- 2 Department of Hepatobiliary Surgery, the First Affiliated Hospital, Medical School of Xi'an Jiaotong University , Xi'an, China .,4 Institute of Advanced Surgical Technology and Engineering, Xi'an Jiaotong University , Xi'an, China
| | - Kaili Pan
- 5 Department of Pediatrics (No. 2 Ward), Northwest Women's and Children's Hospital , Xi'an, China
| | - Xiaoge Zhang
- 1 Department of Pediatrics (No. 3 Ward), Northwest Women's and Children's Hospital , Xi'an, China
| | - Guoqiang Chen
- 1 Department of Pediatrics (No. 3 Ward), Northwest Women's and Children's Hospital , Xi'an, China
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12
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Abstract
PURPOSE OF REVIEW Episodic hypoglycemia is an almost inevitable consequence of exogenous insulin treatment of type 1 diabetes, and in up to 30% of patients, this can lead to impaired awareness of hypoglycemia. This predisposes to recurrent severe hypoglycemia and has a huge impact on quality of life. Although many patients can get resolution of severe hypoglycemia through novel education and technology, some patients continue to have ongoing life-threatening hypoglycemia. Islet transplantation offers an alternative therapeutic option for these patients, in whom these conventional approaches have been unsuccessful. This review discusses the selection process of identifying suitable candidates based on recent clinical data. RECENT FINDINGS Results from studies of islet transplantation suggest the optimal recipient characteristics for successful islet transplantation include age >35 years, insulin requirements <1.0/kg, and weight < 85 kg. Islet transplantation can completely resolve hypoglycemia and near-normalize glucose levels, achieving insulin independence for a limited period of time in up to 40% of patients. The selection of appropriate candidates, optimizing donor selection, the use of an optimized protocol for islet cell extraction, and immunosuppression therapy have been proved to be the key criteria for a favorable outcome in islet transplantation.
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Affiliation(s)
- Nantia Othonos
- Department of Diabetes, King's College London, Denmark Hill, London, SE5 9RJ, UK
| | - Pratik Choudhary
- Department of Diabetes, King's College London, Denmark Hill, London, SE5 9RJ, UK.
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13
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Peixoto E, Vendrame F, Arnau A, Padilla N, Baidal D, Alvarez A, Delmonte V, Fornoni A, Ricordi C, Alejandro R. Ten Years of Preserved Kidney Function After Islet Transplant Graft Failure. Diabetes Care 2016; 39:e209-e211. [PMID: 27650978 PMCID: PMC5127237 DOI: 10.2337/dc16-1093] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 08/29/2016] [Indexed: 02/03/2023]
Affiliation(s)
- Eduardo Peixoto
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL.,Department of Internal Medicine, Framingham Union Hospital, MetroWest Medical Center, Boston, MA
| | - Francesco Vendrame
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL.,Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Alvaro Arnau
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL.,Servicio de Nefrología, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Fundación Marqués de Valdecilla-IFIMAV, Cantabria, Spain
| | - Nathalia Padilla
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | - David Baidal
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL.,Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Ana Alvarez
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Valentina Delmonte
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL.,Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Alessia Fornoni
- Division of Nephrology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Camillo Ricordi
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Rodolfo Alejandro
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL .,Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
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14
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Regenerative Therapy of Type 1 Diabetes Mellitus: From Pancreatic Islet Transplantation to Mesenchymal Stem Cells. Stem Cells Int 2016; 2016:3764681. [PMID: 27047547 PMCID: PMC4800095 DOI: 10.1155/2016/3764681] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/14/2015] [Indexed: 01/01/2023] Open
Abstract
Type 1 diabetes is an autoimmune disease resulting in the permanent destruction of pancreatic islets. Islet transplantation to portal vein provides an approach to compensate for loss of insulin producing cells. Clinical trials demonstrated that even partial islet graft function reduces severe hypoglycemic events in patients. However, therapeutic impact is restrained due to shortage of pancreas organ donors and instant inflammation occurring in the hepatic environment of the graft. We summarize on what is known about regenerative therapy in type 1 diabetes focusing on pancreatic islet transplantation and new avenues of cell substitution. Metabolic pathways and energy production of transplanted cells are required to be balanced and protection from inflammation in their intravascular bed is desired. Mesenchymal stem cells (MSCs) have anti-inflammatory features, and so they are interesting as a therapy for type 1 diabetes. Recently, they were reported to reduce hyperglycemia in diabetic rodents, and they were even discussed as being turned into endodermal or pancreatic progenitor cells. MSCs are recognized to meet the demand of an individual therapy not raising the concerns of embryonic or induced pluripotent stem cells for therapy.
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15
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Ben Nasr M, Vergani A, Avruch J, Liu L, Kefaloyianni E, D'Addio F, Tezza S, Corradi D, Bassi R, Valderrama-Vasquez A, Usuelli V, Kim J, Azzi J, El Essawy B, Markmann J, Abdi R, Fiorina P. Co-transplantation of autologous MSCs delays islet allograft rejection and generates a local immunoprivileged site. Acta Diabetol 2015; 52:917-27. [PMID: 25808641 PMCID: PMC4968999 DOI: 10.1007/s00592-015-0735-y] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 03/05/2015] [Indexed: 12/29/2022]
Abstract
AIMS Mesenchymal stem cells (MSCs) are multipotent cells with immunomodulatory properties. We tested the ability of MSCs to delay islet allograft rejection. METHODS Mesenchymal stem cells were generated in vitro from C57BL/6 and BALB/c mice bone marrow, and their immunomodulatory properties were tested in vitro. We then tested the effect of a local or systemic administration of heterologous and autologous MSCs on graft survival in a fully allogeneic model of islet transplantation (BALB/c islets into C57BL/6 mice). RESULTS In vitro, autologous, but not heterologous, MSCs abrogated immune cell proliferation in response to alloantigens and skewed the immune response toward a Th2 profile. A single dose of autologous MSCs co-transplanted under the kidney capsule with allogeneic islets delayed islet rejection, reduced graft infiltration, and induced long-term graft function in 30 % of recipients. Based on ex vivo analysis of recipient splenocytes, the use of autologous MSCs did not appear to have any systemic effect on the immune response toward graft alloantigens. The systemic injection of autologous MSCs or the local injection of heterologous MSCs failed to delay islet graft rejection. CONCLUSION Autologous, but not heterologous, MSCs showed multiple immunoregulatory properties in vitro and delayed allograft rejection in vivo when co-transplanted with islets; however, they failed to prevent rejection when injected systemically. Autologous MSCs thus appear to produce a local immunoprivileged site, which promotes graft survival.
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Affiliation(s)
- Moufida Ben Nasr
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Enders Building 5th Floor Room EN511, 300 Longwood Ave, Boston, MA, USA
- Transplant Medicine, Ospedale San Raffaele, Milan, Italy
| | - Andrea Vergani
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Enders Building 5th Floor Room EN511, 300 Longwood Ave, Boston, MA, USA
- Transplant Medicine, Ospedale San Raffaele, Milan, Italy
| | - James Avruch
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Liye Liu
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Eirini Kefaloyianni
- Renal Division, Brigham and Women's Hospital, Harvard Institute of Medicine, HIM510, Harvard Medical School, Boston, MA, 02115, USA
| | - Francesca D'Addio
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Enders Building 5th Floor Room EN511, 300 Longwood Ave, Boston, MA, USA
- Transplant Medicine, Ospedale San Raffaele, Milan, Italy
| | - Sara Tezza
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Enders Building 5th Floor Room EN511, 300 Longwood Ave, Boston, MA, USA
| | - Domenico Corradi
- Pathology and Laboratory Medicine, University of Parma, Parma, Italy
| | - Roberto Bassi
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Enders Building 5th Floor Room EN511, 300 Longwood Ave, Boston, MA, USA
| | | | - Vera Usuelli
- Transplant Medicine, Ospedale San Raffaele, Milan, Italy
| | - James Kim
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Jamil Azzi
- Nephrology Division, Transplantation Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - James Markmann
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Reza Abdi
- Nephrology Division, Transplantation Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Paolo Fiorina
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Enders Building 5th Floor Room EN511, 300 Longwood Ave, Boston, MA, USA.
- Transplant Medicine, Ospedale San Raffaele, Milan, Italy.
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16
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Calcineurin inhibitor-free immunosuppressive regimen in type 1 diabetes patients receiving islet transplantation: single-group phase 1/2 trial. Transplantation 2015; 98:1301-9. [PMID: 25286053 DOI: 10.1097/tp.0000000000000396] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Our final objective is to develop an adoptive therapy with tolerogenic donor-specific type 1 T regulatory cells for patients with type 1 diabetes undergoing islet transplantation. The achievement of this objective depends on the availability of an immunosuppressive treatment compatible with the survival, function, and expansion of type 1 T regulatory cells. METHODS For this purpose, we designed a single-group, phase 1 to 2 trial with an immunosuppression protocol including: (i) rapamycin treatment before the first islet infusion (starting ≥ 30 days before transplantation); (ii) induction therapy with anti-thymocyte globulin (ATG) instead of anti-interleukin-2Ra monoclonal antibody (after the first islet infusion only); (iii) short-term treatment with steroids and interleukin-1Ra (right before and for 2 weeks after each infusion); rapamycin+mycophenolate mofetil treatment as maintenance therapy. The target enrollment was 10 patients. RESULTS Ten of 15 patients who started the pretransplant rapamycin treatment completed it. Nine of 10 patients did not complete the induction therapy with ATG, and three of 10 required adaptation of maintenance immunosuppression caused by side effects. Four of 10 patients acquired insulin independence which can be maintained up to year 3 after last infusion. All six other patients have lost their graft, and the early graft loss was associated with lower dose of ATG during induction. CONCLUSION This protocol resulted feasible, safe but less efficient in maintaining graft survival during the time than other T-cell depletion-based protocols. An adequate induction at the first infusion should be considered to improve the overall clinical outcome.
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17
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Choudhary P, Rickels MR, Senior PA, Vantyghem MC, Maffi P, Kay TW, Keymeulen B, Inagaki N, Saudek F, Lehmann R, Hering BJ. Evidence-informed clinical practice recommendations for treatment of type 1 diabetes complicated by problematic hypoglycemia. Diabetes Care 2015; 38:1016-29. [PMID: 25998294 PMCID: PMC4439532 DOI: 10.2337/dc15-0090] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Problematic hypoglycemia, defined as two or more episodes per year of severe hypoglycemia or as one episode associated with impaired awareness of hypoglycemia, extreme glycemic lability, or major fear and maladaptive behavior, is a challenge, especially for patients with long-standing type 1 diabetes. Individualized therapy for such patients should include a composite target: optimal glucose control without problematic hypoglycemia. Therefore, we propose a tiered, four-stage algorithm based on evidence of efficacy given the limitations of educational, technological, and transplant interventions. All patients with problematic hypoglycemia should undergo structured or hypoglycemia-specific education programs (stage 1). Glycemic and hypoglycemia treatment targets should be individualized and reassessed every 3-6 months. If targets are not met, one diabetes technology-continuous subcutaneous insulin infusion or continuous glucose monitoring-should be added (stage 2). For patients with continued problematic hypoglycemia despite education (stage 1) and one diabetes technology (stage 2), sensor-augmented insulin pumps preferably with an automated low-glucose suspend feature and/or very frequent contact with a specialized hypoglycemia service can reduce hypoglycemia (stage 3). For patients whose problematic hypoglycemia persists, islet or pancreas transplant should be considered (stage 4). This algorithm provides an evidence-informed approach to resolving problematic hypoglycemia; it should be used as a guide, with individual patient circumstances directing suitability and acceptability to ensure the prudent use of technology and scarce transplant resources. Standardized reporting of hypoglycemia outcomes and inclusion of patients with problematic hypoglycemia in studies of new interventions may help to guide future therapeutic strategies.
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Affiliation(s)
| | - Michael R Rickels
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Peter A Senior
- Department of Medicine, Division of Endocrinology, University of Alberta, Edmonton, Canada
| | - Marie-Christine Vantyghem
- Endocrinology and Metabolism Department, INSERM U1190, European Genomics Institute for Diabetes, Lille University Hospital, Lille Cedex, France
| | - Paola Maffi
- Diabetes Research Institute, Scientific Institute Ospedale San Raffaele, Milan, Italy
| | - Thomas W Kay
- Immunology and Diabetes Unit, St. Vincent's Institute, University of Melbourne, Melbourne, Australia
| | - Bart Keymeulen
- Diabetes Clinic and Research Center, Vrije Universiteit Brussel, Brussels, Belgium
| | - Nobuya Inagaki
- Department of Diabetes and Clinical Nutrition, Kyoto University, Kyoto, Japan
| | - Frantisek Saudek
- Diabetes Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Roger Lehmann
- Department of Endocrinology and Diabetology, University of Zurich, Zurich, Switzerland
| | - Bernhard J Hering
- Schulze Diabetes Institute and Department of Surgery, University of Minnesota, Minneapolis, MN
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18
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Abstract
Islet transplantation is considered an advanced therapy in the treatment of type-1 diabetes, with a progressive improvement of clinical results as seen in the Collaborative Islet Transplant Registry (CITR) report. It is an accepted method for the stabilization of frequent hypoglycemia, or severe glycemic lability, in patients with hypoglycemic unawareness, poor diabetic control, or a resistance to intensive insulin-based therapies. Worldwide data confirm a positive trend in this field, with the integrated management of pivotal factors: adequate islet mass, immunosuppressive protocols, additional anti-inflammatory therapy, and pre-transplant allo-immunity assessment. Insulin independence has been observed in several clinical trials with different rate, ranging 100-65% of patients; the maintenance of this condition during the follow-up progressively decreased, actually arranged on 44% 3 years after the last infusion, according to data reported from the CITR. Successful duration is progressively increasing, with ≥13 years being the longest reported insulin-free condition on record. The immediate results of functioning islet transplantation are an improvement in hypoglycemic awareness and a reduction in the glycated hemoglobin level. Furthermore, many studies have shown its influence on the chronic complications of diabetes, such as peripheral neuropathy, retinopathy, and macroangiopathy. Pre-transplant nephropathy remains an exclusion criterion as immunosuppressive therapy can exacerbate kidney-function deterioration. The problems linked to immunosuppression following islet transplantation for the treatment of type-1 diabetes need to be considered in order to achieve the correct risk/benefit ratio for each patient.
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19
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Hanssen NMJ, Russell N, Cooper ME. Recent advances in glucose-lowering treatment to reduce diabetic kidney disease. Expert Opin Pharmacother 2015; 16:1325-33. [PMID: 25912195 DOI: 10.1517/14656566.2015.1041502] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION The epidemic of diabetes has now taken on epic proportions and therefore reducing the impact of diabetic complications represents one of the major global challenges in improving health and well-being worldwide. Preventing the development of diabetic kidney disease (DKD) is particularly important, as diabetes is one of the main risk factors for the development of chronic kidney disease, which in turn is strongly linked to development of cardiovascular disease, end-stage renal failure, hospitalization and premature death. Intensive glucose-lowering treatment has been shown to prevent and slow progression of DKD, yet to date, only certain populations have benefited from this intervention. AREAS COVERED We review the evidence for existing glucose-lowering treatments in the prevention of DKD, and research into techniques to better target individuals who will benefit from these therapies. EXPERT OPINION Diabetic patients with established kidney disease may benefit from glucose-lowering treatment, particularly if a safer side-effect profile of these treatments is achieved. Better understanding of glucose homeostasis and evaluation of compounds inhibiting its downstream effects are required in order to improve the outlook for individuals with DKD. An additional approach to improve the success rate of glucose-lowering treatment is to improve the selection of individuals who may benefit from treatment. A potential means to identify such subjects could involve the use of biomarkers.
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Affiliation(s)
- Nordin M J Hanssen
- Maastricht University, CARIM School of Cardiovascular Diseases, Department of Internal Medicine , Maastricht , The Netherlands
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20
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D'Addio F, Trevisani A, Ben Nasr M, Bassi R, El Essawy B, Abdi R, Secchi A, Fiorina P. Harnessing the immunological properties of stem cells as a therapeutic option for diabetic nephropathy. Acta Diabetol 2014; 51:897-904. [PMID: 24894496 DOI: 10.1007/s00592-014-0603-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 05/17/2014] [Indexed: 12/27/2022]
Abstract
Diabetic nephropathy is the leading and possibly the most devastating complication of diabetes, with a prevalence ranging from 25 to 40 % in diabetic individuals, and as such represents an important challenge for public health worldwide. As a major cause of end-stage renal disease, diabetic nephropathy also accounts for a large proportion of deaths in diabetic individuals. To date, therapeutic options for overt diabetic nephropathy include medical interventions to reduce blood glucose levels and to control blood pressure and proteinuria. Recent evidence suggests a strong role for inflammation in the development and progression of diabetic nephropathy. Various immune cells, cytokines and chemokines have been implicated in the onset of diabetic nephropathy, while immune-related transcription factors and adhesion molecules have been correlated with the establishment of a renal proinflammatory microenvironment. Both inflammation and immune activation may promote severe distress in the kidney, with subsequent increased local fibrosis, ultimately leading to the development of end-stage renal disease. Stem cells are undifferentiated cells capable of regenerating virtually any organ or tissue and bearing important immunoregulatory and anti-inflammatory properties. Due to the aforementioned considerations, significant interest has been ignited with regard to the use of stem cells as novel therapeutics for diabetic nephropathy. Here, we will be examining in detail how anti-inflammatory properties of different populations of stem cells may offer novel therapy for the treatment of diabetic nephropathy.
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21
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Usuelli V, La Rocca E. Novel therapeutic approaches for diabetic nephropathy and retinopathy. Pharmacol Res 2014; 98:39-44. [PMID: 25447794 DOI: 10.1016/j.phrs.2014.10.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 10/03/2014] [Accepted: 10/16/2014] [Indexed: 12/13/2022]
Abstract
Diabetes mellitus is a chronic disease that in the long-term increases the microvascular and macrovascular degenerative complications thus being responsible for a large part of death associated with diabetes. During the years, while preventive care for diabetic patients has improved, the increase in the prevalence of diabetes worldwide is continuous. The detrimental effects of diabetes mellitus result in microvascular diseases, which recognize hyperglycemia as major determinant. A significant number of potential therapeutic targets for the treatment of diabetic microvascular complications have been proposed, but the encouraging results obtained in preclinical studies, have largely failed in clinical trials. Currently, the most successful strategy to prevent microvascular complications of diabetes is the intensive treatment of hyperglycemia or the normalization of glycometabolic control achieved with pancreatic and islet transplantation. In this review, we focus on the novel therapeutic targets to prevent the development and progression of diabetic nephropathy and retinopathy microvascular complications.
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Affiliation(s)
- Vera Usuelli
- Division of Transplant Medicine, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ennio La Rocca
- Division of Transplant Medicine, IRCCS Ospedale San Raffaele, Milan, Italy.
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22
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Pawlick R, Gala-Lopez B, Pepper AR, McCall M, Ziff O, Shapiro AMJ. The combination of anti-NKG2D and CTLA-4 Ig therapy prolongs islet allograft survival in a murine model. Am J Transplant 2014; 14:2367-74. [PMID: 25179027 DOI: 10.1111/ajt.12838] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 05/05/2014] [Accepted: 05/08/2014] [Indexed: 01/25/2023]
Abstract
Islet transplantation is an effective means of treating severe type 1 diabetes in patients with life-threatening hypoglycemia. Improvements in glycemic control with correction of HbA1C enhance quality of life irrespective of insulin independence. By antagonizing the Natural Killer Group 2, member D (NKG2D) receptor expression on NK and CD8+ T cells, in combination with blocking CTLA-4 binding sites, we demonstrate a significant delay of graft rejection in islet allotransplant. Anti-NKG2D combined with CTLA-4 Ig (n = 15) results in prolonged allograft survival, with 84.6 ± 10% of the recipients displaying insulin independence compared to controls (n = 10, p < 0.001). The effect of combination therapy on graft survival is superior to treatments alone (CTLA-4 Ig vs. combination p = 0.024, anti-NKG2D vs. combination p < 0.001) indicating an interaction between these pathways. In addition, combination treatment also improves glucose tolerance when compared to controls (n = 10, p = 0.018). Histologically, NKG2D+ cells were significantly decreased within the allograft after 7 days of combination treatment (n = 6, p = 0.029). T cell proliferation was significantly reduced with anti-NKG2D therapy and CD8+ T cell daughter fractions were also significantly decreased with mAb and combination treatment when measured by in vitro mixed lymphocyte reaction (n = 5, p = 0.015, p = 0.005 and p = 0.048). These results demonstrate that inhibition of NKG2D receptors and costimulatory pathways enhance islet allograft survival.
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Affiliation(s)
- R Pawlick
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
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23
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Tezza S, Ben Nasr M, Vergani A, Valderrama Vasquez A, Maestroni A, Abdi R, Secchi A, Fiorina P. Novel immunological strategies for islet transplantation. Pharmacol Res 2014; 98:69-75. [PMID: 25014184 DOI: 10.1016/j.phrs.2014.06.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 06/27/2014] [Accepted: 06/30/2014] [Indexed: 01/21/2023]
Abstract
Islet transplantation has been demonstrated to improve glycometabolic control, to reduce hypoglycemic episodes and to halt the progression of diabetic complications. However, the exhaustion of islet function and the side effects related to chronic immunosuppression limit the spread of this technique. Consequently, new immunoregulatory protocols have been developed, with the aim to avoid the use of a life-time immunosuppression. Several approaches have been tested in preclinical models, and some are now under clinical evaluation. The development of new small molecules and new monoclonal or polyclonal antibodies is continuous and raises the possibility of targeting new costimulatory pathways or depleting particular cell types. The use of stem cells and regulatory T cells is underway to take advantage of their immunological properties and to induce tolerance. Xenograft islet transplantation, although having severe problems in terms of immunological compatibility, could theoretically provide an unlimited source of donors; using pigs carrying human immune antigens has showed indeed promising results. A completely different approach, the use of encapsulated islets, has been developed; synthetic structures are used to hide islet alloantigen from the immune system, thus preserving islet endocrine function. Once one of these strategies is demonstrated safe and effective, it will be possible to establish clinical islet transplantation as a treatment for patients with type 1 diabetes long before the onset of diabetic-related complications.
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Affiliation(s)
- Sara Tezza
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Transplant Medicine, IRCCS Ospedale San Raffaele, Milano, Italy; Univerista' degli Studi di Roma "Tor Vergata", Rome, Italy
| | - Moufida Ben Nasr
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Transplant Medicine, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Andrea Vergani
- Transplant Medicine, IRCCS Ospedale San Raffaele, Milano, Italy; Dompé Inc. Research and Development Department, Diabetes and Transplantation Unit, New York, NY, USA
| | | | - Anna Maestroni
- Transplant Medicine, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Reza Abdi
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antonio Secchi
- Transplant Medicine, IRCCS Ospedale San Raffaele, Milano, Italy; Universita' Vita-Salute San Raffaele, Milan, Italy
| | - Paolo Fiorina
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Transplant Medicine, IRCCS Ospedale San Raffaele, Milano, Italy.
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Lv C, Chen M, Xu M, Xu G, Zhang Y, He S, Xue M, Gao J, Yu M, Gao X, Zhu T. Influencing factors of new-onset diabetes after a renal transplant and their effects on complications and survival rate. PLoS One 2014; 9:e99406. [PMID: 24911157 PMCID: PMC4050028 DOI: 10.1371/journal.pone.0099406] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 05/14/2014] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To discuss the onset of and relevant risk factors for new-onset diabetes after a transplant (NODAT) in patients who survive more than 1 year after undergoing a renal transplant and the influence of these risk factors on complications and long-term survival. METHOD A total of 428 patients who underwent a renal transplant between January 1993 and December 2008 and were not diabetic before surgery were studied. The prevalence rate of and relevant risk factors for postoperative NODAT were analyzed on the basis of fasting plasma glucose (FPG) levels, and differences in postoperative complications and survival rates between patients with and without NODAT were compared. RESULTS The patients in this study were followed up for a mean of 5.65 ± 3.68 years. In total, 87 patients (20.3%) developed NODAT. Patients who converted from treatment with CSA to FK506 had increased prevalence rates of NODAT (P <0.05). Multi-factor analysis indicated that preoperative FPG level (odds ratio [OR] = 1.48), age (OR = 1.10), body mass index (OR = 1.05), hepatitis C virus infection (OR = 2.72), and cadaveric donor kidney (OR = 1.18) were independent risk factors for NODAT (All P <0.05). Compared with the N-NODAT group, the NODAT group had higher prevalence rates (P < 0.05) of postoperative infection, hypertension, and dyslipidemia; in addition, the survival rate and survival time of the 2 groups did not significantly differ. CONCLUSION Among the patients who survived more than 1 year after a renal transplant, the prevalence rate of NODAT was 20.32%. Preoperative FPG level, age, body mass index, hepatitis C virus infection, and cadaveric donor kidney were independent risk factors for NODAT. Patients who converted from treatment with CSA to FK506 after a renal transplant had aggravated impairments in glycometabolism. Patients with NODAT were also more vulnerable to postoperative complications such as infection, hypertension, and hyperlipidemia.
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Affiliation(s)
- Chaoyang Lv
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Minling Chen
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
- Department of Endocrinology and Metabolism, People's Hospital Affiliated to Fujian University of Traditional Chinese Medicine (The People's Hospital of Fujian Province), Fuzhou, P.R. China
| | - Ming Xu
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai Key Laboratory of Organ Transplantation, Shanghai, P.R. China
| | - Guiping Xu
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
- Department of Cadre's Ward, Fujian Provincial Hospital, Fujian Medical University, Fuzhou, Fujian, P.R. China
| | - Yao Zhang
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Shunmei He
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Mengjuan Xue
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Jian Gao
- Evidence Base Medicine Center, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Mingxiang Yu
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Xin Gao
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, P.R. China
| | - Tongyu Zhu
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai Key Laboratory of Organ Transplantation, Shanghai, P.R. China
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26
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Clinical application of microencapsulated islets: actual prospectives on progress and challenges. Adv Drug Deliv Rev 2014; 67-68:84-92. [PMID: 24184490 DOI: 10.1016/j.addr.2013.09.020] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 07/08/2013] [Accepted: 09/25/2013] [Indexed: 11/21/2022]
Abstract
After 25 years of intense pre-clinical work on microencapsulated intraperitoneal islet grafts into non-immunosuppressed diabetic recipients, the application of this procedure to patients with type 1 diabetes mellitus has been a significant step forward. This result, achieved in a few centers worldwide, underlies the safety of biopolymers used for microencapsulation. Without this advance, no permission for human application of microcapsules would have ever been obtained after years of purification technologies applied to the raw alginates. To improve safety of the encapsulated islet graft system, renewed efforts on the capsules' bioengineering, as well as on insulin-producing cells within the capsular membranes, are in progress. It is hoped that advances in these two critical aspects of the cell encapsulation technology will result in wider human application of this system.
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27
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Fiorina P, Vergani A, Bassi R, Niewczas MA, Altintas MM, Pezzolesi MG, D'Addio F, Chin M, Tezza S, Ben Nasr M, Mattinzoli D, Ikehata M, Corradi D, Schumacher V, Buvall L, Yu CC, Chang JM, La Rosa S, Finzi G, Solini A, Vincenti F, Rastaldi MP, Reiser J, Krolewski AS, Mundel PH, Sayegh MH. Role of podocyte B7-1 in diabetic nephropathy. J Am Soc Nephrol 2014; 25:1415-29. [PMID: 24676639 DOI: 10.1681/asn.2013050518] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Podocyte injury and resulting albuminuria are hallmarks of diabetic nephropathy, but targeted therapies to halt or prevent these complications are currently not available. Here, we show that the immune-related molecule B7-1/CD80 is a critical mediator of podocyte injury in type 2 diabetic nephropathy. We report the induction of podocyte B7-1 in kidney biopsy specimens from patients with type 2 diabetes. Genetic and epidemiologic studies revealed the association of two single nucleotide polymorphisms at the B7-1 gene with diabetic nephropathy. Furthermore, increased levels of the soluble isoform of the B7-1 ligand CD28 correlated with the progression to ESRD in individuals with type 2 diabetes. In vitro, high glucose conditions prompted the phosphatidylinositol 3 kinase-dependent upregulation of B7-1 in podocytes, and the ectopic expression of B7-1 in podocytes increased apoptosis and induced disruption of the cytoskeleton that were reversed by the B7-1 inhibitor CTLA4-Ig. Podocyte expression of B7-1 was also induced in vivo in two murine models of diabetic nephropathy, and treatment with CTLA4-Ig prevented increased urinary albumin excretion and improved kidney pathology in these animals. Taken together, these results identify B7-1 inhibition as a potential therapeutic strategy for the prevention or treatment of diabetic nephropathy.
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Affiliation(s)
- Paolo Fiorina
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Medicine, San Raffaele Scientific Institute, Milan, Italy;
| | - Andrea Vergani
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Medicine, San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Bassi
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Medicine, San Raffaele Scientific Institute, Milan, Italy; DiSTeBA, Universita' del Salento, Lecce, Italy
| | - Monika A Niewczas
- Section on Genetics and Epidemiology, Research Division, Joslin Diabetes Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Mehmet M Altintas
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Marcus G Pezzolesi
- Section on Genetics and Epidemiology, Research Division, Joslin Diabetes Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Francesca D'Addio
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Medicine, San Raffaele Scientific Institute, Milan, Italy
| | - Melissa Chin
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sara Tezza
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Moufida Ben Nasr
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deborah Mattinzoli
- Renal Research Laboratory, Fondazione IRCCS Ospedale Maggiore Policlinico and Fondazione D'Amico per la Ricerca sulle Malattie Renali, Milan, Italy
| | - Masami Ikehata
- Renal Research Laboratory, Fondazione IRCCS Ospedale Maggiore Policlinico and Fondazione D'Amico per la Ricerca sulle Malattie Renali, Milan, Italy
| | - Domenico Corradi
- Department of Biomedical, Biotechnological and Translational Sciences, Unit of Pathology, University of Parma, Parma, Italy
| | - Valerie Schumacher
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lisa Buvall
- Nephrology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Chih-Chuan Yu
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jer-Ming Chang
- Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | | | - Giovanna Finzi
- Pathology Department, Ospedale di Circolo, Varese, Italy
| | - Anna Solini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Flavio Vincenti
- Kidney Transplant Service, University of San Francisco, San Francisco, California
| | - Maria Pia Rastaldi
- Renal Research Laboratory, Fondazione IRCCS Ospedale Maggiore Policlinico and Fondazione D'Amico per la Ricerca sulle Malattie Renali, Milan, Italy
| | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Andrzej S Krolewski
- Section on Genetics and Epidemiology, Research Division, Joslin Diabetes Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Peter H Mundel
- Nephrology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Mohamed H Sayegh
- Transplantation Research Center, Brigham and Women's Hospital, Boston, Massachusetts; and American University of Beirut, Beirut, Lebanon
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Xiao F, Ma L, Zhao M, Huang G, Mirenda V, Dorling A, Lechler R, Lombardi G. Ex vivo expanded human regulatory T cells delay islet allograft rejection via inhibiting islet-derived monocyte chemoattractant protein-1 production in CD34+ stem cells-reconstituted NOD-scid IL2rγnull mice. PLoS One 2014; 9:e90387. [PMID: 24594640 PMCID: PMC3940883 DOI: 10.1371/journal.pone.0090387] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 01/28/2014] [Indexed: 12/12/2022] Open
Abstract
Type 1 diabetes mellitus (T1DM) is an autoimmune disease caused by immune-mediated destruction of insulin-secreting β cells of the pancreas. Near complete dependence on exogenous insulin makes T1DM very difficult to control, with the result that patients are exposed to high blood glucose and risk of diabetic complications and/or intermittent low blood glucose that can cause unconsciousness, fits and even death. Allograft transplantation of pancreatic islets restores normoglycemia with a low risk of surgical complications. However, although successful immediately after transplantation, islets are progressively lost, with most of the patients requiring exogenous insulin within 2 years post-transplant. Therefore, there is an urgent requirement for the development of new strategies to prevent islet rejection. In this study, we explored the importance of human regulatory T cells in the control of islets allograft rejection. We developed a pre-clinical model of human islet transplantation by reconstituting NOD-scid IL2rγnull mice with cord blood-derived human CD34+ stem cells and demonstrated that although the engrafted human immune system mediated the rejection of human islets, their survival was significantly prolonged following adoptive transfer of ex vivo expanded human Tregs. Mechanistically, Tregs inhibited the infiltration of innate immune cells and CD4+ T cells into the graft by down-regulating the islet graft-derived monocyte chemoattractant protein-1. Our findings might contribute to the development of clinical strategies for Treg therapy to control human islet rejection. We also show for the first time that CD34+ cells-reconstituted NOD-scid IL2rγnull mouse model could be beneficial for investigating human innate immunity in vivo.
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Affiliation(s)
- Fang Xiao
- Medical Research Council (MRC) for Transplantation, King's College London, London, United Kingdom
| | - Liang Ma
- Medical Research Council (MRC) for Transplantation, King's College London, London, United Kingdom
| | - Min Zhao
- Department of Diabetes & Endocrinology, King's College London, London, United Kingdom
| | - Guocai Huang
- Department of Diabetes & Endocrinology, King's College London, London, United Kingdom
| | - Vincenzo Mirenda
- Medical Research Council (MRC) for Transplantation, King's College London, London, United Kingdom
| | - Anthony Dorling
- Medical Research Council (MRC) for Transplantation, King's College London, London, United Kingdom
| | - Robert Lechler
- Medical Research Council (MRC) for Transplantation, King's College London, London, United Kingdom
| | - Giovanna Lombardi
- Medical Research Council (MRC) for Transplantation, King's College London, London, United Kingdom
- * E-mail:
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29
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Vergani A, Tezza S, Fotino C, Visner G, Pileggi A, Chandraker A, Fiorina P. The purinergic system in allotransplantation. Am J Transplant 2014; 14:507-14. [PMID: 24433446 DOI: 10.1111/ajt.12567] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 10/31/2013] [Accepted: 10/31/2013] [Indexed: 01/25/2023]
Abstract
The purine nucleotide adenosine triphosphate (ATP) is a universal source of energy for any intracellular reaction. Under specific physiological or pathological conditions, ATP can be released into extracellular spaces, where it binds and activates the purinergic receptors system (i.e. P2X, P2Y and P1 receptors). Extracellular ATP (eATP) binds to P2X or P2Y receptors in immune cells, where it mediates proliferation, chemotaxis, cytokine release, antigen presentation and cytotoxicity. eATP is then hydrolyzed by ectonucleotidases into adenosine diphosphate (ADP), which activates P2Y receptors. Ectonucleotidases also hydrolyze ADP to adenosine monophosphate and adenosine, which binds P1 receptors. In contrast to P2X and P2Y receptors, P1 receptors exert mainly an inhibitory effect on the immune response. In transplantation, a prominent role has been demonstrated for the eATP/P2X7R axis; the targeting of this pathway in fact is associated with long-term graft function and reduced graft versus host disease severity in murine models. Novel P2X receptor inhibitors are available for clinical use and are under assessment as immunomodulatory agents. In this review, we will focus on the relevance of the purinergic system and on the potential benefits of targeting this system in allograft rejection and tolerance.
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Affiliation(s)
- A Vergani
- Nephrology Division, Boston Children's Hospital, Harvard Medical School, Boston, MA; Department of Medicine, San Raffaele Scientific Institute, Milan, Italy
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30
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Zinger A, Leibowitz G. Islet transplantation in type 1 diabetes: hype, hope and reality - a clinician's perspective. Diabetes Metab Res Rev 2014; 30:83-7. [PMID: 24123789 DOI: 10.1002/dmrr.2484] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 04/15/2013] [Accepted: 05/07/2013] [Indexed: 01/20/2023]
Abstract
The β-cell replacement by islet transplantation is an attractive approach for normalizing blood glucose without hypoglycaemia in patient with type 1 diabetes mellitus (T1D). A pioneer study by the Edmonton group more than a decade ago showed that alloislet transplantation may result in insulin independence for at least 1 year after transplantation. This breakthrough excited researchers, physicians and patients, who felt that the ultimate goal of cure for T1D was at hand. Longer follow-up of patients who underwent islet transplantation showed less favourable results, with only approximately 10% of the patients remaining insulin-free 5 years after transplantation. In the last few years, progress has been made, and the success rate of islet transplantation has steadily increased. Important hurdles, however, related to limited tissue supply and need for life-long immunosuppressive drugs have yet to be overcome. Herein, we review recent achievements in islet transplantation and the challenges that still need to be addressed before this procedure can become a standard therapy for T1D.
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Affiliation(s)
- Adar Zinger
- Endocrinology and Metabolism Service, Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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31
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D'Addio F, Maffi P, Vezzulli P, Vergani A, Mello A, Bassi R, Nano R, Falautano M, Coppi E, Finzi G, D'Angelo A, Fermo I, Pellegatta F, La Rosa S, Magnani G, Piemonti L, Falini A, Folli F, Secchi A, Fiorina P. Islet transplantation stabilizes hemostatic abnormalities and cerebral metabolism in individuals with type 1 diabetes. Diabetes Care 2014; 37:267-76. [PMID: 24026546 PMCID: PMC3867995 DOI: 10.2337/dc13-1663] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Islets after kidney transplantation have been shown to positively affect the quality of life of individuals with type 1 diabetes (T1D) by reducing the burden of diabetes complications, but fewer data are available for islet transplantation alone (ITA). The aim of this study was to assess whether ITA has a positive impact on hemostatic and cerebral abnormalities in individuals with T1D. RESEARCH DESIGN AND METHODS Prothrombotic factors, platelet function/ultrastructure, and cerebral morphology, metabolism, and function have been investigated over a 15-month follow-up period using ELISA/electron microscopy and magnetic resonance imaging, nuclear magnetic resonance spectroscopy, and neuropsychological evaluation (Profile of Mood States test and paced auditory serial addition test) in 22 individuals with T1D who underwent ITA (n = 12) or remained on the waiting list (n = 10). Patients were homogeneous with regard to metabolic criteria, hemostatic parameters, and cerebral morphology/metabolism/function at the time of enrollment on the waiting list. RESULTS At the 15-month follow-up, the group undergoing ITA, but not individuals with T1D who remained on the waiting list, showed 1) improved glucose metabolism; 2) near-normal platelet activation and prothrombotic factor levels; 3) near-normal cerebral metabolism and function; and 4) a near-normal neuropsychological test. CONCLUSIONS ITA, despite immunosuppressive therapy, is associated with a near-normalization of hemostatic and cerebral abnormalities.
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32
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Kim JI, Stott RT, Soohoo J, Lee KM, Zhao G, Yeh H, Deng S, Markmann JF. Elevated levels of interferon-γ production by memory T cells do not promote transplant tolerance resistance in aged recipients. PLoS One 2013; 8:e82856. [PMID: 24340063 PMCID: PMC3858330 DOI: 10.1371/journal.pone.0082856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 10/28/2013] [Indexed: 11/18/2022] Open
Abstract
Immunosenescence predisposes the elderly to infectious and autoimmune diseases and impairs the response to vaccination. We recently demonstrated that ageing also impedes development of transplantation tolerance. Unlike their young counterparts (8-12 weeks of age) aged male recipients (greater than 12 months of age) transplanted with a full MHC-mismatched heart are resistant to tolerance mediated by anti-CD45RB antibody. Surprisingly, either chemical or surgical castration restored tolerance induction to levels observed using young recipients. Based on the strong impact of endocrine modulation on transplant tolerance, we explored the impact of ageing and castration on the immune system. Here we report a significant increase in the percentage of T cells that produce interferon-γ (IFN-γ) in aged male versus young male animals and that the overall increase in IFN-γ production was due to an expansion of IFN-γ-producing memory T cells in aged animals. In contrast to IFN-γ production, we did not observe differences in IL-10 expression in young versus old male mice. We hypothesized that endocrine modulation would diminish the elevated levels of IFN-γ production in aged recipients, however, we observed no significant reduction in the percentage of IFN-γ+ T cells upon castration. Furthermore, we neutralized interferon-γ by antibody and did not observe an effect on graft survival. We conclude that while elevated levels of interferon-γ serves as a marker of tolerance resistance in aged mice, other as yet to be identified factors are responsible for its cause. Defining these factors may be relevant to design of tolerogenic strategies for aged recipients.
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Affiliation(s)
- James I. Kim
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ryan T. Stott
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Julie Soohoo
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kang Mi Lee
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Gaoping Zhao
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Surgery, Sichuan Provincial People’s Hospital and Sichuan Academy of Medical Sciences, Chengdu, Sichuan Province, China
| | - Heidi Yeh
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Shaoping Deng
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Surgery, Sichuan Provincial People’s Hospital and Sichuan Academy of Medical Sciences, Chengdu, Sichuan Province, China
| | - James F. Markmann
- Transplantation Unit, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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33
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O'Connell PJ, Holmes-Walker DJ, Goodman D, Hawthorne WJ, Loudovaris T, Gunton JE, Thomas HE, Grey ST, Drogemuller CJ, Ward GM, Torpy DJ, Coates PT, Kay TW. Multicenter Australian trial of islet transplantation: improving accessibility and outcomes. Am J Transplant 2013; 13:1850-8. [PMID: 23668890 DOI: 10.1111/ajt.12250] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 03/14/2013] [Accepted: 03/14/2013] [Indexed: 01/25/2023]
Abstract
Whilst initial rates of insulin independence following islet transplantation are encouraging, long-term function using the Edmonton Protocol remains a concern. The aim of this single-arm, multicenter study was to evaluate an immunosuppressive protocol of initial antithymocyte globulin (ATG), tacrolimus and mycophenolate mofetil (MMF) followed by switching to sirolimus and MMF. Islets were cultured for 24 h prior to transplantation. The primary end-point was an HbA1c of <7% and cessation of severe hypoglycemia. Seventeen recipients were followed for ≥ 12 months. Nine islet preparations were transported interstate for transplantation. Similar outcomes were achieved at all three centers. Fourteen of the 17 (82%) recipients achieved the primary end-point. Nine (53%) recipients achieved insulin independence for a median of 26 months (range 7-39 months) and 6 (35%) remain insulin independent. All recipients were C-peptide positive for at least 3 months. All subjects with unstimulated C-peptide >0.2 nmol/L had cessation of severe hypoglycemia. Nine of the 17 recipients tolerated switching from tacrolimus to sirolimus with similar graft outcomes. There was a small but significant reduction in renal function in the first 12 months. The combination of islet culture, ATG, tacrolimus and MMF is a viable alternative for islet transplantation.
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Affiliation(s)
- P J O'Connell
- National Pancreas Transplant Unit, University of Sydney at Westmead Hospital, Australia.
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Barton FB, Rickels MR, Alejandro R, Hering BJ, Wease S, Naziruddin B, Oberholzer J, Odorico JS, Garfinkel MR, Levy M, Pattou F, Berney T, Secchi A, Messinger S, Senior PA, Maffi P, Posselt A, Stock PG, Kaufman DB, Luo X, Kandeel F, Cagliero E, Turgeon NA, Witkowski P, Naji A, O'Connell PJ, Greenbaum C, Kudva YC, Brayman KL, Aull MJ, Larsen C, Kay TWH, Fernandez LA, Vantyghem MC, Bellin M, Shapiro AMJ. Improvement in outcomes of clinical islet transplantation: 1999-2010. Diabetes Care 2012; 35:1436-45. [PMID: 22723582 PMCID: PMC3379615 DOI: 10.2337/dc12-0063] [Citation(s) in RCA: 510] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To describe trends of primary efficacy and safety outcomes of islet transplantation in type 1 diabetes recipients with severe hypoglycemia from the Collaborative Islet Transplant Registry (CITR) from 1999 to 2010. RESEARCH DESIGN AND METHODS A total of 677 islet transplant-alone or islet-after-kidney recipients with type 1 diabetes in the CITR were analyzed for five primary efficacy outcomes and overall safety to identify any differences by early (1999-2002), mid (2003-2006), or recent (2007-2010) transplant era based on annual follow-up to 5 years. RESULTS Insulin independence at 3 years after transplant improved from 27% in the early era (1999-2002, n = 214) to 37% in the mid (2003-2006, n = 255) and to 44% in the most recent era (2007-2010, n = 208; P = 0.006 for years-by-era; P = 0.01 for era alone). C-peptide ≥0.3 ng/mL, indicative of islet graft function, was retained longer in the most recent era (P < 0.001). Reduction of HbA(1c) and resolution of severe hypoglycemia exhibited enduring long-term effects. Fasting blood glucose stabilization also showed improvements in the most recent era. There were also modest reductions in the occurrence of adverse events. The islet reinfusion rate was lower: 48% by 1 year in 2007-2010 vs. 60-65% in 1999-2006 (P < 0.01). Recipients that ever achieved insulin-independence experienced longer duration of islet graft function (P < 0.001). CONCLUSIONS The CITR shows improvement in primary efficacy and safety outcomes of islet transplantation in recipients who received transplants in 2007-2010 compared with those in 1999-2006, with fewer islet infusions and adverse events per recipient.
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Tabatabai-Mir H, Sataranatarajan K, Lee HJ, Bokov AF, Fernandez E, Diaz V, Choudhury GG, Richardson A, Kasinath BS. Rapamycin selectively alters serum chemistry in diabetic mice. PATHOBIOLOGY OF AGING & AGE RELATED DISEASES 2012; 2:PBA-2-15896. [PMID: 22953036 PMCID: PMC3417581 DOI: 10.3402/pba.v2i0.15896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 03/12/2012] [Accepted: 03/20/2012] [Indexed: 12/24/2022]
Abstract
The study was undertaken to explore the effect of rapamycin, an anti-inflammatory agent, on the metabolic profile of type 2 diabetic mice. Seven-month-old diabetic db/db mice and their lean littermate non-diabetic controls (db/m) were randomized to receive control chow or chow mixed with rapamycin (2.24 mg/kg/day) (each group n =20, males and females) for 4 months and sacrificed. Serum samples were analyzed for the measurement of glucose, creatinine, blood urea nitrogen (BUN), alkaline phosphatase (ALP), alanine aminotransferase (ALT), total cholesterol, total triglyceride, and total protein, using the automated dry chemistry analysis. Rapamycin elevated serum glucose in female diabetic mice. Serum creatinine tended to be higher in diabetic mice but was not affected by rapamycin; there was no difference in BUN levels among the groups. Serum ALP was elevated in diabetic mice and rapamycin lowered it only in female diabetic mice; serum ALT levels were increased in female diabetic mice, unaffected by rapamycin. Serum total protein was elevated in diabetic mice of both genders but was not affected by rapamycin. Diabetic mice from both genders had elevated serum cholesterol and triglycerides; rapamycin did not affect serum cholesterol but decreased serum total triglycerides in male diabetic mice. We conclude that rapamycin elicits complex metabolic responses in aging diabetic mice, worsening hyperglycemia in females but improving ALP in female diabetic and total triglycerides in male diabetic mice, respectively. The metabolic effects of rapamycin should be considered while performing studies with rapamycin in mice.
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Affiliation(s)
- Hooman Tabatabai-Mir
- Department of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
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Fotino C, Pileggi A. Blockade of leukocyte function antigen-1 (LFA-1) in clinical islet transplantation. Curr Diab Rep 2011; 11:337-44. [PMID: 21755435 DOI: 10.1007/s11892-011-0214-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Carmen Fotino
- Diabetes Research Institute, University of Miami, Miami, FL 33136, USA.
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Abstract
Insulin represents a life-saving therapy for patients with type 1 diabetes but, despite appropriate treatment, it prevents only partially long-term diabetic complications, while generating fatal hypoglycemic episodes. Islet transplantation gained attention because of its safety, effectiveness, and minimal invasiveness; however it remains a procedure reserved for a selected group of patients. The introduction of the Edmonton Protocol in 2000, based on a newly designed steroid-free immunosuppressive protocol, revamped the course of islet transplantation. The main goal of islet transplantation remains insulin independence, although the effect of islet transplantation can be more comprehensively evaluated in terms of frequency of hypoglycemic episodes and impact on diabetic complications and quality of life. Islet transplantation was shown to have positive consequences on cardiovascular, renal, neurologic, and ocular diabetic complications. The proof of concept for cellular replacement therapy in diabetes has been established with islet transplantation, it only needs to be improved and rendered widely available.
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Affiliation(s)
- Roberto Bassi
- Transplantation Research Center, Nephrology Division, Children's Hospital/Harvard Medical School, Boston, MA 02115, USA.
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Reduced progression of diabetic microvascular complications with islet cell transplantation compared with intensive medical therapy. Transplantation 2011; 91:373-8. [PMID: 21258272 DOI: 10.1097/tp.0b013e31820437f3] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effect of islet cell transplantation (ICT) on the progression of diabetic microvascular complications is not well understood. METHODS We have conducted a prospective, crossover, cohort study comparing ICT with intensive medical therapy on the progression of diabetic nephropathy, retinopathy, and neuropathy. RESULTS The rate of decline in glomerular filtration rate is slower after ICT than on medical therapy. There was significantly more progression of retinopathy in medically treated patients than post-ICT. There was a nonsignificant trend for improved nerve conduction velocity post-ICT. CONCLUSIONS ICT is associated with less progression of microvascular complications than intensive medical therapy. Multicenter, randomized trials are needed to further study the role of ICT in slowing the progression of diabetic complications.
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Successes and disappointments with clinical islet transplantation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2010; 654:749-69. [PMID: 20217523 DOI: 10.1007/978-90-481-3271-3_33] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Transplantation of pancreatic islets is considered a therapeutic option for patients with type 1 diabetes mellitus who have life-threatening hypoglycaemic episodes. After the procedure, a decrease in the frequency and severity of hypoglycaemic episodes and sustained graft function as indicated by detectable levels of C-peptide can be seen in the majority of patients. However, true insulin independence, if achieved, usually lasts for at most a few years. Apart from the low insulin independence rates, reasons for concern regarding this procedure are the side effects of the immunosuppressive therapy, allo-immunization, and the high costs. Moreover, whether islet transplantation prevents the progression of diabetic micro- and macrovascular complications is largely unknown. Areas of current research include the development of less toxic immunosuppressive regimens, the control of the inflammatory reaction immediately after transplantation, the identification of the optimal anatomical site for islet infusion, and the possibility to encapsulate transplanted islets to protect them from the allo-immune response. At present, pancreatic islet transplantation is still an experimental procedure, which is only indicated for a highly selected group of type 1 diabetic patients with life-threatening hypoglycaemic episodes.
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Leitão CB, Froud T, Cure P, Tharavanij T, Pileggi A, Ricordi C, Alejandro R. Nonalbumin proteinuria in islet transplant recipients. Cell Transplant 2009; 19:119-25. [PMID: 19878623 DOI: 10.3727/096368909x478641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The aim of this study was to evaluate the importance of nonalbumin-predominant proteinuria on kidney function (KF) after islet transplantation (ITx). Twenty-four-hour proteinuria and albuminuria were available in 27 recipients. KF was assessed by serum creatinine and estimated glomerular filtration rate (eGFR) was calculated by Modification of Diet in Renal Disease formula. Correlations between eGFR and albuminuria (r = -0.422, p < 0.001) were higher than with proteinuria (r = -0.223, p < 0.001; p = 0.006 for comparison between correlations). Nineteen (70%) subjects had proteinuria >or= 300 mg/24 h during the follow-up. Subjects were divided into three groups according to urinary protein excretion patterns: no proteinuria (n = 8), nonalbumin-predominant (n = 8), and albumin-predominant (n = 11) proteinuria. Proteinuria >or= 500 mg/24 h was observed only among patients with albumin-predominant proteinuria (64%; p = 0.002) and these patients had the lowest eGFR means post-ITx (no proteinuria: 84.2 +/- 16.4 vs. nonalbumin: 69.1 +/- 13.8 vs. albumin-predominant proteinuria: 65.5 +/- 16.6 ml/min/1.73 m(2), p = 0.044 for first vs. last group). In conclusion, high frequency of proteinuria was observed after ITx. However, it seems to be milder and have less impact on KF when albumin is not the major source of proteinuria. Prospective evaluation of proteinuria, including tubular function markers, should be performed to elucidate the mechanisms of kidney damage in this population.
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Affiliation(s)
- Cristiane B Leitão
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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A new bioartificial pancreas utilizing amphiphilic membranes for the immunoisolation of porcine islets: a pilot study in the canine. ASAIO J 2009; 55:400-5. [PMID: 19506465 DOI: 10.1097/mat.0b013e3181a8deba] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
We have developed a replaceable bioartificial pancreas to treat diabetes utilizing a unique cocontinous amphiphilic conetwork membrane created for macroencapsulation and immunoisolation of porcine islet cells (PICs). The membrane is assembled from hydrophilic poly(N,N-dimethyl acrylamide) and hydrophobic/oxyphilic polydimethylsiloxane chains cross-linked with hydrophobic/oxyphilic polymethylhydrosiloxane chains. Our hypothesis is that this membrane allows the survival of xenotransplanted PICs in the absence of prevascularization or immunosuppression because of its extraordinarily high-oxygen permeability and small hydrophilic channel dimensions (3-4 nm). The key components are a 5-10 microm thick semipermeable amphiphilic conetwork membrane reinforced with an electrospun nanomat of polydimethylsiloxane-containing polyurethane, and a laser-perforated nitinol scaffold to provide geometric stability. Devices were loaded with PICs and tested for their ability to maintain islet viability without prevascularization, prevent rejection, and reverse hyperglycemia in three pancreatectomized dogs without immunosuppression. Tissue tolerance was good and there was no systemic toxicity. The bioartificial pancreas protected PICs from toxic environments in vitro and in vivo. Islets remained viable for up to 3 weeks without signs of rejection. Neovascularization was observed. Hyperglycemia was not reversed, most likely because of insufficient islet mass. Further studies to determine long-term islet viability and correction of hyperglycemia are warranted.
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Vantyghem MC, Kerr-Conte J, Arnalsteen L, Sergent G, Defrance F, Gmyr V, Declerck N, Raverdy V, Vandewalle B, Pigny P, Noel C, Pattou F. Primary graft function, metabolic control, and graft survival after islet transplantation. Diabetes Care 2009; 32:1473-8. [PMID: 19638525 PMCID: PMC2713623 DOI: 10.2337/dc08-1685] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the influence of primary graft function (PGF) on graft survival and metabolic control after islet transplantation with the Edmonton protocol. RESEARCH DESIGN AND METHODS A total of 14 consecutive patients with brittle type 1 diabetes were enrolled in this phase 2 study and received median 12,479 islet equivalents per kilogram of body weight (interquartile range 11,072-15,755) in two or three sequential infusions within 67 days (44-95). PGF was estimated 1 month after the last infusion by the beta-score, a previously validated index (range 0-8) based on insulin or oral treatment requirements, plasma C-peptide, blood glucose, and A1C. Primary outcome was graft survival, defined as insulin independence with A1C < or =6.5%. RESULTS All patients gained insulin independence within 12 days (6-23) after the last infusion. PGF was optimal (beta-score > or =7) in nine patients and suboptimal (beta-score < or =6) in five. At last follow-up, 3.3 years (2.8-4.0) after islet transplantation, eight patients (57%) remained insulin independent with A1C < or =6.5%, including seven patients with optimal PGF (78%) and one with suboptimal PGF (20%) (P = 0.01, log-rank test). Graft survival was not significantly influenced by HLA mismatches or by preexisting islet autoantibodies. A1C, mean glucose, glucose variability (assessed with continuous glucose monitoring system), and glucose tolerance (using an oral glucose tolerance test) were markedly improved when compared with baseline values and were significantly lower in patients with optimal PGF than in those with suboptimal PGF. CONCLUSIONS Optimal PGF was associated with prolonged graft survival and better metabolic control after islet transplantation. This early outcome may represent a valuable end point in future clinical trials.
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Mineo D, Pileggi A, Alejandro R, Ricordi C. Point: steady progress and current challenges in clinical islet transplantation. Diabetes Care 2009; 32:1563-9. [PMID: 19638527 PMCID: PMC2713646 DOI: 10.2337/dc09-0490] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Davide Mineo
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, Florida
- Department of Internal Medicine and University Policlinic, Tor Vergata University, Rome, Italy
| | - Antonello Pileggi
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, Florida
- DeWitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Rodolfo Alejandro
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, Florida
- Department of Medicine, Division of Endocrinology, University of Miami Miller School of Medicine, Miami, Florida
| | - Camillo Ricordi
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, Florida
- DeWitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
- Department of Medicine, Division of Endocrinology, University of Miami Miller School of Medicine, Miami, Florida
- Department of Biomedical Engineering, University of Miami Miller School of Medicine, Miami, Florida
- Wake Forest Institute for Regenerative Medicine, Winston-Salem, North Carolina
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Yuasa T, Rivas-Carrillo JD, Navarro-Alvarez N, Soto-Gutierrez A, Kubota Y, Tabata Y, Okitsu T, Noguchi H, Matsumoto S, Nakaji S, Tanaka N, Kobayashi N. Neovascularization Induced around an Artificial Device Implanted in the Abdomen by the Use of Gelatinized Fibroblast Growth Factor 2. Cell Transplant 2009; 18:683-8. [PMID: 19775531 DOI: 10.1177/096368970901805-625] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The development of a bioartificial pancreas (BAP) with immunoisolating fashion has been gaining attention as a new method for treating diabetes. We have been proceeding with the development of a bag-type BAP that can be easily implanted and that allows for the optional injection or rejection of cells at any time. If fibrosis develops around a BAP device, then the permeability of substances transmitted through a semipermeable membrane will decrease, thereby reducing the reactivity with glucose, so it is necessary for the material of the device to have an excellent histocompatibility. Furthermore, in order to improve the efficacy of BAP treatment, it is important to maintain an environment of ample blood flow around the device. We have created a bag-type device for BAP that is 20 × 20 mm in size and comprises two layers of membranes. We have used an EVAL membrane for the outer membrane of the two layers. The EVAL membrane is a semipermeable membrane with good insulin permeability, which functions as an immunoisolation membrane. The inner membrane consists of PAU-coated HD-PE (nonwoven material processed with polyaminourethan) and it is designed to function as a scaffold for cells. We used Lewis rats to determine whether the effectiveness of fibroblast growth factor 2 (bFGF) can be improved by concomitantly using bFGF with a capacity for blood vessel regeneration as well as bFGF immersed in a sheet of gelatin. We placed the BAP in the abdominal cavity and covered it with the greater omentum. We were able to significantly increase the blood flow and the number of new blood vessels in the tissue surrounding the BAP device by using gelatinized bFGF. There were only a few instances of fibrosis as a biological reaction to the EVAL membrane, and the infiltration of inflammatory cells was mild. There were no adverse effects related to implantation of the device. We confirmed in this study that the use of an implantable BAP device and bFGF allowed for a better blood flow around the BAP device. There were only minor instances of fibrosis and inflammation reaction around the BAP, thus indicating the BAP that we are currently developing to have an excellent histocompatibility.
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Affiliation(s)
- Takeshi Yuasa
- Department of Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama 700-8558, Japan
| | - Jorge D. Rivas-Carrillo
- Department of Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama 700-8558, Japan
| | - Nalú Navarro-Alvarez
- Department of Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama 700-8558, Japan
| | - Alejandro Soto-Gutierrez
- Department of Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama 700-8558, Japan
| | - Yasuhiro Kubota
- Department of Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama 700-8558, Japan
| | - Yasuhiko Tabata
- Department of Organ Reconstruction and Biomaterials, Institute for Frontier Medical Sciences, Kyoto University, Kyoto 606-8507, Japan
| | - Teru Okitsu
- Department of Transplant Surgery, Kyoto University Hospital, Kyoto 606-8507, Japan
| | - Hirofumi Noguchi
- Baylor Institution for Immunology Research, Islet Cell Transplantation Laboratory, Baylor Research Institute, Dallas, TX, USA
- Department of Biomedical Engineering, Okayama University of Science, Okayama 700-0005, Japan
| | - Shinichi Matsumoto
- Baylor Institution for Immunology Research, Islet Cell Transplantation Laboratory, Baylor Research Institute, Dallas, TX, USA
- Department of Biomedical Engineering, Okayama University of Science, Okayama 700-0005, Japan
| | - Shuhei Nakaji
- Department of Biomedical Engineering, Okayama University of Science, Okayama 700-0005, Japan
| | - Noriaki Tanaka
- Department of Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama 700-8558, Japan
| | - Naoya Kobayashi
- Department of Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama 700-8558, Japan
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Leitão CB, Cure P, Messinger S, Pileggi A, Lenz O, Froud T, Faradji RN, Selvaggi G, Kupin W, Ricordi C, Alejandro R. Stable renal function after islet transplantation: importance of patient selection and aggressive clinical management. Transplantation 2009; 87:681-8. [PMID: 19295312 PMCID: PMC2741421 DOI: 10.1097/tp.0b013e31819279a8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Proteinuria development and decrease in glomerular filtration rate (GFR) have been observed after successful islet transplantation. The aim of this study was to determine clinical, laboratory, and immunosuppressant-related factors associated with kidney dysfunction in islet transplant recipients. METHODS A retrospective cohort study was conducted in 35 subjects submitted to pancreatic islet transplantation for treatment of unstable type 1 diabetes mellitus. Demographic, anthropometrical, and laboratory data, as well as immunosuppressive and antihypertensive therapy were recorded. Kidney function was assessed by albuminuria and estimated GFR (eGFR), calculated by modification of diet in renal disease formula. RESULTS Age was the only independent risk factor for low eGFR (<60 mL/min/1.73 m2) (odds ratio [OR]=1.78 [1.22-2.61]). Low-density lipoprotein cholesterol (OR=2.90 [1.37-6.12]) and previous microalbuminuria (OR=6.42 [1.42-29.11]) were risk factors for transient macroalbuminuria. Interestingly, tacrolimus was a protective factor for macroalbuminuria (OR=0.12 [0.06-0.26]). Six of 30 (20%) normoalbuminuric subjects at baseline progressed to microalbuminuria. No subject developed sustained macroalbuminuria. Surprisingly, overall eGFR remained stable during follow-up (before transplant: 74.0+/-2.0; during immunosuppressive therapy: 75.4+/-2.8; and after withdrawal: 76.3+/-5.3 mL/min/1.73 m2; P>0.05). Even subjects with low eGFR and microalbuminuria at baseline (n=10) maintained stable values posttransplantation (61.13+/-3.25 mL/min/1.73 m2 vs. 63.32+/-4.36 mL/min/1.73 m2, P=0.500). CONCLUSIONS Kidney function remained stable after islet transplantation alone. The unchanged kidney function found in this sample may be attributed to healthier kidney status at baseline and possibly to prompt treatment of modifiable risk factors. Aggressive treatment of risk factors for nephropathy, such as blood pressure, low-density lipoprotein cholesterol, and careful tacrolimus levels monitorization, should be part of islet transplant recipient care.
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Affiliation(s)
- Cristiane B. Leitão
- Diabetes Research Institute, 1450 NW 10 Avenue, Miami, FL 33136, USA
- Endocrine Division of Hospital de Clínicas de Porto Alegre, 2350 Ramiro Barcelos, Porto Alegre, RS 90035-003, Brazil
| | - Pablo Cure
- Diabetes Research Institute, 1450 NW 10 Avenue, Miami, FL 33136, USA
| | - Shari Messinger
- Diabetes Research Institute, 1450 NW 10 Avenue, Miami, FL 33136, USA
- Department of Epidemiology and Public Health, University of Miami Miller School of Medicine, 1120 NW 14 Avenue, Suite 1054, Miami, FL, USA
| | - Antonello Pileggi
- Diabetes Research Institute, 1450 NW 10 Avenue, Miami, FL 33136, USA
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, 1611 NW 12 Avenue, Miami, FL 33136, USA
| | - Oliver Lenz
- Department of Nephrology, University of Miami Miller School of Medicine, 1611 NW 12 Avenue, Miami, FL 33136, USA
| | - Tatiana Froud
- Diabetes Research Institute, 1450 NW 10 Avenue, Miami, FL 33136, USA
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, 1611 NW 12 Avenue, Miami, FL 33136, USA
- Department of Radiology, University of Miami Miller School of Medicine, 1611 NW 12 Avenue, Miami, FL 33136, USA
| | - Raquel N. Faradji
- Diabetes Research Institute, 1450 NW 10 Avenue, Miami, FL 33136, USA
- Department of Medicine, University of Miami Miller School of Medicine, 1611 NW 12 Avenue, Miami, FL 33136, USA
| | - Gennaro Selvaggi
- Diabetes Research Institute, 1450 NW 10 Avenue, Miami, FL 33136, USA
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, 1611 NW 12 Avenue, Miami, FL 33136, USA
- Jackson Memorial Hospital-University of Miami Transplant Institute, University of Miami Miller School of Medicine, 1611 NW 12 Avenue, Miami, FL 33136, USA
| | - Warren Kupin
- Department of Nephrology, University of Miami Miller School of Medicine, 1611 NW 12 Avenue, Miami, FL 33136, USA
| | - Camillo Ricordi
- Diabetes Research Institute, 1450 NW 10 Avenue, Miami, FL 33136, USA
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, 1611 NW 12 Avenue, Miami, FL 33136, USA
- Department of Medicine, University of Miami Miller School of Medicine, 1611 NW 12 Avenue, Miami, FL 33136, USA
- Jackson Memorial Hospital-University of Miami Transplant Institute, University of Miami Miller School of Medicine, 1611 NW 12 Avenue, Miami, FL 33136, USA
| | - Rodolfo Alejandro
- Diabetes Research Institute, 1450 NW 10 Avenue, Miami, FL 33136, USA
- Department of Medicine, University of Miami Miller School of Medicine, 1611 NW 12 Avenue, Miami, FL 33136, USA
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Eliaschewitz FG, Franco DR, Mares-Guia TR, Noronha IL, Labriola L, Sogayar MC. Transplante de ilhotas na prática clínica: estado atual e perspectivas. ACTA ACUST UNITED AC 2009; 53:15-23. [DOI: 10.1590/s0004-27302009000100004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Accepted: 11/19/2008] [Indexed: 02/08/2023]
Abstract
O transplante de ilhotas é um procedimento em desenvolvimento, como alternativa para o tratamento do diabetes tipo 1 que está na fronteira entre o experimental e o clínico. É uma terapia celular na qual as células são implantadas em território diferente do fisiológico em que apenas determinado número incerto conseguirá se adaptar. Aperfeiçoar este processo para obter os mesmos resultados que no transplante de pâncreas, representa um desafio para o qual convergem contribuições da biologia celular, da imunologia e das técnicas de laboratório que se entrelaçam de maneira extremamente complexa. Este trabalho revisa a literatura expondo a evolução do procedimento, a sua metodologia atual e os resultados clínicos obtidos. As perspectivas futuras do transplante diante dos recentes avanços também são discutidas.
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Affiliation(s)
- Freddy Goldberg Eliaschewitz
- Universidade de São Paulo; Centro de Pesquisa Clínica; Hospital Heliópolis; notre-Dame intermédica Sistema de Saúde
| | - Denise Reis Franco
- Universidade de São Paulo; Centro de Pesquisa Clínica; Hospital Heliópolis
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2007 update on allogeneic islet transplantation from the Collaborative Islet Transplant Registry (CITR). Cell Transplant 2009; 18:753-67. [PMID: 19796497 DOI: 10.3727/096368909x470874] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
As of October 1, 2007, 25 North American medical institutions and one European islet transplant center reported detailed information to the Registry on 315 allograft recipients, of which 285 were islet alone (IA) and 30 were islet after kidney (IAK). Of the 114 IA recipients expected at 4 years after their last infusion, 12% were insulin independent, 16% were insulin dependent with detectable C-peptide, 40% had no detectable C-peptide, and 32% had missing C-peptide data or were lost to follow-up. Of the IA recipients, 72% achieved insulin independence at least once over 3 years and multiple infusions. Factors associated with achievement of insulin independence included islet size >1.0 expressed as IEQs per islet number [hazard ratio (HR) = 1.5, p = 0.06], additional infusions given (HR = 1.5, p = 0.01), lower pretransplant HbA(1c) (HR = 1.2 each %-age unit, p = 0.02), donor given insulin (HR = 2, p = 0.003), daclizumab given at any infusion (HR = 1.9, p = 0.06), and shorter cold storage time (HR = 1.04, p = 0.03), mutually adjusted in a multivariate model. Severe hypoglycemia prevalence was reduced from 78-83% preinfusion to less than 5% throughout the first year post-last infusion, and to 18% adjusted for missing data at 3 years post-last infusion. In Year 1 post-first infusion for IA recipients, 53% experienced a Grade 3-5 or serious adverse event (AE) and 35% experienced a severe AE related to either an infusion procedure or immunosuppression. In Year 1 post-first infusion, 33% of IA subjects and 35% of IAK subjects had an AE related to the infusion procedure, while 35% of IA subjects and only 27% of IAK subjects had an AE related to the immunosuppression therapy. Five deaths were reported, of which two were classified as probably related to the infusion procedure or immunosuppression, and 10 cases of neoplasm, of which two were classified as probably related to the procedure or immunosuppression. Islet transplantation continues to show short-term benefits of insulin independence, normal or near normal HbA(1C) levels, and sustained marked decrease in hypoglycemic episodes.
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Affiliation(s)
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- The EMMES Corporation, Rockville, MD 20850, USA.
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48
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Bibliography. Current world literature. Neuro opthalmology. Curr Opin Ophthalmol 2008; 19:541-4. [PMID: 18854700 DOI: 10.1097/icu.0b013e328317c7c4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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49
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Mineo D, Sageshima J, Burke GW, Ricordi C. Minimization and withdrawal of steroids in pancreas and islet transplantation. Transpl Int 2008; 22:20-37. [PMID: 18855850 DOI: 10.1111/j.1432-2277.2008.00761.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
For reducing the corticosteroid (CS)-related side-effects, especially cardiovascular events, CS-sparing protocols have become increasingly common in pancreas transplantation (PT). Lympho-depleting induction antibodies, such as rabbit anti-thymocyte globulin (rATG) or alemtuzumab, have been widely used in successful trials. The results of various CS-sparing protocols combining calcineurin inhibitors (CNI) and mycophenolate or sirolimus, have been mixed for rejection and survival rates. Most of the studies were uncontrolled trials of low-risk patients, therefore the grade of evidence is limited. Large-scale prospective studies with long-term follow up are necessary to assess risks and benefits of CS-sparing regimens in PT before recommending such strategies as standard practice. Islet allo-transplantation for patients with brittle type 1 diabetes mellitus, less invasive and safer procedure than PT, has been attempted since late 1980s, but diabetogenic immunosuppressants at maintenance, mainly CS and high-dose CNI, prevented satisfactory results (10% insulin-independence at 1-year post-transplant). Since 2000, CS-free and CNI-reducing protocols, including more potent induction [daclizumab, OKT3gamma1(ala-ala) anti-CD3 antibody, rATG] and maintenance (sirolimus, mycophenolate) agents, have significantly improved short-term outcomes whereas long-term are still inadequate (from 80% to 20% insulin-independence from 1- to 5-year post-transplant). Main limitations are allo- and autoimmunity, immunosuppression-related islet and systemic toxicity and transplant site unsuitability, which tolerogenic protocols and biotechnological solutions may solve.
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Affiliation(s)
- Davide Mineo
- Diabetes Research Institute, University of Miami, FL 33136, USA
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Abstract
The Edmonton protocol was undoubtedly a major step forward in the history of islet transplantation. Its immunosuppression regimen was largely based on the mTOR inhibitor rapamycin (sirolimus), which remains the most frequently used immunosuppressive drug in clinical islet transplant protocols. As time reveals the somewhat disappointing long-term results achieved with the Edmonton protocol, a number of publications have appeared addressing the potential beneficial or deleterious role of rapamycin on islet cell engraftment, function survival and regeneration, as well as on its side-effects in human subjects. This paper reviews the sometimes contradictory evidence on the impact of rapamycin in islet transplantation.
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Affiliation(s)
- Thierry Berney
- Division of Transplantation and Visceral Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland.
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