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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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2
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Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Lernmark Å, Metzger BE, Nathan DM, Kirkman MS. Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus. Diabetes Care 2023; 46:e151-e199. [PMID: 37471273 PMCID: PMC10516260 DOI: 10.2337/dci23-0036] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/11/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Numerous laboratory tests are used in the diagnosis and management of diabetes mellitus. The quality of the scientific evidence supporting the use of these assays varies substantially. APPROACH An expert committee compiled evidence-based recommendations for laboratory analysis in screening, diagnosis, or monitoring of diabetes. The overall quality of the evidence and the strength of the recommendations were evaluated. The draft consensus recommendations were evaluated by invited reviewers and presented for public comment. Suggestions were incorporated as deemed appropriate by the authors (see Acknowledgments). The guidelines were reviewed by the Evidence Based Laboratory Medicine Committee and the Board of Directors of the American Association for Clinical Chemistry and by the Professional Practice Committee of the American Diabetes Association. CONTENT Diabetes can be diagnosed by demonstrating increased concentrations of glucose in venous plasma or increased hemoglobin A1c (HbA1c) in the blood. Glycemic control is monitored by the people with diabetes measuring their own blood glucose with meters and/or with continuous interstitial glucose monitoring (CGM) devices and also by laboratory analysis of HbA1c. The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of ketones, autoantibodies, urine albumin, insulin, proinsulin, and C-peptide are addressed. SUMMARY The guidelines provide specific recommendations based on published data or derived from expert consensus. Several analytes are found to have minimal clinical value at the present time, and measurement of them is not recommended.
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Affiliation(s)
- David B. Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD
| | - Mark Arnold
- Department of Chemistry, University of Iowa, Iowa City, IA
| | - George L. Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, University of Chicago Medicine, Chicago, IL
| | - David E. Bruns
- Department of Pathology, University of Virginia Medical School, Charlottesville, VA
| | - Andrea R. Horvath
- New South Wales Health Pathology Department of Chemical Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Åke Lernmark
- Department of Clinical Sciences, Lund University/CRC, Skane University Hospital Malmö, Malmö, Sweden
| | - Boyd E. Metzger
- Division of Endocrinology, Northwestern University, The Feinberg School of Medicine, Chicago, IL
| | - David M. Nathan
- Massachusetts General Hospital Diabetes Center and Harvard Medical School, Boston, MA
| | - M. Sue Kirkman
- Department of Medicine, University of North Carolina, Chapel Hill, NC
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3
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Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Lernmark Å, Metzger BE, Nathan DM, Kirkman MS. Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus. Clin Chem 2023:hvad080. [PMID: 37473453 DOI: 10.1093/clinchem/hvad080] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/12/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Numerous laboratory tests are used in the diagnosis and management of diabetes mellitus. The quality of the scientific evidence supporting the use of these assays varies substantially. APPROACH An expert committee compiled evidence-based recommendations for laboratory analysis in screening, diagnosis, or monitoring of diabetes. The overall quality of the evidence and the strength of the recommendations were evaluated. The draft consensus recommendations were evaluated by invited reviewers and presented for public comment. Suggestions were incorporated as deemed appropriate by the authors (see Acknowledgments). The guidelines were reviewed by the Evidence Based Laboratory Medicine Committee and the Board of Directors of the American Association of Clinical Chemistry and by the Professional Practice Committee of the American Diabetes Association. CONTENT Diabetes can be diagnosed by demonstrating increased concentrations of glucose in venous plasma or increased hemoglobin A1c (Hb A1c) in the blood. Glycemic control is monitored by the people with diabetes measuring their own blood glucose with meters and/or with continuous interstitial glucose monitoring (CGM) devices and also by laboratory analysis of Hb A1c. The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of ketones, autoantibodies, urine albumin, insulin, proinsulin, and C-peptide are addressed. SUMMARY The guidelines provide specific recommendations based on published data or derived from expert consensus. Several analytes are found to have minimal clinical value at the present time, and measurement of them is not recommended.
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Affiliation(s)
- David B Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD, United States
| | - Mark Arnold
- Department of Chemistry, University of Iowa, Iowa City, IA, United States
| | - George L Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, University of Chicago Medicine, Chicago, ILUnited States
| | - David E Bruns
- Department of Pathology, University of Virginia Medical School, Charlottesville, VA, United States
| | - Andrea R Horvath
- New South Wales Health Pathology Department of Chemical Pathology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Åke Lernmark
- Department of Clinical Sciences, Lund University/CRC, Skane University Hospital Malmö, Malmö, Sweden
| | - Boyd E Metzger
- Division of Endocrinology, Northwestern University, The Feinberg School of Medicine, Chicago, IL, United States
| | - David M Nathan
- Massachusetts General Hospital Diabetes Center and Harvard Medical School, Boston, MA, United States
| | - M Sue Kirkman
- Department of Medicine, University of North Carolina, Chapel Hill, NC, United States
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Thomas S, Ouhtit A, Al Khatib HA, Eid AH, Mathew S, Nasrallah GK, Emara MM, Al Maslamani MA, Yassine HM. Burden and Disease Pathogenesis of Influenza and Other Respiratory Viruses in Diabetic Patients. J Infect Public Health 2022; 15:412-424. [DOI: 10.1016/j.jiph.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 02/24/2022] [Accepted: 03/07/2022] [Indexed: 02/07/2023] Open
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Ziegler AG, Danne T, Daniel C, Bonifacio E. 100 Years of Insulin: Lifesaver, immune target, and potential remedy for prevention. MED 2021; 2:1120-1137. [PMID: 34993499 PMCID: PMC8730368 DOI: 10.1016/j.medj.2021.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
In this review, we bring our personal experiences to showcase insulin from its breakthrough discovery as a life-saving drug 100 years ago to its uncovering as the autoantigen and potential cause of type 1 diabetes and eventually as an opportunity to prevent autoimmune diabetes. The work covers the birth of insulin to treat patients, which is now 100 years ago, the development of human insulin, insulin analogues, devices, and the way into automated insulin delivery, the realization that insulin is the primary autoimmune target of type 1 diabetes in children, novel approaches of immunotherapy using insulin for immune tolerance induction, the possible limitations of insulin immunotherapy, and an outlook how modern vaccines could remove the need for another 100 years of insulin therapy.
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Affiliation(s)
- Anette-Gabriele Ziegler
- Institute of Diabetes Research, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany
- German Center for Diabetes Research (DZD), Munich, Germany
- Forschergruppe Diabetes, Technical University Munich, at Klinikum rechts der Isar, Munich, Germany
- Lead Contact
| | - Thomas Danne
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus AUF DER BULT, 30173 Hannover, Germany
| | - Carolin Daniel
- Institute of Diabetes Research, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany
- German Center for Diabetes Research (DZD), Munich, Germany
- Division of Clinical Pharmacology, Department of Medicine IV, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Ezio Bonifacio
- Technische Universität Dresden, Center for Regenerative Therapies Dresden, Dresden, Germany
- Paul Langerhans Institute Dresden of the Helmholtz Center Munich at University Hospital Carl Gustav Carus and Faculty of Medicine, TU Dresden, Germany
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6
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Marfil-Garza BA, Hefler J, Bermudez De Leon M, Pawlick R, Dadheech N, Shapiro AMJ. Progress in Translational Regulatory T Cell Therapies for Type 1 Diabetes and Islet Transplantation. Endocr Rev 2021; 42:198-218. [PMID: 33247733 DOI: 10.1210/endrev/bnaa028] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 02/06/2023]
Abstract
Regulatory T cells (Tregs) have become highly relevant in the pathophysiology and treatment of autoimmune diseases, such as type 1 diabetes (T1D). As these cells are known to be defective in T1D, recent efforts have explored ex vivo and in vivo Treg expansion and enhancement as a means for restoring self-tolerance in this disease. Given their capacity to also modulate alloimmune responses, studies using Treg-based therapies have recently been undertaken in transplantation. Islet transplantation provides a unique opportunity to study the critical immunological crossroads between auto- and alloimmunity. This procedure has advanced greatly in recent years, and reports of complete abrogation of severe hypoglycemia and long-term insulin independence have become increasingly reported. It is clear that cellular transplantation has the potential to be a true cure in T1D, provided the remaining barriers of cell supply and abrogated need for immune suppression can be overcome. However, the role that Tregs play in islet transplantation remains to be defined. Herein, we synthesize the progress and current state of Treg-based therapies in T1D and islet transplantation. We provide an extensive, but concise, background to understand the physiology and function of these cells and discuss the clinical evidence supporting potency and potential Treg-based therapies in the context of T1D and islet transplantation. Finally, we discuss some areas of opportunity and potential research avenues to guide effective future clinical application. This review provides a basic framework of knowledge for clinicians and researchers involved in the care of patients with T1D and islet transplantation.
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Affiliation(s)
| | - Joshua Hefler
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Mario Bermudez De Leon
- Department of Molecular Biology, Centro de Investigación Biomédica del Noreste, Instituto Mexicano del Seguro Social, Monterrey, Nuevo Leon, Mexico
| | - Rena Pawlick
- Department of Surgery, University of Alberta, Edmonton, Canada
| | | | - A M James Shapiro
- Department of Surgery, University of Alberta, Edmonton, Canada.,Clinical Islet Transplant Program, University of Alberta, Edmonton, Canada
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Triolo TM, Bellin MD. Lessons from Human Islet Transplantation Inform Stem Cell-Based Approaches in the Treatment of Diabetes. Front Endocrinol (Lausanne) 2021; 12:636824. [PMID: 33776933 PMCID: PMC7992005 DOI: 10.3389/fendo.2021.636824] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/01/2021] [Indexed: 12/15/2022] Open
Abstract
Diabetes mellitus is characterized by the body's inability to control blood glucose levels within a physiological range due to loss and/or dysfunction of insulin producing beta cells. Progressive beta cell loss leads to hyperglycemia and if untreated can lead to severe complications and/or death. Treatments at this time are limited to pharmacologic therapies, including exogenous insulin or oral/injectable agents that improve insulin sensitivity or augment endogenous insulin secretion. Cell transplantation can restore physiologic endogenous insulin production and minimize hyper- and hypoglycemic excursions. Islet isolation procedures and management of transplant recipients have advanced over the last several decades; both tight glycemic control and insulin independence are achievable. Research has been conducted in isolating islets, monitoring islet function, and mitigating the immune response. However, this procedure is still only performed in a small minority of patients. One major barrier is the scarcity of human pancreatic islet donors, variation in donor pancreas quality, and variability in islet isolation success. Advances have been made in generation of glucose responsive human stem cell derived beta cells (sBCs) and islets from human pluripotent stem cells using directed differentiation. This is an emerging promising treatment for patients with diabetes because they could potentially serve as an unlimited source of functional, glucose-responsive beta cells. Challenges exist in their generation including long term survival of grafts, safety of transplantation, and protection from the immune response. This review focuses on the progress made in islet allo- and auto transplantation and how these advances may be extrapolated to the sBC context.
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Affiliation(s)
- Taylor M. Triolo
- The Barbara Davis Center for Diabetes, School of Medicine, University of Colorado Denver, Aurora, CO, United States
- *Correspondence: Taylor M. Triolo,
| | - Melena D. Bellin
- Department of Pediatrics, School of Medicine, University of Minnesota, Minneapolis, MN, United States
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Siu JH, Motallebzadeh R, Pettigrew GJ. Humoral autoimmunity after solid organ transplantation: Germinal ideas may not be natural. Cell Immunol 2020; 354:104131. [DOI: 10.1016/j.cellimm.2020.104131] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/11/2020] [Accepted: 05/11/2020] [Indexed: 12/22/2022]
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Pestana N, Malheiro J, Silva F, Silva A, Ribeiro C, Pedroso S, Almeida M, Dias L, Henriques AC, Martins LS. Impact of Pancreatic Autoantibodies in Pancreas Graft Survival After Pancreas-Kidney Transplantation. Transplant Proc 2020; 52:1370-1375. [PMID: 32245621 DOI: 10.1016/j.transproceed.2020.02.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 02/07/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND In simultaneous pancreas-kidney transplantation (SPKT), persistence or recurrence of pancreatic autoantibodies (PAs) has been associated with pancreas graft (PG) autoimmune-driven injury. Our aim was to analyze the impact of PAs on PG survival. METHODS Between January 1, 2000, and December 31, 2017, we studied 139 patients with post-SPKT anti-glutamic acid decarboxylase (GAD) autoantibody. Alloimmune (ALI) events were defined as PG rejection and/or de novo donor-specific antibodies (DSA). Hence, 3 groups were defined: patients without ALI events or anti-GAD (n = 42), those with ALI events (n = 14), or those only with autoimmune events (positive for anti-GAD and no ALI events; n = 83). RESULTS Male sex was predominant (n = 72, 52%). Median age was 35 years (interquartile range: 31-39) and median follow-up was 6-7 years (interquartile range: 4.1-9.2). Regarding anti-GAD positivity post-SPKT (n = 90, 65%), no differences were observed concerning age, sex, anti-HLA antibodies, HLA mismatch number and de novo DSA. ALI events were present in 10% (n = 14). PG survival 15 years post-SPKT was better in patients without immune events (96%) followed by those with ALI (69%) and autoimmune events (63%) (P = .025). Anti-GAD was associated to higher annualized mean Hb1AC (P = .006) and lower mean C-peptide (P = .013). According to pre- and post-SPKT anti-GAD status, conversion from negative to positive was associated to worse (63%) 10-year PG survival (P = .044), compared to persistence of negative (100%) or positive anti-GAD (88%). Anti-islet cell and anti-insulin autoantibodies had no impact. CONCLUSION Anti-GAD presence post-SPKT was associated to higher pancreas disfunction and lower PG survival. De novo anti-GAD seems to offer a particular risk of PG failure.
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Affiliation(s)
- Nicole Pestana
- Nephrology Department, Hospital Central do Funchal, Funchal, Portugal.
| | - Jorge Malheiro
- Nephrology Department, Renal and Pancreatic Transplant Units, Centro Hospitalar Universitário do Porto, Lg Prof Abel Salazar, Portugal
| | - Filipa Silva
- Nephrology Department, Renal and Pancreatic Transplant Units, Centro Hospitalar Universitário do Porto, Lg Prof Abel Salazar, Portugal
| | - Andreia Silva
- Nephrology Department, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Catarina Ribeiro
- Nephrology Department, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Porto, Portugal
| | - Sofia Pedroso
- Nephrology Department, Renal and Pancreatic Transplant Units, Centro Hospitalar Universitário do Porto, Lg Prof Abel Salazar, Portugal
| | - Manuela Almeida
- Nephrology Department, Renal and Pancreatic Transplant Units, Centro Hospitalar Universitário do Porto, Lg Prof Abel Salazar, Portugal
| | - Leonídio Dias
- Nephrology Department, Renal and Pancreatic Transplant Units, Centro Hospitalar Universitário do Porto, Lg Prof Abel Salazar, Portugal
| | - António Castro Henriques
- Nephrology Department, Renal and Pancreatic Transplant Units, Centro Hospitalar Universitário do Porto, Lg Prof Abel Salazar, Portugal
| | - La Salete Martins
- Nephrology Department, Renal and Pancreatic Transplant Units, Centro Hospitalar Universitário do Porto, Lg Prof Abel Salazar, Portugal
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Argente-Pla M, Martínez-Millana A, Del Olmo-García MI, Espí-Reig J, Pérez-Rojas J, Traver-Salcedo V, Merino-Torres JF. Autoimmune Diabetes Recurrence After Pancreas Transplantation: Diagnosis, Management, and Literature Review. Ann Transplant 2019; 24:608-616. [PMID: 31767825 PMCID: PMC6896746 DOI: 10.12659/aot.920106] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background Pancreas transplantation can be a viable treatment option for patients with type 1 diabetes mellitus (T1DM), especially for those who are candidates for kidney transplantation. T1DM may rarely recur after pancreas transplantation, causing the loss of pancreatic graft. The aim of this study was to describe the prevalence of T1DM recurrence after pancreas transplantation in our series. Material/Methods Eighty-one patients transplanted from 2002 to 2015 were included. Autoantibody testing (GADA and IA-2) was performed before pancreas transplantation and during the follow-up. Results The series includes 48 males and 33 females, mean age 37.4±5.7 years and mean duration of diabetes 25.5±6.5 years. Patients received simultaneous pancreas kidney (SPK) transplantation. After SPK transplantation, 56 patients retained pancreatic graft, 8 patients died, and 17 patients lost their pancreatic graft. T1DM recurrence occurred in 2 of the 81 transplanted patients, yielding a prevalence of 2.5%, with an average time of appearance of 3.3 years after transplant. Pancreatic enzymes were normal in the 2 patients, ruling out pancreatic rejection. T1DM recurrence was confirmed histologically, showing selective lymphoid infiltration of the pancreatic islets. Conclusions T1DM recurrence after pancreas transplantation is infrequent; however, it is one of the causes of pancreatic graft loss that should always be ruled out. Negative autoimmunity prior to transplantation does not ensure that T1DM does not recur.
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Affiliation(s)
- María Argente-Pla
- Department of Endocrinology and Nutrition, La Fe University and Polytechnic Hospital, Valencia, Spain.,Mixed Research Unit of Endocrinology, Nutrition and Dietetics, La Fe Health Research Institute, Valencia, Spain
| | | | - María Isabel Del Olmo-García
- Department of Endocrinology and Nutrition, La Fe University and Polytechnic Hospital, Valencia, Spain.,Mixed Research Unit of Endocrinology, Nutrition and Dietetics, La Fe Health Research Institute, Valencia, Spain
| | - Jordi Espí-Reig
- Department of Nephrology, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Judith Pérez-Rojas
- Department of Pathological Anatomy, La Fe University and Polytechnic Hospital, Valencia, Spain
| | | | - Juan Francisco Merino-Torres
- Department of Endocrinology and Nutrition, La Fe University and Polytechnic Hospital, Valencia, Spain.,Mixed Research Unit of Endocrinology, Nutrition and Dietetics, La Fe Health Research Institute, Valencia, Spain.,Department of Medicine, University of Valencia, Valencia, Spain
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Balke EM, Demeester S, Lee D, Gillard P, Hilbrands R, Van de Velde U, Van der Auwera BJ, Ling Z, Roep BO, Pipeleers DG, Keymeulen B, Gorus FK. SLC30A8 polymorphism and BMI complement HLA-A*24 as risk factors for poor graft function in islet allograft recipients. Diabetologia 2018; 61:1623-1632. [PMID: 29679103 DOI: 10.1007/s00125-018-4609-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
Abstract
AIMS/HYPOTHESIS HLA-A*24 carriership hampers achievement of insulin independence in islet allograft recipients. However, less than half of those who fail to achieve insulin independence carry the allele. We investigated whether genetic polymorphism at the recipients' zinc transporter 8-encoding SLC30A8 gene (rs13266634) could complement their HLA-A*24 status in predicting functional graft outcome. METHODS We retrospectively analysed data of a hospital-based patient cohort followed for 18 months post transplantation. Forty C-peptide-negative type 1 diabetic individuals who received >2 million beta cells (>4000 islet equivalents) per kg body weight in one or two intraportal implantations under similar immunosuppression were genotyped for SLC30A8. Outcome measurements included achievement and maintenance of graft function. Metabolic benefit was defined as <25% CV of fasting glycaemia in the presence of >331 pmol/l C-peptide, in addition to achievement of insulin independence and maintenance of C-peptide positivity. RESULTS In multivariate analysis, HLA-A*24 positivity, presence of SLC30A8 CT or TT genotypes and BMI more than or equal to the group median (23.9 kg/m2) were independently associated with failure to achieve insulin independence (p = 0.015-0.046). The risk increased with the number of factors present (p < 0.001). High BMI interacted with SLC30A8 T allele carriership to independently predict difficulty in achieving graft function with metabolic benefit (p = 0.015). Maintenance of C-peptide positivity was mainly associated with older age at the time of implantation. Only HLA-A*24 carriership independently predicted failure to maintain acceptable graft function once achieved (p = 0.012). CONCLUSIONS/INTERPRETATION HLA-A*24, the SLC30A8 T allele and high BMI are associated with poor graft outcome and should be considered in the interpretation of future transplantation trials. TRIAL REGISTRATION ClinicalTrials.gov NCT00798785 and NCT00623610.
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Affiliation(s)
- Else M Balke
- Diabetes Research Center, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium.
| | - Simke Demeester
- Diabetes Research Center, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - DaHae Lee
- Diabetes Research Center, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Gillard
- Diabetes Research Center, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Robert Hilbrands
- Diabetes Research Center, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Ursule Van de Velde
- Diabetes Research Center, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Bart J Van der Auwera
- Diabetes Research Center, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Zhidong Ling
- Diabetes Research Center, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Bart O Roep
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
- Department of Diabetes Immunology, Diabetes and Metabolism Research Institute, Beckman Research Institute at the City of Hope, Duarte, CA, USA
| | - Daniël G Pipeleers
- Diabetes Research Center, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Bart Keymeulen
- Diabetes Research Center, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Frans K Gorus
- Diabetes Research Center, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
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12
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Sharples EJ, Mittal SM, Friend PJ. Challenges in pancreas transplantation. Acta Diabetol 2016; 53:871-878. [PMID: 27283012 DOI: 10.1007/s00592-016-0865-x] [Citation(s) in RCA: 16] [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: 11/03/2015] [Accepted: 02/22/2016] [Indexed: 01/26/2023]
Abstract
Whole-organ pancreas transplantation, either alone or combined with a kidney transplant, is the only definitive treatment for many patients with type 1 diabetes that restores normal glucose homoeostasis and insulin independence. Pancreas transplantation delays, or potentially prevents, secondary diabetes complications and is associated with improvement in patient survival when compared with either patients remaining on the waiting list or those receiving kidney transplant alone. Pancreas transplantation is safe and effective, with 1-year patient survival >97 % and graft survival rates of 85 % at 1 year and 76 % at 5 years in recent UK data. This review focuses on some current areas of interest in pancreas transplantation.
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Affiliation(s)
- E J Sharples
- Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals, Old Road, Headington, Oxford, OX3 7LE, UK.
| | - S M Mittal
- Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals, Old Road, Headington, Oxford, OX3 7LE, UK
| | - P J Friend
- Nuffield Department of Surgery, Oxford University, Oxford, UK
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13
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Abstract
Islet autoantibodies are the main markers of pancreatic autoimmunity in type 1 diabetes (T1D). Islet autoantibodies recognize insulin (IAA), glutamic acid decarboxylase (GADA), protein phosphatase-like IA-2 (IA-2A), and ZnT8 (ZnT8A), all antigens that are found on secretory granules within pancreatic beta cells. Islet antibodies, measured by sensitive and specific liquid phase assays, are the key parameters of the autoimmune response monitored for diagnostics or prognostics in patients with T1D or for disease prediction in at-risk individuals before T1D onset. Islet autoantibodies have been the main tool used to explore the natural history of T1D; this review summarizes the current knowledge about the autoantigens and the phenotype of islets autoantibodies acquired in large prospective studies from birth in children at risk of developing T1D.
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Affiliation(s)
- Vito Lampasona
- Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, via Olgettina 60, 20132, Milano, Italy.
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, via Olgettina 60, 20132, Milano, Italy.
| | - Daniela Liberati
- Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, via Olgettina 60, 20132, Milano, Italy
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, via Olgettina 60, 20132, Milano, Italy
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14
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Vendrame F, Hopfner Y, Diamantopoulos S, Virdi SK, Allende G, Snowhite IV, Reijonen HK, Chen L, Ruiz P, Ciancio G, Hutton JC, Messinger S, Burke GW, Pugliese A. Risk Factors for Type 1 Diabetes Recurrence in Immunosuppressed Recipients of Simultaneous Pancreas-Kidney Transplants. Am J Transplant 2016; 16:235-45. [PMID: 26317167 PMCID: PMC5053280 DOI: 10.1111/ajt.13426] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 05/29/2015] [Accepted: 06/15/2015] [Indexed: 01/25/2023]
Abstract
Patients with type 1 diabetes (T1D) who are recipients of pancreas transplants are believed to rarely develop T1D recurrence in the allograft if effectively immunosuppressed. We evaluated a cohort of 223 recipients of simultaneous pancreas-kidney allografts for T1D recurrence and its risk factors. With long-term follow-up, recurrence was observed in approximately 7% of patients. Comparing the therapeutic regimens employed in this cohort over time, lack of induction therapy was associated with recurrence, but this occurs even with the current regimen, which includes induction; there was no influence of maintenance regimens. Longitudinal testing for T1D-associated autoantibodies identified autoantibody positivity, number of autoantibodies, and autoantibody conversion after transplantation as critical risk factors. Autoantibodies to the zinc transporter 8 had the strongest and closest temporal association with recurrence, which was not explained by genetically encoded amino acid sequence donor-recipient mismatches for this autoantigen. Genetic risk factors included the presence of the T1D-predisposing HLA-DR3/DR4 genotype in the recipient and donor-recipient sharing of HLA-DR alleles, especially HLA-DR3. Thus, T1D recurrence is not uncommon and is developing in patients treated with current immunosuppression. The risk factors identified in this study can be assessed in the transplant clinic to identify recurrent T1D and may lead to therapeutic advances.
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Affiliation(s)
- F. Vendrame
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - Y‐Y. Hopfner
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - S. Diamantopoulos
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL,Department of Pediatrics, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - S. K. Virdi
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - G. Allende
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - I. V. Snowhite
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL
| | | | - L. Chen
- Department of Surgery, Division of Transplantation, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - P. Ruiz
- Department of Surgery, Division of Transplantation, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - G. Ciancio
- Department of Surgery, Division of Transplantation, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - J. C. Hutton
- Barbara Davis Center for Childhood DiabetesUniversity of Colorado DenverAuroraCO
| | - S. Messinger
- Department of Epidemiology and Public Health Sciences, Division of Biostatistics, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - G. W. Burke
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL,Department of Surgery, Division of Transplantation, Leonard Miller School of MedicineUniversity of MiamiMiamiFL
| | - A. Pugliese
- Diabetes Research InstituteLeonard Miller School of MedicineUniversity of MiamiMiamiFL,Department of Medicine, Division of Endocrinology and Metabolism, Leonard Miller School of MedicineUniversity of MiamiMiamiFL,Department of Microbiology and ImmunologyLeonard Miller School of MedicineUniversity of MiamiMiamiFL
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Burke GW, Vendrame F, Virdi SK, Ciancio G, Chen L, Ruiz P, Messinger S, Reijonen HK, Pugliese A. Lessons From Pancreas Transplantation in Type 1 Diabetes: Recurrence of Islet Autoimmunity. Curr Diab Rep 2015; 15:121. [PMID: 26547222 DOI: 10.1007/s11892-015-0691-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Type 1 diabetes recurrence (T1DR) affecting pancreas transplants was first reported in recipients of living-related pancreas grafts from twins or HLA identical siblings; given HLA identity, recipients received no or minimal immunosuppression. This observation provided critical evidence that type 1 diabetes (T1D) is an autoimmune disease. However, T1DR is traditionally considered very rare in immunosuppressed recipients of pancreas grafts from organ donors, representing the majority of recipients, and immunological graft failures are ascribed to chronic rejection. We have been performing simultaneous pancreas-kidney (SPK) transplants for over 25 years and find that 6-8 % of our recipients develop T1DR, with symptoms usually becoming manifest on extended follow-up. T1DR is typically characterized by (1) variable degree of insulitis and loss of insulin staining, on pancreas transplant biopsy (with most often absent), minimal to moderate and rarely severe pancreas, and/or kidney transplant rejection; (2) the conversion of T1D-associated autoantibodies (to the autoantigens GAD65, IA-2, and ZnT8), preceding hyperglycemia by a variable length of time; and (3) the presence of autoreactive T cells in the peripheral blood, pancreas transplant, and/or peripancreatic transplant lymph nodes. There is no therapeutic regimen that so far has controlled the progression of islet autoimmunity, even when additional immunosuppression was added to the ongoing chronic regimens; we hope that further studies and, in particular, in-depth analysis of pancreas transplant biopsies with recurrent diabetes will help identify more effective therapeutic approaches.
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Affiliation(s)
- George W Burke
- Miami Transplant Institute, 1801 NW 9th Ave, Highland Professional Building, Miami, FL, 33136, USA.
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Francesco Vendrame
- Department of Medicine, Division of Endocrinology and Metabolism, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Sahil K Virdi
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - G Ciancio
- Miami Transplant Institute, 1801 NW 9th Ave, Highland Professional Building, Miami, FL, 33136, USA
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Linda Chen
- Miami Transplant Institute, 1801 NW 9th Ave, Highland Professional Building, Miami, FL, 33136, USA
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Phillip Ruiz
- Miami Transplant Institute, 1801 NW 9th Ave, Highland Professional Building, Miami, FL, 33136, USA
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Shari Messinger
- Department of Epidemiology and Public Health Sciences, Division of Biostatistics, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Alberto Pugliese
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Medicine, Division of Endocrinology and Metabolism, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL, USA
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Mujtaba MA, Fridell J, Book B, Faiz S, Sharfuddin A, Wiebke E, Rigby M, Taber T. Re-exposure to beta cell autoantigens in pancreatic allograft recipients with preexisting beta cell autoantibodies. Clin Transplant 2015; 29:991-6. [PMID: 26289931 DOI: 10.1111/ctr.12619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2015] [Indexed: 11/28/2022]
Abstract
Re-exposure to beta cell autoantigens and its relevance in the presence of donor-specific antibodies (DSA) in pancreatic allograft recipients is not well known. Thirty-three patients requiring a pancreas transplant were enrolled in an IRB approved study. They underwent prospective monitoring for DSA and beta cell autoantibody (BCAA) levels to GAD65, insulinoma-associated antigen 2 (IA-2), insulin (micro-IAA [mIAA]), and islet-specific zinc transporter isoform-8 (ZnT8). Twenty-five (75.7%) had pre-transplant BCAA. Twenty had a single antibody (mIAA n = 15, GAD65 n = 5); five had two or more BCAA (GAD65 + mIAA n = 2, GAD65 + mIAA+IA-2 n = 2, GA65 + mIAA+IA-2 + ZnT8 = 1). No changes in GAD65 (p > 0.29), IA-2 (>0.16), and ZnT8 (p > 0.07) were observed between pre-transplant and post-transplant at 6 or 12 months. A decrease in mIAA from pre- to post-6 months (p < 0.0001), 12 months (p < 0.0001), and from post-6 to post-12 months (p = 0.0002) was seen. No new BCAA was observed at one yr. Seven (21.0%) developed de novo DSA. The incidence of DSA was 24% in patients with BCAA vs. 25% in patients without BCAA (p = 0.69). Pancreatic allograft function of patients with vs. without BCAA, and with and without BCAA + DSA was comparable until last follow-up (three yr). Re-exposure to beta cell autoantigens by pancreas transplant may not lead to increased levels or development of new BCAA or pancreatic allograft dysfunction.
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Affiliation(s)
- Muhammad Ahmad Mujtaba
- Division of Nephrology/Transplant, Department of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Jonathan Fridell
- Division of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Benita Book
- Transplant Immunology Lab, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sara Faiz
- Department of Pathology, University of Texas Medical Branch, Galveston, TX, USA
| | - Asif Sharfuddin
- Division of Nephrology/Transplant, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eric Wiebke
- Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark Rigby
- Transplant Immunology Lab, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tim Taber
- Division of Nephrology/Transplant, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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17
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The current challenges for pancreas transplantation for diabetes mellitus. Pharmacol Res 2015; 98:45-51. [DOI: 10.1016/j.phrs.2015.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Revised: 01/26/2015] [Accepted: 01/27/2015] [Indexed: 12/27/2022]
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Monti P, Vignali D, Piemonti L. Monitoring Inflammation, Humoral and Cell-mediated Immunity in Pancreas and Islet Transplants. Curr Med Chem 2015; 11:135-43. [PMID: 25777058 PMCID: PMC5398085 DOI: 10.2174/1573399811666150317125820] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 02/19/2015] [Accepted: 02/19/2015] [Indexed: 12/23/2022]
Abstract
Type 1 diabetes (T1D) is caused by the chronic autoimmune destruction of insulin producing beta cells. Beta cell replacement therapy through whole pancreas or islet transplantation is a therapeutic option for patients in which a stable glucose control is not achievable with exogenous insulin therapy. Long-term insulin independence is, however, hampered by the recipient immune response that includes activation of inflammatory pathways and specific allo- and autoimmunity. The identification and monitoring of soluble and cellular biomarkers are of critical relevance for the prediction of graft damage, for the evaluation of responses to immune-modulating therapy, and for target pathways identification to generate novel drugs or therapeutic approaches. The final objective of immune monitoring is to find ways to improve the outcome of pancreas and islet transplantation. In this review, we discuss the available tools to monitor the innate, humoral and cellular responses after islet and pancreas transplantation, and the most relevant findings generated by these measurements.
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Affiliation(s)
- Paolo Monti
- Diabetes Research Institute (DRI), IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
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19
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Martins LS. Autoimmune diabetes recurrence should be routinely monitored after pancreas transplantation. World J Transplant 2014; 4:183-187. [PMID: 25346891 PMCID: PMC4208081 DOI: 10.5500/wjt.v4.i3.183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 05/21/2014] [Accepted: 07/17/2014] [Indexed: 02/05/2023] Open
Abstract
Autoimmune type 1 diabetes recurrence in pancreas grafts was first described 30 years ago, but it is not yet completely understood. In fact, the number of transplants affected and possibly lost due to this disease may be falsely low. There may be insufficient awareness to this entity by clinicians, leading to underdiagnosis. Some authors estimate that half of the immunological losses in pancreas transplantation are due to autoimmunity. Pancreas biopsy is the gold standard for the definitive diagnosis. However, as an invasive procedure, it is not the ideal approach to screen the disease. Pancreatic autoantibodies which may be detected early before graft dysfunction, when searched for, are probably the best initial tool to establish the diagnosis. The purpose of this review is to revisit the autoimmune aspects of type 1 diabetes and to analyse data about the identified autoantibodies, as serological markers of the disease. Therapeutic strategies used to control the disease, though with unsatisfactory results, are also addressed. In addition, the author’s own experience with the prospective monitoring of pancreatic autoantibodies after transplantation and its correlation with graft outcome will be discussed.
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Martins LS, Henriques AC, Fonseca IM, Rodrigues AS, Oliverira JC, Dores JM, Dias LS, Cabrita AM, Silva JD, Noronha IL. Pancreatic autoantibodies after pancreas-kidney transplantation - do they matter? Clin Transplant 2014; 28:462-9. [PMID: 24655222 DOI: 10.1111/ctr.12337] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 02/05/2023]
Abstract
Type 1 diabetes recurrence has been documented in simultaneous pancreas-kidney transplants (SPKT), but this diagnosis may be underestimated. Antibody monitoring is the most simple, noninvasive, screening test for pancreas autoimmune activity. However, the impact of the positive autoimmune markers on pancreas graft function remains controversial. In our cohort of 105 SPKT, we studied the cases with positive pancreatic autoantibodies. They were immunosuppressed with antithymocyte globulin, tacrolimus, mycophenolate, and steroids. The persistence or reappearance of these autoantibodies after SPKT and factors associated with their evolution and with graft outcome were analyzed. Pancreatic autoantibodies were prospectively monitored. Serum samples were collected before transplantation and at least once per year thereafter. At the end of the follow-up (maximum 138 months), 43.8% of patients were positive (from pre-transplant or after recurrence) for at least one autoantibody - the positive group. Antiglutamic acid decarboxylase was the most prevalent (31.4%), followed by anti-insulin (8.6%) and anti-islet cell autoantibodies (3.8%). Bivariate analysis showed that the positive group had higher fasting glucose, higher glycated hemoglobin (HbA1c), lower C-peptide levels, and a higher number of HLA-matches. Analyzing the sample divided into four groups according to pre-/post-transplant autoantibodies profile, the negative/positive group tended to present the higher HbA1c values. Multivariate analysis confirmed the significant association between pancreas autoimmunity and HbA1c and C-peptide levels. Positivity for these autoantibodies pre-transplantation did not influence pancreas survival. The unfavorable glycemic profile observed in the autoantibody-positive SPKT is a matter of concern, which deserves further attention.
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Affiliation(s)
- La Salete Martins
- Nephrology Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal; Transplantation Department, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal
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21
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Wang P, Moore A. Theranostic MRI: the future for Type 1 diabetes management? ACTA ACUST UNITED AC 2014. [DOI: 10.2217/iim.13.67] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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22
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Gruessner RWG, Pugliese A, Reijonen HK, Gruessner S, Jie T, Desai C, Sutherland DER, Burke III GW. Development of diabetes mellitus in living pancreas donors and recipients. Expert Rev Clin Immunol 2014; 7:543-51. [DOI: 10.1586/eci.11.19] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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23
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Abstract
Antigen-experienced T-cells directly target and destroy insulin-producing beta cells in patients with Type 1 diabetes. Consequently, T-cells are also major targets of immunomodulatory strategies that aim to prevent or delay the immune mediated loss of islet beta-cell function. These strategies have had modest success, prompting efforts into better defining the mechanisms that drive the differentiation of quiescent autoreactive clones into pathogenic effector and memory T-cells. Recent and novel findings now indicate that in addition to the classic mechanisms of antigenic recognition, autoreactive T-cell differentiation and expansion can be boosted by the homeostatic cytokine interleukin-7. In this article, we discuss recent evidence of the role of IL-7 mediated T-cell proliferation in the pathogenesis of Type 1 diabetes and the rationale for including immunomodulatory molecules targeting the IL-7/IL-7R axis in immunotherapeutic strategies to control beta-cell autoimmunity.
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Affiliation(s)
- Paolo Monti
- Diabetes Research Institute (DRI), IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy,
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Pretransplantation GAD-autoantibody status to guide prophylactic antibody induction therapy in simultaneous pancreas and kidney transplantation. Transplantation 2013; 96:745-52. [PMID: 23912172 DOI: 10.1097/tp.0b013e3182a012cc] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Daclizumab and antithymocyte globulin (ATG) have been shown to reduce allograft rejection. We assessed the safety and efficacy of daclizumab or ATG prophylaxis in combination with triple immunotherapy in simultaneous pancreas-kidney transplant (SPKT) recipients. METHODS Thirty-nine type 1 diabetic patients scheduled for primary SPKT were randomized to receive prophylactic therapy with either daclizumab or ATG. A group of 27 patients without prophylactic antibodies was used for retrospective comparison. All patients received cyclosporine and mycophenolate mofetil and gradually tapered prednisone. Autoantibodies and cellular autoreactivity were measured to assess recurrent autoreactive responses. RESULTS Baseline and transplant characteristics were comparable among groups. Both daclizumab and ATG therapy resulted in a significant reduction in acute rejection episodes. The incidence of rejection episodes was significantly higher in pretransplantation GAD autoantibody-positive daclizumab-treated recipients compared with GAD autoantibody-negative or ATG-treated recipients. IA-2 islet autoantibodies showed no association with rejection. There were no significant differences between the groups for in vitro autoreactivity, clinical outcome, or functional parameters. CONCLUSIONS Daclizumab or ATG combined with a maintenance immunosuppressive regime consisting of cyclosporine, mycophenolate mofetil, and prednisolone were well tolerated and equally effective in reducing the incidence of acute rejection episodes in SPKT recipients. Up to 3 years, no adverse sequelae of the immunoprophylaxis or clinical and ex vivo recurrent autoimmunity were observed. We propose that the pretransplantation existence of GAD65 autoantibodies serves as a marker guiding the choice for prophylactic therapy in pancreas transplantation.
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Abstract
Type 1 diabetes (T1D) is an autoimmune disease in which the insulin-producing beta-cells are destroyed. Islet or pancreas transplantation can restore insulin secretion and are established therapies for subgroups of T1D patients. Long-term insulin-independence is, however, hampered by recurrent autoimmunity and rejection. Accurate monitoring of these immune events is therefore of critical relevance for the timely detection of deleterious immune responses. The identification of relevant immune biomarkers of allo- and autoreactivity has allowed a more accurate monitoring of disease progression and responses to therapy at early stages, allowing proper therapeutic intervention, and possibly improvements in the success rate of islet and pancreas transplantation. This review describes the tools established and validated to monitor immune correlates of auto- and alloreactivity that associate with clinical outcome and identifies challenges that current immunosuppression strategies trying to preserve islet graft function face.
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Affiliation(s)
- J R F Abreu
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, E3-Q, P.O. Box 9600, NL-2300Rc, Leiden, The Netherlands
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26
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Homeostatic T cell proliferation after islet transplantation. Clin Dev Immunol 2013; 2013:217934. [PMID: 23970924 PMCID: PMC3736509 DOI: 10.1155/2013/217934] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 07/01/2013] [Indexed: 01/08/2023]
Abstract
Pancreatic islet transplantation in patients with type 1 diabetes mellitus is performed under immunosuppression to avoid alloreactive T cell responses and to control the reactivation of autoreactive memory T cells. However, lymphopenia associated with immunosuppression and T cell depletion can induce a paradoxical expansion of lymphocyte subsets under the influence of homeostatic proliferation. Homeostatic T cell proliferation is mainly driven by the IL-7/IL-7 receptor axis, a molecular pathway which is not affected by standard immune-suppressive drugs and, consequently, represents a novel potential target for immuno-modulatory strategies. In this review, we will discuss how homeostatic T cell proliferation can support autoimmunity recurrence after islet transplantation and how it can be targeted by new therapeutic approaches.
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27
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Piemonti L, Everly MJ, Maffi P, Scavini M, Poli F, Nano R, Cardillo M, Melzi R, Mercalli A, Sordi V, Lampasona V, Espadas de Arias A, Scalamogna M, Bosi E, Bonifacio E, Secchi A, Terasaki PI. Alloantibody and autoantibody monitoring predicts islet transplantation outcome in human type 1 diabetes. Diabetes 2013; 62:1656-64. [PMID: 23274902 PMCID: PMC3636624 DOI: 10.2337/db12-1258] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Long-term clinical outcome of islet transplantation is hampered by the rejection and recurrence of autoimmunity. Accurate monitoring may allow for early detection and treatment of these potentially compromising immune events. Islet transplant outcome was analyzed in 59 consecutive pancreatic islet recipients in whom baseline and de novo posttransplant autoantibodies (GAD antibody, insulinoma-associated protein 2 antigen, zinc transporter type 8 antigen) and donor-specific alloantibodies (DSA) were quantified. Thirty-nine recipients (66%) showed DSA or autoantibody increases (de novo expression or titer increase) after islet transplantation. Recipients who had a posttransplant antibody increase showed similar initial performance but significantly lower graft survival than patients without an increase (islet autoantibodies P < 0.001, DSA P < 0.001). Posttransplant DSA or autoantibody increases were associated with HLA-DR mismatches (P = 0.008), induction with antithymocyte globulin (P = 0.0001), and pretransplant panel reactive alloantibody >15% in either class I or class II (P = 0.024) as independent risk factors and with rapamycin as protective (P = 0.006) against antibody increases. DSA or autoantibody increases after islet transplantation are important prognostic markers, and their identification could potentially lead to improved islet cell transplant outcomes.
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Affiliation(s)
- Lorenzo Piemonti
- Diabetes Research Institute, San Raffaele Hospital Scientific Institute, Milan, Italy.
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28
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Boggi U, Vistoli F, Egidi FM, Marchetti P, De Lio N, Perrone V, Caniglia F, Signori S, Barsotti M, Bernini M, Occhipinti M, Focosi D, Amorese G. Transplantation of the pancreas. Curr Diab Rep 2012; 12:568-79. [PMID: 22828824 DOI: 10.1007/s11892-012-0293-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pancreas transplantation consistently induces insulin-independence in beta-cell-penic diabetic patients, but at the cost of major surgery and life-long immunosuppression. One year after grafting, patient survival rate now exceeds 95 % across recipient categories, while insulin independence is maintained in some 85 % of simultaneous pancreas and kidney recipients and in nearly 80 % of solitary pancreas transplant recipients. The half-life of the pancreas graft currently averages 16.7 years, being the longest among extrarenal grafts, and substantially matching the one of renal grafts from deceased donors. The difference between expected (100 %) and actual insulin-independence rate is mostly explained by technical failure in the postoperative phase, and rejection in the long-term period. Death with a functioning graft remains a further major issue, especially in uremic patients who have undergone prolonged periods of dialysis. Refinements in graft preservation, surgical techniques, immunosuppression, and prophylactic treatments are expected to further improve the results of pancreas transplantation.
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Affiliation(s)
- Ugo Boggi
- Division of General and Transplant Surgery, Azienda Ospedaliera Universitaria Pisana, Università di Pisa, Via Paradisa 2, 56124, Pisa, Italy.
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Faustman DL, Wang L, Okubo Y, Burger D, Ban L, Man G, Zheng H, Schoenfeld D, Pompei R, Avruch J, Nathan DM. Proof-of-concept, randomized, controlled clinical trial of Bacillus-Calmette-Guerin for treatment of long-term type 1 diabetes. PLoS One 2012; 7:e41756. [PMID: 22905105 PMCID: PMC3414482 DOI: 10.1371/journal.pone.0041756] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 06/25/2012] [Indexed: 12/17/2022] Open
Abstract
Background No targeted immunotherapies reverse type 1 diabetes in humans. However, in a rodent model of type 1 diabetes, Bacillus Calmette-Guerin (BCG) reverses disease by restoring insulin secretion. Specifically, it stimulates innate immunity by inducing the host to produce tumor necrosis factor (TNF), which, in turn, kills disease-causing autoimmune cells and restores pancreatic beta-cell function through regeneration. Methodology/Principal Findings Translating these findings to humans, we administered BCG, a generic vaccine, in a proof-of-principle, double-blind, placebo-controlled trial of adults with long-term type 1 diabetes (mean: 15.3 years) at one clinical center in North America. Six subjects were randomly assigned to BCG or placebo and compared to self, healthy paired controls (n = 6) or reference subjects with (n = 57) or without (n = 16) type 1 diabetes, depending upon the outcome measure. We monitored weekly blood samples for 20 weeks for insulin-autoreactive T cells, regulatory T cells (Tregs), glutamic acid decarboxylase (GAD) and other autoantibodies, and C-peptide, a marker of insulin secretion. BCG-treated patients and one placebo-treated patient who, after enrollment, unexpectedly developed acute Epstein-Barr virus infection, a known TNF inducer, exclusively showed increases in dead insulin-autoreactive T cells and induction of Tregs. C-peptide levels (pmol/L) significantly rose transiently in two BCG-treated subjects (means: 3.49 pmol/L [95% CI 2.95–3.8], 2.57 [95% CI 1.65–3.49]) and the EBV-infected subject (3.16 [95% CI 2.54–3.69]) vs.1.65 [95% CI 1.55–3.2] in reference diabetic subjects. BCG-treated subjects each had more than 50% of their C-peptide values above the 95th percentile of the reference subjects. The EBV-infected subject had 18% of C-peptide values above this level. Conclusions/Significance We conclude that BCG treatment or EBV infection transiently modified the autoimmunity that underlies type 1 diabetes by stimulating the host innate immune response. This suggests that BCG or other stimulators of host innate immunity may have value in the treatment of long-term diabetes. Trial Registration ClinicalTrials.gov NCT00607230
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Affiliation(s)
- Denise L Faustman
- The Immunobiology Laboratory, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America.
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Zinc transporter 8 autoantibodies increase the predictive value of islet autoantibodies for function loss of technically successful solitary pancreas transplant. Transplantation 2011; 92:674-7. [PMID: 21792090 DOI: 10.1097/tp.0b013e31822ae65f] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite the success rate of solitary pancreas transplantation in type 1 diabetes with preserved kidney function has greatly improved in recent years, a residual proportion of failures persists. METHODS With the aim of investigating autoimmunity as an unrecognized cause of graft failure, we measured autoantibodies to glutamic acid decarboxylase (GADA), insulinoma-associated protein 2 (IA-2A) and the recently discovered zinc transporter 8 antigen (ZnT8A) in 25 recipients of technically successful solitary pancreas transplantation. RESULTS The overall pancreas graft survival was 92%, 88%, and 80% at 2, 4, and 6 years, respectively. Fourteen patients (56%) had one or more autoantibodies before transplantation, with no effect on subsequent pancreas graft outcome. After transplantation, major autoantibody changes (serum conversion from negative to positive, spreading from one to multiple autoantibodies, or titer increase) were observed in 5 of 25 recipients: in four patients, the autoantibody change was followed by the loss of graft function (95% sensitivity, 80% positive predictive value), with a significantly lower graft survival compared with patients without autoantibodies (P<0.0001). The addition of ZnT8A to GADA and IA-2A increased the number of identified autoantibody changes from three to five of 25 recipients and the number of predicted graft function loss from two to four out of five graft losses. CONCLUSIONS Detection of major autoantibody changes after technically successful solitary pancreas transplantation is predictive of subsequent loss of graft function. ZnT8A in addition to GADA and IA-2A are a useful marker to be included in the screening panel of posttransplant immune monitoring.
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31
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Burke GW, Vendrame F, Pileggi A, Ciancio G, Reijonen H, Pugliese A. Recurrence of autoimmunity following pancreas transplantation. Curr Diab Rep 2011; 11:413-9. [PMID: 21660419 PMCID: PMC4018301 DOI: 10.1007/s11892-011-0206-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pancreas transplantation is a therapeutic option for patients with type 1 diabetes. Advances in immunosuppression have reduced immunologic failures, and these are usually categorized as chronic rejection. Yet studies in our cohort of pancreas transplant recipients identified several patients in whom chronic islet autoimmunity led to recurrent diabetes, despite immunosuppression that prevented rejection. Recurrent diabetes in our cohort is as frequent as chronic rejection, and thus is a significant cause of immunologic graft failure. Our studies demonstrated islet autoimmunity by the presence of autoantibodies and autoreactive T cells, which mediated ß-cell destruction in a transplantation model. Biopsy of the transplanted pancreas revealed variable degrees of ß-cell loss, with or without insulitis, in the absence of pancreas and kidney transplant rejection. Additional research is needed to better understand recurrent disease and to identify new treatment regimens that can suppress autoimmunity, as in our experience this is not effectively inhibited by conventional immunosuppression.
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Affiliation(s)
- George W. Burke
- Department of Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, 1801 NW 9th Avenue, Miami FL 33136, Tel. 305-355-5000 Fax 305-355-5134
| | - Francesco Vendrame
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, 1450 NW 10th Avenue, Miami, FL 33136 USA, Tel. 305-243-5353 Fax 305-243-4404
| | - Antonello Pileggi
- Diabetes Research Institute and Department of Surgery, Leonard Miller School of Medicine, 1450 NW 10th Avenue, Miami, FL 33136 USA, Tel. 305-243-2924 Fax 305-243-4404
| | - Gaetano Ciancio
- Departments of Urology and Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, 1801 NW 9th Avenue, Miami FL 33136, Tel. 305-355-5000 Fax 305-355-5134
| | - Helena Reijonen
- Benaroya Research Institute, 1201 Ninth Avenue, Seattle, WA 98101, Tel. 206-223-8813 Fax 206-223-7638
| | - Alberto Pugliese
- Diabetes Research Institute, Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, and Department of Microbiology and Immunology, Leonard Miller School of Medicine, 1450 NW 10th Avenue, Miami, FL 33136 USA, Tel. 305-243-5348 Fax 305-243-4404
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32
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Abstract
The liver is the current site of choice for pancreatic islet transplantation, even though it is far from being an ideal site because of immunologic, anatomic, and physiologic factors leading to a significant early graft loss. A huge amount of alternative sites have been used for islet transplantation in experimental animal models to provide improved engraftment and long-term survival minimizing surgical complications. The pancreas, gastric submucosa, genitourinary tract, muscle, omentum, bone marrow, kidney capsule, peritoneum, anterior eye chamber, testis, and thymus have been explored. Site-specific differences exist in term of islet engraftment, but few alternative sites have potential clinical translation and generally the evidence of a post-transplant islet function better than that reached after intraportal infusion is still lacking. This review discusses site-specific benefits and drawbacks taking into account immunologic, metabolic, and technical aspects to identify the ideal microenvironment for islet function and survival.
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Affiliation(s)
- Elisa Cantarelli
- San Raffaele Diabetes Research Institute, San Raffaele Scientific Institute, Milan, Italy.
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Kalache S, Dinavahi R, Pinney S, Mehrotra A, Cunningham MW, Heeger PS. Anticardiac myosin immunity and chronic allograft vasculopathy in heart transplant recipients. THE JOURNAL OF IMMUNOLOGY 2011; 187:1023-30. [PMID: 21677143 DOI: 10.4049/jimmunol.1004195] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Chronic allograft vasculopathy (CAV) contributes to heart transplant failure, yet its pathogenesis is incompletely understood. Although cellular and humoral alloimmunity are accepted pathogenic mediators, animal models suggest that T cells and Abs reactive to graft-expressed autoantigens, including cardiac myosin (CM), could participate. To test the relationship between CAV and anti-CM autoimmunity in humans, we performed a cross-sectional study of 72 heart transplant recipients: 40 with CAV and 32 without. Sera from 65% of patients with CAV contained anti-CM Abs, whereas <10% contained Abs to other autoantigens (p < 0.05), and only 18% contained anti-HLA Abs (p < 0.05 versus anti-CM). In contrast, 13% of sera from patients without CAV contained anti-CM Abs (p < 0.05; odds ratio [OR], associating CAV with anti-CM Ab = 13, 95% confidence interval [CI] 3.79-44.6). Multivariable analysis confirmed the association to be independent of time posttransplant and the presence of anti-HLA Abs (OR = 28, 95% CI 5.77-133.56). PBMCs from patients with CAV responded more frequently to, and to a broader array of, CM-derived peptides than those without CAV (p = 0.01). Detection of either CM-peptide-reactive T cells or anti-CM Abs was highly and independently indicative of CAV (OR = 45, 95% CI 4.04-500.69). Our data suggest detection of anti-CM immunity could be used as a biomarker for outcome in heart transplantation recipients and support the need for further studies to assess whether anti-CM immunity is a pathogenic mediator of CAV.
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Affiliation(s)
- Safa Kalache
- Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA
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Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Kirkman MS, Lernmark A, Metzger BE, Nathan DM. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Diabetes Care 2011; 34:e61-99. [PMID: 21617108 PMCID: PMC3114322 DOI: 10.2337/dc11-9998] [Citation(s) in RCA: 316] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 02/28/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Multiple laboratory tests are used to diagnose and manage patients with diabetes mellitus. The quality of the scientific evidence supporting the use of these tests varies substantially. APPROACH An expert committee compiled evidence-based recommendations for the use of laboratory testing for patients with diabetes. A new system was developed to grade the overall quality of the evidence and the strength of the recommendations. Draft guidelines were posted on the Internet and presented at the 2007 Arnold O. Beckman Conference. The document was modified in response to oral and written comments, and a revised draft was posted in 2010 and again modified in response to written comments. The National Academy of Clinical Biochemistry and the Evidence-Based Laboratory Medicine Committee of the American Association for Clinical Chemistry jointly reviewed the guidelines, which were accepted after revisions by the Professional Practice Committee and subsequently approved by the Executive Committee of the American Diabetes Association. CONTENT In addition to long-standing criteria based on measurement of plasma glucose, diabetes can be diagnosed by demonstrating increased blood hemoglobin A(1c) (HbA(1c)) concentrations. Monitoring of glycemic control is performed by self-monitoring of plasma or blood glucose with meters and by laboratory analysis of HbA(1c). The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of autoantibodies, urine albumin, insulin, proinsulin, C-peptide, and other analytes are addressed. SUMMARY The guidelines provide specific recommendations that are based on published data or derived from expert consensus. Several analytes have minimal clinical value at present, and their measurement is not recommended.
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Affiliation(s)
- David B Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland, USA.
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35
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Sacks DB, Arnold M, Bakris GL, Bruns DE, Horvath AR, Kirkman MS, Lernmark A, Metzger BE, Nathan DM. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem 2011; 57:e1-e47. [PMID: 21617152 DOI: 10.1373/clinchem.2010.161596] [Citation(s) in RCA: 300] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Multiple laboratory tests are used to diagnose and manage patients with diabetes mellitus. The quality of the scientific evidence supporting the use of these tests varies substantially. APPROACH An expert committee compiled evidence-based recommendations for the use of laboratory testing for patients with diabetes. A new system was developed to grade the overall quality of the evidence and the strength of the recommendations. Draft guidelines were posted on the Internet and presented at the 2007 Arnold O. Beckman Conference. The document was modified in response to oral and written comments, and a revised draft was posted in 2010 and again modified in response to written comments. The National Academy of Clinical Biochemistry and the Evidence Based Laboratory Medicine Committee of the AACC jointly reviewed the guidelines, which were accepted after revisions by the Professional Practice Committee and subsequently approved by the Executive Committee of the American Diabetes Association. CONTENT In addition to long-standing criteria based on measurement of plasma glucose, diabetes can be diagnosed by demonstrating increased blood hemoglobin A(1c) (Hb A(1c)) concentrations. Monitoring of glycemic control is performed by self-monitoring of plasma or blood glucose with meters and by laboratory analysis of Hb A(1c). The potential roles of noninvasive glucose monitoring, genetic testing, and measurement of autoantibodies, urine albumin, insulin, proinsulin, C-peptide, and other analytes are addressed. SUMMARY The guidelines provide specific recommendations that are based on published data or derived from expert consensus. Several analytes have minimal clinical value at present, and their measurement is not recommended.
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Affiliation(s)
- David B Sacks
- Department of Laboratory Medicine, National Institutes of Health, Bethesda, MD 20892-1508, USA.
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Dinavahi R, George A, Tretin A, Akalin E, Ames S, Bromberg JS, Deboccardo G, Dipaola N, Lerner SM, Mehrotra A, Murphy BT, Nadasdy T, Paz-Artal E, Salomon DR, Schröppel B, Sehgal V, Sachidanandam R, Heeger PS. Antibodies reactive to non-HLA antigens in transplant glomerulopathy. J Am Soc Nephrol 2011; 22:1168-78. [PMID: 21566057 DOI: 10.1681/asn.2010111183] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Although T and B cell alloimmunity contribute to transplant injury, autoimmunity directed at kidney-expressed, non-HLA antigens may also participate. Because the specificity, prevalence, and importance of antibodies to non-HLA antigens in late allograft injury are poorly characterized, we used a protein microarray to compare antibody repertoires in pre- and post-transplant sera from several cohorts of patients with and without transplant glomerulopathy. Transplantation routinely induced changes in antibody repertoires, but we did not identify any de novo non-HLA antibodies common to patients with transplant glomerulopathy. The screening studies identified three reactivities present before transplantation that persisted after transplant and strongly associated with transplant glomerulopathy. ELISA confirmed that reactivity against peroxisomal-trans-2-enoyl-coA-reductase strongly associated with the development of transplant glomerulopathy in independent validation sets. In addition to providing insight into effects of transplantation on non-HLA antibody repertoires, these results suggest that pretransplant serum antibodies to peroxisomal-trans-2-enoyl-coA-reductase may predict prognosis in kidney transplantation.
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Affiliation(s)
- Rajani Dinavahi
- Department of Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Pugliese A, Reijonen HK, Nepom J, Burke GW. Recurrence of autoimmunity in pancreas transplant patients: research update. ACTA ACUST UNITED AC 2011; 1:229-238. [PMID: 21927622 DOI: 10.2217/dmt.10.21] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Type 1 diabetes is an autoimmune disorder leading to loss of pancreatic β-cells and insulin secretion, followed by insulin dependence. Islet and whole pancreas transplantation restore insulin secretion. Pancreas transplantation is often performed together with a kidney transplant in patients with end-stage renal disease. With improved immunosuppression, immunological failures of whole pancreas grafts have become less frequent and are usually categorized as chronic rejection. However, growing evidence indicates that chronic islet autoimmunity may eventually lead to recurrent diabetes, despite immunosuppression to prevent rejection. Thus, islet autoimmunity should be included in the diagnostic work-up of graft failure and ideally should be routinely assessed pretransplant and on follow-up in Type 1 diabetes recipients of pancreas and islet cell transplants. There is a need to develop new treatment regimens that can control autoimmunity, as this may not be effectively suppressed by conventional immunosuppression.
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Affiliation(s)
- Alberto Pugliese
- Diabetes Research Institute, University of Miami Miller School of Medicine, 1450 NW 10th Avenue, Miami, FL 33136, USA
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38
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Islet transplantation using donors after cardiac death: report of the Japan Islet Transplantation Registry. Transplantation 2010; 90:740-7. [PMID: 20811319 DOI: 10.1097/tp.0b013e3181ecb044] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND This report summarizes outcomes of islet transplantation employing donors after cardiac death (DCD) between 2004 and 2007 as reported to the Japan Islet Transplantation Registry. METHOD Sixty-five islet isolations were performed for 34 transplantations in 18 patients with insulin-dependent diabetes mellitus, including two patients who had prior kidney transplantation. All but one donor (64/65) was DCD at the time of harvesting. RESULTS Factors influencing criteria for islet release included duration of low blood pressure of the donor, cold ischemic time, and usage of Kyoto solution for preservation. Multivariate analysis selected usage of Kyoto solution as most important. Of the 18 recipients, 8, 4, and 6 recipients received 1, 2, and 3 islet infusions, respectively. Overall graft survival defined as C-peptide level more than or equal to 0.3 ng/mL was 76.5%, 47.1%, and 33.6% at 1, 2, and 3 years, respectively, whereas corresponding graft survival after multiple transplantations was 100%, 80.0%, and 57.1%, respectively. All recipients remained free of severe hypoglycemia while three achieved insulin independence for 14, 79, and 215 days. HbA1c levels and requirement of exogenous insulin were significantly improved in all patients. CONCLUSION Islet transplantation employing DCD can ameliorate severe hypoglycemic episodes, significantly improve HbA1c levels, sustain significant levels of C-peptide, and achieve insulin independence after multiple transplantations. Thus, DCD can be an important resource for islet transplantation if used under strict releasing criteria and in multiple transplantations, particularly in countries where heart-beating donors are not readily available.
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Abstract
For several decades, allograft rejection was believed to be mediated almost exclusively by cellular immune responses, but it is now realized that humoral responses also play a major role. Although directed typically against donor human leukocyte antigen, it is becoming increasingly evident that the antibody response can also target autoantigens that are shared between donor and recipient and that this autoantibody may contribute to graft rejection. Many aspects of transplant-induced humoral autoimmunity remain poorly understood and key questions persist; not least what triggers the response and how autoantibody causes graft damage. Here, we collate results from recent clinical and experimental studies in transplantation and autoimmune diseases to propose answers to these questions.
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Matsuoka KI, Kim HT, McDonough S, Bascug G, Warshauer B, Koreth J, Cutler C, Ho VT, Alyea EP, Antin JH, Soiffer RJ, Ritz J. Altered regulatory T cell homeostasis in patients with CD4+ lymphopenia following allogeneic hematopoietic stem cell transplantation. J Clin Invest 2010; 120:1479-93. [PMID: 20389017 DOI: 10.1172/jci41072] [Citation(s) in RCA: 178] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Accepted: 01/27/2010] [Indexed: 12/13/2022] Open
Abstract
CD4+CD25+Foxp3+ Tregs have an indispensable role in the maintenance of tolerance after allogeneic HSC transplantation (HSCT). Patients with chronic graft-versus-host disease (GVHD) have fewer circulating Tregs, but the mechanisms that lead to this deficiency of Tregs after HSCT are not known. Here, we analyzed reconstitution of Tregs and conventional CD4+ T cells (Tcons) in patients who underwent allogeneic HSCT after myeloablative conditioning. Following transplant, thymic generation of naive Tregs was markedly impaired, and reconstituting Tregs had a predominantly activated/memory phenotype. In response to CD4+ lymphopenia after HSCT, Tregs underwent higher levels of proliferation than Tcons, but Tregs undergoing homeostatic proliferation also showed increased susceptibility to Fas-mediated apoptosis. Prospective monitoring of CD4+ T cell subsets revealed that Tregs rapidly expanded and achieved normal levels by 9 months after HSCT, but Treg levels subsequently declined in patients with prolonged CD4+ lymphopenia. This resulted in a relative deficiency of Tregs, which was associated with a high incidence of extensive chronic GVHD. These studies indicate that CD4+ lymphopenia is a critical factor in Treg homeostasis and that prolonged imbalance of Treg homeostasis after HSCT can result in loss of tolerance and significant clinical disease manifestations.
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Affiliation(s)
- Ken-ichi Matsuoka
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts 02115, USA
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Vendrame F, Pileggi A, Laughlin E, Allende G, Martin-Pagola A, Molano RD, Diamantopoulos S, Standifer N, Geubtner K, Falk BA, Ichii H, Takahashi H, Snowhite I, Chen Z, Mendez A, Chen L, Sageshima J, Ruiz P, Ciancio G, Ricordi C, Reijonen H, Nepom GT, Burke GW, Pugliese A. Recurrence of type 1 diabetes after simultaneous pancreas-kidney transplantation, despite immunosuppression, is associated with autoantibodies and pathogenic autoreactive CD4 T-cells. Diabetes 2010; 59:947-57. [PMID: 20086230 PMCID: PMC2844842 DOI: 10.2337/db09-0498] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate if recurrent autoimmunity explained hyperglycemia and C-peptide loss in three immunosuppressed simultaneous pancreas-kidney (SPK) transplant recipients. RESEARCH DESIGN AND METHODS We monitored autoantibodies and autoreactive T-cells (using tetramers) and performed biopsy. The function of autoreactive T-cells was studied with in vitro and in vivo assays. RESULTS Autoantibodies were present pretransplant and persisted on follow-up in one patient. They appeared years after transplantation but before the development of hyperglycemia in the remaining patients. Pancreas transplant biopsies were taken within approximately 1 year from hyperglycemia recurrence and revealed beta-cell loss and insulitis. We studied autoreactive T-cells from the time of biopsy and repeatedly demonstrated their presence on further follow-up, together with autoantibodies. Treatment with T-cell-directed therapies (thymoglobulin and daclizumab, all patients), alone or with the addition of B-cell-directed therapy (rituximab, two patients), nonspecifically depleted T-cells and was associated with C-peptide secretion for >1 year. Autoreactive T-cells with the same autoantigen specificity and conserved T-cell receptor later reappeared with further C-peptide loss over the next 2 years. Purified autoreactive CD4 T-cells from two patients were cotransplanted with HLA-mismatched human islets into immunodeficient mice. Grafts showed beta-cell loss in mice receiving autoreactive T-cells but not control T-cells. CONCLUSIONS We demonstrate the cardinal features of recurrent autoimmunity in three such patients, including the reappearance of CD4 T-cells capable of mediating beta-cell destruction. Markers of autoimmunity can help diagnose this underappreciated cause of graft loss. Immune monitoring during therapy showed that autoimmunity was not resolved by the immunosuppressive agents used.
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Affiliation(s)
- Francesco Vendrame
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Antonello Pileggi
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, Miami, Florida
- Department of Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | | | - Gloria Allende
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Ainhoa Martin-Pagola
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - R. Damaris Molano
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Stavros Diamantopoulos
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Nathan Standifer
- Benaroya Research Institute, Seattle, Washington
- Clinical Immunology, Amgen Inc., Seattle, Washington
| | | | - Ben A. Falk
- Benaroya Research Institute, Seattle, Washington
| | - Hirohito Ichii
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, Miami, Florida
- Department of Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Hidenori Takahashi
- Department of Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Isaac Snowhite
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Zhibin Chen
- Department of Microbiology and Immunology, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Armando Mendez
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, Miami, Florida
- Department of Medicine, Division of Endocrinology and Metabolism, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Linda Chen
- Department of Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Junichiro Sageshima
- Department of Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Phillip Ruiz
- Department of Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Gaetano Ciancio
- Department of Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Camillo Ricordi
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, Miami, Florida
- Department of Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, Miami, Florida
- Department of Microbiology and Immunology, Leonard Miller School of Medicine, University of Miami, Miami, Florida
- Department of Medicine, Division of Endocrinology and Metabolism, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | | | | | - George W. Burke
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, Miami, Florida
- Department of Surgery, Division of Transplantation, Leonard Miller School of Medicine, University of Miami, Miami, Florida
| | - Alberto Pugliese
- Diabetes Research Institute, Leonard Miller School of Medicine, University of Miami, Miami, Florida
- Department of Microbiology and Immunology, Leonard Miller School of Medicine, University of Miami, Miami, Florida
- Department of Medicine, Division of Endocrinology and Metabolism, Leonard Miller School of Medicine, University of Miami, Miami, Florida
- Corresponding author: Alberto Pugliese,
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42
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Ishida-Oku M, Iwase M, Sugitani A, Masutani K, Kitada H, Tanaka M, Iida M. A case of recurrent type 1 diabetes mellitus with insulitis of transplanted pancreas in simultaneous pancreas-kidney transplantation from cardiac death donor. Diabetologia 2010; 53:341-5. [PMID: 19911164 DOI: 10.1007/s00125-009-1593-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 10/08/2009] [Indexed: 11/25/2022]
Abstract
AIMS/HYPOTHESIS A 41-year-old woman undergoing simultaneous pancreas-kidney transplantation from an HLA-mismatched cardiac death donor abruptly developed overt hyperglycaemia under standard immunosuppressive therapy at 48 months after transplantation. Unexpectedly, we found insulitis in the transplanted pancreas and characterised the insulitis. METHODS Pancreas graft biopsies were performed 3 years before and after the development of hyperglycaemia and the specimens were examined histologically. RESULTS Insulitis was absent in the first biopsy, although oxidative DNA changes revealed by 8-hydroxy-2'-deoxyguanosine (8-OHdG) staining were diffusely present both in islet cells and exocrine cells. No Ki67-positive proliferating cells were seen in the islets. Anti-glutamic acid decarboxylase antibody was undetectable 6 months earlier but increased to 6.3 U/l at the development of hyperglycaemia. The level of anti-insulinoma-associated protein 2 antibody was 18.5 U/l. Insulin secretion was severely suppressed and insulin therapy was resumed. In the second biopsy, although acute allograft rejection was minimal, insulin-positive beta cells were markedly reduced, and glucagon-positive alpha cells predominated. CD3-positive T lymphocytes, CD8-positive cytotoxic T lymphocytes and CD68-positive macrophages infiltrated around and into islets. The infiltrating cells expressed Fas ligand as well as granzyme B. More than 80% of islets were affected by insulitis. 8-OHdG-positive cells were also present in islets and exocrine tissue. The percentage of Ki67-positive cells in total islet cells was 1.5%. There were no TUNEL-positive apoptotic cells in the islet cells. CONCLUSIONS/INTERPRETATION The histological features of insulitis in transplanted pancreas were consistent with common type 1 diabetes mellitus, but the clinical course of the recurrence appeared to be more rapid.
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Affiliation(s)
- M Ishida-Oku
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka 812-8582, Japan
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Affiliation(s)
- David M Harlan
- National Institute of Diabetes and Digestive and Kidney Diseases/National Institutes of Health, Diabetes Branch, Bethesda, Maryland, USA.
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Corrêa-Giannella ML, Raposo do Amaral AS. Pancreatic islet transplantation. Diabetol Metab Syndr 2009; 1:9. [PMID: 19825146 PMCID: PMC2761853 DOI: 10.1186/1758-5996-1-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 09/21/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND No formulation of exogenous insulin available to date has yet been able to mimic the physiological nictemeral rhythms of this hormone, and despite all engineering advancements, the theoretical proposal of developing a mechanical replacement for pancreatic beta cell still has not been reached. Thus, the replacement of beta cells through pancreas and pancreatic islet transplantation are the only concrete alternatives for re-establishing the endogenous insulin secretion in type 1 diabetic patients. Since only 1 to 1.5% of the pancreatic mass corresponds to endocrine tissue, pancreatic islets transplantation arises as a natural alternative. Data from the International Islet Transplant Registry (ITR) from 1983 to December 2000 document a total of 493 transplants performed around the world, with progressively worse rates of post-transplant insulin independence. In 2000, the "Edmonton Protocol" introduced several modifications to the transplantation procedure, such as the use of a steroid-free immunosuppression regimen and transplantation of a mean islet mass of 11,000 islet equivalents per kilogram, which significantly improved 1-year outcomes. Although the results of a 5-year follow-up in 65 patients demonstrated improvement in glycemic instability in a significant portion of them, only 7.5% of the patients have reached insulin independence, indicating the need of further advances in the preservation of the function of transplanted islet. In addition to the scarcity of organs available for transplantation, islets transplantation still faces major challenges, specially those related to cell loss during the process of islet isolation and the losses related to the graft site, apoptosis, allorejection, autoimmunity, and immunosuppression. The main strategies to optimize islet transplantation aim at improving all these aspects. CONCLUSION Human islet transplantation should be regarded as an intervention that can decrease the frequency of severe hypoglycemic episodes and improve glycemic control in selected patient for whom benefits of 4-5 years duration would be very valuable. Its limitations, however, indicate that the procedure in its current format is not suitable for all patients with type 1 diabetes.
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Affiliation(s)
- Maria Lúcia Corrêa-Giannella
- Laboratory of Cellular and Molecular Endocrinology (LIM25) - University of São Paulo Medical School, São Paulo, Brazil
| | - Alexandre S Raposo do Amaral
- Laboratory of Cellular and Molecular Endocrinology (LIM25) - University of São Paulo Medical School, São Paulo, Brazil
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Martins L, Malheiro J, Henriques AC, Dias L, Dores J, Oliveira F, Seca R, Almeida R, Sarmento AM, Cabrita A, Teixeira M. Pancreas-kidney transplantation and the evolution of pancreatic autoantibodies. Transplant Proc 2009; 41:913-5. [PMID: 19376387 DOI: 10.1016/j.transproceed.2009.01.068] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The recurrence or persistence of pancreatic autoantibodies after pancreas-kidney transplantation (PKT) is an intriguing finding. We prospectively analyzed 77 PKTs, searching for risk factors for the expression of these autoimmune markers and their impact on pancreas graft function. Among the 77 PKTs, 24.7% had 0 HLA matches, 20.8% displayed delayed graft function, and 14.3% had acute rejection episodes. Immunosuppression included antithymocyte globulin (ATG), tacrolimus, mycophenolate mofetil (MMF), and steroids. Sixty-five patients had both grafts functioning as a follow-up of more than 6 months. In 11 patients anti-glutamic acid decarboxylase (GAD) positivity persists (n = 8) or has recurred (n = 3), 4 of whom show increasing titers. Two patients maintain positive islet cell antibodies (ICA) and anti-GAD antibodies. The 9 patients positive for ICA included 2 who were negative before PKT and 7 who remain positive. The "positive" group (22 patients with positive ICA and/or anti-GAD) did not differ from the global group of 65 functioning PKT in terms of acute rejection episodes, HLA match, and steroid withdrawal. Among the positive patients, there were 2 with borderline glucose levels; however, among the entire "positive" group, the mean fasting glucose, HbA1c, and C-peptide measurements were not significantly different, when compared with the other 65 PKTs. In conclusion, pancreatic autoantibodies may be persistently positive or recur after PKT, despite appropriate immunosuppression. Its impact on long-term pancreas graft survival is unknown. We could not identify risk factors for their expression. An extended follow-up with monitoring and search for other risk factors may be necessary to increase our knowledge in this field.
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Affiliation(s)
- L Martins
- Nephrology Department, Hospital Santo António, Centro Hospitalar do Porto, Portugal.
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Abstract
PURPOSE OF REVIEW Pancreas transplantation is considered the optimal therapy for patients with insulin-dependent diabetes. Successful pancreas transplantation achieves euglycemia and allows freedom from insulin therapy. Long-term allograft success may be limited by the development of impaired glucose metabolism. The objectives of the present review are to summarize the possible reasons for endocrine pancreatic dysfunction and to focus on its prevention and management and emphasize the role of immunosuppression. RECENT FINDINGS The diabetogenic effects of current immunosuppressive agents have been well established. Regimens without corticosteroids and calcineurin-inhibitor minimization or avoidance have been promoted. Recent studies have revisited the pathogenesis of type I and type II diabetes and demonstrated common pathways, including apoptosis induction, for the exhaustion and destruction of the pancreatic islets. SUMMARY The immunosuppressive regimens in pancreatic transplantation should be designed and appropriately modified according to the graft immunological and metabolic conditions. New molecules that are able to preserve islet function and maintain optimal insulin secretion should be considered for pancreas transplant recipients.
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Monti P, Scirpoli M, Maffi P, Ghidoli N, De Taddeo F, Bertuzzi F, Piemonti L, Falcone M, Secchi A, Bonifacio E. Islet transplantation in patients with autoimmune diabetes induces homeostatic cytokines that expand autoreactive memory T cells. J Clin Invest 2008; 118:1806-14. [PMID: 18431516 DOI: 10.1172/jci35197] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2008] [Accepted: 03/19/2008] [Indexed: 12/23/2022] Open
Abstract
Successful transplantation requires the prevention of allograft rejection and, in the case of transplantation to treat autoimmune disease, the suppression of autoimmune responses. The standard immunosuppressive treatment regimen given to patients with autoimmune type 1 diabetes who have received an islet transplant results in the loss of T cells. In many other situations, the immune system responds to T cell loss through cytokine-dependant homeostatic proliferation of any remaining T cells. Here we show that T cell loss after islet transplantation in patients with autoimmune type 1 diabetes was associated with both increased serum concentrations of IL-7 and IL-15 and in vivo proliferation of memory CD45RO(+) T cells, highly enriched in autoreactive glutamic acid decarboxylase 65-specific T cell clones. Immunosuppression with FK506 and rapamycin after transplantation resulted in a chronic homeostatic expansion of T cells, which acquired effector function after immunosuppression was removed. In contrast, the cytostatic drug mycophenolate mofetil efficiently blocked homeostatic T cell expansion. We propose that the increased production of cytokines that induce homeostatic expansion could contribute to recurrent autoimmunity in transplanted patients with autoimmune disease and that therapy that prevents the expansion of autoreactive T cells will improve the outcome of islet transplantation.
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Affiliation(s)
- Paolo Monti
- Immunology of Diabetes Unit and Clinical Transplant Unit, Telethon-Juvenile Diabetes Research Foundation Center for Beta Cell Replacement, San Raffaele Scientific Institute, Milan, Italy
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Huurman VAL, Hilbrands R, Pinkse GGM, Gillard P, Duinkerken G, van de Linde P, van der Meer-Prins PMW, Versteeg-van der Voort Maarschalk MFJ, Verbeeck K, Alizadeh BZ, Mathieu C, Gorus FK, Roelen DL, Claas FHJ, Keymeulen B, Pipeleers DG, Roep BO. Cellular islet autoimmunity associates with clinical outcome of islet cell transplantation. PLoS One 2008; 3:e2435. [PMID: 18560516 PMCID: PMC2426735 DOI: 10.1371/journal.pone.0002435] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 04/22/2008] [Indexed: 02/04/2023] Open
Abstract
Background Islet cell transplantation can cure type 1 diabetes (T1D), but only a minority of recipients remains insulin–independent in the following years. We tested the hypothesis that allograft rejection and recurrent autoimmunity contribute to this progressive loss of islet allograft function. Methodology/Principal Findings Twenty-one T1D patients received cultured islet cell grafts prepared from multiple donors and transplanted under anti-thymocyte globulin (ATG) induction and tacrolimus plus mycophenolate mofetil (MMF) maintenance immunosuppression. Immunity against auto- and alloantigens was measured before and during one year after transplantation. Cellular auto- and alloreactivity was assessed by lymphocyte stimulation tests against autoantigens and cytotoxic T lymphocyte precursor assays, respectively. Humoral reactivity was measured by auto- and alloantibodies. Clinical outcome parameters - including time until insulin independence, insulin independence at one year, and C-peptide levels over one year- remained blinded until their correlation with immunological parameters. All patients showed significant improvement of metabolic control and 13 out of 21 became insulin-independent. Multivariate analyses showed that presence of cellular autoimmunity before and after transplantation is associated with delayed insulin-independence (p = 0.001 and p = 0.01, respectively) and lower circulating C-peptide levels during the first year after transplantation (p = 0.002 and p = 0.02, respectively). Seven out of eight patients without pre-existent T-cell autoreactivity became insulin-independent, versus none of the four patients reactive to both islet autoantigens GAD and IA-2 before transplantation. Autoantibody levels and cellular alloreactivity had no significant association with outcome. Conclusions/Significance In this cohort study, cellular islet-specific autoimmunity associates with clinical outcome of islet cell transplantation under ATG-tacrolimus-MMF immunosuppression. Tailored immunotherapy targeting cellular islet autoreactivity may be required. Monitoring cellular immune reactivity can be useful to identify factors influencing graft survival and to assess efficacy of immunosuppression. Trial Registration Clinicaltrials.gov NCT00623610
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Affiliation(s)
- Volkert A. L. Huurman
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | - Robert Hilbrands
- Diabetes Research Center, Brussels Free University-VUB, Brussels, Belgium
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | - Gabriëlle G. M. Pinkse
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | - Pieter Gillard
- Diabetes Research Center, Brussels Free University-VUB, Brussels, Belgium
- Laboratory for Experimental Medicine & Endocrinology (LEGENDO), University Hospital Gasthuisberg, Catholic University of Leuven-KUL, Leuven, Belgium
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | - Gaby Duinkerken
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | - Pieter van de Linde
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | - Petronella M. W. van der Meer-Prins
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | | | - Koen Verbeeck
- Diabetes Research Center, Brussels Free University-VUB, Brussels, Belgium
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | - Behrooz Z. Alizadeh
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | - Chantal Mathieu
- Laboratory for Experimental Medicine & Endocrinology (LEGENDO), University Hospital Gasthuisberg, Catholic University of Leuven-KUL, Leuven, Belgium
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | - Frans K. Gorus
- Diabetes Research Center, Brussels Free University-VUB, Brussels, Belgium
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | - Dave L. Roelen
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | - Frans H. J. Claas
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | - Bart Keymeulen
- Diabetes Research Center, Brussels Free University-VUB, Brussels, Belgium
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | - Daniel G. Pipeleers
- Diabetes Research Center, Brussels Free University-VUB, Brussels, Belgium
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
| | - Bart O. Roep
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
- JDRF Center for Beta Cell Therapy in Diabetes, Brussels, Belgium
- * E-mail:
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Fiorina P, Vergani A, Petrelli A, D'Addio F, Monti L, Abdi R, Bosi E, Maffi P, Secchi A. Metabolic and immunological features of the failing islet-transplanted patient. Diabetes Care 2008; 31:436-8. [PMID: 18071001 DOI: 10.2337/dc07-1831] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This retrospective study was designed to identify metabolic and immune predictors of early islet allograft failure. RESEARCH DESIGN AND METHODS We measured several metabolic and immunological markers at the time of pretransplant and several time points posttransplantation in 17 patients with long-term functioning graft (long fx) and 20 patients with short-term functioning graft (short fx). RESULTS The short fx group showed higher insulin resistance, altered proinsulin processing, lower soluble interleukin-2 receptor (sIL-2r) (marker of T-cell activation), and higher soluble FasL (marker of apoptosis) during the entire follow-up, particularly at time of failure. CONCLUSIONS Patients who experienced an early failure of islet allograft showed specific metabolic and immunological signs long before islet failure.
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Affiliation(s)
- Paolo Fiorina
- Department of Medicine, San Raffaele Scientific Institute, Milan, Italy
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Abstract
Type 1 diabetes mellitus (T1DM) is a disease that results from the selective autoimmune destruction of insulin-producing beta-cells. This disease process lends itself to cellular therapy because of the single cell nature of insulin production. Murine models have provided opportunities for the study of cellular therapies for the treatment of diabetes, including the investigation of islet transplantation, and also the possibility of stem cell therapies and islet regeneration. Studies in islet transplantation have included both allo- and xeno-transplantation and have allowed for the study of new approaches for the reversal of autoimmunity and achieving immune tolerance. Stem cells from hematopoietic sources such as bone marrow and fetal cord blood, as well as from the pancreas, intestine, liver, and spleen promise either new sources of islets or may function as stimulators of islet regeneration. This review will summarize the various cellular interventions investigated as potential treatments of T1DM.
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Affiliation(s)
- D D Lee
- Section of Transplantation, Department of Surgery, The University of Chicago, IL 60637, USA
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