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Anwar IJ, Berman DM, DeLaura I, Gao Q, Willman MA, Miller A, Gill A, Gill C, Perrin S, Ricordi C, Ruiz P, Song M, Ladowski JM, Kirk AD, Kenyon NS. The anti-CD40L monoclonal antibody AT-1501 promotes islet and kidney allograft survival and function in nonhuman primates. Sci Transl Med 2023; 15:eadf6376. [PMID: 37647390 PMCID: PMC10990482 DOI: 10.1126/scitranslmed.adf6376] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 07/26/2023] [Indexed: 09/01/2023]
Abstract
Prior studies of anti-CD40 ligand (CD40L)-based immunosuppression demonstrated effective prevention of islet and kidney allograft rejection in nonhuman primate models; however, clinical development was halted because of thromboembolic complications. An anti-CD40L-specific monoclonal antibody, AT-1501 (Tegoprubart), was engineered to minimize risk of thromboembolic complications by reducing binding to Fcγ receptors expressed on platelets while preserving binding to CD40L. AT-1501 was tested in both a cynomolgus macaque model of intrahepatic islet allotransplantation and a rhesus macaque model of kidney allotransplantation. AT-1501 monotherapy led to long-term graft survival in both islet and kidney transplant models, confirming its immunosuppressive potential. Furthermore, AT-1501-based regimens after islet transplant resulted in higher C-peptide, greater appetite leading to weight gain, and reduced occurrence of cytomegalovirus reactivation compared with conventional immunosuppression. These data support AT-1501 as a safe and effective agent to promote both islet and kidney allograft survival and function in nonhuman primate models, warranting further testing in clinical trials.
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Affiliation(s)
- Imran J. Anwar
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Dora M. Berman
- Diabetes Research Institute, University of Miami; Miami, FL 33136, USA
- Department of Surgery, University of Miami; Miami, FL 33136, USA
| | - Isabel DeLaura
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Qimeng Gao
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | | | - Allison Miller
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Alan Gill
- ALS Therapy Development Institute; Cambridge, MA 02472, USA
| | - Cindy Gill
- ALS Therapy Development Institute; Cambridge, MA 02472, USA
| | | | - Camillo Ricordi
- Diabetes Research Institute, University of Miami; Miami, FL 33136, USA
- Department of Surgery, University of Miami; Miami, FL 33136, USA
- Department of Microbiology and Immunology, University of Miami; Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami; Miami, FL 33136, USA
- Department of Medicine, University of Miami; Miami, FL 33136, USA
| | - Philip Ruiz
- Department of Surgery, University of Miami; Miami, FL 33136, USA
| | - Mingqing Song
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Joseph M Ladowski
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Allan D. Kirk
- Duke Transplant Center, Department of Surgery, Duke University School of Medicine; Durham, NC 27710, USA
| | - Norma S. Kenyon
- Diabetes Research Institute, University of Miami; Miami, FL 33136, USA
- Department of Surgery, University of Miami; Miami, FL 33136, USA
- Department of Microbiology and Immunology, University of Miami; Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami; Miami, FL 33136, USA
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2
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Berman DM, Lee AY, Lesurf R, Patel PG, Ebrahimizadeh W, Bayani J, Lee LA, Boufaied N, Selvarajah S, Jamaspishvili T, Guérard KP, Dion D, Kawashima A, Clarke GM, How N, Jackson CL, Scarlata E, Siddiqui K, Okello JBA, Aprikian AG, Moussa M, Finelli A, Chin J, Brimo F, Bauman G, Loblaw A, Venkateswaran V, Buttyan R, Chevalier S, Thomson A, Park PC, Siemens DR, Lapointe J, Boutros PC, Bartlett JMS. Multimodal Biomarkers That Predict the Presence of Gleason Pattern 4: Potential Impact for Active Surveillance. J Urol 2023; 210:257-271. [PMID: 37126232 DOI: 10.1097/ju.0000000000003507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 04/20/2023] [Indexed: 05/02/2023]
Abstract
PURPOSE Latent grade group ≥2 prostate cancer can impact the performance of active surveillance protocols. To date, molecular biomarkers for active surveillance have relied solely on RNA or protein. We trained and independently validated multimodal (mRNA abundance, DNA methylation, and/or DNA copy number) biomarkers that more accurately separate grade group 1 from grade group ≥2 cancers. MATERIALS AND METHODS Low- and intermediate-risk prostate cancer patients were assigned to training (n=333) and validation (n=202) cohorts. We profiled the abundance of 342 mRNAs, 100 DNA copy number alteration loci, and 14 hypermethylation sites at 2 locations per tumor. Using the training cohort with cross-validation, we evaluated methods for training classifiers of pathological grade group ≥2 in centrally reviewed radical prostatectomies. We trained 2 distinct classifiers, PRONTO-e and PRONTO-m, and validated them in an independent radical prostatectomy cohort. RESULTS PRONTO-e comprises 353 mRNA and copy number alteration features. PRONTO-m includes 94 clinical, mRNAs, copy number alterations, and methylation features at 14 and 12 loci, respectively. In independent validation, PRONTO-e and PRONTO-m predicted grade group ≥2 with respective true-positive rates of 0.81 and 0.76, and false-positive rates of 0.43 and 0.26. Both classifiers were resistant to sampling error and identified more upgrading cases than a well-validated presurgical risk calculator, CAPRA (Cancer of the Prostate Risk Assessment; P < .001). CONCLUSIONS Two grade group classifiers with superior accuracy were developed by incorporating RNA and DNA features and validated in an independent cohort. Upon further validation in biopsy samples, classifiers with these performance characteristics could refine selection of men for active surveillance, extending their treatment-free survival and intervals between surveillance.
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Affiliation(s)
- D M Berman
- Queen's University Cancer Research Institute, Kingston, Ontario, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - A Y Lee
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - R Lesurf
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
- Now with Hospital for Sick Children, Toronto, Ontario, Canada
| | - P G Patel
- Queen's University Cancer Research Institute, Kingston, Ontario, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
- Now with Hospital for Sick Children, Toronto, Ontario, Canada
| | - W Ebrahimizadeh
- Department of Surgery, McGill University and the Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
- Now with IMV Inc, Dartmouth, Nova Scotia, Canada
| | - J Bayani
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, Ontario, Canada
| | - L A Lee
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - N Boufaied
- Department of Surgery, McGill University and the Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | - S Selvarajah
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
- Now with University Health Network, Toronto, Ontario, Canada
| | - T Jamaspishvili
- Queen's University Cancer Research Institute, Kingston, Ontario, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - K-P Guérard
- Department of Surgery, McGill University and the Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | - D Dion
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - A Kawashima
- Queen's University Cancer Research Institute, Kingston, Ontario, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
- Now with Osaka University, Osaka, Japan
| | - G M Clarke
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - N How
- Queen's University Cancer Research Institute, Kingston, Ontario, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - C L Jackson
- Queen's University Cancer Research Institute, Kingston, Ontario, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - E Scarlata
- Department of Surgery, McGill University and the Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | - K Siddiqui
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- Now with Sultan Qaboos University Hospital, Seeb, Oman
| | - J B A Okello
- Queen's University Cancer Research Institute, Kingston, Ontario, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - A G Aprikian
- Department of Surgery, McGill University and the Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | - M Moussa
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
| | - A Finelli
- Princess Margaret Cancer Centre. Toronto, Ontario, Canada
- Departments of Surgery and Oncology, University of Toronto, Toronto, Ontario, Canada
| | - J Chin
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
| | - F Brimo
- Department of Surgery, McGill University and the Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
- Department of Pathology, McGill University, Montreal, Quebec, Canada
| | - G Bauman
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- London Regional Cancer Program, London Health Sciences Centre, London, Ontario, Canada
| | - A Loblaw
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Departments of Radiation Oncology and Health Policy Management and Evaluation, University of Toronto, Toronto
| | - V Venkateswaran
- Departments of Surgery and Oncology, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - R Buttyan
- Vancouver Prostate Centre, Vancouver, British Columbia, Canada
- Departments of Experimental Medicine and Interdisciplinary Oncology, Vancouver, British Columbia, Canada
| | - S Chevalier
- Department of Surgery, McGill University and the Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | - A Thomson
- Department of Surgery, McGill University and the Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
- Now with College of Science and Engineering Biology, University of Edinburgh, Edinburgh, United Kingdom
| | - P C Park
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
- Now with Department of Pathology, Shared Health, Winnipeg, Manitoba, Canada
| | - D R Siemens
- Queen's University Cancer Research Institute, Kingston, Ontario, Canada
- Departments of Urology, Oncology and Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - J Lapointe
- Department of Surgery, McGill University and the Research Institute of the McGill University Health Centre, Montréal, Québec, Canada
| | - P C Boutros
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Now with University of California, Los Angeles, Los Angeles, California, United States
| | - J M S Bartlett
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, Ontario, Canada
- Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, United Kingdom
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3
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Paez-Mayorga J, Campa-Carranza JN, Capuani S, Hernandez N, Liu HC, Chua CYX, Pons-Faudoa FP, Malgir G, Alvarez B, Niles JA, Argueta LB, Shelton KA, Kezar S, Nehete PN, Berman DM, Willman MA, Li XC, Ricordi C, Nichols JE, Gaber AO, Kenyon NS, Grattoni A. Implantable niche with local immunosuppression for islet allotransplantation achieves type 1 diabetes reversal in rats. Nat Commun 2022; 13:7951. [PMID: 36572684 PMCID: PMC9792517 DOI: 10.1038/s41467-022-35629-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 12/14/2022] [Indexed: 12/27/2022] Open
Abstract
Pancreatic islet transplantation efficacy for type 1 diabetes (T1D) management is limited by hypoxia-related graft attrition and need for systemic immunosuppression. To overcome these challenges, we developed the Neovascularized Implantable Cell Homing and Encapsulation (NICHE) device, which integrates direct vascularization for facile mass transfer and localized immunosuppressant delivery for islet rejection prophylaxis. Here, we investigated NICHE efficacy for allogeneic islet transplantation and long-term diabetes reversal in an immunocompetent, male rat model. We demonstrated that allogeneic islets transplanted within pre-vascularized NICHE were engrafted, revascularized, and functional, reverting diabetes in rats for over 150 days. Notably, we confirmed that localized immunosuppression prevented islet rejection without inducing toxicity or systemic immunosuppression. Moreover, for translatability efforts, we showed NICHE biocompatibility and feasibility of deployment as well as short-term allogeneic islet engraftment in an MHC-mismatched nonhuman primate model. In sum, the NICHE holds promise as a viable approach for safe and effective islet transplantation and long-term T1D management.
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Affiliation(s)
- Jesus Paez-Mayorga
- grid.63368.380000 0004 0445 0041Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX USA ,grid.419886.a0000 0001 2203 4701School of Medicine and Health Sciences, Tecnologico de Monterrey, Monterrey, NL Mexico
| | - Jocelyn Nikita Campa-Carranza
- grid.63368.380000 0004 0445 0041Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX USA ,grid.419886.a0000 0001 2203 4701School of Medicine and Health Sciences, Tecnologico de Monterrey, Monterrey, NL Mexico
| | - Simone Capuani
- grid.63368.380000 0004 0445 0041Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX USA ,grid.410726.60000 0004 1797 8419University of the Chinese Academy of Sciences (UCAS), Shijingshan, Beijing, China
| | - Nathanael Hernandez
- grid.63368.380000 0004 0445 0041Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX USA
| | - Hsuan-Chen Liu
- grid.63368.380000 0004 0445 0041Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX USA
| | - Corrine Ying Xuan Chua
- grid.63368.380000 0004 0445 0041Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX USA
| | - Fernanda Paola Pons-Faudoa
- grid.63368.380000 0004 0445 0041Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX USA
| | - Gulsah Malgir
- grid.63368.380000 0004 0445 0041Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX USA
| | - Bella Alvarez
- grid.63368.380000 0004 0445 0041Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX USA ,grid.419886.a0000 0001 2203 4701School of Medicine and Health Sciences, Tecnologico de Monterrey, Monterrey, NL Mexico
| | - Jean A. Niles
- grid.63368.380000 0004 0445 0041Center for Tissue Engineering, Houston Methodist Research Institute, Houston, TX USA
| | - Lissenya B. Argueta
- grid.63368.380000 0004 0445 0041Center for Tissue Engineering, Houston Methodist Research Institute, Houston, TX USA
| | - Kathryn A. Shelton
- grid.240145.60000 0001 2291 4776Department of Comparative Medicine, Michael E. Keeling Center for Comparative Medicine and Research, MD Anderson Cancer Center, Bastrop, TX USA
| | - Sarah Kezar
- grid.240145.60000 0001 2291 4776Department of Comparative Medicine, Michael E. Keeling Center for Comparative Medicine and Research, MD Anderson Cancer Center, Bastrop, TX USA
| | - Pramod N. Nehete
- grid.240145.60000 0001 2291 4776Department of Comparative Medicine, Michael E. Keeling Center for Comparative Medicine and Research, MD Anderson Cancer Center, Bastrop, TX USA ,grid.267308.80000 0000 9206 2401The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX USA
| | - Dora M. Berman
- grid.26790.3a0000 0004 1936 8606Diabetes Research Institute, University of Miami, Miami, FL USA ,grid.26790.3a0000 0004 1936 8606Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL USA
| | - Melissa A. Willman
- grid.26790.3a0000 0004 1936 8606Diabetes Research Institute, University of Miami, Miami, FL USA
| | - Xian C. Li
- grid.63368.380000 0004 0445 0041Department of Surgery, Houston Methodist Hospital, Houston, TX USA ,grid.63368.380000 0004 0445 0041Immunobiology and Transplant Science Center, Houston Methodist Hospital, Houston, TX USA
| | - Camillo Ricordi
- grid.26790.3a0000 0004 1936 8606Diabetes Research Institute, University of Miami, Miami, FL USA
| | - Joan E. Nichols
- grid.63368.380000 0004 0445 0041Center for Tissue Engineering, Houston Methodist Research Institute, Houston, TX USA ,grid.63368.380000 0004 0445 0041Department of Surgery, Houston Methodist Hospital, Houston, TX USA
| | - A. Osama Gaber
- grid.63368.380000 0004 0445 0041Department of Surgery, Houston Methodist Hospital, Houston, TX USA
| | - Norma S. Kenyon
- grid.26790.3a0000 0004 1936 8606Diabetes Research Institute, University of Miami, Miami, FL USA ,grid.26790.3a0000 0004 1936 8606Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL USA ,grid.26790.3a0000 0004 1936 8606Department of Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, FL USA ,grid.26790.3a0000 0004 1936 8606Department of Biomedical Engineering, University of Miami, Miami, FL USA ,grid.26790.3a0000 0004 1936 8606Department of Biochemistry and Molecular Biology, University of Miami, Miami, FL USA
| | - Alessandro Grattoni
- grid.63368.380000 0004 0445 0041Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX USA ,grid.63368.380000 0004 0445 0041Department of Surgery, Houston Methodist Hospital, Houston, TX USA ,grid.26790.3a0000 0004 1936 8606Department of Biochemistry and Molecular Biology, University of Miami, Miami, FL USA ,grid.63368.380000 0004 0445 0041Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX USA
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4
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Stock AA, Gonzalez GC, Pete SI, De Toni T, Berman DM, Rabassa A, Diaz W, Geary JC, Willman M, Jackson JM, DeHaseth NH, Ziebarth NM, Hogan AR, Ricordi C, Kenyon NS, Tomei AA. Performance of islets of Langerhans conformally coated via an emulsion cross-linking method in diabetic rodents and nonhuman primates. Sci Adv 2022; 8:eabm3145. [PMID: 35767620 PMCID: PMC9242596 DOI: 10.1126/sciadv.abm3145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 05/10/2022] [Indexed: 06/15/2023]
Abstract
Polyethylene glycol (PEG)-based conformal coating (CC) encapsulation of transplanted islets is a promising β cell replacement therapy for the treatment of type 1 diabetes without chronic immunosuppression because it minimizes capsule thickness, graft volume, and insulin secretion delay. However, we show here that our original CC method, the direct method, requiring exposure of islets to low pH levels and inclusion of viscosity enhancers during coating, severely affected the viability, scalability, and biocompatibility of CC islets in nonhuman primate preclinical models of type 1 diabetes. We therefore developed and validated in vitro and in vivo, in several small- and large-animal models of type 1 diabetes, an augmented CC method-emulsion method-that achieves hydrogel CCs around islets at physiological pH for improved cytocompatibility, with PEG hydrogels for increased biocompatibility and with fivefold increase in encapsulation throughput for enhanced scalability.
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Affiliation(s)
- Aaron A. Stock
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami, Miami, FL 33146, USA
| | - Grisell C. Gonzalez
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Sophia I. Pete
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami, Miami, FL 33146, USA
| | - Teresa De Toni
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami, Miami, FL 33146, USA
| | - Dora M. Berman
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Alexander Rabassa
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Waldo Diaz
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - James C. Geary
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Melissa Willman
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Joy M. Jackson
- Department of Biomedical Engineering, University of Miami, Miami, FL 33146, USA
| | - Noa H. DeHaseth
- Department of Biomedical Engineering, University of Miami, Miami, FL 33146, USA
| | - Noel M. Ziebarth
- Department of Biomedical Engineering, University of Miami, Miami, FL 33146, USA
| | - Anthony R. Hogan
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Camillo Ricordi
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami, Miami, FL 33146, USA
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Norma S. Kenyon
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami, Miami, FL 33146, USA
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Alice A. Tomei
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Biomedical Engineering, University of Miami, Miami, FL 33146, USA
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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5
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Kenyon NS, Willman MA, Han D, Leeman RS, Rabassa A, Diaz WL, Geary JC, Poumian-Ruiz E, Griswold AJ, Van Booven DJ, Thompson R, Ordoukhanian P, Head SR, Kenyon NM, McHenry KG, Salomon DR, Bartholomew AM, Berman DM. Extended survival versus accelerated rejection of nonhuman primate islet allografts: Effect of mesenchymal stem cell source and timing. Am J Transplant 2021; 21:3524-3537. [PMID: 34008325 PMCID: PMC9034438 DOI: 10.1111/ajt.16693] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/23/2021] [Accepted: 05/06/2021] [Indexed: 01/25/2023]
Abstract
Mesenchymal stem cells (MSC) have been shown to be immunomodulatory, tissue regenerative, and graft promoting; however, several questions remain with regard to ideal MSC source and timing of administration. In this study, we utilized a rigorous preclinical model of allogeneic islet cell transplantation, incorporating reduced immune suppression and near to complete mismatch of major histocompatibility antigens between the diabetic cynomolgus monkey recipient and the islet donor, to evaluate both the graft promoting impact of MSC source, that is, derived from the islet recipient, the islet donor or an unrelated third party as well as the impact of timing. Co-transplant of MSC and islets on post-operative day 0, followed by additional IV MSC infusions in the first posttransplant month, resulted in prolongation of rejection free and overall islet survival and superior metabolic control for animals treated with recipient as compared to donor or third-party MSC. Immunological analyses demonstrated that infusion of MSC from either source did not prevent alloantibody formation to the islet or MSC donor; however, treatment with recipient MSC resulted in significant downregulation of memory T cells, decreased anti-donor T cell proliferation, and a trend toward increased Tregulatory:Tconventional ratios.
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Affiliation(s)
- Norma S. Kenyon
- Diabetes Research Institute, University of Miami, Miami, Florida, USA,Department of Surgery, University of Miami, Miami, Florida, USA,Department of Microbiology and Immunology, University of Miami, Miami, Florida, USA,Department of Biomedical Engineering, University of Miami, Miami, Florida, USA
| | | | - Dongmei Han
- Diabetes Research Institute, University of Miami, Miami, Florida, USA
| | - Rachel S. Leeman
- Diabetes Research Institute, University of Miami, Miami, Florida, USA
| | - Alex Rabassa
- Diabetes Research Institute, University of Miami, Miami, Florida, USA
| | - Waldo L. Diaz
- Diabetes Research Institute, University of Miami, Miami, Florida, USA
| | - James C. Geary
- Diabetes Research Institute, University of Miami, Miami, Florida, USA
| | - Ena Poumian-Ruiz
- Diabetes Research Institute, University of Miami, Miami, Florida, USA
| | - Anthony J. Griswold
- John P. Hussman Institute for Human Genomics, University of Miami, Miami, Florida, USA,The Dr. John T. Macdonald Foundation Department of Human Genetics, University of Miami, Miami, Florida, USA
| | - Derek J. Van Booven
- John P. Hussman Institute for Human Genomics, University of Miami, Miami, Florida, USA
| | - Ryan Thompson
- The Scripps Research Institute, La Jolla, California, USA
| | - Philip Ordoukhanian
- The Scripps Research Institute, La Jolla, California, USA,The Scripps Research Institute Genomics Core Facility, La Jolla, California, USA
| | - Steven R. Head
- The Scripps Research Institute, La Jolla, California, USA,The Scripps Research Institute Genomics Core Facility, La Jolla, California, USA
| | - Norman M. Kenyon
- Diabetes Research Institute, University of Miami, Miami, Florida, USA,Department of Surgery, University of Miami, Miami, Florida, USA
| | - Kenton G. McHenry
- National Center for Supercomputing Applications, University of Illinois, Urbana-Champaign, Chicago, Illinois, USA
| | | | | | - Dora M. Berman
- Diabetes Research Institute, University of Miami, Miami, Florida, USA,Department of Surgery, University of Miami, Miami, Florida, USA
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6
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Chenard S, Jackson C, Vidotto T, Chen L, Hardy C, Jamaspishvilli T, Berman DM, Siemens DR, Koti M. Investigating sexual dimorphism in the tumour immune microenvironment of non-muscle invasive bladder cancer. Urol Oncol 2020. [DOI: 10.1016/j.urolonc.2020.10.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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7
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Safley SA, Kenyon NS, Berman DM, Barber GF, Cui H, Duncanson S, De Toni T, Willman M, De Vos P, Tomei AA, Sambanis A, Kenyon NM, Ricordi C, Weber CJ. Microencapsulated islet allografts in diabetic NOD mice and nonhuman primates. Eur Rev Med Pharmacol Sci 2020; 24:8551-8565. [PMID: 32894560 DOI: 10.26355/eurrev_202008_22651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Our goal was to assess the efficacy of encapsulated allogeneic islets transplanted in diabetic NOD mice and streptozotocin (STZ)-diabetic nonhuman primates (NHPs). MATERIALS AND METHODS Murine or NHP islets were microencapsulated and transplanted in non-immunosuppressed mice or NHPs given clinically-acceptable immunosuppressive regimens, respectively. Two NHPs were treated with autologous mesenchymal stem cells (MSCs) and peri-transplant oxygen therapy. Different transplant sites (intraperitoneal [i.p.], omental pouch, omental surface, and bursa omentalis) were tested in separate NHPs. Graft function was monitored by exogenous insulin requirements, fasting blood glucose levels, glucose tolerance tests, percent hemoglobin A1c (% HbA1c), and C-peptide levels. In vitro assessment of grafts included histology, immunohistochemistry, and viability staining; host immune responses were characterized by flow cytometry and cytokine/chemokine multiplex ELISAS. RESULTS Microencapsulated islet allografts functioned long-term i.p. in diabetic NOD mice without immunosuppression, but for a relatively short time in immunosuppressed NHPs. In the NHPs, encapsulated allo-islets initially reduced hyperglycemia, decreased exogenous insulin requirements, elevated C-peptide levels, and lowered % HbA1c in plasma, but graft function diminished with time, regardless of transplant site. At necropsy, microcapsules were intact and non-fibrotic, but many islets exhibited volume loss, central necrosis and endogenous markers of hypoxia. Animals receiving supplemental oxygen and autologous MSCs showed improved graft function for a longer post-transplant period. In diabetic NHPs and mice, cell-free microcapsules did not elicit a fibrotic response. CONCLUSIONS The evidence suggested that hypoxia was a major factor for damage to encapsulated islets in vivo. To achieve long-term function, new approaches must be developed to increase the oxygen supply to microencapsulated islets and/or identify donor insulin-secreting cells which can tolerate hypoxia.
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Affiliation(s)
- S A Safley
- Department of Surgery, Emory University, Atlanta, GA, USA.
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8
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Stabler CL, Giraldo JA, Berman DM, Gattás-Asfura KM, Willman MA, Rabassa A, Geary J, Diaz W, Kenyon NM, Kenyon NS. Transplantation of PEGylated islets enhances therapeutic efficacy in a diabetic nonhuman primate model. Am J Transplant 2020; 20:689-700. [PMID: 31597005 PMCID: PMC7042048 DOI: 10.1111/ajt.15643] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/19/2019] [Accepted: 09/29/2019] [Indexed: 01/25/2023]
Abstract
Islet cell transplantation can lead to insulin independence, reduced hypoglycemia, and amelioration of diabetes complications in patients with type 1 diabetes. The systemic delivery of anti-inflammatory agents, while considered crucial to limit the early loss of islets associated with intrahepatic infusion, increases the burden of immunosuppression. In an effort to decrease the pharmaceutical load to the patient, we modified the pancreatic islet surface with long-chain poly(ethylene glycol) (PEG) to mitigate detrimental host-implant interactions. The effect of PEGylation on islet engraftment and long-term survival was examined in a robust nonhuman primate model via three paired transplants of dosages 4300, 8300, and 10 000 islet equivalents per kg body weight. A reduced immunosuppressive regimen of anti-thymocyte globulin induction plus tacrolimus in the first posttransplant month followed by maintenance with sirolimus monotherapy was employed. To limit transplant variability, two of the three pairs were closely MHC-matched recipients and received MHC-disparate PEGylated or untreated islets isolated from the same donors. Recipients of PEGylated islets exhibited significantly improved early c-peptide levels, reduced exogenous insulin requirements, and superior glycemic control, as compared to recipients of untreated islets. These results indicate that this simple islet modification procedure may improve islet engraftment and survival in the setting of reduced immunosuppression.
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Affiliation(s)
- CL Stabler
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL USA,Diabetes Research Institute, University of Miami, Miami, FL USA,Corresponding Authors: Prof Cherie Stabler, ; Prof Norma Kenyon,
| | - JA Giraldo
- Diabetes Research Institute, University of Miami, Miami, FL USA
| | - DM Berman
- Diabetes Research Institute, University of Miami, Miami, FL USA,Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136
| | - KM Gattás-Asfura
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL USA,Diabetes Research Institute, University of Miami, Miami, FL USA
| | - MA Willman
- Diabetes Research Institute, University of Miami, Miami, FL USA
| | - A Rabassa
- Diabetes Research Institute, University of Miami, Miami, FL USA
| | - J Geary
- Diabetes Research Institute, University of Miami, Miami, FL USA
| | - W Diaz
- Diabetes Research Institute, University of Miami, Miami, FL USA
| | - NM Kenyon
- Diabetes Research Institute, University of Miami, Miami, FL USA
| | - NS Kenyon
- Diabetes Research Institute, University of Miami, Miami, FL USA,Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136,Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, FL 33136,Biomedical Engineering, University of Miami, Miami, FL 33136,Corresponding Authors: Prof Cherie Stabler, ; Prof Norma Kenyon,
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9
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Abdulreda MH, Berman DM, Shishido A, Martin C, Hossameldin M, Tschiggfrie A, Hernandez LF, Hernandez A, Ricordi C, Parel JM, Jankowska-Gan E, Burlingham WJ, Arrieta-Quintero EA, Perez VL, Kenyon NS, Berggren PO. Operational immune tolerance towards transplanted allogeneic pancreatic islets in mice and a non-human primate. Diabetologia 2019; 62:811-821. [PMID: 30701283 PMCID: PMC6451664 DOI: 10.1007/s00125-019-4814-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 12/14/2018] [Indexed: 12/31/2022]
Abstract
AIMS/HYPOTHESIS Patients with autoimmune type 1 diabetes transplanted with pancreatic islets to their liver experience significant improvement in quality of life through better control of blood sugar and enhanced awareness of hypoglycaemia. However, long-term survival and efficacy of the intrahepatic islet transplant are limited owing to liver-specific complications, such as immediate blood-mediated immune reaction, hypoxia, a highly enzymatic and inflammatory environment and locally elevated levels of drugs including immunosuppressive agents, all of which are injurious to islets. This has spurred a search for new islet transplant sites and for innovative ways to achieve long-term graft survival and efficacy without life-long systemic immunosuppression and its complications. METHODS We used our previously established approach of islet transplant in the anterior chamber of the eye in allogeneic recipient mouse models and a baboon model of diabetes, which were treated transiently with anti-CD154/CD40L blocking antibody in the peri-transplant period. Survival of the intraocular islet allografts was assessed by direct visualisation in the eye and metabolic variables (blood glucose and C-peptide measurements). We evaluated longitudinally the cytokine profile in the local microenvironment of the intraocular islet allografts, represented in aqueous humour, under conditions of immune rejection vs tolerance. We also evaluated the recall response in the periphery of the baboon recipient using delayed-type hypersensitivity (DTH) assay, and in mice after repeat transplant in the kidney following initial transplant with allogeneic islets in the eye or kidney. RESULTS Results in mice showed >300 days immunosuppression-free survival of allogeneic islets transplanted in the eye or kidney. Notably, >70% of tolerant mice, initially transplanted in the eye, exhibited >400 days of graft survival after re-transplant in the kidney without immunosuppression compared with ~30% in mice that were initially transplanted in the kidney. Cytokine and DTH data provided evidence of T helper 2-driven local and peripheral immune regulatory mechanisms in support of operational immune tolerance towards the islet allografts in both models. CONCLUSIONS/INTERPRETATION We are currently evaluating the safety and efficacy of intraocular islet transplantation in a phase 1 clinical trial. In this study, we demonstrate immunosuppression-free long-term survival of intraocular islet allografts in mice and in a baboon using transient peri-transplant immune intervention. These results highlight the potential for inducing islet transplant immune tolerance through the intraocular route. Therefore, the current findings are conceptually significant and may impact markedly on clinical islet transplantation in the treatment of diabetes.
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Affiliation(s)
- Midhat H Abdulreda
- Diabetes Research Institute and Cell Transplant Center, University of Miami Miller School of Medicine, 1450 NW 10th Ave, Miami, FL, 33136, USA.
- Department of Surgery, 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.
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Dora M Berman
- Diabetes Research Institute and Cell Transplant Center, University of Miami Miller School of Medicine, 1450 NW 10th Ave, Miami, FL, 33136, USA
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Alexander Shishido
- Diabetes Research Institute and Cell Transplant Center, University of Miami Miller School of Medicine, 1450 NW 10th Ave, Miami, FL, 33136, USA
| | - Christopher Martin
- Diabetes Research Institute and Cell Transplant Center, University of Miami Miller School of Medicine, 1450 NW 10th Ave, Miami, FL, 33136, USA
| | - Maged Hossameldin
- Diabetes Research Institute and Cell Transplant Center, University of Miami Miller School of Medicine, 1450 NW 10th Ave, Miami, FL, 33136, USA
| | - Ashley Tschiggfrie
- Diabetes Research Institute and Cell Transplant Center, University of Miami Miller School of Medicine, 1450 NW 10th Ave, Miami, FL, 33136, USA
| | - Luis F Hernandez
- Diabetes Research Institute and Cell Transplant Center, University of Miami Miller School of Medicine, 1450 NW 10th Ave, Miami, FL, 33136, USA
| | - Ana Hernandez
- Diabetes Research Institute and Cell Transplant Center, University of Miami Miller School of Medicine, 1450 NW 10th Ave, Miami, FL, 33136, USA
| | - Camillo Ricordi
- Diabetes Research Institute and Cell Transplant Center, University of Miami Miller School of Medicine, 1450 NW 10th Ave, Miami, FL, 33136, USA
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Diabetes Research Institute Federation, Hollywood, FL, USA
| | - Jean-Marie Parel
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ewa Jankowska-Gan
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - William J Burlingham
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | | | - Victor L Perez
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
- Duke Ophthalmology, Duke University, Durham, NC, USA
| | - Norma S Kenyon
- Diabetes Research Institute and Cell Transplant Center, University of Miami Miller School of Medicine, 1450 NW 10th Ave, Miami, FL, 33136, USA
- Department of Surgery, 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
| | - Per-Olof Berggren
- Diabetes Research Institute and Cell Transplant Center, University of Miami Miller School of Medicine, 1450 NW 10th Ave, Miami, FL, 33136, USA.
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
- The Rolf Luft Research Center for Diabetes and Endocrinology, Karolinska Institutet, Karolinska University Hospital L1, SE-17176, Stockholm, Sweden.
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10
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Berman DM, Ruiz P, Blandino-Rosano M, Bernal-Mizrachi E, Kenyon NS. Steroid-Free Immune Suppression Impairs Glycemic Control in a Healthy Cynomolgus Monkey. Cell Transplant 2019; 28:262-268. [PMID: 30675800 PMCID: PMC6425109 DOI: 10.1177/0963689718823505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The need for chronic immune suppression (IS) is one of the hurdles precluding widespread use of islet cell transplantation to restore glycemic control in patients with type 1 diabetes. We report the case of a healthy nonhuman primate (NHP) treated on and off for over 2.5 years with steroid-free IS, consisting of daclizumab induction and maintenance therapy with rapamycin and low dose tacrolimus. Treatment for 1 year resulted in a striking destabilization of glycemic control, with concomitant decreases in fasting c-peptide and insulin levels. Although these changes gradually reversed during a wash out period of 7 months, retreatment with the same therapy led to accelerated deterioration in glycemic control. Intravenous glucose tolerance and percentage of glycosylated hemoglobin testing further supported a dramatic effect on metabolic control. IS also led to decreases in weight during treatment. Histological evaluation of the pancreas revealed islet hyperplasia, with varying sizes and endocrine cell ratios that differed from normal islet composition, and parenchymal infiltration with adipose tissue. These deleterious effects of IS on glucose control and endocrine components in the native pancreas of a healthy NHP suggest that IS agents commonly utilized for islet transplantation may contribute to failure in islet allograft function in long-term transplant patients.
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Affiliation(s)
- Dora M Berman
- 1 Diabetes Research Institute, Miller School of Medicine, University of Miami, FL, USA.,2 Department of Surgery, Miller School of Medicine, University of Miami, FL, USA
| | - Phillip Ruiz
- 3 Department of Pathology and Microbiology, Miller School of Medicine, University of Miami, FL, USA
| | - Manuel Blandino-Rosano
- 4 Department of Internal Medicine, Division of Endocrinology, Metabolism and Diabetes, Miller School of Medicine, University of Miami, FL, USA
| | - Ernesto Bernal-Mizrachi
- 4 Department of Internal Medicine, Division of Endocrinology, Metabolism and Diabetes, Miller School of Medicine, University of Miami, FL, USA
| | - Norma S Kenyon
- 1 Diabetes Research Institute, Miller School of Medicine, University of Miami, FL, USA.,2 Department of Surgery, Miller School of Medicine, University of Miami, FL, USA.,5 Department of Immunology, Miller School of Medicine, University of Miami, FL, USA
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11
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Safley SA, Kenyon NS, Berman DM, Barber GF, Willman M, Duncanson S, Iwakoshi N, Holdcraft R, Gazda L, Thompson P, Badell IR, Sambanis A, Ricordi C, Weber CJ. Cover Image, Volume 25, Issue 6. Xenotransplantation 2018. [DOI: 10.1111/xen.12480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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12
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Safley SA, Kenyon NS, Berman DM, Barber GF, Willman M, Duncanson S, Iwakoshi N, Holdcraft R, Gazda L, Thompson P, Badell IR, Sambanis A, Ricordi C, Weber CJ. Microencapsulated adult porcine islets transplanted intraperitoneally in streptozotocin-diabetic non-human primates. Xenotransplantation 2018; 25:e12450. [PMID: 30117193 DOI: 10.1111/xen.12450] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 05/18/2018] [Accepted: 06/26/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Xenogeneic donors would provide an unlimited source of islets for the treatment of type 1 diabetes (T1D). The goal of this study was to assess the function of microencapsulated adult porcine islets (APIs) transplanted ip in streptozotocin (STZ)-diabetic non-human primates (NHPs) given targeted immunosuppression. METHODS APIs were encapsulated in: (a) single barium-gelled alginate capsules or (b) double alginate capsules with an inner, islet-containing compartment and a durable, biocompatible outer alginate layer. Immunosuppressed, streptozotocin-diabetic NHPs were transplanted ip with encapsulated APIs, and graft function was monitored by measuring blood glucose, %HbA1c, and porcine C-peptide. At graft failure, explanted capsules were assessed for biocompatibility and durability plus islet viability and functionality. Host immune responses were evaluated by phenotyping peritoneal cell populations, quantitation of peritoneal cytokines and chemokines, and measurement of anti-porcine IgG and IgM plus anti-Gal IgG. RESULTS NHP recipients had reduced hyperglycemia, decreased exogenous insulin requirements, and lower percent hemoglobin A1c (%HbA1c) levels. Porcine C-peptide was detected in plasma of all recipients, but these levels diminished with time. However, relatively high levels of porcine C-peptide were detected locally in the peritoneal graft site of some recipients at sacrifice. IV glucose tolerance tests demonstrated metabolic function, but the grafts eventually failed in all diabetic NHPs regardless of the type of encapsulation or the host immunosuppression regimen. Explanted microcapsules were intact, "clean," and free-floating without evidence of fibrosis at graft failure, and some reversed diabetes when re-implanted ip in diabetic immunoincompetent mice. Histology of explanted capsules showed scant evidence of a host cellular response, and viable islets could be found. Flow cytometric analyses of peritoneal cells and peripheral blood showed similarly minimal evidence of a host immune response. Preformed anti-porcine IgG and IgM antibodies were present in recipient plasma, but these levels did not rise post-transplant. Peritoneal graft site cytokine or chemokine levels were equivalent to normal controls, with the exception of minimal elevation observed for IL-6 or IL-1β, GRO-α, I-309, IP-10, and MCP-1. However, we found central necrosis in many of the encapsulated islets after graft failure, and explanted islets expressed endogenous markers of hypoxia (HIF-1α, osteopontin, and GLUT-1), suggesting a role for non-immunologic factors, likely hypoxia, in graft failure. CONCLUSIONS With donor xenoislet microencapsulation and host immunosuppression, APIs corrected hyperglycemia after ip transplantation in STZ-diabetic NHPs in the short term. The islet xenografts lost efficacy gradually, but at graft failure, some viable islets remained, substantial porcine C-peptide was detected in the peritoneal graft site, and there was very little evidence of a host immune response. We postulate that chronic effects of non-immunologic factors, such as in vivo hypoxic and hyperglycemic conditions, damaged the encapsulated islet xenografts. To achieve long-term function, new approaches must be developed to prevent this damage, for example, by increasing the oxygen supply to microencapsulated islets in the ip space.
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Affiliation(s)
- Susan A Safley
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Norma S Kenyon
- Diabetes Research Institute, Miami, Florida.,Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida.,Department of Microbiology & Immunology, Miller School of Medicine, University of Miami, Miami, Florida.,Department of Pathology, Miller School of Medicine, University of Miami, Miami, Florida
| | - Dora M Berman
- Diabetes Research Institute, Miami, Florida.,Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida.,Department of Microbiology & Immunology, Miller School of Medicine, University of Miami, Miami, Florida.,Department of Pathology, Miller School of Medicine, University of Miami, Miami, Florida
| | | | | | - Stephanie Duncanson
- Department of Biomedical Engineering, School of Chemical & Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Neal Iwakoshi
- Department of Surgery, Emory University, Atlanta, Georgia
| | | | | | - Peter Thompson
- Department of Surgery, Emory University, Atlanta, Georgia
| | - I Raul Badell
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Athanassios Sambanis
- Department of Biomedical Engineering, School of Chemical & Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Camillo Ricordi
- Diabetes Research Institute, Miami, Florida.,Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida.,Department of Microbiology & Immunology, Miller School of Medicine, University of Miami, Miami, Florida.,Department of Pathology, Miller School of Medicine, University of Miami, Miami, Florida.,Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida
| | - Collin J Weber
- Department of Surgery, Emory University, Atlanta, Georgia
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13
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Rodriguez-Diaz R, Molano RD, Weitz JR, Abdulreda MH, Berman DM, Leibiger B, Leibiger IB, Kenyon NS, Ricordi C, Pileggi A, Caicedo A, Berggren PO. Paracrine Interactions within the Pancreatic Islet Determine the Glycemic Set Point. Cell Metab 2018; 27. [PMID: 29514065 PMCID: PMC5872154 DOI: 10.1016/j.cmet.2018.01.015] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Every animal species has a signature blood glucose level or glycemic set point. These set points are different, and the normal glycemic levels (normoglycemia) of one species would be life threatening for other species. Mouse normoglycemia can be considered diabetic for humans. The biological determinants of the glycemic set point remain unclear. Here we show that the pancreatic islet imposes its glycemic set point on the organism, making it the bona fide glucostat in the body. Moreover, and in contrast to rodent islets, glucagon input from the alpha cell to the insulin-secreting beta cell is necessary to fine-tune the distinctive human set point. These findings affect transplantation and regenerative approaches to treat diabetes because restoring normoglycemia may require more than replacing only the beta cells. Furthermore, therapeutic strategies using glucagon receptor antagonists as hypoglycemic agents need to be reassessed, as they may reset the overall glucostat in the organism.
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Affiliation(s)
- Rayner Rodriguez-Diaz
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, 1580 NW 10(th) Avenue, Miami, FL 33136, USA; Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA; The Rolf Luft Research Center for Diabetes and Endocrinology, Karolinska Institutet, Stockholm 17177, Sweden.
| | - R Damaris Molano
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Jonathan R Weitz
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, 1580 NW 10(th) Avenue, Miami, FL 33136, USA
| | - Midhat H Abdulreda
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Dora M Berman
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Barbara Leibiger
- The Rolf Luft Research Center for Diabetes and Endocrinology, Karolinska Institutet, Stockholm 17177, Sweden
| | - Ingo B Leibiger
- The Rolf Luft Research Center for Diabetes and Endocrinology, Karolinska Institutet, Stockholm 17177, Sweden
| | - Norma S Kenyon
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Camillo Ricordi
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Antonello Pileggi
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Alejandro Caicedo
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, 1580 NW 10(th) Avenue, Miami, FL 33136, USA; Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA; Department of Physiology and Biophysics, Miller School of Medicine, University of Miami, Miami, FL 33136, USA; Program in Neuroscience, Miller School of Medicine, University of Miami, Miami, FL 33136, USA.
| | - Per-Olof Berggren
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA; The Rolf Luft Research Center for Diabetes and Endocrinology, Karolinska Institutet, Stockholm 17177, Sweden; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Pancreatic Islet Biology and Diabetes Consortium, Imperial College, London, UK.
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14
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Cabrera O, Jacques-Silva MC, Berman DM, Fachado A, Echeverri F, Poo R, Khan A, Kenyon NS, Ricordi C, Berggren PO, Caicedo A. Automated, High-Throughput Assays for Evaluation of Human Pancreatic Islet Function. Cell Transplant 2017; 16:1039-1048. [DOI: 10.3727/000000007783472408] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
An important challenge in pancreatic islet transplantation in association with type 1 diabetes is to define automatic high-throughput assays for evaluation of human islet function. The physiological techniques presently used are amenable to small-scale experimental samples and produce descriptive results. The postgenomic era provides an opportunity to analyze biological processes on a larger scale, but the transition to high-throughput technologies is still a challenge. As a first step to implement high-throughput assays for the study of human islet function, we have developed two methodologies: multiple automated perifusion to determine islet hormone secretion and high-throughput kinetic imaging to examine islet cellular responses. Both technologies use fully automated devices that allow performing simultaneous experiments on multiple islet preparations. Our results illustrate that these technologies can be applied to study the functional status and explore the pharmacological profiles of islet cells. These methodologies will enable functional characterization of human islet preparations before transplantation and thereby provide the basis for the establishment of predictive tests for β-cell potency.
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Affiliation(s)
- Over Cabrera
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
- The Rolf Luft Research Center for Diabetes and Endocrinology, Karolinska Institutet, Stockholm, Sweden
| | | | - Dora M. Berman
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Alberto Fachado
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | | | - Ramon Poo
- Biorep® Technologies, Inc., Miami, FL, USA
| | - Aisha Khan
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Norma S. Kenyon
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Camillo Ricordi
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Per-Olof Berggren
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
- The Rolf Luft Research Center for Diabetes and Endocrinology, Karolinska Institutet, Stockholm, Sweden
| | - Alejandro Caicedo
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
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15
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Baidal DA, Ricordi C, Berman DM, Alvarez A, Padilla N, Ciancio G, Linetsky E, Pileggi A, Alejandro R. Bioengineering of an Intraabdominal Endocrine Pancreas. N Engl J Med 2017; 376:1887-1889. [PMID: 28489987 PMCID: PMC5572072 DOI: 10.1056/nejmc1613959] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- David A Baidal
- University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - Camillo Ricordi
- University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - Dora M Berman
- University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - Ana Alvarez
- University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - Nathalia Padilla
- University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - Gaetano Ciancio
- University of Miami Leonard M. Miller School of Medicine, Miami, FL
| | - Elina Linetsky
- University of Miami Leonard M. Miller School of Medicine, Miami, FL
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16
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Berman DM, Molano RD, Fotino C, Ulissi U, Gimeno J, Mendez AJ, Kenyon NM, Kenyon NS, Andrews DM, Ricordi C, Pileggi A. Bioengineering the Endocrine Pancreas: Intraomental Islet Transplantation Within a Biologic Resorbable Scaffold. Diabetes 2016; 65:1350-61. [PMID: 26916086 PMCID: PMC5384628 DOI: 10.2337/db15-1525] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 02/17/2016] [Indexed: 12/15/2022]
Abstract
Transplantation of pancreatic islets is a therapeutic option to preserve or restore β-cell function. Our study was aimed at developing a clinically applicable protocol for extrahepatic transplantation of pancreatic islets. The potency of islets implanted onto the omentum, using an in situ-generated adherent, resorbable plasma-thrombin biologic scaffold, was evaluated in diabetic rat and nonhuman primate (NHP) models. Intraomental islet engraftment in the biologic scaffold was confirmed by achievement of improved metabolic function and preservation of islet cytoarchitecture, with reconstitution of rich intrainsular vascular networks in both species. Long-term nonfasting normoglycemia and adequate glucose clearance (tolerance tests) were achieved in both intrahepatic and intraomental sites in rats. Intraomental graft recipients displayed lower levels of serum biomarkers of islet distress (e.g., acute serum insulin) and inflammation (e.g., leptin and α2-macroglobulin). Importantly, low-purity (30:70% endocrine:exocrine) syngeneic rat islet preparations displayed function equivalent to that of pure (>95% endocrine) preparations after intraomental biologic scaffold implantation. Moreover, the biologic scaffold sustained allogeneic islet engraftment in immunosuppressed recipients. Collectively, our feasibility/efficacy data, along with the simplicity of the procedure and the safety of the biologic scaffold components, represented sufficient preclinical testing to proceed to a pilot phase I/II clinical trial.
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MESH Headings
- Animals
- Biocompatible Materials/adverse effects
- Biocompatible Materials/chemistry
- Biomarkers/blood
- Diabetes Mellitus, Experimental/blood
- Diabetes Mellitus, Experimental/immunology
- Diabetes Mellitus, Experimental/pathology
- Diabetes Mellitus, Experimental/surgery
- Feasibility Studies
- Female
- Hyperglycemia/prevention & control
- Immunosuppression Therapy/adverse effects
- Islets of Langerhans/cytology
- Islets of Langerhans/ultrastructure
- Islets of Langerhans Transplantation/adverse effects
- Islets of Langerhans Transplantation/immunology
- Islets of Langerhans Transplantation/methods
- Islets of Langerhans Transplantation/pathology
- Macaca fascicularis
- Male
- Microscopy, Electron, Scanning
- Omentum
- Pancreas, Artificial/adverse effects
- Plasma/chemistry
- Plasma/metabolism
- Rats, Inbred Lew
- Rats, Inbred WF
- Recombinant Proteins/adverse effects
- Recombinant Proteins/chemistry
- Recombinant Proteins/metabolism
- Surface Properties
- Thrombin/adverse effects
- Thrombin/chemistry
- Thrombin/metabolism
- Tissue Engineering
- Tissue Scaffolds/adverse effects
- Tissue Scaffolds/chemistry
- Transplantation, Heterologous/adverse effects
- Transplantation, Heterotopic/adverse effects
- Transplantation, Isogeneic/adverse effects
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Affiliation(s)
- Dora M Berman
- Cell Transplant Center, Diabetes Research Institute, University of Miami, Miami, FL The DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL
| | - R Damaris Molano
- Cell Transplant Center, Diabetes Research Institute, University of Miami, Miami, FL
| | - Carmen Fotino
- Cell Transplant Center, Diabetes Research Institute, University of Miami, Miami, FL
| | - Ulisse Ulissi
- Cell Transplant Center, Diabetes Research Institute, University of Miami, Miami, FL
| | - Jennifer Gimeno
- Cell Transplant Center, Diabetes Research Institute, University of Miami, Miami, FL
| | - Armando J Mendez
- Cell Transplant Center, Diabetes Research Institute, University of Miami, Miami, FL Department of Medicine, University of Miami, Miami, FL
| | - Norman M Kenyon
- Cell Transplant Center, Diabetes Research Institute, University of Miami, Miami, FL The DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL
| | - Norma S Kenyon
- Cell Transplant Center, Diabetes Research Institute, University of Miami, Miami, FL The DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL Department of Microbiology and Immunology, University of Miami, Miami, FL Department of Biomedical Engineering, University of Miami, Miami, FL
| | | | - Camillo Ricordi
- Cell Transplant Center, Diabetes Research Institute, University of Miami, Miami, FL The DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL Department of Medicine, University of Miami, Miami, FL Department of Microbiology and Immunology, University of Miami, Miami, FL Department of Biomedical Engineering, University of Miami, Miami, FL
| | - Antonello Pileggi
- Cell Transplant Center, Diabetes Research Institute, University of Miami, Miami, FL The DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL Department of Microbiology and Immunology, University of Miami, Miami, FL Department of Biomedical Engineering, University of Miami, Miami, FL
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17
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Berman DM. Isolation of Pancreatic Islets from Nonhuman Primates. Adv Exp Med Biol 2016; 938:57-66. [PMID: 27586422 DOI: 10.1007/978-3-319-39824-2_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Nonhuman primates (NHP) constitute a highly relevant pre-clinical animal model to develop strategies for beta cell replacement. The close phylogenetic and immunologic relationship between NHP and humans results in cross-reactivity of various biological agents with NHP cells, as well as a very similar cytoarchitecture between islets from human and NHP that is strikingly different from that observed in rodent islets. The composition and location of endocrine cells in human or NHP islets, randomly distributed and associated with blood vessels, have functional consequences and a predisposition for paracrine interactions. Furthermore, translation of approaches that proved successful in rodent models to the clinic has been limited. Consequently, data collected from NHP studies can form the basis for an IND submission to the FDA. This chapter describes in detail the key aspects for isolation of islets from NHP, from organ procurement up to assessment of islet function, comparing and emphasizing the similarities between isolation procedures for human and NHP islets.
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Affiliation(s)
- Dora M Berman
- Diabetes Research Institute, University of Miami Leonard M. Miller School of Medicine, 1450 NW 10 Avenue, Miami, FL, USA.
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18
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Ladas EJ, Bhatia M, Chen L, Sandler E, Petrovic A, Berman DM, Hamblin F, Gates M, Hawks R, Sung L, Nieder M. The safety and feasibility of probiotics in children and adolescents undergoing hematopoietic cell transplantation. Bone Marrow Transplant 2015; 51:262-6. [PMID: 26569091 DOI: 10.1038/bmt.2015.275] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 09/18/2015] [Accepted: 10/07/2015] [Indexed: 12/19/2022]
Abstract
Hematopoietic cell transplantation (HCT) has become a standard treatment for many adult and pediatric conditions. Emerging evidence suggests that perturbations in the microbiota diversity increase recipients' susceptibilities to gut-mediated conditions such as diarrhea, infection and acute GvHD. Probiotics preserve the microbiota and may minimize the risk of developing a gut-mediated condition; however, their safety has not been evaluated in the setting of HCT. We evaluated the safety and feasibility of the probiotic, Lactobacillus plantarum (LBP), in children and adolescents undergoing allogeneic HCT. Participants received once-daily supplementation with LBP beginning on day -8 or -7 and continued until day +14. Outcomes were compliance with daily administration and incidence of LBP bacteremia. Administration of LBP was feasible with 97% (30/31, 95% confidence interval (CI) 83-100%) of children receiving at least 50% of the probiotic dose (median 97%; range 50-100%). We did not observe any case of LBP bacteremia (0% (0/30) with 95% CI 0-12%). There were not any unexpected adverse events related to LBP. Our study provides preliminary evidence that administration of LBP is safe and feasible in children and adolescents undergoing HCT. Future steps include the conduct of an approved randomized, controlled trial through Children's Oncology Group.
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Affiliation(s)
- E J Ladas
- Division of Pediatric Hematology/Oncology/Stem Cell Transplant, Columbia University Medical Center, New York, NY, USA.,Institute of Human Nutrition, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY, USA
| | - M Bhatia
- Division of Pediatric Hematology/Oncology/Stem Cell Transplant, Columbia University Medical Center, New York, NY, USA
| | - L Chen
- Children's Oncology Group, Acadia, CA, USA.,Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA
| | - E Sandler
- Division of Hematology/Oncology, Nemours Children's Health System, Jacksonville, FL, USA
| | - A Petrovic
- Blood and Bone Marrow Transplantation, All Children's Hospital John Hopkins Medicine, St Petersburg, FL, USA
| | - D M Berman
- Division of Pediatric Infectious Diseases, All Children's Hospital, John Hopkins Medicine, St Petersburg, FL, USA
| | - F Hamblin
- All Children's Hospital, John Hopkins Medicine, St Petersburg, FL, USA
| | - M Gates
- All Children's Hospital, John Hopkins Medicine, St Petersburg, FL, USA
| | - R Hawks
- Division of Pediatric Hematology/Oncology/Stem Cell Transplant, Columbia University Medical Center, New York, NY, USA
| | - L Sung
- Division of Haematology/Oncology, The Hospital for Sick Kids, Toronto, Ontario, Canada
| | - M Nieder
- Department of Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL, USA
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19
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Booth CM, Siemens DR, Li G, Peng Y, Kong W, Berman DM, Mackillop WJ. Curative therapy for bladder cancer in routine clinical practice: a population-based outcomes study. Clin Oncol (R Coll Radiol) 2014; 26:506-14. [PMID: 24954284 DOI: 10.1016/j.clon.2014.05.007] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 04/08/2014] [Accepted: 05/13/2014] [Indexed: 10/25/2022]
Abstract
AIMS Definitive therapy of bladder cancer involves cystectomy or radiotherapy; controversy exists regarding optimal management. Here we describe the management and outcomes of patients treated in routine practice. MATERIALS AND METHODS Treatment records were linked to the Ontario Cancer Registry to identify all cases of bladder cancer in Ontario treated with cystectomy or radiotherapy in 1994-2008. Practice patterns are described in three study periods: 1994-1998, 1999-2003, 2004-2008. Logistic regression, Cox model and propensity score analyses were used to evaluate factors associated with treatment choice and survival. RESULTS In total, 3879 cases (74%) underwent cystectomy and 1380 (26%) were treated with primary radiotherapy. Cystectomy use increased over time (66, 75, 78%), whereas radiotherapy decreased (34, 25, 22%), P < 0.001. There was substantial regional variation in the proportion of cases undergoing radiotherapy (range 16-51%). Five year cancer-specific survival (CSS) and overall survival were 40 and 36% for surgical cases and 35 and 26% for radiotherapy cases (P < 0.001). In multivariate Cox model and propensity score analyses, there was no significant difference in CSS between surgery and radiotherapy (hazard ratio 0.99, 95% confidence interval 0.91-1.08); radiotherapy was associated with slightly inferior overall survival (hazard ratio 1.08, 95% confidence interval 1.00-1.16). CONCLUSION Utilisation of cystectomy for bladder cancer in routine practice has increased over time with no evidence of a significant difference in CSS between radiotherapy and cystectomy.
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Affiliation(s)
- C M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Queen's University, Kingston, Canada; Department of Oncology, Queen's University, Kingston, Canada.
| | - D R Siemens
- Department of Oncology, Queen's University, Kingston, Canada; Department of Urology, Queen's University, Kingston, Canada
| | - G Li
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Queen's University, Kingston, Canada
| | - Y Peng
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Queen's University, Kingston, Canada; Department of Pathology and Molecular Medicine, Queen's University, Kingston, Canada
| | - W Kong
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Queen's University, Kingston, Canada
| | - D M Berman
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Canada
| | - W J Mackillop
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Queen's University, Kingston, Canada; Department of Oncology, Queen's University, Kingston, Canada; Department of Public Health Sciences, Queen's University, Kingston, Canada
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Pedraza E, Brady AC, Fraker CA, Molano RD, Sukert S, Berman DM, Kenyon NS, Pileggi A, Ricordi C, Stabler CL. Macroporous three-dimensional PDMS scaffolds for extrahepatic islet transplantation. Cell Transplant 2012; 22:1123-35. [PMID: 23031502 DOI: 10.3727/096368912x657440] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Clinical islet transplantation has demonstrated success in treating type 1 diabetes. A current limitation is the intrahepatic portal vein transplant site, which is prone to mechanical stress and inflammation. Transplantation of pancreatic islets into alternative sites is preferable, but challenging, as it may require a three-dimensional vehicle to confer mechanical protection and to confine islets to a well-defined, retrievable space where islet neovascularization can occur. We have fabricated biostable, macroporous scaffolds from poly(dimethylsiloxane) (PDMS) and investigated islet retention and distribution, metabolic function, and glucose-dependent insulin secretion within these scaffolds. Islets from multiple sources, including rodents, nonhuman primates, and humans, were tested in vitro. We observed high islet retention and distribution within PDMS scaffolds, with retention of small islets (< 100 µm) improved through the postloading addition of fibrin gel. Islets loaded within PDMS scaffolds exhibited viability and function comparable to standard culture conditions when incubated under normal oxygen tensions, but displayed improved viability compared to standard two-dimensional culture controls under low oxygen tensions. In vivo efficacy of scaffolds to support islet grafts was evaluated after transplantation in the omental pouch of chemically induced diabetic syngeneic rats, which promptly achieved normoglycemia. Collectively, these results are promising in that they indicate the potential for transplanting islets into a clinically relevant, extrahepatic site that provides spatial distribution of islets as well as intradevice vascularization.
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Affiliation(s)
- Eileen Pedraza
- Diabetes Research Institute, University of Miami, Miami, FL 33136, USA
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21
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Tittelbach TJ, Berman DM, Nicklas BJ, Ryan AS, Goldberg AP. Racial Differences in Adipocyte Size and Relationship to the Metabolic Syndrome in Obese Women. ACTA ACUST UNITED AC 2012; 12:990-8. [PMID: 15229339 DOI: 10.1038/oby.2004.121] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine whether racial differences exist in the relationship of the abnormalities defining the metabolic syndrome (MS) to regional adiposity and fat cell size (FCS) in obese postmenopausal women. RESEARCH METHODS AND PROCEDURES We determined the relationship of metabolic variables associated with the MS to regional body composition and abdominal (ABD) and gluteal (GLT) FCS in 25 white (CAU) and 25 African-American (AF-AMER) older women matched for age (58 +/- 5 years; mean +/- SD) and BMI (35 +/- 4 kg/m2). RESULTS MS was present in 36% of the AF-AMER and 57% of the CAU women. There were no differences in total body, trunk, gluteofemoral fat mass or regional FCS, but AF-AMER women had 22% lower visceral fat, 24% higher insulin, and 31% lower triglyceride levels than CAU women (p < 0.05). Multiple regression analysis with body fat, visceral ABD fat area, and FCS as independent variables showed that GLT FCS was independently correlated with 2-hour insulin (r = 0.56), triglyceride (r = 0.62), and high-density lipoprotein cholesterol (r = -0.72) levels in AF-AMER women but not in CAU women, where only systolic blood pressure correlated with subcutaneous ABD fat area (r = 0.57) (p < 0.05). DISCUSSION The associations between GLT FCS and metabolic dysfunction in obese AF-AMER but not CAU women suggest that central obesity is a less valid predictor of the MS in obese postmenopausal AF-AMER women than in CAU women and that GLT FCS may be a more sensitive indicator of risk for the MS in AF-AMER women.
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Affiliation(s)
- Thomas J Tittelbach
- Baltimore VA Medical Center, Geriatric Research, Education, and Clinical Center (BT/GR/18), 10 N. Greene Street, MD 21201, USA.
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22
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Han D, Berman DM, Willman M, Buchwald P, Rothen D, Kenyon NM, Kenyon NS. Choice of Immunosuppression Influences Cytomegalovirus DNAemia in Cynomolgus Monkey (Macaca fascicularis) Islet Allograft Recipients. Cell Transplant 2010; 19:1547-61. [DOI: 10.3727/096368910x513973] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This retrospective study reviews the results of our experience with the occurrence of CMV DNAemia in islet cell transplanted cynomolgus monkeys subjected to different immunosuppressive protocols, including induction treatment with thymoglobulin (TMG), with a combination of thymoglobulin and fludarabine (FLUD), with cyclophosphamide, or with daclizumab. CMV DNA in the peripheral blood (CMV DNAemia) of 47 monkeys was quantified by real-time PCR on a weekly to biweekly basis. As compared to other immunosuppressive regimens, and in association with greater decreases in WBC, lymphocyte, CD3+CD4+, and CD3+CD8+ lymphocyte counts, frequent CMV DNAemia occurred earlier (within the first month posttransplant), and was of greater severity and duration in recipients of TMG ± FLUD. Treatment of recipients with alternative induction agents that resulted in less dramatic reductions in WBC and lymphocyte counts, however, resulted in occurrence of CMV DNAemia after postoperative day 60. The frequency, average intensity, duration, and area under the curve (AUC) for CMV DNAemia in animals receiving TMG ± FLUD were 75–100%, 4.02 ± 1.75 copies/ng DNA, 23.0 ± 5.3 days, and 367.0 ± 121.1 days x copies/ng DNA, respectively; corresponding values in animals receiving other treatments (0–44%, 0.19 ± 0.10 copies/ng DNA, 0.5 ± 0.3 days, and 75.4 ± 40.2 days x copies/ng DNA, respectively) were significantly different. The value of WBC, T and B cells at the nadir of cell depletion greatly affects the occurrence of CMV DNAemia. No animals developed CMV DNAemia within the next 3 weeks when the lowest value of WBC, lymphocyte, CD3+, CD3+CD4+, CD3+CD8+, or CD20+ cells was above 4500, 1800, 300, 200, 150, or 300 cells/μl, respectively. Oral valganciclovir prophylaxis did not completely prevent the appearance of CMV DNAemia.
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Affiliation(s)
- Dongmei Han
- Diabetes Research Institute, University of Miami School of Medicine, Miami, FL, USA
| | - Dora M. Berman
- Diabetes Research Institute, University of Miami School of Medicine, Miami, FL, USA
- Department of Surgery, University of Miami School of Medicine, Miami, FL, USA
| | - Melissa Willman
- Diabetes Research Institute, University of Miami School of Medicine, Miami, FL, USA
| | - Peter Buchwald
- Diabetes Research Institute, University of Miami School of Medicine, Miami, FL, USA
- Department of Molecular and Cellular Pharmacology, University of Miami School of Medicine, Miami, FL, USA
| | - Daniel Rothen
- Division of Veterinary Resources, University of Miami School of Medicine, Miami, FL, USA
| | - Norman M. Kenyon
- Diabetes Research Institute, University of Miami School of Medicine, Miami, FL, USA
| | - Norma S. Kenyon
- Diabetes Research Institute, University of Miami School of Medicine, Miami, FL, USA
- Department of Surgery, University of Miami School of Medicine, Miami, FL, USA
- Department of Medicine, University of Miami School of Medicine, Miami, FL, USA
- Department of Microbiology and Immunology, University of Miami School of Medicine, Miami, FL, USA
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23
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Berman DM, Willman MA, Han D, Kleiner G, Kenyon NM, Cabrera O, Karl JA, Wiseman RW, O'Connor DH, Bartholomew AM, Kenyon NS. Mesenchymal stem cells enhance allogeneic islet engraftment in nonhuman primates. Diabetes 2010; 59:2558-68. [PMID: 20622174 PMCID: PMC3279532 DOI: 10.2337/db10-0136] [Citation(s) in RCA: 157] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To test the graft-promoting effects of mesenchymal stem cells (MSCs) in a cynomolgus monkey model of islet/bone marrow transplantation. RESEARCH DESIGN AND METHODS Cynomolgus MSCs were obtained from iliac crest aspirate and characterized through passage 11 for phenotype, gene expression, differentiation potential, and karyotype. Allogeneic donor MSCs were cotransplanted intraportally with islets on postoperative day (POD) 0 and intravenously with donor marrow on PODs 5 and 11. Recipients were followed for stabilization of blood glucose levels, reduction of exogenous insulin requirement (EIR), C-peptide levels, changes in peripheral blood T regulatory cells, and chimerism. Destabilization of glycemia and increases in EIR were used as signs of rejection; additional intravenous MSCs were administered to test the effect on reversal of rejection. RESULTS MSC phenotype and a normal karyotype were observed through passage 11. IL-6, IL-10, vascular endothelial growth factor, TGF-β, hepatocyte growth factor, and galectin-1 gene expression levels varied among donors. MSC treatment significantly enhanced islet engraftment and function at 1 month posttransplant (n = 8), as compared with animals that received islets without MSCs (n = 3). Additional infusions of donor or third-party MSCs resulted in reversal of rejection episodes and prolongation of islet function in two animals. Stable islet allograft function was associated with increased numbers of regulatory T-cells in peripheral blood. CONCLUSIONS MSCs may provide an important approach for enhancement of islet engraftment, thereby decreasing the numbers of islets needed to achieve insulin independence. Furthermore, MSCs may serve as a new, safe, and effective antirejection therapy.
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Affiliation(s)
- Dora M. Berman
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, Florida
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Melissa A. Willman
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, Florida
| | - Dongmei Han
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, Florida
| | - Gary Kleiner
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida
- Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida
| | - Norman M. Kenyon
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, Florida
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Over Cabrera
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, Florida
| | - Julie A. Karl
- Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison, Wisconsin
| | - Roger W. Wiseman
- Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison, Wisconsin
| | - David H. O'Connor
- Wisconsin National Primate Research Center, University of Wisconsin-Madison, Madison, Wisconsin
- Department of Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Norma S. Kenyon
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, Florida
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, Florida
- Department of Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, Florida
- Department of Biomedical Engineering, University of Miami, Miami, Florida
- Corresponding author: Norma S. Kenyon,
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Abstract
Islet transplantation is a promising cellular therapy for the treatment of type 1 diabetes (T1D). The immunogenicity of isolated islets has been of interest to the transplant community for many years, as upon transplantation, islets are damaged or destroyed through specific and nonspecific inflammatory and immune events. Antigen presenting cells (APC) are crucial intermediates in the generation of both innate and specific immune responses, and it has long been understood that some APC are resident in islets in situ, as well as after isolation. Our aim was to identify and characterize intraislet resident populations of APC and other immune cells in islets from nonhuman primates (Macaca fascicularis) in situ (pancreas biopsies obtained prerecovery) and after isolation using immunohistochemistry, confocal microscopy, and flow cytometry. The numbers of cells obtained in situ are similar to those in islets postisolation. Each isolated islet equivalent contains an average of 21.8 immune cells, 14.7 (67%) of which are APC. Many of these APC are dentritic cells and, surprisingly, 50% are B lymphocytes. The number of islet-resident immune cells increases with islet size, with greater numbers in large versus small islets (p < 0.001). The APC were localized around the exterior or spread evenly throughout the islets, with no definitive orientation identified. This knowledge will be useful to develop tailored modulation strategies to decrease immunogenicity, enhance engraftment, and ultimately prevent islet rejection.
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Affiliation(s)
- Lane C K Coffey
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
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25
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Berman DM, O’Neil JJ, Coffey LC, Chaffanjon PC, Kenyon NM, Ruiz P, Pileggi A, Ricordi C, Kenyon NS. Long-term survival of nonhuman primate islets implanted in an omental pouch on a biodegradable scaffold. Am J Transplant 2009; 9:91-104. [PMID: 19133931 PMCID: PMC4441095 DOI: 10.1111/j.1600-6143.2008.02489.x] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The aim of this study was to test whether an omental pouch can be used as an alternative site for islet implantation in diabetic monkeys. Here we report the successful engraftment of islets in diabetic cynomolgus monkeys when loaded on a synthetic biodegradable scaffold and placed in an omental pouch. One autologous and five allogeneic diabetic monkey transplants under the cover of steroid-free immune suppression (SFIS) were undertaken. Fasting blood glucose (FBG) and C-peptide (CP), exogenous insulin requirements (EIR), intravenous glucose tolerance test (IVGTT), A1C and histopathology were used to assess islet engraftment and survival. All animals achieved CP levels > 1.0 ng/mL following transplant, a 66-92% posttransplant decrease in EIR and reduced A1C. Following graft removal, CP became negative and histopathological analysis of the explanted grafts demonstrated well-granulated and well-vascularized, insulin-positive islets, surrounded by T-cell subsets and macrophages. Compared to intrahepatic allogeneic islet transplants (n = 20), there was a delayed engraftment for omental pouch recipients but similar levels of CP production were ultimately achieved, with a broad range of IEQ/kg transplanted in both sites. Our results suggest this extrahepatic transplantation site has potential as an alternative site for clinical islet cell transplantation.
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Affiliation(s)
- Dora M. Berman
- Diabetes Research Institute, Miami, Florida, 33136,Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136
| | | | - Lane C.K. Coffey
- Diabetes Research Institute, Miami, Florida, 33136,Department of Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, FL 33136
| | - Philippe C.J. Chaffanjon
- Department of Thoracic, Vascular and Endocrine Surgery, Universitary Hospital of Grenoble, BP 217 - 38043 Grenoble Cedex 09, France
| | - Norman M. Kenyon
- Diabetes Research Institute, Miami, Florida, 33136,Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136
| | - Phillip Ruiz
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136,Department of Pathology, Miller School of Medicine, University of Miami, Miami, FL 33136
| | - Antonello Pileggi
- Diabetes Research Institute, Miami, Florida, 33136,Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136
| | - Camillo Ricordi
- Diabetes Research Institute, Miami, Florida, 33136,Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136,Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33136,Department of Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, FL 33136
| | - Norma S. Kenyon
- Diabetes Research Institute, Miami, Florida, 33136,Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL 33136,Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL 33136,Department of Microbiology and Immunology, Miller School of Medicine, University of Miami, Miami, FL 33136
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Fiaschi-Taesch NM, Berman DM, Sicari BM, Takane KK, Garcia-Ocaña A, Ricordi C, Kenyon NS, Stewart AF. Hepatocyte growth factor enhances engraftment and function of nonhuman primate islets. Diabetes 2008; 57:2745-54. [PMID: 18820214 PMCID: PMC2551685 DOI: 10.2337/db08-1085] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Adenoviral delivery of hepatocyte growth factor (HGF) to rodent islets improves islet graft survival and function, markedly reducing the number of islets required to achieve glucose control. Here, we asked whether these prior observations in rodent models extend to nonhuman primate (NHP) islets. RESEARCH DESIGN AND METHODS NHP islets were transduced with murine (Ad.mHGF) or human (Ad.hHGF) adenoviral HGF (Ad.HGF) at low multiplicity of infection and studied in vitro. To study the function of Ad.HGF-transduced NHP islets in vivo, a renal subcapsular marginal mass islet transplant model was developed in streptozotocin-induced diabetic NOD-SCID mice. RESULTS Baseline glucose values were 454.7 +/- 11.3 mg/dl (n = 7). Transplant of 500 NHP islet equivalents (IE) had only a marginal effect on blood glucose (369.1 +/- 9.7 mg/dl, n = 5). In striking contrast, 500 NHP IE transduced with Ad.mHGF promptly and continuously corrected blood glucose (142.0 +/- 6.2 mg/dl, n = 7) for the 6-week duration of the experiment. Unilateral nephrectomy resulted in an immediate return of glucose to baseline diabetic levels. Interestingly, adenoviral DNA, as well as mouse HGF (mHGF) mRNA derived from the adenovirus, were present for 42 days posttransplantation. Surprisingly, transplant of 500 IE with Ad.hHGF, as compared with Ad.mHGF, resulted in only marginal correction of blood glucose, suggesting that human HGF is less efficient than mHGF in this system. CONCLUSIONS These studies demonstrate that mHGF markedly improves islet transplant outcomes in the highest preclinical species examined to date. HGF has promise as an agent that can improve islet mass and function in transplant models and likely in other models of types 1 and 2 diabetes.
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Affiliation(s)
- Nathalie M Fiaschi-Taesch
- Division of Endocrinology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Cabrera O, Jacques-Silva MC, Speier S, Yang SN, Köhler M, Fachado A, Vieira E, Zierath JR, Kibbey R, Berman DM, Kenyon NS, Ricordi C, Caicedo A, Berggren PO. Glutamate is a positive autocrine signal for glucagon release. Cell Metab 2008; 7:545-54. [PMID: 18522835 PMCID: PMC4396785 DOI: 10.1016/j.cmet.2008.03.004] [Citation(s) in RCA: 153] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Revised: 01/09/2008] [Accepted: 03/10/2008] [Indexed: 11/15/2022]
Abstract
An important feature of glucose homeostasis is the effective release of glucagon from the pancreatic alpha cell. The molecular mechanisms regulating glucagon secretion are still poorly understood. We now demonstrate that human alpha cells express ionotropic glutamate receptors (iGluRs) that are essential for glucagon release. A lowering in glucose concentration results in the release of glutamate from the alpha cell. Glutamate then acts on iGluRs of the AMPA/kainate type, resulting in membrane depolarization, opening of voltage-gated Ca(2+) channels, increase in cytoplasmic free Ca(2+) concentration, and enhanced glucagon release. In vivo blockade of iGluRs reduces glucagon secretion and exacerbates insulin-induced hypoglycemia in mice. Hence, the glutamate autocrine feedback loop endows the alpha cell with the ability to effectively potentiate its own secretory activity. This is a prerequisite to guarantee adequate glucagon release despite relatively modest changes in blood glucose concentration under physiological conditions.
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Affiliation(s)
- Over Cabrera
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
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Cabrera O, Jacques-Silva MC, Berman DM, Fachado A, Echeverri F, Poo R, Khan A, Kenyon NS, Ricordi C, Berggren PO, Caicedo A. Automated, high-throughput assays for evaluation of human pancreatic islet function. Cell Transplant 2008; 16:1039-1048. [PMID: 18351020 PMCID: PMC3529176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
An important challenge in pancreatic islet transplantation in association with type 1 diabetes is to define automatic high-throughput assays for evaluation of human islet function. The physiological techniques presently used are amenable to small-scale experimental samples and produce descriptive results. The postgenomic era provides an opportunity to analyze biological processes on a larger scale, but the transition to high-throughput technologies is still a challenge. As a first step to implement high-throughput assays for the study of human islet function, we have developed two methodologies: multiple automated perifusion to determine islet hormone secretion and high-throughput kinetic imaging to examine islet cellular responses. Both technologies use fully automated devices that allow performing simultaneous experiments on multiple islet preparations. Our results illustrate that these technologies can be applied to study the functional status and explore the pharmacological profiles of islet cells. These methodologies will enable functional characterization of human islet preparations before transplantation and thereby provide the basis for the establishment of predictive tests for beta-cell potency.
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Affiliation(s)
- Over Cabrera
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
- The Rolf Luft Research Center for Diabetes and Endocrinology, Karolinska Institutet, Stockholm, Sweden
| | | | - Dora M. Berman
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Alberto Fachado
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | | | - Ramon Poo
- Biorep® Technologies, Inc., Miami, FL, USA
| | - Aisha Khan
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Norma S. Kenyon
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Camillo Ricordi
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Per-Olof Berggren
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
- The Rolf Luft Research Center for Diabetes and Endocrinology, Karolinska Institutet, Stockholm, Sweden
| | - Alejandro Caicedo
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
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Berman DM, Cabrera O, Kenyon NM, Miller J, Tam SH, Khandekar VS, Picha KM, Soderman AR, Jordan RE, Bugelski PJ, Horninger D, Lark M, Davis JE, Alejandro R, Berggren PO, Zimmerman M, O'Neil JJ, Ricordi C, Kenyon NS. Interference with tissue factor prolongs intrahepatic islet allograft survival in a nonhuman primate marginal mass model. Transplantation 2007; 84:308-15. [PMID: 17700154 DOI: 10.1097/01.tp.0000275401.80187.1e] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tissue factor (TF) expression on islets can result in an instant blood-mediated inflammatory reaction (IBMIR) that contributes to early islet loss. We tested whether peritransplant protection of islets from IBMIR with a monoclonal anti-TF antibody (CNTO859) would enhance engraftment in our nonhuman primate marginal mass model. METHODS Each of six pairs of cynomolgus monkeys (CM) with streptozotocin-induced diabetes was closely matched for metabolic control and was transplanted with 5,000 IEQ/kg allogeneic, ABO-compatible islets from the same donor under the cover of steroid-free immunosuppression. For each pair, experimental animals received islets cultured with 20 microg/mL anti-TF and were dosed with 6 mg/kg anti-TF intravenously, 10-25 min before islet infusion; control monkeys received an equal number of islets from the same preparation cultured without anti-TF and no in vivo treatment. RESULTS Early fasting C-peptide (CP) values were different between (P<0.01), but not within, pairs and correlated with in vitro functional capacity of islets as assessed by perifusion (r=0.60; P=0.022). Compared to their matched controls, experimental animals had decreased posttransplant markers of coagulation, higher fasting CP levels (1 month posttransplant and end of study) and prolonged graft function. CONCLUSIONS These data suggest that pretreatment of islets and the recipient with anti-TF may limit the effects of IBMIR, thereby enhancing islet engraftment and survival.
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Affiliation(s)
- Dora M Berman
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL 33136, USA.
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Barbé-Tuana FM, Klein D, Ichii H, Berman DM, Coffey L, Kenyon NS, Ricordi C, Pastori RL. CD40-CD40 ligand interaction activates proinflammatory pathways in pancreatic islets. Diabetes 2006; 55:2437-45. [PMID: 16936191 DOI: 10.2337/db05-1673] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Pancreatic islet transplantation is becoming an alternative to insulin therapy in patients suffering from brittle type 1 diabetes. A major obstacle to the procedure is the early graft loss caused by nonspecific inflammation at the site of implantation. We recently discovered that CD40, a member of tumor necrosis factor (TNF) receptor family, is expressed in pancreatic beta-cells. CD40 expression in nonhematopoietic cells is generally associated with inflammation. Therefore, we investigated the potential proinflammatory role of CD40 in human and nonhuman primate islets. Islet beta-cells responded to CD40L interaction by secreting interleukin (IL)-6, IL-8, monocyte chemoattractant protein-1, and macrophage inflammatory protein (MIP)-1beta, the latter a chemokine first reported to be produced by islets. Induction of IL-8 and MIP-1beta was confirmed at the transcriptional level by quantitative RT-PCR. MIP-1beta expression in beta-cells was verified by double-immunofluorescence staining. CD40-CD40L interaction activates extracellular signal-regulated kinase 1/2 and nuclear factor-kappaB pathways in insulinoma NIT-1 cells, and inhibitors of either pathway suppress cytokine/chemokine production in islets. Moreover, ligation of CD40 receptor upregulates intercellular adhesion molecule-1, associated with inflammation, at both transcriptional and translational levels. Our results in vitro indicate that the CD40 receptor expressed by beta-cells could be activated in vivo, inducing proinflammatory responses contributing to early islet graft loss after transplantation.
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Affiliation(s)
- Florencia M Barbé-Tuana
- Diabetes Research Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL 33136, USA
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Abstract
OBJECTIVE To determine the effects of weight loss (WL) alone and combined with aerobic exercise on visceral adipose tissue (VAT), intramuscular fat, insulin-stimulated glucose uptake, and the rate of decline in free fatty acid (FFA) concentrations during hyperinsulinemia. RESEARCH METHODS AND PROCEDURES We studied 33 sedentary, obese (BMI = 32 +/- 1 kg/m(2)) postmenopausal women who completed a 6-month (three times per week) program of either WL alone (n = 16) or WL + aerobic exercise (AEX) (n = 17). Glucose utilization (M) was measured during a 3-hour hyperinsulinemic-euglycemic clamp (40 mU/m(2) per minute). M/I, the amount of glucose metabolized per unit of plasma insulin (I), was used as an index of insulin sensitivity. RESULTS Body weight, total fat mass, and percentage fat decreased similarly in both groups (p < 0.01). VAT, subcutaneous abdominal adipose tissue, mid-thigh subcutaneous fat, and intramuscular fat decreased to a similar extent in both groups and between 14% and 27% after WL and WL+AEX (p < 0.05). WL alone did not change M or M/I; however, M and M/I increased 15% and 21% after WL+AEX (p < 0.05). Fasting concentrations and rate of decline of FFA did not change in either group. In stepwise regression models to determine the independent predictors of changes in M and M/I, the change in VAT was the single independent predictor of M (r(2) = 0.30) and M/I (r(2) = 0.33). DISCUSSION Intramuscular fat decreases similarly with 6 months of moderate WL alone or with aerobic exercise in postmenopausal women. In contrast, only WL combined with exercise results in increased glucose utilization and insulin sensitivity. These findings should be validated in a larger population.
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Affiliation(s)
- Alice S Ryan
- Department of Medicine, Division of Gerontology at the University of Maryland School of Medicine, VA Maryland Health Care System, Baltimore, MD 21201, USA.
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Cabrera O, Berman DM, Kenyon NS, Ricordi C, Berggren PO, Caicedo A. The unique cytoarchitecture of human pancreatic islets has implications for islet cell function. Proc Natl Acad Sci U S A 2006; 103:2334-9. [PMID: 16461897 PMCID: PMC1413730 DOI: 10.1073/pnas.0510790103] [Citation(s) in RCA: 844] [Impact Index Per Article: 46.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The cytoarchitecture of human islets has been examined, focusing on cellular associations that provide the anatomical framework for paracrine interactions. By using confocal microscopy and multiple immunofluorescence, we found that, contrary to descriptions of prototypical islets in textbooks and in the literature, human islets did not show anatomical subdivisions. Insulin-immunoreactive beta cells, glucagon-immunoreactive alpha cells, and somatostatin-containing delta cells were found scattered throughout the human islet. Human beta cells were not clustered, and most (71%) showed associations with other endocrine cells, suggesting unique paracrine interactions in human islets. Human islets contained proportionally fewer beta cells and more alpha cells than did mouse islets. In human islets, most beta, alpha, and delta cells were aligned along blood vessels with no particular order or arrangement, indicating that islet microcirculation likely does not determine the order of paracrine interactions. We further investigated whether the unique human islet cytoarchitecture had functional implications. Applying imaging of cytoplasmic free Ca2+ concentration, [Ca2+]i, we found that beta cell oscillatory activity was not coordinated throughout the human islet as it was in mouse islets. Furthermore, human islets responded with an increase in [Ca2+]i when lowering the glucose concentration to 1 mM, which can be attributed to the large contribution of alpha cells to the islet composition. We conclude that the unique cellular arrangement of human islets has functional implications for islet cell function.
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Affiliation(s)
- Over Cabrera
- *Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL 33136; and
| | - Dora M. Berman
- *Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL 33136; and
| | - Norma S. Kenyon
- *Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL 33136; and
| | - Camillo Ricordi
- *Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL 33136; and
| | - Per-Olof Berggren
- *Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL 33136; and
- The Rolf Luft Center for Diabetes Research, Department of Molecular Medicine, Karolinska Institutet, SE-171 76 Stockholm, Sweden
- To whom correspondence may be addressed at:
The Rolf Luft Center for Diabetes Research, Department of Molecular Medicine, Karolinska Institutet, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden. E-mail:
| | - Alejandro Caicedo
- *Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL 33136; and
- To whom correspondence may be addressed at:
Diabetes Research Institute, Miller School of Medicine, University of Miami, 1450 NW 10th Avenue, Miami, FL 33136. E-mail:
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Abstract
BACKGROUND Although nucleic acid derangements are the hallmark of melanocytic dysplasia, the gold standard for its diagnosis remains the microscopic evaluation of haematoxylin and eosin stained slides. However, light microscopy is subjective and crucial genomic changes do not always show as changes in histology. AIMS To introduce the nucleic acid index (NAI) as a means of analysing nucleic acid derangements in histological sections at the level of the individual cell and within the context of its microenvironment. METHODS Confocal laser scanning microscopy was performed on melanocytic lesions stained with acridine orange (AO), a fluorescent stain for DNA and RNA. The NAI, calculated by measuring the fluorescence intensities of AO in nuclei relative to the surrounding cytoplasm, reflects the concentration of DNA relative to RNA. RESULTS When applied to benign naevi, dysplastic naevi, and melanoma, a very strong significant association was seen between lower NAI and malignant potential (p < 0.0001). Strong inverse correlations were found between NAI and both mitotic index and Breslow thickness. Interestingly, the NAI for dysplastic naevi is between that of melanoma and most benign naevi, consistent with their intermediate biological behaviour and histological appearance. CONCLUSION By providing a quantitative measure for melanocytic neoplasia, the NAI may improve the diagnosis of melanocytic lesions and the selection of treatment.
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Affiliation(s)
- D M Berman
- Laboratory of Pathology, National Cancer Institute, Bldg 10-2N212, 10 Center Drive Bethesda, MD 20896, USA.
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Berman DM, Nicklas BJ, Ryan AS, Rogus EM, Dennis KE, Goldberg AP. Regulation of lipolysis and lipoprotein lipase after weight loss in obese, postmenopausal women. ACTA ACUST UNITED AC 2004; 12:32-9. [PMID: 14742840 DOI: 10.1038/oby.2004.6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To test the hypothesis that the greater beta-adrenoceptor (beta-AR)-stimulated lipolysis and sensitivity (half-maximal lipolytic response) in abdominal (ABD) adipocytes, greater gluteal (GLT) adipose tissue-lipoprotein lipase (AT-LPL) activity, and dyslipidemia associated with obesity in older women are modifiable by weight loss (WL) and are not due to menopause or aging. RESEARCH METHODS AND PROCEDURES The metabolic effects of 6 months of hypocaloric diet and low-intensity walking WL program on the regional regulation of in vitro lipolysis and AT-LPL activity in subcutaneous ABD and GLT adipocytes were measured in 34 obese (48.7 +/- 0.7% body fat, mean +/- SE) postmenopausal (59 +/- 1 years) white women. RESULTS The lipolytic responsiveness to the beta-AR agonist isoproterenol and basal lipolysis in the presence of 1 U/mL adenosine deaminase-uninhibited (lipolysis) were greater (p < 0.01) in ABD than GLT adipocytes before and after WL, but there were no regional differences in postreceptor (dibutyryl 3',5'-cyclic adenosine monophosphate)-stimulated lipolysis. beta-AR sensitivity was greater in ABD than GLT adipocytes before (p < 0.01) but not after WL. Regional AT-LPL did not change after WL, but the change in the activity of ABD (but not GLT) AT-LPL correlated with the baseline adenosine deaminase-uninhibited lipolysis (r = 0.38, p = 0.03). There were no relationships between the declines in plasma triglyceride or increases in high-density lipoprotein cholesterol associated with WL and the changes in regional fat cell metabolism. DISCUSSION Thus, despite improving lipoprotein lipid profiles in obese, postmenopausal women, WL does not affect the regulation of regional fat metabolism, and a greater tonic inhibition of basal lipolysis by endogenous adenosine may increase the activity of AT-LPL after WL and predispose older women to develop ABD adiposity.
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Affiliation(s)
- Dora M Berman
- Division of Gerontology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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You T, Berman DM, Ryan AS, Nicklas BJ. Effects of hypocaloric diet and exercise training on inflammation and adipocyte lipolysis in obese postmenopausal women. J Clin Endocrinol Metab 2004; 89:1739-46. [PMID: 15070939 DOI: 10.1210/jc.2003-031310] [Citation(s) in RCA: 154] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The purpose of this study was to determine whether a hypocaloric diet with and without exercise training is effective in reducing plasma C-reactive protein, IL-6, TNFalpha, and their soluble receptors (sIL-6R, sTNFR1, and sTNFR2), and whether changes in these inflammatory markers are related to changes in regional lipolysis in obese (body mass index, 32.78 +/- 4.73) postmenopausal women (diet alone, n = 17; diet plus exercise, n = 17). All inflammatory markers were measured by an ELISA method. In vitro lipolysis was evaluated by measuring glycerol release using a one-step enzymatic fluorometric technique. Six months of diet and diet plus exercise decreased total and abdominal fat to a similar degree. Diet plus exercise, but not diet alone, decreased plasma levels of C-reactive protein, IL-6, sIL-6R, and sTNFR1 and increased basal and postreceptor stimulated lipolysis in both abdominal and gluteal regions. Changes in abdominal stimulated lipolysis correlated significantly with changes in plasma IL-6 (r = -0.39) and TNFR1 (r = -047). Thus, diet plus exercise training, but not diet alone, is effective in reducing chronic inflammation in obese postmenopausal women. In addition, modification of chronic inflammation is associated with changes in local adipose tissue metabolism in response to diet and exercise.
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Affiliation(s)
- Tongjian You
- Section on Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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Abstract
OBJECTIVE The purpose of this study was to determine changes in adiponectin levels with moderate weight loss, weight loss plus aerobic exercise, or weight loss plus resistive exercise in overweight and obese, sedentary postmenopausal women. DESIGN Longitudinal, clinical intervention study of 6-month (3 x /week) program of either weight loss (WL, n=15), weight loss + aerobic exercise (WL+AEX, n=16), or weight loss + resistive exercise (WL+RT, n=9) SUBJECTS We studied 40 sedentary, overweight and obese (body mass index, BMI=32+/-1 kg/m(2), X+/-s.e.m.) postmenopausal (57+/-1y) women. MEASUREMENTS Fat mass and fat-free mass (FFM) by dual-energy X-ray absorptiometry, plasma insulin, leptin, and adiponectin by radioimmunoassay. RESULTS Age, body weight, BMI, waist and hip circumferences, waist-to-hip ratio, VO(2)max, percent fat, total body fat mass, FFM, and fasting plasma glucose, insulin, leptin, and adiponectin concentrations were similar among WL, WL+AEX, and WL+RT groups before the interventions. In all women combined, body weight, BMI, and waist and hip circumferences decreased (P < 0.001). There was a significant absolute decrease in percent body fat from 47 to 44%, representing a 13% decrease in total fat mass and a -1.6% change in FFM. Fasting concentrations of plasma adiponectin did not change (40+/-16%, P=NS), whereas fasting plasma glucose, insulin, and leptin all decreased (P<0.001). CONCLUSIONS Plasma adiponectin levels do not change with a 6-month moderate weight reduction program even when accompanied by aerobic or resistive exercise training in overweight and obese postmenopausal women.
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Affiliation(s)
- A S Ryan
- Department of Medicine, Division of Gerontology at the University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Ryan AS, Berman DM, Nicklas BJ, Sinha M, Gingerich RL, Meneilly GS, Egan JM, Elahi D. Plasma adiponectin and leptin levels, body composition, and glucose utilization in adult women with wide ranges of age and obesity. Diabetes Care 2003; 26:2383-8. [PMID: 12882866 DOI: 10.2337/diacare.26.8.2383] [Citation(s) in RCA: 198] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The purpose of this study was to determine the relationships between plasma adiponectin and leptin levels, total and central obesity, and glucose utilization across the adult age span. RESEARCH DESIGN AND METHODS We studied 148 women aged 18-81 years with a BMI range of 17.2-44.3 kg/m(2). Total percent body fat was determined by dual-energy X-ray absorptiometry and abdominal fat by computed tomography. Glucose tolerance in non-type 2 diabetic volunteers was determined with an oral glucose tolerance test. Glucose utilization (M) was measured during the last 60 min of hyperinsulinemic-euglycemic clamps (240 pmol x m(-2) x min(-1)). Plasma adiponectin levels were measured by radioimmunoassay. The women were separated into three age-groups: young, middle, and old (<40, 40-59, and >or=60 years, respectively), as well as by glucose tolerance status. RESULTS Adiponectin concentrations did not differ by age-groups. There were significant age effects for BMI, percent body fat, visceral fat, subcutaneous abdominal fat, VO(2max), and M. Adiponectin levels were lower in the prediabetic women (n = 18) than in the normal glucose-tolerant women (n = 108) and the women with type 2 diabetes (n = 22) (both P < 0.05). Univariate correlations revealed significant negative relationships between plasma adiponectin levels and BMI, percent body fat, visceral fat, subcutaneous abdominal fat, fasting leptin, and fasting insulin and positive relationship with M (all P < 0.05). In a multiple stepwise regression model to predict adiponectin, only M remained in the model at P < 0.001. Multivariate analyses revealed a significant relation for M as a function of adiponectin, insulin, and VO(2max). CONCLUSIONS The data suggest that plasma adiponectin does not change with age but levels are negatively associated with percent body fat, visceral fat, subcutaneous abdominal fat, insulin, and leptin levels in women. Adiponectin is positively associated with M across the age span in women.
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Affiliation(s)
- Alice S Ryan
- Department of Medicine, Division of Gerontology, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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Nicklas BJ, Penninx BWJH, Ryan AS, Berman DM, Lynch NA, Dennis KE. Visceral adipose tissue cutoffs associated with metabolic risk factors for coronary heart disease in women. Diabetes Care 2003; 26:1413-20. [PMID: 12716798 DOI: 10.2337/diacare.26.5.1413] [Citation(s) in RCA: 143] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study determined whether there is a critical level of visceral adipose tissue (VAT) associated with elevated coronary heart disease (CHD) risk factors in a cohort of women >45 years of age. RESEARCH DESIGN AND METHODS Measurements of body composition (dual-energy X-ray absorptiometry), body fat distribution (computed tomography), fasting and 2-h postprandial (75-g) glucose concentrations, and fasting lipoprotein lipid and insulin concentrations were performed in 233 perimenopausal (9%) and postmenopausal women (age 59 +/- 6 years, 79% Caucasian, 16% on hormone replacement therapy). RESULTS Women in the lowest VAT quintile (< or =105 cm(2)) had higher concentrations of HDL and HDL(2) cholesterol, lower LDL/HDL cholesterol ratios and triglyceride concentrations, and lower fasting glucose and insulin concentrations than women in the remaining four quintiles (P values <0.05-0.001). Women in the second lowest VAT quintile (106-139 cm(2)) had higher HDL and HDL(2) cholesterol and lower LDL/HDL ratios than women with a VAT > or =163 cm(2) (P < 0.05). Logistic regression analyses showed that women with a VAT of 106-162 cm(2) are 2.5 times more likely to have a low HDL cholesterol (P < 0.05), while women with a VAT > or =163 cm(2) are 5.5 times more likely to have a low HDL cholesterol (P < 0.01) and approximately 4.0 times more likely to have a high LDL/HDL ratio (P < 0.05) compared with women with a VAT < or =105 cm(2). Women with a VAT > or =163 cm(2) are at a higher risk of having impaired glucose tolerance (P < 0.01). CONCLUSIONS A VAT > or =106 cm(2) is associated with an elevated risk, and a VAT > or =163 cm(2) with an even greater risk, for these metabolic CHD risk factors compared with women with a VAT < or =105 cm(2). These values may prove useful for defining "visceral obesity" and for identifying women most likely to benefit from preventative interventions.
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Affiliation(s)
- Barbara J Nicklas
- Section on Gerontology and Geriatric Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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Nicklas BJ, Dennis KE, Berman DM, Sorkin J, Ryan AS, Goldberg AP. Lifestyle intervention of hypocaloric dieting and walking reduces abdominal obesity and improves coronary heart disease risk factors in obese, postmenopausal, African-American and Caucasian women. J Gerontol A Biol Sci Med Sci 2003; 58:181-9. [PMID: 12586858 DOI: 10.1093/gerona/58.2.m181] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There are few empirical data to support the claim that weight loss improves coronary heart disease (CHD) risk factors in postmenopausal women; nor is it known if there are racial differences in changes of body fat distribution, lipids, glucose tolerance, and blood pressure with weight loss. This study determined the efficacy of a lifestyle weight loss intervention in reducing total and abdominal obesity and improving CHD risk factors in obese Caucasian and African-American postmenopausal women. METHODS Body composition (dual-energy x-ray absorptiometry), abdominal fat areas (computed tomography scan), lipoprotein lipids, insulin, glucose tolerance, and blood pressure were measured before and after 6 months of hypocaloric diet and low-intensity walking in 76 overweight or obese (body mass index > 25 kg/m(2)), Caucasian (72%) or African-American (28%), postmenopausal (age = 60 +/- 5 years) women who completed the study. RESULTS Absolute amount of body weight lost was similar in Caucasians (-5.4 +/- 3.6 kg) and African Americans (-3.9 +/- 3.6 kg), but Caucasian women lost relatively more fat mass (p <.05). Both groups decreased their subcutaneous abdominal fat, and Caucasian women decreased their visceral fat area, but there were no racial differences in the magnitude of abdominal fat lost. The intervention decreased triglyceride and increased high-density lipoprotein and high-density lipoprotein 2 cholesterol in both races, and it decreased total and low-density lipoprotein cholesterol in Caucasian women (p <.05-.0001). Fasting glucose and glucose area during the oral glucose tolerance test decreased (p <.0001) in Caucasian women, whereas insulin area decreased in both Caucasian (p <.01) and African-American (p <.05) women. Blood pressure decreased the most in women with higher blood pressures at baseline. Changes in lipids, fasting glucose and insulin, their responses during the oral glucose tolerance test, and blood pressure were not different between racial groups. CONCLUSIONS Weight loss achieved through a lifestyle intervention of energy restriction and increased physical activity is an equally effective therapy in African-American and Caucasian obese, postmenopausal women for improving glucose and lipid CHD risk factors.
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Affiliation(s)
- Barbara J Nicklas
- Department of Medicine, Division of Gerontology, University of Maryland School of Medicine, Baltimore, Maryland, USA.
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Abstract
OBJECTIVE This study determines whether maximal oxygen consumption (VO2 max) is higher in perimenopausal women compared with similarly aged postmenopausal women and whether the lower VO2 max in postmenopausal women is associated with a higher total and visceral fat mass, less favorable lipid and glucose metabolism, and lower bone mineral density (BMD). DESIGN Participants were 18 perimenopausal women (mean +/- SD; irregular menstrual cycle in the past 6 months) aged 49 +/- 4 years and 18 postmenopausal women (no menstrual cycle in the past year) aged 52 +/- 2 years who were matched for body mass index and race. Women were sedentary, and none were on hormone replacement therapy. Body composition (dual-energy x-ray absorptiometry and CT), VO2 max, fasting concentrations of sex steroid hormones, lipoproteins, insulin, and glucose were determined. RESULTS VO2 max was 17% lower (22 +/- 3 v 27 +/- 7 mL.kg.min; P </= 0.01) and resting metabolic rate was 5% lower (P = 0.06) in postmenopausal women compared with perimenopausal women. Percent body fat was 11% higher, and visceral fat area was 42% higher in postmenopausal women, whereas total body and lumbar spine (L2 -L4) BMD were 5% and 11% lower, respectively (P < 0.05). Low-density lipoprotein cholesterol, low-density lipoprotein cholesterol.high-density lipoprotein cholesterol ratio, and fasting glucose concentrations were 21%, 20%, and 8% higher, respectively, in postmenopausal versus perimenopausal women (P < 0.05). Except for total body and lumbar spine BMD, the effect of menopause status on these variables is independent of age. In all women, percent body fat, visceral adipose tissue, and low-density lipoprotein cholesterol.high-density lipoprotein cholesterol ratios related indirectly to VO2 max (P < 0.05). CONCLUSIONS Our data suggest that postmenopausal women have a lower VO2 max than perimenopausal women of a similar age and adiposity, which may be associated with an increased risk of total and central obesity and cardiovascular disease.
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Affiliation(s)
- Nicole A Lynch
- Department of Medicine, University of Maryland School of Medicine, Baltimore, USA
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Abstract
Changes in adipose tissue metabolism may contribute to the changes in body fat distribution seen during the menopause transition. We compared in vitro abdominal and gluteal sc adipose tissue metabolism [basal and stimulated lipolysis and activity of adipose tissue lipoprotein lipase (AT-LPL)] in postmenopausal and perimenopausal women (n = 12/group), matched for race, body mass index (29.5 +/- 3.8 kg/m(2); mean +/- SD), and percentage body fat (42 +/- 6%). The postmenopausal women were older (54 +/- 3 vs. 48 +/- 3 yr; P < 0.01) and had higher FSH (55.5 +/- 26.4 vs. 16.6 +/- 22.5 IU/ml; P < 0.01) and lower estradiol (33.8 +/- 14.9 vs. 97.4 +/- 61.7 pmol/liter; P < 0.05) concentrations than the perimenopausal women. Despite similar fat cell size and beta-adrenergic receptor and postreceptor (dibutyryl-cAMP)-stimulated lipolysis, basal lipolysis was 77% lower in gluteal adipose cells from postmenopausal compared with perimenopausal women (P < 0.05). Within each group, AT-LPL activity in the gluteal region was significantly higher than in the abdominal region (P < 0.05). In addition, AT-LPL activity was significantly higher in the postmenopausal compared with perimenopausal women in both gluteal (4.9 +/- 3.6 vs. 2.0 +/- 1.4 nmol free fatty acid/g.min; P < 0.05) and abdominal (3.2 +/- 2.6 vs. 1.3 +/- 0.9 nmol free fatty acid/g.min; P < 0.05) adipose cells. The results of this study suggest that menopause status is associated with differences in adipose tissue metabolism in both the abdominal and gluteal fat depots. The lower lipolysis and higher AT-LPL activity in postmenopausal women may predispose them to gain body fat after menopause.
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Affiliation(s)
- Cynthia M Ferrara
- Department of Medicine, University of Maryland School of Medicine, and the Geriatric Research, Education and Clinical Center, Baltimore VA Medical Center, Baltimore, Maryland 21201, USA.
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Nicklas BJ, Ferrell RE, Bunyard LB, Berman DM, Dennis KE, Goldberg AP. Effects of apolipoprotein E genotype on dietary-induced changes in high-density lipoprotein cholesterol in obese postmenopausal women. Metabolism 2002; 51:853-8. [PMID: 12077730 DOI: 10.1053/meta.2002.33337] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Lipid responses to a dietary intervention are highly variable between individuals. Part of this variation may be accounted for by individual differences in lipid-regulating genes that interact with diet to induce changes in lipoprotein metabolism. This study determined whether apolipoprotein E (APOE) genotype affects lipid responses to a low-fat, low-cholesterol diet in obese, postmenopausal women. Body weight and lipoprotein lipid responses to a 10-week, dietary intervention (American Heart Association [AHA] Step I) were compared in 61 women with the APOE 2/3 and APOE 3/3 genotype (APOE4-) and 18 women with the APOE 3/4 genotype (APOE4+) of a similar age, body composition, and maximal aerobic capacity. Body weight decreased by 2% in both groups, but changes in body weight correlated only with changes in low-density lipoprotein-cholesterol (LDL-C) (r =.27, P <.05). The dietary intervention decreased total cholesterol and LDL-C to a similar degree in both genotype groups. However, APOE4- women decreased high-density lipoprotein-cholesterol (HDL-C) by 17% +/- 11% and increased triglycerides by 20% +/- 41% in response to the diet, while APOE4+ women had a smaller decrease in HDL-C (-8% +/- 12%) and no change in plasma triglyceride. These group differences were significant for HDL-C (P <.01) and approached significance for triglycerides (P =.08). Moreover, APOE4- women decreased HDL(2)-C by 32% +/- 45%, while APOE4+ women increased HDL(2)-C by 12% +/- 62% (P <.01 between groups). It may be prudent to genotype older women before initiating low-fat diet therapy, as those with the APOE4 allele benefit the most, while the lipid profile could worsen in women without the APOE4 allele.
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Affiliation(s)
- Barbara J Nicklas
- Department of Medicine, Division of Gerontology, University of Maryland School of Medicine, and the Geriatric Research, Education and Clinical Center (GRECC), Baltimore VA Medical Center, Baltimore, MD, USA
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Abstract
OBJECTIVE To determine whether racial differences in insulin resistance between African American (AA) and white women exist in postmenopausal women and whether they are related to physical fitness and/or obesity. RESEARCH METHODS AND PROCEDURES We studied 35 obese AA (n = 9) and white (n = 26) women of comparable maximal oxygen consumption, obesity, and age. Total body fat was measured by DXA. Abdominal and mid-thigh low-density lean tissue (a marker of intramuscular fat) were determined with computed tomography. Glucose utilization (M) was measured during the last 30 minutes of a 3-hour hyperinsulinemic-euglycemic clamp. Insulin sensitivity was estimated from the relationship of M to the concentration of insulin during the last 30 minutes of the clamp. RESULTS The percentage of fat and total body fat mass were similar between AA and white women, whereas fat-free mass was higher in African American women. Visceral adipose tissue was not different between groups, but subcutaneous abdominal fat was 17% higher in the AA than in the white women. AA women had an 18% greater mid-thigh muscle area (p < 0.01) and a 34% greater mid-thigh low-density lean tissue area than the white women. Fasting glucose concentrations were not different, but fasting insulin concentrations were 29% higher in AA women. Glucose utilization was 60% lower in the AA women because of a lower non-oxidative glucose disposal. Insulin sensitivity was 46% lower in the AA women. DISCUSSION AA postmenopausal women have more mid-thigh intramuscular fat, lower glucose utilization, and are less insulin sensitive than white women despite comparable fitness and relative body fat levels.
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Affiliation(s)
- Alice S Ryan
- Department of Medicine, Division of Gerontology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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Abstract
OBJECTIVE The purpose of this study was to determine whether insulin sensitivity differs between postmenopausal women taking estradiol, women on estrogen plus progesterone hormone replacement therapy (HRT), and women not on HRT and whether differences are explained by the differences in total and/or abdominal adiposity and fat deposition in the muscle. RESEARCH DESIGN AND METHODS We studied 28 obese, sedentary postmenopausal Caucasian women. Women taking oral estrogen (n = 6) were matched for age (57 +/- 3 vs. 58 +/- 2 years), weight (87.9 +/- 6.0 vs. 83.0 +/- 3.9 kg), and BMI (33.9 +/- 1.7 vs. 33.9 +/- 1.9 kg/m(2)) with women not on HRT (n = 6). Eight women taking oral estrogen plus progesterone were matched with eight different women not on HRT for age (59 +/- 2 vs. 60 +/- 2 years), weight (82.8 +/- 3.7 vs. 83.7 +/- 4.1 kg), and BMI (30.7 +/- 1.0 vs. 29.9 +/- 1.3 kg/m(2)). RESULTS VO(2max) (maximal aerobic capacity), percentage of fat, total body fat mass, and fat-free mass (FFM) were similar between groups. Visceral fat, subcutaneous abdominal fat, sagittal diameter, and mid-thigh low-density lean tissue (intramuscular fat) did not differ by hormone status. Basal carbohydrate and fat utilization was not different among groups. Fasting plasma glucose and insulin did not differ by hormone use. Glucose utilization (M) was measured during the last 30 min of a 3-h hyperinsulinemic-euglycemic clamp (40 mU. m(2). min(-1)). Postmenopausal women taking oral estrogen had a 31% lower M than women not on HRT (42.7 +/- 4.0 vs. 61.7 +/- 4.7 micromol. kg(FFM). min(-1), P < 0.05). M was 26% lower in women taking estrogen plus progesterone (44.0 +/- 3.5 vs. 59.7 +/- 6.2 micromol. kg(FFM). min(-1), P < 0.05) than women not on HRT. M/I, the amount of glucose metabolized per unit of plasma insulin (I), an index of insulin sensitivity, was 36% lower in women taking estrogen compared with matched women not on HRT (P < 0.05) and 28% lower in women taking estrogen plus progesterone compared with matched women not on HRT (P < 0.05). CONCLUSIONS Postmenopausal women taking oral estrogen or those taking a combination of estrogen and HRT are more insulin-resistant than women not on HRT, even when women are of comparable total and abdominal adiposity.
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Affiliation(s)
- Alice S Ryan
- Department of Medicine, Division of Gerontology at the University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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Nicklas BJ, van Rossum EF, Berman DM, Ryan AS, Dennis KE, Shuldiner AR. Genetic variation in the peroxisome proliferator-activated receptor-gamma2 gene (Pro12Ala) affects metabolic responses to weight loss and subsequent weight regain. Diabetes 2001; 50:2172-6. [PMID: 11522688 DOI: 10.2337/diabetes.50.9.2172] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study determined the effects of the peroxisome proliferator-activated receptor (PPAR)-gamma2 Pro12Ala variant on body composition and metabolism and the magnitude of weight regain in 70 postmenopausal women (BMI 25-40 kg/m(2)) who completed 6 months of a hypocaloric diet. At baseline, BMI, percent body fat, intra-abdominal and subcutaneous abdominal fat areas, resting metabolic rate, substrate oxidation, and postprandial glucose and insulin responses were not different between genotypes (Pro/Pro = 56, Pro/Ala and Ala/Ala = 14). The intervention similarly decreased body weight by 8 +/- 1% in women homozygous for the Pro allele and by 7 +/- 1% in women with the Ala allele (P < 0.0001). Fat oxidation did not change in Pro/Pro women but decreased 19 +/- 9% in women with the Ala allele (P < 0.05). Changes in glucose area were not different between groups; however, women with the Ala allele decreased their insulin area more than women homozygous for the Pro allele (P < 0.05). Weight regain during follow-up was greater in women with the Ala allele than women homozygous for the Pro allele (5.4 +/- 0.9 vs. 2.8 +/- 0.4 kg, P < 0.01). PPAR-gamma2 genotype was the best predictor of weight regain (r = 0.50, P < 0.01), followed by the change in fat oxidation (partial r = 0.35, P < 0.05; cumulative r = 0.58). Thus, the Pro12Ala variant of the PPAR-gamma2 gene may influence susceptibility for obesity.
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Affiliation(s)
- B J Nicklas
- University of Maryland School of Medicine, Department of Medicine, Baltimore VA Medical Center, Maryland 21201, USA.
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Abstract
OBJECTIVE The ACE insertion/deletion (I/D) polymorphism has been identified as a genetic risk factor for coronary heart disease (CHD). The deletion (D) allele of the ACE gene may be associated with higher insulin sensitivity. Individuals who are homozygous for the DD allele have higher ACE levels and possibly more angiotensin II, which, when infused exogenously, causes an increase in insulin sensitivity. The purpose of this study was to investigate the association of the I/D polymorphism of the ACE gene with insulin sensitivity and CHD risk factors. RESEARCH DESIGN AND METHODS The study included 66 women (ages 57 +/- 1 years) who were overweight or obese (means +/- SEM, BMI = 33 +/- 1 kg/m(2)) and sedentary (VO(2max) = 19.6 +/- 0.4 ml. kg(-1). min(1)). Total body fat mass and percent fat were determined by dual-energy X-ray absorptiometry, and abdominal fat was by computed tomography. Insulin sensitivity was measured during the last 30 min of 3-h hyperinsulinemic-euglycemic clamps (40 mU. m(-2). min(-1)). Comparisons were made among women with the II (n = 9), ID (n = 36), and DD (n = 21) genotypes. RESULTS Age, percent body fat, waist-to-hip ratio, visceral and subcutaneous abdominal fat areas, plasma lipid levels, and systolic and diastolic blood pressures did not differ by ACE genotype. Fasting glucose and 2-h glucose levels were similar among genotypes, but fasting plasma insulin levels were lower in DD women than in ID women (P < 0.05). Glucose utilization was higher in women with the DD genotype than in women with the II genotype (53.1 +/- 3.9 vs. 36.0 +/- 3.8 micromol. kg(-1) FFM. min(-1), P = 0.01) and was higher in ID women than in II women (48.5 +/- 2.5 micromol. kg(-1) FFM. min(-1), P = 0.04). CONCLUSIONS These data suggest that the I/D polymorphism is not associated with risk factors for CHD in overweight sedentary women; however, women who are homozygous for the D allele of the ACE gene are more insulin sensitive, whereas women who are homozygous for the I allele of the ACE gene have greater insulin resistance and potential risk for type 2 diabetes.
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Affiliation(s)
- A S Ryan
- Department of Medicine, Division of Gerontology at the University of Maryland School of Medicine, Baltimore, MD, USA.
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Lynch NA, Nicklas BJ, Berman DM, Dennis KE, Goldberg AP. Reductions in visceral fat during weight loss and walking are associated with improvements in VO(2 max). J Appl Physiol (1985) 2001; 90:99-104. [PMID: 11133898 DOI: 10.1152/jappl.2001.90.1.99] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The accumulation of visceral fat is independently associated with an increased risk for cardiovascular disease. The aim of this study was to determine whether the loss of visceral adipose tissue area (VAT; computed tomography) is related to improvements in maximal O(2) uptake (VO(2 max)) during a weight loss (250-350 kcal/day deficit) and walking (3 days/wk, 30-40 min) intervention. Forty obese [body fat 47 +/- 1 (SE) %], sedentary (VO(2 max) 19 +/- 1 ml. kg(-1). min(-1)) postmenopausal women (age 62 +/- 1 yr) participated in the study. The intervention resulted in significant declines in body weight (-8%), total fat mass (dual-energy X-ray absorptiometry; -17%), VAT (-17%), and subcutaneous adipose tissue area (-17%) with no change in lean body mass (all P < 0.001). Women with an average 10% increase in VO(2 max) reduced VAT by an average of 20%, whereas those who did not increase VO(2 max) decreased VAT by only 10%, despite comparable reductions in body fat, fat mass, and subcutaneous adipose tissue area. The decrease in VAT was independently related to the change in VO(2 max) (r(2) = 0.22; P < 0. 01) and fat mass (r(2) = 0.08; P = 0.05). These data indicate that greater improvements in VO(2 max) with weight loss and walking are associated with greater reductions in visceral adiposity in obese postmenopausal women.
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Affiliation(s)
- N A Lynch
- Division of Gerontology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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Berman DM, Rodrigues LM, Nicklas BJ, Ryan AS, Dennis KE, Goldberg AP. Racial disparities in metabolism, central obesity, and sex hormone-binding globulin in postmenopausal women. J Clin Endocrinol Metab 2001; 86:97-103. [PMID: 11231984 DOI: 10.1210/jcem.86.1.7147] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Increased total and intraabdominal fat (IAF) obesity as well as other metabolic conditions associated with the insulin resistance syndrome (IRS) are related to low levels of sex hormone-binding globulin (SHBG) in young and older Caucasian (CAU) and young African-American (AA) women. We examined whether postmenopausal AA women, a population with a high incidence of obesity and IRS despite low IAF, would have higher levels of circulating SHBG compared with CAU women, and whether there would be negative relationships between indexes of obesity and risk factors associated with IRS and SHBG levels. We measured body composition, SHBG, free testosterone, leptin, glucose tolerance, insulin, and lipoprotein lipids in 55 CAU (mean +/- SD, 59 +/- 7 yr) and 35 AA (57 +/- 6 yr) sedentary women of comparable obesity (48% body fat, by dual energy x-ray absorptiometry). Compared with CAU women, AA women had larger waist (101 vs. 96 cm), larger fat mass (44.9 +/- 8.8 vs. 39.9 +/- 8.1 kg), larger sc fat area (552 +/- 109 vs. 452 +/- 109 cm(2)), and lower IAF/SC ratio (0.28 +/- 0.12 vs. 0.38 +/- 0.15; P < 0.01), but similar waist to hip ratio (0.83). Both groups had similar SHBG (117 vs. 124 nmol/L) and free testosterone (3.7 vs. 3.4 pmol/L) levels, but AA women had a 35% higher leptin, 34% higher fasting insulin, and 39% greater insulin response to a glucose load (P < 0.05) compared with CAU women. In CAU, but not AA, women SHBG correlated negatively with body mass index (r = -0.28; P < 0.05), waist (r = -0.36; P = 0.01), IAF (r = -0.34; P = 0.01), and insulin response to oral glucose (r = -0.37; P < 0.05) and positively with high density lipoprotein cholesterol (r = 0.30; P = 0.03). The relationship between insulin area and SHBG in CAU women disappeared after adjusting for IAF, whereas the relationship between high density lipoprotein cholesterol and SHBG persisted after adjusting for IAF, but not for fat mass. Leptin was positively related to fat mass (P < 0.05) in both groups, but it was related to insulin only in the Caucasian women (P< 0.01). There was a racial difference in the slopes (P< 0.05) of the relationships of leptin to fat mass (P < 0.05). Racial differences in leptin disappeared after adjustment for fasting insulin. These results suggest that the metabolic relationships between total and regional obesity, glucose, and lipid metabolism with SHBG in CAU women are different from those in postmenopausal obese AA women.
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Affiliation(s)
- D M Berman
- Division of Gerontology, Department of Medicine, University of Maryland School of Medicine, Baltimore Veterans Affair Medical Center, Baltimore, Maryland 21201, USA.
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Nicklas BJ, Rogus EM, Berman DM, Dennis KE, Goldberg AP. Responses of adipose tissue lipoprotein lipase to weight loss affect lipid levels and weight regain in women. Am J Physiol Endocrinol Metab 2000; 279:E1012-9. [PMID: 11052955 DOI: 10.1152/ajpendo.2000.279.5.e1012] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This study determines whether changes in abdominal (ABD) and gluteal (GLT) adipose tissue lipoprotein lipase (LPL) activity in response to a 6-mo weight loss intervention, comprised of a hypocaloric diet and low-intensity walking, affect changes in body composition, fat distribution, lipid metabolism, and the magnitude of weight regain in 36 obese postmenopausal women. Average adipose tissue LPL activity did not change with an average 5.6-kg weight loss, but changes in LPL activity were inversely related to baseline LPL activity (ABD: r = -0.60, GLT: r = -0.48; P < 0.01). The loss of abdominal body fat and decreases in total and low-density lipoprotein cholesterol were greater in women whose adipose tissue LPL activity decreased with weight loss despite a similar loss of total body weight and fat mass. Moreover, weight regain after a 6-mo follow-up was less in women whose adipose tissue LPL activity decreased than in women whose LPL increased (ABD: 0.9 +/- 0.5 vs. 2.8 +/- 0.6 kg, P < 0.05; GLT: 0.2 +/- 0.5 vs. 2.8 +/- 0.5 kg, P < 0.01). These results suggest that a reduction in adipose tissue LPL activity with weight loss is associated with improvements in lipid metabolic risk factors with weight loss and with diminished weight regain in postmenopausal women.
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Affiliation(s)
- B J Nicklas
- Department of Medicine, Division of Gerontology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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