Blockade of IL-21 promotes the induction of T regulatory cells in healthy controls and IBD patients (P5158)

T regulatory cells (Treg) play a critical role in maintaining immune homeostasis and tolerance to self-antigen. A subset of Treg induced by activation in the presence of TGF-β (induced or iTreg) has been shown to play a role in regulating immune responses and preventing autoimmune disease (AID). IL-21 is a pleiotropic cytokine involved in both innate and adaptive immune responses. Recent data in mouse models has shown that modulation of IL-21 function can influence Treg development and function, but the effect of IL-21 on human Treg is unknown. Therefore, we investigated the role of IL-21 in development of iTreg from T cells from healthy control (HC) and Crohn’s disease (CD) patients. Induced Treg were generated from CD4+CD25- T cells by activation in the presence of IL-2 and TGFβ. Exogenous IL-21 or blocking anti-IL-21 monoclonal antibody was also included on day 0 and cells were stained for intracellular IL-21 and FoxP3 expression on day 7. There was a significant reduction in the number of Foxp3+ T cells (p<0.03) in the presence of exogenous IL-21 and a significant increase when anti-IL-21 antibody was included (p<0.02). These effects on iTreg development were seen in both HC and CD patients. These data suggest targeting IL-21 with neutralizing antibodies can increase iTreg development and hence has promising potential as a novel therapeutic approach for the treatment of AID such as CD.

IL-21 neutralizing antibody inhibits human TFH proliferation and TFH-mediated maturation of naïve B cells (P5220)

The hallmark of T follicular helper (TFH) cells is the ability to help B cells generate humoral immune responses. Recent evidence suggests that aberrant function of TFH cells plays a key role in the generation of autoantibodies, which can inflict autoimmune pathologies. TFH cells are characterized by their unique master regulator (Bcl6), surface marker expression (CXCR5 and ICOS), and production of the pro-inflammatory cytokine interleukin-21 (IL-21). In mice, IL-21 is described as a regulator of TFH cell differentiation and B cell maturation, but its role in human TFH cells remains incompletely understood. In the present study, we sorted TFH subsets from human tonsils or TFH-like cells from human blood to characterize IL-21 production and the functional consequences of blocking IL-21 with a neutralizing antibody. IL-21 was highest in TFHHI cells (CXCR5++ICOS++), detectable in TFHINT cells (CXCR5+ICOS+), and minimal in non-TFH cells. Anti-IL-21 caused a moderate decrease in anti-CD3 stimulated TFH proliferation. Peripheral CXCR5+ TFH-like cells also had elevated IL-21 production, but anti-IL-21 had little effect on TFH-like proliferation. When TFHINT, TFHHI, or TFH-like cells were co-incubated with naïve B cells, anti-IL-21 decreased B cell maturation and Ig production in a dose-dependent manner. Together, these findings indicate that anti-IL-21 inhibits TFH generation and B cell help, and is a promising therapeutic for autoimmune disorders involving autoantibody production.

Increased serum β2-microglobulin is associated with clinical and immunological markers of disease activity in systemic lupus erythematosus patients

The objective of this study was to explore the relationship between serum levels of β2-microglobulin (β2MG), which some studies suggest reflect disease activity in systemic lupus erythematosus (SLE), and various clinical and immunological markers of disease activity in SLE. Twenty-six SLE patients and 10 healthy controls were included. Disease activity was assessed by: SLEDAI, 24 hr-proteinuria, circulating levels of complement C3, anti-double-stranded DNA (anti-dsDNA), β2MG and various pro-inflammatory and anti-inflammatory cytokines (IL-6, IL-8, IL-10, IL-18) measured with a multiplex assay, IFN-α assessed with a reporter gene assay, and a combined expression score of 12 IFN-α inducible genes in peripheral blood mononuclear cells.

Median serum levels of β2MG were significantly higher in SLE patients vs controls (2.8 mg/L, range: 1.1–21.6 and 1.2 mg/L, range: 0.9–1.7, respectively, p < 0.001). β2MG was correlated with SLEDAI score ( R = 0.68, p < 0.001), 24 hr-proteinuria ( R = 0.64, p < 0.001), and complement C3 ( R = −0.52, p = 0.007). The cytokines were significantly correlated with β2MG: IL-6 ( R = 0.45, p = 0.02), IL-8 ( R = 0.75, p < 0.001), IL-10 ( R = 0.67, p < 0.001) and IL-18 ( R = 0.71, p < 0.001) as were serum IFN-α ( R = 0.45, p = 0.02) and the IFN-α inducible gene-score ( R = 0.51, p = 0.01). The results support that β2MG may serve as a marker of disease activity in SLE. The correlations with the measured cytokines indicate that increased β2MG in SLE reflects immunological activity.

Immune activation in advanced cancer patients treated with recombinant IL-21: multianalyte profiling of serum proteins

PURPOSE

Recombinant interleukin-21 (rIL-21) is an immune stimulating cytokine recently tested in two Phase 1 trials for immune responsive cancers. A secondary objective of these trials was to characterize pharmacodynamic responses to rIL-21 in patients. Here, we report the effects of systemic rIL-21 on serum markers of immune stimulation.

EXPERIMENTAL DESIGN

Recombinant IL-21 was administered by intravenous bolus injection at dose levels from 1 to 100 microg/kg using two distinct treatment regimens: thrice weekly ('3/w') for 6 weeks; or once daily for five consecutive days followed by nine dose-free days ('5 + 9'). In the absence of dose limiting toxicity, additional cycles of dosing were initiated immediately following the nine dose-free days. An array of 70 different proteins was profiled in subject serum samples from several time points during the course of the study. Hierarchical clustering analysis was performed on a normalized subset of these data.

RESULTS

Systemic administration of rIL-21 affected the serum levels of several cytokines, chemokines, acute-phase proteins and cell adhesion proteins. The magnitude and duration of response were dose dependent for a subset of these biomarkers. The 5 + 9 dosing regimen generally produced cyclic changes that were of greater magnitude, as compared to a more chronic stimulation with the 3/w dosing regimen. Despite these differences, rIL-21 effects on many analytes were similar between regimens when averaged over the time of treatment. Based on similar temporal, between-subject and dose response changes, groups of analytes were identified that exhibited distinct components of the rIL-21-mediated immune activation. Biomarkers indicative of lymphocyte activation (increased IL-16, decreased RANTES), acute phase response (increased CRP, ferritin), myeloid activation (increased MDC, MIP-1 alpha), and leukocyte chemotaxis/trafficking (increased sCAMs, MCP-1) were strongly modulated in subjects treated with rIL-21.

CONCLUSIONS

Administration of rIL-21 resulted in activation of multiple cell types and immune response pathways. The changes observed in serum proteins were consistent with coincident processes of lymphoid and myeloid cell activation and trafficking, and acute phase response.

Clinical and biological efficacy of recombinant human interleukin-21 in patients with stage IV malignant melanoma without prior treatment: a phase IIa trial

PURPOSE

Human interleukin-21 (IL-21) is a class I cytokine that mediates activation of CD8(+) T cells, natural killer (NK) cells, and other cell types. We report final clinical and biological results of a phase II study of recombinant human IL-21 (rIL-21) in patients with metastatic melanoma.

EXPERIMENTAL DESIGN

Open-label, single-arm, two-stage trial.

ELIGIBILITY CRITERIA

unresectable metastatic melanoma, measurable disease by Response Evaluation Criteria in Solid Tumors, no prior systemic therapy (adjuvant IFN permitted), adequate major organ function, good performance status, no significant autoimmune disease, and life expectancy at least 4 months.

PRIMARY OBJECTIVE

antitumor efficacy (response rate).

SECONDARY OBJECTIVES

safety, blood biomarkers, and generation of anti-rIL-21 antibodies. rIL-21 (30 microg/kg/dose) was administered by intravenous bolus injection in 8-week cycles (5 dosing days followed by 9 days of rest for 6 weeks and then 2 weeks off treatment).

RESULTS

Stage I of the study comprised 14 patients. One confirmed complete response (CR) was observed, and as per protocol, 10 more patients were accrued to stage II (total n = 24: 10 female and 14 male). Best tumor response included one confirmed CR and one confirmed partial response, both with lung metastases. Treatment was overall well tolerated. Biomarker analyses showed increases in serum soluble CD25, frequencies of CD25(+) NK and CD8(+) T cells, and mRNA for IFN-gamma, perforin, and granzyme B in CD8(+) T and NK cells.

CONCLUSIONS

rIL-21 administered at 30 microg/kg/d in 5-day cycles every second week is biologically active and well tolerated in patients with metastatic melanoma. Confirmed responses, including one CR, were observed.

Characterization of the interleukin-17 isoforms and receptors in lesional psoriatic skin

BACKGROUND

Th17 cells are a lineage of proinflammatory T helper cells producing interleukin (IL)-17. The importance of Th17 cells in inflammation and autoimmunity has now been recognized. The IL-17 cytokine family consists of six isoforms (IL-17A-IL-17F) whereas five members of the IL-17 receptor (IL-17R) family have been identified (IL-17RA-IL-17RE).

OBJECTIVES

To characterize the expression of the IL-17 isoforms and receptors in lesional and nonlesional psoriatic skin. Methods Keratome and punch biopsies taken from patients with psoriasis were examined by enzyme-linked immunosorbent assay and quantitative reverse transcription-polymerase chain reaction in order to measure the IL-17 isoforms and receptors.

RESULTS

We demonstrated significantly increased mRNA expression of IL-17A, IL-17C and IL-17F in psoriatic skin. In contrast, the mRNA expression of IL-17B and IL-17D was significantly decreased in lesional compared with nonlesional skin, while IL-17E mRNA was undetectable. The increased mRNA expression of IL-17A, IL-17C and IL-17F was paralleled by an increased protein accumulation of these cytokines in psoriatic skin. Analysis of the IL-17R mRNA expression revealed significantly impaired mRNA expression of IL-17RB, IL-17RC, IL-17RD and IL-17RE in lesional psoriatic skin, whereas the mRNA expression of IL-17RA was similar in lesional and nonlesional psoriatic skin.

CONCLUSIONS

This study characterizes the mRNA profile of the IL-17 isoforms and receptors in psoriatic skin lesions. Furthermore, we demonstrate for the first time augmented protein levels of IL-17A, IL-17C and IL-17F in psoriatic skin lesions, indicating a possible role for IL-17C in addition to IL-17A and IL-17F in the pathogenesis of psoriasis.

PolyI:C induction of diabetes is controlled by Iddm4 in rats with a full regulatory T cell pool

The Iddm4 gene controls diabetes in rats depleted of regulatory T cells (T reg) and immune-activated via treatment with the toll-like receptor 3 (TLR-3) ligand, polyI:C. Both diabetes-resistant (BBDR) and diabetes-prone (BBDP) BB rats carry dominant permissive alleles of Iddm4, while the recessive Wistar Furth (WF) rat allele is protective. Iddm4 is positioned close to Iddm2 on chromosome 4, but when we introgressed BBDP-derived parts of this region--either containing both genes or Iddm2 alone--into the WF genome, none of these congenic strains developed spontaneous diabetes. Although both strains harbor two copies of the recessive Iddm2 allele of the BBDP rat, making these animals devoid of T reg cells, immune activation in itself via polyI:C treatment did not induce overt diabetes. Interestingly, TLR-3 ligation without depletion of T regs resulted in diabetes and insulitis development in nonlymphopenic F1-offspring of mating the Iddm4+Iddm2 congenic strain to WF. This demonstrates that the diabetogenic allele of Iddm4 is able to confer diabetes susceptibility even in a nonlymphopenic host with a full T reg pool, and that homozygosity for Iddm2--although responsible for an almost total lack of T regs-delays the disease process. Finally, we have confirmed the position of Iddm4 in truly congenic strains.

Interleukin-21 activates human natural killer cells and modulates their surface receptor expression

Interleukin (IL)-21 is a novel cytokine that has been shown to enhance proliferation and activation of CD8+ T cells, enhance natural killer (NK) cell activity and costimulate anti-CD40-driven B-cell proliferation in mice. Several studies have furthermore demonstrated antitumour effects of IL-21 administration in mouse models. In this study we have investigated how IL-21 affects the survival and cytotoxicity of human NK cells and modulates their expression of surface receptors and of the effector molecules granzyme B and perforin. In contrast to murine NK cells, where IL-21 alone cannot sustain survival, IL-21 and IL-2 were equally efficient in sustaining survival of human NK cells. In the absence of other cytokines, IL-21 had little effect on expression of a panel of surface receptors on human NK cells. However, IL-21 synergized with IL-2 to up-regulate several surface receptors, including NKG2A, CD25, CD86 and CD69. The CD25+ CD86+ NK cells were CD56(bright) and were large and granular. Expression of the effector molecules perforin and granzyme A and B was up-regulated by IL-21 at both mRNA and protein levels. Furthermore, IL-21 increased the cytotoxicity of NK cells against K562 target cells. These findings suggest that IL-21 modulates NK cell activity through induction of intracellular effector molecules as well as modulation of surface receptor expression.

Inhibition of NKG2D receptor function by antibody therapy attenuates transfer-induced colitis in SCID mice

A role for the activating NK-receptor NKG2D has been indicated in several autoimmune diseases in humans and in animal models of type 1 diabetes and multiple sclerosis, and treatment with monoclonal antibodies to NKG2D attenuated disease severity in these models. In an adoptive transfer-induced model of colitis, we found a significantly higher frequency of CD4(+)NKG2D(+) cells in blood, mesenteric lymph nodes, colon, and spleen from colitic mice compared to BALB/c donor-mice. We, therefore, wanted to study the effect of anti-NKG2D antibody (CX5) treatment initiated either before onset of colitis, when the colitis was mild, or when severe colitis was established. CX5 treatment decreased the detectable levels of cell-surface NKG2D and prophylactic administration of CX5 attenuated the development of colitis significantly, whereas a more moderate reduction in the severity of disease was observed after CX5 administration to mildly colitic animals. CX5 did not attenuate severe colitis. We conclude that the frequency of CD4(+)NKG2D(+) cells increase during development of experimental colitis. NKG2D may play a role in the early stages of colitis in this model, since early administration of CX5 attenuated disease severity.

An Open-Label, Two-Arm, Phase I Trial of Recombinant Human Interleukin-21 in Patients with Metastatic Melanoma

Purpose: Human interleukin-21 (IL-21) is a pleiotropic class I cytokine that activates CD8+ T cells and natural killer cells. We report a phase 1 study of recombinant human IL-21 in patients with surgically incurable metastatic melanoma. The primary objective was to investigate safety and tolerability by determining dose-limiting toxicity (DLT). The secondary objectives were to identify a dose response for various biomarkers in the peripheral blood, estimate the minimum biologically effective dose, determine the pharmacokinetics of IL-21, determine if anti-IL-21 antibodies were induced during therapy, and measure effects on tumor size according to Response Evaluation Criteria in Solid Tumors.

Experimental Design: Open-label, two-arm, dose escalation trial of IL-21 administered by i.v. bolus injection at dose levels from 1 to 100 μg/kg using two parallel treatment regimens: thrice weekly for 6 weeks (3/wk) or three cycles of daily dosing for 5 days followed by 9 days of rest (5+9).

Results: Twenty-nine patients entered the study. IL-21 was generally well tolerated and no DLTs were observed at the 1, 3, and 10 μg/kg dose levels. In the 3/wk regimen, DLTs were increased in alanine aminotransferase, neutropenia, and lightheadedness with fever and rigors. DLTs in the 5+9 regimen were increased in aspartate aminotransferase and alanine aminotransferase, neutropenia, fatigue, and thrombocytopenia. The maximum tolerated dose was declared to be 30 μg/kg for both regimens. Effects on biomarkers were observed at all dose levels, including increased levels of soluble CD25 and up-regulation of perforin and granzyme B mRNA in CD8+ cells. One partial tumor response observed after treatment with IL-21 for 2 × 6 weeks (3/wk) became complete 3 months later.

Conclusions: IL-21 is biologically active at all dose levels administered and is generally well tolerated, and phase 2 studies have commenced using 30 μg/kg in the 5+9 regimen.

Flow sorting from organ material by intracellular markers

BACKGROUND

Fluorescence-activated cell sorting (FACS) is an attractive technique for gene or protein expression studies in rare cell populations. For cell types where specific surface markers are not known, intracellular markers can be used. However, this approach is currently held to be difficult, as the required fixation and permeabilization may cause protein modification and RNA degradation.

METHODS AND RESULTS

Using the rat thyroid gland as model, rare (parafollicular) and frequent (follicular) endocrine cell types were sorted based on immunostaining for intracellular calcitonin peptide and thyroglobulin protein expression. The sorted cells were compatible with Western blot analysis of proteins, immunoassay detection of calcitonin peptide hormone and RT-PCR.

CONCLUSION

We developed a robust FACS protocol that allows flow sorting of rare cells from dissociated organ material, based on intracellular markers. Our FACS protocol is compatible with downstream analysis of proteins, peptides, and mRNA in the sorted cells.

Characteristics of Rat CD4+CD25+ T Cells and Their Ability to Prevent Not Only Diabetes But Also Insulitis in an Adoptive Transfer Model in BB Rats

Human and mouse CD4(+)CD25(+) T cells have been intensively studied through the last decade. However, little is known about this subset in other species. This study describes the phenotype of rat CD4(+)CD25(+) Foxp3(+) T cells and the site in which they exert regulation in a transfer-induced autoimmune diabetes model. Several proteins and mRNAs are up-regulated in unstimulated rat CD4(+)CD25(+) T cells compared with CD4(+)CD25(-) T cells, including Foxp3, Lag-3, CD80, interleukin 10 (IL-10) and CTLA-4. To investigate CD4(+)CD25(+) T cells in vivo, we transferred three million diabetogenic T cells either alone or in combination with two million CD4(+)CD25(+) T cells to 30-day-old BB rats. The pancreas and the pancreatic lymph nodes were examined as two potential regulatory sites. Time-course analysis of pancreatic histology following diabetogenic T-cell transfers revealed insulitis from about 14 days after transfer. By contrast, rats receiving both diabetogenic T cells and CD4(+)CD25(+) T cells had no insulitis at any time. Moreover, the frequency of diabetogenic T cells in the pancreatic lymph nodes 2 days after transfer was significantly reduced in rats receiving both subsets. These data indicate that the primary site of T-cell regulation is in the draining lymph nodes and not the pancreas in our model.

Reconstitution of Scid mice with CD4+CD25- T cells leads to rapid colitis: an improved model for pharmacologic testing

Improved experimental colitis models are needed for evaluation of treatment strategies for IBD. Most current models either lack resemblance to IBD, are complicated to establish, or the colitis occurs slowly and inconsistently. Our aim was to characterize the course of colitis in C.B-17 Scid mice reconstituted with syngeneic CD25-depleted CD4+ cells, including the identification of useful biomarkers, and assessment of the similarities to IBD with focus on the relationship between colonic epithelial proliferation and inflammatory parameters. Groups of reconstituted and un-reconstituted mice were sacrificed weekly from week 1 to 4. Clinical signs of colitis occurred approximately 2 weeks after reconstitution. Disease onset and severity based on histopathology correlated well with the colonic weight:length ratio, fecal consistency score, presence of occult blood in feces, and fecal IL-1beta content. Loss in body weight was not apparent until colitis was well established and exhibited lower coefficient of correlation to the histologic score. Early colonic histopathology was dominated by epithelial hyperproliferation, loss of mucus and mild lymphoid infiltration. Epithelial hyperproliferation was paralleled by increased fecal soluble tumor necrosis factor receptor II content. Cytokines in colonic tissue homogenates exhibited a Th1-like profile. We conclude that adoptive transfer of CD4+CD25- T cells results in colitis resembling IBD with a rapid onset and limited variability between individuals. Purification of CD4+CD25- T cells is a simple procedure, and does not require flow-cytometric sorting. Fecal consistency score and colonic weight:length ratio are readily measurable and consistent disease parameters. This model is thus highly suitable for pharmacological testing of intervention strategies.

Reactivity of naive CD4+CD25- T cells against gut microflora in healthy mice

We have previously shown that conventional as well as germ-free CD4+ T cells depleted of CD25+ cells from the gut-associated lymphoid tissue and the periphery proliferate specifically in response to enterobacterial antigen exposure whereas unfractionated CD4+ T cells are not reactive under these conditions. Here we show that the majority of the enteroantigen-specific CD4+ CD25- T cells are naive cells expressing a CD45RB high, CD62L high and CD44 low phenotype. These cells are also present in the thymus and data from adult thymectomized mice show that they represent late (>6 weeks) thymic emigrants. Upon enteroantigen activation, the CD4+ CD25- T cells secrete IL-4, IL-5, IL-10, granulocyte macrophage colony-stimulating factor, tumor necrosis factor-alpha and IFN-gamma. Clonotype mapping of the TCRBV regions 1-18 of enteroantigen-reactive CD4+ CD25- T cells by TCR clonotype mapping revealed the polyclonal nature of this subset. In conclusion, we have for the first time demonstrated the presence of an evolutionary, functionally conserved subset of CD4+ T cells, which are reactive against enterobacterial antigens. This subset resides both in the thymus and the periphery; it is not dependent on previous antigen experience and represents late thymic emigrants, which by enteroantigen-induced activation express a mixed Th 1-Th 2 phenotype. At homeostatic conditions, CD25+ T cells maintain peripheral tolerance in this CD4+ T cell subset.

In vivo control of diabetogenic T-cells by regulatory CD4+CD25+ T-cells expressing Foxp3

To understand the ability of regulatory T-cells to control diabetes development in clinically relevant situations, we established a new model of accelerated diabetes in young DP-BB rats by transferring purified T-cells from DR-BB rats made acutely diabetic. Transfer of 3, 5, 10, or 23 million pure in vitro-activated T-cells accelerated diabetes onset in >90% of the recipients, with the degree of acceleration being dosage dependent. Cotransfer of unfractionated leukocytes from healthy donors prevented diabetes. Full protection was achieved when protective cells were transferred 3-4 days before diabetogenic cells, whereas transfer 2 days before conferred only partial protection. Protection resided in the CD4(+) fraction, as purified CD4(+) T-cells prevented the accelerated diabetes. When CD25(+) cells were depleted from these cells before they were transferred, their ability to prevent diabetes was impaired. In contrast, two million CD4(+)CD25(+) cells (expressing Foxp3) prevented the accelerated diabetes when transferred both before and simultaneously with the diabetogenic T-cells. In addition, 2 million CD4(+)CD25(+) T-cells prevented spontaneous diabetes, even when given to rats age 42 days, whereas 20 million CD4(+)CD25(-) cells (with low Foxp3 expression) were far less effective. We thus demonstrated that CD4(+)CD25(+) cells exhibit powerful regulatory potential in rat diabetes.

A co-transfer system in young prediabetic BB rats: reactivated autoreactive T cells can be partly controlled

A transfer model for studying both the development and prevention of diabetes in rats is described in detail. Diabetes was induced in BBDR rats by combining RT6-depletion with PolyI:C treatment. Autoreactive cells were isolated from acutely diabetic donors, reactivated in vitro and transferred intravenously into young (<34-day-old) BBDP rats. Accelerated diabetes occurred 13+/-3 days or 18+/-4 days after transfer of reactivated splenocytes or purified T cells (42/43 or 26/27 recipients, respectively). Freshly isolated mesenteric and splenic leukocytes from adult, healthy BBDR rats prevented spontaneous diabetes in BBDP rats, but were not able to prevent the accelerated diabetes when co-transferred with the autoreactive cells. By contrast, diabetes was significantly delayed (P<0.001) when protective cells were transferred 4 days prior to the autoreactive cells (16+/-3 days). In vivo tracking studies of the two types of transferred cells suggest different homing patterns which may explain this finding. The data suggest that leukocytes from BBDR contain cells with the ability to regulate reactivated autoreactive T cells in an autoimmune environment. This in vivo model of recurrent diabetes can therefore be used to define which type of cells are most effective in suppressing established autoimmune destruction of beta-cells.

Improved beta-cell survival and reduced insulitis in a type 1 diabetic rat model after treatment with a beta-cell-selective K(ATP) channel opener

Treatment with ATP-sensitive K(+) channel openers (KCOs) leads to inhibition of insulin secretion and metabolic "rest" in beta-cells. It is hypothesized that in type 1 diabetes this may reduce beta-cell death resulting from metabolic stress as well as reduce the immunogenicity of the beta-cells during autoimmune beta-cell destruction. We have investigated whether the beta-cell-selective KCO compound, NN414, can be used to improve beta-cell survival in DR-BB rats rendered diabetic by modulation of their immune system. The rats were treated three times daily on days 1-19 with NN414, diazoxide, or vehicle. On day 21, an intravenous glucose tolerance test was conducted to assess beta-cell function. Postmortem histological analysis of rats' pancreata assessed the degree of insulitis and beta-cell volume. Among NN414-treated rats, 46% (16 of 35) were found to have a beta-cell mass similar to that of nondiabetic controls and significant glucose-stimulated C-peptide values, whereas only 11% (4 of 36) of vehicle-treated rats possessed a normal beta-cell mass and function (P < 0.002, by chi(2) test). Furthermore, responsive NN414-treated rats were almost free of insulitis. Thus, this study demonstrated that treatment with KCO compounds can indeed lead to preservation of beta-cell function and reduction of insulitis in a rat diabetes model.