Pancreas-specific protein. New serum marker for graft rejection in pancreas-transplant recipients

A radioimmunoassay for a novel human pancreatic protein (pancreas-specific protein, PASP) has been developed. We studied the possibility that serum PASP levels reflect pancreas-graft rejections in human pancreas-transplant recipients. Ten patients subjected to combined pancreas-kidney transplantation and 4 patients subjected to pancreas transplantation alone were studied. Twelve kidney recipients served as control subjects. On several occasions, PASP levels were elevated at kidney rejections in patients with combined pancreas-kidney grafts and then decreased after antirejection therapy, although no other indications for concomitant pancreas-graft rejection were at hand. In the recipients of pancreas grafts alone, PASP levels increased before or at the same time as graft rejections were indicated by current methods. In two cases of chronic graft rejection, PASP rose to high levels long before hyperglycemia occurred. In the control group of kidney-graft recipients, PASP levels were stable and were not affected by high serum creatinine levels, kidney-rejection episodes, or antirejection therapy. This study indicates that PASP may be a good serum marker for pancreas-graft rejection.

Effects of pancreas transplantation on metabolic and hormonal profiles in IDDM patients

The diurnal patterns of relevant metabolites and hormones in five pancreas-kidney-transplanted patients (aged 36 +/- 2 yr, mean +/- SD) with insulin-dependent diabetes mellitus (IDDM) were compared with those in five kidney-transplanted nondiabetic patients (aged 28 +/- 2 yr). The groups were matched for body mass and current dose and type of immunosuppressive treatment. The serum creatinine levels did not differ between the two study groups, but the serum urea level in the nondiabetic patients was slightly but significantly higher than in the diabetic patients. In the pancreas-kidney-transplanted group the investigation was performed 8-47 mo posttransplantation; in the kidney-transplanted nondiabetic patients, 12-18 mo posttransplantation. The mean 24-h levels and rhythms of blood glucose, free fatty acid, 3-hydroxybutyrate, and alanine did not differ between the groups. The mean 24-h levels of blood lactate and glycerol were moderately but significantly higher in the pancreas-kidney-transplanted diabetic patients. At fasting, the level of serum immunoreactive insulin was more than twice as high in the pancreas-kidney-transplanted patients, whereas the plasma C-peptide levels did not differ significantly between the two groups. The meal-induced increases in serum insulin as well as in the plasma C-peptide levels were more marked in the pancreas-kidney-transplanted patients. The findings suggest that the hyperinsulinemia in these patients was due to both the systemic delivery of insulin and an increase in insulin resistance, the latter being particularly apparent in the postprandial phase.(ABSTRACT TRUNCATED AT 250 WORDS)

Fifteen years' experience with pancreas transplantation with pancreaticoenterostomy

We report on 92 pancreas transplantations with exocrine diversion by pancreaticoenterostomy. All recipients suffered from long-term type I (insulin-dependent) diabetes. In most transplantations, cadaveric segmental grafts were used (n = 89). In a few patients, segmental grafts from related donors were used (n = 3), and in a few other patients, whole-organ cadaveric grafts were used (n = 4). There were 9 retransplantations. Most pancreas transplantations were performed in uremic diabetic patients in combination with a kidney transplantation (n = 58). In a few patients the pancreas transplantation was performed after a kidney transplantation (n = 6). The remaining transplantations were in nonuremic diabetic patients who received only a pancreas (n = 25). Over the years, the results have improved considerably; in the 1986-1987 series the overall 1-yr patient survival (ps) and graft survival (gs) rates were 97 and 56%, respectively. The best results were achieved with the combined procedure (ps 100%, gs 77%); with pancreas only, the figures were inferior (ps 92%, gs 34%). Several factors explain the improved results. The incidence of graft thrombosis has been reduced by the use of anticoagulation, and posttransplantation pancreatitis has been reduced by avoiding ischemic injury to the graft. Cyclosporin has helped reduce the incidence of graft rejection, and monitoring of the exteriorized pancreatic juice has helped in the diagnosis of rejection.

Quality of life in diabetic patients after combined pancreas-kidney or kidney transplantation

The quality of life was compared between 14 combined pancreas-kidney-transplant patients (group 1) and 16 diabetic kidney-transplant patients (group 2). Minimum follow-up was 2 yr with functioning grafts. Two-thirds of both groups' patients were working, but 90% in group 1 and 50% in group 2 had full-time occupations. Also 7% in group 1 and 43% in group 2 had to modify their activity posttransplantation. The amount of lost workdays was calculated during periods of 2 yr pre- and posttransplantation: the figure decreased by 44% in group 1 (from 278 to 155) and was unchanged in group 2 (from 211 to 213). The number of sickness pensions paid increased from 28% of the patients pretransplantation to 42% in October 1987 in group 1 and from 20 to 62% in group 2. Over the last 2 yr, an average of 12 days of hospitalization were necessitated in group 1 compared to 25 days in group 2. When physical activity was evaluated, both groups judged their present state of health as good or very good (group 1, 78%; group 2, 73%). In group 1, 80% claimed they had recovered the same or better quality of life as they had before renal failure, compared to 50% in group 2. The investigation showed that group 1 seemed to achieve a better quality of life than group 2; all combined pancreas-kidney-transplant patients returned to a normal diet and achieved a less restricted life-style.

Markers for pancreas-graft rejection in humans

Rejection episodes were studied in 15 patients, in whom no kidney graft could serve as a marker for rejection, subjected to pancreas transplantation with pancreatoenterostomy and temporary exteriorization of the pancreatic juice (10 pancreas alone, 3 pancreas after kidney, and 2 combined pancreas and kidney in which the kidney was not functioning.) Twelve patients (80%) had a total of 18 rejection episodes. In the first 11 patients, 13 rejection episodes were diagnosed by a decline in amylase activity in the pancreatic juice, whereas in the next 4 patients, 5 rejection episodes were diagnosed by positive cytology in the pancreatic juice. Neopterin in pancreatic juice and immunoreactive anionic trypsin in serum showed promise as rejection markers, whereas serum neopterin, serum amylase, and serum immunoreactive cationic trypsin did not. Unspecific signs of rejections were an increase in white blood cell count, clinical symptoms such as fever, abdominal pain, and arthralgia. All acute rejection episodes were successfully reversed by antirejection treatment. However, late rejections diagnosed by impaired endocrine function were seen in 6 of the 15 (40%) patients, and the prognoses for these rejections were worse: 4 patients (27%) lost their grafts because of chronic rejections, and 2 patients still had impaired endocrine function.

Effects of culture conditions on formation and hormone content of fetal porcine isletlike cell clusters

To establish methods for stimulation of the growth and differentiation of fetal endocrine pancreatic cells, a technique for the in vitro production of fetal porcine isletlike cell clusters (ICCs) was used. By varying the composition of the culture medium with different glucose concentrations and the addition to the culture medium of insulin, growth hormone (GH), amino acids, or nicotinamide, we estimated the formation of ICCs and their hormone content. High glucose content (28.0 mM) stimulated the formation of abundant ICCs that contained decreased amounts of insulin. In contrast, culture at a low (5.6-mM) glucose concentration increased the ICC insulin content but decreased the number of ICCs formed. Addition of seven times the normal amount of amino acids hampered both the formation of ICCs and their insulin content. Neither insulin nor GH supplementation of the medium influenced the ICC insulin content, but GH stimulated an abundant outgrowth of ICCs containing relatively high insulin concentrations. However, ICCs formed under these circumstances contained less than 10% of the insulin content of adult islets, and further work has to be carried out to identify factors responsible for further differentiation of the fetal porcine pancreas.

Long-term metabolic control in recipients of segmental-pancreas grafts with pancreaticoenterostomy or duct obstruction

Metabolic control in recipients of segmental-pancreas grafts with pancreaticoenterostomy (performed in Stockholm) or duct obstruction by polymer injection (performed in Oslo) were compared. The recipients were uremic diabetic patients and also received a kidney from the same donor. Because the patient population in the two Scandinavian countries is very similar and the immunosuppressive protocols used are almost identical, such a comparison seemed reasonable. The number of patients available for study at 1, 2, and 3 yr was 22, 10, and 4, respectively, with duct injection and 28, 10, and 3 with pancreaticoenterostomy. The mean age of the patients was somewhat higher in the Oslo series. There were no significant differences regarding immunosuppression or kidney-graft function as estimated by serum creatinine at 1, 2, and 3 yr. No significant differences were found in fasting blood glucose, glycosylated hemoglobin, and intravenous glucose tolerance between the two groups at 1, 2, and 3 yr.

Tissue culture of human fetal pancreas. Effects of nicotinamide on insulin production and formation of isletlike cell clusters

Human fetal pancreas (HFP) is a potential source of beta-cells for transplantation to insulin-dependent diabetic patients. We have previously described a method for tissue culture of HFP that results in the in vitro development of isletlike cell clusters (ICCs) containing a minority of insulin-positive cells. Recently we found that nicotinamide, an inhibitor of poly(ADP-ribose) synthetase, induces an increased islet cell DNA replication both in vivo and in vitro. In this study, this culture technique was used to evaluate the effects of addition of 10 mM nicotinamide on HFP explants cultured in RPMI-1640 medium plus 10% human serum. ICCs developed in 11 of 19 consecutive cultures with nicotinamide increased the yield of ICCs by 40%. Also, the insulin content of ICCs increased approximately 50% with nicotinamide supplementation, although measurements of DNA indicated an unchanged number of cells in each ICC. Neither the rates of insulin release in response to 16.7 mM glucose plus 5 mM theophylline nor the (pro)insulin or total protein biosynthesis rates were affected by nicotinamide addition. The combined results of this study suggest that nicotinamide is useful for stimulating the formation of ICCs from HFP.

Experimental pancreatic transplantation in diabetes

Although transplantations of vascularized pancreas in diabetic patients show steadily improving results, the immediate operative risks and life-long immunosuppressive medication involved represent considerable disadvantages. Efforts are being made to develop simpler and safer methods of transplantation with isolated pancreatic islet grafts, e.g., isolated islets, fetal pancreas, or dispersed adult pancreas. Iso-, allo-, and xenografts of such preparations have been shown to reverse diabetes in animals. However, attempts to apply these techniques in clinical practice have remained largely unsuccessful, and major technical advances are needed before success is achieved. Attempts to use whole, segmented, or isolated islets from pancreatic grafts as a cure for diabetes in animals and in diabetic patients are reviewed. The importance to the graft's permanent function, of adequate preparation and storage of the graft, and of beta-cell growth and vascularization are reviewed. Various forms of immunomodulation by pretreatment of grafts in vitro have been employed in animal models of diabetes, but none of these have yet been employed with long-term success in humans. Recurrence of a specific autoimmune response toward the beta-cell in a spontaneously diabetic recipient is a potential mechanism for destruction of transplanted islet tissue.

Long-term follow-up of the first successful bone marrow transplantation in Gaucher disease

A 9-year-old girl with juvenile Gaucher disease underwent splenectomy and allogeneic bone marrow transplantation. Her HLA-identical brother with normal cerebroside-beta-glucosidase activity served as donor. One month after transplantation, cerebroside-beta-glucosidase activity in the lymphocytes were normal. Plasma glucosylceramide normalized already after splenectomy and further decreased after marrow transplantation. Glucosylceramide in the erythrocytes was normal around a year after transplantation. The enlarged liver normalized in size by 2 years. Gaucher cells were still present in the bone marrow 1 year after transplantation but had completely disappeared at 3 years. The patient has grown 29 cm during the 5 years that have passed after transplantation compared to 1 cm/year during 3 years before. The patient has a slight obstructive ventilatory impairment, and chest deformities have appeared. Wechsler intelligence scale performance has slowly decreased after transplantation. This may be caused by continued neuronal storage of glucosylceramide. Otherwise, this patient is active and healthy 5 years after bone marrow transplantation.

Tissue culture of human fetal pancreas. Effects of human serum on development and endocrine function of isletlike cell clusters

The human fetal pancreas represents a source of insulin-producing beta-cells with a potential for transplantation to diabetic patients. It has previously been shown that such cells can be viably maintained in tissue culture media containing fetal calf serum (FCS) and that these explants continue to synthesize and release insulin. In this study the effects of human serum (HS) on the growth and function of human fetal pancreatic explants have been compared with those of FCS. For this purpose, pancreatic glands, obtained after prostaglandin-induced abortions, were briefly exposed to collagenase, and the digest was cultured in RPMI-1640 medium plus 10% pooled HS or FCS. The outgrowth of isletlike cell clusters (ICCs) was monitored. In 31 of 58 consecutively explanted glands, development of ICCs was observed. In the presence of FCS the outgrowth of ICC took place on top of a fibroblast monocellular cell layer; HS effected less growth of fibroblasts and increased the formation of ICCs about sevenfold compared with explants from the same glands maintained in FCS. However, in the explant cultures with HS, the cell number per ICC, expressed as DNA content, was reduced by 50%. In both FCS and HS the insulin content of the medium showed great variability and progressively declined from day 2 to day 5. The medium glucagon concentration also decreased but not to the same extent as that of insulin. Immunocytochemical-stained ICCs showed insulin- and glucagon-positive cells scattered among most nonstained, presumably nonendocrine cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Tissue culture of human fetal pancreas: growth hormone stimulates the formation and insulin production of islet-like cell clusters

The human fetal pancreas (HFP) is a potential source of insulin-producing B-cells for transplantation to insulin-dependent diabetic patients. We recently described a technique for culturing HFP tissue in vitro which results in the development of islet-like cell clusters (ICC). These clusters exhibited (pro)insulin biosynthesis and a modest rate of insulin secretion, and immunocytochemical staining indicated the presence of insulin-positive cells in the cell clusters. In this study this technique was used to evaluate the effects of the addition of 1000 micrograms/L GH to HFP cultured in medium RPMI-1640 plus 10% human serum. ICCs developed in 21 of 33 consecutive cultures. GH increased the yield of ICC by 35% compared to explants supplemented with human serum alone. The insulin content of the ICCs also was increased, but the size of individual ICCs was not affected by GH, as reflected by an unchanged DNA content. GH also caused increased insulin release when the ICCs were stimulated with 16.7 mM glucose plus 5 mM theophylline. However, (pro)insulin biosynthesis was not affected by the addition of GH. These results suggest that GH stimulates the formation of both ICCs and insulin production within the explants. These observations are relevant both for the production of human fetal B-cells intended for transplantation into insulin-dependent diabetic patients and for our knowledge of the growth regulation of the HFP B-cell.

Effects of combined pancreatic and renal transplantation on diabetic neuropathy: a two-year follow-up study

To investigate whether diabetic neuropathy can be reversed after pancreatic transplantation 13 diabetic patients were examined by means of conventional electroneurography and tests on autonomic function before and 6, 12, and 24 months after combined renal and pancreatic transplantation. 15 diabetic patients receiving a kidney graft only and 15 non-diabetic kidney graft recipients served as controls. Before transplantation neuropathy was most advanced in the two diabetic groups. Both diabetic groups showed a similar slight but significant improvement of nerve conduction after transplantation. In the non-diabetic group nerve conduction became essentially normal. No group showed improvement in autonomic dysfunction. The improvement in nerve conduction after combined kidney and pancreas transplantation was most probably due to the elimination of uraemia. Furthermore, 2 years of normoglycaemia did not reverse the diabetic neuropathy to an important extent at this late stage of the disease.