The in vivo and in vitro effect of 15-deoxyspergualin on pancreatic islet function

Effects of Caffeine and Acetylcholine on Glucose-Stimulated Insulin Release from Islet Transplants in Mice

In mouse islet grafts under the kidney capsule, the potentiating responsiveness to acetylcholine was markedly attenuated after a few weeks. The question arose as to whether transplanted islets show an decreased responsiveness to potentiators in general. The effect of caffeine on glucose-induced insulin secretion was, therefore, examined. Intrastrain transplantation was performed in NMRI and BALB/c mice, and islet grafts were removed and perifused in vitro after 3 and 12 wk. In grafts from both NMRI and BALB/c mice, 16.7 mmol/L glucose induced a biphasic insulin release. When 1 or 5 mmol/L caffeine was included in the perifusion medium, there was a marked potentiation of the glucose-induced insulin release that was at least as responsiveness as fresh untransplanted islets. In the absence of caffeine, 3-wk-old BALB/c grafts reacted less strongly to acetylcholine than did untransplanted islets. The addition of 1 mmol/L caffeine did not enhance the potentiating effect of acetylcholine, whether in untransplanted or transplanted islets. Rather, the interaction between caffeine and acetylcholine appeared negative. We concluded that the glucose-induced insulin secretion exhibits a diminished potentiatory responsiveness to acetylcholine but not to caffeine. The displacement and denervation of transplanted islets is likely to affect either the cholinergic receptors or their mediated influence on intracellular calcium. Copyright © 1997 Elsevier Science Inc.

[Pancreatic islets transplantation in the treatment of diabetes mellitus: present and future]

Diabetes treatment with insulin does no prevent the development of secondary complications. For this reason, treatments other than conventional ones are needed, which could bring about an <<almost physiological>> metabolic regulation. This can only be done by transplanting insulin producing tissue, such as vascularised pancreas transplantation, which is an already consolidated clinical procedure these days, or by islets transplantation, which is still a procedure in the clinical research phase. This has the same metabolic objectives as the vascularised transplant, but without the risks of major abdominal surgery, since the islets are implanted in the liver with minimal surgery or using interventionist radiology by means of a catheter. A clinical trial (Edmonton Protocol) was published in the year 2000, which improved the results after islet transplantation by obtaining normoglycaemia periods of more than one year in a consecutive patient series with type 1 diabetes and without using corticoids. This protocol has been endorsed in other centre in different trials. Although the initial results were good, the progress of these patients has shown that many islets transplantations do not manage to maintain insulin-independence indefinitely.

Pancreatic Islet Cell Transplantation

Pancreatic islet cell transplantation as a treatment for diabetes has hitherto been confined to small patient cohorts with limited success. This article summarizes the results of islet cell transplantation before and after the advent of the new 'Edmonton protocol' of immunosuppression and management of the donor pancreas. Adopting this regimen has achieved unprecedented success and renewed interest in this potential cure for diabetes. Central to recent improvements in the technique has been the transplantation of an adequate islet mass. Improved methods to procure, isolate, and purify islets for clinical use are now being adopted as a new 'gold standard'. The use of new immunosuppressive drugs has further improved clinical results. Corticosteroid sparing-based regimens, and agents such as humanized monoclonal antibodies, are likely to form the mainstay of immunosuppressive protocols with the aim of achieving donor-specific tolerance. Alternative sources of islet cells are also required to expand the technique in an era of reduced numbers of donor pancreata. Manipulation of stem cells and xenotransplantation may yet yield sufficient islets to overcome the problem of donor shortage. Islet cell transplantation now forms the basis of a prospective multicenter trial under the aegis of the Immune Tolerance Network. The results of this are awaited, but it appears that islet cell transplantation may yet emerge as an effective treatment option for some members of the diabetic population.

Human islet cell transplantation--future prospects

BACKGROUND

Islet transplantation has the potential to cure diabetes mellitus. Nevertheless despite successful reversal of diabetes in many small animal models, the clinical situation has been far more challenging. The aim of this review is to discuss why insulin-independence after islet allotransplantation has been so difficult to achieve.

METHODS

A literature review was undertaken using Medline from 1975 to July 2000. Results reported to the International Islet Transplant Registry (ITR) up to December 1998 were also analysed.

RESULTS

Up to December 1998, 405 islet allotransplants have been reported the ITR. Of those accurately documented between 1990 and 1998 (n = 267) only 12% have achieved insulin-independence (greater than 7 days). However with refined peri-transplant protocols insulin independence at 1 year can reach 20%.

CONCLUSIONS

There are many factors which can explain the failure of achieving insulin-independence after islet allotransplantation. These include the use of diabetogenic immunosuppressive agents to abrogate both islet allo-immunity and auto-immunity, the critical islet mass to achieve insulin-independence and the detrimental effects of transplanting islets in an ectopic site. However recent evidence most notably from the Edmonton group demonstrates that islet allotransplantation still has great potential to become an established treatment option for diabetic patients.

Clinical islet cell transplantation. Are we there yet?

Diabetes mellitus is perhaps the most devastating chronic disease of all time. A brief history of the evolution of treatment modalities is provided, culminating in the rationale for the physiologic replacement of a functioning beta-cell mass by transplantation. Vascularized pancreas transplantation is discussed briefly as an introduction to the transplantation of the isolated islet. A detailed review of the current state of human islet transplantation for the cure of diabetes is then described. Finally, areas for future development are highlighted.

Post-transplant diabetes mellitus. The role of immunosuppression

Immunosuppressive agents increase the risk of death due to coronary disease or stroke by their ability to cause 3 different adverse effects: dyslipidaemia, hypertension and hyperglycaemia. Post-transplant diabetes mellitus has emerged as a major adverse effect of immunosuppressants. As recipients of organ transplants survive longer, the secondary complications of diabetes mellitus have assumed greater importance. There is a need for a precise definition of post-transplant diabetes mellitus to facilitate inter-centre comparison and to study the natural history of post-transplant diabetes mellitus. We recommend broad criteria to define hyperglycaemia, as a fasting blood glucose level of > 400 mg/dl at any point or > 200 mg/dl for 2 weeks, or a need for insulin treatment for at least 2 weeks. We also recommend serial measurements of HbA1c. Cyclosporin and tacrolimus cause post-transplant diabetes mellitus by a number of mechanisms, including decreased insulin secretion, increased insulin resistance or a direct toxic effect on the beta cell. For corticosteroids, the induction of insulin resistance seems to be the predominant factor. However, few studies have examined the mechanism of diabetogenicity at the molecular level. This may hold the key for pharmacological manipulation of current immunosuppressive regimens which may result in decreased metabolic complications. Corticosteroid sparing regimens have been shown to reduce the metabolic complications of immunosuppressants including post-transplant diabetes mellitus. However, their use should be balanced against the increased incidence of transplant rejections. Post-transplant diabetes mellitus may be organ-specific irrespective of the immunosuppressant used. Tacrolimus causes a high incidence of post-transplant diabetes mellitus in recipients of kidney transplants (upto 20% in some reports); the diabetogenicity of cyclosporin-based regimens is comparable with that of tacrolimus-based regimens in recipients of liver transplants. A few clinical studies in which attempts were made to discontinue cyclosporin resulted in an unacceptable loss of the transplant. In the case of tacrolimus, complete withdrawal of immunosuppression may be possible in selected patients with liver transplants. However, post-transplant recipients who may benefit from this approach are difficult to identify. In some early series, patients received doses of tacrolimus that were approximately 2 to 3 times higher than those currently used, which may have resulted in a higher incidence of post-transplant diabetes mellitus. More recently, it has been shown that tacrolimus was successful in salvaging whole pancreatic grafts which were maintained on cyclosporin. Tacrolimus-based immunosuppression as primary therapy was also used with remarkable success in solitary whole pancreas transplants. Strategies to reduce the metabolic complications of immunosuppressants should be pursued aggressively as this will directly lead to a decrease in long term cardiovascular adverse effects.

Toxicity in vivo of different immunosuppressive drugs in fetal porcine pancreatic islets

Clinical transplantation of fetal porcine islet-like cell clusters (ICC) to kidney transplanted diabetic patients has shown both morphological and biochemical evidence of prolonged xenograft survival, but no effect was seen on the insulin requirement of the transplanted patients. One possible explanation for this relative lack of success might have been the influence of the immunosuppressive drugs on the differentiation of ICC grafts. In this study, the effects of a number of immunosuppressive drugs on ICC differentiation were investigated. Normoglycemic C57BL/6 nu/nu mice were transplanted with 2x3 microliter ICC under the renal capsule. During a four-week period the animals were treated daily with azathioprine (2.0 mg/kg b.wt.), prednisolone (0.5 mg/kg b.wt.), cyclosporine (5.0 mg/kg b.wt.), cyclophosphamide (5.0 mg/kg b.wt.) 15-deoxyspergualin (5.0 mg/kg b.wt.), leflunomide (30 mg/kg b.wt.) or saline. In order to estimate rates of beta-cell DNA synthesis in the ICC grafts the mice were injected with 3H-thymidine one hour before killing and slides of the grafts were evaluated with regard to autoradiographical labeling. Other ICC grafts were evaluated by measurement of their insulin and DNA contents. Both the DNA content of ICC grafts and the beta cell labeling index in the cyclosporine animals were significantly decreased. Perfusion experiments with graft-bearing kidneys of cyclosporine-treated animals showed a significantly decreased insulin secretion in response to glucose plus theophylline. None of the other drugs influenced the differentiation of grafted ICC as evaluated in this study. Thus, it is obvious that cyclosporine inhibits both the growth and functional differentiation of transplanted ICC, which might be one reason for the relative lack of success in the clinical transplantation of porcine ICC to diabetic patients.

Evolution of kidney, pancreas, and islet transplantation for patients with diabetes at the University of Minnesota

Transplantation began at the University of Minnesota in 1963. Treatment of diabetes and its complications has been emphasized since 1966, when the first pancreas-kidney transplant was done. Of 3,640 kidneys transplanted by 1992, 1,373 were for diabetic recipients, including 658 from living donors and 715 from cadaver donors. The results progressively improved; since 1984, survival rates of kidney grafts have been similar for diabetic and nondiabetic recipients, with three fourths of the grafts functioning at 4 years. As of 1992, 501 pancreas transplants had been done, including 170 simultaneous with a kidney, 142 after a kidney, and 188 alone for nonuremic diabetic patients; again, the results have improved: by the 1990s, graft survival rates were similar in the 3 recipient categories. Successful pancreas transplants have been shown by our coworkers to stabilize or improve neuropathy and prevent recurrence of diabetic nephropathy in kidney grafts. In an attempt to simplify endocrine replacement therapy, we have done 63 human islet transplants, 34 as allografts for patients with type I diabetes and 29 as autografts after total pancreatectomy to treat chronic pancreatitis. Insulin independence occurs for about 50% of islet autograft recipients. Two recent islet allograft recipients treated with 15-deoxyspergualin have had sustained insulin independence. We anticipate that endocrine replacement therapy by transplantation will become routine for diabetic patients as methods to prevent rejection are refined.