Islet Transplantation in Pediatric Patients: Current Indications and Future Perspectives

Reversal of autoimmunity by mixed chimerism enables reactivation of β cells and transdifferentiation of α cells in diabetic NOD mice

Cure of autoimmune type 1 diabetes (T1D) requires both reversal of autoimmunity and regeneration or resupply of insulin-producing β cells. We have observed that combination therapy with induction of haploidentical mixed chimerism and administration of gastrin and epidermal growth factor (EGF) cures firmly established T1D. The predominant source of β cell regeneration in mice comes from reactivation of dysfunctional insulin^lo β cells and transdifferentiation of α cells. These studies have provided insights into β cell regeneration mechanisms in firmly established autoimmune T1D, in particular, reactivation of the insulin^lo β cells after reversal of autoimmunity by induction of haploidentical mixed chimerism. These studies also provide a preclinical scientific basis for the feasibility of cure of long-standing T1D in humans.

Type 1 diabetes (T1D) results from the autoimmune destruction of β cells, so cure of firmly established T1D requires both reversal of autoimmunity and restoration of β cells. It is known that β cell regeneration in nonautoimmune diabetic mice can come from differentiation of progenitors and/or transdifferentiation of α cells. However, the source of β cell regeneration in autoimmune nonobese diabetic (NOD) mice remains unclear. Here, we show that, after reversal of autoimmunity by induction of haploidentical mixed chimerism, administration of gastrin plus epidermal growth factor augments β cell regeneration and normalizes blood glucose in the firmly established diabetic NOD mice. Using transgenic NOD mice with inducible lineage-tracing markers for insulin-producing β cells, Sox9⁺ ductal progenitors, Nestin⁺ mesenchymal stem cells, and glucagon-producing α cells, we have found that both reactivation of dysfunctional low-level insulin expression (insulin^lo) β cells and neogenesis contribute to the regeneration, with the latter predominantly coming from transdifferentiation of α cells. These results indicate that, after reversal of autoimmunity, reactivation of β cells and transdifferentiation of α cells can provide sufficient new functional β cells to reach euglycemia in firmly established T1D.

Necessities for a Clinical Islet Program

For more than two decades we have been refining advances in islet cell transplantation as a clinical therapy for patients suffering from type 1 diabetes. A great deal of effort has gone to making this a viable therapy for a broader range of patients with type 1 diabetes. Clinical results have progressively improved, demonstrating clinical outcomes on par with other organ transplants, specifically in terms of insulin independence, graft and patient survival. We are now at the point where islet cell transplantation, in the form of allotransplantation, has become accepted as a clinical therapy in adult patients affected by type 1 diabetes, in particular those suffering from severe hypoglycaemic unawareness. This chapter provides an overview on how this has been undertaken over the years to provide outcomes on par with other organ transplantation results. In particular this chapter focuses on the processes and facilities that are required to establish a clinical islet isolation and transplantation program. It also outlines the very important underpinning processes of selection of the organ donor for islet isolation, the processes of organ donor operation and preservation of the pancreas by various means and the ideal ways to best improve outcomes for human islet cell isolation. Providing these more optimal conditions we can underpin the isolation processes to provide islets for transplantation and as such a safe, effective and feasible therapeutic option for an increasing number of patients suffering from type 1 diabetes with severe hypoglycaemic unawareness.