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Rickels MR, Bellin MD, Stefanovski D, Peleckis AJ, Dalton-Bakes C, Markmann E, Nguyen HL, Townsend RR, Hering BJ, Naji A. α- or β-Adrenergic blockade does not affect transplanted islet cell responses to hypoglycemia in type 1 diabetes. Am J Physiol Endocrinol Metab 2024; 327:E290-E301. [PMID: 38984949 DOI: 10.1152/ajpendo.00002.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 06/28/2024] [Accepted: 07/03/2024] [Indexed: 07/11/2024]
Abstract
Type 1 diabetes recipients of intrahepatic islet transplantation exhibit glucose-dependent suppression of insulin and activation of glucagon secretion in response to insulin-induced hypoglycemia associated with clinical protection from hypoglycemia. Whether sympathetic activation of adrenergic receptors on transplanted islets is required for these responses in defense against hypoglycemia is not known. To evaluate the adrenergic contribution to posttransplant glucose counterregulation, we performed a randomized, double-blind crossover study of responses during a hyperinsulinemic euglycemic-hypoglycemic clamp under phentolamine (α-adrenergic blockage), propranolol (β-adrenergic blockage), or placebo infusion. Characteristics of participants (5 females/4 males) were as follows: median (range) age 53 (34-63) yr, diabetes duration 29 (18-56) yr, posttransplant 7.0 (1.9-8.4) yr, HbA1c 5.8 (4.5-6.8)%, insulin in-/dependent 5/4, all on tacrolimus-based immunosuppression. During the clamp, blood pressure was lower with phentolamine and heart rate was lower with propranolol versus placebo (P < 0.05). There was no difference in the suppression of endogenous insulin secretion (derived from C-peptide measurements) during the euglycemic or hypoglycemic phases, and although levels of glucagon were similar with phentolamine or propranolol vs. placebo, the increase in glucagon from eu- to hypoglycemia was greater with propranolol vs. placebo (P < 0.05). Pancreatic polypeptide was greater with phentolamine versus placebo during the euglycemic phase (P < 0.05), and free fatty acids were lower and the glucose infusion rate was higher with propranolol versus placebo during the hypoglycemic phase (P < 0.05 for both). These results indicate that neither physiological α- nor β-adrenergic blockade attenuates transplanted islet responses to hypoglycemia, suggesting sympathetic reinnervation of the islet graft is not necessary for posttransplant glucose counterregulation.NEW & NOTEWORTHY Whether adrenergic input to islets is necessary for glucose homeostasis in humans is debated. Here, the adrenergic contribution to intrahepatically transplanted islet cell responses to hypoglycemia in individuals with type 1 diabetes was investigated through α- or β-adrenergic receptor blockade during hyperinsulinemic euglycemic-hypoglycemic clamps. Neither α- nor β-adrenergic blockage affected the suppression of endogenous insulin or activation of glucagon secretion, suggesting that sympathetic reinnervation of islet grafts is not required for posttransplant defense against hypoglycemia.
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Affiliation(s)
- Michael R Rickels
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Melena D Bellin
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States
| | - Darko Stefanovski
- Department of Biostatistics, University of Pennsylvania School of Veterinary Medicine, Kennett Square, Pennsylvania, United States
| | - Amy J Peleckis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Cornelia Dalton-Bakes
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Eileen Markmann
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Huong-Lan Nguyen
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Raymond R Townsend
- Division of Nephrology and Hypertension, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Bernhard J Hering
- Schulze Diabetes Institute, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, United States
| | - Ali Naji
- Division of Transplant Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
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Latres E, Greenbaum CJ, Oyaski ML, Dayan CM, Colhoun HM, Lachin JM, Skyler JS, Rickels MR, Ahmed ST, Dutta S, Herold KC, Marinac M. Evidence for C-Peptide as a Validated Surrogate to Predict Clinical Benefits in Trials of Disease-Modifying Therapies for Type 1 Diabetes. Diabetes 2024; 73:823-833. [PMID: 38349844 DOI: 10.2337/dbi23-0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/05/2024] [Indexed: 02/15/2024]
Abstract
Type 1 diabetes is a chronic autoimmune disease in which destruction of pancreatic β-cells causes life-threatening metabolic dysregulation. Numerous approaches are envisioned for new therapies, but limitations of current clinical outcome measures are significant disincentives to development efforts. C-peptide, a direct byproduct of proinsulin processing, is a quantitative biomarker of β-cell function that is not cleared by the liver and can be measured in the peripheral blood. Studies of quantitative measures of β-cell function have established a predictive relationship between stimulated C-peptide as a measure of β-cell function and clinical benefits. C-peptide levels at diagnosis are often high enough to afford glycemic control benefits associated with protection from end-organ complications of diabetes, and even lower levels offer protection from severe hypoglycemia in type 1 diabetes, as observed in large prospective cohort studies and interventional trials of islet transplantation. These observations support consideration of C-peptide not just as a biomarker of β-cell function but also as a specific, sensitive, feasible, and clinically meaningful outcome defining β-cell preservation or restoration for clinical trials of disease-modifying therapies. Regulatory acceptance of C-peptide as a validated surrogate for demonstration of efficacy would greatly facilitate development of disease-modifying therapies for type 1 diabetes. ARTICLE HIGHLIGHTS
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Affiliation(s)
| | | | | | | | - Helen M Colhoun
- Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, U.K
| | - John M Lachin
- Biostatistics Center, George Washington University, Rockville, MD
| | - Jay S Skyler
- Diabetes Research Institute, University of Miami, Miami, FL
| | - Michael R Rickels
- Institute for Diabetes, Obesity and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Simi T Ahmed
- New York Stem Cell Foundation Research Institute, New York, NY
| | | | - Kevan C Herold
- Departments of Immunobiology and Internal Medicine, Yale School of Medicine, New Haven, CT
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3
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Mou L, Wang TB, Wang X, Pu Z. Advancing diabetes treatment: the role of mesenchymal stem cells in islet transplantation. Front Immunol 2024; 15:1389134. [PMID: 38605972 PMCID: PMC11007079 DOI: 10.3389/fimmu.2024.1389134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024] Open
Abstract
Diabetes mellitus, a prevalent global health challenge, significantly impacts societal and economic well-being. Islet transplantation is increasingly recognized as a viable treatment for type 1 diabetes that aims to restore endogenous insulin production and mitigate complications associated with exogenous insulin dependence. We review the role of mesenchymal stem cells (MSCs) in enhancing the efficacy of islet transplantation. MSCs, characterized by their immunomodulatory properties and differentiation potential, are increasingly seen as valuable in enhancing islet graft survival, reducing immune-mediated rejection, and supporting angiogenesis and tissue repair. The utilization of MSC-derived extracellular vesicles further exemplifies innovative approaches to improve transplantation outcomes. However, challenges such as MSC heterogeneity and the optimization of therapeutic applications persist. Advanced methodologies, including artificial intelligence (AI) and single-cell RNA sequencing (scRNA-seq), are highlighted as potential technologies for addressing these challenges, potentially steering MSC therapy toward more effective, personalized treatment modalities for diabetes. This review revealed that MSCs are important for advancing diabetes treatment strategies, particularly through islet transplantation. This highlights the importance of MSCs in the field of regenerative medicine, acknowledging both their potential and the challenges that must be navigated to fully realize their therapeutic promise.
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Affiliation(s)
- Lisha Mou
- Department of Endocrinology, Institute of Translational Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, Guangdong, China
- MetaLife Lab, Shenzhen Institute of Translational Medicine, Shenzhen, Guangdong, China
| | - Tony Bowei Wang
- Biology Department, Skidmore College, Saratoga Springs, NY, United States
| | - Xinyu Wang
- Department of Endocrinology, Institute of Translational Medicine, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, Guangdong, China
| | - Zuhui Pu
- Imaging Department, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, Guangdong, China
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4
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Oppler SH, Hocum Stone LL, Leishman DJ, Janecek JL, Moore MEG, Rangarajan P, Willenberg BJ, O’Brien TD, Modiano J, Pheil N, Dalton J, Dalton M, Ramachandran S, Graham ML. A bioengineered artificial interstitium supports long-term islet xenograft survival in nonhuman primates without immunosuppression. SCIENCE ADVANCES 2024; 10:eadi4919. [PMID: 38181083 PMCID: PMC10776017 DOI: 10.1126/sciadv.adi4919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 12/02/2023] [Indexed: 01/07/2024]
Abstract
Cell-based therapies hold promise for many chronic conditions; however, the continued need for immunosuppression along with challenges in replacing cells to improve durability or retrieving cells for safety are major obstacles. We subcutaneously implanted a device engineered to exploit the innate transcapillary hydrostatic and colloid osmotic pressure generating ultrafiltrate to mimic interstitium. Long-term stable accumulation of ultrafiltrate was achieved in both rodents and nonhuman primates (NHPs) that was chemically similar to serum and achieved capillary blood oxygen concentration. The majority of adult pig islet grafts transplanted in non-immunosuppressed NHPs resulted in xenograft survival >100 days. Stable cytokine levels, normal neutrophil to lymphocyte ratio, and a lack of immune cell infiltration demonstrated successful immunoprotection and averted typical systemic changes related to xenograft transplant, especially inflammation. This approach eliminates the need for immunosuppression and permits percutaneous access for loading, reloading, biopsy, and recovery to de-risk the use of "unlimited" xenogeneic cell sources to realize widespread clinical translation of cell-based therapies.
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Affiliation(s)
- Scott H. Oppler
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | | | - David J. Leishman
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Jody L. Janecek
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Meghan E. G. Moore
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MN, USA
| | | | - Bradley J. Willenberg
- Department of Internal Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Timothy D. O’Brien
- Department of Veterinary Population Medicine, University of Minnesota, St. Paul, MN, USA
| | - Jaime Modiano
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, MN, USA
| | - Natan Pheil
- Cell-Safe LifeSciences, Skokie, IL, USA
- Medline UNITE Foot and Ankle, Medline Industries LP, 3 Lakes Drive, Northfield, IL, USA
| | | | | | | | - Melanie L. Graham
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA
- Department of Veterinary Population Medicine, University of Minnesota, St. Paul, MN, USA
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Tinklepaugh J, Mamrak NE. Imaging in Type 1 Diabetes, Current Perspectives and Directions. Mol Imaging Biol 2023; 25:1142-1149. [PMID: 37934378 DOI: 10.1007/s11307-023-01873-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/12/2023] [Accepted: 10/30/2023] [Indexed: 11/08/2023]
Abstract
Type 1 diabetes (T1D) is characterized by the autoimmune-mediated attack of insulin-producing beta cells in the pancreas, leading to reliance on exogenous insulin to control a patient's blood glucose levels. As progress is being made in understanding the pathophysiology of the disease and how to better develop therapies to treat it, there is an increasing need for monitoring technologies to quantify beta cell mass and function throughout T1D progression and beta cell replacement therapy. Molecular imaging techniques offer a possible solution through both radiologic and non-radiologic means including positron emission tomography, magnetic resonance imaging, electron paramagnetic resonance imaging, and spatial omics. This commentary piece outlines the role of molecular imaging in T1D research and highlights the need for further applications of such methodologies in T1D.
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Affiliation(s)
- Jay Tinklepaugh
- Research Department, JDRF, 200 Vesey Street, New York, NY, USA
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6
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Stabler CL, Russ HA. Regulatory approval of islet transplantation for treatment of type 1 diabetes: Implications and what is on the horizon. Mol Ther 2023; 31:3107-3108. [PMID: 37865099 PMCID: PMC10638039 DOI: 10.1016/j.ymthe.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/09/2023] [Accepted: 10/09/2023] [Indexed: 10/23/2023] Open
Affiliation(s)
- Cherie L Stabler
- J. Crayton Pruitt Family Department of Biomedical Engineering, Herbert Wertheim College of Engineering, University of Florida, Gainesville, FL 32611, USA; Diabetes Institute, University of Florida, Gainesville, FL 32610, USA.
| | - Holger A Russ
- Department of Pharmacology and Therapeutics, College of Medicine, University of Florida, Gainesville, FL 32610, USA; Diabetes Institute, University of Florida, Gainesville, FL 32610, USA.
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Macon EL, Devore MH, Lin YK, Music MB, Wooten M, McMullen CA, Woodcox AM, Marksbury AR, Beckner Z, Patel BV, Schoeder LA, Iles AN, Fisher SJ. Current and future therapies to treat impaired awareness of hypoglycemia. Front Pharmacol 2023; 14:1271814. [PMID: 37942482 PMCID: PMC10628050 DOI: 10.3389/fphar.2023.1271814] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/05/2023] [Indexed: 11/10/2023] Open
Abstract
In order to achieve optimal glycemic control, intensive insulin regimes are needed for individuals with Type 1 Diabetes (T1D) and insulin-dependent Type 2 Diabetes (T2D). Unfortunately, intensive glycemic control often results in insulin-induced hypoglycemia. Moreover, recurrent episodes of hypoglycemia result in both the loss of the characteristic warning symptoms associated with hypoglycemia and an attenuated counterregulatory hormone responses. The blunting of warning symptoms is known as impaired awareness of hypoglycemia (IAH). Together, IAH and the loss of the hormonal response is termed hypoglycemia associated autonomic failure (HAAF). IAH is prevalent in up to 25% in people with T1D and up to 10% in people with T2D. IAH and HAAF increase the risk of severe hypoglycemia 6-fold and 25-fold, respectively. To reduce this risk for severe hypoglycemia, multiple different therapeutic approaches are being explored that could improve awareness of hypoglycemia. Current therapies to improve awareness of hypoglycemia include patient education and psychoeducation, the use of novel glycemic control technology, pancreas/islet transplantation, and drug therapy. This review examines both existing therapies and potential therapies that are in pre-clinical testing. Novel treatments that improve awareness of hypoglycemia, via improving the counterregulatory hormone responses or improving hypoglycemic symptom recognition, would also shed light on the possible neurological mechanisms that lead to the development of IAH. To reduce the risk of severe hypoglycemia in people with diabetes, elucidating the mechanism behind IAH, as well as developing targeted therapies is currently an unmet need for those that suffer from IAH.
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Affiliation(s)
- Erica L. Macon
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Micah H. Devore
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Yu Kuei Lin
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Megan B. Music
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Mason Wooten
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Colleen A. McMullen
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Andrea M. Woodcox
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Ashlee R. Marksbury
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Zachary Beckner
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Bansi V. Patel
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Lily A. Schoeder
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Ashley N. Iles
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Simon J. Fisher
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, United States
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Buemi A, Mouard NI, Darius T, Devresse A, Kanaan N, Gianello P, Mourad M. Continuous vs. discontinuous purification of isolated human islets: functional and morphological comparison. Front Endocrinol (Lausanne) 2023; 14:1195545. [PMID: 37455917 PMCID: PMC10348810 DOI: 10.3389/fendo.2023.1195545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/09/2023] [Indexed: 07/18/2023] Open
Abstract
Background The COBE 2991 cell processor, commonly used for pancreatic islet isolation, is no longer distributed in Europe, leading to a search for alternative purification procedures with equivalent efficacy. The aim of this study was to evaluate the efficacy of an alternative method based on the discontinuous purification of islets. Methods The conventional isolation procedure using a standard continuous islet purification with COBE 2991 of n = 4 human pancreas was compared to n = 8 procedures using a discontinuous purification with a "bottle" method from donors of similar characteristics. Islet equivalents, purity, and dynamic glucose-stimulated insulin secretion were evaluated. Results A similar islet yield was obtained using continuous vs. discontinuous purification methods (76,292.5 ± 40,550.44 vs. 79,625 ± 41,484.46 islet equivalents, p = 0.89). Islets from both groups had similar purity (78.75% ± 19.73% vs. 55% ± 18.16%, p = 0.08) and functionality both in terms of stimulation index (3.31 ± 0.83 vs. 5.58 ± 3.38, p = 0.22) and insulin secretion (1.26 ± 0.83 vs. 1.53 ± 1.40 mean AUC, p = 0.73). Moreover, the size of the islets was significantly larger in the discontinuous vs. continuous purification group (19.2% ± 10.3% vs. 45.4% ± 18.8% of islets less than 100 µm, p = 0.0097 and 23.7% ± 5.3% vs. 15.6% ± 5.8% of 200-250 µm islet size, p = 0.03). Conclusion Compared to the conventional purification procedure, discontinuous purification with a bottle method shows similar results with regard to isolation yield and islet secretory function. Furthermore, this alternative technique allows for obtaining larger islets.
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Affiliation(s)
- Antoine Buemi
- Department of Surgery, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Surgery and Abdominal Transplantation Unit, Brussels, Belgium
| | - Nizar I. Mouard
- Pôle de chirurgie expérimentale et transplantation, Université catholique de Louvain, Brussels, Belgium
| | - Tom Darius
- Department of Surgery, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Surgery and Abdominal Transplantation Unit, Brussels, Belgium
| | - Arnaud Devresse
- Department of Surgery, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Surgery and Abdominal Transplantation Unit, Brussels, Belgium
- Department of Internal Medicine, Nephrology Division, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Nada Kanaan
- Department of Internal Medicine, Nephrology Division, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Pierre Gianello
- Pôle de chirurgie expérimentale et transplantation, Université catholique de Louvain, Brussels, Belgium
| | - Michel Mourad
- Department of Surgery, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Surgery and Abdominal Transplantation Unit, Brussels, Belgium
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Chetboun M, Drumez E, Ballou C, Maanaoui M, Payne E, Barton F, Kerr-Conte J, Vantyghem MC, Piemonti L, Rickels MR, Labreuche J, Pattou F. Association between primary graft function and 5-year outcomes of islet allogeneic transplantation in type 1 diabetes: a retrospective, multicentre, observational cohort study in 1210 patients from the Collaborative Islet Transplant Registry. Lancet Diabetes Endocrinol 2023; 11:391-401. [PMID: 37105208 PMCID: PMC10388704 DOI: 10.1016/s2213-8587(23)00082-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 03/04/2023] [Accepted: 03/06/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Allogeneic islet transplantation is a validated therapy in type 1 diabetes; however, there is decline of transplanted islet graft function over time and the mechanisms underlying this decline are unclear. We evaluated the distinct association between primary graft function (PGF) and 5-year islet transplantation outcomes. METHODS In this retrospective, multicentre, observational cohort study, we enrolled all patients from the Collaborative Islet Transplant Registry who received islet transplantation alone (ITA recipients) or islet-after-kidney transplantation (IAK recipients) between Jan 19, 1999, and July 17, 2020, with a calculable PGF (exposure of interest), measured 28 days after last islet infusion with a validated composite index of islet graft function (BETA-2 score). The primary outcome was cumulative incidence of unsuccessful islet transplantation, defined as an HbA1c of 7·0% (53 mmol/mol) or higher, or severe hypoglycaemia (ie, requiring third-party intervention to correct), or a fasting C-peptide concentration of less than 0·2 ng/mL. Secondary outcomes were graft exhaustion (fasting C-peptide <0·3 ng/mL); inadequate glucose control (HbA1c ≥7·0% [53 mmol/mol] or severe hypoglycaemia); and requirement for exogenous insulin therapy (≥14 consecutive days). Associations between PGF and islet transplantation outcomes were explored with a competing risk analysis adjusted for all covariates suspected or known to affect outcomes. A predictive model based on PGF was built and internally validated by using bootstraps resampling method. FINDINGS In 39 centres worldwide, we enrolled 1210 patients with a calculable PGF (of those without missing data, mean age 47 years [SD 10], 712 [59·5%] were female, and 865 (97·9%) were White), who received a median of 10·8 thousand islet-equivalents per kg of bodyweight (IQR 7·4-13·5). 986 (82·4%) were ITA recipients and 211 (17·6%) were IAK recipients. Of 1210 patients, 452 (37·4%) received a single islet infusion and 758 (62·6%) received multiple islet infusions. Mean PGF was 14·3 (SD 8·8). The 5-year cumulative incidence of unsuccessful islet transplantation was 70·7% (95% CI 67·2-73·9), and was inversely and linearly related to PGF, with an adjusted subhazard ratio (sHR) of 0·77 (95% CI 0·72-0·82) per 5-unit increase of BETA-2 score (p<0·0001). Secondary endpoints were similarly related to PGF. The model-adjusted median C-statistic values of PGF for predicting 5-year cumulative incidences of unsuccessful islet transplantation, graft exhaustion, inadequate glucose control, and exogenous insulin therapy were 0·70 (range 0·69-0·71), 0·76 (0·74-0·77), 0·65 (0·64-0·66), and 0·72 (0·71-0·73), respectively. INTERPRETATION This global multicentre study reports a linear and independent association between PGF and 5-year clinical outcomes of islet transplantation. The main study limitations are its retrospective design and the absence of analysis of complications. FUNDING Public Health Service Research, National Institutes of Health, Juvenile Diabetes Research Foundation International, Agence National de la Recherche, Fondation de l'Avenir, and Fonds de Dotation Line Renaud-Loulou Gasté.
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Affiliation(s)
- Mikaël Chetboun
- Université Lille, U1190 Translational Research for Diabetes, INSERM, Institut Pasteur de Lille, Lille, France; CHU Lille, Department of General and Endocrine Surgery, Lille, France
| | - Elodie Drumez
- CHU Lille, ULR 2694 Évaluation des technologies de santé et des pratiques médicales (METRICS), Lille, France
| | - Cassandra Ballou
- Collaborative Islet Transplant Registry, The EMMES Company, Rockville, MD, USA
| | - Mehdi Maanaoui
- Université Lille, U1190 Translational Research for Diabetes, INSERM, Institut Pasteur de Lille, Lille, France; CHU Lille, Department of Nephrology, Lille, France
| | - Elizabeth Payne
- Collaborative Islet Transplant Registry, The EMMES Company, Rockville, MD, USA
| | - Franca Barton
- Collaborative Islet Transplant Registry, The EMMES Company, Rockville, MD, USA
| | - Julie Kerr-Conte
- Université Lille, U1190 Translational Research for Diabetes, INSERM, Institut Pasteur de Lille, Lille, France
| | - Marie-Christine Vantyghem
- Université Lille, U1190 Translational Research for Diabetes, INSERM, Institut Pasteur de Lille, Lille, France; CHU Lille, Department of Endocrinology, Diabetology, and Metabolism, Lille, France
| | - Lorenzo Piemonti
- Diabetes Research Institute, IRCCS, Ospedale San Raffaele, 20132 Milan, Italy
| | - Michael R Rickels
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Institute for Diabetes, Obesity, and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Julien Labreuche
- CHU Lille, ULR 2694 Évaluation des technologies de santé et des pratiques médicales (METRICS), Lille, France
| | - François Pattou
- Université Lille, U1190 Translational Research for Diabetes, INSERM, Institut Pasteur de Lille, Lille, France; CHU Lille, Department of General and Endocrine Surgery, Lille, France.
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