Original Article
Islet Transplantation in Seven Patients with Type 1 Diabetes Mellitus Using a Glucocorticoid-Free Immunosuppressive Regimen
N Engl J Med 2000; 343:230-238July 27, 2000
- Abstract
Background
Registry data on patients with type 1 diabetes mellitus who undergo pancreatic islet transplantation indicate that only 8 percent are free of the need for insulin therapy at one year.
Methods
Seven consecutive patients with type 1 diabetes and a history of severe hypoglycemia and metabolic instability underwent islet transplantation in conjunction with a glucocorticoid-free immunosuppressive regimen consisting of sirolimus, tacrolimus, and daclizumab. Islets were isolated by ductal perfusion with cold, purified collagenase, digested and purified in xenoprotein-free medium, and transplanted immediately by means of a percutaneous transhepatic portal embolization.
Results
All seven patients quickly attained sustained insulin independence after transplantation of a mean (±SD) islet mass of 11,547±1604 islet equivalents per kilogram of body weight (median follow-up, 11.9 months; range, 4.4 to 14.9). All recipients required islets from two donor pancreases, and one required a third transplant from two donors to achieve sustained insulin independence. The mean glycosylated hemoglobin values were normal after transplantation in all recipients. The mean amplitude of glycemic excursions (a measure of fluctuations in blood glucose concentrations) was significantly decreased after the attainment of insulin independence (from 198±32 mg per deciliter [11.1±1.8 mmol per liter] before transplantation to 119±37 mg per deciliter [6.7±2.1 mmol per liter] after the first transplantation and 51±30 mg per deciliter [2.8±1.7 mmol per liter] after the attainment of insulin independence; P<0.001). There were no further episodes of hypoglycemic coma. Complications were minor, and there were no significant increases in lipid concentrations during follow-up.
Conclusions
Our observations in patients with type 1 diabetes indicate that islet transplantation can result in insulin independence with excellent metabolic control when glucocorticoid-free immunosuppression is combined with the infusion of an adequate islet mass.
Media in This Article
Figure 1
Length of Follow-up after the Initial Islet Transplantation and the Time at Which Subsequent Transplantations Were Performed.Figure 3
Fluctuations in Blood Glucose Concentrations over a 24-Hour Period One Month before Transplantation (Panel A) and after the Attainment of Insulin Independence (Panel B) in a Representative Patient.Article Activity
- Article
Islet transplantation has been investigated as a treatment for type 1 diabetes mellitus in selected patients with inadequate glucose control despite insulin therapy. However, the perennial hope that such an approach would result in long-term freedom from the need for exogenous insulin, with stabilization of the secondary complications of diabetes, has failed to materialize in practice. Of the 267 allografts transplanted since 1990, only 12.4 percent have resulted in insulin independence for periods of more than one week, and only 8.2 percent have done so for periods of more than one year.1 In the majority of these procedures, the regimen of immunosuppression consisted of antibody induction with an antilymphocyte globulin combined with cyclosporine, azathioprine, and glucocorticoids.1
In the past 10 years, techniques for isolating large numbers of human islets have advanced, permitting renewed attempts at islet transplantation.2,3 With the increase in the availability of new and more potent immunosuppressive agents, strategies can now be developed specifically for islet transplantation that will provide greater immunologic protection without diabetogenic side effects.
For any type of transplantation procedure, a balance is sought between efficacy and toxicity. With respect to islet transplantation a further difficulty is that many of the current agents damage beta cells or induce peripheral insulin resistance.4 To address this problem, we developed a glucocorticoid-free immunosuppressive protocol that includes sirolimus, low-dose tacrolimus, and a monoclonal antibody against the interleukin-2 receptor (daclizumab) for use in a trial of islet transplantation alone for patients with brittle type 1 diabetes. Most previous islet transplantations have been performed in combination with kidney transplantation in patients with end-stage diabetic nephropathy.1 We limited our procedure to islet transplantation alone and in doing so selected patients who had severe hypoglycemia (defined as multiple hypoglycemic episodes) or uncontrolled diabetes despite compliance with an insulin regimen.
Methods
Patients
Patients who were considered to have had type 1 diabetes for more than five years on the basis of a stimulated serum C-peptide concentration of less than 0.48 ng per milliliter (0.16 nmol per liter) were eligible to undergo islet transplantation if their serum glucose concentrations remained uncontrolled despite exogenous insulin therapy. Patients also had to have recurrent severe hypoglycemia with coma or metabolic instability to such an extent that the global risk of transplantation and immunosuppression was judged to be less than the risk of continued uncontrolled diabetes. All protocols were approved by the health research ethics board of the University of Alberta, and each patient gave written informed consent.
Glucocorticoid-Free Immunosuppression
Immunosuppression was initiated immediately before transplantation. Sirolimus (Rapamune, Wyeth–Ayerst Canada) was given orally at a loading dose of 0.2 mg per kilogram of body weight, followed by a dose of 0.1 mg per kilogram per day, with monitoring of drug levels to maintain them in the range of 12 to 15 ng per milliliter for the first three months and in the range of 7 to 10 ng per milliliter thereafter. Low-dose tacrolimus (Prograf, Fujisawa Canada) was given orally at an initial dose of 1 mg twice daily, and the dose was subsequently adjusted to maintain a trough concentration at 12 hours of 3 to 6 ng per milliliter (IMX enzyme immunoassay, Abbott). Daclizumab (Zenapax, Roche Canada) was given intravenously at a dose of 1 mg per kilogram every 14 days for a total of five doses. If the second transplantation procedure occurred more than 10 weeks after the first, the course of daclizumab was repeated. No glucocorticoids were given at any time during the trial.
Conditioning Regimen and Post-Transplantation Therapy
As soon as there were sufficient numbers of islets for transplantation, the patient was given intravenous antibiotics prophylactically (500 mg of vancomycin and 500 mg of imipenem), and oral supplementation with vitamin E (800 IU per day), vitamin B6 (100 mg per day), and vitamin A (25,000 IU per day) was initiated.5 Inhaled pentamidine (300 mg once a month) was given after transplantation to prevent infection with Pneumocystis carinii, and oral ganciclovir (1 g three times per day) was given for 14 weeks after transplantation irrespective of the patient's cytomegalovirus status to reduce the risk of graft loss6,7 and to protect against lymphoproliferative disorder.8
Islet Preparation
Pancreases were removed from brain-dead donors and stored in chilled University of Wisconsin solution after informed consent had been obtained from the donors' relatives. Donors were selected according to the results of a multivariate analysis of factors that influence the success of islet isolation.9
To isolate the islets, the ducts were perfused in a controlled fashion with a cold enzyme (Liberase human islet, Roche). The islets were then separated by gentle mechanical dissociation and purified with the use of continuous gradients of Ficoll–diatrizoic acid (Seromed-Biochrom) in an apheresis system (model 2991, Cobe Laboratories).2,3,10-13 The use of xenoprotein products (such as fetal-calf serum) was avoided during islet isolation and purification, and 25 percent human albumin was used instead. To minimize the risk of islet injury as a result of cold ischemia, we transplanted freshly prepared islets immediately after harvesting them, thus eliminating the need for islet culture.
Samples were collected in duplicate for the quantification of the islets, expressed in terms of islet equivalents, the standard unit for reporting variations in the volume of islets, with the use of a standard islet diameter of 150 μm.14 Islet grafts were characterized with respect to cell composition, total cellular insulin, DNA, and the extent of insulin secretion in vitro during a glucose challenge.15 In brief, the islets were incubated for 24 hours at 37°C in CMRL 1066 medium with 10 percent fetal-calf serum and 25 mmol HEPES buffer. A known number of duplicate aliquots of islets were incubated in a low concentration of glucose (50 mg per deciliter [2.8 mmol per liter]) and a high concentration of glucose (360 mg per deciliter [20 mmol per liter]) for two hours, and the amount of insulin generated in response to the high-glucose challenge was divided by the amount generated by the low-glucose challenge to yield the mean insulin-release stimulation index.
Islet Transplantation
Islet preparations that had more than 4000 islet equivalents per kilogram of the recipient's body weight in a packed-tissue volume of less than 10 ml were judged safe for transplantation.16 Each islet preparation from a donor was matched to the recipient's blood type and cross-matched for lymphocytotoxic antibodies, but no attempt at HLA matching was made.
Patients were sedated, and a percutaneous transhepatic approach was used to gain access to the portal vein under fluoroscopic guidance. Once access was confirmed, we used the Seldinger technique to place a 5-French Kumpe catheter within the main portal vein. Portal venous pressure was measured at base line and after islet infusion. The final islet preparation was suspended in 120 ml of medium 199 that contained 500 U of heparin and 20 percent human albumin and was infused over a period of five minutes. In all but the first 2 of the 15 procedures, on completion of the islet infusion, as the catheter was partially removed, gelatin-sponge (Gelfoam) particles were embolized into the peripheral catheter tract in the liver. Doppler ultrasonography of the portal vein and liver-function tests were performed within 24 hours after transplantation.
Assessment of Glycemic Control after Transplantation
Insulin therapy was discontinued after each transplantation and was not resumed unless serum glucose concentrations rose above 200 mg per deciliter (11.1 mmol per liter), in which case another transplantation was performed. Serum glucose concentrations were monitored by memory capillary glucose meters, and the resulting data were analyzed by computer (with Medisense and Precision Link software). To determine the extent of fluctuations in glucose concentrations in each patient, we measured the mean amplitude of glycemic excursions, which was calculated as the mean of the differences in the major fluctuations in high and low glucose values during two 24-hour periods17; a minimum of seven measurements of capillary glucose were obtained (before a meal, two hours after a meal, at bedtime, and at 3 a.m.). The patients also underwent oral glucose-tolerance testing and mixed-meal testing. The homeostatic model assessment was used to calculate insulin sensitivity.18 We also measured glycosylated hemoglobin and serum C-peptide, creatinine, and lipid concentrations.
Statistical Analysis
Results are expressed as means ±SD or, in the case of nonparametric variables, as medians and ranges. Analysis of variance was conducted with use of the Sigmastat program.
Results
Characteristics of the Patients
Seven consecutive patients (median age, 44 years; range, 29 to 54) who had had type 1 diabetes mellitus for a median of 35 years (range, 18 to 50) underwent islet transplantation between March 11, 1999, and January 23, 2000. As of June 2000, the median duration of follow-up was 11.9 months (range, 4.4 to 14.9). In all seven patients, exogenous insulin therapy quickly became unnecessary once sufficient numbers of islets were transplanted. At the time of the most recent follow-up, all patients remained free of the need for exogenous insulin. The patient who received the smallest number of islets (Patient 1) has briefly required 4 to 10 U of insulin per day on four occasions during times of stress from intercurrent illness. One patient required a total of 7 U of insulin on a single occasion during a two-day illness.
There have been no episodes of acute cellular rejection, as determined by measurements of glycemic control, serum insulin, and C peptide. None of the patients have died. Six of the seven required a second islet infusion from a second donor pancreas a median of 29 days (range, 14 to 70) after the first procedure (Figure 1Figure 1
Length of Follow-up after the Initial Islet Transplantation and the Time at Which Subsequent Transplantations Were Performed.) to become insulin independent. One patient, the most obese (weight, 93 kg), required a third infusion to achieve insulin independence. The third infusion combined islets from two donors because of mechanical failure in one of the purification runs.All patients had had repeated episodes of severe hypoglycemia before transplantation but have had no further episodes since transplantation. This change has dramatically improved their quality of life.
The mean (±SD) total number of islets required to induce insulin independence was 11,547±1604 islet equivalents per kilogram of the recipient's body weight, with a mean total beta-cell mass per transplant of 132±67×106 (Table 1Table 1
Characteristics of the Islet Allografts.). A mean packed-cell volume of 3.5±1.3 ml was infused, and this did not change the portal pressure significantly (mean increase, 0.8 mm Hg; P=0.8). The results of tests of liver function 24 hours after transplantation were within the normal range. Doppler ultrasonography demonstrated no evidence of thrombus within the portal vein in any of the patients. The patients were hospitalized for a median of 2.3 days (range, 0.5 to 14.7), and three patients who underwent transplantation most recently (40 percent) were discharged within 24 hours after the procedure.Glycemic Control and Serum C-Peptide Concentrations after Islet Transplantation
Insulin requirements decreased in all patients after the first transplantation (Figure 2Figure 2
Mean (±SE) 24-Hour Blood Glucose Concentrations (Panel A), Mean (±SE) Daily Insulin Requirements (Panel B), Mean (±SE) Amplitude of Glycemic Excursions (Panel C), and Mean Percentage of Glucose Values That Fell within a Given Range (Panel D) Three Days before the First Islet Transplantation, Three Days before the Second Transplantation, One Week after the Attainment of Insulin Independence, and at the Most Recent Follow-up Visit.). Computer analysis of data from capillary glucose meters showed a marked improvement in glycemic control in all patients. Overall mean serum glucose concentrations decreased and the mean amplitude of glycemic excursions decreased significantly with sequential islet transplantation (Figure 2). The lability of glycemic control in a 24-hour period also decreased dramatically (Figure 3Figure 3Fluctuations in Blood Glucose Concentrations over a 24-Hour Period One Month before Transplantation (Panel A) and after the Attainment of Insulin Independence (Panel B) in a Representative Patient.). All patients had normal glycosylated hemoglobin values after transplantation (Table 2Table 2
Results of Assessments of Oral Glucose Tolerance, Mixed-Meal Tolerance, Glycosylated Hemoglobin Values, and Serum Creatinine and Lipid Concentrations before and after Transplantation.). Serum C-peptide concentrations were undetectable in all patients before transplantation (less than 0.48 ng per milliliter after an overnight fast and in response to the mixed-meal test). Three months and six months after transplantation all patients had detectable serum C-peptide concentrations (P<0.001 by analysis of variance for the comparison with values before transplantation), and the concentrations did not decrease over time: at three months, the mean fasting value was 2.4±0.3 ng per milliliter (0.8±0.1 nmol per liter), and the mean value after a meal was 5.7±0.9 ng per milliliter (1.9±0.3 nmol per liter); at six months, the mean fasting value was 2.5±0.2 ng per milliliter (0.8±0.1 nmol per liter), and the mean value after a meal was 5.7±0.6 ng per milliliter (1.9±0.2 nmol per liter).Autoantibody Analyses
Serum was analyzed for anti-insulin antibody, islet-cell antibody 512, and glutamic acid decarboxylase antibody before and after transplantation.19 Mean serum anti-insulin antibody concentrations fell from 0.26±0.06 IU before transplantation to 0.07±0.03 IU after transplantation (P=0.04 by t-test); this change may represent a beneficial effect of systemic immunosuppression. Serum glutamic acid decarboxylase antibody was undetectable before and after transplantation. One of four patients for whom data were available was positive for islet-cell antibody 512 before transplantation and remained so after transplantation.
Assessments of Oral Glucose Tolerance, Mixed-Meal Tolerance, and Homeostasis
The results of oral glucose-tolerance tests, completed after insulin independence had been achieved, indicated that none of the seven patients met current American Diabetes Association criteria for diabetes (Table 2).20 However, in five patients, the response to the test at 120 minutes was impaired (glucose, 142 to 195 mg per deciliter [7.9 to 10.8 mmol per liter]), and two had fasting glucose concentrations that were at or above the upper limit of the normal range (110 mg per deciliter [6.1 mmol per liter]).
We used the homeostatic model assessment18 to estimate insulin sensitivity on the basis of paired fasting glucose and insulin data from the transplant recipients after they had achieved insulin independence and from normal subjects without diabetes. The values in the two groups did not differ significantly (103± 14 percent among transplant recipients and 118±12 percent among control subjects, P=0.43).
Transplantation-Related Complications
None of the patients have had cytomegalovirus infection, despite the fact that four were seronegative for the virus before transplantation and received an allograft from a seropositive donor. In the first 2 of the 15 procedures, moderate bleeding occurred at the site of the transhepatic puncture and required transfusion. This complication was subsequently avoided by injecting a Gelfoam plug through the catheter and by reducing the intraportal dose of heparin from 5000 to 500 U.
All patients had minor, superficial ulcerations of the buccal mucosa that resolved after the dose of sirolimus was reduced and the capsule formulation of sirolimus was substituted for the liquid form. None of the patients had sirolimus-related cytopenia. After transplantation, there were no significant increases in lipid concentrations and no patient required lipid-lowering therapy (Table 2). There were no significant changes in serum concentrations of creatinine (P=0.92), cholesterol (P=0.90), or triglycerides (P=0.46) during follow-up (Table 2). As of this writing, there has been insufficient follow-up for us to perform a prospective evaluation of secondary diabetic complications.
Discussion
We found that in patients with type 1 diabetes the use of a glucocorticoid-free immunosuppressive protocol in conjunction with islet transplantation quickly resulted in sustained freedom from the need for exogenous insulin. Our results represent an improvement in outcome as compared with previous reports.1 Transplantation of an initial, suboptimal islet mass halted the episodes of severe hypoglycemia in our patients. Sirolimus, low-dose tacrolimus, and daclizumab provided effective immunosuppression, with no apparent diabetogenic or toxic effects. Indeed, there were no clinically evident episodes of graft rejection, and this combination appears to be effective in preventing autoimmune recurrence of diabetes.
A recent review of the potential barriers to insulin independence after islet transplantation identified several factors.21 The number of beta cells may be inadequate owing to insufficient engraftment of islets and immediate cellular loss through apoptosis and other nonimmune-mediated inflammatory pathways.22,23 The graft may be rejected as a result of ineffective immunosuppression of both alloimmune and autoimmune pathways.24 This event is hard to identify initially, given the lack of tools available for the early diagnosis of rejection.25 The high metabolic demand on the islets that results from preexisting insulin resistance in most patients who undergo combined islet and kidney transplantation is aggravated by the use of diabetogenic immunosuppressant agents.4,26 We addressed each of these key factors by transplanting an adequate number of viable, well-characterized islets, which had been prepared in xenoprotein-free medium, and minimizing the duration of cold ischemia. Nonspecific coating of islets by a xenoprotein could theoretically target such cells for immediate destruction. The immunosuppressive regimen that we used protected against alloimmune and autoimmune reactivity. The use of a glucocorticoid-free protocol that included low-dose tacrolimus and daclizumab further minimized the possibility of damaging beta cells and increasing insulin resistance.
Interest in the use of sirolimus increased when its molecular structure was found to be similar to that of tacrolimus.27 Sirolimus-based trials of kidney transplantation reported a substantial reduction in the rate of acute rejection with minimal nephrotoxicity.28,29 Preclinical studies of the use of sirolimus with islet transplantation reported prolonged allograft survival and enhanced autograft function.30,31 In vitro studies suggested that sirolimus and tacrolimus could not be used in combination, since both drugs bind to the same cytosolic binding proteins (FKBP-12 and FKBP-25).32 This interaction does not occur when the two are used in vivo, and indeed, there is a strong synergistic potentiation of efficacy.33,34 The combination of sirolimus, low-dose tacrolimus, and glucocorticoids in liver, kidney, and pancreas transplantation has been associated with extremely low rates of rejection.35
To avoid the diabetogenic effect of glucocorticoids in islet transplantation, we replaced them with daclizumab. This monoclonal antibody against the interleukin-2 receptor has been shown to be safe and effective in renal transplantation, and its use lowered the rates of rejection.36 Daclizumab therapy is given over a 10-week period, thus allowing an extended period for a supplemental islet-transplant procedure. The combined glucocorticoid-free strategy of tacrolimus, sirolimus, and daclizumab therapy prevents activation of the immune cascade by inhibiting T-cell activation, the production of interleukin-2 and other cytokines, binding of the interleukin-2 receptor to its ligand, and the clonal expansion of lymphocytes.37
Our findings show that an infusion of islets from a single donor (a mean of 389,016±73,769 islet equivalents in the first transplant) did not result in insulin independence. Since glucocorticoids were not used and thus did not exert any adverse effects on islet function, other factors must be involved. The quantity of islets required to achieve insulin independence is approximately double that reported previously.1 Recently, one center achieved insulin independence in 14.3 percent of patients after the transplantation of islets from a single donor, but insulin was not withdrawn until a mean of 10.6 months after transplantation.38 In our study the need for more than one donor pancreas per recipient may be interpreted as a drawback, given the shortage of donors. At present, however, less than one third of available cadaveric pancreases are actually transplanted (United Network for Organ Sharing Registry: unpublished data).
In patients with type 1 diabetes, glycemic control can also be achieved with intensive insulin therapy and pancreatic transplantation. Intensive insulin therapy does not normalize glycosylated hemoglobin values and may cause severe hypoglycemia.39 Pancreatic transplantation provides excellent glycemic control, and although the outcome of the procedure has improved dramatically over the past decade, it remains an invasive procedure with a substantial risk of morbidity.40 Our findings indicate that islet transplantation alone is associated with a minimal risk and results in good metabolic control, with normalization of glycosylated hemoglobin values and sustained freedom from the need for exogenous insulin.
Supported by the Alberta Foundation for Diabetes Research, by a grant from the Medical Research Council–Juvenile Diabetes Foundation, by the Alberta Health Services Research Innovation Fund, by institutional support from the University of Alberta Hospitals Capital Health Authority, by the Muttart Diabetes Research and Training Centre, and by the Edmonton Civic Employees Charitable Assistance Fund, by the C.F. (“Curly”) MacLachlan and Gladys B. MacLachlan Fund, and by the University Hospital Foundation. Drs. Lakey and Korbutt are recipients of scholarships from the Canadian Diabetes Association and the Alberta Heritage Foundation for Medical Research. Drs. Warnock and Kneteman are Senior Scholars of the Alberta Heritage Foundation for Medical Research.
We are indebted to Roche Canada, Wyeth–Ayerst Canada, and Fujisawa Canada for their generous gifts of daclizumab, sirolimus, and tacrolimus, respectively; to all the technical staff members of the human islet transplant laboratory, including Dr. Tatsuya Kin, for their expertise; to Barbara Waters and Ingrid Larsen (islet transplantation coordinators) for excellent patient care; to Dr. Dalila Barama, Dawn Saik, Sharleen Imes, and the staff members of the clinical investigation unit and the University of Alberta Hospitals metabolic center for assistance with metabolic monitoring of patients; to our colleagues in interventional radiology for their assistance; to the organ-procurement programs in Alberta and across Canada for identifying cadaveric donors; to Dr. George Eisenbarth, Barbara Davis Diabetes Center, Denver, for assistance with the evaluation of autoimmune markers; and to Dr. Jonathan Levy, Radcliffe Infirmary, Oxford, United Kingdom, for providing the Homadisk program.
Source Information
From the Surgical–Medical Research Institute and the Department of Surgery (A.M.J.S., J.R.T.L., G.S.K., G.L.W., N.M.K., R.V.R.) and the Department of Medicine (E.A.R., E.T.), University of Alberta, Edmonton, Alta., Canada.
Address reprint requests to Dr. Shapiro at 2D4.37 Department of Surgery, University of Alberta Hospitals, Mackenzie Health Sciences Center, 8440 112 St., Edmonton, AB T6G 2B7, Canada, or at amjs@powersurfr.com.
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- Citing Articles (1385)
Citing Articles
1
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Juan L. Contreras, Cheryl A. Smyth, Guadalupe Bilbao, Christopher Eckstein, Carlton J. Young, J. Anthony Thompson, David T. Curiel, Devin E. Eckhoff. (2003) Coupling endoplasmic reticulum stress to cell death program in isolated human pancreatic islets: effects of gene transfer of Bcl-2. Transplant International 16:7, 537-542
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Juan L. Contreras, Hongju Wu, Cheryl A. Smyth, Christopher P. Eckstein, Carlton J. Young, Toshiro Seki, Guadalupe Bilbao, David T. Curiel, Devin E. Eckhoff. (2003) DOUBLE GENETIC MODIFICATION OF ADENOVIRUS FIBER WITH RGD POLYLYSINE MOTIFS SIGNIFICANTLY ENHANCES GENE TRANSFER TO ISOLATED HUMAN PANCREATIC ISLETS1. Transplantation 76:1, 252-261
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James F. Markmann, Shaoping Deng, Xiaolun Huang, Niraj M. Desai, Ergun H. Velidedeoglu, Chengyang Lui, Adam Frank, Eileen Markmann, Maral Palanjian, Kenneth Brayman, Bryan Wolf, Ewan Bell, Marko Vitamaniuk, Nicolai Doliba, Franz Matschinsky, Clyde F. Barker, Ali Naji. (2003) Insulin Independence Following Isolated Islet Transplantation and Single Islet Infusions. Annals of Surgery 237:6, 741-750
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Christian Toso, Jose Oberholzer, Ion Ceausoglu, Frederic Ris, Bertrand Rochat, Annemie Rehor, Pascal Bucher, Christine Wandrey, Ute Schuldt, Jacques Belenger, Domenico Bosco, Philippe Morel, David Hunkeler. (2003) Intra-portal injection of 400-mum microcapsules in a large-animal model. Transplant International 16:6, 405-410
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Kupa K. Bilolo, Jun Ouyang, Xiang Wang, Shengyun Zhu, Wenlei Jiang, Shijie Qi, Dasheng Xu, Marie J. Hebert, Ihor Bekersky, William E. Fitzsimmons, Huifang Chen. (2003) Synergistic effects of malononitrilamides (FK778, FK779) with tacrolimus (FK506) in prevention of acute heart and kidney allograft rejection and reversal of ongoing heart allograft rejection in the rat1. Transplantation 75:11, 1881-1887
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James F. Markmann, Shaoping Deng, Niraj M. Desai, Xiaolun Huang, Ergun Velidedeoglu, Adam Frank, Chengyang Liu, Kenneth L. Brayman, Moh Moh Lian, Bryan Wolf, Ewan Bell, Marko Vitamaniuk, Nicolai Doliba, Franz Matschinsky, Eileen Markmann, Clyde F. Barker, Ali Naji. (2003) The use of non-heart-beating donors for isolated pancreatic islet transplantation. Transplantation 75:9, 1423-1429
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Thomas Laumonier, Nicolas Potiron, Françoise Boeffard, Carine Chagneau, Sophie Brouard, Cécile Guillot, Jean-Paul Soulillou, Ignacio Anegon, Brigitte Le Mauff. (2003) CTLA4Ig Adenoviral Gene Transfer Induces Long-Term Islet Rat Allograft Survival, Without Tolerance, After Systemic but Not Local Intragraft Expression. Human Gene Therapy 14:6, 561-575
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Peter G. Stock. (2003) The Year in Review - ATC 2002. American Journal of Transplantation 3:4, 373-380
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Jan P. Lerut. (2003) Avoiding steroids in solid organ transplantation. Transplant International 16:4, 213-224
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Riccardo Calafiore. (2003) Alginate microcapsules for pancreatic islet cell graft immunoprotection: struggle and progress towards the final cure for type 1 diabetes mellitus. Expert Opinion on Biological Therapy 3:2, 201-205
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Paolo Fiorina, Franco Folli, Paola Maffi, Claudia Placidi, Massimo Venturini, Giovanna Finzi, Federico Bertuzzi, Alberto Davalli, Armando D???Angelo, Carlo Socci, Chiara Gremizzi, Elena Orsenigo, Stefano la Rosa, Maurilio Ponzoni, Massimo Cardillo, Mario Scalamogna, Alessandro del Maschio, Carlo Capella, Valerio di Carlo, Antonio Secchi. (2003) Islet transplantation improves vascular diabetic complications in patients with diabetes who underwent kidney transplantation: a comparison between kidney-pancreas and kidney-alone transplantation1. Transplantation 75:8, 1296-1301
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Yoshiichiroh Nakamura, Yohichi Yasunami, Masayuki Satoh, Eiji Hirakawa, Hitoshi Katsuta, Junko Ono, Masafumi Kamada, Satoru Todo, Toshinori Nakayama, Masaru Taniguchi, Seiyo Ikeda. (2003) Acceptance of islet allografts in the liver of mice by blockade of an inducible costimulator1. Transplantation 75:8, 1115-1118
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A. N. Balamurugan, Yuanjun Gu, Yasuhiko Tabata, Masaaki Miyamoto, Wanxing Cui, Hiroshi Hori, Akira Satake, Natsuki Nagata, Wenjing Wang, Kazutomo Inoue. (2003) Bioartificial Pancreas Transplantation at Prevascularized Intermuscular Space: Effect of Angiogenesis Induction on Islet Survival. Pancreas 26:3, 279-285
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Dwaine F Emerich. (2002) Islet transplantation for diabetes: current status and future prospects. Expert Opinion on Biological Therapy 2:8, 793-803
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Maikel P Peppelenbosch, C Arnold Spek. (2002) Type I diabetes: a role for tissue factor in pancreatic islet transplantation?. The Lancet 360:9350, 1999-2000
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L Moberg, H Johansson, A Lukinius, C Berne, A Foss, R Källen, Ø Østraat, K Salmela, A Tibell, G Tufveson, G Elgue, K Nilsson Ekdahl, O Korsgren, B Nilsson. (2002) Production of tissue factor by pancreatic islet cells as a trigger of detrimental thrombotic reactions in clinical islet transplantation. The Lancet 360:9350, 2039-2045
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Rene Schramm, Claudia Scheuer, Junichiro Yamauchi, Brigitte Vollmar, Michael D. Menger. (2002) Heat shock preconditioning impairs revascularization of freely transplanted pancreatic islets1. Transplantation 74:11, 1544-1550
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Erin Connor, Masayuki Sakamoto, Kenichi Fujikawa, Terence Law, Nader Rifai. (2002) Measurement of Whole Blood Sirolimus by an HPLC Assay Using Solid-Phase Extraction and UV Detection. Therapeutic Drug Monitoring 24:6, 751-756
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Juan L. Contreras, Cheryl A. Smyth, Guadalupe Bilbao, Carlton J. Young, J. Anthony Thompson, Devin E. Eckhoff. (2002) 17??-Estradiol protects isolated human pancreatic islets against proinflammatory cytokine-induced cell death: molecular mechanisms and islet functionality1. Transplantation 74:9, 1252-1259
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Naoki Kumagai, John J. O???Neil, Rolf N. Barth, John C. LaMattina, Ryu Utsugi, Shannon G. Moran, Shin Yamamoto, Parsia A. Vagefi, Hiroshi Kitamura, Chisako Kamano, David H. Sachs, Kazuhiko Yamada. (2002) Vascularized islet-cell transplantation in miniature swine. I. Preparation of vascularized islet kidneys. Transplantation 74:9, 1223-1230
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Barbara J. Olack, Andrés Jaramillo, Nicholas D. Benshoff, Zahid Kaleem, Carol J. Swanson, Jeffrey A. Lowell, T. Mohanakumar. (2002) Rejection of porcine islet xenografts mediated by CD4+ T cells activated through the indirect antigen recognition pathway. Xenotransplantation 9:6, 393-401
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David J. Kaczorowski, Ethan S. Patterson, William E. Jastromb, Michael J. Shamblott. (2002) Glucose-responsive insulin-producing cells from stem cells. Diabetes/Metabolism Research and Reviews 18:6, 442-450
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Per-Ola Carlsson, Fredrik Palm. (2002) Oxygen tension in isolated transplanted rat islets and in islets of rat whole-pancreas transplants. Transplant International 15:11, 581-585
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Shinichi Matsumoto, Sabrina A. Qualley, Shilpa Goel, Derek K. Hagman, Ian R. Sweet, Vincent Poitout, D. Michael Strong, R. Paul Robertson, Jo Anna Reems. (2002) Effect of the two-layer (University of Wisconsin solution???perfluorochemical plus O2) method of pancreas preservation on human islet isolation, as assessed by the Edmonton Isolation Protocol1. Transplantation 74:10, 1414-1419
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Juan L. Contreras, Cheryl A. Smyth, Guadalupe Bilbao, Carlton J. Young, J. Anthony Thompson, Devin E. Eckhoff. (2002) Simvastatin induces activation of the serine-threonine protein kinase AKT and increases survival of isolated human pancreatic islets. Transplantation 74:8, 1063-1069
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Emma L Masteller, Jeffrey A Bluestone. (2002) Immunotherapy of insulin-dependent diabetes mellitus. Current Opinion in Immunology 14:5, 652-659
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John J. Casey, Jonathan R. T. Lakey, Edmond A. Ryan, Breay W. Paty, Richard Owen, Kevin O???Kelly, Sulaiman Nanji, Ray V. Rajotte, Gregory S. Korbutt, David Bigam, Norman N. Kneteman, A. M. James Shapiro. (2002) Portal venous pressure changes after sequential clinical islet transplantation. Transplantation 74:7, 913-915
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Martin Drage, Paola Zaccone, Jenny M. Phillips, Ferdinando Nicoletti, Janet Dawson, J. Andrew Bradley, Anne Cooke. (2002) Nondepleting anti-CD4 and soluble interleukin-1 receptor prevent autoimmune destruction of syngeneic islet grafts in diabetic NOD mice1. Transplantation 74:5, 611-619
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Benoît Barrou, Lydia Bertry-Coussot, Sylvie Morin, Julie Sainz, Bruno Lucas, Marc Olivier Bitker, Patrice Debré, Patricia Lemarchand. (2002) Prolonged Islet Allograft Survival by Adenovirus-Mediated Transfer of sICAM-1/Ig Immunoadhesin Gene. Human Gene Therapy 13:12, 1441-1450
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Michael A. Curran, M. Sofia Ochoa, R. Damaris Molano, Antonello Pileggi, Luca Inverardi, Norma S. Kenyon, Garry P. Nolan, Camillo Ricordi, Elizabeth S. Fenjves. (2002) Efficient transduction of pancreatic islets by feline immunodeficiency virus vectors1. Transplantation 74:3, 299-306
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Akira Shiroi, Masahide Yoshikawa, Hiroshi Yokota, Hiroshi Fukui, Shigeaki Ishizaka, Kouko Tatsumi, Yoshiko Takahashi. (2002) Identification of Insulin-Producing Cells Derived from Embryonic Stem Cells by Zinc-Chelating Dithizone. Stem Cells 20:4, 284-292
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Donald E. Hricik, Hany A. S. Anton, Thomas C. Knauss, Victoria Rodriguez, David Seaman, Christopher Siegel, John Valente, James A. Schulak. (2002) Outcomes of African American kidney transplant recipients treated with sirolimus, tacrolimus, and corticosteroids. Transplantation 74:2, 189-193
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Lynne P. Rutzky, Szczepan Bilinski, Malgorzata Kloc, Tammy Phan, Huimin Zhang, Stephen M. Katz, Stanislaw M. Stepkowski. (2002) Microgravity culture condition reduces immunogenicity and improves function of pancreatic islets1. Transplantation 74:1, 13-21
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Shimon Efrat. (2002) Cell replacement therapy for type 1 diabetes. Trends in Molecular Medicine 8:7, 334-340
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Dirk Homann, Angelika Jahreis, Tom Wolfe, Anna Hughes, Bryan Coon, Marianne J.B van Stipdonk, Kiley R Prilliman, Stephen P Schoenberger, Matthias G von Herrath. (2002) CD40L Blockade Prevents Autoimmune Diabetes by Induction of Bitypic NK/DC Regulatory Cells. Immunity 16:3, 403-415
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Jacques Pirenne, Takaaki Koshiba, Karel Geboes, Marie Paule Emonds, Patrick Ferdinande, Martin Hiele, Frederik Nevens, Mark Waer. (2002) Complete freedom from rejection after intestinal transplantation using a new tolerogenic protocol combined with low immunosuppression. Transplantation 73:6, 966-968
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Caterina Vizzardelli1*, R. Damaris Molano, Antonello Pileggi, Thierry Berney, Pierre Cattan1+, Elizabeth S. Fenjves, Alyson Peel, Chris Fraker, Camillo Ricordi, Luca Inverardi1,5. (2002) Neonatal porcine pancreatic cell clusters as a potential source for transplantation in humans: Characterization of proliferation, apoptosis, xenoantigen expression and gene delivery with recombinant AAV. Xenotransplantation 9:1, 14-24
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NOBUYUKI ASANUMA, TETSUHIRO KITAMURA, XIN XU, SATORU SUMITANI, HIROSHI SAITO, SOJI KASAYAMA, HARUHIKO KOUHARA, ICHIRO KAWASE. (2002) New Analytical Method for Pancreas and Liver Regeneration: Normalization of Streptozotocin-Induced Hyperglycemia by Retrograde Injection of Insulin Producing Cells.. Endocrine Journal 49:4, 449-457
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Pierre Y. Benhamou. (2002) IMMUNOMODULATION WITH CTLA4-Ig IN ISLET TRANSPLANTATION. Transplantation 73:Supplement, S40-S42
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Diego Cantarovich, Gilles Blancho, Nicolas Potiron, Nathalie Jugeau, Maryse Fiche, Carine Chagneau, Eric Letessier, Francoise Boeffard, Philippe Loth, Georges Karam, Jean-Paul Soulillou, Brigitte Le Mauff. (2002) Rapid failure of pig islet transplantation in non human primates. Xenotransplantation 9:1, 25-35
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RICCARDO CALAFIORE, GIOVANNI LUCA, MARIO CALVITTI, LUCA M. NERI, GIUSEPPE BASTA, SILVANO CAPITANI, ENNIO BECCHETTI, PAOLO BRUNETTI. (2001) Cellular Support Systems for Alginate Microcapsules Containing Islets, as Composite Bioartificial Pancreas. Annals of the New York Academy of Sciences 944:1, 240-252
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JOSÉ OBERHOLZER, CHRISTIAN TOSO, FRÉDÉRIC RIS, PASCAL BUCHER, FRÉDÉRIC TRIPONEZ, ALP DEMIRAG, JINNING LOU, PHILIPPE MOREL. (2001) β Cell Replacement for the Treatment of Diabetes. Annals of the New York Academy of Sciences 944:1, 373-387
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KLEARCHOS K. PAPAS, CLARK K. COLTON, JOHN S. GOUNARIDES, ERIC S. ROOS, MARY ANN C. JAREMA, MICHAEL J. SHAPIRO, LEO L. CHENG, GARY W. CLINE, GERALD I. SHULMAN, HAIYAN WU, SUSAN BONNER-WEIR, GORDON C. WEIR. (2001) NMR Spectroscopy in β Cell Engineering and Islet Transplantation. Annals of the New York Academy of Sciences 944:1, 96-119
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F. Vargas, J. F. Julián, J. F. Llamazares, F. Garcia-Cuyàs, M. Jiménez, R. Pujol-Borrell, M. Vives-Pi. (2001) Engraftment of Islets Obtained by Collagenase and Liberase in Diabetic Rats: A Comparative Study. Pancreas 23:4, 406-413
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Barry D. Kahan, Joseph S. Camardo. (2001) RAPAMYCIN: CLINICAL RESULTS AND FUTURE OPPORTUNITIES1. Transplantation 72:7, 1181-1193
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Peter J. Dyck, Jorge A. Velosa, John M. Pach, Sylvester Sterioff, Timothy S. Larson, Jane E. Norell, Peter C. O???Brien, P. James B. Dyck. (2001) INCREASED WEAKNESS AFTER PANCREAS AND KIDNEY TRANSPLANTATION1. Transplantation 72:8, 1403-1408
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Robert W.G. Johnson, Henri Kreis, Rainer Oberbauer, Christina Brattstrom, Kerstin Claesson, Josette Eris. (2001) SIROLIMUS ALLOWS EARLY CYCLOSPORINE WITHDRAWAL IN RENAL TRANSPLANTATION RESULTING IN IMPROVED RENAL FUNCTION AND LOWER BLOOD PRESSURE1,2,10. Transplantation 72:5, 777-786
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Teru Okitsu, Stephen T. Bartlett, Gregg A. Hadley, Cinthia B. Drachenberg, Alan C. Farney. (2001) Recurrent Autoimmunity Accelerates Destruction of Minor and Major Histoincompatible Islet Grafts in Nonobese Diabetic (NOD) Mice. American Journal of Transplantation 1:2, 138-145
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Zhongmin Ma, Alan Bohrer, Mary Wohltmann, Sasanka Ramanadham, Fong-Fu Hsu, John Turk. (2001) Studies of phospholipid metabolism, proliferation, and secretion of stably transfected insulinoma cells that overexpress group VIA phospholipase A2. Lipids 36:7, 689-700
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A.M. James Shapiro, Er Geng Hao, Jonathan R.T. Lakey, Walter J. Yakimets, Thomas A. Churchill, Paraskevi G. Mitlianga, George K. Papadopoulos, John F. Elliott, Ray V. Rajotte, Norman M. Kneteman. (2001) NOVEL APPROACHES TOWARD EARLY DIAGNOSIS OF ISLET ALLOGRAFT REJECTION1. Transplantation 71:12, 1709-1718
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David E. R. Sutherland, Rainer W. G. Gruessner, David L. Dunn, Arthur J. Matas, Abhinav Humar, Raja Kandaswamy, S. Michael Mauer, William R. Kennedy, Frederick C. Goetz, R. Paul Robertson, Angelika C. Gruessner, John S. Najarian. (2001) Lessons Learned From More Than 1,000 Pancreas Transplants at a Single Institution. Annals of Surgery 233:4, 463-501
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