VV E HAVE PREVIOUSLY reported several factors contributing to the initial success of clinical islet cell transplantation.‘..” Despite improved initial success, longterm insulin independence after either islet after kidney (IAK) or simultaneous islet-kidney (SIK) transplantation has occurred infrequently.4 Investigators are therefore obligated to continuously re-evaluate and update the biochemical and clinical information from those few individuals achieving success. Thus, the present study provides a 3-year update of the clinical and biochemical parameters from a 3%year-old white man with insulin-dependent diabetes mellitus (IDDM) of 32 years duration who remains completely insulin independent at 36 months after a 1993 kidney/islet transplant at Washington University Medical Center. This study reports the subjective and objective beneficial effects of long-term insulin independence after islet cell transplantation in this unique patient.

Pancreas transplantation is an accepted treatment for a subset of patients with diabetes mellitus, in particular those with renal failure who also require a kidney transplant and those with life-threatening hypoglycaemic unawareness. As results have improved and demand has risen, attention has focused on increasing the availability of pancreas transplantation by utilising pancreases from less than ideal donors, as well as addressing factors that limit the longevity of graft survival. The development of islet transplantation has posed additional demands on donor pancreas availability, as well as posing new challenges for donor organ allocation. This review focuses upon some of the current areas of interest in pancreatic transplantation.

INCE 1985,27 transplants have occurred at Washington University School of Medicine (WUMS) in St. Louis and 4 transplants in conjunction with the University of Western Ontario, London, Ontario. The majority of suc- cessful transplants have occurred since 1989 when we entered into the era of better immunosuppression, early intensive insulin therapy, purer preparations, immunoalter- ation by 24°C culture, and cryopreservation resulting in larger transplanted islet preparations. The two groups of patients most extensively followed at WUMS were patients with established kidney grafts followed by islet transplant (EKI, n = 8) and those receiving simultaneously trans- planted kidney and islet transplant (SKI, n = 9). Several controversies concerning islet transplantation still exist. For example, should islet transplantation occur simultaneous with or following renal transplant? Does cryopreservation and/or islet culture make a difference in islet function? What is the role of human leukocyte antigen (HLA) matching? Does islet mass improve or hamper long-term islet function? Presented here are the results of a retrospec- tive study addressing these questions in regard to our EKI and SKI patients.

OBJECTIVE The majority of islet transplant recipients remain insulin-requiring, although many have near-normal connecting peptide (CP) levels. Insulin resistance may be one possible cause of the continuing need for exogenous insulin in islet transplant recipients. To assess this, we have studied the insulin sensitivity index (S1) in one patient with near-normal CP levels after islet transplant who remained insulin-requiring. RESEARCH DESIGN AND METHODS The islet transplant recipient is a 36-year-old woman with no residual CP who received a kidney transplant, followed 7 days later by an islet transplant. The islets were infused into the liver via the umbilical vein. Induction immunosuppression consisted of OKT3, prednisone, cyclosporin A, and azathioprine, with maintenance on the latter three. RESULTS Maximum CP levels after a standardized Sustacal meal were 2.09, 1.18, 0.85, and 0.81 nmol/l at 1,6,18, and 24 months posttransplant, respectively. Insulin requirements at the same times were 0.27, 0.45, 0.49, and 0.62 U·kg−1·d−1, while S1 was 36.3, 53.3, and 13.2 min −1·nmol−1·ml at 6,18, and 24 months, respectively. This compares with S1 values of 43.3 ± 10.0 min−1·nmol−1·ml for normal subjects. CONCLUSIONS This patient had near-normal S1 and CP levels, but she was unable to discontinue insulin therapy, suggesting that other factors are critical. Despite this, she maintained normal or near-normal glycated hemoglobins, indicating metabolic benefit from the islet transplant.

Purified porcine islets were prepared by collagenase digestion and density gradient purification, and transplanted under the kidney capsule of C57B/B6 mice with streptozotocin-induced diabetes which were receiving varying temporary immunosuppressive therapies. Islets that had been cultured for 1 day at 37 degree C were rejected after : 9+/-0.1 (mean+/-SE) days in control mice: 14+/-3 days in mice receiving mouse antilymphocyte serum (MLS) plus porcine antilymphocyte serum (PLS) on day of transplant (day 0); 43+/-6 days in mice treated for 1 week with anti-CD4 antibody (aCD4); 36+/-4 days in mice given aCD4 for 1 week plus PLS on days 0 and 7; 47+/-3 days in mice treated with aCD4 for 1 week plus MLS and PLS on day 21. Porcine islet survival in these latter three groups was significantly (P<0.01) and similarly longer than in the control and MLS plus PLS groups. Then, we transplanted islets that had been either cultured at 24 degrees C for 7 days or cryopreserved into 7-day aCD4-treated mice, to evaluate whether low temperature culture or the freezing-thawing procedure could affect survival. Neither 7-day, low temperature culture (mean survival time: 37+/-2 days) nor cryopreservation (mean survival time: 39+/-2 days) prolonged islets function further. Thus, the present study demonstrates that prolonged survival can be achieved with discordant porcine islet xenografts, and shows the greater efficacy of aCD4 treatment, which was not improved by additional immunosuppressive therapies we tested, nor by culture or cryopreservation of the islets.

About 20 years after investigators began work on the isolation of animal islets, we are now poised to use such cells to control blood sugar levels in humans. Studies in various laboratories have led to development of transplantation techniques that obviate the need for chronic immunosuppression; equally important, the techniques also appear to avoid the problem of graft rejection.

It is still a controversial question whether insulin suppresses its own secretion. We prepared pure human islets from three pancreases by collagenase digestion and density gradient purification. Aliquots of 200 islet equivalents (IE, 150-μm sized-islets) were sequentially perifused at 37°C with 3.3 mmol/l glucose (3.3G, 40 min), 16.7 mmol/l glucose (16.7G, 30 min) and again 3.3G (30 min) after 24 h, 37°C culture in CMRL 1066 medium with or without the addition of either 200 or 400 μU/ml human insulin in the incubation medium (6 replicates each). Insulin secretion was assessed by C-peptide (Cp) measurement in the perufusate. Without added insulin (C) and with 200 (Ins200) or 400 (Ins400) μU/ml added insulin, basal Cp release was 0.12±0.03, 0.14±0.02 and 0.14±0.04 ng/ml, respectively. At 16.7G, the first-phase secretion peak (expressed as Cp value) was significantly lower with Ins200 (0.47±0.13 ng/ml,P<0.02) and Ins400 (0.68±0.15 ng/ml,P<0.05) than C (0.83±0.15 ng/ml). The second-phase secretion peak was also significantly (P<0.05) reduced with added insulin (Ins200: 0.47±0.08 ng/ml; Ins400: 0.45±0.07 ng/ml) than in its absence (C: 0.65±0.09 ng/ml). Accordingly, total Cp secretion was lower with Ins200 (10.6±2.3 ng/ml,P=0.03) and Ins400 (11.8±2.3 ng/ml) than with C (16.0±2.2 ng/ml). Thus, the addition for 24 h of either 200 or 400 μU/ml insulin in the culture medium caused a significant decrease of insulin (as assessed by Cp measurement) secretion from perifused human islets, suggesting that feedback suppression of insulin release is at least in part due to a direct action of insulin on the islets.

Highly purified islets of Langerhans were prepared in the present study from adult pigs by collagenase digestion and density gradient purification. After overnight culture, the tissue was equilibrated with DMSO at 25 degrees C, supercooled to -7.5 degrees C, nucleated, slowly cooled at 0.25 degrees C/min to -40 degrees C, and stored at -130 degrees C. Then, after variable periods of storage, the islets were rapidly thawed at 37 degrees C. Postthaw actual islet and islet equivalent (150-microns sized islets) recovery were 75 +/- 7% and 66 +/- 4%, respectively. The frozen-thawed porcine islets maintained good morphology on histological staining by hematoxylin-eosin and aldehyde-fuchsin. Upon perifusion, basal insulin secretion was 43 +/- 10 and 67 +/- 18 pmol/L from noncryopreserved, control islets, and cryopreserved islets, respectively (P = 0.2). Peak insulin release at 16.7 mmol/L glucose was 85 +/- 28 pmol/L from noncryopreserved islets and 157 +/- 48 pmol/L from the frozen-thawed islets (P = 0.1). When 10 mmol/L theophylline was added to 16.7 mmol/L glucose, the secretion of the hormone peaked to 221 +/- 83 (control islets) and 479 +/- 140 pmol/L (cryopreserved islets, P = 0.1). Total insulin secretion differed significantly for the noncryopreserved and the cryopreserved islets at both 16.7 mmol/L (1412 +/- 306 vs. 3756 +/- 764 pmol/L, respectively, P = 0.007) and 16.7 mmol/L glucose plus 10 mmol/L theophylline (2161 +/- 371 vs. 7505 +/- 2075 pmol/L, respectively, P = 0.011). Normoglycemia was restored within 7 days from implantation in temporarily immunosuppressed (aL3T4 antibody) mice with streptozotocin-induced diabetes by transplanting 1500-2000 cryopreserved porcine islets under the kidney capsule. Mean survival time of frozen-thawed islet xenografts (39 +/- 3 days) was similar to that of noncryopreserved islet xenografts (43 +/- 6 days). This study demonstrates that cryogenic storage is feasible of isolated porcine islets, with the frozen-thawed pancreatic endocrine tissue maintaining morphological integrity and both in vitro and in vivo viability. Further studies are needed to define the effect of cryopreservation on the immunogenic properties of porcine islets.

Insulin secretion from the pancreas is pulsatile. The precise site and function of the pacemaker that regulates insulin periodicity in humans have not been determined. We isolated human pancreatic islets from five cadaver organ donors by collagenase digestion and density gradient purification. After 24 h of culture in CMRL-1066 medium at 37 degrees C, aliquots of 200 islets were perifused (1 ml/min for 120 min) with glucose and other secretagogues in oxygenated Krebs-Ringer bicarbonate solution at 37 degrees C. Samples for insulin measurement were taken every minute, and insulin secretion was analyzed by the Clifton and Steiner cycle detection technique. With 3.3 mM glucose (n = 17), insulin oscillations were demonstrated with a periodicity of 9.8 +/- 0.1 min (means +/- SE), mean amplitude was 16.8 +/- 1.8 pM, and overall mean insulin release was 43.8 +/- 4.2 pM. With 16.7 mM glucose (n = 14), no change of insulin periodicity was observed (10.2 +/- 0.9 min), mean amplitude was 41.4 +/- 10.2 pM (P < 0.01 vs. 3.3 mM glucose), and mean insulin release was 118.2 +/- 19.2 pM (P < 0.01 vs. 3.3 mM glucose). Both at 3.3 and 16.7 mM glucose, the addition of 1.4 mM glucagon (n = 4), 15 mM arginine (n = 4), or 100 micrograms/ml tolbutamide (n = 4) caused no change of insulin periodicity but enhanced mean amplitude and mean insulin release compared with glucose alone. These results show that a pacemaker is located within the islets that regulates pulsatile insulin secretion in humans; the pacemaker is remarkably stable, because its periodicity is not affected by factors altering insulin secretion.

Human islets were macroencapsulated in permselective hollow fiber membrane devices and successfully allotransplanted subcutaneously with > 90% viability after 2 weeks in situ. Recipients were patients with type I or type II diabetes and normal control subjects; none was immunosuppressed. Between 150 and 200 islet equivalents were implanted in each of the nine patients. No adverse patient complications were observed. Biocompatibility of devices was excellent. Insulin-positive beta-cells were confirmed in encapsulated islets recovered from the implanted devices in all patient populations including the type I diabetic patients. Glucose-stimulated insulin release could be demonstrated in vitro from recovered islets. These data demonstrate that macroencapsulated human islets can survive at the subcutaneous site and that permselective membranes can be designed to protect against both allogeneic immune responses as well as the autoimmune component of type I diabetes.

Induction of tolerance to concordant rat islet xenografts (150 Wistar-Furth [WF] islets) in streptozocin-induced (STZ) diabetic mice (C57BU/6) was determined at three different sites for islet implantation (thymus, kidney capsule, and liver). Islets transplanted into the thymus or kidney capsule were either fresh or cultured at 24°C for 7 days, and the mice received a single injection of either anti-mouse lymphocyte serum (MALS) alone or anti-rat lymphocyte serum (RALS) and MALS. Islets transplanted into the liver via the portal vein were cultured at 24°C for 7 days, and the mice received a single injection of MALS and RALS. To document the induction of tolerance, recipients with islet xenografts surviving >100 days were made diabetic again by STZ (thymus and liver) or nephrectomy (kidney capsule) and received a second transplant of 150 fresh WF islets in the kidney capsule. Kidney capsule placement of fresh or cultured islets with MALS alone or MALS and RALS did not induce tolerance in a significant number of recipients. The intrathymic transplantation of fresh or cultured islets with MALS alone resulted in prolonged WF islet xenog raft survival (mean survival time of 39.7 ± 7.9 days) but did not result in tolerance, whereas the administration of MALS and RALS with the intrathymic placement of fresh or cultured islets induced tolerance in ∼50% of the mice. Intrahepatic transplantation of cultured islets with MALS and RALS resulted in tolerance to donor islets in 90% of the recipients. Donor specificity was evaluated by a third major histocompatability complex–disparate fresh Lewis islet xenograft. Approximately 50% of these xenografts were not rejected, suggesting that the tolerance may not be haplotype-specific. The mechanisms involved in inducing tolerance to islet xenografts are not clearly established; however, this study clearly demonstrates that tolerance to xenogeneic islets can be achieved by using a brief period of immunosuppression in the intrathymic or intrahepatic transplantation site, with intrahepatic implantation achieving tolerance in a higher percentage of recipients than the intrathymic site.