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Background: Long-term data of patients with type 1 diabetes mellitus (T1D) after simultaneous islet-kidney (SIK) or islet-after-kidney transplantation (IAK) are rare and have never been compared to intensified insulin therapy (IIT)., Methods: Twenty-two patients with T1D and end-stage renal failure undergoing islet transplantation were compared to 70 patients matched for age and diabetes duration treated with IIT and to 13 patients with kidney transplantation alone or simultaneous pancreas-kidney after loss of pancreas function (waiting list for IAK [WLI]). Glycemic control, severe hypoglycemia, insulin requirement, and direct medical costs were analyzed., Results: Glycated hemoglobin decreased significantly from 8.2 ± 1.5 to 6.7 ± 0.9% at the end of follow-up (mean 7.2 ± 2.5 years) in the SIK/IAK and remained constant in IIT (7.8 ± 1.0% and 7.6 ± 1.0) and WLI (7.8 ± 0.8 and 7.9 ± 1.0%). Daily insulin requirement decreased from 0.53 ± 0.15 to 0.29 ± 0.26 U/kg and remained constant in IIT (0.59 ± 0.19 and 0.58 ± 0.23 U/kg) and in WLI (0.76 ± 0.28 and 0.73 ± 0.11 U/kg). Severe hypoglycemia dropped in SIK/IAK from 4.5 ± 9.7 to 0.3 ± 0.7/patient-year and remained constant in IIT (0.1 ± 0.7 and 0.2 ± 0.8/patient-year). Detailed cost analysis revealed US $57,525 of additional cost for islet transplantation 5 years after transplantation. Based on a 5- and 10-year analysis, cost neutrality is assumed to be achieved 15 years after transplantation., Conclusions: This long-term cohort with more than 7 years of follow-up shows that glycemic control in patients with T1D after SIK/IAK transplantation improved, and the rate of severe hypoglycemia decreased significantly as compared to control groups. Cost analysis revealed that islet transplantation is estimated to be cost neutral at 15 years after transplantation.

Objectives: The objective was to test whether chromogranin A (CgA), neuron-specific enolase (NSE), and pancreatic polypeptide (PP) are released from the pancreas during the selective arterial calcium stimulation and hepatic venous sampling test (ASVS) in patients with insulinomas., Methods: We determined CgA, NSE, PP, insulin, C-peptide, and proinsulin in blood samples obtained during the ASVS test in 19 patients with insulinomas. Levels following calcium injection into the arteries supplying the tumor were compared with levels following calcium stimulation of arteries supplying healthy pancreatic tissue., Results: After calcium injection into the artery supplying the insulinoma, a significant 8-fold increase in insulin (range, 2.3-117; P < 0.001), a 3.8-fold increase in C-peptide (1.7-32.4; P < 0.001), and a 1.9-fold increase in proinsulin (0.7-5.3, P < 0.001) were detectable whereas NSE and CgA did not increase. No significant increases in insulin, C-peptide, proinsulin, CgA, and NSE concentrations were found after calcium injection into control arteries. Pancreatic polypeptide increased 1.5-fold (0.8-4.5; P = 0.017) after calcium injection into the tumor artery and 2.4-fold (0.8-7.9; P = 0.016) after injection into the control artery., Conclusions: Insulin, C-peptide, and proinsulin are released by insulinoma cells in response to arterial calcium stimulation, whereas CgA and NSE are not released. Also from our study it seems that PP may be released by healthy islet cells after calcium stimulation.

Protein kinase B (PKB)/Akt is considered to be a key target downstream of insulin receptor substrate 2 (IRS2) in the regulation of beta-cell mass. However, while deficiency of IRS2 in mice results in diabetes with insulin resistance and severe failure of beta-cell mass and function, only loss of the PKBbeta isoform leads to a mild metabolic phenotype with insulin resistance. Other isoforms were reported not to be required for metabolic regulation. To clarify the roles of the three PKB isoforms in the regulation of islet mass and glucose homeostasis, we assessed the metabolic and pancreatic phenotypes of Pkbalpha, Pkbbeta, and Pkbgamma-deficient mice. Our study uncovered a novel role for PKBalpha in the regulation of glucose homeostasis, whereas it confirmed that Pkbbeta(-/)(-) mice are insulin resistant with compensatory increase of islet mass. Pkbalpha(-/)(-) mice displayed an opposite phenotype with improved insulin sensitivity, lower blood glucose, and higher serum glucagon concentrations. Pkbgamma(-/)(-) mice did not show metabolic abnormalities. Additionally, our signaling analyses revealed that PKBalpha, but not PKBbeta or PKBgamma, is specifically activated by overexpression of IRS2 in beta-cells and is required for IRS2 action in the islets.

Ligand-activated insulin receptor (IR) attracts and phosphorylates various substrates such as insulin receptor substrates 1-4 (IRS) and Shc. To investigate how binding affinity for substrate affects signalling we generated chimeric receptors with the beta-chain of the insulin receptor containing NPXY motives with different affinities for receptor substrates. We found that the extent of receptor tyrosine phosphorylation positively correlates with binding affinity towards IRS1/2 but not towards Shc. Moreover, overexpression of IRS1 or IRS2 but not of Shc increased IR tyrosine phosphorylation in a dose-dependent manner, also independent of insulin. Molecular truncations of IRS1 revealed that neither the isolated PH and PTB domains nor the C-terminus with the tyrosine phosphorylation sites alone are sufficient for substrate-dependent receptor activation. Overexpression of IRS1 and IRS2 impaired insulin-induced internalization of the IR in a dose-dependent manner suggesting that IRS proteins prevent endosome-associated receptor dephosphorylation/inactivation. IRS1 and IRS2 could therefore target the activated IR to different cellular compartments. Overexpression of IRS1 and IRS2 inhibited insulin-stimulated activation of the MAP kinases Erk1/2 while it increased/induced activation of Akt/PKB. Finally, overexpression of IRS1 and IRS2 but not of Shc induced DNA synthesis in starved CHO-IR cells independent of exogenous growth factors. Our results demonstrate that variations in cellular IRS1 and IRS2 concentration affect insulin signalling both upstream and downstream and that IRS proteins could play instructive rather than just permissive roles in signal transmission.

The Per-ARNT-Sim (PAS) domain serine/threonine kinase PASKIN, or PAS kinase, links energy flux and protein synthesis in yeast and regulates glycogen synthase in mammals. A recent report suggested that PASKIN mRNA, protein, and kinase activity are increased in pancreatic islet beta-cells under hyperglycemic conditions and that PASKIN is necessary for insulin gene expression. We previously generated Paskin knockout mice by targeted replacement of the kinase domain with the beta-geo fusion gene encoding beta-galactosidase reporter activity. Here we show that no 5-bromo-4-chloro-3-indolyl-ss-d-galactopyranoside (X-gal) staining was observed in islet beta-cells derived from Paskin knockout mice, irrespective of the ambient glucose concentration, whereas adenoviral expression of the lacZ gene in beta-cells showed strong X-gal staining. No induction of PASKIN mRNA could be detected in insulinoma cell lines or in islet beta-cells. Increasing glucose concentrations resulted in PASKIN-independent induction of insulin mRNA levels and insulin release. PASKIN mRNA levels were high in testes but undetectable in pancreas and in islet beta-cells. Finally, blood glucose levels and glucose tolerance after intraperitoneal glucose injection were indistinguishable between Paskin wild-type and knockout mice. These results suggest that Paskin gene expression is not induced by glucose in pancreatic beta-cells and that glucose-stimulated insulin production is independent of PASKIN.

Objective: Weight gain is an unwanted side effect of improved glycaemic control in type 1 diabetes, associated with increased blood pressure (BP) and worsening lipid profiles. While improved glycaemic control per se should improve long-term patient outcomes, increases in BP and worsening lipid profiles may counteract these benefits. The aim of this modelling study was to assess whether the increased body weight and associated worsening of lipid profile and blood pressure would negate the improvements in glycaemic control seen with intensive therapy in patients with type 1 diabetes., Methods: A validated diabetes model projected life expectancy (LE), quality-adjusted LE (QALE) and total lifetime costs of complications in type 1 diabetes cohorts with the characteristics of patients from the Diabetes Control and Complications Trial (DCCT). The following four cohorts (A-D) were created based on increased body weight under either conventional or intensive therapy: A) conventional glycaemic control in the subgroup with lowest weight-gain quartile after 6.5 years (HbA1c increased by 11% from baseline); B) conventional control in the highest weight-gain quartile (no change in HbA1c from baseline); C) intensive control in the lowest quartile of weight gain (with 16.1% decrease in HbA1c, but no increase in weight or associated BP, and improved lipid profile); D) intensive control in the highest quartile of weight gain (with 21% decrease in HbA1c, increased systolic BP of 6 mmHg, and worsened lipid profile). Data were derived from DCCT and other published sources., Results: Intensive control, even with weight gain, led to major improvements in LE and QALE, and reduction in costs of complications versus conventional therapy. Intensive therapy with no weight increase led to a higher LE (increased by 0.57 years) and higher QALE (increased by 0.28 years) and lower costs of complications (reduced by 523 dollars/patient), compared to intensive therapy with the highest quartile of weight gain., Conclusions: Concerns about weight gain should not deter intensive insulin therapy. However, the value of improving glycaemic control without increasing body weight (and associated increased BP and worsening of lipid profile) has been confirmed.

Objective: The aim of this study was to compare insulin concentrations measured by a traditional radioimmunoassay (RIA) and a more specific enzyme-linked immunosorbent assay (ELISA) in blood samples obtained during the arterial stimulation and venous sampling (ASVS) test in patients with insulinoma., Design: Prospective case series., Methods: In 14 patients with an insulinoma undergoing an ASVS test, blood samples were obtained from the hepatic vein at baseline and 60 s after calcium injection into an artery supplying the tumour and a control artery (supplying pancreatic tissue without tumour). A selective arterial calcium stimulation was performed in five additional patients without evidence for an insulinoma. We measured insulin by a traditional RIA and a specific immunoassay., Results: In patients with insulinoma, insulin concentrations increased between 2.3- and 24.2-fold (median 8.2-fold) when measured by RIA and between 7.3- and 59.4-fold (median 16) when measured by ELISA following calcium injection into the artery supplying the tumour. Following calcium injection into the control artery, insulin concentrations were 0.6 to 1.3 times (median 1.0) the baseline values by RIA and 0.5 to 2.5 times (median 1.1) the baseline values by ELISA. In patients without insulinoma, insulin concentrations increased following calcium stimulation between 0.7- and 2.1-fold (median 1.3-fold) when measured by RIA and between 0.6- and 4.7-fold (median 1.3-fold) when measured by ELISA., Conclusions: When insulin is measured by specific immunoassays, a higher cut-off (i.e. five- to sixfold increase) rather than the traditional criterion of a twofold increase should be used to localise an insulinoma during the ASVS test. The increase in insulin concentrations following calcium stimulation is significantly higher when insulin is measured by a specific assay compared with results obtained with traditional RIAs.

Abstract: The aim of this study was to assess safety and efficacy of islet transplantation after initial pancreas transplantation with subsequent organ failure. Patients undergoing islet transplantation at our institution after pancreas organ failure were compared to a control group of patients with pancreas graft failure, but without islet transplantation and to a group receiving pancreas retransplantation. Ten patients underwent islet transplantation after initial pancreas transplantation failed and were followed for a median of 51 months. The primary end point of HbA1c <7.0% and freedom of severe hypoglycemia was met by nine of 10 patients after follow‐up after islet transplantation and in all three patients in the pancreas retransplantation group, but by none of the patients in the group without retransplantation (n = 7). Insulin requirement was reduced by 50% after islet transplantation. Kidney function (eGFR) declined with a rate of ‐1.0 mL ± 1.2 mL/min/1.73 m2 per year during follow‐up after islet transplantation, which tended to be slower than in the group without retransplantation (P = .07). Islet transplantation after deceased donor pancreas transplant failure is a method that can safely improve glycemic control and reduce the incidence of severe hypoglycemia and thus establish similar glycemic control as after initial pancreas transplantation, despite the need of additional exogenous insulin. [ABSTRACT FROM AUTHOR]

Background & Aims Non-alcoholic fatty liver disease ( NAFLD) is a major health problem and occurs frequently in the context of metabolic syndrome and type 2 diabetes mellitus. Hepatocyte-specific Pten-deficiency in mice was shown previously to result in hepatic steatosis due to hyperactivated AKT2. However, the role of peripheral insulin-sensitive tissues on PTEN- and AKT2-dependent accumulation of hepatic lipids has not been addressed. Methods Effects of systemically perturbed PTEN/ AKT2 signalling on hepatic lipid content were studied in Pten-haplodeficient ( Pten +/− /Akt2 +/+) mice and Pten-haplodeficient mice lacking Akt2 ( Pten +/−/ Akt2−/−). The liver and skeletal muscle were characterized by histology and/or analysis of insulin signalling. To assess the effects of AKT2 activity in skeletal muscle on hepatic lipid content, AKT2 mutants were expressed in skeletal muscle of Pten +/+ /Akt2 +/+ and Pten +/− /Akt2 +/+ mice using adeno-associated virus 8. Results Pten +/− /Akt2 +/+ mice were found to have a more than 2-fold reduction in hepatic lipid content, at a level similar to that observed in Pten +/−/ Akt2−/− mice. Insulin signalling in the livers of Pten +/− /Akt2 +/+ mice was enhanced, indicating that extrahepatic factors prevent lipid accumulation. The skeletal muscle of Pten +/− /Akt2 +/+ mice also showed enhanced insulin signalling. Skeletal muscle-specific expression of constitutively active AKT2 reduced hepatic lipid content in Pten +/+ /Akt2+/+ mice, and dominant negative AKT2 led to an increase in accumulation of hepatic lipids in both Pten +/+ /Akt2+/+ and Pten +/− /Akt2 +/+ mice. Conclusion Our results demonstrate that AKT2 activity in skeletal muscle critically affects lipid accumulation in the livers of Pten +/+ /Akt2+/+ and Pten +/− /Akt2 +/+ mice, and emphasize the role of skeletal muscle in the pathology of NAFLD. [ABSTRACT FROM AUTHOR]

OBJECTIVE--Adverse effects of hypercaloric, high-fructose diets on insulin sensitivity and lipids in human subjects have been shown repeatedly. The implications of fructose in amounts close to usual daily consumption, however, have not been well studied. This study assessed the effect of moderate amounts of fructose and sucrose compared with glucose on glucose and lipid metabolism. RESEARCH DESIGN AND METHODS--Nine healthy, normal-weight male volunteers (aged 21-25 years) were studied in this double-blind, randomized, cross-over trial. All subjects consumed four different sweetened beverages (600 mL/day) for 3 weeks each: medium fructose (MF) at 40 g/day, and high fructose (HF), high glucose (HG), and high sucrose (HS) each at 80 g/day. Euglycemic-hyperinsulinemic clamps with [6,6]-²H2 glucose labeling were used to measure endogenous glucose production. Lipid profile, glucose, and insulin were measured in fasting samples. RESULTS--Hepatic suppression of glucose production during the clamp was significantly lower after HF (59.4 ± 11.0%) than HG (70.3 ± 10.5%, P < 0.05), whereas fasting glucose, insulin, and C-peptide did not differ between the interventions. Compared with HG, LDL cholesterol and total cholesterol were significantly higher after MF, HF, and HS, and free fatty acids were significantly increased after MF, but not after the two other interventions (P < 0.05). Subjects' energy intake during the interventions did not differ significantly from baseline intake. CONCLUSIONS--This study clearly shows that moderate amounts of fructose and sucrose significantly alter hepatic insulin sensitivity and lipid metabolism compared with similar amounts of glucose. [ABSTRACT FROM AUTHOR]

Abstract: The objective of the study was to characterize ethnic differences in lipid levels and low-density lipoprotein (LDL) particle size and subclasses in black and white South African women and to explore the associations with insulin sensitivity (S I), body composition, and lifestyle factors. Fasting serum lipids and LDL size and subclasses, body composition (dual-energy x-ray absorptiometry), and S I (frequently sampled intravenous glucose tolerance test) were measured in normal-weight (body mass index <25 kg/m2) black (n = 15) and white (n = 15), and obese (body mass index >30 kg/m2) black (n = 13) and white (n = 13) women. Normal-weight and obese black women had lower triglycerides (0.59 ± 0.09 and 0.77 ± 0.10 vs 0.89 ± 0.09 and 0.93 ± 0.10 mmol/L, P < .05) and high-density lipoprotein cholesterol (1.2 ± 0.1 and 1.1 ± 0.1 vs 1.7 ± 0.1 and 1.6 ± 0.3 mmol/L, P < .01) than white women. The LDL particle size was not different, but obese black women had more LDL subclass IV (17.3% ± 1.0% vs 12.5% ± 1.0%, P < .01). In white women, triglycerides and LDL particle size correlated with S I (P < .01), whereas cholesterol levels correlated with body fat (P < .05). Low socioeconomic status, low dietary protein intake, and injectable contraceptive use were the major determinants of unfavorable lipid profiles in black women. Black women had lower triglyceride and high-density lipoprotein cholesterol levels and more small dense LDL particles than white women. The major determinants of serum lipids in black women were socioeconomic status and lifestyle factors, whereas in white women, S I and body composition most closely correlated with serum lipids. [ABSTRACT FROM AUTHOR]

Many factors influence the outcome of islet transplantation. As islets in the early posttransplant setting are supplied with oxygen by diffusion only and are in a hypoxic state in the portal system, we tested whether small human islets are superior to large islets both in vitro and in vivo. We assessed insulin secretion of large and small islets and quantified cell death during hypoxic conditions simulating the intraportal transplant environment. In the clinical setting, we analyzed the influence of transplanted islet size on insulin production in patients with type 1 diabetes. Our results provide evidence that small islets are superior to large islets with regard to in vitro insulin secretion and show a higher survival rate during both normoxic and hypoxic culture. Islet volume after 48 h of hypoxic culture decreased to 25% compared with normoxic culture at 24 h due to a preferential loss of large islets. In human islet transplantation, the isolation index (islet volume as expressed in islet equivalents/islet number), or more simply the islet number, proved to be more reliable to predict stimulated C-peptide response compared with islet volume. Thus, islet size seems to be a key factor determining human islet transplantation outcome. Diabetes 56:594-603, 2007 [ABSTRACT FROM AUTHOR]

PURPOSE: To describe the potential and limitations of selective arterial calcium stimulation and hepatic venous sampling (ASVS) in the evaluation of patients with hyperinsulinemic hypoglycemia. MATERIALS AND METHODS: Twenty-seven consecutive adult patients with documented hyperinsulinemic hypoglycemia undergoing an ASVS test and histologically confirmed diagnosis were included. RESULTS: By histology, 24 patients were found to have an insulinoma, two had islet cell hyperplasia, and one had insulin-secreting neuroendocrine carcinoma of the liver. ASVS correctly predicted the source of excessive insulin secretion in 26 of 27 (sensitivity, 96%) patients. In two patients with an insulinoma, ASVS had to be repeated for correct diagnosis; in one patient with a glucose-sensitive insulinoma, ASVS was falsely negative. In one patient, a falsely negative ASVS test was caused by diazoxide treatment; in another patient a falsely negative ASVS test occurred because of extraordinarily high baseline insulin levels when the calcium stimulation was performed. CT and/or MR imaging correctly predicted the source of excessive insulin secretion in 59% of patients, the sensitivity of the intraoperative exploration was 88%. CONCLUSIONS: In the authors'' experience, the ASVS test is superior to CT/MR imaging and even the intraoperative exploration in identifying the source of excessive insulin secretion in patients with hyperinsulinemic hypoglycemia. To prevent false negative ASVS tests, medications with an influence on insulin secretion have to be discontinued prior to ASVS and two baseline blood samples should be obtained before the calcium stimulation is performed. [Copyright &y& Elsevier]

Abnormal proinsulin processing in insulinomas may result in secretory granules containing both insulin and proinsulin, a finding not encountered in healthyβ-cells. The aim of this study was to test whether such abnormalities in the proinsulin to insulin conversion have clinical implications in patients with hypoglycaemic disorders.Case-series.Fifteen patients with histologically confirmed insulinoma and two patients with islet cell hyperplasia were included. The immunohistochemical distribution pattern of proinsulin within the tumour cells was classified as Golgi pattern (predominantly perinuclear immunolabelling) or diffuse pattern (immunolabelling in the periphery of the cells, indicating the presence of proinsulin in secretory granules). Data obtained from the 72-h fast and arterial calcium stimulation and hepatic venous sampling (ASVS) test were related to the morphological classification.Six insulinomas exhibited a diffuse proinsulin distribution pattern, while nine insulinomas and two islet cell hyperplasias disclosed a Golgi pattern. Median proinsulin concentrations at the termination of the fast tended to be higher in patients with the diffuse proinsulin distribution pattern than in patients with the Golgi pattern (86·9vs.18·8 pmol/l,P = 0·07). Higher insulin (P < 0·005) and proinsulin (P < 0·05) concentrations were significantly correlated with earlier occurrence of hypoglycaemia during the prolonged fast. During the ASVS test, tumours with the diffuse proinsulin distribution pattern exhibited a higher increase in both insulin (median, 37·3-vs.10·5-fold,P < 0·05) and proinsulin (6·3-vs.1·6 fold,P < 0·005) concentrations following calcium stimulation than the tumours with the Golgi pattern.Abnormalities in the proinsulin to insulin conversion in patients with insulinomas and islet cell hyperplasia correlate with impaired regulation of both insulin and proinsulin secretion during the prolonged fast as well as the ASVS test. [ABSTRACT FROM AUTHOR]

The fast translation of islet transplantation into clinical practice is hampered by the shortage of suitable organs and the high amount of islet tissue (islets of several donor pancreata) required to achieve insulin independence. We have previously shown that small islets have a higher insulin secretion and a better survival under hypoxic conditions in vitro. The aim of the present evaluation was to assess the in vivo function of differently sized islets in human islet transplantation. Maximal stimulated C-peptide values from l0 transplanted patients were measured during a mixed-meal tolerance test at 3 month post-transplant. There was no correlation between stimulated C-peptide and IEQ/kg recipient weight, but a good correlation for islet number (IN)/kg recipient weight (R²=0.76; figure 1), and between stimulated C-peptide/(IEQ/kg recipient weight) and the isolation index (R²=0.84; figure 2). This is the first study demonstrating the superiority of small islets in human islet transplantation: Instead of islet volume as expressed as IEQ we propose to use the isolation index, or even easier the total islet number to predict clinical outcome. In our experience the critical threshold for islet number to achieve insulin independence is 7000 IN/kg recipient weight. By using islet isolations with an islet volume, which so far has been considered insufficient for a good clinical outcome, but with an adequate islet number, more islet isolations could be used for transplantation. In conclusion, implementation of our findings might result in a better prediction of islet transplantation outcomes, and economic savings by increasing the percentage of transplantable islet isolations. [ABSTRACT FROM AUTHOR]

Background: Traditional criteria to diagnose hyperinsulinaemic hypoglycaemia are based on insulin measurements by unspecific insulin assays. This study was performed to test whether these traditional criteria can be applied when insulin is measured by specific immunoassays. Methods: 29 consecutive patients undergoing a prolonged fast were included; 11 patients with insulinoma and 18 healthy individuals. We determined plasma glucose, insulin, C-peptide, proinsulin, and β-hydroxybutyrate concentrations at the termination of the fast. Insulin was measured by an unspecific radioimmunoassay (RIA) and a specific enzyme-linked immunosorbent assay (ELISA). Results: In 11 insulinoma patients, insulin concentrations at median plasma glucose concentration of 2.1 (range 1.3–2.5) mmol/l were 170 (76–340) pmol/l measured by RIA and 61 (11–156) pmol/l by ELISA. Insulin concentrations measured by RIA confirmed hyperinsulinaemia (i.e., >36 pmol/l, the proposed cut-off value for traditional insulin assays) in all insulinoma patients, whereas insulin concentrations measured by ELISA were <36 pmol/l in four patients. In three insulinoma patients, insulin concentrations measured by ELISA were <18 pmol/l, a proposed cut-off level to diagnose hyperinsulinaemia for specific insulin assays. Conclusion: When insulin concentrations are measured by specific immunoassays in patients evaluated for fasting hypoglycaemia, traditional reference values cannot be applied. [Copyright &y& Elsevier]