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The safety and effectiveness of islet transplantation has been proven through world-wide trials. However, acute and chronic islet loss has hindered the ultimate objective of becoming a widely used treatment option for type 1 diabetes. A large islet loss is attributed, in part, to the liver being a less-than-optimal site for transplantation. Over half of the transplanted islets are destroyed shortly after transplantation due to direct exposure to blood and non-specific inflammation. Successfully engrafted islets are continuously exposed to the liver micro-environment, a unique immune system, low oxygen tension, toxins and high glucose, which is toxic to islets, leading to premature islet dysfunction/death. Investigations have continued to search for alternate sites to transplant islets that provide a better environment for prolonged function and survival. This article gathers courses and conditions that lead to islet loss, from organ procurement through islet transplantation, with special emphasis on hypoxia, oxidative stress, and antigen non-specific inflammation, and reviews strategies using pharmacological agents that have shown effectiveness in protecting islets, including a new treatment approach utilizing siRNA. Pharmacological agents that support islet survival and promote β-cell proliferation are also included. Treatment of donor pancreata and/or islets with these agents should increase the effectiveness of islets transplanted into extrahepatic sites. Furthermore, the development of methods designed to release these agents over an extended period, will further increase their efficacy. This requires the combined efforts of both islet transplant biologists and bioengineers.

Collagenase infusion into the pancreatic duct is an essential step in human islet isolation. We developed a new method for ductal canulation and collagenese infusion.A total of 53 pancreata were divided into two groups: group 1 (n=23), the new tube method, and group 2 (n=30), the standard angiocatheter method. In group 1, a polyethylene tube was inserted into the duct and pushed to the tail. The tail was first expanded, followed by expansion of the body and then the head, by pulling out the tube.Total islet number and number/g pancreas (mean+/-SE) were significantly higher in group 1 (481,123+/-43,218 and 8,010+/-722) (mean+/-SE) than in group 2 (300,974+/-35,122 and 5,090+/-515, P0.01). Total islet equivalent number and islet equivalent number per gram pancreas were also significantly higher in group 1 (319,176+/-39,354 and 5,455+/-652) than in group 2 (202,022+/-23,331 and 3,722+/-468, P0.04). Islet purity and fragmentation showed no differences between the groups.The tube method improved islet yields. We recommended this method for human islet isolation.

The most critical factors that affect the outcome of clinical pancreatic islet transplantation are the number and quality of donor islets available for transplantation. Toward this goal, we attempted to obtain islets that are both of better quality and higher number than are obtainable by the islet-isolation process that is now widely used. We paid special attention to two critical components of the isolation procedure: minimizing the exposure of pancreatic tissue and freed islets to warm enzyme solution, and development of a preservation solution suitable for islets during cold storage of digested pancreatic tissue-free islets. For this purpose, we developed both a two-step procedure for pancreas digestion and a new cold preservation solution, the LAP-1 solution (Los Angeles preservation solution 1). In this study, we evaluated the effect of four preservation solutions by storing digested pancreatic tissues on ice for 90 min. After the cold storage, islets were purified on three layers of Euro-Ficoll solutions in a 50-ml tube, and the islet yield, viability, and function were determined. These experiments were performed by using samples from 10 consecutive islet isolations. Results with LAP-1, original University of Wisconsin solution (oUW), and modified UW solution (mUW;UW without hydroxyethyl starch) were compared with those obtained with Hank's balanced salt solution (HBSS). The islet yield was significantly higher in the LAP-1 and mUW groups as compared with the HBSS group (p < 0.01). The islet purity was significantly better in the LAP-1, oUW, and mUW groups than the HBSS (p < 0.001). The islet viability was lowest in the HBSS group immediately after purification (vs. LAP-1, oUW, and mUW, p < 0.05) and further decreased during culture (p < 0.01). Both the number and viability of cultured islets were the highest with LAP-1 solution but without statistical significance between mUW and oUW. Electron microscopic examination showed only slight damage to cell membranes immediately after purification of islets stored in LAP-1 solution and their complete recovery within 1-2 days of culture. These islets also exhibited normal insulin responses to high glucose by static incubation and perifusion assays.

Pancreatic islet transplantation has a high potential for treating diabetes mellitus, but long-lasting insulin independence has not been achieved in type I diabetic patients. In order to obtain better results, improvement is needed in many areas. The first area is the islet isolation process. The requirements for an islet isolation method are: 1) to produce a maximum number of healthy islets without demanding a high quality of donor pancreas; 2) to be able to perform the procedure with fewer numbers of personnel who may be without extensive skills and expertise; and 3) to lower isolation costs. In order to achieve these objectives, we have made two important modifications to the isolation process. One is the development of a new preservation solution, LAP-I and the other is the use of a two-step process for pancreas digestion, involving a short warm collagenase digestion, followed by cold mechanical digestion without collagenase. We also use a clear plastic digestion chamber in order to visualize the process. The chamber cover is designed to facilitate frequent removal of digested tissue fragments. The overall procedure is simple and straightforward, requires less manpower and is cost effective. Our procedure is described in detail, and its advantages are discussed.

The objective of this study was to analyze allogeneic lymphocyte proliferative responses to cultured human pancreatic islets after gene transfer of viral interleukin (IL)-10 to the islets using replication-defective adenoviral vector. Human islets, either whole or dispersed into single cells, were cocultured with adenovector containing an expression cassette encoding the viral IL-10 gene under control of an SV40 promoter, this sequence replacing viral E1A and part of E1B early viral protein sequences. Subsequent production of recombinant protein by islets was determined by ELISA, and was found dependent on the multiplicity of infection (or ratio of vector to target cells). Protein was secreted by transfected islets at high levels 3-7 days after gene transfer. At high multiplicity of infection (100:1), islet viability was normal, but insulin secretion in response to glucose stimulation was blunted by 50%. Low-level recombinant viral IL-10 secretion by the islets was associated with increased allogeneic lymphocyte proliferation in mixed islet lymphocyte reactions. At protein levels in islet supernatant above 5 ng/ml, lymphocyte proliferation was significantly reduced. This pattern of viral IL-10 effect on lymphocyte proliferation correlated well with mixed lymphocyte reaction assays using purified protein. We conclude that transferred cytokine sequences are secreted by transfected islets as a function of the initial vector inoculum. The functional effect of the secreted cytokine viral IL-10 on allogeneic lymphocyte proliferation is dose dependent. Low-level recombinant protein secretion tended to augment lymphocyte proliferation, whereas high-level secretion significantly down-regulates this response.

We have used the pig as a large animal model for studies of fetal pancreas transplantation. Fetal pig pancreas (FPP) has also been proposed as a potential source of endocrine cells for the treatment of diabetes mellitus. Among the approaches to prevent rejection, the irradiation of donor islets with ultraviolet B light has been used for its immunomodulating properties. Our goal was to study in vitro the effects of UV-B irradiation of FPP on the function and immunogenicity of the tissue. FPP were collagenase-digested and cultured for 1-29 days prior to UV-B irradiation. Static incubation tests were used to measure glucose-theophylline stimulated insulin release. Data obtained at 300 J/m2 revealed no impairment of insulin release (78% to 129% of controls, P = ns). At 500 J/m2, a significant reduction of glucose-theophylline stimulated insulin release was observed with 50-60-day-old FPP (35% to 66% of controls, P0.05), but not with 80-day-old FPP (93% of controls, P = ns). At both doses, prolonged observation in culture did not show any alteration of the growth and proliferation of islet cell clusters. UV-irradiated (300 J/m2) adult and fetal pig islet allografts released C-peptide and survived200 days. The immunogenicity of irradiated tissues was determined in vitro with allogeneic mixed islet-lymphocyte cultures (MILC). Proliferative responses of allogeneic lymphocytes to UV-irradiated FPP were very significantly decreased by 52-91% at both 300 and 500 J/m2 doses. This effect was observed from 1 to 10 days following UV irradiation and was not modulated by exposure of the tissues to gamma-interferon. We conclude that UVB-irradiation of FPP at a dose of 300 J/m2 does not alter its endocrine function and growth and is effective in reducing tissue immunogenicity. This treatment may be a useful approach for fetal islet transplantation in large animal models.

Genetic manipulation of pancreatic islets before transplantation has the potential to alter cellular immunity as well as islet function. The purpose of this study was to examine the feasibility of gene transfer to islets, using replication-defective adenoviral vectors. Newborn mouse islets were infected with AdHCMVsp1LacZ vector encoding Escherichia coli beta-galactosidase (beta-gal). Islets were cocultured with vector, at virus-to-target cell ratios of 10:1, for 1 hr. Gene transfer was assessed by specific histochemical stain for beta-gal (X-gal). Islet DNA and RNA were analyzed by Southern and PCR for beta-gal and adeno sequences, and recombinant protein production by western and ONPG assays. Islet integrity after gene transfer was assessed by static incubations and transplantation to nondiabetic and to diabetic mice. Southern analysis and PCR confirmed the presence of E coli beta-galactosidase and the E4 adeno DNA in infected islets, but not in controls. Reverse-transcription PCR and western analysis demonstrated expression and protein production of inserted E coli beta-galactosidase, but not E4 message. Insulin release in response to static incubations was unimpaired in infected islets. Syngeneic islet grafts stained positively for insulin for up to 7 days. Transplanted, genetically manipulated islets functioned similarly to control islets in reversing murine drug-induced diabetes. Thus, gene transfer into islets can be accomplished using adenovirus-based vectors. The capacity of this virus to infect non-dividing cells allows insertion of cDNA into pancreatic islets, with potential application to the transplant setting.

One of the major steps toward successful islet transplantation for the treatment of type diabetes is to obtain islets of sufficient number and viability. Using a standardized method of isolating islets, the goal of this study was to analyze the factors influencing the outcome of islet isolation. A total of 104 cadaveric human pancreata were processed for islets by the same team. Data from the islet-processing charts were reviewed retrospectively. The two endpoints were the recovery of islets, viable after 2 days of culture (group V = viable, group NV = nonviable) and the islet yield. Viable islets were recovered in 61% of cases (n = 63). Minimal blood glucose recorded during hospitalization was very significantly lower in group V (124 +/- 5 vs. 148 +/- 9, P = 0.01). Lack of significant medical history in the donor was associated with better viability as compared with various donor predispositions (chi-2 4.21, P = 0.04). Cold ischemia time (8.1 +/- 0.5 hr in group V vs. 9.8 +/- 0.9 hr in group NV, P = 0.07) and collagenase lot (5 lots tested, chi-2 13.1, P = 0.01) also affected the recovery of viable islets. Hospital time was shorter in group V (65.3 +/- 6.8 vs. 80.9 +/- 17.9 hr, P = 0.35). Multivariate logistic regression analyses of viable islet recovery identified minimal blood glucose (P = 0.03) and collagenase lot (P = 0.06) as the most significant risk factors. However, the best multivariate predictive model--which includes blood glucose, collagenase lot, donor age and surgical procurement team--correctly predicted 66.2% of cases only. Multivariate analysis of final islet yield designed hospitalization length, cardiorespiratory arrest, surgical procurement team, and collagenase lot as the best predictors. These data obtained in a large series of pancreata emphasized several donor and technical factors that should target the attention of islet transplant researchers in order to improve islet yield and viability.

Dendritic cells (DC) isolated from various lymph node (LN) groups of pre-diabetic non-obese diabetic (NOD) (4-20 weeks of age) and age-sex-matched control mice were analysed for their surface antigen phenotype and their ability to cluster lymphocytes. The draining LN of the pancreas (PLN) of 8-week-old NOD mice with active autoimmune disease were significantly enlarged in comparison to the axillary LN of the same NOD mice and the PLN from control mice. NOD DC isolated from PLN and other LN demonstrated classical DC morphology, were highly major histocompatibility complex (MHC) class II antigen positive, and were 50-70% 33D1+ (DC-specific antibody). In an assay for DC-T cell clustering, DC from the PLN of 8-20-week-old NOD formed large clusters (greater than 10 cells) with PLN cells at a frequency three to 20 times greater than that observed with DC and LN cells from the PLN of 8-week-old control mice, the PLN of 4-week-old NOD mice, and axillary/inguinal LN of 8-week-old NOD mice. Clustered cells were 80% Thy-1.2+ (56% L3T4, 17% Lyt-2+). Specificity of clustering was demonstrated as PLN DC clustered only PLN T cells in the assay; axillary/inguinal (A/I) DC added to PLN LC did not induce clustering nor did PLN DC induce clustering of the A/I population. Cell proliferation in isolated PLN DC/LC clusters was markedly greater than that of A/I clusters and of non-clustered PLN cells. These data demonstrate that DC from the PLN of NOD mice with active autoimmune disease form stable clusters with T cells from the PLN and these clusters are the major source of proliferating T cells in these LN. We hypothesize that PLN DC may play an important role in the autoimmune disease of the NOD mouse.

Three in vivo techniques were used to establish the specificity of tumor immunity induced after sensitization of F344 rats to syngeneic MCA-induced sarcomas: (1) post-excision resistance to tumor challenge, (2) passive tumor neutralization (the Winn test), and (3) concomitant immunity. In general, these assays revealed unique non-cross-reactive antigens associated with each of three sarcomas, FMF1, FMM2, and FMM3. However, spleen cells from tumor-sensitized rats did not demonstrate cell-mediated cytotoxicity in vitro corresponding to the specificity of tumor resistance in vivo. In the (3H)-proline cytotoxicity assay, spleen cells from FMM3 tumor-bearing rats or from FMM3 tumor-immune rats were not selectively cytotoxic for cultured FMM3 target cells. Parallel analysis of spleen cells from normal or FMM3-sensitized rats using the Winn assay and the (3H)-proline assay revealed that (1) spleen cell cytotoxicity in vitro did not correlate with effective tumor protection in vivo; and (2) normal spleen cells were cytotoxic against cultured sarcoma target cells in vitro and inhibited tumor growth in vivo. Thus, passive tumor protection by normal spleen cells in vivo corresponded with the demonstration of natural cytotoxicity in vitro, but induced specific anti-tumor reactivity was observed only in vivo.

The development of autoimmune diabetes in the nonobese diabetic (NOD) mouse is controlled by at least three recessive loci, including one linked to the MHC. To determine whether any of these genetic loci exert their effects via the immune system, radiation bone marrow chimeras were constructed in which (NOD X B10)F1-irradiated recipients were reconstituted with NOD bone marrow cells. Unmanipulated (NOD X B10)F1 mice, or irradiated F1 mice reconstituted with F1 or B10 bone marrow, did not display insulitis or diabetes. In contrast, insulitis was observed in a majority of the NOD----F1 chimeras and diabetes developed in 21% of the mice. These data demonstrate that expression of the diabetic phenotype in the NOD mouse is dependent on NOD-derived hematopoietic stem cells. Diabetogenic genes in the NOD mouse do not appear to function at the level of the insulin-producing beta cells since NOD----F1 chimeras not only developed insulitis and diabetes but also rejected beta cells within pancreas transplants from newborn B10 mice. These data suggest that the beta cells of the NOD mouse do not express a unique antigenic determinant that is the target of the autoimmune response.

Genetic analysis of the development of diabetes and insulitis has been performed in the nonobese diabetic (NOD) mouse strain, a model of insulin-dependent (type I) diabetes mellitus. (NOD X C57BL/10)F1, F2, and (F1 X NOD) first-, second-, and third-backcross generations were studied. The data obtained were consistent with the hypothesis that diabetes is controlled by at least three functionally recessive diabetogenic genes, or gene complexes, one of which is linked to the MHC of the NOD. In contrast, pancreatic inflammation leading to insulitis was found to be controlled by a single incompletely dominant gene. One of the two diabetogenic loci that is not linked to the MHC appears to be essential for the development of severe insulitis. This diabetogenic gene may be identical to the gene that controls the initiation of the autoimmune response that progresses to insulitis. Although this gene appears to be functionally recessive in its control of diabetes, it is incompletely dominant in its control of insulitis. The MHC-linked diabetogenic gene, although not required for the development of insulitis, apparently influences the progression of the autoimmune response since NOD MHC homozygotes in the backcross generations displayed the highest incidence and most severe cases of insulitis. Interestingly, we have found two MHC heterozygous backcross females that have become diabetic, suggesting that either the MHC-linked diabetogenic gene is not strictly recessive or that a recombination event has occurred between the diabetogenic gene and the K or I-A regions of the MHC. The third diabetogenic locus appears to influence the progression of severe insulitis to overt diabetes. In animals homozygous at this locus, diabetes may result from a decreased ability to develop a protective suppressor response to the autoimmune process.

We have investigated glucose homeostasis and insulin response to glucose in seven rats before, during and after pregnancy, who were previously successfully transplanted with a single fetal pancreas. Increased need for insulin during pregnancy provides an opportunity to test the reserve capacity of the transplanted organ. Plasma glucose in seven rats was normal before pregnancy (7.3 +/- 0.7 mmol/l), during pregnancy (6.6 +/- 1 mmol/l) and after parturition (6.7 +/- 0.3 mmol/l). Fasting plasma glucose was lower after parturition (5.1 +/- 1 mmol/l) than before pregnancy (6.1 +/- 0.7 mmol/l). The disappearance rate of injected glucose was the same before (2.3 +/- 0.2%/min) as after pregnancy (2.6 +/- 0.2%/min). Basal plasma insulin before pregnancy was elevated and there was no rise from glucose; after parturition the basal and pattern of response was normal. The total insulin content of the transplants (859 +/- 154 mU) was only 21% of that of normal rats; we conclude that this provides a reserve adequate for the needs of pregnancy.

Rectangular skin flaps based on the right superficial epigastric vessels were designed on the groins of 36 rats. Preoperative control, intraoperative, and postoperative readings of oxygen tension (PO2) were made at proximal, central, and distal sites on the flaps with a transcutaneous PO2 (tcPO2) monitor under various conditions of oxygen inspiration. The results of this experimental work indicated that the tcPO2 monitor was useful in continuously and rapidly measuring changes in oxygen concentration in skin flaps in a noninvasive fashion. The monitoring demonstrated that the response time of the flaps to changes in the concentration of inspired oxygen was rapid (less than 15 seconds). The monitoring also was valuable in assessing viability of the flaps, in predicting flap survival, and in detecting any systemic factors influencing oxygen transport, such as pneumonia. As a result of the experimental series, tcPO2 monitoring was used clinically to evaluate 18 flaps in 16 patients. As in the experimental series, the clinical measurements were significant and reproducible. They demonstrated that the tcPO2 monitor provides safe, reliable monitoring of peripheral oxygenation in the microcirculation that is rapid, continuous, and totally noninvasive. It is concluded that simultaneous tcPO2 measurements at control and flap sites provides a continuous record of the status of a flap that can improve the postoperative management of the surgical patient.