Hepatic Insulin Gene Therapy in Insulin-Dependent Diabetes Mellitus

Insulin-dependent diabetes mellitus (IDDM) is an autoimmune disease resulting in destruction of the pancreatic beta-cells in the islets of Langerhans. Commonly employed treatment of IDDM requires periodic insulin therapy, which is not ideal because of its inability to prevent chronic complications such as nephropathy, neuropathy and retinopathy. Although pancreas or islet transplantation are effective treatments that can reverse metabolic abnormalities and prevent or minimize many of the chronic complications of IDDM, their usefulness is limited as a result of shortage of donor pancreas organs. Gene therapy as a novel field of medicine holds tremendous therapeutic potential for a variety of human diseases including IDDM. This review focuses on the liver-based gene therapy for generation of surrogate pancreatic beta-cells for insulin replacement because of the innate ability of hepatocytes to sense and metabolically respond to changes in glucose levels and their high capacity to synthesize and secrete proteins. Recent advances in the use of gene therapy to prevent or regenerate beta-cells from autoimmune destruction are also discussed.     

Prolonged Insulin Independence After Islet Allotransplants in Recipients with Type 1 Diabetes

We sought to determine the long‐term outcomes in type 1 diabetic recipients of intraportal alloislet transplants on a modified immunosuppressive protocol. Six recipients with hypoglycemia unawareness received one to two islet infusions. Induction therapy was with antithymocyte globulin (ATG) plus etanercept for tumor necrosis factor‐α blockade. Recipients received cyclosporine and everolimus for maintenance immunosuppression for the first year posttransplant, with mycophenolic acid or mycophenolate mofetil subsequently substituted for everolimus. Recipients have been followed for 1173 ± 270 days since their last infusion for islet graft function (insulin independence, hemoglobin A_1c levels and C‐peptide production) and for adverse events associated with the study protocol. Of the six recipients, five were insulin‐independent at 1 year, and four continue to be insulin‐independent at a mean of 3.4 ± 0.4 years posttransplant. None of the six recipients experienced recurrence of severe hypoglycemia. Measured glomerular filtration rate decreased from 110.5 ± 21.2 mL/min/1.73 m² pretransplant to 82.6 ±19.1 mL/min/1.73 m² at 1 year posttransplant. In conclusion, islet transplants restored insulin independence for a mean of >3 years in four of six recipients treated with ATG and etanercept induction therapy and with cyclosporine and, initially, everolimus for maintenance. Our results suggest this immunosuppressive protocol may allow long‐term graft survival.     

DL-ethionine Treatment of Adult Pancreatic Donors: Amelioration of Diabetes in Multiple Recipients with Tissue From a Single Donor

Transplantation of adult rat pancreatic islet tissue as a free graft requires the separation of islet from exocrine tissue to avoid host injury or graft destruction by digestive enzymes. The poor yield from islet isolation techniques currently necessitates the use of multiple donors to ameliorate diabetes in a single recipient. DL-ethionine (DLE) is an agent selectively toxic to the exocrine pancreas. We examined the effect of DLE administration on pancreatic digestive enzyme content and islet mass in adult Lewis rats and the ability of such pancreatic tissue dispersed by collagenase digestion without specific islet isolation to ameliorate diabetes when transplanted to the portal vein of syngeneic rats with streptozotocin induced diabetes. Rats fed normal chow supplemented with 0.5% DLE for 14-20 days showed a logarithmic loss of pancreatic mass. Total pancreatic amylase content declined to 0.3 + 0.1 mg, less than 3% of control values (14.3 +/- 1.0 mg). Total insulin content in DLE treated rats was 87 +/- 8 microg, not significantly different from control rats (101 +/- 7 microg). Histological examination confirmed the selective atrophy of exocrine tissue in DLE treated rats. Fresh pancreatic tissue prepared from a single DLE treated donor ameliorated diabetes 75% of the time when transplanted to one or two recipients and 65% of the time when divided between three of four recipients. Tissue prepared from a single DLE treated donor and stored for 24-48 hours ameliorated diabetes 91% of the time when divided between one or two recipients. Only four of 31 diabetic rats transplanted with fresh pancreatic tissue from untreated adult donors became normoglycemic. Pretreatment of adult rats with DLE induces selective exocrine atrophy, permits dispersed pancreatic tissue from a single donor to ameliorate experimental diabetes in up to four recipients, and allows tissue to be preserved by culture for up to 48 hours without specific islet isolation.     

体重<15kg儿童DCD单侧供肾用于成人肾移植的临床观察

目的评估体重15kg的儿童DCD(公民逝世后器官捐献,包括脑死亡捐献和心脏死亡捐献)供者单侧供肾用于成人肾移植的早期安全性及临床效果。方法回顾分析本院2013年2月至2015年2月间行体重15kg的儿童供肾成人肾移植18例(儿童供肾组),与同期成人供肾成人肾移植62例(成人供肾组)的临床资料,分析两组患者术后并发症;1个月、3个月、6个月及1年移植肾eGFR;术后6个月及1年人、移植肾存活率;儿童供肾组术后移植肾长径、eGFR的变化情况,蛋白尿、血尿发生情况。结果儿童供肾组DGF、AR、血管及泌尿系并发症发生率分别为22.22%、5.56%、5.56%和5.56%,成人供肾组为20.03%、3.26%、0%和0%(P均0.05);所有受者观察期间均未死亡,术后1个月儿童供肾组eGFR明显低于成人供肾组(P0.05),术后3个月、6个月及1年,两组eGFR无差异(P0.05)。儿童供肾组术后6个月及1年移植物存活率分别为93.80%和93.80%,而成人供肾组为98.20%和98.20%(P0.05);儿童供肾组移植肾eGFR、长径与术后时间呈正相关增长,观察期内儿童供肾组蛋白尿发生率与成人组相当,血尿发生率高于成人组。结论本组体重15kg的儿童DCD单侧供肾成人肾移植术后并发症、功能(依据eGFR评价)与成人组相当,供肾长径及移植肾eGFR在术后3~6个月可增至成人水平,低体重儿童单侧供肾成人肾移植手术并发症率低,近期效果满意,远期效果有待进一步观察。     

Pediatric Post-Transplant Diabetes: Data From a Large Cohort of Pediatric Heart-Transplant Recipients

A retrospective analysis of 381 pediatric heart-transplant recipients was performed to determine the frequency, characteristics, and risk factors for post-transplant diabetes. The rate of post-transplant diabetes was 1.8% with antithymocyte globulin, cyclosporine and azathioprine as primary immunosuppressive therapy. Time from transplant to diabetes was 0.25-13 years. Diabetes was characterized by reversibility, and lack of insulinopenia and autoimmunity. The post-transplant diabetes rate in tacrolimus-converted children (n = 45) was 8.8%. In tacrolimus-converted children, age at transplant, mean and maximum tacrolimus blood levels, and first-year rejection episodes were higher in the post-transplant diabetes group, which also consistently had DR-mismatched transplants and HLA DR3/DR4 haplotypes. Body mass index was not different between diabetic and control tacrolimus-converted children. In conclusion, pediatric post-transplant diabetes may be related to reversible insulin resistance. Tacrolimus levels, HLA DR mismatch, and older age at transplant may predispose to post-transplant diabetes.     

Urodynamic Evaluation in Simultaneous Insulin-Dependent Diabetes Mellitus and End Stage Renal Disease

Purpose

We evaluated the urodynamic changes produced by insulin-dependent diabetes mellitus with end stage renal disease.

Materials and Methods

A urodynamic evaluation was performed on 51 young patients (mean age plus or minus standard deviation 35 plus/minus 6 years) with long-term diabetes mellitus (average 21 plus/minus 6 years) and end stage renal disease (86 percent on dialysis).

Results

The urodynamic study was abnormal in 84 percent of the patients. The bladder was hypersensitive in 39 percent and hyposensitive in 30 percent of the cases, and maximum vesical capacity was greater than 600 ml. in 33 percent. An acontractile detrusor was noted in 6 percent of the patients, while 4 percent had detrusor hyperreflexia and 35 percent had bladder outlet obstruction.

Conclusions

A high frequency of vesical alterations was observed, which were modified by association of progressive vesical dysfunction and diabetes mellitus. In diabetes mellitus dialysis protects against detrusor hypocontractility but predisposes the patients to have bladder obstruction.     

Impaired Insulin Sensitivity as an Underlying Mechanism Linking Hepatitis C and Posttransplant Diabetes Mellitus in Kidney Recipients

Aim of this study was to investigate the mechanism/s associating hepatitis C virus (HCV) infection and posttransplant diabetes mellitus in kidney recipients. Twenty HCV‐positive and 22 HCV‐negative kidney recipients, 14 HCV‐positive nontransplant patients and 24 HCV‐negative nontransplant (healthy) subjects were analyzed. A 3‐h intravenous glucose tolerance test was performed; peripheral insulin sensitivity was assessed by minimal modeling. Pancreatic insulin secretion, hepatic insulin uptake, pancreatic antibodies and proinflammatory cytokines in serum (tumor necrosis factor‐α, intereukin‐6, high‐sensitive C‐reactive protein) were also assessed. HCV‐positive recipients showed a significantly lower insulin sensitivity as compared to HCV‐negative recipients (3.0 ± 2.1 vs. 4.9 ± 3.0 min^?1.μU.mL^{? 1}.10⁴, p = 0.02), however, insulin secretion and hepatic insulin uptake were not significantly different. Pancreatic antibodies were negative in all. HCV status was an independent predictor of impaired insulin sensitivity (multivariate analysis, p = 0.008). The decrease of insulin sensitivity due to HCV was comparable for transplant and non‐transplant subjects. No significant correlation was found between any of the cytokines and insulin sensitivity. Our results suggest that impaired peripheral insulin sensitivity is associated with HCV infection irrespective of the transplant status, and is the most likely pathogenic mechanism involved in the development of type 2 diabetes mellitus associated with HCV infection.     

Bone Mineral in Pre- and Postmenopausal Women with Insulin-Dependent and Non-insulin-Dependent Diabetes Mellitus

We have recently shown that bone radiogrammetric dimensions are associated with vitamin D receptor gene polymorphism. Since parathyroid hormone (PTH) plays a central role in maintaining calcium homeostasis and in bone remodeling, we investigated whether bone radiogrammetric dimensions are associated with a PTH gene polymorphism in 91 healthy Caucasian women, who were premenopausal at entry into the study. These women had assessments of bone by radiogrammetry every five years for a median period of 20 years (range 4–27). DNA was extracted from white blood cells. A segment of the PTH gene with a polymorphism at a BstBI restriction site was amplified by polymerase chain reaction. Diameter, cortical thickness and cross-sectional area at standard sites of the metacarpals, radius and femur were measured with radiogrammetry. Higher metacarpal diameter and cross-sectional cortical area, and a slower decrease in radial cortical area with age, were associated with the absence of the BstBI restriction site of the PTH gene. PTH gene polymorphism accounts for about 7–9% of the total variances of bone dimensional variables. These findings suggest that the dimensions of long bones are influenced by allelic variations in the PTH gene or in genes nearby. Received: 29 January 1998 / Accepted: 3 August 1998     

肾移植术后糖尿病临床分析

目的探讨肾移植术后糖尿病(PTDM)的发病情况及相关因素。方法回顾分析217例肾移植术后患者临床资料。按免疫抑制治疗方案分为两组,组Ⅰ:173例(环孢素A 骁悉 激素);组Ⅱ:44例(他克莫司 骁悉 激素);并比较PTDM与非PTDM患者临床资料。结果PTDM发病率6.9%(15/217),PTDM在组Ⅰ、组Ⅱ中的发病率分别为6.4%(11/173)及9.1%(4/44),两组比较无统计学差异(P>0.05);PTDM患者与同期非PTDM患者相比,在年龄、体重、激素用量及肾功能异常、阳性糖尿病家族史方面有显著差异(P<0.05或P<0.01)。结论环孢素A和他克莫司对肾移植PTDM的作用相近,患者激素用量、体重、年龄、移植肾功能状况及糖尿病阳性家族史是PTDM的易发因素。     

Renal Reserve Filtration Capacity in Patients With Type 1 (Insulin-Dependent) Diabetes Mellitus

Glomerular hyperfiltration is one of the factors held responsiblefor the development of diabetic nephropathy. A supranormal glomerularfiltration rate (GFR) can be found in diabetic patients evenwhen they are well controlled. Infusion of low-dose dopaminedemonstrates that glomerular hyperfiltration in well-controlledinsulin-dependent diabetic patients is not based on a predominantvasodilatation of the efferent arteriole. In the present studythis is confirmed, since the dopamine-induced rise in GFR ofcontrol subjects (13.5%±2.2) did not differ from thatof patients with insulin-dependent diabetes mellitus (10.8%±2.1).In animal studies it has been demonstrated that the increasedGFR in diabetes mellitus is caused by a predominant decreasein resistance of the afferent arteriole. Protein loading andinfusion of amino acids also increase GFR by dilatation of theafferent arteriole. Thus, protein loading or amino acid infusionmay be used to test the existence of afferent vasodilatation.The present study investigates the effect of amino acid infusionon GFR of control subjects and insulin-dependent diabetic subjects.The amino acid-induced rise in GFR tended to be lower in thediabetic patients (6.9%±2.8) compared with controls (13.2%±2.7).Percentage amino acid-induced change in GFR appeared to declinewith increasing baseline GFR in the diabetic subjects (r=–0.83;P<0.001). In controls, no such relationship was established(r=–0.22; n.s.). Our results suggest the existence ofafferent vasodilatation in diabetic patients with a high GFR.The cause of this vasodilatation warrants further study.     

Clinical and Histopathologic Comparative Analysis Between Kidney Transplant Recipients From Expanded-Criteria Donors and Standard-Criteria Donors

Owing to the disparity between the supply of kidney donors and demand, the use of organs from older deceased donors was initiated in recent years. The potentially poor outcome of these grafts is a major concern. This retrospective study compares graft and patient 1-year survivals between recipients from expanded-criteria donors (ECD; n = 30) and standard-criteria donors (SCD; n = 104). Rates of delayed graft function (DGF), acute rejection (AR), and chronic injury in the pre-implantation biopsy were also assessed. Increasing donor age was associated with increased rates of DGF, and DGF correlated with AR. Cold ischemia time >30 hours was associated with worse graft outcomes. Induction with Simulect correlated with better patient survival compared with Timoglobulina. Chronic injury pre-implantation biopsy correlated with worse renal function, but graft survival was similar. Death-censored graft survival at 1 year was 90% and patient survival 82%, and these were similar in ECD and SCD recipients. Selection of transplant candidates for ECD kidneys must be performed with caution. One-year graft survival was similar to that of SCD kidneys, but kidney function was worse during the same period. This may result in poorer graft survival over longer follow-up.     

Hemoderivative Transfusion in Liver Transplantation: Comparison Between Recipients of Grafts From Brain Death Donors and Recipients of Uncontrolled Donors After Circulatory Death

IntroductionIntraoperative bleeding during liver transplantation has been correlated with a higher risk of morbidity and mortality and decrease in patient and graft survival.Materials and MethodsBetween January 2006 and December 2016 we performed 783 orthotopic liver transplants. After applying exclusion criteria, we found liver grafts from donors after circulatory death (DCD, group A) were used in 69 patients and liver grafts from donors after brain death (group B) were used in 265 patients.ResultsNo difference was found in terms of sex, body mass index, Model for End-Stage Liver Disease score, indication for transplantation, intensive care unit stay, and Child-Pugh score. The mean transfusion of hemoderivates was as follows: red blood cell 9 (0-28) units in group A vs 6 (0-20) units in group B (P = .004) and fresh frozen plasma 10 (0-29) units in group A vs 9.5 (0-23) in group B (P = .000). The only 2 factors related to massive blood transfusion (>6 units of red blood cell) were uncontrolled DCD condition (odds ratio = 2.38; 95% confidence interval, 1.32-4.31; P = .004), and higher Model for End-Stage Liver Disease score (odds ratio = 2.63; 95% confidence interval, 1.53-4.55; P = .001). Survival at 1, 3, and 5 years was 81.3%, 70.2%, and 68.9% in group A vs 89%, 83.7%, and 78% in group B (P = .070).ConclusionThe use of liver grafts from DCDs is associated with increased necessity of transfusion of hemoderivates in comparison with the use of liver grafts from donors after brain death.     

Kidney Transplantation in Old Recipients From Old Donors: A Single-Center Experience

Purpose

The program Old for Old or European Senior Program (ESP), allocates donors aged ≥65 years to recipients of ≥65, within a narrow geographic area in order to minimize cold ischemia time, decrease the waiting time for elderly patients listed for kidney transplantation and expand the transplant resource in this group. The ESP is not officially applied in Greece. In our center, the Old for Old criteria have been used since 2003 for elderly patients who are candidates for kidney transplantation.

儿童DCD供肾成人单肾移植与标准DCD供肾移植临床疗效比较研究

目的比较儿童DCD供肾成人单肾移植与标准DCD供肾移植(成人供肾成人单肾移植)的临床疗效。方法回顾性分析本院2011年11月至2014年4月完成的97例DCD供肾移植供受者的临床资料。根据供者年龄将其分为儿童DCD供肾成人单肾移植组(SPKT组,3岁年龄18岁,20例)和标准DCD供肾移植组(SCDKT组,年龄≥18岁,73例),比较两组供受者一般情况、受者术后不同时间点血肌酐水平、各种并发症的发生率及移植肾和人的1年存活率。结果 SPKT组供者年龄、体重、移植肾长度显著小于SCDKT组,差异具有统计学意义(P0.01);SPKT组受者术后1年内蛋白尿发生率显著高于SCDKT组(P0.01);两组受者移植肾和人的1年存活率比较无统计学差异(P0.05);供受者其它指标比较均无统计学差异(P0.05)。结论与标准DCD供肾移植相比,尽管蛋白尿发生率较高,但儿童DCD供肾成人单肾移植近期临床效果良好,远期效果有待进一步研究。     

Predicted Lifetimes for Adult and Pediatric Split Liver Versus Adult Whole Liver Transplant Recipients

Split liver transplantation allows 2 recipients to receive transplants from one organ. Comparisons of predicted lifetimes for two alternatives (split liver for an adult and pediatric recipient vs. whole liver for an adult recipient) can help guide the use of donor livers. We analyzed mortality risk for 48,888 waitlisted candidates, 907 split and 21,913 whole deceased donor liver transplant recipients between January 1, 1995 and February 26, 2002. Cox regression models for pediatric and adult patients assessed average relative wait list and post-transplant death risks, for split liver recipients. Life years gained compared with remaining on the waiting list over a 2-year period were calculated. Seventy-six splits (152 recipients) and 24 re-transplants resulted from every 100 livers (13.1% [adult] and 18.0% [pediatric] 2-year re-transplant rates, respectively). Whole livers used for 93 adults also utilized 100 livers (re-transplant rate 7.0%). Eleven extra life years and 59 incremental recipients accrued from each 100 livers used for split compared with whole organ transplants. Split liver transplantation could provide enough organs to satisfy the entire current demand for pediatric donor livers in the United States, provide more aggregate years of life than whole organ transplants and result in larger numbers of recipients.     

Primary Nonfunction on Kidney Transplant Recipients From Donation After Circulatory Death Donors

BackgroundThe need for donor pool expansion remains an important task for kidney transplantation. The aim of this study is the evaluation of primary nonfunction (PNF) from donation after circulatory death (DCD) kidneys.MethodsBetween 1996 and 2017, 100 kidney transplants from DCD donors were conducted in our department. We retrospectively analyzed PNF of kidney transplant recipients from DCD donors in terms of donors’ and recipients’ epidemiologic characteristics.ResultsOf 100 grafts, 95 recipients (95.0%) had discontinued hemodialysis at the time of hospital discharge. Only 5 recipients (5.0%) developed PNF. All 5 PNF recipients received a single graft from an expanded criteria donor (ECD). The mean donor age in the PNF group was 65.0 (SD, 6.2) years. Significant differences between the PNF group and discontinued dialysis group were found for donor age (P < .01) and for the use of ECD kidneys (P < .02). Nevertheless, no significant difference was found between groups for several factors: a history of hypertension and cerebrovascular events, terminal creatinine levels, and graft weight.ConclusionThe incidence of PNF from DCD kidneys was very low. Although ECD kidneys in older donors might be a significant risk factor for PNF, these findings suggest that DCD kidneys should be used more frequently for donor expansion.     

Steroid Withdrawal Using Everolimus in ABO-Incompatible Kidney Transplant Recipients With Post-Transplant Diabetes Mellitus

Background

The effectiveness of everolimus (EVR) for ABO-incompatible (ABOi) kidney transplantation is unknown. We evaluated outcomes of conversion from steroid to EVR in ABOi kidney transplant recipients.