From insulin injections to islet transplantation: An overview of the journey.

When, in 1869, Paul Langerhans detected the "islands of tissue" in the pancreas, he took the first step on a journey towards islet transplantation as a treatment for type 1 diabetes. The route has embraced developments across biosciences, surgery, gene therapy and clinical research. This review highlights major milestones along that journey involving whole pancreas transplantation, islet transplantation, the creation of surrogate insulin-secreting cells and novel islet-like structures using genetic and bio-engineering technologies. To obviate the paucity of human tissue, pluripotent stem cells and non-ß-cells within the pancreas have been modified to create physiologically responsive insulin-secreting cells. Before implantation, these can be co-cultured with endothelial cells to promote vascularisation and with immune defence cells such as placental amnion cells to reduce immune rejection. Scaffolds to contain grafts and facilitate surgical placement provide further opportunities to achieve physiological insulin delivery. Alternatively, xenotransplants such as porcine islets might be reconsidered as opportunities exist to circumvent safety concerns and immune rejection. Thus, despite a long and arduous journey, the prospects for increased use of tissue transplantation to provide physiological insulin replacement are drawing ever closer.

The potential role of multifunctional human amniotic epithelial cells in pancreatic islet transplantation.

Pancreatic islet cell transplantation has proven efficacy as a treatment for type 1 diabetes mellitus, chiefly in individuals who are refractory to conventional insulin replacement therapy. At present its clinical use is restricted, firstly by the limited access to suitable donor organs but also due to factors associated with the current clinical transplant procedure which inadvertently impair the long-term functionality of the islet graft. Of note, the physical, biochemical, inflammatory, and immunological stresses to which islets are subjected, either during pretransplant processing or following implantation are detrimental to their sustained viability, necessitating repeated islet infusions to attain adequate glucose control. Progressive decline in functional beta (ß)-cell mass leads to graft failure and the eventual re-instatement of exogenous insulin treatment. Strategies which protect and/or preserve optimal islet function in the peri-transplant period would improve clinical outcomes. Human amniotic epithelial cells (HAEC) exhibit both pluripotency and immune-privilege and are ideally suited for use in replacement and regenerative therapies. The HAEC secretome exhibits trophic, anti-inflammatory, and immunomodulatory properties of relevance to islet graft survival. Facilitated by ß-cell supportive 3D cell culture systems, HAEC may be integrated with islets bringing them into close spatial arrangement where they may exert paracrine influences that support ß-cell function, reduce hypoxia-induced islet injury, and alter islet alloreactivity. The present review details the potential of multifunctional HAEC in the context of islet transplantation, with a focus on the innate capabilities that may counter adverse events associated with the current clinical transplant protocol to achieve long-term islet graft function.

Ultrasound Surveillance of Common Iliac Artery Aneurysms.

BACKGROUND: The surveillance of patients with common iliac artery aneurysms (CIAA) does not follow a defined protocol such as the one adopted for the management of abdominal aortic aneurysms. This study explores CIAA growth rate, and seeks to determine correlations with related parameters which may serve to influence aneurysm expansion with the view of devising an effective local surveillance protocol. METHODS: Vascular laboratories across the UK were invited to participate in an online survey. Questions were designed to assess current clinical practice in regards to the surveillance of patients with CIAA. Additionally, a retrospective audit was performed using the clinical reports of patients attending a regional vascular laboratory to undergo an aorto-iliac duplex scan (USS). Expansion rate of aneurysms was studied in patients who had ≥2 USS scans; data was recorded at 6 and/or 12 monthly intervals up to 5 years. Kaplan Meier estimates of patient mortality (all cause) and intervention rate during the surveillance period were performed. Patient age, initial CIAA diameter, bilateral/unilateral CIAA and coinciding aortic aneurysm diameter were recorded to determine if these specific features were associated with CIAA growth rates. Pearson's correlation coefficient was used to determine the strength of association between variables. RESULTS: Nine hundred and ninety-five of one thousand and sixty patient records were suitable for review: 21.6% (215/995) of patients had a CIAA. Isolated CIAA accounted for 23% (50/215). Mean CIAA growth was 1.5 ± 0.3 mm/year. A strong correlation was found between CIAA diameter versus time from diagnosis (r = 0.820; P = 0.004); CIAA with smaller initial diameters (15-20 mm) expanded more rapidly than those of larger diameter at diagnosis (r = 0.871; P = 0.005). CIAA measured at >30 mm demonstrated an unpredictable growth trajectory which was also evident in those CIAA coinciding with larger AAA (>50 mm; r = 0.208; P = 0.655). CONCLUSIONS: The results obtained in this study may form the basis for a dedicated CIAA surveillance protocol.

Rotational culture and integration with amniotic stem cells reduce porcine islet immunoreactivity in vitro and slow xeno-rejection in a murine model of islet transplantation.

BACKGROUND: Pre-transplant modification of porcine islets may improve their suitability for clinical use in diabetes management by supporting graft function and reducing the potential for xeno-rejection. The present study investigates intra-graft incorporation of stem cells that secrete beta (ß)-cell trophic and immunomodulatory factors to preserve function and alter immune cell responsiveness to porcine islets. METHODS: Isolated porcine islets were maintained in a three-dimensional rotational cell culture system (RCCS) to facilitate aggregation with human amniotic epithelial cells (AECs). Assembled islet constructs were assessed for functional integrity and ability to avoid xeno-recognition by CD4+ T-cells using mixed islet:lymphocyte reaction assays. To determine whether stem cell-mediated modification of porcine islets provided a survival advantage over native islets, structural integrity was examined in a pig-to-mouse islet transplant model. RESULTS: Rotational cell culture system supported the formation of porcine islet:AEC aggregates with improved insulin-secretory capacity compared to unmodified islets, whilst the xeno-response of purified CD4+ T-cells to AEC-bearing grafts was significantly (P < 0.05) attenuated. Transplanted AEC-bearing grafts demonstrated slower rejection in immune-competent recipients compared to unmodified islets. CONCLUSIONS/INTERPRETATION: Rotational culture enables pre-transplant modification of porcine islets by integration with immunomodulatory stem cells capable of subduing xeno-reactivity to CD4+ T-cells. This reduces islet rejection and offers translational potential to widen availability and improve the clinical effectiveness of islet transplantation.

Low gravity rotational culture and the integration of immunomodulatory stem cells reduce human islet allo-reactivity.

Modification of human islets prior to transplantation may improve long-term clinical outcome in terms of diabetes management, by supporting graft function and reducing the potential for allo-rejection. Intragraft incorporation of stem cells secreting beta (ß)-cell trophic and immunomodulatory factors represents a credible approach, but requires suitable culture methods to facilitate islet alteration without compromising integrity. This study employed a three-dimensional rotational cell culture system (RCCS) to achieve modification, preserve function, and ultimately influence immune cell responsiveness to human islets. Islets underwent intentional dispersal and rotational culture-assisted aggregation with amniotic epithelial cells (AEC) exhibiting intrinsic immunomodulatory potential. Reassembled islet constructs were assessed for functional integrity, and their ability to induce an allo-response in discrete T-cell subsets determined using mixed islet:lymphocyte reaction assays. RCCS supported the formation of islet:AEC aggregates with improved insulin secretory capacity compared to unmodified islets. Further, the allo-response of peripheral blood mononuclear cell (PBMC) and purified CD4+ and CD8+ T-cell subsets to AEC-bearing grafts was significantly (p < 0.05) attenuated. Rotational culture enables pre-transplant islet modification involving their integration with immunomodulatory stem cells capable of subduing the allo-reactivity of T cells relevant to islet rejection. The approach may play a role in achieving acute and long-term graft survival in islet transplantation.

Pre-transplant signal induction for vascularisation in human islets.

Human islet transplant success is partially impaired by slow revascularisation. Our study investigated the potential for rotational cell culture (RC) of human islets combined with thiazolidinedione (TZD) stimulation of peroxisome proliferator-activated receptor gamma (PPARγ) to upregulate vascular endothelial growth factor (VEGF) expression in the islets. Four groups of human islets were studied: static culture (SC) with and without 25 mmol/L TZD and RC with and without 25 mmol/L TZD. These were assessed for insulin secretion and soluble VEGF-A release. Both proteins were quantified by enzyme-linked immunosorbent assay (ELISA), supported with qualitative immunofluorescence staining. RC + TZD increased insulin secretion by >20% (p < 0.05-0.001) in response to 16.7 mmol/L glucose and 16.7 mmol/L glucose + 10 mmol/L theophylline (G + T). This effect was seen at all time intervals compared with SC and without addition of TZD. Soluble VEGF-A release was significantly augmented by RC and TZD exposure with an increased effect of >30% (p < 0.001) at 72 h under both SC and RC conditions. RC supplemented with a TZD enhances and prolongs the release of insulin and soluble VEGF-A by isolated human islets.

Human amniotic epithelial cells induce localized cell-mediated immune privilege in vitro: implications for pancreatic islet transplantation.

Chronic systemic immunosuppression in cell replacement therapy restricts its clinical application. This study sought to explore the potential of cell-based immune modulation as an alternative to immunosuppressive drug therapy in the context of pancreatic islet transplantation. Human amniotic epithelial cells (AEC) possess innate anti-inflammatory and immunosuppressive properties that were utilized to create localized immune privilege in an in vitro islet cell culture system. Cellular constructs composed of human islets and AEC (islet/AEC) were bioengineered under defined rotational cell culture conditions. Insulin secretory capacity was validated by glucose challenge and immunomodulatory potential characterized using a peripheral blood lymphocyte (PBL) proliferation assay. Results were compared to control constructs composed of islets or AEC cultured alone. Studies employing AEC-conditioned medium examined the role of soluble factors, and fluorescence immunocytochemistry was used to identify putative mediators of the immunosuppressive response in isolated AEC monocultures. Sustained, physiologically appropriate insulin secretion was observed in both islets and islet/AEC constructs. Activation of resting PBL proliferation occurred on exposure to human islets alone but this response was significantly (p < 0.05) attenuated by the presence of AEC and AEC-conditioned medium. Mitogen (phytohaemagglutinin, 5 µg/ml)-induced PBL proliferation was sustained on contact with isolated islets but abrogated by AEC, conditioned medium, and the islet/AEC constructs. Immunocytochemical analysis of AEC monocultures identified a subpopulation of cells that expressed the proapoptosis protein Fas ligand. This study demonstrates that human islet/AEC constructs exhibit localized immunosuppressive properties with no impairment of ß-cell function. The data suggest that transplanted islets may benefit from the immune privilege status conferred on them as a consequence of their close proximity to human AEC. Such an approach may reduce the need for chronic systemic immunosuppression, thus making islet transplantation a more attractive treatment option for the management of insulin-dependent diabetes.

Striatal susceptibility to a dopaminergic neurotoxin is independent of sex hormone effects on cell survival and DAT expression but is exacerbated by central aromatase inhibition.

The aim of this study was to investigate further the hormone-dependent processes underlying sex differences in neurotoxic responses within the rat nigrostriatal dopaminergic (NSDA) pathway after partial lesioning with 6-OHDA, a state thought to mimic the early stages of Parkinson's disease where, in humans and animal models alike, males appear to be more susceptible. Contrary to our hypotheses, hormone manipulations (gonadectomy +/- oestrogen or androgen treatment) failed to alter survival of tyrosine hydroxylase immunoreactive cells in the substantia nigra pars compacta (SNc) after lesioning; this indicates that, unlike inherent sex differences in toxin-induced striatal dopamine depletion, sex differences in cell loss were not hormonally generated, and that hormone-dependent changes in dopamine depletion can occur independently of cell survival. In addition, hormonally induced changes in striatal expression of the dopamine transporter (DAT), an important factor for 6-OHDA toxicity, did not correlate with hormonal influences on striatal dopamine loss and, in males, central inhibition of aromatase prior to 6-OHDA infusion exacerbated striatal dopamine loss with no effect on SNc tyrosine hydroxylase-immunoreactive survival, suggesting locally generated oestrogen is neuroprotective. These results support the novel view that sex steroid hormones produced peripherally and centrally play a significant, sex-specific role within the sexually dimorphic NSDA pathway to modulate plastic, compensatory responses aimed at restoring striatal dopamine functionality, without affecting cell loss.

Preservation of glucose responsiveness in human islets maintained in a rotational cell culture system.

The diminution of glucose responsiveness in isolated human islets maintained under conventional static culture (CSC) conditions represents a major limitation for the long-term storage of islet tissue and precludes extensive study of beta (beta)-cell biology. In the present investigation, we examined the effect of culturing primary human islets in a rotational cell culture system (RCCS) to determine its' ability to sustain both the structural integrity and functional viability of these fragile cell constructs. Over a 10-day culture period both structural integrity and glucose-stimulated insulin release (GSIR) were preserved in islets maintained within the RCCS whilst those held under CSC conditions exhibited progressive fragmentation and rapid loss of secretory function. In addition, intentionally dissociated islet cells maintained within the RCCS demonstrated the ability to re-aggregate and form tight islet-like structures with enhanced secretory capacity compared to whole islets maintained in static culture. These findings suggest a novel use for the RCCS and illustrate its potential as an experimental tool for in vitro study of human islet/beta-cell physiology.

Sex dimorphisms in the neuroprotective effects of estrogen in an animal model of Parkinson's disease.

The incidence of certain neurological disorders, including Parkinson's disease, appears to be more prevalent in men. Studies involving estrogen treatment of ovariectomised rodents attribute this largely to the neuroprotective effects of estrogen. However, a neuroprotective role for physiological levels of circulating hormones in males and females is less clear. Using the 6-hydroxydopamine (6-OHDA) model of Parkinson's disease to lesion the nigrostriatal dopaminergic (NSDA) pathway, we have shown that in females, endogenously produced estrogen is neuroprotective, whereas in males, gonadal factors increase striatal 6-OHDA toxicity. Intriguingly, estrogen, but not dihydrotestosterone, a nonaromatizable androgen, reversed the effects of orchidectomy on lesion size, raising the novel the hypothesis that enhanced male susceptibility may be attributable to the effects of endogenous testosterone only after its aromatization to estrogen. Thus, estrogen appears to exert opposite effects in the NSDA in males and females, being neuroprotective in females, but not in males, where it may even exacerbate neurodegenerative responses, with important implications for the clinical potential of estrogen-related compounds as neuroprotective agents. Preliminary experiments support the hypothesis that sex differences in the adult NSDA may result from the organisational actions of gonadal steroids during the critical neonatal period for the masculinization of the brain. Further studies are needed to determine whether this early organisation of a sexually differentiated neural circuitry may contribute to the emergence of neurodegenerative conditions such as Parkinson's disease.

Differences in dopaminergic neuroprotective effects of estrogen during estrous cycle.

Previous studies suggest that estrogen treatment protects nigrostriatal dopaminergic neurons, but have not examined whether the changes in estrogen levels during estrous cycle can influence the susceptibility of these neurons to neurotoxins. Here we show that the loss of dopaminergic neurons in the substantia nigra was greater in animals lesioned at diestrus (low estrogen) using 6-hydroxydopamine or buffered iron chloride, when compared with animals lesioned at proestrus (high estrogen). Lesioning at diestrus with 6-hydroxydopamine reduced the striatal dopamine content, whereas the dopamine content was preserved in animals lesioned at proestrus. The density of the dopamine transporter, upon which 6-hydroxydopamine toxicity is dependent, was lower when circulating estrogen was high. These results thus support a neuroprotectory role for estrogen.