Beta-cell Replacement Research Articles

Beta-cell replacement therapy: current outcomes and future landscape.

This article provides a summary of the current outcomes of β-cell replacement strategies, an algorithm for choosing a specific modality while highlighting associated advantages and disadvantages, and outlines remaining challenges and areas of active investigation in β-cell replacement therapy. The most recent reports of islet cell allotransplantation have shown improvements over previous eras and now rival some outcomes of pancreas alone transplantation. Active areas of investigation are focused on improving techniques for islet isolation, graft monitoring, and managing challenges posed by the innate and alloimmune systems. Patients with insulin-dependent diabetes who continue to experience life threatening hypoglycemia despite maximal medical management can benefit from β-cell replacement. Emerging nontransplant technologies have not provided a physiologic euglycemic state to the extent offered by transplantation. Islet transplantation eliminates hypoglycemic episodes/unawareness, facilitates normalization of hemoglobin A1c (HbA1c), decreases microvascular disease progression, and improves quality of life for patients with problematic diabetes. Mid- and long-term outcomes of islet transplantation performed at expert centers approximate those of registry reports of solitary pancreas transplant, whereas the complication profile is quite favorable.

Innate and adaptive immunity to human beta cell lines: implications for beta cell therapy.

Aims/hypothesisGenetically engineered human beta cell lines provide a novel source of human beta cells to study metabolism, pharmacology and beta cell replacement therapy. Since the immune system is essentially involved in beta cell destruction in type 1 diabetes and after beta cell transplantation, we investigated the interaction of human beta cell lines with the immune system to resolve their potential for immune intervention protocol studies.MethodsHuman pancreatic beta cell lines (EndoC-βH1 and ECi50) generated by targeted oncogenesis in fetal pancreas were assessed for viability after innate and adaptive immune challenges. Beta cell lines were pre-conditioned with T helper type 1 (Th1) cytokines or high glucose to mimic inflammatory and hyperglycaemia-stressed conditions. Beta cells were then co-cultured with auto- and alloreactive cytotoxic T cells (CTL), natural killer (NK) cells, supernatant fraction from activated autoreactive Th1 cells, or alloantibodies in the presence of complement or effector cells.ResultsLow HLA expression protected human beta cell lines from adaptive immune destruction, but it was associated with direct killing by activated NK cells. Autoreactive Th1 cell inflammation, rather than glucose stress, induced increased beta cell apoptosis and upregulation of HLA, increasing beta cell vulnerability to killing by auto- and alloreactive CTL and alloreactive antibodies.Conclusions/interpretationWe demonstrate that genetically engineered human beta cell lines can be used in vitro to assess diverse immune responses that may be involved in the pathogenesis of type 1 diabetes in humans and beta cell transplantation, enabling preclinical evaluation of novel immune intervention strategies protecting beta cells from immune destruction.Electronic supplementary materialThe online version of this article (doi:10.1007/s00125-015-3779-1) contains peer-reviewed but unedited supplementary material, which is available to authorised users.

Canine diabetes mellitus: what is new?

Recent developments in genetic research have increased our understanding of the most common form of diabetes affecting pet dogs. This research starts to explain why certain breeds seem more susceptible to developing diabetes; in the long run it could lead to revolutionary screening and prevention strategies. Nevertheless, the genetics do not completely explain the ultimate establishment of the diabetic state, therefore the search continues for other (epigenetic and environmental) factors involved in this process. Clinicians should remain open-minded for the existence of a variety of different types of canine diabetes mellitus. Knowing the aetiology is important, since this will enable development of superior treatment strategies. An entire female diabetic dog usually benefits from prompt neutering, since diabetic remission is possible in a subset of cases and achieving diabetic control will prove easier even if remission is not achieved. Currently, routine treatment of diabetic dogs is based on matching insulin activity, usually provided by twice-daily insulin injections, with post-prandial hyperglycaemia. Being strategic in the timing of injection versus feeding can prove beneficial. Studies with relatively novel drugs such as GLP-1 agonists are currently ongoing and seem promising. In the future, canine diabetes mellitus will probably best be treated through complete pancreatic beta-cell replacement, either by transplantation, regenerative medicine or the use of an artificial pancreas. Gene therapy could play a distinct role and has already been implemented in small trials. Development of a veterinary practice-based diabetes team working closely with dog owners will enable individualisation and optimisation of diabetic pet care whichever shape it takes in the future. Veterinary nurses should play a crucial role in such a team, mirroring the situation in human diabetic care. Where possible, clinic-wide diabetes protocols should be adapted and made flexible, paying particular attention to co-morbidities and their impact on glycaemic control, as well as on the quality of life of the diabetic dog and owner. The use of available quality of life measurement tools should be actively encouraged by any clinic taking individualised diabetic care seriously.

Transplantable bioartificial pancreas devices: current status and future prospects.

Islet transplantation has become a valuable therapy for patients with diabetes mellitus type 1.However, only selected patients with exhausted insulin therapy characterized by instable metabolic control and repeated severe hypoglycemia are transplant candidates. This strict indication is mainly due to the requirement for lifelong immunosuppression and the critical shortage for donor organs. Therefore, numerous research activities address these issues in order to provide beta cell replacement therapy to a broader cohort of patients with diabetes. The encapsulation of pancreatic islets within mainly alginate-based macro- or microcapsules withvarious physical configurations may allow protecting the islet graft without the need for immunosuppressive agents and moreover expanding the donor pool to animal tissue and novel insulin-producing cells. Despite major advances in encapsulation technology, a significant translation into clinical application is not evident. There are still issues that need to be resolved associated with graft oxygenation, immunprotection, inflammatory response, material biocompatibility, and transplantation site to list some of them. The recent advances in xenotransplantation and particularly in the field of stem cell-derived beta cells have generated a renewed scientific interest in encapsulation. This review aims to provide an overview on current encapsulation technologies as a treatment modality in cell replacement therapy for type 1 diabetes.

Monitoring Inflammation, Humoral and Cell-mediated Immunity in Pancreas and Islet Transplants.

Type 1 diabetes (T1D) is caused by the chronic autoimmune destruction of insulin producing beta cells. Beta cell replacement therapy through whole pancreas or islet transplantation is a therapeutic option for patients in which a stable glucose control is not achievable with exogenous insulin therapy. Long-term insulin independence is, however, hampered by the recipient immune response that includes activation of inflammatory pathways and specific allo- and auto-immunity. The identification and monitoring of soluble and cellular biomarkers are of critical relevance for the prediction of graft damage, for the evaluation of responses to immune-modulating therapy, and for target pathways identification to generate novel drugs or therapeutic approaches. The final objective of immune monitoring is to find ways to improve the outcome of pancreas and islet transplantation. In this review, we discuss the available tools to monitor the innate, humoral and cellular responses after islet and pancreas transplantation, and the most relevant findings generated by these measurements.

50 years forward: beta cells.

Our understanding of beta cell development and function has increased substantially these past 50 years but much remains to be learned before this knowledge can be put to clinical use. A comprehensive business plan will be necessary to develop a detailed molecular and functional blueprint of the beta cell in health and disease based on an integrated approach involving all necessary research disciplines. This blueprint will provide a platform for the development of novel therapeutic strategies for the treatment of both major forms of diabetes, foremost among them beta cell replacement therapy. This is one of a series of commentaries under the banner '50 years forward', giving personal opinions on future perspectives in diabetes, to celebrate the 50th anniversary of Diabetologia (1965-2015).

Toward beta cell replacement for diabetes.

The discovery of insulin more than 90 years ago introduced a life-saving treatment for patients with type 1 diabetes, and since then, significant progress has been made in clinical care for all forms of diabetes. However, no method of insulin delivery matches the ability of the human pancreas to reliably and automatically maintain glucose levels within a tight range. Transplantation of human islets or of an intact pancreas can in principle cure diabetes, but this approach is generally reserved for cases with simultaneous transplantation of a kidney, where immunosuppression is already a requirement. Recent advances in cell reprogramming and beta cell differentiation now allow the generation of personalized stem cells, providing an unlimited source of beta cells for research and for developing autologous cell therapies. In this review, we will discuss the utility of stem cell-derived beta cells to investigate the mechanisms of beta cell failure in diabetes, and the challenges to develop beta cell replacement therapies. These challenges include appropriate quality controls of the cells being used, the ability to generate beta cell grafts of stable cellular composition, and in the case of type 1 diabetes, protecting implanted cells from autoimmune destruction without compromising other aspects of the immune system or the functionality of the graft. Such novel treatments will need to match or exceed the relative safety and efficacy of available care for diabetes.

Mitochondria as a Target for Future Diabetes Treatments

Diabetes mellitus is rapidly becoming the world’s most dangerous serial killer. Type 1 diabetes (T1D) is a currently incurable autoimmune disease marked by progressive, and eventually exhaustive, destruction of the insulin-producing pancreatic beta cells. Type 2 diabetes (T2D) describes the combination of insulin resistance in peripheral tissue, insufficient insulin secretion from the pancreatic beta cells, and excessive glucagon secretion from the pancreatic alpha cells. T1D as well as severe cases of T2D are treated with insulin replacement, which can merely be considered as life support for the acute phases of the disease. Islet replacement of insulin-producing pancreatic beta cells represents a potential treatment method for both insulin-depleted diabetes (T1D) and insulin-resistant diabetes (T2D) and may shift diabetes management from life saving measures to a cure. One of the key challenges in islet transplants is the generation of reactive oxygen species (ROS) and the associated oxidative stress, which restricts graft longevity. A major leak of ROS takes place during oxidative phosphorylation at mitochondrial electron transport chain (ETC). Additionally, hyperglycemia-induced superoxide (O2•-) production has been linked to the development and progression of diabetic complications, both macrovascular and microvascular. Decreasing ROS in diabetic patients may prevent the incidence of long term diabetes complications. This review provides an overview of the role of mitochondria in diabetes, introducing them as a possible target for future treatment of diabetes.

Stem Cell-Derived Beta Cells for Treatment of Type 1 Diabetes?

Stem Cell-Derived Beta Cells for Treatment of Type 1 Diabetes?

From Beta cell replacement to beta cell regeneration: implications for antidiabetic therapy.

Diabetes is affecting more than 25.8 million people in the United States, causing huge burden on the health care system and economy. Insulin injection, which is the predominant treatment for diabetes, is incapable of replenishing the lost insulin-producing beta cell in patients. Restoring beta cell mass through replacement therapy such as islet transplantation or beta cell regeneration through in vitro and in vivo strategies has attracted particular attentions in the field due to its potential to cure diabetes. In the aspect of islet transplantation, gene therapy, stem cell therapy, and more biocompatible immunosuppressive drugs have been tested in various preclinical animal models to improve the longevity and function of human islets against the posttransplantation challenges. In the islet regeneration aspect, insulin-producing cells have been generated through in vitro transdifferentiation of stem cells and other types of cells and demonstrated to be capable of glycemic control. Moreover, several biomarkers including cell-surface receptors, soluble factors, and transcriptional factors have been identified or rediscovered in mediating the process of beta cell proliferation in rodents. This review summarizes the current progress and hurdles in the preclinical efforts in resurrecting beta cells. It may provide some useful insights into the future drug discovery for antidiabetic purposes.

Enhanced Survival and Function of Islet-Like Clusters Differentiated from Adipose Stem Cells on a Three-Dimensional Natural Polymeric Scaffold: AnIn VitroStudy

Autologous adipose stem cells owing to its pluripotent nature offer a valuable source for pancreatic beta cell replacement in the treatment of diabetes mellitus. However, maintaining longevity and functionality of stem cell-derived islet-like cells for long-term in vitro culture is challenging. Signaling interaction between islets and surrounding extracellular matrix (ECM) is an important factor for islet survival and function. Tissue engineering strategy to use scaffolds as substitute for ECM is a key to the problem. In the present study, we fabricated a three-dimensional (3D) biodegradable scaffold comprised of natural polymers dextran and gelatin (DEXGEL) for differentiation of adipose stem cells to islet-like clusters (ILCs). Adipose stem cells derived from subcutaneous fat of New Zealand white rabbits were differentiated to ILCs on DEXGEL scaffold and two-dimensional (2D) culture plates via three stage protocol using cocktail of growth factors. The ILCs differentiated on DEXGEL scaffold exhibited characteristic islet morphology, and expressed islet-specific hormones (insulin, glucagon, and somatostatin). The insulin secretion in response to glucose challenge and viability of ILCs on DEXGEL scaffold were significantly higher in comparison to ILCs on 2D culture. Our results demonstrated for the first time that DEXGEL scaffold simulated an extracellular environment for effective differentiation of rabbit adipose stem cells to ILCs.

Severe hypoglycaemia in type 1 diabetes mellitus: underlying drivers and potential strategies for successful prevention.

Hypoglycaemia remains an over-riding factor limiting optimal glycaemic control in type 1 diabetes. Severe hypoglycaemia is prevalent in almost half of those with long-duration diabetes and is one of the most feared diabetes-related complications. In this review, we present an overview of the increasing body of literature seeking to elucidate the underlying pathophysiology of severe hypoglycaemia and the limited evidence behind the strategies employed to prevent episodes. Drivers of severe hypoglycaemia including impaired counter-regulation, hypoglycaemia-associated autonomic failure, psychosocial and behavioural factors and neuroimaging correlates are discussed. Treatment strategies encompassing structured education, insulin analogue regimens, continuous subcutaneous insulin infusion pumps, continuous glucose sensing and beta-cell replacement therapies have been employed, yet there is little randomized controlled trial evidence demonstrating effectiveness of new technologies in reducing severe hypoglycaemia. Optimally designed interventional trials evaluating these existing technologies and using modern methods of teaching patients flexible insulin use within structured education programmes with the specific goal of preventing severe hypoglycaemia are required. Individuals at high risk need to be monitored with meticulous collection of data on awareness, as well as frequency and severity of all hypoglycaemic episodes.

Robotic-assisted pancreas transplantation

To analyze the current status of robotic-assisted pancreas transplantation as a treatment option for diabetic patients. Pancreas transplant recipients continue to suffer high rates of technical complications, including wound infections, fascial dehiscence, and postoperative ventral hernias. Robotic technology can potentially contribute to decreasing these dangerous complications and improve the postoperative course of pancreas transplantation. Current literature on both robotic pancreas and robotic kidney transplant were reviewed in order to determine feasibility, safety, and efficacy of robotic pancreas transplantation. To date, only three cases of robotic pancreas transplantation, two of which were solely pancreas transplantation and one combined pancreas-kidney transplantation, have been reported in a single publication by an Italian group. Their preliminary data show that robotic pancreas transplantation is feasible and well tolerated. The authors believe that robotic pancreas transplantation could have a prominent role in lone pancreas transplantation performed in overweight recipients, in parallel to their experience with fully robotic kidney transplant in morbidly obese candidates. Broader experience with this innovative approach will be necessary to establish if robotic pancreas transplantation will be a beneficial option for diabetic patients needing beta-cell replacement.

Immune Intervention for Type 1 Diabetes, 2012–2013

Immune Intervention for Type 1 Diabetes, 2012–2013

MiRNA-375 promotes beta pancreatic differentiation in human induced pluripotent stem (hiPS) cells

Islet transplantation is considered as an ultimate option for the treatment of type I diabetes. Human induced pluripotent stem cells (hiPSCs) have raised the possibility that patient-specific insulin-secreting cells might be derived from somatic cells through cell fate reprogramming. However, current protocols mostly rely on the use of several cytokines and inhibitors for directing differentiation towards pancreatic fate. Given the high manufacturing cost of these recombinant proteins, this approach is prohibitive for clinical applications. Knowing that microRNAs (miRNAs) are key players in various stages of pancreatic development, we present a novel and cost-effective strategy in which over-expression of miR-375 promotes pancreatic differentiation in hiPSCs in the absence of any other stimulator. We used a polycistronic viral vector expressing Sox2, Klf4, c-Myc, and Oct4 to drive hiPSCs from human foreskin fibroblasts. The established hiPSCs are similar to human embryonic stem cells in many aspects including morphology, passaging, surface and pluripotency markers, and gene expression. For differentiation induction, miR-375 was lentivirally overexpressed in these hiPSCs. Morphological assessment, immunocytochemistry, and expression analysis of islet marker genes confirmed that islet like cells were obtained in miR-375 transduced cells compared to controls. Our differentiated clusters secreted insulin in a glucose-dependant manner, showing in vitro functionality. We demonstrated for the first time that miRNAs might be ideal substitutes to induce pancreatic differentiation in hiPSCs. This work provides a new approach to study the role of miRNAs in pancreatic specification and increase the feasibility of using patient-specific iPSCs for beta cell replacement therapy for type I diabetes.

The Potential of Cell-based Therapy for Diabetes and Diabetes-related Vascular Complications

Cell therapy has enormous potential for the treatment of conditions of unmet medical need. Cell therapy may be applied to diabetes mellitus in the context of beta cell replacement or for the treatment of diabetic complications. A large number of cell types including hematopoietic stem cells, mesenchymal stem cells, umbilical cord blood, conditioned lymphocytes, mononuclear cells, or a combination of these cells have been shown to be safe and feasible for the treatment of patients with diabetes mellitus. The first part of this review article will focus on the current perspective of the role of embryonic stem cells and inducible pluripotent stem cells for beta cell replacement and the current clinical data on cell-based therapy for the restoration of normoglycemia. The second part of this review will highlight the therapeutic role of MSCs in islet cells cotransplantation and the management of diabetes related vascular complications.

Adipose stem cell-based regenerative medicine for reversal of diabetic hyperglycemia.

Diabetes mellitus (diabetes) is a devastating disease that affects millions of people globally and causes a myriad of complications that lead to both patient morbidity and mortality. Currently available therapies, including insulin injection and beta cell replacement through either pancreas or pancreatic islet transplantation, are limited by the availability of organs. Stem cells provide an alternative treatment option for beta cell replacement through selective differentiation of stem cells into cells that recognize glucose and produce and secrete insulin. Embryonic stem cells, albeit pluripotent, face a number of challenges, including ethical and political concerns and potential teratoma formation. Adipose tissue represents an alternative source of multipotent mesenchymal stem cells, which can be obtained using a relatively simple, non-invasive, and inexpensive method. Similarly to other adult mesenchymal stem cells, adipose-derived stem cells (ADSCs) are capable of differentiating into insulin-producing cells. They are also capable of vasculogenesis and angiogenesis, which facilitate engraftment of donor pancreatic islets when co-transplanted. Additionally, anti-inflammatory and immunomodulatory effects of ADSCs can protect donor islets during the early phase of transplantation and subsequently improve engraftment of donor islets into the recipient organ. Although ADSC-therapy is still in its infancy, the potential benefits of ADSCs are far reaching.

Inflammatory response in islet transplantation.

Islet cell transplantation is a promising beta cell replacement therapy for patients with brittle type 1 diabetes as well as refractory chronic pancreatitis. Despite the vast advancements made in this field, challenges still remain in achieving high frequency and long-term successful transplant outcomes. Here we review recent advances in understanding the role of inflammation in islet transplantation and development of strategies to prevent damage to islets from inflammation. The inflammatory response associated with islets has been recognized as the primary cause of early damage to islets and graft loss after transplantation. Details on cell signaling pathways in islets triggered by cytokines and harmful inflammatory events during pancreas procurement, pancreas preservation, islet isolation, and islet infusion are presented. Robust control of pre- and peritransplant islet inflammation could improve posttransplant islet survival and in turn enhance the benefits of islet cell transplantation for patients who are insulin dependent. We discuss several potent anti-inflammatory strategies that show promise for improving islet engraftment. Further understanding of molecular mechanisms involved in the inflammatory response will provide the basis for developing potent therapeutic strategies for enhancing the quality and success of islet transplantation.

Analysis of Transcription Factors Key for Mouse Pancreatic Development Establishes NKX2-2 and MNX1 Mutations as Causes of Neonatal Diabetes in Man

SummaryUnderstanding transcriptional regulation of pancreatic development is required to advance current efforts in developing beta cell replacement therapies for patients with diabetes. Current knowledge of key transcriptional regulators has predominantly come from mouse studies, with rare, naturally occurring mutations establishing their relevance in man. This study used a combination of homozygosity analysis and Sanger sequencing in 37 consanguineous patients with permanent neonatal diabetes to search for homozygous mutations in 29 transcription factor genes important for murine pancreatic development. We identified homozygous mutations in 7 different genes in 11 unrelated patients and show that NKX2-2 and MNX1 are etiological genes for neonatal diabetes, thus confirming their key role in development of the human pancreas. The similar phenotype of the patients with recessive mutations and mice with inactivation of a transcription factor gene support there being common steps critical for pancreatic development and validate the use of rodent models for beta cell development.

Perspective of stem cell research & therapy in diabetes

In the area of regenerative medicine, researchers have been exploring the potential of Stem Cells in preclinical and clinical studies to improve therapies that can resolve injuries by enhancing endogenous repair, opening a new paradigm in cell therapy.Stem cells may it be embryonic stem cells (ESC), induced pluripotent stem cells (iPSC) or adult stem cells have been used as potential sources for beta cell replacement therapy across the globe. Numerous studies have shown the differentiation potential of ESCs and iPSCs towards producing pancreatic progenitors but after terminal differentiation into insulin producing cells these lacked various important pancreatic markers and have low index of glucose stimulated insulin secretion (GSIS). This along with other ethical conundrums makes it difficult to use ESCs as a source for cell therapy. Adult stem cells provide clinically and ethically accepted option over embryonic or induced pluripotent stem cells, as they can be used as autologous source for cell transplant in treatment of diabetes. Widely used option of cadaveric islet therapy has its own problems due to insufficient amount of islets available for transplantation. Hence, our research is focused on increasing islet mass from various adult stem cells using neutraceutic bioactive compounds isolated from a plant demonstrating efficient anti-diabetic activity and further explored them as potent differentiating agent under in-vitro and in-vivo condition. In-vitro differentiated islets from various adult stem cells sources were assessed at morphological, molecular, immunological and functional level and further evaluated for glucose lowering effect after transplantation in Streptozotocin (STZ) induced diabetic balb/c mice.