HUMAN ISLET ISOLATION AND ALLOTRANSPLANTATION IN 22 CONSECUTIVE CASES 1,2

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1 /92/ $03.00/0 TRANSPLANTATION Copyright 1992 by Williams & Wilkins Vol. 53, , No.2, Febrary 1992 Printed in U. S. A. HUMAN ISLET ISOLATION AND ALLOTRANSPLANTATION IN 22 CONSECUTIVE CASES 1,2 CAMILLO RICORDI,3 ANDREAS G. TZAKIS, PATRICIA B. CARROLL, YIJUN ZENG, HORACIO L. RODRIGUEZ RILO, RODOLFO ALEJANDRO, RON SHAPIRO, JOHN J. FUNG, ANTHONY J. DEMETRIS, DANIEL H. MINTZ, AND THOMAS E. STARZL University of Pittsbrgh, Transplant Institte, Pittsbrgh, Pennsylvania 15213; and The Diabetes Research Institte, University of Miami, Miami, Florida This report provides or initial experience in islet isolation and intrahepatic allotransplantation in 21 patients. In grop 1, 10 patients nderwent combined liver-islet allotransplantation following pper-abdominal exenteration for cancer. In grop 2, 4 patients received a combined liver-islet allograft for cirrhosis and diabetes. One patient had plasma C-peptide >3 pm and was therefore exclded from analysis. In grop 3, 7 patients received 8 combined cadaveric kidney-islet grafts (one retransplant) for end-stage renal disease secondary to type 1 diabetes mellits. The islets were separated by a modification of the atomated method for hman islet isolation and the preparations were infsed into the portal vein. Immnosppression was with FK506 (grop 1) pls steroids (grops 2 and 3). Six patients in grop 1 did not reqire inslin treatment for 5 to >16 months. In grops 2 and 3 none of the patients became inslin-independent, althogh decreased inslin reqirement and stabilization of diabetes were observed. Or reslts indicate that rejection is still a major factor limiting the clinical application of islet transplantation in patients with type 1 diabetes mellits, althogh other factors sch as steroid treatment may contribte to deteriorate islet engraftment and/or fnction. Diabetes mellits is the most common endocrine disease and is a worldwide pblic health problem, being the forth leading case of death by disease in Western contries (1). Estimates for inslin-dependent diabetes (type 1) indicate a prevalence of 0.26 percent by age 20 in the United States (2). There is evidence that the incidence of this disease is increasing in several world poplations (3). Prolongation of life is achieved by crrent maintenance therapy with inslin, bt an increased nmber of diabetic patients are treated for complications (4) inclding end-stage renal failre, now representing 10-40% of new patients on dialysis (5). Diabetes is also the leading case of new cases of blindness in patients over the age of 20 (1). In patients with type 1 diabetes mellits, inslin prodction by the pancreatic islets progressively declines and finally disappears, as the beta cells within the islets are destroyed by an atoimmne process reslting from a complex interplay between genetic and nknown environmental factors (6). Re- 1 Presented at the 17th Annal Meeting of the American Society of Transplant Srgeons, May 29-31, 1991, Chicago, IL. 2 This work was spported by Research Grant No from the Jvenile Diabetes Fondation International. 3 Address correspondence to: Camillo Ricordi, M.D., The Transplant Institte, University of Pittsbrgh School of Medicine, 5C Falk Clinic, 3601 Fifth Avene, Pittsbrgh, PA placement therapy with exogenos inslin is imperfect and has been ineffective in preventing the chronic complication of the disease. Ths, alternative methods for total endocrine replacement have been explored, inclding transplantation of isolated islets as free grafts (7) was a significant year for clinical islet transplantation. In fact, almost a centry after the first attempt to treat a diabetic child by transplantation of pancreatic tisse (8), reports of short-term (9) and prolonged (10-13) inslin independence following hman islet allotransplantation indicated that it is possible to replace the endocrine fnction of the pancreas by an islet transplant in man. These encoraging reslts have been the prodct of recent improvements in isolation technology and immnosppressive therapy. In fact, the procedres developed for the isolation (14) of rodent islets were ineffective to separate islets from the pancreas of larger mammals, inclding man. It is estimated that the hman pancreas contains approximately 1 million islets, which are mainly composed of inslinprodcing cells (15). The development of more effective procedres for islet isolation and prification from large animals (16-20) and hman (21-26) pancreases have reslted in significant progress in both nmber and prity of the islets that can be obtained from each pancreas. In addition, the se of more powerfl immnosppressive agents sch as cyclosporine A (9, 11,25) or FK506 (10) reslted in prolonged hman islet allograft srvival in some cases. This report provides or initial experience in islet isolation and intrahepatic allotransplantation in 21 patients. MATERIALS AND METHODS Patients. Twenty-two intrahepatic islet allografts were performed in 21 patients between Janary 10, 1990, and May 4, One patient had significant C-peptide prodction before islet transplantation and was therefore exclded from data analysis. Data on patients with a follow-p of at least 2 months are smmarized in Table 1. Grop 1: Ten patients aged 8-58 years nderwent combined liverislet allotransplantation following pper-abdominal exenteration for tmors too extensive to be removed with less drastic procedres (27, 28). Preliminary reslts on nine of these patients have been reported previosly (10). Liver, pancreas, spleen, stomach, dodenm, proximal jejnm, terminal ilem, ascending and transverse colon (three cases), and part of the right atrim (one case) were removed. A cadaveric orthotopic liver allograft was done (28) and the graft portal vein was anastomosed to the recipient sperior mesenteric vein. Arterialization was from the recipient aorta or celiac axis. A 14G catheter with a heparin lock was placed in a sperior mesenteric vein (10). Bowel continity was reestablished and biliary drainage was via a choledocojejnostomy. 407

2 408 TRANSPLANTATION Vol. 53, No.2 Patient No. and diagnosis TABLE 1. Description of recipients with a follow-p of at least 2 months and clinical otcome Age/sex Metabolic otcome Grop 1 (clster-islets) 1 Hepatocelllar Ca 17/F NIR' 2 Hepatocelllar Ca 8/M IR,d 6 U/day 3 Pancreatic AdCa 55/M IR, 14 U/day 4 Neroendocrine 36/F IR, 6 U/day 5 Leiomyosarcoma 58/M NIR 6 Periampllary AdCa 52/F NIR-O' 7 Metastatic AdCa colon 46/M NIR 8 Cholangiocarcinoma 44/F NIR 9 Cholangiocarcinoma 33/F IR, 10 months Post- C-peptide HbAlc" b operative Otcome (basal/stirn) month 6.3% 1.14/ Fll activity 6.1% 0.30/ Died: recrrence NA 0.07/ Died: mltiplesystemic failre 5.4% 0.54/ Died: mltiplesystemic failre 4.6% 1.50/ Died: recrrence 6.2% 1.56/ Fll activity 5.1% 0.90/ Died: recrrence 6.6% 1.68/ Fll activity 5.6% 1.50/ Fll activity Grop 2 (liver-islets) 1 Cirrhosis 20 hepatitis C 56/F IR, 15 U/day 2 Cirrhosis 20 ETOH 42/M IR Grop 3 (kidney-islets) 1 ESRD 20 type 1 DM 38/M IR, 20 U/day 2 ESRD 20 type 1 DM 28/M IR, 60 U/day 3 ESRD 20 type 1 DM 35/M IR, 12 U/day 4 ESRD 20 type 1 DM 36/F IR, 30 U/day 5 ESRD 20 type 1 DM 36/M IR, 40 U/day 6 ESRD 20 type 1 DM 32/M IR, 50 U/day a HbAlc: glycosylated hemoglobin (nl ), most recent vales. b C-peptide plasma levels (pmol/m\), most recent vales., Non-inslin-reqiring. d inslin-reqiring., on oral hypoglycemic agent. Grop 2: For patients aged years received a combined liverislet allograft. The indications for liver transplantation were cirrhosis secondary to cystic fibrosis, cirrhosis secondary to hepatitis C, alcoholic cirrhosis, and cryptogenic cirrhosis. All patients except one had type 1 diabetes as evidenced by an absent C-peptide response to glcagon or Sstacal challenge test. One patient (cystic fibrosis), who was tested in the operating room before the islet transplant, had basal and stimlated plasma C-peptide >3 pm and was therefore exclded from analysis. Grop 3: Seven patients aged years received 8 combined cadaveric kidney-islet grafts (one retransplant) for end-stage renal disease secondary to type 1 diabetes mellits. Immediately after renal transplantation, an pper midline incision was performed and a 16-18G catheter was placed in a jejnal vein for islet infsion. All patients had negative C-peptide in response to a Sstacal challenge test performed before islet transplantation. Organ procrement. The cadaveric donor ABO types were the same as, or compatible with, the recipient ABO types. HLA matching was random and the antigen match was 0 to 3. There were two positive cytotoxic crossmatches in grop 1 (clster-islet) and two in grop 2 (liver-islet). The livers, kidneys, and pancreases were obtained from mltiorgan donors (27-29). In sit perfsion of the abdominal aorta was with ml of University of Wisconsin soltion. An additional ml of UWS was infsed directly into the liver via the portal vein, which was encircled below the catheter tip to prevent retrograde leakage. Venos hypertension of the pancreas was avoided by venting the portal and/or splenic vein. The specimens were immersed in UWS and packed on ice. The pancreas of the liver or kidney donor was the sorce of the primary islet graft for all patients except one patient in grop 1 and one patient in grop 3 who received islets from a third-party pancreas donor. For patients in grop 1 and two patients in grop 3 were given 4.1% 0.74/ Fll activity 3.8% 0.76/ Died: hepatitis B, sepsis 6.6% 0.36/ Fll activity 8.4% 0.59/ Fll activity 6.5% 0.38/ Fll activity 7.0% 0.05/ Fll activity 8.1% 0.08/ Fll activity 7.0% 0.14/ Fll activity islets from 1-2 additional donors 1-5 days after the principal operation. One patient in grop 3 was retransplanted (kidney-islet) 7 months after the first combined graft becase of irreversible kidney rejection. Islet preparation and administration. Cold ischemia time of the 28 pancreases averaged 7.5 hors (range 4-12), with no statistically significant difference between grops. The hman islets were obtained by a modification (19) of the atomated method for hman islet isolation (22). Briefly, after cannlation of the pancreatic dct 350 ml of Hanks soltion containing 2 mg/ml collagenase soltion (Boeringher-Mannheim, Type P) was injected throgh the dct. The pancreas was loaded into a stainless steel digestion chamber and islets were separated dring a continos digestion process that lasted min. The main modification of the isolation procedre compared with the atomated method previosly described (22) was the isolation chamber, whose volme is now 475 ml with an otlet port diameter of 6 mm, which is significantly wider than that of the previosly sed chamber. In addition, the pore size of the screen was increased from 280 to 400 /1-, and the cooling system was eliminated, as well as the heating circit bypass, reslting in a simpler isolation apparats (Fig. 1). Dring the recirclation phase (flow rate 85 ml/min) intrachamber temperatre was increased at a rate of 2 C/min by passage of the soltion throgh a stainless steel coil immersed in a water bath (50 C). The chamber containing the distended pancreas was gently agitated and samples were taken every 2 min to monitor digestion. After approximately min of recirclation the digestion was stopped by diltion (4 C Hanks, 400 ml/min flow rate) and cooling. In this phase the digested tisse was rapidly collected in I-liter sterile bottles containing 400 ml Hanks soltion (4 C) with 10% fetal calf serm. The diltion phase lasted min. Upon initiation of the diltion phase the chamber was connected to a shaker with oscillation amplitde of 10 em and a variable rate of oscillation/min. Erocollins soltion was sed as vehicle for the Ficoll powder (Ficoll

3 Febrary 1992 RICaRD! ET AL Sampling port Temperatre I probe... :'. Peristaltic pmp () Pancreas Marbles Collecting liask Hanks soltion Recirclating cylinder Heating circit FIGURE 1. Modified atomated procedre for islet separation. (A) Lines that are occlded dring the recirclation phase; (B) lines that are occlded dring the diltion phase. In the first phase, collagenase soltion recirclates in a closed system, in which the collagenase soltion and the pancreas are progressively heated to 37 C. In a second phase, the islets that are progressively released from the digesting pancreas are saved in collecting flasks or bottles. DL-400, Sigma, St. Lois, MO). Erocollins-Ficoll at densities of 1.108, 1.096, was sed in a three-layer discontinos gradient (10), in which the digested pancreatic tisse was bottom-loaded with the layer. A cell separator (COBE 2991, Lakewood, CO) was sed for centrifgation of the gradients (30,31). Determination of nmber, volme, and prity of the hman islets obtained after islet separation and prification was performed according to recently proposed criteria (32). Briefly, the final islet preparation was sspended in 250 ml Hank's soltion; 100-ILI samples were stained with dithizone to assess total islet yield, which was converted to total nmber of islets of an average diameter of 150 IL (leq) (32). The contribtion of the different size grops to the total islet volme was then expressed in Ill. The preparation was pelleted and sspended in 100 ml Hank's soltion containing 10% hman albmin and infsed into the portal vein catheter over min. Portal venos pressre was measred and in some cases the portal flow was assessed by color doppler ltrasonography. In patients who received more than one islet preparation, the portal vein catheter was flshed every 6 hr with 2 ml saline containing heparin (100 U/ml). The catheter was removed after completion of the last islet infsion. Immnosppressive management. In grop 1, immnosppression with FK506 began with intravenos doses of mg/kg every 12 hr followed by 0.15 mg/kg orally every 12 hr. The dose was adjsted on clinical gronds and by monitoring plasma FK506 levels. In grop 2, FK506 was administered at a dose of 0.1 mg/kg i.v. over 24 hr, beginning immediately after transplantation. In addition, the patients received a 1000-mg i.v. bols of methylprednisolone dring the operation, followed by a maintenance dose of 20 mg prednisolone i.v. daily, ntil conversion to the oral rote. The oral dose of FK506 was 0.15 mg/kg every 12 hr (0.3 mg/kg per day), and 20 mg of prednisone per day was given. This dose was redced and discontined according to clinical criteria. In grop 3, FK506 was given as in grop 2. Following the intraoperative i.v. bols of 1000 mg methylprednisolone, a decreasing prednisone dose (from 200 to 20 mg/day) was administered over 6 days. When possible, the steroid dose was tapered over the first several weeks and stopped. Spplementary steroids or OKT3 was given if rejection was sspected clinically or diagnosed by biopsy. Pretransplant assessment of recipient islet fnction. Basal and stim- lated plasma C-peptide levels were measred in all recipients before the infsion of the islets. The provocative tests were 1 mg glcagon i.v. (grop 1) and a Sstacal (6 Kcal/kg) (33) or glcagon (grops 2 and 3) challenges. There were no C-peptide responses except in one patient in grop 2 who had high pretransplant basal and stimlated C-peptide levels (>3 pm) dring a glcagon test performed in the operating room. Posttransplant assessment of donor islet fnction. After islet transplantation, plasma glcose and C-peptide levels were monitored. An intravenos glcose tolerance test was sed as provocative test of C peptide secretion in patients in grop 1. IVGTT was chosen to avoid interpretative problems in the evalation of the reslts, since the patients of this grop nderwent significant gastrointestinal resections. In grops 2 and 3, a Sstacal tolerance test was selected as provocative test of C-peptide secretion. Glycosylated hemoglobin (HbA1c) was measred before and every 6 weeks after transplantation, or when the patients were evalated in follow-p clinics. RESULTS Islet isolation and prification. Islet isolation and prification reslts are smmarized in Table 2. Pancreas cold ischemia time before the islet isolation and prification procedre was comparable in the three grops, ranging 4 to 12 hr. In grop 1, the 14 hman islet preparations that were transplanted comprised an average of 392,100 islets, representing an average of 279,800 IEq with an endocrine volme of approximately 495 ILL Prity in islets was 61 % (range 25-80%). In grop 2, 3 islet preparation yielded an average of over 800,000 islets, representing 625,300 IEq. Average endocrine volme and prity in islets were 1105 ILl and 67%, respectively. In grop 3, 11 islet isolations reslted in an average of 644,600 islets (597,000 IEq) with an endocrine volme of 1055 Ill. The average prity in islets was 72%. Patients in grops 2 and 3 received a nmber of islets that was significantly higher (P<0.05) compared with the clsterislet patients of grop 1. No significant difference was observed in the degree of prity in islets infsed in the three grops, and in the nmber of islets transplanted in grops 2 and 3.

4 410 TRANSPLANTATION Vol. 53, No.2 Patient No. TABLE 2. Intrahepatic islet transplantation: donor data and description of isolation otcome Pancreas Transplanted islets Donor age Cold ischemia Weight No. Ieq. No. Volme Prity time (hr) (g) (X1OOO) (XlOOO)" (1'1) (% islets) Grop 1 (clster-islets) Mean SEM Grop 2 (liver-islets) l Mean SEM Grop 3 (kidney-islets) l Mean SEM P NS NS NS 1:2=<0.01 1:2=0.05 1:2=0.05 NS 1:3=<0.03 1:3=<0.03 1:3=<0.03 2:3=NS 2:3=NS 2:3=NS a l50-micron eqivalents. +Preparation transplanted with 2nd kidney. N.B.: Where more than one donor was sed, mean vales/patient were sed in calclations. Patient srvival. Following or preliminary report on clster- A second patient, who demonstrated significant islet fnction islet allotransplantation (10), two additional patients died from for the first 5 postoperative months, died of hepatitis Band cancer recrrence 9 and 14 months following transplantation, sepsis 6 months after transplantation. leaving 5 of 10 patients in grop 1 with follow-p of 16, 14, 13, In grop 3 (n=7), one patient died 5 days following combined 13, and 1 month. kidney-islet transplantation as a reslt of aspiration pnemonia In grop 2 (n=3), one patient died 36 hr following combined on postoperative day 3. liver-islet transplantation. The patient had a positive cross- Posttransplant islet fnction. The metabolic otcome of inmatch (100%) with her liver-islet donor and had primary he- trahepatic hman islet allotransplantation is smmarized in patic non fnction becase of hmoral (hyperacte) rejection. Table 1.

5 Febrary 1992 RICORD! ET AL. 411 In grop 1, six patients did not reqire inslin for 5 to over 16 months. The first patient, who received the islet allograft on Janary 10, 1990, is still inslin-independent over 16 months postoperatively. Nevertheless, 9 months after transplantation the average vale of pre- and postprandial blood glcose determinations progressively increased ntil the 14th postoperative month, bt spontaneosly improved dring the last 60 days (Fig. 2). It is of interest that this patient reqired over 3000 and 2000 nits of intravenos inslin on her forth and fifth postoperative days, respectively (Fig. 3). Two patients who recently died did not reqire inslin at the time of tmor recrrence and expired with fnctioning islet grafts 9 and 14 months after transplantation. In one patient (No.6) who was inslin-dependent (10), the islet fnction progressively improved and inslin treatment Glcose Inslin METABOLIC PROFILES OVER TIME CL USTER - ISLET PATIENT M.A. ;>.. 250, <0 "CI 300 '"0 " tuj rn -' S 200 >:: 200 ;::l T r.n 150.L 0 Z -'l ::::> -'l 100 ::::> c..? 100 r.n Z II POSTOPERATIVE TIME (MOS) FIGURE 2. Plasma glcose and daily inslin reqirements of a clster-islet patient (grop 1, No.1, Tables 1 and 2), who is still inslin independent over 16 months following liver-islet allotransplantation. INSULIN AND GLUCOSE PROFILES CLUSTER-ISLET PT M.A..,,4 -Glcose!nslln ;> <0 "CI '"0 " "-... tuj (/) >:: ::::> i:.:l r.n Z ::::> 1000 :3...:; ::::> c..? 50 r.n 500 Z TIME (DAYS) FIGURE 3. Plasma glcose and inslin reqirements in patient No. (grop 1, Tables 1 and 2) dring the first postoperative week, demonstrating an episode of significant inslin resistance in which over nits i.v. per day were administered. was discontined dring the third postoperative month. She did not reqire inslin for 5 months. Inslin treatment was resmed 8 months after islet allotransplantation ( nits/ day, s.c.) for increased fasting plasma glcose levels (>120 mg/ di). The patient was converted to oral hypoglycemic agents (glibenc1amide 5 mg/day) 14 months after transplantation, since her inslin reqirement was minimal. She now reqires no inslin. One patient (No.8) did not reqire daytime inslin treatment, bt was nable to discontine night parenteral ntrition (10 nits of inslin/night, i.v.). One patient (No.9) did not reqire inslin ntil the 10th postoperative month, when sdden development of symptomatic hyperglycemia in the absence of any evidence of liver rejection imposed reinstittion of exogenos inslin treatment. In grop 2, one patient is alive 7 months after transplantation. She had a 100% positive cytotoxic crossmatch and a rejection episode dring the first postoperative week. An approximately 80% decrease in her inslin reqirement was observed over the first 6 postoperative months (from 70 to 15 nits of inslin per day; Fig. 4). It was evident that glycemic control was extremely stable compared with preoperative vales and HbAlc has been within the normal range «5.9%). In addition, Sstacal challenge tests 2, 3, and 6 months after transplantation have shown progressive improvement of plasma C-peptide (Fig. 5). A delay in C-peptide secretion and prolonged elevation dring the challenge was evident in this patient, as previosly reported in islet allograft recipients (10). The second patient, who died 6 months after transplantation from hepatitis B and sepsis, also demonstrated significant islet fnction. His inslin reqirement rapidly decreased dring the first 3 postoperative weeks (Fig. 6). A rejection episode in week 4 imposed a significant increment in the daily inslin dose, which never retrned to prerejection levels (Fig. 6). The islets were not completely rejected, as docmented by persistence of significant basal and stimlated C-peptide levels of 0.76 and 1.59 pm, respectively (Sstacal challenge, 2 months posttransplant). LIVER - ISLET PT. G. M. WEEKLY METABOLIC PROFILES Glcose -+- Inslin ;>.. <0 "CI '"0 " tuj (/) 5 >:: i:.:l ::::> r.n 0 Z ::::>...:l...:l ::::> c..? r.n... Z TIME (WEEKS) FIGURE 4. Plasma glcose and daily inslin reqirements before and after hman islet allotransplantation in one type 1 diabetic patient who received a combined liver-islet graft (grop 2, No.1, Tables 1 and 2).

6 412 TRANSPLANTATION Vol. 53, No.2 LIVER-ISLET I)T. G.M. Preoperative S.T.T. 2 mos. S.1'.1'. Glcose -. C-peplide Glcose. C-peplide A/- B 2.00 S 2.00 S -. 0 bo ::=;t IlO ::=;t El 150 a El a c _-..' c c III 1/1 "lj "lj / oJ 0... <.> a.. <.> a "lj 300 "lj '. ;:1 t:l , c ::J c CI CI. I t:l I a Time (minles) Time (mintes) 3 mos. S.T.T. 6 mos. S.T.T. Glcose. C-pepllde Glcose. C-peplide C D.. _-.. _._- -,.. El._,'.. El "lj 300 //a.,./ "\._. _ ", "lj bo ::=;t IlO :::;: El, 1.50.IIi a.. El,, 1.50 a.., II> II>,.- c III III :: "0 III 100 "0 0 0 <.>... /... () p., p., ::J 100 II> ::J CIJ 100 p., t:l 050 a.. t:l 0.50 I I U U a Time (mintes) 'Time (mintes) FIGURE 5. Plasma glcose and C-peptide following Sstacal Tolerance Test (STT) before and 2, 3, and 6 months after hman islet allotransplantation (grop 2, No.1, Tables 1 and 2). In grop 3, none ofthe patients became inslin-independent. All patients had at least one rejection episode in the first postoperative month. One patient lost the transplanted kidney de to rejection. Of interest in this patient was docmentation of islet fnction with basal and stimlated C-peptide of 0.30 and 0.75 pm, respectively, after the kidney was completely rejected. The patient received a second kidney-islet graft 6 months after the first combined transplant, bt never became inslin-independent despite receiving the highest nmber of islets (>2,000,000 IEq) in the stdy. C-peptide was measrable in all cases, althogh only three of six patients with a followp of more than 1 month had significant basal and stimlated plasma C-peptide (basal = 1.62/0.36/0.38 and peak = 1.95/.57/.93 pm) following a Sstacal challenge test 4-8 weeks postoperatively_ Two patients had 48% (Fig. 7) and 70% redction in inslin reqirements following transplantation. It is of interest that basal and stimlated C-peptide levels in both clster-islet and liver-islet grops were higher than in kidney-islet recipients (Fig. 8). Diabetes was stabilized in all patients, despite the fact that they all had at least one episode of rejection confirmed on biopsy. DISCUSSION Several cases of intrahepatic hman islet allografts have been reported recently (9-12) with transient (9) or prolonged (10-12) inslin independence. Two patients with type 1, inslindependent diabetes mellits (11, 12) received islets from mltiple donors (4 and 5 pancreases). One of these patients (12) was still inslin-independent 1 year after islet allotransplantation. In the present report, prolonged (5 to >16 months) inslin independence was observed in six patients who nderwent pper abdominal exenteration and liver-islet replacement (10). For of them received islets from two donors. The first patient of this series is still inslin-independent over 16 months after the islet allograft and received islets from a single donor. In contrast, in or experience none of the type 1 diabetic patients who received either a liver-islet or a kidney-islet alio-

7 Febrary 1992 RICORDI ET AL. 413 LIVER-ISLET PATIENT F.C. WEEKL Y METABOLIC PROFILES Glcose Inslin > (1j '"d 150 '"Cl ' QO 200 rn E.- w T 150 \ T 100 ::l lfl \ \ 0 1\ \ Z I \ 100 \ I \ ::3 i. I \...:I, I \ '-', I lfl ' 50 :::> 50 I Z ' I 0 I TIME (WEEKS) FIGURE 6. Plasma glcose and daily inslin reqirements in a type 1 diabetic recipient of combined liver-islet allograft (grop 2, No.2, Tables 1 and 2). Inslin reqirement rapidly decreased dring the first 3 weeks following transplantation. A rejection episode in week 4 imposed a significant increment in the daily inslin dose, which never retrned to pre rejection levels. KIDNEY-ISLET PT. G.S. WEEKL Y METABOLIC PROFILES Glcose Inslin > "T n:l "0 75 "0 ' QO ' (/J E 240 -' i=: W 50 :::> lfl Z U :::>...:I...:I 25 :::> '-' 80 lfl Z o 0 -& TIME (WEEKS) FIGURE 7. Plasma glcose and daily inslin reqirements in a type 1 diabetic patient who received a combined kidney-islet allograft (grop 3, No.1, Tables 1 and 2). Daily inslin reqirement decreased by 48% in the first 40 weeks posttransplant, compared with pretransplant reqirements. graft are inslin-independent. Althogh or best reslt in type 1 diabetic patients was obtained in a case of positive crossmatch (100%), we crrently consider a positive crossmatch as an absolte contraindication to hman islet allotransplantation, becase of the increased risk of morbidity and mortality in this grop. Differences in islet isolation and/or prification techniqes can not explain the inferior reslts obtained in the combined kidney-islet grop, since the patients in the three grops represent consective cases in which the same separation and prification procedre was sed for hman islet isolation. Pos- S ' s "'" ;:: c.. "'" c.. I BASAL AND STIMULATED C- PEPTIDE _ KIDNEY-ITx _ LIVER-ITx c:::=:j CLUSTER-ITx BASAL MAX STIM FIGURE 8. Basal and stimlated plasma C-peptide levels in patients following kidney-islet (n=7), liver-islet (n=2), and clster-islet (n=9) allotransplantation. C-peptide appears higher in clster-islet patients than in liver-islet and kidney-islet recipients. sible explanations for which there is experimental spport inclde: (1) metabolic dysfnction and/or impaired vasclar engraftment de to long-standing diabetes mellits (34, 35); (2) steroid treatment, which may have a detrimental effect on islet engraftment and/or fnction (36), was not sed in the clster-islet patients, and was higher in the kidney-islet grop than in liver-islet recipients; (3) the immne barrier to islet acceptance might be lowered by the presence of a liver from the same donor (37). Based on or data we favor the hypothesis of the protective effect of the simltaneos liver graft and/or the detrimental effect of steroid treatment. In addition, weight loss was observed dring the first 2-3 postoperative months in all patients receiving a clster-islet graft. The ntritional problem associated with pper abdominal exenteration cold also reslt in redced inslin reqirement in these patients. In conclsion, or reslts indicate that rejection is still a major factor limiting the clinical application of islet transplantation in patients with type 1 diabetes mellits, althogh other factors sch as steroid treatment may contribte to deteriorate islet engraftment and/or fnction. ORAL DISCUSSION DR. R. FERGUSON (Colmbs, OH): It seems that if yo're a type 1 diabetic, yo have troble with islet transplants. Can yo separate the diabetes by placing the islets in an allogeneic environment or in a syngeneic environment? Let me explain. The transplants seemed to work when the islets were syngeneic to the liver, both being allogeneic to the host. Do yo have strategies to separate the components or contribtions of each effect-that is, an allogeneic effect on the one hand and the effect of type 1 diabetes or perhaps its recrrence on the other hand? Might this relate to the failres among the diabetic kidney islet patients? DR. RICORDI: I believe the liver transplanted with the islets can confer a protective effect, bt this does not necessarily reqire that the liver comes from the same donor as the islets. One of or best reslts occrred when a patient received islets from one donor and a liver from another donor. We did not se

8 414 TRANSPLANTATION Vol. 53, No.2 any indction therapy with OKT3 or ALG, and it may be that we sed inadeqate immnosppression for type 1 diabetic patients. It is possible that a pancreas transplant wold have similar problems with rejection sing the same immnosppressive regimen sed for the islets. It seems that the combined kidney-islet transplant in type 1 diabetic patients was more vlnerable. The liver has a protective effect on the srvival of any other allograft, as has already been reported. DR. DUBERNARD: If I nderstood yor presentation, none of yor patients with type 1 diabetes reached inslin independence. DR. RICORDI: Correct. DR. I>UBERNARD: In type 2 diabetes, do yo think that factors independent of inslin might be involved? Perhaps the islets are insfficient? DR. RICORDI: Those patients did not have type 2 diabetes, bt nderwent total pancreatectomy as part of the clster resection. We did not have a grop with type 2 diabetes. REFERENCES 1. Harris MI, Hanaman RF, eds. 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