Benefits and Risks of Solitary Islet Transplantation for Type 1 Diabetes Using Steroid-Sparing Immunosuppression

The National Institutes of Health experience

  1. Boaz Hirshberg, MD1,
  2. Kristina I. Rother, MD1,
  3. Benigno J. Digon III, MD1,
  4. Janet Lee, MD2,
  5. Jason L. Gaglia, MD1,
  6. Kenneth Hines, BS, MT (ASCP)2,
  7. Elizabeth J. Read, MD2,
  8. Richard Chang, MD3,
  9. Bradford J. Wood, MD3 and
  10. David M. Harlan, MD1
  1. 1Transplantation and Autoimmunity Branch, National Institutes of Health/Department of Health and Human Services, Bethesda, Maryland
  2. 2Clinical Center Department of Transfusion Medicine, National Institutes of Health/Department of Health and Human Services, Bethesda, Maryland
  3. 3Special Procedures–Diagnostic Radiology Department, National Institutes of Health/Department of Health and Human Services, Bethesda, Maryland
  1. Address correspondence and reprint requests to David M. Harlan, MD, Chief, Transplantation and Autoimmunity Branch, NIDDK, National Institutes of Health/Department of Health and Human Services, Building 10, Room BN307, Bethesda, MD 20892. E-mail: davidmh{at}intra.niddk.nih.gov

Abstract

OBJECTIVE—The aim of this study was to describe the National Institutes of Health’s experience initiating an islet isolation and transplantation center, including descriptions of our first six recipients, and lessons learned.

RESEARCH DESIGN AND METHODS—Six females with chronic type 1 diabetes, hypoglycemia unawareness, and no endogenous insulin secretion (undetectable serum C-peptide) were transplanted with allogenic islets procured from brain dead donors. To prevent islet rejection, patients received daclizumab, sirolimus, and tacrolimus.

RESULTS—All patients noted less frequent and less severe hypoglycemia, and one-half were insulin independent at 1 year. Serum C-peptide persists in all but one patient (follow-up 17–22 months), indicating continued islet function. Two major procedure-related complications occurred: partial portal vein thrombosis and intra-abdominal hemorrhage. While we observed no cytomegalovirus infection or malignancy, recipients frequently developed transient mouth ulcers, diarrhea, edema, hypercholesterolemia, weight loss, myelosuppression, and other symptoms. Three patients discontinued immunosuppressive therapy: two because of intolerable toxicity (deteriorating kidney function and sirolimus-induced pneumonitis) while having evidence for continued islet function (one was insulin independent) and one because of gradually disappearing islet function.

CONCLUSIONS—We established an islet isolation and transplantation program and achieved a 50% insulin-independence rate after at most two islet infusions. Our experience demonstrates that centers not previously engaged in islet transplantation can initiate a program, and our data and literature analysis support not only the promise of islet transplantation but also its remaining hurdles, which include the limited islet supply, procedure-associated complications, imperfect immunosuppressive regimens, suboptimal glycemia control, and loss of function over time.

Footnotes

  • A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

    • Accepted August 26, 2003.
    • Received May 23, 2003.
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