Abstract: Insulin production in pancreatic beta-cells is critically linked to mitochondrial oxidative phosphorylation. Increased ATP production triggered by blood glucose represents the beta-cells' glucose sensor. Type-2 diabetes mellitus results from insulin resistance in peripheral tissues and impaired insulin secretion. Pathology of diabetic beta-cells might be reflected by the altered morphology of mitochondrial network. Its characterization is however hampered by the complexity and density of the three-dimensional (3D) mitochondrial tubular networks in these cell types. Conventional confocal microscopy does not provide sufficient axial resolution to reveal the required details; electron tomography reconstruction of these dense networks is still difficult and time consuming. However, mitochondrial network morphology in fixed cells can also be studied by 4Pi microscopy, a laser scanning microscopy technique which provides an approximately 7-fold improved axial resolution ( approximately 100nm) over conventional confocal microscopy. Here we present a quantitative study of these networks in insulinoma INS-1E cells and primary beta-cells in Langerhans islets. The former were a stably-transfected cell line while the latter were transfected with lentivirus, both expressing mitochondrial matrix targeted redox-sensitive GFP. The mitochondrial networks and their partial disintegration and fragmentation are revealed by carefully created iso-surface plots and their quantitative analysis. We demonstrate that beta-cells within the Langerhans islets from diabetic Goto Kakizaki rats exhibited a more disintegrated mitochondrial network compared to those from control Wistar rats and model insulinoma INS-1E cells. Standardization of these patterns may lead to development of morphological diagnostics for Langerhans islets, for the assessment of beta-cell condition, before their transplantations.
Abstract: An alternative prevascularized bed with a subcutaneously located entrance would substantially improve islet engraftment, requiring much less invasive surgery. Studies have described times necessary for the creation of an artificial pouch suitable for subsequent islet transplantation. Polymeric mesh shaped in rounded scaffolds were implanted both subcutaneously and into the major omentum of Brown Norway female rats (n = 7). The connective tissue together with vessels were embedded into scaffolds at 1 week without regard to site. In contrast to the major omentum, vessels within the subcutaneous connective tissue surrounding the devices started to decline in 2 weeks and almost disappeared 1 week later. Magnetic resonance imaging (MRI) detected changes in fibrous tissue surrounding the wall, but only large veins located beside the devices were visible using basic MRI. The blood supply to the internal surface of the created beds was important for islet engraftment, but information could be obtained only by using dynamic contrast-enhanced MRI.
Abstract: BACKGROUND: The two-layer organ preservation method (TLM) based on oxygenated perfluorocarbon overlaid with University of Wisconsin (UW) solution has been successfully used in clinical islet and experimental heart and intestine transplantation. We tested whether this technique would prevent tissue damage and improve kidney function in a model of syngeneic kidney transplantation with prolonged ischemia time. METHODS: Kidneys were stored for 24 h either in UW solution (n = 16), with TLM (n = 16) or transplanted immediately (control group, n = 12). In half of the animals, survival was observed and in the other animals grafts were procured for semiquantitative histological scoring and TUNEL apoptosis assessment 24 h after transplantation. RESULTS: One-month survival rates in the UW, TLM and control groups were 12.5, 62.5 and 100%, respectively (UW vs. TLM, p < 0.01). Median creatinine levels 24 h after transplantation were 381, 299 and 121 microM, respectively (UW vs. TLM, p < 0.02). Histological scoring showed more severe tissue damage in the UW group than in the TLM group (p < 0.05). Apoptosis was more frequent in the UW group than in the TLM group (p < 0.05). CONCLUSION: We demonstrated for the first time that conservation with TLM significantly improves the outcome of kidney transplantation in a rat model and should therefore be further studied in larger animals.
Abstract: OBJECTIVE: MRI has recently been introduced as a promising method of monitoring the transplanted pancreatic islets labelled with superparamagnetic iron oxide (SPIO). However, the traditional [Formula: see text]-weighted approach frequently yields ambiguous results because of the negative contrast of the SPIO particles on the background of other body components. This obstacle could be overcome with the use of a novel method known as echo-dephased steady state free precession (SSFP), generating positive contrast in the presence of paramagnetic material. METHODS: In phantoms, we achieved exact localisation and clear positive contrast visualisation of human SPIO labelled islets. Using the proposed method we demonstrated the ability to detect even a single pancreatic islet against a homogeneous background. RESULTS: In vivo experiments in rats confirmed reliable and accurate localisation of transplanted SPIO labelled islets. CONCLUSION: The echo-dephased SSFP technique could successfully visualise SPIO-labelled human and rat pancreatic islets yielding a positive contrast.
Abstract: Adult pancreatic nonendocrine cells represent a potential alternative source of insulin-producing tissue for the treatment of diabetes. Differentiation of these cells is regulated by various signaling pathways including the phosphoinositide 3-kinase (PI3K) pathway. Therefore, we evaluated the effect of PI3K on this process. Compared with untreated cells the differentiation of human nonendocrine pancreatic cells into insulin-producing elements was increased after treatment with IGF-1, EGF, and Exendin-4, growth factors known to be activators of the PI3K pathway (12.2 +/- 3.2% vs 9.1 +/- 3.2%). Treatment with PI3K pathway inhibitor wortmannin reduced the number of differentiated beta cells from 9.1 +/- 3.2 to 0.7 +/- 0.4%. Reverse transcriptase polymerase chain reaction (RT-PCR) analysis revealed that insulin-like growth factor-1 (IGF-1), epidermal growth factor (EGF), and Exendin-4 significantly increased the expression of the transcription factor neurogenin-3, whereas the expressions of pancreatic and duodenal homeobox 1 (PDX-1), neurogenic differentiation 1 (NeuroD) were increased only among samples treated with ZnCl2 and not significantly affected by treatment with the tested growth factors. Successful differentiation of IGF-1, EGF-, and Exendin-4-treated cells into functional beta cells was confirmed by C-peptide secretion in response to 5 versus 20 mmol glucose stimulation (0.24 vs 0.91 pmol C-peptide/microg DNA). These results showed that activation of the PI3K signaling pathway might be used to stimulate the differentiation of nonendocrine pancreatic cells into insulin-producing elements.
Abstract: INTRODUCTION: We compared the incidence of severe complications among 123 consecutive simultaneous pancreas and kidney (SPK) recipients randomized for treatment either with tacrolimus plus mycophenolate mofetil (MMF) or tacrolimus plus sirolimus during their initial postoperative hospital stay. METHODS: Patients with type 1 diabetes mellitus (T1DM) and renal failure with no age limit who underwent SPK were randomly assigned to tacrolimus/sirolimus or tacrolimus/MMF immunosuppressive protocols. We analyzed the rate of adverse events that led to death, graft loss, operative revision, or prolonged hospital stay. RESULTS: From 2002 to 2009, 62 recipients were included in the MMF and 61 in the Rapamycin (Rapa) groups. More than 2/3 of recipients suffered from at least 1 complication: 74% MMF and 77 % Rapa group (P > .05). No patient died in the MMF and 3 in the Rapa group (P = .11). Pancreas graftectomy was performed in 13% of the MMF group and in 5% of the Rapa group (P = .20). Ten of 62 recipients in the MMF and 13/61 in the Rapa group required operative treatment of wound infections (P = .49). There were no differences in the rates of gastrointestinal bleeding (11% and 8%), kidney lymphocele (6% and 5%), ileus (1.6% both), pancreatic leak (1.6% both), or ureteral leak (0 and 3%) between the groups. CONCLUSION: We did not observe a difference in the rate of severe postoperative complications between groups. With the use of extraperitoneal placement of the pancreatic graft, fluid collections and wound infections remain the most frequent albeit curable postoperative complications.
Abstract: In our study we confirmed the potential of human umbilical cord blood cells to differentiate into insulin-producing cells following transplantation into immunocompromised mice. The average number of C-peptide-positive human cells per animal was 18 +/- 13 as assessed by immunofluorescence staining and fluorescence in situ hybridization specific for human ALU sequence. Differentiation into insulin-producing cells was further confirmed by reverse transcription-polymerase chain reaction specific for human insulin mRNA. Successful differentiation required sublethal irradiation of xenogeneic recipient at least at a dose of 3 Gy. However, transplantation of human umbilical cord blood cells did not improve hyperglycaemia in diabetic animals. The results of our study show that human umbilical cord blood may be considered as a potential source of stem cells for treatment of diabetes mellitus.
Abstract: AIM: Assessment of islet mass before islet transplantation requires a reliable technique to enable exact analysis of islet volume. This study aimed to test the applicability of digital image analysis (DIA) for evaluation of samples of purified and non-purified islets. METHODS: Pancreatic islets were isolated from 10 Lewis rats. Samples of purified (n = 10) and non-purified islets (n = 30) were counted conventionally and by using a computerized method. The equipment for the computerized counting consisted of a digital camera installed on a stereomicroscope and connected to a personal computer. Images of 2272x1704 pixels were processed using a previously described non-commercial program originally developed for this purpose. Islets were converted to equivalents using globe and ellipsoid models. The insulin content of purified islets was assessed using radioimmunoassay and was correlated to the absolute and standardized islet number. RESULTS: Mean absolute numbers of purified islets +/- SD were 908 +/- 130 and 1049 +/- 230 (manually and DIA respectively). Mean insulin content +/- SD obtained from purified islets was 161 +/- 45 mU. The mean equivalents of purified islets (1589 +/- 555 for globe and 1219 +/- 452 for ellipsoid) significantly correlated with insulin content. However, this correlation was not significant when absolute islet numbers were used, counted using either method. There was no significant difference in absolute non-purified islet numbers assessed by manual and computerized methods (average +/- SD in 50 microl samples; 12.6 +/- 4.1 and 13.3 +/- 5.3 respectively; p = 0.22). The manual method showed a significantly higher yield of islet equivalents (IE; p < 0.001 for both globe and ellipsoid). CONCLUSION: The computer-based system for islet counting correlated better to insulin content than conventional islet estimation and prevented overestimation. Reproducibility and ease of assessment make it potentially applicable to clinical islet transplantation.
Abstract: Diabetes is a disorder characterized by beta-cell loss or exhaustion and insulin deficiency. At present, knowledge is lacking on the underlying causes and for the therapeutic recovery of the beta-cell mass. A better understanding of diabetes pathogenesis could be obtained through exact monitoring of the fate of beta-cells under disease and therapy conditions. This could pave the way for a new era of intervention by islet replacement and regeneration regimens. Monitoring the beta-cell mass requires a reliable method for noninvasive in vivo imaging. Such a method is not available at present due to the lack of a beta-cell-specific contrast agent. The only existing method to monitor islet cells in vivo consists of labeling islet transplants with iron nanoparticles prior to transplantation and visualization of the transplanted islets by magnetic resonance imaging (MRI). Therefore, accurate assessment of the native beta-cell mass is still limited to autopsy studies. Endeavors to find a biological structure specific for beta-cells led to the discovery of potential candidates that have been tested for noninvasive imaging. Among them are the ligand to the vesicular monoamine transporter type 2 (VMAT-2), which is called dihydrotetrabenazine (DTBZ), antibodies to zinc transporter (ZnT-8) and the monoclonal antibody IC2. While DTBZ and antibodies to ZnT-8 showed binding activities to more than beta-cells, the anti-IC2 monoclonal antibody showed binding properties exclusively to insulin-producing beta-cells. This effect was demonstrated in many previous investigations, and has been further substantiated more recently. Thus, at present, IC2 seems to be the only useful marker for noninvasive functional imaging of native beta-cells. Experiments with a radioisotope-chelated IC2 structure on pancreas ex vivo showed that the tracer specifically bound to the beta-cell surface and could be detected by nuclear imaging. In the near future, these promising findings may offer a new way to monitor the beta-cell mass in vivo under disease and therapy conditions so that we can learn more about diabetes pathogenesis and options for disease prevention.
Abstract: The Immunosuppression in Pancreas Transplantation was historically based on the fact that the pancreas is an extremely immunogenic organ. Quadruple drug therapy with polyclonal or monoclonal antibodies induction was the mainstay therapy since the introduction of Cyclosporine A. In the modern era of Immunosuppression, Mycophenolate Mofetil replaced Azathioprine while Tacrolimus-another potent calcineurin inhibitor-had-and still has-a difficult challenge to replaced Cyclosporine A, due to its potential diabetogenic effect. Thanks to the first two EuroSPK studies which prospectively tried to answer several questions in that field. But, the future challenge will be in understanding the impact of innate immunity and ischemic reperfusion injuries on the long-term graft function. Hopefully, new drugs will be available and tested to block unspecific deleterious reactions to attenuate the proinflammatory response. It will be the aim of the third Euro SPK Study.
Abstract: The existence of an adult PSC that may be used in the treatment of diabetes is still a matter of scientific debate as conclusive evidence of such a stem cell in the adult pancreas has not yet been presented. The main reason why putative PSC has not yet been identified is the lack of specific markers that may be used to isolate and purify them. In order to increase the list of potential PSC markers we have focused on the human pancreatic cells that express cell surface receptor CXCR4, a marker of stem cells derived from different adult tissues. Here we report that CXCR4-positive pancreatic cells express markers of pancreatic endocrine progenitors (neurogenin-3, nestin) and markers of pluripotent stem cells (Oct-4, Nanog, ABCG2, CD133, CD117). Upon in vitro differentiation, these cells form ILCC and produce key islet hormones including insulin. Based on our results, we assume that CXCR4 marks pancreatic endocrine progenitors and in combination with other cell surface markers may be used in the attempt to identify and isolate PSC.
Abstract: We previously described an in vivo method for pancreatic islet visualization using magnetic resonance imaging with the aid of superparamagnetic nanoparticles of iron oxide (Resovist) or by magnetic beads precoated with antibodies (Dynabeads). The aim of this study was to investigate the in vitro effect of islet labeling on their quality. Isolated rat islets were cultivated for 48 hours with a contrast agent or, in the case of magnetic antibody-coated beads, for only 2 hours. The ability to secrete insulin was tested by a static insulin release assay and the results were expressed as a stimulation index. Staining with propidium iodide and acridine orange was performed to determine the ratio of live to dead cells. Stimulation indices in the Resovist islets (n = 23) vs controls (n = 14) were 15.3 and 15.0, respectively, and in the Dynabeads islets (n = 15) vs controls (n = 12) 21.3 and 19.9, respectively. The vitality of the Resovist islets vs controls determined by live/dead cells ratio was 90.8% and 91.1%, respectively (n = 20), and in the Dynabeads islets vs controls was 89.4% and 91.8%, respectively (n = 11). Islet labeling with the contrast agent as well as with specific antibodies with iron beads did not change the vitality and insulin-secreting capacity assessed in vitro (P > .05). Magnetic resonance using iron nanoparticles represents the only method for in-vivo visualization of transplanted islets so far. Our data represent an important contribution for its clinical use.
Abstract: Superparamagnetic agents can be reliably used for magnetic resonance imaging (MRI) of pancreatic islets located in the liver sinusoids. However, the main disadvantages seemed to be the rather long culture time necessary for islet labeling and the low specificity of these agents. In the present study we investigated a more specific approach with a shorter labeling time using immunomagnetic particles. Isolated rat islets were cultivated with immunomagnetic beads coated with antibody against rat MHC class I antigen. Labeled islets were transplanted into the livers of syngeneic rats. The animals were examined weekly by MRI or livers explanted 10 minutes after islet transplantation for in vitro experiments. In both in vitro and in vivo studies, labeled transplanted islets were imaged as hypointensive spots, diffusely distributed throughout the liver. This experiment represents an alternative way of islet imaging by magnetic resonance, which is as effective as the use of known superparamagnetic contrast agents and more specific owing to targeting to specific donor antigens.
Abstract: In order to assess the quality of freshly isolated and cultivated pancreatic islets designed for experimental transplantation in rats we combined the vitality staining test, in vitro measurement of insulin secretion capacity, and assessment of islet respiration. Oxygen consumption was measured using the respirometer Oxygraph 2K equipped with polarographic oxygen sensors. The results of oxymetry demonstrated a linear correlation between islet number and oxygen consumption. Respiration per unit of viable islet tissue was constant. Oxygen consumption tests were in good correlation with the results of insulin release assays, with a correlation coefficient of 0.82. We found no significant differences in all three vitality-testing methods performed with fresh and 24-hour cultivated islets (P > .05). We conclude that polarographic oxymetry provides a fast and easy evaluation test of islet quality. After appropriate standardization, the oxymetric technique can be used for routine clinical pretransplant islet quality testing. In addition, cell membrane integrity and mitochondrial function could be assessed after addition of specific respiration inhibitors or stimulators.
Abstract: OBJECTIVE: A role of autoreactive T cells for type 1 diabetes pathogenesis is considered crucial. In our pilot study we addressed if autoreactive mononuclear cells are present also in peripheral blood of patients with other specific forms of diabetes as cystic fibrosis related diabetes (CFRD). METHODS: Cellular immune responses to a known beta-cell autoantigen (GAD65 and GAD65 derived peptides) were analysed by ELISPOT (IFN-gamma) and by protein microarray analysis in four patients suffering from CFRD, in four cystic fibrosis (CF) patients without diabetes, in eight type 1 diabetes patients (without CF) and in four healthy controls. RESULTS: Response to the autoantigen GAD65 (protein and peptides) was observed in 7/8 patients suffering from CF and in all type 1 diabetes patients. Post-stimulation production of Th1 cytokines (IFN-gamma, TNF-beta) was observed in 2/4 CFRD, 1/4 CF patients and in 7/8 type 1 diabetes patients. All these patients carry prodiabetogenic HLA-DQ genotype. Th2- and Th3 type of cytokine pattern was observed in 2/4 CF patients. Production of IL-8 was observed in the third CFRD as well as in the third CF patient and in 1/8 type 1 diabetes patient and borderline production of this chemokine was also observed in 2/4 healthy controls. No reaction was observed in the other 2/4 healthy controls and in the fourth CFRD patient who carried a strongly protective genotype and did not produce autoantibodies. The most potent peptide of GAD65 was amino acids 509-528. CONCLUSIONS: We consider our observations as a sign of a reaction directed against the self-antigen GAD65 that are closely connected to type 1 diabetes. In CF patients who do not develop diabetes autoreactive mechanisms are very probably efficiently suppressed by immune self-tolerance mechanisms. CFRD patients are a heterogenic group. To disclose those who may display features of autoimmune diabetes could have an impact for their therapy and prognosis.
Abstract: Our study was designed to determine effect of gemcitabine on acute rejection of liver in rats. Liver transplantation was performed in rats of the Dark Agouti (DA) and Lewis (LEW) strains. Recipients were divided into three groups: A, DA-to-LEW without immunosuppression; B, DA-to-LEW, treated with cyclosporine A; C, DA-to-LEW, treated with gemcitabine. Immunosuppressants were subcutaneously injected for seven consecutive days after transplantation. On day 7, blood samples and liver graft tissue specimens were harvested. Group A showed severe rejection changes (RAI 8/9); in group B no rejection changes were present (RAI 0/9), and in group C moderate rejection changes were observed (RAI 6/9). Differences were significant between B vs C and A vs C groups; P<0.05. Serum creatinine and urea levels in the gemcitabine group were significantly lower than those in the cyclosporine A group. We did not confirm gemcitabine ability to prevent liver allograft rejection.
Abstract: BACKGROUND: Single-centre and retrospective studies suggest superiority of tacrolimus over cyclosporin as cornerstone immunosuppressive therapy for simultaneous pancreas-kidney (SPK) transplantation. This open-label, multicentre trial compared the efficacy and safety of tacrolimus with cyclosporin microemulsion (ME) in diabetic patients with end-stage renal disease undergoing their first cadaveric SPK transplantation. The 3-year results are reported. METHODS: Patients were recruited from 10 centres in Europe and one centre in Israel: 103 were randomized to receive tacrolimus (initial dose: 0.2 mg/kg/day p.o.) and 102 to cyclosporin-ME (7 mg/kg/day p.o.). All patients received concomitant rabbit anti-T-cell globulin induction, mycophenolate mofetil (MMF) and short-term corticosteroids. RESULTS: Fewer patients receiving tacrolimus (36.9%) than cyclosporin-ME (57.8%) were discontinued from treatment (P = 0.003). The initial episodes of biopsy-proven rejection were moderate or severe in just one out of 31 (3%) tacrolimus-treated patients compared with 11 out of 39 (28%) patients receiving cyclosporin-ME (P = 0.009). While 3-year patient and kidney survival rates were similar in the two treatment groups, pancreas survival was superior with tacrolimus (89.2 vs 72.4%; P = 0.002). Thrombosis resulted in pancreas graft loss in 10 patients receiving cyclosporin-ME and in only two treated with tacrolimus (P = 0.02). Overall adverse event frequency was similar in both groups, but MMF intolerance was more frequent with tacrolimus and hyperlipidaemia more frequent with cyclosporin-ME. CONCLUSIONS: In this 3-year study, tacrolimus was more effective than cyclosporin-ME in preventing moderate or severe kidney or pancreas rejection after SPK transplantation. It also provided superior pancreas survival and reduced the risk of pancreas graft thrombosis.
Abstract: This 3-year study compared tacrolimus versus cyclosporine (CsA) microemulsion (ME) in conjunction with rATG induction, mycophenolate mofetil (MMF) and short-term corticosteroids in primary simultaneous pancreas-kidney (SPK) transplantation. PATIENTS AND METHODS: This large, prospective, multicenter study was conducted in 10 European centers and one center in Israel. Of the 205 SPK transplants performed from 1998 to 2000, 103 patients were randomly assigned to tacrolimus and 102 to CsA ME. All patients received concomitant rATG induction therapy, MMF, and short-term corticosteroids. RESULTS: In total, 36.9% patients receiving tacrolimus and 57.8% receiving CsA ME discontinued treatment (P = .003). Although 3-year patient and kidney graft survival rates were similar in both groups, pancreas survival was superior with tacrolimus (89.2% versus 72.4%; P = .002). Thrombosis resulted in pancreatic allograft loss in 10 patients receiving CsA ME and in 2 treated with tacrolimus (P = .02). The first episode of biopsy-proven rejection was moderate or severe in 1 of 31 tacrolimus-treated patients and 11 of 39 patients receiving CsA ME (P = .009). Overall adverse event frequency was similar in both groups, but surgical events were lower in the tacrolimus treated group. CONCLUSION: Tacrolimus was more effective than CsA-ME to prevent moderate or severe kidney or pancreas rejection after SPK transplantation. It also provided superior pancreatic graft survival and reduced the risk of pancreas thrombosis.
Abstract: BACKGROUND: The minimally invasive method of skin biopsy with intraepidermal nerve fiber (IENF) counts may be used to analyze nerve regeneration in pancreas transplant (PTx) recipients. We assessed IENF counts as a database for long-term follow-up of diabetic neuropathy. METHODS: Skin biopsies were performed using a 3-mm punch from lower thigh and upper calf areas of 16 (13 pancreas/kidney, 3 pancreas alone) PTx patients (mean +/- SD: age, 45+/-8 years; type 1 diabetes duration, 27 +/- 8 years) at 1 month posttransplant. Ten healthy gender- and age-matched controls (C) were also examined. After fixation and freezing, 40-microm sections were stained using rabbit polyclonal antibody to the panaxonal marker PGP 9.5 followed by mouse antirabbit IgG antibody conjugated with rhodamine. Samples were imaged with a digital camera, mounted on a microscope, and equipped for fluorescence. The average number of IENF per millimeter length of epidermis was derived. Clinical neuropathy was assessed by foot vibration perception thresholds (VPT) with a biothesiometer (normal values < mean + 2 SD of C). RESULTS: Significantly lower IENF densities were found in skin biopsies from PTx (PTx vs C: thigh, 0.74 +/- 0.88 vs 9.74 +/- 2.41 IENF/mm; calf, 0.34 +/- 0.91 vs 7.66 +/- 3.16 IENF/mm; P < .001). IENF were totally absent from the thigh and calf samples of 7 and 12 PTxs, respectively. Clinical neuropathy (VPT > 21 V) was present in all but one PTx. CONCLUSIONS: Severe intraepidermal nerve fiber depletion is present in the lower limb area of pancreas transplant recipients with neuropathy. Long-term follow-up would probably be necessary to assess the possibility of posttransplant nerve fiber regeneration.
Abstract: Metabolic effects of immunosuppressive agents are of great importance in pancreas or islet transplantation. The aim of our study was to compare effects of tacrolimus-based immunosuppression in conjunction with sirolimus (RAPA) versus mycophenolate mofetil (MMF) on glucose metabolism in type 1 diabetic recipients following a simultaneous pancreas and kidney transplantation (SPK). We examined 30 insulin-independent patients after SPK with venous systemic drainage of the pancreatic graft. All recipients had good kidney graft function. Fasting glycemia, insulin levels, glycosylated hemoglobin (HbA(lc)), standard intravenous glucose tolerance test (IVGTT), and trough RAPA levels were assessed in pancreas recipients before elective steroid withdrawal. Insulin sensitivity was evaluated using the homeostasis model assessment (HOMA-IR). The groups did not differ in age, BMI, posttransplant period, steroid daily dose, HbA(lc), and fasting glycemia. We did not find any significant difference in the IVGTT response. Area under the curve of insulin levels during IVGTT and HOMA-IR were significantly lower in the RAPA group. Trough levels of RAPA had no significant impact on any of the examined parameters. Glucose tolerance measured with the use of IVGTT was similar in patients treated with RAPA and MMF. However, recipients on sirolimus treatment had significantly lower insulinemia during the test and consequently more favorable indices of insulin action as assessed by HOMA-IR.
Abstract: BACKGROUND: We have recently described a magnetic resonance (MR) method for detection of rat pancreatic islets transplanted into the liver after labeling with superparamagnetic iron oxide nanoparticles. The aim of this work was to study whether this technique could be applicable over a longer period after transplantation and whether it could help to detect islet rejection. METHODS: Islets from Lewis and Wistar rats were cultured in the presence of iron oxide nanoparticles. Two thousand of Lewis (n=6) or Wistar (n=8) iron-labeled islets were transplanted into the portal vein of Lewis diabetic animals. Serial MR imaging of the liver were performed at 1, 2, 3, 4, 5, and 6 weeks. RESULTS: Although all allogeneic islets were rejected by 12 days, syngeneic animals remained normoglycemic throughout the study. At week 1, the labeled islets were visualized on MR scans as distinct hypointense spots homogeneously distributed in the liver. While their number declined only insignificantly in the syngeneic group, in the allogeneic group the number of spots gradually decreased until approximately 35% of their initial count. Although syngeneic islets showed a normal histology, the allogeneic islets were completely rejected. Iron particles, localized in macrophages, were detected only in the syngeneic islets and were absent in the rejected islet structures. In vitro incubation tests did not reveal any differences in insulin secretion between labeled and nonlabeled islets. CONCLUSIONS: MR imaging of iron-labeled pancreatic islets can be used for verification of the technical success of the transplantation procedure itself and for the detection of the decreasing relative islet mass due to rejection.
Abstract: Pancreas transplantation is a routine method for the treatment of diabetes mellitus. One of the main challenges of a transplant with extraperitoneal placement of the pancreatic graft is impaired wound healing due to massive amylase and lipase secretion by the pancreatic graft, evoking edemtous fluid. From February 2002 through January 2003, we performed pancreatic transplant procedures in 21 patients who were prospectively and randomly assigned to two groups: 8 organ donors and the recipients were administered somatostatin by continuous infusion. Thirteen grafts were harvested and transplanted without somatostatin infusion. The two groups did not show significantly differences in mean donor or recipient ages, weights, of serum amylase and lipase content values or drain output until day 6. There was a significantly lower lipase in the drain output of transplant recipients given somatostatin (12.5 and 54.2 micromol/L, respectively; P <.05). Neither the post-pancreatic transplant wound healing nor the number of rejection episodes were affected by somatostatin administration.
Abstract: A promising treatment method for type 1 diabetes mellitus is transplantation of pancreatic islets containing beta-cells. The aim of this study was to develop an MR technique to monitor the distribution and fate of transplanted pancreatic islets in an animal model. Twenty-five hundred purified and magnetically labeled islets were transplanted through the portal vein into the liver of experimental rats. The animals were scanned using a MR 4.7-T scanner. The labeled pancreatic islets were clearly visualized in the liver in both diabetic and healthy rats as hypointense areas on T2*-weighted MR images during the entire measurement period. Transmission electron microscopy confirmed the presence of iron-oxide nanoparticles inside the cells of the pancreatic islets. A significant decrease in blood glucose levels in diabetic rats was observed; normal glycemia was reached 1 week after transplantation. This study, therefore, represents a promising step toward possible clinical application in human medicine.
Abstract: Although the number of pancreas transplants has increased significantly in previous years, debate continues concerning the optimum technique for exocrine pancreas drainage. Enteric drainage (ED) has recently been increasingly popular due to the long-term complications with bladder drainage (BD). We prospectively assigned 40 consecutive pancreas transplant recipients to either bladder (n = 20) or enteric (n = 20) drainage. Patient, kidney, and pancreas graft survival rates at 1 year after simultaneous kidney-pancreas transplantation were 95%, 95%, 85%, for BD group and 90%, 85%, 85% for ED group, respectively. Surgical complications were not significantly different between the two groups. The incidence of acute rejection, major infections, and CMV disease were similar between groups. The length of the initial hospital stay was likewise comparable. However, the BD group showed a slight increase in the number of urologic complications, metabolic acidosis, and dehydration. Based on the results of our study, patient and graft survivals were excellent irrespective of technique.
Abstract: BACKGROUND AND CASE: Simultaneous pancreas and kidney transplantation (SPK) is applied almost exclusively in C-peptide-negative type 1 diabetic patients, although some data on SPK in type 2 diabetes have been published as well. Nothing is known about SPK in the autosomal diabetes form, maturity-onset diabetes of the young (MODY). SPK was performed in a 47-year old man who has MODY3 because of a Arg272His mutation in the hepatocyte nuclear factor-1alphagene. He developed overt diabetes mellitus at 19 years and end-stage diabetic nephropathy 26 years thereafter. Before SPK, the patient had measurable fasting serum C-peptide levels, but lacked beta-cell response to intravenous glucose and glucagon. He was treated with 34 IU of insulin per day. At 2 years post-transplantation, the patient remains normoglycemic and insulin independent. A hyperglycemic clamp test showed a normal beta-cell function. CONCLUSION: Identification of MODY3 among all C-peptide-positive patients with advanced diabetic nephropathy might help to select a specific group profiting from SPK.
Abstract: BACKGROUND: Simultaneous pancreas-kidney transplantation (SPK) transplantation has become an accepted therapy for type 1 diabetic patients with end-stage renal disease. This open-label, multicenter study compared the efficacy and safety of tacrolimus with the microemulsion (ME) formulation of cyclosporine in a clinical setting. The 1-year results are reported here. METHODS: The study was conducted in 10 European centers and one center in Israel. One hundred three patients were randomly assigned to tacrolimus and 102 to cyclosporine-ME. All patients received concomitant rabbit anti-T-cell globulin induction therapy, mycophenolate mofetil (MMF), and short-term cortico-steroids. The initial daily oral doses were 0.2 mg/kg for tacrolimus, 7 mg/kg for cyclosporine-ME, and 2 to 3 g for MMF. RESULTS: The 1-year incidence of biopsy-proven kidney or pancreas acute rejection was lower with tacrolimus (27.2%) than with cyclosporine-ME (38.2%; P = 0.09). Pancreas graft survival at 1 year was 91.3% with tacrolimus and 74.5% with cyclosporine-ME (P <0.0005). Renal graft survival was similar in the two study groups. There were no significant treatment-related differences in pancreatic or renal graft function. In total, 34 patients switched treatment from cyclosporine-ME to tacrolimus, but only 6 patients receiving tacrolimus required alternative therapy. Mean doses of MMF at 1 year were also lower in the tacrolimus group (1.36 vs. 1.67 g/day; P = 0.007). CONCLUSION: These findings support the use of tacrolimus therapy for uremic patients with type 1 diabetes who are undergoing SPK transplantation.
Abstract: Transplantation of donor bone marrow cells (BMTx) has been proven to be capable of including allogeneic transplant tolerance. In our previous experiments we reported the positive effect of BMTx together with short-term tacrolimus/hydrocortisone therapy on pancreatic islet survival in recipients haploidentical with donors. In this project we used the same transplant protocol to further investigate this effect in a fully mean histocompatibility system-mismatched model. Lewis male rats and Brown-Norway female rats were used as donors and recipients, respectively. Diabetic animals were treated according to four different protocols. Recipients in group I (n = 12) underwent islet transplantation (ITx) only. Group II (n = 12) and group III (n = 11) included animals treated for 52 days with tacrolimus (0.5 mg/kg) and hydrocortisone (2 mg/kg). Diabetes was induced by intravenously applied streptozocin (50 mg/kg). Seven days later islets were injected intrahepatically through the portal vein. In addition, rats in group III underwent BMTx on day 10. In group IV (n = 6) tacrolimus therapy, ITx and BMTx were used according to the previously published protocol of Ricordi et al. After more than 120 days, cumulative survival rates were 56% and 64% for recipients in groups II and III, respectively (p > 0.05). All animals in group I became hyperglycemic by day 11 following transplantation. Despite positive detection of lymphocyte microchimerism, we did not observe improved survival of allogeneic islets in animals treated with BMTx. Surprisingly, better islet survival was not found in group IV either (survival rate at 100 days: 33%). We conclude that demonstration of lymphocyte microchimerism, as detected by a sensitive polymerase chain reaction method, did not improve allogeneic islet survival in vivo and was not able to block mixed lymphocyte reaction in vitro. Whether a larger amount of transplanted hematopoietic cells could induce tolerance in this model remains to be evaluated.
Abstract: In previous years, the number of pancreas transplants has increased significantly. Debate continues over the optimum technique for exocrine drainage. Enteric drainage (ED) has recently been increasingly popular owing to the long-term complications of bladder drainage (BD). We prospectively evaluated 40 consecutive pancreas transplant recipients undergoing either bladder (n = 20) or enteric (n = 20) drainage. After simultaneous kidney-pancreas transplantation 1-year patient, kidney, and pancreas graft survival rates were 95%, 95%, 85% for the BD group, and 90%, 85%, 85%, for the ED group. Surgical complications were not significantly different between the two groups. The incidence of acute rejection, major infections and cytomegalovirus disease were also similar. The length of the initial hospital stay was likewise comparable. However, the BD group was characterized by a slight increase in the number of urologic complications, metabolic acidosis, and dehydration. Our results suggest excellent patient and graft survival irrespective of the drainage technique.
Abstract: Only marginally improved results have been observed in standard autonomic function tests (AFT) in follow-up studies after simultaneous pancreas and kidney transplantation (SPK). We therefore used power spectral analysis (PSA) of heart rate variability (HRV) to assess the effect of SPK on autonomic neuropathy in patients with type I diabetes mellitus (DM I). We evaluated 82 patients with DM I who were insulin and dialysis free following SPK. Both pre- and posttransplant (at [mean +/- SD], 25 +/- 15 months post-SPK) examinations were performed in 29 patients. Posttransplant evolution was examined in another 60 patients with two serial examinations at 20 +/- 20 and 43 +/- 27 months after SPK. Comparisons included 32 age-matched healthy controls and 13 patients with kidney transplant alone (KTA) matched for age and duration of DM I at a comparable time point posttransplant. Short-term time (modified Ewing battery) and frequency domain (PSA of HRV: LF-low, HF-high frequency, and TP-total spectral power) analysis was performed with a telemetric, on-line, computer-aided system. Significantly worse results in all standard AFT and PSA indexes were obtained for SPK patients compared with controls at all time points. No significant improvement was seen in SPK patients in the posttransplant period and no differences were found compared with KTA patients. Thus the results of a power spectral analysis of HRV failed to show improvement following SPK. This examination adds little positive information to that obtained from standard autonomic function tests.
Abstract: Transplantation of pancreas is presently the only way of treating diabetes of the 1st type, capable to secure a long-term normoglycemia. In spite of the fact that the surgical technique and tactics of the whole intervention has been standardized over the last years, surgical complications and more specifically vascular complications still pose a certain risk of the graft loss. The thrombosis of vessels of the transplanted pancreas occurred in our group in 4.1 per cent of cases. The other rare complications included a false aneurysm of the supplying artery and stenosis of the out-coming vein from the pancreatic graft. Both these complications were successfully treated by a radio-invasive approach. A refinement of the surgical technique and the introduction of new immunosuppressive drugs manifests favorably in decreasing occurrence of vascular complications after the transplantation of pancreas.
Abstract: Digital image analysis (DIA) is a new method in assessment of islet amount, which is expected to provide reliable and consistent results. We compared this method with conventional counting of small numbers of rat islets. Islets were isolated from 8 pancreases and counted in 24 samples in duplicate, first routinely by sizing according to estimated diameters under a calibrated reticule and then by processing of islets pictures taken by camera. As presumed, no significant difference was found in absolute numbers of islets per sample between DIA and conventional assessment. Volumes of islets per sample measured by DIA were on average more than 10% higher than amounts evaluated conventionally, which was statistically significant. DIA has been shown to be an important method to remove operator bias and provide consistent results. Evaluation of only two dimensions of three-dimensional objects still represents a certain limitation of this technique. With lowering of computer prices the system could become easily available for islet laboratories.
Abstract: AIMS/HYPOTHESIS: The aim of this study was to examine the prevalence and nature of mutations in HNF4alpha/MODY1, GCK/MODY2 and HNF-1alpha/MODY3 genes in Czech subjects with clinical diagnosis of MODY. METHODS: We studied 61 unrelated index probands of Czech origin (28 males, 33 females) with a clinical diagnosis of MODY and 202 family members. The mean age of probands was 22.7+/-12.0 years (range, 6-62) and the mean age at the first recognition of hyperglycaemia was 14.7+/-6.0 years (range, 1-25). The promotor and coding regions inclusive intron exon boundaries of the HNF-4alpha, GCK and HNF-1alpha genes were examined by PCR-dHPLC (HNF-1alpha and GCK) and direct sequencing. RESULTS: We identified 20 different mutations in the HNF-4alpha, GCK and HNF-1alpha in 29 families (48% of all families studied), giving a relative prevalence of 5% of MODY1, 31% of MODY2 and 11.5% of MODY3 among the Czech kindred with MODY. Three of 3, 10 of 11 and 1 of 6 of the mutations identified in HNF-4alpha, GCK and HNF-1alpha respectively, were new. CONCLUSION/INTERPRETATION: Of the families 48% carried mutations in the MODY1-3 genes and of the identified mutations 70% were new. In 52% of Czech families with clinical characteristics of MODY, no mutations were found in the analysed genes. This finding shows that the majority of MODY mutations in a central European population are local and that other MODY genes could be responsible for autosomal dominant transmission of diabetes mellitus.
Abstract: Multiple genetic factors are involved in the pathogenesis of type 1 and 2 diabetes mellitus. A defect, which could be ascribed to a single or only few genes, has not been established yet. An exception represents the Maturity Onset Diabetes of the Young (MODY) which is rather rare and is caused by mutations in some of 6 known genes. Principles of gene therapy focus mainly on generation of replenishable sources of insulin producing tissue. Which could be used for replacement of the destroyed or failing beta-cells. Current approaches include stimulation of embryonic or adult stem cell proliferation and differentiation into beta-cells, beta-cell proliferation, transdifferentiation of non-islet cells into glucose-sensitive insulin-producing cells and xenotransplantation. Genetic modification is being studied to prevent islet rejection (e.g. local expression of immuno-suppressive cytokines or ligands inducing T-cell apoptosis, knock-out of specific animal genes or transfer of human genes into animal tissue donors) or to construct "superislets" resistant to apoptosis or oxidative stress. For prevention of type 1 diabetes and perhaps for induction of specific immune tolerance vaccination with DNA fragments encoding for specific auto or alloantigens represents a promising approach. In addition, gene therapy offers some hope for the future treatment of diabetic vascular complication, neuropathy and syndromes of insulin resistance.
Abstract: BACKGROUND: Because they generally are older and frequently have co-morbidities, patients with type 2 diabetes mellitus and end-stage renal disease seldom are selected for renal transplantation. Thus, information on transplantation results from controlled studies in this high-risk category of patients is scarce. We have compared the results of kidney transplantations in type 2 diabetic patients with carefully matched non-diabetic subjects. METHODS: All first cadaveric renal transplants performed in type 2 diabetic patients from January 1, 1988 to December 31, 1998 in our centre were included. Non-diabetic controls were individually matched with diabetic patients with respect to year of transplantation, sex, age, selected immunological parameters, and graft cold ischaemia. RESULTS: We included 64 type 2 diabetic and 64 non-diabetic patients who were followed for a mean period of 37+/-27 and 41+/-31 months, respectively, after renal transplantation. Patient survival at 1 and 5 years post-transplant was 85 and 69 vs 84 and 74% (P=0.43, NS), while graft survival rates censored for patient death were 84 and 77 vs 82 and 77% for diabetic and non-diabetic subjects, respectively (P=0.52, NS). With graft survival results not censored for death with functioning graft, no significant change was seen (diabetic vs non-diabetic group: 77 and 54 vs 73 and 61%, P=0.19, NS). Age, but not the presence of diabetes, was the only factor significantly affecting patient survival when both patient groups were pooled. With regard to post-transplant complications requiring hospitalization, there was a significant difference only in the number of patients who had amputations (diabetic vs non-diabetic group: 8 vs 0, P=0.01). CONCLUSIONS: Patient and graft survival after kidney transplantation was similar in type 2 diabetic and matched non-diabetic subjects, with more amputations occurring in the diabetic group. Thus, at a single-centre level renal transplantation results almost equivalent to those in non-diabetic patients may be achieved in type 2 diabetes mellitus.
Abstract: Hyperglycemia is an important factor in the development and progression of the complications of diabetes. Pancreas transplantation is currently the only method able to achieve sustained normoglycemia in type I diabetes. By now, this procedure has become an accepted treatment option combined with kidney transplantation for selected patients with end-stage diabetic nephropathy. The definite benefits of pancreas transplantation comprise relieve from insulin administration, superb glycemic control, improved quality of life and long-term survival of patient with severe autonomic neuropathy. Presumed benefits represent stabilization or slowing of progression of microvascular complications. Definite disadvantages are the risk of the surgical procedure, graft rejection and the necessity of permanent immunosuppression. Isolated pancreas transplantation in nonuremic type-1 diabetic patients is still controversial. Diabetic complications of the potential recipient have to be potentially correctable by the transplantation and their significance must exceed all risks of the operation and life-long immunosuppression. Currently, approx. 25 combined transplants are performed per year in IKEM with the results comparable to those reported by the International Pancreas Transplant Registry. Seven nonuremic type-1 diabetic recipients of 8 operated in IKEM by June 2000 have been insulin-independent for 1-33 months. The main indication for isolated pancreas transplantation is brittle diabetes with hypoglycemia unawareness syndrome and labile diabetes with severe autonomic neuropathy and rapid progression of microangiopathy despite appropriate intensified insulin therapy.
Abstract: The authors present the results of 100 pancreatico-duodenal grafts placed extraperitoneally with the bladder drainage. The onset of pancreatic graft function was immediate in all cases and the patients became insulin free. Despite the extraperitoneal graft placement the incidence of surgical complications was low. The only exception was slightly impaired wound healing. The Authors claim that this surgical technique allows the elimination of intraperitoneal infection and easy performance of the graft biopsy.
Abstract: Differences between the immunocytochemical behaviour of antisera to partially purified porcine gastrins and antisera to either synthetic human gastrin-17-I or highly purified porcine gastrin-17-I raised the hypothesis that hog antral gastrin extracts contain peptides different from somatostatin and gastrin that are responsible for the immunocytochemical reaction of the former antisera in the D (delta) cells of the gastro-entero-pancreatic (GEP) endocrine system. This study was performed to prove this hypothesis. A discard fraction obtained after gel filtration of hog antral gastrin extracts on Sephadex G-50 Superfine was employed to immunize five rabbits. The discard fraction is highly heterogeneous on two-dimensional electrophoresis and contains merely traces of somatostatin and gastrin in RIA. However, rabbit antisera to the discard fraction give strongly positive immunocytochemical reactions exclusively in the D cells of the human antroduodenal mucosa and of the pancreatic islets. Absorption of the antisera with the lyophilized discard fraction abolishes the staining of the D cells, whereas absorption of the antisera with several somatostatins does not affect the staining. Vice versa, staining of the D cells with antisera to cyclic somatostatin-14 is abolished by absorption of the antisera with somatostatin-14 but not by absorption with excess of the discard fraction. In RIA, antisera to the discard fraction do not bind radiolabelled (Tyr(1))-somatostatin-14, Tyr-somatostatin-28 or synthetic human gastrin-17-I. Two-dimensional electrophoresis of acid extracts of isolated canine pancreatic islets followed by Western blotting shows different patterns of distribution of immunoreactive spots obtained with antisera to the discard fraction, to somatostatin-14, and to human proinsulin respectively. These results indicate the existence of a novel population of peptides of the D cells of the GEP endocrine system, for which we propose the term deltins.
Abstract: OBJECTIVE: Specific immune tolerance achieved by induction of lymphocyte chimerism could reduce the need for immunosuppressive therapy in pancreatic islet transplantation. The aim of the experiment was to assess the effect of pre-treatment with donor specific bone marrow on the function of allogeneic islets under the conditions of a short-term immunosuppression. METHODS: Male Lewis-Brown Norway and female Brown Norway rats were used as donors and recipients, respectively. In all recipients diabetes was induced by streptozotocin. In Group 1, 5 animals were treated only by islet transplantation. In Group 2, 7 rats underwent islet transplantation after previous 45-day therapy with tacrolimus 1 mg/kg and hydrocortisone 2 mg/kg, which was stopped 6 days after islet transplantation. Recipients in Group 3 (n = 16) were treated as Group 2 (n = 7) and, in addition, underwent transplantation of 10(8) bone marrow cells 10 days after initiation of immunosuppressive therapy. RESULTS: In Group 1, islets were rejected after a median survival time of 11 days. In Groups 2 and 3, islet function has been demonstrated for more than 70 days in all animals. CONCLUSIONS: Short-term immunosuppressive therapy prevented islet rejection for at least 70 days. Longer follow-up period is needed to show whether peripheral microchimerism induced by bone marrow transplantation will further improve islet survival in non-immunosuppressed recipients.
Abstract: In pancreas recipients with advanced diabetic eye disease, conflicting ophthalmologic results over different follow-up periods have been reported. In the present prospective study we performed ophthalmologic evaluation groups of type I diabetic patients: 1) normoglycemic recipients of pancreas and kidney grafts (group SPK, n = 43, follow-up 44.9 +/- 35.1 months), 2) pancreas and kidney graft recipients with nonfunctioning pancreatic graft, and recipients of isolated kidney graft (group K, n = 45, follow-up 60.3 +/- 34.2 months). The examinations were performed before transplantation, at the end of follow-up (at least 1 year), and in 63 recipients also at 3 years posttransplant. Visual acuity results at baseline and at the end of follow-up were 0.48 +/- 0.39 vs. 0.50 +/- 0.39 in the SPK group, and 0.46 +/- 0.38 vs. 0.40 +/- 0.39 in the K group. While intragroup changes were not significant, the changes were significantly different between the groups (p < 0.05). Fundoscopic findings at the end of follow-up were improved, stabilized, or deteriorated in the SPK group in 21.3%, 61.7%, and 17.0%, respectively. The respective figures for the K group were 6.1%, 48.8%, and 45.1% (p < 0.001). Similar results were obtained when evaluating findings at 3 years posttransplant. Before transplantation, 78% of the SPK group and 81% of the K group had been treated by laser. The need for additional posttransplant laser therapy was significantly lower in the SPK (31%) than in the K group (58%; p < 0.001). In conclusion, pancreas transplant exerts a beneficial effect on the course of diabetic retinopathy even in its late stage.
Abstract: Cryopreservation is the only available technique for long-term storage of pancreatic islets. The freezing/thawing protocol may cause considerable loss of viable islet tissue and impair its function in vivo. The aim of this study was to investigate glucose and insulin levels after transplantation of fresh and cryo/thawed rat islets. Rat pancreatic islets were isolated following intraductal collagenase injection and Ficoll gradient purification. After isolation, islets were cultured for 24 h and then either transplanted or frozen after stepwise addition of DMSO according to Rajotte et al. and stored in liquid nitrogen. After rapid thawing islets were stepwise transferred into RPMI medium and cultured for another 24 h. The recipients were athymic mice with streptozotocine-induced diabetes. Two hundred fresh (n=13) or cryo/thawed (n=15) islets were transplanted beneath the renal capsule. Glucose levels were measured for 14 days and blood samples for insulin determination were obtained 15 min after i.p. glucagon (10 mg/kg) administration on day 14. Glucose levels were normalized (<9 mmol/l) in all recipients within 3 days since transplantation. On day 14, mean fasting values+/-SE in fresh and cryo/thawed islet groups were 4.0+/-0.6 and 4.4+/-0.4 mmol/l, respectively (P>0.05). Fasting insulin levels were higher in the cryo/thaw than in the fresh islet group (1.67+/-0.33 vs 0.57+/-0.13 ng/ml; P<0.01). Post-glucagon levels did not differ significantly (1.45+/-0.24 vs 0.86+/-0.24 ng/ml; P=0.06). While glucagon significantly increased insulin levels (P<0.01) in the fresh islet group, no change in insulin levels was observed (P>0.05) in the cryo/thaw group. Immunohistochemical staining demonstrated fragmentation of viable islet tissue which was more apparent in the cryo/thaw group. We conclude that in a short-term study cryo/thawed rat islets produce higher insulin levels than fresh islets transplanted into nude mice. This may be due to better islet survival or loss of feed-back regulation.
Abstract: The treatment of diabetic retinopathy (DR) is one of the most challenging problems in ophthalmology. The possibility of modulating DR by successful combined kidney and pancreas transplantation thus holds an attractive promise for the ophthalmologist. From June 1983 until April 1997, a total of 86 combined kidney and pancreas transplantation procedures were performed at the Prague-based Institute for Clinical and Experimental Medicine. All recipients are on close follow-up in terms of their ophthalmic status. However, evaluation of the effect of transplantation is problematic because of the advanced status of DR prior to the procedure. We divided the transplant recipients into two groups according to type of transplantation. In Group I (segmental transplantation), proliferative DR was present in 100% eyes, 70% had undergone vitrectomy, and there were 21% of blind eyes. All eyes had been treated by laser. In this group, long-term stabilization of the finding was observed in three patients. In Group II (whole pancreas transplantation), proliferative and non-proliferative DR was diagnosed in 86% and 14%, respectively. There were 12% of blind eyes, and 70% had been treated by laser prior to transplantation. After a successful transplantation, stabilization was found in 60%, improvement in 18%, and deterioration in 22% of eyes in this group. The stabilization and improvement can be explained by subsequent normoglycemia (HbAlc 5.6%). By contrast, we were unable to provide a satisfactory explanation for the deterioration and progression of these findings. While the effect of immunosuppression on DR remains unclear, it obviously accelerates the existing cataract. CONCLUSION: Successful combined transplantation has a beneficial effect on DR and is worthwhile even for patients at the end stage on account of its beneficial psychosocial effect and prevention of dolorous glaucoma. However, many effects of the procedure on the eye of diabetics remain to be identified in future studies.
Abstract: The most frequently used surgical technique in transplantations of the pancreas is to connect the duodenum of the graft with the urinary bladder of the recipient. Introduction of this method led during the last five years to marked improvement of results. On the other hand duodenocystoanastomosis is a frequent cause of metabolic and urological complications in patients after transplantation. The authors present the case-record of a female patient after combined transplantation of the pancreas and kidney where surgical conversion of the drainage of pancreatic juice from the urinary bladder to the gut was necessary.
Abstract: BACKGROUND: By transplantation of the pancreas in diabetics type 1 long-term-term independence on exogenous insulin can be achieved. The extent of normalization of the carbohydrate metabolism can depend on the applied surgical technique. The objective of the submitted work was to compare indicators of compensation of diabetes one year after combined transplantation of the kidney and pancreas, using the method of transplantation of a segment of the pancreas with obliteration of the pancreatic duct by a polymer and the method of transplantation of the whole pancreas with drainage of the pancreatic duct into the urinary bladder. METHODS AND RESULTS: The authors examined two groups of recipients, 13 subjects each with full function of the pancreatic graft one year after transplantation where a combined transplantation of the kidney and pancreatic segment (group SP) had been performed or of the kidney and whole pancreas (group CP). The authors investigated the blood sugar level, glycated haemoglobin, intravenous glucose tolerance test, free insulin level and C-peptide as well as some indicators of the lipid metabolism and acid base balance. In both groups normal blood sugar levels were achieved, though the mean values in the course of the day were higher in group SP than in group CP (mean +/- SE 5.48 +/- 0.11 as compared with 4.98 +/- 0.09; p < 0.01). Glycated haemoglobin declined in group SP from the pretransplantation value of 9.31 +/- 0.09 to 6.40 +/- 0.10% and in group CP from 9.49 +/- 0.15 to 4.92 +/- 0.08%. In group CP the glycated haemoglobin after transplantation was significantly lower (p < 0.01), similarly as the coefficient of glucose assimilation (1.83 +/- 0.03 as compared with 1.25 +/- 0.15; p < 0.05). Indicators of the acid base balance did not differ. Recipients in group CP were however permanently treated with bicarbonate. CONCLUSIONS: With both transplantation method it is possible to achieve compensation of diabetes close to normal. The carbohydrate tolerance is however better after transplantation of the whole pancreas.
Abstract: The number of combined transplantations of the pancreas and kidney in type I diabetics with chronic renal failure is increasing every year. The authors present their experience with a new technique of duodenocystostomy during this transplantation. The use of a circular stapler to create the duodenocystoanastomosis can hasten the surgical procedure and reduce at the same time the risk of development of a pancreatic fistula.
Abstract: BACKGROUND: Transplantation of isolated islets of Langerhans is a perspective method of treating type 1 diabetes. The first prerequisite for its implementation is to obtain sufficient amounts of vital islets. The objective to the authors' experiments was to introduce a method of massive isolation of islets of Langerhans from dogs which would serve as a model pro obtaining islets of Langerhans from humans and would permit to use them in future in clinical practice. METHODS AND RESULTS: After excision of the dog pancreas the authors injected into the ducts a 1% collagenase solution and the tissue was deposited in a specially developed semi-automatic isolation system which consisted of a vibrating isolation chamber in which an isolation solution with controlled temperature circulated. As soon as the islets started to be released, the system was cooled and the disintegrated tissue was collected. The islets were separated from the acinar mass by centrifuging in a ficoll mass gradient. The islet function was tested by transplantation to athymic diabetic mice. A total of 15 isolations of dog islets was performed, incl. 5 which were evaluated quantitatively. In a similar way twice isolation from a human cadaverous pancreas was implemented. On average 6336 +/- 745 (+/-SD) purified dog islets were obtained. Their function was tested by normalization of the blood sugar after transplantation to diabetic mice. The authors obtained also vital highly purified human islets. CONCLUSIONS: The authors developed a method of isolation of dog and human islets of Langerhans which makes it possible to obtain sufficient amounts of vital islet tissue which could be used for transplantation. A further task will be to standardize the process and adjust it to hygienic norms essential for clinical use.
Abstract: The authors present the case-record of a patient after combined transplantation of the pancreas and kidney who developed a chronic duodenocutaneous fistula. The case was resolved by elimination of the duodenocystoanastomosis of the transplanted pancreas and by obliteration of the pancreatic duct of the graft by a polymer. One year after surgery the patient has no complaints and the function of both transplanted organs is satisfactory.
Abstract: BACKGROUND: Successful transplantation of the pancreas is at present the only way how to ensure on a long-term basis an almost physiological regulation of the carbohydrate metabolism in type 1 diabetics. So far it is, however, indicated mainly in patients with already advanced microangiopathy where at the same time also renal transplantation is planned and long-term experience is so far limited. The objective of the submitted paper is to report on the development of metabolic compensation and its impact on the development of microangiopathic changes in type 1 diabetics where the complete function of both grafts persisted more han five years. METHODS AND RESULTS: From a group of 34 combined transplantations of a pancreatic segment with an obliterated duct and a kidney, implemented in 1983-1988 in the Institute of Clinical and Experimental Medicine, a group of nine type 1 diabetics was followed up where the independence on exogenous insulin and haemodialyzation treatment persisted for or still persists for 5-8 years. After annual intervals the blood sugar level was examined, the intravenous glucose to tolerance test, free insulin levels, glycosylated haemoglobin, an ophthalmological and neurological examination was made, incl. the peripheral and autonomous system, and by means of a standard questionnaire the quality of life before and after transplantation was assessed. In all examined subjects normal blood sugar levels were recorded. The fasting insulin levels in transplant recipients were higher than in healthy subjects (22 vs. 10.2 microU/ml, p < 0.01) while in the course of the blood sugar curve corresponding levels were recorded. Glycosylated haemoglobin remained after 5 years quite or almost normal (4.2-7.2%). The coefficient of glucose assimilation after 5 years varied in the range from 0.7 to 1.9% min. Hypoglycaemic states were not recorded. In none of the recipients in the course of the investigation deterioration of the ophthalmological finding was observed and in three patients improvement was recorded. Symptoms of somatic polyneuropathy improved in all patients but signs of vegetative neuropathy remained unchanged. In all recipients psychic, physical and social rehabilitation as well as the general quality of life improved markedly. CONCLUSIONS: Although the group of investigated patients is so far small, the authors provided evidence that combined transplantation of the pancreas and kidney can influence in a very favourable way the quality of life and development of microangiopathic complications. As the success rate of transplantations of the pancreas in increasing and the risk of surgical complications is declining due to improving surgical techniques, the authors conclude that combined transplantation of the pancreas and kidney is at present the optimal therapeutic procedure in type 1 diabetics with chronic renal insufficiency and that indication for transplantation of the pancreas could be moved to earlier stages of diabetes when it would be possible to influence the development of diabetic microangiopathy more favourably.
Abstract: Glucose tolerance, insulin secretion and in vitro insulin action were examined in streptozotocin-induced diabetic rats following pancreatic islet allotransplantation treated with combination of oral cyclosporine A (10 mg/kg) and hydrocortisone (1.5 mg/kg) intramuscularly. 1400 pure islets from multiple donors were implanted either into the portal vein (n = 10) or under the renal capsule (n = 11). Ten sham-operated non-diabetic animals receiving the same immunosuppressive therapy, 8 healthy animals without any treatment and 10 diabetic animals without immunosuppression following islet transplantation were used as controls. In all transplanted animals blood glucose was normalized by day 3 after transplantation with lower levels in those transplanted intraportally (p < 0.05). Non-immunosuppressed animals rejected the graft after 6.5 +/- 1.2 days after transplantation, immunosuppressed animals in both groups remained normoglycaemic till the end of the experiment on day 28. Oral glucose tolerance tests and insulin levels on days 10 and 28 improved dramatically. No differences in glucose and insulin levels between intraportal and subcapsular groups were found. Post-load glucose levels in immunosuppressed non-transplanted animals were higher on day 28 than before treatment and were also higher than in the healthy non-treated group (p < 0.05). In vitro insulin action determined by the incorporation of labelled glucose into adipose tissue was impaired only in animals in which islets were transplanted into the liver (p < 0.05 vs other groups). In conclusion, therapy with cyclosporine A and hydrocortisone prevents allogeneic islet rejection in rats during a short-term experiment. Although glucose tolerance is not completely normalized following transplantation, slight impairment is also demonstrable in healthy animals on the same drug therapy.
Abstract: BACKGROUND: One of the substances used in recent years to suppress immune reactions after organ and tissue transplantations is mouse IgG2a globulin which acts selectively on CD3 lymphocytes; it is known under the name of Orthoclone (Ortho Co.) An analogous preparation was developed in the Institute of Molecular Genetics, Academy of Sciences, Czech Republic, although the idiotype is different. The authors submit a report on the experience with treatment of rejection of transplanted kidneys. METHODS RESULTS: Monoclonal mouse globulin IgG2a (Cedetrin) was administered to 20 patients after renal transplantation on account of a rejection episode or progressing rejection; the mean interval after transplantation was 16.1 (range 0.25-96) months; the rejection episode or progressing rejection responded little in the majority of patients to 6-alpha-methyl prednisolone (Urbason, Hoechst, Solu-Medrol, Upjohn). For prophylactic immunosuppression the following combinations were used: cyclosporin + azathioprine + prednisone (17x) or azathioprine + prednisone (3x). Cedetrin was administered by the i.v. route in two to 11 doses a 3 mg substance. Of 20 patients in 6 Cedetrin administration had to be discontinued (allergy, infection, leucopenia, hyperhydration). In 14 the tolerance was satisfactory, the type and frequency of side-effects was similar as after Orthoclone; the antibody formation was less frequent. The specificity of Cedetrin as regards its action on T lymphocytes was confirmed. The effect was good to very good in 6 of 8 patients where the rejection filtrate was histologically active. In 9 patients treated during the first year after renal transplantation the cumulative survival of the graft at the end of the 12th, 24th and 36th month following transplantation was 89%, 67% and 56% resp. Because the therapeutic effect depended on histologically proved rejection activity, the authors consider biopsy of the graft before Cedetrin treatment essential. CONCLUSIONS: The therapeutic administration of monoclonal mouse globulin IgG2a A1CD3 (Cedetrin), developed in the Institute of Molecular Genetics, Academy of Sciences, Czech Republic, produced by Exbio Co., CR) has a favourable effect on rejection episodes or progressing rejection of transplanted kidneys. Treatment is indicated in confirmed histologically active rejection.
Abstract: BACKGROUND: Glucose tolerance depends essentially on insulin secretion and its action in target tissues. Diabetes mellitus type II (insulin-nondependent diabetes) is a disease conditioned by a dysbalance between insulin secretion and effect; it has not been decided whether the cause is insulin resistance or impaired insulin secretion, although a defect of insulin secretion for the manifestation of the disease is generally accepted. The purpose of the submitted study was to assess to what extent insulin secretion and its effect after an oral glucose load and a hyperglycaemic clamp is affected in different groups of non-obese patients with diabetes type II. METHODS AND RESULTS: The authors examined 21 men with diabetes type II (age 41 +/- 2.6 years, BMI 26.2 +/- 3.2, HbA1,c 9.4 +/- 2.9%) in the course of one year after detection of the disease, treated by diet alone. The second group was formed by 20 patients with diabetes type II (age 46.1 +/- 3.6 years, BMI 26.0 +/- 2.1, HbA1,c 6.94 +/- 1.6%) who suffered from diabetes for 5-10 years and who were treated by diet alone. The third group was formed by 32 diabetics type II (age 51.8 +/- 6.1 years, BMI 26.7 +/- 2.2, HbA1,c 8.7 1.2% +/-) who suffered from diabetes for 5-10 years and were treated with oral antidiabetics. The control group was formed by 42 healthy men matched for body weight and age (age 39.9 years, BMI 25.3, blood sugar level 4.8 mmol/l). Although the diabetic groups did not differ in the fasting blood sugar level (8.0-8.29-8.2 mmol/l), the glycosylated haemoglobin HbA1,c level is lowest in the group of diabetics treated by diet alone, similarly as the rise of the blood sugar level 120 mins, following oral administration of 75 g of glucose (10.3 mmol/l, as compared with 16.2 mmol/l and 15.5 mmol/l in the other groups). The authors found in all groups of diabetic patients, as compared with controls, a comparable drop of the insulin effect evaluated as the metabolic glucose clearance during an hyperinsulinaemic euglycaemic (5 mmol/l) or isoglycaemic (fasting blood sugar level) clamp, the insulin level being 75 microU/ml (controls 10.9 +/- 3.3 ml/kg.min., first group 5.35 +/- 2.7 ml/kg.min., second group 5.47 +/- 2.35 ml/kg.min., third group 5.38 +/- 2.1 ml/kg.min. The differences, as compared with controls, were significant in all groups, p < 0.01). At an insulin level of 1500 microU/ml the results are similar (controls 17.4 +/- 3.8 ml/kg.min., as compared with 13.3 +/- 3.3 in the first group, 13.3 +/- 3.0 in the second group and 12.5 +/- 3.0 ml/kg.min. in the third group: statistical significance in all three groups, as compared with controls, is p < 0.05). The authors did not reveal any differences in the specific insulin bond to insulin receptors of erythrocytes. The total glucose consumption during an isoglycaemic clamp in diabetics and a euglycaemic clamp in controls did not differ. In all diabetic groups, as compared with controls, higher C peptide values and insulin values (IRI) were found on fasting and a slower rise and longer persistence of higher levels after oral glucose administration, although an inadequate secretory response during the hyperglycaemic clamp in diabetics is apparent. Hyperinsulinism was significantly higher in the second group. The number of insulin receptors on erythrocytes, the affinity for insulin, regardless whether the receptors were free or occupied, did not differ significantly between groups. CONCLUSIONS: All investigated groups of type II diabetics had a comparable degree of insulin resistance which did not depend on the duration of diabetes, its compensation or the type of treatment. Although impaired insulin action was proved, the total glucose utilization in relation to hyperglycaemia is not reduced. The differences in the degree of glucose intolerance in the investigated groups of diabetics type II depend on the degree of impairment of insulin secretion.
Abstract: Insulin action and insulin specific binding to erythrocytes were examined in ten recipients of a pancreatic segment and renal graft (Group 1), in nine non-diabetic kidney recipients (Group 2) and in ten age- and weight-matched healthy control subjects (Group 3). All transplant recipients were normoglycaemic without need of insulin, received the same immunosuppression and had good renal graft function at 11-18 months post-transplantation, when the investigation was performed. Using the insulin clamp technique, insulin action was expressed as the metabolic clearance rate of glucose at insulin infusion rates of 1.0 (MCRsubmax) and 10.0 (MCRmax) mU.kg-1.min-1. In comparison with the healthy control subjects, fasting free insulin and C-peptide levels were significantly higher in Groups 1 and 2, but no differences between Groups 1 and 2 were found (p greater than 0.05). Mean values +/- SEM of MCRsubmax in Groups 1, 2 and 3 were 6.30 +/- 0.55, 6.09 +/- 0.69 and 10.52 +/- 1.10 ml.kg-1.min-1 respectively, and of MCRmax 12.65 +/- 0.78, 13.14 +/- 0.92 and 19.28 +/- 1.42 ml.kg-1.min-1 respectively. Insulin action was significantly decreased in Groups 1 and 2 at the low as well as the high insulin infusion rates but there was no difference between the two groups of recipients (p greater than 0.05). No differences in binding data (specific binding, number of binding sites per cell) were found. It is concluded that insulin resistance is common to all immunosuppressed organ recipient and is not related to the pancreas graft. The decrease maximal response to insulin and normal insulin binding to erythrocytes tend to suggest a post-receptor defect in insulin action.
Abstract: In the decade 1979-1988, 658 biopsies were collected from 568 cadaveric renal allografts. In 118 grafts a non-proliferative insudative vasculopathy (IVA) was found in afferent vessels. Immunosuppression was based on azathioprine (AZA) or on cyclosporin A (CsA), from 1983. The prevalence and extent of IVA has increased significantly since 1984. Light microscopy showed fibrinoid and hyaline masses of varying extent; transmural insudative "knobs", intimal oedema with metachromasia, and microthrombosis were also seen with CsA. The ultrastructure of the insudates was unremarkable but CsA grafts displayed early oedema and hypergranulation of endothelial cells with a disarray of smooth muscle cell (SMC) microfibrils, and pronounced degenerative changes of SMC. Rebiopsy showed stationary IVA in AZA grafts and progression in one-half of CsA-treated patients. Nephrectomy specimens revealed, however, a marked predominance of late rejection endarteritis; in only 3 cases was IVA and/or microthrombosis the possible cause of nephrectomy. The mean donor age was higher in severe IVA in CsA grafts and the mean post-transplantation interval at the time of diagnosis of IVA was significantly shorter in CsA-treated patients. No important differences in cumulative graft survival were seen between grafts with absent, moderate or severe IVA. Unused cadaveric donors' kidneys of comparable age exhibited normal arterioles or a slight focal insudative or hyaline lesion.
Abstract: Sixteen type I diabetics were followed up from the neurological aspect and by electromyography for 6 to 42 months following successful combined transplantation of the pancreas and kidney. Before transplantation all patients suffered from medium severe to severe peripheral polyneuropathy, grade 3-5 according to the commonly used quantitative classification. All patients reported after transplantation subjective improvement, e.g. of the muscular strength or steadiness of gait. In six patients the clinical and in eight patients the electromyographic finding improved by one grade, in four patients at least the conductivity in the nerves of the upper extremities improved. In four patients the neurological and electromyographic finding did not change; none of the patients after successful transplantation deteriorated. The authors discuss the favourable effect not only of elimination of the uraemic syndrome, but also the effect of the improved carbohydrate metabolism on regenerating processes in the peripheral nervous system.
Abstract: The authors compared the survival of four groups of patients and of renal grafts: 1. diabetics after renal transplantation (24 subjects), 2. diabetics after transplantation of the kidney and pancreas (35 subjects), 3. diabetics where transplantation was indicated but who were treated only by dialysis and 4. non-diabetics after transplantation of the kidney (170 subjects). The two-year cumulative survival of the entire group of diabetics regardless of the type of treatment was 59%. The two-year survival of diabetics after transplantation of the kidney alone was 95%, after transplantation of the kidney and pancreas 70% and in non-diabetics after transplantation of the kidney 90%. In diabetics treated by dialysis it was 33%. The two-year survival of the function of renal grafts in the entire group of diabetics treated by transplantation of the kidney was 61%, in non-diabetics 68% and the three-year survival was in both groups 61%. As compared with the EDTA register, the results of transplantation treatment are favourable, the results of dialyzation treatment are poor. From the results the authors draw conclusions for indication of different ways of replacement of renal function in diabetics in relation to the general health status of the patients.
Abstract: Diabetic nephropathy affects half the type 1 diabetics and is the most frequent cause of death there. While in some countries diabetics account for 25-30% of all patients newly admitted in dialysis and transplantation programmes, in Czechoslovakia the number of diabetics treated by dialysis or transplantation is small. From August 1985 to June 1988, 15 isolated kidney transplant operations were performed on 13 diabetics with serious late complications of diabetes. By the time of writing, all recipients had been surviving (for 1 up to 35 months), and only two were receiving artificial kidney treatment. Progressive vascular complications were in two cases the cause of gangrene of the lower extremity, one patient had a central cerebrovascular attack. Despite this, successful transplantation resulted in a marked improvement of the patients' general condition and quality of life. Due to intensified insulin therapy, diabetes, too, was satisfactorily compensated in the majority of the recipients. As experience so far indicates, if the patient is prepared in good time, which includes diabetological, nephrological and ophthalmological treatment, the results of transplantation in diabetics can be comparable to those achieved in non-diabetic patients. Renal transplantation in diabetics should be developed in all transplantation centres in Czechoslovakia, and uraemic diabetics should not be eliminated from the dialysis-transplantation programme except in cases of serious contraindication.
Abstract: Pharmacokinetics of cefoperazone was studied in 10 healthy volunteers and in 11 patients with liver cirrhosis. In the same persons, we also examined the clearance of ujoviridin--a preparation of indocyanine green. Within 12 h, 31.8 (+/- 7.6)% of the 2 g dose of cefoperazone was eliminated in the urine of healthy persons and 74.3 (+/- 7.9)% (mean +/- SD) was eliminated in the urine of cirrhotics. The biological half-life (beta-phase) of cefoperazone in healthy volunteers and in cirrhotics was 1.77 (+/- 0.25) and 4.29 (+/- 1.16) h, total clearance 1.009 (+/- 0.187) and 0.583 (+/- 0.169) ml/s and hepatic clearance 0.694 (+/- 0.174) and 0.152 (+/- 0.079) ml/s, respectively. The differences are statistically significant (p less than 0.001). We also found good correlation between total clearance of cefoperazone and clearance of ujoviridin (r = 0.842) and even better between hepatic clearance of cefoperazone and ujoviridin clearance (r = 0.957), both statistically significant. The findings suggest that the dosage of cefoperazone should be reduced in patients with liver cirrhosis and that the ujoviridin clearance test is a good indicator of impaired cefoperazone elimination.
Abstract: Continuous subcutaneous insulin infusion (CSII) was combined with antirejection therapy in four diabetic recipients of pancreas and kidney grafts with persisting hyperglycemia due to pancreas rejection. In three of the patients, full function of the pancreas was restored after as many as 40, 86, and 139 days of CSII. In another patient, the dose of insulin was halved, and his graft function was classified as partial. Pancreas rejection treated without CSII was reversible only in one of four other recipients. We conclude that restoration of the function of a pancreas graft damaged by rejection can be achieved even after a long period with the help of CSII therapy.
Abstract: Results of pars plana vitrectomy (PPV) were compared in two groups of patients. The first group was formed from 105 eyes of 87 diabetics without clinical signs of the diabetic nephropathy or nephropathy without decrease of renal functions. The other group was formed from 64 eyes of 50 diabetics suffering from diabetic nephropathy in the stage of the renal insufficiency. In the first group PPV was successful during the mean observatory period of 26 months, in 59 from 105 eyes (56%) and the mean visual acuity was 0.12. In the second group PPV was successful, during the mean observatory period of 18 months, in 34 from 64 eyes (53%) and the mean visual acuity was 0.09. Number of the successfully treated PPV was steadily decreasing according to the prolonged period of the further observations, in both mentioned groups: from 85 (81%) after 3 months on 62 (41%) after the interval of 3 years. The mean visual acuity in both followed groups was, with respect to the length of observation, moderately increased. Diabetic nephropathy in the stage of the renal insufficiency was without negative effect on the prognosis of PPV in complicated diabetic retinopathy. The more advanced organ complications of diabetes were not evaluated as contraindications of PPV and the operation may significantly improve the quality of the life of an otherwise heavily ill diabetic patient.
Abstract: Diabetic nephropathy affects half the type I diabetics and is their most frequent cause of death. While in some countries diabetics account for 25-30% of all newly admitted patients in dialyzation-transplantation programmes, in the CSSR the number of diabetic patients treated by dialyzation or transplantation is small. From August 1985 to June 1988 in the Institute of Clinical and Experimental Medicine a total of 15 isolated transplantations of the kidneys were made in 13 diabetics with serious late complications of diabetes. At present all recipients survive (1-35 months) and only two are treated by an artificial kidney. Progressing vascular complications were in two instances the cause of gangrene of the lower extremity, one recipient had a central cerebrovascular attack. Despite this, successful transplantation caused a marked improvement of the general condition and quality of life. The compensation of diabetes was also, due to intensified insulin therapy, satisfactory in the majority of recipients. Hitherto assembled experience indicates that when the patient is prepared in time, which includes diabetological, nephrological and opthalmological treatment, the results of transplantation treatment in diabetic patients can be comparable with results in should be developed in all transplantation centres in the CSSR and uraemic diabetics should be eliminated from the dialyzation transplantation programme only in case of fundamental contraindications.
Abstract: Having reviewed the state-of-the art trends in pancreas transplantation over the world, the authors describe their own experimental studies preceding elaboration of the technique of pancreatic segment transplantation with duct obliteration. In their technique, the splenic artery is interposed in the course of the iliac arteries of the recipient. The procedure of the selection of diabetic patients suitable for a combined pancreas and kidney transplantation is presented. The results in 13 recipients with insulin-dependent diabetes and progressed organ complications are evaluated. In these patients a combined pancreas and kidney transplantation is of a better prognosis compared with the conventional treatment methods.
Abstract: Pharmacokinetics of cefoperazone was studied in 10 healthy volunteers following 15 min intravenous infusion of 2 g. Cefoperazone levels in the blood serum and in the urine were determined microbiologically. At the end of the infusion, mean serum concentrations of the antibiotic were 340.4 (+/- 81.5) mg/l, at the 4th hour after the infusion 38.4 (+/- 10.3) mg/l, and 12 hours after the infusion all subjects had detectable concentrations with the mean value 2.2 (+/- 0.7) mg/l. Within 12 hours, 33.3 (+/- 6.1) % of the total dose of cefoperazone had been eliminated in the urine. The fitting of the individual serum concentration curves and the determination of pharmacokinetic constants were done according to a two-compartment model with the aid of nonlinear least-squares regression analysis on a programmable calculator TI 59. The mean value of the biological half-life (beta phase) of cefoperazone was 1.77 (+/- 0.25) h, mean serum clearance was 61.7 (+/- 12.1) ml/min and the mean distribution volume (Vd area) was 9.44 (+/- 2.2) 1. Our data are in agreement with those previously reported in the literature. The only exception is the distribution volume, which we found to be smaller.
