Dixon B. Kaufman - US grants

The primary goal of this pilot study is to achieve long-term (>1 year) insulin independence by transplanting cadaver adult islets, aided by a new immunosuppressive agent, 15-deoxyspergualin (DSG), in patients that have previously received a successul kidney transplant, but remain C- peptide negative, type I diabetics.

DESCRIPTION: (Adapted from the applicant's abstract) Islet transplantation for the treatment of type I diabetes has failed to fulfill its promise, which was generated by a large number of highly successful experiments in rodents. Recent evidence suggests that the failure of islets to engraft and survive for prolonged periods of time is due to many nonspecific as well as allospecific reactions. The overall objective of this proposal is to define the mechanisms of injury produced by these host immune responses. The investigators are planning to examine the requirement for functional interaction between host pro-inflammatory cytokines that accumulate at the graft site and corresponding cytokine receptors expressed by the transplanted islets. It is hypothesized that accumulation of pro-inflammatory cytokines such as TNF and IL-1 produced by the host have direct adverse effects on islet isograft functional outcome. It is also hypothesized that this mechanism of islet transplant injury occurs in the setting of host T_cell-dependent, perforin and Fas-independent, non-cytolytic alloimmune responses, and that the adverse effects are operative via functional interactions between the host pro-inflammatory cytokines and the corresponding cytokine receptors expressed by the transplant islets. The investigators, for this purpose, will transplant islets from mice with genetic functional deletion of TNF and IL-1 receptors into streptozotocin-induced diabetic recipients in a functional mouse islet transplant model. By defining these cytokine ligand receptor interactions, the investigators hope to develop new strategies utilizing gene-targeted therapeutics to modulate islet cytokine receptor expression ex-vivo prior to transplantation, strategies designed to ameliorate early detrimental effects of specific pro-inflammatory cytokines.

[unreadable] DESCRIPTION (provided by applicant): Our ultimate goal is to contribute in a meaningful way to the cure of diabetes through islet transplantation. We posit that early loss of transplant islet mass at the implantation site significantly reduces the functional potential of the freshly purified islet preparation. Certain anatomic and immunologic variables impact on the early fate of the implanted cells. The overall goal of the proposal is to define how the transplant location, the make-up of the transplanted cells (free cells, cellular matrix structures, or islets), and the immune responsiveness of the host affect cellular viability and function. We hypothesize that: 1) early loss of viable islet mass significantly reduces the functional potential of the freshly purified islet preparation; 2) that rates of loss of cell viability depend on engraftment site, the vigor of immediate host non-specific inflammatory responses, and the composition of the cellular structures transplanted. The specific aims are: 1. To develop a useful method of real-time bioluminescent imaging as a modality to monitor the fate of transplanted "tagged" islets from transgenic rat insulin II promoter (RIP)-luciferase donor strain mice. 2. To create effective adeno and adeno-associated viral vectors containing the RIP with two reporter genes: luciferase and green fluorescent protein for transfection of purified mouse and human islets. 3.To apply bioluminescent imaging techniques to monitor the fate of transplanted MIN6 [unreadable]-cell lines expressing luciferase using a scaffold matrix. The aims will be accomplished by applying the general methods of real-time, non-invasive bioluminescent imaging to the specific field of islet transplantation. This imaging modality will permit visualization of "tagged' transplanted islets or [unreadable]-cells in the living mouse. Through serial post-transplant monitoring, it will be possible to define how the fate of the viable islet mass is affected by anatomic and immunologic considerations that directly relate to transplant functional outcome.

human therapy evaluation; pancreatic islet transplantation; insulin dependent diabetes mellitus; diabetes mellitus therapy; immune response; T lymphocyte; uremias; patient oriented research; clinical research; human subject;

DESCRIPTION (provided by applicant): Islet transplantation is an intriguing therapeutic platform for treatment of T1D but will not become a widespread clinical reality until it can be proven that the islet product can safely provide a substantial therapeutic benefit on a consistent basis in an efficient manner. To address these challenges the Clinical Islet Transplant (CIT) Consortium was formed. The aim of the Continuation Award is to complete the existing CIT islet transplant studies to substantially improve treatment of T1D and obtain licensure of the human islet product. Three study protocols have been developed. The Specific Aims as they relate to each protocol are: 1. To determine the safety and efficacy of peri-transplant administration of deoxyspergualin (DSG) on the engraftment and function of pancreatic islet transplants in T1D patients (CIT Protocol 03). 2. To determine the safety and efficacy of a steroid-free, tacrolimus sparing immunosuppressive protocol in T1D patients receiving pancreatic islet transplants (CIT Protocol 07). 3. To determine the efficacy of islet transplantation in T1D kidney allograft recipients (CIT Protocol 06). To achieve the aims of CIT-03, Northwestern will participate in a prospective, randomized, three-center, open-label trial assessing the safety and efficacy of DSG on post-transplant islet function in subjects with long-standing TID that is refractory to intensive insulin therapy. The three centers in the study. Northwestern, Minnesota and UCSF, will collectively transplant 20 recipients using DSG (ClT-03) and contribute 12 of the 48 recipients into the CIT-07 protocol that is the registration trial component and also serves as the control group for the DSG study. Northwestern will transplant a minimum of 10-11 subjects in CIT-03/-07, and 4 patients in CIT-06. To expedite the completion of these trials, Northwestern aims to transplant 4 subjects under ClT-03 and 2 subjects under ClT-07 before the conclusion of the current grant award. Northwestern has met the CIT consortium site qualification criteria for quality islet isolation standards using the CIT batch record, and for clinical experience based on volume of activity and quality outcomes. Site activation has been achieved. To date, Northwestern has transplanted 3 patients, all randomized to the ClT-03 study. Northwestern is well positioned to continue as an active participant in the CIT clinical trials. RELEVANCE (provided by the applicant): Type 1 diabetes (T1D) afflicts nearly 2 million people in the United States, most of them children or young adults, and untreated, it is a fatal disease. Insulin therapy can be administered, but does not result in good health-related quality of life and can lead to diabetic retinopathy and nephropathy, which are the most common causes of adult blindness and kidney transplant respectively. The goal is to achieve insulin independence for Type 1 diabetes patients with Islet Transplantation, improving their overall quality of life and disease management with less risk than whole pancreas transplant.

Tomotherapy and Hematopoietic Stem Cells for Tolerance to Kidney Transplants    ABSTRACT      The  overarching  goal  of  this  project  is  to  develop  a  tolerance  induction  protocol  for  MHC  disparate  kidney  transplants in rhesus macaques and to elucidate the underlying mechanisms of the induction and maintenance  of mixed chimerism and tolerance in this model. The primary hypothesis is that tolerance to MHC mismatched  kidney transplants can be safely and effectively achieved by establishing a mixed chimeric state using a newly  established  post?transplant  non?myeloablative,  helical  tomotherapy?based  total  lymphoid  irradiation  (TLI)? based  conditioning  regimen  followed  by  donor  bone  marrow?CD34+  hematopoietic  cell  (HSC)  infusions.  In  addition,  we  will  elucidate  mechanisms  of  host  immunoregulatory  characteristics  that  are  associated  with  successful HSC engraftment and maintenance of the chimeric state. We propose to test our hypotheses by means  of  2  specific  aims:  1.)  Combined  Bone  Marrow  Hematopoietic  Cell/Kidney  Transplants  to determine  the  proportion of rhesus macaque recipients of disparate unrelated donor kidney transplants that achieve chimerism  (without  GVHD)  and  can  be  withdrawn  from  all  immunosuppressive  drugs  for  greater  than  2  years  while  maintaining normal allograft function and without rejection. We will measure the state of mixed chimerism in  recipients as a function of time post?transplant and according to various peripheral blood and bone marrow cell  types  using  DNA  (STR)  analysis,  and  with  flow  cytometry  using  rhesus  antibodies  specific  for  MHC  class  I  Mamu alleles of the donor.  2) Immune Monitoring, Immunopathology and Immunocompetence.  We will: a.)  determine  early  recipient  immunoregulatory  changes  of  host  myeloid  cells  induced  by  the  TLI?based  conditioning regimen that correlate with the success of bone marrow engraftment, b.) determine if the mixed  chimeric  state  induces  changes  of  host  dendritic  cell  acquisition  of  donor  MHC  class  I  antigen  and  PD?LI  expression  at  serial  time  points  during  and  after  withdrawing  immunosuppression,  c.)  characterize  the  development of renal allograft immune and non?immune injury by analysis of serial renal allograft biopsies, and  d.) determine the degree of recipient immune?competency after immunosuppressive drug withdrawal by testing  the  recall  T  cell  responses  to  cytomegalovirus  antigens  and  tetanus  toxoid.  Knowledge  gained  through  this  rhesus  tolerance  induction  protocol,  including  the  underlying  immunological  mechanisms,  will  have  direct  relevance  to  a  variety  of  deceased  donor  transplants.  Furthermore,  it  will  set  a  new  course  of  healthcare  innovation and delivery that will greatly benefit transplant patients, and other patient populations.                                                            

PROJECT SUMMARY The UW Transplant Research Training Program represents an essential funding mechanism for post- doctoral trainees and residents at our own institution and nationwide. The overall goal of the ?UW Transplant Research Training Program? is to provide postdoctoral trainees who are strongly motivated toward a career in transplant related research, with a two-year, comprehensive, hypothesis-based research experience. Trainees will be exposed to a curriculum including principles of clinical trials, research design, management, ethics and data analysis. The training program will foster the development of knowledge, skills, professional attitudes, and experience required for successful academic careers. The program will maintain two trainees per year for a two-year training experience (accepting two new trainees each year). Our trainer pool includes a total of 12 faculty, representing six departments, including Cell and Regenerative Medicine, Medical Microbiology and Immunology, Medicine, Pathology and Laboratory Medicine, Pediatrics, and Surgery. Trainers have been selected based on extramural research support, prior mentoring experience, relevance of research goals to the training program, and already existing collaborations in the pursuit of translational research. Collectively, they have mentored over 115 post-doctoral trainees over the past 10 years including both MDs and PhDs. The specific objectives of this program are: (A) to provide training in the conduct of basic, translational and clinical transplant research focused on improving human health through participation in an individual and tailored didactic and mentoring program, and (B) to develop MD and PhD post-doctoral trainees as skilled team-oriented scientists with an emphasis on transplant research. The three areas of focus chosen for the program encompass the major research initiatives in transplant research at University of Wisconsin: i.) Immunobiology/ Immune Regulation, ii) Cellular Therapies/Regenerative Medicine, and iii) Translational research via large animal models. The strengths of the program include the breadth of funded research covering basic cellular in vitro projects, murine models, primates and human studies; an experienced trainer pool; collaboration with the UW Institute for Clinical and Translational Research (ICTR) funded by a CTSA; and a training model that encourages interactions and cross-training between clinicians and scientists. Additionally this program boasts individualized training plans, extensive institutional resources to enhance training, an experienced administrative infrastructure to assist with management of the program, a plan to promote diversity by recruiting and retaining both women and minorities, and a comprehensive plan for training in the responsible conduct of research. The administrative structure includes an Executive Committee, an External Advisory Board, a Diversity Advisory Committee, as well as program support and coordination utilizing an existing training grant program administrator within the Department of Surgery.