Yogish C. Kudva

Improvement in Outcomes of Clinical Islet Transplantation: 1999–2010

OBJECTIVE To describe trends of primary efficacy and safety outcomes of islet transplantation in type 1 diabetes recipients with severe hypoglycemia from the Collaborative Islet Transplant Registry (CITR) from 1999 to 2010. RESEARCH DESIGN AND METHODS A total of 677 islet transplant-alone or islet-after-kidney recipients with type 1 diabetes in the CITR were analyzed for five primary efficacy outcomes and overall safety to identify any differences by early (1999–2002), mid (2003–2006), or recent (2007–2010) transplant era based on annual follow-up to 5 years. RESULTS Insulin independence at 3 years after transplant improved from 27% in the early era (1999–2002, n = 214) to 37% in the mid (2003–2006, n = 255) and to 44% in the most recent era (2007–2010, n = 208; P = 0.006 for years-by-era; P = 0.01 for era alone). C-peptide ≥0.3 ng/mL, indicative of islet graft function, was retained longer in the most recent era (P < 0.001). Reduction of HbA1c and resolution of severe hypoglycemia exhibited enduring long-term effects. Fasting blood glucose stabilization also showed improvements in the most recent era. There were also modest reductions in the occurrence of adverse events. The islet reinfusion rate was lower: 48% by 1 year in 2007–2010 vs. 60–65% in 1999–2006 (P < 0.01). Recipients that ever achieved insulin-independence experienced longer duration of islet graft function (P < 0.001). CONCLUSIONS The CITR shows improvement in primary efficacy and safety outcomes of islet transplantation in recipients who received transplants in 2007–2010 compared with those in 1999–2006, with fewer islet infusions and adverse events per recipient.

Hypoglycemia with Intensive Insulin Therapy: A Systematic Review and Meta-Analyses of Randomized Trials of Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Injections

CONTEXT Hypoglycemia limits the efficacy of intensive insulin therapy. The extent to which continuous insulin infusion (CSII) overcomes this limitation is unclear. OBJECTIVE The aim was to summarize evidence on the effect of CSII and multiple daily injections (MDIs) on glycemic control and hypoglycemia. DATA SOURCES We searched electronic databases between 2002 and March 2008. STUDY SELECTION We selected published randomized trials of CSII vs. MDI. DATA EXTRACTION Reviewers working in duplicate and independently extracted study characteristics and quality and differences in glycosylated hemoglobin (HbA1c) and hypoglycemic events. DATA SYNTHESIS We found 15 eligible randomized trials of moderate quality, with elevated baseline and end-of-study HbA1c levels. Patients with type 1 diabetes using CSII had slightly lower HbA1c [random-effects weighted mean difference, -0.2%; 95% confidence interval (CI), -0.3, -0.1, compared with MDI], with no significant difference in severe (pooled odds ratio, 0.48; 95% CI, 0.23, 1.00) or nocturnal hypoglycemia (pooled odds ratio 0.82, 95% CI 0.33, 2.03). Adolescents and adults with type 1 diabetes enrolled in crossover trials had nonsignificantly fewer minor hypoglycemia episodes per patient per week (-0.08; 95% CI, -0.21, 0.06) with CSII than MDI; children enrolled in parallel trials had significantly more episodes (0.68; 95% CI, 0.16, 1.20; P(interaction) = 0.03). Outcomes were not different in patients with type 2 diabetes. CONCLUSIONS Contemporary evidence indicates that compared to MDI, CSII slightly reduced HbA1c in adults with type 1 diabetes, with unclear impact on hypoglycemia. In type 2 diabetes, CSII and MDI had similar outcomes. The effect in patients with hypoglycemia unawareness or recurrent severe hypoglycemia remains unclear because of lack of data.

Single dose streptozotocin-induced diabetes: considerations for study design in islet transplantation models

Streptozotocin (STZ)-induced diabetes mellitus (DM) offers a very cost-effective and expeditious technique that can be used in most strains of rodents, opening the field of DM research to an array of genotypic and phenotypic options that would otherwise be inaccessible. Despite widespread use of STZ in small animal models, the data available concerning drug preparation, dosing and administration, time to onset and severity of DM, and any resulting moribundity and mortality are often limited and inconsistent. Because of this, investigators inexperienced with STZ-induced diabetes may find it difficult to precisely design new studies with this potentially toxic chemical and account for the severity of DM it is capable of inducing. Until a better option becomes available, attempts need to be made to address shortcomings with current STZ-induced DM models. In this paper we review the literature and provide data from our pancreatic islet transplantation experiments using single high-dose STZ-induced DM in NCr athymic nude mice with hopes of providing clarification for study design, suggesting refinements to the process, and developing a more humane process of chemical diabetes induction.

Patient Survival and Cardiovascular Risk After Kidney Transplantation: The Challenge of Diabetes

An increasing proportion of kidney recipients have diabetes mellitus (DM). Herein, we assessed the impact of DM on morbidity and mortality. The study included 933 recipients of first transplants. DM was present in 212 (23%). Compared to non‐diabetics (NoDM), DM were older, heavier and had more pretransplant cardiovascular (CV) disease (16% vs. 48%, p < 0.0001). DM had reduced survival (5 years, 93% vs. 70%, p < 0.0001) and higher incidence of CV events (9% vs. 37%, p < 0.0001). CV disease was the most common cause of death in DM (61%) but not in NoDM (26%). Mortality from infections was also higher in DM (p = 0.001). In NoDM, survival related to recipient age (hazard ratio (HR) = 1.07, p < 0.0001) and dialysis pretransplant HR = 2.21, p = 0.01, while in DM, survival related to dialysis (HR = 2.89, p = 0.01) and pretransplant CV disease (HR = 2.79, p = 0.007). In NoDM, the incidence of posttransplant CV events was related to traditional CV risk factors, while in DM only the pretransplant CV history related to this outcome. In conclusion, survival differs between NoDM and DM recipients quantitatively, by cause of death and by risk factors. In NoDM, survival is excellent, and the main threat to survival relates to immunosuppression. In DM, survival is inferior primarily due to CV disease generally present prior to transplantation.

Obesity in living kidney donors: clinical characteristics and outcomes in the era of laparoscopic donor nephrectomy.

Acceptance of obese individuals as living kidney donors is controversial related to possible increased risk for surgical complications and concern that obesity may contribute to long‐term renal disease. We retrospectively examined 553 consecutive hand‐assisted laparoscopic living kidney donations between October 1, 1999 and April 1, 2003. We stratified donors into quartiles by baseline body mass index (BMI) assessing perioperative complications and 6–12 months post‐donation metabolic and renal function. Compared to BMI <25 kg/m2, high BMI donors (≥35 kg/m2) had slightly longer operative times (mean increase 19 min), more overall perioperative complications (mostly minor wound complications), yet the same low rate of major surgical complications (conversion to open and re‐operation) and similar length‐of‐stay (2.3 vs. 2.4 days). At 6–12 months after donation (mean 11 months), renal function and microalbuminuria did not differ with BMI. These results suggest that laparoscopic donor nephrectomy is generally safe in selected obese donors and does not result in a high rate of major perioperative complications. Obese donors have higher baseline cardiovascular risk and warrant risk reduction for long‐term health. While early results are encouraging, we advocate careful study of obese donors and do not support their widespread use until longer follow‐up is available.

Small heat shock proteins inhibit in vitro Aβ1–42 amyloidogenesis

We demonstrate that small heat shock proteins (sHsp) inhibit in vitro amyloid formation by the Alzheimers Aβ1–42 polypeptide as detected by a thioflavine T fluorescence assay and electron microscopy. Human sHsp27 (0.50–3.0 μM) inhibited amyloid formation from 20 μM Aβ1–42 by 23–75% in 24 h. In contrast, treatment of pre‐formed amyloid with 0.5–3.0 μM sHsp27 only reduced the fluorescence signal by 6–36%. The data suggest that ordered fibril formation may represent a form of off‐pathway aggregation that can be prevented by chaperone action. The data raise the possibility that age‐related changes in chaperone function could contribute toward the pathogenesis of Alzheimers and other amyloid‐associated diseases.

Indolactam V/GLP-1-mediated differentiation of human iPS cells into glucose-responsive insulin-secreting progeny.

Nuclear reprogramming of somatic tissue enables derivation of induced pluripotent stem (iPS) cells from an autologous, non-embryonic origin. The purpose of this study was to establish efficient protocols for lineage specification of human iPS cells into functional glucose-responsive, insulin-producing progeny. We generated human iPS cells, which were then guided with recombinant growth factors that mimic the essential signaling for pancreatic development. Reprogrammed with four stemness factors, human fibroblasts were here converted into authentic iPS cells. Under feeder-free conditions, fate specification was initiated with activin A and Wnt3a that triggered engagement into definitive endoderm, followed by priming with fibroblast growth factor 10 (FGF10) and KAAD-cyclopamine. Addition of retinoic acid, boosted by the pancreatic endoderm inducer indolactam V (ILV), yielded pancreatic progenitors expressing pancreatic and duodenal homeobox 1 (PDX1), neurogenin 3 (NGN3) and neurogenic differentiation 1 (NEUROD1) markers. Further guidance, under insulin-like growth factor 1 (IGF-1), hepatocyte growth factor (HGF) and N-[N-(3,5-Difluorophenacetyl)-L-alanyl]-S-phenylglycine t-butyl ester (DAPT), was enhanced by glucagon-like peptide-1 (GLP-1) to generate islet-like cells that expressed pancreas-specific markers including insulin and glucagon. Derived progeny demonstrated sustained expression of PDX1, and functional responsiveness to glucose challenge secreting up to 230 pM of C-peptide. A pancreatogenic cocktail enriched with ILV/GLP-1 offers a proficient means to specify human iPS cells into glucose-responsive hormone-producing progeny, refining the development of a personalized platform for islet-like cell generation.

Can Serum β-Hydroxybutyrate Be Used to Diagnose Diabetic Ketoacidosis?

OBJECTIVE—Current criteria for the diagnosis of diabetic ketoacidosis (DKA) are limited by their nonspecificity (serum bicarbonate [HCO3] and pH) and qualitative nature (the presence of ketonemia/ketonuria). The present study was undertaken to determine whether quantitative measurement of a ketone body anion could be used to diagnose DKA. RESEARCH DESIGN AND METHODS—A retrospective review of records from hospitalized diabetic patients was undertaken to determine the concentration of serum β-hydroxybutyrate (βOHB) that corresponds to a HCO3 level of 18 mEq/l, the threshold value for diagnosis in recently published consensus criteria. Simultaneous admission βOHB and HCO3 values were recorded from 466 encounters, 129 in children and 337 in adults. RESULTS—A HCO3 level of 18 mEq/l corresponded with βOHB levels of 3.0 and 3.8 mmol/l in children and adults, respectively. With the use of these threshold βOHB values to define DKA, there was substantial discordance (∼≥20%) between βOHB and conventional diagnostic criteria using HCO3, pH, and glucose. In patients with DKA, there was no correlation between HCO3 and glucose levels on admission and a significant but weak correlation between βOHB and glucose levels (P < 0.001). CONCLUSIONS—Where available, serum βOHB levels ≥3.0 and ≥3.8 mmol/l in children and adults, respectively, in the presence of uncontrolled diabetes can be used to diagnose DKA and may be superior to the serum HCO3 level for that purpose. The marked variability in the relationship between βOHB and HCO3 is probably due to the presence of other acid-base disturbances, especially hyperchloremic, nonanion gap acidosis.OBJECTIVE Current criteria for the diagnosis of diabetic ketoacidosis (DKA) are limited by their nonspecificity (serum bicarbonate [HCO(3)] and pH) and qualitative nature (the presence of ketonemia/ketonuria). The present study was undertaken to determine whether quantitative measurement of a ketone body anion could be used to diagnose DKA. RESEARCH DESIGN AND METHODS A retrospective review of records from hospitalized diabetic patients was undertaken to determine the concentration of serum beta-hydroxybutyrate (betaOHB) that corresponds to a HCO(3) level of 18 mEq/l, the threshold value for diagnosis in recently published consensus criteria. Simultaneous admission betaOHB and HCO(3) values were recorded from 466 encounters, 129 in children and 337 in adults. RESULTS A HCO(3) level of 18 mEq/l corresponded with betaOHB levels of 3.0 and 3.8 mmol/l in children and adults, respectively. With the use of these threshold betaOHB values to define DKA, there was substantial discordance (approximately > or = 20%) between betaOHB and conventional diagnostic criteria using HCO(3), pH, and glucose. In patients with DKA, there was no correlation between HCO(3) and glucose levels on admission and a significant but weak correlation between betaOHB and glucose levels (P < 0.001). CONCLUSIONS Where available, serum betaOHB levels > or = 3.0 and > or = 3.8 mmol/l in children and adults, respectively, in the presence of uncontrolled diabetes can be used to diagnose DKA and may be superior to the serum HCO(3) level for that purpose. The marked variability in the relationship between betaOHB and HCO(3) is probably due to the presence of other acid-base disturbances, especially hyperchloremic, nonanion gap acidosis.

Diurnal Pattern to Insulin Secretion and Insulin Action in Healthy Individuals

Evaluation of the existence of a diurnal pattern of glucose tolerance after mixed meals is important to inform a closed-loop system of treatment for insulin requiring diabetes. We studied 20 healthy volunteers with normal fasting glucose (4.8 ± 0.1 mmol/L) and HbA1c (5.2 ± 0.0%) to determine such a pattern in nondiabetic individuals. Identical mixed meals were ingested during breakfast, lunch, or dinner at 0700, 1300, and 1900 h in randomized Latin square order on 3 consecutive days. Physical activity was the same on all days. Postprandial glucose turnover was measured using the triple tracer technique. Postprandial glucose excursion was significantly lower (P < 0.01) at breakfast than lunch and dinner. β-Cell responsivity to glucose and disposition index was higher (P < 0.01) at breakfast than lunch and dinner. Hepatic insulin extraction was lower (P < 0.01) at breakfast than dinner. Although meal glucose appearance did not differ between meals, suppression of endogenous glucose production tended to be lower (P < 0.01) and insulin sensitivity tended to be higher (P < 0.01) at breakfast than at lunch or dinner. Our results suggest a diurnal pattern to glucose tolerance in healthy humans, and if present in type 1 diabetes, it will need to be incorporated into artificial pancreas systems.

Time Lag of Glucose From Intravascular to Interstitial Compartment in Humans

The accuracy of continuous interstitial fluid (ISF) glucose sensing is an essential component of current and emerging open- and closed-loop systems for type 1 diabetes. An important determinant of sensor accuracy is the physiological time lag of glucose transport from the vascular to the interstitial space. We performed the first direct measurement of this phenomenon to our knowledge in eight healthy subjects under an overnight fasted condition. Microdialysis catheters were inserted into the abdominal subcutaneous space. After intravenous bolus administrations of glucose tracers, timed samples of plasma and ISF were collected sequentially and analyzed for tracer enrichments. After accounting for catheter dead space and assay noise, the mean time lag of tracer appearance in the interstitial space was 5.3–6.2 min. We conclude that in the overnight fasted state in healthy adults, the physiological delay of glucose transport from the vascular to the interstitial space is 5–6 min. Physiological delay between blood glucose and ISF glucose, therefore, should not be an obstacle to sensor accuracy in overnight or fasting-state closed-loop systems of insulin delivery or open-loop therapy assessment for type 1 diabetes.