The discovery of insulin changed the expected outcomes of type 1 insulin-dependent diabetic patients (IDDM) (1). Almost 80 years later, with the success of the Edmonton Protocol, pancreatic islet transplantation (PIT) is receiving acknowledgment as a potential cure for type 1 IDDM. Between 1893 and December 2000, 493 adult PITs were performed, with only two maintaining posttransplant insulin independence for greater than 60 months (2). However, in July 2000, Shapiro et al. (3) introduced the glucocorticoid-free immunosuppressive regimen termed the Edmonton Protocol and reported the achievement of insulin independence in seven consecutive patients with type 1 IDDM using PIT.
Although immunosuppressive protocols are easily disseminated, the Food and Drug Administration’s (FDA) regulatory, clinical, and financial aspects of PIT are significant and make it infeasible for most academic institutions to establish PIT and pancreatic islet isolation (PII) centers. In September 2000, the FDA reiterated that allogeneic pancreatic islets for transplantation are regulated as biologic products used for cellular therapy (4) and meet the definition of “drug” in the Federal Food, Drug, and Cosmetic Act (FD&C Act) of 1938 (5). An approved investigational new drug (IND) application is required before initiating PIT studies and, consequently, pancreatic islets must be prepared in facilities meeting the guidelines set forth in the FD&C Act as good manufacturing practices (GMP) (6). The costs to develop a GMP-certified laboratory for PII will exceed $1 to $2 million (7) for development and annual maintenance alone. In addition to the costs of building the GMP facility, establishing a PII facility also requires technical personnel trained in PII, FDA certified quality control and quality assurance personnel with 24 hour availability, as well as personnel to maintain the records needed for FDA compliance. Together, these financial and regulatory demands make the development of PIT and PII center daunting for most transplant centers.
Because PIT is considered clinical research versus the standard of care and because of current United Network for Organ Sharing (UNOS) allocation schemes, PIT centers will only be offered pancreata in the event that a local or regional whole-organ program has declined the organ. It will take a developing PII facility a number of donor pancreata to develop the skills necessary to reliably isolate human pancreatic islets. This limited supply of pancreata and islets therefore makes the use of a proven PII center a prudent and judicious choice for emerging PIT programs. In addition, outsourcing the PII allows new PIT programs to focus on PIT and the requisite pre-, peri-, and posttransplant care. Finally, concentrating PII expertise within a limited number of PII centers will also allow experimental isolation protocols to be completed in a timely fashion. Benefits will also be seen with the addition of new PIT centers by providing additional outcomes.
Therefore, to ensure patient safety and quality care, to use donor pancreata in a judicious manner, and to advance the field of PIT by providing additional outcomes, the most prudent course of action when establishing a PIT program is to partner with an experienced PII/PIT center. In our experience, establishing a collaborative relationship with an established PIT/PII center is critical to developing a PIT program in a safe, timely, and effective manner. The intent of this communication is to review our experience in establishing a human PIT program by using four key elements: (1) form a collaborative relationship with an experienced PII/PIT center (2); obtain institutional review board (IRB) and FDA IND approval at both institutions (3); jointly develop the standard operating procedures (SOPs) addressing organ procurement, transportation of pancreata to the PII center, techniques of PII, release criteria for the islet product at both the isolation and transplant center, transportation of the islets back to the transplant center, transplantation of the islets, and posttransplant care (4); and assemble a multidisciplinary health care team to implement transplant protocols.
At the outset, a collaborative relationship with an established PII center was developed within 3 months. The center chosen, the University of Miami, Diabetes Research Institute (DRI), was remotely located across state lines and had more than 3 decades of experience in PII and PIT. Once the cooperative academic relationship was established, a letter of agreement was endorsed, which outlined the relationship and responsibilities of the PII and PIT centers (Table 1).
Subsequently, each institution was required to comply with its own guidelines for research and apply to its respective IRB to participate in this collaborative relationship. Specifically, the remote PII must obtain approval to isolate and then ship isolated pancreatic islets, and the PIT center must obtain a separate approval to transplant shipped pancreatic islet allografts. The responsibilities of each institution were demarcated in the respective IRB proposals. After IRB approval, the PIT and the collaborative PII centers each developed an application to proceed with the clinical study of an IND under the guidelines set forth in the Guidance for Human Somatic Cell Therapy and Gene Therapy and reiterated in the Letter to Transplant Centers: Allogeneic Pancreatic Islets for Transplantation (4,6). Before being granted permission by the FDA to perform this clinical study, the FDA required that three separate sets of pancreatic islet allografts be isolated and transported in a temperature controlled, closed system from the DRI to the Methodist Hospital/Baylor College of Medicine Islet Transplant program. Upon arrival in Houston, the viability, sterility, and potency had to be tested and shown to not have been adversely affected by transport from the DRI to the Methodist/Baylor program. Upon successful completion of these requirements, permission was granted from the FDA to proceed with the investigational protocols. Eleven months passed from the development of the first draft IRB in May 2000 until the IRB and IND approvals were granted in April 2001.
Once all approvals were granted, with responsibilities agreed upon between the PIT and remote PII facilities, SOPs were written. Over the course of 6 months, complete SOPs for recipient selection, multi-organ donor selection, techniques of organ procurement and preservation, pancreatic-islet processing, timely transportation of pancreata and islets, final processing of islets (including sterility and viability assessments), product release criteria, transplantation techniques, immunosuppression regimens, and evaluation of long-term survival and function of the islet allografts were developed. In addition, a variance was approved by the UNOS Kidney and Pancreas subcommittee allowing our center to receive pancreata that had been refused by local whole-organ transplant programs before regional and national whole-organ pancreas allocation (excluding regional and national 6-antigen matches).
Simultaneously, a multidisciplinary health care and research team was recruited to perform specific functions within the PIT program. This multidisciplinary team included FDA-approved medical professionals from the departments of surgery, medicine, and radiology. The principal investigator, who also serves as the procurement surgeon and recipient primary care provider, recruited a transplant nurse coordinator and FDA regulatory specialist. Responsibilities of the coordinator beyond standard nursing and patient care included arranging evaluations for potential islet recipients, listing patients with UNOS, coordinating PITs, preparing case report forms for the FDA, reporting adverse events to FDA, and maintaining data in patient charts and the Collaborative Islet Transplant Registry. The regulatory specialist assisted the principal investigator with IRB and FDA IND applications, annual reports, and any necessary communication with the IRB or FDA. The participation of two diabetologists was enlisted to evaluate and determine the suitability of potential PIT candidates and to evaluate patient outcomes from an endocrinology perspective. In addition, two board certified interventional radiologists were engaged to perform the pancreatic islet infusions. Similar specialists from the remote DRI transplant center provided guidance to those at the transplanting site before the first transplant and were physically present during the first two PITs in Houston, Texas. Last, a working relationship was established with the GMP-certified Center for Cell and Gene Therapy laboratory at the transplanting institution, and the director of that GMP laboratory was recruited as a collaborative researcher. In turn, two cell-processing technicians from the laboratory were designated to perform the posttransport pancreatic islet testing and infusion preparation, which includes islet washing, demonstrating final product sterility through gram stain and endotoxin testing and islet viability, counting the pancreatic islet allografts, and preparing the final islet product for transplantation into 100 mL intervenous bags containing 17.5 units heparin/kg of body weight, transplant media, and islet tissue.
Between January 17, 2002 and April 9, 2003, 22 PITs were performed at our transplant center in 10 type 1 IDDM patients. As per our IRB and FDA IND approved protocol, each patient received transplants with greater than 5,000 islet equivalents (IEQ)/kg of body weight (Table 2). Pancreata for these transplants were procured locally by our team in all cases except two (20 local, 2 remote) and were preserved using the static two-layer cold storage method with layered University of Wisconsin solution and perfluorodecalin (8) and flown by dedicated jet to the remote PII center. The remaining two pancreata were procured by affiliates of the remote DRI PII center and offered to our program after the DRI recipient was found to have a positive crossmatch. Pancreatic islets were successfully isolated at the remote PII center in 61% of the attempts made on behalf of our PIT center, and a median of 379,217 IEQs were isolated (range 46,025–973,133) (Table 3). All pancreata were transported to the remote PII center by way of a dedicated jet and arrived at the PII facility within a median of 5.4 (range 4.0–7.3) hours. Once greater than 5,000 IEQ/kg pancreatic islets were isolated with a median of 7,135 (range 5,038–11,316) IEQ/kg and islets had met the predetermined FDA approved release criteria, they were packaged and flown back to our transplant center’s GMP laboratory (average travel time from the DRI to Houston 3.5 hours). Before shipment, the pancreatic islets were packaged at the DRI into 3 L LifeCell tissue culture flasks (Nexcell, Prod. No. R4R2113, Irving, CA) continuing CMRL 1066-based (Mediatech, Herndon, VA) transport media. The pancreatic islets were packaged according to purity: if the purity of the preparation equaled or exceeded 70%, 200,000 IEQs were placed into 550 mL media and packaged into a single flask; if the purity was less than 70%, 100,000 IEQs were placed into a tissue culture flask containing 550 mL tissue culture media. The flasks were then placed into an insulated cooler containing Sebra (Sebra, Tucson, AZ) room temperature gel packs and a temperature monitoring unit. The cooler was then labeled according to UNOS guidelines and sealed with tamper resistant tape. Upon arrival, the pancreatic islets were washed and packaged in 100 mL bags. Samples were collected at the PII facility before shipment and again at the Baylor College of Medicine, Center for Cell and Gene Therapy during final islet preparation to demonstrate islet sterility (gram stain and endotoxin), viability (propidium iodide and fluorescein diacetate), purity, and function (glucose stimulation assays) (9). Manual counting of the islets was performed at both centers, and as per our IND, could not vary by greater than 30% for product release. All PITs were performed in an interventional radiology suite at the transplanting center by one of two radiologists by way of percutaneous transhepatic portal venous access using ultrasound guidance (10), and patients recovered in the surgical intensive care unit.
Currently, five patients have completed the PIT protocol, receiving greater than 15,000 IEQs/kg, and all five have achieved insulin independence. Four additional patients have received greater than 10,000 IEQs and have achieved metabolic stability and improved glycemic control while requiring 25% to 50% of their prePIT insulin; however, these patients have not yet achieved insulin-independence and will require an additional PIT. The variability of the response to PIT is difficult to understand at this time and demonstrates the need that exists for an in vitro pretransplant assay that will accurately predict the clinical performance of the pancreatic islet allograft. Several assays are being evaluated experimentally, including the in vitro glucose stimulation index, the oxygen consumption response, and in vivo nonobese diabetic, severe combined immunodeficiency disease mouse model; however, to date, none have been found to be applicable and validated for multicenter application. Specifically, in our patients, it is difficult to understand the variation in clinical response because there was no difference in allograft viability or in vitro potency when compared with preshipment values at the DRI, and we do not feel that shipment had any adverse consequences on these islets. It is also important to note that our protocol uses fresh pancreatic islets and does not allow for the benefit of in vitro pretransplant room temperature culture; therefore, our patients may require a larger number of pancreatic islets to achieve insulin independence. All patients have been shown to produce both basal and stimulated levels of c-peptide, and their HbA1C results are now within or approaching the normal range (Table 2). One patient has since been removed from the study after a nonspecific islet-allograft dysfunction verified by a glucose stimulated c-peptide result of less than 0.5 ng/mL.
Collaborating with an established PII/PIT program proved to be a safe, effective, and timely method for the development of our PIT program. Less than 18 months passed from our PIT program’s inception in July 2000 to the time of the first transplant, because of, in large part, our collaboration with an experienced PII/PIT center. Twenty-one transplants have followed the use of this collaborative relationship. In our experience, routinely using a small, dedicated team of health care professionals at the transplanting center ensured that the protocol was consistently followed, that patient safety was paramount, and that advances in the processing, infusion, and immunosuppressive therapy could be realized in a relatively short period of time. Moreover, access to a dedicated jet service provided the safe and timely transportation of organs and islets.
In conclusion, establishing a collaborative relationship with an existing PII and PIT center can allow developing PIT programs to proceed in a safe, effective, and timely manner. Concentrating PII and recovery at a small number of regional centers is preferable to establishing many small and disparate isolation centers, and collaborating with experienced PIT programs enhances developing clinical protocols. Using an experienced, yet remotely located, PII center allows developing programs to focus on patient safety and quality care, use scarce pancreata in a prudent manner, and advance the field of PIT by providing additional patient outcomes.
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