Steroid-free and Long-term Calcineurin-free Trial in Islet Cell Transplantation

The purposes of this study are:

1. To reverse hyperglycemia and insulin dependency in patients with type 1 diabetes mellitus through islet transplantation utilizing steroid free, calcineurin-inhibitor free immunosuppression.
2. To assess the long-term function of successful islet transplants in patients with type 1 diabetes mellitus utilizing islets that have undergone a period of culture.
3. To determine whether the natural history of the microvascular, macrovascular, and neuropathic complications are altered following the successful transplantation of islets.

Study Overview

• Status: Completed
• Conditions: Type 1 Diabetes Mellitus
• Intervention / Treatment: Drug: Islet transplantation

Detailed Description

STUDY DESIGN:

The initial proposal submitted to the JDRFI was to compare 3 different groups of patients receiving islet cell transplants utilizing steroid-free, calcineurin-free protocols. The 3 groups were as follows:

1. Zenapax, Rapamycin & MMF
2. Campath, Rapamycin & MMF, and
3. Thymoglobulin, Rapamycin & MMF.

The grant was awarded in December 2003, however the recommendations were to focus on a single group (group 3 or 4) in order to determine the relative efficacy and toxicity of a new immunosuppressive drug combination. We elected to perform the group utilizing Campath, since we have a similar protocol utilizing the same immunosuppressive regimen with the addition of CD34+ enriched donor bone marrow cells (2000/0024). The results of this trial utilizing a steroid-free/calcineurin-free protocol will be compared with the standard "Edmonton Protocol" (2000/0196), which we are currently conducting (14 patients have been transplanted). In addition, the results will be compared with those in 2000/0024.

Protocol 2000/0024 (utilizing the same immunosuppressive regimen; Campath, Rapamycin, Tacrolimus-switched to MMF at 3 months) is being followed by a DSMB established at the NIH.

We propose to evaluate 12 patients with steroid free, long term calcineurin inhibitor free immunosuppression regimens which can be directly compared to our historical group of patients who underwent the Miami version of the Edmonton protocol (Islet Cell Transplantation Alone in Patients with Type 1 Diabetes Mellitus: Steroid-Free Immunosuppression - Protocol # 2000/196) and with the concurrent tolerogenic protocol (Islet Cell Transplantation Alone and CD34+ Enriched Donor Bone Marrow Cell Infusion in Patients with Type 1 Diabetes Mellitus; Steroid Free Regimen - Protocol # 2000/0024) which uses the same immunosuppressive regimen combined with CD34+ stem cell enriched donor bone marrow infusions.

The regimen will consist of Campath 1-H induction, maintenance immunosuppression with sirolimus and tacrolimus for 3 months with subsequent introduction of mycophenolate mofetil (MMF) and removal of tacrolimus completely and TNF-alpha inhibition (etanercept) in the peri-transplant period.

• Study Type: Interventional
• Enrollment (Actual): 3
• Phase: Phase 2

Contacts and Locations

Study Locations

• United States
  • Florida
    • Miami, Florida, United States, 33136
      • Diabetes Research Institute

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 65 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

Potential candidates must have type 1 diabetes mellitus and fulfill one or more of the following:

1. Manifest signs and symptoms that are severe enough to be incapacitating. Incapacitating signs and symptoms include hypoglycemic episodes requiring assistance by others and hypoglycemia unawareness (the inability to recognize low blood glucoses; glucoses < 54 mg/dl). These patients are at high risk for involvement in accidents (they can lose consciousness or act irrationally), thus causing harm to themselves and/or others.
2. Patients with poor diabetes control (HbA1c > 8.0% but < 12%), despite intensive insulin therapy, as defined by: self monitoring of blood glucose ≥ 4 times/day, multiple insulin injections (≥ 3/day) or insulin pump, and close monitoring of blood glucose control by an endocrinologist. These patients can experience acute, rapid hyperglycemia secondary to several stress factors, that can lead to dehydration, disorientation, and in some instances, ketoacidosis.
3. Progressive diabetic complications. These patients with chronically poor glycemic control are at higher risk for the development of a wide variety of complications (retinopathy, neuropathy, nephropathy, and cardiovascular disease) associated with diabetes.

Exclusion Criteria:

Potential candidates will be excluded as per the following criteria:

1. Age < 18 or > 65 years
2. Duration of diabetes < 5 years
3. Do not have a physician that is monitoring diabetes for > 6 months
4. Body mass index > 26
5. Weight > 80 kg
6. Insulin requirement > 1.0 u/kg/d
7. HbA1c > 12%
8. Stimulated or basal C-peptide > 0.3 ng/ml
9. Corrected creatinine clearance < 60 ml/min
10. Serum creatinine consistently above 1.6 mg/dl
11. Macroalbuminuria (> 300 mg/24 hours)
12. Anemia (hemoglobin < 12.0 g/dl for males; < 11 g/dl for females)
13. Hyperlipidemia (fasting low-density lipoprotein [LDL] cholesterol > 130 mg/dl and/or fasting triglycerides > 200 mg/dl)
14. Abnormal liver function tests (consistently > 1.5 x normal range)
15. Serological evidence of HIV, HBsAg and/or HBcAb, HBsAb without history of vaccination, human t cell lymphotropic virus 1 (HTLV-1), or hepatitis C virus (HCV)
16. Negative serology for Epstein-Barr virus (EBV) or evidence of acute or chronic infection (IgM ≥ IgG)
17. Lack of updated immunizations per current Centers for Disease Control (CDC) guidelines (including lack of immunization against hepatitis B, pneumococcus and influenza - during season)
18. Presence of panel reactive antibodies > 20%
19. Prostate-specific antigen (PSA) > 4 ng/ml unless malignancy is ruled out
20. Positive tuberculin test (unless proof of adequate treatment for latent tuberculosis can be provided)
21. X-ray evidence of pulmonary infection or other significant pathology
22. Gall stones and/or portal hypertension and/or hemangioma on liver ultrasound
23. Abnormal abdominal or pelvic ultrasound (evidence of masses that are considered suspicious for malignancy or adenopathy)
24. Active peptic ulcer disease
25. Active infections
26. Unstable cardiovascular status (including positive stress echocardiography if age > 35)
27. Untreated or unstable proliferative diabetic retinopathy
28. Previous/concurrent organ transplantation (except for failed islet cell or pancreas transplantation)
29. Malignancy or previous malignancy
30. Any medical condition requiring chronic use of steroids
31. Active alcohol or substance abuse; smoking in the last 6 months.

32. Sexually active females who are not:

    • post-menopausal,
    • surgically sterile, or
    • not using an acceptable method of contraception (oral contraceptives, Norplant, Depo-Provera, and barrier devices with spermicide are acceptable; condoms used alone are not acceptable)
33. Positive pregnancy test or intent for future pregnancy, or male subject's intent to procreate
34. Any condition or any circumstances that make it unsafe to undergo an islet cell transplant
35. Psychogenically unable to comply
36. Failed psychological evaluation
37. Persistent leukopenia (white blood cell count < 3,000/uL on more than 3 occasions)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: islet transplantation; Islet Alone Transplantation under Alentuzumab (Campath1H) induction.	Drug: Islet transplantation; Islet transplantation; Other Names: islet

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Measurement of Glycemic Control by HbA1c and Prevention of Severe Hypoglycemia	Number of subjects at 1 year with HbA1c < 6.5% and absence of severe hypoglycemia	1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Islet Allograft Function	Number of subjects with basal C-peptide greater than 0.5 ng/ml	1 year
Improvement in Metabolic Control as Evidenced by Hemoglobin A1c < 6.5%	Number of subjects with a hemoglobin A1c < 6.5% at 1year after islet transplantation	1 year
Elimination of Severe Hypoglycemia	The number of subjects with severe hypoglycemia after transplantation	1 year
Restoration of Hypoglycemia Awareness 1 Year After Transplantation	The number of subjects with restoration of hypoglycemia awareness 1 year after islet transplantation	1 year

Collaborators and Investigators

• Sponsor: Rodolfo Alejandro
• Collaborators: Juvenile Diabetes Research Foundation
• Investigators: Principal Investigator: Rodolfo Alejandro, M.D., Diabetes Research Institute - University of Miami

Publications and helpful links

General Publications

• Froud T, Baidal DA, Faradji R, Cure P, Mineo D, Selvaggi G, Kenyon NS, Ricordi C, Alejandro R. Islet transplantation with alemtuzumab induction and calcineurin-free maintenance immunosuppression results in improved short- and long-term outcomes. Transplantation. 2008 Dec 27;86(12):1695-701. doi: 10.1097/TP.0b013e31819025e5.
• Tharavanij T, Betancourt A, Messinger S, Cure P, Leitao CB, Baidal DA, Froud T, Ricordi C, Alejandro R. Improved long-term health-related quality of life after islet transplantation. Transplantation. 2008 Nov 15;86(9):1161-7. doi: 10.1097/TP.0b013e31818a7f45.

Helpful Links

• Diabetes Research Institute web site

Study record dates

Study Major Dates

• Study Start: July 1, 2005
• Primary Completion (Actual): January 1, 2014
• Study Completion (Actual): January 1, 2014

Study Registration Dates

• First Submitted: April 14, 2006
• First Submitted That Met QC Criteria: April 14, 2006
• First Posted (Estimate): April 18, 2006

Study Record Updates

• Last Update Posted (Actual): May 25, 2017
• Last Update Submitted That Met QC Criteria: April 18, 2017
• Last Verified: April 1, 2017

More Information

Terms related to this study

• Keywords: Islet Transplantation
• Additional Relevant MeSH Terms: Glucose Metabolism Disorders; Metabolic Diseases; Immune System Diseases; Autoimmune Diseases; Endocrine System Diseases; Diabetes Mellitus; Diabetes Mellitus, Type 1
• Other Study ID Numbers: 2004-0205

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No