Minimal Islet Transplant at Diabetes Onset (MITO)

A Monocentric, Open-label Pilot Study to Assess the Safety and Efficacy of Minimal Islet Transplantation in Patients With New-onset Type 1 Diabetes

This is a prospective phase 2, single-arm, mono-center pilot study. It has been designed to investigate whether giving the combination therapy consisting of minimal islet transplantation (1500 EIQ/Kg body weight), Thymoglobulin® (ATG), Rapamune® (rapamycin) and Neulasta® (pegfilgastrim) to patients with Type 1 Diabetes (T1D) at onset is safe and secondarily, if it will preserve insulin production. It will involve 6 patients with new-onset T1D. Each patient will be involved in the study for a screening period and a post-islet transplantation study period of 52±2 weeks, to include 1 treatment cycles of 12 weeks, assessment during treatment and 5 follow-up visits scheduled at weeks 2±1 (14 days), 4±1 (month 1), 12±2 (month 3), 26±2 (month 6) and 52±2 (month 12).

Study Overview

• Status: Completed
• Conditions: Diabetes Mellitus, Type 1
• Intervention / Treatment: Biological: Human pancreatic islet; Drug: ATG; Drug: Pegylated G-CSF; Drug: Rapamycin

• Study Type: Interventional
• Enrollment (Actual): 6
• Phase: Phase 2

Contacts and Locations

Study Locations

• Italy
  • Milan, Italy, 20132
    • IRCCS San Raffaele Scientific Institute

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 45 years (Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Ability to provide written informed consent
• Mentally stable and able to comply with the protocol procedures for the duration of the study, including scheduled follow-up visits and examinations
• New-onset T1D (diagnosis of diabetes within 180 days prior to enrolment). Documentation of the diagnosis of T1DM (and not just insulin deficiency), including the date of diagnosis, must be obtained from the diagnosing physician.
• Residual beta-cell function (fasting C-peptide >0.3 ng/mLwhen plasma glucose level is > 70 mg/dL and ≤ 200 mg/dL.
• Positive for at least one of the following autoantibodies typically associated with T1DM: antibody to glutamic acid decarboxylase (anti-GAD) antibody to protein tyrosine phosphatase-like protein (anti-IA-2), zinc transporter autoantibodies; or an insulin autoantibody (IAA). Please note: A subject who is positive for IAA and negative for the other autoantibodies will not be eligible if the subject has been using insulin for a total of ≥7 days.
• Currently requires insulin for T1DM treatment, or has required insulin therapy (for at least 7 days) for diabetes at some time between the date of diagnosis and the first dose of study drug. Note: subjects currently taking twice daily commercially available pre-mixed insulin will not be eligible.
• MinimalHLA I A and B mismatch and at least one HLA DR match

Exclusion Criteria:

• Body mass index (BMI) ≥ 32.0 kg/m2 or patient weight ≤50kg
• Insulin requirement of >1.0 IU/kg/day
• HbA1c >10%
• Blood Pressure: SBP >160 mmHg or DBP >100 mmHg.
• Chronic disease apart from diabetes, including type 2 diabetes
• Moderate to severe renal impairment as per calculated creatinine clearance (CLcr) < 90 mL/min according to the Cockcroft-Gault formula (Cockcroft-Gault , 1976)
• Presence or history of macroalbuminuria (>300mg/g creatinine).
• Hepatic dysfunction defined by increased ALT/AST upper limit of normal (ULN) and increased total bilirubin > 3 mg/dL [>51.3 μmol/L]
• Pregnant or breast feeding women. Unwillingness to use effective contraceptive measures up to 4 months after the end of study drug administration (females and males)
• Active infection including hepatitis B, hepatitis C, HIV, or tuberculosis (TB) as determined by a positive skin test or clinical presentation, or under treatment for suspected TB. Positive tests are acceptable only if associated with a history of previous vaccination in the absence of any sign of active infection. Positive tests are otherwise not acceptable, even in the absence of any active infection at the time of evaluation.
• Negative screen for Epstein-Barr Virus (EBV) by IgG determination
• Invasive aspergillus, histoplasmosis, or coccidioidomycosis infection within one year prior to study enrollment
• Any history of malignancy except for completely resected squamous or basal cell carcinoma of the skin
• Known active alcohol or substance abuse
• Baseline Hb below the lower limits of normal at the local laboratory; lymphopenia (<1,000/µL), neutropenia (<1,500/µL), or thrombocytopenia (platelets <100,000/µL). Participants with lymphopenia are allowed if the investigator determines there is no additional risk and obtains clearance from a hematologist
• A history of Factor V deficiency
• Any coagulopathy or medical condition requiring long-term anticoagulant therapy (e.g., warfarin) after transplantation (low-dose aspirin treatment is allowed) or patients with an international normalized ratio (INR) >1.5

• Severe co-existing cardiac disease, characterized by any one of these conditions:

  • a) recent myocardial infarction (within past 6 months)
  • b) evidence of ischemia on functional cardiac exam within the last year
  • c) left ventricular ejection fraction <30%.
• Symptomatic cholecystolithiasis.
• Acute or chronic pancreatitis.
• Symptomatic peptic ulcer disease.
• Severe unremitting diarrhea, vomiting or other gastrointestinal disorders potentially interfering with the ability to absorb oral medications
• Hyperlipidemia despite medical therapy (fasting low-density lipoprotein [LDL] cholesterol >130 mg/dL, treated or untreated; and/or fasting triglycerides >200 mg/dL)
• Receiving treatment for a medical condition requiring chronic use of systemic steroids, except for the use of ≥ 5 mg prednisone daily, or an equivalent dose of hydrocortisone, for physiological replacement only.
• Treatment with any anti-diabetic medication other than insulin within 4 weeks of enrollment
• Use of any investigational agents within 4 weeks of enrollment.
• Administration of live attenuated vaccine(s) within 2 months of enrollment.
• Any medical condition that, in the opinion of the investigator, will interfere with safe participation in the trial.
• Treatment with any immunosuppressive regimen at the time of enrollment.

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: Treated; The investigational treatment will be islet transplant in the presence of induction with ATG/G-CSF and rapamycin treatment for one month. One thousand and five hundred (1,500) equivalent islet for Kg of body weight, isolated from a single brain-dead donor, will be infused into the patient's liver. ATG will be administered IV (central vein) at a total dose of 6 mg/kg up to day 6 post-transplant. Pegylated G-CSF (6 mg/dose) will be administered SC every 2 weeks for 6 doses (12 weeks) beginning after the last ATG infusion. Rapamycin will be administered orally at a starting dose of 0.2 mg/kg once a day, then targeted to blood trough level of 8-10 ng/mL and suspended one month after transplant.

Biological: Human pancreatic islet; One thousand and five hundred (1,500) equivalent islet for Kg of body weight, isolated from a single brain-dead donor, will be infused into the patient's liver.; Drug: ATG; ATG will be administered IV (central vein) at a total dose of 6 mg/kg up to day 6 post-transplant; Drug: Pegylated G-CSF; Pegylated G-CSF (6 mg/dose) will be administered SC every 2 weeks for 6 doses (12 weeks) beginning after the last ATG infusion; Drug: Rapamycin; Rapamycin will be administered orally at a starting dose of 0.2 mg/kg once a day, then targeted to blood trough level of 8-10 ng/mL and suspended one month after transplant.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
plasma C-peptide AUC (mixed meal tolerance test [MMTT])	Mean change from baseline of stimulated plasma C-peptide AUC (mixed meal tolerance test [MMTT])	52 weeks
Incidence of Adverse Events (AEs) and Serious Adverse Events (SAEs)		52 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
plasma C-peptide AUC (MMTT)	Mean change from baseline in stimulated plasma C-peptide AUC (MMTT) at week 4, 12, 26 and month 18, 24, 36, 48, 60	4,12, 26 weeks and 18, 24, 36, 48, 60 months
stimulated plasma C-peptide	Maximum stimulated plasma C-peptide (the highest value at any time point during the MMTT after the mixed meal injection) at baseline, week 4, week 12, week 26 and week 52 and month 18, 24, 36, 48, 60	4,12, 26 weeks and 12, 18, 24, 36, 48, 60 months
glucagon AUC (MMTT)	Mean change from baseline in glucagon AUC (MMTT) at week 4, week 12, week 26 and week 52	4,12, 26, 52 weeks
HbA1c	Change from baseline in HbA1c at week 52 and HbA1c over time	4,12, 26 weeks and 12, 18, 24, 36, 48, 60 months
daily insulin dose	Change from baseline in mean daily insulin dose for the 3 days preceding the visit at weeks 4, 12, 26, 52 and month 18, 24, 36, 48, 60. The mean daily insulin dose value will be calculated, in units of U/kg/day, as the mean of the values of amount of insulin used per day on each of the 3 consecutive days.	4,12, 26 weeks and 12, 18, 24, 36, 48, 60 months
hypoglycaemic events	Number of hypoglycaemic events with confirmed self plasma glucose monitoring <3.1 mmol/L (<56 mg/dL) and/or requiring 3rd party intervention (i.e., severe, documented symptomatic and asymptomatic hypoglycaemic events) overall and in 3 monthly intervals	4,12, 26 weeks and 12, 18, 24, 36, 48, 60 months
72-hour Continuous Glucose Monitoring	Time spent with a plasma glucose <3.9 mmol/L, between 3.9 and 10.0 mmol/L, and >10.0 mmol/L, respectively as performed by 72-hour CGM at baseline, week 26, week 52 and month 24, 36, 48, 60	26 and 52 weeks and 24, 36, 48, 60 months

Collaborators and Investigators

• Sponsor: Ospedale San Raffaele
• Collaborators: Italian Diabetes Foundation
• Investigators: Principal Investigator: Lorenzo Piemonti, MD, IRCCS Ospedale San Raffaele; Study Chair: Emanuele Bosi, MD, IRCCS Ospedale San Raffaele

Study record dates

Study Major Dates

• Study Start (Actual): April 1, 2015
• Primary Completion (Actual): May 1, 2018
• Study Completion (Actual): December 1, 2023

Study Registration Dates

• First Submitted: July 21, 2015
• First Submitted That Met QC Criteria: July 21, 2015
• First Posted (Estimated): July 22, 2015

Study Record Updates

• Last Update Posted (Estimated): February 22, 2024
• Last Update Submitted That Met QC Criteria: February 21, 2024
• Last Verified: February 1, 2024

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Glucose Metabolism Disorders; Metabolic Diseases; Immune System Diseases; Autoimmune Diseases; Endocrine System Diseases; Diabetes Mellitus; Diabetes Mellitus, Type 1; Physiological Effects of Drugs; Anti-Infective Agents; Antineoplastic Agents; Immunosuppressive Agents; Immunologic Factors; Anti-Bacterial Agents; Antibiotics, Antineoplastic; Antifungal Agents; Sirolimus
• Other Study ID Numbers: DRI-MITO 1/2014