Omental Islet Transplant

Inclusion Criteria:

1. Male and female patients age 18 to 65 years of age.
2. Ability to provide written informed consent.
3. Mentally stable and able to comply with the procedures of the study protocol.
4. Clinical history compatible with T1D with onset of disease at <40 years of age, insulin-dependence for > 5 years at the time of enrollment, and a sum of subject age and insulin-dependent diabetes duration of ≥28.
5. Absent stimulated c-peptide (<0.3 ng/mL) in response to a MMTT (Boost® 6 mL/kg body weight to a maximum of 360 mL; another product with equivalent caloric and nutrient content may be substituted for Boost®) measured at 60 and 90 min after the start of consumption.
6. Involvement in intensive diabetes management, defined as self-monitoring of glucose values no less than a mean of three times each day averaged over each week and by the administration of three or more insulin injections each day or insulin pump therapy. Such management must be under the direction of an endocrinologist, diabetologist, or diabetes specialist, with at least 3 clinical evaluations during the 12 months prior to study enrollment.
7. At least one episode of severe hypoglycemia in the 12 months prior to study enrollment.
8. Reduced awareness of hypoglycemia as defined by a Clarke score of 4 or more OR A HYPO score greater than or equal to the 90th percentile (1047) during the screening period; OR Marked glycemic lability characterized by wide swings in blood glucose (BG) despite optimal diabetes therapy and defined by an LI score greater than or equal to the 90th percentile (43 mmol/L2/h·wk-1) during the screening period; OR A composite of a Clarke score of 3 or less and a HYPO score greater than or equal to the 75th percentile (423) and a LI greater than or equal to the 75th percentile (329) during the screening period.

Exclusion Criteria:

1. Body Mass Index (BMI) >30 kg/m2 or patient weight ≤50 kg.
2. Insulin requirement of >1.0 IU/kg/day or <15 U/day.
3. HbA1c >10%.
4. Untreated proliferative diabetic retinopathy.
5. Blood Pressure: systolic blood pressure (SBP) >160 mmHg or diastolic blood pressure (DBP) >100 mmHg.
6. Measured glomerular filtration rate <80 mL/min/1.73 m2 calculated using the subject's measured serum creatinine and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation1 or Modification of Diet in Renal Disease [MDRD] study estimation formula). Strict vegetarians (vegans) with a calculated GFR <70 mL/min/1.73m2 are excluded. The absolute (raw) GFR value will be used for subjects with body surface areas >1.73m2
7. Presence or history of macroalbuminuria (>300mg/g creatinine).
8. Presence or history of panel-reactive anti-HLA antibodies above background by flow cytometry.
9. For female subjects: Serum or urine Positive pregnancy test, presently breast-feeding, or unwillingness to use effective contraceptive measures for the duration of the study and 4 months after discontinuation. For male subjects: intent to procreate during the duration of the study or within 4 months after discontinuation or unwillingness to use effective measures of contraception. If sexually active, subject must use at least two medically accepted methods of birth control from the following list: oral contraceptives, Norplant®, Depo-Provera®, intrauterine device (IUD), barrier devices with spermicide. Condoms used alone are not acceptable. Instead of the male condom, it is acceptable to use a female condom with one of the other methods for women listed above.
10. Presence or history of active infection including hepatitis B, hepatitis C, HIV, or tuberculosis (TB) Subjects with laboratory evidence of active infection are excluded even in the absence of clinical evidence of active infection.
11. Negative screen for Epstein-Barr Virus (EBV) by IgG determination.
12. Invasive aspergillus, histoplasmosis, and coccidioidomycosis infection within one year prior to study enrollment.
13. Any history of malignancy except for completely resected squamous or basal cell carcinoma of the skin.
14. Known active alcohol or substance abuse.
15. 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 obtain clearance from a hematologist.
16. A history of Factor V deficiency.
17. 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.

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

    1. recent myocardial infarction (within past 6 months).
    2. evidence of ischemia on functional cardiac exam within the last year.
    3. left ventricular ejection fraction <30%.
19. Persistent elevation of liver function tests at the time of study entry. Persistent serum glutamic-oxaloacetic transaminase (SGOT [AST]), serum glutamate pyruvate transaminase (SGPT [ALT]), Alk Phos or total bilirubin, with values >1.5 times normal upper limits will exclude a patient.
20. Symptomatic cholecystolithiasis.
21. Acute or chronic pancreatitis.
22. Symptomatic peptic ulcer disease.
23. Severe unremitting diarrhea, vomiting, or other gastrointestinal disorders potentially interfering with the ability to absorb oral medications.
24. Hyperlipidemia despite medical therapy (fasting low-density lipoprotein [LDL] cholesterol > 130 mg/dL (3.36 mmol/L), treated or untreated; and/or fasting triglycerides > 200 mg/dL (2.26 mmol/L)).
25. 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.
26. Treatment with any anti-diabetic medications other than insulin within 4 weeks of enrollment.
27. Use of any investigational agents within 4 weeks of enrollment.
28. Administration of live attenuated vaccine(s) within 2 months of enrollment.
29. Any medical condition that, in the opinion of the investigator, will interfere with the safe participation in the trial.
30. Treatment with any immunosuppressive regimen at the time of enrollment.
31. A previous islet transplant.
32. A previous pancreas transplant, unless the graft failed within the first week due to thrombosis, followed by pancreatectomy and the transplant occurred more than 6 months prior to enrollment.
33. Inflammatory bowel disease.
34. History of intestinal obstructions.
35. Previous major abdominal surgery.
36. History of peritonitis.