Interspecies organogenesis generates autologous functional islets

Journal name:
Nature
Volume:
542,
Pages:
191–196
Date published:
DOI:
doi:10.1038/nature21070
Received
Accepted
Published online

Abstract

Islet transplantation is an established therapy for diabetes. We have previously shown that rat pancreata can be created from rat pluripotent stem cells (PSCs) in mice through interspecies blastocyst complementation. Although they were functional and composed of rat-derived cells, the resulting pancreata were of mouse size, rendering them insufficient for isolating the numbers of islets required to treat diabetes in a rat model. Here, by performing the reverse experiment, injecting mouse PSCs into Pdx-1-deficient rat blastocysts, we generated rat-sized pancreata composed of mouse-PSC-derived cells. Islets subsequently prepared from these mouse–rat chimaeric pancreata were transplanted into mice with streptozotocin-induced diabetes. The transplanted islets successfully normalized and maintained host blood glucose levels for over 370 days in the absence of immunosuppression (excluding the first 5 days after transplant). These data provide proof-of-principle evidence for the therapeutic potential of PSC-derived islets generated by blastocyst complementation in a xenogeneic host.

At a glance

Figures

  1. Generation of apancreatic rats by TALEN-mediated mutagenesis.
    Figure 1: Generation of apancreatic rats by TALEN-mediated mutagenesis.

    a, Schema of concept for treatment of diabetes by interspecies blastocyst complementation. b, Schema of TALEN target site on the rat Pdx1 genome. Left TALEN was designed 3–17 bp downstream of initiation codon; right TALEN was designed 33–49 bp downstream of initiation codon. The uppercase ‘ATG’ represents the start codon of Pdx1. c, Variety of mutations found after TALEN injection. d, Macroscopic appearance of pancreata (dotted line) in rat. Left, newborn wild-type rat; right, absence of pancreata in age-matched Pdx1mu/mu homozygous mutant rat. Scale bars, 0.5 mm.

  2. Generation of rat pancreata by blastocyst complementation.
    Figure 2: Generation of rat pancreata by blastocyst complementation.

    a, Results of embryo manipulation and genotyping of adult rats. b, Macroscopic images at adult stage of rat-PSC-derived pancreata in a Pdx1mu/mu chimaera rat (left) and of chimaeric pancreata generated in a Pdx1+/mu rat. Scale bars, 5 mm. c, Immunohistological appearance of sections of pancreata from a Pdx1mu/mu rat. Sections were stained with haematoxylin and eosin (H&E) (upper) and for EGFP and 4′,6-diamidino-2-phenylindole (DAPI) (lower). Scale bars, 200 μm. d, Immunofluorescence appearance of islets from Pdx1mu/mu rat. Sections were stained for EGFP, anti-insulin antibodies and DAPI. Scale bars, 50 μm. e, Results of GTTs in Pdx1mu/mu (n = 2 females), Pdx1+/mu complemented with rat ES cells (n = 4; 3 males and 1 female), wild-type chimaera rat (WT chimaera; n = 2 males) and wild-type rat (WT; n = 3 males). The mean values ± s.d. were obtained from 2, 3 or 4 independent experiments.

  3. Generation of mouse pancreata in rat by interspecies blastocyst complementation.
    Figure 3: Generation of mouse pancreata in rat by interspecies blastocyst complementation.

    a, Bright-field images of pancreata in Pdx1mu/mu rat generated by blastocyst complementation with mPSCs (upper left) and of Pdx1+/mu rat generated by blastocyst complementation with mPSCs (upper right). Fluorescence images of pancreata in Pdx1mu/mu chimaeric rat (lower left) and of Pdx1+/mu chimaeric rat (lower right). Scale bars, 5 mm. b, Bright-field images of pancreata isolated from 9-week-old wild-type Wistar rat (upper left), 9-week-old Pdx1mu/mu + mPSCs rat (upper right), and 9-week-old wild-type C57BL/6N mouse. Scale bars, 1 cm. c, Immunohistological appearance, sections obtained from pancreata generated in Pdx1mu/mu + mPSCs rat (left panel) and in Pdx1+/mu + mPSCs rat (right panel). Sections were stained with H&E, EGFP and DAPI. Scale bars, 200 μm. d, Immunofluorescence appearance of islet from Pdx1mu/mu + mPSCs rat (left panel) and of Pdx1+/mu + mPSCs rat (left panel). Sections were stained with EGFP (lower left), anti-insulin antibodies (lower right) and DAPI (upper right). Scale bars, 50 μm. e, Results of GTTs in Pdx1mu/mu + mPSCs rat (n = 6; 2 females and 4 males), Pdx1+/mu + mPSCs rat (n = 3 males) and wild-type rat (n = 3 males). The mean values ± s.d. were obtained from 3 or 6 independent experiments.

  4. Transplantation of mouseR islets into mice with drug-induced diabetes.
    Figure 4: Transplantation of mouseR islets into mice with drug-induced diabetes.

    a, Bright-field (left) and fluorescence (middle) images of mouseR islets isolated from Pdx1+/mu (upper) and Pdx1mu/mu (lower) rats. Scale bars, 200, μm. b, FACS images, dissociated islet-containing tissues from C57BL/6N mouse (upper left), Wistar rat (upper right), mouseR in Pdx1+/mu rat (lower left), and mouseR in Pdx1mu/mu rat (lower right). Cells were stained with anti-CD31 antibodies. c, Blood glucose time course after transplantation of islets into male C57BL/6N mice with STZ-induced diabetes. Each mouse received 100 islets. Arrows indicate time points of administration of anti-inflammatory antibodies and tacrolimus. Nonfasting blood glucose levels were measured weekly for 12 months after transplantation. Glucose levels are shown for mice with STZ-induced diabetes transplanted with mouseR islets taken from Pdx1mu/mu host (1st trial, n = 3; 2nd trial, n = 3), Pdx1+/mu host rat (n = 3), with islets derived from syngenic strain of host strain (C57BL/6N) as a positive control (n = 3), and with islets derived from Wistar rat as a negative control (n = 3). Sham transplantation control mice were used as a negative control (n = 3). All data were obtained from 3 independent experiments. NC, negative control; PC, positive control. d, Results of GTTs 60 days after islet transplantation. The mean values ± s.d. were obtained from 3 independent experiments.

  5. The birth rate of Pdx1mu/mu rats and phenotype of Pdx1+/mu rats.
    Extended Data Fig. 1: The birth rate of Pdx1mu/mu rats and phenotype of Pdx1+/mu rats.

    a, Results of mating Pdx1+/muA with Pdx1+/muB. Wild-type, Pdx1+/mu and Pdx1mu/mu rats were born in the mendelian ratio (Χ2 = 2, P = 0.37 by chi-squared test). b, Results of GTTs in Pdx1+/mu. MODY-like hyper-glycaemia were observed in Pdx1+/muA (2 of 6 rats) and Pdx1+/muB (3 of 6 rats). c, Amino acid sequences of Pdx1muA, Pdx1muB and wild-type Pdx1, which are predicted from full-length cDNA derived from mRNA in duodenum of Pdx1muA/muB or Pdx1+/+ rats.

  6. Immunofluorescence photomicrographs of rES-cell-derived pancreata generated in Pdx1mu/mu chimaeric rats.
    Extended Data Fig. 2: Immunofluorescence photomicrographs of rES-cell-derived pancreata generated in Pdx1mu/mu chimaeric rats.

    a, Pancreata sections were stained with antibodies against rat glucagon, rat insulin, rat somatostatin, rat CK19 and rat α-amylase. Scale bars, 100 μm. b, Quantitative analysis of sections of pancreata. Percentages of EGFP-expressing areas in areas that were positive for insulin, glucagon, somatostatin, CK19 or α-amylase were analysed by image J software (n = 3). The mean values ± s.d. were obtained from 3 biological replicates. c, The area under glucose curve (AUC glucose), calculated from GTT data in Fig. 2e. The mean values ± s.d. were obtained from 2 (Pdx1mu/mu + rES cells, WT chimaera), 3 (WT), or 4 (Pdx+/mu + rES cells) independent experiments (P = 0.24 Pdx1+/mu + rESCs versus Pdx1mu/mu + rESCs; P = 0.88 Pdx1mu/mu + rESCs versus WT; P = 0.08 WT chimaera versus WT; P = 0.19 WT chimaera versus Pdx1+/mu + rESCs; Student’s t-test).

  7. Immunofluorescence photomicrographs of miPSC-derived-pancreata generated in Pdx1mu/mu chimaeric rats.
    Extended Data Fig. 3: Immunofluorescence photomicrographs of miPSC-derived-pancreata generated in Pdx1mu/mu chimaeric rats.

    a, Pancreata sections were stained with antibodies against mouse glucagon, mouse insulin, mouse somatostatin, mouse CK19 and mouse α-amylase. Scale bars, 100 μm. b, Quantitative analysis of sections of pancreata. Percentages of EGFP-expressing areas in areas that were positive for insulin, glucagon, somatostatin, CK19 or α-amylase were analysed by Image J software (n = 3). The mean values ± s.d. were obtained from 3 biological replicates. c, AUC glucose, calculated from GTT data in Fig. 3e. The mean values ± s.d. were obtained from 3 (Pdx+/mu + mPSCs; WT), or 6 (Pdxmu/mu + mPSCs) independent experiments (P = 0.20 Pdx1+/mu + mPSCs versus Pdx1mu/mu + mPSCs; P = 0.14 Pdx1mu/mu + mPSCs versus WT; Student’s t-test).

  8. Clinical biochemistry and histologic observations in Pdx1mu/mu chimaeric rat with diabetic-like symptoms.
    Extended Data Fig. 4: Clinical biochemistry and histologic observations in Pdx1mu/mu chimaeric rat with diabetic-like symptoms.

    a, GTTs results, 6 weeks and 10 weeks after birth, in Pdx1mu/mu chimaeric rats that possess mPSC-derived pancreata (chimaeras 183 and 186). Blood sampling at the same time points as in Fig. 3e. Chimaera 186 showed diabetic-like symptoms. b, Photomicrographs of pancreata of Pdx1mu/mu chimaeric rat (chimaera 186) (left) and C57BL/6N mouse pancreata (right). IL, islet of Langerhans; PD, pancreatic duct.

  9. Injection studies of pancreatic duct through common bile duct.
    Extended Data Fig. 5: Injection studies of pancreatic duct through common bile duct.

    PBS-containing trypan blue was injected from the duodenum into the common bile duct (see diagram, bottom) of a wild-type Wistar rat (upper left, before injection; lower left, after injection), Pdx1+/mu chimaeric rat (upper middle, before injection; lower middle, after injection), and a Pdx1mu/mu chimaeric rat (upper right, before injection; lower right, after injection). PBS diffused throughout the pancreata in wild-type rat and Pdx1+/mu chimaeric rat, whereas, in the Pdx1mu/mu chimaeric rat, the PBS was retained in common bile duct and flowed backward to duodenum.

  10. Analysis of transplanted islets.
    Extended Data Fig. 6: Analysis of transplanted islets.

    a, Bright-field (top) and fluorescent (bottom) images of hemi-nephrectomized kidney with (right) or without (left) transplanted islets. b, Transplanted islets, kidney capsule; anti-CD3 and –CD11b, hematoxylin counterstain. Islets lie inside the dotted line (Scale bars: 100 nm). c, Immunohistological analysis of engrafted islets under kidney capsule. Sections were stained with antibody against EGFP, insulin, glucagon and somatostatin and with DAPI. Scale bars, 100 nm. d, Quantitative analysis of sections of engrafted islets. Ratio of insulin-, glucagon- and somatostatin-positive cells were analysed by Image J software (n = 3). The mean values ± s.d. were obtained from 3 biological replicates (P = 0.93 insulin+ area in mouseR islets versus in WT mouse islets; P = 0.89 glucagon+ area in mouseR islets versus in WT mouse islets; P = 0.77 somatostatin+ area in mouseR islets versus in WT mouse islets; Student’s t-test). e, Top, FACS diagrams, dispersed small samples of WT rat kidney (left), WT mouse kidney (middle) and mouse kidney with transplanted islets (right). Cells were stained with fluorophore-tagged antibodies against mouse and rat CD31 (mCD31 and rCD31, respectively). Bottom, FACS diagram, EGFP expression by dispersed cells of mouse kidney with transplanted islets (right) (n = 3).

  11. Analysis of mouseR islets transplanted mice.
    Extended Data Fig. 7: Analysis of mouseR islets transplanted mice.

    a, AUC glucose, calculated from GTT data in Fig. 4d. The mean values ± s.d. were obtained from 3 independent experiments (P < 0.01 A, B or C versus D, E or F, Student’s t-test). b, Nonfasting mouse c-peptide level (pmol l−1) in serum from Pdx1muA/muB + mPSCs chimaera, mouse transplanted with mouseR islets, and C57BL/6 mouse. The lowest value of the x axis represent the lowest limit of detection. The mean values ± s.d. were obtained from 3 biological replicates except for Pdx1mu/mu + mPSCs that was from 2 biological replicates (P < 0.01 Pdx1mu/mu + mPSCs chimaera and mouseR islets transplanted mouse versus STZ treated mouse; P < 0.01 STZ treated mouse versus WT mouse; Student’s t-test). c, Nonfasting rat c-peptide level (pmol l−1) in serum of Pdx1muA/muB + miPSCs chimaera, mouse transplanted with mouseR islets, C57BL/6 mouse and Wistar rat. Values are mean ± s.d. N.D., not detected. The lowest value of the x axis represent the lowest limit of detection. The mean values ± s.d. were obtained from 3 biological replicates, except for Pdx1mu/mu + mPSCs, for which they were obtained from 2 biological replicates.

Tables

  1. Sequence analysis of predicted off-target sites of Pdx1 TALEN
    Extended Data Table 1: Sequence analysis of predicted off-target sites of Pdx1 TALEN

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Author information

  1. These authors contributed equally to this work.

    • Tomoyuki Yamaguchi &
    • Hideyuki Sato

Affiliations

  1. Division of Stem Cell Therapy, Center for Stem Cell Biology and Regenerative Medicine, Institute of Medical Science, University of Tokyo, Minato-ku, Tokyo, Japan

    • Tomoyuki Yamaguchi,
    • Hideyuki Sato,
    • Megumi Kato-Itoh,
    • Naoaki Mizuno,
    • Toshihiro Kobayashi,
    • Ayaka Yanagida,
    • Ayumi Umino,
    • Sanae Hamanaka,
    • Hideki Masaki &
    • Hiromitsu Nakauchi
  2. Center for Genetic Analysis of Behavior, National Institute for Physiological Sciences, Okazaki, Aichi, Japan

    • Teppei Goto,
    • Hiromasa Hara,
    • Makoto Sanbo &
    • Masumi Hirabayashi
  3. Department of Pathology, Research Hospital, Institute of Medical Science, University of Tokyo, Minato-ku, Tokyo, Japan

    • Yasunori Ota
  4. Centre of Stem Cells and Regenerative Medicine and Institute of Liver Studies, King’s College London, UK

    • Sheikh Tamir Rashid
  5. Institute for Stem Cell Biology and Regenerative Medicine, Department of Genetics, Stanford University School of Medicine, Stanford, California, USA

    • Sheikh Tamir Rashid &
    • Hiromitsu Nakauchi

Contributions

T.Y. and H.S. designed, performed, and analysed all experiments and wrote the manuscript. M.I.-K., T.G., H.H., M.S., T.K., A.Y., and A.U. performed embryo manipulation. N.M. performed data analysis. Y.O. performed histopathological analysis. S.H. performed establishment of iPSCs. H.M. performed data analysis. D.T.R. wrote the manuscript. M.H. performed embryo manipulation and data analysis. H.N. designed the study and wrote the manuscript.

Competing financial interests

H.N. is a co-founder and shareholder of iCELL Inc., ChimaERA Corporation and ReproCELL Inc.

Corresponding author

Correspondence to:

Reviewer Information Nature thanks H. Lickert, Q. Zhou and the other anonymous reviewer(s) for their contribution to the peer review of this work.

Author details

Extended data figures and tables

Extended Data Figures

  1. Extended Data Figure 1: The birth rate of Pdx1mu/mu rats and phenotype of Pdx1+/mu rats. (324 KB)

    a, Results of mating Pdx1+/muA with Pdx1+/muB. Wild-type, Pdx1+/mu and Pdx1mu/mu rats were born in the mendelian ratio (Χ2 = 2, P = 0.37 by chi-squared test). b, Results of GTTs in Pdx1+/mu. MODY-like hyper-glycaemia were observed in Pdx1+/muA (2 of 6 rats) and Pdx1+/muB (3 of 6 rats). c, Amino acid sequences of Pdx1muA, Pdx1muB and wild-type Pdx1, which are predicted from full-length cDNA derived from mRNA in duodenum of Pdx1muA/muB or Pdx1+/+ rats.

  2. Extended Data Figure 2: Immunofluorescence photomicrographs of rES-cell-derived pancreata generated in Pdx1mu/mu chimaeric rats. (823 KB)

    a, Pancreata sections were stained with antibodies against rat glucagon, rat insulin, rat somatostatin, rat CK19 and rat α-amylase. Scale bars, 100 μm. b, Quantitative analysis of sections of pancreata. Percentages of EGFP-expressing areas in areas that were positive for insulin, glucagon, somatostatin, CK19 or α-amylase were analysed by image J software (n = 3). The mean values ± s.d. were obtained from 3 biological replicates. c, The area under glucose curve (AUC glucose), calculated from GTT data in Fig. 2e. The mean values ± s.d. were obtained from 2 (Pdx1mu/mu + rES cells, WT chimaera), 3 (WT), or 4 (Pdx+/mu + rES cells) independent experiments (P = 0.24 Pdx1+/mu + rESCs versus Pdx1mu/mu + rESCs; P = 0.88 Pdx1mu/mu + rESCs versus WT; P = 0.08 WT chimaera versus WT; P = 0.19 WT chimaera versus Pdx1+/mu + rESCs; Student’s t-test).

  3. Extended Data Figure 3: Immunofluorescence photomicrographs of miPSC-derived-pancreata generated in Pdx1mu/mu chimaeric rats. (800 KB)

    a, Pancreata sections were stained with antibodies against mouse glucagon, mouse insulin, mouse somatostatin, mouse CK19 and mouse α-amylase. Scale bars, 100 μm. b, Quantitative analysis of sections of pancreata. Percentages of EGFP-expressing areas in areas that were positive for insulin, glucagon, somatostatin, CK19 or α-amylase were analysed by Image J software (n = 3). The mean values ± s.d. were obtained from 3 biological replicates. c, AUC glucose, calculated from GTT data in Fig. 3e. The mean values ± s.d. were obtained from 3 (Pdx+/mu + mPSCs; WT), or 6 (Pdxmu/mu + mPSCs) independent experiments (P = 0.20 Pdx1+/mu + mPSCs versus Pdx1mu/mu + mPSCs; P = 0.14 Pdx1mu/mu + mPSCs versus WT; Student’s t-test).

  4. Extended Data Figure 4: Clinical biochemistry and histologic observations in Pdx1mu/mu chimaeric rat with diabetic-like symptoms. (730 KB)

    a, GTTs results, 6 weeks and 10 weeks after birth, in Pdx1mu/mu chimaeric rats that possess mPSC-derived pancreata (chimaeras 183 and 186). Blood sampling at the same time points as in Fig. 3e. Chimaera 186 showed diabetic-like symptoms. b, Photomicrographs of pancreata of Pdx1mu/mu chimaeric rat (chimaera 186) (left) and C57BL/6N mouse pancreata (right). IL, islet of Langerhans; PD, pancreatic duct.

  5. Extended Data Figure 5: Injection studies of pancreatic duct through common bile duct. (306 KB)

    PBS-containing trypan blue was injected from the duodenum into the common bile duct (see diagram, bottom) of a wild-type Wistar rat (upper left, before injection; lower left, after injection), Pdx1+/mu chimaeric rat (upper middle, before injection; lower middle, after injection), and a Pdx1mu/mu chimaeric rat (upper right, before injection; lower right, after injection). PBS diffused throughout the pancreata in wild-type rat and Pdx1+/mu chimaeric rat, whereas, in the Pdx1mu/mu chimaeric rat, the PBS was retained in common bile duct and flowed backward to duodenum.

  6. Extended Data Figure 6: Analysis of transplanted islets. (842 KB)

    a, Bright-field (top) and fluorescent (bottom) images of hemi-nephrectomized kidney with (right) or without (left) transplanted islets. b, Transplanted islets, kidney capsule; anti-CD3 and –CD11b, hematoxylin counterstain. Islets lie inside the dotted line (Scale bars: 100 nm). c, Immunohistological analysis of engrafted islets under kidney capsule. Sections were stained with antibody against EGFP, insulin, glucagon and somatostatin and with DAPI. Scale bars, 100 nm. d, Quantitative analysis of sections of engrafted islets. Ratio of insulin-, glucagon- and somatostatin-positive cells were analysed by Image J software (n = 3). The mean values ± s.d. were obtained from 3 biological replicates (P = 0.93 insulin+ area in mouseR islets versus in WT mouse islets; P = 0.89 glucagon+ area in mouseR islets versus in WT mouse islets; P = 0.77 somatostatin+ area in mouseR islets versus in WT mouse islets; Student’s t-test). e, Top, FACS diagrams, dispersed small samples of WT rat kidney (left), WT mouse kidney (middle) and mouse kidney with transplanted islets (right). Cells were stained with fluorophore-tagged antibodies against mouse and rat CD31 (mCD31 and rCD31, respectively). Bottom, FACS diagram, EGFP expression by dispersed cells of mouse kidney with transplanted islets (right) (n = 3).

  7. Extended Data Figure 7: Analysis of mouseR islets transplanted mice. (173 KB)

    a, AUC glucose, calculated from GTT data in Fig. 4d. The mean values ± s.d. were obtained from 3 independent experiments (P < 0.01 A, B or C versus D, E or F, Student’s t-test). b, Nonfasting mouse c-peptide level (pmol l−1) in serum from Pdx1muA/muB + mPSCs chimaera, mouse transplanted with mouseR islets, and C57BL/6 mouse. The lowest value of the x axis represent the lowest limit of detection. The mean values ± s.d. were obtained from 3 biological replicates except for Pdx1mu/mu + mPSCs that was from 2 biological replicates (P < 0.01 Pdx1mu/mu + mPSCs chimaera and mouseR islets transplanted mouse versus STZ treated mouse; P < 0.01 STZ treated mouse versus WT mouse; Student’s t-test). c, Nonfasting rat c-peptide level (pmol l−1) in serum of Pdx1muA/muB + miPSCs chimaera, mouse transplanted with mouseR islets, C57BL/6 mouse and Wistar rat. Values are mean ± s.d. N.D., not detected. The lowest value of the x axis represent the lowest limit of detection. The mean values ± s.d. were obtained from 3 biological replicates, except for Pdx1mu/mu + mPSCs, for which they were obtained from 2 biological replicates.

Extended Data Tables

  1. Extended Data Table 1: Sequence analysis of predicted off-target sites of Pdx1 TALEN (1,960 KB)

Comments

  1. Report this comment #69421

    Majid Ali said:

    Shifting Focus From Glycemic Status to Insulin Homeostasis

    Type 2 Diabetes (T2D) is rapidly eclipsing other chronic diseases in becoming the preeminent threat to human health worldwide. In 2013, prevalence rate of 50.1% for prediabetes and T2D among the Chinese adults was reported (ref. 1). When relevant data becomes available, the prevalence of T2D in India and some other countries is likely to exceed this rate.

    The work of Yamaguchi and colleagues must be celebrated in this larger context. Their previous work involved generation of whole organs from donor pluripotent stem cells using their chimaera-forming ability to complement organogenesis-disabled host animals in vivo (ref. 2). They now report generation of autologous functional islets with interspecies organogenesis through interspecies blastocyst complementation (ref.3). This stellar work advances the goal of treating diabetes with islet transplantation. Here, Yamaguchi et al. also put forth a serious challenge to us physicians: How do we protect transplanted islet cells from the host elements that caused hyperinsulinism leading to Type 2 diabetes in the first place?

    Hyperinsulinism is the underlying molecular lesion of T2D since it predates the disease by five to ten or more years. Prior to its progression to T2D, it exerts several well-established adverse metabolic, inflammatory, cardiovascular, and neurologic effects (ref. 4). Earlier this year, this writer and his coworkers reported prevalence rate of 75.1% for hyperinsulinism in 684 subjects in the general population of New York Metropolitan area (ref. 5). Hyperinsulinism in this study was established with fasting, 1-hour, 2-hour, and 3-hour post-glucose-challenge blood insulin concentrations. Notably, in a companion study, mild-to-moderate degrees of hyperinsulinism were encountered in the majority of 25 children with autism (12) and dysautonomia (13), (ref. 6).

    Effective hyperinsulinism modification strategy to preserve transplanted islet cells and prevent T2D requires a clear understanding of core aspects of optimal insulin homeostasis, for the clinician as well as the patient, including differential responses to carbohydrate and non-carbohydrate challenges in insulin-based care of metabolic disorders, such as prediabetes, T2D, and gestational diabetes (ref. 7,8).

    Yamaguchi et al (ref.3) provide us with tools to meet the challenge of large-scale islet transplantation through laboratory generation of unlimited quantities of replacement cells and tissues. Now we physician need to make robust efforts to protect the transplanted islet cells from dietary, gut-related, environmental, and lifestyle stress factors that set the stage for hyperinsulinism-to-T2D continuum. This will require shifting focus from glycemic status to insulin homeostasis for stemming global tides of hyperinsulinism and diabetes (ref. 5).

    References

    1. 1. Xu Y, Wang L, He J. et al. Prevalence of diabetes in Chinese adults. JAMA. 2013.
    2. Kobayashi T, Yamaguchi T, Hamanaka S, et al. Generation of rat pancreas in mouse by interspecies blastocyt injection of pluripotent stem cells. Cell. 2010;142:787-799.
    3. Yamaguchi T, Sato H, Kato-Itoh MInterspecies organogenesis generates autologous functional islets. Nature. 2017;542:191-6.
    4. Shoelson SE, Lee J, Goldfine AB. Inflammation and insulin resistance. J. ClinInvest. 2006;116:1793-1801.
    5. Ali M, Fayemi AO, Ali O, Dasoju S, Chaudhary D, Hameedi S, Amin J, Ali K, and Svoboda B. Shifting focus from glycemic status to insulin homeostasis for stemming global tides of hyperinsulinism and Type 2 diabetes. Townsend Letter – The examiner of Alternative Medicine. 2017;402:91-96.
    6. Ali M. Molecular basis of Autism and Dysautonomia. Townsend Letter – The examiner of Alternative Medicine . In Press.
    7. Ali M. Desoju S, Karim N, Amin J, et al. et al. Study of responses to carbohydrate and non-carbohydrate challenges in insulin-based care of metabolic disorders. Townsend Letter-The examiner of Alternative Medicine. 2016;391:48-51.
    8. Ali M. Importance of Subtyping Diabetes Type 2 Into Diabetes Type 2A and Diabetes Type 2B. Townsend Letter-The examiner of Alternative Medicine. 2014; 369:56-58.

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