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Overcoming barriers in clinical islet transplantation: current limitations and future prospects.

Type 1 diabetes (T1D) has been determined to be an autoimmune disease involving the selective destruction of insulin-producing β-cells in the pancreatic islets of Langerhans that results in the progressive loss of insulin secretion and ultimately in glycometabolic dysregulation. As many as 3 million Americans may have T1D, and according to the most recent population-based estimates of diabetes incidence and prevalence, the number of youth with T1D will increase by more than 20% over the next 40 years. Complications associated with long-standing T1D include retinopathy, neuropathy, and nephropathy, as well as cerebrovascular and cardiovascular disease. Discovering strategies that could prevent or arrest the onset and progression of autoimmune T1D, reverse β-cell destruction, and permanently restore glycometabolic control preferably without long-term immunosuppression is the ultimate goal of clinical intervention. The current treatment for T1D is primarily focused on the combination of intensive diet management along with lifelong insulin administration, either by multiple daily injections or more recently through pump delivery. Tight glucose control through insulin therapy has succeeded in preventing and even reversing long-term complications of T1D in some patients, but the treatment often renders patients susceptible to severe episodes of hypoglycemia and hypoglycemic unawareness. Recent innovations in insulin therapy have succeeded in achieving more physiological glycometabolic control. For instance, genetically modified recombinant human insulin analogues, aspart and lispro insulin, are rapid acting, with faster onset and offset than regular insulin given subcutaneously, which allows both prandial and corrective boluses. BIOD-123 and BIOD-125 are ultrarapid-acting recombinant human insulin analogues with acceptable injection site toleration that have an even faster absorption rate and onset of action compared with insulin lispro. Degludec, an ultralong-acting basal insulin analogue, was shown to improve glycemic control and lower the risk of nocturnal hypoglycemia better than long-acting insulin analogue, glargine, in basal-bolus treatment with mealtime insulin aspart in patients with T1D. Similarly, development of the “artificial pancreas,” an integrated closed-loop control system that combines continuous glucose monitoring with subcutaneous insulin infusion, has been shown to significantly improve glycemic control, although refinement for routine ambulatory use is still in evolution. Despite advances such as these, insulin therapy alone has not been successful in reducing the frequency of hypoglycemic