This chapter will review studies that examine the immune response to porcine neonatal pancreatic cell clusters (NPCC) in small and large animal models; specifically, the immune mechanisms that lead to the rejection of transplanted islet cells in mice, nonhuman primates, and humans will be discussed. In addition, current research on the in vitro and in vivo human immune responses to porcine NPCC is also included. Research into the immune responses that lead to islet cell death posttransplant allows for further understanding of how to better protect transplanted porcine NPCC in humans. Furthermore, this chapter will examine immune‐related strategies that have shown to extend the life and/or function of porcine NPCC in vitro and in vivo, including techniques that work to modulate the immune system of the islet cell donor and/or the recipient. Finally, this chapter will identify future areas of research that have yet to be examined extensively in the literature, mostly pertaining to the human immune response to porcine NPCC in the clinical setting.
- complement and innate immunology
- cell and tissue xenotransplantation
- neonatal pancreatic cell clusters (NPCC)
Clinical islet cell transplantation is currently considered as an alternative option for the treatment of unstable type 1 diabetes. Despite recent progress in the field, transplant recipients continue to experience a progressive loss of insulin independence for reasons that are not well understood . In addition, the shortage of human islet cell donors and the necessity of chronic immunosuppressant drugs are major barriers to the widespread application of islet cell transplantation in clinical practice.
Xenotransplantation addresses the shortage of available human donors in transplantation medicine. Porcine neonatal pancreatic cell clusters (NPCC) remain a strong option for islet cell xenotransplantation due to their relative ease of acquisition and low cost, as well as similarities in physiology between pig and human islet cells . Similar to islet cell allotransplantation, the efficacy of transplanted porcine NPCC into animal models is limited by posttransplant cell damage likely resulting from acute host‐mediated inflammatory and oxidative stress, as well as chronic immune cell‐mediated responses.
This chapter will review studies that examine the immune response to porcine NPCC in small and large animal models; specifically, the immune mechanisms that lead to the rejection of transplanted islets in mice, nonhuman primates, and humans will be discussed. Research into the immune responses that lead to islet cell death posttransplant allows for further understanding of how to better protect transplanted porcine NPCC in humans. Furthermore, this chapter will examine immune‐related strategies that have shown to extend the life and/or function of porcine NPCC both
2. Background and history
Islet transplantation began in the 1970s, when Ballinger et al. demonstrated that diabetic rats could be made normoglycemic through injection of islet isografts into the portal vein . Not long afterwards, the University of Minnesota performed successful autologous islet transplantations in patients that had undergone near‐complete pancreatectomies . From these experiments arose the goal of clinical islet transplantation as a viable treatment for type 1 diabetes.
However, the integration of islet transplantation into the clinical setting has seen several setbacks. Firstly, islet transplant recipients invariably return to a hyperglycemic state. Long‐term follow‐up of the earliest successful transplant recipients found that over 80% of these patients did not remain normoglycemic at the end of 2 years, even with adequate immunosuppression . Further understanding of islet isolation protocols and the immune response to islet transplants has allowed for the 2‐year failure rate to fall to 50% ; however, this remains a large barrier to the use of islet transplantation in a clinical setting. Secondly, as is true across the field of transplantation, there is a large shortage of donor tissue available. Xenotransplantation attempts to address this issue.
While the idea of xenotransplantation dates back to the sixteenth century, it was not until the 1980s that a better understanding of immunosuppression allowed for clinical islet xenotransplantation to be attempted with any success . From 1990 to 1993, Groth et al. performed islet xenotransplants with NPCC into 10 type 1 diabetic patients . Though all 10 patients remained insulin dependent, 4 patients secreted small amounts of insulin up to 400 days posttransplant. In 2002, at the XIXth International Congress of the Transplantation Society, Valdes‐Gonzalaez et al. reported 12 transplants of NPCC into children with type‐1 diabetes . At 1‐year posttransplant, five of the patients who received transplants required less insulin, and one patient was entirely insulin‐independent. Most recently, Matsumoto et al. demonstrated that transplantation of encapsulated NPCC into the peritoneal cavity of patients with type 1 diabetes was able to maintain normoglycemia in these patients for over 600 days posttransplant without immunosuppression . These experiments demonstrate that transplantation of NPCC could have a place in the clinical treatment of type 1 diabetes.
While xenotransplantation comes with its own set of immune‐related complications, scientists still believe that islet xenografts are a good alternative to islet allografts. Because they are much less vascular, islet transplants are less immunogenic than full organ transplants, and so do not present the same challenges that a heart or kidney xenotransplantation would present. In addition, NPCC are relatively low cost and easily acquired, and would therefore solve the problem of islet donor shortage. Unfortunately, the problem of islet transplant recipients’ inevitable return to a hyperglycemic state is also a problem in xenotransplantation.
As is seen in islet allotransplantation, immunosuppression techniques increase the lifespan of islet xenografts
3. Ideal age of porcine islet donors
3.1. Adult porcine islets
Successful autograft, allograft, and xenograft transplantation has been done using adult porcine islets. There are several advantages to obtaining islets from older pigs. Firstly, larger numbers of islets can be obtained from a single adult pig pancreas. Secondly, these mature islets, when isolated, are individually larger in size (Figure 1) and the potential for insulin secretion is greater . This has been demonstrated in several studies, which have shown that the return to normoglycemia is faster post transplantation in experiments with mice and nonhuman primates [12, 14, 15]. Lastly, adult porcine islets express certain immunogenic antigens, such as galactose alpha 1,3‐galactose (alpha Gal) to a lesser extent than neonatal  or fetal porcine islets .
Unfortunately, adult porcine islets are delicate. They are more susceptible to ischemic injury and so are difficult to keep viable in culture [17, 18]. Also, the quality of islets obtained from adult pigs varies greatly depending on the exact age and breed of the donor pig [13, 19]. Lastly, although adult porcine islets express certain antigens to a lesser extent as stated above, it is thought that islets isolated from adult pigs are overall more immunogenic than islets from neonatal or fetal pigs, increasing the need for immunosuppressive drug regimens [2, 16].
3.2. Porcine neonatal pancreatic cell clusters
Porcine NPCC have also been used to successfully reverse diabetes in small [8, 10, 20] and large animal models [9, 21]. It is widely believed that neonatal pigs are the best source of islets for xenotransplantation, for several reasons. Firstly, the pancreas of a neonatal pig is less fibrous and the islets are easier to isolate than those of an adult pig. Porcine NPCC also maintain growth capacity after isolation, and may continue to grow even after transplantation . They also appear to be less susceptible to ischemic injury after isolation and keep better in culture [17, 18].
Disadvantages of using porcine NPCC include an increased time to return islet recipients to normoglycemia due to their immature nature compared to adult islets (Figure 1). NPCC also have an increased presence of antigens on their surface (i.e., alpha Gal), and require a high number of donor pigs for a single transplantation [2, 13, 18].
3.3. Porcine fetal pancreatic cell clusters (FPCC)
Porcine FPCC have many of the same advantages that porcine NPCC have, including the resilience of the cells to ischemic injury and the ability to mature and maintain growth capacity after isolation .
However, fetal islets have shown to secrete very small amounts of insulin in response to glucose stimulation and can take up to months to achieve normoglycemia, even in small animal models. Much like porcine NPCC, many donor pigs are required for a single transplantation . Neither large animal islet allotransplantation nor nonhuman primate xenotransplantation has been successfully achieved with porcine FPCC.
4. Immune response in mouse
Many studies examining the postporcine NPCC transplantation immune response have been performed in rodent models. Mice are often used as a mammalian model organism, due to relative ease of acquisition, short gestation period, and well‐studied and sequenced genome. C57BL/6 mice in particular are the most widely used rodent in laboratory experiments, and have been used extensively in the study of postislet transplantation environment.
4.1. Hyperacute rejection
If the serum of the transplant recipient has natural preformed antibodies with specificity for antigens on the transplanted tissue, a process known as hyperacute rejection can occur. This can lead to an antibody‐mediated destruction of the transplant that begins immediately after transplantation. The presence of preformed natural antibodies against the transplant can occur from prior exposure to either the antigen present on the transplant or an antigen similar enough that it can be recognized by the same antibody. This becomes especially important in xenotransplantation, as different species express antigens that can be recognized by preformed natural antibodies commonly made by the human immune system.
The main difference in hyperacute rejection of pig‐to‐rodent transplants is that these species share a similarity that pigs and nonhuman primates and pigs and humans do not. Pigs and rodents, along with most other mammals, synthesize the enzyme alpha 1,3‐galactosyltransferase and produce alpha Gal, and so do not produce anti‐Gal antibodies . Some nonhuman primates and humans lack this enzyme, and therefore do produce anti‐alpha Gal antibodies. Hyperacute rejection occurs in pig‐to‐nonhuman primates and pig‐to‐human xenotransplants when preformed natural antibodies in the recipient, largely anti‐alpha Gal antibodies, recognize alpha Gal present within the transplanted tissue. Anti‐alpha Gal antibody‐mediated rejection does not occur in the mouse model. Because of this difference and the resulting lack of clinical application, hyperacute rejection in mouse models is not a main focus of xenotransplantation research.
4.2. Instant blood‐mediated inflammatory reaction (IBMIR)
Islet transplantation triggers an inflammatory reaction when transplanted intravascularly in mice. This reaction involves activation of the coagulation cascade and complement pathways, which damages the transplanted islets. These events are known to occur in all transplants, including autologous transplants, but it has been shown that IBMIR occurs on a larger scale in xenotransplantation .
However, IBMIR in the pig‐to‐mouse model has been poorly researched. This is because islet transplantation in mice is often not done by injecting the porcine NPCC into the portal vein and is instead done through injecting the porcine NPCC into the peritoneum (for encapsulated porcine NPCC) or under the kidney capsule. This does not allow for an IBMIR response that would be comparable to nonhuman primate or human islet transplantation models.
A study that did attempt transplantation into the portal vein of mice showed that the inflammatory mediators in the posttransplant environment are largely acute‐phase cytokines, such as TNFα and IFN‐γ . It has been shown that blockade of these inflammatory pathways, such as by using an anti‐TNFα antibody, improved the survival of the islet transplant and improved glucose tolerance
4.3. Adaptive immune response
T cell‐mediated rejection is key in the rejection of porcine NPCC xenografts by mouse recipients . There are two pathways of antigen recognition by T cells that are important in transplantation: the direct pathway and the indirect pathway. The direct pathway occurs when T cells recognize an antigen that is presented on the surface of a donor antigen‐presenting cell (APC). The indirect pathway occurs when the T cells recognize an antigen that is presented on the surface of a host APC. Activation of either of these pathways can lead to subsequent activation of T cells and destruction of a transplant .
The indirect pathway of T cell activation becomes increasingly dominant as the evolutionary disparity between the transplant donor and recipient increases; likewise, the direct pathway of T cell activation is dominant in the rejection of allotransplants. As expected, in the pig‐to‐mouse xenotransplant, the indirect pathway is responsible for T cell‐mediated rejection [25, 26]. It has been demonstrated that CD4+ T cell activation is essential for porcine NPCC xenograft rejection to occur, whereas CD8+ T cells are only minimally involved .
5. Immune response in nonhuman primate
Nonhuman primates (NHP), specifically old world monkeys, constitute the only research animal in which the occurrence of transplant rejection and the efficacy of immunosuppression can be observed in the presence of a human‐like complicated and redundant immune system. As such, numerous studies of pig‐to‐NHP islet xenotransplantation have been responsible for the discovery of important immune mechanisms involved in causing posttransplantation graft damage.
5.1. Hyperacute rejection
As previously stated, the difference in evolutionary diversity between pigs and monkeys cause a different hyperacute rejection process than in the pig‐to‐rodent model. The carbohydrate alpha Gal is accepted to be the epitope responsible for immediate xenograft destruction of porcine islets in nonhuman primates .
Alpha Gal is expressed by all animal species, including pigs, and many bacterial species. However, in humans and old world monkeys, the evolutionary loss of enzyme alpha 1,3‐galactosyltransferase has led to the inability to synthesize alpha Gal. It is hypothesized that exposure to microorganisms shortly after birth cause humans and old world monkeys to synthesize anti‐alpha Gal antibodies [27, 28]. These antibodies remain in blood circulation and are thought to be responsible for the destruction of Gal‐expressing porcine NPCC within minutes of transplantation .
As discussed above, porcine NPCC show the most promise in islet transplantation. Unfortunately, porcine NPCC have a higher expression of alpha Gal when compared to adult porcine islets, which express alpha Gal only minimally . The use of genetically modified pigs that have the enzyme alpha 1,3‐galactosyltransferase knocked out (GTKO) remains a large area of research interest for this reason. However, even with the use of GTKO porcine NPCC, acute rejection still occurs (though to a lesser extent) . This suggests that more porcine NPCC antigens are recognized by antibodies in nonhuman primates. Two have been identified: N‐glycolylneuraminic acid (NeuGc) and β1,4 N‐acetylgalactosaminyltransferase (B4GALNT2) . Interestingly, Stewart et al. have demonstrated that treating nonhuman primates with alpha adrenergic agonist clonidine inhibits the production of these additional “antinon‐Gal” antibodies .
Porcine NPCC are susceptible to IBMIR when exposed to the blood of nonhuman primates . This reaction involves platelet activation, complement cascade activation, and mononuclear cell infiltration in the first hours to days following transplantation . Alpha Gal is also thought to be implicated in this inflammatory response. When Komoda et al. developed a transgenic pig that overexpresses an enzyme, which prevented the formation of alpha Gal and transplanted NPCC from this pig to diabetic nonhuman primates, the transplant did not undergo hyperacute rejection and showed less activation of the complement cascade .
This reaction occurs regardless of immune cell‐mediated rejection and is thought to involve tissue factor production, but the specific pathways behind this event are poorly understood. It has been shown that even with the depletion of the components of the complement system in nonhuman primates, IBMIR still occurs, although the destruction of the islet graft is decreased .
Innate immune cells have also been implicated in islet xenograft rejection. In nonhuman primate models, neutrophils and macrophages have been temporally associated with the failure of porcine NPCC grafts .
5.3. Adaptive immune response
Aside from the antibody‐mediated rejection of xenografts that was mentioned during the discussion of hyperacute rejection, the response of the adaptive immune system to porcine NPCC in the nonhuman primate model has not been studied to the extent that it has been in the rodent model.
Available research shows through analysis of transcript levels in inadequately immunosuppressed nonhuman primates that a T cell‐dependent antibody response occurs posttransplantation, resulting in high levels of antiporcine IgG . The results of other studies support this idea, and have demonstrated that immunosuppressive agents that result in a blockade of T cell costimulation maintain normoglycemia in diabetic monkeys for over a year .
6. Immune response in human
The immune response to porcine NPCC in human models is poorly understood, due to a lack of a suitable experimental model. Because it is not possible to assess the human immune response
6.1. Hyperacute rejection
Because of the evolutionary similarity between nonhuman primates and humans, the immune response to porcine NPCC transplant may be very similar in both species. As in nonhuman primates, the carbohydrate alpha Gal is accepted to be the epitope responsible for the hyperacute destruction of porcine NPCC when exposed to human blood
As previously stated, evolutionary loss of enzyme alpha 1,3‐galactosyltransferase in humans and old world monkeys led to the inability of either species to synthesize alpha Gal. It is hypothesized that exposure to microorganisms shortly after birth causes humans and old world monkeys to synthesize anti‐alpha Gal antibodies [27, 28]. This becomes an issue especially with the use of porcine NPCC, as they express alpha Gal on their surface to a significant extent .
Much like is seen in the immune response in nonhuman primates, islet grafts undergo IBMIR once exposed to human blood. Studies have shown that this damage affects the integrity and viability of the cell membranes within the islet cell cluster and leads to an initial 25% loss of transplanted islets in
In studies involving the exposure of porcine NPCC to human blood, activation of the coagulation cascade produced proinflammatory thrombin at high concentrations, which exacerbated the destruction of the transplanted islet cells . In reconstituted animal models, complement activation was demonstrated by the increase in concentration of complement proteins in the serum of transplant recipients . Specifically, complement proteins C4d and C5b‐9 have been implicated in IBMIR, implicating the classical complement pathway in xenograft destruction . Complement protein Bb, a marker of the alternative complement pathway, also appears to be involved in IBMIR‐related graft destruction, but not when islets from genetically engineered pigs (GTKO/CD46) are used .
In addition, activated neutrophils interacting with components of the coagulation cascade appear to be essential in the early loss of xenograft function in human models . It has been demonstrated that the mechanisms by which this loss occurs include phagocytosis and secretion of reactive oxygen species (ROS) and proteinases by neutrophils .
6.3. Adaptive immune response
The response of the adaptive immune system to porcine NPCC in the human model is poorly studied, aside from what is understood about hyperacute rejection. What is known, however, is that the rejection of porcine NPCC xenografts
Little research has been done into the specific pathways of T cell rejection of porcine NPCC due to the lack of a suitable experimental model. Murray et al. demonstrated that islet rejection likely occurs via a CD4+ T cell‐directed response, with NK cell and CD8+ T cell‐mediated injury of the xenograft not contributing to islet loss . Additionally, a study by Lalain et al . examined the adaptive immune response
Our preliminary results suggest that there are significant differences in the strength and kinetics of
7. Strategies and recommendations
There are many potential strategies to improve the viability and the function of islet xenografts. The following are a selection of strategies that do not involve an immunosuppressive regimen, and instead involve making changes to the islets themselves or the posttransplant environment that attempts to minimize damage from the recipient's immune system.
7.1. Immune modulation
Modulating the immune response before transplantation of the porcine NPCC into the recipient may allow for increasing the viability and function of the xenograft without the need for more immunosuppressive drugs. One example of this strategy would be the culturing of porcine NPCC with protective agents, such as antioxidants, prior to transplantation.
It has been shown that oxidative stress is a likely contributor to cellular damage in the posttransplant environment . Luca et al. have demonstrated that treating porcine NPCC with antioxidants vitamin D3 and E results in increased
7.2. Immune modulation
Immunoisolation, or attempting to prevent exposure of the transplant to the recipient's immune system, is another method that can be utilized in islet xenotransplantation. Microencapsulation, macroencapsulation, and immunosuppressive scaffolding are all variants of this strategy.
Encapsulation involves placing islets inside a protective barrier, or capsule, prior to transplantation. Microencapsulation and macroencapsulation differ only in the number of islets inside each capsule. Microcapsules contain a single islet or very few islets, whereas macrocapsules contain a greater number of islets. Ideally, these capsules protect porcine NPCC from immune‐mediated damage but allow for exchange of oxygen, nutrients, and waste. Advancement in the materials used for encapsulation, which now include cellulose, agarose, alginate, and protamine‐heparin complex , have resulted in prolonged survival of islet xenografts in mice  and nonhuman primates . Similarly, scaffolding involves transplanting islets on a porous, biodegradable material. This offers some of the protection of encapsulation with evidence for longer term function and survival of islet xenografts compared to encapsulation .
Other strategies involve administering immunomodulatory (but not immunosuppressive) agents to transplant recipients to prolong the life of the xenograft. As previously mentioned, Stewart et al. have demonstrated that treating nonhuman primates with alpha adrenergic agonist clonidine inhibits the production of anti‐pig antibodies by the transplant recipient .
7.3. Manipulation of islet cell donors
Genetically modifying the pig donors allows for a minimization of hyperacute rejection and the IBMIR‐related damage and cell loss that occurs shortly after transplant. An example of this has already been mentioned. Porcine NPCC from GTKO pigs can prevent anti‐Gal‐mediated damage to the islet graft [29, 32]. Additional genetic engineering of donor pigs can knockout other antigens present on NPCC, such as NeuGc . Donor pigs can also be engineered to knockout tissue factor, a factor needed in coagulation , in order to successfully prevent IBMIR.
In addition to knocking out harmful genes, genetic engineering can also be used to add helpful genetic material. Komoda et al. performed a study in which porcine NPCC from
8. Future research directions
There are several directions for future research that have become apparent throughout this chapter. Firstly, a better understanding of the human immune response to porcine NPCC is needed, both
There is also no clear consensus on the best transplant sites for optimizing xenograft function and minimizing immune‐mediated damage to the islets. Injection of porcine NPCC into the portal vein, traditionally accepted as the site of islet transplantation, causes a sizable and immediate immune response and results in islet loss . More recently, porcine NPCC have been transplanted into the peritoneal cavity in an attempt to minimize the recipient's immune response; however, it is hypothesized that this transplant site leads to a lag time between islets sensing blood glucose levels and releasing insulin, resulting in poorer glycemic control . Other transplant sites, such as within the omentum or under the skin, have been proposed but not investigated.
Scaffolding and encapsulation allows for protection of the islet grafts from the recipient's immune system without the need for additional immunosuppressive drugs. There are challenges with long‐term survival of islet transplants with encapsulation, as encapsulation can prevent revascularization and remodeling posttransplantation. Scaffolding can address these issues, as scaffolds are porous and allow for tissue ingrowth and revascularization. While studies with encapsulated islets have been performed in mice [10, 20, 24, 25], nonhuman primates , and humans  with success, fewer experiments have been performed using scaffolds and more research is needed into their utility.
Lastly, little research has been done into multiple dose transplantation. Because long‐term survival of islet xenotransplantation has not yet been achieved, multiple dose transplantation becomes an important consideration. There are implications for the immunosuppression regime necessary if multiple islet xenotransplants are needed in a single patient, as it is reasonable to assume that the recipient would develop immunological memory to xenoantigens present in the islet graft. This is an important area of future research that has major implications in using islet transplantation as a clinical treatment of type 1 diabetes.
Islet xenotransplantation addresses the shortage of available human islet donors for clinical islet transplantation and has the potential to become a viable treatment of type 1 diabetes. Porcine islets remain the best option for islet transplantation, due to their ease of acquisition and similar physiology to human islet cells. Neonatal pigs appear to be the best source for transplantable islets because of their resilience to ischemic damage and growth potential postcollection. Like islet allotransplantation, islet xenotransplantation has been limited by posttransplant graft destruction from the recipient's immune response.
The immune response in rodent, nonhuman primate, and human models can be separated into hyperacute rejection, IBMIR, and adaptive immune responses. While each species group has a slightly different immune response to porcine NPCC xenografts, there are also some similarities. Antigens present on the porcine NPCC, such as alpha Gal, are largely responsible for hyperacute rejection in humans and nonhuman primates. However, other xenoantigens that need to be identified also may contribute to this response. In addition, it appears that the indirect pathway of T cell activation is an essential part of xenograft rejection in all species groups, with CD4+ T cells dominating the rejection process.
There are several strategies that can be utilized in islet xenotransplantation to improve the viability and function of the islet grafts that do not involve immunosuppressive drug regimens. These include culturing the islets with immune‐modulating agents pretransplantation, transplanting encapsulated or scaffolded islets, or genetically modifying the islet cell donors to dampen the recipient's immune response. Future research directions include eliciting the specific mechanism of islet xenotransplant rejection in the human model, ideally
We are grateful for the technical assistance of Ping Wu, Mazzen Black, and Eric Boivin as well as funding support by Mr. and Mrs. John Burton, Mr. and Mrs. Ken Cantor, Mrs. Martine Farand, and Colliers International Inc.
Barton FB, Rickels MR, Alejandro R, et al. Improvement in outcomes of clinical islet transplantation: 1999-2010. Diabetes Care. 2012; 35(7):1436-1445
Hering BJ, Walawalker N. Pig‐to‐nonhuman primate islet xenotransplantation. Transplant Immunology. 2009 Jun; 21(2):81-86
Kirk A. Textbook of Organ Transplantation. West Sussex, UK: Wiley Blackwell; 2014
Deschamps JY, Roux FA, Saï P, et al. History of xenotransplantation. Xenotransplantation. 2005; 12:91-109
Groth CG, Korsgren O, Tibell A, et al. Transplantation of porcine fetal pancreas to diabetic patients. Lancet. 1994 Nov 19; 344(8934):1402-1404
Valdes‐Gonzalaez RA, Elliot RB, Dorantes LM, et al. Porcine islet xenografts can survive and function in type 1 diabetic patients in the presence of both pre‐existing and elicited anti‐pig antibodies. Transplantation. 2002; 74(Suppl 4):94
Matsumoto S, Abalovich A, Wechsler C, Wynyard S, Elliott RB. Clinical benefit of islet xenotransplantation for the treatment of type 1 diabetes. EBioMedicine. 2016; 12:255-262
Appel MC, Banuelos SJ, Greiner DL, et al. Prolonged survival of neonatal porcine islet xenografts in mice treated with a donor‐specific transfusion and anti‐CD154 antibody. Transplantation. 2004; 77:1341-1349
Cardona K, Korbutt GS, Milas Z, et al. Long‐term survival of neonatal porcine islets in nonhuman primates by targeting costimulation pathways. Nature Medicine. 2006 ; 12:304-306
Kobayashi T, Harb G, Rayat GR. Prolonged survival of microencapsulated neonatal porcine islets in mice treated with a combination of anti‐CD154 and anti‐LFA‐1 monoclonal antibodies. Transplantation. 2005; 80:821-827
Rood PP, Bottino R, Balamurugan AN, et al. Reduction of early graft loss after intraportal porcine islet transplantation in monkeys. Transplantation. 2007; 83:202-210
Wennberg L, Song Z, Bennet W, et al. Diabetic rats transplanted with adult porcine islets and immunosuppressed with cyclosporine A, mycophenolate mofetil, and leflunomide remain normoglycemic for up to 100 days. Transplantation. 2001; 71:1024-1033
Nagaraju S, Bottino R, Wijkstrom M, et al. Islet xenotransplantation: What is the optimal age of the islet‐source pig? Xenotransplantation. 2015; 22:7-19
Dufrane D, Goebbels T, Fdilat I, et al. Impact of porcine islet size on cellular structure and engraftment after transplantation: Adult versus young pigs. Pancreas. 2005; 30:138-147
Kirchof N, Shibata S, Wijkstrom M, et al. Reversal of diabetes in non‐immunosuppressed rhesus macaques by intraportal porcine islet xenografts precedes acute cellular rejection. Xenotransplantation. 2004; 11:396-407
Rayat GR, Rajotte RV, Hering BJ, et al. In vitro and in vivo expression of Galalpha‐(1,3)Gal on porcine islet cells is age dependent. The Journal of Endocrinology. 2003 Apr; 177(1):127-135
Emamaulle JA, Shapiro AM, Rajotte RV, et al. Neonatal porcine islets exhibit natural resistance to hypoxia‐induced apoptosis. Transplantation. 2006; 82:945-952
Rayat GR, Rajotte RV, Korbutt GS. Potential application of neonatal porcine islets as treatment for type 1 diabetes: A review. Annals of The New York Academy of Sciences. 1999; 875:175-188
Zhu H‐T, Wang W‐L, Yu L, et al. Pig‐islet xenotransplantation: Recent progress and current perspectives. Frontiers in Surgery. 2014; 1:7
Rayat GR, Rajotte RV, Ao Z, et al. Microencapsulation of neonatal porcine islets: Protection from human antibody/complement‐mediated cytolysis in vitro and long‐term reversal of diabetes in nude mice. Transplantation. 2000; 69:1084-1090
Kin T, Korbutt GS, Kobayashi T, et al. Reversal of diabetes in pancreatectomized pigs after transplantation of neonatal porcine islets. Diebetes. 2005; 54:1032-1039
Cooper DKC, Ezzelarab MB, Hara H, et al. The pathobiology of pig‐to‐primate xenotransplantation: A historical review. Xenotransplantation. 2016; 23:83-105
Ekser B, Cooper DK. Overcoming the barriers to xenotransplantation: Prospects for the future. Expert Review of Clinical Immunology. 2010; 6(2):219-230
Itoh T, Hata Y, Nishinakamura H, et al. Islet‐derived damage‐associated molecular pattern molecule contributes to immune responses following microencapsulated neonatal porcine islet xenotransplantation in mice. Xenotransplantation. 2016; 23:393-404
Kobayashi T, Harb G,Rajotte RV, et al. Immune mechanisms associated with the rejection of encapsulated neonatal porcine islet xenografts. Xenotransplantation. 2006; 13:547-559
Rayat GR, Johnson ZA, Beilke JN, et al. The degree of phylogenetic disparity of islet grafts dictates the reliance on indirect CD4 T‐cell antigen recognition for rejection. Diabetes. 2003 Jun; 52(6):1433-1440
Ezzelarab M, Ayares D, Cooper DK. Carbohydrates in xenotransplantation. Immunology & Cell Biology. 2005; 83:396-404
Kobayashi T, Cooper DK. Anti‐Gal, alpha‐Gal epitopes, and xenotransplantation. Subcellular Biochemistry. 1999; 32:229-257
Bottino R, Trucco M. Use of genetically‐engineered pig donors in islet transplantation. World Journal of Transplantation. 2015; 5(4):243-250
Stewart JM, Tarantal AF, Hawthorne WJ, et al. Clonidine inhibits anti‐non‐Gal IgM xenoantibody elicited in multiple pig‐to‐primate models. Xenotransplantation. 2015; 22(6):413-426
Komoda H, Miyagawa S, Omori T, et al. Survival of adult islet grafts from transgenic pigs with N‐acetylglucosaminyltransferase‐III (GnT‐III) in cynomolgus monkeys. Xenotransplantation. 2005; 12:209-216
Nagaraju S, Bottino R, et al. Islet xenotransplantation from genetically engineered pigs. Current Opinion in Organ Transplantation. 2013 Dec; 18(6):695-702
Kanak MA, Takita M, Kunnathodi F, et al. Inflammatory response in islet transplantation. International Journal of Endocrinology. 2014; 2014:451035
Liuwantara D, Chew YV, Favaloro EJ, et al. Characterizing the mechanistic pathways of the instant blood‐mediated inflammatory reaction in xenogeneic neonatal islet cell transplantation. Transplantation Direct. 2016; 2(6):e77
Ji M, Jin X, Phillips P, et al. A humanized mouse model to study human immune response in xenotransplantation. Hepatobiliary Pancreatic Diseases International. 2012; 11(5):494-498
Nagaraju S, Bertera S, Tanaka T, et al. In vitro exposure of pig neonatal islet like cell clusters to human blood. Xenotransplantation. 2015; 22:317-324
Murray AG, Nelson RC, Rayat GR, et al. Neonatal porcine islet cells induce human CD4+, but not CD8+, lymphocyte proliferation and resist cell‐mediated cytolytic injury in vitro. Diabetes. 1999 Sep; 48(9):1713-1719
Yi S, Ji M, Wu J, et al. Adoptive transfer with in vitro expanded human regulatory T cells protects against porcine islet xenograft rejection via interleukin‐10 in humanized mice. Diabetes. 2012; 61(5):1180-1191
Lalain S, Chaillous L, Gouin E, et al. Intensity and mechanisms of in vitro xenorecognition of adult pig pancreatic islet cells by CD4+ and CD8+ lymphocytes from type I diabetic or healthy subjects. Diabetologia. 1999; 42:330-335
Luca G, Nastruzzi C, Basta G, et al. Effects of anti‐oxidizing vitamins on in vitro cultured porcine neonatal pancreatic islet cells. Diabetes Nutrition & Metabolism. 2000 Dec; 13(6):301-307
Gibly RF, Zhang X, Lowe WL, et al. Porous scaffolds support extrahepatic human islet transplantation, engraftment and function in mice. Cell Transplantation. 2013; 22(5): 811-819