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Simultaneous heart and intramuscolar islet transplantation in type 1 diabetes mellitus and acute heart failure

Federico Bertuzzi¹, Mario Marazzi², Cosimo V Sansalone⁴, Roberto Paino⁶, Claudio Russo³, Barbara Antonioli², Livio Luzi⁵, Maria Frigerio³

¹Diabetes Unit; ²Tissue Bank; ³Cardiovascular Department; ⁶Intensive Cardiac Care Unit, Niguarda Hospital, Milan, Italy; ⁴General Surgery Division, Vigevano Hospital, Pavia; ⁵Department of Sport, Nutrition and Health Sciences, University of Milan, Milan, Italy

Alternative site to liver for islet transplantation have been studied for long time, although few studies are reported in humans. Here we described the case report of the first intramuscle pancreatic islet allo transplantation. A 44 years old female affected by type 1 diabetes mellitus and by a severe post-myocardial infarction cardiopathy was admitted to the hospital for refractory heart failure and underwent heart transplantion from a multiorgan donor. Pre transplant insulin requirement was about 80u of insulin, c-peptide value was <0.1ng/ml. The day after heart transplantation 257000 equivalent islets (4283 EI/kgb.w.) by the same organ donor were transplanted into the brachioradial muscle. Liver was not suitable for islet implantation due to the severe intrahepatic blood stasis. The immunosuppression therapy was based on ATG induction, and high doses steroid, mycofenolate and cyclosporine as maintenance therapy. The post-transplant course was complicated by early heart graft dysfunction requiring high-dose inotropic support, two cardiac arrests that required resuscitation and defibrillation, sepsis, and coma due to drug-induced neurological toxicity. Then the patient stabilized. After transplantation glucose homeostasis remained acceptable with a reduced insulin requirement up to 35 units, HbA1c=7.2% and c-peptide 0.2-0.4 ng/ml (at 6 month 2.1 ng/ml after glucagon test). At two years follow up the patient is still in general good condition, with basal c-peptide 0.2ng/ml, 35u insulin requirement. Intramuscolar islet transplantation appears an interesting alternative site to the liver for islet implant in selected patients, and deserves evaluation in future studies.