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Currently, islet cells are transplanted into the liver via portal vein infusion. One disadvantage of this approach is that it is not possible to adequately biopsy the islets in the liver to assess for rejection. Islet Tx into the gastric submucosal space (GSMS) can be performed endoscopically, and has the potential advantage of histological evaluation by endoscopic biopsy. The aim of this study was to determine whether a representative allograft sample could be obtained endoscopically. We performed islet Tx into the GSMS in non-immunosuppressed pigs using simple endoscopic submucosal injection. Islets were transplanted at 4 sites. Endoscopic ultrasonography and biopsy of the transplanted islets at 2 sites by modified endoscopic submucosal dissection were carried out successfully in all pigs 5 days after islet Tx. Tissue obtained at both biopsy and necropsy (including full-thickness sections of the gastric wall around the sites of the remaining islets and biopsies) were examined by histology and immunohistochemistry to confirm the presence of the islet grafts and any features of rejection. Representative allograft sampling was successfully obtained from all biopsy sites. All biopsies included islets with insulin-positive staining. There was significant CD3+ and CD68+ cell infiltration in the islet masses obtained at biopsy and from sections taken at necropsy, with similar histopathological features. Endoscopic biopsy of islet allografts in the GSMS is feasible, provides accurate histopathological data, and would provide a significant advance if translated into clinical practice.

Genetically modified pMSC is significantly less immunogenic than WT pMSC. GTKO/CD46 pMSC downregulates the human T-cell responses to pig antigens as efficiently as human MSC, which can be advantageous for therapeutic cell xenotransplantation.

Background aims The immunomodulatory and anti-inflammatory effects of mesenchymal stromal cells (MSC) could prove to be a potential therapeutic approach for prolongation of survival of cell xenotransplantation. Adipose (Ad) MSC from genetically modified pigs could be an abundant source of pig donor-specific MSC. Methods Pig (p) MSC were isolated from adipose tissue of α1,3-galactosyltransferase gene knock-out pigs transgenic for human (h) CD46 (GTKO/ hCD46), a potential source of islets. After characterization with differentiation and flow cytometry (FCM), AdMSC were compared with bone marrow (BM) MSC of the same pig and human adipose-derived (hAd) MSC. The modulation of human peripheral blood mononuclear cell (hPBMC) responses to GTKO pig aortic endothelial cells (pAEC) by different MSC was compared by measuring 3H-thymidine uptake. The supernatants from the AdMSC cultures were used to determine the role of soluble factors. Results GTKO/hCD46 pAdMSC (i) did not express galactose-α1,3-galactose (Gal) but expressed hCD46, (ii) differentiated into chondroblasts, osteocytes and adipocytes, (iii) expressed stem cell markers, (iv) expressed lower levels of Swine Leucocyte Antigen I (SLAI), Swine Leucocyte Antigen II DR (SLAIIDR) and CD80 than pAEC before and after pig interferon (IFN)-γ stimulation. The proliferative responses of hPBMC to GTKO/hCD46 pAdMSC and hAdMSC stimulators were similar, and both were significantly lower than to GTKO pAEC (P < 0.05). The proliferation of hPBMC to GTKO pAEC was equally suppressed by GTKO/hCD46 pAdMSC and hAdMSC (P > 0.05). The supernatant from GTKO/hCD46 pAdMSC did not suppress the human xenoresponse to GTKO pAEC, which was cell–cell contact-dependent. Conclusions Initial evidence suggests that genetically modified pAdMSC function across the xenogeneic barrier and may have a role in cellular xenotransplantation.

Purpose of review Solid organ xenotransplantation could be the future of transplantation, but improved outcomes are required in experimental models before clinical trials are justified. This review summarizes recent advances in solid organ xenotransplantation using organs from α1,3-galactosyltransferase gene-knockout (GTKO) pigs (with or without other genetic modifications) and novel therapeutic approaches. Recent findings Work on the development of genetically-engineered pigs has been considerable during the past few years, with many research institutes reporting the outcomes of research. Multiple gene modifications on a GTKO background have been reported, and the results of transplantation using organs from these pigs have been published. Progress, however, has been variable, and several obstacles, e.g., coagulation dysregulation, have been identified. Heterotopic pig heart xenotransplantation has been associated with graft survival exceeding 8 months, but kidney graft survival has not improved significantly. Summary The availability of GTKO pigs with additional genetic modifications aimed towards expression of multiple complement-regulatory proteins and/or human thromboregulatory genes, combined with novel immunosuppressive regimens, e.g., the inclusion of B cell-depleting agents, should improve pig organ survival in the near future.