Anti-inflammatory Therapy to Improve Outcomes in Patients With Chronic Pancreatitis Undergoing Total Pancreatectomy Islet Autotransplantation
Phase: PHASE4
Conditions: Pancreatitis, Chronic; Diabetes; Transplant
Sponsor: University of Minnesota

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Anti-inflammatory therapy to improve outcomes in 
patients with chronic pancreatitis undergoing total 
pancreatectomy islet autotransplantation  
 
 
Protocol Version:  2.2 
Version Date: 08 August 2017 
IRB#:  1602M84765 
 
 
 

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Primary Investigator: 
Melena Bellin MD 
University of Minnesota Health 
East Building Rm MB-671 
2450 Riverside Ave S 
Minneapolis, MN 55454 
Phone:  612-624-5409 
Fax:  612-626-5262 
 
 

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Protocol Synopsis 
Study Title 
Anti-inflammatory therapy to improve outcomes in patients with chronic pancreatitis 
undergoing total pancreatectomy islet autotransplantation  
Principal Investigator  
Melena Bellin, MD 
Participating Site 
University of Minnesota  
Accrual Objective 
Up to 60 patients with chronic pancreatitis undergoing total pancreatectomy and islet 
autotransplant (IAT) will be enrolled for screening.  Up to 48 participants will be randomized to 
treatment, with accrual goal of 45 completing 90 days of follow up. 
Study Design 
Single center randomized, open-label  
Study Duration 
8 years (2.5-3 years recruitment + 5 years follow up) 
Study Objectives 
SPECIFIC AIM #1:  To determine if anti-inflammatory treatment with etanercept or 
alpha-1 antitrypsin during the critical peri-transplant engraftment period improves islet 
engraftment and function after islet autotransplant, as assessed by area under the curve for 
C-peptide on mixed meal tolerance testing (oral stimuli), acute insulin response to glucose-
potentiated arginine stimulation (IV stimuli), and insulin requirements at day 90 post-transplant. 
The primary endpoint of the maximally stimulated acute insulin response to arginine (AIRmax) 
from GPAIS at day 90 will allow us to rapidly identify the most promising therapeutic agent for 
further development and testing in a large randomized trial. 
SPECIFIC AIM #2:  To gather pilot data on the long-term impact of etanercept or alpha-1 
antitrypsin administered during the peri-transplant period by evaluating islet function at 1 
and 2 years post-transplant, as assessed by area under the curve for C-peptide on mixed meal 
tolerance testing (oral stimuli), acute insulin response to glucose-potentiated arginine stimulation 
(IV stimuli), and insulin requirements (units/kg/day) at 1 year post-TPIAT.  In addition, insulin 
requirements and fasting/stimulated C-peptide by MMTT will be assessed at yearly intervals from 
year 3-5 post-transplant. 
SPECIFIC AIM #3:  To evaluate the mechanistic effects of etanercept and alpha-1 
antitrypsin on inflammation, islet cell viability/survival, and beta cell apoptosis.  This will 
be assessed by circulating cytokine and chemokine levels and measurement of circulating 
unmethylated DNA (a recently validated marker of beta cell death in T1DM) in patient serum. 
The goal of the current research is to select the anti-inflammatory agent with the greatest potential 
to preserve islet mass early after TPIAT.   
 
Study Endpoints 
Primary Endpoint: 
1)  AIRmax from the Day 90 visit (obtained from glucose potentiated arginine-induced 
insulin secretion):  We have data from UMN that supports this as the strongest correlate 
with beta cell mass, so this measure best addresses our research question.  The early 
endpoint is chosen to rapidly translate pilot results into randomized clinical trials.  
Patients are not expected to achieve insulin independence in this population before day 
90. 
Key Secondary Endpoints: 
1) Insulin independence:  At day 365 and day 730.  Defined as no insulin use for >14 days, 
with fasting blood sugar <126 mg/dL; 90 minute mixed meal glucose <180 mg/dL, and 
HbA1c <6.5% 
2) Insulin dose (unit/day):   At day 90, 365, and 730. 
3) ACRmax, derived from GPAIS at days 90, 365, and 730 
4) AIRglucose and ACRglucose, derived from the IVGTT at days 90, 365, and 730 
5) AUC C-peptide from 2 hour MMTT, at days 90, 365, and 730 
6) AUC glucose from 2 hour MMTT, at days 90, 365, and 730 
7) Absence of severe hypoglycemic episodes (inclusive of day 90- 365) and HbA1c <7% 
at day 365 
8) Absence of severe hypoglycemic episodes (inclusive of day 365-730) and HbA1c <7% 
at day 730 

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Inclusion Criteria 
1)  Age 18- 68 years.  . 
2)  Scheduled for total pancreatectomy and IAT at UM.  All patients who are approved for 
pancreatectomy and IAT at UM are reviewed by a multi-disciplinary committee including 
surgeons, gastroenterologists specializing in pancreatic disease, a pain specialist, 
psychologist, and endocrinologist to confirm the diagnosis of chronic pancreatitis and 
candidate suitability for surgery. 
3)  Able to provide informed consent  
Exclusion Criteria 
1) Pre-existing diagnosis of diabetes mellitus, fasting blood glucose >115 mg/dl, or hemoglobin 
A1c level >6.0% because these are all evidence of inadequate beta-cell mass. 
2) Use of any of the following treatments in the 30 days prior to enrollment: insulin, metformin, 
sulfonylureas, glinides, thiazolidinediones, GLP-1 agonists, DPP-4 inhibitors, or amylin. 
3) IgA deficiency (serum level <5 mg/dL), which has been associated with hypersensitivity to 
alpha-1 antitrypsin. 
4) ALT or AST>2.5 times the upper limit of normal (ULN).  Bilirubin >ULN, unless due to 
benign diagnosis such as Gilbert’s. 
5) Known history of HIV infection, hepatitis B (chronic), or hepatitis C (chronic). 
6) History of tuberculosis (latent or active disease), or positive TB skin test. 
7) History of symptomatic fungal lung infection. 
8) History of multiple sclerosis, transverse myelitis, Guillain Barre, or other suspected 
demyelinating disease, due to risk of exacerbation of these conditions with use of etanercept; 
or prior history of systemic lupus erythematosus  
9) Any of the following hematologic abnormalities:  severe anemia (hgb <10 g/dL), 
thrombocytopenia (<150/mm3), or neutropenia (<1.0 x109/L). 
10) Current use or expected use of oral or injected corticosteroids, or any mediation likely to 
affect glucose tolerance.  However, use of hydrocortisone for physiologic replacement, or 
use of any topical, inhaled, or intranasal glucocorticoid is permitted. 
11) Current or expected use of any other immunosuppressive agent.  
12)  Known hypersensitivity to etanercept or A1AT. 
13) Any condition that is likely, in the opinion of the patient’s medical providers, to necessitate 
use of TNF alpha therapeutically in the future (such as psoriatic arthritis).   
14) Known coagulopathy, or need for anticoagulant therapy preoperatively (coumadin, 
enoxaparin), or any history of pulmonary embolism. 
15)  For females, plans to become pregnant or unwillingness to use birth control for the study 
duration.   
16)  Inability to comply with the study protocol. 
17) Untreated psychiatric illness that may interfere with ability to give informed consent, or other 
developmental delay or neurocognitive disorder that impairs with a patient’s ability to 
consent on their own behalf. 
18)  Any other medical condition that, in the opinion of the investigator, may interfere with the 
patient’s ability to successfully and safely complete the trial. 
Treatment Description 
Forty-five patients undergoing TP-IAT (day 0) at a single center will be randomized 1:1:1 to 
receive during the peri-operative period either: 1) etanercept (50 mg on day 0 SQ; 25 mg SQ on 
days 3, 7, 10, 14, and 21),  2) alpha-1 antitrypsin (90 mg/kg IV infusion on days -1, and +3, 7, 
14, 21, and 28 post-transplant) or 3) standard care.   
Study Procedures 
Patients will be seen within 4 weeks prior to surgery (screening/baseline), and at day 90 (± 14 
days), day 365 (± 28 days), and day 730 (± 56 days) post-transplant.  These will occur over two 
days.  The following metabolic testing will be performed at each visit: 
1)  10 minute IV glucose tolerance test 
2) Glucose potentiated arginine induced insulin secretion (GPAIS), performed on same 
morning as the IVGTT 
3) Mixed meal tolerance test (2 hour, Boost HP) 
In addition, patients will have serum draws for mechanistic assessments and safety labs in the 
first month post-transplant as detailed in the protocol.  The mechanistic assessments will 
include unmethylated insulin DNA and cytokine/chemokine profiles.   For long-term follow up 
of participants, patients will receive routine care subsequent to the day 730 visit, which includes 
a HbA1c and mixed meal test at yearly intervals.  Study investigators will review results from 
these annual labs and have a telephone follow up with the participant at years 3, 4 and 5 for 
insulin requirements, blood glucose review, and hypoglycemia history. 

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Study Abstract 
Chronic pancreatitis is associated with incapacitating pain, frequent hospitalization and risk of narcotic 
dependence. If endoscopic procedures do not provide sufficient pain relief, total pancreatectomy (TP) may be 
considered.  This results in certain diabetes unless the islets are returned with autologous islet transplantation 
(IAT). In this procedure, the patient’s pancreas is completely removed, and the islets are isolated and infused into 
the portal vein. The islets engraft and potentially survive long term in the liver, releasing insulin in response to 
glucose. While 90% of patients have some function of the transplanted islet graft, only about 1/3rd come 
completely off insulin.  The high prevalence of postsurgical diabetes is a major barrier for many patients and 
providers in considering TPIAT for treatment of chronic pancreatitis.  The long-term goal of the proposed 
research is to develop new therapies that will increase the number of patients who are non-diabetic after TPIAT. 
Following islet transplantation, the islets must acutely survive the stress of the procedure, and then they must 
engraft in the liver and establish a vascular supply. The greater the functional islet mass engrafted, the lower the 
risk of post-operative diabetes. It has been estimated that more than half of the islet mass may be lost in the early 
post-transplant period in islet transplant recipients.  Beta cell apoptosis is common during the first month post-
transplant and is upregulated in the presence of inflammatory cytokines such as TNF-α. Thus, a major 
contributor to islet loss is the inflammatory damage sustained by the transplanted islets in the early post-
transplant period; we propose to directly target this destructive process.   
Two promising anti-inflammatory therapies are available to address this problem: (1) the TNFα inhibitor 
etanercept and (2) alpha-1 antitrypsin.  Both agents are clinically available and prime for clinical trials.  
Etanercept functions by binding TNFα, thus preventing its interaction with the TNFα receptor.  Proof of 
principle is demonstrated in type 1 diabetic allotransplant recipients, in whom a 10 day course of etanercept early 
post-transplant significantly improved insulin independence rates up to 5 years after transplantation, postulated 
due to better survival of the transplanted beta cell mass in the engraftment period.  Alpha-1 antitrypsin (A1AT) 
is a serine protease inhibitor. A1AT reduces inflammatory cytokines and islet cellular infiltrates, protects against 
cytokine-induced beta cell apoptosis, and prolongs islet graft survival in mice and non-human primates, notably 
including in syngeneic transplant in mice and marginal mass intraportal islet autotransplantation in monkeys, 
settings that closely replicate the TPIAT scenario.   
This 3-arm drug-treatment clinical trial will investigate the use of Etanercept and A1AT to improve IAT 
function at 90 days and 1 and 2 years post-transplant compared to standard care of TPIAT recipients.  We 
hypothesize that either anti-inflammatory treatment will reduce post-transplant beta cell apoptosis and improve 
islet engraftment, and that this will be reflected in higher stimulated insulin and C-peptide secretion at day 90.    
Forty-five patients undergoing TPIAT at a single center will be randomized 1:1:1 to receive either: 1) etanercept 
(50 mg on day 0; 25 mg on days 3, 7, 10, 14, and 21), 2) alpha-1 antitrypsin (90 mg/kg IV days -1, +3, 7, 14, 21, 
28) or 3) standard care in the peri-operative period.  Patients will have mechanistic assessments drawn in the early 
post-operative period including inflammatory cytokines and chemokines and measures of beta cell loss 
(circulating unmethylated insulin DNA, released by dying beta cells).  Patients will return for sophisticated 
metabolic testing at 90 days, and (to gather preliminary long-term efficacy data) 1 and 2 years post-transplant.  
Because the number of islets cannot be directly counted after islet infusion, we will use stimulatory testing as a 
surrogate measure of islet mass.  At 90, 365, and 730 days post-TPIAT, patients will undergo mixed meal 
tolerance testing, IV glucose tolerance testing, and glucose-potentiated arginine-induced insulin secretion 
(GPAIS).  The latter measures the maximally stimulated acute insulin response, or AIRmax, which is the best 
estimate of islet mass and the primary endpoint (at day 90) for this study.  Results will be used to select the most 
promising agent for further study in a randomized, blinded multi-center clinical trial.   
 
 

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BACKGROUND 
Chronic pancreatitis affects as many as 1 in every 2,500 persons and is associated with incapacitating pain, 
frequent hospitalization and risk of narcotic dependence (1).  The health and economic costs of pancreatitis are 
great. Nearly $300 million dollars are spent on emergency department visits alone in the US each year (2).  More 
than 90% of patients with chronic pancreatitis have been hospitalized, half use narcotic analgesics regularly, and 
one-fourth are on disability (3).  The lifetime risk of diabetes mellitus is as high as 70% (4, 5).  Chronic 
pancreatitis is a significant health burden with few treatment options.   
While endoscopic procedures are often employed as a first-line therapy, if ERCP procedures do not provide 
sufficient pain relief, surgical therapy including total pancreatectomy (TP) may be considered to relieve the root 
cause of pain.  TP results in certain diabetes unless the islets are returned with autologous islet transplantation 
(IAT). In this procedure, the patient’s pancreas is completely removed, mechanically and enzymatically digested 
with collagenase, and the islets are isolated and infused into the portal vein. The islets engraft and potentially 
survive long term in the liver, releasing insulin in response to glucose (6).   IAT results in complete insulin 
independence in 1/3rd of patients. Another 1/3rd require only small doses of insulin, while the remaining patients 
are completely insulin dependent (4).   
The field of TPIAT is growing, with improved acceptance of this procedure in the medical GI community.  This 
is reflected in growth of the number of centers performing the procedure and the number of procedures performed 
within the past decade.  With no medical therapies available to halt the progression of the disease, TPIAT is likely 
to remain the only treatment option for many patients, particularly those with debilitating small duct chronic 
pancreatitis. However, the high prevalence of postsurgical diabetes is a major barrier for many patients and 
providers in considering TPIAT for treatment of chronic pancreatitis.  By reducing the risk of diabetes after 
TPIAT, we have the opportunity to substantially increase the applicability of TPIAT as a treatment option 
for patients with severe chronic pancreatitis.  
Following islet transplantation, the islets must acutely survive the stress of the procedure, and then they must 
engraft in the liver and establish a vascular 
supply. The greater the functional islet 
mass engrafted, the lower the risk of post-
operative diabetes (6-10).  Preventing early 
post-operative hyperglycemia reduces but 
does not prevent beta cell apoptosis.  Even 
under conditions of adequate glycemic 
control, beta cell apoptosis is common 
during the first month post-transplant (11, 
12) and is upregulated in the presence of 
inflammatory cytokines such as TNF-α. It 
has been estimated that more than half of 
the islet mass may be lost in the early post-
transplant period (13).  Thus, a major 
contributor 
to 
islet 
loss 
is 
the 
inflammatory damage sustained by the 
transplanted islets in the early post-
transplant period; this in turn adversely 
impact long-term diabetes outcomes. We 
propose to directly target this destructive process.   
Dramatic increases in beta cell apoptosis relative to that present in the native pancreas are observed in vitro in 
human islets and in vivo in animal models after islet isolation, increasing over the first 10 days post-transplant 
(12, 14), and worsened in the presence of inflammatory cytokines, such as TNFα (15).  In vitro exposure of islets 
to TNFα alone or with IL-1 induces beta cell apoptosis (15).  Expression of damaging inflammatory cytokines 
has been documented both in islet graft (16), and in total pancreatectomy islet autotransplant (TPIAT) recipients, 

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even under conditions of strict glycemic control (17, 18), presumably due to the stress of surgery. While 
inflammation may occur in the native pancreas due to recurrent acute and chronic pancreatitis prior to TPIAT, 
the isolated and intrahepatically transplanted islets are uniquely and acutely vulnerable to this inflammatory 
stress, because the islets are devascularized, hypoxic, and directly exposed to the intraportal blood after TPIAT. 
By developing therapies to protect beta cell mass from the damaging effects of inflammation during islet 
engraftment, we have the opportunity to increase the success of total pancreatectomy and islet autotransplant for 
patients with chronic pancreatitis. 
These observations present an opportunity to intervene; blockade of the innate inflammatory response – 
which is directly damaging to beta cells— holds the potential to substantially improve the engrafted islet 
mass and thereby reduce diabetes risk after TPIAT. Two promising anti-inflammatory therapies are the TNFα 
inhibitor etanercept and alpha-1 antitrypsin.  Both agents are clinically available and prime for clinical trials.  
There are reasons to believe that either drug may be more efficacious than the other.  Etanercept is a potent anti-
inflammatory drug which targets TNFα, a key central inflammatory mediator in beta loss after transplant. Alpha-
1 antitrypsin has a more generalized anti-inflammatory effect and may directly inhibit beta cell apoptosis.  
However, there are currently not enough data available to determine the optimal therapeutic agent.  To select the 
agent with the greatest potential for efficacy and favorable benefit-risk ratio, the two therapies must be compared 
head-to-head, as well as compared to standard care.  This is the focus of this pilot study, and represents an 
essential first-step to select the most promising drug for clinical development.     
The short-term goal is to perform a pilot study with etanercept and alpha-1 antitrypsin to determine which 
is the most promising anti-inflammatory drug in TPIAT, which will inform future clinical trials.  To 
accomplish this goal, we will randomize 45 TPIAT patients to receive either: 1) standard care, 2) etanercept, or 
3) alpha-1 antitrypsin in the early peri-operative period.  Outcome assessments will focus on inflammation and 
islet loss in the perioperative period, and engrafted islet mass at 90 days post-transplant, with pilot data collected 
for long-term (1 and 2 year) diabetes outcomes.   
The proposed agents have shown promise in preclinical trials. In addition, etanercept has shown clinical efficacy 
in allotransplantation and the survival of marginal mass autologous islet transplants in non-human primates—a 
situation nearly analogous to TPIAT—are dramatically improved under simultaneous short-term administration 
of A1AT.  However, no controlled clinical trials to date have been conducted in TPIAT using these agents. We 
have a novel opportunity to test these agents formally in clinical trials in TPIAT, using the large volume of patients 
with pancreatitis seen for this procedure at our institution.      
 
While the primary indication for total pancreatectomy and islet autotransplant is to relieve pain and improve 
health-related quality of life (HRQOL), preventing or minimizing diabetes is an important secondary outcome 
which benefits recipients’ long-term health and HRQOL 
Because TPIAT is a major surgical procedure, with risk of diabetes, patients with chronic pancreatitis are carefully 
considered for this procedure by a multi-disciplinary team, and selected based on clear diagnosis of pancreatic 
disease causing pain, narcotic dependence or severely impaired quality of life, and failure to respond to maximal 
medical/ endoscopic therapy (19).  Patients at our institution since 2007 have been enrolled in a prospective cohort 
study to follow pain symptoms, narcotic use, and HRQOL, in addition to diabetes outcomes, after this procedure.  
At 1, 2, and 3 years after TPIAT, 84-86% of patients report pain as resolved or significantly improved compared 
to before pancreatectomy.  Mean summary scores for HRQOL obtained from the SF-36-—a standardized HRQOL 
questionnaire— are 2 standard deviations below the population average for physical functioning and 1 standard 
deviation below the population mean for mental functioning before surgery, reflecting the severity of disease in 
this population, but improve by >1 standard deviation at 1 year and 2 years after TPIAT (7). 
 
Insulin independence is observed in approximately 30% of patients at any given time between 1-3 years post-
transplant (figure, below). Thus, there is significant room for improvement in diabetes outcomes after the IAT 
procedure.  About 90% of patients have functioning islets, but this function is insufficient to achieve total insulin 
independence in many cases.  Twenty percent of patients are unable to maintain their hemoglobin A1c level <7% 

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(7), the glycemic goal recommended by the American Diabetes Association and shown by the Diabetes Control 
and Complications Trial to reduce risk of microvascular complications of diabetes (20).   
 
While insulin dependent patients do exhibit improvement in overall HRQOL and self-report diabetes as a more 
manageable chronic disease than pancreatitis, there 
are important differences in HRQOL scores in the 
diabetic patients.  On HRQOL subscales derived 
from the SF-36, insulin independent patients had 
higher scores for physical functioning, physical 
role, and vitality at 2 years compared to those 
patients requiring insulin therapy.  Perhaps more 
importantly, failure of the islet autograft puts 
patients at risk for diabetes complications, 
including 
retinopathy, 
nephropathy, 
and 
neuropathy.  Thus, improving the proportion of 
patients who have a successful diabetes outcome is 
critical to optimizing our management of this group 
of patients afflicted with intractable chronic 
pancreatitis. 
 
 
Successful islet engraftment during the first few months after TPIAT is critical to long-term prevention of 
diabetes 
The first hurdle to a successful islet transplant is the number of islets available, and thus the transplanted islet 
mass is an important predictor of subsequent diabetes risk (7-9, 21). However significant variability in diabetes 
outcomes is seen for any given transplanted islet mass.  Approximately 70% of IAT recipients with >5000 islet 
equivalents (IEQ)/ kilogram body weight transplanted will achieve insulin independence, while 30% never come 
off insulin despite the large number of islets infused.  In contrast,  nearly 10% of those patients with a very low 
islet mass (<2500 IEQ/kg) will maintain insulin independence, sometimes for years (7).  This variability can 
largely be explained by the difference between the transplanted islet mass and the engrafted islet mass.  Beta cell 
apoptosis and loss occurs in the immediate post-operative period due to the stress of the procedure and transplant 
environment. High levels of beta cell apoptosis are observed, particularly in the 7 days after surgery, with 
apoptosis observed even at 30 days (11, 12). It has been estimated that more than half of the islet mass may be 
lost in this early post-transplant period in islet transplant recipients (13). The innate inflammatory response, 
triggered by islet infusion, hypoxia, and hyperglycemic stress, is an important contributor to beta cell loss.  In 
alloislet transplant, successful engraftment of transplanted islets, as demonstrated by functional testing at 3 
months, is strongly predictive of diabetes remission at 1 year, even more so than the initial number of islets 
transplanted (22).  Thus, this is a critical early window in which to intervene to optimize engrafted islet mass. 
 
Islets are damaged by inflammatory cytokines, which are expressed in the islet graft and upregulated in the 
TPIAT recipient immediately after surgery 
Cytokines are expressed from the islet graft itself, induced by the stress of isolation and transplant.  Montolio et 
al demonstrated that TNFα and IL-1 were both highly upregulated in islet tissue immediately after isolation and 
following a one day culture period, and increased after transplantation into streptozotocin-induced diabetic Lewis 
rats (day 1, 3, and 7 post-transplant) even when conditions of normoglycemia were maintained (17).  When islets 
are infused into the intraportal environment, islet expression of tissue factor triggers an instant blood mediated 
inflammatory reaction (IBMIR), in which the complement and coagulation cascades are activated. That, in turn, 
exacerbates the non-specific inflammatory response, leading to neutrophil and macrophage infiltration into the 
graft, increased local cytokine expression, and ultimately islet loss (23-26).  Cytokines, particularly TNFα and 
IL1β, are directly damaging to islets in vitro and are proposed to mediate similar damage in vivo post-
transplantation (15, 16, 27, 28).  Islet isolation itself induces high rates of beta cell apoptosis, due to the stress of 
Islet Graft Function by  Time after  TPIAT
0
12
24
36
0
20
40
60
80
100
Insulin  Dependent-Basal Bolus
Insulin  Dependent-Partial
Insulin independent
Months after TP-IAT
Percentage of All TPIAT patients

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the isolation procedure, and this apoptosis is unfortunately exacerbated when islets are exposed post-isolation to 
TNFα (15).  Thus, the immediate post-operative period is an opportunity for meaningful intervention. 
 
Further contributing to a pro-inflammatory milieu is the major surgical procedure of total pancreatectomy and 
islet autotransplantation in patients with underlying history of chronic and/or recurrent acute pancreatitis.  
Multiple pro-inflammatory cytokine/ chemokine pathways are upregulated in the one week period following 
surgery in clinical TPIAT recipients (18).  Itoh et al demonstrated that the “danger signal” high-mobility group 
box-1 (HMGB-1) was upregulated in islet grafts from clinical TPIAT recipients and that elevated HMGB-1 levels 
were directly correlated with greater post-transplant inflammation which in turn was negatively associated with 
islet graft outcomes, as measured by insulin independence (18).  Pro-inflammatory cytokines are notably much 
following TPIAT with an adequate islet graft compared to pancreatectomy alone or TPIAT with very few islets, 
demonstrating that in fact this inflammatory response is elicited by the intraportal infusion of the islet graft and 
not simply a consequence of the major surgery (26). 
   
 
Promisingly, therapeutic agents that target damaging inflammation are clinically available 
We have the opportunity to intervene by targeting this early inflammatory response with clinically available 
medications.  Based on preclinical studies and/or experience in islet allotransplantation, two therapeutic agents 
are particularly promising—Alpha-1-antitrypsin (A1AT) and etanercept.  Both agents are FDA-approved for 
indications other than IAT and have been used extensively in humans.  A1AT is approved for use in adults with 
A1AT deficiency, and is currently under study as a beta-cell protective agent in type 1 diabetes; this agent has 
substantial preclinical data that suggest a preservation of islet mass and higher likelihood of diabetes cure when 
administered in the early post-operative period.  Etanercept is FDA approved for use in both children and adults 
with particular forms of inflammatory arthritis or psoriasis.  Etanercept has been studied in non-controlled clinical 
trials in islet allotransplantation and appears within this setting to convey substantial benefit in long-term 
engraftment and survival of islet mass, even when administered for a short duration (10 days post-transplant).  
We have the opportunity to study both agents in a head-to-head comparison, and against a standard care control 
arm, to determine utility of each agent in protecting early islet engraftment and to select which agent is most 
promising for further study and development for clinical use in TPIAT. 
 
Alpha-1 antitrypsin 
Alpha-1-antitrypsin 
is 
a 
safe, 
clinically 
available drug that may downregulate innate 
inflammation, 
and may have additional 
protective effects on transplanted islets 
Alpha-1-antitrypsin (A1AT), also known as 
alpha1-protease inhibitor, is a serine protease 
inhibitor.  A1AT inhibits the enzymatic activity 
of neutrophil elastase, thrombin, cathepsin G, 
proteinase 3, trypsin, and chymotrypsin.  A 
sterile, 
stable, 
lyophilized 
preparation 
is 
manufactured for clinical use by purification 
from human plasma, and is marketed by several 
manufacturers under different product names, 
including Aralast NP (Baxter, CA).  The product 
is indicated for use in adults with lung disease 
due to alpha-1-antitrypsin deficiency but has 
been studied for other indications, including pain management in fibromyalgia and beta cell preservation in new 
onset type 1 diabetes mellitus (29-31).  While preclinical data is promising, there are currently no clinical trials 
underway studying this agent in patients with pancreatitis undergoing TPIAT. 
 

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A1AT is directly relevant to the current proposal because of its anti-inflammatory effect.  
A1AT downregulates inflammatory cytokines, inhibits complement activation, and reduces cellular infiltrates, all 
of which mediate beta cell damage post-transplant (32-35).  It has been demonstrated to reverse diabetes in NOD 
mice (36, 37), protect against streptozotocin- mediated beta cell toxicity (33), protect against cytokine-induced 
beta cell apoptosis (38, 39), prolong islet allograft survival in mice (33, 34, 36, 40), and preserve islet architecture 
when islets are co-cultured with acinar proteases (41).  Importantly, A1AT has been shown to downregulate 
transcription of multiple inflammatory pathways that are activated in diabetes and islet transplant (42-44).  TNFα 
is an important central mediator in the inflammatory pathways targeted by A1AT, but many other innate 
inflammatory cytokines (IL-6, IL-8) and chemokines are affected by A1AT; thus, A1AT may be advantageous 
compared to other immune agents in its ability to target the greater inflammatory milieu, rather than a single 
cytokine pathway.  Treatment with A1AT in clinical islet autotransplant recipients has the potential to preserve 
peri-transplant beta cell mass by downregulating innate inflammatory cytokines. In addition, A1AT has been 
proposed to directly protect beta cells from apoptosis, and to protect transplanted islets against potentially 
damaging effects from co-transplanted exocrine tissue. 
 
Alpha-1 antitrypsin has other appealing properties, including the ability to reverse diabetes in mice and inhibit 
beta cell apoptosis   
Treatment with A1AT protects against both development of STZ-induced diabetes in mice and spontaneous 
development of autoimmune diabetes in NOD mice (33, 36, 39).  Lower levels of A1AT have been observed in 
children with type 1 diabetes (45) and adults with type 2 diabetes (46).   These findings suggest a general 
protective effect against islet damage in diabetes.  Furthermore, A1AT may have a direct inhibitory effect on beta 
cell apoptosis,  which is increased 10-fold after islet isolation and transplantation (12, 47), and exacerbated by 
inflammatory cytokines and hyperglycemia (12, 13). In a mouse insulinoma cell line exposed to TNFα in vitro, 
treatment with A1AT greatly reduced apoptosis and entirely abolished caspase 3 expression (39).  In another 
study, beta cell apoptosis was reduced in A1AT-treated versus untreated cultured islets exposed to either TNFα 
or a three cytokine cocktail with TNFα /IL-1β/ INF-γ (38).   Koulmanda et al demonstrated a 14-fold reduction 
in cleaved caspase 3 expression (a pro-apoptotic marker) at day 3 post-transplant in mice treated with A1AT 
receiving syngeneic islet grafts (43).  
 
Alpha-1 antitrypsin protects transplanted islets from the exocrine proteases that are invariably co-transplanted 
with the islet product. 
One of the less considered areas that could potentially influence human islet transplantation outcomes and 
functional capacity is the release of activated proteolytic enzymes (e.g., trypsin, chymotrypsin, and elastase) by 
dying acinar cells during the isolation process, culture, and post-transplantation.   Invariably, some exocrine tissue 
is co-cultured in the case of allografts or cotransplanted in the case of auto- and allografts.  Autologous islet 
preparations in particular often contain as much exocrine as endocrine tissue, because aggressive purification of 
islets must be avoided to maximize the islet mass available for transplant.  This acinar tissue that accompanies 
the islets may have a detrimental impact on the islet graft in the peri-transplant period.  Co-transplantation of 
islets with acinar tissue in impure preparations causes islets to be surrounded by exocrine cells in the portal vein 
capillaries. The active proteolytic enzymes released from the acinar tissue (trypsin, chymotrypsin, and elastase) 
continuously degrade insulin produced from the islet cells, which may negatively impact early glycemic control.  
More importantly, acinar proteases may be directly damaging to the transplanted beta cell.  In a recent analysis 
of 110 islet after kidney transplantations performed within the Nordic Network for Clinical Islet Transplantation, 
for every milliliter of exocrine tissue transplanted, there was a reduction in islet graft function equivalent to a loss 
of 100,000 IEQ (48).  Protease exposed human islets show insulin degranulation and microstructural damage on 
electron microscopy (41), with a reduction of insulin granules and broken beta cells compared to intact beta cells 
and insulin granules in untreated isolated islets (electron microscopy figure below).   
 

11 
 
 
 
Preclinical data in mice and non-human primates demonstrates dramatically increased rates of diabetes 
reversal with marginal mass islet grafts when alpha-1 antitrypsin therapy is administered; Pilot data in TPIAT 
recipients suggests a benefit when endogenous A1AT levels are elevated 
Preclinical trials in which a short duration course of A1AT is administered in the immediate post-operative period 
demonstrate clear efficacy in both allogeneic and syngeneic murine transplant models (32-34, 40, 43).  C57BL/6 
mice that were rendered diabetic with streptozotocin exhibited prolonged islet allograft survival when treated with 
human A1AT compared to an untreated control group, lasting until the time of development of human A1AT 
antibodies.  Reduced neutrophilic inflammation was observed in the islet grafts of A1AT treated mice at 24 and 
48 hours after transplant compared to controls (33).  A second study confirmed these findings—streptozotocin-
induced diabetic mice that were treated with human A1AT exhibit superior islet allograft survival, in a dose-
dependent fashion, with mice treated for 30 days having superior outcomes (100% 30 day graft survival) 
compared to those treated for 14 days (50% diabetes reversal) compared to no diabetes reversal in untreated (34).  
Grafts of treated mice had low levels of expression of pro-inflammatory mediators/cytokines (34).  
Streptozotocin-induced diabetic mice genetically programmed to express human A1AT exhibited prolonged 
survival (>100 days) of islet allografts whereas control animals and those treated with inactive truncated A1AT 
rejected islets within 10 days, supporting a role for the active A1AT (32).   
 
Notably, these findings have been confirmed in a syngeneic non-autoimmune model (43) and in non-human 
primate autografts (49).  C75BL/6 mice receiving syngeneic marginal mass islet grafts— a scenario analogous to 
clinical islet autograft recipients, who lack immunogenicity and often receive marginal mass islet grafts--- 
exhibited superior islet graft survival when treated with A1AT (Aralast). Of those treated with A1AT, 100% had 
islet graft function at day 3, compared to 10% in the placebo group, and 70% retained graft function for 60 days, 
compared to none in the placebo group.  Mechanistic analysis revealed downregulation of multiple pro-
inflammatory pathways including reduced transcription of chemokines, chemokine receptors, and innate 
inflammatory cytokines including IL-6 and IL-8.  Islet grafts from treated animals had superior survival of intact 
islets at day 3, with highly reduced apoptosis (cleaved caspase 3 detected in only 5% of the islets of A1AT treated 
vs 70% of control islets).   More critically, these results were replicated in non-human primates receiving marginal 
mass islet autografts infused intraportally following subtotal pancreatectomy and streptozotocin treatment (49).  
Because these are autografts, and the infusion is intraportal, the clinical TPIAT scenario is closely replicated.  In 
this study, all 5 monkeys treated with 4 doses of A1AT over 2 weeks (day -1 to 14 days post-transplant at 60 
mg/kg IV) maintained normoglycemia off insulin for >1-3 years (no failures to date of publication), whereas all 
4 untreated monkeys all had graft failure by day 180 post-transplant. 
 
In a small cohort of patients at our institution, endogenous alpha-1 
antitrypsin levels were higher in those patients who subsequently 
demonstrated superior islet graft function.  Islet graft function was 
measured at 3 months by C-peptide production from mixed meal 
tolerance testing.  Those patients with high C-peptide levels (above the 
median) at 3 months versus low C-peptide levels (below the median) 
had higher endogenous alpha-1 antitrypsin levels.  Notably, there was 
Normal insulin granules  and intact beta 
cell in control group
Less insulin granules and broken beta cell in 
Protease Cocktail treated group 
Figure: Endogenous A1AT at day 3 post-
IAT and C-peptide on MMTT

12 
 
significant correlation between the day 3 alpha-1 antitrypsin level and graft function at 3 months, as measured by 
area under the curve for C-peptide. 
 
Alpha-1 antitrypsin is safe and well-tolerated in clinical use and clinical trials for other indications 
The product is indicated for use in adults with lung disease due to alpha-1-antitrypsin deficiency and is generally 
well-tolerated in this population.  Commonly reported side effects include increased liver enzymes, cough or 
upper respiratory symptoms, chest discomfort, and dizziness (50).  Transmission of serious viral infection has not 
been reported.  The conventional replacement dose of A1AT studied in patients with pulmonary disease related 
to deficiency state is 60 mg/kg body weight infused intravenously once weekly.  However, higher doses have 
been studied, up to 250 mg/kg for 2 consecutive weeks, with more potent suppression of neutrophil-mediated 
proteolysis (marker of lung inflammation) at the higher dose (51).  ClinicalTrials.gov cites 5 clinical trials 
evaluating A1AT in new onset type 1 diabetes, at doses as high as 90 mg/kg IV weekly, and in patients as young 
as 8 years of age (31).   
 
Etanercept 
Etanercept, a TNFα inhibitor, targets this key inflammatory cytokine implicated in β-cell apoptosis, with strong 
clinical evidence for efficacy based on studies in islet allotransplantation for type 1 diabetes 
Etanercept is a dimeric fusion protein 
containing an extracellular ligand-binding 
portion of the TNF receptor linked to the Fc 
portion of human IgG. Etanercept functions by 
binding TNFα, thus preventing its interaction 
with the TNFα receptor.   
 
TNFα is a particularly appealing therapeutic 
target in TPIAT recipients for several reasons.  
Islet grafts themselves release TNFα in 
response to the stress of islet isolation (17, 23), 
in addition to the pro-inflammatory milieu of 
the post-operative patient.  TNFα is directly 
toxic to islets, and potentiates the effect of 
toxicity 
induced 
by 
other 
circulating 
cytokines, including IL-1, as demonstrated by 
in vitro data (15, 27, 28).  In vitro, the addition 
of anti-TNFα inhibitor to islets in standard culture media reduced TNFα secretion by >60%, reduced beta cell 
apoptosis by 26%, and increased stimulated insulin secretion (16).  TNFα inhibitor therapy has been studied in 
murine models of islet transplantation and in non-controlled studies of islet allotransplantation, but these findings 
have never been translated to TPIAT recipients. 
 
In murine models, administration of a TNFα inhibitor prolonged islet allograft survival, shifted the circulating 
cytokines towards an anti-inflammatory profile, and increased expression of anti-apoptotic pathways within the 
islet graft (52).  In a separate study, when human islets were transduced via an adenoviral vector to express a 
soluble type 1 tumor necrosis factor receptor (TNFR) immunoglobulin-Fc fusion transgene (TNFR-Ig), which 
blocks TNF signaling, these TNFR-Ig expressing islets were protected from cytokine-induced apoptosis in vitro, 
and when these islets were transplanted into a diabetic mouse model, insulin independence was successfully 
restored for longer durations than untreated islets (53). Etanercept therapy has been administered in several 
clinical trials of alloislet transplantation for type 1 diabetic recipients, in addition to standard immunosuppression 
(54-56).  Recipients were given a 10 day course of etanercept early post-transplant (50 mg on day 0, and 25 mg 
on days 3, 7, and 10).  In recent analyses conducted by our institution and the Collaborative Islet Transplant 
registry, patients who received etanercept had significantly improved insulin independence rates up to 5 years 
after transplantation compared to those who had not.  Because the drug was given early in the early post-operative 

13 
 
stage, we postulated that TNFα inhibition led to better engraftment and survival of the transplanted beta cell mass, 
thus allowing longer duration of insulin independence over conventional immunosuppression alone (54, 57).  In 
a preliminary analysis of 12 TPIAT recipients at our institution, higher levels of TNFα at 3 days post-transplant 
were associated with lower C-peptide levels at 3 months (r= -0.38, p=0.2).   
 
Etanercept is FDA approved for treatment of ankylosing spondylitis, rheumatoid arthritis, and psoriatic arthritis 
and moderate to severe plaque psoriasis in adults.  The standard adult dose for arthritic conditions is 50 mg once 
weekly, although doses as high as 50 mg twice weekly for 3 months are approved for treatment of severe plaque 
psoriasis.  Etanercept is FDA approved for the treatment of juvenile idiopathic arthritis in children 2 years of age 
or older at a dose of 0.8 mg/kg weekly (50).  Clinical trials with etanercept have focused on these conditions and 
other immune, rheumatic, or skin disorders, in children and adults (58-68).  The most common adverse events are 
injection site reactions.  Other potential safety concerns include risk for opportunistic infection, demyelinating 
disorder, or malignancy.  However, current long-term follow up studies suggest a favorable safety profile, even 
with prolonged use (60, 69),   In 58 children treated with etanercept for JIA for up to 8 years under an open-label 
extension study, the overall rate of serious adverse events was low at 0.12 SAE per patient-year, with no cases of 
tuberculosis, opportunistic infection, lymphoma, other malignancy, or demyelinating disease observed over the 
study period (64).  Similar findings are reported in 380 adults treated for rheumatoid arthritis and followed for 5 
years (69)-- the most common adverse event was upper respiratory tract infection; serious adverse events included 
one case of tuberculosis but no other opportunistic infections, blood dyscrasias, or demyelinating disease.   
 
Etanercept has been studied in new onset diabetes mellitus as a strategy to preserve beta cell mass.  In a cohort 
of 18 children with new onset type 1 diabetes randomized to receive etanercept at a dose of 0.4 mg/kg twice 
weekly (maximum 25 mg twice weekly) for 24 weeks, hemoglobin A1c was lower in treated subjects, and area 
under the curve for C-peptide from mixed meal tolerance testing increased by 39% at 24 weeks compared to a 
20% decrease in C-peptide in the placebo group, suggesting a beta cell-protective effect of etanercept (70). 
 
Measures of islet function serve as surrogate measures of islet mass 
In order to adequately assess the impact of any therapy on islet engraftment, it is important to have endpoints that 
reflect islet mass. Because it is not possible to directly quantify the number of islets that engraft and survive in 
the liver post-transplant, we have carefully selected surrogate endpoints that reflect beta cell function and mass. 
We will assess several previously validated measures: 1) C-peptide response to a mixed meal tolerance test 
(MMTT), 2) the acute C-peptide and insulin response to intravenous glucose tolerance (IVGTT), and glucose 
potentiated arginine-induced insulin secretion (GPAIS).   
 
The oral stimulus used most often in the TPIAT setting and in trials of new onset type 1 diabetes mellitus is the 
mixed meal tolerance test, in which the subject ingests a standard amount of Boost High Protein or a similar 
beverage. The MMTT is an accepted measure of beta cell function in islet transplant and diabetes studies (7, 71, 
72), and it is simple to perform in the clinic setting. However, it may be less useful than the intravenous stimuli 
as a direct measure of islet mass (73). Intravenous stimuli—dextrose and/or arginine—have been shown to 
correlate with islet mass in animal and clinical transplant models (74-76).  Both the acute insulin response to 
glucose (AIRglu) derived from the IVGTT and the maximal acute insulin response to arginine (AIRmax) 
measured from GPAIS correlate strongly with transplanted islet mass in patients who maintain euglycemia long-
term (74).  While transplanted islet mass is not the same as engrafted islet mass, these studies were performed in 
patients who were specially selected from those with optimal long-term beta cell function, and so were likely the 
recipients with the best engraftment.  Thus, they appear to be reasonable surrogate measure for engrafted beta cell 
mass.  Both measures were superior to a simple arginine stimulation test (22). In allotransplant patients, the 
AIRglu and AIRmax at 3 months post-transplant predicted insulin independence at 1 year.  Thus, this test 
performed early after transplant was predictive of key long-term clinical outcomes (22). 
 
Measures of islet loss 

14 
 
Another approach to measuring engraftment is to use surrogate measures of islet loss.  Recently, a novel assay 
developed by Herold et al, measuring circulating levels of unmethylated insulin DNA as a measure of beta cell 
death, was validated in type 1 diabetes (77).  When studied in 80 diabetic patients (37 treated with teplizumab), 
researchers found that the levels of unmethylated insulin DNA were higher in new onset diabetics than in healthy 
controls, due to accelerated beta cell turnover.  Those type 1 diabetic patients treated with teplizumab had lower 
levels of unmethylated DNA than the untreated patients, consistent with the observation that the teplizumab group 
preserved beta cell mass and function (based on C-peptide secretion from MMTT).  In collaboration with Dr. 
Herold, we have a novel opportunity to measure this marker in the early post-transplant period as a measure of 
islet loss.    
 
Summary of significance 
Approximately 4 in every 10,000 persons in the U.S. suffer from chronic pancreatitis, with few treatment options 
available (1).  Chronic pancreatitis can result from genetic or obstructive factors, trauma, or alcohol use, or, often, 
unknown causes;  it is a disabling disease that affects many young adults with an otherwise long lifespan ahead 
of them. 
 
While TPIAT can provide pain relief and restore quality of life, application of this procedure is limited by the 
high rate of postsurgical diabetes mellitus (7, 19).  Success of the IAT is hampered by early islet loss. In fact, 
insulin independence has been observed in low islet mass recipients (<2500 IEQ/kg) (7), suggesting a high success 
rate could be achieved with a much lower number of islets if engraftment is optimized. Islet engraftment and 
surviving beta cell mass is compromised by the innate inflammation that occurs following intraportal islet 
infusion. We have the opportunity to test the efficacy of two anti-inflammatory therapies, A1AT and etanercept, 
in patients undergoing TPIAT.  This study will pave the way for a larger, definitive multicenter trial by helping 
to define the appropriate therapeutic agent. While our study is focused on patients with pancreatitis at risk for 
surgical diabetes after TPIAT, findings would also be applicable to the field of islet allotransplantation for type 
1 diabetes mellitus.   
 
 
 

15 
 
OBJECTIVES AND SPECIFIC AIMS 
This drug-treatment clinical trial will investigate the use of etanercept and A1AT to improve IAT beta cell 
function at 90 days post-transplant compared to standard care of TP-IAT recipients.  Our overall hypothesis is 
that one or both anti-inflammatory drugs will reduce post-transplant beta cell apoptosis, improve islet 
engraftment, and that this will be reflected in higher stimulated insulin and C-peptide secretion at day 90.  
Mechanistic data from the early post-transplant period and graft function at day 90 will be used to select the most 
promising agent for further clinical development.   
There are reasons to believe that one strategy may be more impactful than the other.  Alpha-1 antitrypsin has a 
generalized anti-inflammatory effect and directly inhibits beta cell apoptosis, which makes this agent appealing.  
Etanercept is a more potent anti-inflammatory that directly targets a central mediator in post-transplant beta cell 
damage—TNFα—and thus may be more effective.  The most efficient approach to select the best therapy is to 
compare these two agents head-to-head.  Thus, we propose the following sub-hypothesis for the study: 
• Sub-hypothesis #1: The efficacy of etanercept will be superior to that of A1AT because it specifically 
targets the cytokine most clearly implicated in beta cell apoptosis. 
• Sub-hypothesis #2:  The efficacy of A1AT will be superior to that of etanercept because it both inhibits 
cytokine production and it blocks protease activity. 
Specific Aims 
Forty-five patients undergoing TP-IAT (day 0) at a single center will be randomized 1:1:1 to receive during the 
peri-operative period either: 1) etanercept (50 mg SQ on day 0; 25 mg SQ on days 3, 7, 10, 14, and 21),  2) 
alpha-1 antitrypsin (90 mg/kg IV infusion on days -1, and +3, 7, 14, 21, and 28 post-transplant) or 3) standard 
care.   
SPECIFIC AIM #1:  To determine if anti-inflammatory treatment with etanercept or alpha-1 antitrypsin 
during the critical peri-transplant engraftment period improves islet engraftment and function after islet 
autotransplant, as assessed by area under the curve for C-peptide on mixed meal tolerance testing (oral stimuli), 
acute insulin response to glucose-potentiated arginine stimulation (IV stimuli), and insulin requirements at day 
90 post-transplant. The primary endpoint of the maximally stimulated acute insulin response to arginine 
(AIRmax) from GPAIS at day 90 will allow us to rapidly identify the most promising therapeutic agent for further 
development and testing in a large randomized trial. 
SPECIFIC AIM #2:  To gather pilot data on the long-term impact of etanercept or alpha-1 antitrypsin 
administered during the peri-transplant period by evaluating islet function at 1 and 2 years post-
transplant, as assessed by area under the curve for C-peptide on mixed meal tolerance testing (oral stimuli), acute 
insulin response to glucose-potentiated arginine stimulation (IV stimuli), and insulin requirements (units/kg/day) 
at 1 year post-TPIAT.  In addition, insulin requirements and fasting/stimulated C-peptide by MMTT will be 
assessed at yearly intervals from year 3-5 post-transplant. 
SPECIFIC AIM #3:  To evaluate the mechanistic effects of etanercept and alpha-1 antitrypsin on 
inflammation, islet cell viability/survival, and beta cell apoptosis.  This will be assessed by circulating 
cytokine and chemokine levels and measurement of circulating unmethylated DNA (a recently validated marker 
of beta cell death in T1DM) in patient serum. 
The goal of the current research is to select the anti-inflammatory agent with the greatest potential to preserve 
islet mass early after TPIAT.   
 
 
 

16 
 
STUDY DESIGN OVERVIEW 
Overview of Clinical Trial Design for All Aims 
In this randomized, controlled non-masked trial, 45 patients age 18-65 years with chronic pancreatitis who are 
accepted for TPIAT procedure based on standard clinical criteria will be enrolled and randomized 1:1:1 to three 
study arms: 
1) Alpha-1 antitrypsin (A1AT), 90 mg/kg/week IV, administered days -1, and +3, 7, 14, 21, and 28.   
2) Etanercept administered as 50 mg SQ prior to the islet infusion (day 0) and 25 mg SQ on days 3, 7, 10, 
14, 21 post-transplant.   
3) Standard TPIAT care 
 
Patients will be seen in follow up at 90 days and 1 year post-transplant for metabolic testing.  The maximally 
stimulated acute insulin response (AIRmax) obtained from glucose potentiated arginine-induced insulin secretion 
(GPAIS) at 90 days post-transplant is the primary endpoint for the study. AIRmax has previously been 
demonstrated to correlate best with islet mass in human and animal models; by assessing AIRmax at 90 days post-
transplant, we will be able to rapidly evaluate the therapeutic impact of these agents and select the agent most 
promising for further study and development. Mechanistic studies will be performed frequently throughout the 
early transplant period. Inflammatory cytokines will be measured by repeated serum sampling in the first 1 week 
post-transplant. Unmethylated insulin DNA levels will be monitored in the first 1 month post-transplant. Insulin 
requirements and fingerstick blood glucoses will be monitored throughout the study duration. Key secondary 
endpoints include the area under the curve (AUC) for C-peptide from mixed meal tolerance testing, the acute 
insulin response (AIRglu) on IV glucose tolerance test, the acute C-peptide response to glucose (ACRglu) on 
IVGTT, and the maximally stimulated C-peptide response (ACRmax) from GPAIS at day 90 and 1 and 2 years, 
and the AIRmax at 1 and 2 years, as well as average daily insulin requirements at each time point.   As an 
exploratory component, we will continue to collect the basic clinically available measures of insulin use/dose, 
HbA1c, and simple fasting and stimulated glucose and C-peptide from a mixed meal test annually for years 3-5 
post-transplant, all part of the patients’ routine cares. 
 
 
 

17 
 
Study Treatment 
Study drugs: The two investigational agents administered in this study are as follows: 
1) Alpha-1 antitrypsin (Aralast NP) intravenously at a dose of 90 mg/kg IV weekly.  Treatment will be started 
1 day prior to surgery and on days +3, 7, 14, 21, and 28 after infusion.  This is infused as a rate of no more 
than 0.2 mL/kg body weight/minute, and may be slowed depending on patient tolerability. 
2) Etanercept:  dosing in adult recipients is 50 mg SQ on day 0, and 25 mg SQ on days 3, 7, 10, 14, 21.   
 
All medication doses will be administered in the hospital (during post-operative hospitalization) or in the research 
center by an RN.   
 
Randomization Patients will be randomized to one of the three arms in a 1:1:1 ratio to A1AT, or etanercept, or  
standard care.  Randomization will be stratified on BMI (< or >27 kg/m2).  The investigational pharmacist will 
dispense study medication according to the randomization schedule provided by the biostatistician.  Because of 
the nature of the drugs, given intravenously and subcutaneously, this initial study will not be blinded, to minimize 
the burden on participants.   
 
Rationale for study drug dosing regimen 
Alpha-1 antitrypsin doses of 90 mg/kg/week are currently administered in 8-35 year old participants in the 
Research Trial of Aralast in New Onset Diabetes (RETAIN), sponsored by the NIAID, Immune Tolerance 
Network, and Juvenile Diabetes Research Foundation.  This is a dose that has been administered without serious 
adverse events to adults and children (down to 8 years of age) in the RETAIN trial (personal communications, 
Drs. Kevan Herold and Eva Tsalikian). Although there are multiple clinical grade A1AT products, Aralast was 
selected for this trial based on: 1) pre-clinical studies which have primarily used Aralast; and 2) use of Aralast 
NP in clinical trials in new onset type 1 diabetes. Treatment with A1AT for 14-30 days post-transplant has been 
observed to be efficacious in murine models of islet transplantation, with benefits sustained beyond the period of 
treatment, and even 14 days of treatment (4 doses) was effective in permitting long-term survival of marginal islet 
mass grafts in non-human primates (49). Thus, we have focused therapy specifically in this early post-islet 
infusion period where it is likely to yield benefit, in the first one month after islet infusion.  The first 1-3 months 
post-transplant in clinical TPIAT recipients are critical to long-term outcomes.   Clinically, C-peptide to glucose 
ratios (SUITO index) at 1 month after transplant and the acute insulin response to glucose at 3 months after 
transplant appear to predict achievement of insulin independence in auto and allo-islet transplantation (22, 78, 
79).  Thus, establishing early engraftment is key to improving later success.  The short-term post-operative 
treatment duration proposed for this clinical trial targets this critical period of early islet engraftment—by 
protecting engrafted islet mass with short-term peri-transplant treatment, we expect to achieve superior long-term 
metabolic outcomes.   
 
Etanercept has been administered as part of multiple clinical trials in allotransplantation.  The dosing regimen is 
extrapolated from the experience with islet allotransplantation, in which doses are administered on day 0, 3, 7, 
and 10.  Although this short duration of treatment appears efficacious in islet allotransplantation, because TPIAT 
patients undergo a more significant surgical procedure than those patients who receive a cadaveric donor alloislet 
infusion for type 1 diabetes (a relatively minor procedure with rapid recovery), we have extended the treatment 
duration in the TPIAT trial to 21 days. 
 
PRIMARY AND KEY SECONDARY ENDPOINTS FOR THE STUDY 
Primary Endpoint: 
1)  AIRmax from the Day 90 visit (obtained from glucose potentiated arginine-induced insulin secretion):  
We have data from UMN that supports this as the strongest correlate with beta cell mass, so this measure 
best addresses our research question.  The early endpoint is chosen to rapidly translate pilot results into 
randomized clinical trials.  Patients are not expected to achieve insulin independence in this population 
before day 90. 
Key Secondary Endpoints: 

18 
 
1) Insulin independence:  At day 365 and day 730.  Defined as no insulin use for >14 days, with fasting blood 
sugar <126 mg/dL; 90 minute mixed meal glucose <180 mg/dL, and HbA1c <6.5% 
2) Insulin dose (unit/day):   At day 90, 365, and 730. 
3) ACRmax, derived from GPAIS at days 90, 365, and 730 
4) AIRglucose and ACRglucose, derived from the IVGTT at days 90, 365, and 730 
5) AUC C-peptide from 2 hour MMTT, at days 90, 365, and 730 
6) AUC glucose from 2 hour MMTT, at days 90, 365, and 730 
7) Absence of severe hypoglycemic episodes (inclusive of day 90- 365) and HbA1c <7% at day 365 
8) Absence of severe hypoglycemic episodes (inclusive of day 365-730) and HbA1c <7% at day 730 
 
Key exploratory and safety endpoints: 
1) Mean HbA1c by study group over the duration of the study 
2)  Number of patients experiencing at least 1 hypoglycemic event; and the incidence of SHE (events per subject-
years) over the course of the study by study group 
 
 
STUDY SUBJECTS 
Study Subjects: inclusion and exclusion criteria to select suitable candidates for study 
Inclusion Criteria  
1)  Age 18- 68 years.  . 
2)  Scheduled for total pancreatectomy and IAT at UM.  All patients who are approved for pancreatectomy 
and IAT at UM are reviewed by a multi-disciplinary committee including surgeons, gastroenterologists 
specializing in pancreatic disease, a pain specialist, psychologist, and endocrinologist to confirm the 
diagnosis of chronic pancreatitis and candidate suitability for surgery. 
3)  Able to provide informed consent  
 
Exclusion Criteria  
1) Pre-existing diagnosis of diabetes mellitus, fasting blood glucose >115 mg/dl, or hemoglobin A1c level >6.0% 
because these are all evidence of inadequate beta-cell mass. 
2) Use of any of the following treatments in the 30 days prior to enrollment: insulin, metformin, sulfonylureas, 
glinides, thiazolidinediones, GLP-1 agonists, DPP-4 inhibitors, or amylin. 
3) IgA deficiency (serum level <5 mg/dL), which has been associated with hypersensitivity to alpha-1 
antitrypsin. 
4) ALT or AST>2.5 times the upper limit of normal (ULN).  Bilirubin >ULN, unless due to benign diagnosis 
such as Gilbert’s. 
5) Known history of HIV infection, hepatitis B (chronic), or hepatitis C (chronic). 
6) History of tuberculosis (latent or active disease), or positive TB skin test. 
7) History of symptomatic fungal lung infection. 
8) History of multiple sclerosis, transverse myelitis, Guillain Barre, or other suspected demyelinating disease, 
due to risk of exacerbation of these conditions with use of etanercept; or prior history of systemic lupus 
erythematosus  
9) Any of the following hematologic abnormalities:  severe anemia (hgb <10 g/dL), thrombocytopenia 
(<150/mm3), or neutropenia (<1.0 x109/L). 
10) Current use or expected use of oral or injected corticosteroids, or any mediation likely to affect glucose 
tolerance.  However, use of hydrocortisone for physiologic replacement, or use of any topical, inhaled, or 
intranasal glucocorticoid is permitted. 
11) Current or expected use of any other immunosuppressive agent.  
12)  Known hypersensitivity to etanercept or A1AT. 
13) Any condition that is likely, in the opinion of the patient’s medical providers, to necessitate use of TNF alpha 
therapeutically in the future (such as psoriatic arthritis).   
14) Known coagulopathy, or need for anticoagulant therapy preoperatively (coumadin, enoxaparin), or any history 
of pulmonary embolism. 

19 
 
15)  For females, plans to become pregnant or unwillingness to use birth control for the study duration.   
16)  Inability to comply with the study protocol. 
17) Untreated psychiatric illness that may interfere with ability to give informed consent, or other developmental 
delay or neurocognitive disorder that impairs with a patient’s ability to consent on their own behalf. 
18)  Any other medical condition that, in the opinion of the investigator, may interfere with the patient’s ability 
to successfully and safely complete the trial. 
 
 
SUBJECT RECRUITMENT AND INFORMED CONSENT PROCESSES 
Study subject recruitment and rationale for study site 
Subjects will be recruited from patients who are scheduled to undergo TPIAT at the University of Minnesota.  
Importantly, all patients are screened for TPIAT procedure on clinical grounds, after review by a multi-
disciplinary 
committee 
to 
confirm 
the 
diagnosis of pancreatitis, maximal medical 
management, and impaired quality of life 
and/or narcotic dependence, as previously 
described (19).   
 
The University of Minnesota (UMN) performs 
the greatest number of islet autotransplants per 
year of any institution in the United States, 
making it an ideal site for a clinical trial in this 
population. Since 1977, over 550 islet 
autografts have been performed, with an 
anticipated 
patient 
volume 
of 
55-60 
patients/year. The patient volume by year 
through 2014 is displayed in the graphic below. 
 
 
We expect at least 60% of our TPIAT 
population, or ~33subjects per year will meet eligibility criteria for the proposed trial.  We anticipate enrolling 45 
participants over 2.5- 3 years based on our prior experience with drug-treatment clinical trials in adults (25- 30 
patients enrolled per year).  Patient interest in study participation has been very high.  Patients from this population 
are interested in clinical trials for several reasons, including an altruistic desire to help others who have suffered 
with similar chronic disease.   
 
The multidisciplinary UMN team has complementary expertise in medical and surgical management of chronic 
pancreatitis, diabetes, metabolic testing of islet mass and function, and manufacturing and testing of human islet 
products.  It is in a unique position to help improve islet transplant protocols for both auto- and alloislet transplant. 
 
Description of the recruitment process 
Recruitment plan 
Patients will be recruited from the pool of eligible participants scheduled for total pancreatectomy and islet 
autotransplant at the University of Minnesota (UMN).  These patients are known to the PI, as a member of the 
TPIAT team.  Potential surgical patients undergo a comprehensive multi-disciplinary evaluation at UMN at an 
initial consult visit.  Participants will be informed of the study by the patient’s physician (medical doctor on the 
IAT team) or the transplant coordinator for the TPIAT program at the time of the initial consult.  Patients will be 
offered a brief descriptive hand out for more information regarding the study.  It will be clearly emphasized that 
participation in not required to have TPIAT surgery at the UMN.  Those interested in the study will be contacted 
by the primary investigator to review the study protocol, including risks and benefits of participation.  Patients 
will be provided with the informed consent document in advance of the initial visit to obtain informed consent.  
Once the patients have reviewed the written description of the study, and after telephone conversation with the PI 

20 
 
to answer questions, if patients remain interested in study participation, they will be scheduled in the research 
center for an informed consent visit.   
 
 
 
Travel reimbursement and compensation plan 
Seventy-five percent of the TPIAT patients seen at the University of Minnesota are referred from out of state, and 
must travel by airplane or prolonged car trip, and stay overnight at a hotel, to participate in the study.  Thus, it is 
not possible to reliably get patients back for study visits without providing some compensation for travel expenses.  
The study will reimburse patients who are from more than 60 miles away from the study center for mileage and/or 
airfare, airport transportation, meals ($25/day), and hotel up to a total maximum reimbursement for travel of $750 
per visit at the day 90, 365, and 730 follow up visits (when the extended metabolic testing is performed).  
Screening can be coordinated during the patient’s preoperative visit in the week prior to surgery; however, 
because this will often require one additional night in Minnesota, we will provide reimbursement for one night’s 
hotel, up to $250.  In addition, because the metabolic tests are cumbersome, time consuming, and require a 
morning off of work, both local patients and those who travel will be given a stipend of $50 per study day ($100 
total for 2 days) for completing the metabolic testing at each follow up interval.  This is consistent with standard 
stipends provided to participants in diabetes studies at our institution.  
 
Recruitment and advertisement materials 
The study will include a one page informational handout which briefly describes the purpose of the study and the 
medications being tested.  This hand out will include an “opt out” phone number that the patients can call if they 
do not wish to be contacted with any additional information.  In addition, as per standard guidelines for clinical 
trials, the study will be posted on clinicaltrials.gov.  It will be clearly emphasized that participation in a study is 
not required to have TPIAT surgery. 
 
Description of the informed consent process 
As detailed in the preceding section, interested patients will be mailed a copy of the informed consent document 
to review prior to the informed consent visit.  Informed consent will occur when the patient returns for the 
screening study visit.  Informed consent will be obtained by the primary investigator, or one of the co-
investigators.  Because this is a treatment study, a physician will always be involved in the initial informed consent 
process.  Following review of the study protocol and the informed consent document, patients’ understanding of 
the study will be assessed with directed questions, and informed consent will be confirmed and documented in 
the patient’s record.  The informed consent process will take place before any protocol-driven screening studies 
are done, and within 4 weeks of the patient’s surgery date.  The informed consent process will occur in the clinical 
research center within the University of Minnesota CTSI.   
 
Adults that are unable to consent for themselves due to developmental delay or severe psychiatric illness will not 
be recruited for this study. 
 
Because patients are sent the informed consent document prior to the informed consent visit, they are provided 
opportunity to review the study protocol including risks and benefits, in writing, prior to the consent visit.  Patients 
are encouraged to discuss the study details and informed consent with significant others, family, and their local 
physicians.   
 
Any significant changes in the risk profile of study medications, other risks, study medication administration, or 
testing/labs would prompt a change in the informed consent document.  Updated informed consent will be 
obtained at the patient’s next study visit, before any study testing is done. 
 
 
STUDY VISITS AND ASSESSMENTS 
Outline of study visits and endpoint assessments 

21 
 
Patients will be seen prior to surgery (“Baseline”), during the treatment phase for medication administration and 
safety labs , at 90 days (± 15 days; “Day 90 visit”), at 365 days (± 28 days, “Year 1”), and at 730 days (±56 days, 
“Year 2”).   The year 1 and year 2 study visits will provide detailed pilot data on the long-term function of the 
islet grafts in treated and untreated patients. 
 
A local follow up with telephone or face-to-face encounter to review insulin requirements, blood glucose logs, 
and obtain local mixed meal tolerance test results (part of standard clinical care) will occur at years 3, 4, and 5 
(all ± 2 months) for exploratory data on long-term efficacy.  This information will be readily available, as it is 
part of the standard routine care of all TPIAT recipients at UM.   
 
Subject screening visit 
Subjects’ medical history will be reviewed from the electronic medical record and from history obtained from the 
patient to confirm eligibility.  In addition, the following screening assessments will be performed at a screening 
visit within 4 weeks prior to the scheduled surgery date, after informed consent has been obtained: 
• Complete metabolic battery (includes hepatic panel, creatinine, fasting glucose) 
• CBC with differential and platelets 
• Urine pregnancy test in women with child-bearing potential (if >7 days since screen, repeat prior to first 
dose of study drug administration; UPT not necessary in females s/p hysterectomy procedure) 
• Hepatitis C and hepatitis B serology,  HIV ELISA 
• IgA level 
• Mantoux skin test or Quantiferon (serum) for TB screening 
• Hemoglobin A1c level 
• Mixed Meal Tolerance Test 
• IV glucose tolerance test 
• Glucose potentiated arginine-induced insulin secretion 
 
Table.  Study Flowchart (year 0-2) 
 
screening 
Days  
0-7 
Days  
7, 14,  
21, 28  
Day 
60 
Day 
90 
Day 365 
(Year 1) 
Day 730 
(Year 2) 
Study Visit Assessments (abbreviated) 
 
 
 
 
 
 
 
Insulin Use/Dose (u/kg/day, endpoint) 
 
 
X 
 
X 
X 
X 
Mixed Meal Tolerance Test (AUC C-
X 
 
 
 
X 
X 
X 
IVGTT (AIRglu, ACRglu) 
X 
 
 
 
X 
X 
X 
GPAIS (AIRmax, ACRmax) 
X 
 
 
 
X 
X 
X 
HbA1c level 
X 
 
 
 
X 
X 
X 
iPro2 (6 day CGM) 
 
 
 
 
X 
X 
X 
Complete metabolic panel, CBC 
X 
 
X* 
 
X 
X 
X 
Random morning C-peptide and 
glucose 
 
 
Day 7, 
14 
 
 
 
 
Fasting glucose, C-peptide, creatinine 
X 
 
Day 28 
 
X 
X 
X 
Drug safety assessments (PE, hx, labs) 
 
X 
X 
 
 
 
 
Inflammatory cytokines (see text)** 
 
X 
 
 
 
 
 
Unmethylated insulin DNA levels** 
 
X 
X 
 
 
 
 
Safety assessment (phone visit for 
symptoms) 
 
 
 
X 
 
 
 
Islet Assessments (see text) 
 
Day 0 
 
 
 
 
 
* Years 3, 4, and 5:  Telephone or face-to-face review of insulin use/dose; labs (HbA1c, clinical MMTT) 
** Drawn at multiple time points, as detailed in the methods for Specific Aim #3. 
 

22 
 
Design and Methods to Evaluate Specific Aim #1 
SPECIFIC AIM #1:  To determine if anti-inflammatory treatment with etanercept or alpha-1 antitrypsin 
during the critical peri-transplant engraftment period improves islet engraftment and function after islet 
autotransplant, as assessed by area under the curve for C-peptide (AUC C-pep) on mixed meal tolerance testing 
(oral stimuli), acute insulin response to glucose-potentiated arginine stimulation (AIRmax, IV stimuli), and 
insulin requirements at day 90 post-transplant.   
Hypothesis 1:  Etanercept and A1AT groups will have higher AIRmax per islet transplanted than the control 
group.   
Hypothesis 2:  Etanercept and A1AT groups will have higher acute insulin response to glucose (AIRglu), 
higher acute C-peptide response to glucose (ACRglu) and greater AUC C-pep than the control group. 
Hypothesis 3:  A1AT group will have superior AIRmax, AIRglu, and AUC C-pep compared to etanercept 
group, because A1AT has a more generalized effect on the inflammatory milieu.   
Hypothesis 4: Conversely, etanercept group will have superior AIRmax, AIRglu, and AUC C-pep compared 
to A1AT group, because of the central role of TNFα in beta cell loss. 
 
There are reasons to believe that either of A1AT or etanercept may be superior to the other (hypotheses 3 and 
4), in view of their relative mechanisms.  Thus it is important to compare these two agents head-to-head, in 
order to select the more promising therapy.   
 
Definitions and procedures for metabolic assessments  
For this aim, patients will be asked to return for testing at day 90 +/- 15 days after TPIAT.  Patients will continue 
their basal insulin analog (if applicable) but will be instructed to withhold any rapid acting insulin in the 4 hours 
prior to the start of testing.  The following tests will be performed over 2 mornings, following a 10 hour fast: 
1. Two Hour Mixed Meal Tolerance Test (MMTT): Glucose and C-peptide are drawn at baseline and every 
half hour for 2 hours. The patient is given Boost HP 6 cc/kg (max 360 ml), ingested within 5 min, after 
the time 0 blood draw. Area under the curve for glucose (AUC glucose) and C-peptide (AUC C-peptide) 
will be evaluated.  AUC C-peptide is the standard endpoint for assessment of beta cell function in the trial 
net studies for type 1 diabetes, and in the alloislet transplant trials in the Clinical Islet Transplant 
consortium.  Scheduled on a separate morning from the IVGTT and GPAIS testing.    An additional 2 mL 
plasma will be collected from each time point in a collection tube including protease and DPP-4 inhibitors; 
these samples will be stored for potential later analyses of incretin hormones and glucagon (which require 
the special inhibitor cocktail to avoid sample degradation). 
2. Simple intravenous glucose tolerance test (IVGTT):  A bolus of 0.3 grams/kg of dextrose is administered 
at time 0, and insulin, C-peptide, and glucose are sampled at times -10, -5, -1, and 1, 2, 3, 4, 5, 7, and 10 
minutes.  The AUC for the 10 minute insulin values minus baseline are used to calculate the acute insulin 
response to glucose (AIRglu) and acute C-peptide response to glucose (ACRglu).  Glucose levels will be 
drawn additionally at +12, 14, 16, 18, and 20 minutes to calculate the glucose disposal rate 
(Kg=ln(glucose)/min x 100).   
3. * Glucose potentiated arginine stimulation (GPAIS): Immediately following the IVGTT (at time +20 
minutes), dextrose (D20%) is infused at a variable rate to maintain blood glucose at ~230 mg/dL until 
completion of the test.  Glucose levels are drawn and measured by bedside autoanalyzer every 5 minutes 
to maintain glucose in target range.  Following at least 30 minutes of continuous D20% infusion at target 
BG (~230 mg/dL), baseline samples for glucose, insulin, and C-peptide are drawn (three samples over 10 
minutes), a bolus of 5 grams arginine is administered (time 60 minutes), and samples for glucose, insulin, 
and C-peptide are obtained at 2, 3, 4, 5, 7 and 10 minutes after the arginine bolus.  Results are used to 
calculate the maximal potentiated arginine induced insulin secretion (AIRmax), a sensitive marker of beta 
cell mass, and the maximal C-peptide secretion (ACRmax). AIRmax is the *primary endpoint for the 
study.  This is selected as the primary endpoint because it is the measure that most directly relates to islet 
mass in diabetes and transplant studies in humans and animal models. 

23 
 
4. Continuous glucose monitoring (CGM):  6 days of CGM monitoring (minimum of 72 hours for endpoint 
inclusion) at day 90, 365, and 730 will be obtained for mean glucose, standard deviation, % of time in 
hypo- and hyperglycemia (80). 
5. Hemoglobin A1c level is measured as a marker of average glycemic control. 
6. Insulin use is assessed from glucose and insulin diaries maintained by patients for 14 consecutive days, 
overlapping with day 90.  Calculated as units/kg/day. 
7. Hypoglycemic episodes:  All severe hypoglycemic events will be recorded.  This is defined based on 
American Diabetes Association criteria as a hypoglycemic episode <54 mg/dL or (if not measured) 
associated with prompt recovery upon administration of glucose in which a patient is mentally or 
physically incapacitated and requires assistance from another person in order to treat hypoglycemia.   
8. Health related quality of life:  Assessed by the SF-36, from which 8 subscale scores can be generated for 
physical and mental/emotional HRQOL, as well as standardized physical composite summary and mental 
composite summary scores.  In addition specific diabetes burden will be assessed by the  Problem Areas 
in Diabetes (Diabetes Distress Scale).  These instruments are administered as part of our standard follow 
up protocol in all TPIAT recipients at 3 months, 6 months, and yearly after surgery.  
 
In addition, at 90 days post-transplant, patients will have a fasting C-peptide and fasting glucose drawn (as part 
of MMTT), to calculate basic measures of early function, including: 1) Fasting C-peptide to glucose ratio; and 2) 
SUITO index (calculated as fasting C-peptide [ng/ml] / (fasting blood glucose - 63 [mg/dl]) × 1500) (78).   In 
addition, a random glucose and C-peptide level are obtained at day 7,14, and day 28 after surgery. 
 
In between visits at the study center, patients will be asked to continually maintain a log of self-monitored blood 
glucoses and insulin doses.  Patients will be instructed to check fingerstick blood glucose at least 4 times per day 
(pre-meal and bedtime).  Patients will be instructed to send logs to the study PI and coordinator at least once 
monthly for adjustment of insulin dosing.  Insulin doses are adjusted by the PI based on site standard protocol, to 
maintain the following goals: fasting glucose <126 mg/dL, 2 hours after a meal <180 mg/dL, and HbA1c <6.5%.  
Patients have HbA1c levels drawn quarterly for clinical monitoring (standard of care). Any patient not meeting 
these goals off insulin is not considered insulin independent per protocol. 
 
Safety monitoring:  The PI and study coordinators will monitor for adverse events throughout the study period, 
as described in the human subjects monitoring plan.  The coordinator or investigator will collect a history for 
safety assessment at day 60 (may be done by telephone visit if patient is not able to return to study center).  
Additional monitoring for safety will include history at each scheduled visit day 0- 30 for symptoms of DVT or 
PE (using Wells criteria) with lower extremity ultrasound or spiral CT performed if response moderately to highly 
suspicious for deep vein thrombosis (DVT) in the lower extremities (Well’s>2) or pulmonary embolism (PE) 
(Well’s >4) respectively. Note that in this population all patients are expected to have a Wells score of 3 (meets 
‘moderate’ suspicion threshold) as 100% are immobilized and nearly 100% have intermittent tachycardia from 
pain and thus a score of 4 or greater will be achieved only in the context of symptoms to suggest PE.  Likewise, 
the Well’s score of >2 accounts for the surgery, immobilization and bilateral lower edema swelling (normal post-
TPIAT) that will occur in all patients.  At day 60, the telephone encounter will include assessment of symptoms 
for PE or DVT.  An EKG will be performed at baseline, day 28 and day 90. 
 
 
 
Design and Methods to Evaluate Specific Aim #2 
SPECIFIC AIM #2:  To gather pilot data on the long-term impact of etanercept or alpha-1 antitrypsin 
administered during the peri-transplant period by evaluating islet function at 1 and 2 years post-
transplant, as assessed by area under the curve for C-peptide on mixed meal tolerance testing (oral stimuli), acute 
insulin response to glucose-potentiated arginine stimulation (IV stimuli), and insulin requirements (units/kg/day) 
at 1 and 2 years post-TPIAT. 

24 
 
Hypothesis 1: AIRmax, AIRglu, and AUC C-pep from metabolic testing performed at yearly intervals post-
transplant will be greater in the A1AT-treated patients and etanercept-treated patients, compared to 
controls.   
Hypothesis 2:   Mean daily insulin requirements (units/kg/day) will be lower in the A1AT-treated group vs 
control and in the etanercept treated vs control. 
Hypothesis 3: AIRmax and AIRglu at 3 months will predict insulin independence at 1 year and 2 years post-
transplant. 
For specific aim #2, patients will return to the study center at day 365 ± 28 days and 730 ± 56 days post-
transplant for repeat metabolic testing.  Testing performed will be identical to that described under approach for 
specific aim 1.  Both insulin use and the proportion of patients insulin independent will be recorded.   
 
As an exploratory analysis, patients will continue to be followed yearly by a telephone or face-to-face visit, 
depending on whether they are returning to UMN for clinical care, at which time mean daily insulin use will be 
recorded, and records will be reviewed for home blood glucometer results, hemoglobin A1c level, and mixed 
meal fasting and stimulated glucose and C-peptide performed at the patient’s local lab, per our usual routine for 
clinical follow up.   
 
In addition to the metabolic data collected under this protocol, all TPIAT patients are enrolled in a prospective 
follow up study tracking diabetes, pain, and health related quality of life outcomes on an ongoing basis.  Under 
this protocol, patients complete the SF-36 health related quality of life instrument and institutional derived 
questionnaires that include self-report of daily insulin use, pain symptoms, and pain medications.  These 
instruments are administered at 3 months and 6 months after TPIAT and then once yearly after TPAIT.  Copies 
of these instruments are included in the supplementary materials for reference. These assessments will permit 
long-term follow up of the study participants for both insulin requirements and health-related quality of life 
outcomes. 
 
 
 
 
Design and Methods to Evaluate Specific Aim #3 
SPECIFIC AIM #3:  To evaluate the mechanistic effects of etanercept or alpha-1 antitrypsin on 
inflammation, islet cell viability/survival, and beta cell apoptosis.  This will be assessed by repeated 
measurement of circulating cytokine and chemokine levels and circulating unmethylated DNA (a recently 
validated marker of beta cell death in T1DM) in patient serum during days 0 - 28. 
Hypothesis 1:  Peak levels and area under the curve for inflammatory cytokines will be lower in recipients 
treated with alpha-1 antitrypsin and etanercept.   
Hypothesis 2:  Lower rates of beta cell death will be observed post-transplant in the A1AT-treated and 
etanercept-treated groups, compared to standard of care, as evidenced by lower levels of circulating 
unmethylated insulin DNA in the patient serum. 
To evaluate the potential mechanistic effects of the two drug therapies, we will obtain frequent serum 
measurements in recipients for critical markers including key cytokines/chemokines and markers of coagulation 
(the instant blood mediated inflammatory reaction), and markers of circulating exocrine tissue (trypsinogen).  In 
addition, we will profile in each patient beta cell death (islet loss) using the novel marker for unmethylated insulin 
DNA.  Unmethylated insulin DNA is specific to beta cells, and elevated levels in serum indicate beta cell death.  
Patient assessments are described in detail below. 
 
1) Patient assessments: 
a. Inflammatory Cytokines:  Patient serum will be assayed for TNFα, IL-1, IL-6, IL-8, IL-10, MCP-1, 
IP-10, and CCL2—at pre-surgical (x2 draws) and pre-infusion baseline, and at times 1, 3, 6, 12, 24, 

25 
 
and 72 hours and 7 days after islet infusion. Assays will be performed using a Luminex ® multiplex 
bead cytokine kit. These measures were selected based on the literature suggesting relative 
importance in islet transplantation.  These assessments are run in a CLIA certified cytokine laboratory 
(University of Minnesota cytokine laboratory). 
In addition, thrombin-antithrombin complexes, C3a, and C-peptide will be obtained pre-infusion and 
at times 1, 3, and 24 hours post-transplant, as a marker of the instant blood mediated inflammatory 
response.     
b. Unmethylated insulin DNA:  This novel marker has recently been validated as a measure of beta cell 
loss in new onset type 1 diabetes.  Dying beta cells release unmethylated insulin DNA into the serum 
(43).  The assay technique is performed as described by Herold et al (43).  DNA is purified from 200 
microliters of serum, using QIAamp DNA blood kits, and bilsufite treated using EZ DNA methylation 
kit.  Unmethylated insulin DNA is measured by real-time PCR.  Levels are elevated preoperatively 
and in new onset T1DM, but lowered when T1DM subjects are treated with teplizumab to preserve 
beta cell mass. Thus, we propose that this novel marker will provide critical mechanistic data on post-
transplant loss of beta cell mass. This marker will be drawn prior to surgery and infusion (x 2 samples) 
and at 15 min, 30 min, 1, 3, 6, 12, 24, 72 hours,  and 7, 14, and 28 days post-transplant, and repeated 
at each follow up visit (90 day, 1 year, 2 year).   
c. Alpha-1 antitrypsin levels:  Measured at pre-treatment and prior to each infusion in the A1AT-treated 
group.  In the control and etanercept groups, these levels will be measured at baseline and weekly 
through day 28 for comparison. 
d. Trypsin and Trypsinogen activated peptide (TAP):  To determine if dying acinar cells release 
activated proteases which degrade the insulin molecules in systemic circulation, trypsin levels will 
be measured in the patient’s serum pre- and at 12 and 24 hours post-islet infusion and by detection of 
TAP in the urine at 24 hours post-transplant by enzyme immunoassay (81).  TAP is a small, 
measureable peptide that is released when trypsinogen is activated to trypsin.   
e. Serum markers of hepatocyte, Kupffer, and sinusoidal endothelial cell injury:  Serum obtained at pre-
infusion baseline and at 3, 12, 24, and 72 hours, and 7 days after islet infusion will be used for 
assessment of markers of  liver cell injury, which may occur in islet transplant recipients, especially 
when exocrine acinar tissue is co-transplanted with the islets.  We hypothesize that A1AT and 
etanercept may reduce occurrence of acute liver injury that is associated with islet infusion, and may 
thereby promote a more hospitable hepatic environment for islet engraftment.   
i. CK-19 and CK-18 fragments, and additional serum markers such as F-protein, and 
Glutathione-S transferase can serve as markers of hepatocyte damage or death (82-84). 
ii. Hyaluronic acid, vWF, thrombomodulin, -- markers of sinusoidal endothelial injury (85).   
 
2) Islet graft and pancreas assessments: 
a. The islet isolation team will provide key descriptive data for the islet product.  Because chronic 
pancreatitis may theoretically inflict damage on the isolated islets, these assessments will provide 
information on baseline comparability of the islet grafts between the three treatment groups.  The 
following islet assessments will be performed using a small islet aliquot (<2,000 IEQ total required 
combined for all assays) for all study participants: 
i. Islet count, expressed as total islet equivalents (IEQ) and IEQ/kg body weight, which is a 
routine measure for all clinical transplants.  
ii.   Oxygen consumption ratio (OCR)/ viability: Assay method is refined from that described 
by Papas et al (86) and/or assessed by newer Seahorse technology; this assay measures the 
viable islet tissue to be transplanted.  This has been shown to be a superior measure of islet 
viability over FDA/PI.   
iii. An aliquot of 500 IEQ islets and a pancreatic biopsy will be embedded into paraffin and 
available for analysis of insulin content, glucagon content, replication markers (Ki67), and 
apoptosis (TUNL).   

26 
 
iv. Nuclei counts:  A nuclei count is performed using the digest counting sample. 
v. Beta cell count:  Derived from proportion of insulin-positive staining islet cells in the 
histopathology sample (i.e. the fractional representation of beta cells in the graft) multiplied 
by the nuclei count obtained from the digest sample.   
 
 
 
SAMPLE SIZE AND PLAN FOR DATA ANALYSIS 
This is a pilot, parallel-arm study to compare etanercept, A1AT, and control groups; the primary outcome is 
maximal potentiated arginine induced insulin secretion (AIRmax) measured at 90 days posttransplant. We 
propose to enroll 15 patients in each group which will give 80% power to detect a difference between any two 
groups of at least 1.06*(within-group standard deviation of the outcome).  From preliminary data for AIRmax 
measured more than one year post-transplant, the study will have 80% power to detect a difference of at least 33 
mU/mL in pairwise comparisons of AIRmax between each of the 3 groups, corresponding to a 24% increase over 
standard treatment (control group).   
 
The table below shows estimated minimum detectable differences for main outcomes, based on means and 
standard deviations from preliminary testing performed at 1 year post-transplant (for IVGTT and MMTT) or 
beyond 1 year post transplant (GPIAS) in this population of TPIAT recipients.   
 
Test 
Derived Measure 
minimum 
detectable 
difference 
n 
Mean 
SD 
GPAIS 
AIRmax (mU/mL) 
33 
10 
137 
31 
IVGTT 
AIRglu (mU/mL*min) 
162 
33 
169 
153 
ACRglu (ng/mL *min) 
8.8 
36 
9.8 
8.3 
MMTT 
AUC C-peptide (ng/mL *min) 
147 
39 
295 
139 
AUC glucose (mg/dL *min) 
3790 
39 
16,037 
3,579 
 
For specific aim 1, the primary outcome, AIRmax, and other measurements at day 90 will be compared between 
treatment groups with a linear model to adjust for transplanted islet mass and the randomization stratum, BMI (< 
or >27 kg/m2). For aim 2, the same analysis will be performed for measurements made at 1 year and 2 years post-
transplant.  In addition, we will assess whether day 90 AIRmax and AIRglu measurements predict insulin 
independence at 1 and 2 years post-transplant using a logistic regression model.  For aim 3, repeated 
measurements during the weeks immediately post-transplant will be summarized by peak and area under the curve 
for comparison by the same linear model used for aim 1, i.e., adjusting for transplanted islet mass and the 
randomization stratum.  We will also compare the groups based on the longitudinal series of measurements using 
a mixed-effects linear model with fixed effects of treatment group, transplanted islet mass and randomization 
stratum, and a random intercept for each participant to model the correlation between repeated measurements 
from the same person. 
 
 
POTENTIAL RISKS AND BENEFITS 
Forseeable Risks 
Medical risks arise from two primary components of the study:  the study medications, and the islet functional 
(metabolic testing).  Non-medical risks include risk of breech of privacy. 
 
Risks of metabolic testing:  IV placement is required for study testing, and can be associated with bruising or 
discomfort.  The IV placement is done only by trained personnel using standard hospital technique.  Because 
these patients have difficult IV access, the IV is often placed by the hospital vascular access team using ultrasound 

27 
 
guidance, to make the process as tolerable as possible for the patient.  The mixed meal test requires Boost HP 
which can cause nausea or discomfort.  There is modest hyperglycemia with the IVGTT and GPAIS which may 
cause increased urination or thirst, but this is transient (<1 hours) and not associated with any long-term sequelae 
for the patient or islet graft.  Blood draws for both days of metabolic testing will total up to 118 mL over the 2 
day study visit. 
 
The total amount of blood drawn over a 2 year period is 620 mL.  This includes the screening, all early post-
transplant labs, and the three follow up visits for metabolic testing.  Subsequent to 2 years, only routine clinical 
yearly labs are obtained at the patient’s local laboratory (no additional study labs). 
 
Risks of study drugs:  The known potential risks of alpha-1 antitrypsin (Aralast NP) and etanercept are detailed 
in the table below, as described by package insert and Micromedex/DRUGDEX.  Patients with the highest risk 
of an infusion reaction from A1AT—those with IgA deficiency (IgA level<5 mg/dL)—are excluded from this 
trial. 
 
Both products are overall well tolerated.  Aralast NP has been associated with elevation of liver enzymes, which 
were generally transient and normalized within 3 months despite continued administration of Aralast NP, in 11% 
of patients.  Other patient symptoms include headache, cough, muscle aches, and rash or pruritus.  Infusion 
reactions are rare.  Although other A1AT products have been associated with cough, sinus, or respiratory 
symptoms, this may be a manifestation of the underlying disease in the clinically treated population (A1AT 
deficient) and were not seen with Aralast NP. 
 
Etanercept (Enbrel) is generally administered long-term for management of autoimmune disease, particularly 
arthritis and psoriasis.  Treated patients often are pre-disposed to autoimmunity, are treated long-term with this 
agent, and often receive other immunomodulating drugs.  Major differences in this trial as compared to the 
conventional use of this medication include the short-term duration of treatment and lack of other 
immunosuppressive treatments; this is expected to overall reduce the risk of infection and other serious adverse 
events.  Enbrel administration (long-term) for management of arthritis or psoriasis has been associated with 
increased risk of infection (including, rarely, tuberculosis and opportunistic infections) and sepsis.  Serious 
infectious AEs most often occurred in patients who were treated with other concomitant immunosuppressive 
therapy; such drugs are prohibited in the current trial.  The drug is halted or interrupted in case of sepsis or other 
serious infection. 
 
The most common AE associated with Enbrel is injection site reaction (occurs in about 1/3rd of patients).  Most 
cases are mild and do not necessitate drug discontinuation.  Mild infections --most frequently URI, and less often 
UTI, bronchitis, sinusitis-- are also commonly reported in treated patients.  Such infections were also present in 
a high frequency of adult patients with rheumatoid arthritis who were on placebo treatment (infection in 32% of 
placebo patients vs 35% of Enbrel-treated).  Post-marketing surveillance suggests a statistically higher incidence 
of tuberculosis (in 0.006- 0.02% of treated patients), and therefore patients are screened for latent TB at screening.  
There are case reports of more serious or unusual pathogens that are of unclear relationship to Enbrel given the 
confines of few patient events and frequent co-administration of other immuosuppressives in these patients; these 
have included reports of septic arthritis, herpes zoster, legionella, pneumocystis, histoplasmosis, apergillosis, 
coccidiomycosis, and listeriosis.  DRUGDEX ® notes that according to the FDA adverse event reporting system 
(AERS) the majority of patients affected by unusual or serious infections were receiving other concomitant 
immunosuppressive therapy. 
 
Other potential serious adverse events associated with Enbrel include exacerbation of CNS demyelinating disease, 
hematologic cytopenias (anemia, neutropenia, thromobocytopenia), and malignancy of unclear causal 
relationship.  To reduce risk in this trial, we are excluding patients with prior history of neurologic demyelinating 
disease, and patients with significant anemia (hgb<10), thrombocytopenia (plt<150), or neutropenia (<1.0).  
Given the short duration of treatment, we do not expect malignancy to be a significant concern in this population.  
Other case reports of rare congestive heart failure, one case of membranous glomerulonephritis, are of unclear 

28 
 
relationship to Enbrel.  There is one post-marketing report of new onset diabetes, one of new onset 
hyperthyroidism, and one of new hypothyroidism, which are likely related to underlying autoimmune 
predisposition and not the drug.   Because there is at least the theoretical risk of developing immunogenicity 
against etanercept with its use, we will exclude from the study patients known to have conditions for which Enbrel 
may be later indicated. 
 
 
Mild to moderate 
Serious 
Alpha-1 antitrypsin 
(Aralast NP ®) 
Elevated liver enzymes (ALT or AST, 11%) 
Headache (0.3- 7%) 
Musculoskeletal discomfort (0-7%) 
Pharyngitis (1.6%) 
Cough (0.6%) 
Somnolence (0.3%) 
Rash (1.5%) 
Pruritus (1%) 
Altered taste (1.5%) 
Decreased platelet count (1.5%) 
Joint swelling (1.5%) 
Infusion reactions: fever, chills, chest pain, 
shortness of breath, dizziness, visual change 
(0.1%) 
Transient leukocytosis 
 
Anaphylaxis 
Etanercept (Enbrel ®) 
Injection site reaction (37%) 
Mild infection (most often URI, 35%) 
Headache (17%) 
Rhinitis (12%) 
Pharyngitis (9%) 
Cough (6%) 
New autoantibodies (3-15%) 
 
Present in <5%: 
Dyspepsia/GI upset or pain, rash, edema, 
sinusitis, and elevated liver enzymes 
 
Other: 
Hematologic Cytopenia 
Skin cancer (non-melinoma) 
Opportunistic infection including legionella, 
listeria, fungal pneumonia 
Anaphylaxis 
Serious infection 
Sepsis 
Opportunistic infection, 
including TB 
Demyelinating disease 
Blood dyscrasia/ blood 
malignancy 
 
 
Risk of loss of privacy:  There is a risk that a subject’s study medical records will be viewed by those outside the 
study.  Precautions taken to avoid breach of privacy include using study ID numbers rather than names on 
labs/documents that are not a component of the clinical record, maintaining electronic records on password 
protected and secure computers serviced by the University of Minnesota Academic Health Center, and storing 
study binders in a locked storage area within the PI’s locked office.  
 
Only the primary investigator, co-investigators, and study staff (coordinators) will have access to the patient’s 
private study records.  As indicated above, some labs obtained as a part of the study will be posted to the medical 

29 
 
record and may be viewed by other providers’ caring for the patient in a clinical setting.  These will be limited to 
test results that are important component of the patient’s routine clinical care.   
 
Risk management and emergency response 
The primary investigator or one of the co-investigators will be on call for any medical concerns during routine 
study visits or infusion of the study medication.   Patients will receive emergency or first aid care if an injury or 
illness occurs during the study visit, or during medication infusion.  All doses of medication are administered in 
the hospital or in the adjacent clinical research center, with a hospital rapid response and code team available on 
site in case of an emergency.    
 
If patients experience an illness or symptom between during the study that could be related to the study drug, they 
will be directed to receive routine clinical care from their primary physician.   
 
Potential Benefits: 
Direct benefits:  If the study treatment is successful, then those participants treated with study drug (A1AT or 
etanercept) may require less insulin or be more likely to come off insulin than those patients receiving standard 
care.   
 
If the treatment is successful, the potential benefit of the study treatment is significant, including potential for 
reduced incidence of diabetes, or better controlled diabetes after surgery.  The total pancreatectomy and islet 
autotransplant is a major surgical procedure.  Minor complications (including nausea/ vomiting, delayed gastric 
emptying, pain) are not uncommon and recovery is gradual. There is a high risk of partial or total diabetes.  A1AT 
or etanercept used only temporarily, and have relatively few safety risks over this short duration of treatment.  
Thus, we expect the additional study treatment to contribute only minor risks compared to the overall risks of the 
total pancreatectomy and islet autotransplant. 
 
Other benefits:  The knowledge gained from the extensive metabolic and islet graft assessments performed in this 
trial will advance the understanding of islet autotransplantation.   
 
 
ADVERSE EVENT DOCUMENTATION AND TERMINATION CRITERIA 
Adverse events:  All adverse events will be recorded for all subjects, and graded according to the CTCAE version 
4.0.  All AEs, regardless of severity will be collected from day 0 to the day 90 visit (drug exposure window).  
Subsequent to day 90, only severe AE’s (as subsequently defined) are collected, from day 90 to the final face to 
face visit at day 730. AE’s include new or worsening symptoms reported by the subject, signs on physical exam 
(performed at each study visit), and/or abnormalities on study labs.  AE’s will be reviewed by the DSMB as 
described in the section below.  Serious adverse events will be reported to the IRB per institutional guidelines 
(within 10 days for an event that meets rapid reporting requirements), and to the DSMB and the FDA within 72 
hours in accordance with IND regulations.   
 
Each event will be analyzed to determine is relatedness to study medication (definitely, probably, possibly, 
unlikely, or unrelated) and the severity will be graded as follows, modified from the Common Toxicity Criteria: 
• 
MILD (Grade 1) – transient or mild discomfort; no limitation in activity; no medical intervention require. 
• 
MODERATE (Grade 2) – mild to moderate limitation in activity, some assistance may be needed; no or 
minimal medical intervention/therapy required. 
• 
SEVERE (Grade 3) – marked limitation in activity, some assistance usually required; medical 
intervention/therapy required, hospitalization is possible. 
• 
LIFE-THREATENING or DISABLING (Grade 4) – extreme limitation in activity, significant assistance 
required; significant medical intervention/therapy required, hospitalization or hospice care probable. 
• 
DEATH (Grade 5) – event is a direct cause of death. 

30 
 
All adverse events will be graded as mild, moderate, or severe, according to the guidelines established in the 
current Common Terminology Criteria for Adverse Events (CTCAE). 
 
Serious Adverse Events (SAE) 
Defined as any adverse event that suggests a significant hazard, contraindication, side effect, or precaution. This 
includes, but may not be limited to any of the following events: 
1. Death: A death occurring during the study or which comes to the attention of the investigator during the 
protocol-defined follow-up after the completion of therapy, whether or not considered treatment-related, 
must be reported. 
2. Life-threatening: Any adverse therapy experience that places the patient or subject, in the view of the 
investigator, at immediate risk of death from the reaction as it occurred (i.e., it does not include a reaction 
that, had it occurred in a more serious form, might have caused death). 
3. In-patient hospitalization or prolongation of existing hospitalization. 
4. Persistent or significant disability or incapacity. 
5. Congenital anomaly/birth defect. 
6. Other serious (Important medical events). 
 
 
Events of special interest:  Any infectious event will be specifically recorded, in as much detail as possible, for 
patients in all three study arms.  While the lack of concomitant immunosuppressive therapy and short duration of 
treatment with Enbrel is expected to result in a lower risk of infection risk compared to that reported in post-
marketing studies (in patients with long-term treatment and other immunomodulators), we recognize that this 
patient population has special risks associated with the major surgical procedure.  As detailed below, drug therapy 
will be suspended in the cases of sepsis or serious infection that requires procedural intervention for treatment; 
more than one such infection in a single treatment arm will prompt DSMB review. 
 
Regulatory oversight:  The study will be reviewed by the human subjects committee of the Institutional Review 
Board as per standard research practice.  Because the drugs being studied are currently FDA-approved, we have 
requested the FDA to review our protocol to determine if it meets criteria for a new IND.  If the FDA determines 
that this protocol is non-exempt due to the unique patient population, we will request an investigator-initiated 
IND from the FDA for etanercept and alpha-1 antitrypsin.  The study will be reviewed for safety at every 6 month 
intervals by the islet transplant data safety and monitoring board at UMN.  In addition the DSMB will be contacted 
regarding any SAE felt possibly related to study drug, within 72 hours of the event.  This is further described 
below. 
 
Clinical trial monitor:  A clinical trial monitor external to the study and not paid by the study will be provided by 
the Clinical Translational Sciences Institute (CTSI).  The study monitor will review study conduct every 6 months.  
The purpose of the CTSI clinical monitor is to verify that: (1) the rights and well-being of human subjects are 
protected; (2) trial data are accurate, complete, and verifiable; and (3) conduct of the trial is in compliance with 
GCP guidelines and with applicable regulatory requirements.  Activities of the CTSI monitor include (but are not 
limited to) review of facilities, storage and dispensing of investigational products, protocol compliance, informed 
consent, appropriate recruitment and screening of subjects, case report forms, accurate data recording, and adverse 
event reporting. 
 
 
 
Drug or Study Termination 
Study drug termination in an individual patient: This is an intent-to-treat study.  Any patient treated with study 
drug will be followed for endpoint assessment (unless the patient withdraws from the study). 
 
Study drug will be discontinued and the patient will continue to be followed for any of these events: 

31 
 
• Serious allergic reaction 
• patient refusal to continue study drug (but willingness to continue with endpoint assessment) 
• ALT or AST >5x ULN and bilirubin >1.5x ULN.  Note that elevation in ALT and AST is expected to 
occur as a result of islet infusion itself.  However, bilirubin elevation is uncommon.  If ALT and/or AST 
subsequently fall to <5x ULN and bilirubin to <1.5x ULN, the study drug will be resumed, if in the 
opinion of the investigator, enzyme elevations were suspected secondary to the surgical procedure.    
• Serious infection including sepsis (positive blood culture AND suspicion of sepsis due to associated 
hypotension, need for vasopressors, or organ failure; or significant physician concern for sepsis due to 
latter symptoms in the absence of a positive blood culture) or intra-abdominal abscess requiring an 
operative intervention. Treatment will be temporarily held until the infection is adequately treated, and 
then resumed if, in the opinion of the patient’s physician, it is safe to do so.    Hypotension and tachycardia 
are common on POD 0- POD 1, due to the surgery, and alone, would not necessitate halting therapy.  
Antibiotic prophylaxis is routinely given in this population. 
• Wound infection or minor infection – Superficial wound infections are relatively common in this 
population. In the etanercept arm only, etanercept will be held until infection is treated with antimicrobial 
therapy, per standard care with this agent. 
• Any diagnosis of malignancy 
• Any new diagnosis of CNS demyelinating disease, including multiple sclerosis, optic neuritis, transverse 
myelitis, or a new diagnosis of Guillan Barre. 
• Pregnancy (not expected in first few months after major abdominal surgery) 
• Other new medical condition which in the opinion of the investigators, or the patient’s surgical and 
medical team, present a contra-indication to continuing treatment. 
• Occurrence of diabetic ketoacidosis  
• Occurrence of DVT or PE 
 
Study Termination/ Study arm termination:   If two or more patients in one arm experience any of the following 
safety events:  (1) documented sepsis,  (2) an intra-abdominal infection that requires drainage and/or operative 
intervention (excludes superficial wound infection), (3) PE or DVT, or (4) diabetic ketoacidosis, all within the 
first 90 days of  surgery, the study will be temporarily halted, and the external DSMB will be asked to review the 
data.  The study arm in question (alpha-1 antitrypsin or etanercept) will be resumed only with permission from 
the DSMB.  If the DSMB deems that the serious infections were likely related to the study drug, no additional 
patients will be treated with this agent.  Any patient death, regardless of relation to study drug will prompt halting 
of study pending DSMB review.     
 
The data safety and monitoring board for islet transplantation at the University of Minnesota is headed by Dr. 
Bruce Redmon.  The DSMB meets every 6 months to review all active islet transplant clinical trials.  The DSMB 
will review the study semi-annually, to ensure safety of the study participants.   
 
 
STUDY PERSONNEL AND ORGANIZATION 
Study Investigators/ Collaborators: 
Dr. Melena Bellin is the primary investigator on the project.  Dr. Bellin is an Assistant Professor of Pediatric 
Endocrinology at the University of Minnesota and the Director of Research for the Islet Autotransplant Program.  
She will be responsible for the overall planning and conduct of the trial.  Dr. Bellin will directly supervise the 
nurse and CMA research coordinators, and will direct the efforts of the collaborators.  Dr. Bellin will assume the 
primary role for subject recruitment, retention, and follow up.  She has previously successfully conducted trials 
within the IAT population. 
 
The surgery team includes co-investigators Drs. Gregory Beilman, Ty Dunn, Timothy Pruett, and Srinath 
Chinnakotla.  They will assist with subject recruitment and subject visits, and help supervise subject care while 
patients are in the hospital setting post-operatively, and will also provide academic input.  While Dr. Chinnakotla 

32 
 
is the pediatric transplant surgeon, his patients include young adults (18- early 20s) and he assists with coverage 
for the adult service and thus remains an important contributor.   Dr. Gregory Beilman is a COL in the armed 
forces reserve and will have a significant academic role in the project.  Dr. Ty Dunn will also assume a larger role 
in providing back up coverage for PI Dr. Bellin when Dr. Bellin is not available on site. 
 
Dr. Bernhard Hering is the Scientific Director of the Schulze Diabetes Institute.  He has extensive experience in 
islet transplantation research, including auto-transplant, allotransplant, and xenotransplants.  He will assist in 
project planning and will provide academic support to Dr. Bellin. 
 
Dr. James Hodges will provide biostatistical support for randomization and data analysis, as well as assist in 
sample size planning for future studies based on preliminary data gathered in this trial. 
 
Josh Wilhelm MS oversees the islet isolation lab, coordinates islet graft assessments, and maintains the islet 
isolation database.  He will also provide academic input, particularly on assessing the comparability of the islet 
product between study groups.     
 
Outside collaborators:  Dr. Kevan Herold is a Professor of Immunobiology and Medicine (Endocrinology) at 
Yale, and will provide academic expertise on a novel assay to measure loss of beta cells in the immediate post-
operative period.  Dr. Herold additionally has expertise in alpha-1 antitrypsin through his role in the RETAIN 
trial of alpha-1 antitrypsin in type 1 diabetes. 
 
Other key study staff 
RN Coordinator and CMA Coordinator will have a vital role in the day to day operations of the study.  The 
coordinators will be the primary contact between the study and the study participant.  They will be responsible 
for scheduling subject visits, maintaining communication between study visits, adverse event monitoring, 
maintaining study documentation, and performing the metabolic testing.  The RN coordinator will also be 
responsible for study drug administration.  Thus, the RN coordinator will have a more prominent role in drug 
administration and monitoring drug AEs, while the CMA coordinator will focus on performing lab draws, 
metabolic assessments, scheduling, 
and maintaining contact with study 
participants. 
 
The 
coordinators 
operate under direct supervision from 
the study PI.  The study coordinators 
will have previous experience in 
clinical trials research within this 
population, and are certified clinical 
research 
coordinators 
(CCRC, 
certification obtained through the 
Association of Clinical Research 
Professionals).  In addition, our 
regulatory 
coordinator 
(Jean 
Witson), 
who 
has 
extensive 
experience with IND / FDA regulated 
studies in islet transplant, will work 
with the study coordinators to be sure 
that all regulatory requirements are 
met. 
 
 
 
 

33 
 
 
 
 
 
External monitoring 
A clinical trial monitor will be provided by the University of Minnesota CTSI, and will monitor the study to 
ensure compliance with GCP and FDA regulations (21 CFR 312 and 812).  This individual is external to the 
study. 
 
A data safety and monitoring board (DSMB) for islet transplantation at the University of Minnesota will review 
the safety and efficacy data, with particular attention to subject safety, every 6 months. 
 
 
 
 
Lab facilities 
The majority of lab assays will be run in the Fairview Hospital lab facilities, affiliated with the University of Minnesota.  
However, the following are not available or are inadequate at the Fairview lab and will be run in the facilities described 
below: 
• Insulin levels (GPAIS and IVGTT):  To obtain accurate results in this population, we require an insulin 
assay that is resistant to interference from hemolysis.  Fairview does not offer an adequate assay for this 
purpose.  We will ship serum for insulin levels to the Northwest Lipid Research Laboratories at the 
University of Washington.  Timed test glucose and C-peptide measures will also be run at NWLRL due 
to their ability to handle such timed, repeated measures specimens.   
• Unmethylated insulin DNA: This specialized assay will be run by Dr. Kevan Herold’s lab at Yale 
University 
• Trypsinogen, TAP, and liver injury markers:  ELISA kits for the respective assays will be purchased and 
the laboratory assessments run by the technician in Dr. Gregory Beilman’s lab.   
For labs that require shipping, all specimens are labeled with the study ID number and contain no identifying 
information.  Specimens are shipped overnight by FedEx on dry ice.  All study personnel performing specimen 
shipping are trained in shipping through a session offered to research staff at the University of Minnesota.  
Appropriate precautions and labeling for biohazard materials are undertaken. 
 

34 
 

35 
 
 
 
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