Research and development

• Understanding the evolution of type 1 diabetes (T1D)

It is important to note that the incidence of T1D is increasing, making primary prevention a major public-health goal. Early identification of neonates and infants who are at risk of T1D is essential and can now be achieved before β-cell autoantibody markers arise by using genetic markers. In this context, the Global Platform for the Prevention of Autoimmune Diabetes (GPPAD) has established a screening program (GPPAD-02) to identify high genetic risk newborns and ask them to participate in a primary prevention study, the Primary Oral Insulin Trial (POInT). Afterwards, participants will be followed and monitored for early diagnosis of T1D. (For more information, click on FREDER1K)

Clinical onset of T1D develops when β-cell mass drops beneath 20% of its initial value. Initiation of insulin treatment leads to metabolic stress release and a recovery of endogenous insulin secretion in 60% of patients. This period, called partial remission or the honeymoon period, is associated with a better disease control characterized by lower daily injection requirements and lower glycemic variability. The duration of the partial remission can be variable but it lasts 9 months in average. As β–cell demise progresses, partial remission will only last for few months with consecutive increase of patients’ glucose variability and HbA1C levels (Fig. 1).

Figure 1. Evolution of glycated hemoglobin in a healthy patient developing type 1 diabetes. On the left, in a healthy patient, there is few circulating glucose molecule and therefore few glycated hemoglobin. On the right, in a diabetic patient there is many circulating glucose molecule, which will promote its binding on hemoglobin, thus increasing the glycated hemoglobin level. The glycated hemoglobin is a stable molecule, so it allows the following of blood glucose evolution of the diabetic patient over the last 3 months.

Considering these elements, partial remission represents a key period to understand mechanisms responsible for T1D and to identify patients susceptible to benefit from pharmacological interventions for β-cell mass preservation (For more information, click on DIATAG and [1, 2]). At some point, we are therefore witnessing the end of partial remission, which is associated with a difficulty in maintaining glycemic control. It has been observed by clinicians that for some patients with partial remission, glycemic control is more difficult to control when this period ends, and that the resulting imbalance may become chronic. It seems that the longer the duration of partial remission, the greater the risk of glycemic imbalance. This correlation, however, is an intuitive observation, which the literature does not mention (For more information, click on DIABHONEY).

In the follow-up of diabetic patients, hypoglycemia is a major obstacle to the correct stabilization of blood glucose. According to ISPAD guidelines, 70 mg/dL of blood glucose is usually the cutoff used to define hypoglycemia and consider glucose administration. Hypoglycemia is the most common complication of T1D, resulting from inadequate insulin levels in relation to diet or physical activity. If hypoglycemia seems to be inevitable in patients with T1D, the correct management and understanding of these episodes is necessarily an important part of the management of this disease (For more information, click on EPHICA).

• Finding a cure for type 1 diabetes (T1D)

Finding a cure for T1D means finding strategies to restore spontaneous insulin secretion capacity. In this way, two possible areas of investigation exist: (1) the preservation of the function of β cells after the onset of the disease; (2) the restoration of the mass of β cells by transplantation of new β cells or β-like cells.

Current strategies for β-cell mass preservation – including immunotherapy, and vaccination – have globally failed to show significant effects on disease control in terms of HbA1C levels. Replacement of pancreatic β cells is an attractive therapy for T1D [3] and proof-of-concept has been provided with islet transplantation, which is dependent on the availability of organ donors. Therefore, there is a need to find efficient ways to derive β cells from other cell sources whose use is unarguably compatible with clinical procedures.

Our group has discovered a new pancreatic cell progenitor with the potential to produce new β cells in vitro and to decrease glucose levels of diabetic animals after transplantation [4, 5].

We previously showed the possibility to derive cells from purified human pancreatic ducts that can produce massive amounts of reprogrammable cells. Recent developments in our research showed the possibility to bring these human duct-derived cells (HDDCs) towards functional insulin secretion after treatment with transcription factor MAFA. To avoid the use of DNA-based techniques associated with a risk of genomic integration, we designed a new system of transcription factor overexpression based on synthetic modified RNA (smRNA). Our protocol of MAFA smRNA transfection yielded 37% of HDDCs that expressed hallmarks of β cells, including functional insulin secretion and capacities to mitigate hyperglycemia after transplantation into diabetic SCID-beige mice.

Our study represent one of the pioneer works that showed the possibility to transdifferentiate human somatic cells into functional cells with curative potential, using a non-integrative, reliable, cost-effective, and specific (i.e., virtually without “off-target” effects) smRNA-based system. SmRNAs bear also the advantage for in situ delivery, as recently demonstrated in the liver and the lung, or for tendon healing, emphasizing the multiple potential implications of the smRNA technology in the cure of human disease.

Also, we characterized the evolution of T1D in a pediatric cohort of patients [1] and we are now studying the principal determinants of the partial remission occurring after diagnosis (in 60% of patients), with the aim of identifying patients that could benefit from treatments to preserve β-cell function and insulin secretion. Effectively, some drugs such as gliflozins or new genetic tools such as CRISPR/Cas9 presented several advantages that may be exploited to preserve β-cell mass (for more information, click on GLUCOTOXICITY and INFLAMMATION).

• Helping children with type 1 diabetes (T1D) to do sports

Patients with T1D have to face various challenges to maintain blood glucose levels into the normal range, while performing physical activity. Children and adolescents are even more prone to hyper- and hypoglycemia, because of the lack of clear recommendations for insulin adaptation and carbohydrate (carb) intake. In a recent study, called the TREAD-DIAB trial, we evaluated the needs of children and adolescents in terms of insulin and carb modifications during sports. After a first round of exercise sessions, we developed an algorithm that helps us to precisely adapt insulin and carbs during exercise sessions, specifically for each individual patient (for more information, click on CAR2DIAB and [6]). Our results showed the possibility to normalize blood glucose for patients under pump therapy. Because this was more challenging in young patients under insulin injections, we are now conducting a new study CAR2DIAB, the trial at Cliniques universitaires Saint Luc, to ensure we may provide fine-tuning of insulin injection and carb intake to everyone. This is done with the partnership of Professor Stéphane Moniotte in the Division of Pediatric Cardiology.

• Taking care of others forms of diabetes as well

Diabetes is referring to a heterogeneous group of diseases with various etiologies and distinct therapeutic options. Besides the two main forms of diabetes (T1D and T2D), there are rare subtypes of the disease called monogenic diabetes (or MODY) that are hardly diagnosed because of their resemblance to T1D or T2D. Since these monogenic diabetes may appear early in life, a consortium of expert pediatric clinical centers was created under a clinical research initiative to develop tools for accurate diagnosis of rare diabetes and to propose appropriate care to these children and adolescents wrongly assigned to T1D or T2D cohorts (GENEPEDIAB study).

Finding the right insulin and carbs intake dosages during sessions of exercise is challenging for young patients with T1D.

We are conducting a new study in collaboration with the Cliniques universitaires Saint Luc and the Professor Stéphane Moniotte in the Division of Pediatric Cardiology. The aim of the study is to ensure we may provide fine-tuning of insulin injection and carb intake to everyone.

Study of the correlation between the partial remission duration and the future type 1 diabetes imbalance

The aim is to understand the correlation between the partial remission duration and the difficulty to maintain glycemic control after this particular period. Firstly, we identified T1D patients with or without partial remission and its duration. Secondly, we compared the managing difficulties of glucose variations in patients who experienced partial remission, compared to patients without residual endogenous insulin secretion.

This study could trigger the reinforcement of therapeutic education for T1D patients with longstanding partial remission.

Working group:

• Caroline Daems

Phenotypic and genotypic characterization of a cohort of pediatric patients with new-onset type 1 diabetes

We initiated a collaborative consortium including six centers in Belgium and one in Switzerland to better characterize new-onset T1D patients. Our primary objective is to identify correlations between the presence of biomarkers and the clinical development of PR in children or adolescents with new-onset T1D. These data will set the groundwork for the development of models for prediction of β-cell mass evolution in the medium and long term in patients with newly diagnosed T1D.

Prediction of β-cell mass and its evolution in new-onset T1D patients is essential to identify those having significant high probability of β-cell mass persistence. This could be used as a screening tool to select patients for enrollment in T1D prevention trials. Furthermore, our study will help better understand the key elements at play in the early phases of β-cell destruction in T1D. This may lead to the identification of new molecular targets for therapeutic interventions.

Working group:

• Paola Gallo
• Olivier Polle
• Julie Lemmer

Evaluation of hypoglycemia and hyperglycemia in children and adolescents with continuous glucose monitoring.

The implementation of continuous glucose monitoring system, since 3 years in Belgium is for us an opportunity to analyze hypo- and hyper-glycemic events in patients with T1D. The study of these hypo- and hyper-glycemic events would allow us to evaluate their recurrence and the way they may be interconnected, with the aim of proposing patient-tailored preventive educational protocols. Indeed, we believe that the elaboration of individual protocols may help to avoid that every diabetic patient, even under well-managed treatment, might be confronted daily with episodes of hypo- and hyperglycemia.

Working group:

• Paola Gallo
• Augustin Renard

Prediction and prevention of type 1 diabetes (T1D) in neonates: a new trial program in Europe

This clinical trial is carried by 7 main centers located in Germany, Belgium, Poland, Sweden and UK. The aim of the study is to identify infants with a high genetic risk to develop multiple beta-cell autoantibodies before the age of 6 years, a sub-group comprising 1% of the general population, using a genetic score based on:

• 47 susceptibility SNPs (single-nucleotide polymorphism)
• first degree-family history for T1D

Families of high-risk infants receive counselling and are offered participation in POInT, a randomized, double-blinded, multicenter phase IIb primary prevention trial. The primary endpoint of the study is to determine whether daily administration of oral insulin from age 4-7 months until age of 3 years in children with elevated genetic risk for T1D reduces the cumulative incidence of beta-cell autoantibodies and diabetes in childhood. Target is 300,000 screened infants and 1040 enrolled infants in POInT in 3.5 years.

Working group:

• Paola Gallo
• Olivier Polle
• Julie Lemmer

Since several years, SGLT2 (sodium/glucose cotransporter 2) inhibitors appeared as a useful approach to alleviate hyperglycemia in patients with diabetes. SGLT2 are low-affinity, high-capacity glucose transporters located in the renal proximal tubule. Preclinical studies provided arguments for a beneficial impact on β-cell mass and/or function of a specific glucose-lowering therapy, and fueled the need to evaluate the β-cell mass protection effects of SGLT2 inhibitors during the development of T1D.

Also, a 2017 study revealed the unexpected potential of GABA to stimulate β-cell regeneration through recruitment of cells inside the α-cell pool that undergo transdifferentiation after repression of Arx expression, in a context of β-cell ablation. These findings provoked a deep interest in the GABA molecule, particularly because the processes of β-cell regeneration are independent of disease mechanisms, and could be applied both to T1D and T2D.

The aim of our study was to investigate the potential of empagliflozin, a SGLT2 inhibitor, in prolonging the β-cell survival and function in a mouse model of T1D. The adjunctive effects of GABA were also evaluated in combination protocols for it potential to alleviate the metabolic stress of β cells and foster their survival immediately after T1D onset.

The preliminary results of this ongoing study were presented in various scientific sessions:

• Poster presentation during the ATTD congress 2019 in Berlin (Germany).
• Oral and poster presentation during the SBP congress 2019 in Brussels (Belgium).
• Submitted for presentation during ESPE congress 2019 in Vienna (Austria).

IL1R1 & IFNGR1 Knock-Down Using CRISPR/Cas9 Technology Improves MIN6 Survival And Function After Cytokine Treatment

Inflammation plays an essential role in triggering the development of T1D. Inflammation is thereby a key target for T1D treatment. Cytokine antagonist therapies failed to induce any improvement of the β-cell survival or showed positive effects on β-cell survival during treatment administration, yet without long-term beneficial effects after treatment discontinuation. In this study, we aimed to improve β-cell survival during T1D onset through inflammation downregulation. Our aim is to specifically target pancreas inflammation and not the general immunity to avoid unwanted side effects. We designed a potential T1D therapy using a genome-editing tool, the CRISPR/Cas9 (clustered regularly interspaced short palindromic repeats/CRISPR associated protein 9) system.

The preliminary results of this ongoing study were submitted for presentation during ESPE congress 2019 in Vienna (Austria).

Working group:

• Caroline Daems

With the collaboration of the Division of Pediatric Cardiology in the Cliniques universitaires Saint-Luc, we are targeting patients treated for atrial fibrillation, ventricular tachycardia, Wolff-Parkinson-White syndrome with amiodarone. We will evaluate thyroid function tests in a cohort of pediatric patients treated with amiodarone.

Working group:

• Sarah Montenez