Islets Co-engineered with Thrombomodulin and CD47 Achieve Sustained Survival in Allogeneic Recipients without Chronic Immunosuppression

Allogeneic islet transplantation is an effective treatment for type 1 diabetes, but its clinical use is limited by rejection involving innate and adaptive immune responses, requiring life-long immunosuppression. We herein engineered islets by transiently display two immunomodulators chimeric with streptavidin (SA), thrombomodulin (SA-TM) and CD47 (SA-CD47) for localized modulation of both innate and adaptive immune responses. The engineering process did not impact islet viability, glucose responsiveness, and metabolic activity. Intraportal transplantation into allogeneic recipients achieved sustained survival, with 8/11 grafts surviving 120-330 days without immunosuppression. In contrast, non-engineered islets were acutely rejected [median survival time (MST) = 12 days], while islets engineered with SA-TM showed delayed rejection [Median survival time (MST) = 13.5 days], and those with SA-CD47 exhibited prolonged survival (MST = 24 days). Double-engineered islets generated a localized tolerogenic immune environment characterized by low frequencies of inflammatory innate immune cells and increased frequencies of M2 macrophages, myeloid-derived suppressor cells, and CD4+FoxP3+ T regulatory cells. The transcriptomic analysis showed downregulation of proinflammatory and upregulation of immune regulatory pathways. Our results demonstrate that transient co-display of immunomodulatory molecules on the islet surface is a versatile platform with significant translational potential for islet transplantation. .