The Extra-Islet Pancreas Supports Autoimmunity in Human Type 1 Diabetes


In autoimmune Type 1 diabetes (T1D), immune cells progressively infiltrate and destroy the islets of Langerhans, islands of endocrine tissue dispersed throughout the pancreas. However, it is unclear how this process, called insulitis, develops and progresses within this organ. Here, using highly multiplexed CO-Detection by indEXing (CODEX) tissue imaging and cadaveric pancreas samples from pre-T1D, T1D, and non-T1D donors, we examine pseudotemporalspatial patterns of insulitis and exocrine inflammation within large pancreatic tissue sections. We identify four sub-states of insulitis characterized by CD8+T cells at different stages of activation. We further find that exocrine compartments of pancreatic lobules affected by insulitis have distinct cellularity, suggesting that extra-islet factors may make particular lobules permissive to disease. Finally, we identify staging areas, immature tertiary lymphoid structures away from islets where CD8+T cells appear to assemble before they navigate to islets. Together, these data implicate the extra-islet pancreas in autoimmune insulitis, greatly expanding the boundaries of T1D pathogenesis.

Competing Interest Statement

P.L.B.: Founder, Halo Biosciences. N.N.: Founder, Halo Biosciences. PLB, NN and GK have filed intellectual property around 4-MU. PLB, NN and GK hold a financial interest in Halo Biosciences, a company that is developing 4-MU for various indications. G.P.N. has received research grants from Vaxart and Celgene during the course of this work and has equity in and is a scientific advisory board member of Akoya Biosciences. Akoya Biosciences makes reagents and instruments that are dependent on licenses from Stanford University. Stanford University has been granted US patent 9909167, which covers some aspects of the technology described in this paper. J.A.B.: Board of director for Gilead and CEO and President of Sonoma Biotherapeutics; scientific advisory boards of Arcus Biotherapeutics and Cimeio Therapeutics; consultant for Rheos Medicines, Provention Bio; stockholder in Rheos Medicines, Vir Therapeutics, Arcus Biotherapeutics, Solid Biosciences, Celsius Therapeutics; Gilead Sciences, Provention Bio, Sonoma Biotherapeutics. C.M.S.: Scientific advisory board of, stock options in, research funding from Enable Medicine, Inc.

Funding Statement

This research was performed with the support of the Network for Pancreatic Organ donors with Diabetes (nPOD; RRID:SCR_014641), a collaborative type 1 diabetes research project supported by JDRF (nPOD: 5-SRA-2018-557-Q-R) and The Leona M. & Harry B. Helmsley Charitable Trust (Grant#2018PG-T1D053, G-2108-04793). The content and views expressed are the responsibility of the authors and do not necessarily reflect the official view of nPOD. Organ Procurement Organizations (OPO) partnering with nPOD to provide research resources are listed at Research reported in this publication was supported by the National Cancer Institute and National Institute of Allergy and Infectious Diseases of the National Institutes of Health under Award Numbers K99CA246061, 5U54CA209971-05, 5U2CCA233195-02, 1U2CCA233238-01, 5U2CCA233195-02, 5U01AI101984-09.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.


The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Cadaveric pancreatic tissue sections were obtained through the nPOD program, sponsored by the Juvenile Diabetes Research Fund. The use of cadaveric human tissue samples was approved by Stanford University Institutional Review Board.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.


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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.


Data Availability

All primary code is attached with the submission files and will be posted on the Nolan Lab github upon acceptance. Processed single cell dataframes are accessible in the dropbox link provided in the Key Resources Table. We are in communication with the Human Cell Atlas Data Portal for hosting the raw imaging data which is on the order of 20TB. Currently, we can provide access to raw data but cannot do so anonymously.

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