Biochemical Pharmacology 100 (2016) 1227

Contents lists available at ScienceDirect

Biochemical Pharmacology
journal homepage: www.elsevier.com/locate/biochempharm

Research update

The bioarticial pancreas (BAP): Biological, chemical and engineering

challenges
Veronica Iacovacci* , Leonardo Ricotti, Arianna Menciassi, Paolo Dario
The BioRobotics Institute, Scuola Superiore SantAnna, Viale R. Piaggio 34, 56025 Pontedera (PI), Italy

A R T I C L E I N F O A B S T R A C T

Article history: The bioarticial pancreas (BAP) represents a viable solution for the treatment of type 1 diabetes (T1D). By
Received 25 May 2015 encapsulating pancreatic cells in a semipermeable membrane to allow nutrient, insulin and glucose
Accepted 26 August 2015 exchange, the side effects produced by islets and whole organ transplantation-related immunosuppres-
Available online 4 September 2015
sive therapy can be circumvented. Several factors, mainly related to materials properties, capsule
morphology and biological environment, play a key role in optimizing BAP systems.
Keywords: The BAP is an extremely complex delivery system for insulin. Despite considerable efforts, in some
Bioarticial pancreas
instances meeting with limited degree of success, a BAP capable of restoring physiological pancreas
Cell encapsulation
Type 1 diabetes
functions without the need for immunosuppressive drugs and of controlling blood glucose levels
Biomaterials especially in large animal models and a few clinical trials, does not exist. The state of the art in terms of
Stem cells materials, fabrication techniques and cell sources, as well as the current status of commercial devices and
clinical trials, are described in this overview from an interdisciplinary viewpoint. In addition, challenges
to the creation of effective BAP systems are highlighted including future perspectives in terms of
component integration from both a biological and an engineering viewpoint.
2015 Elsevier Inc. All rights reserved.

1. Introduction
The pancreas, from the Greek pan (all) and kreas (esh), is a 12
15 cm-long soft, lobulated, retroperitoneal organ with both
exocrine and endocrine functions [1]. The islets of Langerhans,
representing approximately 2 million cells in human adults (about
1% of pancreatic tissue), enable endocrine functions [2]. In
particular, islets b-cells are responsible for the regulation of blood
glucose levels through the production of insulin. When pancreatic
b-cells are missing or damaged due to autoimmune mechanisms,
type I diabetes (T1D) mellitus occurs resulting in a disorder of
glucose homeostasis, insulin deciency and hyperglycemia [3,4].
The rst description of diabetes symptoms dates back to the
16th century BC, but the awareness of diabetes associated with
pancreatic functions, and the rst attempts to treat it through
transplantation or, later on, through exogenous insulin supply,
dates back to the late 19th century [5]. Diabetes is a highly
widespread disease with approximately 347 million individuals
affected worldwide (10% of whom have T1D) [6]. In America alone,
* Corresponding author. Tel.: +39 050 883074.
E-mail address: v.iacovacci@sssup.it (V. Iacovacci).
more than 29 million suffer from this disease [7] with the number
of deaths due to diabetes expected to double in the next decade [8].
T1D is typically managed by exogenous insulin via the use of
insulin pens, multiple injections or subcutaneous pumps. The
amount of insulin is calculated on the basis of multiple daily self-
monitoring blood glucose (BG) measurements performed by the
patient and of rules identied by diabetologists. In all cases,
discrete monitoring and bolus-type insulin administration occur.
These strategies are unable to reproduce a physiological insulin
prole, thus markedly affecting the daily life of patients and giving
rise to secondary complications, such as hyperglycemia or
hypoglycemic events that affect the patients health and wellbeing
in the long run.
In order to overcome the limitations of currently available
therapeutic strategies, several solutions have been evaluated,
ranging from whole pancreas or islet transplantation, to articial
pancreas (AP) systems [9]. This latter solution represents a holy
grail of diabetes treatment and has been accomplished, albeit only
partially, by developing and then combining together portable and
implantable insulin pumps, continuous glucose monitoring
systems (CGMs) and closed loop control algorithms [1012].
Currently available APs show several limitations mainly related to
the delays in glucose sensing and insulin absorption due to the
subcutaneous site (most commonly exploited both for sensing and

http://dx.doi.org/10.1016/j.bcp.2015.08.107
0006-2952/ 2015 Elsevier Inc. All rights reserved.
 V. Iacovacci et al. / Biochemical Pharmacology 100 (2016) 1227
delivery). Another issue is the relatively short lifetime of glucose
sensors [13]. Current research efforts are aimed at enhancing AP
performance in order to develop a totally implantable articial
organ characterized by a more effective insulin supply route e.g.,
the intraperitoneal route, new glucose sensing technologies
[14,15], higher reliability, longer lifetime and new control
algorithms that reect real time blood glucose levels [16,17].
Smart procedures that have been recently proposed include
miniaturized tools for articial organ relling, functionalized
materials, etc. which may in time enable the development of a
totally implantable AP [18,19]. Considerable work is still needed to
achieve reliable and safe solutions.
Another intriguing approach is based on insulin-containing and
glucose-responsive materials, which are able to automatically
release insulin when the glucose level in the microenvironment is
above a certain threshold [2025]. Although based on smart
materials and highly miniaturized technologies, this research line
can be considered as a part of the fully articial pancreas
approach, since no living elements are embedded in the system.
Despite good promises, the issue of insulin depletion in these small
reservoirs (thus limiting their lifetime) is still unsolved.
Whole pancreas transplantation represents an effective
solution to restore normoglycemia [26]. The introduction of this
type of procedure dates back to 1894 (about 30 years or so before
the discovery of insulin) when the rst xenogenic pancreas
transplantations were performed [27]. On the one hand, this
solution can avoid exogenous insulin supply and physiologically
restore patient responsiveness to the increased blood glucose
levels. On the other hand, the shortage of donors, the complexity
of transplantation surgical procedures and the need for
immunosuppressive drug therapy to avoid organ rejection,
which by itself produces severe side effects, make pancreas
replacement a controversial solution for T1D treatment. It is
often considered a viable option when kidney replacement is
necessary as well.
Fig. 1. The bioarticial paancreas approach. (A) Schematic representation of the diffusion mechanism across a semipermeable membrane. The membrane should favor
glucose and nutrients diffusion inside the capsule and insulin and waste diffusion out of it. At the same time, the entry of immune cells should be avoided. (B) Typical
bioarticial pancreas (BAP) implant sites, ranging from the subcutaneous site and peritoneal cavity (most common ones) to the kidney capsule and omentum pouch. (C)
Classication and average dimensions of extravascular encapsulation devices.
13
A compromise for reproducing a natural insulin release prole
while avoiding some of the drawbacks of whole pancreas
transplantation, is represented by islets of Langerhans or b-cell
transplantation. The implantation of whole islets was proposed for
the rst time by Lacy and Kostianovsky in 1967 [28]. As in the case
of pancreas transplantation, irrespective of the source of the
implanted islets, immunosuppressive drug administration is
required to avoid rejection of the foreign tissue. Thus, methods
for cell transplantation which do not require the use of
immunosuppressive drugs are highly desirable. To this aim, the
development of semi-permeable, immunoisolating and biocom-
patible membranes for b-cells or pancreatic islet encapsulation has
been pursued. The encapsulating membrane, typically polymeric,
has to be designed to allow the selective permeation of oxygen,
glucose, nutrients, waste products and insulin, and should be also
able to inhibit immune rejection of the encapsulated cells. When
referring to b-cells or pancreatic islets encapsulated within a
semipermeable, biocompatible membrane, the term bioarticial
pancreas (BAP) is used [29].
This research overview focuses on some of the issues related to
BAP design, with the aim to give an original viewpoint on the topic,
based not only on biology and materials science, but also on
engineering and mechatronic approaches. Thus, the description of
BAP development and pre-clinical/clinical applications has been
enriched via a highly interdisciplinary approach. Section 2
describes a classication of BAP systems, highlighting the
advantages and disadvantages of the different strategies reported
in the literature. Section 3 deals with the materials and with the
fabrication techniques exploited for islet encapsulation, highlight-
ing current and future trends of these research efforts. Section 4
provides an insight on the most critical aspects of the biology and
the challenges that need to be taken into account for BAP
development. The traditional cell sources used and the promise of
stem cell and tissue engineering-based strategies will be analyzed
as well. Insights on recent successful devices, encapsulation
14 V. Iacovacci et al. / Biochemical Pharmacology 100 (2016) 1227
strategies and clinical trials are described in Section 5 with a view
to documenting progress in the clinical scenario. Finally Section 6
outlines advances in technological components and engineering
solutions, which could contribute in the future to the production of
safe and effective BAPs.
2. The bioarticial pancreas approach
Islet transplantation has been explored as a solution for the
treatment of T1D since the development of collagenase digestion
of the pancreas [30], the initial step in islet isolation. The rst case
of human insulin-independence after the transplantation of
pancreatic islets through intraportal hepatic infusion occurred
in 1989 [31]. The most outstanding clinical trial in the eld of islet
transplantation with steroid-free immunosuppression is known as
the Edmonton protocol and was successfully performed in 2000
by Shapiro et al. [32]. Seven recipients were insulin-independent a
year after transplantation with an acceptable reduction in insulin
dependency and hypoglycemia episodes, but at year 5 the graft
survival rate was only 10% [33]. The risks associated with this type
of procedure include: thrombogenesis caused by blood-mediated
inammatory reaction; the loss of graft mass; the inability to
retrieve the islets from the liver [34]; and the immunosuppressive
drug therapy required to allow tissue engraftment and immuno-
logic acceptance. In general, even if a reduction in immunosup-
pressive therapy is feasible [35], it is still required for islet
transplants. The complications associated with immunosuppres-
sant administration include an increased incidence of infection
and malignancy, decreased wound healing and renal dysfunction
[3641]. Islet-transplant immunosuppressive regimes can also
attenuate the efcacy of the therapy itself, by reducing glucose
responsivity [42].
A BAP has the potential to provide all the benets of islet
transplantation without the morbidities associated with immuno-
suppressive drugs making xenografts a reality also. The concept of
a BAP derived from the success of islet transplantation in so-called
immunoprivileged sites, e.g., the anterior chamber of the eye
[43]. The idea of encapsulating cells in a semipermeable
membrane (Fig. 1A) was developed: the introduction of this
technology dates back to 1933 with the work of Bisceglie et al. [44].
Since then efforts have focused on reducing material immunoge-
nicity and optimizing the implant site (Fig. 1B), capsule dimen-
sions, characterization and testing procedures, cell sources, and
other issues to make this technology sufciently mature for clinical
use [45].
To be efcacious, an encapsulation system should permit
optimal viability and function of the pancreatic cells including: (i)
immunoisolation, to avoid the encapsulated cells coming into
contact with immune cells, antibodies, complement, etc.; (ii)
sensitivity to stimulus and rapidity in reactionencapsulated cells
should be able to rapidly detect an increase in the blood glucose
level and to promptly release insulin, thus preventing delays in
blood glucose regulation and avoiding the hormone from staying in
proximity to the cell; (iii) biocompatibilitythe material infrastruc-
ture of the BAP should not stimulate brosis and should not
activate inammatory processes; (iv) ease of implantation via the
use of minimally invasive surgical procedures; (v) long life; and (vi)
retrievability in case of failure or unexpected complications.
The eld of BAP is an area of intensive research with an entire
issue of Advanced Drug Delivery Reviews dedicated to the topic in
2014 [46]. To better characterize BAPs and their design require-
ments, an accurate classication of these systems is required. One
classication criterion describes the amount of islet cells
encapsulated within the semipermeable membrane, thus the
dimensions of the implantable capsules provide a system in order
to distinguish between macrocapsules (cm), microcapsules (250
1000 mm) and nanocapsules (<100 mm; Fig. 1C).
2.1. Macroencapsulation
A macrocapsule is an implantable device in which a large
number of pancreatic cells is entrapped with encapsulation
dimensions in the centimeter range. Depending on the implant
site, macroencapsulation systems can be distinguished into:
extravascular, typically placed in the peritoneal cavity or subcuta-
neously or intravascular, which are connected to the patient's
cardiovascular system via a shunt [47]. Due to their relatively large
dimension, extravascular macrocapsules can be made of different
materials: one for the extracellular matrix (ECM) enabling islet
viability [48], another for the immunoisolating membrane, and an
external surface coating to promote neovascularization [49]. Their
dimensions also favor the formation of cell clusters, enabling
intercellular communication and better mimicking organ physiol-
ogy [50]. Furthermore, both the dimensions and implant site allow
the use of minimally invasive surgical procedures and enable
capsule retrieve in case of failure. Macrocapsules can rely on
diffusion mechanisms or ultraltration. Diffusion chambers have
been adopted both for intravascular and extravascular devices
whereas ultraltration has been explored only in intravascular
systems.
The main drawbacks of extravascular macrocapsules involve
low surface-to-volume ratios and constraints related to the eligible
implant site that do not promote neovascularization. Due to the
lack of a direct vascular access, oxygen and glucose diffusion time,
and insulin release delay are worsened, increasing the risk of
necrosis of cells far from the semipermeable membrane and thus
calling for small devices. At the same time, due to the dimensions, a
relatively low cell density (
510% of the macrocapsule volume) is
desirable, to ensure adequate nutrition [51]. This is somehow
contradictory: lower cell densities claim for larger devices, which
imply more signicant diffusion problems. A compromise between
these conicting needs must be targeted.
Intravascular macrocapsules allow implanted pancreatic islets
to remain in direct contact with blood vessels, allowing more
accurate tracking of blood glucose level, insulin absorption delay
reduction and optimal oxygenation of the implanted cells [52].
These devices however, also have limitations. Their implantation
as shunts in blood vessels is a complex procedure while blood
coagulation and platelet deposition, latter causing thrombosis, are
potential complications. Blood coagulation is highly limiting, as
patients affected by T1D cannot be treated with systemic
anticoagulation medication. These adverse events have led to a
decrease in intravascular macrocapsule development, although
advances in materials science and technology have renewed
interest in this approach [50].
2.2. Microencapsulation
An alternative to macrocapsules are microcapsules that consist
of a semipermeable membrane enclosing a small number of islets
of Langerhans (usually 13), suspended in a polymeric gel matrix
(e.g., alginate). The smaller dimensions and the higher surface-to-
volume ratio assure better diffusion characteristics and enable
implantation by means of minimally invasive procedures in
locations such as the peritoneal cavity, the kidney capsule or
subcutaneous sites [5254]. However, the limited vascularization
of these sites hampers BAP function. Thus, alternative implant sites
such as the omentum pouches have been investigated [55]. In any
case, the size of microcapsules makes them difcult to retrieve in
the event of failure [56].
 V. Iacovacci et al. / Biochemical Pharmacology 100 (2016) 1227 15

Fabrication strategies and the choice of materials are critical
issues in the development of microencapsulation systems. Optimal
pore size and a proper membrane thickness are required to provide
immunoprotection and a correct nutrient diffusion. Furthermore,
the constitutive material itself should favor cell viability resem-
bling as closely as possible the natural environment of the cells
[57].
A spherical shape is advantageous since it guarantees a high
surface-to-volume ratio, a short and uniform diffusion time and
allows the implantation via injection. As already mentioned,
microcapsules range in size from 250 to 1000 mm in diameter. A
practical rule in designing a microencapsulation system is to have
cells no more than 200 mm from the membrane [54,56,58] to
ensure an effective exchange of insulin and glucose, nutrients,
oxygen and waste for all encapsulated cells.
2.3. Nanoencapsulation
To exploit narrower implant sites and overcome diffusion-
related issues, nanoencapsulation devices have been investigated.
These are less than 100 mm in diameter and can envelop single
pancreatic b-cells in a semipermeable membrane, directly bound
to the cell membrane with a thickness varying between some
nanometers to some micrometers. Different polyelectrolytes have
been successfully investigated to this aim [59,60] and nano-
capsules appear particularly advantageous in terms of nutrients
diffusion and insulin release thanks to their really small
dimensions. One great challenge, but at the same time a great
possibility, offered by nanoencapsulation lies in the possibility to
embed other nanocomponents, e.g., nanoparticles, in the nano-
layers enhancing BAP acceptability and function [61,62].

Fig. 2. Overview of islet encapsulation materials and classication. They can be grouped in polymers, either natural or synthetic, and inorganic materials. For each material
class, details on specic materials (blue box) are provided including chemical formulation, fabrication techniques employed (in red) and a picture from literature showing an
example of encapsulation system with such specic material (references to picture sources are reported in the gure). Natural polymers include: collagen-alginate spheroids
(adapted from [87], reproduced with permission of Elsevier), agarose-based porcine islets encapsulation (adapted with permission from [84] (copyright: Creative Commons))
and alginate-encapsulated human islets (adapted from [205], reproduced with permission of Springer) are reported. Within synthetic polymers, the most commonly
employed materials and material classes are polyethylene glycol (PEG), thermoplastic polymers such as polyvinyl alcohol (PVA) and polyelectrolytes. Examples from
literature are reported (adapted and reproduced from [156] and [130] with permission of Elsevier, and from [154] with permission of American Chemical Society,
respectively). Inorganic materials include silicon (adapted from [134], reproduced with permission of Elsevier), aluminium oxide (adapted from [131], reproduced with
permission of Elsevier), titanium oxide (adapted from [143], reproduced with permission of American Chemical Society) and SU-8 (adapted from [146], reproduced with
permission of AIP Publishing LCC). Membranes pictures based on these materials are reported as examples. The green box points out the techniques that can be exploited for
nanoencapsulation. (For interpretation of the references to color in this gure legend, the reader is referred to the web version of this article.)
16 V. Iacovacci et al. / Biochemical Pharmacology 100 (2016) 1227
3. Biomaterials for islet encapsulation
While islet cell encapsulation represents a promising solution
for the treatment of T1D, appropriate functional biomaterials that
are suitable for this application and allow BAPs to function
correctly are required.
Biomaterials can be distinguished from any other material for
their ability to enter in contact with tissues of the human body
without causing unacceptable consequences for the recipient [63].
For islet encapsulation, material biocompatibility is a fundamental
issue where biocompatibility is dened as the ability of a material
to perform with an appropriate host response in a specic
application [64]. In the case of encapsulated cells, an inamma-
tory response can result in cell overgrowth on the capsule surface
that inhibits the diffusion of nutrients and insulin across the
membrane. In the context of BAPs, biotolerability is a better
descriptor than biocompatibility and can be dened as the ability
of a material to reside in the body for long periods of time with only
low degrees of inammatory reactions [65].
Various biomaterials have been exploited for islet encapsulation
ranging from traditional polymers to inorganic materials and also
more innovative ones involving micro/nanofabrication (Fig. 2).
When selecting the material and fabrication technique for an
encapsulation device, whether a macrodevice or a micro/nano-
capsule, this should confer specic features in terms of membrane
thickness, surface properties, pore dimensions and distribution
[66,67]. Pores must be sufciently large to facilitate the transport of
nutrients, insulin (1.352.75 nm) [68], glucose (0.4 nm) [69] and
waste products and should be small enough to block the mediators
(e,g., IgG radius = 5.9 nm) and cells (radius = 10 mm) responsible for
immune rejection [7072]. This can be dened during membrane
design, but it is challenging to ensure the required permeability or
molecular weight cut off value for encapsulation membranes [73,74].
Studies have shown that capsules with a pore size of even a few tens
of nanometers may immunoprotect transplanted cells even if IgGs
and complement proteins permeate the capsule [75,76], whereas
others have found that inhibiting the cytokine- and chemokine-
mediated cross-talk between grafted and immune cells may be
benecial for cell survival [77,78]. Membrane thickness can inuence
diffusion and capsule dimension, while surface properties affect the
immune response. Hydrophobic surfaces promote protein adsorp-
tion and denaturation that can potentially activate immune
reactions; so they are usually discarded in favor of hydrophilic ones.
For the same reason, a negative zeta charge is preferred to a positive
one [79]. Mechanical stability is also important. The material
selected should not be biodegradable and should last at least as long
as the cells are alive [73].
The different classes of materials exploited so far for islet
encapsulation, are described in the following, together with the
corresponding micro/nanofabrication techniques.
3.1. Encapsulation with polymers
Polymers are the most commonly employed materials for the
fabrication of encapsulating membranes [67]. Both natural and
synthetic polymers can be employed: the former are usually used
as hydrogels due to their viscoelastic behavior, tissue-resembling
properties and reduced ability to evoke an inammatory response
[80]; the latter enable easier and more standardized fabrication
processes and are readily available with higher purity, thus
resulting in a good efciency in terms of immunoisolation and
nutrient diffusion [81].
3.1.1. Natural polymers
Among natural polymers, polysaccharides are widely employed
as they do not interfere with cell viability and functionality and
allow easy capsule fabrication [82]. Agarose [83,84], cellulose
sulfate [85,86] and collagen [87] are also used for cell encapsula-
tion with alginate being the most successfully employed natural
polymer [88].
Agarose, was used by Iwata et al. in 1988 for the encapsulation
of pancreatic islets and successfully tested in mice [84,89], and
dogs [83]. It can be used both for micro and macroencapsulation
systems by using temperature-induced gelation processes, and
simple extrusion systems [90] and by varying the agarose
concentration to rene the mechanical properties of the beads
[91]. To facilitate immunoprotection and graft survival time,
increasing agarose concentration, altering coatings or combining
agarose with other polymers such as collagen and alginate, have
been evaluated as possible strategies. However, many unexpected
host reactions occurred in animals that reect the need to use toxic
molecules in the fabrication process [92,93], and the capability of
some complement factors and IgGs to access agarose pores [94],
thus making this natural polymer less advantageous as compared
to alginate.
Collagen is a highly versatile polymer able to form hydrogels
that can be exploited for the fabrication of beads with different
geometries, membranes, matrices, etc. In the eld of pancreatic
cell encapsulation, it has been used together with crosslinkers [95],
with other polymers such as alginates [87], or with outer shells/
coatings, e.g., tetrapolymers of 2-hydroxyethyl methylacrylate
(HEMA) [96,97] to overcome and control its weak mechanical
properties and limited stability.
Alginate is a natural anionic polymer composed of 1,40 -linked
b-D-mannuronic acid (M) and a-L-guluronic acid (G) residues in
different sequences. The ratio of M and G blocks inuences
hydrogel mechanical properties. Due to its good biotolerability,
potentially high degree of purity and easy fabrication without the
need to use toxic solvents, alginate is the most successfully
investigated polymer for pancreatic cell encapsulation.
3.1.2. Fabrication with natural polymers
Different fabrication techniques can be applied to alginate and
to other natural polymer-based hydrogels to produce micro-
capsules, as well as membranes and sheets that can be used in
macrodevices. Animal studies and clinical trial results obtained
with alginate-based BAPs (described further in Section 5) encour-
aged further research to enhance alginate immunoprotective and
mechanical properties. In this sense, conformal coatings [98] or
coatings based on cationic synthetic polymers (e.g., poly-L-lysine
[99] and poly-L-ornithine [100]) can be employed to overcome
inhomogeneous pore distribution and reduce membrane size to
ensure better immunoprotection, even in the case of xenotrans-
plants [101,102]. Ultra-purication processes can be used to obtain
more chemically stable and biotolerable capsules [103]; further
efforts to enhance alginate-based capsule mechanical stability
involve exploring coatings based on polyethylene glycol (PEG)
[104] and covalent crosslinking molecules including photoactive
crosslinkers [105,106], aldehyde or hydroxyl groups [107,108].
Alginate microcapsules are usually manufactured through
solgel processes and then by extruding the polymer-cell solution
in a crosslinking bath containing divalent cations such as Ca 2+, Ba2
+
, etc. [109]. The capsules can be then transferred to a cationic
polyamino acid solution to form a semipermeable membrane
around the alginate and then into an alginate solution to form an
additional alginate layer to reduce the immunogenicity of the
structure [102,110]. Extrusion relies on gravitational force and
diameters usually approach 2000 mm with such techniques [111].
To reduce the capsule diameter, surface tension needs to be
reduced by using additional energy sources, e.g., air ow, electric
elds or vibrations [112]. Electrostatic-mediated extrusion exploits
a potential difference between the extrusion needle and the gelling
 V. Iacovacci et al. / Biochemical Pharmacology 100 (2016) 1227
cationic bath. The exploitation of mechanical energy sources such
as vibrations [113] or cutting wires [114116] is an alternative
especially to increase the extrusion rate even if viscosity and cell
damage related issues are associated with these techniques. An
alternative technique to simple droplet extrusion was proposed by
Poncelet et al. [117], and optimized by Hoesli et al. using an
emulsion-based encapsulation involving internal gelation [118].
3.1.3. Synthetic polymers
An alternative to natural polymers is represented by synthetic
polymers that can be synthetized in large quantities via
standardized processes. They can be chemically modied to
enhance biotolerability, mechanical properties and morphological
features, e.g., membrane thickness and pore size [81,119]. Synthetic
polymers can lead to biocompatibility issues since many of the
fabrication processes involve toxic solvents that could affect cell
viability. For this reason, synthetic polymers are mainly used to
fabricate semipermeable membranes for macrocapsules [67] in
the absence of cells. PEG can be used for nano-, micro- and macro-
encapsulation due to a lack of toxic solvents in the fabrication
process and is thus one of the most successfully employed
synthetic materials. It is often used as a hydrogel, sometimes in
conjunction with alginate [120] due to its ability to embed a large
amount of water and has a short diffusion time [121]. PEG can be
polymerized by using UV [122] or physical/chemical crosslinking
mechanisms [123]. However, in animals, PEG membranes cannot
prevent the passage of cytotoxic molecules that can activate the
immune response [124].
Another class of synthetic polymers is represented by
thermoplastic polymers, which are eligible for cell encapsulation
due to their greater mechanical and chemical stability.
Polyurethane [125,126], polytetrauoroethylene (PTFE) [127],
polyvinyl alcohol (PVA) [128130] and their copolymers have
been successfully used in islet encapsulation. They are often
used with other polymers acting as substrates for cell adhesion in
the inner part of the capsule and have been employed both in
micro and macroencapsulation systems, due to their ability to
form membranes and hollow bers and to be processed in a
variety of shapes through heat melting followed by cooling
processes [67].
3.2. Encapsulation with inorganic materials
Inorganic materials, e.g., silicon, titanium and aluminum
oxides, have been successfully used in islet encapsulation to
fabricate membranes with high stability and tight pore size
(typically below 100 nm except for titanium oxide membranes that
have slightly larger pores [56]). The technologies used for the
fabrication of inorganic material-based membranes are less
mature as compared with those of polymeric systems, but have
signicant potentials for future applications in both macro- and
micro-capsules. The risk of biocompatibility-related issues is
higher for this class of materials than for polymers [131,132]
requiring the development of coatings to reduce protein adsorp-
tion and enhance membrane biocompatibility [133].
Silicon (Si) membranes are fabricated using photolithography,
etching and deposition processes allowing thin membranes to be
obtained with highly controllable pore distribution and dimen-
sions. These membranes were used to encapsulate pancreatic cells
in the late 1990s [134]. Their advantages lie in the potential to
create hierarchical structures, in their optical transparency and
easiness of biofunctionalization [135] and they have been
successfully tested in rats, thus revealing strict dependence from
pore dimensions [134,136]. Similarly to hydrogel capsules, surface
chemistry modication and specic coatings can aid in producing
improved outcomes.
17
Aluminum oxide (Al2O3) and titanium oxide (TiO2) membranes
can be produced via anodization techniques that result in
membranes with controlled thickness and porosity. On average,
the pores are larger than those obtained with microfabricated
structures, whereas membrane thickness is greater than that of Si
membranes, but smaller than their polymeric counterparts.
However, the cheap fabrication process and the high mechanical
stability, as well as the high pore density, which compensates for
the increased thickness from a diffusion view point, are among the
advantages of these systems. In vitro and in vivo tests revealed that
after coating with PEG, the brotic overgrowth and inammatory
response on Al2O3 membranes were quite limited [131,137140].
TiO2 membranes based on titanium nanotubes are also produced
using anodization processes. Many research efforts are currently
employed to produce membranes based on Ti nanotubes with
different tube dimensions and arrangements obtained by varying
the anodization parameters [141145]. These systems seem
promising especially for their application in macrocapsule devices,
where it is possible to introduce another matrix favoring cell
adhesion and viability
3.3. Other approaches
Other approaches used for pancreatic islet encapsulation
include the exploitation of photosensitive polymers, e.g., SU-8,
to fabricate nanoimprinted nanoporous membranes. These are
devised to be used in conjunction with microfabricated cuboids to
enable the encapsulation of single cells or cell clusters [146,147].
SU-8 microstructures are MRI transparent, have good mechanical
stability and good diffusion and immunoprotection. However,
oxygen diffusion is not efcient and there are biocompatibility
issues still to be faced [148]. 2D micro and nanofabrication
techniques have been employed to produce nanoporous containers
for cell encapsulation as well. In particular, this concept is inspired
by Japanese origami art and involves the fabrication of 2D self-
folding structures that, relying on the minimization of surface
energy, enable the development of 3D structures that can
potentially be exploited for cell encapsulation [149151]. These
microstructures can be fabricated by using nickel, copper, gold and
several polymeric materials.
3.4. Biomaterials and techniques for nanoencapsulation
In addition to improving the immunoisolation, biotolerability,
pancreatic cell viability and functional properties of existing
systems, there is considerable ongoing effort to miniaturize b-cell
encapsulation systems. By using nanotechnology, capsule dimen-
sions and wall thickness can be signicantly reduced to enhance
diffusional processes and glucose sensing. Smaller implant sites
can also be targeted [152]. Two approaches are being pursued:
conformal coatings or molecular camouage [153] and fabricat-
ing nanocapsules by exploiting polyelectrolytes and layer-by-layer
(LBL) deposition methods [154].
Molecular camouage can immunoprotect pancreatic islets
while keeping overall dimensions as low as possible (coatings have
thickness below 100 mm). Polymers, sometimes in the form of
hydrogels, can covalently bind certain cell membrane constituents
e.g., membrane proteins [155]. The most exploited material for this
application is PEG [156]. The ability of these coatings to provide
immunoisolation was demonstrated in vitro and in vivo, also by
means of pre-clinical studies. However, open issues are related to
the long term stability of such conformal coatings [100].
A second approach to reduce the overall dimensions of
encapsulated pancreatic islets is the LBL technique that involves
the creation of an immunoisolating coating on a single cell or cell
aggregate by alternating the deposition of polycation and
18 V. Iacovacci et al. / Biochemical Pharmacology 100 (2016) 1227

polyanion layers to create protective membranes that are only a
few nanometers thick [45]. This can improve diffusion, increase
responsivity to glucose level, reduce implant volume and enhance
neovascularization. The polyelectrolytes that can accomplish this
task include polyallylamine hydrochloride (PAH) [154]. and PVA
conjugated to a single layer of PEG-phospholipids [59] or biotin/
streptavidin [157]. In vitro and in vivo tests in rodents indicated
that the LBL technique can guarantee good BAP performance for up
to 100 days [61].
4. Biological issues and tissue engineering
The replacement of insulin-producing cells in T1D patients is a
challenge that has been addressed by using different strategies
over the last decades. This section highlights the established

Fig. 3. (A) Simplied scheme representing the key developmental steps occurring for the specication of embrionic stem cells (ESCs) into mature b-cells. Relevant pathways
are reported in red, while lateral ones are reported in blue. For each step, the most important known transcription factors governing the process are specied. (B)
Immunouorescence images and photon emission maps for human ESC-derived pancreatic cells engrafted in mice. (Adapted from [187] and reproduced with permission of
Elsevier). (C) Comparison between primary human islets and human ESCs differentiated in vitro to achieve a mature pancreatic phenotype. Immunouorescence images
demonstrate that ESC-derived cells show complete co-localization of insulin with green-uorescent protein (GFP), thus suggesting a good differentiation level. However, the
graphs show that they do not replicate primary cell functionality, since they do not secrete enough insulin in response to high glucose. LG = low glucose; HG = high glucose;
HG + KCl = high glucose plus direct depolarization. (Adapted from [188] and reproduced with permission of Springer). (D) Differentiation of iPSCs in b cells: differentiation
protocol scheme and immunouorescence images showing the expression of C-peptide, glucagon (GCG), somatostatin (SST) and insulin (INS) proteins in cells at day 22.
(Adapted from [193] and reproduced with permission of Nature Publishing Group). (For interpretation of the references to color in this gure legend, the reader is referred to
the web version of this article.)
 V. Iacovacci et al. / Biochemical Pharmacology 100 (2016) 1227
approaches toward the extraction, culture and engineering of key
cell types, the biological issues to be considered in this framework
and the potential of recent approaches involving the use of specic
stem cell types.
4.1. Cell sources: limitations and opportunities
The use of cells from human organ donors to replenish diabetic
patient b-cell mass dates back to 1966 with the rst allogenic
transplant attempts [158] and has been enhanced by improved
surgical techniques [159]. Pancreatic transplants efciently restore
metabolic control in diabetic patients. However, the procedure is
severe and it has several drawbacks, already discussed, leading to a
shift towards the use of single cells or islets.
Human islet isolation from the bulk donor pancreas is
performed by digestion and purication steps [32]. Whole islets
have a greater efciency than single b-cells as they retain the
complex multicellular interactions that play a key role in the
down-regulation of insulin secretion during hypoglycemic epi-
sodes [160].
As a result, allotransplantations using rat and pig islets as
primary xenogeneic tissues have been studied [39,161]. Porcine
islets are preferred, due to the close homology between porcine
and human insulin and the islet morphological similarity between
the two species [74]. However, microencapsulation has had more
negative effects on porcine islets than on rat and human ones
[162]. Porcine islets are obtained by using the same protocols as
described for human tissues, with the advantage of a potentially
unlimited supply. However, issues in using porcine tissue are the
risk of retroviral disease transmission and the absolute need for
effective immunobarriers, since they induce a more aggressive
immune rejection than human cells [163].
The use of immortalized human pancreatic cell lines is another
approach that would allow allogeneic instead of xenogeneic
transplants thus reducing the need for immunoprotection. The
different cell lines produced for this purpose include: (i) bLox5, an
adult b-cell-derived cell line that has been used to clarify the role
of mitochondria in immune cell-mediated b-cell death, [164] and
expresses autoantigens typical of T1D and is a reliable b-cell
surrogate in cell-mediated lymphocytotoxicity assays; (ii) HP62 is a
cell line obtained by transfecting human islets with the SV40 virus
that has been used to study b-cell death mechanisms and to
investigate isolation-specic mechanisms associated with the
progression to T1D in vivo [165]; (iii) 1.1B4, a cell line obtained by
electrofusion of the exocrine cell line (PANC-1) and freshly isolated
b-cells that have been used to investigate mechanisms of
autoimmune destruction of pancreatic b-cells, in particular
molecular toxicity mechanisms after exposure to the proinam-
matory cytokines IL-1b, IFN-g and TNF-a [166]; (iv) EndoC-bH1, a
cell line developed from fetal pancreatic tissue using the lentiviral
vector SV40T. By using an insulin promoter, only insulin-producing
cells were immortalized. In mice, these cells showed rather good
results, although not comparable with those obtained with
primary b-cells [167]; (v) EndoC-bH2 is a second generation
version of the EndoC-bH1 cell that more closely resembles
primary cells [168]. While these cell lines are interesting models
for studying b-cell insulin-secretory mechanisms, immunological
processes etc., they are currently inappropriate for cell-replace-
ment purposes, due to scarce reactivity to glucose and low insulin
production [169].
4.2. Reprogramming exocrine cells into insulin-producing ones
An intriguing approach, which is recently attracting interest in
the scientic community, is based on reprogramming acinar cells,
which have an exocrine function in the pancreas, to insulin-
19
producing b-cells. Adenovirus and other vectors have been used to
induce the expression of cardinal islet developmental regulators,
both in vitro and in vivo [170172]. Recently, it has been found that
a more efcient reprogramming can be achieved by using a forced
expression of four pancreatic transcription factors, namely Pdx1,
Ngn3, Pax4 and MafA, in combination with growth factors such as
betacellulin and exendin-4, the vitamin nicotinamide, and small
molecules that facilitate DNA binding of transcription factors [173].
Although the reprogramming techniques still need to be furtherly
developed, in order to guarantee high efcacy and safety, this
approach appears to be very promising: the exocrine pancreatic
tissue that is normally discarded after the islet isolation procedure,
in fact, can be used and, after few weeks a second batch of islets
derived from the same donor is available for the recipient.
4.3. ESCs and iPSCs: toward allogenic/autogenic islet transplantation
Stem cells represent a novel approach for the production of
transplantable b-cells. Pluripotent stem cells have the unique
abilities to: self-renew in an undifferentiated state enabling large-
scale expansion in vitro, and to differentiate towards different
phenotypes, allowing the generation of all
200 cell types of the
human body [174,175]. Thus, theoretically they can be used to
generate insulin-producing b-cells, multicellular islets or even the
whole pancreas [176,177]. The development of mature b-cells from
embryonic stem cells (ESCs) is an extremely complex process still
at an early stage [178180]. A simplied scheme of the main
developmental steps of pancreas organogenesis is shown in
Fig. 3A. This complex interplay of signaling events and transcrip-
tional networks results in endocrine progenitors, which give rise to
ve different hormone-secreting cells: glucagon-secreting a cells,
somatostatin-releasing d cells, ghrelin-producing e cells, pancre-
atic polypeptide-secreting PP cells, and insulin-secreting b-cells.
ESCs have been extensively studied over the last decade, with a
focus on producing mature b-cells. Activin A, a transforming
growth factor b (TGFb) family member, induces the emergence of
denitive endoderm [181,182] with retinoic acid supporting
foregut induction from which multipotential pancreatic cells arise
[183]. Expression of Pdx1 (Pancreatic and duodenal homeobox
1 also known as insulin promoter factor 1), along with other
factors, is a biomarker for the development of pancreatic
progenitors (Fig 3A). Pdx1 expression can be induced by treating
ESCs with noggin (a bone morphogenetic protein antagonist) or
dorsomorphin (a small molecule analog) [181,182,184]. The nal
steps needed to convert pancreatic progenitors to fully differenti-
ated b-cells are currently unclear [177]. For this reason, the most
promising results obtained to date have been obtained by
implanting ESCs in immunocompromised mice at the pancreatic
progenitor stage, allowing the cells to mature in vivo [185187]
(Fig. 3B). Nicotinamide, insulin-like growth factor 1 (IGF1) and
hepatocyte growth factor (HGF) have been used to induce mature
phenotypes in vitro but have resulted in immature and non-
glucose-responsive phenotypes [188,189] (Fig. 3C).
Induced pluripotent stem cells (iPSCs) represent another
paradigm with signicant potential in regenerative medicine
and stem cell-based therapies. Retroviral expression of a limited
set of genes (Oct4, Sox 2, Klf4 and c-Myc) can convert adult cells to
a pluripotent state, with transcriptional and epigenetic features
similar to those of ESCs. The ability to reprogram adult cells
provides a means to use patients own cells to build tissues/organs
thus facilitating autogenic implants [190192]. The derivation of
endoderm from iPSCs has been recently reported [192] where
Pdx1-positive pancreatic progenitor cells were obtained from
iPSCs at high efciency and further matured by treatment with
forskolin, dexamethasone, Alk5 inhibitor II and nicotinamide in a
3D culture [193] (Fig. 3D). The signaling events modulating this
20 V. Iacovacci et al. / Biochemical Pharmacology 100 (2016) 1227

process were also claried [194] with high oxygen conditions
facilitating iPSC differentiation into mature b-cells [195]. Micro-
RNA (miRNA) insertion can also promote pancreatic b-cell
differentiation [196]. Finally, differentiated iPSCs have been
implanted in diabetic mouse models and reversed hyperglycemia
[197] providing an initial proof of principle for the clinical
application of reprogrammed somatic cells in the treatment of
diabetes. The ability of iPSCs to differentiate into fully functional
pancreatic b-cells, remains controversial due to a limited ability to
retain insulin secretory competence upon glucose stimulation.

Fig. 4. Examples of commercial BAP systems. (A) bAir1 chamber system for islet macroencapsulation in its assembled form with connected access ports and X-ray image of
an implanted recipient (adapted with permission from [212] (copyright: Creative Commons)); (B) TheraCyteTM system schematization showing structure and diffusive
mechanisms across the membrane (Reproduced with Theracyte Inc., permission); (C) VC-01TM system in which vascularization is evident (reproduced with permission from
[216]: Nature Publishing Group); (D) Sernovas Cell Pouch SystemTM and its constitutive components (reproduced with permission from [223]: Elsevier); (E) Islet Sheet
system: electron micrograph image and a picture showing the sheet in its implant site are reported respectively (Photo courtesy Scott King/Islet Sheet Medical).
 V. Iacovacci et al. / Biochemical Pharmacology 100 (2016) 1227
Nonetheless, a scalable differentiation protocol able to generate
hundreds of millions of glucose-responsive b cells from human
pluripotent stem cells in vitro has been described [198]. As a sign of
incomplete maturation, the iPSC-derived b-cells may co-express
multi-hormones, but they lack the expression of specic mature
pancreatic b-cell markers such as Nkx6.1 and MafA [199]. Despite
some unclear issues that have still to be faced, iPSCs represent the
most promising cell type for BAP applications [200201].
5. Recent encapsulation system development and clinical trials
In this section, attention is focused on the most recent and
successful micro- and macro-encapsulation systems (Fig. 4).
Nanocapsulation systems are still at an early stage of development
and neither clinical trials nor commercial products have been
identied, yet.
5.1. Microcapsules
Alginate-poly-L-ornithine-alginate microcapsules (PLO)
[202,203], barium alginate microcapsules [53], alginate-encapsu-
lated human islets implanted into the intraperitoneal cavity, under
immunosuppression [204] and alginate-based capsules to correct
diabetes in immunodecient mice [205] are within the most
successful systems developed by research teams all over the world.
Important advancements have been pursued by companies as
well; the most outstanding example is represented by a system,
namely DIABECELL1 [206], consisting of neonatal pig islets
encapsulated in an alginate-based matrix and implanted in the
peritoneal cavity [207]. Clinical trials revealed a 70% reduction in
hypoglycemic events and a 20% reduction in insulin dose. However,
the need of exogenous insulin injections was not fully eliminated
[208]
5.2. Macrocapsules
Concerning macrocapsule devices, mainly extravascular ones,
the number of products under development or already on the
market is signicantly higher. Some interesting examples are
reported in the following.
bAir1 device (Fig. 4A) is a subcutaneous insulin bioreactor
containing pancreatic cells immobilized in two at alginate sheet
supplied with oxygen via a gas chamber placed between the
membranes (relled daily by means of an external port) [209211].
The chamber is housed in a plastic case, providing mechanical
protection to the encapsulation device, wrapped in a porous PTFE
membrane impregnated with hydrophobically modied alginate
to avoid immunologic communication between the recipient and
the graft tissue. In animals [212] and patients with long-standing
T1D [213], graft function and regulated insulin secretion were
observed without the need for immunosuppressive drugs.
TheraCyteTM system (Fig. 4B) [214] is a composite structure that
includes two PTFE membranes bound to a polymeric structure: the
exterior membrane has tighter pores promoting neovasculariza-
tion, whereas the inner one provides for pancreatic cell immu-
noisolation. Animal studies have been encouraging [215,216] with
the possibility to enhance system performance by infusing
vascular endothelial growth factor (VEGF) [217], pre-implanting
the device to induce neovascularization before transplantation
[218], or exploiting ESCs [45].
VC-01TM is a subcutaneous macrocapsule based on ESCs and a
semipermeable membrane made of undisclosed polymers (Fig. 4C)
[219]. It produced encouraging results in mice in terms of
neovascularization and blood glucose regulation. Clinical trials
for this BAP have been initiated although there have been some
questions as to whether independence from exogenous insulin
21
could be achieved without multiple implants due to the relatively
low cell density of the device (24,000 cells versus the 400,000 re-
quired) [209].
Cell Pouch SystemTM (Fig. 4D) is a biocompatible polymeric
macrocapsule devised for subcutaneous implantation that can
reproduce a natural environment in the body for the long-term
survival and function of therapeutic pancreatic cells. The
combination with sertolin, a testicular protein that can protect
insulin producing islets from immune system attack, reduces or
eliminates the need for immunosuppressive agents [220222].
Islet sheet device [223] (Fig. 4E) is another macroencapsulation
system consisting of a thin alginate sheet in which pancreatic islets
are entrapped. The main advantages of this system lie in the easy
implantation, in the peritoneal cavity or subcutaneous site, and in
its easy retrieval. Each sheet is expected to host about
100,000 islets, requiring several islet sheets to achieve exogenous
insulin independence [224]. Acceptable neovascularization and
insulin secretion have been observed in animals trials, but graft
survival in large animals may be an issue. Both large animal testing
and clinical trials have been scheduled [225226,45].
5.3. Caveats
Due to the complexity of the problem and to a lack of adequate
characterization of materials and encapsulation systems, BAP is
still far from being an imminent clinical reality, due to
unavailability of a fully reliable solution. Several efforts have
focused, in the last decades, on the synthesis or modication of
advanced materials for islet encapsulation. Interesting insights
have been recently highlighted, in this eld. However, alginate still
remains the most suitable polymer used in BAPs, despite its
limitations in terms of fabrication reliability and pore dimensions.
Despite the breadth of research efforts also in miniaturizing
encapsulation systems, macrodevices appear to be the most
promising BAPs due to the ability to retrieve them in case of failure,
to perform biopsies and to easily incorporate other materials or
additional systems that are able to enhance BAP function (e.g., cell
viability, revascularization, oxygenation, etc.). However, macro-
capsule-based BAPs are affected by critical issues related to the
implant site, to esthetics and to the need for the patient to care for
the device.
6. Technological issues and engineering challenges
In this section the contribution of engineering tools to the
development of more advanced and functional BAP systems is
discussed. By enabling/enhancing stem cell differentiation pro-
cesses, donor shortage and xenograft-related problems could be
eliminated while micro- and nano-components, such as sensors
and actuators, could enable the translation of some of the
advantages of macrocapsular systems e.g., supply of oxygen or
VEGF provided by reservoirs or pumps, to microdevices. Finally, it
is possible that on board sensors may in time provide self-
monitoring of BAP function.
6.1. Miniaturized technologies for stem cell differentiation
The use of technologies at the milli-, micro- and nano-scale may
provide more efcient methods to differentiate pluripotent stem
cells, accelerating their clinical translation for islet tissue
engineering and subsequent allogenic (in the case of ESCs) or
even autogenic (in the case of iPSCs) transplantation. External
signals controlling stem cell fate (stem cell niche) are both
biochemical and biophysical [227,228], such that an effective niche
engineering process must thus include both signal types, in order
to reproduce the complex series of stimuli that facilitate
22 V. Iacovacci et al. / Biochemical Pharmacology 100 (2016) 1227
specialization from totipotent stem cells to partly committed
progenitors and to terminally differentiated and functional cells
[229331].
Cellcell and cell-material interactions based on biochemical
cues are the main driver for stem cell commitment [232,233].
However, surface topography at the cell/scaffold interface also
plays a key role. Micro- and nano-structuring of this interface can
mimic ECM organization, triggering or regulating specic cellular
activities [234], as substrate stiffness can [235]. New technologies
for fabricating substrates with different surface topographies and
elastic moduli are useful tools for providing pluripotent stem cells
with precise instructions, promoting their phenotypic maturation
before their implantation. Other miniaturized tools that can be
used to this purpose include microuidic systems that provide a
wide range of uidic cues and shear stresses that are recognized
as crucial for the production of mature phenotypes [229].
Parallel-plate channels can also be used to reproduce physiologi-
cally relevant shear stress values in vitro. More complex
integrated and multiplexed systems can also be fabricated that
control medium composition, oxygen concentration, pH, ow
prole, ow rate and shear rate [236]. Mechanical forces (e.g.,
traction and compression) inuence gene expression and cell
function making technologies for applying cyclic uniaxial
stretching, equiaxial strain, auxotonic loads and other mechanical
inputs useful tools in the stem cell niche [237,238]. Additionally,
mechanical forces can be applied to cells via ultrasonic pressure
waves [239].
Electrical inputs can effectively manipulate cell behavior,
especially when the target is an electrically responsive cell
[240]. Planar type microelectrode arrays (MEAs), consisting of
electrodes embedded in a cell culture platform enable simulta-
neous effects on cell growth and differentiation [241]. Indium tin
oxide (ITO) microelectrodes [242] and micro-engineered conduc-
tive polymers [243] subserve a similar function while optical,
magnetic and thermal inputs can also inuence cell behavior,
although to a limited degree [229]. Pulsed infrared lasers
integrated in optical bers, optomechanical systems, miniaturized
electromagnets and miniaturized heating systems are additional
examples of technologies that can drive stem cell differentiation
[244,245]. Synergies between active nanomaterials, internalized
by cells, and external energy sources represent another strategy for
engineering cell differentiation and regulating cell function
[246248].
6.2. Models, new technological components and BAP development
Insufcient oxygenation due to a lack of neovascularization or
to inadequate diffusion is a major cause of BAP failure [130,249]. In
designing a new encapsulation system, microcapsule or macro-
device, typical engineering tools can be used to predict oxygen
diffusive mechanisms. Both analytical models, exploiting simple
geometries and zero or rst order kinetic laws [250253] and nite
elements analysis methods (FEMs) [254257], applied to nonlinear
kinetics, and more realistic geometries, have been used to study
oxygenation, nutrients and glucose diffusion in the capsule to
avoid cell necrosis. Local oxygen partial pressure, oxygen
membrane permeability and capsule geometry are only a few of
the issues inuencing oxygen diffusion, and cell viability. Modeling
and diffusion equation solving, could aid in dening BAP systems in
terms of the number of cells to be embedded, overall capsule
dimensions, membrane diffusion coefcient, constitutive materi-
als properties, etc. [258] that would also optimize in vitro and in
vivo testing phases.
Engineering paradigms can also aid BAP development by
providing micro and nano components such as sensors, electro-
mechanical systems and actuators as well as nanomaterials.
Glucose nanosensors, based on optical signaling have been
developed in the form of smart tattoos or systems based on
enzymes and quantum dots [259,260]. NEMS technology has
enabled the possibility to embed miniaturized pumps and infusion
systems based on smart reservoirs or release mechanisms, in
implantable drug delivery devices [261,262]. This technology has
been developed for AP systems, but would logically be applied to
BAP systems.
In addition to their use in the design and validation phases to
verify BAP operation in terms of oxygen and glucose diffusion,
these components may also enable the development of hybrid
devices, i.e., embedding both biological and technological
components. For example, NEMS-based pumps could be used
to provide an encapsulation device with substances that enhance
cell viability or close the insulin supply loop in case of implant
failure. Similarly, glucose and oxygen nanosensors could enhance
and support BAP sensing capabilities and monitor the correct
operation of the implant. In this way articial components can be
devised as tools to compensate eventual BAP problems, making
systems in some ways redundant but more efcient and reliable.
Currently available nanosensors and actuators are insufciently
mature from a technological standpoint to promote cross-
fertilization between the different BAP functions but with
additional research focused on addressing the various defects
using a multidisciplinary approach could change this situation in
the near future.
7. Concluding remarks
Despite considerable research efforts since the discovery of
insulin and the rst pancreatic transplantation, no optimal
solution to treat T1D has emerged. Many approaches, ranging
from whole organ or islet transplant, to AP or BAP systems, have
been explored to develop a long-term alternative to daily insulin
injections. Encapsulation of pancreatic islets, cells and stem cells
using semipermeable membranes can avoid the immunosuppres-
sive therapy required for transplants, but these membranes also
need to be able to allow exchange of insulin, glucose, nutrients and
waste products with the surrounding environment to provide a
physiological milieu. This requires extensive assessment of the
materials used to create BAPs. Alginate, especially if provided with
proper coatings, emerged as the elective material for pancreatic
cell encapsulation, with encouraging clinical trial outcomes. The
development of easier encapsulation systems that provide
adequate vascularization and oxygen supply are seen as the key
to achieve implants that are more tolerable for the patient, able to
avoid graft rejection and have a good life expectancy.
The development of a functional BAP will require the
collation and analysis of the benets and limitations of the
prototypes that are currently in the clinical trial arena, with a
view to identifying and prioritizing the technological aspects that
need optimization.
Recently, exciting preclinical results were achieved, thus
demonstrating the high dynamism of this research eld. Veiseh
and colleagues demonstrated that in vivo biocompatibility is
largely governed by material geometry: 1.5-mm alginate capsules
were able to restore bloodglucose control in rodents and non-
human primates for 180 days, a period ve times longer than for
conventional grafts, based on 0.5-mm alginate capsules [263]. In
parallel, Pepper et al. transplanted islets into a prevascularized,
subcutaneous site created by the temporary placement of a
vascular access catheter, in mice. The authors demonstrated that a
controlled foreign-body response can be used to generate a
prevascularized subcutaneous site supporting islet engraftment,
yet preventing the formation of an avascular brotic granular
 V. Iacovacci et al. / Biochemical Pharmacology 100 (2016) 1227
capsule and a chronic inammatory response, which contribute to
graft failure [264].
An increase in system complexity will probably be the key to
achieving better performances, thanks to the integration of
instruments typical of biology, tissue engineering, nanotechnology
and micro-mechatronics. An ideal BAP would be able to
autonomously modulate body reactions by responding to micro-
environmental changes, maintaining at maximum levels its
stability and functionality overtime, yet resulting unobtrusive
for the patient. Although a lifelong BAP is still far to be envisioned,
future efforts will focus on extending implant lifetime and making
it long enough (at least 23 years) to justify the surgical procedures
needed to install it. The ongoing development of materials, which
increasingly integrate several functionalities [265], and engineer-
ing tools raise promises to address this challenge.
Conict of interest
The authors declare no conicts of interest.
Acknowledgments
The authors would like to thank Professor Igor Lack (Polymer
Institute, Slovak Academy of Sciences, Slovak Republic) for his
support and precious suggestions.
This work has been supported by the Smart APP (Smart
Articial Pancreas relled by mechatronic Pills) and the GeT Small
(TarGeted therapy at Small scale) projects, both funded by the
Scuola Superiore di Studi Universitari e di Perfezionamento
SantAnna (Pisa, Italy).
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