WO2025235670A1

WO2025235670A1 - Use of anti-cd40 ligand antibodies for immunosuppression in islet cell transplantation

Info

Publication number: WO2025235670A1
Application number: PCT/US2025/028223
Authority: WO
Inventors: Steven N. Perrin
Original assignee: Eledon Pharmaceuticals Inc
Current assignee: Eledon Pharmaceuticals Inc
Priority date: 2024-05-07
Filing date: 2025-05-07
Publication date: 2025-11-13
Anticipated expiration: 2026-11-07

Abstract

The disclosure provides uses of anti-CD40 ligand antibodies for immunosuppression in islet cell transplantation in subjects having type 1 diabetes (T1D). The disclosure also provides uses of compounds that block the interaction between CD40 and CD40 ligand, including such anti-CD40 ligand antibodies and antigen binding fragments thereof, for preventing or reducing islet cell allograft rejection in subjects having T1D, for restoring physiological insulin secretion or hypoglycemia awareness in a subject having T1D, or for treating subjects having T1D and/or treating subjects having T1D and partial graft function of islet cells where the subjects have had a previous allogenic islet cell transplant.

Description

USE OF ANTI-CD40 LIGAND ANTIBODIES FOR IMMUNOSUPPRESSION IN ISLET CELL TRANSPLANTATION

CROSS-REFERENCES TO RELATED APPLICATIONS

[0001] The present application claims priority to U.S. Provisional Patent Application No. 63/643,866, filed May 7, 2024, and U.S. Provisional Patent Application No. 63/713,013, filed October 28, 2024; which applications are incorporated by reference herein in their entirety.

REFERENCE TO SEQUENCE LISTING FILED ELECTRONICALLY

[0002] The content of the electronically submitted Sequence Listing XML (File Name: 5577_001PC01_Sequencelisting_ST26.xml; Size: 91,181 bytes; Date of Creation: May 6, 2025) filed with the application is incorporated herein by reference in its entirety.

BACKGROUND

Field

[0003] The present disclosure relates to type 1 diabetes and human pancreatic islets transplantation and provides methods related to preventing or reducing islet cell allograft rejection in subjects having type 1 diabetes.

Background

[0004] Type 1 diabetes (T1D) is a T-cell mediated autoimmune disease with progressive loss of insulin-producing pancreatic beta cells, decreased insulin production, and uncontrolled hypoglycemia. Appropriate therapy with exogenous insulin aims to control glucose to near-normal levels, and to prevent ketoacidosis and serious hypoglycemia, both of which can be life-threatening. However, this degree of control is not always achievable and some individuals with T1D can develop impaired awareness of hypoglycemia (IAH) which may result in life-threatening serious hypoglycemic events (SHEs) that are not amenable to medical therapy, decreased quality of life, associated comorbidities and excess mortality. T1D patients with more severe glucose variability, which has been labeled as brittle T1D, are estimated to account for approximately 80,000 individuals in the U.S. Brittle T1D is characterized by severe instability of blood glucose levels with frequent and unpredictable episodes of hypoglycemia often requiring hospitalization. Brittle T1D is particularly difficult to treat as the risk of severe hypoglycemia and sudden death increases with more intensive insulin regimens.

[0005] Beyond intensive insulin therapy, treatment for patients with brittle T1D had been limited to whole pancreas transplant, which carries with it both surgical and postprocedural risk and is not appropriate for all brittle T1D patients. Pancreatic islet transplantation (ITx) is increasingly being performed as a therapeutic option for T1D in some parts of the world because it can restore physiological insulin secretion, minimize the risk of hypoglycemic unawareness, and reduce the risk of death due to serious hypoglycemia. Additionally, diabetic patients who receive ITx benefit from years of insulin independence, a functional cure for diabetes, and prolonged survival compared to those who remain dependent on insulin. However, important issues continue to hamper the success of ITx, including the acute loss of transplanted islets with current immunosuppressive treatments due to islet cell toxicity and alloreactive immunologic responses to transplanted islets. For example, the use of calcineurin inhibitors, such as tacrolimus, in islet transplant procedures is associated with toxicity towards the transplanted islets and renal toxicity. The progressive loss of islet cells and islet cell function over time often leads to the need for multiple donors, and thus multiple transplantations, to achieve insulin independence. New and safer therapeutic approaches to preventing ITx rejection are therefore needed to advance the success of this procedure.

[0006] Cluster of differentiation 40 (CD40) is a costimulatory type I membrane protein found on antigen presenting cells (APCs) that is required for their activation. CD40 ligand (CD40L) is a costimulatory type II membrane receptor for CD40 found on T helper cells. The binding of CD40 ligand to CD40 activates CD40, inducing multiple downstream immune and inflammatory responses. CD40:CD40 ligand interactions mediate the magnitude and quality of humoral and cell-mediated immunity. CD40 ligand blockade can abolish many effector mechanisms of inflammation, prevent and intervene in the progression of autoimmunity, and instill transplant tolerance. Thus, the availability of antibodies that specifically bind CD40 ligand and block this ligand-receptor interaction can provide immune tolerance, for example, to reduce or prevent ITx rejection.

[0007] One such antibody, AT-1501, has been shown to promote islet survival in nonhuman primates. Anwar, I. J. et al., “The Anti-CD40L Monoclonal Antibody AT-1501 Promotes Islet and Kidney Allograft Survival and Function in Nonhuman Primates,” 15(711): 1-15 (2023). AT-1501 prolonged graft survival compared to tacrolimus in nonhuman primates, including rejection-free survival and overall islet graft survival. In addition, AT-1501 was associated with improved metabolic control and healthier animals overall. Thus, CD40 ligand blockade shows promise as a therapeutic agent for preventing or reducing islet cell allograft rejection in subjects having type 1 diabetes.

BRIEF SUMMARY

[0008] The present disclosure provides methods of preventing or reducing islet cell allograft rejection in a subject having type 1 diabetes comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 100 mg/kg.

[0009] The present disclosure also provides methods of treating type 1 diabetes in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, wherein the subject has been administered purified allogenic islet cells and wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 100 mg/kg.

[0010] The present disclosure also provides methods of restoring physiological insulin secretion in a subject having type 1 diabetes, comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand.

[0011] The present disclosure also provides methods of restoring hypoglycemia awareness in a subject having type 1 diabetes, comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand.

[0012] In some aspects of the methods described herein, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 100 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 50 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg, 5 mg/kg, 10 mg/kg, 15 mg/kg, or 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 10 mg/kg.

[0013] In some aspects of the methods described herein, the antibody or antigen binding fragment thereof is AT- 1501. In some aspects, the antibody or antigen binding fragment thereof comprises: (a) a heavy chain variable region (VH) comprising: (i) a CDR1 domain comprising the sequence set forth in SEQ ID NO: 75; (ii) a CDR2 domain comprising the sequence set forth in SEQ ID NO: 76; and (iii) a CDR3 domain comprising the sequence set forth in SEQ ID NO. 77; and (b) a light chain variable region (VL) comprising: (i) a CDR1 domain comprising the sequence set forth in SEQ ID NO: 72; (ii) a CDR2 domain comprising the sequence set forth in SEQ ID NO: 73; and (iii) a CDR3 domain comprising the sequence set forth in SEQ ID NO: 74. In some aspects, the antibody or antigen binding fragment thereof further comprises an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 79.

[0014] In some aspects of the methods described herein, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 61. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence set forth in SEQ ID NO: 61. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 79. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence set forth in SEQ ID NO: 79. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises the amino acid sequence set forth in SEQ ID NO: 64 and the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66. In some aspects of the antibody or antigen binding fragment thereof, the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66 and an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 61. In some aspects of the antibody or antigen binding fragment thereof, the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66 and an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 79.

[0015] In some aspects of the methods described herein, the type 1 diabetes comprises brittle type 1 diabetes.

[0016] In some aspects of the methods described herein, the method further comprises administering one or more additional pharmaceutically effective compounds. In some aspects, the one or more additional pharmaceutically effective compounds targets T-cells by one or more of clearing T-cells from circulation; or modulating T-cell activation, homing, or cytotoxic activities. In some aspects, the compound that targets T-cells is selected from an anti -thymocyte globulin. In some aspects, the one or more additional pharmaceutically effective compounds inhibits inosine monophosphate dehydrogenase. In some aspects, the compound that inhibits inosine monophosphate dehydrogenase is selected from a mycophenolate mofetil or a mycophenolate sodium. In some aspects, the one or more additional pharmaceutically effective compounds inhibits binding of tumor necrosis factor (TNF)-alpha to cell surface TNF receptors. In some aspects, the compound that inhibits binding of tumor necrosis factor (TNF)-alpha to cell surface TNF receptors is selected from etanercept or infliximab.

[0017] In some aspects of the methods described herein, the method further comprises administering a therapeutically effective amount of purified allogenic islet cells. In some aspects, the purified allogenic islet cells are human purified allogenic islet cells.

[0018] In some aspects of the methods described herein, the antibody or antigen binding fragment thereof is administered at least once every 3 weeks. In some aspects, the antibody or antigen binding fragment thereof is administered as a maintenance dose at least once every 3 weeks. In some aspects, the antibody or antigen binding fragment thereof is administered 3 days, 2 days, or 1 day before administering the islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered the same day of administering the islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered one or more of 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days after administering the islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered on days -2, 0, 1, 3, 7, 14, 21, and 28 and every 21 ± 2 days thereafter after administering the islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for a total of 12 months or for longer than 12 months after administering the islet cells.

[0019] In some aspects of the methods described herein, the method further comprises administering a second therapeutically effective amount of purified allogenic islet cells. In some aspects, the purified allogenic islet cells are human purified allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered at least once every 3 weeks following administration of the second therapeutically effective amount of purified allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered as a maintenance dose at least once every 3 weeks following administration of the second therapeutically effective amount of purified allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered 3 days, 2 days, or 1 day before administration of the second therapeutically effective amount of purified allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered the same day of administering the second therapeutically effective amount of purified allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered one or more of 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days after administration of the second therapeutically effective amount of purified allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered on days 0, 3, and 7 and every 21 ± 2 days thereafter after administration of the second therapeutically effective amount of purified allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for a total of 12 months or for longer than 12 months after administration of the second therapeutically effective amount of purified allogenic islet cells.

[0020] In some aspects of the methods described herein the wherein method further comprises administering a second therapeutically effective amount of purified allogenic islet cells, the therapeutically effective amount of the antibody is about 1 mg/kg to about 100 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 50 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg, 5 mg/kg, 10 mg/kg, 15 mg/kg, or 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 10 mg/kg.

[0021] In some aspects of the methods described herein, the method further comprises administering one or more additional pharmaceutically effective compounds concurrently with or following the administration of a second therapeutically effective amount of purified allogenic islet cells. In some aspects, the one or more additional pharmaceutically effective compounds inhibits binding of IL-2 to IL-2 receptors. In some aspects, the compound inhibits binding of IL-2 to IL-2 receptors is basiliximab. In some aspects, the one or more additional pharmaceutically effective compounds inhibits inosine monophosphate dehydrogenase. In some aspects, the compound that inhibits inosine monophosphate dehydrogenase is selected from a mycophenolate mofetil or a mycophenolate sodium. In some aspects, the one or more additional pharmaceutically effective compounds inhibits binding of TNF-alpha to cell surface TNF receptors. In some aspects, the compound that inhibits binding of tumor necrosis factor (TNF)-alpha to cell surface TNF receptors is selected from etanercept or infliximab. [0022] In some aspects of the methods described herein, the antibody or antigen binding fragment thereof is administered parenterally or intravenously. In some aspects, the antibody or antigen binding fragment thereof is administered by injection or infusion. In some aspects, the injection is one or more of intravenous, intramuscular, or subcutaneous injection.

[0023] The present disclosure also provides methods of treating a subject having type 1 diabetes and partial graft function of islet cells, comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand.

[0024] In some aspects of the methods described herein, the subject is a human. In some aspects, the type 1 diabetes comprises brittle type 1 diabetes.

[0025] In some aspects of the methods involving partial graft function described herein, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 100 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 50 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg, 5 mg/kg, 10 mg/kg, 15 mg/kg, or 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 10 mg/kg.

[0026] In some aspects of the methods involving partial graft function described herein, the antibody or antigen binding fragment thereof compound is AT- 1501.

[0027] In some aspects of the methods involving partial graft function described herein, the antibody or antigen binding fragment thereof comprises: (a) a heavy chain variable region (VH) comprising: (i) a CDR1 domain comprising the sequence set forth in SEQ ID NO: 75; (ii) a CDR2 domain comprising the sequence set forth in SEQ ID NO: 76; and (iii) a CDR3 domain comprising the sequence set forth in SEQ ID NO. 77; and (b) a light chain variable region (VL) comprising: (i) a CDR1 domain comprising the sequence set forth in SEQ ID NO: 72; (ii) a CDR2 domain comprising the sequence set forth in SEQ ID NO: 73; and (iii) a CDR3 domain comprising the sequence set forth in SEQ ID NO: 74. In some aspects, the antibody or antigen binding fragment thereof further comprises an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 79.

[0028] In some aspects of the methods involving partial graft function described herein, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 61. In some aspects, n the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence set forth in SEQ ID NO: 61. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 79. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence set forth in SEQ ID NO: 79. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises the amino acid sequence set forth in SEQ ID NO: 64 and the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66. In some aspects of the antibody or antigen binding fragment thereof, the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66 and an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 61. In some aspects of the antibody or antigen binding fragment thereof, the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66 and an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 79.

[0029] In some aspects of the methods involving partial graft function described herein, the method further comprises administering one or more additional pharmaceutically effective compounds. In some aspects, the one or more additional pharmaceutically effective compounds inhibits binding of IL-2 to IL-2 receptors. In some aspects, the compound inhibits binding of IL-2 to IL-2 receptors is basiliximab. In some aspects, the one or more additional pharmaceutically effective compounds inhibits inosine monophosphate dehydrogenase. In some aspects, the compound that inhibits inosine monophosphate dehydrogenase is selected from a mycophenolate mofetil or a mycophenolate sodium. In some aspects, the one or more additional pharmaceutically effective compounds inhibits binding of TNF-alpha to cell surface TNF receptors. In some aspects, the compound that inhibits binding of tumor necrosis factor (TNF)-alpha to cell surface TNF receptors is selected from etanercept or infliximab.

[0030] In some aspects of the methods involving partial graft function described herein, the method further comprises administering a therapeutically effective amount of purified allogenic islet cells. In some aspects, the purified allogenic islet cells are human purified allogenic islet cells.

[0031] In some aspects of the methods involving partial graft function described herein, the antibody or antigen binding fragment thereof is administered at least once every 3 weeks following administration of a therapeutically effective amount of purified allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered as a maintenance dose at least once every 3 weeks following administration of a therapeutically effective amount of purified allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered 3 days, 2 days, or 1 day before administration of a therapeutically effective amount of purified allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered the same day of administering a therapeutically effective amount of purified allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered one or more of 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days after administration of a therapeutically effective amount of purified allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered on days 0, 3, and 7 and every 21 ± 2 days thereafter after administration of a therapeutically effective amount of purified allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for a total of 12 months or for longer than 12 months after administration of a therapeutically effective amount of purified allogenic islet cells.

[0032] In some aspects of the methods involving partial graft function described herein, the antibody or antigen binding fragment thereof is administered parenterally or intravenously. In some aspects, the antibody or antigen binding fragment thereof is administered by injection or infusion. In some aspects, the injection is by one or more of intravenous, intramuscular, or subcutaneous injection.

[0033] The present disclosure also provides methods of modulating the level or concentration of at least one biomarker in a subject having type 1 diabetes, the method comprising administering to the subject a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, wherein the subject has been administered purified allogenic islet cells and wherein the biomarkers are selected from the group consisting of HbAlc, c-peptide, and a combination thereof. In some aspects, the subject is a human.

[0034] In some aspects of the methods described herein of modulating the level or concentration of at least one biomarker, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 100 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 50 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg, 5 mg/kg, 10 mg/kg, 15 mg/kg, or 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 10 mg/kg. [0035] In some aspects of the methods described herein of modulating the level or concentration of at least one biomarker, the antibody or antigen binding fragment thereof is AT-1501.

[0036] In some aspects of the methods described herein of modulating the level or concentration of at least one biomarker, the antibody or antigen binding fragment thereof comprises: (a) a heavy chain variable region (VH) comprising: (i) a CDR1 domain comprising the sequence set forth in SEQ ID NO: 75; (ii) a CDR2 domain comprising the sequence set forth in SEQ ID NO: 76; and (iii) a CDR3 domain comprising the sequence set forth in SEQ ID NO. 77; and (b) a light chain variable region (VL) comprising: (i) a CDR1 domain comprising the sequence set forth in SEQ ID NO: 72; (ii) a CDR2 domain comprising the sequence set forth in SEQ ID NO: 73; and (iii) a CDR3 domain comprising the sequence set forth in SEQ ID NO: 74. In some aspects, the antibody or antigen binding fragment thereof further comprises an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 79.

[0037] In some aspects of the methods described herein of modulating the level or concentration of at least one biomarker, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 61. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence set forth in SEQ ID NO: 61. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 79. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence set forth in SEQ ID NO: 79. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises the amino acid sequence set forth in SEQ ID NO: 64 and the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66. In some aspects of the antibody or antigen binding fragment thereof, the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66 and an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 61. In some aspects of the antibody or antigen binding fragment thereof, the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66 and an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 79.

[0038] In some aspects of the methods described herein of modulating the level or concentration of at least one biomarker, the type 1 diabetes comprises brittle type 1 diabetes.

[0039] In some aspects of the methods described herein of modulating the level or concentration of at least one biomarker, the method further comprises administering one or more additional pharmaceutically effective compounds. In some aspects, the one or more additional pharmaceutically effective compounds targets T-cells by one or more of clearing T-cells from circulation; or modulating T-cell activation, homing, or cytotoxic activities. In some aspects, the compound that targets T-cells is an anti-thymocyte globulin. In some aspects, the one or more additional pharmaceutically effective compounds inhibits inosine monophosphate dehydrogenase. In some aspects, the compound that inhibits inosine monophosphate dehydrogenase is selected from a mycophenolate mofetil or a mycophenolate sodium. In some aspects, the one or more additional pharmaceutically effective compounds inhibits binding of tumor necrosis factor (TNF)-alpha to cell surface TNF receptors. In some aspects, the compound that inhibits binding of tumor necrosis factor (TNF)-alpha to cell surface TNF receptors is selected from etanercept or infliximab.

[0040] In some aspects of the methods described herein of modulating the level or concentration of at least one biomarker, the method further comprises administering a therapeutically effective amount of purified allogenic islet cells. In some aspects, the purified allogenic islet cells are human purified allogenic islet cells.

[0041] In some aspects of the methods described herein of modulating the level or concentration of at least one biomarker, the antibody or antigen binding fragment thereof is administered at least once every 3 weeks. In some aspects, the antibody or antigen binding fragment thereof is administered as a maintenance dose at least once every 3 weeks. In some aspects, the antibody or antigen binding fragment thereof is administered 3 days, 2 days, or 1 day before the islet cells have been administered. In some aspects, the antibody or antigen binding fragment thereof is administered the same day of administering the islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered one or more of 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days after administration of the islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered on days -2, 0, 1, 3, 7, 14, 21, and 28 and every 21 ± 2 days thereafter after administration of the islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for a total of 12 months or for longer than 12 months after administration of the islet cells.

[0042] In some aspects of the methods described herein of modulating the level or concentration of at least one biomarker, the antibody or antigen binding fragment thereof is administered parenterally or intravenously. In some aspects, the antibody or antigen binding fragment thereof is administered by injection or infusion. In some aspects, the injection is one or more of intravenous, intramuscular, or subcutaneous injection.

[0043] In some aspects of the methods described herein of modulating the level or concentration of at least one biomarker, the level or concentration of the at least one biomarker decreases following administration of the antibody or antigen binding fragment thereof. In some aspects, the level or concentration of the at least one biomarker increases following administration of the antibody or antigen binding fragment thereof. In some aspects, the level or concentration of the HbAlc biomarker is < 7% (53 mmol/mol) following administration of the antibody or antigen binding fragment thereof. In some aspects, the level or concentration of the HbAlc biomarker is < 6.5% (48 mmol/mol) following administration of the antibody or antigen binding fragment thereof. In some aspects, the level or concentration of the HbAlc biomarker is < 5.7% following administration of the antibody or antigen binding fragment thereof. In some aspects, the level or concentration of the c-peptide biomarker is > 0.3 ng/mL following administration of the antibody or antigen binding fragment thereof.

[0044] In some aspects of the methods described herein, the subject is insulinindependent following administration of the antibody or antigen binding fragment thereof.

[0045] In some aspects of the methods described herein, the subject has a reduced number of or no serious hypoglycemic events following administration of the antibody or antigen binding fragment thereof.

[0046] In some aspects of the methods described herein, the subject has a concentration of HbAlc < 7% following administration of the antibody or antigen binding fragment thereof. In some aspects, the subject has a baseline HbAlc level of about 7.0% (48 mmol/mol) to about 9.5% (80 mmol/mol).

[0047] In some aspects of the methods described herein, the subject has a concentration of c-peptide > 0.3 ng/mL following administration of the antibody or antigen binding fragment thereof. In some aspects, the subject has an absence of stimulated c-peptide (< 0.3 ng/mL) in response to a 240-minute mixed-meal tolerance test (MMTT).

[0048] In some aspects of the methods described herein, the subject has a body mass index (BMI) of < 30 kg/m².

[0049] In some aspects of the methods described herein, the subject has been diagnosed with type 1 diabetes for > 5 years and/or has onset of disease at < 40 years of age.

[0050] In some aspects of the methods described herein, the antibody or antigen binding fragment thereof is formulated in a pharmaceutical composition comprising a pharmaceutically acceptable carrier.

BRIEF DESCRIPTION OF THE DRAWINGS

[0051] FIG. 1 depicts a graph showing the HbAlc level, daily insulin use, and body weight of a subject pre-transplant, 1 week post-transplant, 2 weeks post-transplant, 3 weeks post-transplant, 4 weeks post-transplant, 7 weeks post-transplant, day 75 posttransplant, 3 months post-transplant, 4 months post-transplant, 2 weeks after a second transplant, and 5 weeks after the second transplant; as well as the period in time in which the subject became insulin independent.

[0052] FIGs. 2A and 2B depicts graphs showing glucose and c-peptide levels, respectively, in the same subject as in FIG. 1 as determined by a 240-minute mixed-meal tolerance test (MMTT) conducted pre-transplant and on day 75 post-transplant.

[0053] FIG. 3 depicts a graph showing the HbAlc, daily insulin use, and body weight of a subject pre-transplant, 1 week post-transplant, 2 weeks post-transplant, 3 weeks posttransplant, 4 weeks post-transplant, 7 weeks post-transplant, 10 weeks post-transplant, and 13 weeks post-transplant; as well as the period in time in which the subject became insulin independent.

[0054] FIGs. 4A and 4B depicts graphs showing glucose and c-peptide levels, respectively, in the same subject as in FIG. 3 as determined by a 240-minute mixed-meal tolerance test (MMTT) conducted pre-transplant, on day 30 post-transplant, and on day 75 post-transplant.

[0055] FIG. 5 depicts a graph showing ratios of area under the plasma concentration-time curve (AUC) for c-peptide: AUC for glucose:islet equivalent (IEQ) for subjects receiving ITx and either the calcineurin inhibitor tacrolimus or anti-CD40 ligand antibody AT- 1501.

[0056] FIG. 6 depicts a graph showing AUC for c-peptide for subjects receiving ITx and either the calcineurin inhibitor tacrolimus or anti-CD40 ligand antibody AT-1501.

DETAILED DESCRIPTION

[0057] The present disclosure describes methods of preventing or reducing islet cell allograft rejection in a subject having type 1 diabetes (T1D) by administering a therapeutically effective amount of a compound that blocks the interaction between CD40 and CD40 ligand, such as an antibody or antigen binding fragment thereof that specifically binds CD40 ligand. The disclosure also describes treating T ID in a subject who has been administered purified allogenic islet cells and methods for restoring physiological insulin secretion or hypoglycemia awareness in a subject having T1D using the compounds described herein. Also described herein are methods for treating subjects having T1D and partial graft function of islet cells where the subjects have had a previous allogenic islet cell transplant. As shown in the present disclosure, administering a compound that blocks the interaction between CD40 and CD40 ligand, such as an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, provides improved islet cell engraftment compared to use of a calcineurin inhibitor such as tacrolimus. And as described herein, dosing of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, as well as a dosing schedule, can reduce islet cell allograft rejection and provide, inter alia, improved blood glucose control, stable islet graft function, insulin independence, eliminate hypoglycemic episodes, and/or reduce human leukocyte antigen (HLA) antibodies.

Definitions

[0058] Unless defined otherwise, all technical and scientific terms used herein have the same meaning as is commonly understood by one of ordinary skill in the art. All patents, applications, published applications and other publications referenced herein are incorporated by reference in their entirety unless stated otherwise.

[0059] One of ordinary skill in the art will appreciate that starting materials, biological and chemical materials, biological and chemical reagents, synthetic methods, purification methods, analytical methods, assay methods, and biological methods other than those specifically exemplified can be employed in the practice of the disclosure without resort to undue experimentation. All art-known functional equivalents, of any such materials and methods are intended to be included in this disclosure.

[0060] In this specification and the appended claims, the singular forms “a,” “an” and “the” include plural referents unless the context clearly dictates otherwise. The terms “a” (or “an”), as well as the terms “one or more,” and “at least one” can be used interchangeably herein. In certain aspects, the term “a” or “an” means “single.” In other aspects, the term “a” or “an” includes “two or more” or “multiple.”

[0061] Furthermore, “and/or” where used herein is to be taken as specific disclosure of each of the two specified features or components with or without the other. Thus, the term “and/or” as used in a phrase such as “A and/or B” herein is intended to include “A and B,” “A or B,” “A” (alone), and “B” (alone). Likewise, the term “and/or” as used in a phrase such as “A, B, and/or C” is intended to encompass each of the following aspects: A, B, and C; A, B, or C; A or C; A or B; B or C; A and C; A and B; B and C; A (alone); B (alone); and C (alone). [0062] The use of the conjunction “or” is used interchangeably with at “least one of.” For example: where a composition comprises A or B, the method must comprise at least one of A and B but may also comprise both A and B. Likewise a composition comprising “A, B, C or D” must comprise at least one of the group of A, B, C and D, but may also comprise all or any combination of A, B, C and D.

[0063] The term “about” as used in connection with a numerical value throughout the specification and the claims denotes an interval of accuracy, familiar and acceptable to a person skilled in the art. Such interval of accuracy is ± 10 %.

[0064] Amino acid substitutions are denoted by the convention in which the original amino acid, the position of the amino acid in the specified sequence and the replacement amino acid are identified, for example, Cl IS would indicate that the cysteine at position 11 of the polypeptide sequence is replaced with a serine.

[0065] Humanized antibodies are antibodies produced from non-human species whose protein sequences have been modified to increase their similarity to antibody variants produced naturally in humans. The process of “humanization” is usually applied to monoclonal antibodies developed for administration to humans (for example, antibodies developed as anti-cancer drugs).

[0066] Currently it is common to humanize a non-human antibody by insertion of relevant complementary determining regions (CDRs) from antibodies created in a non- human animal into a human antibody “scaffold.” “Direct” creation of a humanized antibody can be accomplished by inserting the appropriate CDR coding segments (responsible for the desired binding properties) into a human antibody “scaffold.” This may be achieved through recombinant DNA methods using an appropriate vector and expression in mammalian cells. That is, after an antibody is developed to have the desired properties in a mouse (or other non-human), the DNA coding for that antibody can be isolated, cloned into a vector and sequenced. The DNA sequence corresponding to the antibody CDRs can then be determined. Once the precise sequence of the desired CDRs is known, a strategy can be devised for inserting these sequences appropriately into a construct containing the DNA for a human antibody variant. The CDRs may also be varied, e.g., to increase specificity, prior to insertion into the scaffold.

[0067] The term “human antibody” refers to an antibody which possesses an amino acid sequence which corresponds to that of an antibody produced by a human and/or has been made using any technique for making human antibodies. This definition of a human antibody specifically excludes a humanized antibody comprising non-human antigen binding residues.

[0068] The term “variant” as used herein is defined as a modified or altered form of a wild-type sequence, e.g., where one or more amino acids may be replaced by other amino acid(s) or non-amino acid(s) which do not substantially affect function. In some embodiments, the variant may contain an altered side chain for at least one amino acid residue.

[0069] The term “antigen” as used herein is defined as an entity that can stimulate the production of antibodies and specifically combine with them and/or an entity which elicits an immune system response. For example, a cell surface protein or a specific linear or non- linear portion thereof. The term herein may be abbreviated to “Ag.”

[0070] An “antigen binding antibody fragment” refers to a molecule other than an intact antibody that comprises a portion of an intact antibody that binds the antigen to which the intact antibody binds. Examples of antibody fragments include but are not limited to Fv, Fab, Fab', Fd fragments, dAb fragments, Fab'-SH, F(ab')2; diabodies; triabodies; linear antibodies; single-chain antibody molecules (e.g., scFv); and multispecific antibodies formed from antibody fragments, minimal recognition units consisting of the amino acid residues that mimic the hypervariable region of an antibody (e.g., an isolated complementarity determining region (CDR) such as a CDR3 peptide). An antigen binding fragment as disclosed in the present application binds to the antigen CD40 ligand.

[0071] An antigen-binding fragment of an antibody will typically comprise at least one variable domain. The variable domain may be of any size or amino acid composition and will generally comprise at least one CDR which is adjacent to or in frame with one or more framework sequences. In antigen-binding fragments having a VH domain associated with a VL domain, the VH and VL domains may be situated relative to one another in any suitable arrangement. For example, the variable region may be dimeric and contain VH-VH, VH-VL or VL-VL dimers. Alternatively, the antigen-binding fragment of an antibody may contain a monomeric VH or VL domain.

[0072] The terms “full length antibody,” “intact antibody,” and “whole antibody” are used herein interchangeably to refer to an antibody having a structure substantially similar to a native antibody structure or having heavy chains that contain an Fc region.

[0073] 5c8” refers to the mouse anti-human antibody that binds CD40 ligand and is produced by the hybridoma that is available from the ATCC having the accession number HB10916 and is described in U.S. Pat. No. 5,474,771. “hu5c8” refers to a humanized version of 5c8 the sequence of which is disclosed in Karpusas, et al., “Structure of CD40 Ligand in Complex with the Fab Fragment of a Neutralizing Humanized Antibody,” Structure 9(4):321-329 (2001).

[0074] The term “specifically binds,” or the like, means that an antibody or antigenbinding fragment thereof forms a complex with an antigen that is relatively stable under physiological conditions. Specific binding may be characterized by an equilibrium dissociation constant (KD) of about 3000 nM or less (i.e., a smaller KD denotes a tighter binding), about 2000 nM or less, about 1000 nM or less; about 500 nM or less; about 300 nM or less; about 200 nM or less; about 100 nM or less; about 50 nM or less; about 1 nM or less; or about 0.5 nM. Specific binding for a particular antigen or an epitope may be exhibited, for example, by an antibody having a KD for an antigen or epitope of at least about 1 x 10'⁴ M, at least about 1 x 10'⁵ M, at least about 1 x 10'⁶ M, at least about 1 x 10" 7 M, at least about 1 x 10'⁸ M, at least about 1 x 10'⁹ M, alternatively at least about 1 x 10’ 1⁰ M, at least about 1 x 10'¹¹ M, at least about 1 x 10'¹² M, or greater, where KD refers to a equilibrium dissociation constant of a particular antibody-antigen interaction. Typically, an antibody that specifically binds an antigen will have a KD that is 20-, 50-, 100-, 500-, 1000-, 5,000-, 10,000- or more times greater for a control molecule relative to the antigen or epitope. Also, specific binding for a particular antigen or an epitope may be exhibited, for example, by an antibody having a Ka for an antigen or epitope of at least 20-, 50-, 100-, 500-, 1000-, 5,000-, 10,000- or more times greater for the epitope relative to a control, where Ka refers to an association rate of a particular antibody- antigen interaction.

[0075] The term “neutralizing antibody” includes an antibody that is capable of inhibiting and/or neutralizing the biological activity of CD40 ligand, for example an antibody or antigen fragment thereof that specifically binds CD40 ligand, which inhibits or prevents or diminishes the binding of CD40 ligand to CD40, and thus inhibiting or reducing the signaling pathway triggered by CD40 ligand and/or inhibiting or reducing the binding of CD40 ligand to CD40.

[0076] The terms “antagonistic antibody” or “antagonist antibody” are used herein equivalently and include an antibody that is capable of inhibiting and/or neutralizing the biological signaling activity of CD40 ligand, as described for a neutralizing antibody supra. [0077] CD40 ligand is also known as CD40L, CD154, gp39, T-BAM, 5c8 antigen, or TNF related activation protein (TRAP).

[0078] CD40 is also known as Bp50, TNFRSF5, P50, Tumor Necrosis Factor Receptor Superfamily Member 5, CD40L receptor, B Cell Surface Antigen CD40, or CDW40. Where use of an antibody or antigen binding fragment thereof that specifically binds to CD40 ligand is described herein, such use is understood to alternatively describe use of an antibody or antigen binding fragment thereof that specifically binds to CD40.

[0079] Throughout this specification, unless the context requires otherwise, the words “comprise,” “comprises,” and “comprising” will be understood to imply the inclusion of a stated step or element or group of steps or elements but not the exclusion of any other step or element or group of steps or elements. By “consisting of’ is meant including, and limited to, whatever follows the phrase “consisting of.” Thus, the phrase “consisting of’ indicates that the listed elements are required or mandatory, and that no other elements may be present. By “consisting essentially of’ is meant including any elements listed after the phrase and limited to other elements that do not interfere with or contribute to the activity or action specified in the disclosure for the listed elements. Thus, the phrase “consisting essentially of’ indicates that the listed elements are required or mandatory, but that other elements are optional and may or may not be present depending upon whether or not they materially affect the activity or action of the listed elements.

[0080] As used herein, the term “isolated” refers to a substance and/or entity that has been (1) separated from at least some of the components with which it was associated when initially produced (whether in nature and/or in an experimental setting), and/or (2) produced, prepared, and/or manufactured by the hand of man. Isolated substances and/or entities may be separated from equal to, about, at least, at least about, not more than, or not more than about, 10%, about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, about 95%, about 98%, about 99%, substantially 100%, or 100% of the other components with which they were initially associated (or ranges including and/or spanning the aforementioned values). In some embodiments, isolated agents are, are about, are at least, are at least about, are not more than, or are not more than about 80%, about 85%, about 90%, about 91%, about 92%, about 93%, about 94%, about 95%, about 96%, about 97%, about 98%, about 99%, substantially 100%, or 100% pure (or ranges including and/or spanning the aforementioned values). As used herein, a substance that is “isolated” may be “pure” (e.g., substantially free of other components). As an example, description of an “isolated cell” may refer to a cell not contained in a multi-cellular organism or tissue.

[0081] The term “isolated protein” or “isolated polypeptide” (e.g., an isolated antibody or isolated antigen binding fragment) is a protein or polypeptide that by virtue of its origin or source of derivation is not associated with naturally associated components that accompany it in its native state; is substantially free of other proteins from the same species; is expressed by a cell from a different species; or does not occur in nature. Thus, a polypeptide that is chemically synthesized or synthesized in a cellular system different from the cell from which it naturally originates will be “isolated” from its naturally associated components. A protein may also be rendered substantially free of naturally associated components by isolation, using protein purification techniques well known in the art.

[0082] As used herein, “nucleic acid,” “nucleic acid molecule,” or “nucleotide” refers to polynucleotides or oligonucleotides such as deoxyribonucleic acid (DNA) or ribonucleic acid (RNA), oligonucleotides, fragments generated by the polymerase chain reaction (PCR), and fragments generated by any of ligation, scission, endonuclease action, exonuclease action, and by synthetic generation. Nucleic acid molecules can be composed of monomers that are naturally occurring nucleotides (such as DNA and RNA), or analogs of naturally occurring nucleotides (e.g., enantiomeric forms of naturally occurring nucleotides), or a combination of both. Nucleic acids can be either single stranded or double stranded.

[0083] The terms “peptide,” “polypeptide,” and “protein” as used herein have their plain and ordinary meaning as understood in light of the specification and refer to macromolecules comprised of amino acids linked by peptide bonds. Numerous functions of peptides, polypeptides, and proteins are known in the art, and include but are not limited to enzymes, structure, transport, defense, hormones, or signaling. Peptides, polypeptides, and proteins are often, but not always, produced biologically by a ribosomal complex using a nucleic acid template, although chemical syntheses are also available. By manipulating the nucleic acid template, peptide, polypeptide, and protein mutations such as substitutions, deletions, truncations, additions, duplications, or fusions of more than one peptide, polypeptide, or protein can be performed.

[0084] Reference in the specification is made to percent identity between polypeptide or amino acid sequences. The percent identity between the two sequences is a function of the number of identical positions shared by the sequences, taking into account the number of gaps, and the length of each gap, which need to be introduced for optimal alignment of the two sequences. Identity can be measured as “local identity” or “global identity.” Local identity refers the degree of sequence relatedness between polypeptides as determined by the match between strings of such sequences. Global identity refers to the degree of sequence relatedness of a polypeptide compared to the full-length of a reference polypeptide. Unless specified otherwise, as used herein, identity means global identity. For the purposes of this disclosure, the percentages for global identity are calculated using Needleman and Wunsch ((1970) J. Mol. Biol. 48:444-453) algorithm using a Blossum 62 scoring matrix with a gap penalty of 12, a gap extend penalty of 4, and a frameshift gap penalty of 5. There are many publicly available software programs that incorporate the Needleman and Wunsch algorithm, e.g., the GAP program in the GCG software package.

[0085] The term “gene” generally refers to a portion of a nucleic acid that encodes a protein or functional RNA; however, the term may optionally encompass regulatory sequences. It will be appreciated by those of ordinary skill in the art that the term “gene” may include gene regulatory sequences (e.g., promoters, enhancers, etc.) and/or intron sequences. It will further be appreciated that definitions of gene include references to nucleic acids that do not encode proteins but rather encode functional RNA molecules such as tRNAs and miRNAs. In some aspects, the gene includes regulatory sequences involved in transcription, or message production or composition. In some aspects, the gene comprises transcribed sequences that encode for a protein, polypeptide, or peptide. In keeping with the terminology described herein, an “isolated gene” may comprise transcribed nucleic acid(s), regulatory sequences, coding sequences, or the like, isolated substantially away from other such sequences, such as other naturally occurring genes, regulatory sequences, polypeptide, or peptide encoding sequences, etc. In this respect, the term “gene” is used for simplicity to refer to a nucleic acid comprising a nucleotide sequence that is transcribed, and the complement thereof. As will be understood by those in the art, this functional term “gene” includes both genomic sequences, RNA or cDNA sequences, or smaller engineered nucleic acid segments, including nucleic acid segments of a non-transcribed part of a gene, including but not limited to the non-transcribed promoter or enhancer regions of a gene. Smaller engineered gene nucleic acid segments may express or may be adapted to express using nucleic acid manipulation technology, proteins, polypeptides, domains, peptides, fusion proteins, mutants and/or such like. [0086] The terms “individual,” “subject,” “host,” or “patient” are used interchangeably herein and include a human or a non-human mammal. The term “mammal” is used in its usual biological sense. Thus, it specifically includes, but is not limited to, primates, including simians (chimpanzees, apes, monkeys), humans, cattle, horses, sheep, goats, swine, rabbits, dogs, cats, rodents, rats, mice, or guinea pigs.

[0087] The terms “treating,” “treatment,” or “therapy,” as used herein refer to any indicia of success in arresting or ameliorating type I diabetes in a subject, including partially or completely alleviating, ameliorating, improving, relieving, delaying onset of, inhibiting progression of, reducing severity of, reducing incidence of, or attenuating one or more of the symptoms associated with type I diabetes, or any combination thereof.

[0088] The term “therapeutically effective amount” means an amount of a compound, such as an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, that is needed to produce the desired therapeutic effect, which for the present disclosure is an amount sufficient to inhibit, or allow an improvement in, the disorder or condition being treated (including treatment of T1D or prevention or reduction of islet cell allograft rejection) when administered alone or in conjunction with another pharmaceutically effective compound or treatment in a particular subject or subject population.

[0089] As used herein “effective amount,” e.g., of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand or a pharmaceutical formulation thereof, refers to an amount effective, at dosages and for periods of time necessary, to achieve the desired therapeutic or prophylactic result.

[0090] “Affinity” refers to the strength of the sum total of noncovalent interactions between a single binding site of a molecule (e.g., an antibody) and its binding partner (e.g., an antigen). Unless indicated otherwise, as used herein, “binding affinity” refers to intrinsic binding affinity which reflects a 1 : 1 interaction between members of a binding pair (e.g., antibody and antigen). The affinity of a molecule X for its partner Y may generally be represented by the equilibrium dissociation constant (KD), a ratio of k₀ff/k₀n, between the antibody and its antigen. KD and affinity are inversely related. The KD value relates to the concentration of antibody (the amount of antibody needed for a particular experiment) and so the lower the KD value (lower concentration) and thus the higher the affinity of the antibody. Affinity may be measured by common methods known in the art, including those described herein. Specific, illustrative, and exemplary embodiments for measuring binding affinity may be measured by radioimmunoassays (RIA), Surface Plasmon Resonance (SPR) on a BIAcore® instrument (GE Healthcare Europe GmbH, Glattbrugg, Switzerland) by capturing the antibody on a protein-A coupled CM5 research grade sensor chip (GE Healthcare Europe GmbH, Glattbrugg, Switzerland; BR- 1000- 14) with a human CD40 ligand polypeptide used as analyte. Other methods may include radioimmunoassays, and the Kinetic Exclusion Assay. The Kinetic Exclusion Assay is a general-purpose immunoassay platform that is capable of measuring equilibrium dissociation constants, and association and dissociation rate constants for antigen/anti- body interactions.

[0091] “Effector functions” refer to those biological activities attributable to the Fc region of an antibody, which vary with the antibody isotype. Examples of antibody effector functions include: Clq binding and complement dependent cytotoxicity (CDC); Fc receptor binding; antibody-dependent cell-mediated cytotoxicity (ADCC); phagocytosis; down regulation of cell surface receptors (e.g., B cell receptor); and B cell activation. One effector function is ability of the Fc or constant region of an antibody to bind proteins including, but not limited to, an Fc receptor (FcR) (e.g., high affinity Fc region of IgG receptor la (FCyRIa) (CD64), low affinity immunoglobulin gamma Fc region acceptor Ila (FCyRIIa) (CD32), low affinity immunoglobulin gamma Fc region receptor Illa (FCyRIIIA) (CD 16a), low affinity immunoglobulin gamma Fc region receptor Illb (FCyRIIIb) (CD16b)). In some embodiments, where the antibodies and antigen binding fragments thereof, have an Fc domain, the Fc domain has been engineered to reduce or eliminate one or more Fc effector function. In a preferred embodiment the Fc domain has been engineered to reduce or eliminate platelet activation and/or platelet aggregation and the concomitant risk of thromboembolism.

[0092] The term “brittle type 1 diabetes” as used herein means type 1 diabetes in patients who have impaired awareness of hypoglycemia (IAH), serious hypoglycemic events (SHEs), or both IAH and SHE.

[0093] The term “serious hypoglycemic event” (SHE) as used herein means an event (e.g., memory loss; confusion; uncontrollable behavior; irrational behavior; unusual difficulty in awakening; suspected seizure; seizure; loss of consciousness; or visual symptoms) in which the patient is unable to treat him/herself and which is associated with either a blood glucose level < 54 mg/dL [3.0 mmol/L] or prompt recovery after oral carbohydrate, intravenous glucose, or glucagon administration. [0094] The term “impaired awareness of hypoglycemia” (IAH) as used herein means a Clarke Score of 4 or more. The Clarke survey involves participant completion of 8 questions scored by the Principal Investigator according to an answer key that gives a total score between 0 and 7 (most severe), where scores of 4 or more indicate reduced awareness of hypoglycemia and increased risk for SHEs.

[0095] The term “insulin independent” as used herein means islet transplant recipients who are able to titrate off insulin therapy for at least 2 weeks and meet the following criteria: HbAlc < 6.5% or a > 2.5% absolute decrease from baseline (criteria not required for Day 28 assessment); glucose time in range per day of 70 - 180 mg/dL (3.9 - 10.0 mmol/L) > 70%; time < 70 mg/dL (3.9 mmol/L) < 4%; and time > 180 mg/dL (10.0 mmol/L) < 25% from continuous glucose monitors (CGMS) worn for the previous 10 days; post-prandial serum glucose < 180 mg/dL (10.0 mmol/L) during the MMTT; fasting serum glucose level < 126 mg/dL (7.0 mmol/L); at least one fasting or stimulated c- peptide > 0.5 ng/mL.

[0096] The term “insulin dependent” as used herein means an islet transplant recipient who does not meet the criteria for insulin independence.

[0097] The term “full islet graft function” or “full graft function” as used herein means islet transplant recipients who are insulin independent.

[0098] The term “partial graft function” as used herein means islet cell transplant recipients who do not meet criteria for insulin independence but have either a basal or stimulated c-peptide level > 0.3 ng/mL (0.1 nmol/L).

[0099] The term “graft failure” as used herein is defined as an absence of insulin production by transplanted islets, as evidenced by c-peptide < 0.3 ng/mL. This can be determined by: (1) c-peptide < 0.3 ng/mL on random testing, followed by, (2) c-peptide < 0.3 ng/mL at baseline and after mixed-meal tolerance test (MMTT).

Methods of Treatment

[0100] The present disclosure provides methods of preventing or reducing islet cell allograft rejection in a subject having type 1 diabetes (T1D) by administering a therapeutically effective amount of a compound that blocks the interaction between CD40 and CD40 ligand, such as an antibody or antigen binding fragment thereof that specifically binds CD40 ligand or an antibody or antigen binding fragment thereof that specifically binds CD40. The disclosure also provides treating T1D in a subject who has been administered purified allogenic islet cells and methods for restoring physiological insulin secretion or hypoglycemia awareness in a subject having T1D using the compounds described herein. While the detailed disclosure includes antibodies and antigen binding fragments that specifically bind CD40 ligand for use in the methods described herein, also disclosed are antibodies and antigen binding fragments that specifically bind CD40 and other compounds that block the interaction between CD40 and CD40 ligand, such as a small molecule or other inhibitor, which are disclosed in the art as inhibiting CD40-CD40L interaction. See, e.g., Chen, J., et al., “Small-Molecule Inhibitors of the CD40-CD40L Costimulatory Protein-Protein Interaction,” J. Med. Chem. 60(21):8906-22 (2017); Solanki, K., et al., “Novel Peptide Inhibitors Targeting CD40 and CD40L Interaction: A Potential for Atherosclerosis Therapy,” Curr. Res. Struct. Biol. 6: 100110 (2023); Inf 1 Publ. Appl. No. WO2024/152001.

[0101] For example, the present disclosure relates to a method of preventing or reducing islet cell allograft rejection in a subject having type 1 diabetes comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand. As used herein, reducing islet cell allograft rejection is relative to a subject that has not received a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, has received a previous dose or dosing regimen of a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, or has received a calcineurin inhibitor.

[0102] In aspects, the present disclosure also provides a method of treating type 1 diabetes in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, wherein the subject has been administered purified allogenic islet cells.

[0103] In aspects, the present disclosure provides a method of restoring physiological insulin secretion in a subject having type 1 diabetes, comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand.

[0104] In aspects, the present disclosure provides a method of restoring hypoglycemia awareness in a subject having type 1 diabetes, comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand.

[0105] In aspects, the present disclosure provides a method of treating a subject having type 1 diabetes and partial graft function of islet cells, comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand.

[0106] In aspects, the present disclosure provides a method of modulating the level or concentration of at least one biomarker in a subject having type 1 diabetes, the method comprising administering to the subject a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, wherein the subject has been administered purified allogenic islet cells and wherein the biomarkers are selected from the group consisting of HbAlc, c-peptide, and a combination thereof.

[0107] In some aspects, the level or concentration of the at least one biomarker decreases following administration of the antibody or antigen binding fragment thereof. In some aspects herein, the level or concentration of the at least one biomarker increases following administration of the antibody or antigen binding fragment thereof.

[0108] In some aspects, the level or concentration of the HbAlc biomarker in the subject is < 9.5% (80 mmol/mol) following administration of the antibody or antigen binding fragment thereof according to the methods described herein. In some aspects, the level or concentration of the HbAlc biomarker is < 7% (53 mmol/mol) following administration of the antibody or antigen binding fragment thereof. In some aspects, the level or concentration of the HbAlc biomarker is < 6.5% (48 mmol/mol) following administration of the antibody or antigen binding fragment thereof. In some aspects, the level or concentration of the HbAlc biomarker is < 5.7% following administration of the antibody or antigen binding fragment thereof. In some aspects the level or concentration of the HbAlc biomarker in the subject is > 5.7% before islet cell transplant and following administration of the antibody or antigen binding fragment thereof according to the methods described herein the level or concentration of the HbAlc biomarker is < 5.7%. In some aspects the level or concentration of the HbAlc biomarker is < 5.7% following administration of the antibody or antigen binding fragment thereof and is sustained for at least 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 1 year, 2 years, 3 years, 4 years, 5 years, or more than 5 years.

[0109] In some aspects, the level or concentration of the c-peptide biomarker is > 0.3 ng/mL following administration of the antibody or antigen binding fragment thereof.

[0110] In some aspects, the c-peptide/glucose/creatinine ratio (CPGCR) is determined from the fasting (basal) glucose and c-peptide, and a simultaneous serum creatinine. This measure accounts for both the dependence of c-peptide secretion on the ambient glucose concentration and the dependence of c-peptide clearance on kidney function, as disclosed in Zavaroni, et al., “Renal Metabolism of C-peptide in Man,” J. Clin. Endocrinol. Metab. 65(3):494-498, (1987) and Zerbini, et al., “Higher Post- Ab sorptive C-peptide Levels in Type 1 Diabetic Patients Without Renal Complications,” Diabet. Med. 16(12): 1048-1048 (1999). The CPGCR is calculated as (c-peptide [ng/mL] * 100)/(glucose [mg/dL] * creatinine [mg/dL]). An index of islet graft function, this measure correlates with the 90- minute glucose levels during a MMTT.

[OHl] In some aspects, the subject’s daily insulin dose decreased or is decreasing compared to prior to islet cell transplant. In some aspects herein, the subject is insulin independent following administration of the antibody or antigen binding fragment thereof.

[0112] In some aspects, the subject has a reduced BETA-2 score following administration of the antibody or antigen binding fragment thereof in the methods described herein. The BETA-2 score is a validated way to assess islet graft function and/or to predict long term insulin independence. It relies on 3 values obtained by a single blood draw: fasting c- peptide levels, fasting glucose and HbAlc, as well as the subject’s insulin requirements. The BETA-2 score is calculated as follows: fasting c — peptide [nmol/L] x M — insulin dose

BETA — 2 score = ^{V g 7} ' x 1000 .. . , mmol] ... . . fasting plasma glucose I — j- — I x HbAlc _r [_n %_{/ 1} J

Scores < 17.4 are predictive of achievement of insulin independence, as disclosed in

Bachul, et al., “BETA-2 Score is an Early Predictor of Graft Decline and Loss of Insulin Independence After Pancreatic Islet Allotransplantation,” Am. J. Transplant. 20(3): 844- 851 (2020).

[0113] In some aspects herein, the subject is a mammalian subject. In some aspects herein, the subject is a human. [0114] In some aspects of the methods described herein, the subject has a body mass index (BMI) of < 30 kg/m². In some aspects, the subject has a baseline HbAlc level of about 7.0% (48 mmol/mol) to about 9.5% (80 mmol/mol). In some aspects, the subject at baseline has an absence of stimulated c-peptide (< 0.3 ng/mL) in response to a 240- minute mixed-meal tolerance test (MMTT). In some aspects, the subject has a weight > 50 kg. In some aspects, the subject’s systolic blood pressure (SBP) is < 140 mmHg and/or diastolic blood pressure (DBP) < 90 mmHg. In some aspects, the subject has an estimated glomerular filtration rate (eGFR) calculated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation > 60 mL/min/1.73 m². In some aspects, the subject has a serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) value less than or equal to 3 times the upper limit of normal (ULN) and/or a total bilirubin < 1.5 ULN. In some aspects, the subject has fasting low-density lipoproteins (LDL) cholesterol < 130 mg/dL and/or triglycerides < 200 mg/dL.

[0115] In some aspects, the subject has been diagnosed with type 1 diabetes for > 5 years. In some aspects, the onset of disease is < 40 years of age. In some aspects, the subject has been diagnosed with type 1 diabetes for > 5 years with onset of disease at < 40 years of age. In some aspects, the subject has an insulin requirement < 1.0 unit/kg/day or > 15 units/day.

[0116] In some aspects, the type 1 diabetes comprises brittle type 1 diabetes. In some aspects, a subject has type 1 diabetes and one or more symptoms selected from severe hypoglycemia, severe hyperglycemia, severe glycemic instability, severe glucose variability, or recurrent episodes of diabetic ketoacidosis (DKA).

[0117] In some aspects, the subject has a reduced number of or no serious hypoglycemic events following administration of the antibody or antigen binding fragment thereof.

[0118] In some aspects herein, the antibody or antigen binding fragment thereof is AT- 1501.

[0119] In some aspects, the antibody or antigen binding fragment thereof competitively inhibits the binding of AT- 1501 to CD40 ligand. In some aspects, the antibody or antigen binding fragment thereof competitively inhibits the binding of 5c8 to CD40 ligand. In some aspects, the antibody or antigen binding fragment thereof competitively inhibits the binding of hu5c8 to CD40 ligand.

[0120] In some aspects, the antibody or antigen binding fragment thereof is a modified version of the anti-CD40 ligand antibody hu5c8 that comprises a human IgGl consensus framework having the variable light chain and the variable heavy chain CDR sequences of hu5c8 with an Fc domain modified to prevent platelet activation.

[0121] In some aspects, the antibody or antigen binding fragment thereof comprises an anti-CD40 ligand antibody or antigen binding fragment thereof as known to a person of skill in the art. In some aspects, such antibody or antigen binding fragment thereof is dapirolizumab pegol, as disclosed, e.g., in U.S. Pat. No. 11,142,794B2. In some aspects, such antibody or antigen binding fragment thereof is any one or more antibodies or antigen binding fragments thereof as disclosed in U.S. Pat. No. 8,435,514; 9,044,459; 10,106,618; 10,683,356; 11,014,990; 11,248,055; 11,692,040; 11,384,152, in U.S. Publ. Appl. Nos. 20220380478A1, 20240059781A1, 20240392022A1, or in Int’l Publ. Appl. No. WO2023/230538, WO2023/230526, or WO2024/222895A1.

[0122] In some aspects, the antibody or antigen binding fragment thereof comprises an anti-CD40 antibody or antigen binding fragment thereof as known to a person of skill in the art. In some aspects, such antibody or antigen binding fragment thereof is iscalimab, as disclosed in, e.g., U.S. Publ. Appl. Nos. 20240287198 Al, 20230203176A1, 20220332836A1, 20220195061A1, and 20220098315A1, 20240383994A1. In some aspects, such anti-CD40 antibody or antigen binding fragment thereof is any one or more antibodies or antigen binding fragments thereof as disclosed in U.S. Pat. No. 8,778,345. In some aspects, such anti-CD40 antibody or antigen binding fragment thereof is any one or more antibodies or antigen binding fragments thereof as disclosed in U.S. Patent No. 11,926,673. In some aspects, such anti-CD40 antibody or antigen binding fragment thereof is any one or more antibodies or antigen binding fragments thereof as disclosed in Int’l Publ. Appl. No. W02024/140903A1. In some aspects, such anti-CD40 antibody or antigen binding fragment thereof includes, e.g., ravagalimab, bleselumab, or BI665064.

[0123] In some aspects, the antibody or antigen binding fragment thereof comprises one or more sequences set forth in Table 1 (underlined text identifies CDR sequences unless indicated otherwise).

Table 1

[0124] In some aspects herein, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 90%, or at least 91%, or at least 92%, or at least 93%, or at least 94%, or at least 95%, or at least 96% or at least 97%, or at least 98% or at least 99% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 90%, or at least 91%, or at least 92%, or at least 93%, or at least 94%, or at least 95%, or at least 96%, or at least 97%, or at least 98%, or at least 99% sequence identity with SEQ ID NO: 59, and the Fc region comprises an amino acid sequence having at least at least 90%, or at least 91%, or at least 92%, or at least 93%, or at least 94%, or at least 95%, or at least 96%, or at least 97%, or at least 98%, or at least 99% sequence identity with SEQ ID NO: 60, wherein the Fc region comprises one or a combination of substitutions selected from the group consisting of C5S, Cl IS, C14S, and P23S. In some aspects the Fc region comprises one or a combination of substitutions selected from the group consisting of Cl IS, C14S, and P23S. In some aspects, the light chain variable region does not comprise any of T33W, S26D, and Q27E substitutions. In some aspects, the light chain variable region comprises the substitution R28K.

[0125] In some aspects herein, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 90%, or at least 91%, or at least 92%, or at least 93%, or at least 94%, or at least 95%, or at least 96% or at least 97%, or at least 98% or at least 99% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 90%, or at least 91%, or at least 92%, or at least 93%, or at least 94%, or at least 95%, or at least 96%, or at least 97%, or at least 98%, or at least 99% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence having at least 90%, or at least 91%, or at least 92%, or at least 93%, or at least 94%, or at least 95%, or at least 96%, or at least 97%, or at least 98%, or at least 99% sequence identity with SEQ ID NO: 61.

[0126] In some aspects herein, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 90%, or at least 91%, or at least 92%, or at least 93%, or at least 94%, or at least 95%, or at least 96% or at least 97%, or at least 98% or at least 99% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 90%, or at least 91%, or at least 92%, or at least 93%, or at least 94%, or at least 95%, or at least 96%, or at least 97%, or at least 98%, or at least 99% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence set forth in SEQ ID NO: 61.

[0127] In some aspects herein, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 90%, or at least 91%, or at least 92%, or at least 93%, or at least 94%, or at least 95%, or at least 96% or at least 97%, or at least 98% or at least 99% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 90%, or at least 91%, or at least 92%, or at least 93%, or at least 94%, or at least 95%, or at least 96%, or at least 97%, or at least 98%, or at least 99% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence having at least 90%, or at least 91%, or at least 92%, or at least 93%, or at least 94%, or at least 95%, or at least 96%, or at least 97%, or at least 98%, or at least 99% sequence identity with SEQ ID NO: 79.

[0128] In some aspects herein, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 90%, or at least 91%, or at least 92%, or at least 93%, or at least 94%, or at least 95%, or at least 96% or at least 97%, or at least 98% or at least 99% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 90%, or at least 91%, or at least 92%, or at least 93%, or at least 94%, or at least 95%, or at least 96%, or at least 97%, or at least 98%, or at least 99% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence set forth in SEQ ID NO: 79.

[0129] In some aspects, the CDRs of the heavy chain variable region (VH) comprises (i) a CDR1 comprising the sequence set forth in SEQ ID NO: 75; (ii) a CDR2 domain comprising the sequence set forth in SEQ ID NO: 76; and (iii) a CDR3 domain comprising the sequence set forth in SEQ ID NO. 77, and the CDRs of the light chain variable region (VL) comprises (i) a CDR1 domain comprising the sequence set forth in SEQ ID NO: 72; (ii) a CDR2 domain comprising the sequence set forth in SEQ ID NO: 73; and (iii) a CDR3 domain comprising the sequence set forth in SEQ ID NO: 74.

[0130] In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises the amino acid sequence set forth in SEQ ID NO: 58 and the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66.

[0131] In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises the amino acid sequence set forth in SEQ ID NO: 64 and the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66.

[0132] In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 62 and the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66.

[0133] In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises the amino acid sequence set forth in SEQ ID NO: 68 and the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66.

[0134] In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises the amino acid sequence set forth in SEQ ID NO: 64 and the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 70.

[0135] In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises the amino acid sequence set forth in SEQ ID NO: 68 and the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 70.

[0136] In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises the amino acid sequence set forth in SEQ ID NO: 64, the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66 and an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 61.

[0137] In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises the amino acid sequence set forth in SEQ ID NO: 64, the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66 and an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 79. [0138] In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 5 and the heavy chain comprises a heavy chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 4. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 5 and the heavy chain comprises a heavy chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 3. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 5 and the heavy chain comprises a heavy chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 2. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 5 and the heavy chain comprises a heavy chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 1. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 6 and the heavy chain comprises a heavy chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 4. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 6 and the heavy chain comprises a heavy chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 1. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 7 and the heavy chain comprises a heavy chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 4. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 7 and the heavy chain comprises a heavy chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 1. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 7 and the heavy chain comprises a heavy chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 2. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 8 and the heavy chain comprises a heavy chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 3. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 8 and the heavy chain comprises a heavy chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 1. In some aspects, the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 8 and the heavy chain comprises a heavy chain variable region comprising the amino acid sequence set forth in SEQ ID NO: 2.

[0139] In some aspects, the antibody or antigen binding fragment thereof is formulated in a pharmaceutical composition comprising a pharmaceutically acceptable carrier.

Pharmaceutical Compositions and Methods of Administration

[0140] To treat a patient as described herein, pharmaceutical compositions for use in accordance with the methods of the present disclosure may be formulated in a conventional manner using one or more physiologically acceptable carriers. Pharmaceutically acceptable carriers are determined in part by the particular composition being administered, as well as by the particular method used to administer the composition. Accordingly, there are a wide variety of suitable formulations of the compounds useful in the methods of the present disclosure (see, e.g., Remington: The Science and Practice of Pharmacy, 20th ed., Gennaro et al. Eds., Lippincott Williams and Wilkins, 2000).

[0141] Formulations suitable for parenteral administration include aqueous and nonaqueous, isotonic sterile injection or infusion solutions, which can contain antioxidants, buffers, bacteriostats, and solutes that render the formulation isotonic with the blood of the intended recipient, and aqueous and nonaqueous sterile suspensions that can include suspending agents, solubilizers, thickening agents, stabilizers, and preservatives. For example, such compositions comprising a pharmaceutically acceptable carrier can comprise buffers such as neutral buffered saline, phosphate buffered saline and the like; carbohydrates such as glucose, mannose, sucrose or dextrans, mannitol; proteins; polypeptides or amino acids such as glycine; antioxidants; chelating agents such as EDTA or glutathione; adjuvants (e.g., aluminum hydroxide); and preservatives.

[0142] According to the present disclosure the compounds as described herein, such as antibodies and antigen binding fragments thereof, can be administered by any suitable means, which can vary, for example, depending on the type of disorder being treated and on the nature of the compound itself. For example, the compounds may be administered orally, parenterally, or topically. For proteins such as antibodies, administration routes include parenteral, e.g., intramuscular, intravenous, intraarterial, intraperitoneal, or subcutaneous. For example, the parenteral dosing is given by injection, including intravenous, intramuscular, or subcutaneous injection, or infusion. The amount to be administered will depend on a variety of factors such as the clinical symptoms, weight of the individual, and whether other drugs are administered. It should be appreciated that determination of proper dosage forms, dosage amounts, and routes of administration is within the level of ordinary skill in the pharmaceutical and medical arts, and is described below.

[0143] In one exemplary pharmaceutical composition containing the antibody or antigenbinding fragment thereof that specifically binds CD40 ligand, the composition is formulated as a sterile, preservative-free solution of the antibody or antigen-binding fragment thereof for intravenous or subcutaneous administration, including by infusion or injection. The formulation may be supplied as either a single-use, prefilled pen, as a single-use, for example containing about 1 mL prefilled glass syringe, or as a single-use institutional use vial. For example, the pharmaceutical composition containing the antibody or antigen-binding fragment thereof that specifically binds CD40 ligand is clear and colorless, with a pH of about 5.0 to about 6.9, preferably a pH of about 5.0 to about 6.5, or a pH ranging from about 5.0 to about 6.0. In various aspects, the formulations comprising the pharmaceutical compositions may contain from about 500 mg to about 1 mg, or from about 400 mg to about 10 mg, or from about 300 mg to about 30 mg or from about 200 mg to about 50 mg of the antibody or antigen-binding fragment thereof per mL of solution when reconstituted and administered to the subject.

[0144] Selecting an administration regimen for a therapeutic depends on several factors, including the serum or tissue turnover rate of the entity, the level of symptoms, the immunogenicity of the entity, and the accessibility of the target cells in the biological matrix, general health of the patient, the prior medical history of the patient, and the like. Preferably, an administration regimen maximizes the amount of therapeutic delivered to the patient consistent with an acceptable level of side effects. Accordingly, the amount of biologic delivered depends in part on the particular entity and the severity of the condition being treated. It should be appreciated that determination of proper dosage forms, dosage amounts, and routes of administration is within the level of ordinary skill in the pharmaceutical and medical arts.

Dosing Regimens

[0145] To treat a patient as described herein, the methods as described herein comprise, among other things, administering to the subject a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand. The antibody or antigen binding fragment thereof that specifically binds CD40 ligand may be administered alone (monotherapy) or in combination with other compounds. Thus, in some aspects herein, the methods of treating a patient as described herein include administering one or more additional pharmaceutically effective compounds. In some aspects herein, the one or more additional pharmaceutically effective compounds is selected from an anti-thymocyte globulin (ATG) or basiliximab, a mycophenolate mofetil and/or a mycophenolate sodium, everolimus, etanercept or infliximab, and a combination thereof. In some aspects herein, the one or more additional pharmaceutically effective compounds includes anti-thymocyte globulin, mycophenolate mofetil or mycophenolate sodium, or etanercept. In some aspects herein, the one or more additional pharmaceutically effective compounds includes anti-thymocyte globulin, everolimus, or etanercept. In some aspects herein, the one or more additional pharmaceutically effective compounds includes basiliximab, mycophenolate mofetil or mycophenolate sodium, or etanercept. In some aspects herein, the one or more additional pharmaceutically effective compounds includes basiliximab, everolimus, or etanercept. In some aspects herein, the one or more additional pharmaceutically effective compounds includes anti-thymocyte globulin, mycophenolate mofetil or my cophenolate sodium, or infliximab. In some aspects herein, the one or more additional pharmaceutically effective compounds includes anti -thymocyte globulin, everolimus, or infliximab. In some aspects herein, the one or more additional pharmaceutically effective compounds includes basiliximab, mycophenolate mofetil or mycophenolate sodium, or infliximab. In some aspects herein, the one or more additional pharmaceutically effective compounds includes basiliximab, everolimus, or infliximab. In some aspects herein, the methods of treating a patient as described herein include administering a therapeutically effective amount of purified, allogenic islet cells.

[0146] In some aspects of the methods described herein, the therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand is administered by an intravenous injection or infusion. A predetermined dose of the antibody or antigen binding fragment thereof that specifically binds CD40 ligand is administered, for example, over a period of an hour or two hours to five hours.

[0147] In some aspects of the methods described herein, the therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand is administered by a subcutaneous injection and/or infusion. A predetermined dose of the antibody or antigen binding fragment thereof that specifically binds CD40 ligand is administered, for example, over a period of an hour, or a period of two hours, or a period of three hours, or a period of four hours, or a period of five hours or longer.

[0148] In some aspects of the methods described herein, the therapeutically effective amount of the antibody or antigen binding fragment thereof that specifically binds CD40 ligand is selected based on the target transplant tissue, which as described herein is allogenic islet cells. Whereas a similar or greater therapeutically effective amount may be used for allogenic islet cells as for transplant of a more complex tissue, such as an organ or xeno-tissue, differences in, among other things, vasculature or platelet activation, can provide different dosing considerations and strategies than for islet cells. Thus, a therapeutically effective amount of the antibody or antigen binding fragment thereof that specifically binds CD40 ligand for use according to the methods described herein, may be less than a therapeutically effective amount of the antibody or antigen binding fragment thereof used for immunosuppression in combination with an organ transplant, such as a kidney transplant. [0149] In some aspects of the methods described herein, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 200 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 100 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 90 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 80 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment is about 1 mg/kg to about 70 mg/kg. In some aspects therein, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 60 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 50 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 40 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 30 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 10 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 5 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 5 mg/kg to about 10 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 10 mg/kg to about 15 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 15 mg/kg to about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 20 mg/kg to about 25 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 25 mg/kg to about 30 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 30 mg/kg to about 35 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 35 mg/kg to about 40 mg/kg. [0150] In some aspects of the methods described herein, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg, 2.5 mg/kg, 5 mg/kg, 7.5 mg/kg, 10 mg/kg, 12.5 mg/kg, 15 mg/kg, 17.5 mg/kg, 20 mg/kg, 22.5 mg/kg, 25 mg/kg, 30 mg/kg, 35 mg/kg, or 40 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 10 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 50 mg/kg.

[0151] In some aspects of the methods described herein, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 200 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 100 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 90 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 80 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 70 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 60 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 50 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 40 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 30 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 10 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 5 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 5 mg/kg to 10 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 10 mg/kg to 15 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 15 mg/kg to 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 20 mg/kg to 25 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 25 mg/kg to 30 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 30 mg/kg to 35 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 35 mg/kg to 40 mg/kg.

[0152] In some aspects of the methods described herein, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg, 2.5 mg/kg, 5 mg/kg, 7.5 mg/kg, 10 mg/kg, 12.5 mg/kg, 15 mg/kg, 17.5 mg/kg, 20 mg/kg, 22.5 mg/kg, 25 mg/kg, 30 mg/kg, 35 mg/kg, or 40 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 10 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 50 mg/kg.

[0153] In some of the methods described herein, the antibody or antigen binding fragment thereof is administered at least once every 3 weeks. In some aspects, the antibody or antigen binding fragment thereof is administered as a maintenance dose at least once every 3 weeks. In some aspects, the antibody or antigen binding fragment thereof is administered at least once every 4 weeks. In some aspects, the antibody or antigen binding fragment thereof is administered as a maintenance dose at least once every 4 weeks. In some aspects, the antibody or antigen binding fragment thereof is administered 7 days, 5 days, or 4 days before administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered 3 days, 2 days, or 1 day before administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered the same day of administering the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered one or more of 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 15 days, 16 days, 17 days, 18 days, 19 days, 20 days, or 21 days after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered every 21 ± 2 days after administration of the therapeutically effective amount of purified, allogenic islet cells, beginning on any one or more of day 0, 1, 3, 7, 14, 21, or 28 after administration. In some aspects, the antibody or antigen binding fragment thereof is administered every 28 ± 2 days after administration of the therapeutically effective amount of purified, allogenic islet cells, beginning on any one or more of day 0, 1, 3, 7, 14, 21, or 28 after administration. In some aspects, the antibody or antigen binding fragment thereof is administered on days -2, 0, 1, 3, 7, 14, 21, and 28 and every 21 ± 2 days thereafter after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered on days -2, 0, 1, 3, 7, 14, 21, and 28 and every 28 ± 2 days thereafter after administration of the therapeutically effective amount of purified, allogenic islet cells.

[0154] In some aspects of the methods described herein, the antibody or antigen binding fragment thereof is administered on days -2, 0, 1, 3, 7, 14, 21, and 28 and every 21 ± 2 days thereafter after administration of the therapeutically effective amount of purified, allogenic islet cells and the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 20 mg/kg.

[0155] In some aspects of the methods described herein, the antibody or antigen binding fragment thereof is administered on days -2, 0, 1, 3, 7, 14, 21, and 28 and every 21 ± 2 days thereafter after administration of the therapeutically effective amount of purified, allogenic islet cells and the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 10 mg/kg.

[0156] In some aspects, the antibody or antigen binding fragment thereof is administered for about 6 months after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for about 9 months after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for about 12 months after administration of the therapeutically effective amount of purified, allogenic islet cells or for longer than 12 months after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for about 15 months after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for about 18 months after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for about 21 months after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for about 24 months after administration of the therapeutically effective amount of purified, allogenic islet cells.

[0157] In some aspects, the antibody or antigen binding fragment thereof is administered for 6 months after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for 9 months after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for 12 months after administration of the therapeutically effective amount of purified, allogenic islet cells or for longer than 12 months after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for 15 months after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for 18 months after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for 21 months after administration of the therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for 24 months after administration of the therapeutically effective amount of purified, allogenic islet cells.

[0158] In some aspects, the one or more additional pharmaceutically effective compounds targets T-cells. In some aspects, the one or more additional pharmaceutically effective compounds targets T-cells by one or more of: clearing T-cells from circulation or modulating T-cell activation, homing, or cytotoxic activities. In some aspects, the compound that targets T-cells is an anti -thymocyte globulin (ATG). In some aspects, the compound that targets T-cells inhibits binding of interleukin (IL)-2 to IL-2 receptors. In some aspects, the compound that targets T-cells is an 0X40 antibody. In some aspects, the compound that targets T-cells is an anti-CD2 antibody.

[0159] In some aspects, the one or more pharmaceutically effective compounds is antithymocyte globulin. In some aspects, the anti-thymocyte globulin is sourced from a species other than humans. In some aspects, the anti-thymocyte globulin is sourced from rabbit. In some aspects, the anti-thymocyte globulin is sourced from horse. In some aspects, the anti -thymocyte globulin is sourced from goat. In some aspects, the antithymocyte globulin is sourced from pig. In some aspects a total of 1 mg/kg to 50 mg/kg of anti -thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 4.5 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3- 7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 5 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3- 7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 5.5 mg/kg of anti -thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 6 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 6.5 mg/kg of anti -thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 7 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 7.5 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 8 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 8.5 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 9 mg/kg of anti -thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 9.5 mg/kg of antithymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 10 mg/kg of anti -thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 10.5 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3- 7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 15 mg/kg of anti -thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 20 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 25 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant.

[0160] In some aspects, the one or more pharmaceutically effective compounds that targets T cells inhibits binding of IL-2 to IL-2 receptors. In some aspects, the compound that inhibits binding of IL-2 to IL-2 receptors is basiliximab. In some aspects, basiliximab is administered as a 1 mg to 50 mg IV dose within 2 hours prior to islet cell transplantation. In some aspects, basiliximab is administered 5 mg IV on day 0 within 2 hours prior to islet cell transplantation and 5 mg IV on day 4 post-transplant. In some aspects, basiliximab is administered 10 mg IV on day 0 within 2 hours prior to islet cell transplantation and 10 mg IV on day 4 post-transplant. In some aspects, basiliximab is administered 15 mg IV on day 0 within 2 hours prior to islet cell transplantation and 15 mg IV on day 4 post-transplant. In some aspects, basiliximab is administered 20 mg IV on day 0 within 2 hours prior to islet cell transplantation and 20 mg IV on day 4 posttransplant. In some aspects, basiliximab is administered 25 mg IV on day 0 within 2 hours prior to islet cell transplantation and 25 mg IV on day 4 post-transplant.

[0161] In some aspects, the one or pharmaceutically effective compounds is an inhibitor of mammalian target of rapamycin (mTOR).. In some aspects, the compound that inhibits mTOR is everolimus. In some aspects, everolimus is administered as a 0.25 mg dose orally twice daily. In some aspects, everolimus is administered as a 0.5 mg dose orally twice daily. In some aspects, everolimus is administered as a 0.75 mg dose orally twice daily. In some aspects, everolimus is administered as a 1 mg dose orally twice daily. In some aspects, everolimus is administered as a 1.25 mg dose orally twice daily. In some aspects, everolimus is administered as a 1.5 mg dose orally twice daily. In some aspects, everolimus is administered as a 1.75 mg dose orally twice daily. In some aspects, everolimus is administered as a 2 mg dose orally twice daily. In some aspects, everolimus administration begins as soon as possible after transplantation. In some aspects, everolimus administration begins 30 days after transplantation. In some aspects, everolimus is administered for 6 months post-transplant, 9 months post-transplant, 12 months post-transplant, 18 months post-transplant, 21 months post-transplant, or 24 months post-transplant. In some aspects, everolimus is administered for the life of the subject.

[0162] In some aspects, the one or more additional pharmaceutically effective compounds inhibits inosine monophosphate dehydrogenase. In some aspects, the compound that inhibits inosine monophosphate dehydrogenase is selected from a mycophenolate mofetil or a mycophenolate sodium. In some aspects, mycophenolate mofetil is administered as a 500 mg to 1,500 mg dose orally twice daily. In some aspects, mycophenolate mofetil is administered as a 500 mg dose orally twice daily. In some aspects, mycophenolate mofetil is administered as a 750 mg dose orally twice daily. In some aspects, mycophenolate mofetil is administered as a 1,000 mg dose orally twice daily. In some aspects, mycophenolate mofetil is administered as a 1,250 mg dose orally twice daily. In some aspects, mycophenolate mofetil is administered as a 1,500 mg dose orally twice daily. In some aspects, mycophenolate mofetil is administered beginning on the day of administration of a T-cell depleting agent. In some aspects, mycophenolate mofetil is administered for 6 months post-transplant, 9 months post-transplant, 12 months post-transplant, 18 months post-transplant, 21 months post-transplant, or 24 months posttransplant. In some aspects, mycophenolate mofetil is administered for the life of the subject. In some aspects, mycophenolate sodium is administered as a 360 mg to 1,080 mg dose orally twice daily. In some aspects, mycophenolate sodium is administered as a 360 mg dose orally twice daily. In some aspects, mycophenolate sodium is administered as a 540 mg dose orally twice daily. In some aspects, mycophenolate sodium is administered as a 720 mg dose orally twice daily beginning on the day of administration of a T-cell depleting agent. In some aspects, mycophenolate sodium is administered as a 900 mg dose orally twice daily. In some aspects, mycophenolate sodium is administered as a 1,080 mg dose orally twice daily. In some aspects, mycophenolate sodium is administered beginning on the day of administration of a T-cell depleting agent. In some aspects, mycophenolate sodium is administered for 6 months post-transplant, 9 months posttransplant, 12 months post-transplant, 18 months post-transplant, 21 months posttransplant, or 24 months post-transplant. In some aspects, mycophenolate sodium is administered for the life of the subject.

[0163] In some aspects, the one or more additional pharmaceutically effective compounds inhibits binding of tumor necrosis factor (TNF)-alpha to cell surface TNF receptors. In some aspects, the compound that inhibits binding of TNF-alpha to cell TNF receptors is selected from etanercept or infliximab. In some aspects, etanercept is administered at a dose of 50 mg to 100 mg IV on day 0 prior to transplant, and 25 mg to 50 mg SC on days 3, 7, and 10 post-transplant. In some aspects, etanercept is administered at a dose of 100 mg IV on day 0 prior to transplant, and 50 mg SC on days 3, 7, and 10 post-transplant. In some aspects, etanercept is administered at a dose of 50 mg IV on day 0 prior to transplant, and 25 mg SC on days 3, 7, and 10 post-transplant. In some aspects, infliximab is administered as a 1 mg/kg IV dose to a 50 mg/kg IV dose 2 hours-pre transplant. In some aspects, infliximab is administered as a 5 mg/kg IV dose 2 hours pre-transplant. In some aspects, infliximab is administered as a 10 mg/kg IV dose 2 hours pre-transplant. In some aspects, infliximab is administered as a 15 mg/kg IV dose 2 hours pre-transplant. In some aspects, infliximab is administered as a 20 mg/kg IV dose 2 hours pre-transplant. In some aspects, infliximab is administered as a 25 mg/kg IV dose 2 hours pre-transplant.

[0164] In some aspects, a therapeutically effective amount of purified, allogenic islet cells is administered. In some aspects, the purified allogenic islet cells are human purified allogenic islet cells. Sufficient quantity and quality of islet mass are transplanted in the setting of favorable local conditions at the engraftment site for optimal islet mass engraftment. Results from the Edmonton group, for example, indicate that transplantation of an islet mass over 5,000 lEQ/kg per transplant and a total cumulative islet mass of 10,000 lEQ/kg are important for effective engraftment and subsequent insulin independence. See, e.g., Shapiro, J.M.S., et al. “Islet Transplantation in Seven Patients with Type 1 Diabetes Mellitus Using a Glucocorticoid-Free Immunosuppressive Regimen,” NEJM 343(4):230-8 (2000). For example, the Edmonton group has shown that patients required IEQ of 11,547+/- 1,604 lEQ/kg to maintain insulin independence for at least 1 year. Trials conducted by, for example, the Clinical Islet Transplantation Consortium (CIT) allowed transplantation of 5,000 lEQ/kg during the first and 4,000 lEQ/kg during the second transplant with good clinical outcomes. However, it is also possible that transplantation of an islet mass less than 5,000 lEQ/kg per transplant may also lead to effective engraftment and/or subsequent insulin independence, as shown herein. In some aspects, the final product is supplied in 500 mL or less of fluid containing a dose of > 1,000 lEQ/kg recipient body weight for the transplant. In some aspects, the final product is supplied in 500 mL or less of fluid containing a dose of > 2,000 lEQ/kg recipient body weight for the transplant. In some aspects, the final product is supplied in 500 mL or less of fluid containing a dose of > 3,000 lEQ/kg recipient body weight for the transplant.

[0165] In some aspects therein, the final purified allogenic islet cells is a 200 mL sterile suspension of > 70% viable, > 30% pure, allogeneic human purified islet cells in CMRL 1066 Transplant Media for administration by intraportal infusion. The final product is supplied in 500 mL or less of fluid containing a dose of > 5,000 lEQ/kg recipient body weight for the transplant.

[0166] In some aspects, the present disclosure provides a method of preventing or reducing islet cell allograft rejection in a subject having type 1 diabetes comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 20 mg/kg, wherein the method further comprises administering one or more additional pharmaceutically effective compounds selected from an anti-thymocyte globulin (ATG) or basiliximab, a mycophenolate mofetil and/or a mycophenolate sodium, etanercept or infliximab, and a combination thereof, wherein the islet cells are human purified allogenic islet cells, and wherein the antibody or antigen binding fragment thereof is administered at least once every 3 weeks. In some aspects, the one or more additional pharmaceutically effective compounds are as described in Tables 2 or 3. In some aspects, the antibody or antigen binding fragment thereof that specifically binds CD40 ligand is administered according to the regimen described in Tables 2 or 3. In some aspects, the antibody or antigen binding fragment thereof that specifically binds CD40 ligand is administered on days -2, 0, 1, 3, 7, 14, 21, and 28 and every 21 ± 2 days thereafter after administering the islet cells.

[0167] In some aspects, the present disclosure also provides a method of treating type 1 diabetes in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, wherein the subject has been administered purified allogenic islet cells, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 20 mg/kg, wherein the method further comprises administering one or more additional pharmaceutically effective compounds selected from an anti-thymocyte globulin (ATG) or basiliximab, a mycophenolate mofetil and/or a mycophenolate sodium, etanercept or infliximab, and a combination thereof, wherein the islet cells are human purified allogenic islet cells, and wherein the antibody or antigen binding fragment thereof is administered at least once every 3 weeks. In some aspects, the one or more additional pharmaceutically effective compounds are as described in Tables 2 or 3. In some aspects, the antibody or antigen binding fragment thereof that specifically binds CD40 ligand is administered according to the regimen described in Tables 2 or 3. In some aspects, the antibody or antigen binding fragment thereof that specifically binds CD40 ligand is administered on days -2, 0, 1, 3, 7, 14, 21, and 28 and every 21 ± 2 days thereafter after administering the islet cells.

[0168] In some aspects, the present disclosure provides a method of restoring physiological insulin secretion in a subject having type 1 diabetes, comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 20 mg/kg, wherein the method further comprises administering one or more additional pharmaceutically effective compounds selected from an anti-thymocyte globulin (ATG) or basiliximab, a mycophenolate mofetil and/or a mycophenolate sodium, etanercept or infliximab, and a combination thereof, wherein the islet cells are human purified allogenic islet cells, and wherein the antibody or antigen binding fragment thereof is administered at least once every 3 weeks. In some aspects, the one or more additional pharmaceutically effective compounds are as described in Tables 2 or 3. In some aspects, the antibody or antigen binding fragment thereof that specifically binds CD40 ligand is administered according to the regimen described in Tables 2 or 3. In some aspects, the antibody or antigen binding fragment thereof that specifically binds CD40 ligand is administered on days -2, 0, 1, 3, 7, 14, 21, and 28 and every 21 ± 2 days thereafter after administering the islet cells.

[0169] In some aspects, the present disclosure provides a method of restoring hypoglycemia awareness in a subject having type 1 diabetes, comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 20 mg/kg, wherein the method further comprises administering one or more additional pharmaceutically effective compounds selected from an anti -thymocyte globulin (ATG) or basiliximab, a mycophenolate mofetil and/or a mycophenolate sodium, etanercept or infliximab, and a combination thereof, wherein the islet cells are human purified allogenic islet cells, and wherein the antibody or antigen binding fragment thereof is administered at least once every 3 weeks. In some aspects, the one or more additional pharmaceutically effective compounds are as described in Tables 2 or 3. In some aspects, the antibody or antigen binding fragment thereof that specifically binds CD40 ligand is administered according to the regimen described in Tables 2 or 3. In some aspects, the antibody or antigen binding fragment thereof that specifically binds CD40 ligand is administered on days -2, 0, 1, 3, 7, 14, 21, and 28 and every 21 ± 2 days thereafter after administering the islet cells.

[0170] In some aspects, a second therapeutically effective amount of purified, allogenic islet cells is administered. In some aspects, the purified allogenic islet cells are human purified allogenic islet cells. In some aspects, the final purified allogenic islet cells is a 200 mL sterile suspension of > 70% viable, > 30% pure, allogenic human purified islet cells in CMRL 1066 Transplant Media for administration by intraportal infusion. The final product is supplied in 500 mL or less of fluid containing a dose of > 4,000 lEQ/kg recipient body weight for subsequent transplants.

[0171] In some aspects, the antibody or antigen binding fragment thereof is administered at least once every 3 weeks following administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered as a maintenance dose at least once every 3 weeks following administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered at least once every 4 weeks following administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered as a maintenance dose at least once every 4 weeks following administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered 7 days, 5 days, or 4 days before administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered 3 days, 2 days, or 1 day before administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered the same day of administering the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered one or more of 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 15 days, 16 days, 17 days, 18 days, 19 days, 20 days, or 21 days after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered every 21 ± 2 days after administration of the second therapeutically effective amount of purified, allogenic islet cells, beginning on any one or more of day 0, 3, or 7 after administration. In some aspects, the antibody or antigen binding fragment thereof is administered every 28 ± 2 days after administration of the second therapeutically effective amount of purified, allogenic islet cells, beginning on any one or more of day 0, 3, or 7 after administration.

In some aspects, the antibody or antigen binding fragment thereof is administered on days 0, 3, 7 and every 21 ± 2 days thereafter after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered on days 0, 3, 7 and every 28 ± 2 days thereafter after administration of the second therapeutically effective amount of purified, allogenic islet cells.

[0172] In some aspects, the antibody or antigen binding fragment thereof is administered for about 6 months after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for about 9 months after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for about 12 months after administration of the second therapeutically effective amount of purified, allogenic islet cells or for longer than 12 months after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for about 15 months after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for about 18 months after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for about 21 months after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for about 24 months after administration of the second therapeutically effective amount of purified, allogenic islet cells.

[0173] In some aspects, the antibody or antigen binding fragment thereof is administered for 6 months after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for 9 months after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for 12 months after administration of the second therapeutically effective amount of purified, allogenic islet cells or for longer than 12 months after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for 15 months after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for 18 months after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for 21 months after administration of the second therapeutically effective amount of purified, allogenic islet cells. In some aspects, the antibody or antigen binding fragment thereof is administered for 24 months after administration of the second therapeutically effective amount of purified, allogenic islet cells.

[0174] In some aspects, the therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand is administered by a subcutaneous injection. A predetermined dose of the antibody or antigen binding fragment thereof that specifically binds CD40 ligand is administered, for example, over a period of an hour, or a period of two hours, or a period of three hours, or a period of four hours, or a period of five hours or longer.

[0175] In some aspects of the methods described herein, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 200 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 100 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 90 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 80 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment is about 1 mg/kg to about 70 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 60 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 50 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 40 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 30 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 10 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 5 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 5 mg/kg to about 10 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 10 mg/kg to about 15 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 15 mg/kg to about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 20 mg/kg to about 25 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 25 mg/kg to about 30 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 30 mg/kg to about 35 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 35 mg/kg to about 40 mg/kg.

[0176] In some aspects of the methods described herein, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg, 2.5 mg/kg, 5 mg/kg, 7.5 mg/kg, 10 mg/kg, 12.5 mg/kg, 15 mg/kg, 17.5 mg/kg, 20 mg/kg, 22.5 mg/kg, 25 mg/kg, 30 mg/kg, 35 mg/kg, or 40 mg/kg. In some aspects therein, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 50 mg/kg.

[0177] In some aspects of the methods described herein, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 200 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 100 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 90 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 80 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 70 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 60 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 50 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 40 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 30 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 10 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg to 5 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 5 mg/kg to 10 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 10 mg/kg to 15 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 15 mg/kg to 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 20 mg/kg to 25 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 25 mg/kg to 30 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 30 mg/kg to 35 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 35 mg/kg to 40 mg/kg.

[0178] In some aspects of the methods described herein, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 1 mg/kg, 2.5 mg/kg, 5 mg/kg, 7.5 mg/kg, 10 mg/kg, 12.5 mg/kg, 15 mg/kg, 17.5 mg/kg, 20 mg/kg, 22.5 mg/kg, 25 mg/kg, 30 mg/kg, 35 mg/kg, or 40 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 10 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 20 mg/kg. In some aspects, the therapeutically effective amount of the antibody or antigen binding fragment thereof is 50 mg/kg.

[0179] In some aspects, one or more additional pharmaceutically effective compounds are administered concurrently with or following administration of the second therapeutically effective amount of purified allogenic islet cells.

[0180] In some aspects, the one or more additional pharmaceutically effective compounds targets T-cells. In some aspects, the one or more additional pharmaceutically effective compounds targets T-cells by one or more of: clearing T-cells from circulation or modulating T-cell activation, homing, or cytotoxic activities. In some aspects, the compound that targets T-cells is an anti -thymocyte globulin (ATG). In some aspects, the compound that targets T-cells inhibits binding of interleukin (IL)-2 to IL-2 receptors. In some aspects, the compound that targets T-cells is an inhibitor of mammalian target of rapamycin (mTOR). In some aspects, the compound that targets T-cells is an 0X40 antibody. In some aspects, the compound that targets T-cells is an anti-CD2 antibody.

[0181] In some aspects, the compound that targets T-cells is an anti -thymocyte globulin. In some aspects, the anti -thymocyte globulin is sourced from a species other than humans. In some aspects, the anti-thymocyte globulin is sourced from rabbit. In some aspects, the anti -thymocyte globulin is sourced from horse. In some aspects, the antithymocyte globulin is sourced from goat. In some aspects, the anti-thymocyte globulin is sourced from pig. In some aspects a total of 1 mg/kg to 50 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 4.5 mg/kg of antithymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 5 mg/kg of antithymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 5.5 mg/kg of anti -thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 6 mg/kg of anti -thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 6.5 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3- 7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 7 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3- 7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 7.5 mg/kg of anti -thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 8 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 8.5 mg/kg of anti -thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 9 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 9.5 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 10 mg/kg of anti -thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 10.5 mg/kg of anti -thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 15 mg/kg of antithymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 20 mg/kg of anti -thymocyte globulin is administered by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant. In some aspects, a total of 25 mg/kg of anti-thymocyte globulin is administered by IV infusion in divided doses over 3- 7 days within 2-6 weeks prior to the first islet cell transplant.

[0182] In some aspects, one or more additional pharmaceutically effective compounds is administered. In some aspects, the compound that targets T-cells inhibits binding of interleukin (IL)-2 to IL-2 receptors. In some aspects, the compound that inhibits binding of IL-2 to IL-2 receptors is basiliximab. In some aspects, basiliximab is administered as a 1 mg to 50 mg IV dose within 2 hours prior to islet cell transplantation. In some aspects, basiliximab is administered 5 mg IV on day 0 within 2 hours prior to islet cell transplantation and 5 mg IV on day 4 post-transplant. In some aspects, basiliximab is administered 10 mg IV on day 0 within 2 hours prior to islet cell transplantation and 10 mg IV on day 4 post-transplant. In some aspects, basiliximab is administered 15 mg IV on day 0 within 2 hours prior to islet cell transplantation and 15 mg IV on day 4 posttransplant. In some aspects, basiliximab is administered 20 mg IV on day 0 within 2 hours prior to islet cell transplantation and 20 mg IV on day 4 post-transplant. In some aspects, basiliximab is administered 25 mg IV on day 0 within 2 hours prior to islet cell transplantation and 25 mg IV on day 4 post-transplant.

[0183] In some aspects, the compound that targets T-cells is an inhibitor of mTOR. In some aspects, the compound that inhibits mTOR is everolimus. In some aspects, everolimus is administered as a 0.25 mg dose orally twice daily. In some aspects, everolimus is administered as a 0.5 mg dose orally twice daily. In some aspects, everolimus is administered as a 0.75 mg dose orally twice daily. In some aspects, everolimus is administered as a 1 mg dose orally twice daily. In some aspects, everolimus is administered as a 1.25 mg dose orally twice daily. In some aspects, everolimus is administered as a 1.5 mg dose orally twice daily. In some aspects, everolimus is administered as a 1.75 mg dose orally twice daily. In some aspects, everolimus is administered as a 2 mg dose orally twice daily. In some aspects, everolimus administration begins as soon as possible after transplantation. In some aspects, everolimus administration begins 30 days after transplantation. In some aspects, everolimus is administered for 6 months post-transplant, 9 months post-transplant, 12 months post-transplant, 18 months post-transplant, 21 months post-transplant, or 24 months post-transplant. In some aspects, everolimus is administered for the life of the subject.

[0184] In some aspects, the one or more additional pharmaceutically effective compounds inhibits inosine monophosphate dehydrogenase. In some aspects, the compound that inhibits inosine monophosphate dehydrogenase is selected from a mycophenolate mofetil or a mycophenolate sodium. In some aspects, mycophenolate mofetil is administered as a 500 mg to 1,500 mg dose orally twice daily. In some aspects, mycophenolate mofetil is administered as a 500 mg dose orally twice daily. In some aspects, mycophenolate mofetil is administered as a 750 mg dose orally twice daily. In some aspects, mycophenolate mofetil is administered as 1,000 mg dose orally twice daily. In some aspects, mycophenolate mofetil is administered as a 1,250 mg dose orally twice daily. In some aspects, mycophenolate mofetil is administered as a 1,500 mg dose orally twice daily. In some aspects, mycophenolate mofetil is administered beginning on the day of administration of a T-cell depleting agent. In some aspects, mycophenolate mofetil is administered for 6 months post-transplant, 9 months post-transplant, 12 months posttransplant, 18 months post-transplant, 21 months post-transplant, or 24 months posttransplant. In some aspects, mycophenolate mofetil is administered for the life of the subject. In some aspects, mycophenolate sodium is administered as a 360 mg to 1,080 mg dose orally twice daily. In some aspects, mycophenolate sodium is administered as a 360 mg dose orally twice daily. In some aspects, mycophenolate sodium is administered as a 720 mg dose orally twice daily. In some aspects, mycophenolate sodium is administered as a 900 mg dose orally twice daily. In some aspects, mycophenolate sodium is administered as a 1,080 mg dose orally twice daily. In some aspects, mycophenolate sodium is administered beginning on the day of administration of a T-cell depleting agent. In some aspects, mycophenolate sodium is administered for 6 months post-transplant, 9 months post-transplant, 12 months post-transplant, 18 months post-transplant, 21 months post-transplant, or 24 months post-transplant. In some aspects, mycophenolate sodium is administered for the life of the subject.

[0185] In some aspects, the one or more additional pharmaceutically effective compounds inhibits binding of tumor necrosis factor (TNF)-alpha to cell surface TNF receptors. In some aspects, the compound that inhibits binding of TNF-alpha to cell TNF receptors is selected from etanercept or infliximab. In some aspects, etanercept is administered at a dose of 50 mg to 100 mg IV on day 0 prior to transplant and 25 mg to 50 mg SC on days 3, 7, and 10 post-transplant. In some aspects, etanercept is administered at a dose of 100 mg IV on day 0 prior to transplant, and 50 mg SC on days 3, 7, and 10 post-transplant. In some aspects, etanercept is administered at a dose of 50 mg IV on day 0 prior to transplant, and 25 mg SC on days 3, 7, and 10 post-transplant. In some aspects, infliximab is administered as a 1 mg/kg to 50 mg/kg IV dose 2 hours pretransplant. In some aspects, infliximab is administered as a 5 mg/kg IV dose 2 hours pretransplant. In some aspects, infliximab is administered as a 10 mg/kg IV dose 2 hours pretransplant. In some aspects, infliximab is administered as a 15 mg/kg IV dose 2 hours pretransplant. In some aspects, infliximab is administered as a 20 mg/kg IV dose 2 hours pretransplant. In some aspects, infliximab is administered as a 25 mg/kg IV dose 2 hours pretransplant. [0186] In some aspects of the methods described herein, the subject receives no more than two transplants of therapeutically effective amounts of purified, allogenic islet cells. In some aspects of the methods described herein, the subject receives no more than three transplants of therapeutically effective amounts of purified, allogenic islet cells.

Kits and Articles of Manufacture

[0187] Further provided are kits containing the antibody or antigen binding fragments thereof described herein and instructions for use according to the methods described herein. Kits typically include a packaged combination of reagents in predetermined amounts with instructions and a label indicating the intended use of the contents of the kit. The term label or instruction includes any writing, or recorded material supplied on or with the kit, or which otherwise accompanies the kit at any time during its manufacture, transport, sale, or use. It can be in the form prescribed by a governmental agency regulating the manufacture, use or sale of pharmaceuticals or biological products, which notice reflects approval by the agency of the manufacture, use or sale for administration to a human or for veterinary use. The label or instruction can also encompass advertising leaflets and brochures, packaging materials, and audio or video instructions.

EXAMPLE 1

A Pilot Study Assessing the Safety of Using a Monoclonal Antibody Against CD40 Ligand to Achieve a Calcineurin Inhibitor-Free Immunosuppression Regimen in Patients with Type 1 Diabetes Mellitus (T1D) and Problematic Hypoglycemia Undergoing Islet Cell Transplantation.

[0188] This study aimed to assess whether the transplantation of purified human pancreatic islet cells and administration of AT-1501, in combination with anti -thymocyte globulin (ATG) or basiliximab, etanercept, and mycophenolate mofetil/mycophenolate sodium (MMF/MPS), can prevent allograft rejection, restore physiological insulin secretion and restore hypoglycemia awareness in patients with T1D with impaired awareness of hypoglycemia (IAH) and unexplained episodes of serious hypoglycemia (brittle T1D). An immunosuppression regimen free of calcineurin inhibitors can avoid the adverse effects of these drugs in islet recipients, including painful mouth ulceration, peripheral edema, proteinuria, hypercholesterolemia, and hypertension. Sirolimus in particular exerts an antiproliferative effect in renal tubular cells and may hinder recovery of an injured kidney. Chronic tacrolimus exposure can cause cardio-, neuro- and nephrotoxicity, an increased incidence of malignancies and opportunistic infections, and impairment of beta cell function and beta cell loss. CD40 ligand blockade with AT- 1501 has the potential to 1) mitigate cellular and antibody mediated responses associated with islet engraftment, 2) prevent T cell mediated autoimmune responses to endogenous beta cells, and 3) prevent rejection in ITx in T1D. If found to be efficacious and safe, an antibody or antigen binding fragment thereof that specifically binds to CD40 ligand substitution for tacrolimus could markedly improve engraftment, reducing the number of islets needed to achieve normoglycemia and long-term survival of allogeneic islets without causing renal toxicity.

[0189] The objectives of this study were to assess the safety and tolerability of transplanted islet cells and immunomodulation with AT-1501, in combination with ATG or basilixmab, etanercept and MMF/MPS in adults with brittle T1D; to assess the efficacy of transplanted islet cells and immunomodulation in adults with brittle T1D; and to evaluate the PK of AT-1501.

[0190] This study was a single-arm, open-label trial to assess safety, tolerability, and efficacy of transplanted islet cells and immunomodulation with AT-1501 in combination with ATG or basiliximab, etanercept and MMF/MPS in adults with brittle T1D. Participants who met all eligibility criteria and signed informed consent forms were enrolled and assigned a unique study identification number. Participants received AT- 1501 as part of a regimen that also included ATG, etanercept and MMF/MPS induction, followed by maintenance with daily MMF/MPS and AT-1501 as an IV infusion. Exogenous insulin was given as appropriate.

[0191] Participants received AT-1501 20 mg/kg as a 1-hour IV infusion in an induction and maintenance dose regimen where Study Day 0 is the day of the islet cell transplant: Days -2, 0, 1, 3, 7, 14, 21, 28 and every 21 ±2 days thereafter for a total of 12 months.

[0192] Interruptions in the dosing schedule of AT-1501 was permitted in the case of medical/surgical events or logistical reasons not related to the study drug. Participants restarted the study drug as soon as possible but no later than 7 days following the interruption, unless otherwise discussed with the Principal Investigator. Participants who skipped 2 or more consecutive AT-1501 doses throughout the study (due to nonadherence, Principal Investigator discretion, or other reasons) were considered to have discontinued study treatment and were not allowed to reinitiate treatment with AT-1501. [0193] Participants received a total of 4.5 mg/kg ATG by IV infusion in divided doses over 3-7 days within 2-6 weeks prior to the first islet cell transplant.

[0194] Participants received etanercept (Enbrel) at a dose of 50 mg intravenously on Day 0 prior to transplant, and 25 mg subcutaneously on Days 3, 7 and 10 post-transplant. The doses were administered as directed on the package insert.

[0195] Participants received Myfortic 720 mg or CellCept 1 g twice daily starting on the day of ATG infusion for the duration of the study in order to titer (establish) an optimal dose, that the participant can tolerate without side effects and prevent rebound immunity. Either preparation was used and switching between them was allowed. The doses were administered as directed on the package insert. Downward adjustment of the dose for safety concerns was allowed at the discretion of the Principal Investigator.

[0196] Participants received up to 500 mL or less of fluid containing a dose of > 4,000 islet cell equivalents (IEQ)/kg recipient body weight (BW) for the first transplant. Each bag contained a 200 mL sterile suspension of > 70% viable, > 30% pure, allogeneic human purified islet cells in CMRL 1066 Transplant Media for administration by intraportal infusion. Alternatively, a mesenteric or omental venous tributary of the portal vein was obtained by mini-laparotomy under general anesthesia if percutaneous access was not achieved or if the transplant site so preferred.

[0197] The administration of the islet cell mixture was conducted by the transplant center in accordance with their institutional guidelines. In general, the islet cell mixture was delivered slowly via gravity drainage from a bag attached to the catheter in the portal vein or portal vein tributary. Access to the portal vein was achieved by percutaneous transhepatic access under fluoroscopic, ultrasonographic, or real-time computed tomography (CT) guidance. Alternatively, access to a mesenteric or omental venous tributary of the portal vein was obtained by mini-laparotomy under general anesthesia in the rare circumstance that percutaneous access was not achieved or if the transplant site so preferred.

[0198] At a minimum, portal pressure was monitored before the infusion of the islet cell product began, after 25% of the infusion had been administered, after 50% of the infusion had been administered, after 75% of the infusion had been administered, and after the infusion had been completed. Portal pressure measurements were documented in the medical record. If the portal pressure exceeded 15 mmHg on any measurement, the infusion was paused until the pressure returned to < 10 mmHg. If the pressure failed to normalize, the procedure was terminated.

[0199] The study treatment regimen is shown in Tables 2 and 3 below.

Table 2 Study Treatment Regimen

Table 3 Treatment Regimen Schedule a. AT-1501 infusion was given on Days -2, 0, 1, 3, 7, 14, 21 and 28 (day 0, 3, 7 after second ITx) then every 21 ± 2 days for a total of 12 months after final ITx. b. Etanercept was administered at a dose of 50 mg IV on Day 0 prior to transplant, and 25 mg SC on Days 3, 7 and 10 post-transplant. c. MMF/MPS was given twice daily for the duration of the study starting on the first day of ATG infusion. d. AT-1501 infusion completed at least 4 hours prior to transplant. e. A total of 4.5 mg/kg was given by IV infusion in divided doses over up to 7 days within 2-6 weeks prior to the first islet cell transplant.

[0200] The composition of final purified human pancreatic islets is shown in Table 4 below.

Table 4 Composition of Final Purified Human Pancreatic Islets

[0201] Study participants with a functioning graft at Day 365 post-transplant were followed for safety and graft survival as part of the long-term follow-up program. If graft rejection is diagnosed at any time point of the study, the participant will receive a standard antirejection treatment, which may include steroids, plasmapheresis, IVIG, rituximab, and/or ATG. If graft failure occurs after Day 365, participants may receive additional medical therapy, which may have included supplementary islet transplantation (ITx) with agents other than AT-1501. Clinical events and outcomes pertaining to graft survival were collected.

[0202] Study participants with partial graft function were considered for a second transplant between Day 28 and Month 12 post-initial transplant. Partial graft function was defined as transplant recipients who do not meet the criteria for insulin independence but have either a basal or stimulated c-peptide level > 0.3 ng/mL (0.1 nmol/L). To be considered for a second transplant, participants must have met this definition and the additional requirements described below:

1. Participant received > 5,000 lEQ/kg with the first transplant, but failed to achieve or maintain insulin independence.

2. Participant had been compliant with study assessments and prescribed study treatment.

3. Participant has no unresolved serious adverse events (SAEs).

4. Participant had no evidence of progressive renal dysfunction, with blood creatinine rising above 2.0 mg/dL (177 pmol/L).

5. Participant had no evidence of hypersensitization, allergic responses, or other potentially serious drug reactions to medications required by the protocol.

6. Participant had alloantibody specificity which was not cross-reactive with antigen(s) present in the subsequent islet preparation (in order to avoid unacceptable antigen[s]).

7. Absence of any medical condition that, in the opinion of the Principal Investigator, would interfere with a safe and successful second islet transplant.

[0203] Participants who received a second transplant received AT-1501, in combination with basiliximab and etanercept induction; and maintenance with twice daily MMF/MPS and AT-1501. AT-1501 was administered at day 0, 3, 7 and every 21 days for a total of 12 months of treatment. Basiliximab was administered as a 20 mg dose on day 0 within 2 hours prior to islet cell transplantation and a second dose of 20 mg was given on day 4 post-transplant. The doses of etanercept and MMF/MPS were the same as for the initial transplant. Participants received an islet cell dose of > 4,000 lEQ/kg recipient BW for the second transplant. The study treatment regimen for this second transplant is shown in Tables 2 and 3 above.

[0204] Participants who experienced graft failure, defined as an absence of insulin production by transplanted islets, as evidenced by (1) c-peptide < 0.3 ng/mL on random testing, followed by, (2) c-peptide < 0.3 ng/mL at baseline, and after a 240-minute mixed- meal tolerance test (MMTT), were eligible for a second islet transplant with AT-1501 treatment, unless graft failure was caused by rejection based on the presence of de novo Donor Specific HLA Antibodies (DSA), then AT-1501 was stopped. Hyperglycemia was managed with exogenous insulin as appropriate, and an appropriate immunosuppression regimen was given if there is a possibility that the participant will receive a future transplant.

[0205] Study participants who experienced graft failure after their second ITx discontinued treatment with AT-1501, may have elected to obtain a subsequent ITx with tacrolimus replacing AT-1501. Those who elected to discontinue immunosuppression continued to follow up according to a modified study follow-up schedule.

[0206] Post-transplant, all participants received comprehensive multidisciplinary diabetes care from the transplant team, consisting of the transplant surgeon, the endocrinologist, and the diabetes nurses. Insulin was administered as needed to maintain glucose levels in the target range. Starting at the Day 28 Visit, the total daily dose of insulin for the 7 days prior to the visit was recorded. Pre-prandial glucose levels was targeted to 80-120 mg/dL. Participants recorded blood glucose (BG) 5 times per day (AM fasting, before lunch, 2 hours after lunch, before supper, and at bedtime) either by capillary testing or interrogation of their CGM device. Participants’ daily BG levels was reviewed by a study nurse and/or one of the Principal Investigators at least 3 times per week until 28 days post-transplant, and then at least weekly during Month 2 and beyond for those who failed to achieve insulin independence. Participants also reported any hypoglycemia to the team as quickly as possible. Exogenous insulin was withdrawn or adjusted as needed. [0207] Participants were eligible for consideration for the study only if all of the following criteria applied at the time of Screening:

1. Men and women 18-65 years of age.

2. A diagnosis of T1D > 5 years, with onset of disease at < 40 years of age.

3. Ability to provide informed consent.

4. Able to comply with study procedures, including the requirement to utilize continuous glucose monitoring (CGM).

5. Involvement in appropriate diabetes management in accordance with the standard of care, as directed by an endocrinologist or diabetologist with at least 4 (quarterly) clinical evaluations within the 12 months prior to Screening; using an insulin pump or multiple daily injection (MDI) insulin therapy; and, unable to achieve acceptable metabolic control because of the occurrence of unexplained SHEs.

6. At least 3 unexplained SHEs not secondary to a missed meal or dosing error, in the 12 months prior to Screening.

7. HbAlc level 7.0% (48 mmol/mol) to 9.5% (80 mmol/mol), inclusive.

8. Absence of stimulated c-peptide (< 0.3 ng/mL) in response to a 240-minute MMTT.

9. IAH as defined by a Clarke Score of 4 or more at the time of Screening, during the Screening period, and within the last 6 months prior to the transplant.

10. If female, must be surgically sterile or 2 years postmenopausal. Women of childbearing potential may be enrolled if a serum pregnancy test is negative at Screening/baseline. Women of childbearing potential and men with partners that are of childbearing potential must agree to use 2 forms of highly effective methods of contraception from Screening, throughout the study, and while receiving immunosuppressive therapy for the functioning graft after the conclusion of the study. Contraception use must continue for 90 days after the last administration of the study drug. Male participants must refrain from donating sperm for the duration of the study and agree to not donate sperm for 90 days after last administration of the study drug.

11. Patients with COVID-19 negative test result.

[0208] Participants were excluded from the study if any of the following criteria applied at the time of Screening: Any previous solid organ or islet allotransplant. Body mass index (BMI) > 30 kg/m². Weight < 50 kg. Insulin requirement > 1.0 unit/kg/day or < 15 units/day. Treatment with any anti-diabetic medication other than insulin within 4 weeks of Screening. Untreated proliferative diabetic retinopathy. Blood pressure: systolic blood pressure (SBP) > 140 mmHg or diastolic blood pressure (DBP) > 90 mmHg. Estimated glomerular filtration rate (eGFR) calculated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation < 60 mL/min/1.73 m². Diagnosis of macroalbuminuria (> 300 mg/g creatinine). For female participants: Positive pregnancy test, presently breast-feeding, or unwillingness to use effective contraceptive measures for the duration of the study and 90 days after discontinuation. For male participants: intent to procreate during the duration of the study or within 90 days after discontinuation or unwillingness to use effective measures of contraception. History of malignancy except for completely resected squamous or basal cell carcinoma of the skin. History of a thromboembolic event (TE), known hypercoagulable state, or condition requiring long-term anti coagulation: a. Participants with a history of clotted venous access not requiring long-term anti coagulation may be included at the Principal Investigator’s discretion if they have no other history of TEs or known hypercoagulable state. Known heparin allergy. Receiving treatment for a medical condition requiring chronic use of systemic steroids, except for physiologic replacement. Presence of ongoing active infection including tuberculosis (TB), human immunodeficiency virus (HIV), hepatitis B, hepatitis C. Laboratory evidence of active infection even in the absence of clinical symptoms of infection is exclusionary. Invasive aspergillus, histoplasmosis or coccidioidomycosis infection within one year prior to Screening Negative screen for Epstein-Barr Virus (EBV) by IgG determination. Current treatment with any immunosuppressive regimen, and treatment with biologic immune modulating agents, j anus kinase (JAK) inhibitors, sphingosine- 1- phosphate (SIP) receptor agonists, azathioprine, mercaptopurine (6-MP), or systemic corticosteroids in the previous 5 years. Persistent elevation of serum aspartate aminotransferase (AST) or alanine aminotransferase (ALT) value greater than 3 times the upper limit of normal (ULN); elevation of total bilirubin > 1.5 ULN. Any history of receiving experimental cell or gene therapy. Exposure to any other experimental or investigational agent within 30 days or 5 half-lives; whichever is longer. History of substance abuse within the past 2 years. Severe cardiovascular disease characterized by any one of these conditions: a) stroke; b) recent myocardial infarction (within past 6 months); c) evidence of ischemia on functional cardiac exam within the last year; d) left ventricular ejection fraction < 30%. History of significant gastrointestinal disease such as symptomatic cholecystolithiasis; acute or chronic pancreatitis; symptomatic peptic ulcer disease; severe unremitting diarrhea, vomiting or other disorders potentially interfering with the ability to absorb oral medications. Significant hyperlipidemia despite medical therapy defined as fasting low-density lipoproteins (LDL) cholesterol > 130 mg/dL and/ or triglycerides > 200 mg/dL. History of any conditions that can interfere in the assessment of I4b Ale due to increased red blood cell turnover or requirement for regular blood transfusions such as sickle cell disease (HbSS, HbSC, HbS/beta thalassemia); Beta thalassemia major; Alpha Thalassemia (HbH) disease, Hemoglobin H-Constant Spring. History of any other acute or chronic medical condition or pre-planned medical/surgical procedure that, in the opinion of the Principal Investigator, would compromise the safety of participants or the integrity of study results; non- compliance with recommended diabetes care in the preceding 12 months. Baseline Hb below the lower limits of normal at the local laboratory; lymphopenia (< 1,000/pL), neutropenia (< 1,500/pL), or thrombocytopenia (platelets < 100,000/pL). Participants with lymphopenia are allowed if the Principal Investigator determines there is no additional risk and obtains clearance from a hematologist.

28. Any coagulopathy or medical condition requiring long-term anticoagulant therapy (e.g., warfarin) after islet cell transplantation (low-dose aspirin treatment is allowed) or participants with an international normalized ratio (INR) > 1.5. The use of Plavix is allowed only when portal vein access is obtained using a minilaparotomy procedure at the time of islet cell transplant.

29. History of factor V deficiency.

30. Administration of live attenuated vaccine(s) within 2 months of Screening.

31. Any previous treatment with AT-1501 or any therapy including another antibody or antigen binding fragment thereof that specifically binds CD40 ligand.

32. Allergy to the Boost drink necessary for MMTT.

33. Baseline panel reactive antibodies (PRA) over 20%.

34. Patients with COVID-19 positive result.

[0209] Safety, efficacy, and exploratory endpoints are as follows:

Safety Endpoints:

• Incidence of adverse events (AEs), serious adverse events (SAEs) and AEs of special interest (AEoSI).

Efficacy Endpoints:

• Proportion of participants who were insulin-independent at Day 75 and Day 365 post-first and final transplant.

• Proportion of participants with HbAlc < 7.0% (53 mmol/mol) at Day 365 AND free of SHEs from Day 28 to Day 365 post-first and final transplant.

• Proportion of participants with HbAlc < 6.5% (48 mmol/mol) at Day 365 AND free from SHEs from Day 28 to Day 365 post-first and final transplant.

• Proportion of participants with graft failure at Day 365 post final transplant.

Exploratory Endpoints:

• Proportion of participants with IAH (using the method of Clarke), at Day 75 and 365 after final islet cell transplant. • Change in glycemic lability and variability (using a Continuous Glucose Monitoring System® [CGMS]) at Day 75 and 365 after final islet cell transplant.

• Change in albumin excretion ratio (AER), estimated glomerular filtration rate (eGFR), and percent new macroalbuminuria at Day 365 post-first and final transplant.

• PK parameters (AUC, Cmax, clearance [CL], volume of distribution at steady state [Vdss], half-life [tl/2]) were derived from blood samples of AT-1501.

• Exploratory biomarkers of tissue damage and inflammation (such as Human map, HMPC1 11, CXCL13) at multiple time points post-transplant.

Results

[0210] A 42-year old female subject weighing 88.5 kg (194 lbs) at treatment intake (BMI 30 kg/m²) received a first transplant of islet cells (IEQ 363,000, with an lEQ/kg of 4092) and 20 mg/kg AT-1501 and showed decreased HbAlc through 4 months post-transplant (FIG. 1). At day 75 post-transplant, the subject’s blood glucose and c-peptide, as determined by a 240-minute mixed-meal tolerance test (MMTT), were improved compared to pre-transplant blood glucose and c-peptide levels (FIGS. 2A and 2B). The subject’s HbAlc level improved to 6.1% (from 8.4% at baseline) and daily insulin dose decreased by 50 units/day (from 80 units per day at baseline) (FIG. 2A). At 90 days posttransplant, the subject’s HbAlc level improved to 6.0% and daily insulin dose decreased to 16 units per day. At 16 weeks, after a second transplant of islet cells (IEQ 505,000, with an lEQ/kg of 5,500), the subject achieved insulin independence two weeks later, maintaining improved HbAlc levels of 5.4% afterwards (FIG. 1).

[0211] A 30-year old female subject weighing 50 kg (110 lbs) at treatment intake (BMI 21 kg/m²) received a first transplant of islet cells (IEQ 326,000, with an lEQ/kg of 6775) and 20 mg/kg AT-1501 and showed decreased HbAlc through 13 weeks post-transplant. The subject stopped insulin support (from 60 units per day at baseline) four weeks after the islet transplant and HbAlc levels improved to 5.8% and below (from 8.5% at baseline) starting at 7 weeks after the transplant (FIG. 3). At days 30 and 75 posttransplant, the subject’s blood glucose and c-peptide as determined by a 240-minute mixed-meal tolerance test (MMTT) were improved compared to pre-transplant blood glucose and c-peptide levels (FIGS. 4A and 4B). [0212] A 37-year old male subject weighing 92 kg at treatment intake (BMI 29.9 kg/m²) received a first transplant of islet cells (IEQ 376,000, with lEQ/kg of 4086) and 20 mg/kg AT-1501 and showed decreased insulin usage three days following transplant (from 90 units of insulin to 29 units of insulin). The subject had a baseline HbAlC of 9.3% and continues on an insulin independence trajectory.

[0213] Subjects receiving AT-1501 in the treatment regimen experienced improved blood glucose control with no need for insulin support, presented stable islet graft function (approximately six months post-transplant), had no unexpected adverse events, no severe hypoglycemic episodes, no site infections or thromboembolic events, no signs of rejection, no new HL A antibodies, and no signs kidney and neurotoxicity as after receiving tacrolimus. Subjects receiving AT-1501 achieved 3-5 fold higher islet cell engraftment (measured by graft function standardized to the number of islets infused), as compared to subjects receiving comparable transplants using the calcineurin inhibitor tacrolimus (FIGS.s 5 and 6). The higher engraftment provided with AT-1501 suggests treatment with AT-1501 is less toxic to transplanted islets resulting in improved graft survival and function.

Claims

WHAT IS CLAIMED IS:

1. A method of preventing or reducing islet cell allograft rejection in a subject having type 1 diabetes comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 100 mg/kg.

2. A method of treating type 1 diabetes in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, wherein the subject has been administered purified allogenic islet cells and wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 100 mg/kg.

3. A method of restoring physiological insulin secretion in a subject having type 1 diabetes, comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand.

4. A method of restoring hypoglycemia awareness in a subject having type 1 diabetes, comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand.

5. The method of claim 3 or 4, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 100 mg/kg.

6. The method of any one of claims 1-5, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 50 mg/kg.

7. The method of any one of claims 1-6, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 20 mg/kg.

8. The method of any one of claims 1-7, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg, 5 mg/kg, 10 mg/kg, 15 mg/kg, or 20 mg/kg.

9. The method of any one of claims 1-8, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 20 mg/kg.

10. The method of any one of claims 1-8, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 10 mg/kg.

11. The method of any one of claims 1-10, wherein the antibody or antigen binding fragment thereof is AT- 1501.

12. The method of any one of claims 1-10, wherein the antibody or antigen binding fragment thereof comprises:

(a) a heavy chain variable region (VH) comprising:

(i) a CDR1 domain comprising the sequence set forth in SEQ ID NO: 75;

(ii) a CDR2 domain comprising the sequence set forth in SEQ ID NO: 76; and

(iii) a CDR3 domain comprising the sequence set forth in SEQ ID NO. 77; and

(b) a light chain variable region (VL) comprising:

(i) a CDR1 domain comprising the sequence set forth in SEQ ID NO: 72;

(ii) a CDR2 domain comprising the sequence set forth in SEQ ID NO: 73; and

(iii) a CDR3 domain comprising the sequence set forth in SEQ ID NO: 74.

13. The method of claim 12, wherein the antibody or antigen binding fragment thereof further comprises an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 79.

14. The method of any one of claims 1-10, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 61.

15. The method of any one of claims 1-10, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence set forth in SEQ ID NO: 61.

16. The method of any one of claims 1-10, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 79.

17. The method of any one of claims 1-10, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence set forth in SEQ ID NO: 79.

18. The method of any one of claims 1-10, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises the amino acid sequence set forth in SEQ ID NO: 64 and the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66.

19. The method of claim 18, wherein the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66 and an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 61.

20. The method of claim 18, wherein the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66 and an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 79.

21. The method of any one of claims 1-20, wherein the type 1 diabetes comprises brittle type 1 diabetes.

22. The method of any one of claims 1-21, wherein the method further comprises administering one or more additional pharmaceutically effective compounds.

23. The method of claim 22, wherein the one or more additional pharmaceutically effective compounds targets T-cells by one or more of clearing T-cells from circulation; or modulating T-cell activation, homing, or cytotoxic activities.

24. The method of claim 23, wherein the compound that targets T-cells is selected from an anti -thymocyte globulin.

25. The method of any one of claims 22-24, wherein the one or more additional pharmaceutically effective compounds inhibits inosine monophosphate dehydrogenase.

26. The method of claim 25, wherein the compound that inhibits inosine monophosphate dehydrogenase is selected from a mycophenolate mofetil or a mycophenolate sodium.

27. The method of any one of claims 22-26, wherein the one or more additional pharmaceutically effective compounds inhibits binding of tumor necrosis factor (TNF)- alpha to cell surface TNF receptors.

28. The method of claim 27, wherein the compound that inhibits binding of tumor necrosis factor (TNF)-alpha to cell surface TNF receptors is selected from etanercept or infliximab.

29. The method of any one of claims 1-28, wherein the method further comprises administering a therapeutically effective amount of purified allogenic islet cells.

30. The method of claim 29, wherein the purified allogenic islet cells are human purified allogenic islet cells.

31. The method of any one of claims 1-30, wherein the antibody or antigen binding fragment thereof is administered at least once every 3 weeks.

32. The method of any one of claims 1-31, wherein the antibody or antigen binding fragment thereof is administered as a maintenance dose at least once every 3 weeks.

33. The method of any one of claims 29-32, wherein the antibody or antigen binding fragment thereof is administered 3 days, 2 days, or 1 day before administering the islet cells.

34. The method of any one of claims 29-33, wherein the antibody or antigen binding fragment thereof is administered the same day of administering the islet cells.

35. The method of any one of claims 29-34, wherein the antibody or antigen binding fragment thereof is administered one or more of 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days after administering the islet cells.

36. The method of any one of claims 29-35, wherein the antibody or antigen binding fragment thereof is administered on days -2, 0, 1, 3, 7, 14, 21, and 28 and every 21 ± 2 days thereafter after administering the islet cells.

37. The method of any one of claims 29-36, wherein the antibody or antigen binding fragment thereof is administered for a total of 12 months or for longer than 12 months after administering the islet cells.

38. The method of any one of claims 1-37, wherein the method further comprises administering a second therapeutically effective amount of purified allogenic islet cells.

39. The method of claim 38, wherein the purified allogenic islet cells are human purified allogenic islet cells.

40. The method of claim 38 or 39, wherein the antibody or antigen binding fragment thereof is administered at least once every 3 weeks following administration of the second therapeutically effective amount of purified allogenic islet cells.

41. The method of any one of claims 38-40, wherein the antibody or antigen binding fragment thereof is administered as a maintenance dose at least once every 3 weeks following administration of the second therapeutically effective amount of purified allogenic islet cells.

42. The method of any one of claims 38-41, wherein the antibody or antigen binding fragment thereof is administered 3 days, 2 days, or 1 day before administration of the second therapeutically effective amount of purified allogenic islet cells.

43. The method of any one of claims 38-42, wherein the antibody or antigen binding fragment thereof is administered the same day of administering the second therapeutically effective amount of purified allogenic islet cells.

44. The method of any one of claims 38-43, wherein the antibody or antigen binding fragment thereof is administered one or more of 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days after administration of the second therapeutically effective amount of purified allogenic islet cells.

45. The method of any one of claims 38-44, wherein the antibody or antigen binding fragment thereof is administered on days 0, 3, and 7 and every 21 ± 2 days thereafter after administration of the second therapeutically effective amount of purified allogenic islet cells.

46. The method of any one of claims 38-45, wherein the antibody or antigen binding fragment thereof is administered for a total of 12 months or for longer than 12 months after administration of the second therapeutically effective amount of purified allogenic islet cells.

47. The method of any one of claims 38-46, wherein the therapeutically effective amount of the antibody is about 1 mg/kg to about 100 mg/kg.

48. The method of any one of claims 38-47, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 50 mg/kg.

49. The method of any one of claims 38-48, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 20 mg/kg.

50. The method of any one of claims 38-49, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg, 5 mg/kg, 10 mg/kg, 15 mg/kg, or 20 mg/kg.

51. The method of any one of claims 38-50, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 20 mg/kg.

52. The method of any one of claims 38-50, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 10 mg/kg.

53. The method of any one of claims 38-52, wherein the method further comprises administering one or more additional pharmaceutically effective compounds.

54. The method of claim 53, wherein the one or more additional pharmaceutically effective compounds inhibits binding of IL-2 to IL-2 receptors.

55. The method of claim 54, wherein the compound inhibits binding of IL-2 to IL-2 receptors is basiliximab.

56. The method of any one of claims 53-55, wherein the one or more additional pharmaceutically effective compounds inhibits inosine monophosphate dehydrogenase.

57. The method of claim 56, wherein the compound that inhibits inosine monophosphate dehydrogenase is selected from a mycophenolate mofetil or a mycophenolate sodium.

58. The method of any one of claims 53-57, wherein the one or more additional pharmaceutically effective compounds inhibits binding of TNF-alpha to cell surface TNF receptors.

59. The method of claim 58, wherein the compound that inhibits binding of tumor necrosis factor (TNF)-alpha to cell surface TNF receptors is selected from etanercept or infliximab.

60. The method of any one of claims 1-59, wherein the antibody or antigen binding fragment thereof is administered parenterally or intravenously.

61. The method of any one of claims 1-60, wherein the antibody or antigen binding fragment thereof is administered by injection or infusion.

62. The method of claim 61, wherein the injection is one or more of intravenous, intramuscular, or subcutaneous injection.

63. A method of treating a subject having type 1 diabetes and partial graft function of islet cells, comprising administering to the subject in need thereof a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand.

64. The method of claim 63, wherein the subject is a human.

65. The method of claim 63 or 64, wherein the type 1 diabetes comprises brittle type 1 diabetes.

66. The method of any one of claims 63-65, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 100 mg/kg.

67. The method of any one of claims 63-66, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 50 mg/kg.

68. The method of any one of claims 63-67, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 20 mg/kg.

69. The method of any one of claims 63-68, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg, 5 mg/kg, 10 mg/kg, 15 mg/kg, or 20 mg/kg.

70. The method of any one of claims 63-69, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 20 mg/kg.

71. The method of any one of claims 63-69, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 10 mg/kg.

72. The method of any one of claims claim 63-71, wherein the antibody or antigen binding fragment thereof compound is AT- 1501.

73. The method of any one of claims 63-71, wherein the antibody or antigen binding fragment thereof comprises:

(a) a heavy chain variable region (VH) comprising:

(i) a CDR1 domain comprising the sequence set forth in SEQ ID NO: 75;

(ii) a CDR2 domain comprising the sequence set forth in SEQ ID NO: 76; and

(iii) a CDR3 domain comprising the sequence set forth in SEQ ID NO. 77; and

(b) a light chain variable region (VL) comprising:

(i) a CDR1 domain comprising the sequence set forth in SEQ ID NO: 72;

(ii) a CDR2 domain comprising the sequence set forth in SEQ ID NO: 73; and

(iii) a CDR3 domain comprising the sequence set forth in SEQ ID NO: 74.

74. The method of claim 73, wherein the antibody or antigen binding fragment thereof further comprises an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 79.

75. The method of any one of claims 63-71, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 61.

76. The method of any one of claims 63-71, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence set forth in SEQ ID NO: 61.

77. The method of any one of claims 63-71, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 79.

78. The method of any one of claims 63-71, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence set forth in SEQ ID NO: 79.

79. The method of any one of claims 63-71, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises the amino acid sequence set forth in SEQ ID NO: 64 and the heavy chain comprises the amino acid sequence of SEQ ID NO: 66.

80. The method of claim 79, wherein the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66 and an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 61.

81. The method of claim 79, wherein the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66 and an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 79.

82. The method of any one of claims 63-81, wherein the method further comprises administering one or more additional pharmaceutically effective compounds.

83. The method of claim 82, wherein the one or more additional pharmaceutically effective compounds inhibits binding of IL-2 to IL-2 receptors.

84. The method of claim 83, wherein the compound inhibits binding of IL-2 to IL-2 receptors is basiliximab.

85. The method of any one of claims 82-84, wherein the one or more additional pharmaceutically effective compounds inhibits inosine monophosphate dehydrogenase.

86. The method of claim 85, wherein the compound that inhibits inosine monophosphate dehydrogenase is selected from a mycophenolate mofetil or a mycophenolate sodium.

87. The method of any one of claims 82-86, wherein the one or more additional pharmaceutically effective compounds inhibits binding of TNF-alpha to cell surface TNF receptors.

88. The method of claim 87, wherein the compound that inhibits binding of tumor necrosis factor (TNF)-alpha to cell surface TNF receptors is selected from etanercept or infliximab.

89. The method of any one of claims 63-88, wherein the method further comprises administering a therapeutically effective amount of purified allogenic islet cells.

90. The method of claim 89, wherein the purified allogenic islet cells are human purified allogenic islet cells.

91. The method of any one of claims 63-90, wherein the antibody or antigen binding fragment thereof is administered at least once every 3 weeks following administration of a therapeutically effective amount of purified allogenic islet cells.

92. The method of any one of claims 63-91, wherein the antibody or antigen binding fragment thereof is administered as a maintenance dose at least once every 3 weeks following administration of a therapeutically effective amount of purified allogenic islet cells.

93. The method of any one of claims 63-92, wherein the antibody or antigen binding fragment thereof is administered 3 days, 2 days, or 1 day before administration of a therapeutically effective amount of purified allogenic islet cells.

94. The method of any one of claims 63-93, wherein the antibody or antigen binding fragment thereof is administered the same day of administering a therapeutically effective amount of purified allogenic islet cells.

95. The method of any one of claims 63-94, wherein the antibody or antigen binding fragment thereof is administered one or more of 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days after administration of a therapeutically effective amount of purified allogenic islet cells.

96. The method of any one of claims 63-95, wherein the antibody or antigen binding fragment thereof is administered on days 0, 3, and 7 and every 21 ± 2 days thereafter after administration of a therapeutically effective amount of purified allogenic islet cells.

97. The method of any one of claims 63-96, wherein the antibody or antigen binding fragment thereof is administered for a total of 12 months or for longer than 12 months after administration of a therapeutically effective amount of purified allogenic islet cells.

98. The method of any one of claims 63-97, wherein the antibody or antigen binding fragment thereof is administered parenterally or intravenously.

99. The method of any one of claims 63-98, wherein the antibody or antigen binding fragment thereof is administered by injection or infusion.

100. The method of claim 99, wherein the injection is by one or more of intravenous, intramuscular, or subcutaneous injection.

101. A method of modulating the level or concentration of at least one biomarker in a subject having type 1 diabetes, the method comprising administering to the subject a therapeutically effective amount of an antibody or antigen binding fragment thereof that specifically binds CD40 ligand, wherein the subject has been administered purified allogenic islet cells and wherein the biomarkers are selected from the group consisting of HbAlc, c-peptide, and a combination thereof.

102. The method of claim 101, wherein the subject is a human.

103. The method of claim 101 or 102, wherein therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 100 mg/kg.

104. The method of any one of claims 101-103, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 50 mg/kg.

105. The method of any one of claims 101-104, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg to about 20 mg/kg.

106. The method of any one of claims 101-105, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 1 mg/kg, 5 mg/kg, 10 mg/kg, 15 mg/kg, or 20 mg/kg.

107. The method of any one of claims 101-106, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 20 mg/kg.

108. The method of any one of claims 101-106, wherein the therapeutically effective amount of the antibody or antigen binding fragment thereof is about 10 mg/kg.

109. The method of any one of claims 101-108, wherein the antibody or antigen binding fragment thereof i s AT -1501.

110. The method of any one of claims 101-109, wherein the antibody or antigen binding fragment thereof comprises:

(a) a heavy chain variable region (VH) comprising:

(i) a CDR1 domain comprising the sequence set forth in SEQ ID NO: 75;

(ii) a CDR2 domain comprising the sequence set forth in SEQ ID NO: 76; and

(iii) a CDR3 domain comprising the sequence set forth in SEQ ID NO. 77; and

(b) a light chain variable region (VL) comprising:

(i) a CDR1 domain comprising the sequence set forth in SEQ ID NO: 72;

(ii) a CDR2 domain comprising the sequence set forth in SEQ ID NO: 73; and

(iii) a CDR3 domain comprising the sequence set forth in SEQ ID NO: 74.

111. The method of claim 110, wherein the antibody or antigen binding fragment thereof further comprises an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 79.

112. The method of any one of claims 101-109, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 61.

113. The method of any one of claims 101-109, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence set forth in SEQ ID NO: 61.

114. The method of any one of claims 101-109, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 79.

115. The method of any one of claims 101-109, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises a light chain variable region comprising an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 58, the heavy chain comprises a variable heavy chain region and an Fc region, wherein the heavy chain variable region comprises an amino acid sequence having at least 95% sequence identity with SEQ ID NO: 59, and the Fc region comprises the amino acid sequence set forth in SEQ ID NO: 79.

116. The method of any one of claims 101-109, wherein the antibody or antigen binding fragment thereof comprises a light chain and a heavy chain, wherein the light chain comprises the amino acid sequence set forth in SEQ ID NO: 64 and the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66.

117. The method of claim 116, wherein the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66 and an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 61.

118. The method of claim 116, wherein the heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 66 and an Fc region comprising the amino acid sequence set forth in SEQ ID NO: 79.

119. The method of any one of claims 101-118, wherein the type 1 diabetes comprises brittle type 1 diabetes.

120. The method of any one of claims 101-119, wherein the method further comprises administering one or more additional pharmaceutically effective compounds.

121. The method of claim 120, wherein the one or more additional pharmaceutically effective compounds targets T-cells by one or more of clearing T-cells from circulation; or modulating T-cell activation, homing, or cytotoxic activities.

122. The method of claim 121, wherein the compound that targets T-cells is an anti-thymocyte globulin.

123. The method of any one of claims 120-122, wherein the one or more additional pharmaceutically effective compounds inhibits inosine monophosphate dehydrogenase.

124. The method of claim 123, wherein the compound that inhibits inosine monophosphate dehydrogenase is selected from a mycophenolate mofetil or a mycophenolate sodium.

125. The method of any one of claims 120-124, wherein the one or more additional pharmaceutically effective compounds inhibits binding of tumor necrosis factor (TNF)- alpha to cell surface TNF receptors.

126. The method of claim 125, wherein the compound that inhibits binding of tumor necrosis factor (TNF)-alpha to cell surface TNF receptors is selected from etanercept or infliximab.

127. The method of any one of claims 101-126, wherein the method further comprises administering a therapeutically effective amount of purified allogenic islet cells.

128. The method of claim 127, wherein the purified allogenic islet cells are human purified allogenic islet cells.

129. The method of any one of claims 101-128, wherein the antibody or antigen binding fragment thereof is administered at least once every 3 weeks.

130. The method of any one of claims 101-129, wherein the antibody or antigen binding fragment thereof is administered as a maintenance dose at least once every 3 weeks.

131. The method of any one of claims 127-130, wherein the antibody or antigen binding fragment thereof is administered 3 days, 2 days, or 1 day before the islet cells have been administered.

132. The method of any one of claims 127-131, wherein the antibody or antigen binding fragment thereof is administered the same day of administering the islet cells.

133. The method of any one of claims 127-132, wherein the antibody or antigen binding fragment thereof is administered one or more of 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days after administration of the islet cells.

134. The method of any one of claims 127-133, wherein the antibody or antigen binding fragment thereof is administered on days -2, 0, 1, 3, 7, 14, 21, and 28 and every 21 ± 2 days thereafter after administration of the islet cells.

135. The method of any one of claims 127-134, wherein the antibody or antigen binding fragment thereof is administered for a total of 12 months or for longer than 12 months after administration of the islet cells.

136. The method of any one of claims 101-135, wherein the antibody or antigen binding fragment thereof is administered parenterally or intravenously.

137. The method of any one of claims 101-136, wherein the antibody or antigen binding fragment thereof is administered by injection or infusion.

138. The method of claim 137, wherein the injection is one or more of intravenous, intramuscular, or subcutaneous injection.

139. The method of any one of claims 101-138, wherein the level or concentration of the at least one biomarker decreases following administration of the antibody or antigen binding fragment thereof.

140. The method of any one of claims 101-138, wherein the level or concentration of the at least one biomarker increases following administration of the antibody or antigen binding fragment thereof.

141. The method of any one of claims 101-139, wherein the level or concentration of the HbAlc biomarker is < 7% (53 mmol/mol) following administration of the antibody or antigen binding fragment thereof.

142. The method of any one of claims 101-139, wherein the level or concentration of the HbAlc biomarker is < 6.5% (48 mmol/mol) following administration of the antibody or antigen binding fragment thereof.

143. The method of any one of claims 101-139, wherein the level or concentration of the HbAlc biomarker is < 5.7% following administration of the antibody or antigen binding fragment thereof.

144. The method of any one of claims 101-138 or 140, wherein the level or concentration of the c-peptide biomarker is > 0.3 ng/mL following administration of the antibody or antigen binding fragment thereof.

145. The method of any one of claims 1-144, wherein the subject is insulin-independent following administration of the antibody or antigen binding fragment thereof.

146. The method of any one of claims 1-145, wherein the subject has a reduced number of or no serious hypoglycemic events following administration of the antibody or antigen binding fragment thereof.

147. The method of any one of claims 1-146, wherein the subject has a concentration of HbAlc < 7% following administration of the antibody or antigen binding fragment thereof.

148. The method of any one of claims 1-147, wherein the subject has a baseline HbAlc level of about 7.0% (48 mmol/mol) to about 9.5% (80 mmol/mol).

149. The method of any one of claims 1-148, wherein the subject has a concentration of c- peptide > 0.3 ng/mL following administration of the antibody or antigen binding fragment thereof.

150. The method of any one of claims 1-149, wherein the subject has an absence of stimulated c-peptide (< 0.3 ng/mL) in response to a 240-minute mixed-meal tolerance test (MMTT).

151. The method of any one of claims 1-150, wherein the subject has a body mass index (BMI) of < 30 kg/m².

152. The method of any one of claims 1-151, wherein the subject has been diagnosed with type 1 diabetes for > 5 years and/or has onset of disease at < 40 years of age.

153. The method of any one of claims 1-152, wherein the antibody or antigen binding fragment thereof is formulated in a pharmaceutical composition comprising a pharmaceutically acceptable carrier.