Precision Medicine in Surgery

Abstract

Objective:

This article presents a methodological framework for studying the effects of lacritin peptide on β-cell proliferation, islet viability, and immune modulation using a combination of in vitro and in vivo models.

Background:

Immunologic and inflammatory diseases, including autoimmune disorders and organ-specific injuries, present significant therapeutic challenges owing to persistent inflammation and limited tissue regeneration. Therapies that combine immunomodulation and cellular regeneration may address this need in conditions such as Crohn disease, heart failure, pulmonary fibrosis, chronic kidney disease, and neurological injuries. ‘Lacritin’ displays both immunomodulatory and regenerative activities, and is significantly deficient in T1 diabetics

Methods:

Pancreatic islet in vitro testing, mass cytometry, imaging mass cytometry, and single-cell RNA sequencing to assess immune cell interactions. In addition, in vivo transplantation of lacritin peptide-treated islets into diabetic mouse recipients and immunologic studies in the nonobese diabetic mouse model support the preclinical evaluation of lacritin in its therapeutic potential.

Results:

In this article, we discuss the increasing need for precision medicine for immunologic and surgical diseases. Within our experimental framework, we generate valuable insights into immune cell behavior, tissue architecture, and regenerative dynamics with lacritin intervention at the preclinical stage.

Conclusions:

Through this study, we aimed to facilitate further investigations into future precision medicine strategies, including lacritin peptide and other peptide-based therapeutics for immunologic and surgical diseases.

The relationship between dysregulated immune systems, chronic inflammation, and the associated limited regenerative capacity of affected tissues remains poorly understood.¹ A diverse range of diseases are covered by these conditions, including autoimmune disorders such as type 1 diabetes (T1D), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), scleroderma, ulcerative colitis (UC), Crohn disease, Sjögren’s syndrome dry eye (DED) disease, and systemic inflammatory responses such as septicemia, systemic inflammatory response syndrome (SIRS), and sepsis syndrome. These autoimmune and inflammatory diseases lead to the progressive destruction of functional tissues, organ failure, and a significant decline in quality of life.

Traditional therapeutic strategies for autoimmune and inflammatory diseases primarily focus on mitigating immune hyperactivation and suppressing inflammation through immunosuppressive drugs, biologicals, or targeted cytokine inhibitors. However, these treatments often fail to reverse the tissue damage or loss of function. Long-term immune suppression increases the risk of opportunistic infections, development of malignancies, and long-term organ dysfunction.² Given these limitations, a focus on precision medicine is required. This concept is driven by the identification of predictive immune biomarkers for early intervention, involving immune modulation and cellular regeneration that together are preventive and reparative.

This article is intended to serve as a conceptual roadmap to outline emerging precision medicine strategies, mechanistic tools, and translational frameworks to guide research in immune and surgical diseases.

AUTOIMMUNE DISEASES SHARE COMMON IMMUNOPATHOGENIC MECHANISMS

Despite clinical heterogeneity, autoimmune diseases often share immunopathogenic mechanisms (Fig. 1A). Abnormal immune disturbances cause the immune systems to mistakenly recognize self-tissues as foreign and react to the normal constituents of the host.³ Both innate and adaptive immune responses lead to chronic inflammation, tissue destruction, and impaired regeneration in multiple diseases. Genetic dispositions, within the human leukocyte antigen complex, are significant contributors to various autoimmune conditions.⁴ Beyond genetics, molecular pathways, such as lysosomal function and Fc gamma receptor-mediated phagocytosis play key roles in different autoimmune diseases, suggesting that impaired antigen processing and presentation are central to their pathogenesis.^3,5 In addition, shared environmental triggers, such as viral infections (Fig. 1A), can exacerbate the onset of various autoimmune diseases by promoting molecular mimicry, a process in which the immune system mistakenly attacks host tissues owing to similarities with viral antigens.⁵

FIGURE 1.

A, Common immunopathogenic mechanisms across autoimmune diseases. Created with BioRender.com. B, Common disease progression of autoimmune diseases, with a focus on type 1 diabetes (T1D, red color), rheumatoid arthritis (RA, green color), and systemic lupus erythematosus (SLE, black color).

Autoimmune diseases such as T1D, RA, and SLE differ in clinical presentation, but display overlapping patterns of immune dysregulation (Fig. 1B). In T1D, significant β-cell loss leads to insulin deficiency. RA involves persistent joint inflammation, resulting in cartilage and bone erosion. SLE is a complex immune disorder that affects multiple organs. The progression of these diseases follows a shared pattern marked by chronic inflammation, immune-mediated tissue damage, and functional decline across multiple organ systems (Fig. 1B). Persistent activation of autoreactive T cells, dysregulated B-cell responses, and excessive production of pro-inflammatory cytokines such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) drive sustained inflammation and progressive tissue damage under these conditions.^6–8 Beyond systemic autoimmune diseases, localized conditions such as DED also share key immune pathways with systemic autoimmune diseases such as T1D and RA, in which the immune system mistakenly attacks exocrine glands, leading to reduced tear production, persistent damage to the ocular surface, and impaired vision.⁹

IMMUNE DYSREGULATION ACROSS AUTOIMMUNE, INFLAMMATORY, AND SYSTEMIC DISEASES

In addition to autoimmune diseases, diseases such as scleroderma and other systemic fibrotic diseases highlight the connection between immune dysfunction and fibrosis.¹⁰ Chronic immune activation triggers excessive extracellular matrix deposition, which results in tissue stiffening, impaired function, and ultimately irreversible organ damage.¹¹ Similarly, chronic immune dysregulation causes gastrointestinal inflammatory diseases, including UC and Crohn disease. Persistent gut inflammation damages the intestinal mucosal barrier, impairs nutrient absorption, and leads to systemic health complications.¹² The interaction between the immune system and the gut microbiome is a key factor that exacerbates inflammation, weakens immune tolerance, and triggers autoimmune responses.¹³

In systemic inflammatory conditions such as septicemia, SIRS, and sepsis syndrome, immune system dysregulation results in widespread tissue damage and multiorgan failure.¹⁴ Although these acute immune responses differ from chronic autoimmunity in their triggers and progression, they often involve overlapping inflammatory signaling pathways such as IL-6 and NF-κB.¹⁵ These intersections offer opportunities for precision-targeted interventions without implying mechanistic unification. These conditions often arise as complications from infections, trauma, or surgical interventions and are characterized by an excessive release of inflammatory cytokines, a phenomenon known as cytokine storm.¹⁵ One of the most severe consequences of systemic inflammation is acute kidney injury (AKI), which results from immune-mediated damage to the renal endothelial cells, tubular injury, and impaired renal perfusion. AKI is associated with high morbidity and mortality rates in critically ill patients. Targeting the immune responses that drive AKI could help prevent multiorgan dysfunction and significantly improve survival outcomes.¹⁶ Systemic inflammatory conditions can also appear after major surgical procedures, particularly in high-risk interventions such as cardiac surgery.^14,17 In these cases, postoperative immune dysregulation shares similar immune patterns observed in sepsis and SIRS, often resulting in complications, such as delayed wound healing, increased infection risk, and prolonged recovery periods. Immunomodulation after surgery is necessary to reduce complications and facilitate tissue regeneration, which can accelerate healing and improve the postoperative outcomes.¹⁷

The complexity and heterogeneity of autoimmune, inflammatory, and systemic diseases demand effective treatment strategies other than suppressing dysregulated immune responses. Although shared signaling nodes exist, we do not suggest a one-size-fits-all solution. Instead, we propose precision-targeted strategies that adapt to individual immunologic profiles and disease contexts. As immune responses vary widely from person to person, conventional treatments often lead to inconsistent results and unpredictable disease progression. Hence, there is an urgent need for precise treatment strategies that consider the individual immunologic profiles and regenerative potential for efficient disease intervention.

IMMUNODIAGNOSTICS AND ADVANCED ANALYTICAL TOOLS

Immunodiagnostics have been well recognized as a revolutionary approach for managing autoimmune and inflammatory diseases by predicting immune system activities in response to therapeutic interventions, disease progression, or external triggers.¹⁸ Predicting immune responses is essential for diseases such as T1D, RA, SLE, and Crohn disease, as it can guide early diagnosis, monitor therapeutic response, and stratify patient risk based on immunologic signatures.¹⁸ Taking advantage of advanced analytical technologies to identify key biomarkers (Table 1), immunodiagnostics can optimize treatment strategies, enhance therapeutic efficacy, and minimize side effects through precision medicine.

TABLE 1.

Immunodiagnostics and Disease Biomarkers

Disease	Predictive biomarkers
Type 1 diabetes (T1D)	GAD65, IA-2, ZnT8 autoantibodies; HLA-DR3/DR4-DQ819,20
Systemic lupus erythematosus (SLE)	Anti-dsDNA, anti-Sm, IFN gene signature8,21
Rheumatoid arthritis (RA)	RF, anti-CCP, HLA-DRB11,22
Celiac disease	Anti-TTG, anti-EMA, HLA-DQ2/DQ81,4
Multiple sclerosis (MS)	Oligoclonal bands, HLA-DRB1*15:01, anti-MOG3,4
Inflammatory bowel disease (IBD)	ASCA, pANCA12,23
Crohn disease	NOD212
Autoimmune thyroid disease	Anti-TPO, anti-thyroglobulin1,4
Sepsis	Procalcitonin, IL-6, sTREM-1, presepsin15,16
Acute kidney injury (AKI)	Neutrophil gelatinase-associated lipocalin (NGAL), KIM-1, cystatin C16
Systemic inflammatory response syndrome (SIRS)	Cytokines (IL-6, TNF-α, IL-1β), CRP, procalcitonin15,18

This table summarizes the current predictive biomarkers used for the clinical diagnosis of autoimmune, inflammatory, and surgical diseases. These immunodiagnostic biomarkers play key roles in supporting early diagnosis, risk stratification, and medical interventions.

Anti-dsDNA indicates anti-double-stranded DNA; CRP, C-reactive protein; HLA, human leukocyte antigen.

The key to immunodiagnostics is the identification of biomarkers that reflect the functionality of immune system. These biomarkers provide informative insights into disease onset, severity, and progression. For instance, cytokine profiles such as elevated levels of IL-6 and TNF-α are associated with increased inflammation in RA and Crohn disease.^7,8,22,24. Similarly, autoantibodies like anti-double-stranded DNA (anti-dsDNA) in SLE correlate with disease activity and organ damage.²¹ These predictive markers enable the tailoring of early-stage preventive interventions before irreversible tissue destruction occurs.

Recent advances in high-resolution analytical tools have significantly enhanced immunodiagnostics by providing a deeper understanding of immune responses. Advances in analytical tools such as single-cell RNA sequencing (scRNAseq), mass cytometry (CyTOF), and imaging mass cytometry (IMC) offer high-dimensional analyses of gene expression and protein markers at the single-cell level, while preserving the complexity of tissue’s spatial context.^23,25–27 These technologies can be used to identify genetic predispositions and mutations that may affect immune function, leading to autoimmune diseases. Proteomic profiling tools, such as mass spectrometry (MS/MS) and SOMAscan, reveal disease-specific protein and metabolite signatures that could potentially be used as biomarkers for early diagnosis and therapeutic targeting.²⁸

Advanced analytical tools and proteomic profiling tools also prevent post-surgical immune responses by enabling real-time monitoring and prediction of immune system activities. These technologies are useful in identifying high-risk patients for postoperative complications, such as SIRS, sepsis, or AKI, allowing for the intervention of precision medicine for personalized strategies to mitigate excessive immune activation.

USING T1D MODELS TO STUDY PRECISION MEDICINE FOR IMMUNOMODULATORY AND REGENERATIVE THERAPIES

To effectively study immunomodulatory and regenerative therapies for autoimmune and inflammatory diseases, it is crucial to select models that accurately capture the complexity of disease processes. T1D is a robust and well-characterized autoimmune disease. T1D research explores both autoimmune-mediated tissue destruction and immune dysregulation that could serve as a platform beyond diabetes, for broader applications in immunologic, inflammatory, and surgical diseases.

T1D is a prototypical autoimmune disease in which autoreactive T cells specifically target and destroy pancreatic β cells.²⁹ This dysregulated immune response results in insulin deficiency and metabolic dysfunction.²⁹ T-cell dysregulation, chronic inflammation, and impaired immune tolerance are common in other autoimmune diseases, including multiple sclerosis (MS), RA, and SLE⁶ (Fig. 1B). Progressive tissue damage driven by autoimmunity in these diseases often similarly results in permanent functional impairments. Therefore, T1D serves as an ideal model for investigating autoimmune treatment strategies that may be translatable to other autoimmune and inflammatory diseases.

Beyond T1D, which serves as an autoimmune disease model, islet transplantation offers a clinical framework for studying transplantation and surgical immunology. Similar to other organ transplants, islet transplantation faces significant challenges, including immune rejection, inflammation-related graft loss, and ischemic reperfusion injury.²⁹ These challenges mirror those in other transplant settings, such as kidney, liver, and stem cell-derived tissues, where immune activity induced destruction significantly challenges to long-term graft survival. Islet transplantation models can thus be used to explore how immune modulation strategies can potentially improve transplant survival, reduce rejection rates, and promote the functional integration of transplanted tissues across multiple organ systems.³⁰

Advanced analytical tools, including scRNAseq, CyTOF, and IMC, provide advantages in T1D research by obtaining high-resolution spatial and molecular data on immune cell populations, β-cell function, and regenerative processes.³¹ These tools with the T1D model allow for a deeper understanding of immune cell infiltration, inflammatory signaling pathways, and tissue repair mechanisms in response to immune modulation and cell regeneration across various therapies. Beyond studying autoimmunity and transplant rejection, T1D and its associated models also provide valuable insights into post-surgical immune responses. T1D models, particularly those involving islet transplantation, evaluate immunomodulating strategies that modulate post-surgical immune responses, improve wound healing, and reduce the risk of other post-surgical complications. This understanding could also be applied to other chronic conditions where immune dysregulation and impaired tissue repair contribute to disease progression, such as chronic kidney disease and fibrotic disorders.

AN EXAMPLE OF CONNECTIONS IN AUTOIMMUNE DISEASE: THE MECHANISMS AND THERAPEUTIC IMPLICATIONS BETWEEN SJÖGREN’S SYNDROME DRY EYE DISEASE AND TYPE 1 DIABETES

An example in our study is based on the shared mechanisms and therapeutic connections between DED and T1D (Fig. 2). Although the 2 diseases affect distinct tissues and manifest as different clinical conditions, they share similar underlying immune mechanisms. Both autoimmune diseases involve improper targeting of self-tissue by the immune system, resulting in immune-mediated cell destruction and functional impairment.³²

FIGURE 2.

Connections between Sjögren’s syndrome dry eye disease and type 1 diabetes. The illustrative schematic illustrates the shared mechanisms and therapeutic implications of DED and T1D. In brief, both diseases share key autoimmune features and impaired tissue regeneration. Blue (immune dysfunction): activation of T-helper (Th1, Th17) cells, infiltration of CD4⁺ and CD8⁺ T cells, regulatory T-cell (Treg) dysfunction, and B-cell hyperactivity contribute to sustained autoimmunity; orange (chronic inflammation): elevated levels of pro-inflammatory cytokines (IL-6, IL-17, and TNF-α) drive persistent inflammation, leading to progressive tissue destruction in both organs; and green (regeneration inhibition): The inflammatory microenvironment suppresses lacrimal gland progenitor cells and pancreatic β-cell regeneration, exacerbating disease progression. Created with BioRender.com.

Both diseases are driven by the chronic activation of autoimmunity, involving T-helper (Th1 and Th17) cells and B cells (Fig. 2). In DED, autoimmunity-driven T cells infiltrate the lacrimal glands, leading to chronic inflammation, diminished tear production, and progressive damage to the ocular surface.³³ This results in glandular dysfunction, fibrosis, and the loss of tissue regenerative potential. The autoreactive T-helper cells secrete pro-inflammatory cytokines such as IL-6, interleukin-17 (IL-17), and TNF-α, leading to sustained local inflammation and progressive dysfunction of the lacrimal glands.^9,34 Similarly, in T1D, autoreactive CD4+ and CD8+ T cells infiltrate the pancreatic islets and specifically target insulin-producing β-cells, which are critical for glucose homeostasis.¹⁹ Pro-inflammatory cytokines such as IL-6, IL-17, and TNF are associated with chronic immune responses leading to β-cell destruction, insulin deficiency, and metabolic complications.³⁵ Another shared feature of both diseases is regulatory T-cell (Treg) dysfunction (Fig. 2), which leads to unpredictable immune activation caused by failure to suppress autoreactive T cells.^34,36 This dysfunction leads to chronic inflammation and irreversible tissue destruction in both the lacrimal glands and pancreatic islets. B-cell hyperactivity also contributes to the autoimmune process in both conditions.^20,37 In DED, B cells produce autoantibodies, such as anti-Ro/SSA and anti-La/SSB, which contribute to glandular destruction and systemic complications.³⁸ Similarly, in T1D, hyperactivated B cells produced autoantibodies targeting glutamic acid decarboxylase (GAD65) and insulinoma-associated antigen-2 (IA-2) recognize GAD65 and IA-2 as “foreign” antigens, which contribute to β-cell destruction and disease progression.²⁰

In addition to immune dysregulation, both diseases share a notable deficiency in cellular regeneration capacity (Fig. 2). In DED, inflammation disrupts the lacrimal gland progenitor cell niche, leading to impaired glandular repair and eventual fibrosis. Over time, this results in glandular atrophy and permanent reduction in tear production.³⁹ Similarly, in T1D, chronic inflammation inhibits β-cell proliferation and regeneration, leading to progressive decline in pancreatic function.⁴⁰ Both diseases are further connected by inflammatory microenvironment activities, which also contribute to the inhibition of regeneration. The increased levels of IL-1β, IFN-γ, and TNF-α not only promote immune-mediated tissue destruction but also result in local tissue disruption, reducing the ability of both lacrimal gland and pancreatic β-cells to regenerate.^39–41

Given these shared mechanisms, there is a strong rationale for therapeutic strategies that simultaneously target immune modulation and promote regeneration with a cross-disease capacity. An especially promising approach involves leveraging therapies that were originally developed for dry eye disease to treat T1D. For example, lacritin, a glycoprotein initially studied for its regenerative properties in DED,^42,43 may reduce inflammation and protect pancreatic β cells from immune-mediated destruction, thereby benefiting β-cell regeneration.

POTENTIAL OF LACRITIN AS A PRECISION MEDICINE IN IMMUNOMODULATION AND REGENERATIVE THERAPIES

With the increasing recognition of shared immunopathogenic mechanisms across autoimmune diseases, therapies that integrate immune modulation and tissue regeneration should be strong candidates for advance treatments, such as precision medicine. One strong candidate is lacritin. Lacritin is a naturally occurring glycoprotein, identified as a novel secretion-enhancing factor in the human lacrimal gland.^44,45 Lacritin was initially studied for its rescue of human corneal epithelial cells from inflammatory cytokine-induced death, thereby supporting epithelial homeostasis.^46,47 Lacritin synthetic derivate peptides were then developed and tested in clinical settings to reduce the symptoms of dry eye disease and restore corneal health.^48,49 Lacritin and its synthetic peptides have the potential to extend beyond ocular application. It may have therapeutic effects in various systemic autoimmune diseases.

Although lacritin was initially characterized as an epithelial-specific secreted protein—primarily from lacrimal and salivary glands—recent updates from the UniProt database (UniProt, 2024) have confirmed its presence in human blood plasma, an observation also made by us. Lacritin may be delivered to pancreatic and other tissue through the bloodstream. This supports its circulatory and systemic potential, beyond local epithelial compartments.

Lacritin’s downstream signaling has been shown to involve autophagy activation⁴⁷ and engagement of the NFAT and mTOR pathways,^42,43 which are critically involved in T-cell metabolism, function, and survival. As an agonist of both NFAT and mTOR, lacritin bridges immune modulation and surgical applications, including transplantation and the prevention of associated complications. By transiently enhancing autophagy, lacritin helps clear proteins and organelles damaged by inflammatory stress and supports the restoration of oxidative phosphorylation.⁴⁷ These effects may contribute to re-establishing tissue homeostasis, including the promotion of nerve regeneration.

Taking advantage of lacritin and the shared features and mechanisms across autoimmune, inflammatory, and systemic diseases (Fig. 2), our team explored the possibility of using lacritin as a precision medicine for autoimmune diseases such as T1D. Our study found that circulating lacritin levels were inversely correlated with T1D severity. Moreover, our team found that lacritin peptide is therapeutically beneficial for T1D treatment and prevention across various mouse models in both immunomodulation and β-cell regeneration (Fig. 3). These findings expand the potential for exploring lacritin-based therapies for a broader array of autoimmune and inflammatory diseases, particularly those characterized by chronic immune activation and impaired tissue repair.

FIGURE 3.

Experimental framework for lacritin’s evaluation in type 1 diabetes study. This schematic illustrates the experimental workflow for evaluating the benefits of lacritin in T1D, using in vivo and in vitro models. The framework includes immunodiagnostic tools (mass spectrometry, SomaScan), in vivo islet transplantation, NOD mouse models to assess immunopathogenic mechanisms, and in vitro experimental tests using mouse and human islet models. High-resolution spatial analysis techniques, including single-cell RNA sequencing (scRNAseq), imaging mass cytometry (IMC), and mass cytometry (CyTOF), have been used to investigate the immunomodulatory effects. Created with BioRender.com.

In this article, to fully explore the potential of lacritin, an experimental framework (Fig. 3) utilizing advanced immunodiagnostic tools and high-resolution analytical technologies is essential. Techniques such as scRNAseq, CyTOF, and IMC offer valuable insights into immune cell behavior, tissue architecture, and regenerative dynamics. We hope to use our experimental framework for T1D lacritin study to serve as a comprehensive experimental guide, including step-by-step workflows visualized through BioRender figures, to enhance reproducibility and accessibility (Fig. 3). Here, we outline the best practices for immunomodulatory and regenerative lacritin studies. This methodological resource aims to facilitate further investigations into lacritin peptide and other peptide-based therapeutics for autoimmune and inflammatory diseases.

PROTEOMIC DISCOVERY OF BIOMARKERS AND RISK FACTORS FOR T1D: A PRECISION MEDICINE APPROACH

Precision medicine relies on the identification of disease-specific biomarkers to facilitate early detection, risk stratification, and targeted treatment.⁵⁰ In the context of T1D, proteomic analyses have been used to identify circulating proteins that exhibit significant alterations in individuals with T1D compared with their healthy counterparts. This approach provides valuable insights into the molecular basis of disease progression and design of therapeutic strategies that target both immune modulation and cellular regeneration.

Multiple proteomic techniques have been utilized to validate precision medicine strategies for T1D, with the aim of achieving comprehensive protein profiling and biomarkers discovery. Mass spectrometry (MS)-based proteomics, including liquid chromatography-tandem mass spectrometry (LC-MS/MS), provides a broad survey of differentially expressed proteins.²⁸ Complementary SomaScan proteomic assays, using slow off-rate modified aptamers (SOMAmers), allow for high-throughput detection of low-abundance proteins that might not be easily captured by traditional MS techniques.²⁸ These methodologies enabled unbiased identification of circulating biomarkers, revealing proteins with significant expression changes associated with T1D pathology.

DISCUSSION

The rapid evolution of precision medicine calls for research strategies that go beyond the conventional therapeutic developments. Integrating biomarker discovery, advanced analytical technologies, and targeted experimental designs is essential for refining disease models and driving therapeutic innovation.^18,25 By combining high-throughput proteomics, advanced analytical tools, functional assays, and in vitro and in vivo disease models, we demonstrated the power of technology-driven methodologies in identifying and validating potential precision medicine.

A key focus of this study was the application of immunodiagnostics and advanced analytical tools to identify disease-relevant biomarkers. With advanced proteomics including MS and SOMAscan, we captured a broad spectrum of proteins, from high-abundance markers to low-expression regulators, implicated in disease progression. This biomarker discovery process directs the identification of precision medicine candidates, allowing the identification of key molecular alterations that drive disease pathology. Validating candidates through independent assays reinforces their relevance and establishes a foundation for functional studies. Another major takeaway from this study is the potential of biomarker-driven therapies to transform precision surgical interventions. Our findings, which identify lacritin as a key protein downregulated in T1D, underscore how biomarker discovery can guide personalized treatment strategies discovery. We recognize the potential need for further mechanistic studies on local production of lacritin and immune interactions other than the bloodstream lacritin delivery system. In a surgical setting, a similar approach could be used to stratify patient risk, predict responses to intervention, and tailor postoperative management. When integrated with precision therapeutic interventions, pre-surgical biomarker profiling has the potential to enhance surgical outcomes, particularly for transplant recipients and patients undergoing procedures for autoimmune-related complications. As the field advances, proteomic, transcriptomic, and metabolomic technologies will continue to refine predictive and adaptive treatment strategies, ensuring that patients receive highly individualized care. This structured approach is not limited to T1D but is widely applicable to diseases characterized by immune dysregulation and tissue degeneration.

We recognize that immune disorders vary widely in their underlying mechanisms and clinical presentation. Our intention is not to suggest a single pathway can explain or treat all forms of immune dysfunction. Instead, we aim to point out that certain signaling pathways, such as IL-6, NF-κB, and mTOR, are recurrently involved across different conditions. Understanding these points of overlap can help guide more focused and context-specific therapies. This perspective does not oversimplify complex diseases but encourages a thoughtful approach to identifying shared mechanisms that may be targeted with precision. Lacritin serves as one example of a therapeutic candidate that interacts with these shared pathways, and its use must be tailored to the specific immune environment and disease context.

A defining feature of this study was the integration of high-dimensional immunoprofiling techniques, including CyTOF and scRNAseq. These technologies provide a detailed map of cellular responses at single-cell resolution, capturing the dynamic shifts in immune populations and their functional states. By using CyTOF, we were able to analyze complex immune interactions within disease-affected tissues, whereas scRNAseq provided transcriptional insights into the molecular mechanisms driving disease progression. The use of spatial imaging techniques, such as IMC, further enhances the impact of this study by preserving the tissue architecture while allowing for multiparameter profiling. This approach is particularly relevant to autoimmune diseases, where the spatial distribution of immune cells and tissue remodeling influence disease progression. These tools are critical for precision medicine, as they allow for the identification of patient-specific immune signatures and guide the development of targeted immunotherapies. The application of these methodologies in preclinical research strengthens the translational potential of novel therapies, offering a deeper understanding of how candidate molecules regulate immune and cellular pathways, which can be translated from preclinical to clinical applications. In the current framework, lacritin seems to serve a dual role. It functions as a marker of epithelial and immune stress, indicated by its reduced levels in disease, and also acts as an active modulator of immune and metabolic dysfunction when restored. In this way, it may respond to inflammation while also contributing to the rebalancing of immune responses. We do not believe that lacritin promotes indiscriminate regeneration. Rather, its effect seems to be selective and context-dependent.

Beyond T1D, this study provides a framework for managing immune dysfunction in surgical and post-surgical settings. Excessive immune activation is a frequent cause of many post-surgical complications, mirroring the immune-driven tissue destruction observed in T1D. Conditions such as AKI after major surgery and SIRS after trauma or infection share key immunopathogenic mechanisms with autoimmune diseases.^14,16 Our findings suggest that targeted immune recalibration, modeled after lacritin’s role in immune tolerance, could offer a novel strategy to mitigate post-surgical inflammation while preserving protective immune function. This approach has broad implications for improving patient outcomes in high-risk surgical procedures, where immune dysregulation plays a significant role in postoperative complications. Beyond just technological advancements, this study highlights the importance of strategic experimental design in precision medicine research. Careful selection of therapeutic windows, whether through early intervention or late-stage administration, provides critical insights into identifying the optimal timing for therapeutic efficacy. In addition, the inclusion of multiple control groups (eg, untreated, vehicle-treated, and scrambled peptide-treated conditions) ensured that the observed treatment effects were specific and not influenced by external variables. These considerations emphasize a key aspect of precision medicine: experimental models must be designed to accurately mimic clinical scenarios and account for inter-individual variability.

This study presents a transformative model for precision medicine in surgical care that integrates immune modulation, cellular regeneration, and biomarker-driven therapeutic strategies. With personalized, biomarker-guided immune and regenerative therapies, this research paves the way for innovative treatment paradigms that can enhance surgical recovery, extend transplant longevity, and improve outcomes for patients with autoimmune-related surgical complications. Ultimately, lacritin-based therapy in T1D offers broader insight into the systematic application of precision medicine to bridge the gap between immunology, regenerative medicine, and surgical innovation.

In conclusion, this study highlights the increasing need for precision medicine in immunologic and surgical diseases. Within our experimental framework, we integrated advanced immunodiagnostic tools, high-resolution analytical technologies, and well-designed in vitro and in vivo models to generate valuable insights into immune cell behavior, tissue architecture, and regenerative dynamics with lacritin intervention at the preclinical stage. Through this study, we aimed to facilitate further investigations into future precision medicine strategies, including lacritin peptide and other peptide-based therapeutics for immunologic and surgical diseases.

DISCUSSANT

Dr. Jean C. Emond (New York, NY)

I’m honored to have the opportunity to comment on the paper, and I have no disclosures other than I had to spend about 6 weeks in the library to fully appreciate this complex work.

I thank Dr Brayman and his colleagues for the chance to review the presentation and the manuscript in advance.

This is clearly just a small part of a comprehensive research program centered on applying precision medicine and advanced mechanistic tools to characterize immune dysregulation in autoimmunity in general and in type 1 diabetes in particular, including application to islet cell transplant.

The authors have sought to characterize events in type 1 diabetes in all phases of the disease, as you saw, from the pre-diabetic phase before the widespread loss of beta cells through the hyperglycemic phase and on to the chronic phase associated with the failure of beta cell regeneration.

The novelty here is the transdisciplinary recognition of the relevance of lacritin, a glycoprotein. A Google search reveals nothing about diabetes, only references related to ocular disease. Lacritin is deficient in people with dry eye disease, a condition characterized by immune dysregulation and dysfunction of lacrimal duct cells leading to corneal inflammation.

Nonetheless, the compelling information that was presented here shows that there could well be global parallels in the pathophysiology.

So, the authors demonstrated that lacritin is deficient in established type 1 diabetes in preclinical and human models and that restoration by lacritin analogs can restore homeostasis and ameliorate type 1 through attenuation of autoreactive T cells and regulation of B-cell responses, as well as reduction in pro-inflammatory cytokines.

In conclusion, the authors advocate for a broad application of these advanced analytic techniques in approaches to all diseases or certainly surgical diseases.

So, I have 3 questions, the first of which is complicated. Lacritin protects corneal inflammation and is deficient in type 1 diabetes. But I couldn’t tell from your paper or the literature if it is known what cells produce lacritin in the pancreas and how they interact with the immune environment. How does lacritin interact with T cells and B cells in its protective role? I wondered whether lacritin was a chicken or an egg in this story.

Second, speaking of regeneration, hepatocytes are the best example of the capacity of mammalian cells to regenerate. Are you suggesting that lacritin can make any cell regenerate? Because I always imagine that beta cells were not good at regeneration.

Third, in the background discussion of the paper, you suggest that chronic disorders of adaptive immunity, such as auto reactivity, and acute disorders associated with innate immunity might have a single pathway to address. Is that realistic?

Thank you for the chance to learn and comment.

Response by Kenneth L. Brayman

Thank you for your insightful questions. We don’t know for sure what cells make lacritin, but obviously we’re trying to identify that. We know what lacritin binds to, what some of the immunologic pathways are.

But the effects of lacritin are protean. It has effects both on the target tissue and on the immune system. So, whether there’s some direct binding of lacritin to some cells that could favor the development of regulatory T cells is certainly out there and under investigation through some new collaborations.

Hepatocytes are a great example of regeneration. I think there’s a lot that is unknown about hepatocyte regeneration after liver resection. And trying to figure out the chicken-and-egg phenomenon with lacritin may be useful in the hepatocyte model because there may be multiple mechanisms responsible for regeneration.

But if you take the example of an individual who has the development of chronic liver disease that you can identify before the liver is cirrhotic and fibrotic, then perhaps intervene to favor regeneration and halt the ongoing immune attack.

The problem with many of the autoimmune diseases, autoimmune hepatitis and other diseases is that you could favor regeneration, but you’re not doing anything about immunomodulating the underlying disease.

What’s very exciting about this compound is the simultaneous effect on immunomodulation and regeneration. Whether it’s an epiphenomenon or not remains to be determined, but I think trying to define peptides like this that could be applied prospectively in certain diseases may be useful in preventing fibrosis, which is a common final pathway for renal failure and for liver failure and, in some measure, heart failure.

So those are all good questions. The chronic disorders of adaptive immunity are becoming more and more of a focus for several underlying diseases—Crohn disease, ulcerative colitis and so forth. Wouldn’t it be great if we could treat Crohn in a way that would prevent the development of progression and the need for surgery?

I think this falls within the realm of possibility for several diseases, and it requires special focus to tease it out. Thank you for your questions.

Dr. Rifat Latifi (Tucson, AZ)

Thank you very much. I congratulate the authors on this outstanding study and excellent presentation. I had to go to the library to learn more about this. Thank you for the opportunity to do that.

Your exploration of lacritin N-104’s role in enhancing beta cell regeneration and modulating immune responses offers, in my opinion, exciting insight into precision medicine and surgical applications.

This innovative dual-action approach has the potential to transform treatment strategies not only for diabetes, but for other immunologic and inflammatory conditions, unless I’m reading too much into this, but I don’t think I am.

I have 3 questions. One, given the promising results observed on PEG 104 in regenerative and immunomodulating functions, what are the next steps in the clinical development of this peptide for broader application beyond diabetes, type 1 diabetes?

Two, how do you envision integrating the finding of this study into exciting treatment and protocols of chronic autoimmune conditions—and you alluded to that in your last discussion—particularly in relation to surgical interventions?

And finally, is there a potential of this protein in addressing other immunosenescence cells and perhaps inflammaging that we are all going through right now? Thank you.

Response by Kenneth L. Brayman

Thank you. Those are great questions. I know you’ve had an interest in regeneration in a variety of different diseases, so I appreciated your questions.

The N-104s are merely one analog that we worked with, but using very sophisticated structural analyses, we have about 12,000 other potential compounds. One of our foci in the lab is to try to find and develop some assays where we can screen the top 200 candidates to see if there’s organ-specific or autoimmune disease-specific peptides in the lacritin family that could function more effectively.

So, we have a lot of work ahead of us. I think we’re applying for grant funding to try to figure out other potential useful compounds in that family. And we need to develop assays and bioassays so that we can have read-outs to figure out which are more effective.

I’ve been really intrigued by this diminution in circulating lacritin levels with aging. I wouldn’t say it’s a fountain of youth yet, but wouldn’t it be interesting if a family of peptides was identified that falls with aging that could potentially be replaced to prevent the typical development of immune senescence, susceptibility to cancers, fibrosis, and so forth? Those are some of the big-picture issues, which you insightfully touched on.

I missed your second question, but I hope that I answered the other 2.

Dr. Rifat Latifi (Tucson, AZ)

I think you addressed it.

Response by Kenneth L. Brayman

Okay, thank you.

Dr. Hasan Alam (Chicago, IL)

Very intriguing data. I have a comment and a simple question about your human data.

You showed that lacritin levels go down with age, and for every age bracket the levels are lower in diabetic individuals. What I noticed was that your confidence intervals are rather wide, and that tells me that the linkage may not be very tight.

You could easily have an older, non-diabetic individual with lower lacritin levels than a younger individual who’s diabetic. And within each age bracket, the diabetic and non-diabetic groups show a significant overlap.

My question is, when you take it forward into a clinical trial, how would you pick your target patients?

Response by Kenneth L. Brayman

The samples that we used for human analysis were obtained from companies that store blood, and oftentimes the demographic information on those patients is not complete.

What really needs to be done, as you alluded to, is a multivariant analysis where you look at a variety of different issues—diabetic, non-diabetic, other diseases, medicines that people are on and so forth.

And so that was just a broad brushstroke overview. But you’re right. It needs to be done to establish a firm correlation. Thank you for the question.

Dr. Raphael Lee (Chicago, IL)

Thank you very much for this insightful contribution. I totally agree that the time has come to approach more dynamic therapeutics in precision medicine.

Regarding the diabetes model that you used, specifically as it relates to precision, streptozotocin, we know, is a known inducer of the endoplasmic, unfolded protein stress response, which is a known primary mediator of type 1 diabetes pathogenesis. And I think the cellular stress response generates systemic inflammation and then a secondary immune response.

Your discussion focused on the cellular autoimmunity as the therapeutic target for Lacritin N-104. I wonder whether it is also blocking the unfolded protein response and how the islets might respond.

Response by Kenneth L. Brayman

Thank you for the question. We did look at whether lacritin alone could reverse streptozotocin-induced diabetes, and it does not.

There are some animals that can spontaneously recover from a diabetic state, but it’s an artificial form of diabetes development because there’s no autoimmune model. So, we wanted to answer specific questions regarding human islets in a nonimmunologic situation.

In those animals, if you follow them along and then you do the nephrectomy and take out the kidney, then they become diabetic again. So, it is clear there has been no spontaneous recovery, but it’s not the best model.

What we need to do is identify the best compounds and then go through the requisite talks and preclinical studies and then try to get an IND to see if this will work in humans. So, that is our goal, and I’m hoping that we can accomplish that. Thank you so much.