James Cantley

Type 1 diabetes (T1D) is caused by autoimmune destruction of insulin‐producing pancreatic β‐cells, resulting in hyperglycaemia. The first‐line treatment for symptomatic T1D is exogenous insulin replacement to maintain glycaemic control. Islet transplant therapy is available to a small number of individuals, and stem cell‐derived islet transplant therapies are in clinical development. Recent advances in immunotherapy for T1D enable β‐cells to be protected from autoimmune destruction, delaying disease progression. Set against this therapeutic landscape, innate pancreatic β‐cell regeneration strategies have the potential to reverse β‐cell loss in T1D, restoring regulated, endogenous insulin secretion and stable glycaemic control. In this review, we evaluate the preclinical literature investigating β‐cell regeneration strategies via proliferation of residual β‐cells. We cover therapeutic goals for a potential regenerative therapy, drawing on lessons from studies of residual β‐cell function, immunotherapy and islet transplantation in T1D. We review the role of 14 distinct targets/mechanisms with in vitro and/or in vivo data supporting their role in β‐cell proliferation and potential for therapeutic regeneration. In particular, we focus on the role of DYRK1A in β‐cell proliferation, evaluating the range of small molecule inhibitors and in vivo studies underpinning this well‐validated target. We provide perspectives on how future clinical translation could be optimised, including improved drug development, considerations for clinical trial metrics, patient stratification and the potential for combinatorial regenerative and immunotherapy approaches to shield nascent regenerating β‐cells.

Freezing-of-gait (FOG) and impaired walking are common features of Parkinson’s disease (PD). Provision of external stimuli (cueing) can improve gait, however, many cueing methods are simplistic, increase task loading or have limited utility in a real-world setting. Closed-loop (automated) somatosensory cueing systems have the potential to deliver personalised, discrete cues at the appropriate time, without requiring user input. Further development of cue delivery methods and FOG-detection are required to achieve this. In this feasibility study, we aimed to test if FOG-initiated vibration cues applied to the lower-leg via wearable devices can improve gait in PD, and to develop real-time FOG-detection algorithms. 17 participants with Parkinson’s disease and daily FOG were recruited. During 1 h study sessions, participants undertook 4 complex walking circuits, each with a different intervention: continuous rhythmic vibration cueing (CC), responsive cueing (RC; cues initiated by the research team in response to FOG), device worn with no cueing (NC), or no device (ND). Study sessions were grouped into 3 stages/blocks (A-C), separated by a gap of several weeks, enabling improvements to circuit design and the cueing device to be implemented. Video and onboard inertial measurement unit (IMU) data were analyzed for FOG events and gait metrics. RC significantly improved circuit completion times demonstrating improved overall performance across a range of walking activities. Step frequency was significantly enhanced by RC during stages B and C. During stage C, > 10 FOG events were recorded in 45% of participants without cueing (NC), which was significantly reduced by RC. A machine learning framework achieved 83% sensitivity and 80% specificity for FOG detection using IMU data. Together, these data support the feasibility of closed-loop cueing approaches coupling real-time FOG detection with responsive somatosensory lower-leg cueing to improve gait in PD.

Since the discovery of glucagon 100 years ago, the hormone and the pancreatic islet alpha cells that produce it have remained enigmatic relative to insulin-producing beta cells. Canonically, alpha cells have been described in the context of glucagon’s role in glucose metabolism in liver, with glucose as the primary nutrient signal regulating alpha cell function. However, current data reveal a more holistic model of metabolic signalling, involving glucagon-regulated metabolism of multiple nutrients by the liver and other tissues, including amino acids and lipids, providing reciprocal feedback to regulate glucagon secretion and even alpha cell mass. Here we describe how various nutrients are sensed, transported and metabolised in alpha cells, providing an integrative model for the metabolic regulation of glucagon secretion and action. Importantly, we discuss where these nutrient-sensing pathways intersect to regulate alpha cell function and highlight key areas for future research.

There is a growing understanding that the early phases of type 1 diabetes (T1D) are characterised by a deleterious dialogue between the pancreatic beta cells and the immune system. This, combined with the urgent need to better translate this growing knowledge into novel therapies, provided the background for the JDRF–DiabetesUK–INNODIA–nPOD symposium entitled ‘Islet cells in human T1D: from recent advances to novel therapies’, which took place in Stockholm, Sweden, in September 2022. We provide in this article an overview of the main themes addressed in the symposium, pointing to both promising conclusions and key unmet needs that remain to be addressed in order to achieve better approaches to prevent or reverse T1D.

The year 2023 marks 100 years since publication of the first report of a hyperglycemic factor in pancreatic extracts which CP Kimball and John R Murlin named glucagon (from GLUCose AGONist). Glucagon has a range of profound effects on metabolism including, but not limited to, stimulation of hepatic glucose production. Dysregulation of glucagon secretion is a key feature of both major forms of diabetes, leading to the concept that diabetes is a bihormonal disorder. Still, work to fully understand the production and biological effects of glucagon has proceeded at a slower pace compared to that of insulin. A recent resurgence of interest in the islet α cell, the predominant site of glucagon production, has been facilitated in part by technological innovations. This work has led to significant developments in the field, from defining how alpha cells develop, how glucagon is secretion from pancreatic alpha cells is regulated, through to determining the role of glucagon in metabolic homeostasis and the progression of both major forms of diabetes. In addition, glucagon is considered to be a promising target for diabetes therapy, with many new potential applications arising from research in this field. This collection of reviews, led by Guest Editors James Cantley, Rebecca Hull-Meichle and Vincent Poitout, is intended to capture the field’s current understanding of glucagon and alpha cell biology, as well stimulate additional interest and research on this important hormone.

Objective: Certain ethnicities such as South Asians and East Asians have higher rates of type 2 diabetes mellitus, in part, driven by insulin deficiency. Insulin deficiency can be due to beta-cell insufficiency, low beta-cell mass, or early cell death. Transcription factor XBP1 maintains beta-cell function and prevents early cell death by mitigating cellular endoplasmic reticulum stress. We examine the role of XBP1 expression in maintaining glucose homeostasis, glycaemic control, and response to diabetes therapeutics. Research Design and Methods: Colocalisation analyses were used to determine if expression of XBP1 in pancreatic islets and type 2 diabetes shared common causal genetic variants. We identify a lead eQTL variant associated exclusively with XBP1 expression and examine its association HOMA-B and stimulated glucose in cohorts of newly diagnosed Asian Indians from Dr. Mohan’s Diabetes Specialities Centre, India (DMDSC) and the Telemedicine Project for Screening diabetes and complications in rural Tamil Nadu (TREND). We then examine longer term glycaemic control using HbA1c in Asian Indian cohorts, the Tayside Diabetes Study (TDS) of white European ancestry in Scoltand, and the Genes & Health (G&H) study of British South Asian Bangladeshi and Pakistani ancestry. Finally, we assess the effect of eQTL variant on drugs designed to improve insulin secretion (sulphonylureas and GLP1-RA). Results: Variants affecting XBP1 expression in the pancreatic islets colocalised with variants associated with T2DM risk in East Asians but not in white Europeans. Lower expression of XBP1 was associated with higher risk of T2DM. rs7287124 was the lead eQTL variant and had a higher risk allele frequency in East (65%) and South Asians (50%) compared to white Europeans (25%). In 470 South Asian Indians, the variant was associated with lower beta-cell function and higher stimulated glucose (β _{log HOMAB} =-0.14, P=5×10 ^-3 ). Trans-ancestry meta-analysed effect of the variant in 179,668 individuals was 4.32 mmol/mol (95%CI:2.60,6.04, P=8×10 ^-7 ) per allele. In 477 individuals with young onset diabetes with non-obese BMI, the per allele effect was 6.41 mmol/mol (95%CI:3.04, 9.79, P =2×10 ^-4 ). Variant carriers showed impaired response to sulphonylureas. Conclusion: XBP1 expression is a novel target for T2DM with particular value for individuals of under-researched ancestries who have greater risk of young, non-obese onset diabetes. The effect of XBP1 eQTL variant was found to be comparable with or greater that the effect of novel glucose-lowering therapies. Visual Visual ER: Endoplasmic Reticulum, UPR: Unfolded Protein Response, IRE1:Inositol-Requiring Enzyme 1, mRNA: messenger ribonucleic acid, ERAD: Endoplasmic Reticulum Associated protein Degradation, eQTL: expression Quantitative Trait Loci, HbA1c: glycated haemoglobin. Created with Biorender.com

Obesity-related insulin resistance is a highly prevalent and growing health concern, which places stress on the pancreatic islets of Langerhans by increasing insulin secretion to lower blood glucose levels. The glucose transporters GLUT1 and GLUT3 play a key role in glucose-stimulated insulin secretion in human islets, while GLUT2 is the key isoform in rodent islets. However, it is unclear whether other glucose transporters also contribute to insulin secretion by pancreatic islets. Herein, we show that SLC2A6 (GLUT6) is markedly upregulated in pancreatic islets from genetically obese leptin-mutant (ob/ob) and leptin receptor-mutant (db/db) mice, compared to lean controls. Furthermore, we observe that islet SLC2A6 expression positively correlates with body mass index in human patients with type 2 diabetes. To investigate whether GLUT6 plays a functional role in islets, we crossed GLUT6 knockout mice with C57BL/6 ob/ob mice. Pancreatic islets isolated from ob/ob mice lacking GLUT6 secreted more insulin in response to high-dose glucose, compared to ob/ob mice that were wild type for GLUT6. The loss of GLUT6 in ob/ob mice had no adverse impact on body mass, body composition, or glucose tolerance at a whole-body level. This study demonstrates that GLUT6 plays a role in pancreatic islet insulin secretion in vitro but is not a dominant glucose transporter that alters whole-body metabolic physiology in ob/ob mice.

Dysregulated glucagon secretion from pancreatic alpha-cells is a key feature of type-1 and type-2 diabetes (T1D and T2D), yet our mechanistic understanding of alpha-cell function is underdeveloped relative to insulin-secreting beta-cells. Here we show that the enzyme acetyl-CoA-carboxylase 1 (ACC1), which couples glucose metabolism to lipogenesis, plays a key role in the regulation of glucagon secretion. Pharmacological inhibition of ACC1 in mouse islets or αTC9 cells impaired glucagon secretion at low glucose (1 mmol/l). Likewise, deletion of ACC1 in alpha-cells in mice reduced glucagon secretion at low glucose in isolated islets, and in response to fasting or insulin-induced hypoglycaemia in vivo. Electrophysiological recordings identified impaired K_ATP channel activity and P/Q- and L-type calcium currents in alpha-cells lacking ACC1, explaining the loss of glucose-sensing. ACC-dependent alterations in S-acylation of the K_ATP channel subunit, Kir6.2, were identified by acyl-biotin exchange assays. Histological analysis identified that loss of ACC1 caused a reduction in alpha-cell area of the pancreas, glucagon content and individual alpha-cell size, further impairing secretory capacity. Loss of ACC1 also reduced the release of glucagon-like peptide 1 (GLP-1) in primary gastrointestinal crypts. Together, these data reveal a role for the ACC1-coupled pathway in proglucagon-expressing nutrient-responsive endocrine cell function and systemic glucose homeostasis.