Perspectives in Diabetes

Repair of Pancreatic p-Cells

A Relevant Phenomenon in Early IDDM?
DECIO L. EIZIRIK, STELLAN SANDLER, AND JERRY P. PALMER

Most studies dealing with the pathogenesis of IDDM

have emphasized the immune assault against p-cells.
In this perspective, we review the data that suggest
that the p-cell destruction of IDDM depends on a
balance between p-cell damage and repair. The
progressive p-cell damage leading to IDDM seems to
follow markedly different temporal courses in
individual patients. Some individuals at high risk for
developing IDDM, and presenting with impaired p-cell
function, appear to recover p-cell function when
followed prospectively. Moreover, after the clinical
onset of IDDM, most patients experience a transitory
period of improved insulin secretion. In vitro and in
vivo experimental data suggest that p-cells are indeed
able to repair themselves after damage. Dispersed
p-cells or whole islets can survive and regain their
function after a toxic assault. Furthermore, the
abnormal insulin release and glucose oxidation of
islets isolated from NOD mice during the prediabetic
period is completely restored after 1 wk in tissue
culture. Finally, treatment of NOD mice with
monoclonal antibodies directed against infiltrating
T-cells reverses the altered glucose metabolism of
p-cells. Note that p-cell repair after exposure to
different toxic agents can be enhanced both in vivo
and in vitro. Potential enhancers of p-cell repair are
nicotinamide, glucose, protein-rich diets, and branched
chain amino acids. A basic question that remains to be
answered is the nature of the repair mechanisms
From the Department of Medical Cell Biology, Uppsala University, Uppsala,
Sweden; and the Veterans Administration Medical Center and Department of
Medicine, University of Washington, Seattle, Washington.
Address correspondence and reprint requests to Dr. Decio L. Eizirik,
Department of Medical Cell Biology, Uppsala University, P.O. Box 571, S-751
23, Uppsala, Sweden.
Received for publication 11 May 1993 and accepted in revised form 29
June 1993.
IDDM, insulin-dependent diabetes mellitus; HSP, heat shock protein; STZ,
streptozocin; ALX, alloxan; MMS, methyl methanesulfonate; IL-1, interleukin-1; IgG, immunoglobulin G; PARP, poly(ADP-ribose) polymerase; HLA,
human leukocyte antigen; MHC, major histocompatibility complex; TNF,
tumor necrosis factor; gadd, growth arrest and DNA damage-inducible; CHO,
Chinese hamster ovary; NIDDM, non-insulin-dependent diabetes mellitus;
ICA, islet cell antibody; AIR, acute insulin response.

DIABETES, VOL. 42, OCTOBER 1993

triggered by p-cells. Some of the p-cell responses to

injury include expression of heat shock proteins
32,000, 65,000, 70,000, and 90,000 Mr, activation of the
enzyme poly(ADP-ribose) polymerase, induction of the
growth arrest and DNA damage inducible genes 45
and 153, and enhanced manganese superoxide
dismutase activity. The heat shock protein 70 is of
special interest because it has been shown to be both
induced by interleukin-1 and protective of p-cells
against the deleterious effects of this cytokine. The
findings mentioned above suggest that repair
mechanisms activated after p-cell injury are an
important component of the IDDM disease process. It
is conceivable that a detailed characterization of the
cellular and molecular mechanisms involved in p-cell
repair may contribute to the development of early
preventive therapy for IDDM. Diabetes 42:1383-91,1993

n IDDM, tolerance to the pancreatic p-cells is lost, and

immunological effector mechanisms are selectively
directed against this cell type. Classical cell-mediated
and humoral immune responses to p-cell antigens are
involved. Many of the cytokines released by activ^ed
immune cells have direct toxic effects on islet cells and
other cell types, including eosinophils; NK-cells and
macrophages may also actively participate in the IDDM
process. But p-cells are probably not passive to this
attack. Considerable evidence suggests that in response
to injury, protective and/or repair mechanisms are activated within the p-cells. Moreover, there may also be
limited p-cell regeneration. In this perspective, we focus
on these protective and/or repair mechanisms, review the
potential cellular and molecular bases for these mechanisms, and discuss some clinical observations suggesting that the degree of p-cell damage in IDDM is in part
determined by the balance between p-cell injury and
p-cell defense and repair and/or p-cell proliferation (Fig.
1). This latter issue has been reviewed previously (1,2)
and will not be discussed further herein.

1383

|^-CELL REPAIR IN IDDM

IMMUNE ASSAULT
(CYTOTOXIC T CELLS;
FREE RADICALS; CYTOKINES)

60-

- 600

JL

^ -

P-CELL MASS
CELL
PROLIFERATION

FIG. 1. In IDDM-prone individuals, the prevailing p-cell mass may

depend on a delicate balance between p-cell damage and p-cell repair
and/or regeneration.

EXPERIMENTAL EVIDENCES FOR p-CELL REPAIR UNDER

IN VITRO AND IN VIVO CONDITIONS
Experimental evidence for p-cell repair after injury came
initially from in vitro studies (3,4). Thus, when purified
p-cells were acutely exposed to different cytotoxic substances, i.e., the diabetogenic drugs STZ or ALX, the
free-radical generator f-butylhydroperoxide, or p-cell
surface antibodies plus complement, some of these cells
were able to survive (3). The observation that cell mortality varied with the culture conditions prevailing between the initial toxic insult and the assessment of cell
death (performed after a 20-h culture period) suggested
that defense mechanisms in pancreatic p-cells may have
been activated (3). Additional observations supporting
this hypothesis came from studies in which whole rodent
islets of Langerhans were exposed to MMS (5), nitroso/V-methylurea (5), ALX (6), IL-1 (7-9), or elevated temperatures (heat shock) (10). In all of these cases, the
p-cells went through an initial phase of suppressed
glucose metabolism and decreased insulin release in
response to glucose. However, after 3-7 days of culture
in the absence of the toxic agent, the surviving p-cells
were able to completely regain their function (5-10).
Moreover, purified p-cells exposed for 20 h to IL-1 also
regained their function after an additional 3-days culture
in the absence of the cytokine (11). The exception was
pancreatic islets exposed to STZ (12-14). Under these
circumstances, long-lasting damage to p-cells was characterized by a persistent impairment in glucose metabolism at the mitochondrial level and a defective insulin
response to glucose (13-15).
These in vitro observations are more likely attributable
to p-cell repair rather than compensatory p-cell regeneration. The replicatory capacity of adult p-cells under
culture conditions is <2% for both rat and mouse islets
(1,2), and this value is further decreased in cultured
purified p-cells (16). Moreover, p-cell proliferation does
not increase significantly after in' vitro islet exposure to
STZ (17,18).
p-cell repair also has been demonstrated after in vivo
p-cell damage. Perhaps one of the best suited experimental models for IDDM is the NOD mouse (19,20).
Starting around 5 wk of age, these mice develop a
progressive mononuclear cell infiltration in and around
their pancreatic islets. This infiltrate will eventually evolve
into a destructive insulitis, and by 18-24 wk of age most

1384

0
Day

-0
0

7
NOD

7
NMRI

7
NOD

7
NMRI

FIG. 2. Insulin release (A) and glucose oxidation (B) from Isolated
pancreatic islets of 12-wk-old female NOD mice ( E l ) or 12-wk-old
NMRI mice ( ) . For insulin release determinations, islets were
incubated for 60 min at 16.7 mM glucose. For glucose oxidation
studies, islets were Incubated for 90 mln at 16.7 mM glucose and
D-[U-14C]glucose. Both insulin release and glucose oxidation rates
were measured immediately after Islet Isolation (day 0) and after 7
days In culture (day 7). Data are means SE of 14-16 observations
(insulin release) or 7-11 observations (glucose oxidation). 'P < 0.01;
"P < 0.001 when comparing islets from the same animal on day 0
against day 7, using the paired Student's f test. Note that islets
isolated from diabetes-prone NOD mice have decreased insulin
release and glucose oxidation on day 0 and show clear functional
improvement after 1 wk In culture. On the other hand, islets obtained
from non-diabetes-prone NMRI mice present similar insulin release
and glucose oxidation on days 0 and 7. Data are adapted from
Strandell et al. (22) and Eizirik et al. (23).

female mice are overtly diabetic (21). When pancreatic

islets with insulitis were isolated from female NOD mice
5-7, 8-11, or 12-13 wk of age, the islets showed a
deficient glucose-induced insulin release that progressively worsened with age. The observed p-cell dysfunction had a close correlation to the severity of the
mononuclear cell infiltration and was accompanied by
defective glucose metabolism (22,23). However, when
these islets were cultured for 7 days, during which the
islet mononuclear cell infiltrate was mostly depleted, both
insulin release and glucose oxidation completely recovered (22,23) (Fig. 2). In a subsequent series of experiments, female 12- to 13-wk-old NOD mice were treated
with monoclonal antibodies directed against infiltrating
T-cells, and their islets isolated after a 10-day period
(24). Islets obtained from control NOD mice, treated in
parallel with vehicle only or with normal rat IgG, had a
severe mononuclear cell infiltration and altered glucose
metabolism. The monoclonal antibody treatment markedly reduced the islet inflammatory reaction and restored
islet glucose metabolism (24). These data suggest that in
prediabetic NOD mice, a population of suppressed
and/or partially damaged, but still viable, p-cells exist. If
the immune assault is arrested, either by removing the
islets from the in vivo environment (22,23) or by eliminating the invading T-cells with specific monoclonal antibodies (24), these cells can use repair mechanisms and
regain normal function. Thus, both in vitro and in vivo
experimental data point to the existence of efficient p-cell
repair mechanisms.
POTENTIAL ENHANCERS OF p-CELL REPAIR
The vitamin B3-derived compound nicotinamide has
attracted considerable interest as a potential therapeutic

DIABETES, VOL. 42, OCTOBER 1993

D.L EIZIRIK. S. SANDLER. AND J.P. PALMER

agent that might affect the development of IDDM (2527). Nicotinamide can counteract STZ-induced diabetes
in rodents (28), even when administered for up to 2 h
after injection of STZ (29). It has been proposed that the
protective effect of nicotinamide may be mediated by
inhibition of STZ-induced PARP activation after DNA
alkylation (30-32). Addition of nicotinamide to the culture
medium immediately after exposure of isolated rat p-cells
to either STZ or f-butylhydroperoxide or, to a lesser
extent, ALX, inhibited cytotoxicity (3). It is likely that these
in vitro effects of nicotinamide are accomplished by
PARP inhibition, because the nicotinamide concentration
was <10 mM. However, when using nicotinamide at a
concentration >10 mM, the compound might also scavenge free oxygen radicals (33,34). At these higher concentrations, nicotinamide can also block the toxicity of
chemically generated nitric oxide and of IL-1 to islet cells
(35,36). In vivo experiments suggest that nicotinamide
administration can prevent the outbreak of diabetes in
NOD mice, attenuate the symptoms of already diabetic
NOD mice (37), and counteract islet allograft destruction
in NOD mice (38). The exact role of nicotinamide in p-cell
recovery remains to be defined, but the combination of
retarded activation of PARP and scavenging of free
radicals might enhance the efficacy of other cellular
repair mechanisms (see below).
Glucose at high concentrations (20-56 mM) has been
shown to partly counteract damage to rodent p-cell in
vitro, when present after the exposure of islet cells to
various types of stress. Thus, culturing in high glucose
limited the deleterious effects of ALX (3), f-butylhydroperoxide (3), STZ (3,39), p-cell surface antibodies plus
complement (3), IL-1 (40-42), and cryopreservation
(43). The mechanisms behind these beneficial effects of
glucose remain unclear, but they may be related to
acutely providing an energy source that allows the
p-cells to activate energy-dependent processes involved in cellular repair. Indeed, the islet ATP contents
declined after exposure to STZ (13,44,45) and IL-1
(42,46). Conversely, hyperglycemia may also exacerbate
the IDDM disease process, because in vitro exposure of
human islets to high glucose levels leads to both p-cell
dysfunction (47,48) and increased expression of islet
autoantigens, including glutamic acid decarboxylase
(49-51). The interactions of glucose with p-cells in early
IDDM are complex and multifactorial; which of these
effects predominate and consequently whether the net
effect of the hexose on the IDDM disease process is
positive, negative, or neutral will require additional investigation.
From experiments with rats fed a high-protein diet
(52,53) or a balanced diet supplemented with branched
chain amino acids (54), we and others have shown that
STZ-induced diabetes can be alleviated. This effect was
associated with increased pancreatic insulin content and
serum insulin levels (53), which could not be explained
by increased p-cell proliferation (D.L.E, A. Hadad, and
R.H. Migliorini, unpublished observations). Interestingly,
diet supplementation with branched chain amino acids
decreased the severity of encephalomyocarditis virusinduced diabetes in mice (55). These findings suggest

DIABETES, VOL. 42, OCTOBER 1993

that some amino acids can modulate p-cell repair, although peripheral effects on glucose homeostasis cannot
be excluded.
p-CELL RESPONSES TO INJURY
HSPs. One of the best characterized responses of eukaryotic cells to noxious stimuli is the heat shock or stress
response (56-58). This response features a rapid and
coordinated increase in the expression of a group of
proteins referred to as heat shock or stress proteins. A
decrease in the synthesis of other cell proteins occurs
simultaneously. Under physiological conditions, several
HSPs function as molecular chaperones, i.e., they mediate the folding and assembly of other polypeptides and
help direct them to their correct intracellular location
(58,59). Under conditions of cell stress, HSPs (mostly
HSP60 and HSP70) may stabilize denatured proteins and
allow for either their subsequent refolding or disposal
(56,59,60). Indeed, HSPs seem to be essential for the
survival of cells exposed to environmental insults (58,61).
Pancreatic islets exposed either to high temperatures
(heat shock; 42C) (10,62), the cytokine IL-1 (62-65), or
STZ (64), express three of these proteins, with -32,000,
70,000-72,000, and 90,000 Mr The 70,000-/Wr protein
was identified by Western blot analysis as a member of
the HSP70 family (62,64,65), whereas the 32,000-H
protein was identified as heme oxygenase (62). Heme
oxygenase has antioxidant properties (66). Neonatal rat
islets exposed to IL-1 present increased expression of
this protein, and this was interpreted as a p-cell defense
response to cytokine-induced oxygen free radical generation (62).
The major HSP70 seems to be of special interest in the
context of diabetes. First, when purified HSP70 proteins
are introduced into pancreatic islet cells by the liposome
technique, they protect p-cells against the deleterious
effects of IL-1 p (67). Second, HSP70 genes have been
localized within the HLA class III region of the MHC in
humans (68). The HSP70 genes also have been located
in the rat MHC (69) and the mouse H-2 complex (70). In
humans, the duplicated locus encoding the HSP70 is
located between the genes for complement and TNF
(68). This area of the genome displays polymorphism,
and differences in the frequencies of HSP70 and TNF-p
genotypes between IDDM patients and control populations have been reported (71-74). The cytokine TNF
potentiates the deleterious effects of IL-1 on p-cells
(75,76). Because TNF may contribute to p-cell damage
in early IDDM and HSP70 may have a role in p-cell
defense, it is conceivable that susceptibility to IDDM is
enhanced by unfavorable combinations of these genes
(72). Clearly, this intriguing possibility deserves further
investigation.
A recent study using immunocytochemical localization
demonstrated the presence of the HSP60 in pancreatic
islets obtained from both control SJL mice and prediabetic female NOD mice (77). In control mice, HSP60 was
associated mostly with mature insulin granules and mitochondria, whereas in NOD mice with advanced insulitis, the HSP60 protein was also localized in the cytoplasm

1385

|^-CELL REPAIR IN IDDM

and cell membranes (77). As described above, p-cells

of prediabetic NOD mice have a decreased insulin
release and impaired mitochondrial function (22,23).
HSP60 may have a role in preventing protein denaturation, both in cytosol and mitochondria (58,60). It is thus
possible that immune-mediated p-cell dysfunction may
be a signal for redistribution of the HSP60, perhaps as
part of activation of a defense mechanism in the p-cell.
DNA repair. Another possible consequence of different
cell assaults is induction of DNA damage. Repair of DNA
involves a network of enzymatic reactions catalyzed by a
group of interacting gene products (78,79). Note that
enzymes related to both DNA replication and repair are
less prevalent in nonreplicating cells (79,80). Moreover,
although it is well known that DNA damage in proliferating cells may lead to tumorogenesis, the impact of similar
damage in cells with low rates of proliferation, like p-cells
and neurons, still remains unknown (80).
The most well-characterized p-cell response to DNA
damage, specially induced by alkylating agents such as
STZ, is activation of the enzyme PARP (81). The enzyme
uses NAD as substrate and catalyzes intracellular formation of poly(ADP-ribose) (81). Several roles for PARP in
DNA repair have been suggested, such as inhibition of a
Ca2+/Mg2+-dependent endonuclease, regulation of
chromatin structure, dissociation and reassociation of
histones with DNA (so-called DNA shuttling), linkage
between DNA and nuclear matrix, reversible blockade of
free ends of DNA, and regulation of gene transcription
(82-84). Furthermore, when the cell faces widespread
DNA damage, it has been suggested that PARP may
elicit cellular suicide to prevent tumorogenesis (85).
When exposed to an acute assault, most cellular
activities nonrelated to actual cell repair are decreased
(56). One of the mechanisms by which this decrease is
effected is by synthesis of negative modulators of gene
transcription and cell replication. Two genes related to
this function are the growth arrest and DNA damage
inducible genes 45 and 153 (86,87). The gadd genes
were isolated after induction by DNA damage in CHO
cells (88). Later, induction of gadd genes was observed
after different noxious stimuli, like serum reduction (89),
covalent modification of proteins (90), increase in intracellular Ca 2+ (91), or hypoxia (92). We have observed
recently that rat pancreatic islets and HIT cells, a clonal
hamster insulin-secreting cell line, increase the expression of gadd 45 and gadd 153 genes in response to the
alkylating agents STZ and MMS (93). This increased
expression is especially marked after MMS treatment.
Because p-cells can recover their function completely
after MMS exposure, but not after STZ administration
(5,13,14,94), it may be worthwhile to further elucidate the
role of gadd genes in repair of islet cell damage.
Finally, it must be mentioned that DNA repair in insulinproducing cells is not a homogeneous process. Thus,
after an alkylation injury, active genes, such as the insulin
gene, seem to be preferentially repaired compared with
less active genes (95).
Manganese superoxide dismutase. A protein that may
also be involved in p-cell repair and/or protection against
subsequent injury is Mn-containing superoxide dismu-

1386

P-CELL ASSAULT

DEFICIENT INSULIN
RELEASE

FIG. 3. A model for the p-cell outcome after exposure to different

assaults.

tase, an enzyme that catalyzes scavenging of toxic free

oxygen radicals. After islet exposure to IL-ip, both Mncontaining superoxide dismutase mRNA and enzyme
activity increase (96). Such an increase might be beneficial to p-cells in early IDDM, a situation in which these
radicals are probably generated by cytokines and immune-effector cells in the islets.
Possible p-cell outcome after injury. A model for the
p-cell outcome after different assaults is provided in Fig.
3. After damage, these cells undergo an initial stage of
impaired function, characterized by decreased insulin
release in response to glucose and a defective substrate
metabolism at the mitochondrial level (4,14,97). During
this phase, different repair mechanisms may be activated. Depending on the type and intensity of the cell
assault, and on the effectiveness of p-cell repair mechanisms, the cells may or may not survive. In most cases,
surviving p-cells regain their function and completely
recover once the initial aggression is arrested (4). However, it appears that some forms of DNA damage, such
as that induced by the alkylating agent STZ, lead to
permanent p-cell dysfunction (4,12-14). This dysfunction is also characterized by a selective defect in glucose-induced insulin release and impaired islet nutrient
metabolism (13,14,97). A similar selective defect in glucose-stimulated insulin release is observed in NIDDM
(98) and in nondiabetic subjects during the preclinical
stage of IDDM (99), suggesting that this may be a
common response of p-cells to damage.
CLINICAL OBSERVATIONS
The fundamental, underlying biochemical lesion of IDDM
is insulin deficiency. It is commonly assumed that this is
a result of p-cell destruction and, based primarily on
partial pancreatectomy experiments (100), that hyperglycemia only occurs after -90% of the p-cells have been
lost. Although nearly complete p-cell loss does characterize the final stages of the IDDM disease process (101),
during the preclinical period and early after diagnosis, it
is likely that p-cell loss is <90% and that much of the
insulin deficiency present at these times is a result of
functional inhibition of insulin secretion. In the context of
this perspective, this concept is very important, because

DIABETES, VOL. 42, OCTOBER 1993

D.L EIZIRIK. S. SANDLER. AND J.P. PALMER

one cannot postulate recovery from cell death, only from

injury. Within 3-6 mo after the initial diagnosis of IDDM
and subsequent treatment, most patients experience
some recovery of p-cell function as reflected by increased C-peptide levels (102). Sometimes sufficient
recovery of p-cell function allows patients to maintain
normal or near-normal glucose levels temporarily, without
the need for exogenous insulin. Moreover, cyclosporin A
treatment of recently diagnosed IDDM patients results in
more frequent and more prolonged remissions (103).
These observations strongly suggest that at the time of
IDDM diagnosis, some of the insulin deficiency is caused
by functional inhibition of insulin release and that this
inhibition is at least partially reversible. As discussed
previously, data from the NOD mouse also supports the
concept that early in the IDDM disease process much of
the p-cell dysfunction is caused by a reversible lesion,
p-cell function is markedly impaired when islets are
isolated from mice with severe insulitis, but this p-cell
function recovers with experimental procedures that reverse or block the insulitis process in vivo or in vitro
(22-24) (Fig. 2).
Two additional observations provide further support for
the concept that functional inhibition of insulin release is
an important component of the islet lesion of IDDM. In
vitro exposure of cultured islets or islet cells to cytokines
such as IL-1, TNF, and interferon-7, especially in combination, results in profound inhibition of insulin release and
cytotoxicity, but these two cytokine effects can be discriminated, depending on the particular cytokine examined, the concentration used, and the combinations
tested (104-106). By measuring insulin release and
cytotoxicity separately, we have recently found that for
some doses and combinations of IL-1 and TNF, the
inhibition of insulin release is associated with islet cell
death. Other doses, in contrast, cause loss of insulin
secretion with little or no cytotoxicity (V.K. Metha, W. Hao,
B.M. Brooks-Worrel, J.P. Palmer, unpublished observations). Similarly, Ling et al. (11) found that IL-1 caused
both cytotoxicity and inhibition of insulin release from
cultured islets, but only inhibition of insulin release from
cultured purified p-cells.
The second observation comes from our studies correlating in vivo p-cell function with p-cell mass and
pancreatic p-cell content in baboons receiving various
doses of STZ. All three measurements were highly correlated, but pancreatic insulin content and in vivo measures of p-cell function approached zero when 40-50%
of p-cell mass was still detectable histologically (107).
These in vivo p-cell function tests are the same as those
used to evaluate p-cells in human preclinical IDDM.
Therefore, if these observations post-STZ are relevant to
the islet lesion of human IDDM, 50% rather than only
10% of p-cells may remain when high-risk individuals
develop severely abnormal p-cell function tests. As we
learn more about how to stimulate p-cell recovery, treatment may become available that can stimulate these
remaining but insulin-deficient p-cells to regain normal or
near-normal secretory function.
Since the discovery of ICAs in newly diagnosed IDDM
patients in 1974 (108) and the subsequent observation

DIABETES, VOL. 42, OCTOBER 1993

10080-

60-

1 40H
<

20s

0-

/
D

-20
-20

20

40

60

80

100

Months
FIG. 4. p-cell function, measured as the AIR to glucose and
expressed in percentiles, compared with the normal population, from 4
ICA + nondlabetic individuals followed prospectlvely In the Seattle
Family Study. (X), developed clinical IDDM after 28 mo.

that nondiabetic individuals were frequently ICA+ years

before the onset of clinical IDDM, several groups initiated
programs to identify and prospectively evaluate nondiabetic individuals at increased risk of subsequent clinical
IDDM. As part of these studies, p-cell function tests are
periodically performed, and in some individuals, a progressive decline in p-cell function is observed before the
onset of IDDM. Initially, investigators from the Joslin
Diabetes Center (Boston, MA) proposed that the fall in
p-cell function was linear (109); therefore, the time to
clinical IDDM could be accurately predicted (110). Subsequent studies by our group and others have observed
more variable p-cell function over time (111-116). When
p-cell function has been measured over several years in
ICA+ first-degree relatives of IDDM patients, we have
uncommonly observed a progressive decline in p-cell
function. As illustrated by 4 separate individuals from the
Seattle Family Study (Fig. 4), a few individuals with low
p-cell function when first evaluated have had a further
decrease and subsequently developed clinical IDDM; in
many others, p-cell dysfunction is relatively stable and/or
shows considerable fluctuation over time. We have proposed previously that in individuals with slightly impaired
but stable p-cell function, this is likely the result of a prior
p-cell insult from which the cells have partially recovered
(113). The wide fluctuations in p-cell function may well
represent transient episodes of immune attack followed
by periods of relative quiescence and p-cell recovery.
Our finding that glucose tolerance during the intravenous
glucose tolerance test is strongly correlated with p-cell
function in first-degree relatives of diabetic patients
suggests that these changes in p-cell function over time
are not normal physiological changes.
Perhaps the data that best support the concept of
p-cell repair and recovery of function come from Kobayashi et al. (117). They evaluated a group of ICA+
diabetic patients who subsequently became ICA~. This
change in ICA status was associated with an improvement in both insulin secretion and carbohydrate tolerance. In contrast, p-cell function continued to deteriorate

1387

I^-CELL REPAIR IN IDDM

in those patients who were persistently ICA+. These

observations may represent an immune attack on the
p-cell with transient loss of function followed by recovery,
and raise the question of how commonly this sequence of
events occurs. We suggest the possibility that this is
quite common and explains the finding that in the general
population clinical IDDM will occur in only 5-10% of ICA+
people (118). Suppression of the immune attack on
p-cells followed by p-cell repair and recovery (Fig. 3)
may be the norm. Clinical IDDM occurs only when these
mechanisms fail. Even though this frequency can only be
offered as hypothetical at this time, it underscores the
potential importance of the p-cell defense and repair
mechanisms reviewed in this perspective.

p-cells, they may be extended to human IDDM. In this

respect, the first step will probably be to assess whether
a polymorphism exists in the expression of genes encoding these proteins and whether any correlation exists
between specific alleles and the prevalence of IDDM.
Perhaps to succeed in solving the IDDM puzzle we must
follow G.K. Chesterton's advice from The Man Who Was
Thursday.

FUTURE STUDIES
Up to now, most studies dealing with the pathogenesis of
IDDM have been directed toward the possible mediators
of the immune assault against p-cells. The observations
described above suggest that attention must also be
paid to the repair mechanisms activated by p-cells after
injury. Indeed, a detailed understanding of the cellular
and molecular mechanisms mediating p-cell damage
and repair may lead to the development of effective early
treatments to prevent p-cell destruction in IDDM. The
genes and proteins discussed above are probably only a
minor part of a complex network of repair mechanisms.
As new repair mechanisms are discovered in other cell
systems, it will be of importance to evaluate their presence both in rodent and human p-cells and to correlate
their expression after cell damage with p-cell survival
and functional outcome. Moreover, in vitro manipulation
of these systems, both by introducing the desired proteins into p-cells with liposome techniques (67) or by cell
transfection with the gene of interest (119), can provide
direct evidence for the role of the potential protecting
agent against different p-cell toxins. Such experiments
may be extended to in vivo models by preparing transgenic mice, in which putative protective agents, e.g.,
HSP70 or Mn-containing superoxide dismutase, are
linked to the insulin promoter. Nearly all transgenic mice
designed to study diabetes pathogenesis to date have
been related either to expression of p-cell antigens or to
expression of potential mediators of p-cell destruction,
like cytokines (120,121). Thus, it would be of interest to
induce expression of p-cell defense proteins and test the
resistance of these animals to drug, viral, or immunemediated p-cell destruction. Finally, it will be extremely
important to characterize whether some or all of the
putative repair mechanisms are expressed in p-cells
during the prediabetic period, using both NOD mice and
BB rats. This may be achieved by immunocytochemical
and in situ hybridization techniques. Both techniques
have already been used successfully to study expression
of gene transcripts and proteins involved in immunemediated p-cell destruction in early diabetes in rodents
(122,123).

ACKNOWLEDGMENTS
Work by authors included in this perspective was supported by the Juvenile Diabetes Foundation International;
the Swedish Medical Research Council (12X-109, 12X9886, 12X-8273, 12X-9237, 12P-10739); the Swedish
Diabetes Association; the Novo Nordisk Insulin Fund;
Centrala forsoksdjursnamnden; the Family Ernfors Fund;
the Procordia Research Fund; National Institutes of
Health Grants DK-07456, DK-41801, DK-17047, and
RR-00037; and the Medical Research Service of the
Department of Veterans Affairs.
We are grateful to Drs. Claes Hellerstrom, Carla J.
Greenbaum, and David K. McCulloch for critical evaluation of this manuscript.

Once these experimental studies provide a clearer

picture of relevant repair mechanisms expressed by

1388

You only see the tree by the light of the lamp. I wonder
when you would ever see the lamp by the light of the
tree.

Indeed, it may be time to start seeing IDDM not only by

the light of the immune effector cells, but by the light of
the p-cells.

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