Through the studies of a number of pathologists, the past has taught us a great deal
about islet pathology. A reduction in the quantity of β-cells in hyperglycemic individuals
was described over 110 years ago by Eugene Opie (1) in an elegant report that included
hand-drawn color micrographs. These illustrations clearly bring attention to the fact
that the islet has lost numerous cells and that it also contains hyaline deposits,
which we now recognize may be part of the destructive process. The past also included
quantification of the number of endocrine cells by MacLean and Ogilvie (2) who demonstrated
that β-cell mass is decreased in patients with phenotypic type 2 diabetes, but that
the mass of α-cells is not diminished. And then, over 50 years ago, Bell (3) published
a report of his studies of hyalinosis in islets that were based on the examination
of pancreas sections from 3,959 individuals who were not known to have diabetes and
1,661 with diabetes. He observed hyaline to be more frequent in individuals with diabetes
and that the number of affected individuals increased with age. While diabetes was
certainly not the epidemic we now face, Bell stated in his commentary that “Hyaline
islets are an expression of unrecognized or potential diabetes”—a clear recognition
of the link of these deposits to diabetes and the problem of undiagnosed diabetes.
The present includes the study by Saisho et al. (4), which appears in this issue of
Diabetes Care. This article builds on the past and the present. The authors describe
their findings in pancreas samples obtained at the autopsies of 167 subjects with
no known history of diabetes, who were lean or obese and ranged from 20 to 102 years
of age. The authors report that obesity is associated with an increase in the number
of β-cells and that with aging the number of β-cells appears to be well preserved,
but the exocrine pancreas atrophies. Interestingly, they did not observe increases
in either β-cell replication or apoptosis. These measures of β-cell turnover are made
at a single point in time, and thus dynamic changes can easily be missed or may have
occurred earlier in life. Such are the limitations of studies of the human pancreas.
However, the use of human samples should not be ignored as they clearly inform and
are essential since changes in animal models of diabetes, and particularly rodents,
do not always duplicate those in human health or disease.
The obstacles faced in studying samples of human pancreas from a specimen bank are
further highlighted in the study by Saisho et al. The authors used imaging technology
in live humans to gain estimates of pancreas volume and have used these population-based
volume data in conjunction with microscopy-based measurements on a small piece of
pancreas to calculate changes in β-cell mass. While this is an interesting approach,
it does not substitute fully for the determination of β-cell mass when morphological
assessments—including endocrine cell quantification—are made on the same pancreas
that has been dissected and weighed at the time of an autopsy. When the indirect and
direct findings are similar, it is comforting and informative. However, when they
are not, reality may be a lot more difficult to discern. This discrepancy is also
highlighted in the article by Saisho et al., where the findings of no change in islet
endocrine composition with aging contrast with the recent study by Rahier et al. (5),
which reported aging to be associated with a small decline in β-cell mass.
What else have human studies in the present era taught us? First, the studies by Saisho
et al. and others previously reported that obesity is associated with an increase
in β-cells (5–7). Second, programmed cell death, known as apoptosis, is increased
in type 2 diabetes and prediabetes and is associated with a decrease in β-cells (5,6,8,9).
Third, the hyalinosis our predecessors described so well is amyloid, localized to
the islet and the result of the aggregation of one of the β-cell’s own secretory products,
islet amyloid polypeptide (10). Fourth, the increase in β-cell apoptosis observed
in diabetes is linked, at least in part, to increased islet amyloid deposition (9).
And finally, the amyloid observed so classically in type 2 diabetes is also a nonimmune
cause of the loss of β-cells following islet transplantation (11).
Present day cellular biology has provided us with insight into the mechanisms that
may explain the loss of β-cell mass observed in type 2 diabetes. This knowledge has
again relied in large part on work using animal tissues with some understanding derived
from cultured human islets and autopsy samples. From these data it appears that glucose,
fatty acids, and amyloid induce toxic effects on the β-cells that are not all mediated
by the same mechanisms, but include the development of oxidative stress (12,13) and
a more recently described process termed endoplasmic reticulum stress (14–16). The
result of increased activity in these pathways is apoptosis, a form of programmed
cell death, which has been demonstrated in human pancreas samples. It has also now
been shown in human islets that exposure for a prolonged period to high glucose or
to islet amyloid polypeptide induces inflammation (17,18). The result of this process
is the production of the cytokine interleukin-1β, a molecule we have more traditionally
considered to be a factor in β-cell loss in type 1 diabetes (19,20). Interesting avenues
of exploration in the future will be to see whether the two forms of diabetes have
more than cell loss and cytokine production as common features.
What then of the need? Clearly there are many—too many to detail here. However, to
develop approaches that can slow or prevent the loss of β-cell mass that characterizes
type 2 diabetes, we need a deeper understanding of its pathogenesis. We also need
to answer the intriguing question of whether there is a genetic basis for this. Such
is more than likely, given that many of the genes that have been identified are linked
to the β-cell, and a number of them are related to molecules we may associate with
cell growth rather than primarily function (21). However, to link genotype to a mass
phenotype is going to take a Herculean effort in the number of samples on which we
make estimates of endocrine cell type. The morphological assessments could be through
sample banks, but for many reasons the genotypic ones may be more difficult on archived
samples. Thus, one may have to look forward to the development of novel technology
that will allow us to add measurements of endocrine cell numbers in living individuals
to our armamentarium. These will need to be sophisticated and sensitive, allowing
us to discern decreases in cell numbers in individuals where the loss may be as little
as 10%. As an alternative, and possibly as an early marker of disease onset or risk,
markers of underlying damage such as “hyalinosis” (amyloid) could be targeted for
imaging. Imaging methodology could also allow us to recognize whether targeted interventions
can increase β-cell regeneration and restore β-cell numbers. Regardless of the magnitude
of the challenge, human nature is such that groups have not shirked at the challenge,
and progress has been reported (22). Thus, it is not unreasonable to expect the future
will meet the need by continuing to build on the solid foundation laid by many in
the past and the present.