Review Article

Pancreatic β-cell failure, clinical implications, and therapeutic

strategies in type 2 diabetes
Daxin Cui1, Xingrong Feng2, Siman Lei3, Hongmei Zhang1, Wanxin Hu2, Shanshan Yang1, Xiaoqian Yu1, Zhiguang Su1,2,3
1
Molecular Medicine Research Center and Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China;
2
State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China;
3
Clinical Translational Innovation Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China.

Abstract
Pancreatic β-cell failure due to a reduction in function and mass has been defined as a primary contributor to the progression of
type 2 diabetes (T2D). Reserving insulin-producing β-cells and hence restoring insulin production are gaining attention in trans-
lational diabetes research, and β-cell replenishment has been the main focus for diabetes treatment. Significant findings in β-cell
proliferation, transdifferentiation, pluripotent stem cell differentiation, and associated small molecules have served as promising
strategies to regenerate β-cells. In this review, we summarize current knowledge on the mechanisms implicated in β-cell dynamic
processes under physiological and diabetic conditions, in which genetic factors, age-related alterations, metabolic stresses, and
compromised identity are critical factors contributing to β-cell failure in T2D. The article also focuses on recent advances in
therapeutic strategies for diabetes treatment by promoting β-cell proliferation, inducing non-β-cell transdifferentiation, and
reprograming stem cell differentiation. Although a significant challenge remains for each of these strategies, the recognition of the
mechanisms responsible for β-cell development and mature endocrine cell plasticity and remarkable advances in the generation
of exogenous β-cells from stem cells and single-cell studies pave the way for developing potential approaches to cure diabetes.
Keywords: Pancreatic β-cell regeneration; Diabetes; Insulin; Dedifferentiation; Transdifferentiation; Stem cell

Introduction reduction, may lead to the disruption of glucose homeosta-

sis and eventually the onset and progression of diabetes.[5]
Diabetes is the most common multidimensional metabolic At the early stage of T2D, pancreatic β-cells adaptively
disorder in humans. It is estimated that over 537 million
compensate for insulin resistance by expanding their mass
adults worldwide suffered from diabetes in 2021, and this
and augmenting insulin production. As the disease develops,
number is expected to increase to 783 million by 2045.[1]
the β-cell compensatory response fails and functional β-cell
Type 2 diabetes (T2D) characterized by peripheral insulin
mass loss occurs.[6] Therefore, targeting pancreatic β cells
resistance and progressive β-cell dysfunction is the most
by maintaining or restoring their mass and function with
prevalent form of diabetes, and its progression may increase
various endogenous and exogenous approaches serves as a
the risk of various micro- or macrovascular complications,
such as retinopathy, nephropathy, foot ulcers, cardiomyopa- promising strategy for diabetes treatment.[7]
thy, and cerebral or peripheral vascular disease.[2] Presently,
In this review, we first introduce the endogenous regula-
although many different classes of antihyperglycemic thera-
tion of insulin biogenesis and secretion and then highlight
pies can improve glucose tolerance and temporally maintain
recent findings on the mechanisms driving β-cell alteration
blood glucose homeostasis, no real cure exists for T2D.[3,4]
during the progression of T2D. Finally, we focus mainly
Most patients with late-stage T2DM are still dependent on
on advances in therapeutic strategies for better prevention
insulin injection,[2] which is often associated with side effects
and treatment of T2D by targeting β-cells.
even life-threatening hypoglycemic episodes.

Pancreatic β-cells located in the islets of Langerhans are Normal β-cell Physiology
responsible for insulin synthesis as well as storage and
secretion, playing an essential role in the regulation of blood Pancreatic β-cells are essential for metabolic homeostasis,
glucose levels. β-cell failure, either functional decline or mass particularly the homeostatic glucose setpoint by producing

Daxin Cui, Xingrong Feng, and Siman Lei contributed equally to this work.
Access this article online Correspondence to: Zhiguang Su, Molecular Medicine Research Center, West China
Hospital, Sichuan University, Keyuan 4th Road, Gaopeng Street, Chengdu, Sichuan
Quick Response Code: Website: 610041, China
www.cmj.org E-Mail: [email protected]
Copyright © 2024 The Chinese Medical Association, produced by Wolters Kluwer, Inc. under the
CC-BY-NC-ND license. This is an open access article distributed under the terms of the Creative
DOI: Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is
10.1097/CM9.0000000000003034 permissible to download and share the work provided it is properly cited. The work cannot be
changed in any way or used commercially without permission from the journal.
Chinese Medical Journal 2024;137(7)
Received: 13-10-2023; Online: 13-03-2024 Edited by: Jing Ni

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an appropriate amount of insulin. Under physiological but sustained insulin secretion. The first phase involves
conditions, insulin synthesis and secretion are tightly a triggering pathway that is activated by the glycolytic
controlled by nutrient availability. and oxidative metabolism of glucose. Elevated circulating
blood glucose (>8–10 mmol/L) is transported into β-cells
through the membrane glucose transporter. Intracellular
Insulin biogenesis glucose is metabolized to generate pyruvate via a glyco-
Insulin is initially produced as preproinsulin, which is lytic pathway. Afterward, pyruvate is transported into
composed of a signal peptide (SP) followed by an entire mitochondria and is oxidized via the tricarboxylic acid
proinsulin, including a B-chain at the N-terminus, an cycle to produce a larger amount of adenosine-5′-triphos-
A-chain at the C-terminus, and an intermediate con- phate (ATP), which is subsequently transferred into the
necting C-peptide. Preproinsulin is transported into the cytoplasm by the ATP/adenosine diphosphate (ADP)
endoplasmic reticulum (ER) lumen via both cotrans- transport complex. The increase in cytoplastic ATP
lational and posttranslational translocation routes.[8] induces the closure of ATP-sensitive potassium (KATP)
Once delivered to the ER lumen, the SP domain is channels, giving rise to cellular depolarization followed
rapidly removed from the preproinsulin molecules to by an activation of voltage-gated Ca2+ channels (VGCC)
yield proinsulin, which undergoes folding and acquires and a resultant rapid Ca2+ influx. This in turn prompts
three disulfide bonds at A20–B19, A7–B7, and A6–A11. the assembly of a tetrameric complex consisting of Sec1/
Folded proinsulin dimerizes in the ER, and cleavage of the Munc18-like (SM) and three soluble N-ethylmaleimide-
C-peptide by prohormone convertases (PC1/3 and PC2) sensitive factor attachment protein receptor (SNARE)
and carboxypeptidase E converts proinsulin into mature proteins.[10] The SM/SNARE quaternary complex forms a
insulin. Upon translocation into the Golgi complex, the molecular zipper structure that bridges the insulin secre-
proinsulin dimers begin to form zinc-containing hexamers tory granules to the plasma membrane of maximum Ca2+
that are then loaded into immature secretory granules. concentration. Along with additional Ca2+ sensors, such
Alongside insulin maturation, the secretory granules as synaptotagmin (Syt), double C2 domain (DOC2) and
also progressively mature by refining their composition, Ca2+-dependent activator protein for secretion (CAPS),
such as luminal acidification, lipid composition changes, the SM/SNARE complex facilitates the exocytosis of
membrane cholesterol enrichment, membrane adaptor insulin from a “readily releasable” pool. Insulin granule
protein exposure, removal of unwanted cargoes and solu- exocytosis is further potentiated during the second phase,
ble components, and formation of Zn2+-mediated dense which relies on an amplifying pathway that is independent
insulin cores.[9] Thus, the granules acquire the competence of the KATP channel and is predominantly activated by the
needed for insulin storage and stimulus-response secre- accumulation of metabolic intermediates, such as citrate
tion. Ultrastructurally, a β-cell possesses approximately and malate.[11] The second phase of insulin secretion can
10,000 dense-core secretory granules with Zn2-insulin6 be maintained during the entire postprandial state, causing
complex vesicles in these dense-core granules. Each granule the release of membrane-associated primed granules and
contains 300,000 or more insulin molecules, which cell-internal insulin into the storage pool.
corresponds to 8–9 fg insulin. Only a small fraction of
(1–5%) granules are distributed into a “ready releasable”
Insulin secretion is regulated by β-cell autocrine
pool that is docked to the cell membrane, and they are
secreted on demand without any further modification; actions
Major (95–99%) insulin granules are stored in a reserve Autocrine signaling refers to the effect of extracellular dif-
pool and they undergo a series of preparatory reactions fusible messengers on the same cells or nearby cells of the
before acquiring release competence.[5] same type from which they have been released. Abundant
evidence has indicated that autocrine signaling is involved
in the regulation of β-cell function.[12]
Insulin secretion
Although a range of metabolic fuels including amino acids,
α-ketoacid ketoisocaproate, and fatty acids can stimulate Insulin
insulin secretion, glucose is the primary physiological Pancreatic β-cells possess the necessary components of
stimulator for insulin release.[5] In addition to multiple the insulin signaling pathway, such as insulin receptor
metabolic signals, intraislet local signals, including auto- (IR), insulin receptor substrate (IRS), phosphatidylinositol
crine transmitters of β-cells and paracrine signals between 3-kinase (PI3K), AKT, and mammalian target of rapa-
β-cells and other adjoining cells, notably α-cells and δ-cells, mycin (mTORC1). Therefore, insulin may directly act
also govern islet function and insulin secretion. on β-cells to regulate its own synthesis and secretion.
The autocrine action of insulin on its own secretion is
Insulin secretion is regulated by metabolic signals modulated by the microenvironments around β-cells,
such as insulin or glucose concentrations and exposure
Pancreatic β-cells sense changes in the blood glucose time. In mouse islets, insulin secretion is stimulated by
level and secrete appropriate insulin to maintain blood low-concentration (nanomolar) insulin but is inhibited by
glucose in a homeostatic range. A prominent feature of high concentrations (micromolar) of insulin. In rat islets,
insulin secretion is its two-defined phasic pattern, dis- insulin secretion is inhibited after prolonged (30 min)
playing a transient first phase with a rapid rise in insulin exposure to exogenous insulin but is potentiated by acute
secretion followed by a prolonged second phase of lower treatment. In humans, endogenous glucose-stimulated

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insulin secretion increases by 40% after a 4-h exposure The contribution of various P2 receptors to insulin exocy-
to insulin.[13] Mechanistically, insulin induces Ca2+ release tosis in β-cells merits further investigation.
from ER stores through the activation of the IR/IRS/PI3K
signaling pathway under physiological conditions, thus
increasing the cytosolic Ca2+ concentration and triggering γ-aminobutyric acid (GABA)
granule exocytosis.[14] In addition, the insulin autocrine GABA is a neurotransmitter that is mainly produced
regulation pathway may also be mediated by the PI3K- in islet β-cells and the brain.[19] GABA is synthesized
AKT-mTORC1 pathway. At high concentrations of insulin in the cytosol from the precursor glutamic acid by the
during states of insulin resistance or hyperinsulinemia, enzyme glutamic acid decarboxylase. While GABA is
insulin may activate PI3K-dependent KATP channels, thus predominantly cytoplasmic in β-cells, it is also present
hyperpolarizing the cell membrane and inhibiting glu- in insulin secretory granules and synaptic-like microve-
cose-induced Ca2+ oscillations, resulting in an inhibition sicles in GABA transporter-expressing β-cells. Cytosolic
of granule exocytosis.[15] This positive and negative auto- GABA is secreted from β-cells via a nonvesicular path-
crine regulation of insulin coordinately accommodates way, and vesicular GABA in insulin granules is released
insulin demand. Initially, insulin enhances its secretion upon glucose stimulation via Ca2+-dependent exocytosis.
in response to glucose stimulation; However, when the The function of GABA in β-cells depends on its binding
local insulin concentration becomes high, secretion is to its specific membrane receptor A (GABARA) or B
inhibited. (GABARB).[20] GABARA is a ligand-gated Cl− channel that
controls β-cell excitability by modulating the membrane
potential (Vm). In excited β-cells with a more electroposi-
Islet amyloid polypeptide (IAPP)/amylin
tive Vm, activation of GABARA can inhibit insulin release
IAPP or amylin is a 37 amino-acid peptide that resides in by clamping Vm to the equilibrium chloride potential
insulin secretory granules and is cosecreted with insulin (ECl−) or hyperpolarizing the membrane back toward
in a molar ratio of approximately 1:100 in response to ECl−. GABARB is an inhibitory G protein (Gi)–coupled
glucose and other stimuli. Recent studies have found receptor that stimulates the opening of G protein-coupled
that IAPP, akin to insulin, exerts a dual action on insulin inwardly rectifying K+ channels and inhibits adenylyl
secretion, potentiating basal insulin release at very low cyclase, giving rise to lower cyclic AMP (cAMP) and
concentrations with nanomolar levels and suppressing inhibition of VGCC and concurrent reduction in insulin
glucose-stimulated insulin secretion at very high concen- secretion. Mice lacking GABARB exhibit increased insulin
trations with micromolar levels.[16] These findings support secretion in response to glucose stimulation and improved
the notion that endogenous IAPP plays an inhibitory role glucose tolerance[20]. Overall, the effect of GABA on insulin
in insulin secretion and limits blood glucose elimination. secretion is dependent on the integrated response of β-cells
In accordance with this notion, IAPP knockout mice dis- to metabolic, ionotropic, and metabotropic signals.
play an increased insulin response and concurrent rapid
blood glucose elimination, while human IAPP transgenic Insulin secretion is mediated by paracrine communica-
mice show the opposite effects. Likewise, a truncated-IAPP
tion in islets
peptide acting as an antagonist may stimulate insulin
secretion upon glucose stimulation in isolated rat islets. Paracrine communication reflects the actions of signaling
The complex influence of IAPP on insulin secretion might molecules produced by one cell on nearby cells of a dif-
result from the interaction between calcitonin receptors ferent type. In addition to the insulin-producing β-cells
and receptor activity modifier proteins (RAMPs).[17] that account for approximately 50–75% of human and
60–80% of mouse endocrine cells, islets also contain
some other endocrine cells, such as the glucagon-secreting
ATP α-cells that make up 25–35% of human and 15–20%
ATP is present in insulin granules and is cosecreted with of mouse islet mass, somatostatin-secreting δ-cells that
insulin through Ca2+-dependent exocytosis in isolated rat comprise up to 22% of human and only 6% of mouse
islets or human β-cells challenged with glucose, and the islet cell number, and pancreatic polypeptide (PP)-cells
released ATP in turn potentiates insulin release. Human that account for <5% of human and <2% of mouse islet
β-cells express ATP-sensing P2 purinergic receptors, mass.[21] These endocrine cells are densely packed and
which are divided into ligand-gated ionotropic P2X and engage in the regulation of insulin secretion by paracrine
G protein-coupled metabotropic P2Y receptors.[18] Extra- signals.[22]
cellular ATP binds P2 receptors and induces Ca2+ release
from intracellular stores, leading to an increase in cyto- Insulin secretion is regulated by paracrine signals of
plasmic free Ca2+ and acute insulin release in response to
α-cells
glucose stimulation. ATP-potentiated insulin secretion is
significantly attenuated by P2 receptor antagonists and Glucagon secreted by islet α-cells is traditionally thought
extracellular ATP scavengers in rat islets. Moreover, both of as a counter-regulatory hormone to preventing hypo-
P2X and P2Y receptor agonists may potentiate insulin glycemia by stimulating hepatic glycogenolysis and
release upon glucose stimulation in human islets. After gluconeogenesis.[23] However, new studies have also
release from β-cells, ATP can be rapidly hydrolyzed to revealed that glucagon stimulates insulin secretion, which
ADP and adenosine monophosphate (AMP). ADP may is dependent on the dose and duration of glucagon expo-
also modulate insulin secretion via different P2 receptors. sure as well as the nutritional status. In overnight-fasted

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mice, exogenous glucagon increases blood glucose levels gastrointestinal D-cells and accounts for 65% of the total
without changes in insulin levels, while administration of body somatostatin.[27] Various nutrients, such as glucose,
glucagon along with glucose diminishes the rise in blood leucine and arginine, may stimulate somatostatin secre-
glucose levels and concurrently increases insulin levels. tion in a KATP-channel-dependent way similar to that of
In fed mice, a challenge of 20 µg/kg glucagon increases β-cell insulin secretion. Somatostatin activates somato-
blood glucose levels without impacting insulin levels, statin receptors on α- or β-cells, leading to inactivation
while an administration of 1 mg/kg glucagon decreases of adenylyl cyclase and thereby reduction in intracellular
blood glucose and increases insulin levels.[22] Mechanis- cAMP levels and cAMP-induced exocytosis of glucagon
tically, glucagon binds to the β-cell glucagon receptor and insulin.[28] Somatostatin may also inhibit VGCC and
(GCGR), resulting in the activation of adenylyl cyclase activate G-protein-activated inward rectifier K+ channels,
and the subsequent generation of cAMP. The increase which induce membrane repolarization and inhibit elec-
in intracellular cAMP activates protein kinase A (PKA), trical activity, resulting in less release of glucagon and
which subsequently phosphorylates the SUR1 subunit of insulin. Such paracrine inhibition of β-cells would ensure
the KATP channel and Cav1/2 of the Ca2+ channel, and that insulin release is restrained in a timely manner to
thereby inactivates the KATP-channel and activates the counterbalance nutrient stimulation, thus avoiding hypo-
Ca2+-channel, resulting in Ca2+ influx and insulin secre- glycemia caused by excess insulin release.
tion. Additionally, cAMP may also bind to EPAC2A,
which is a guanine nucleotide exchange factor to facilitate
Pathogenesis of T2D: Insulin Resistance and Pancreatic β-cell
interaction with RAP1, a small GTPase. The EPAC2A/
RAP1 complex activates the ryanodine receptor (RyR) on Damage
the ER, resulting in Ca2+ release from the ER. The increase Hyperglycemia accompanied by obesity, particularly
in the cytoplastic Ca2+ concentration enhances recruit- visceral adiposity, causes insulin resistance, and more
ment of insulin granules to the cell membrane. There is insulin is needed to override the ineffectiveness of insulin.
also evidence that EPAC2A interacts with Rim2α, Rab3, Pancreatic β-cells detect this requirement and adaptively
and Piccolo, which are all needed for cAMP-regulated augment insulin synthesis and secretion through com-
granule exocytosis. Furthermore, EPAC2 can also interact pensatory expansion of β-cell mass, restoring glucose
with the KATP channel to inhibit the functioning of the homeostasis.[6] Ultimately, with increasing time, the
KATP channel and potentiate insulin release.[22] However, number of β-cells as well as their secretory function pro-
glucagon is only a modulatory signal, which has no stimu- gressively decline, and glucose homeostasis is impaired,
latory effect on insulin secretion in the absence of glucose. eventually causing diabetes.
In addition to glucagon, glucagon-like peptide 1 (GLP-1) is
also an α-cell–derived insulin secretion-stimulating signal. Insulin resistance
Both glucagon and GLP-1 are derived from the common Insulin exerts its physiological effects by binding to plasma
precursor proglucagon, which is divergently processed to membrane–bound receptors of target cells. Although IRs
GLP-1 by prohormone convertase (PC) 1/3 or glucagon by are ubiquitously distributed in diverse tissues, the role
PC2.[24] Islet α-cells normally express PC2 for the produc- of insulin in glucose homeostasis is typified by insulin’s
tion of glucagon, and they are also capable of expressing direct effects on skeletal muscle, liver, and white adipo-
PC 1/3 and producing GLP-1 under certain circumstances. cytes.[29] Insulin resistance is a pathological condition
GLP-1 specifically binds to the β-cell GLP-1 receptor in which target tissues are unable to respond normally
(GLP1R) and stimulates insulin exocytosis through a to plasma insulin levels and thus fail to coordinate the
signaling cascade closely aligning with the signaling events glucose-lowering response.[29] Since insulin stimulation of
of glucagon. In human β-cells, GLP1R is approximately glucose consumption is primarily involved in skeletal mus-
twice as highly expressed as GCGR.[5] At physiological cle, and because muscular glucose uptake and glycogen
plasma concentrations (<50 pmol/L), each ligand specifi- synthesis are highly dependent on intact insulin action,
cally binds to its cognate receptor, but glucagon is also able muscle insulin resistance could affect whole-body glucose
to activate GLP1R at nanomolar concentrations, whereas homeostasis and is indeed a principal component of T2D.
GLP-1 does not act on GCGR.[25] The potential effects Insulin in the liver promotes net glucose disposal by coor-
of both glucagon and GLP1 on insulin secretion either in dinately suppressing gluconeogenesis and glycogenolysis
isolated islets ex vivo or in mice and humans in vivo are and activating the deposition of glucose as glycogen.[3]
glucose-concentration dependent,[26] and deciphering their Defective suppression of hepatic gluconeogenesis in insulin
relative contributions to the regulation of insulin secretion resistance and thereby the increase in glucose production
is an ongoing line of investigation. are key drivers of fasting hyperglycemia that defines T2D.
Meanwhile, insulin also fails to control hepatic glycogen
Effects of δ-cell-derived somatostatin on insulin metabolism under insulin-resistant conditions, and fasting
secretion and postprandial hepatic glycogen content is indeed lower
in T2D patients. Insulin action in white adipose tissue
Islet δ-cells primarily secrete the somatostatin-14 isoform strengthens the suppression of hepatic gluconeogenesis
(SS-14), which is derived from the posttranslational through the inhibition of triglyceride lipolysis, which
process of prosomatostatin.[27] In addition to SS-14, decreases both the glycerol substrate of gluconeogenesis
prosomatostatin is also the precursor of the somatosta- and acetyl-CoA of pyruvate carboxylase allosteric activa-
tin-28 isoform (SS-28), which is mainly generated by tor.[29] Therefore, adipocyte insulin resistance will increase

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hepatic glucose production and thereby contribute to the secretory granules; Melatonin receptor 1B (MTNR1B),
pathogenesis of T2D. which is specifically expressed in β-cells, and its activa-
tion leads to decreased cAMP levels and insulin secretion;
And peptidylglycine α-amidating monooxygenase (PAM),
Decreased β-cell mass and function in T2D progression which amidates the bioactive peptides in β-cell secretory
Upon peripheral insulin resistance, pancreatic β-cells granules, and loss of PAM function causes reduced insu-
adaptively enhance insulin production to meet the elevated lin exocytosis in response to glucose. In addition, some
metabolic demand. However, long-term overnutrition and associated variants are found to be in transcription fac-
insulin resistance will lead to prolonged hyperinsulinemia, tors that are essential to β-cell development and insulin
which desensitizes IRs and further deteriorates insulin production, including mutations in NK6 homeobox 3
resistance. Once β-cells cannot adequately respond to (NKX6-3), GATA-binding factor 6 (GATA6), hepato-
insulin resistance, they lose their compensatory ability and cyte nuclear factor 4α (HNF4α), glucokinase (GCK),
switch to a pathological response, resulting in progressive hepatocyte nuclear factor 4α (HNF1α), pancreatic and
loss of cell mass and/or function and thereby diabetes duodenal homeobox protein 1 (PDX1), neuronal differen-
onset. In fact, multiple autopsy studies have quantified tiation 1 (NEUROD1), and hepatocyte nuclear factor 1β
β-cells in T2D, and it is assumed that β-cell mass is reduced (HNF1β), which are also the cause of monogenic forms
by approximately 40–60% in most people with T2D.[30] of diabetes.[33] Moreover, recent single-cell epigenomic
Importantly, even people with impaired fasting glucose analysis revealed that the T2D-associated genetic vari-
also show approximately 40% deficit in β-cell volume ant rs231361 at the noncoding region of the potassium
density, indicating that a decline in β-cells occurs early in voltage-gated channel subfamily Q member 1 (KCNQ1)
the prediabetic stage. In addition to mass reduction, β-cell locus regulates β-cell chromatin accessibility and insulin
functional deficits are also evident in T2D patients. Along synthesis.[34] Overall, these results provide evidence that
with the progressive loss of insulin-producing cells, the both β-cell function and development are responsible for
remaining β-cells concurrently make functional adapta- T2D pathogenesis. Further analysis should identify more
tions in response to increased insulin demand. Over time, β-cell function-associated genes and functionally validate
β-cells become progressively maladaptive and are eventually their therapeutic potential.
defective in secretory function. As described above, β-cell
mass is reduced by approximately 40–60% in T2D Aging
patients, while their insulin secretion capacity is decreased
by 50–97%, indicating a contribution of β-cell function A substantial body of data has shown that aged individ-
to insulin insufficiency.[31] Moreover, dysfunctional β-cells uals display a gradual deterioration in the regulation of
are unable to efficiently process proinsulin to mature glucose homeostasis, and this metabolic alteration is par-
insulin, further magnifying the degree of insulin deficits. tially due to inadequate β-cell compensatory adaptation
Human studies have demonstrated that these deficits are to peripheral insulin resistance.[35] In fact, β-cell prolifera-
present not only in overt T2D patients but also in people tion rates decline rapidly following the first 2 years of life
with glucose intolerance or impaired fasting glucose. and thereafter maintain an unaltered very low replicative
rate. To accompany the decrease in β-cell division in
aged human β-cells, the mitogenic transcription factor
Mechanisms Leading to β-cell Failure FOXM1, cell cycle activators including cyclin A1 and
A2 (CCNA1 and CCNA2) and cyclin-dependent kinases
Several hypotheses for the explanation of β-cell failure
(CDK1, CDK4, and CDK6), and proliferation-regulating
have been proposed, including genetic background, age,
platelet-derived growth factor (PDGF) receptor (PDGFR)
amylin cytotoxicity, β-cell identity loss, ER and oxidative are downregulated. Conversely, the cell cycle inhibitor
stress, mitochondrial dysfunction, and islet inflammation. CDKN2A (also known as P16INK4a) and its upstream
Better recognition of the molecular mechanisms under- activator transforming growth factor-beta (TGFβ) are
pinning β-cell dysfunction could identify new therapeutic upregulated during the process of aging.[36] Furthermore,
targets or lead to more specific approaches to diabetes the islet blood vessel network, which is essential to the
management. production and spread of mitogenic signals for β-cell
proliferation, is decreased in elderly subjects.[35] In addi-
Genetics tion, telomeric DNA lengths decrease gradually with
aging, and eventually, telomere shortening triggers β-cell
Genetics plays an important role in T2D, and genome- proliferation arrest and senescence.[35] Of note, recent
wide association studies show that the majority of studies suggest that aging correlates with a noticeable
T2D-associated genomic polymorphisms are linked reduction in global m6A mRNA methylation, and deple-
to disturbances in β-cell function or mass.[32] Although tion of m6A in β-cells decreases β-cell proliferation and
many genetic variants associated with T2D are located in insulin secretion.[37] Furthermore, aged β-cells may acquire
intergenic regions, some are specifically in certain genes. markers of senescence and secrete a senescence-associated
The most consistently associated genes include cyclin-de- secretory phenotype, which accelerates adjacent β-cell
pendent kinase 5 (CDK5) regulatory subunit-associated senescence and dysfunction in a paracrine manner.[35]
protein-like 1 (CDKAL1), which modifies tRNALys at
position 37 to strengthen amino acid incorporation and Apart from proliferation, β-cell identity may be altered
proinsulin processing; Zinc transporter 8 (SLC30A8), in older individuals. Recent accumulating evidence in
which is responsible for zinc homeostasis in insulin rodents has shown that aged animals and senescent islets

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tend to express less β-cell transcription factors (Pdx-1, oncogene homolog A (MAFA).[42] In addition, ROS
Nkx6.1, FoxO1, and MafA) and functionally important accumulation can stabilize hypoxia-inducible factor-1α
genes (Ins1, Ins2, Slc2a2, and Slc30a8), along with more (HIF-1α), which is a transcription factor of some glyco-
expression of β-cell dedifferentiation markers (Sox9 and lytic enzymes, such as pyruvate dehydrogenase kinase 1
Aldh1a3).[38] Similarly, in the human pancreas, PDX1 (PDK1) and LDH, resulting in excessive expression of
expression is markedly downregulated with aging.[39] LDH and PDK1.[42] Consequently, pyruvate is primarily
Remarkably, a single-cell RNA-seq analysis revealed converted to lactate rather than acetyl-CoA for mitochon-
that the number of bihormonal cells that simultaneously drial oxidative phosphorylation, leading to a reduction
expressed both insulin and glucagon mRNA increased in ATP production and insulin secretion. ROS may also
with age, and the presence of such transcriptionally noisy damage β-cells by inducing mitochondrial injury and
cells suggests a fate drift between α- and β-cells in the its associated abnormal oxidative metabolism.[41] Aside
aging pancreas, resulting in a loss of β-cell identity and from the breakage of mitochondrial DNA and protein
function. Likewise, these transcriptionally noisy cells denaturation, oxidative stress is also believed to induce
associated with aging are also observed in pancreatic islet aberrant mitochondrial fusion by suppressing mitochon-
cells from cynomolgus monkeys.[40] drial fission 1 protein (FIS-1), thus forming elongated
giant mitochondria with impaired function to change the
metabolic pattern of β-cells.
Oxidative stress
Pancreatic islets of T2D patients and rodent models are ER stress
often subjected to oxidative stress, which arises when
intracellular reactive oxygen species (ROS) generation Insulin is translated and formed into its native structure
exceeds the antioxidant responses of the cell. β-cells express in the ER of β-cells. Approximately 1 million proinsulin
substantially less antioxidant enzymes, such as superoxide molecules are produced per minute in a healthy β-cell.
dismutase and glutathione peroxidase, rendering them Thus, β-cells must adapt their ER machinery to a rise
highly vulnerable to oxidative stress.[41] Under hyperg- in glucose to support insulin production. As proinsulin
lycemic conditions, the continuously increased cellular is quite susceptible to misfolding, it is estimated that
glucose augments β-cell glycolysis and pyruvate produc- around 20% of proinsulin is misfolded.[44] Thus, under
tion. However, pyruvate in β-cells cannot be metabolized hyperglycemic conditions, the high secretory demand of
via the lactate pathway due to the disallowed expression insulin inevitably causes an accumulation of unfolded or
of lactate dehydrogenase (LDH) and monocarboxylate misfolded proteins, which may overwhelm the ER folding
transporter-1. Thus, glucose in β-cells is almost oxidized capacity to trigger unfolded protein responses (UPRs) and
through mitochondrial oxidative phosphorylation, leading ER stress. The UPR is initiated by the dissociation of the
to an increased production of ATP along with elevated ROS ER chaperone GRP78 from ER transmembrane proteins
generation.[42] Of note, the increase in intracellular Ca2+ including protein kinase RNA (PKR)-like ER kinase
induced by glucose oxidative metabolism triggers endoge- (PERK), inositol-requiring enzyme 1 (IRE1), and ATF6,
nous ROS production through PKC-dependent activation which are normally bound to GRP78 to remain inactive.
of NADPH oxidase, which in turn stimulates superoxide Under ER stress conditions, the UPR not only inhibits
anion (O2•–) formation by transferring electrons from protein translation via PERK-mediated inhibition of eIF2α
intracellular NADPH to extracellular molecular oxygen. and IRE1α-mediated mRNA degradation to attenuate ER
Thereafter, O2•– is either transported into the cytosol to load but also upregulates the expression of ER chaperones
initiate intracellular signaling or dismutated to H2O2 by via ATF6 to increase folding capacity. Furthermore, the
extracellular SOD. Furthermore, the insulin-maturing pro- UPR can remove misfolded or unfolded proteins through
cess is unavoidably accompanied by ROS generation. As the IRE1α-XBP1-mediated ER-associated degradation
the formation of three proper disulfide bonds is crucial for (ERAD) pathway and autophagy.[45] Although the adap-
insulin biofunction, and each formation of a disulfide bond tive UPR output can protect β-cells against ER stress, if ER
produces one molecule of ROS, it is anticipated that three stress is prolonged and unresolvable, the UPR eventually
molecules of ROS are produced with each production of triggers proapoptotic pathways by initiating the expression
one molecule of insulin. Thus, a 50-fold increase in insulin of critical proapoptotic proteins, such as CHOP, RIDD,
biosynthesis under hyperglycemic conditions inevitably DR5, and PUMA.[46] Recent studies have implicated that
results in the production of millions of ROS molecules per some cytosolic proteins, such as RACK1 and the ABL fam-
minute in every β-cell.[41] ily of tyrosine kinases, can translocate to ER membrane
and interact with IRE1α, regulating ER stress-mediated
Biologically, low physiological concentrations of ROS β-cell apoptosis through modulation of IRE1α RNase
act as second messengers to participate in diverse cellular activity.[45] In addition, the β-cell apoptosis induced by
processes, and transient and moderate ROS can stimulate ER stress is associated with TXNIP, which is upregulated
β-cell proliferation and potentiate glucose-stimulated by the PERK and IRE1 pathways.[45] Moreover, recent
insulin secretion by inducing ryanodine receptor-mediated studies have found that irremediable ER stress induces
Ca2+ release.[43] However, long-term exposure to excessive the expression of thyroid adenoma associated (THADA),
amounts of ROS causes β-cell impairment. ROS may which interacts with SERCA2 and RyR2 to decrease ER
activate stress-induced mitogen-activated protein kinases Ca2+ stores and aggravate ER stress-induced apoptosis.[47]
(MAPKs) such as JNK and p38 MAPK, which in turn
potentiate the degradation of β-cell key transcription fac- It is crucial to emphasize that oxidative and ER stresses are
tors PDX-1 and V-maf musculoaponeurotic fibrosarcoma tightly entwined, and they are potent in exacerbating one

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another. For example, lipotoxicity-induced ROS triggers a intracellular oxidative stress, ER stress, or inflammatory
reduction in ER Ca2+ storage, leading to compromised ER cytokines.[53] Upon dedifferentiation, β-cells progressively
folding capacity, which further aggravates ROS through lose their specific transcription factors such as FOXO1,
ER oxidoreductase ER member 1α (ERO1α). Moreover, PDX1, MAfA, NEUROD1, and NKX6.1; Lose the
mitochondria and the ER actively communicate through “disallowed” genes, including Ldh, Mct1, and acyl-CoA
their membrane contacts called mitochondria-associated thioesterase 7 (Acot7); and reactivate endocrine progen-
membranes (MAMs), which also participate in Ca2+ dis- itor markers, such as Ngn3, Aldh1a3, andSox9.[54] These
tribution and ROS diffusion between these organelles.[48] alterations lead to β-cell reconfiguration in metabolism
Therefore, oxidative and ER stresses form a vicious cycle and structure, resulting in loss of β-cell characteristics and
and profoundly impact β-cell function, and targeting ultimately deficits in insulin production and secretion.
both forms of stress should be more effective in disease Although there is evidence that β-cell dedifferentiation
treatment. is positively correlated with β-cell deficits and T2D
severity,[55] the contribution of dedifferentiation to the
loss of β-cell mass and function in humans is controversial
Inflammation and not yet clear. One study using synaptophysin as the
Islet immune cells are mainly composed of resident dedifferentiation marker identified 32% dedifferentiated
macrophages, which have the capacity to produce proin- β-cells in T2D patients compared with only 9% in control
flammatory mediators, such as interleukin (IL)-1β and individuals,[54] while a subsequent study using chromogra-
tumor necrosis factor α (TNF-α). Evidence from both nin A as a dedifferentiation indicator found that the β-cell
rodents and humans clearly indicates that the number dedifferentiation was quantitatively small in both T2D
of macrophages in T2D or obese islets is increased and and nondiabetic controls.[56] Similarly, one bulk mRNA
that they are recognized as key contributors to β-cell sequencing study also did not observe distinct cell types
inflammation.[49] Transcriptomic analyses of isolated among T2D islets or unaltered levels of maturation and
islets found that T2D is associated with overexpressed identity genes between T2D and nondiabetic donors.[57]
macrophage markers such as APOE and CD163L1,[50] However, another single-cell RNA sequencing study on
islets reported that the β-cell transcriptomic profiles in
further supporting macrophage accumulation in T2D
T2D donors resemble those in their juvenile counter-
islets. Simultaneously, several proinflammatory cytokines
parts, suggestive of partial dedifferentiation.[58] These
(IL-1β, TNF-α, and IL-24) and a few chemokines (CCL-2,
contradictory results are possibly attributed to clinically
5, -7, -13, -16, -21, and -25, CX3CL-1,-11, and -12, and
different T2D subtypes, different patient characteristics,
CCL-3, -8, and -26) are also upregulated in diabetic islet
or distinct β-cell subpopulations, which warrant further
samples,[51] providing molecular evidence of islet inflam-
investigation.
mation and immune cell infiltration in T2D. Apart from
local resident macrophages, β-cells can also secrete IL-1β Apart from dedifferentiation, lineage-tracing studies indi-
in proinflammatory circumstances, such as prolonged cate that β-cells lacking NKX2.2 or PDX1 or activating
exposure to high concentrations of glucose or free fatty the α-cell transcription factor aristaless related homeobox
acids.[52] Moreover, there is evidence that proinflammatory (ARX) can be converted into glucagon-producing α-cells
factors such as IL-1β, IL-6, and TNF-α are progressively or somatostatin-producing δ-cells.[54] This process is
increased from prediabetic to T2D patients.[52] These referred to as β-cell transdifferentiation, which causes
inflammatory cytokines could activate the nuclear factor a reduction in insulin production, hyperglucagonemia,
(NF)-κB and JNK signaling pathways, which subsequently and hyperglycemia. Although it remains unclear whether
repress the expression of β-cell identity genes such as transdifferentiation affects endogenous α-cell function
Slc2a2, Pdx1, and MafA and ultimately cause β-cell dedif- and glucagon production, minimizing the transdifferen-
ferentiation. Additionally, NF-κB activation in β cells may tiation of β-cells to α-cells might provide a new avenue
also repress the expression of SERCA2b, which encodes to delay or prevent the progression of diabetes. However,
an ER calcium pump, dampening insulin secretion by it is unclear whether β-cell transdifferentiation is a cause
exacerbating ER stress.[52] Moreover, a recent study or an effect of T2D. Additionally, it is undetermined
has shown that proinflammatory cytokines can activate whether β-cells first differentiate into progenitor-like cells
proapoptotic BCL-2 proteins and induce mitochondrial before they initiate transdifferentiation. There is evidence
stress, leading to β-cell apoptosis. In addition to the pro- suggesting that transdifferentiation occurs after differen-
duction of proinflammatory cytokines, islet-associated tiation.[54] However, both rodent diabetes models and T2D
macrophages can decrease insulin secretion in obesity by patients have also revealed that a distinct subset of islet
phagocytosing β-cell insulin secretory granules, and this cells can secrete both insulin and glucagon under hyper-
effect is mediated by direct contact between β-cells and glycemic conditions,[53,59] thus implying the existence of
intraislet macrophages. Furthermore, islet macrophages a more direct transdifferentiation process between endo-
are associated with abnormal proinsulin processing during crine cells. Further exploration is needed to understand
obesity, which could be attributed to their detrimental the mechanisms that regulate the conversion between
effect on the adaptive UPR in β-cells.[49] pancreatic endocrine cells.

β-cell dedifferentiation and transdifferentiation Targeting Pancreatic β-cells for Diabetes Treatment
Mature β-cells can lose their features through dedifferen- At present, no real cure exists for diabetes. Although a
tiation in response to increased physiological demand, variety of pharmacological therapies are lifesaving, such

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as metformin, sulfonylurea drugs, meglitinides, GLP1R adaptive β-cell proliferation, including GLP-1 and its
agonists, dipeptidyl peptidase 4 (DPP-4) inhibitors, analog exendin-4, T-cell cytokines such as IL6 and IL2,
sodium glucose cotransporter 2 (SGLT2) inhibitors, hepatocyte-derived factors such as insulin-like growth
thiazolidinediones, Ca2+ channel blockers, alpha-glucosi- factor (IGF) and serpinB1, adipocyte-derived serum fac-
dase inhibitors, and bile acid sequestrants, they often have tors such as leptin and adiponectin, and lactogens such
limited glucose-lowering properties and insulin injection as prolactin placental lactogen.[61] Additionally, multiple
remains the common care for patients with late-stage T2D.[4] extracellular matrix (ECM) components including
Although the administration of recombinant exogenous collagen, laminin, fibronectin and heparan sulfate, and
insulin can effectively maintain glycemic control, over- ECM-sequester growth factors such as connective tissue
delivery may result in life-threatening hypoglycemic growth factor (CTGF, also known as cellular communica-
episodes. Given that endogenous insulin secreted by islet tion network 2, CCN2), fibroblast growth factor, vascular
β-cells is fine-tuned and reduction in functional β-cell endothelial growth factor, and hepatocyte growth factor
mass is a hallmark feature of T2D, β-cell replenishment have also been implicated in promoting β-cell prolifera-
through transplantation of whole pancreas or pancreatic tion by establishing a homeostatic islet microenvironment.
islet cells or stem cell-derived β-cells or expansion of Recently, CCN4/WISP1, which is abundant in preweaning
endogenous β-cells may serve as a promising approach to mouse blood, was shown to promote the proliferation of
improve diabetes therapy [Figure 1]. Recent decades have endogenous and transplanted adult β-cells in vivo.[62] In
witnessed considerable progress in the development of addition to ECM components and ECM-localized factors,
β-cell regenerative therapies for the treatment of diabetes. ECM remodeling driven by paracrine signaling from mac-
rophages and intraislet endothelial cells is also implicated
in driving β-cell proliferative activity.[63] Recent studies
Inducing endogenous β-cell proliferation
have demonstrated that islet macrophages from obese
In principle, the induction of β-cell proliferation is the mice are able to promote β-cell proliferation through
most effective and straightforward approach to regenerate PDGF–PDGFR signaling[49] and the lack of PDGFR signa-
β-cells, but this is quite difficult for β-cells due to their ling in β-cells leads to compromised β-cell replication in
extremely low replication rate, particularly in adult aged mice and humans.[64]
humans.[60] The β-cell population in healthy individuals
is largely stable throughout adult life, and long-lived β-cell intracellular signaling pathways including IRS-
β-cells are as aged as the body. However, adult β-cells PI3K-mTOR, glycogen synthase kinase 3 (GSK3),
are also plastic and able to reenter the cell cycle under carbohydrate-responsive element-binding protein
certain pathophysiological conditions such as obesity and (ChREBP), and extracellular signal-regulated kinase
pregnancy, indicating their maintenance of proliferative (ERK) pathways are stimulated by extracellular signals,
capacity. Thus, stimulating β-cell proliferation may be regulating proliferative capacity in adult β cells,[65,66] For
a viable alternative to compensate for the severe loss of example, glucose and insulin can activate the PI3K-AKT-
β-cells in diabetes. mTOR signaling pathway to increase β-cell replication in
both mouse and human β cells. p16INK4A accumulation
blocks β-cell proliferation in both mice and humans, a
Endogenous signals promoting β-cell proliferation histone–lysine N/methyltransferase enzyme encoded by
A number of endogenous molecules secreted by non- the enhancer of zeste homolog 2 (EZH2) can effectively
pancreatic organs have been shown to be involved in repress p16INK4A expression to enhance β-cell replication
in mice <8 months, and PDGF receptor signals may
maintain EZH2 expression and EZH2-dependent β-cell
replication in 14-month-old mice.[64] Osteoprotegerin,
a target of prolactin receptor signaling, can bind to
receptor activator of NF-κB ligand (RANKL/TNFSF11)
to activate the cAMP-response element-binding protein
(CREB) pathway and inhibit GSK3 to stimulate rodent
and human β-cell replication.[67] SerpinB1, a liver-derived
protease inhibitor, promotes the proliferation of human,
mouse, and zebrafish β-cells by activating several key
proteins in the insulin/IGF-1 signaling pathways including
MAPK, GSK3, and PKA.[68] Likewise, reduction of the
tumor repressor menin encoded by the Men1 gene activates
the MAPK pathway to increase the proliferation of mouse
and human adult β cells.[69] Calcineurin–nuclear factor
activated in T cells (NFAT) is a major mitogenic stimu-
Figure 1: Strategies for β-cell regenerative therapies. β-cell replenishment through exog- lator of β-cell replication; it promotes the cell cycle by
enous transplantation of pancreas or pancreatic islet cells or stem cell-derived β-cells and
transactivating cyclins E and A and repressing p16INK4A,
endogenous expansion of β-cells via cell proliferation or transdifferentiation. Both pan-
creatic endocrine cells, such as islet α-cells, δ-cells, and γ-cells, acinar cells, duct cells, p14ARF, and p57KIP2.[70] Recently, it has been reported that
and gastrointestinal tract cells, can be reprogramed into insulin-producing β-like cells. ELAPOR1 (also known as inceptor) suppresses insulin
Stem cell-derived β-cells have positioned hPSCs, typically including ESCs and iPSCs, as a signaling specifically in pancreatic β-cells by clathrin-me-
promising and theoretically unlimited source of insulin-producing cells. ESCs: Embryonic diated degradation of IR, resulting in decreased β-cell
stem cells; hPSCs: human pluripotent stem cells; iPSCs: induced pluripotent stem cells.
proliferation.[71] Although targeting these intracellular

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signaling pathways may serve as a promising strategy to widely used as an antidepressant, is able to increase β-cell
preserve β-cell expansion, many of them have been iden- proliferation and potentiate glucose-induced insulin
tified in rodents and hence their applicability to human secretion from mouse and human islets at therapeutically
cells needs to be ascertained. relevant concentrations.[80]

With the increasing appreciation of the mechanisms

Small molecules inducing β-cell proliferation involved in promoting human β-cell proliferation and
Currently, no drug can specifically promote islet β-cell the development of high-throughput screening tools, it is
proliferation on the market. However, a substantial num- anticipated that more small molecules and drugs expanding
ber of small molecules have been discovered to induce functional β-cell mass will be identified. However, the
human β-cell replication, such as 5-iodotubercidin (5-IT), determination of their specificity and efficacy in vivo,
harmine, GNF4877, GNF2133, INDY, leucettine-41, and especially in humans over time, will bring new challenges.
CC-401.[72–74] Interestingly, all these compounds suppress
the activities of dual-specificity tyrosine phosphorylation-
Induction of cell transdifferentiation
regulated kinase 1A (DYRK1A), which can terminate
mitogenic signaling by phosphorylating NFAT and thus Diverse lines of evidence have shown that pancreatic
blocking NFAT nuclear localization.[72,73] Moreover, the non-β-cells such as α-, δ-, acinar, and duct cells or liver
combination of DYRK1A inhibitors, such as harmine, cells can convert into new insulin-producing β-like cells.
with other compounds, such as exendin-4 and liraglu- Therefore, the generation of new β-cells from cells not
tide, that are GLP1R agonists,[75] as well as ALK5 that expressing insulin via cellular transdifferentiation could
is a TGFβ-pathway inhibitor[76] induces a synergistic be a promising approach to expand functional β-cell mass.
increase in human β-cell proliferation. In addition, some
phytochemicals show strong inhibitory activity against
DYRK1A, such as aristolactam BIII, licocoumarone, Transdifferentiation from pancreatic non-β-cells
polyandrocarpamines, desmethylbellidifolin, and epigal- The conversion of α- to β-cells has been intensively
locatechin-3-gallate,[77] which offer a potential alternative studied as they develop from a common lineage trajectory.
for promoting β-cell replication. Although DYRK1A Studies in mice have shown that inactivation of ARX that
inhibitors show a robust capacity to promote β-cell is a master regulator of α-cell development, or ectopic
replication, their practical utility remains a concern. Con- expression of PAX4, MAFA, and PDX1 promotes α-cell
sidering the broad expression of DYRK1A, its inhibition to β-cell transdifferentiation.[81] Of note, the combined
could trigger unwanted proliferative responses of non-β- loss of ARX and DNA methyltransferase 1 (DNMT1)
cells, and indeed, systemic administration of DYRK1A
accelerates α-cell transdifferentiation to β-cells.[82] Simi-
inhibitors activates replication of islet α-, δ-, and ductal
larly, α-cell specific MEN1 ablation leads to α- to β-cell
cells.[73] Furthermore, DYRK1A inhibitors also target
conversion but insulinoma formation. Such a deregulation
other signaling molecules in addition to their effects on
of α-cell plasticity also occurs when β-cells are almost
DYRK1A, for example, harmine is also an inducer of the
completely ablated by diphtheria toxin receptor (DTR)
transcriptional regulator MYC, GNF4788 is also a suppres-
in post pubescent mice.[83] Conversion to β-cells also
sor of GSK-3β kinase,[74] and 5-IT is also an inhibitor of
occurs in human α-cells being reprogramed with ectopic
adenosine kinase[72]; Thus, a number of off-target effects
are possible. MAFA and PDX1.[84] In addition to various transcription
factors, endogenous factors such as IGF binding-protein
Denosumab is an FDA-approved antiosteoporosis drug 1 (IGFBP1) also promote α- to β-cell transdifferentiation
that specifically inhibits human RANKL, which is known in both mice and human islets.[85] Long-term GABA
as a brake of β-cell replication.[67] Thus, denosumab acts administration may trigger α- to β-cell conversion and
as a partial functional equivalent of osteoprotegerin to the neo-generated β-like cells are capable of reversing
promote β-cell proliferation. The IR antagonist S961 STZ-induced diabetes in vivo.[86] Artemisinins, an
or the insulin and IGF receptor dual inhibitor OSI-906 antimalarial drug, has been suggested to induce α- to β-
potentiate β-cell proliferation independent of insulin sig- transdifferentiation by promoting the degradation of the
naling. GLP-1R agonists such as liraglutide and exenatide α-cell transcription factor ARX and by stimulating GABA
also promote β-cell proliferation though the cAMP/PKA, signaling.[87] However, such α- to β-cell conversion was
PI3K/AKT, and MAPK multiple signaling pathways. not observed in studies using lineage tracing or in primary
SGLT2 is a Na+ concentration-dependent protein distrib- mouse islets.[88] Other interesting possibilities include
uted in kidneys, and its inhibitors, such as empagliflozin GLP-1 analogs such as liraglutide and SGLT2 inhibitors
and luseogliflozin, have been demonstrated to enhance such as dapagliflozin, which can induce β-cell transdiffer-
β-cell proliferation and increase β-cell area in diabetic entiation from α-cells.[89] A recent study suggested that
mouse models.[78] The adenosine agonist N-ethylcar- sitagliptin and melatonin combination therapy may addi-
boxamidoadenosine (NECA) could promote mouse tively induce α- to β-cell transdifferentiation in diabetic
β-cell proliferation and accelerate the restoration of mice.[90] In addition to α-cells, islet δ-cells and γ-cells (also
normoglycemia following streptozotocin (STZ)-induced known as PP cells) can also transdifferentiate into β-cells
diabetes[79]; Thus, the components of the adenosine path- to compensate for the severe loss of β-cells.[91,92] Notably,
way might be therapeutically targeted for the treatment of δ- to β-cell conversion mainly occurs in prepubescent
diabetes. Most recent evidence indicates that fluoxetine, mice and relies on the suppression of mitogenic FOXO1
a selective serotonin reuptake inhibitor (SSRI) that is signaling.[91]

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Besides endocrine cells, pancreatic exocrine cells such as an immune-privileged site, rendering the gastrointestinal
acinar cells and duct cells retain a degree of plasticity. tract an ideal site either for being reprogramed to func-
Studies from transgenic mice have found that overexpres- tional insulin-producing cells or for the engraftment of
sion of the combination of PDX1, MAFA, and Neurog3 regenerated cells that mimic β-cell function.[103] Upon
(PMN), which are necessary transcription factors for ectopic expression of PMN factors in intestinal crypts,
β-cell development, or even PDX1, induces the direct intestinal cells can convert to insulin-producing and
conversion of acinar cells into insulin-producing β-like glucose-responsive β-like cells that are capable of ame-
cells.[93] Furthermore, rodent acinar cells can also be liorating hyperglycemia in mice.[104] In contrast, somatic
reprogramed into insulin-producing cells following sus- ablation of the transcription factor FOXO1 in Neurog3+
pension culture and the addition of epidermal growth enteroendocrine cells generates β-like cells that release
factor in combination with either leukemia inhibitory insulin in a glucose-regulated manner and are able to
factor or nicotinamide.[94] Growth factor-induced acinar- reverse hyperglycemia in streptozotocin-induced diabetic
to-β-cell conversion is nearly completely suppressed by mice.[103] In addition, GLP-1 treatment converts intestinal
Notch signaling, which antagonizes the expression of the epithelial progenitors into insulin-producing cells in vitro
proendocrine factor Neurog3, whereas Notch inhibition and in vivo that depend on the hepatocyte nuclear fac-
improves β-cell transdifferentiation, with approximately tor 6-mediated expression of Ngn3, and the resulting
30% of acinar cells adopting a β-like phenotype.[95] β-like cells can ameliorate diabetes after implantation
Acinar-to-β-cells conversion is also promising in humans, into STZ-induced diabetic mice.[105] Recent studies have
and ectopic expression of signal transducer and activator revealed that antral stomach tissue is highly amenable
of transcription 3 (STAT3) and MAPK in human acinar to reprograming toward functional insulin-producing
cells can activate Neurog3 expression and induce the conver- cells with robust expression of key β-cell genes, such
sion of acinar cells to insulin-producing β-like cells.[96] as Nkx6.1 and Glut2.[106] Given that cell plasticity and
Similarly, ductal epithelial cells also serve as a source transformation mechanisms vary in different segments of
of β-cells. Extensive tissue damage caused by surgical gastrointestinal tissues, site-specific strategies are expected
pancreatic duct ligation (PDL) or partial pancreatectomy to improve the regenerative capacity of these tissues.
promotes β-cell neoformation from duct cells in rat and
murine models.[97] In addition, the process of duct- to Despite the aforementioned findings in the conversion of
β-cell progression can be stimulated by various genetic non-β-cells into insulin-producing cells, it remains unclear
manipulations, such as overexpression of interferon-γ, whether transdifferentiated cells could preserve their new
simultaneous expression of gastrin and transforming β-like features without retrogression to a prior state. In
growth factor alpha (TGFα) in duct cells, or deletion of addition, it is necessary to determine whether insulin
the tumor suppressor ubiquitin ligase Fbw7 in pancreatic secretion in reprogramed cells is under the control of meta-
duct cells.[98] bolic demand. Furthermore, the conversion rate remains
low, which limits transdifferentiation-derived β-cells for
Transdifferentiation from nonpancreatic cells clinical use.
Due to their substantial plasticity and close lineage
association with pancreatic cells, hepatocytes provide a Supply β-cells via exogenous pancreas or islet
promising source for functional β-cell neogenesis. Ectopic transplantation
expression of pancreatic transcription factors in hepato-
cytes reprograms hepatocytes into insulin-producing β-like Although endogenous approaches deterring the decline of
cells, and the efficiency of this plasticity is determined β-cell mass in diabetes are of encouragement, the treat-
by the activation of the Wnt/β-catenin pathway, which ment falls short of a cure. Pancreatic β-cell replacement
stabilizes a transdifferentiation-permissive epigenome.[99] through whole pancreas or pancreatic islet transplan-
Upon ectopic expression of PDX1 in the mouse liver, tation holds the potential to truly cure diabetes. Whole
certain hepatocytes typically located near the central and pancreas transplantation has been accomplished in
portal veins of the hepatic lobules display a predisposition several thousand diabetic subjects and has achieved long-
to transdifferentiation into β-cells,[100] and additional term insulin independence and good metabolic control
external factors such as high glucose and hyperglycemia in many individuals. Although pancreas transplantation
are necessary conditions for complete conversion into is an effective therapy especially for patients with simul-
functional insulin-producing cells.[101] In addition, hepato- taneous kidney transplantation, the surgical risk remains
cyte-to-β-cell transdifferentiation can be induced by GLP an important consideration. Isolated islet transplantation
analogs, PDGF, Notch inhibitors, TGFβ-induced factor has offered a more favorably safe alternative with less
homeobox 2 (TGIF2), and TGFβ inhibitors.[102] Adult invasion. Since the establishment of the Edmonton pro-
human hepatocytes with ectopic pancreatic transcription tocol,[107] islet transplantation has provided a functional
factors in vitro are also converted into insulin-producing cure for insulin-dependent diabetes, and it is superior to
β-like cells in response to increasing glucose within the exogenous insulin administration regarding stabilizing
physiological range.[102] However, only approximately glycemic control, reducing hypoglycemic events, and
5–15% of the cells display insulin expression. restoring hypoglycemic awareness. However, islet cell
transplantation faces some new challenges, notably the
The gastrointestinal tract, in particular, the intestinal severe shortage of donor islets and deterioration of the
and antral stomach niches, is rich in endocrine cells with cells post transplantation. First, the source of islet cells
highly similar features to pancreatic β-cells and is also for transplantation is limited to donors who have died

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from brain death and cardiac death, which severely limits islets. The resulting β-cells show dynamic insulin secre-
the availability of donor islets. Second, isolated islets tend tion, active calcium signaling, and metabolic maturation
to undergo rapid necrosis under conventional culture of mitochondria. Recently, Hogrebe et al[112] developed a
conditions due to oxygen depletion, and grafted islet cells new planar cell culture technique for generating human
also suffer from immediate loss after transplantation due stem cell-derived β-cells, demonstrating that the polym-
to disruption of the microvascular network and oxygen erization of the actin cytoskeleton controls endocrine
depletion in the isolation process,[108] further aggravating specification by modulating premature Neurog3 expres-
islet scarcity. Therefore, an excessive number of islet sion. Notably, β-cells generated with this protocol display
cells collected from two to three individual donors are dynamic insulin secretion and their transplantation into
needed per transplant for most islet transplant recipi- mice rapidly cures severe preexisting diabetes within
ents.[107] Third, although immunosuppressive drugs are 2 weeks. Most recently, the Deng laboratory devel-
used, there is still a high rejection rate of islet cells after oped a method to reprogram human somatic cells into
transplantation. Patients receiving multiple grafts will pluripotency by using a combination of small-molecule
generate allo- and autoantibodies; Thus, the long-term compounds rather than genetic manipulation.[113] The
effectiveness of islet allografts is not guaranteed. Finally, human chemically induced PSC-derived islets (hCiPSC-is-
the lifelong use of immunosuppressants may increase the lets) generated by this protocol contain insulin granules
risk of infection, bone marrow suppression, kidney dam- as well as α- and δ-like cells, and they display similar
age, and tumorigenesis.[109] features to human islets in gene expression and biphasic
insulin secretion. Implantation of hCiPSC-islets into the
abdominal rectus sheath of diabetic monkeys restores
Generation of β-cells from human pluripotent stem cells endogenous insulin secretion and glycemic stability.[114]
(hPSCs) Currently, several stem cell-based therapies for diabetes
have already entered clinical trials. One notable trial (No.
The limited availability and quality of donor islets for NCT04786262) was conducted by Vertex. Pharmaceuti-
transplantation treatment has fueled the search for alter- cals (Boston, USA), involving the transplantation of stem
native sources of insulin-secreting cells. Recent advances cell-derived islets (VX-880) into T1D patients. VX-880
in the development of stem cell–derived β-cells have posi- can improve glycemic control and reduce the require-
tioned hPSCs as a promising and theoretically unlimited ments of exogenous insulin in all recipients.
source of insulin-producing cells. hPSCs typically include
embryonic stem cells (ESCs) and induced pluripotent stem Although there has been tremendous progress with the
cells (iPSCs). ESCs are derived from the inner cell mass generation of hPSCs in vitro, the generated β-like cells
of blastocysts that occur about 4–5 days after fertiliza- do not recapitulate primary β-cells in some aspects, such
tion and possess the potential to extensively self-renew as calcium response and mitochondrial metabolism,[115]
and differentiate into any desired cell type in the body. and the amount of glucose-stimulated insulin secretion in
In contrast, iPSCs with the same properties as ESCs are hPSC-derived β-cells is lower than that of their primary
generated by genetically reprograming adult cells such as counterparts.[111] Additionally, the reprograming pro-
dermal fibroblasts back to an embryonic-like state using tocols focus on eliminating polyhormonal cells that are
defined factors. Although ESCs represent a promising cell generated in vitro, but a subset of polyhormonal cells
source for cell-based therapy and are potentially applied naturally occur in human islets and particularly in fetal
to treat a host of diseases, human ESCs are derived from islets.[116]
surplus embryos, and their application in medicine has
raised several ethical concerns. Pluripotent and prolifer-
ative iPSCs are derived from adult somatic cells without Conclusions and Perspectives
ethical concerns, and they retain the genetic profile of Different diabetic therapeutics aim to replenish β-cell
the source cells, making them a promising tool for cell mass and hence restore β-cell function. However, the
therapy without immune consequences. existence of heterogeneous β-cell subpopulations poses
many challenges in terms of designing therapeutics or
To truly potentiate hPSCs in β-cell regeneration, reproduci- strategies for modulating this disease. Recent single-cell
ble and efficient protocols that direct the differentiation of analyses support the presence of both mature and imma-
hPSCs to functional β-cells are needed. Exciting advances ture β-cell populations,[117] and SIX2 and SIX3 have been
in the generation of hPSC-derived β-cells occurred in 2019, identified as crucial transcription factors in human β-cell
Velazco-Cruz et al[110] achieved robust dynamic insulin maturation by enhancing insulin content and secretion.
secretion of iPSC-derived β cells by modulating TGFβ In some studies, β-cells are even divided into four distinct
signaling, reducing cell cluster size, and using enriched populations according to the expression of the cell surface
serum-free media in a three-dimensional culture system markers CD9 and ST8SIA1,[118] and CD9+ cells show less
that mimics the pancreatic developmental environment. mature β-cell phenotypes with low levels of NKX6.1,
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