Heterozygous mutations in the gene encoding the pancreatic homeodomain transcription factor pancreatic duodenal homeobox 1 (PDX1) are associated with maturity onset diabetes of the young, type 4 (MODY4) and type 2 diabetes. Pdx1 governs the early embryonic development of the pancreas and the later differentiation of the insulin-producing islet β cells of the endocrine compartment. We derived a Pdx1 hypomorphic allele that reveals a role for Pdx1 in the specification of endocrine progenitors. Mice homozygous for this allele displayed a selective reduction in endocrine lineages associated with decreased numbers of endocrine progenitors and a marked reduction in levels of mRNA encoding the proendocrine transcription factor neurogenin 3 (Ngn3). During development, Pdx1 occupies an evolutionarily conserved enhancer region of Ngn3 and interacts with the transcription factor one cut homeobox 1 (Hnf6) to activate this enhancer. Furthermore, mRNA levels of all 4 members of the transcription factor network that regulates Ngn3 expression, SRY-box containing gene 9 (Sox9), Hnf6, Hnf1b, and forkhead box A2 (Foxa2), were decreased in homozygous mice. Pdx1 also occupied regulatory sequences in Foxa2 and Hnf1b. Thus, Pdx1 contributes to specification of endocrine progenitors both by regulating expression of Ngn3 directly and by participating in a cross-regulatory transcription factor network during early pancreas development. These results provide insights that may be applicable to β cell replacement strategies involving the guided differentiation of ES cells or other progenitor cell types into the β cell lineage, and they suggest a molecular mechanism whereby human PDX1 mutations cause diabetes. IntroductionInsulin deficiency due to reduced pancreatic islet β cell number underlies the progression of both type 1 and type 2 diabetes, prompting efforts to develop β cell replacement therapies. The high hopes for human islet transplantation as such a therapy have been tempered by their limited availability and short-term function after transplantation, resulting in an intense focus on the development of alternate sources of β cells, through the guided differentiation of stem or progenitor cells or the transdifferentiation of more abundant mature cells. Transdifferentiation approaches have focused largely on the expression of a single or a combination of transcription factors that drive β cell development and differentiation and most have relied, at least in part, upon pancreatic duodenal homeobox 1 (Pdx1), a homeodomain transcription factor with critical regulatory roles in early pancreas development and in the mature β cell (1-5). Recent advances in the derivation of insulin-expressing β-like cells from ES cells (6-11) have also been guided by the principles of embryonic pancreas development (reviewed in ref. 12). Clinical translation of these approaches, however, will require improvements in efficiency, fidelity, and stability of generating the β cell phenotype, efforts which will likely be informed by the identification of novel...

The calcium-regulated phosphatase calcineurin intersects with both calcium and cAMP-mediated signaling pathways in the pancreatic ␤-cell. Pharmacologic calcineurin inhibition, necessary to prevent rejection in the setting of organ transplantation, is associated with post-transplant ␤-cell failure. We sought to determine the effect of calcineurin inhibition on ␤-cell replication and survival in rodents and in isolated human islets. Further, we assessed whether the GLP-1 receptor agonist and cAMP stimulus, exendin-4 (Ex-4), could rescue ␤-cell replication and survival following calcineurin inhibition. Following treatment with the calcineurin inhibitor tacrolimus, human ␤-cell apoptosis was significantly increased. Although we detected no human ␤-cell replication, tacrolimus significantly decreased rodent ␤-cell replication. Ex-4 nearly normalized both human ␤-cell survival and rodent ␤-cell replication when co-administered with tacrolimus. We found that tacrolimus decreased Akt phosphorylation, suggesting that calcineurin could regulate replication and survival via the PI3K/ Akt pathway. We identify insulin receptor substrate-2 (Irs2), a known cAMP-responsive element-binding protein target and upstream regulator of the PI3K/Akt pathway, as a novel calcineurin target in ␤-cells. Irs2 mRNA and protein are decreased by calcineurin inhibition in both rodent and human islets. The effect of calcineurin on Irs2 expression is mediated at least in part through the nuclear factor of activated T-cells (NFAT), as NFAT occupied the Irs2 promoter in a calcineurinsensitive manner. Ex-4 restored Irs2 expression in tacrolimustreated rodent and human islets nearly to baseline. These findings reveal calcineurin as a regulator of human ␤-cell survival in part through regulation of Irs2, with implications for the pathogenesis and treatment of diabetes following organ transplantation.New onset diabetes mellitus is a major complication following solid organ transplantation, often leading to decreased graft survival and increased mortality (1-3). As with other forms of diabetes, hyperglycemia ensues when there is inadequate pancreatic ␤-cell mass to meet insulin demand (4). Post-transplant diabetes is strongly associated with the use of calcineurin inhibitors, antirejection medications that are widely used in clinical solid organ transplantation (5). This association has prompted long-standing speculation that the calcineurin inhibitors are ␤-cell toxic and pathogenic in transplant-related ␤-cell failure.Calcineurin is a calcium-activated cytosolic phosphatase that is critical for antigen-stimulated T lymphocyte activation (6). Therefore, pharmacologic calcineurin inhibition is highly effective in preventing allograft rejection. However, calcineurin is also expressed in ␤-cells where it has two well described molecular targets, the nuclear factor of activated T cell (NFAT) 2 family of transcription factors (7), and the cAMP-responsive element-binding protein (CREB) transcriptional co-activator, transducer of regulated CREB activity-2 (TO...

The goal of this investigation was to examine clinical translation of glucose responsiveness of MK-2640, which is a novel insulin saccharide conjugate that can bind the insulin receptor or mannose receptor C type 1 (MRC1), the latter dependent upon glucose concentration. In a rising dose study in 36 healthy adults under euglycemic clamp conditions, rising exposures revealed saturation of MK-2640 clearance, likely due to saturation of clearance by MRC1. Potency of MK-2640 was ~25-fold reduced relative to regular human insulin. In a randomized, 2-period crossover trial in 16 subjects with type 1 diabetes mellitus to evaluate glucose-responsiveness of i.v. administered MK-2640, we were unable to demonstrate a glucose-dependent change in MK-2640 clearance, although a significant glucose-dependent augmentation of glucose infusion rate was observed. These pharmacokinetic (PK) and pharmacodynamic (PD) data provide crucial insights into next steps for developing an insulin saccharide conjugate as a clinically effective glucose-responsive insulin analog.

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