REvIEwS

The α-​cell in diabetes mellitus

Jesper Gromada1*, Pauline Chabosseau2 and Guy A. Rutter   2*
Abstract | Findings from the past 10 years have placed the glucagon-​secreting pancreatic α-​cell
centre stage in the development of diabetes mellitus, a disease affecting almost one in every ten
adults worldwide. Glucagon secretion is reduced in patients with type 1 diabetes mellitus,
increasing the risk of insulin-​induced hypoglycaemia, but is enhanced in type 2 diabetes mellitus,
exacerbating the effects of diminished insulin release and action on blood levels of glucose.
A better understanding of the mechanisms underlying these changes is therefore an important
goal. RNA sequencing reveals that, despite their opposing roles in the control of blood levels of
glucose, α-​cells and β-​cells have remarkably similar patterns of gene expression. This similarity
might explain the fairly facile interconversion between these cells and the ability of the α-​cell
compartment to serve as a source of new β-​cells in models of extreme β-​cell loss that mimic
type 1 diabetes mellitus. Emerging data suggest that GABA might facilitate this interconversion,
whereas the amino acid glutamine serves as a liver-​derived factor to promote α-​cell replication
and maintenance of α-​cell mass. Here, we survey these developments and their therapeutic
implications for patients with diabetes mellitus.

1
Regeneron Pharmaceuticals,
Tarrytown, NY, USA.
2
Section of Cell Biology and
Functional Genomics, Division
of Diabetes, Endocrinology
and Metabolism, Department
of Medicine, Imperial College
London, Hammersmith
Hospital Campus,
London, UK.
*e-​mail: jesper.gromada@
regeneron.com;
g.rutter@imperial.ac.uk
https://doi.org/10.1038/
s41574-018-0097-y
The history of glucagon begins in 1921 when Frederick
Banting and Charles Best tested pancreatic extracts in
depancreatized dogs and detected transient hypergly-
caemia that preceded insulin-​induced hypoglycaemia1.
Murlin et al.2 suggested 2 years later that the early hyper-
glycaemia was due to a contaminant in the pancreatic
extract that had glucose agonist properties. In 1948,
Sutherland and de Duve3 established that the α-​cells
of the endocrine pancreas are the source of glucagon.
Glucagon is a regulator of glucose homeostasis in ani-
mals and humans. This hormone stimulates glycogen-
olysis and gluconeogenesis by the liver and is the key
counter-​regulatory hormone responsible for opposing
the glucose-​lowering effects of insulin. The physiology
and pharmacology of glucagon in health and disease
have been covered in recent reviews4,5.
Here, we summarize the role of the glucagon-​
secreting pancreatic α-​cell in the development and pro-
gression of diabetes mellitus. We review advances in our
understanding of the α-​cell gene expression profile and
signalling mechanisms and discuss how the α-​cell might
become a more prominent target for the treatment
of diabetes mellitus by promoting the reprogramming of
these cells into insulin-​secreting β-​like-cells.
The islet of Langerhans
The pancreatic α-​cell was discovered in 1907 (REF.6)
and is one of four major types of endocrine cells in
the islets of Langerhans: glucagon-​secreting α-​cells,
insulin-​ producing β-​ c ells, somatostatin-​ releasing
δ-​cells and pancreatic polypeptide (PP)-secreting cells.
Rare ghrelin-​producing ε-​cells also exist in the islet. It is
now clear that the human islet cytoarchitecture is similar
to that of rodents7. The islets are made up of subunits
with a central core of β-​cells and a mantle of non-​β-cells,
including α-​cells7. Moreover, good evidence indicates
that the portal blood flow relationships are similar in
humans and rodents7. The anatomical similarities are
important for understanding paracrine regulation
of hormone secretion and for extrapolating decades of
rodent islet research to humans. In particular, the key
observation of β-​cells being upstream from α-​cells was
shown in a study in which insulin antibody was infused
into perfused rat pancreases8 (see later section). This
finding was followed by subsequent studies demonstrat-
ing that the same mechanism was present in the pancre-
ases of dogs, rats, non-​human primates and humans9.
Thus, good evidence suggests that local insulin secretion
has a key role in the suppression of glucagon secretion by
hyperglycaemia in representative mammalian species.
As discussed below, the remaining puzzle is whether
insulin’s suppressive effects are exerted via somatostatin
secretion from δ-​cells or by direct effects of insulin on
α-​cells or, as may well be the case, by both. Using large-​
scale single-​islet cell quantification, the ratio of α-​cells to
β-​cells was shown to be higher in human than in mouse
islets, whereas the number of δ-​cells and PP-​secreting
cells is similar in these species (Fig. 1). However, during
the characterization of pancreatic islet preparations for
clinical trials, it was found that the number of β-​cells
is three times higher than the number of non-​β-islet
cells, including α-​cells10. Interestingly, α-​cells might

Nature Reviews | Endocrinology

Reviews
Key points
• The mechanisms involved in the control of glucagon secretion in pancreatic α-​cells
have now been identified.
• The pancreatic α-​cell has a role in the development of diabetes mellitus.
• Physiological and pharmacological activators and inhibitors of glucagon secretion
might provide therapeutic targets.
• Single α-​cell gene expression profiling in health and disease has resulted in new
insights about the function of α-​cells.
• Advances in understanding α-​cell to β-​cell reprogramming could lead to new
therapeutic strategies for diabetes mellitus.
have distinct roles in humans and rodents in responses
to parasympathetic innervation of the islet, serving in
the former (only) as a source of acetylcholine that then
‘primes’ β-​cells11.
Despite a key role for insulin in suppression of gluca-
gon secretion, the reason for the differences in the ratio
of human α-​cells to β-​cells versus that seen in the rodent
is unknown. In this context, it is also important to further
investigate potential differences in the α-​cell-to-​β-cell
ratio observed between human islet isolation centres.
Mouse Human
50 μm 50 μm
DAPI Insulin Glucagon
α-Cell β-Cell δ-Cell PP cell
Fig. 1 | The localization and number of α-​cells differ between mouse and human
pancreatic islets. Mouse islets have a β-​cell-rich core (insulin stain in green), which is
surrounded by a low number of α-​cells (glucagon stain in red). Human islets are
composed of substructures, each with an arrangement similar to that of mouse islets.
Cell nuclei are stained in blue. The pie charts show the proportions of the major
endocrine cell types in mouse and human islets. DAPI, 4′,6-diamidino-2-phenylindole;
PP, pancreatic polypeptide.
α-​Cell function and mass in T2DM
Type 2 diabetes mellitus (T2DM) is often thought of as
a bi-​hormonal disease characterized by hypoinsulinae-
mia and hyperglucagonaemia with elevated blood levels
of glucose. The hypoinsulinaemia results from insuffi-
cient insulin secretion and is associated with a 25–50%
decrease in β-​cell mass12–18. In contrast to the effects on
levels of insulin, patients with T2DM often show persis-
tent fasting hyperglucagonaemia and lack of suppression
of glucagon levels in the postprandial state19. This hyper-
glucagonaemia aggravates the hyperglycaemia induced
by the hypoinsulinaemia, as the hyperglucagonaemia
enhances hepatic glucose production20. These data sug-
gest a causal role for glucagon in the pathophysiology of
T2DM and support the development of pharmacological
agents that inhibit glucagon secretion (or action) to alle-
viate hyperglycaemia in patients with T2DM. The status
of these agents has been reviewed elsewhere4,5. Briefly,
studies in humans using small-​molecule inhibitors or
blocking antibodies towards the glucagon receptor have
uncovered strong effects on lowering blood levels of
glucose but also on-target adverse effects. The essential
question for drug development is whether these features
can be separated sufficiently to provide a wide enough
therapeutic window to allow for safe long-​term use.
In particular, blockade of glucagon receptors is asso-
ciated with α-​cell hyperplasia, abnormal lipid metabo-
lism, hepatic steatosis and elevated plasma levels of liver
enzymes, making inhibition of α-​cell hypersecretion an
appealing strategy for treatment of T2DM4,5. The mech-
anism for the link between inhibition of glucagon recep-
tors in the liver and induction of α-​cell hyperplasia is
discussed in a subsequent section. This effect is a safety
concern as α-​cell hyperplasia increases the risk of devel-
oping glucagonoma21. Glucagon is known to have potent
hypolipaemic effects22,23, including causing a decrease in
triglyceride and VLDL release by the liver24,25, a reduc-
tion in plasma levels of cholesterol23,25 and stimulation of
free fatty acid β-​oxidation in the liver26. The decrease in
triglyceride and VLDL release is secondary to reduced
VLDL apoprotein production22. Glucagon also reduces
levels of LDL27. Therefore, it is not surprising that gluca-
gon receptor inhibition is associated with increases in
circulating levels of triglycerides and LDL cholesterol
in preclinical models and humans28. The increase in levels
of LDL cholesterol is also attributed to overexpression of
genes with protein products involved in cholesterol syn-
thesis29 and re-​absorption30. LDL cholesterol adversely
influences the risk of cardiovascular disease and increases
levels of LDL cholesterol in the setting of T2DM (the
target population of patients for therapies that block
glucagon receptors), which is a cause for concern as
this effect could potentiate the already elevated risk of
cardiovascular disease in these patients. The increased
risk of developing hepatic steatosis following glucagon
receptor inhibition could be due to reduced free fatty acid
β-​oxidation in the liver31. The reason for the increase in
plasma levels of liver enzymes is unknown. It is impor-
tant to emphasize that although drugs that antagonize
glucagon might be of great benefit for the treatment of
T2DM, sufficient levels of basal insulin are required for
their maximal therapeutic effects32,33.
www.nature.com/nrendo

β-Cell δ-Cell
Glucose ↑Insulin Glucose
Insulin
Somatostatin
Insulin ↑Somatostatin
receptor
Somatostatin
α-Cell receptor
Glucagon
↓cAMP and
PKA signalling
Glucose
β-Adrenergic
receptor
Parasympathetic tone Glucose
Adrenaline and GABAergic neurons
Fig. 2 | intracellular and intercellular mechanisms implicated in the suppression of
glucagon secretion by glucose. Glucose suppresses glucagon secretion by direct
signalling mechanisms involving its uptake and metabolism but also indirectly through
controlling the release of paracrine factors derived from β-​cells and/or other islet cells
and via glucose-​sensing neurons in the brain. PKA , protein kinase A.
Whether α-​c ell mass is unchanged 34,35 or
increased15,17,36,37 in patients with T2DM is not clear.
Importantly, even in the setting of unchanged α-​cell
number, the ratio of α-​cells to β-​cells is higher in patients
with T2DM owing to the reduced β-​cell mass compared
with people who do not have T2DM34. Evidence from
the past few years obtained in mouse and non-​human
primate models of diabetes mellitus and in humans with
T2DM suggests that β-​cells dedifferentiate and adopt
α-​cell characteristics38–40. This finding is substantiated
by the detection of insulin and glucagon bi-​hormonal
cells in islets from patients with T2DM41. However, it
remains to be established whether the dedifferentiated
β-​cells make a notable contribution to decreased insulin
secretion and whether they transdifferentiate into α-​cells
and secrete glucagon.
In patients with type 1 diabetes mellitus (T1DM),
where most (although often not all)42,43 β-​cells are lost,
α-​cells make up three-​quarters of the total cell number
in islets44; however, the absolute mass and therefore the
ratio of α-​cells to δ-​cells to PP cells does not seem to
be altered37. Interestingly, α-​cells might be an important
source of glucagon-​like peptide 1 (GLP1), and other
peptides45,46, capable of stimulating insulin secretion to
lessen the symptoms of T2DM.
Glucagon secretion is regulated by glucose
Appropriate stimulation of glucagon release from α-cells
is particularly important to minimize the impact of acute
insulin-​induced hypoglycaemia. This form of hypo­
glycaemia is a major complication of T1DM, and it is
estimated to be responsible for up to 4% of all deaths in
Nature Reviews | Endocrinology
Reviews
patients with this disease47. Whereas glucagon release is
normally regulated reciprocally to that of insulin, being
stimulated as blood concentrations of glucose fall, the
response to low blood levels of glucose is progressively
diminished in T1DM48,49. Given the preserved α-​cell
mass, the insufficient glucagon secretion could be due
to ‘hypoglycaemia blindness’ in the T1DM α-​cell pop-
ulation. The mechanism underlying the inability of the
α-​cells in patients with T1DM to sense or respond to low
blood levels of glucose is unknown.
Although the molecular mechanisms involved in
the regulation of insulin secretion are increasingly well
understood50, our knowledge of those that mediate the
inhibition of glucagon release remains fragmentary.
Glucose suppresses glucagon secretion by direct signal-
ling mechanisms involving its uptake and metabolism51
but also indirectly through controlling the release of par-
acrine factors derived from β-​cells (or other islet cells)
(Fig. 2) and via glucose-​sensing neurons in the brain52.
These mechanisms are discussed in subsequent sections
and outlined in Supplementary Table 1.
Direct effects of glucose on α-​cells
α-​Cells display spontaneous oscillations in cytosolic lev-
els of Ca2+ at low (<3 mM) concentrations of glucose,
and increases in the glucose concentration lead to both a
decrease in electrical activity53 and a fall in cytosolic con-
centrations and oscillations of Ca2+ (REFS54–56). Although
these changes in Ca2+ are the opposite of those observed
in β-​cells21, evidence suggests that the initial metabolic
sensing of glucose by the α-cells might be similar to that of
β-​cells57 (Supplementary Table 1). In particular, gluco­
kinase (encoded by GCK in humans and Gck in rodents)
is expressed in both cell types58, a feature expected to
allow α-​cells to respond metabolically to changes in
blood concentrations of glucose in the physiological
(3–11 mM) and immediate subphysiological (2–3 mM)
range. Correspondingly, knockout of Gck in α-​cells leads
to hyperglucagonaemia and progressive development of
hyperglycaemia59. Interestingly, the glucose transporter
GLUT2 (encoded by SLC2A2 or Slc2a2 in humans and
rodents, respectively), which has an affinity for glucose
in the physiological range, is largely absent from α-​cells,
whereas the higher-​affinity glucose transporter GLUT1
(encoded by SLC2A1 or Slc2a1 in humans and rodents,
respectively) is present in both mouse60,61 and human62
α-​cells. Glucose 6-phosphatase catalytic subunit 2, which
might dephosphorylate glucose to establish a futile
cycle in β-​cells, is also present in human63, although not
mouse61, α-​cells. The nutrient-​sensitive protein kinases
AMP-​a ctivated protein kinase (AMPK)64 and PAS
domain-​containing serine/threonine-​protein kinase
(PASK)65 are also implicated in α-​cell glucose sensing.
Thus, metabolic sensing of glucose by the α-​cell is likely
to be similar to that of β-​cells but acts through differ-
ent glucose transporters. The differential expression of
GLUT1 and GLUT2 in α-​cells versus β-​cells might affect
the detection glucose range for the sugar and, conceivably,
downstream cellular responses.
Mitochondrial metabolism of glucose is central to
the stimulation of insulin release from β-​cells66,67 and
is abnormal in patients with T2DM68. Both α-​cells and
Reviews

Physiological activators Pharmacological

• GIP activators
• GRP • SGLT2 inhibitor
• Adrenaline • Sulfonylurea
• Acetylcholine
• Cholecystokinin
• Ghrelin
α-Cell

Glucagon

β-Cell
Physiological Pharmacological
inhibitors inhibitors
• Insulin • Sulfonylurea
• Leptin • DPP4 inhibitor
• Secretin • GLP1
• Somatostatin • Amylin
• Serotonin
• GABA
• GLP1

Fig. 3 | Physiological and pharmacological activators and inhibitors of α-​cell function and glucagon secretion.
Physiological activators and inhibitors of α-​cell function and glucagon secretion can act via paracrine mechanisms (for
example, insulin, somatostatin and GABA) or as circulating hormones (such as glucagon-​like peptide 1 (GLP1), glucose-​
dependent insulinotropic peptide (GIP) and ghrelin) or be released from nerve endings within the islets (for example,
acetylcholine and cholecystokinin). Sulfonylureas are therapeutic agents used in the treatment of type 2 diabetes mellitus
(T2DM) and have been reported to both stimulate and inhibit glucagon secretion depending on the experimental
conditions. GLP1 and inhibitors of dipeptidyl peptidase 4 (DPP4), an enzyme that degrades GLP1, are commonly used
agents in the management of T2DM. Part of the glucose-​lowering effect of these agents results from inhibition of
glucagon secretion. The sodium–glucose cotransporter 2 (SGLT2) inhibitor dapagliflozin stimulates glucagon secretion
by an unknown mechanism. GRP, gastrin-releasing peptide.

β-​cells express fairly low levels of lactate dehydro­
genase (LDHA)69,70 and the monocarboxylate transporter
MCT1 (encoded by Slc16a1)71, which are both ‘disal-
lowed’ islet genes (that is, genes for which the expres-
sion is suppressed compared with the majority of cells
in the body)72,73. Thus, oxidative metabolism of glyco­
lytically derived NADH and pyruvate might be crit­
ical for suppressing glucagon secretion. Nonetheless,
a study of fluorescence-​activated cell sorting (FACS)-
purified cells61 revealed that Ldha (sixfold) and Slc16a1
(threefold to fourfold) mRNA levels are significantly
higher in mouse α-​cells than β-​cells61, suggestive of at
least partially distinct signalling mechanisms for glu-
cose in the two cell types. As discussed in a subsequent
section, RNA sequencing of single human α-​cells did
not reveal changes in the expression of genes associated
with glucose metabolism or related pathways in T2DM;
however, the limited sensitivity of this approach might
preclude the detection of changes in the expression of
disallowed genes.
Paracrine control of glucagon secretion
In addition to glucose, numerous paracrine, hormonal
and nervous signals fine-​tune glucagon secretion under
different physiological conditions 74. Possible roles
for key paracrine signalling are presented in Fig. 2 and
discussed in this section.
Insulin. Several studies have provided evidence that
insulin suppresses glucagon secretion75–77. This effect
could be mediated directly via insulin receptors on the
α-​cells or indirectly via increased somatostatin secretion
from neighbouring δ-​cells78 (Fig. 2). The suppression of
glucagon secretion by insulin is, at least in part, mediated
by a reduction of intracellular cAMP levels and weak-
ened protein kinase A (PKA) signalling79. α-​Cells express
somatostatin receptors, and their activation suppresses
glucagon secretion78. In T2DM, altered α-​cell function
could result from a combination of reduced insulin
secretion and impaired insulin action80–82.
Zinc ions. Zn2+ has an important role in the storage of
insulin in β-​cell secretory granules. In 2003, Ishihara
and colleagues83 provided evidence that, in the per-
fused rat pancreas, glucose-​stimulated release of Zn2+
from β-​cells contributed to the inhibition of glucagon
secretion. However, a similar role for Zn2+ in the con-
trol of glucagon secretion from mouse islets has not
been found51. Moreover, glucagon secretion was normal
when measured in islets from mice with inactivation of
the secretory granule Zn2+ transporter ZnT8 (Slc30a8)84
under conditions where release of Zn2+ from the β-​cell
is essentially eliminated85. Interestingly, presumed loss-​
of-function variants in the SLC30A8 gene are associ-
ated with reduced risk of T2DM86, and inactivation87

www.nature.com/nrendo
 Reviews

a
β-Cell δ-Cell
Microbeads

α-Cell
PP cell
ε-Cell
Sequencer
Oil
Isolated pancreas Dissociated islet cells Single-cell capture and sequencing

b c 104 d α-Cell β-Cell

20,000 GCG IAPP

β-Cell (average UMI + 1)

Number of detected genes

INS TTR INS

103
15,000 CRYBA2 HADH
TTR TM4SF4 DLK1
102
10,000 GCG TMEM176B RBP4
PCSK2 NPTX2
5,000 101 ALDH1A1 SHISAL2B
α-Cell β-Cell GC UCHL1
0 100 CHGB GAD2
0 2,500 5,000 7,500 10,000 100 101 102 103 104 FXYD3 SMAD11
Number of cells α-Cell (average UMI + 1)
Fig. 4 | rnA sequencing of single human islet cells reveals a few genes that are enriched in α-​cells and β-​cells
among a large number of detected genes. a | Schematic of workflow from donor to isolation of single human islet cells
being loaded onto a capture and sequencing platform. Dissociated human islet cells, including glucagon-​secreting α-​cells,
insulin-​producing β-​cells, somatostatin-​releasing δ-​cells and pancreatic polypeptide (PP)-secreting cells, as well as rare
ghrelin-​producing ε-​cells, were obtained from isolated pancreatic islets from non-​diabetic donors. The single islet cells,
reagents and single gel beads containing barcoded oligonucleotides were encapsulated into nanolitre-​sized particles
using a capture and sequencing platform. Lysis and barcoded reverse transcription of RNAs from single cells were
performed inside each nanolitre-​sized particle. High-​quality next-​generation sequencing libraries are finished in a single
bulk reaction. b | The number of genes detected in human α-​cells and β-​cells increases with the number of sequenced
cells. c | Scatterplot of all detected genes in human α-​cells and β-​cells (n = 20,757). The top enriched β-​cell (INS) and α-​cell
genes (GCG and TTR) are highlighted. d | The top ten enriched genes for human α-​cells and β-​cells. Please see
Supplementary Table 2 for further details. The data were obtained from REFS103,104. UMI, unique molecular identifier.

or overexpression88 of Slc30a8 selectively in the α-​cell parasympathetic and GABAergic neurons is controlled
enhances or reduces hypoglycaemia-​induced glucagon by glucose in the brain (Fig. 2).
release, respectively, suggesting a possible contribution
to altered T2DM risk. Of note, we have also reported Activators and inhibitors. Figure  3 lists physiolog­
that selective deletion of the T2DM-​associated gene ical and pharmacological activators and inhibitors of
Tcf7l2, which encodes transcription factor 7-like-2 and glucagon secretion. For example, catecholamines stim-
is involved in WNT signalling, from the α-​cell in mice89 ulate glucagon secretion via the activation of adren­
impairs the normal regulation of glucagon secretion ergic receptors on both rodent and human α-​cells94.
by glucose, possibly by increasing Slc30a8 expression Sulfonylureas have been reported to both stimulate and
(as observed after Tcf7l2 silencing in islets)90. Thus, inhibit glucagon release depending on the experimental
the actions of the T2DM-​associated variants present conditions. The intestinal-​derived glucose-​dependent
at the risk loci described here, and some of the ~400 insulinotropic polypeptide (GIP) stimulates glucagon
other T2DM risk loci in humans91, might also, at least secretion and contributes to hyperglycaemia in T2DM95.
in part, be mediated via altered release of glucagon. This Accordingly, an antagonist of the GIP receptor dampens
possibility is an exciting current area of research. hyperglycaemia in T2DM95. Another intestinally derived
peptide, GLP1, inhibits glucagon secretion via para­crine
GABA. GABA92,93 is stored in specialized vesicles in the mechanisms involving stimulation of somatostatin
β-​cells, and GABA release contributes to the inhibition and potentially insulin secretion96. Inhibitors of dipep-
of glucagon secretion in rodents and humans. As men- tidyl peptidase 4 (DDP4), which degrades and inacti-
tioned in a subsequent section, GABA might have a role vates GLP1, also inhibit glucagon secretion4,5. GLP1
in the reprogramming of α-​cells into β-​like-cells. This receptor agonists and DPP4 inhibitors are widely used
effect of GABA holds promise for replenishing the pool anti-​diabetic drugs4,5. Of note, inhibition of the sodium–
of functional β-​cells in diabetes mellitus. glucose cotransporter 2 (SGLT2) with dapagliflozin, a
In addition to insulin, GABA and Zn2+ ions, gluca- treatment now widely used in T2DM to promote glucose
gon secretion is regulated by adrenaline, acting via loss through the kidney, also triggers glucagon secretion
β-​adrenergic receptors, as well as by the parasympa- from α-​cells97. The potential long-​term implications of
thetic tone and GABAergic neurons. The activity of the this unexpected effect of dapagliflozin on the α-​cell

Nature Reviews | Endocrinology

Reviews

a Gcgr–/–
(mice)
Glucagon antibody α-Cell β-Cell Liver Gcgr–/–
(rodent)
(mice)
Glucagon receptor antibody Gcg–/–
(rodent and monkey) (mice)
Glucagon receptor antisense
oligonucleotide knockdown Pcsk2–/–
(rodent) (mice)

Loss-of-function variants Liver Gs–/–

in glucagon receptor (mice)
(human) PP cell
δ-Cell

Inhibition of glucagon action

b Increased α-cell mass

Mouse α-cell Human α-cell

↑Glutamine ↑Amino acids Amino acid

and/or alanine
SLC38A5 ? ? ?

Liver

mTOR Glutamine ↓Amino acid uptake mTOR?

and/or and catabolism
alanine

Glucagon
α-Cell expansion receptor α-Cell expansion
inhibition

↑Glucagon secretion ↑Glucagon secretion

Fig. 5 | The liver–α-​cell axis. a | Genetic or pharmacological disruption of hepatic glucagon signalling is invariably linked
to α-​cell hyperplasia in rodents, non-​human primates and humans. b | Amino acids promote glucagon secretion and α-​cell
expansion to increase amino acid uptake and metabolism by the liver. In mouse α-​cells, the amino acid transporter
SLC38A5 and the amino acid sensor mTOR regulate expansion of α-​cell mass. The amino acid transporters regulating
amino acid uptake in human α-​cells and the involvement of mTOR remain to be established. The green circles represent
the amino acids glutamine or alanine, whereas the pink circles represent any amino acid. PP, pancreatic polypeptide.

remain to be determined. Other activators of α-​cells
and glucagon secretion not mentioned elsewhere in this
Review include gastrin-releasing peptide (GRP), ace-
tylcholine from parasympathetic nerves and ghrelin. In
addition, leptin, secretin and serotonin inhibit glucagon
secretion. The relative contributions of these regulators
of human α-​cell glucagon secretion in physiology and
pathophysiology remain to be determined.
Single α-​cell gene expression profiling
A better understanding of the mechanisms involved in
the control of glucagon secretion, and its dysregulation
in T2DM, has been facilitated by our growing under-
standing of the molecular identity of the α-​cell. In par-
ticular, advances in the past 5 years in single-​cell RNA
sequencing technologies have provided unprecedented
insights into the gene expression profiles of human and
mouse α-​cells63,98–102. Figure 4a exemplifies the workflow
for large-​scale single human islet cell RNA sequencing.
Human α-​cells and β-​cells express at least 17,000–18,000
genes (Fig. 4b). More genes are likely to be detected once
more sensitive RNA sequencing methods become avail-
able. The scatterplot of all expressed genes reveals that
the transcriptomes of human α-​cells and β-​cells are
strikingly similar. In fact, using a stringent report, we
found that only 97 genes (0.47%; n = 20,757 for com-
bined gene sets) are enriched or unique to either cell
type (Fig. 4c). The top ten enriched or unique α-​cell and
β-​cell genes103,104 are shown in Fig. 4d. A brief description
of each gene and its role in α-​cell and β-​cell function is
provided in Supplementary Table 2. Thus, the pheno-
types of α-​cells and β-​cells are determined by a fairly
small number of genes, supporting the observation that
the cells of the endocrine pancreas are highly plastic in
nature105,106. Similar overlap exists between mouse α-​cell
and β-​cell transcriptomes61,107,108. Correspondingly, an
analysis of the expression of islet disallowed genes has
revealed broad overlap between these two cell types in

www.nature.com/nrendo
 Reviews

a Replication

Glucagon secretion
α-Cell
Transcription factors
• ↓ARX and DNMT1
ARX • ↑PDX1 and homeobox
protein Nkx-6.1

Arx–/– Circulating factors

Pax4–/– • ↑Activin A
Foregut Pancreatic Endocrine • ↑IGFBP1
endoderm progenitor progenitor • ↑GABA
PAX4
Extreme β-cell loss
β-Cell
Insulin secretion

Replication

T1DM

GABA
Artemisinins

α/β-Cell GABAAR

Rescue of T1DM

Fig. 6 | α-​cell development and its possible modulation as a therapy in type 1 diabetes mellitus. a | Key genes
and transcription factors regulating α-​cell and β-​cell development, as well as transdifferentiation of α-​cells to β-​cells and
β-​cells to α-​cells. The transcription factor ARX is important for α-​cell development, and lack of Arx expression in mice
(Arx−/−) promotes differentiation of endocrine progenitor cells into β-​cells. PAX4 is important for β-​cell development,
and lack of this transcription factor in mice (Pax4−/−) favours conversion of endocrine progenitor cells into α-​cells. Mature
α-​cells can be reprogrammed into β-​like-cells by reducing the expression of ARX and DNMT1 or increasing the
expression of PDX1 and Nkx-6.1. Extreme β-​cell loss or increasing the concentrations of the circulating factors activin A ,
IGF-binding protein 1 (IGFBP1) and GABA have been shown to promote the reprogramming of α-​cells into β-​cells.
b | β-​cells (green) lost in type 1 diabetes mellitus (T1DM) might be replaced from α-​cell-derived precursors (α/β cells;
shown in purple) in response to treatment with GABA and artemisinins, the latter increasing GABA receptor expression
on α-​cells122. Part b adapted from REF.147, Springer Nature Limited.

mouse islets72. This observation is an important aspect
when considering approaches for reprogramming
α-​cells into β-​like-cells as a novel treatment approach for
patients with diabetes mellitus.
The liver–α-​cell loop
As discussed in the next section, α-​cells might provide
a source of new β-​cells to replace those that are lost or
become dysfunctional in T1DM and T2DM. However,
to avoid a depletion of the α-​cell pool itself, insights are
required as to how the proliferation of these cells might
be controlled. Amino acids constitute an integral part
of a liver–α-​cell axis by promoting glucagon secretion
and serving as substrates in the process of gluconeogen-
esis to produce glucose in the liver109. Disruption of the
liver–α-​cell axis by genetic (using glucagon receptor-
deficient or glucagon-deficient mice or liver-​specific
deletion of Gcgr or the G protein Gs in mice) or phar-
macological inhibition of glucagon action using anti-
bodies to glucagon or the glucagon receptor, as well as
knockdown of the glucagon receptor using an antisense
oligonucleotide approach, has invariably been linked to
increased α-​cell mass (Fig. 5a). This finding is supported
by the observation that rare inactivating mutations in
GCGR in humans are associated with glucagonoma21.
Amino acids, and in particular glutamine, are critical for
promoting α-​cell expansion following disruption of the
glucagon signalling pathway110–113. In mouse α-​cells,
the amino acid transporter SLC38A5 and the amino acid
sensor mTOR have important roles in regulating α-​cell

Nature Reviews | Endocrinology

Reviews
expansion following inhibition of glucagon action111–113
(Fig. 5b). mTOR is also important for α-​cell expansion
during development in mice114, and the increase in α-​cell
mass observed after α-​cell-selective deletion of AMPK
might be explained by a resulting activation of mTORC1,
which is involved in the regulation of cell size115. Little
is known about the pathways regulating human α-​cell
proliferation. Human α-​cells express several amino acid
transporters, but their contribution to α-​cell hyperplasia
following disruption of hepatic glucagon signalling is a
topic for future research113 (Fig. 5b).
α-​Cell to β-​cell reprogramming
Cell reprogramming strategies for the generation of
insulin-​producing β-​like-cells for the treatment of diabe-
tes mellitus have been investigated and hold promise for
the treatment of T1DM and possibly T2DM. The results
are encouraging, and restoration of normal glucose
levels has been achieved in diabetic animal models116.
Several reasons could explain why α-​cells might be a
good source for new β-​cells. First, α-​cells and β-​cells
have the same developmental origin, and these cell types
mostly express similar genes104. Second, α-​cell to β-​cell
reprogramming has been accomplished by repression or
expression of key transcription factors39,117–119 (Fig. 6a),
after extreme β-​cell loss120 or following treatment of
α-​cells with circulating factors and pharmacological
agents, including GABA and artemisinins121–123 (Fig. 6b).
The latter studies have also demonstrated that glucagon
secretion and detection via an autocrine loop help main-
tain the α-​cell phenotype. Thus, GABA-​induced inhibi-
tion of glucagon secretion contributes to the instability
of the α-​cell phenotype and facilitates reprogramming
into β-​cells. Particularly encouraging are transcrip-
tional data indicating that the phenotypes of human
α-​cells and β-​cells are very similar, which might facilitate
reprogramming101. It is important to note, however, that
the findings using the artemisinin artemether have been
questioned124, although it is unclear whether the condi-
tions used in the latter study (notably the culture period)
5.0
log2-fold change versus non-diabetic donors
2.5
0.0
–2.5
–5.0
10–4 10–2 100 102 104
Gene expression (normal counts)
Fig. 7 | differentially regulated genes in single α-cells
from donors with type 2 diabetes mellitus. Gene
expression profiles were compared between single α-cells
from donors with or without type 2 diabetes mellitus.
Differentially regulated genes are highlighted in red.
Adapted with permission from REF.101, Elsevier.
fully mimic those used in the former study122. The physi-
ological role of GABA for α-​cell to β-​cell reprogramming
remains to be established.
An additional reason why α-​cells could be a good
source of β-​cells is that α-​cell mass is maintained in the
diabetic state34,35 (see previous sections). Thus, the rate
of reprogramming of α-​cells into β-​like-cells is unlikely
to be limited by the availability of α-​cells, whereas the
pool of α-​cells will be depleted and affect blood levels
of glucose. This view is supported by an α-​cell ablation
study in mice demonstrating that only 2% of the α-​cell
mass is required for normal α-​cell function, glucagon
signalling and maintenance of blood levels of glucose125.
Furthermore, the mechanisms that regulate DNA
methylation and chromatin modifications are similar
in human α-​cells and β-​cells, which facilitates α-​cell to
β-​cell reprogramming126–132. In addition, human α-​cells
proliferate at a higher rate than other islet cell types and
can be induced to proliferate following disruption of the
hepatic glucagon signalling pathway133–136. α-​Cell prolif-
eration could help maintain the α-​cell mass in a setting
of accelerated reprogramming to β-​like-cells. However,
this maintenance might not be necessary as enhanced
glucagon signalling contributes to the diabetic state and
a partial reduction in α-​cell mass could be beneficial
for maintaining optimal glycaemic control. Finally, the
remaining α-​cells might secrete factors (for example,
GLP1) that could accelerate the maturation and increase
the function of the newly formed β-​like-cells137,138.
These data support the view that further research is
needed to understand the detailed molecular mecha-
nisms that govern α-​cell and β-​cell fates and how to safely
promote α-​cell to β-​cell reprogramming. In patients with
T1DM, efforts towards β-​cell replacement might need to
be combined with immune suppression; however, α-​cell
to β-​cell reprogramming studies in autoimmune non-​
obese diabetic mice did not require immune suppres-
sion to achieve long-​term normalization of blood levels
of glucose116.
Gene expression in T2DM α-​cells
RNA sequencing studies of single human islet cells have
revealed that <0.5% of all detected genes are affected
in T2DM63,101. Stringent inclusion criteria were applied in
the studies to minimize the contribution of, for instance,
donor–donor variability, differences in medication and
glucose control to the observed changes in gene expres-
sion. Of the differentially regulated genes, only a few have
an assigned role in islet cell development, growth or func-
tion. None of the detected genes are involved in nutrient
sensing or intermediary metabolism. Interestingly, 40%
of the affected genes have been implicated in cell growth
in other cell types, whereas 28% have no known func-
tion101. This finding is of interest as reduced β-​cell mass
106 in patients with T2DM contributes to onset and progres-
sion of the disease (see previously). Figure 7 shows the
directionality of change of the affected genes in α-​cells
from patients with T2DM. Future studies of the affected
genes might provide exciting insights into the disease
aetiology and unravel druggable pathways for correction
of defects in glucagon secretion and maintenance of cell
number and phenotype in patients with T2DM.
www.nature.com/nrendo
 Reviews

? population from mice102 and humans63 (reviewed in

H REF.141). Importantly, β-​cells in the intact mouse islet
display functional heterogeneity, with a hierarchy exist-
ing in which subsets of interconnected cells behave as
‘hubs’ and ‘followers’. The former are able to serve as
T1DM pacemakers to control overall islet Ca2+ dynamics and
insulin secretion142,143. Whether similar α-​cell–α-​cell
α-Cell ? connectivity exists and controls overall glucagon secre-
tion remains unclear56 (Fig. 8). Nonetheless, indirect evi-
H
dence in support of this view includes the remarkably
penetrant phenotypes of genetic modifications affecting

Secretion
H only a minority (~14%) of α-​cells in the mouse87. β-​Cell
connectivity is altered in human obesity142, in in vitro
models of T2DM143 and after disruption of several genes
associated with T2DM144–146. Whether similar changes
β-Cell might affect the α-​cell population is an intriguing pro-
?
posal (Fig. 8). Of note, α-​cell heterogeneity and special-
Glucose ization should be borne in mind when considering
Glucagon H therapies that could deplete the α-​cell pool to generate
Insulin new β-​cells.
T2DM
H
Secretion

Conclusions
In this article, we have presented an overview of nutri-
ent and stimulus sensing by the α-​cell and compared the
properties of the α-​cell to those of the β-​cell. We also
described changes that occur in each cell type in T2DM
and highlighted critical differences between them in this
Secretion

disease setting. Finally, we discussed the potential for

α-​cells to serve as a source of new β-​like-cells.
Soon, 100 years will have passed since we learned that
glucagon has an important role in the maintenance of
glucose homeostasis by opposing the glucose-​lowering
Fig. 8 | Potential role of α-​cell–α-​cell connectivity in the control of glucagon effects of insulin. Although long thought of as culprits,
secretion. β-​Cells in islets display functional heterogeneity , with a hierarchy existing in the dysfunction of which contributes to the pathology
which subsets of interconnected cells behave as ‘hubs’ (indicated with an ‘H’). Hub cells of both T1DM and T2DM, it now appears that α-​cells
are able to serve as pacemakers to control overall insulin secretion. A similar α-​cell–α-​cell
might also be saviours, able to provide a new source of
connectivity could exist. Intercellular connectivity is potentially affected in diabetes
β-cells. This theory is supported by exciting studies using
mellitus (dashed lines from the hub cell). β-​Cells are shown in green, and α-​cells are
shown in red. T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus. pharmacological tools to promote the reprogramming
of α-​cells into insulin-​secreting β-​cells in a preclinical
model of T1DM, resulting in normalization of the blood
A novel perspective levels of glucose116. A demonstration of this provocative
Work published in the late 1980s and early 1990s139,140, concept in clinical practice might ultimately herald a
as well as more recent studies using RNA sequencing new era in diabetes mellitus research and treatment.
and other omics approaches at the single-​cell level, have
demonstrated substantial heterogeneity in the β-​cell Published online xx xx xxxx

1. Best, C. H. in Glucagon: Molecular Physiology, Clinical
and Therapeutic Implications Ch. 1 (eds Lefebvre, P. J.
& Unger, R. H.) 1–6 (Pergamon Press, Oxford, 1972).
2. Murlin, J. R., Clough, H. D., Gibbs, C. B. F. & Stokes, A.
M. Aqueous extracts of the pancreas. 1 Influence on the
carbohydrate metabolism of depancreatized animals.
J. Biol. Chem. 56, 253–296 (1923).
3. Sutherland, E. W. & De Duve, C. Origin and
distribution of the hyperglycemic-​glycogenolytic factor
of the pancreas. J. Biol. Chem. 175, 663–674 (1948).
4. Muller, T. D., Finan, B., Clemmensen, C., DiMarchi, R. D.
& Tschop, M. H. The new biology and pharmacology of
glucagon. Physiol. Rev. 97, 721–766 (2017).
5. Sandoval, D. A. & D’Alessio, D. A. Physiology of
proglucagon peptides: role of glucagon and GLP-1 in
health and disease. Physiol. Rev. 95, 513–548 (2015).
6. Lane, M. A. The cytological characters of the areas of
langerhans. Am. J. Anat. 7, 409–422 (1907).
7. Bonner-​Weir, S., Sullivan, B. A. & Weir, G. C. Human
islet morphology revisited: human and rodent islets
are not so different after all. J. Histochem. Cytochem.
63, 604–612 (2015).
8. Maruyama, H., Hisatomi, A., Orci, L., Grodsky, G. M.
& Unger, R. H. Insulin within islets is a physiologic
glucagon release inhibitor. J. Clin. Invest. 74,
2296–2299 (1984).
9. Stagner, J. I. & Samols, E. The vascular order of islet
cellular perfusion in the human pancreas. Diabetes
41, 93–97 (1992).
10. Pisania, A. et al. Quantitative analysis of cell
composition and purity of human pancreatic
islet preparations. Lab. Invest. 90, 1661–1675
(2010).
11. Rodriguez-​Diaz, R. et al. Alpha cells secrete
acetylcholine as a non-​neuronal paracrine signal
priming beta cell function in humans. Nat. Med. 17,
888–892 (2011).
12. Cerasi, E. Insulin deficiency and insulin resistance in
the pathogenesis of NIDDM: is a divorce possible?
Diabetologia 38, 992–997 (1995).
13. Kahn, S. E., Zraika, S., Utzschneider, K. M. & Hull, R. L.
The beta cell lesion in type 2 diabetes: there has to be
a primary functional abnormality. Diabetologia 52,
1003–1012 (2009).
14. Butler, A. E. et al. Beta-​cell deficit and increased
beta-​cell apoptosis in humans with type 2 diabetes.
Diabetes 52, 102–110 (2003).
15. Clark, A. et al. Islet amyloid, increased A-​cells, reduced
B cells and exocrine fibrosis: quantitative changes in
the pancreas in type 2 diabetes. Diabetes Res. 9,
151–159 (1988).
16. Rahier, J., Guiot, Y., Goebbels, R. M., Sempoux, C.
& Henquin, J. C. Pancreatic beta-​cell mass in European
subjects with type 2 diabetes. Diabetes Obes. Metab.
10, 32–42 (2008).
17. Sakuraba, H. et al. Reduced beta-​cell mass and
expression of oxidative stress-​related DNA damage
in the islet of Japanese Type II diabetic patients.
Diabetologia 45, 85–96 (2002).
18. Marselli, L. et al. Are we overestimating the loss
of beta cells in type 2 diabetes? Diabetologia 57,
362–365 (2014).
19. Muller, W. A., Faloona, G. R., Aguilar-​Parada, E.
& Unger, R. H. Abnormal alpha-​cell function in diabetes.
Response to carbohydrate and protein ingestion.
N. Engl. J. Med. 283, 109–115 (1970).

Nature Reviews | Endocrinology

Reviews
20. Myers, S. R. et al. Effects of small changes in
glucagon on glucose production during a euglycemic,
hyperinsulinemic clamp. Metabolism 40, 66–71
(1991).
21. Yu, R. Pancreatic alpha-​cell hyperplasia: facts and myths.
J. Clin. Endocrinol. Metab. 99, 748–756 (2014).
22. Eaton, R. P. Hypolipemic action of glucagon in
experimental endogenous lipemia in the rat.
J. Lipid Res. 14, 312–318 (1973).
23. Guettet, C. et al. Effect of chronic glucagon
administration on lipoprotein composition in
normally fed, fasted and cholesterol-​fed rats.
Lipids 26, 451–458 (1991).
24. Bobe, G., Ametaj, B. N., Young, J. W. & Beitz, D. C.
Potential treatment of fatty liver with 14-day
subcutaneous injections of glucagon. J. Dairy Sci. 86,
3138–3147 (2003).
25. Guettet, C., Mathe, D., Navarro, N. & Lecuyer, B.
Effects of chronic glucagon administration on rat
lipoprotein composition. Biochim. Biophys. Acta
1005, 233–238 (1989).
26. Prip-​Buus, C., Pegorier, J. P., Duee, P. H., Kohl, C.
& Girard, J. Evidence that the sensitivity of carnitine
palmitoyltransferase I to inhibition by malonyl-​CoA is
an important site of regulation of hepatic fatty acid
oxidation in the fetal and newborn rabbit. Perinatal
development and effects of pancreatic hormones
in cultured rabbit hepatocytes. Biochem. J. 269,
409–415 (1990).
27. Brown, N. F., Salter, A. M., Fears, R. & Brindley, D. N.
Glucagon, cyclic AMP and adrenaline stimulate the
degradation of low-​density lipoprotein by cultured rat
hepatocytes. Biochem. J. 262, 425–429 (1989).
28. Nunez, D. J. & D’Alessio, D. Glucagon receptor as a
drug target: a witches’ brew of eye of newt (peptides)
and toe of frog (receptors). Diabetes Obes. Metab. 20,
233–237 (2018).
29. Han, S. et al. Effects of small interfering RNA-​
mediated hepatic glucagon receptor inhibition on
lipid metabolism in db/db mice. J. Lipid Res. 54,
2615–2622 (2013).
30. Guan, H. P. et al. Glucagon receptor antagonism
induces increased cholesterol absorption. J. Lipid Res.
56, 2183–2195 (2015).
31. Bechmann, L. P. et al. The interaction of hepatic lipid
and glucose metabolism in liver diseases. J. Hepatol.
56, 952–964 (2012).
32. Damond, N. et al. Blockade of glucagon signaling
prevents or reverses diabetes onset only if residual
beta-​cells persist. eLife 5, 10 (2016).
33. Holst, J. J. et al. Insulin and glucagon: partners for life.
Endocrinology 158, 696–701 (2017).
34. Henquin, J. C. & Rahier, J. Pancreatic alpha cell mass
in European subjects with type 2 diabetes. Diabetologia
54, 1720–1725 (2011).
35. Stefan, Y. et al. Quantitation of endocrine cell content
in the pancreas of nondiabetic and diabetic humans.
Diabetes 8, 694–700 (1982).
36. Nano, R. et al. Human islet distribution programme
for basic research: activity over the last 5 years.
Diabetologia 58, 1138–1140 (2015).
37. Rahier, J., Goebbels, R. M. & Henquin, J. C. Cellular
composition of the human diabetic pancreas.
Diabetologia 24, 366–371 (1983).
38. Cinti, F. et al. Evidence of beta-​cell dedifferentiation
in human type 2 diabetes. J. Clin. Endocrinol. Metab.
101, 1044–1054 (2016).
39. Gao, T. et al. Pdx1 maintains beta cell identity
and function by repressing an alpha cell program.
Cell Metab. 19, 259–271 (2014).
40. Talchai, C., Xuan, S., Lin, H. V., Sussel, L. & Accili, D.
Pancreatic beta cell dedifferentiation as a mechanism
of diabetic beta cell failure. Cell 150, 1223–1234
(2012).
41. Mezza, T. et al. Beta-​cell glucose sensitivity is linked
to insulin/glucagon bihormonal cells in nondiabetic
humans. J. Clin. Endocrinol. Metab. 101, 470–475
(2016).
42. Keenan, H. A. et al. Residual insulin production and
pancreatic ss-​cell turnover after 50 years of diabetes:
Joslin Medalist Study. Diabetes 59, 2846–2853
(2010).
43. Oram, R. A. et al. The majority of patients with long-​
duration type 1 diabetes are insulin microsecretors
and have functioning beta cells. Diabetologia 57,
187–191 (2014).
44. Orci, L. et al. Hypertrophy and hyperplasia
of somatostatin-​containing D-​cells in diabetes.
Proc. Natl Acad. Sci. USA 73, 1338–1342 (1976).
45. Marchetti, P. et al. A local glucagon-​like peptide 1
(GLP-1) system in human pancreatic islets.
Diabetologia 55, 3262–3272 (2012).
46. Ellingsgaard, H. et al. Interleukin-6 enhances insulin
secretion by increasing glucagon-​like peptide-1 secretion
from L cells and alpha cells. Nat. Med. 17, 1481–1489
(2011).
47. Cryer, P. E. Hypoglycaemia: the limiting factor in
the glycaemic management of Type I and Type II
diabetes*. Diabetologia 45, 937–948 (2002).
48. Gerich, J. E., Langlois, M., Noacco, C., Karam, J. H.
& Forsham, P. H. Lack of glucagon response to
hypoglycemia in diabetes: evidence for an intrinsic
pancreatic alpha cell defect. Science 182, 171–173
(1973).
49. Bolli, G. et al. Abnormal glucose counterregulation
in insulin-​dependent diabetes mellitus. Interaction
of anti-​insulin antibodies and impaired glucagon
and epinephrine secretion. Diabetes 32, 134–141
(1983).
50. Rutter, G. A., Pullen, T. J., Hodson, D. J.
& Martinez-​Sanchez, A. Pancreatic beta cell identity,
glucose sensing and the control of insulin secretion.
Biochem. J. 466, 202–218 (2015).
51. Ravier, M. A. & Rutter, G. A. Glucose or insulin, but
not zinc ions, inhibit glucagon secretion from mouse
pancreatic alpha-​cells. Diabetes 54, 1789–1797
(2005).
52. Lamy, C. M. et al. Hypoglycemia-​activated GLUT2
neurons of the nucleus tractus solitarius stimulate
vagal activity and glucagon secretion. Cell Metab. 19,
527–538 (2014).
53. Rorsman, P. & Hellman, B. Voltage-​activated currents
in guinea pig pancreatic alpha 2 cells. Evidence for
Ca2+-dependent action potentials. J. Gen. Physiol. 91,
223–242 (1988).
54. Berts, A., Gylfe, E. & Hellman, B. Ca2+ oscillations in
pancreatic islet cells secreting glucagon and
somatostatin. Biochem. Biophys. Res. Commun. 208,
644–649 (1995).
55. Berts, A., Ball, A., Gylfe, E. & Hellman, B. Suppression
of Ca2+ oscillations in glucagon-​producing alpha 2-cells
by insulin/glucose and amino acids. Biochim. Biophys.
Acta 1310, 212–216 (1996).
56. Nadal, A., Quesada, I. & Soria, B. Homologous and
heterologous asynchronicity between identified alpha-,
beta- and delta-​cells within intact islets of Langerhans
in the mouse. J. Physiol. 517, 85–93 (1999).
57. Grapengiesser, E., Gylfe, E. & Hellman, B. Glucose
effects on cytoplasmic Ca2+ of individual pancreatic
beta- cells recorded by two procedures for dual-​
wavelength fluorometry. Exp. Clin. Endocrinol. 93,
321–327 (1989).
58. Heimberg, H. et al. The glucose sensor protein
glucokinase is expressed in glucagon-​producing
alpha-​cells. Proc. Natl Acad. Sci. USA 93, 7036–7041
(1996).
59. Basco, D. et al. Alpha-​cell glucokinase suppresses
glucose-​regulated glucagon secretion. Nat. Commun.
9, 546–03034 (2018).
60. Heimberg, H., De Vos, A., Pipeleers, D., Thorens, B.
& Schuit, F. Differences in glucose transporter gene
expression between rat pancreatic alpha- and beta-​
cells are correlated to differences in glucose transport
but not in glucose utilization. J. Biol. Chem. 270,
8971–8975 (1995).
61. Benner, C. et al. The transcriptional landscape
of mouse beta cells compared to human beta
cells reveals notable species differences in long
non-​coding RNA and protein-​coding gene expression.
BMC Genomics 15, 620–615 (2014).
62. Blodgett, D. M. et al. Novel observations from
next-​generation RNA sequencing of highly purified
human adult and fetal islet cell subsets. Diabetes 64,
3172–3181 (2015).
63. Segerstolpe, A. et al. Single-​cell transcriptome
profiling of human pancreatic islets in health and
type 2 diabetes. Cell Metab. 24, 593–607 (2016).
64. Sun, G. et al. LKB1 and AMPKα1 are required in
pancreatic alpha cells for the normal regulation of
glucagon secretion and responses to hypoglycemia.
Mol. Metab. 4, 277–286 (2015).
65. Semplici, F. et al. Cell type-​specific deletion in mice
reveals roles for PAS kinase in insulin and glucagon
production. Diabetologia 59, 1938–1947 (2016).
66. Hutton, J. C. et al. Similarities in the stimulus-​
secretion coupling mechanisms of glucose- and
2-keto acid-​induced insulin release. Endocrinology
106, 203–219 (1980).
67. Maechler, P. & Wollheim, C. B. Mitochondrial signals
in glucose-​stimulated insulin secretion in the beta cell.
J. Physiol. 529, 49–56 (2000).
68. Del Guerra, S. et al. Functional and molecular defects
of pancreatic islets in human type 2 diabetes.
Diabetes 54, 727–735 (2005).
69. Sekine, N. et al. Low lactate dehydrogenase and high
mitochondrial glycerol phosphate dehydrogease in
pancreatic β-​cell. Potential role in nutrient sensing.
J. Biol. Chem. 269, 4895–4902 (1994).
70. Jijakli, H. et al. Relevance of lactate dehydrogenase
activity to the control of oxidative glycolysis in
pancreatic islet B cells. Arch. Biochem. Biophys. 327,
260–264 (1996).
71. Zhao, C., Wilson, C. M., Schuit, F., Halestrap, A. P.
& Rutter, G. A. Expression and distribution of lactate/
monocarboxylate transporter (MCT) isoforms in
pancreatic islets and the exocrine pancreas. Diabetes
50, 361–366 (2001).
72. Pullen, T. J., Huising, M. O. & Rutter, G. A. Analysis
of purified pancreatic islet beta and alpha cell
transcriptomes reveals 11β-hydroxysteroid
dehydrogenase (Hsd11b1) as a novel disallowed gene.
Front. Genet. 8, 41 (2017).
73. Lemaire, K., Thorrez, L. & Schuit, F. Disallowed and
allowed gene expression: two faces of mature islet
beta cells. Annu. Rev. Nutr. 36, 45–71 (2016).
74. Gromada, J., Franklin, I. & Wollheim, C. B. Alpha-​cells
of the endocrine pancreas: 35 years of research but
the enigma remains. Endocr. Rev. 28, 84–116 (2007).
75. Taborsky, G. J. et al. Autonomic mechanism and
defects in the glucagon response to insulin-​induced
hypoglycaemia. Diabetes Nutr. Metab. 15, 318–322
(2002).
76. Maruyama, H., Tominaga, M., Bolli, G., Orci, L.
& Unger, R. H. The alpha cell response to glucose
change during perfusion of anti-insulin serum in
pancreas isolated from normal rats. Diabetologia 28,
836–840 (1985).
77. Kawamori, D. et al. Insulin signaling in alpha cells
modulates glucagon secretion in vivo. Cell Metab. 9,
350–361 (2009).
78. Briant, L. J. B. et al. Delta-​cells and beta-​cells are
electrically coupled and regulate alpha-​cell activity via
somatostatin. J. Physiol. 596, 197–215 (2018).
79. Elliott, A. D., Ustione, A. & Piston, D. W. Somatostatin
and insulin mediate glucose-​inhibited glucagon
secretion in the pancreatic alpha-​cell by lowering
cAMP. Am. J. Physiol. Endocrinol. Metab. 308,
E130–E143 (2015).
80. Lee, Y. et al. Hyperglycemia in rodent models of
type 2 diabetes requires insulin-​resistant alpha cells.
Proc. Natl Acad. Sci. USA 111, 13217–13222 (2014).
81. Faerch, K. et al. Insulin resistance is accompanied
by increased fasting glucagon and delayed glucagon
suppression in individuals with normal and impaired
glucose regulation. Diabetes 65, 3473–3481 (2016).
82. Sharma, A. et al. Impaired insulin action is associated
with increased glucagon concentrations in nondiabetic
humans. J. Clin. Endocrinol. Metab. 103, 314–319
(2018).
83. Ishihara, H., Maechler, P., Gjinovci, A., Herrera, P. L.
& Wollheim, C. B. Islet beta-​cell secretion determines
glucagon release from neighbouring alpha-​cells.
Nat. Cell Biol. 5, 330–335 (2003).
84. Nicolson, T. J. et al. Insulin storage and glucose
homeostasis in mice null for the granule zinc transporter
ZnT8 and studies of the type 2 diabetes-​associated
variants. Diabetes 58, 2070–2083 (2009).
85. Li, D. et al. Imaging dynamic insulin release using a
fluorescent zinc indicator for monitoring induced
exocytotic release (ZIMIR). Proc. Natl Acad. Sci. USA
108, 21063–21068 (2011).
86. Sladek, R. et al. A genome-​wide assocation study
identifies novel risk loci for type 2 diabetes. Nature
445, 881–885 (2007).
87. Solomou, A. et al. The zinc transporter Slc30a8/ZnT8
is required in a subpopulation of pancreatic α cells for
hypoglycemia-​induced glucagon secretion. J. Biol. Chem.
290, 21432–21442 (2015).
88. Solomou, A. et al. Over-expression of Slc30a8/ZnT8
selectively in the mouse alpha cell impairs
glucagon release and responses to hypoglycemia.
Nutr. Metab. 13, 46–0104 (2016).
89. da Silva Xavier, G. et al. Pancreatic alpha cell-​selective
deletion of Tcf7l2 impairs glucagon secretion and
counter-​regulatory responses to hypoglycaemia in mice.
Diabetologia 60, 1043–1050 (2017).
90. da Silva Xavier, G. et al. TCF7L2 regulates late events
in insulin secretion from pancreatic islet beta-​cells.
Diabetes 58, 894–905 (2009).
91. Fuchsberger, C. et al. The genetic architecture of type
2 diabetes. Nature 536, 41–47 (2016).
92. Rorsman, P. et al. Glucose-​inhibition of glucagon
secretion involves activation of GABAA-​receptor
chloride channels. Nature 341, 233–236 (1989).
93. Bailey, S. J., Ravier, M. A. & Rutter, G. A. Glucose-​
dependent regulation of γ-aminobutyric acid (GABA A)
www.nature.com/nrendo

receptor expression in mouse pancreatic islet
alpha-cells. Diabetes 56, 320–327 (2007).
94. Taborsky, G. J. Jr, Ahren, B. & Havel, P. J. Autonomic
mediation of glucagon secretion during hypoglycemia:
implications for impaired alpha-​cell responses in type
1 diabetes. Diabetes 47, 995–1005 (1998).
95. Gasbjerg, L. S. et al. Glucose-​dependent insulinotropic
polypeptide (GIP) receptor antagonists as anti-​diabetic
agents. Peptides 100, 173–181 (2018).
96. Orgaard, A. & Holst, J. J. The role of somatostatin
in GLP-1-induced inhibition of glucagon secretion in
mice. Diabetologia 60, 1731–1739 (2017).
97. Madaan, T., Akhtar, M. & Najmi, A. K. Sodium glucose
cotransporter 2 (SGLT2) inhibitors: current status and
future perspective. Eur. J. Pharm. Sci. 93, 244–252
(2016).
98. Baron, M. et al. A single-​cell transcriptomic map of the
human and mouse pancreas reveals inter- and intra-​cell
population structure. Cell Syst. 3, 346–360 (2016).
99. Muraro, M. J. et al. A single-​cell transcriptome atlas
of the human pancreas. Cell Syst. 3, 385–394 (2016).
100. Li, J. et al. Single-​cell transcriptomes reveal
characteristic features of human pancreatic islet
cell types. EMBO Rep. 17, 178–187 (2016).
101. Xin, Y. et al. RNA sequencing of single human islet
cells reveals type 2 diabetes genes. Cell Metab. 24,
608–615 (2016).
102. Xin, Y. et al. Use of the Fluidigm C1 platform for
RNA sequencing of single mouse pancreatic islet cells.
Proc. Natl Acad. Sci. USA 113, 3293–3298 (2016).
103. Dominguez, G. G. et al. Gene signature of proliferating
human pancreatic alpha-​cells. Endocrinology 159,
3177–3186 (2018).
104. Xin, Y. et al. Pseudotime ordering of single human
beta-​cells reveals states of insulin production and
unfolded protein response. Diabetes 67, 1783–1794
(2018).
105. Tritschler, S., Theis, F. J., Lickert, H. & Bottcher, A.
Systematic single-​cell analysis provides new insights
into heterogeneity and plasticity of the pancreas.
Mol. Metab. 6, 974–990 (2017).
106. Ziv, O., Glaser, B. & Dor, Y. The plastic pancreas.
Dev. Cell 26, 3–7 (2013).
107. Adriaenssens, A. E. et al. Transcriptomic profiling
of pancreatic alpha, beta and delta cell populations
identifies delta cells as a principal target for ghrelin
in mouse islets. Diabetologia 59, 2156–2165
(2016).
108. DiGruccio, M. R. et al. Comprehensive alpha, beta and
delta cell transcriptomes reveal that ghrelin selectively
activates delta cells and promotes somatostatin release
from pancreatic islets. Mol. Metab. 5, 449–458
(2016).
109. Holst, J. J., Wewer Albrechtsen, N. J., Pedersen, J.
& Knop, F. K. Glucagon and amino acids are linked in a
mutual feedback cycle: the liver-​alpha-cell axis. Diabetes
66, 235–240 (2017).
110. Longuet, C. et al. Liver-​specific disruption of the
murine glucagon receptor produces alpha-​cell
hyperplasia: evidence for a circulating alpha-​cell
growth factor. Diabetes 62, 1196–1205 (2013).
111. Solloway, M. J. et al. Glucagon couples hepatic amino
acid catabolism to mTOR-​dependent regulation of
alpha-​cell mass. Cell Rep. 12, 495–510 (2015).
112. Dean, E. D. et al. Interrupted glucagon signaling
reveals hepatic alpha cell axis and role for L-​glutamine
in alpha cell proliferation. Cell Metab. 25, 1362–1373
(2017).
113. Kim, J. et al. Amino acid transporter Slc38a5 controls
glucagon receptor inhibition-​induced pancreatic alpha
cell hyperplasia in mice. Cell Metab. 25, 1348–1361
(2017).
Nature Reviews | Endocrinology
114. Bozadjieva, N. et al. Loss of mTORC1 signaling alters
pancreatic alpha cell mass and impairs glucagon
secretion. J. Clin. Invest. 127, 4379–4393 (2017).
115. Sayers, S. R. et al. Proglucagon promoter cre-​mediated
AMPK deletion in mice increases circulating GLP-1
levels and oral glucose tolerance. PLOS ONE 11,
e0149549 (2016).
116. Xiao, X. et al. Endogenous reprogramming of alpha
cells into beta cells, induced by viral gene therapy,
reverses autoimmune diabetes. Cell Stem Cell 22,
78–90 (2018).
117. Chakravarthy, H. et al. Converting adult pancreatic
islet alpha cells into beta cells by targeting both
Dnmt1 and Arx. Cell Metab. 25, 622–634 (2017).
118. Wilcox, C. L., Terry, N. A., Walp, E. R., Lee, R. A.
& May, C. L. Pancreatic alpha-​cell specific deletion of
mouse Arx leads to alpha-​cell identity loss. PLOS ONE
8, e66214 (2013).
119. Courtney, M. et al. The inactivation of Arx in
pancreatic alpha-​cells triggers their neogenesis and
conversion into functional beta-​like cells. PLOS Genet.
9, e1003934 (2013).
120. Thorel, F. et al. Conversion of adult pancreatic alpha-​
cells to beta-​cells after extreme beta-​cell loss. Nature
464, 1149–1154 (2010).
121. Lu, J. et al. IGFBP1 increases beta-​cell regeneration
by promoting alpha- to beta-​cell transdifferentiation.
EMBO J. 35, 2026–2044 (2016).
122. Ben-​Othman, N. et al. Long-​term GABA administration
induces alpha cell-​mediated beta-​like cell neogenesis.
Cell 168, 73–85 (2017).
123. Brown, M. L., Andrzejewski, D., Burnside, A.
& Schneyer, A. L. Activin enhances alpha- to beta-​cell
transdifferentiation as a source for beta-​cells in male
FSTL3 knockout mice. Endocrinology 157, 1043–1054
(2016).
124. van der Meulen, T. et al. Artemether does not turn
alpha cells into beta cells. Cell Metab. 27, 218–225
(2018).
125. Thorel, F. et al. Normal glucagon signaling and beta-​cell
function after near-​total alpha-​cell ablation in adult mice.
Diabetes 60, 2872–2882 (2011).
126. Ackermann, A. M., Wang, Z., Schug, J., Naji, A.
& Kaestner, K. H. Integration of ATAC-​seq and RNA-​
seq identifies human alpha cell and beta cell signature
genes. Mol. Metab. 5, 233–244 (2016).
127. Bramswig, N. C. et al. Epigenomic plasticity enables
human pancreatic alpha to beta cell reprogramming.
J. Clin. Invest. 123, 1275–1284 (2013).
128. Papizan, J. B. et al. Nkx2.2 repressor complex
regulates islet beta-​cell specification and prevents
beta-​to-alpha-​cell reprogramming. Genes Dev. 25,
2291–2305 (2011).
129. Avrahami, D. et al. Aging-​dependent demethylation
of regulatory elements correlates with chromatin
state and improved beta cell function. Cell Metab. 22,
619–632 (2015).
130. Dhawan, S. et al. DNA methylation directs functional
maturation of pancreatic beta cells. J. Clin. Invest.
125, 2851–2860 (2015).
131. Arda, H. E. et al. Age-​dependent pancreatic gene
regulation reveals mechanisms governing human
beta cell function. Cell Metab. 23, 909–920 (2016).
132. Moran, I. et al. Human beta cell transcriptome
analysis uncovers lncRNAs that are tissue-​specific,
dynamically regulated, and abnormally expressed in
type 2 diabetes. Cell Metab. 16, 435–448 (2012).
133. Wang, Y. J. et al. Single-​cell mass cytometry analysis
of the human endocrine pancreas. Cell Metab. 24,
616–626 (2016).
134. Sipos, B. et al. Glucagon cell hyperplasia and
neoplasia with and without glucagon receptor
Reviews
mutations. J. Clin. Endocrinol. Metab. 100,
E783–E788 (2015).
135. Larger, E. et al. Pancreatic alpha-​cell hyperplasia and
hyperglucagonemia due to a glucagon receptor splice
mutation. Endocrinol. Diabetes Metab. Case Rep.
2016, 16-0081 (2016).
136. Challis, B. G. et al. Heterogeneity of glucagonomas
due to differential processing of proglucagon-​derived
peptides. Endocrinol. Diabetes Metab. Case Rep.
2015, 150105 (2015).
137. Chambers, A. P. et al. The role of pancreatic
preproglucagon in glucose homeostasis in mice.
Cell Metab. 25, 927–934 (2017).
138. Traub, S. et al. Pancreatic alpha cell-​derived glucagon-​
related peptides are required for beta cell adaptation
and glucose homeostasis. Cell Rep. 18, 3192–3203
(2017).
139. Saloman, D. & Meda, P. Heterogeneity and
contact-​dependent regulation of hormone secretion
by individual B cells. Exp. Cell Res. 162, 507–520
(1986).
140. Pipeleers, D. G. Heterogeneity in pancreatic
β-​cell population. Diabetes 41, 777–781 (1992).
141. Gutierrez, G. D., Gromada, J. & Sussel, L.
Heterogeneity of the pancreatic beta cell. Front. Genet.
8, 22 (2017).
142. Hodson, D. J. et al. Lipotoxicity disrupts incretin-​
regulated human beta cell connectivity. J. Clin. Invest.
123, 4182–4194 (2013).
143. Johnston, N. R. et al. Beta cell hubs dictate pancreatic
islet responses to glucose. Cell Metab. 24, 389–401
(2016).
144. Mitchell, R. K. et al. Selective disruption of Tcf7l2
in the pancreatic beta cell impairs secretory function
and lowers beta cell mass. Hum. Mol. Genet. 24,
1390–1399 (2014).
145. Hodson, D. J. et al. ADCY5 couples glucose to insulin
secretion in human islets. Diabetes 63, 3009–3021
(2014).
146. Mitchell, R. K. et al. The transcription factor Pax6
is required for pancreatic beta cell identity, glucose-​
regulated ATP synthesis, and Ca2+ dynamics in adult
mice. J. Biol. Chem. 292, 8892–8906 (2017).
147. Rutter, G. A. GABA signaling: a route to new
pancreatic beta cells. Cell Res. 27, 309–310
(2017).
Acknowledgements
The authors thank Y. Xin and J. Kim for help with preparation
of the manuscript and figures. G.A.R. was supported by MRC
Programmes (MR/J0003042/1, MR/N00275X/1 and MR/
L020149/1 (DIVA)), Wellcome Trust Senior Investigator
Award (WT098424AIA), Diabetes UK (BDA11/0004210 and
BDA/15/0005275) and Biotechnology and Biological
Sciences Research Council (BB/J015873/1) project grants.
Author contributions
All authors contributed to all aspects of the manuscript.
Competing interests
J.G. is an employee and shareholder of Regeneron
Pharmaceuticals, Inc. G.A.R. has received research funding
from Les Laboratoires Servier. P.C. declares no competing
interests.
Supplementary information
Supplementary information is available for this paper at
https://doi.org/10.1038/s41574-018-0097-y.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.