Islet amyloid polypeptide-producing pancreatic islet cell tumor. A clinical and biochemical characterization

Metabolic stress, IAPP and islet amyloid

Amyloid forms within pancreatic islets in type 2 diabetes from aggregates of the β-cell peptide islet amyloid polypeptide (IAPP). These aggregates are toxic to β-cells, inducing β-cell death and dysfunction, as well as inciting islet inflammation. The β-cell is subject to a number of other stressors, including insulin resistance and hyperglycaemia, that may contribute to amyloid formation by increasing IAPP production by the β-cell. β-Cell dysfunction, evident as impaired glucose-stimulated insulin secretion and defective prohormone processing and exacerbated by metabolic stress, is also a likely prerequisite for islet amyloid formation to occur in type 2 diabetes. Islet transplants in patients with type 1 diabetes face similar stressors, and are subject to rapid amyloid formation and impaired proinsulin processing associated with progressive loss of β-cell function and mass. Declining β-cell mass is predicted to increase metabolic demand on remaining β-cells, promoting a feed-forward cycle of β-cell decline.

Inhibition of insulin secretion

Reports of the effects of amylin and amylin agonists on insulin secretion have varied widely. Some confusion can be attributed to the use of human amylin, which has been shown to readily fall out of solution resulting in low estimates of bioactivity. Some confusion can be resolved by assessing the probability that this had happened. The view taken here, supported by authors using reliable and well-characterized ligands (representing the preponderance of recent studies), is that exogenously administered amylin agonists inhibit insulin secretion, at least partly via activation of an amylin-like receptor linked to Gi-mediated inhibition of cAMP in islets. There may additionally be autonomic extrapancreatic effects of amylin on insulin secretion that derive from its action at the area postrema. Studies with amylin receptor antagonists, including human studies, indicate that endogenously secreted amylin may physiologically inhibit beta-cell secretion (insulin and amylin) via feedback inhibition that is characteristic of many other hormones. Part of this inhibition may be local (paracrine), as indicated by the amylin sensitivity of isolated preparations and the fact that the concentration of secreted products in the islet interstitium can be over 100-fold higher than in the circulation (Bendayan, 1993).

Renal Effects

Amylin bound to kidney cortex in a distinctive pattern. Binding appeared specific in that it was displaceable with amylin antagonists. It was associated with activation of cyclic AMP (cAMP), and was thereby likely to represent receptor binding and activation. Amylin's principal effects at the kidney included a stimulation of plasma renin activity, reflected in aldosterone increases at quasi-physiological amylin concentrations. It was unclear whether this was a local or a systemic effect. Other renal effects in rats included a diuretic effect and a natriuretic effect. The latter was mainly driven by the diuresis, since urinary sodium concentration did not change. Amylin had a transient effect to lower plasma potassium concentration. This effect was likely to be a consequence of activation of Na+/K+-ATPase, an action shared with insulin and catecholamines. Amylin lowered plasma calcium, particularly ionized calcium, likely due to an antiresorptive effect at osteoclasts. Immunoreactive amylin was detected in the developing kidney. It appeared to have a trophic effect in kidney, and its absence resulted in renal dysgenesis. Neurons in the subfornical organ (SFO), which has a role in fluid/electrolyte homeostasis, were potently activated by amylin. The dipsogenic and renal effects of amylin may be related to effects at the SFO.

Chromogranin-B regulation of IAPP and insulin secretion

In the endocrine pancreas, chromogranin-A and pancreastatin have been suggested to inhibit islet insulin secretion, whereas chromogranin-B has not been studied in this context. Furthermore, a putative effect by chromogranins on IAPP secretion is unknown. We aimed to elucidate the endogenous effect of chromogranin-A, pancreastatin and chromogranin-B on islet insulin and IAPP secretion from pancreatic NMRI mouse islets. In acute experiments, there was a tendency towards an increase in insulin release, which became more manifest after a 48-h exposure. Moreover, 48 h exposure to chromogranin-B antiserum resulted in a significant increase in (pro)insulin synthesis. Neither antibodies against chromogranin-A nor pancreastatin had any effect on islet hormone secretion. None of the antibodies tested had any effect on islet IAPP or insulin content. We suggest that chromogranin-B released from islets may have an autocrine inhibitory effect on islet IAPP and insulin secretion. Our data imply a regulatory role of chromogranin-B in islet IAPP and insulin secretion.

Leptin regulation of islet amyloid polypeptide secretion from mouse pancreatic islets

Leptin receptors are expressed in pancreatic beta-cells. However, leptin's role in islet hormone secretion is essentially unknown. In the present study, we aimed to elucidate leptin's effect on isolated pancreatic NMRI mouse islets by examining islet amyloid polypeptide (IAPP) and insulin secretion in acute experiments and after 48-hr exposure to leptin (1-100 nM). It was also examined whether a putative effect of leptin was affected by the glucose concentration. Islets were cultured in medium RPMI 1640 + 10% fetal calf serum, and the effects of leptin on islet cell replication, glucose metabolism, and hormone content were subsequently examined. Glucose-stimulated IAPP secretion was reduced both acutely and after 48-hr exposure to leptin, whereas only minor effects were found on insulin release, i.e. an inhibition in islets cultured with 1 nM leptin. An acute inhibitory effect by 10 nM leptin was observed on the ratio of IAPP/insulin release at 5.6-11.1 mM glucose, but this was overcome by 16.7 mM glucose. The islet glucose oxidation rate was enhanced by 1 nM leptin, but decreased at higher concentrations of leptin in acute experiments. In contrast, glucose metabolism was not affected in long-term experiments. Moreover, leptin did not influence islet (pro)insulin synthesis or the cell replication rate after culture. In conclusion, we show that islet IAPP release seems to be more sensitive to leptin than is insulin release. The effect of leptin on islet hormone secretion is dependent on the glucose concentration. The regulation of hormone secretion seems to be dissociated from glucose metabolism, an effect previously described in islets after exposure to certain cytokines. Our data necessarily suggest that a previously proposed negative feedback loop between leptin and insulin can be counteracted by IAPP.

Detection of amyloid deposition in various regions of the feline pancreas by different staining techniques

Deposition of islet amyloid is a common finding in the pancreas of diabetic cats and it may contribute to the deterioration of glucose tolerance. Three techniques for detecting pancreatic amyloid deposition were compared in cats not known to be diabetic. Congo red (CR) staining was used for histological sections (35 cats) and tissue smear preparations (crush and smear [CS] technique; 35 cats, and an immunohistochemical method (18 cats) was used for the detection of amyloid derived from amylin. Six diabetic cats were used as positive controls for the immunohistochemical method. The amount of pancreatic amyloid demonstrated immunohistochemically was significantly correlated with that shown by CR staining in histological sections but not in CS preparations, which were less satisfactory. However, the amount of amyloid determined immunohistochemically was slightly but significantly higher than that seen in CR-stained sections. There was no difference in the amount of amyloid between the left limb middle segment and right limb of the pancreas. Amylin labelling was seen in about 70 to 80% of islet cells, mainly those located in the islet periphery and the labelling was most intense in the cell periphery.

Islet amyloid polypeptide (IAPP) secretion from pancreatic islets isolated from non-obese diabetic (NOD) mice

The secretion of islet amyloid polypeptide (IAPP) during the course of insulin-dependent diabetes mellitus (IDDM) is essentially unknown. In the present study we elucidated this issue by examining IAPP and insulin secretion from isolated pancreatic islets obtained from IDDM-prone female NOD mice aged 6-9 weeks and 12-15 weeks and from non-IDDM-prone male NMRI mice. Basal islet hormone secretion at 1.7 mM glucose and after stimulation with 17 mM glucose or with 17 mM glucose + 5 mM theophylline was studied acutely or after 1 week of tissue culture. The levels of glucose-stimulated insulin release from NOD mouse islets increased after tissue culture, whereas it remained unchanged in NMRI mouse islets. Overall changes in islet insulin secretion were accompanied by similar changes in IAPP secretion. Acute after isolation, islets from NMRI mice displayed a reduced IAPP/insulin secretion ratio in response to the stimulation, which could reflect a destabilized hormone release. When the NOD mouse islets at 6-9 weeks of age were exposed to secretory stimuli the molar ratio of IAPP/insulin secretion declined. At a later stage of advanced insulitis (12-15 weeks) also the basal IAPP/insulin secretory ratio at low glucose tended to decline. If extrapolated to the early prediabetic phase of human IDDM, this would mean that a relative hypersecretion of insulin in relation to IAPP might occur, due to an increased secretory demand for insulin or due to an intrinsic change in the biology of the secretory cells.

Amylin stimulates plasma renin concentration in humans

Although insulin resistance and hypertension are commonly associated, the underlying cause for this association remains unknown. Plasma concentrations of the recently described hormone amylin, which is cosecreted with insulin by the pancreatic beta cell, are reported to be elevated in various states of insulin resistance, including hypertension and obesity. Preliminary studies by our group have suggested that there are amylin binding sites in the kidney. In nine healthy humans an infusion of human amylin that resulted in steady state plasma amylin levels in the subnanomolar range led to significant increases in plasma renin and aldosterone concentrations. These changes occurred in the absence of significant changes in plasma electrolytes, catecholamines, vasopressin, total renin, or osmolality. Diastolic pressure at 30 minutes and plasma glucose at 60 minutes rose modestly. Since amylin has both metabolic and renal actions, this peptide may be an important link between hypertension, insulin resistance, and the renin-angiotensin system.

Non-parallelism of islet amyloid polypeptide (amylin) and insulin gene expression in rats islets following dexamethasone treatment

Islet amyloid polypeptide (IAPP), a novel islet hormone candidate, has been reported to be over-expressed relative to insulin in rats following dexamethasone treatment. In order to investigate the expression of IAPP and insulin following dexamethasone treatment of rats for 12 days, we applied in situ hybridization and immunocytochemistry, allowing us to evaluate islet changes in gene expression and morphology. Tissue concentrations of IAPP and insulin were measured by radioimmunoassay. A low dose of dexamethasone (0.2 mg/kg daily) increased the islet levels of IAPP and insulin mRNA to 249 +/- 13% and 150 +/- 24% of controls, respectively (p < 0.001 and p < 0.01). A high dose of dexamethasone (2.0 mg/kg daily) increased the islet levels of IAPP and insulin mRNA to 490 +/- 13% and 203 +/- 9% of controls, respectively (p < 0.001 and p < 0.001). The pancreatic concentration of IAPP increased more than that of insulin (p < 0.05). Morphometric analysis revealed that dexamethasone treatment induced both hyperplasia and hypertrophy of insulin cells. Changes in the cellular localization of IAPP and insulin mRNA were not observed. Thus, we conclude that the increased level of IAPP mRNA is due to both an increase at the cellular level as well as hyperplasia/hypertrophy of insulin cells. In contrast, the increased level of insulin mRNA appears to be due to hyperplasia/hypertrophy of insulin cells, since insulin gene expression decreased at the cellular level (p < 0.001 vs controls). These observations provide further evidence that IAPP and insulin gene expression are regulated in a non-parallel fashion, which may be relevant to the pathogenesis of non-insulin-dependent diabetes mellitus.

Islet amyloid polypeptide (IAPP) in patients with neuroendocrine tumours

Although IAPP was first discovered and isolated from amyloid deposits in an endocrine pancreatic tumour (EPT), surprisingly few reports have investigated the potential use of IAPP as a marker for neuroendocrine tumour growth. In this study we present results from plasma measurements of IAPP in 102 patients with neuroendocrine tumours. Four of 35 patients (11%) with midgut carcinoid tumours, but none of the patients (4 and 5, respectively) with lung carcinoids or with rectal carcinoids displayed elevated plasma levels of IAPP. Five of 31 patients (16%) with sporadic EPT and 3 of 27 patients (11%) with EPT and multiple endocrine neoplasia type 1 syndrome disclosed elevated IAPP levels. Within the different syndromes, 1/11 individuals with insulinoma, 2/16 with gastrinoma, 0/2 with glucagonoma, 0/3 with VIPoma and 5/26 with non-functioning tumours showed elevated plasma levels of IAPP. In two patients, the plasma IAPP levels were extremely elevated. These patients also exhibited altered glucose homeostasis. In response to a standardised mixed meal test, IAPP increased in parallel to the insulin, pancreatic polypeptide, gastrin and glucose responses. In MEN1 patients with hypercalcaemia due to increased secretion of parathyroid hormone, the plasma levels of IAPP were significantly higher before than after surgical removal of the parathyroid adenomas. However in normocalcaemic patients, no correlation between the blood calcium and plasma IAPP levels was found. Immunocytochemical staining of tumour tissue showed that 9/13 (69%) of insulin producing tumours, 4/14 (29%) of non-functioning tumours and 1/9 (11%) of gastrin producing tumours were IAPP immunoreactive. Amyloid deposits were always IAPP immunoreactive. In conclusion, increased circulating levels of IAPP occurred in 12% of 102 patients with neuroendocrine tumours. In 2 patients with extremely elevated plasma levels of IAPP, effects on glucose homeostasis were recorded. Thus, IAPP may be useful as an additional marker for neuroendocrine tumour growth in selected cases.

Chronic exposure of cultured rat pancreatic islets to elevated concentrations of islet amyloid polypeptide (IAPP) causes a decrease in islet DNA content and medium insulin accumulation

The biological action of islet amyloid polypeptide (IAPP) remains to be established, although a role for IAPP in causing beta-cell failure in diabetes has been proposed. Acute in vitro experiments with IAPP have given controversial results as to beta-cell insulin secretion. We have studied the effect of a long-term exposure of pancreatic islets to elevated IAPP concentrations. Thus, rat pancreatic islets were cultured for 4 days in medium supplemented with 0, 0.1, 1, 10, 100 or 1000 nM of synthetic amidated rat IAPP. Islets exposed to the two highest IAPP concentrations contained about 20% less DNA, whereas the rate of DNA synthesis was unchanged. Culture with 1000 nM IAPP, but not the lower concentrations of the peptide, slightly decreased the glucose oxidation rate. There was a correlation between increasing IAPP concentrations and and a decline in the medium insulin accumulation. The preceding IAPP exposure did, however, neither significantly affect basal and glucose-stimulated insulin secretion nor (pro)insulin and total protein biosynthesis rates, when tested after the culture. The finding of a decreased islet cell DNA content after culture with elevated IAPP concentrations suggests a toxic action to islet cells, whereas a putative inhibition of the islet insulin production appears to be transient.

An improved method for the determination of islet amyloid polypeptide levels in plasma

We describe an improved method for the determination of islet amyloid polypeptide (IAPP) levels in plasma. Plasma is first extracted with acid-acetone, followed by a specific and sensitive radioimmunoassay (RIA) for IAPP using rabbit-anti-human-IAPP serum. Recovery of synthetic IAPP from plasma was 82 +/- 6% (n = 16). Standard samples, prepared in 'hormone-free' serum, were also extracted with acid-acetone. Displacement curves of serially diluted acid-acetone extracted plasma samples were parallel to the standard curve. The lower detection limit of the RIA was 2.3 +/- 0.1 fmol/sample (n = 5). Intra-assay variations for IAPP concentrations of 4, 17 and 32 pM were 16.3% (n = 10), 9.2% (n = 10) and 6.2% (n = 10); interassay variations were 35.9% (n = 14), 19.9% (n = 15) and 15.4% (n = 15), respectively. Non-stimulated IAPP levels ranged from 2.4 to 12 pM (mean 6 +/- 4 pM, n = 10) in healthy control subjects. IAPP was not detectable in type 1 (insulin-dependent) diabetic patients before and after glucagon administration. In type 2 (non-insulin-dependent) diabetic patients basal levels ranged from 2.2 to 14.5 pM and glucagon-stimulated levels ranged from 2.2 to 38.9 pM. The increase in IAPP varied from 0 to 24.4 pM. The anti-human-IAPP serum had full cross-reactivity with rat IAPP (= mouse IAPP). Transgenic mice overexpressing the human IAPP gene showed elevated plasma IAPP levels as compared to (non-transgenic) control mice. It is concluded that the method presented for the determination of IAPP in plasma is reliable and easy to perform, yielding reproducible results.(ABSTRACT TRUNCATED AT 250 WORDS)

Molecular physiology of the islet amyloid polypeptide (IAPP)/amylin gene in man, rat, and transgenic mice

Islet amyloid polypeptide ("amylin") is the major protein component of amyloid deposits in pancreatic islets of type 2 (non-insulin-dependent) diabetic patients. Islet amyloid polypeptide consists of 37 amino acids, is co-produced and co-secreted with insulin from islet beta-cells, can act as a hormone in regulation of carbohydrate metabolism, and is implicated in the pathogenesis of islet amyloid formation and of type 2 diabetes mellitus. Rat islet amyloid polypeptide differs from human islet amyloid polypeptide particularly in the region of amino acids 25-28, which is important for amyloid fibril formation. In rat and mouse, diabetes-associated islet amyloid does not develop. To study the genetic organization and biosynthesis of islet amyloid polypeptide, we have isolated and analyzed the human and rat islet amyloid polypeptide gene and corresponding cDNAs. Both genes contain 3 exons, encoding precursor proteins of 89 amino acids and 93 amino acids, respectively. Apart from a putative signal sequence, these precursors contain amino- and carboxy-terminal flanking peptides in addition to the mature islet amyloid polypeptide. To understand regulation of islet amyloid polypeptide gene expression, we have identified several potential cis-acting transcriptional control elements that influence beta-cell-specific islet amyloid polypeptide gene expression. Using antisera raised against synthetic human islet amyloid polypeptide we developed a specific and sensitive radioimmunoassay to measure levels of islet amyloid polypeptide in plasma and tissue extracts. Also antisera raised against the flanking peptides will be used in studying human islet amyloid polypeptide biosynthesis. Elevated plasma islet amyloid polypeptide levels have been demonstrated in some diabetic, glucose-intolerant, and obese individuals, as well as in rodent models of diabetes and obesity. To examine the potential role of islet amyloid polypeptide overproduction in the pathogenesis of islet amyloid formation and type 2 diabetes, we generated transgenic mice that overproduce either the amyloidogenic human islet amyloid polypeptide or the nonamyloidogenic rat islet amyloid polypeptide in their islet beta-cells. Despite moderately to highly (up to 15-fold) elevated plasma islet amyloid polypeptide levels, no marked hyperglycemia, hyperinsulinemia or obesity was observed. This suggests that chronic overproduction of islet amyloid polypeptide "per se" does not cause insulin resistance. No islet amyloid deposits were detected in mice up to 63 weeks of age, but in every mouse producing human islet amyloid polypeptide (as in man), accumulation of islet amyloid polypeptide was observed in beta-cell lysosomal bodies. This may represent an initial phase in intracellular amyloid fibril formation.(ABSTRACT TRUNCATED AT 400 WORDS)

Inhibition of insulin secretion, but normal peripheral insulin sensitivity, in a patient with a malignant endocrine pancreatic tumour producing high amounts of an islet amyloid polypeptide-like molecule

Islet amyloid polypeptide or amylin is a polypeptide secreted mainly from the pancreatic beta cells together with insulin upon stimulation. High levels of islet amyloid polypeptide have also been shown to increase the peripheral insulin resistance and consequently a role for islet amyloid polypeptide in the glucose homeostasis has been suggested. We have studied the glucose homeostasis in a patient with a malignant endocrine pancreatic tumour producing large amounts of an islet amyloid polypeptide-like molecule (about 400 times the upper reference level for islet amyloid polypeptide). This patient developed insulin-requiring diabetes mellitus shortly after the tumour diagnosis. Both intravenous and oral glucose tolerance tests revealed inhibited early responses in insulin and C-peptide release, but the insulin and C-peptide response to glucagon stimulation was less affected. Aneuglycaemic insulin clamp showed normal insulin-mediated glucose disposal. In vitro experiments, where isolated rat pancreatic islets were cultured with serum from the patient, showed a moderately decreased islet glucose oxidation rate and glucose-stimulated insulin release compared to islets cultured with serum from healthy subjects. However, culture of rat islets with normal human serum supplemented with synthetic rat islet amyloid polypeptide did not affect the glucose-stimulated insulin release. In conclusion, the observed effects show that the diabetic state in this patient was associated with an impaired glucose-stimulated insulin release but not with an increased peripheral insulin resistance.(ABSTRACT TRUNCATED AT 250 WORDS)

Cosecretion of islet amyloid polypeptide (IAPP) and insulin from isolated rat pancreatic islets following stimulation or inhibition of beta-cell function

The aim of this work was to simultaneously study the secretion of islet amyloid polypeptide (IAPP) and insulin from isolated rat pancreatic islets in vitro. For examination of stimulated beta-cells, nutrient secretagogues (16.7 mM glucose, 10 mM leucine + 2 mM glutamine), phosphodiesterase inhibition (5 mM theophylline), a sulphonylurea (0.5 microgram/ml glipizide), a non-nutrient amino acid (10 mM arginine), cholinergic stimulation (0.1 mM carbamylcholine) and insulinotropic peptides (0.1 microM vasoactive intestinal polypeptide and 0.1 microM glucagon), were used. For beta-cell suppression glucose phosphorylation inhibition (10 mM mannoheptulose), depletion of extracellular calcium, activation of the ATP-regulated K(+)-channel (0.5 mM diazoxide), adrenoreceptor stimulation (3 microM adrenaline), paracrine modulation (0.1 microM somatostatin), short-term treatment with a selective beta-cytotoxin (1.1 and 2.2 mM streptozotocin) and long-term treatment with a cytokine (25 U/ml interleukin-1 beta), were studied. The compounds with known effects on insulin secretion exerted their expected actions and this was paralleled by similar relative changes, with a possible exception for glucagon, in the IAPP secretion. The ratio of IAPP/insulin released did not change significantly under any of the tested experimental conditions, except for a slight increase following carbamylcholine stimulation. On a molar basis approx. 1% of IAPP was released when compared with insulin. These results are consistent with the hypothesis that the regulation of IAPP secretion from beta-cells of isolated rat pancreatic islets is essentially regulated by the same mechanisms as insulin secretion.

Amylin

Amylin is a 37 amino-acid peptide which is secreted from the pancreatic islets of Langerhans. It has major sequence homology with calcitonin gene related peptide. Amylin can precipitate out in these cells to form amyloid. Amylin is secreted by similar stimuli to those that secrete insulin. Amylin has a number of effects that may counteract the effect of secreted insulin, i.e., decreased second phase insulin secretion, increased hepatic glucose output, and inhibition of insulin effects on skeletal muscle. It must, however, be recognized that in many cases the doses necessary to produce these effects appear to be supraphysiological. The putative role of amylin in the hyperglycemia of aging and Type II diabetes mellitus therefore remains controversial. Amylin has a number of other effects including inhibition of osteoclastic activity, vasodilatation, anorectic effects and enhanced memory retention. This review postulates a role for amylin in the pathogenesis of a number of age-related changes.