Altered ß-cell Prohormone Processing and Secretion in Type 1 Diabetes
Analysis of data from clinical cohorts and more recently from human pancreatic tissue, indicate that defects in prohormone processing are an early and persistent component of type 1 diabetes pathogenesis. In this Perspectives article, we review the current state of knowledge of alterations in islet prohormone expression and processing in type 1 diabetes, and consider the clinical impact of these findings. Lingering questions, including pathologic etiologies and consequences of altered prohormone expression and secretion in type 1 diabetes, and the natural history of circulating prohormone production in health and disease are considered. Finally, key steps required to move forward in this area are outlined, including longitudinal testing of relevant clinical populations, studies that probe the genetics of altered prohormone processing, the need for combined functional and histologic testing of human pancreatic tissues, continued interrogation of the intersection between prohormone processing and autoimmunity, and optimal assays or approaches for analysis. Successful resolution of these questions may offer the potential to use altered prohormone processing as a pathogenic anchor that can be used to cluster different endotypes enveloping a large set of variables, and inform therapeutic strategies aimed at personalized intervention in the natural history of type 1 diabetes.