Chronic hyperglycemia, a hallmark of type 2 diabetes, can decrease β-cell function and mass (β-cell glucotoxicity); however, the mechanisms are incompletely understood. The objective was to examine the mechanisms of β-cell glucotoxicity using in vivo and ex vivo models. The hypothesis is that oxidative stress plays a causal role in high glucose-induced β-cell dysfunction in vivo via pathways that involve endoplasmic reticulum (ER) stress and JNK. The model of β-cell glucotoxicity was achieved by prolonged i.v. glucose infusion (to achieve hyperglycemia). In Study 1, 48h glucose infusion increased total and mitochondrial superoxide levels in islets, and impaired β-cell function in vivo and ex vivo. Co-infusion of the superoxide dismutase mimetic Tempol decreased total and mitochondrial superoxide, and prevented high glucose-induced β-cell dysfunction in vivo and ex vivo. These results suggest that increased superoxide generation plays a role in β-cell glucotoxicity. In Study 2, 48h glucose infusion increased activation of the unfolded protein response (XBP-1 mRNA splicing and phospho-eIF2α levels). This was partially prevented by Tempol. Co-infusion of the chemical chaperone 4-phenylbutyrate with glucose decreased spliced XBP-1 levels, and prevented high glucose-induced β-cell dysfunction in vivo and ex vivo. Co-infusion of 4-phenylbutyrate also decreased total and mitochondrial superoxide induced by high glucose. These results suggest that 1) ER stress plays a causal role in high glucose-induced β-cell dysfunction, and 2) there is a link between oxidative stress and ER stress in high glucose-induced β-cell dysfunction in vivo. In Study 3, JNK inhibition using the inhibitor SP600125 in rats or JNK-1 null mice prevented high glucose-induced β-cell dysfunction ex vivo and in vivo. SP600125 prevented high-glucose-induced β-cell dysfunction without decreasing total and mitochondrial superoxide levels. Both Tempol and 4-phenylbutyrate prevented JNK activation induced by high glucose. These results suggest a role of JNK activation in high glucose-induced β-cell dysfunction downstream of increased superoxide generation and ER stress in vivo. Together, the results suggest that 1) oxidative stress, ER stress and JNK activation are causally involved in β-cell glucotoxicity, and 2) High glucose-induced oxidative stress and ER stress are linked, and both impair β-cell dysfunction via JNK activation in vivo.

Chronic hyperglycemia, a hallmark of type 2 diabetes, can decrease β-cell function and mass (β-cell glucotoxicity); however, the mechanisms are incompletely understood. The objective was to examine the mechanisms of β-cell glucotoxicity using in vivo and ex vivo models. The hypothesis is that oxidative stress plays a causal role in high glucose-induced β-cell dysfunction in vivo via pathways that involve endoplasmic reticulum (ER) stress and JNK. The model of β-cell glucotoxicity was achieved by prolonged i.v. glucose infusion (to achieve hyperglycemia). In Study 1, 48h glucose infusion increased total and mitochondrial superoxide levels in islets, and impaired β-cell function in vivo and ex vivo. Co-infusion of the superoxide dismutase mimetic Tempol decreased total and mitochondrial superoxide, and prevented high glucose-induced β-cell dysfunction in vivo and ex vivo. These results suggest that increased superoxide generation plays a role in β-cell glucotoxicity. In Study 2, 48h glucose infusion increased activation of the unfolded protein response (XBP-1 mRNA splicing and phospho-eIF2α levels). This was partially prevented by Tempol. Co-infusion of the chemical chaperone 4-phenylbutyrate with glucose decreased spliced XBP-1 levels, and prevented high glucose-induced β-cell dysfunction in vivo and ex vivo. Co-infusion of 4-phenylbutyrate also decreased total and mitochondrial superoxide induced by high glucose. These results suggest that 1) ER stress plays a causal role in high glucose-induced β-cell dysfunction, and 2) there is a link between oxidative stress and ER stress in high glucose-induced β-cell dysfunction in vivo. In Study 3, JNK inhibition using the inhibitor SP600125 in rats or JNK-1 null mice prevented high glucose-induced β-cell dysfunction ex vivo and in vivo. SP600125 prevented high-glucose-induced β-cell dysfunction without decreasing total and mitochondrial superoxide levels. Both Tempol and 4-phenylbutyrate prevented JNK activation induced by high glucose. These results suggest a role of JNK activation in high glucose-induced β-cell dysfunction downstream of increased superoxide generation and ER stress in vivo. Together, the results suggest that 1) oxidative stress, ER stress and JNK activation are causally involved in β-cell glucotoxicity, and 2) High glucose-induced oxidative stress and ER stress are linked, and both impair β-cell dysfunction via JNK activation in vivo.

La glucotoxicité, ou exposition prolongée à de hautes teneurs en glucose, altère la fonction des cellules ß-pancréatiques et participe au développement du diabète. Il a été démontré que dans les cellules ß, la glucotoxicité engendre des modifications de l’expression génique, des altérations des voies de signalisation Ca2+-dépendantes et de l’exocytose ainsi qu’une augmentation de l’apoptose. Les mécanismes moléculaires responsables de ces altérations sont encore peu connus, mais ces observations suggèrent que des changements du profil d’expression génique des cellules ß-pancréatiques en sont à l’origine. Afin de mieux comprendre les conséquences de la glucotoxicité, une étude génomique a été menée dans la lignée de cellules ß-pancréatiques INS-1E. Cette étude a révélé l’existence de variations significatives des taux d’expression de plusieurs gènes importants pour la fonction des cellules ß, codant pour des protéines impliquées notamment dans le métabolisme glucidique et les différentes étapes de la voie de sécrétion d’insuline. D’autre part, cette approche a également révélé de profonds changements dans les voies de signalisation dépendantes de l’AMPc. Si le rôle prédominant du Ca2+ dans la régulation de la voie de sécrétion de l’insuline a été mis en évidence et bien caractérisé, l’implication et l’importance de l’AMPc dans ce processus restent mal définies. L’AMPc, au même titre que le Ca2+, module l’activité de nombreuses protéines de signalisation, régule l’expression génique et intervient également dans le trafic vésiculaire et la sécrétion d’insuline. De manière intéressante, l’expression de l’adénylate cyclase 8 (ADCY8) est fortement diminuée en condition de glucotoxicité. Ceci suggère qu’un défaut de synthèse d’AMPc pourrait être à l’origine du remaniement des voies de signalisation impliquées dans la régulation de la sécrétion d’insuline. Nous avons donc décidé d’étudier, plus en profondeur, les conséquences fonctionnelles de la diminution de l’expression de l’ADCY8 sur ces voies. Nos résultats suggèrent que l’ADCY8, une isoforme peu exprimée dans les cellules ß- pancréatiques? et stimulée par le Ca2+, se trouve au carrefour des voies de signalisation activées par le glucose et le GLP-1. La diminution de son expression est ainsi partiellement responsable des effets induits par la glucotoxicité sur la régulation de la sécrétion d’insuline. D’autre part, plusieurs résultats récents suggèrent l’implication des voies de signalisation AMPc-dépendantes dans la protection des cellules ß contre l’apoptose et dans ce contexte, le rôle de l’ADCY8 dans ces cellules a été abordé. / Glucotoxicity, or prolonged exposure to elevated levels of glucose, alters the function of pancreatic??-cells and is involved in diabetes pathogenesis. It has been demonstrated that glucotoxicity modifies gene expression and induces considerable changes in [Ca2+]i and in cAMP-dependent signalling (Dubois et al, Endocrinology, 148(4):1605-14 ; 2007) as well as a it decreases insulin exocytosis in response to glucose and increases apoptosis. The molecular mechanisms of these effects are not known but several observations suggest that changes in gene expression profiles are involved. To address that, a genomic study has been done in the clonal b-cell line INS-1E and revealed important modifications in the expression rates of many genes involved in glucose metabolism and vesicular traffic. This approach also revealed the alteration of cAMP-mediated signalling pathways and as the role of calcium and the importance of the correlation between cAMP and Ca2+-mediated signalling pathways had been shown, it was interesting to address the role of this second messenger in this process. Actually, cAMP regulates the activity of a large number of signalling proteins, it is also an important messenger involved in vesicular traffic, insulin secretion and gene expression. Interestingly, we also found that the expression of the adenylyl cyclase VIII (ADCY8) was largely diminished by glucotoxicity and this suggests that an alteration of cAMP synthesis could be involved in the decrease of insulin secretion in this condition. For this reason, we decided to address the functional consequences of altered ADCY8 expression on cAMP-mediated signalling pathways and on its correlation with the decrease of insulin secretion in glucotoxicity. Our results demonstrate a requirement for ADCY8 in glucose as well as in GLP-1 activated signalling pathways and strongly suggest a central role for ADCY8 in glucotoxicity. Moreover, recent publications suggest the implication of cAMP-mediated signalling pathways in the protection of b-cells against apoptosis induced by glucotoxicity, and the role of ADCY8 in this process was investigated.

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Implication du PTP dans la mort cellulaire β pancréatique L'hyperglycémie, l'hyperfructosémie et l'ischémie-reperfusion sont délétères pour la viabilité cellulaire β pancréatique, jouant un rôle majeur dans la perte de la masse cellulaire β. Le pore de transition de perméabilité mitochondriale (PTP) est un canal mitochondrial impliqué dans le déclenchement de la mort cellulaire. Des données récentes montrent l'implication du PTP et du stress oxydant dans la toxicité induite par l'ischémie-reperfusion sur cardiomyocytes et également dans la glucotoxicité induite sur cellules endothéliales. La première partie de notre étude a visé à étudier l'implication de l'ouverture du PTP dans la mort cellulaire des cellules INS-1 et des îlots pancréatiques humains soumis à de fortes concentrations de glucose et de fructose. Nous démontrons que l'incubation des cellules INS-1 et des îlots pancréatiques humains en présence de 30 mM de glucose ou 2,5 mM de fructose déclenche une ouverture du PTP et induit la mort cellulaire. La metformine et la Cyclosporine A (CsA) préviennent l'ouverture du PTP et la mort cellulaire induite par le glucose et le fructose. La deuxième partie de notre travail montre que l'exposition des INS-1 à une heure de carence en substrat concomitante d'une hypoxie, suivie d'une restauration des conditions basales conduit à l'ouverture du PTP et à une majoration drastique de la mort cellulaire. Ces deux évènements sont totalement prévenus par l'incubation préalable par la CsA et la metformine mais aussi par la N-Acétyl-Cystéine (NAC) ou par l'exposition à une anoxie, soulignant ainsi le rôle fondamental du stress oxydant dans le déclenchement de l'ouverture du PTP et de la mort cellulaire. Nous montrons qu'au cours de l'ischémie-reperfusion simulée, la production de superoxide est bi-phasique : nous décrivons un premier pic de production au cours de la carence en substrat, lié à un flux reverse d'électrons au sein du complexe I de la chaîne respiratoire. Ce premier pic est suivi d'un deuxième pic de production après la restauration du niveau de substrats et d'O2, lié à l'ouverture du PTP. La NAC, l'anoxie ou la metformine préviennent les deux pics de production de superoxide tandis que la CsA prévient seulement le second pic. Enfin, nous montrons que l'hypoxie seule n'induit ni stress oxydant, ni ouverture du PTP ni mortalité cellulaire. L'ensemble de notre travail démontre le rôle central du PTP dans la gluco-fructotoxicité et dans la toxicité induite par l'ischémie-reperfusion sur la cellule β pancréatique. Ainsi, prévenir l'ouverture du PTP peut-être une approche intéressante pour préserver la viabilité cellulaire β. / PTP involvement in β pancreatic cell death Hyperglycemia, hyperfructosemia and ischemia-reperfusion play a major role in the progression of β cell loss in diabetes mellitus. The permeability transition pore (PTP) is a mitochondrial channel involved in cell death. PTP opening and oxidative stress have been shown to be involved in ischemia-reperfusion injury on cardiomyocytes and in hyperglycemia-induced cell death in endothelial cells. In the first part of this work, we have examined the involvement of PTP opening in INS-1 cells and human pancreatic islets cell death induced by high levels of glucose or fructose. We first reported that Metformin and Cyclosporin A (CsA) prevented Ca2+-induced PTP opening in permeabilized and intact INS-1 cells. We then shown that incubation of INS-1 cells and human islets in the presence of 30 mM glucose or 2.5 mM fructose induced PTP opening and led to cell death. Because both Metformin and CsA prevented glucose and fructose induced PTP opening, and hampered glucose and fructose induced cell death, we conclude that PTP opening is involved in high glucose and high fructose induced INS-1 and human islets cell death. We therefore suggest that preventing PTP opening might be a new approach to preserve β cell viability. In the second part of the work, we demonstrate that the incubation of INS-1 cells in the absence of energy substrates in hypoxic condition for 1 hour followed by incubation in normal condition led to PTP opening and to a dramatic increase in cell death. Both events were totally prevented when PTP opening was inhibited by either Cyclosporin A (CsA) or Metformin or when the cells were incubated in the presence of the antioxidant N-acetyl-cystein (NAC), in anoxia, highlighting the implication of oxidative stress is the commitment of PTP opening. Superoxide production increased during the removal of energy substrates, due to reverse electron flux through complex I and again increased when normal energy substrate and O2 were restored, due to PTP opening. NAC, anoxia or Metformin prevented the two phases of oxidative stress, while CsA prevented only the second one. Hypoxia alone did not induce oxidative stress, PTP opening or cell death. Our work demonstrates the implication of PTP opening in ischemia-reperfusion injury and gluco- fructotoxicty in β pancreatic cells. We therefore suggest that preventing PTP opening might be a new approach to preserve β cell viability.

La mitochondrie et le réticulum endoplasmique (RE) forment un réseau dans les cellules qui contrôle la fonction et le destin cellulaire. La mitochondrie de la cellule ß pancréatique joue un rôle central dans la sécrétion d’insuline en réponse au glucose de par sa capacité à produire de l’ATP. Le RE lui prend en charge la mise en conformation de l’insuline et joue le rôle de stock calcique. Ces 2 organites se rejoignent au niveau de points de contact appelés Mitochondria Associated endoplasmic reticulum Membranes (MAMs,). Les MAMs sont le siège d’échanges calciques et lipidiques entre les 2 organites. Les altérations de la mitochondrie et du RE ont été montrées comme des facteurs contribuant au développement du diabète de type 2. L’implication des MAMs n’a cependant jamais été étudiée dans la cellule ß.La glucotoxicité provoquée par une exposition chronique à des concentrations élevées de glucose, est un facteur clé de la dysfonction ß pancréatique au cours du diabète de type 2. J’ai pu démontrer que la glucotoxicité augmentait la fission mitochondriale et le nombre de MAMs dans les cellules bêta humaines et INS-1E mais que ces MAMs présentaient des défauts d’échanges calciques, pouvant ainsi contribuer au défaut de la sécrétion d’insuline. J’ai ensuite modulé les MAMs soit via une stimulation aigue au glucose soit par l’utilisation d’un siRNA qui rompt partiellement les contacts entre le RE et la mitochondrie ou par l’utilisation d’un linker qui artificiellement force ces contacts. La stimulation aigue au glucose augmente les MAMs et le transfert de calcium du RE vers la mitochondrie alors que la rupture des contacts diminue la secretion d’insuline. Enfin le linker en forçant les rapprochements RE-mitochondrie mime les effets de la glucotoxicité.Ce travail, constitue la première étude structurelle et fonctionnelle des MAMs dans la cellule ß pancréatique, éclairant leur rôle dans la dysfonction ß pancréatique lors du développement du diabète de type 2 / Mitochondria and endoplasmic reticulum (ER) form a network in cells that control cellular function and fate. Mitochondria play a central role in insulin secretion in ß cell by its ability to product ATP. ER takes in charge of insulin folding and is the major cell calcium store. Both organelles interact at contact sites, defined as mitochondria-associated membranes (MAMs), a multiprotein complex implicated in calcium transfer and lipid exchange . Alterations of mitochondria and ER have been shown to contribute to metabolic disorder such as type 2 diabetes. MAMS were recently implicated in the regulation of glucose homeostasis But the role of MAMs in ß cells is still largely unknown and their implication in glucotoxicity-associated ß cell dysfunction remains to be defined.Here, I report that acute glucose stimulation stimulated ER-mitochondria interactions and calcium (Ca2+) exchange in INS-1E cells, whereas disruption of MAMs altered glucose-stimulated insulin secretion (GSIS). Conversely, chronic incubations with high glucose of either INS-1E cells or human pancreatic islets altered GSIS, and concomitantly reduced ER Ca2+ store, increased mitochondrial Ca2+ and reduced ATP-stimulated ER-mitochondria Ca2+ exchanges, despite an increase of organelle interactions. Furthermore, glucotoxicity-induced perturbations of Ca2+ signalling are associated with ER stress, altered mitochondrial respiration and mitochondria fragmentation, and these organelle stresses may participate to increased organelle tethering, as a protective mechanism. Lastly, sustained induction of ER-mitochondria interactions using a linker induced mitochondrial fission and altered GSIS.Therefore, dynamic organelle coupling participates to GSIS in ? cells and over-time disruption of organelle Ca2+ exchange might be a novel mechanism contributing to glucotoxicity-induced ß cell dysfunction in type 2 diabetes

Le diabète de type 2 est une pathologie chronique complexe associant une altération de sécrétion de l'insuline par le pancréas et une résistance à l'insuline au niveau des tissus périphériques, notamment au niveau du foie et du muscle squelettique. Son origine est multifactorielle, alliant des anomalies génétiques et environnementales, en particulier nutritionnelles. Un des mécanismes par lesquels les facteurs nutritionnels (comme les glucides et les lipides en excès) contribuent au développement du diabète et à son aggravation est la glucolipotoxicité. En effet, l'élévation de la glycémie et des lipides plasmatiques, ainsi que l'accumulation ectopique de lipides dans les tissus, participent au développement de l'insulinorésistance hépatique et musculaire et aux dysfonctions des cellules bêta, en partie via l'induction d'un stress métabolique, impliquant notamment le stress oxydant, le stress du réticulum endoplasmique (RE) et la perturbation de l'homéostasie calcique. Nous avons étudié les effets de la glucotoxicité et de la lipotoxicité dans les cellules bêta pancréatiques et les mécanismes impliqués. Nous nous sommes aussi intéressés à des traitements potentiellement protecteurs de la fonction bêta-pancréatique. Nous avons fait l'hypothèse que les effets bénéfiques de l'inhibition du système rénine-angiotensine sur l'incidence du diabète de type 2 chez l'homme étaient médiés par une action directe sur les cellules bêta. Nos résultats montrent que le glucose chronique à une dose élevée entraine une réduction de la sécrétion d'insuline des cellules bêta des îlots de Langerhans humains par une action conjointe sur le stress du RE, le stress oxydant et l'homéostasie calcique. L'inhibition du SRA a permis de restaurer cette fonction grâce notamment à une action inhibitrice sur la voie Phospholipase C-IP3-Calcium / This study addressed the hypothesis that inhibiting the soluble epoxide hydrolase (sEH)-mediated degradation of epoxy-fatty acids, notably epoxyeicosatrienoic acids, has an additional impact against cardiovascular damage in type 2 diabetes, beyond its previously demonstrated beneficial effect on glucose homeostasis. The cardiovascular and metabolic effects of the sEH inhibitor t- AUCB (10 mg/l in drinking water) were compared to those of the sulfonylurea glibenclamide (80 mg/l), both administered for 8 weeks in FVB mice subjected to a high-fat diet (HFD, 60% fat) for 16 weeks. Mice on control chow diet (10% fat) and non-treated HFD mice served as controls. Glibenclamide and t-AUCB similarly prevented the increased fasting glycemia in HFD mice but only t-AUCB improved glucose tolerance and decreased gluconeogenesis, without modifying weight gain. Moreover, t-AUCB reduced adipose tissue inflammation, plasma free fatty acids and LDL cholesterol, and prevented hepatic steatosis. Furthermore, only the sEH inhibitor improved endothelium-dependent relaxations to acetylcholine, assessed by myography in isolated coronary arteries. This improvement was related to a restoration of epoxyeicosatrienoic acid and nitric oxide pathways, as shown by the increased inhibitory effects of the NO-synthase and cytochrome P450 epoxygenase inhibitors, L-NA and MSPPOH, on these relaxations. Moreover, t-AUCB decreased cardiac hypertrophy, fibrosis and inflammation, and improved diastolic function, as demonstrated by the increased E/A ratio (echocardiography) and decreased slope of the enddiastolic pressure-volume relation (invasive hemodynamics). These results demonstrate that she inhibition improves coronary endothelial function and prevents cardiac remodeling and diastolic dysfunction in obese type 2 diabetic mice

<p><b>Background and aims:</b> Type 2 diabetes mellitus is connected with elevated glucose levels, which cause impaired glucose-stimulated insulin secretion (GSIS) and degeneration of β-cells. Mechanisms for such glucotoxic effects were explored in the present study.</p><p><b>Materials and methods:</b> INS-1E cells were cultured for 5 days in 5.5, 11, 20 or 27 mM glucose in the presence or absence of AMPK-agonist AICAR. GSIS was determined from INS-1E cells and islets obtained from type 2 diabetes and control donors. Human islets and INS-1E cells were functionally characterized (GSIS) and protein profiled (SELDI-TOF MS). Glucose-induced <i>de novo</i> synthesis of fatty acyls (HR-MAS NMR spectroscopy), fatty acid composition (GC-MS), triglyceride content and specific proteins (Western blotting) were determined in INS-1E cells.</p><p><b>Results:</b> Impaired GSIS was observed from INS-1E cells exposed to chronic hyperglycaemia and islets isolated from type 2 diabetics compared to INS-1E cells cultured at normal glucose levels and control islets, respectively. Several glucose-regulated proteins were found when type 2 diabetes and control islets or mitochondria from INS-1E cells cultured at different glucose concentrations were protein profiled. Glucose induced lipid <i>de novo</i> synthesis of both saturated and unsaturated fatty acids in specific proportions. Glucose-induced impairment of function and mass was reverted by inclusion of AICAR, which lowered levels of pro-apoptotic protein CHOP but left triglyceride content unaffected.</p><p><b>Conclusions:</b> Impaired GSIS and increased apoptosis observed in β-cells after prolonged exposure to elevated glucose concentrations involved accumulation of lipid species in specific proportions, AMPK-inactivation, ER-stress activation and complex, coordinated changes in expression patterns of mitochondrial and human islet proteins.</p>

<b>Background and aims:</b> Type 2 diabetes mellitus is connected with elevated glucose levels, which cause impaired glucose-stimulated insulin secretion (GSIS) and degeneration of β-cells. Mechanisms for such glucotoxic effects were explored in the present study. <b>Materials and methods:</b> INS-1E cells were cultured for 5 days in 5.5, 11, 20 or 27 mM glucose in the presence or absence of AMPK-agonist AICAR. GSIS was determined from INS-1E cells and islets obtained from type 2 diabetes and control donors. Human islets and INS-1E cells were functionally characterized (GSIS) and protein profiled (SELDI-TOF MS). Glucose-induced de novo synthesis of fatty acyls (HR-MAS NMR spectroscopy), fatty acid composition (GC-MS), triglyceride content and specific proteins (Western blotting) were determined in INS-1E cells. <b>Results:</b> Impaired GSIS was observed from INS-1E cells exposed to chronic hyperglycaemia and islets isolated from type 2 diabetics compared to INS-1E cells cultured at normal glucose levels and control islets, respectively. Several glucose-regulated proteins were found when type 2 diabetes and control islets or mitochondria from INS-1E cells cultured at different glucose concentrations were protein profiled. Glucose induced lipid de novo synthesis of both saturated and unsaturated fatty acids in specific proportions. Glucose-induced impairment of function and mass was reverted by inclusion of AICAR, which lowered levels of pro-apoptotic protein CHOP but left triglyceride content unaffected. <b>Conclusions:</b> Impaired GSIS and increased apoptosis observed in β-cells after prolonged exposure to elevated glucose concentrations involved accumulation of lipid species in specific proportions, AMPK-inactivation, ER-stress activation and complex, coordinated changes in expression patterns of mitochondrial and human islet proteins.

Chronic hyperlipidemia (lipotoxicity) and hyperglycemia (glucotoxicity) have recently been shown to induce Endoplasmic Reticulum (ER) stress, which may contribute to pancreatic beta-cell dysfunction in type 2 diabetes. This thesis examined the involvement of ER stress in beta-cell lipotoxicity and glucotoxicity. Although chronic treatment with saturated free fatty acids (FFA) in vitro induced ER stress, altering ER stress by increasing or knocking-down GRP78 chaperone expression had no effect on apoptosis induction. Conversely, overexpression of ER chaperones rescued the reduction in proinsulin protein levels caused by chronic exposure to high glucose, although it had no effect on the decreased insulin mRNA levels and proinsulin translation rate. Thus, ER stress is likely not the main mechanism involved in saturated FFA-induced beta-cell apoptosis in vitro, but it may contribute to glucotoxic effects on proinsulin levels. These findings have increased our understanding of the link between ER stress and beta-cell dysfunction in type 2 diabetes.