Cellular engineering and gene therapy strategies for insulin replacement in diabetes

In diabetes, insulin secretion is either completely absent (insulin-dependent diabetes mellitus [IDDM]) or inappropriately regulated (non-insulin-dependent diabetes mellitus [NIDDM]). In recent years, new insights into the molecular and biochemical mechanism(s) of fuel-mediated insulin release coupled with advances in gene transfer technology have led to the investigation of molecular strategies for replacement of normal insulin delivery function. Such initiatives have included attempts to engineer glucose-stimulated insulin secretion in cell lines that might serve as surrogates for islets in IDDM. The development of DNA virus gene transfer systems of remarkable efficiency also has suggested ways in which the beta-cell dysfunction of NIDDM might ultimately be repaired by gene therapy. The emerging work in these areas and implications for the future are summarized in this perspective.