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Glucagon is a peptide hormone made by alpha cells in the pancreatic islets. Its mature polypeptide has 29 amino acid residues. Alpha cells store glucagon in secretory granules and release it by exocytosis. Glucagon is a message about fuel availability; glucose is the sugar whose supply it helps regulate. A falling blood glucose concentration favors glucagon release, whereas a rise usually suppresses it. Amino acids can also stimulate release, so a meal containing protein need not produce the same hormone pattern as a meal dominated by carbohydrates. ^[ref]

The principal blood glucose-raising target is the liver. In a hepatocyte, the glucagon receptor is a G protein-coupled receptor: activation of a stimulatory G protein drives adenylyl cyclase, increasing the second messenger cAMP and activating protein kinase A. Downstream phosphorylation, including the phosphorylase kinase relay to glycogen phosphorylase, favors glycogenolysis. Glucagon also supports gluconeogenesis. These are different supplies: glycogenolysis draws on a finite glycogen reserve, whereas gluconeogenesis makes glucose from other substrates and depends on their availability. Longer fasting depletes the glycogen reserve; a stronger hormone signal cannot release material that is no longer there. ^{[ref] [ref]}

Do not copy the liver pathway into every target of insulin. Skeletal muscle uses its own glycogen reserve locally; its glucose uptake and the liver's glucose output are different flows. Nor is direct glucagon-stimulated lipolysis in human adipose tissue as firmly established as its action in the liver. Glucagon action depends on the tissue, other hormones, and available substrates. ^[ref]

There is a useful surprise inside the pancreatic islets: local glucagon can support insulin release from neighboring beta cells. The islet perifusion experiment distinguishes that interaction from glucagon's action on the liver. Thus the two hormones can oppose each other's effects on blood glucose while cooperating locally. Delta cells supply another local brake through somatostatin. ^{[ref] [ref]}

Insulin is a protein hormone. Its mature form has two polypeptide chains; identifying their sequences and protein disulfide bonds provided the motivating example in Sanger's insulin sequencing experiment. See Cooper: insulin as a two-chain hormone, figure 2.16.

A meal illustrates the insulin side of blood glucose homeostasis: rising glucose stimulates beta cells in the pancreatic islets, and released insulin favors uptake and storage of fuel. Alpha cells produce glucagon, while delta cells produce somatostatin, which inhibits release of both insulin and glucagon. The pancreas therefore contains interacting sensor and secretory biological cells, rather than one undifferentiated source of hormones. ^[ref]

Insulin and glucagon are peptide hormones, built from amino acid residues joined by peptide bonds; glucose is a small carbohydrate molecule. A hormone changes signal transduction, not the identity of the fuel it regulates. Human mature insulin has 51 amino acid residues in two polypeptide chains. Beta cells process proinsulin to insulin and C-peptide, storing the products in secretory granules for exocytosis. Increased glucose metabolism raises the ATP-to-ADP ratio, tending to close ATP-sensitive potassium channels; depolarization and entry of calcium ions then trigger exocytosis. This is an important triggering pathway, with additional amplification and modulatory inputs.^[ref]

Binding to the insulin receptor, a receptor tyrosine kinase, starts phosphorylation of the receptor and insulin receptor substrates. Recruitment of phosphoinositide 3-kinase and activation of Akt transmit a major metabolic branch. In skeletal muscle and adipose tissue, that branch helps move GLUT4 to the cell membrane, increasing glucose uptake by facilitated diffusion. GLUT4 is a membrane transport protein, not an insulin receptor. Insulin also favors glycogenesis in skeletal muscle and the liver, and inhibits lipolysis in adipose tissue. In the liver, suppression of glucose output involves enzyme regulation, gene expression, and indirect changes in substrate supply. Its relative direct and indirect contributions are more complex than a single Akt arrow. ^[ref]

Insulin is not a universal permission slip for glucose entry: red blood cells and much of the nervous system use uptake mechanisms that are not acutely dependent on insulin. Nor does the liver use the same GLUT4 switch as skeletal muscle. This is why reduced insulin action can change blood glucose dramatically without stopping all glucose uptake. ^[ref]

Diabetes can disrupt production, response, and counterregulation. Type 1 diabetes usually involves destruction of beta cells and severe loss of endogenous insulin; type 2 diabetes combines insulin resistance with insufficient beta cell compensation. High circulating insulin can therefore coexist with impaired insulin action. Inappropriate glucagon release can add to excessive liver glucose output, and the response to low blood glucose can also be impaired: "more glucagon" is not a complete description of diabetes. These distinctions explain mechanisms, rather than prescribe treatment. ^{[ref] [ref]}

Intraislet glucagon signaling is critical for maintaining glucose homeostasis by Lu Zhu and others tested whether local glucagon supports insulin release. For human pancreatic islets, a computer-controlled flow system delivered a buffer solution at $1\mathrm{ml}/\min$ through a chamber holding 500 pancreatic islets on a nylon filter at $37{}^{\circ }\mathrm{C}$. A fraction collector sampled the outgoing fluid. With an amino acid mixture present, the experiment changed glucose from $3$ to $16.7\mathrm{mM}$ and compared GLP-1 receptor blockade with fluid lacking the blocker. The readout was released insulin and glucagon: blockade reduced glucose-stimulated insulin release without significantly changing glucagon release. ^[ref]

Complementary mouse experiments suppressed alpha cell activity using an engineered G protein-coupled receptor. ELISA assays of minute-by-minute effluent samples measured insulin and glucagon concentrations, providing the hormone release readout. Drug-treated control pancreatic islets lacking that engineered receptor checked for drug effects; adding glucagon restored insulin release in the suppressed preparation. Together, blockade and rescue support local signal transduction from alpha cells to beta cells. Isolated pancreatic islets omit intact circulation and nervous input; the human preparation came from five donors, and blocker specificity and donor variation limit generalization. A chamber response does not directly measure whole-body blood glucose control. ^[ref]

The liver uses glucose sensing chiefly to regulate fuel storage and production, while pancreatic beta cells convert glucose availability into an endocrine signal. The comparison therefore includes transport, metabolism and allosteric control; it should not identify one transporter as the complete sensor in either tissue.

glucokinase phosphorylates glucose to glucose-6-phosphate in both hepatocytes and pancreatic beta cells. Unlike many other hexokinases, it is not strongly inhibited by its product and operates over a higher glucose range. Its monomeric enzyme nevertheless shows a sigmoidal steady-state response to glucose, arising from its kinetic conformational behaviour rather than cooperative binding between several subunits. A glucose half-saturation concentration in the physiological millimolar range makes its flux responsive to changing blood glucose, whereas a low-affinity constant cannot alone establish the in vivo sensing step without considering transport and downstream metabolism.

In beta cells, glucose metabolism through glycolysis and mitochondrial oxidation increases the cellular ATP-to-ADP state. ATP-sensitive potassium channels then close: ATP inhibits the Kir6.2 pore, while Mg-nucleotide effects mediated through SUR1 additionally regulate opening. Reduced potassium conductance produces depolarization, opening voltage-gated calcium channels. Calcium entry triggers exocytosis of insulin-containing secretory granules. Thus the channel senses nucleotides downstream of glucose metabolism; it does not bind extracellular glucose as its initiating ligand. Metabolic amplification and other signals also regulate the amount secreted, so this triggering pathway is necessary context rather than a complete description of every phase of insulin secretion.

glucokinase helps set the glucose threshold for that response. An activating glucokinase mutation associated with familial hyperinsulinism provides evidence that shifting the enzyme's glucose responsiveness can shift whole-body insulin control.^[ref] To separate this interpretation from altered expression, the variant's kinetics should be compared with the normal enzyme and its effect on secretion assessed at matched expression. Inhibiting the potassium channel downstream can bypass part of the sensing chain, whereas preventing calcium entry tests the final electrical-to-secretory coupling.

Glucose transport must be discussed with species in mind. GLUT2 is the prominent transporter in the classical rodent beta-cell model, but human beta cells use predominantly GLUT1 rather than sharing the same abundance of GLUT2. Direct comparison of human and rat preparations found much lower GLUT2 abundance in human cells while glucokinase retained a comparable influence on glucose utilization.^[ref] A transport step with capacity greater than phosphorylation can allow intracellular glucose availability to track the external supply, leaving glucokinase as a major metabolic control point. These observations argue against presenting rodent GLUT2 expression as a universal human sensing mechanism.

In the liver, GLUT2 supports rapid bidirectional facilitated transport. Hepatic glucokinase traps abundant glucose as glucose-6-phosphate, supplying glycogenesis and other metabolic pathways after feeding. glucokinase regulatory protein adds tissue-specific control: at low glucose it binds and sequesters glucokinase in the nucleus; increased glucose promotes release and cytoplasmic use. fructose-6-phosphate favours the inhibitory interaction, while fructose-1-phosphate antagonizes it, coordinating glucose trapping with nutrient context. Hormonal regulation of glucokinase expression adds a slower level of control. Unlike the beta-cell response, the immediate output is a change in hepatic metabolic flux, not release of insulin.

The liver also has an important direct glucose sensor in glycogen phosphorylase. Binding of glucose to liver glycogen phosphorylase a favours an inactive conformation and its dephosphorylation by protein phosphatase 1. Loss of phosphorylase-a activity switches off glycogenolysis and relieves its inhibitory influence on glycogen-synthase phosphatase activity, helping activate glycogen synthase. Glucose administration experiments observed phosphorylase inactivation preceding synthase activation, supporting an ordered switch rather than simultaneous independent responses.^[ref] This direct allosteric route is distinct from glucokinase-mediated metabolic sensing and complements insulin signalling. Together they suit an organ that must stop exporting and begin storing glucose when supply rises, while beta-cell sensing coordinates that transition across multiple tissues.

Diabetes is a disorder of glucose regulation with persistent hyperglycaemia; the glycosuria is a consequence, not a sufficient explanation of its cause. In 1865 the relation between hepatic glycogen, circulating glucose and urinary sugar was actively disputed. A contemporary account could reasonably discuss failure to assimilate food and excessive delivery of sugar from the liver; it could not possess the later demonstration of insulin deficiency. An 1863 discussion of diabetes documents competing interpretations of the hepatic experiments, rather than an agreed single lesion.^[ref]

In the modern account, type 1 diabetes results from destruction of pancreatic beta cells and severe deficiency of insulin. Type 2 diabetes combines insulin resistance with inadequate compensatory insulin secretion. Disease of the pancreas can also cause diabetes. Reduced restraint of hepatic glucose production and impaired peripheral disposal of glucose contribute to hyperglycaemia. These mechanisms distinguish types that were not separated in the question's terminology.^[ref]

When the filtered glucose load exceeds renal reabsorptive capacity, glycosuria causes an osmotic diuresis: loss of water and electrolytes produces polyuria, dehydration and polydipsia. Inadequate use of fuels and increased breakdown of stored fat and protein explain wasting despite appetite. Severe insulin deficiency promotes ketogenesis and can cause diabetic ketoacidosis; it is not correct to make this the inevitable state of everyone with diabetes. Conversely, renal glycosuria can occur without the systemic metabolic disorder, so a urinary sugar test alone does not settle the diagnosis.Symptoms and signs; complications: glycosuria and osmotic diuresis^[ref]

The associated diseases should be separated into predispositions, complications and coincident illnesses. Pulmonary wasting called “phthisis” was prominent in period accounts, but the historical label does not establish that every reported lung cavity was tuberculous.^[ref] Modern diabetes increases susceptibility to active tuberculosis; it does not convert sugar into tubercle. Diabetes also increases susceptibility to some other infections and can accompany recurrent skin infection, poor wound healing and gangrene.^[ref] Long-standing hyperglycaemia is associated with retinopathy, nephropathy and peripheral neuropathy; accelerated atherosclerosis contributes to coronary artery disease, stroke and limb ischemia. Obesity is commonly associated with type 2 diabetes, although severe untreated disease may cause loss of body mass. None of these associations licenses a claim that every diabetic patient has the same anatomical lesions.^[ref]

For an 1865 investigation, repeated urine testing could demonstrate reducing sugar and its variation with diet; simultaneous study of the blood and liver was needed to investigate the source. The distinction between glucose already present during life and glucose formed in an unfixed liver after death is crucial experimental design: post-mortem chemical change must not be mistaken for the living organ's output. Modern diagnosis measures blood glucose and longer-term glycaemic exposure rather than inferring the entire disorder from the taste or appearance of urine.^[ref]