Oscillatory Insulin Secretion Research Articles

Glucokinase activity controls subpopulations of β-cells that alternately lead islet Ca2+ oscillations.

Oscillations in insulin secretion, driven by islet Ca2+ waves, are crucial for glycemic control. Prior studies, performed with single-plane imaging, suggest that subpopulations of electrically coupled β-cells have privileged roles in leading and coordinating the propagation of Ca2+ waves. Here, we used 3D light-sheet imaging to analyze the location and Ca2+ activity of single β-cells within the entire islet at >2 Hz. In contrast with single-plane studies, 3D network analysis indicates that the most highly synchronized β-cells are located at the islet center, and remain regionally but not cellularly stable between oscillations. This subpopulation, which includes 'hub cells', is insensitive to changes in fuel metabolism induced by glucokinase and pyruvate kinase activation. β-cells that initiate the Ca2+ wave ('leaders') are located at the islet periphery, and strikingly, change their identity over time via rotations in the wave axis. Glucokinase activation, which increased oscillation period, reinforced leader cells and stabilized the wave axis. Pyruvate kinase activation, despite increasing oscillation frequency, had no effect on leader cells, indicating the wave origin is patterned by fuel input. These findings emphasize the stochastic nature of the β-cell subpopulations that control Ca2+ oscillations and identify a role for glucokinase in spatially patterning 'leader' β-cells.

In Vivo ZIMIR Imaging of Mouse Pancreatic Islet Cells Shows Oscillatory Insulin Secretion.

Appropriate insulin secretion is essential for maintaining euglycemia, and impairment or loss of insulin release represents a causal event leading to diabetes. There have been extensive efforts of studying insulin secretion and its regulation using a variety of biological preparations, yet it remains challenging to monitor the dynamics of insulin secretion at the cellular level in the intact pancreas of living animals, where islet cells are supplied with physiological blood circulation and oxygenation, nerve innervation, and tissue support of surrounding exocrine cells. Herein we presented our pilot efforts of ZIMIR imaging in pancreatic islet cells in a living mouse. The imaging tracked insulin/Zn2+ release of individual islet β-cells in the intact pancreas with high spatiotemporal resolution, revealing a rhythmic secretion activity that appeared to be synchronized among islet β-cells. To facilitate probe delivery to islet cells, we also developed a chemogenetic approach by expressing the HaloTag protein on the cell surface. Finally, we demonstrated the application of a fluorescent granule zinc indicator, ZIGIR, as a selective and efficient islet cell marker in living animals through systemic delivery. We expect future optimization and integration of these approaches would enable longitudinal tracking of beta cell mass and function in vivo by optical imaging.

Novel Technology for Studying Insulin Secretion: Imaging and Quantitative Analysis by a Bioluminescence Method

We developed a method of video-rate bioluminescence imaging to visualize proteins secreted from living cells. A protein of interest was fused to Gaussia luciferase (GLase), and the luminescence signals of secreted GLase with coelenterazine (luciferin) were visualized at a video-rate of 30-500 ms/frame by using a water-cooled EM-CCD camera. We established a subclonal rat INS-1E cell line, named iGL cells, stably expressing the fusion protein of insulin and GLase (Insulin-GLase). By stimulation with high glucose, 3D-cultured iGL cells showed synchronized oscillatory secretion of insulin for over 1 h, as similarly observed in an isolated rat pancreatic islet. In 2D-cultured iGL cells, the luminescence images indicated that synchronized insulin secretion was localized in intercellular spaces between cells. Further, the relative amount of insulin secretion from iGL cells was easily determined with a luminometer, and we demonstrated that cell-cell interaction of beta cells is fundamental to increase glucose-stimulated insulin secretion by synchronization. Thus, iGL cells would be valuable for studying oscillatory insulin secretion and evaluating anti-diabetic drugs. Our bioluminescence imaging method with GLase could be generally used for investigating protein secretion in 2D and 3D cell culture systems.

"Take Me To Your Leader": An Electrophysiological Appraisal of the Role of Hub Cells in Pancreatic Islets.

The coordinated electrical activity of β-cells within the pancreatic islet drives oscillatory insulin secretion. A recent hypothesis postulates that specially equipped "hub" or "leader" cells within the β-cell network drive islet oscillations and that electrically silencing or optically ablating these cells suppresses coordinated electrical activity (and thus insulin secretion) in the rest of the islet. In this Perspective, we discuss this hypothesis in relation to established principles of electrophysiological theory. We conclude that whereas electrical coupling between β-cells is sufficient for the propagation of excitation across the islet, there is no obvious electrophysiological mechanism that explains how hyperpolarizing a hub cell results in widespread inhibition of islet electrical activity and disruption of their coordination. Thus, intraislet diffusible factors should perhaps be considered as an alternate mechanism.

Quantitative visualization of synchronized insulin secretion from 3D-cultured cells

Quantitative visualization of synchronized insulin secretion was performed in an isolated rat pancreatic islet and a spheroid of rat pancreatic beta cell line using a method of video-rate bioluminescence imaging. Video-rate images of insulin secretion from 3D-cultured cells were obtained by expressing the fusion protein of insulin and Gaussia luciferase (Insulin-GLase). A subclonal rat INS-1E cell line stably expressing Insulin-GLase, named iGL, was established and a cluster of iGL cells showed oscillatory insulin secretion that was completely synchronized in response to high glucose. Furthermore, we demonstrated the effect of an antidiabetic drug, glibenclamide, on synchronized insulin secretion from 2D- and 3D-cultured iGL cells. The amount of secreted Insulin-GLase from iGL cells was also determined by a luminometer. Thus, our bioluminescence imaging method could generally be used for investigating protein secretion from living 3D-cultured cells. In addition, iGL cell line would be valuable for evaluating antidiabetic drugs.

Synapsins I and II Are Not Required for β-Cell Insulin Secretion: Granules Must Pool Their Own Weight

Synapsins I and II Are Not Required for β-Cell Insulin Secretion: Granules Must Pool Their Own Weight

6-Phosphofructo-2-Kinase/Fructose-2,6-Bisphosphatase (PFKFB) Modulates Slow Oscillations in Pancreatic Islets

Glucose-dependent insulin secretion from beta-cells of pancreatic islets is pulsatile, but the source of the underlying oscillations remains unclear. We have developed a computational model of the beta-cell, termed the ‘Dual Oscillator Model’ (DOM), based on the hypothesis that slow oscillations in insulin secretion reflect slow oscillations in glycolysis, which then interact with fast oscillations arising from membrane electrical activity and Ca2+. One version of the DOM predicts that glycolytic oscillations are generated by phosphofructokinase-1 (PFK1) via allosteric activation by its product fructose-1,6-bisphosphate (FBP), and terminated by depletion of the substrate fructose-6-phosphate (F6P). To directly determine whether PFK1 is a control point for slow metabolic oscillations, we experimentally manipulated the flux through PFK1 by altering the activity of 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase (PFKFB). This bifunctional enzyme, which contains an N-terminal kinase domain (PFK2) and C-terminal phosphatase domain (FBPase2), strongly activates PFK1 activity via conversion of F6P to fructose-2,6-bisphosphate, a potent allosteric activator of PFK1. PFKFB has also been proposed to bind and directly activate glucokinase, further accelerating glycolytic flux. Using optical measurements of NAD(P)H and Ca2+, we found that increasing the level of PFK2, but not FBPase2, in islets strongly decreased both the period and amplitude of slow oscillations by ∼40%. In many of the PFK2-expressing islets slow oscillations (period >120s) were either converted to fast oscillations (period <120s) or were abolished. These data are consistent with the predictions of the DOM after modification of the model to include regulation of PFK1 by PFKFB, and furthermore support the hypothesis that slow oscillations are driven by oscillations in glycolysis. Supported by F32DK085960 (M.J.M.), NSF-DMS0917664 (R.B.), NIH/NIDDK Intramural Research Program (A.S.), and R01DK46409 (L.S.).

Metabolic Oscillations in Pancreatic Islets Depend on the Intracellular Ca 2+ Level but Not Ca 2+ Oscillations

Plasma insulin is pulsatile and reflects oscillatory insulin secretion from pancreatic islets. Although both islet Ca 2+ and metabolism oscillate, there is disagreement over their interrelationship, and whether they can be dissociated. In some models of islet oscillations, Ca 2+ must oscillate for metabolic oscillations to occur, whereas in others metabolic oscillations can occur without Ca 2+ oscillations. We used NAD(P)H fluorescence to assay oscillatory metabolism in mouse islets stimulated by 11.1 mM glucose. After abolishing Ca 2+ oscillations with 200 μM diazoxide, we observed that oscillations in NAD(P)H persisted in 34% of islets ( n = 101). In the remainder of the islets (66%) both Ca 2+ and NAD(P)H oscillations were eliminated by diazoxide. However, in most of these islets NAD(P)H oscillations could be restored and amplified by raising extracellular KCl, which elevated the intracellular Ca 2+ level but did not restore Ca 2+ oscillations. Comparatively, we examined islets from ATP-sensitive K + (K ATP) channel-deficient SUR1 −/− mice. Again NAD(P)H oscillations were evident even though Ca 2+ and membrane potential oscillations were abolished. These observations are predicted by the dual oscillator model, in which intrinsic metabolic oscillations and Ca 2+ feedback both contribute to the oscillatory islet behavior, but argue against other models that depend on Ca 2+ oscillations for metabolic oscillations to occur.

Evolution of beta-cell dysfunction in impaired glucose tolerance and diabetes.

Patients with overt Type 2 diabetes consistently have alterations in insulin secretion, including reduced insulin secretory responses to glucose, delayed and blunted meal-induced insulin secretion, increased pro-insulin and abnormal insulin secretory oscillations. More recently, it has become evident that abnormal insulin secretion antedates the onset of overt hyperglycaemia and is present in people with impaired glucose tolerance, i.e. normal fasting glucose and glycohaemoglobin concentrations. These defects are subtle and include shifts to the right in the dose-response curves that relate to glucose and insulin secretion, reduced ability of the beta-cell to detect and respond to oscillatory changes in the plasma glucose concentration and impaired beta-cell compensation for insulin resistance. In order to define the factors responsible for these defects in secretion, we have infused human patients with a lipid emulsion and heparin to raise plasma free fatty acid concentrations. This is associated with reduced ability of the beta-cell to detect and respond to small changes in the plasma glucose concentration. In summary, defects in insulin secretion are consistently present in patients with impaired glucose tolerance and play a critical role in the progression from impaired glucose tolerance to diabetes.

3H-serotonin as a marker of oscillatory insulin secretion in clonal β-cells (INS-1)

Serotonin release from preloaded pancreatic β-cells has been used as a marker for insulin release in studying exocytosis from single cells using the amperometric technique. We found that single pancreatic β-cells exhibited oscillations in exocytosis with a period of 1–1.5 min as measured amperometrically by serotonin release. We also show that 3H-serotonin can be used to monitor exocytosis from intact and streptolysin-O permeabilized clonal insulin-secreting cells preloaded with labeled serotonin and that serotonin release correlated with insulin secretion in the same cells. The use of 3H-serotonin provides a real-time indicator of exocytosis from populations of clonal insulin-secreting cells.

Regular Insulin Secretory Oscillations Despite Impaired ATP Synthesis in Friedreich Ataxia Patients

Friedreich Ataxia is an inherited disorder caused by decreased expression of a mitochondrial protein called frataxin. Deficiency of this protein causes reduced biogenesis of iron-sulfur clusters, and subsequently impaired synthesis and replenishment of ATP IN VIVO. Basal secretion of insulin occurs in an oscillating manner presumably triggered by ATP-dependent feedback inhibition of glycolytic flux. Hence, individuals with reduced ATP synthesis rates should possibly exhibit impaired insulin secretory oscillations if these were solely dependent on ATP. In the present study Friedreich Ataxia patients with a presumptive impairment of ATP synthesis in pancreatic beta-cells were evaluated for regularity of basal secretory oscillations of insulin. Healthy siblings were employed as controls. In conflict with the initial hypothesis, no differences in regards to oscillation patterns were observed between patients and controls. Supported by EX VIVO evidence, these findings tentatively suggest that pulsatile insulin secretion might not be exclusively dependent on ATP feedback inhibition in humans.

Modeling the glucose–insulin regulatory system and ultradian insulin secretory oscillations with two explicit time delays

In the glucose–insulin regulatory system, ultradian insulin secretory oscillations are observed to have a period of 50–150min. After pioneering work traced back to the 1960s, several mathematical models have been proposed during the last decade to model these ultradian oscillations as well as the metabolic system producing them. These currently existing models still lack some of the key physiological aspects of the glucose–insulin system. Applying the mass conservation law, we introduce two explicit time delays and propose a more robust alternative model for better understanding the glucose–insulin endocrine metabolic regulatory system and the ultradian insulin secretory oscillations for the cases of continuous enteral nutrition and constant glucose infusion. We compare the simulation profiles obtained from this two time delay model with those from the other existing models. As a result, we notice many unique features of this two delay model. Based on our intensive simulations, we suspect that one of the possibly many causes of ultradian insulin secretion oscillations is the time delay of the insulin secretion stimulated by the elevated glucose concentration.

Ca2+ controls slow NAD(P)H oscillations in glucose‐stimulated mouse pancreatic islets

Exposure of pancreatic islets of Langerhans to physiological concentrations of glucose leads to secretion of insulin in an oscillatory pattern. The oscillations in insulin secretion are associated with oscillations in cytosolic Ca(2+) concentration ([Ca(2+)](c)). Evidence suggests that the oscillations in [Ca(2+)](c) and secretion are driven by oscillations in metabolism, but it is unclear whether metabolic oscillations are intrinsic to metabolism or require Ca(2+) feedback. To address this question we explored the interaction of Ca(2+) concentration and islet metabolism using simultaneous recordings of NAD(P)H autofluorescence and [Ca(2+)](c), in parallel with measurements of mitochondrial membrane potential (DeltaPsi(m)). All three parameters responded to 10 mm glucose with multiphasic dynamics culminating in slow oscillations with a period of approximately 5 min. This was observed in approximately 90% of islets examined from various mouse strains. NAD(P)H oscillations preceded those of [Ca(2+)](c), but their upstroke was often accelerated during the increase in [Ca(2+)](c), and Ca(2+) influx was a prerequisite for their generation. Prolonged elevations of [Ca(2+)](c) augmented NAD(P)H autofluorescence of islets in the presence of 3 mm glucose, but often lowered NAD(P)H autofluorescence of islets exposed to 10 mm glucose. Comparable rises in [Ca(2+)](c) depolarized DeltaPsi(m). The NAD(P)H lowering effect of an elevation of [Ca(2+)](c) was reversed during inhibition of mitochondrial electron transport. These findings reveal the existence of slow oscillations in NAD(P)H autofluorescence in intact pancreatic islets, and suggest that they are shaped by Ca(2+) concentration in a dynamic balance between activation of NADH-generating mitochondrial dehydrogenases and a Ca(2+)-induced decrease in NADH. We propose that a component of the latter reflects mitochondrial depolarization by Ca(2+), which reduces respiratory control and consequently accelerates oxidation of NADH.

Mitochondrial metabolism reveals a functional architecture in intact islets of Langerhans from normal and diabetic Psammomys obesus.

The cells within the intact islet of Langerhans function as a metabolic syncytium, secreting insulin in a coordinated and oscillatory manner in response to external fuel. With increased glucose, the oscillatory amplitude is enhanced, leading to the hypothesis that cells within the islet are secreting with greater synchronization. Consequently, non-insulin-dependent diabetes mellitus (NIDDM; type 2 diabetes)-induced irregularities in insulin secretion oscillations may be attributed to decreased intercellular coordination. The purpose of the present study was to determine whether the degree of metabolic coordination within the intact islet was enhanced by increased glucose and compromised by NIDDM. Experiments were performed with isolated islets from normal and diabetic Psammomys obesus. Using confocal microscopy and the mitochondrial potentiometric dye rhodamine 123, we measured mitochondrial membrane potential oscillations in individual cells within intact islets. When mitochondrial membrane potential was averaged from all the cells in a single islet, the resultant waveform demonstrated clear sinusoidal oscillations. Cells within islets were heterogeneous in terms of cellular synchronicity (similarity in phase and period), sinusoidal regularity, and frequency of oscillation. Cells within normal islets oscillated with greater synchronicity compared with cells within diabetic islets. The range of oscillatory frequencies was unchanged by glucose or diabetes. Cells within diabetic (but not normal) islets increased oscillatory regularity in response to glucose. These data support the hypothesis that glucose enhances metabolic coupling in normal islets and that the dampening of oscillatory insulin secretion in NIDDM may result from disrupted metabolic coupling.

Perfusion and chemical monitoring of living cells on a microfluidic chip

A microfluidic device that incorporates continuous perfusion and an on-line electrophoresis immunoassay was developed, characterized, and applied to monitoring insulin secretion from single islets of Langerhans. In the device, a cell chamber was perfused with cell culture media or a balanced salt solution at 0.6 to 1.5 microL min(-1). The flow was driven by gas pressure applied off-chip. Perfusate was continuously sampled at 2 nL min(-1) by electroosmosis through a separate channel on the chip. The perfusate was mixed on-line with fluorescein isothiocyanate-labeled insulin (FITC-insulin) and monoclonal anti-insulin antibody and allowed to react for 60 s as the mixture traveled down a 4 cm long reaction channel. The cell chamber and reaction channel were maintained at 37 degrees C. The reaction mixture was injected onto a 1.5 cm separation channel as rapidly as every 6 s, and the free FITC-insulin and the FITC-insulin-antibody complex were separated under an electric field of 500 to 600 V cm(-1). The immunoassay had a detection limit of 0.8 nM and a relative standard deviation of 6% during 2 h of continuous operation with standard solutions. Individual islets were monitored for up to 1 h while perfusing with different concentrations of glucose. The immunoassay allowed quantitative monitoring of classical biphasic and oscillatory insulin secretion with 6 s sampling frequency following step changes in glucose from 3 to 11 mM. The 2.5 cm x 7.6 cm microfluidic system allowed for monitoring islets in a highly automated fashion. The technique should be amenable to studies involving other tissues or cells that release chemicals.

Beta-cell failure in the pathogenesis of type 2 diabetes mellitus.

Type 2 diabetes is the result of a progressive impairment of pancreatic beta-cell function in the setting of worsening insulin resistance. Studies in high-risk populations have demonstrated that during progression to diabetes, beta cells have declining function and lose the first phase of insulin secretion, resulting in less than adequate suppression of hepatic glucose production following meals. In addition, oscillations of insulin secretion become unmatched from their normal coupling with glucose. Several mechanisms are thought to be responsible for impaired beta-cell function, including glucose toxicity and lipotoxicity, and potentially contribute to beta-cell loss. Advances in molecular science have elucidated several cytokines and transcription factors possibly implicated in the loss of beta-cell mass. In the past 15 years, clinical trials have given hope for potential therapies that may either delay or prevent the progression to diabetes. Lifestyle modification and pharmaceutical treatment remain the most promising interventions.

Citrate Oscillates in Liver and Pancreatic Beta Cell Mitochondria and in INS-1 Insulinoma Cells

Oscillations in citric acid cycle intermediates have never been previously reported in any type of cell. Here we show that adding pyruvate to isolated mitochondria from liver, pancreatic islets, and INS-1 insulinoma cells or adding glucose to intact INS-1 cells causes sustained oscillations in citrate levels. Other citric acid cycle intermediates measured either did not oscillate or possibly oscillated with a low amplitude. In INS-1 mitochondria citrate oscillations are in phase with NAD(P) oscillations, and in intact INS-1 cells citrate oscillations parallel oscillations in ATP, suggesting that these processes are co-regulated. Oscillations have been extensively studied in the pancreatic beta cell where oscillations in glycolysis, NAD(P)/NAD(P)H and ATP/ADP ratios, plasma membrane electrical activity, calcium levels, and insulin secretion have been well documented. Because the mitochondrion is the major site of ATP synthesis and NADH oxidation and the only site of citrate synthesis, mitochondria need to be synchronized for these factors to oscillate. In suspensions of mitochondria from various organs, most of the citrate is exported from the mitochondria. In addition, citrate inhibits its own synthesis. We propose that this enables citrate itself to act as one of the cellular messengers that synchronizes mitochondria. Furthermore, because citrate is a potent inhibitor of the glycolytic enzyme phosphofructokinase, the pacemaker of glycolytic oscillations, citrate may act as a metabolic link between mitochondria and glycolysis. Citrate oscillations may coordinate oscillations in mitochondrial energy production and anaplerosis with glycolytic oscillations, which in the beta cell are known to parallel oscillations in insulin secretion.

Pancreatic beta-cell loss and preservation in type 2 diabetes

Background: In most individuals, the need to respond to progressive states of insulin resistance is met by increasing insulin production. For insulin-resistant patients, however, the balance between insulin supply and demand may fail from the progressive loss of pancreatic beta-cell function, eventually leading to type 2 diabetes mellitus. Objective: The aim of this review was to discuss the current concepts underlying potential pancreatic beta-cell failure in the progression toward type 2 diabetes and therapies that may alter the process. Methods: Data included in this review were identified through a MEDLINE search for articles published from 1966 to April 2003. Search terms used were beta cell, diabetes, insulin resistance, obesity, cardiovascular disease, thiazolidinediones, and metformin. Results: Evidence of the progressive loss of beta-cell function may include altered conversion of proinsulin to insulin, changes in pulsed and oscillatory insulin secretion, and quantitative reductions in insulin release. Potential underlying mechanisms are glucose toxicity, lipotoxicity, poor tolerance of increased secretory demand, and a reduction in beta-cell mass. Conclusion: Current clinical management of type 2 diabetes is focused on treatment of the signs and symptoms of late-stage disease rather than addressing potential underlying causes, which may be amenable to currently available therapies, based on a broad understanding of existing data, practice experience, and rational speculation.

Disorganization of cytoplasmic Ca(2+) oscillations and pulsatile insulin secretion in islets from ob/ obmice.

In normal mouse islets, glucose induces synchronous cytoplasmic [Ca(2+)](i) oscillations in beta cells and pulses of insulin secretion. We investigated whether this fine regulation of islet function is preserved in hyperglycaemic and hyperinsulinaemic ob/ obmice. Intact islets from ob/ ob mice and their lean littermates were used after overnight culture for measurement of [Ca(2+)](i) and insulin secretion. We observed three types of [Ca(2+)](i) responses during stimulation by 9 to 12 mmol/l of glucose: sustained increase, rapid oscillations and slow (or mixed) oscillations. They occurred in 8, 18 and 74% of lean islets and 9, 0 and 91% of ob/ ob islets, respectively. Subtle desynchronisation of [Ca(2+)](i) oscillations between regions occurred in 11% of lean islets. In ob/ ob islets, desynchronisation was frequent (66-82% depending on conditions) and prominent: oscillations were out of phase in different regions because of distinct periods and shapes. Only small ob/ ob islets were well synchronised, but sizes of synchronised lean and desynchronised ob/ ob islets were markedly overlapped. The occurrence of desynchronisation in clusters of 5 to 50 islet cells from ob/ obmice and not from lean mice further indicates that islet hypertrophy is not the only causal factor. In both types of islets, synchronous [Ca(2+)](i) oscillations were accompanied by oscillations of insulin secretion. In poorly synchronised ob/ ob islets, secretion was irregular but followed the pattern of the global [Ca(2+)](i) changes. The regularity of glucose-induced [Ca(2+)](i) oscillations is disrupted in islets from ob/ ob mice and this desynchronisation perturbs the pulsatility of insulin secretion. A similar mechanism could contribute to the irregularity of insulin oscillations in Type II (non-insulin-dependent) diabetes mellitus.

Metabolic oscillations in beta-cells.

Whereas the mechanisms underlying oscillatory insulin secretion remain unknown, several models have been advanced to explain if they involve generation of metabolic oscillations in beta-cells. Evidence, including measurements of oxygen consumption, glucose consumption, NADH, and ATP/ADP ratio, has accumulated to support the hypothesis that energy metabolism in beta-cells can oscillate. Where simultaneous measurements have been made, these oscillations are well correlated with oscillations in intracellular [Ca(2+)] and insulin secretion. Considerable evidence has been accumulated to suggest that entry of Ca(2+) into cells can modulate metabolism both positively and negatively. The main positive effect of Ca(2+) is an increase in oxygen consumption, believed to involve activation of mitochondrial dehydrogenases. Negative feedback by Ca(2+) includes decreases in glucose consumption and decreases in the mitochondrial membrane potential. Ca(2+) also provides negative feedback by increasing consumption of ATP. The negative feedback provided by Ca(2+) provides a mechanism for generating oscillations based on a model in which glucose stimulates a rise in ATP/ADP ratio that closes ATP-sensitive K(+) (K(ATP)) channels, thus depolarizing the cell membrane and allowing Ca(2+) entry through voltage-sensitive channels. Ca(2+) entry reduces the ATP/ADP ratio and allows reopening of the K(ATP) channel.