In humans and most other vertebrates, the primary hormone involved in control of blood glucose is insulin. Insulin acts on cells to stimulate glucose, protein, and lipid metabolism, as well as RNA and DNA synthesis, by modifying the activity of a variety of enzymes and transport processes. The importance ofunderstanding insulin action is not limited to simply satisfying the intellectual needs of the curious biochemist or cell biologist. Elucidating the molecular pathways ofinsulin action forms an important cornerstone upon which to unravel the pathogenesis of non-insulin-dependent (type II) diabetes mellitus and a major component of other insulin-resistant states including obesity, uremia, glucocorticoid, and growth hormone excess, as well as a variety of rarer genetic disorders such as leprechaunism, the type A syndrome of insulin resistance, and lipoatrophic diabetes.The actions of insulin at the cellular level are initiated by insulin binding to its plasma membrane receptor (1-4). This receptor is present on virtually all mammalian tissues, although the concentration varies from as few as 40 receptors on circulating erythrocytes to more than 200,000 receptors on adipocytes and hepatocytes. Like the surface membrane receptors for other hormones and growth factors, the insulin receptor serves at least two functions. The first is to recognize the hormone among all other substances in the blood. This is accomplished by binding the hormone with high affinity and a high degree of specificity. The second function is to produce a transmembrane signal that alters intracellular metabolism and mediates the action ofthe hormone. Recognition ofthe insulin molecule by its receptor is a complex molecular event and is closely linked to signal transmission. The binding domain of the insulin molecule is composed of distant portions of the A and B chains, which come together on one surface as a result of three-dimensional folding to form the receptor binding region (5). Among over 200 analogues of insulin studied, there is an almost perfect correlation between receptor-binding affinity and biological effect (1,5,6). No competitive antagonists of insulin action at the receptor level have, as of yet, been uncovered, suggesting that the structural requirements for binding include all the features necessary for biological action. Interestingly, the binding properties of the insulin receptor are better conserved in evolution than are the properties of the insulin molecule itself (7).Address reprint requests to Dr. C. Ronald Kahn, Joslin Diabetes Center, One Joslin Place, Boston, MA 02215.Receivedfor publication 29 June 1988.The insulin receptor is a heterotetrameric glycoprotein consisting of two a-subunits of Mr = 135,000 and two (3-subunits of Mr = 95,000 linked by disulfide bonds to give a ,3-a-a-13 structure (8, 9) (Fig. 1). The a-subunit appears to be entirely extracellular and contains the insulin binding site. This binding site can be affinity labeled using labeled insulin and bifunctional cross-linking agents (8, 9) or photo...