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C-peptide

C-peptide, also known as connecting peptide, is a 31-amino acid polypeptide produced in the pancreatic beta cells as a byproduct of insulin biosynthesis from proinsulin.^[1] It connects the alpha and beta chains of proinsulin and is cleaved by prohormone convertases in the immature secretory granules, resulting in the release of equimolar amounts of C-peptide and insulin into the circulation.^[1]^[2] With a longer half-life of approximately 30–35 minutes compared to insulin's 5–10 minutes, C-peptide is primarily cleared by the kidneys and serves as a reliable biomarker for assessing endogenous insulin secretion, unaffected by exogenous insulin administration.^[1] Beyond its structural role in facilitating proper insulin folding and disulfide bond formation during proinsulin processing, emerging evidence suggests C-peptide may possess independent physiological functions, including potential anti-inflammatory, anti-apoptotic, and cytoprotective effects through binding to unidentified G-protein coupled receptors.^[1] However, these bioactivities remain under investigation, with no specific receptor confirmed to date.^[1] Clinically, C-peptide measurement is widely used to evaluate pancreatic beta-cell function and differentiate types of diabetes mellitus.^[3] In type 1 diabetes, low or undetectable levels (e.g., fasting <0.2 nmol/L) indicate beta-cell destruction and insulin deficiency, while higher levels in type 2 diabetes reflect preserved endogenous production.^[3] It aids in diagnosing causes of hypoglycemia, such as insulinoma (where levels are inappropriately high relative to glucose), and guides therapy decisions, including insulin requirements or eligibility for treatments like insulin pumps.^[4] Testing typically involves fasting plasma assays (normal range: 0.3–0.6 nmol/L or 0.9–1.8 ng/mL), with stimulated tests like glucagon stimulation or mixed-meal tolerance enhancing sensitivity for low-function states.^[3] Low C-peptide levels are also associated with increased risks of microvascular complications in diabetes.^[3]

Biochemistry

Structure

C-peptide is a 31-amino acid straight-chain polypeptide that serves as the connecting segment between the A and B chains in the proinsulin precursor molecule.^[5] Its primary structure in humans consists of the sequence EAEDLQVGQVELGGGPGAGSLQPLALEGSLQ, with a molecular weight of approximately 3020 Da.^[5] This linear chain adopts a predominantly random coil conformation in solution, lacking a stable secondary structure under physiological conditions.^[6] The polypeptide exhibits a negatively charged character, primarily due to multiple glutamic acid residues, and features eight conserved amino acids across mammalian species at positions 1 (Glu), 3 (Glu), 6 (Gln), 11 (Glu), 12 (Leu), 21 (Leu), 27 (Glu), and 31 (Gln).^[1] These conserved residues contribute to structural stability and functional conservation. The C-terminal pentapeptide sequence, Glu-Gly-Ser-Leu-Gln (positions 27-31), is particularly notable for mediating interactions with cell membranes and supporting biological activities such as stimulation of Na⁺,K⁺-ATPase.^[7] Within proinsulin, C-peptide plays a critical role in facilitating proper folding by positioning the A and B chains in proximity, thereby stabilizing the formation of the three essential interchain and intrachain disulfide bonds required for insulin maturation.^[1] This structural contribution ensures efficient assembly of the hormone precursor in the endoplasmic reticulum.

Biosynthesis and Secretion

C-peptide is synthesized in the pancreatic beta cells of the islets of Langerhans as an integral component of the preproinsulin precursor. Preproinsulin, a 110-amino-acid polypeptide, is transcribed from the INS gene and translated on ribosomes bound to the rough endoplasmic reticulum (ER). Upon entering the ER lumen, the N-terminal signal peptide is rapidly cleaved by signal peptidase, yielding proinsulin, which folds into its native structure through the formation of three disulfide bonds essential for stability. This initial processing occurs exclusively in the ER, where proinsulin quality control mechanisms, including chaperone-assisted folding, ensure proper conformation before transit to the Golgi apparatus.^[8]^[9] From the Golgi apparatus, proinsulin is sorted into immature secretory granules, where further maturation takes place in an acidic environment conducive to proteolytic processing. The conversion of proinsulin to insulin and C-peptide is mediated by two prohormone convertases, PC1/3 (also known as PCSK1) and PC2 (PCSK2), which endoproteolytically cleave the precursor at two dibasic sites flanking the C-peptide sequence. Subsequent removal of the exposed C-terminal basic residues (arginine and lysine) is performed by carboxypeptidase E (CPE), yielding mature insulin (comprising A and B chains linked by disulfide bonds) and the connecting C-peptide in equimolar amounts. This stepwise enzymatic cleavage, which occurs progressively as granules mature, ensures efficient production without intermediate accumulation, and disruptions in these enzymes can lead to impaired insulin processing.^[10]^[11]^[12] Secretion of C-peptide is tightly regulated and occurs concurrently with insulin release in response to nutrient stimuli, particularly elevated glucose levels. Glucose metabolism in beta cells increases ATP/ADP ratios, closing ATP-sensitive potassium channels and depolarizing the plasma membrane, which triggers calcium influx and exocytosis of insulin-containing secretory granules. This glucose-stimulated insulin secretion (GSIS) pathway releases C-peptide and insulin in equimolar ratios directly into the portal vein, bypassing significant local degradation and allowing both peptides to enter systemic circulation, though C-peptide serves no direct role in this acute response. The process is pulsatile, with biphasic kinetics reflecting readily releasable and reserve granule pools.^[1]^[13]^[14] In the bloodstream, C-peptide exhibits a plasma half-life of approximately 30 minutes, substantially longer than that of insulin (typically 4-6 minutes), primarily due to its minimal extraction by the liver during first-pass metabolism. Unlike insulin, which undergoes extensive hepatic uptake and degradation (up to 50-80% on initial passage), C-peptide is cleared mainly by the kidneys through glomerular filtration and subsequent tubular reabsorption and degradation. This pharmacokinetic difference makes circulating C-peptide levels a more stable indicator of beta-cell secretory activity over time.^[15]^[16]^[17]

History

Discovery

C-peptide was first identified in 1967 as part of the proinsulin precursor molecule during studies on insulin biosynthesis by Donald F. Steiner and colleagues at the University of Chicago, who demonstrated that insulin is synthesized as a single-chain prohormone in pancreatic beta cells.^[18] This discovery revealed that proinsulin consists of the insulin A and B chains connected by an intervening peptide segment, later named C-peptide, which is cleaved during processing to form mature insulin.^[19] In 1968, Ronald E. Chance and colleagues at Eli Lilly isolated proinsulin from crystalline porcine insulin preparations obtained from pancreas extracts and performed amino acid sequencing, confirming C-peptide as the 33-residue connecting segment between the B and A chains of proinsulin.^[20] This work provided the structural characterization of C-peptide in a mammalian species, establishing its role in the proinsulin molecule and highlighting its release alongside insulin during beta-cell processing. Subsequent studies by Steiner's group in 1971 further purified and sequenced the bovine C-peptide directly from pancreas extracts using acid-ethanol extraction and chromatography, solidifying its identity as an acidic peptide of 26 amino acids.^[21] By the early 1970s, radioimmunoassays enabled detection of C-peptide in human serum, with Franco Melani, Arthur H. Rubenstein, and colleagues reporting in 1970 that it circulates in equimolar amounts to insulin, reflecting endogenous beta-cell secretion without interference from exogenous insulin therapy.^[22] This finding, based on specific immunoassays in healthy and diabetic subjects, confirmed in vivo equimolar release from pancreatic beta cells.^[23] The first clinical observations linking low C-peptide levels to beta-cell destruction in type 1 diabetes appeared in 1977, when Michael B. Block and colleagues measured C-peptide immunoreactivity in juvenile diabetics, showing that undetectable or low levels correlated with absent endogenous insulin production and poorer glycemic control, indicating progressive beta-cell loss. This study in children with recent-onset disease highlighted C-peptide as a direct marker of residual beta-cell function in autoimmune diabetes.^[24]

Key Milestones

In the 1980s, advancements in immunoassay techniques enabled more precise clinical measurement of C-peptide, building on earlier radioimmunoassays to refine detection methods using specific antisera, which facilitated its emerging role as a reliable marker of endogenous insulin secretion.^[25] By the mid-1980s, researchers recognized C-peptide's utility in assessing beta-cell function, particularly in distinguishing insulin-dependent from non-insulin-dependent diabetes, as highlighted in studies evaluating its kinetics during glucose stimulation.^[26] This period also saw initial explorations of C-peptide's potential physiological roles beyond insulin production, though definitive evidence emerged later. The 1990s marked the identification of C-peptide's independent biological activities, including its stimulation of Na⁺,K⁺-ATPase in renal tubular cells, demonstrated in rat models where C-peptide enhanced enzyme activity in synergism with neuropeptide Y, suggesting renal regulatory functions.^[27] Concurrently, comprehensive immunoassay developments, such as those reviewed in 1999, standardized clinical measurements and solidified C-peptide's status as a key indicator of beta-cell secretory capacity, influencing diabetes classification and management protocols.^[28] During the 2000s, clinical trials advanced the therapeutic exploration of C-peptide replacement, with phase II studies in patients with type 1 diabetes and neuropathy showing that subcutaneous C-peptide administration improved nerve conduction velocity and reduced symptoms, as evidenced by a 2007 randomized trial involving 48 participants over six months.^[29] These findings underscored C-peptide's potential to mitigate diabetic complications independently of glycemic control. In the 2010s and 2020s, efforts focused on standardization to enhance inter-laboratory comparability, including a 2007 international comparison across 15 labs that revealed variability in measurements, prompting ongoing initiatives like the 2021 and 2023 manufacturer meetings to harmonize assays.^[30] By 2022, major guidelines from the American Diabetes Association integrated stimulated C-peptide testing into recommendations for diabetes subclassification and insulin therapy decisions. A pivotal 2025 call emphasized unified protocols for C-peptide measurement to improve prediction, diagnosis, and monitoring across diabetes subtypes.^[31] Recent 2025 research has highlighted correlations between low C-peptide levels—indicative of diminished residual beta-cell function—and increased risk of diabetic retinopathy in late-onset type 2 diabetes, with studies showing inverse associations after adjusting for glycemic control and renal function.^[32] These findings reinforce C-peptide's prognostic value in assessing microvascular complications and beta-cell preservation in longstanding diabetes.^[33]

Physiological Functions

Role in Insulin Production

C-peptide plays a crucial role in the biosynthesis of insulin by facilitating the proper folding of proinsulin in the endoplasmic reticulum of pancreatic beta cells. As a connecting peptide linking the A and B chains of proinsulin, it ensures the correct formation of disulfide bridges between these chains, which is essential for the structural integrity of the mature insulin molecule.^[1] Without C-peptide, the folding pathway of proinsulin is disrupted, leading to inefficient disulfide bond formation and potential misfolding.^[34] In addition to aiding folding, C-peptide stabilizes the proinsulin structure to prevent aggregation during transport and processing. This stabilization acts in a chaperone-like manner, promoting efficient conversion of proinsulin to insulin within the secretory granules of beta cells, where prohormone convertases cleave the peptide at dibasic sites.^[1] The 31-amino acid C-peptide sequence contributes to this by maintaining solubility and preventing premature precipitation in the acidic environment of the granules.^[35] Upon glucose stimulation, C-peptide is co-secreted with insulin in equimolar amounts from beta cell secretory vesicles, serving as a reliable byproduct indicator of endogenous insulin production.^[3] Unlike insulin, which undergoes significant first-pass hepatic extraction (up to 50-80% degradation), C-peptide experiences minimal liver metabolism and is primarily cleared by the kidneys, resulting in a longer half-life of approximately 30-35 minutes and more stable circulating levels.^[1] This property makes C-peptide an ideal marker for assessing beta cell function without the confounding effects of hepatic degradation. Furthermore, since exogenous insulin therapy does not produce C-peptide, its measurement allows clear differentiation between endogenous secretion and administered insulin in clinical settings.^[3]

Independent Biological Effects

C-peptide exerts independent biological effects through binding to putative cell surface receptors, potentially G-protein coupled, on various cell types including endothelial cells, renal tubular cells, and neurons; these remain unidentified as of 2025, with no specific receptor confirmed to date despite earlier hypotheses such as GPR146, which have not been supported.^[36] This binding, which occurs at physiological concentrations (0.3-1 nM) without cross-reactivity to insulin or insulin-like growth factors, triggers an influx of extracellular calcium and elevates intracellular calcium levels, initiating downstream cascades such as mitogen-activated protein kinase activation.^[37] Additionally, C-peptide stimulates endothelial nitric oxide synthase expression and activity, resulting in increased nitric oxide production that contributes to vasodilation and improved vascular function.^[38] These signaling events underpin C-peptide's anti-apoptotic and cytoprotective properties, particularly in high-glucose environments associated with diabetes. By inhibiting the translocation and GTPase activity of RAC1, a small GTPase that activates NAD(P)H oxidase, C-peptide reduces the generation of reactive oxygen species (ROS), thereby mitigating oxidative stress-induced cell damage in endothelial and renal cells. Furthermore, C-peptide downregulates NF-κB activation, a key transcription factor in inflammatory and apoptotic pathways, which helps preserve cell viability and function under hyperglycemic conditions. In diabetic animal models, C-peptide administration has demonstrated improvements in endothelial function, as evidenced by enhanced forearm blood flow and reduced vascular permeability. It also ameliorates nerve conduction velocity deficits in type 1 diabetic rats, preventing nodal degeneration and promoting sensory nerve recovery without altering blood glucose levels. Similarly, in streptozotocin-induced diabetic models, C-peptide attenuates glomerular hyperfiltration and microalbuminuria by constricting afferent arterioles and restoring renal hemodynamics.^[38]^[39] C-peptide's potential to reduce inflammation and promote tissue repair is particularly relevant in diabetic complications such as nephropathy and neuropathy. Through its anti-inflammatory actions, including suppression of NF-κB-mediated cytokine release, C-peptide limits inflammatory cell infiltration in renal tissues, aiding in the preservation of glomerular structure. In neuropathy models, it supports nerve fiber regeneration and functional repair, counteracting degenerative changes in peripheral nerves.

Clinical Measurement

Methods and Assays

The primary methods for quantifying C-peptide in biological samples are immunoassays, including enzyme-linked immunosorbent assay (ELISA) and radioimmunoassay (RIA), which utilize monoclonal antibodies targeting specific epitopes on the C-peptide molecule for high specificity and sensitivity.^[40]^[41] These assays enable detection in the low picomolar range, leveraging the peptide's longer plasma half-life compared to insulin to facilitate accurate measurement of endogenous secretion.^[42] Suitable sample types include plasma, which is preferred and typically collected in EDTA tubes to prevent degradation and ensure stability for up to 24 hours at room temperature, as well as serum or urine, the latter reflecting approximately 5-10% of total secreted C-peptide due to renal clearance.^[43]^[44]^[3] Samples should be processed promptly, with plasma centrifuged and separated to minimize variability from storage conditions.^[45] To assess beta-cell reserve, dynamic stimulation tests are employed, such as the glucagon stimulation test, which involves intravenous administration of 1 mg glucagon followed by C-peptide measurements at 6 and 10 minutes post-injection, or the mixed-meal tolerance test, where a standardized meal is ingested after overnight fasting, with C-peptide sampled at intervals (e.g., 30, 60, 90, and 120 minutes) to evaluate postprandial response.^[46]^[47] These protocols provide a more comprehensive assessment of secretory capacity than basal measurements alone.^[48] Recent efforts toward assay standardization, including a 2025 call for harmonization and use of certified reference materials to minimize inter-laboratory variability of up to 20% across commercial kits.^[31]^[49] As of 2025, the C-Peptide Standardization Initiative promotes harmonization using certified reference materials to reduce inter-laboratory variability.^[50] In healthy individuals, normal fasting plasma C-peptide levels range from 0.9-1.8 ng/mL (0.3-0.6 nmol/L), with postprandial values typically rising to 3-9 ng/mL (1-3 nmol/L), though these can vary slightly by assay method and population demographics.^[3]^[51]

Interpretation of Levels

Low fasting C-peptide levels, typically below 0.6 ng/mL (or approximately 0.2 nmol/L), indicate beta-cell dysfunction or failure, as commonly observed in type 1 diabetes where endogenous insulin production is severely impaired.^[52]^[53] In contrast, high C-peptide levels, often exceeding 2.0 ng/mL (or about 0.66 nmol/L), suggest conditions such as insulin resistance in type 2 diabetes, insulinoma, or renal impairment that reduces clearance and prolongs circulation.^[1]^[54]^[53] Several factors influence C-peptide concentrations beyond disease states, including age, body mass index (BMI), renal function, and assay variability. Higher BMI correlates with elevated C-peptide due to increased insulin demand and secretion, while advancing age may contribute to modestly lower levels in some populations.^[55]^[56] Renal function plays a critical role, as C-peptide has a half-life of 30-35 minutes and is primarily cleared by the kidneys; reduced creatinine clearance in chronic kidney disease leads to accumulation and falsely elevated levels.^[57]^[58] Additionally, differences in immunoassay methods can introduce variability of up to 20-30% between laboratories, necessitating standardized reference ranges for accurate interpretation.^[31] Clinical thresholds guide decisions on beta-cell reserve and therapy; for instance, a post-stimulation C-peptide level below 0.2 nmol/L (measured 90 minutes after a mixed-meal tolerance test) signals severe insulin deficiency and poor endogenous production.^[53] C-peptide is secreted in equimolar amounts with insulin, providing a reliable proxy for endogenous insulin despite exogenous administration.^[3] Interpretation of C-peptide levels has limitations, including potential interference from anti-insulin antibodies that cross-react in some immunoassays, leading to artifactual elevations, particularly in insulin autoimmune syndrome.^[59] Sample instability can also affect results if not processed promptly; plasma samples require separation within 2 hours to avoid degradation, though serum is more stable when frozen at -20°C.^[60]

Diagnostic Applications

In Diabetes Management

C-peptide measurement plays a central role in distinguishing type 1 diabetes, characterized by low or undetectable levels due to autoimmune beta-cell destruction, from type 2 diabetes, where levels are typically preserved or elevated reflecting endogenous insulin production.^[61] A fasting C-peptide level below 0.2 nmol/L strongly supports a type 1 diabetes diagnosis and guides initial therapy toward insulin replacement, while higher levels (>0.6 nmol/L) indicate type 2 diabetes and favor oral agents or lifestyle interventions.^[3] This differentiation is particularly valuable in ambiguous cases, such as latent autoimmune diabetes in adults (LADA), where intermediate levels help tailor treatment to avoid unnecessary insulin initiation.^[62] Assessment of residual beta-cell function via C-peptide testing determines insulin independence and eligibility for devices like continuous subcutaneous insulin infusion pumps. In type 1 diabetes, detectable C-peptide (>0.2 nmol/L after a mixed-meal tolerance test) signifies meaningful beta-cell reserve, correlating with reduced insulin requirements and improved outcomes, thus supporting non-insulin therapies when possible.^[53] For Medicare coverage of insulin pumps, criteria require a fasting C-peptide ≤0.5 ng/mL (with concurrent glucose ≤225 mg/dL) to confirm insulin deficiency in type 1 or advanced type 2 diabetes, ensuring appropriate resource allocation.^[63] Serial C-peptide measurements track beta-cell decline in newly diagnosed patients, providing insights into disease progression and the need for intensified therapy. In type 1 diabetes, early post-diagnosis levels often decline over months to years, with home-based serial testing emerging as a practical tool to monitor this trajectory and adjust management proactively.^[64] For young-onset diabetes, repeated assessments help classify evolving phenotypes and predict long-term insulin needs.^[65] Recent 2025 developments emphasize C-peptide-based classification for late-onset diabetes, revealing optimization opportunities in up to 30% of insulin-treated adults through re-evaluation of endogenous secretion.^[66] Additionally, fasting C-peptide levels show a non-linear correlation with diabetic retinopathy risk in type 2 diabetes, where both very low and excessively high concentrations elevate prevalence, informing risk stratification.^[67] Prognostically, higher C-peptide levels in type 2 diabetes predict superior glycemic control, longer time in target glucose range, and reduced insulin dependency, underscoring preserved beta-cell function as a positive indicator for disease management.^[68] In type 1 diabetes, residual secretion associates with lower complication rates and better metabolic outcomes over time.^[69]

In Hypoglycemia Assessment

C-peptide measurement plays a critical role in evaluating hypoglycemia by distinguishing between endogenous and exogenous causes of insulin excess. During episodes of hypoglycemia, elevated C-peptide levels indicate inappropriate endogenous insulin secretion, such as in endogenous hyperinsulinism, which includes conditions like insulinoma—a rare pancreatic beta-cell tumor—and nesidioblastosis, an abnormal proliferation of pancreatic islets.^[70]^[71] In contrast, suppressed C-peptide levels during hypoglycemia suggest non-insulin-mediated etiologies, such as adrenal insufficiency or certain medications, or administration of exogenous insulin, which lacks the associated C-peptide fragment.^[72] The 72-hour supervised fast remains the gold standard protocol for diagnosing hypoglycemia due to endogenous hyperinsulinism, during which plasma glucose, insulin, and C-peptide are serially measured to assess for inappropriate insulin secretion relative to falling glucose levels. This test is typically conducted in a hospital setting, ending when symptomatic hypoglycemia occurs (plasma glucose <55 mg/dL or <40 mg/dL if asymptomatic) or after 72 hours, with blood samples drawn at the time of hypoglycemia for simultaneous analysis of these markers to confirm diagnostic criteria.^[70]^[71] Measuring C-peptide alongside insulin and glucose enhances diagnostic accuracy by verifying endogenous production and ruling out artifacts from sample handling.^[73] In cases of suspected factitious hypoglycemia, C-peptide levels are invaluable for differentiating self-administered exogenous insulin, which suppresses endogenous secretion and results in low C-peptide despite high insulin, from sulfonylurea abuse, where stimulated beta-cell activity leads to elevated C-peptide and insulin levels mimicking insulinoma.^[72]^[74] Diagnosis of sulfonylurea-induced factitious hypoglycemia requires additional screening for these agents in plasma or urine, as the biochemical profile otherwise overlaps with endogenous hyperinsulinism.^[72] Clinical thresholds for C-peptide during hypoglycemia provide quantitative support for an endogenous etiology; levels exceeding 0.6 ng/mL (or ≥200 pmol/L) in the presence of low glucose (<55 mg/dL) and neuroglycopenic symptoms strongly indicate hyperinsulinism from pancreatic sources.^[70]^[71] These criteria, combined with the 72-hour fast findings, guide further imaging and management while excluding exogenous causes.^[75]

Therapeutic Potential

Replacement Therapy

C-peptide replacement therapy involves the exogenous administration of synthetic human C-peptide to type 1 diabetes patients, who lack endogenous production due to beta-cell destruction, aiming to restore physiological plasma levels of approximately 0.3–0.6 nmol/L postprandially. This approach utilizes either intravenous infusion for acute studies or subcutaneous injection for chronic delivery, often divided into multiple daily doses or via continuous subcutaneous infusion pumps, combined with standard insulin therapy to mimic natural co-secretion without directly affecting glucose levels. Clinical trials have demonstrated feasibility in achieving target concentrations, with subcutaneous dosing typically ranging from 10–100 nmol/kg/day to avoid supraphysiological exposure.^[76]^[77] In patients with type 1 diabetes and peripheral neuropathy, 6-month randomized, placebo-controlled trials conducted in the 2000s have shown that subcutaneous C-peptide replacement improves sensory nerve function. For instance, in a multicenter study of 139 patients, daily doses of 1.5 mg (≈500 nmol) or 4.5 mg (≈1,500 nmol) led to significant enhancements in sural sensory nerve conduction velocity by 1.0 m/s compared to placebo (P < 0.014), particularly in those with milder impairment, alongside reductions in neurological symptoms such as vibration perception thresholds (P < 0.002). These benefits are attributed to C-peptide's protective effects on nerve endothelial cells, though longer-term data beyond 6 months remain limited.^[78] For diabetic nephropathy, replacement therapy has demonstrated renoprotective effects through reductions in albuminuria and glomerular hyperfiltration, mediated by endothelial stabilization and afferent arteriole constriction. In a 3-month crossover trial of 21 type 1 diabetes patients with microalbuminuria, subcutaneous administration of 600 nmol/24 h decreased urinary albumin excretion by approximately 40% (from 58 to 34 μg/min, P < 0.01) without altering insulin requirements. Short-term intravenous infusions (e.g., 2 hours at physiological rates) in early-stage patients also lowered glomerular filtration rate by 6–7%, mitigating hyperfiltration, a key precursor to progressive kidney damage.^[77]^[76] The safety profile of C-peptide replacement is favorable, with trials reporting it as generally well-tolerated at replacement doses, and no serious adverse events directly attributable to the peptide. Mild risks include transient hypoglycemia, potentially due to enhanced insulin sensitivity requiring dose adjustments, though incidence rates were comparable to placebo in controlled studies. Common dosing starts at 10–20 nmol/kg/day subcutaneously, titrated up to 100 nmol/kg/day based on tolerance and monitoring. As of 2025, C-peptide remains investigational for replacement therapy, with phase II and III trials completed in the 2010s showing promise but no FDA approval achieved; development efforts, such as those by Cebix for a long-acting formulation, ceased after phase IIb setbacks.^[78]^[76]^[79]

Ongoing Research

Recent meta-analyses of clinical trials in new-onset type 1 diabetes have established C-peptide preservation as a key endpoint, demonstrating that higher stimulated C-peptide levels correlate with improved time in range (TIR) on continuous glucose monitoring and a reduced incidence of hypoglycemic events.^[80]^[81] These findings underscore C-peptide's role in evaluating disease-modifying therapies, with a 24.8% increase in C-peptide associated with a 0.55% reduction in HbA1c after six months of treatment.^[80] Efforts toward global harmonization of C-peptide assays gained momentum in 2025, driven by calls from regulatory and scientific bodies to address inter-laboratory variability and enhance the reliability of measurements in multicenter trials.^[31] Standardization initiatives, including the development of reference materials and validated protocols, aim to minimize discrepancies across immunoassay platforms, thereby supporting more consistent endpoint assessments in diabetes research.^[82]^[83] Emerging 2025 studies have revealed novel correlations between C-peptide levels and diabetic complications, particularly in retinopathy progression among type 2 diabetes patients, where postprandial C-peptide measurements predict disease advancement with moderate sensitivity.^[84] In pediatric type 1 diabetes, investigations into residual beta-cell function highlight detectable C-peptide secretion in children beyond one year post-diagnosis, linking low but persistent levels to improved glycemic stability and reduced complication risks.^[69]^[85] Research into C-peptide's potential expansions continues to explore its protective effects against cardiovascular disease, with preclinical models showing amelioration of endothelial dysfunction through anti-inflammatory mechanisms.^[86] Similarly, immunomodulatory properties are under investigation, as C-peptide supplementation in animal studies modulates immune responses in autoimmune diabetes contexts.^[87] Preclinical data on stem cell-derived C-peptide production from differentiated beta cells demonstrate sustained glucose-responsive secretion, paving the way for regenerative therapies.^[88] Key challenges in advancing C-peptide research include the necessity for extended long-term trials to assess durability of benefits beyond initial endpoints and the development of reliable biomarkers to enable personalized dosing strategies in therapeutic applications.^[31]^[89] These hurdles emphasize the need for integrated approaches combining advanced analytics with clinical validation to translate findings into broader clinical practice.^[90]

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[41]
[PDF] Mixed Meal Test for Postprandial Hypoglycaemia
TEST. • Insert cannula and take blood for baseline plasma glucose at time 0. • Give mixed meal. • Take blood for glucose, insulin and c-peptide at 30, 60, 90 ...
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Kinetics of C-peptide during mixed meal test and its value for ...
Mixed meal tolerance test protocol. MMTT was performed in the morning (between 7 and 10 AM) following an overnight fasting for 10 h (maximum 16 h) at the in ...Kinetics Of C-Peptide During... · 2. Research Design And... · 3. Results
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Call for Standardization of C-Peptide Measurement - PMC
Aug 8, 2025 · Measurement of C-peptide can therefore be used for prediction, diagnosis, and subclassification of diabetes. Furthermore, C-peptide assists in ...Missing: 2020s | Show results with:2020s
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[PDF] 1 2024 C-Peptide Standardization Manufacturer Meeting Minutes
Standardization of C-peptide measurement ... GPP—Guidelines and. Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus.
[45]
The role of C-peptide in diabetes and its complications
Sep 7, 2023 · Furthermore, C-peptide combats high glucose-induced endothelial dysfunction by reducing NF-κB activation, potentially due to C-peptide induced ...
[46]
Normal C-peptide Levels in ng/ml - Dr.Oracle
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C-Peptide: Reference Range, Interpretation, Collection and Panels
Jun 10, 2025 · Mixed meal tolerance test: 90-min C-peptide ≥ 0.2 nmol/L is associated with clinically meaningful β-cell reserve and improved outcomes ...Reference Range · Interpretation · Collection And Panels<|separator|>
[48]
C-Peptide Test: What It Is, Purpose, Procedure & Results
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[49]
Excessive BMI is associated with higher C-peptide level at ...
Apr 27, 2023 · We also separated a group consisted of patients with BMI-SDS >1 (overweight and obese according to centile population charts) (n=22). All ...5. Results · Table 1 · Table 2
[50]
The Influence of Body Mass Index and Age on C-peptide at the ... - NIH
Without appropriate adjustments for BMI and age, younger and thinner children would more likely be excluded from clinical trials than overweight adolescents.
[51]
[PDF] C-peptide: Roles in diabetes, insulinoma, and hypoglycemia
C-peptide measurements are proving to be a useful aid in the diagnosis of diabetes mellitus, hypoglycemia, and insulinoma. This article provides.<|control11|><|separator|>
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The clinical utility of C‐peptide measurement in the care of patients ...
Feb 18, 2013 · In Type 1 diabetes, insulin/C-peptide levels rapidly fall, therefore the utility of C-peptide testing increases from 3 to 5 years post-diagnosis ...
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Assessment and Management of Anti-Insulin Autoantibodies in ... - NIH
In this series, the first clue to IAS came from high insulin concentrations and insulin/C-peptide molar ratios in samples drawn during hypoglycemia.Missing: instability | Show results with:instability
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Multiplexed quantification of insulin and C-peptide by LC-MS/MS ...
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The Predictive Potential of C-Peptide in Differentiating Type 1 ...
Aug 8, 2024 · We aimed to investigate the predictive potential of plasma connecting peptide (C-peptide) in differentiating type 1 diabetes (T1D) from type 2 diabetes (T2D)
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Utility of Fasting C-Peptide for the Diagnostic Differentiation ... - MDPI
Apr 25, 2024 · Conclusions: C-peptide is useful for the diagnostic differentiation of patients with type 1, type 2 diabetes, MODY, and LADA.
[57]
Insulin Pump: C-Peptide Levels as a Criterion for Use - CMS
CMS has determined that fasting C-peptide levels will only be considered valid when a concurrently obtained fasting glucose is ≤ 225 mg/dL.
[58]
Connecting the Spots: Serial Home C-peptide Measurements Paint ...
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Clinical Utility of Serial Monitoring of C-Peptide in...
In this review, we shall discuss regarding the clinical utility of serial monitoring of C-peptide levels in the diagnosis of young-onset diabetes.
[60]
1364-P: C-Peptide–Based Classification of Late-Onset Diabetes ...
Jun 20, 2025 · We aimed to evaluate clinical features and treatment patterns in C-peptide-driven diabetes classification in a large cohort of insulin treated adults with late ...
[61]
Non-linear relationship between fasting C-peptide and retinopathy in p
Apr 7, 2025 · This research sought to explore the inherent connection between fasting C-peptide and the likelihood of DR in individuals with type 2 diabetes (T2D).
[62]
Residual β-Cell Function Is Associated With Longer Time in Range ...
Aug 3, 2023 · One plausible mechanism is that more residual β-cell function improves daily glycemic control, resulting in fewer hypo- and hyperglycemic ...Introduction · Research Design and Methods · Results · Conclusions
[63]
Residual beta-cell function in children with type 1 diabetes after a ...
Jun 17, 2025 · Studies confirm the correlation between detectable C-peptide levels in long-term diabetes and good metabolic control, and additionally, ...
[64]
Insulinoma - Endocrine and Metabolic Disorders - Merck Manuals
The main symptom is fasting hypoglycemia. Diagnosis is by a 48- or 72-hour fast with measurement of glucose and insulin levels, followed by endoscopic ...
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Insulinoma | Choose the Right Test - ARUP Consult
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[66]
Factitious Hypoglycemia - StatPearls - NCBI Bookshelf - NIH
Sep 4, 2023 · When insulin is self-injected, laboratory studies will show high plasma insulin levels in combination with low plasma C-peptide levels during ...
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Evaluation and Management of Adult Hypoglycemic Disorders
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[68]
Factitious Hypoglycemia: Diagnosis by Measurement of Serum C ...
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[69]
Insulin, C-peptide and proinsulin for the biochemical diagnosis of ...
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[70]
The Clinical Potential of C-Peptide Replacement in Type 1 Diabetes
Mar 14, 2012 · After its discovery in 1967 (1), it was believed that C-peptide might exert physiological effects similar to those of insulin. However, no ...
[71]
Beneficial effects of C‐peptide on incipient nephropathy and ...
Dec 24, 2001 · Conclusion These results indicate that combined treatment with C-peptide and insulin for 3 months may improve renal function by diminishing ...
[72]
C-Peptide Replacement Therapy and Sensory Nerve Function in ...
Jan 1, 2007 · In summary, C-peptide treatment in replacement doses for 6 months improves sensory nerve function in patients with diabetic neuropathy and mild ...
[73]
C-Peptide Replacement Therapy in Type 1 Diabetes - NIH
C-peptide proved to be effective in improving motor nerve conduction velocity (MNCV), a common metric of nerve damage in diabetes, in both the STZ and BB/Wor ...
[74]
C-peptide and metabolic outcomes in trials of disease modifying ...
Aug 26, 2025 · The results showed that a 24.8% higher C-peptide level was accompanied by a 0.55% lower HbA1c, after 6 months of treatment.
[75]
Residual C-peptide secretion is associated with better CGM-metrics ...
Abstract. Aim: To investigate whether the risk of hypoglycemia is associated with residual β-cell function in adults with type 1 diabetes (T1D).Missing: endpoint meta- TIR
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Call for Standardization of C-Peptide Measurement | Request PDF
Oct 9, 2025 · Measurement of C-peptide can therefore be used for prediction, diagnosis, and subclassification of diabetes. Furthermore, C-peptide assists in ...Missing: 2020s | Show results with:2020s
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[PDF] Workshop: 21st Century Clinical Trials in New-Onset Type 1 Diabetes
Jun 18, 2025 · 2025 (Current Status): No FDA Guidance on C-Peptide. As of May 19, 2025, no current specific FDA final or draft guidance document discusses the ...
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Correlation between C-peptide and diabetic retinopathy in patients ...
Oct 14, 2025 · The average 30-minute post-prandial C-peptide predicted diabetic retinopathy progress: A retro-prospective study. ... Sci Rep 15, 35896 (2025).
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Residual beta-cell function in children with type 1 diabetes after a ...
Jun 18, 2025 · The aim of the study was to evaluate C-peptide secretion in T1D children with at least 1 year disease duration and to investigate the potential ...
[80]
C-peptide replacement therapy as an emerging strategy for ...
C-peptide replacement therapy is an emerging strategy to prevent diabetic vasculopathy by protecting against vascular damage and maintaining vascular function.
[81]
C-peptide and metabolic outcomes in trials of disease modifying ...
Dec 11, 2023 · We, therefore, aimed to define the relationship between insulin C-peptide as a marker of β-cell function and metabolic outcomes in new-onset type 1 diabetes.
[82]
A wearable device for continuous immunoassay-based monitoring ...
Jul 18, 2025 · Continuous and rapid detection of C-peptide in ISF presents several challenges. One primary difficulty is developing a sensing platform that can ...
[83]
Immune Intervention and Replacement Therapies in Type 1 Diabetes
Mar 18, 2025 · The use of AUC C-peptide as a 6-month dynamic measure not only detected treatment efficacy (i.e., a significant difference between treated and ...