Hypoglycemia and glucose counterregulation in normal and insulin-dependent diabetic subjects

Brain Glucose Sensing and the Problem of Relative Hypoglycemia

"Relative hypoglycemia" is an often-overlooked complication of diabetes characterized by an increase in the glycemic threshold for detecting and responding to hypoglycemia. The clinical relevance of this problem is linked to growing evidence that among patients with critical illness, higher blood glucose in the intensive care unit is associated with higher mortality among patients without diabetes but lower mortality in patients with preexisting diabetes and an elevated prehospitalization HbA1c. Although additional studies are needed, the cardiovascular stress associated with hypoglycemia perception, which can occur at normal or even elevated glucose levels in patients with diabetes, offers a plausible explanation for this difference in outcomes. Little is known, however, regarding how hypoglycemia is normally detected by the brain, much less how relative hypoglycemia develops in patients with diabetes. In this article, we explore the role in hypoglycemia detection played by glucose-responsive sensory neurons supplying peripheral vascular beds and/or circumventricular organs. These observations support a model wherein relative hypoglycemia results from diabetes-associated impairment of this neuronal glucose-sensing process. By raising the glycemic threshold for hypoglycemia perception, this impairment may contribute to the increased mortality risk associated with standard glycemic management of critically ill patients with diabetes.

A 10-second sprint does not blunt hormonal counter-regulation to subsequent hypoglycaemia

AIM

To investigate whether a 10-second (s) sprint impairs the counter-regulatory response to subsequent hypoglycaemia.

METHODS

Nine people (five male, four female) with Type 1 diabetes, aged 21.1 ± 4.5 years, performed a 10-s rest or a 10-s maximum-effort sprint in random order on different days, while subjected to an euinsulinaemic-euglycaemic clamp. This was followed by a hyperinsulinaemic-hypoglycaemic glucose clamp 2.5 h later to induce hypoglycaemia for 40 min. At timed intervals, the counter-regulatory hormonal responses to hypoglycaemia were measured. Blood pressure, heart rate and hypoglycaemic symptoms were also assessed.

RESULTS

During the hypoglycaemic clamp, epinephrine, norepinephrine, growth hormone and cortisol levels increased significantly from baseline, and their responses were similar after both rest and sprint conditions. In particular, plasma epinephrine rose eightfold, from 197 ± 103 pmol/l to 1582 ± 1118 pmol/l after the rest condition, and from 219 ± 119 pmol/l to 1900 ± 898 pmol/l after the sprint condition.

CONCLUSION

A 10-s sprint is unlikely to blunt the subsequent hormonal counter-regulation to hypoglycaemia in individuals with Type 1 diabetes.

Intravenous infusion of donor apoptotic leukocytes before transplantation delays allogeneic islet graft rejection through regulatory T cells

AIM

This study describes the ability of intravenous donor apoptotic leukocyte infusion before islet transplantation to delay allogeneic graft rejection and implicates regulatory T cells (T(reg)) in the effect.

METHODS

Allogeneic FVB (Friend virus B-type) islet transplants were placed under the kidney capsule of BALB/c recipient mice rendered diabetic by streptozotocin. Apoptotic donor leukocytes were infused intravenously 7 days before transplantation. Foxp3/DTR/GFP transgenic C57BL/6 mice were used as recipients to show depletion of T(reg) after apoptotic cell infusion. Control mice received islet transplants without apoptotic cells.

RESULTS

The graft median survival time (MST) in recipient mice was 15±1.5 days when apoptotic cells were infused 7 days prior to transplantation of a 1000-islet-containing allograft and 6±0.5 days in the control mice (P<0.01). The same effect was observed using a 500-islet allograft, with an MST of 9±1.1 days vs. 3±0.8 days with and without (controls) apoptotic cells, respectively (P<0.01). This immunomodulatory effect was not observed when apoptotic cell administration was performed on the day of transplantation. Specific T(reg) depletion in Foxp3/DTR/GFP recipient mice inhibited the beneficial effect of apoptotic cell infusion with an MST of 8±1.5 days after apoptotic cell infusion vs. 2±0.2 days when T(reg) were depleted (P<0.01). Furthermore, T(reg) were specifically detected in the islet grafts of mice infused with apoptotic cells prior to islet transplantation.

CONCLUSION

Infusion of donor apoptotic cells 7 days before allogeneic transplantation delays islet allograft rejection through a process involving T(reg).

Protein and glutamine kinetics during counter-regulatory failure in type 1 diabetes

BACKGROUND AND AIMS

Healthy individuals counteract insulin-induced hypoglycaemia by increasing glutamine utilization but not proteolysis. Glucagon is important to this response because it increases glutamine uptake. In type 1 diabetes (T1DM) glucagon and epinephrine responses to hypoglycaemia are defective. We investigated whether glutamine and amino acid utilization during hypoglycaemia is altered in T1DM with defective counter-regulatory responses.

METHODS AND RESULTS

Eight T1DM patients (duration of diabetes 14+/-4 years and therefore with presumed defective counter-regulatory response) and eight controls (CON) received a 3h hypoglycaemic hyperinsulinaemic (0.65mU/kg per min) clamp coupled to [6,6-(2)H(2)]glucose, [1-(13)C]leucine and [2-(15)N]glutamine to trace the relative kinetics. Post-absorptive plasma glucose and glucose uptake were increased in T1DM (9.09+/-0.99 vs 5.01+/-0.22mmol/l and 19.5+/-0.9 vs 12.6+/-0.8micromol/kg per min, p<0.01). During the clamp T1DM but not CON required exogenous glucose (4.4+/-1.7micromol/kg per min) to maintain the hypoglycaemic plateau because the endogenous glucose production was significantly suppressed (p<0.01). In T1DM the leucine and phenylalanine concentrations were less suppressed from basal (p<0.05) despite a similar insulin suppression of proteolysis (-16+/-2 vs -20+/-4%, p=ns) indicating a defective stimulation of leucine metabolic clearance from basal (+18+/-3% vs +55+/-9%, p<0.01). Glutamine concentration remained unchanged from basal (-7+/-3% vs -35+/-3%, p<0.01) and the clearance of glutamine was markedly defective in T1DM (+6+/-2%) in comparison with controls (+22+/-4%; p=0.02).

CONCLUSIONS

In T1DM, the counter-regulatory failure to hypoglycaemia seems to be associated with a defective glutamine utilization. The failure to clear circulating amino acids, specifically glutamine, during hypoglycaemia may adversely affect gluconeogenesis.

Immunosuppression and procedure-related complications in 26 patients with type 1 diabetes mellitus receiving allogeneic islet cell transplantation

BACKGROUND

The success of sirolimus and low-dose tacrolimus in islet cell transplantation has influenced many transplant centers to utilize this novel regimen. The long-term safety and tolerability of this steroid-free immunosuppressive protocol for allogeneic islet transplantation has yet to be determined.

METHODS

We transplanted 26 adult patients with long standing type 1 diabetes mellitus between April 2000 and June 2004. Immunosuppression consisted of induction with daclizumab and maintenance therapy with tacrolimus and sirolimus. Adverse events (AEs) in patients were followed and graded using the Common Terminology Criteria for Adverse Events, version 3.0 (National Cancer Institute).

RESULTS

To date, the majority of patients were able to remain on the immunosuppression combination for up to 22+/-11 months. Four patients were successfully converted to Mycophenolate Mofetil due to tacrolimus-related toxicity. Withdrawal from immunosuppression was decided in four patients due to hypereosinophilic syndrome, parvovirus infection, aspiration pneumonia, and severe depression, respectively. Six patients required filgrastim therapy for neutropenia. Transient elevation of liver enzymes was observed in most patients early after islet infusion. Increased LDL in 20 patients required medical treatment.

CONCLUSION

There was a varying range of AEs, most of them mild and self-limiting; however, some required urgent medical attention. The majority of patients were able to tolerate and remain on this effective regimen. To date, no deaths, cytomegalovirus disease, graft-versus-host disease, or posttransplant lymphoproliferative disease has been observed.

The effects of dietary flaxseed on the Fischer 344 rat. III. Protection against CCl(4)-induced liver injury

The hepatotoxic effect of carbon tetrachloride (CCl(4)) administered by gavage at 0.25 ml CCl(4) (1:1 in olive oil) per 100 g body weight was examined 24 h later in regular chow fed (RC) and 10% flax chow fed (FC) male and female Fischer 344 rats. CCl(4)-treated RC rats were subdued, lethargic and unkempt. CCl(4)-treated FC rats were much less affected. CCl(4) treatment resulted in loss of weight in RC and FC rats. In males, the weight loss was 6.7% body mass in RC rats compared to 5.6% body mass in FC rats. In females, the weight loss was 7.5% body mass in both RC and FC rats. While CCl(4) treatment increased the level of the liver injury marker plasma alanine aminotransferase (ALT) in RC rats, this CCl(4) effect was significantly attenuated in FC rats. In male rats, the ALT increase was 435-fold in RC rats and 119-fold in FC rats, over that of their respective controls. In female rats, the ALT increase was 454-fold in RC rats and 381-fold in FC rats, over that of their respective controls. These results provide evidence that flax consumption protects the liver against injury and that the extent of the protection is sex dependent. CCl(4) had no effect on the plasma level of gamma-glutamyltranspeptidase (gammaGT) in RC and FC rats supporting the contention that plasma gammaGT is not a useful marker for acute liver injury which is seen in this model. The activity of gammaGT was increased in the livers of FC rats compared to RC rats: 2.7-fold in males and 1.5-fold in females. In RC rats, the activity of liver gammaGT was decreased by CCl(4) treatment: 70% in the male and 25% in the female. However, this CCl(4) effect was reversed or abolished by flax consumption. Compared to RC rats: in male FC rats, CCl(4) actually increased the activity of liver gammaGT 1.28-fold; while in female FC rats, the depressing effect of CCl(4) treatment was abolished. The flax-induced preservation of gammaGT in the liver in response to injury may be involved in the observed hepatoprotection through generation of GSH. In RC male rats, CCl(4) treatment effected a 25% reduction in plasma glucose levels. There was no decrease in CCl(4)-treated FC male rats. In female rats, CCl(4) treatment effected a 21% decrease in plasma glucose levels in both RC and FC rats. In conclusion, multiple parameters for acute CCl(4)-induced injury were attenuated in the FC compared to the RC rat. That flaxseed consumption conferred greater protection against liver injury in the male than in the female suggests an involvement of the estrogenic lignan component of flaxseed. We discuss the possibility that this hepatoprotection is through a flax lignan-induced increase in reduced glutathione related to a flax effect on the activity of liver gammaGT in the resting state and the maintenance of its activity in response to injury.

The effects of elk velvet antler consumption on the rat: development, behavior, toxicity and the activity of liver gamma-glutamyltranspeptidase

The effect of exposure to, followed by consumption of, a diet containing 10% powdered elk velvet antler (EVA) from the 18th day of gestation to the 88th day after birth was examined in male and female Fischer 344 rats. There were no teratogenic effects of EVA exposure in utero or differences in birth outcomes between pups born to regular chow fed and EVA chow fed dams. Growth curves of the EVA fed rats were identical to those of regular chow fed rats, as were developmental milestones of pinna development and eye-opening. Acoustical startle and righting reflexes, developmental and behavioral indices, were identical. Blood glucose levels were comparable in EVA chow fed and regular chow fed rats, indicating that EVA is without effect on glucose balance. There were no signs of toxicity in the EVA chow fed compared to regular chow fed rats as judged from plasma enzyme markers of liver damage: plasma levels of alanine aminotransferase were 50% lower in EVA chow fed rats compared to regular chow fed rats; and plasma levels of gamma-glutamyltranspeptidase (gammaGT) were the same. The activity of gammaGT displayed a decrease in the livers of EVA chow fed rats, more so in the male (22%) than in the female (14%), suggestive of an androgenic effect. A possible hepatobeneficial effect of the EVA induced decrease in liver gammaGT is discussed. In summary, dietary10% EVA chow is without long term effect on growth, development and behavior is non-toxic and may be hepatobeneficial.

Hypoglycemia in Type 1 Diabetes Mellitus

Spontaneous hypoglycemia is uncommon in the general (nondiabetic) population, but iatrogenic hypoglycemia is rife in patients with type 1 diabetes mellitus, among whom hypoglycemia constitutes a barrier to optimal glycemic control. The obligate dependence on exogenous insulin, together with the current imperfection in insulin therapies, generates degrees of blood glucose fluctuations that often exceed physiological boundaries in these patients. Downward swings in blood glucose levels, if sustained, result in hypoglycemia and significant morbidity and mortality. Hypoglycemia in type 1 diabetes indicates an imbalance between caloric supply and glucose use in response to insulin or exercise. Counterregulatory mechanisms that auto-correct iatrogenic hypoglycemia often become progressively impaired in these patients. This defective counterregulation, together with the imperfections in insulin delivery, set the stage for significant morbidity from iatrogenic hypoglycemia. Recurrent episodes of iatrogenic hypoglycemia induce a state of hypoglycemia unawareness and defective counterregulation, which defines the syndrome of hypoglycemia-associated autonomic failure (HAAF). The reduced awareness of, and counterregulatory responses to, hypoglycemia in patients with HAAF lead to worsening episodes of severe hypoglycemia. Approaches to the prevention of hypoglycemia include glucose monitoring, patient education, meal planning, and medication adjustment. In patients with HAAF, scrupulous avoidance of iatrogenic hypoglycemia may restore the symptomatic and counterregulatory responses to hypoglycemia. Behavioral training focusing on recognition of the more subtle symptoms and signs of evolving hypoglycemia may be beneficial to some patients with HAAF. A methodical search for the pattern and etiology of iatrogenic hypoglycemia is a prerequisite for the identification of the best preventive approach. With proper education, patients with type 1 diabetes and their physicians can learn to prevent or minimize the risk of hypoglycemia while pursuing excellence in glycemic control.

Role of corticotrophin-releasing hormone in the impairment of counterregulatory responses to hypoglycemia

We have explored the role of individual elements of the hypothalamic pituitary adrenal axis on the pathogenesis of hypoglycemia-associated autonomic failure. Five groups of male Sprague-Dawley rats were used. Control animals had 3 days of sham treatment followed by a hyperinsulinemic/hypoglycemic glucose clamp on day 4. A second group underwent 3 days of antecedent insulin-induced hypoglycemia then a subsequent clamp. Three more groups underwent pretreatment with corticosterone, adrenocorticotrophic hormone (ACTH), or corticotrophin-releasing hormone (CRH) mirroring the glucocorticoid response of the hypoglycemic group. Subsequent counterregulatory responses showed marked differences. CRH- (and insulin-treated) animals showed markedly reduced epinephrine responses (CRH 1,276 +/- 404 pg/ml, controls 3,559 +/- 563 pg/ml; P < 0.05). In contrast, ACTH pretreatment augmented epinephrine responses (6,681 +/- 814 pg/ml; P = 0.007 versus controls); corticosterone pretreatment caused a similar but nonsignificant enhancement. The same pattern was seen for norepinephrine. CRH pretreatment also suppressed glucagon responses to hypoglycemia (control 157 +/- 21, CRH 68 +/- 10 pg/ml; P = 0.004). The addition of a CRH receptor 1 (CRHr1) antagonist to the antecedent CRH reversed the subsequent suppression of epinephrine. These findings suggest that CRH acting via CRHr1 plays an important role in the sympathoadrenal downregulation seen in this rodent model of antecedent hypoglycemia; this action is not mediated via activation of the hypothalamic-pituitary-adrenal axis.

Residual insulin secretion is not coupled to a maintained glucagon response to hypoglycaemia in long-term type 1 diabetes

OBJECTIVES

To evaluate the influence of residual beta-cell function on glucagon secretion and glucose counter-regulation following hypoglycaemia in type 1 diabetes.

DESIGN AND SUBJECTS

The hormonal counter-regulatory responses to standardized insulin-induced hypoglycaemia were investigated, 18 patients with type 1 diabetes of long duration and 12 healthy subjects were investigated. Nine of the diabetic patients (diabetes duration 17 +/- 1 years) had residual insulin secretion, as reflected by persistent urinary C-peptide excretion. The other nine diabetic patients (diabetes duration 21 +/- 1 years) were C-peptide negative.

RESULTS

Similar hypoglycaemic nadirs were found in all groups (2.1-2.3 mmol L-1), whereas the recovery of plasma glucose levels was delayed similarly in the diabetic groups. In the control subjects, plasma glucagon increased ( approximately 50%). No significant glucagon response was registered in either of the two diabetic groups. The maximum plasma adrenaline and pancreatic polypeptides (PP) responses to hypoglycaemia were comparable in the two diabetic patient groups; the peak values being lower (P < 0.05) than in the controls. Plasma noradrenaline, growth hormone and cortisol responses to hypoglycaemia were similar in all three groups.

CONCLUSION

Residual beta-cell function in patients with long-term type 1 diabetes is not accompanied by preservation of the glucagon response to hypoglycaemia. As the two markers of autonomic function (adrenaline and PP) were similarly reduced in the two diabetic groups, the findings instead favour the concept that the defective glucagon secretory response to hypoglycaemia is because of autonomic nervous dysfunction.

Complications of pediatric and adolescent type 1 diabetes mellitus

Type 1 diabetes mellitus is potentially associated with serious microvascular and macrovascular complications, although these are usually subclinical during the pediatric and adolescent years. There is no "grace" period for the beginnings of such complications. Duration of diabetes, glycemic control, age, and pubertal stage are critical factors contributing toward development of such problems. Other risk factors include family history (genetic predisposition), hyperlipidemia, hypertension, and smoking. The Diabetes Control and Complications Trial (DCCT) proved the importance of glycemic control and emphasized the ability of improved glucose control to prevent or decrease retinopathy, nephropathy, and neuropathy using a multidisciplinary same-philosophy-of-care approach plus targeted glucose and hemoglobin A(1c) values. Other natural history and intervention studies support the findings of the DCCT. Although our current tools are not perfect, they allow us to decrease microangiopathic complications very significantly if we educate our patients and their family members. Metabolic control counts.

Glucoregulation and hormonal changes during prolonged exercise in boys and girls

A group of 17 children, 8.5-11 years old, performed a 60-min cycle exercise at 60% of maximal oxygen uptake (VO2max) 2 h after a standardized breakfast. They were 10 young boys (pubertal stage = 1) and 7 young girls (pubertal stage < or = 2) of similar VO2max (respective values were 48.5 ml min-1 kg-1, SEM 1.8; 42.1 ml min-1 kg-1, SEM 2.4). Blood samples of 5 ml were withdrawn by heparinized catheter, the subjects being in a supine position, 30 min before the test, then after 0, 15, 30 and 60 min of exercise and following 30 min recovery. Haematocrit was immediately measured. Thereafter plasma was analysed for glucose, non-esterified fatty acid, glycerol, catecholamine (noradrenaline, adrenaline), insulin and glucagon concentrations. This study showed two main results. First, the onset of exercise induced a significant glucose decrease (of about 11.4%) in all the children. Secondly, both the glycaemic and the hormonal responses were obviously different according to the sex. In boys only, the initial glucose drop was significantly correlated to the pre-exercise insulin values. Whatever the time, the glycaemic levels and the catecholamine responses were lower in girls than in boys, whereas the insulin values remained higher. However, none of these two hormonal parameters seemed to be really responsible for the lower glucose values in girls. On the one hand, the great individual variability of noradrenaline and adrenaline and differences in their relative intensity at the end of the exercise between boys and girls might contribute to the lower catecholamine levels in girls.(ABSTRACT TRUNCATED AT 250 WORDS)

Impaired hormonal responses to hypoglycemia in spontaneously diabetic and recurrently hypoglycemic rats. Reversibility and stimulus specificity of the deficits

To evaluate the roles of iatrogenic hypoglycemia and diabetes per se in the pathogenesis of defective hormonal counterregulation against hypoglycemia in insulin-dependent diabetes mellitus (IDDM), nondiabetic, and spontaneously diabetic BB/Wor rats were studied using a euglycemic/hypoglycemic clamp. In nondiabetic rats, recurrent (4 wk) insulin-induced hypoglycemia (mean daily glucose, MDG, 59 mg/dl) dramatically reduced glucagon and epinephrine responses by 84 and 94%, respectively, to a standardized glucose fall from 110 to 50 mg/dl. These deficits persisted for > 4 d after restoring normoglycemia, and were specific for hypoglycemia, with normal glucagon and epinephrine responses to arginine and hypovolemia, respectively. After 4 wk of normoglycemia, hormonal counterregulation increased, with the epinephrine, but not the glucagon response reaching control values. In diabetic BB rats (MDG 245 mg/dl with intermittent hypoglycemia), glucagon and epinephrine counterregulation were reduced by 86 and 90%, respectively. Chronic iatrogenic hypoglycemia (MDG 52 mg/dl) further suppressed counterregulation. Prospective elimination of hypoglycemia (MDG 432 mg/dl) improved, but did not normalize hormonal counterregulation. In diabetic rats, the glucagon defect appeared to be specific for hypoglycemia, whereas deficient epinephrine secretion also occurred during hypovolemia. We concluded that both recurrent hypoglycemia and the diabetic state independently lead to defective hormonal counterregulation. These data suggest that in IDDM iatrogenic hypoglycemia magnifies preexisting counterregulatory defects, thereby increasing the risk of severe hypoglycemia.

Gender influences counterregulatory hormone responses to hypoglycemia

It has been generally assumed that counterregulatory hormone responses to hypoglycemia are not influenced by gender. To test this assumption, we analyzed three separate hypoglycemic insulin clamp studies in age-matched, healthy, non-obese females (n = 33) and males (n = 37). In one study (12 females, 17 males), plasma glucose level was rapidly decreased to about 57 mg/dL for 100 minutes with a 0.65-mU/kg/min insulin infusion. Despite an identical decrease in glucose level, the increase in epinephrine (361 +/- 64 v 188 +/- 38 pg/mL, P < .05), norepinephrine (132 +/- 28 v 47 +/- 19 pg/mL, P < .01), and growth hormone ([GH] 16.0 +/- 3.8 v 4.9 +/- 1.9 ng/mL, P < .05) levels, but not glucagon or cortisol levels, were significantly greater in males than in females, respectively. In the second study (10 females, eight males), a 5.0-mU/kg/min insulin infusion was used to decrease glucose levels to 55 mg/dL for 180 minutes. Epinephrine (P < .05) and GH (P < .01) responses were greater in males than in females. In a third study (11 females, 12 males), plasma glucose level was gradually decreased to about 50 mg/dL over 240 minutes. Again epinephrine (P < .01), norepinephrine (P < .01), GH (P < .05), and cortisol (P < .01) responses were nearly twofold greater in males (P < .01). Multivariate analysis of all 70 subjects identified gender as the most significant factor contributing to the epinephrine (P < .001) and norepinephrine (P < .005) responses, and also as a significant contributor to the GH response (P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Diethylnitrosamine-induced increase in γ-glutamyltranspeptidase in rat liver: Its association with thyroid hormone deficiency and its reversal by tri-iodothyronine

1. The nodular phase of hepatic premalignancy was induced in male Fischer 344 rats by the administration of diethylnitrosamine, 200 mg/kg i.p., followed by promotion utilizing the Solt-Farber promoting regime. 2. Relative to the situation in normal non-treated control rats: the activity of gamma-glutamyltranspeptidase was found to be increased 9.42-fold in homogenate and 7.33-fold in plasma membrane fractions prepared from the livers of saline-injected control rats; and 81.37-fold in homogenates and 91.92-fold in plasma membranes prepared from the livers of diethylnitrosamine-injected rats; plasma levels of total T3 and total T4 were found to be decreased 42.06 and 47.45% in saline-injected control rats and 88.7 and 83.2% in diethylnitrosamine-injected rats, respectively. 3. An early pre-nodular phase of hepatic premalignancy was produced in young immature and mature adult male Fischer 344 rats by the administration of diethylnitrosamine, 75 mg/kg, without subsequent application of the promotion regime. 4. Relative to the situation in control rats: the activity of gamma-glutamyltranspeptidase was found to be increased in liver homogenates prepared from diethylnitrosamine-treated rats, 1.62-fold in young immature rats 1.20-fold in mature adult rats; plasma levels of total T3 were found to be reduced in diethylnitrosamine-treated rats, 28% in young immature rats 9% in mature adult rats. 5. Treatment of diethylnitrosamine-injected young immature male Fischer 344 rats at the prenodular phase of hepatic premalignancy with tri-iodothyronine at 0.005 micrograms/kg s.c. daily for 7 days reversed the diethylnitrosamine-induced increase in liver homogenate gamma-glutamyltranspeptidase activity and the decrease in plasma total T3, restoring these parameters to normal levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Amylin and insulin co-replacement therapy for insulin-dependent (type I) diabetes mellitus

Amylin is a proteinaceous hormone secreted form insulin-producing pancreatic beta-cells following stimulation by food molecules such as glucose and arginine. Amylin decreases insulin-stimulated glucose uptake in skeletal muscle and counteracts the ability of insulin to suppress output of glucose from the liver. Substantial evidence supports the view that maylin is a second glucoregulatory hormone produced from islet beta-cells, which can modulate a number of metabolic processes also regulated by insulin. The islet beta-cell may therefore transmit a dual message to peripheral tissues through the two hormones, insulin and amylin. Like insulin, amylin is deficient in individuals with autoimmune diabetes mellitus. Since amylin can modulate processes of fuel metabolism in key tissues, amylin deficiency could contribute to the clinical course in patients with autoimmune diabetes. Here, I propose that amylin lack plays a significant role to promote the tendency to hypoglycemia and defective glycemic control characteristic of insulin-treated patients with autoimmune diabetes. Treatment of such diabetics with injections of amylin as well as insulin is being evaluated with the aim of lessening the incidence and severity of hypoglycemia and improving glycemic control.

Decreased hepatic glucagon responses in type 1 (insulin-dependent) diabetes mellitus

The effect of glucagon infusion on hepatic glucose production during euglycaemia was evaluated in seven Type 1 (insulin-dependent) diabetic patients and in ten control subjects. In the diabetic subjects normoglycaemia was maintained during the night preceding the study by a variable intravenous insulin and glucose infusion. During the study endogenous insulin secretion was suppressed by somatostatin (450 micrograms/h) and replaced by insulin infusion (0.15 mU.kg-1.min-1). 3H-glucose was infused for isotopic determination of glucose turnover. Plasma glucose was clamped at 5 mmol/l for 2 h 30 min and glucagon (1.5 ng.kg-1.min-1) was then infused for the following 3 h. Hepatic glucose production and glucose utilisation were measured during the first, second and third hour of the glucagon infusion. Basal hepatic glucose production (just prior to glucagon infusion) was similar in diabetic (1.2 +/- 0.3 mg.kg-1.min-1) and control (1.6 +/- 0.1 mg.kg-1.min-1) subjects. In diabetic patients hepatic glucose production rose slowly to 2.1 +/- 0.5 mg.kg-1.min-1 during the first hours of glucagon infusion and stabilized at this level (2.4 +/- 0.5 mg.kg-1.min-1) in the third hour. In control subjects hepatic glucose production increased sharply to higher levels than in the diabetic subjects (3.4 +/- 0.3 mg.kg-1.min-1) during the first and second hour of glucagon infusion (p less than 0.05) and then gradually fell (2.9 +/- 0.4 mg.kg-1.min-1) during the third hour. In conclusion, when stimulated with glucagon at a physiologic plasma concentration diabetic patients had 1) an overall reduced hepatic glucose production response and 2) an abnormal sluggish response pattern.(ABSTRACT TRUNCATED AT 250 WORDS)

Glycaemic thresholds for hypoglycaemic symptoms, impairment of cognitive function, and release of counterregulatory hormones in subjects with functional hypoglycaemia

Nine patients with food-relieved hypoglycaemic symptoms, in whom insulinoma and other organic diseases presenting with hypoglycaemia had been ruled out, and nine matched controls, participated in the study. Subjects were studied during a 5-h controlled (Biostator) insulin-induced (1-2 mU kg-1 min-1) hypoglycaemic clamp. After 1 h of euglycaemia, we aimed to lower the glucose level in arterialized venous blood in a stepwise manner at 30-min intervals to 3.5, 3.0, and 2.0 mmol l-1, and to withhold these levels for a further 30 min. At euglycaemia and at the end of the latter steps, the visual reaction time and cognitive function (digit span, letter cancellation and trail making) were tested, together with recording symptoms and signs of hypoglycaemia. Counter-regulatory hormones were measured at 20-min intervals. In the patients, clinical signs and symptoms of hypoglycaemia developed at median blood glucose levels of 2.6-2.8 and 2.8-3.1 mmol l-1, respectively. By contrast, the blood glucose levels were 0.4-0.8 mmol l-1 lower in control subjects (P less than 0.05). Similarly, the median threshold for deterioration of visual reaction time was 2.8 mmol l-1 in patients and 2.1 mmol l-1 in controls (P less than 0.01). A similar trend was observed for the results of the neuropsychological tests. Visual reaction time deteriorated in all subjects, whereas the cognitive function of some of the subjects in each group remained unchanged during hypoglycaemia. The glycaemic thresholds for release of cortisol, glucagon and growth hormone were significantly higher in patients (P less than 0.05), whereas the thresholds for catecholamine release showed no significant difference from controls. Despite the comparable glucose infusion rates required to sustain each of the hypoglycaemic levels in the two groups, the control subjects achieved lower glucose levels, suggesting that there is resistance to insulin or glucose in functional hypoglycaemia. In conclusion, the present study suggests that the existence of a higher threshold for symptoms and signs, as well as for deterioration of brain function, may explain every-day hypoglycaemic symptoms, despite normal glucose levels, in subjects with functional hypoglycaemia. However, the hypothesis should be tested further using a blinded approach, including euglycaemic control studies.

Search for the hypoglycemia receptor using the local irrigation approach

To elucidate the loci for the putative glucoreceptors responding to hypoglycemia we introduced 'brain' and 'liver' clamps. Systemic hypoglycemia was induced by insulin infusion while the area of interest (ie. forebrain, hindbrain, portal-hepatic region) was maintained euglycemic via local glucose irrigation. Utilizing this approach, there appear to be no glucoreceptors residing exclusively in either the forebrain or hindbrain which are essential for the sympathoadrenal response to hypoglycemia. This is true for both moderate and severe hypoglycemic conditions. The possibility of a redundant glucoreceptor system within the brain, as suggested by a subsequent study, remains to be confirmed. The portal-hepatic glucoreceptors appear essential to engendering the full counterregulatory response. Establishing euglycemia across the portal-hepatic region inhibits the sympathoadrenal response to moderate hypoglycemia by over 40%. Further, despite prevailing hypoglycemia and significant elevations in counter-regulatory hormones, the liver demonstrated net glucose extraction during the liver clamp, suggestive of overriding neural input to the liver. Thus, the hepatic afferents appear to be very important for the counterregulatory response to hypoglycemia.

Modifications of rat liver glucocorticoid receptor by insulin-induced hypoglycemia

Stability-, equilibrium- and kinetic binding parameters, transformation rate and sedimentation properties of liver cytosol glucocorticoid receptor from insulin-treated rats were studied. 40% elevation of cytosolic glucocorticoid binding and a lower affinity of the receptor for ligand were observed in hypoglycemic rats as compared to the controls. A small but significant decrease of [3H]triamcinolone acetonide-receptor complexes association rate and an increase of dissociation rate were also found. The rate and the extent of activation of the complexes from insulin-treated rats were somewhat higher compared to the controls, and the complexes from both groups showed higher affinity for the nuclei isolated from insulin-treated animals. Mixing experiments suggested that insulin treatment lead to alterations at the level of both the receptor protein and the nuclear binding sites. Sedimentation properties of transformed and untransformed receptor remained unchanged upon insulin treatment. The physiological relevance of the data was confirmed by hypoglycemia-related stimulation of tyrosine aminotransferase induction by dexamethasone.

Hypoglycemia in diabetes among children and adolescents

Hypoglycemia is one of the most common early complications in insulin-dependent diabetes mellitus (IDDM). Hypoglycemia in children may be considered a risk factor for brain damage and later intellectual impairment, and carries with it a high degree of child and parental anxiety. Recent studies have shown that in IDDM patients, and especially in those on intensive therapy, there is a defect in glucose counter-regulation, increased frequency of hypoglycemic episodes, loss of hypoglycemic awareness and responsiveness. Autonomic neuropathy, glucagon deficiency and low catecholamine response were implied in the pathogenesis of these disorders. In addition, uncontrolled IDDM patients show hypoglycemic symptoms at a higher blood glucose level. These recent observations may suggest that attempts to improve metabolic control may increase the risk of severe hypoglycemia. If so, some alterations in our therapeutic goals must be considered.