1
|
Petersen MC, Shulman GI. Mechanisms of Insulin Action and Insulin Resistance. Physiol Rev 2018; 98:2133-2223. [PMID: 30067154 PMCID: PMC6170977 DOI: 10.1152/physrev.00063.2017] [Citation(s) in RCA: 1382] [Impact Index Per Article: 230.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 03/22/2018] [Accepted: 03/24/2018] [Indexed: 12/15/2022] Open
Abstract
The 1921 discovery of insulin was a Big Bang from which a vast and expanding universe of research into insulin action and resistance has issued. In the intervening century, some discoveries have matured, coalescing into solid and fertile ground for clinical application; others remain incompletely investigated and scientifically controversial. Here, we attempt to synthesize this work to guide further mechanistic investigation and to inform the development of novel therapies for type 2 diabetes (T2D). The rational development of such therapies necessitates detailed knowledge of one of the key pathophysiological processes involved in T2D: insulin resistance. Understanding insulin resistance, in turn, requires knowledge of normal insulin action. In this review, both the physiology of insulin action and the pathophysiology of insulin resistance are described, focusing on three key insulin target tissues: skeletal muscle, liver, and white adipose tissue. We aim to develop an integrated physiological perspective, placing the intricate signaling effectors that carry out the cell-autonomous response to insulin in the context of the tissue-specific functions that generate the coordinated organismal response. First, in section II, the effectors and effects of direct, cell-autonomous insulin action in muscle, liver, and white adipose tissue are reviewed, beginning at the insulin receptor and working downstream. Section III considers the critical and underappreciated role of tissue crosstalk in whole body insulin action, especially the essential interaction between adipose lipolysis and hepatic gluconeogenesis. The pathophysiology of insulin resistance is then described in section IV. Special attention is given to which signaling pathways and functions become insulin resistant in the setting of chronic overnutrition, and an alternative explanation for the phenomenon of ‟selective hepatic insulin resistanceˮ is presented. Sections V, VI, and VII critically examine the evidence for and against several putative mediators of insulin resistance. Section V reviews work linking the bioactive lipids diacylglycerol, ceramide, and acylcarnitine to insulin resistance; section VI considers the impact of nutrient stresses in the endoplasmic reticulum and mitochondria on insulin resistance; and section VII discusses non-cell autonomous factors proposed to induce insulin resistance, including inflammatory mediators, branched-chain amino acids, adipokines, and hepatokines. Finally, in section VIII, we propose an integrated model of insulin resistance that links these mediators to final common pathways of metabolite-driven gluconeogenesis and ectopic lipid accumulation.
Collapse
Affiliation(s)
- Max C Petersen
- Departments of Internal Medicine and Cellular & Molecular Physiology, Howard Hughes Medical Institute, Yale University School of Medicine , New Haven, Connecticut
| | - Gerald I Shulman
- Departments of Internal Medicine and Cellular & Molecular Physiology, Howard Hughes Medical Institute, Yale University School of Medicine , New Haven, Connecticut
| |
Collapse
|
2
|
Preller A, Wilson CAM, Quiroga-Roger D, Ureta T. Hexokinase and not glycogen synthase controls the flux through the glycogen synthesis pathway in frog oocytes. FEBS Lett 2013; 587:2825-31. [PMID: 23831065 DOI: 10.1016/j.febslet.2013.06.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 06/20/2013] [Accepted: 06/21/2013] [Indexed: 10/26/2022]
Abstract
Here we set out to evaluate the role of hexokinase and glycogen synthase in the control of glycogen synthesis in vivo. We used metabolic control analysis (MCA) to determine the flux control coefficient for each of the enzymes involved in the pathway. Acute microinjection experiments in frog oocytes were specifically designed to change the endogenous activities of the enzymes, either by directly injecting increasing amounts of a given enzyme (HK, PGM and UGPase) or by microinjection of a positive allosteric effector (glc-6P for GS). Values of 0.61 ± 0.07, 0.19 ± 0.03, 0.13 ± 0.03, and -0.06 ± 0.08 were obtained for the flux control coefficients of hexokinase EC 2.7.1.1 (HK), phosphoglucomutase EC 5.4.2.1 (PGM), UDPglucose pyrophosphorylase EC 2.7.7.9 (UGPase) and glycogen synthase EC 2.4.1.11 (GS), respectively. These values satisfy the summation theorem since the sum of the control coefficients for all the enzymes of the pathway is 0.87. The results show that, in frog oocytes, glycogen synthesis through the direct pathway is under the control of hexokinase. Phosphoglucomutase and UDPG-pyrophosphorylase have a modest influence, while the control exerted by glycogen synthase is null.
Collapse
Affiliation(s)
- Ana Preller
- Department of Biology, Faculty of Sciences, University of Chile, Las Palmeras 3425, Ñuñoa, Santiago, Chile.
| | | | | | | |
Collapse
|
3
|
Friedrichsen M, Birk JB, Richter EA, Ribel-Madsen R, Pehmøller C, Hansen BF, Beck-Nielsen H, Hirshman MF, Goodyear LJ, Vaag A, Poulsen P, Wojtaszewski JFP. Akt2 influences glycogen synthase activity in human skeletal muscle through regulation of NH₂-terminal (sites 2 + 2a) phosphorylation. Am J Physiol Endocrinol Metab 2013; 304:E631-9. [PMID: 23321478 PMCID: PMC3774094 DOI: 10.1152/ajpendo.00494.2012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Type 2 diabetes is characterized by reduced muscle glycogen synthesis. The key enzyme in this process, glycogen synthase (GS), is activated via proximal insulin signaling, but the exact molecular events remain unknown. Previously, we demonstrated that phosphorylation of Thr³⁰⁸ on Akt (p-Akt-Thr³⁰⁸), Akt2 activity, and GS activity in muscle were positively associated with insulin sensitivity. Here, in the same study population, we determined the influence of several upstream elements in the canonical PI3K signaling on muscle GS activation. One-hundred eighty-one nondiabetic twins were examined with the euglycemic hyperinsulinemic clamp combined with excision of muscle biopsies. Insulin signaling was evaluated at the levels of the insulin receptor, IRS-1-associated PI3K (IRS-1-PI3K), Akt, and GS employing activity assays and phosphospecific Western blotting. The insulin-stimulated GS activity was positively associated with p-Akt-Thr³⁰⁸ (P = 0.01) and Akt2 activity (P = 0.04) but not p-Akt-Ser⁴⁷³ or IRS-1-PI3K activity. Furthermore, p-Akt-Thr³⁰⁸ and Akt2 activity were negatively associated with NH₂-terminal GS phosphorylation (P = 0.001 for both), which in turn was negatively associated with insulin-stimulated GS activity (P < 0.001). We found no association between COOH-terminal GS phosphorylation and Akt or GS activity. Employing whole body Akt2-knockout mice, we validated the necessity for Akt2 in insulin-mediated GS activation. However, since insulin did not affect NH₂-terminal phosphorylation in mice, we could not use this model to validate the observed association between GS NH₂-terminal phosphorylation and Akt activity in humans. In conclusion, our study suggests that although COOH-terminal dephosphorylation is likely necessary for GS activation, Akt2-dependent NH₂-terminal dephosphorylation may be the site for "fine-tuning" insulin-mediated GS activation in humans.
Collapse
|
4
|
Abstract
Glycogen is a branched polymer of glucose that acts as a store of energy in times of nutritional sufficiency for utilization in times of need. Its metabolism has been the subject of extensive investigation and much is known about its regulation by hormones such as insulin, glucagon and adrenaline (epinephrine). There has been debate over the relative importance of allosteric compared with covalent control of the key biosynthetic enzyme, glycogen synthase, as well as the relative importance of glucose entry into cells compared with glycogen synthase regulation in determining glycogen accumulation. Significant new developments in eukaryotic glycogen metabolism over the last decade or so include: (i) three-dimensional structures of the biosynthetic enzymes glycogenin and glycogen synthase, with associated implications for mechanism and control; (ii) analyses of several genetically engineered mice with altered glycogen metabolism that shed light on the mechanism of control; (iii) greater appreciation of the spatial aspects of glycogen metabolism, including more focus on the lysosomal degradation of glycogen; and (iv) glycogen phosphorylation and advances in the study of Lafora disease, which is emerging as a glycogen storage disease.
Collapse
|
5
|
Polakof S, Skiba-Cassy S, Panserat S. Glucose homeostasis is impaired by a paradoxical interaction between metformin and insulin in carnivorous rainbow trout. Am J Physiol Regul Integr Comp Physiol 2009; 297:R1769-76. [PMID: 19793955 DOI: 10.1152/ajpregu.00369.2009] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Utilizing rainbow trout (Oncorhynchus mykiss) as a known model of a "glucose-intolerant" and poor dietary glucose user, we assessed glucose utilization in fish chronically receiving two molecules able to improve glucose homeostasis: insulin and metformin. Our objectives were to assess the ability of rainbow trout to deal with a glucose load and to improve glucose utilization in fish receiving a chronic administration of insulin plus metformin treatments. Fish received (implanted miniosmotic pumps) saline, insulin, metformin, and insulin plus metformin solution for 4 days and then were subjected to a glucose challenge (intraperitoneal injection) to study glucose homeostasis, analyzing plasma glycemia, mRNA levels of glucose metabolism-related proteins, insulin signaling, and glycogen levels in liver and muscle. Control fish received a saline pump implantation and saline intraperitoneal injection. We found no evidence that the "glucose intolerance" in this species could be linked to any of the molecular markers of metabolism in the tissues analyzed. By contrast, very interestingly, we show for the first time, that metformin is not only unable to improve glucose homeostasis in trout, but, in fact, its counteracts the effects of insulin, creating an "insulin resistance," especially in the muscle. These results make trout an attractive original model to study both insulin and metformin effect on biological systems.
Collapse
Affiliation(s)
- S Polakof
- Institut National de la Recherche Agronomique, UMR 1067 Nutrition Aquaculture et Génomique, Saint-Pée-sur-Nivelle, France.
| | | | | |
Collapse
|
6
|
Raja G, Bräu L, Palmer TN, Fournier PA. Fiber-specific responses of muscle glycogen repletion in fasted rats physically active during recovery from high-intensity physical exertion. Am J Physiol Regul Integr Comp Physiol 2008; 295:R633-41. [PMID: 18525011 DOI: 10.1152/ajpregu.00874.2007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Mild physical activity performed immediately after a bout of intense exercise in fasting humans results in net glycogen breakdown in their slow oxidative (SO) muscle fibers and glycogen repletion in their fast twitch (FT) fibers. Because several animal species carry a low proportion of SO fibers, it is unclear whether they can also replenish glycogen in their FT fibers under these conditions. Given that most skeletal muscles in rats are poor in SO fibers (<5%), this issue was examined using groups of 24-h fasted Wistar rats (n=10) that swam for 3 min at high intensity with a 10% weight followed by either a 60-min rest (passive recovery, PR) or a 30-min swim with a 0.5% weight (active recovery, AR) preceding a 30-min rest. The 3-min sprint caused 61-79% glycogen fall across the muscles examined, but not in the soleus (SOL). Glycogen repletion during AR without food was similar to PR in the white gastrocnemius (WG), where glycogen increased by 71%, and less than PR in both the red and mixed gastrocnemius (RG, MG). Glycogen fell by 26% during AR in the SOL. Following AR, glycogen increased by 36%, 87%, and 37% in the SOL, RG, and MG, respectively, and this was accompanied by the sustained activation of glycogen synthase and inhibition of glycogen phosphorylase in the RG and MG. These results suggest that mammals with a low proportion of SO fibers can also replenish the glycogen stores of their FT fibers under extreme conditions combining physical activity and fasting.
Collapse
Affiliation(s)
- G Raja
- School of Exercise Science, The University of Western Australia, Crawley, Western Australia, Australia, 6009
| | | | | | | |
Collapse
|
7
|
Abstract
The field of metabolic engineering encompasses a powerful set of tools that can be divided into (a) methods to model complex metabolic pathways and (b) techniques to manipulate these pathways for a desired metabolic outcome. These tools have recently seen increased utility in the medical arena, and this paper aims to review significant accomplishments made using these approaches. The modeling of metabolic pathways has been applied to better understand disease-state physiology in a variety of cellar, subcellular, and organ systems, including the liver, heart, mitochondria, and cancerous cells. Metabolic pathway engineering has been used to generate cells with novel biochemical functions for therapeutic use, and specific examples are provided in the areas of glycosylation engineering and dopamine-replacement therapy. In order to document the potential of applying both metabolic modeling and pathway manipulation, we describe pertinent advances in the field of diabetes research. Undoubtedly, as the field of metabolic engineering matures and is applied to a wider array of problems, new advances and therapeutic strategies will follow.
Collapse
Affiliation(s)
- Martin L Yarmush
- Center for Engineering in Medicine/Surgical Services, Massachusetts General Hospital, Shriners Burns Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA.
| | | |
Collapse
|
8
|
Chatham JC, Blackband SJ. Nuclear magnetic resonance spectroscopy and imaging in animal research. ILAR J 2001; 42:189-208. [PMID: 11406719 DOI: 10.1093/ilar.42.3.189] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Nuclear magnetic resonance (NMR) spectroscopy and imaging can be used to investigate, noninvasively, a wide range of biological processes in systems as diverse as protein solutions, single cells, isolated perfused organs, and tissues in vivo. It is also possible to combine different NMR techniques enabling metabolic, anatomical, and physiological information to be obtained in the same experiment. This review provides a simple overview of the basic principles of NMR and outlines both the advantages and disadvantages of NMR spectroscopy and imaging. A few examples of potential applications of NMR spectroscopy and imaging are presented, which demonstrate the range of questions that can be asked using these techniques. The potential impact of using NMR techniques in a biomedical research program on the total number of animals required for specific investigations, as well as the number of animals used in research, are discussed. The article concludes with a personal perspective on the impact of continuing improvements in NMR technology for future applications in animal research.
Collapse
Affiliation(s)
- J C Chatham
- Center for NMR Research and Development, Department of Medicine, University of Alabama, Birmingham, Alabama, USA
| | | |
Collapse
|
9
|
Chase JR, Rothman DL, Shulman RG. Flux control in the rat gastrocnemius glycogen synthesis pathway by in vivo 13C/31P NMR spectroscopy. Am J Physiol Endocrinol Metab 2001; 280:E598-607. [PMID: 11254467 DOI: 10.1152/ajpendo.2001.280.4.e598] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
To determine the relative contributions of glucose transport/hexokinase, glycogen synthase (GSase), and glycolysis to the control of insulin-stimulated muscle glycogen synthesis, we combined 13C and 31P NMR to quantitate the glycogen synthesis rate and glucose 6-phosphate (G-6-P) levels in rat (Sprague-Dawley) gastrocnemius muscle during hyperinsulinemia at euglycemic (E) and hyperglycemic (H) glucose concentrations under thiopental anesthesia. Flux control was calculated using metabolic control analysis. The combined control coefficient of glucose transport/hexokinase (GT/Hk) for glycogen synthesis was 1.1 +/- 0.03 (direct measure) and 1.14-1.16 (calculated for a range of glycolytic fluxes), whereas the control coefficient for GSase was much lower (0.011-0.448). We also observed that the increase in in vivo [G-6-P] from E to H (0.22 +/- 0.03 to 0.40 +/- 0.03 mM) effects a supralinear increase in the in vitro velocity of GSase, from 14.6 to 26.1 mU. kg(-1). min(-1) (1.8-fold). All measurements suggest that the majority of the flux control of muscle glycogen synthesis is at the GT/Hk step.
Collapse
Affiliation(s)
- J R Chase
- Department of Molecular Biophysics and Biochemistry, Yale University School of Medicine, New Haven, CT 06510, USA
| | | | | |
Collapse
|
10
|
Ortmeyer HK. In vivo insulin regulation of skeletal muscle glycogen synthase in calorie-restricted and in ad libitum-fed rhesus monkeys. J Nutr 2001; 131:907S-912S. [PMID: 11238784 DOI: 10.1093/jn/131.3.907s] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Chronic calorie restriction in primates has been shown to have profound and unexpected effects on basal and on in vivo insulin action on skeletal muscle glycogen synthase (GS) activity. The decreased ability of insulin to activate skeletal muscle GS is a hallmark of insulin resistance and type 2 diabetes. The mechanism and role of in vivo insulin regulation of skeletal muscle GS are not fully understood. Two pathways for the activation of GS by insulin have been described by Larner and others: 1) insulin activates glucose transport that results in an increase in glucose-6-phosphate (G6P), thereby activating protein phosphatase-1, which in turn dephosphorylates and activates GS, therefore, pushing substrate into glycogen; and 2) insulin activates GS (perhaps by forming low-molecular-weight mediators which may activate protein phosphatase-1 and 2C) and activated GS subsequently pulls intermediates (e.g., G6P and uridine 5'-diphosphoglucose) into glycogen. To determine whether in vivo insulin regulates glycogen synthesis primarily via a push or pull mechanism and how this mechanism might be affected by long-term calorie restriction, skeletal muscle samples were obtained before and during a euglycemic hyperinsulinemic clamp from 41 rhesus monkeys. The monkeys varied widely in their degree of insulin sensitivity and age and included chronically calorie-restricted (CR) monkeys and ad libitum-fed monkeys. The ad libitum-fed monkeys included spontaneously type 2 diabetic, prediabetic and clinically normal animals. The apparent affinity of GS for the allosteric activator G6P (G6P Ka of GS) was measured and compared with G6P content in the muscle samples. Basal G6P Ka of GS was lower in the CR monkeys compared with the 3 ad libitum-fed groups (P: < or = 0.05). Only the normal ad libitum-fed monkeys had a decrease in the G6P Ka of GS with insulin (P: < 0.005). The insulin effect (insulin-stimulated minus basal) on the G6P Ka of GS was strongly positively related to the insulin effect on G6P content (r = 0.80, P: < 0.0001) across the entire group of monkeys. This finding supports the hypothesis that activation/dephosphorylation of GS by insulin is related to a decrease in G6P content and that paradoxical inactivation/phosphorylation of GS by insulin is related to an increase in G6P content (as demonstrated in 4 of 6 CR monkeys). Therefore, during a euglycemic hyperinsulinemic clamp, insulin regulates skeletal muscle glycogen synthesis primarily via a pull mechanism in both CR and in ad libitum-fed rhesus monkeys.
Collapse
Affiliation(s)
- H K Ortmeyer
- University of Maryland, Obesity and Diabetes Research Center, Department of Physiology, School of Medicine, Baltimore, MD 21201, USA.
| |
Collapse
|
11
|
Steinberg GR, Dyck DJ. Development of leptin resistance in rat soleus muscle in response to high-fat diets. Am J Physiol Endocrinol Metab 2000; 279:E1374-82. [PMID: 11093926 DOI: 10.1152/ajpendo.2000.279.6.e1374] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Direct evidence for leptin resistance in peripheral tissues such as skeletal muscle does not exist. Therefore, we investigated the effects of different high-fat diets on lipid metabolism in isolated rat soleus muscle and specifically explored whether leptin's stimulatory effects on muscle lipid metabolism would be reduced after exposure to high-fat diets. Control (Cont, 12% kcal fat) and high-fat [60% kcal safflower oil (n-6) (HF-Saff); 48% kcal safflower oil plus 12% fish oil (n-3)] diets were fed to rats for 4 wk. After the dietary treatments, muscle lipid turnover and oxidation in the presence and absence of leptin was measured using pulse-chase procedures in incubated resting soleus muscle. In the absence of leptin, phospholipid, diacylglycerol, and triacylglycerol (TG) turnover were unaffected by the high-fat diets, but exogenous palmitate oxidation was significantly increased in the HF-Saff group. In Cont rats, leptin increased exogenous palmitate oxidation (21.4 +/- 5.7 vs. 11.9 +/- 1.61 nmol/g, P = 0.019) and TG breakdown (39.8 +/- 5.6 vs. 27.0 +/- 5.2 nmol/g, P = 0.043) and decreased TG esterification (132.5 +/- 14.6 vs. 177.7 +/- 29.6 nmol/g, P = 0.043). However, in both high-fat groups, the stimulatory effect of leptin on muscle lipid oxidation and hydrolysis was eliminated. Partial substitution of fish oil resulted only in the restoration of leptin's inhibition of TG esterification. Thus we hypothesize that, during the development of obesity, skeletal muscle becomes resistant to the effects of leptin, resulting in the accumulation of intramuscular TG. This may be an important initiating step in the development of insulin resistance common in obesity.
Collapse
Affiliation(s)
- G R Steinberg
- Department of Human Biology and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada N1G 2W1
| | | |
Collapse
|
12
|
Azpiazu I, Manchester J, Skurat AV, Roach PJ, Lawrence JC. Control of glycogen synthesis is shared between glucose transport and glycogen synthase in skeletal muscle fibers. Am J Physiol Endocrinol Metab 2000; 278:E234-43. [PMID: 10662707 DOI: 10.1152/ajpendo.2000.278.2.e234] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The effects of transgenic overexpression of glycogen synthase in different types of fast-twitch muscle fibers were investigated in individual fibers from the anterior tibialis muscle. Glycogen synthase was severalfold higher in all transgenic fibers, although the extent of overexpression was twofold greater in type IIB fibers. Effects of the transgene on increasing glycogen and phosphorylase and on decreasing UDP-glucose were also more pronounced in type IIB fibers. However, in any grouping of fibers having equivalent malate dehydrogenase activity (an index of oxidative potential), glycogen was higher in the transgenic fibers. Thus increasing synthase is sufficient to enhance glycogen accumulation in all types of fast-twitch fibers. Effects on glucose transport and glycogen synthesis were investigated in experiments in which diaphragm, extensor digitorum longus (EDL), and soleus muscles were incubated in vitro. Transport was not increased by the transgene in any of the muscles. The transgene increased basal [(14)C]glucose into glycogen by 2.5-fold in the EDL, which is composed primarily of IIB fibers. The transgene also enhanced insulin-stimulated glycogen synthesis in the diaphragm and soleus muscles, which are composed of oxidative fiber types. We conclude that increasing glycogen synthase activity increases the rate of glycogen synthesis in both oxidative and glycolytic fibers, implying that the control of glycogen accumulation by insulin in skeletal muscle is distributed between the glucose transport and glycogen synthase steps.
Collapse
Affiliation(s)
- I Azpiazu
- Department of Molecular Biology and Pharmacology, Washington University School of Medicine, St. Louis, Missouri 63110, USA
| | | | | | | | | |
Collapse
|