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李 雨, 王 瑗, 袁 泉. [Latest Findings on the Role of α-Ketoglutarate in Metabolic Syndrome]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2024; 55:783-792. [PMID: 38948289 PMCID: PMC11211801 DOI: 10.12182/20240560302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Indexed: 07/02/2024]
Abstract
Alpha-ketoglutarate (α-KG), an endogenous intermediate of the tricarboxylic acid cycle, is involved in a variety of cellular metabolic pathways. It serves as an energy donor, a precursor of amino acid biosynthesis, and an epigenetic regulator. α-KG plays physiological functions in immune regulation, oxidative stress, and anti-aging as well. In recent years, it has been reported that the level of α-KG in the body is closely associated with metabolic syndrome, including obesity, hyperglycemia, and other pathological factors. Exogenous supplementation of α-KG improves obesity, blood glucose levels, and cardiovascular disease risks associated with metabolic syndrome. Furthermore, α-KG regulates the common pathological mechanisms of metabolic syndrome, suggesting the potential application prospect of α-KG in metabolic syndrome. In order to provide a theoretical basis for further exploration of the application of α-KG in metabolic syndrome, we focused on α-KG and metabolic syndrome in this article and summarized the latest research progress in the role of α-KG in improving the pathological condition and disease progression of metabolic syndrome. For the next step, researchers may focus on the co-pathogenesis of metabolic syndrome and investigate whether α-KG can be used to achieve the therapeutic goal of "homotherapy for heteropathy" in the treatment of metabolic syndrome.
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Affiliation(s)
- 雨含 李
- 口腔疾病防治全国重点实验室 国家口腔医学中心 国家口腔疾病临床医学研究中心 四川大学华西口腔医院 种植科 (成都 610041)State Key Laboratory of Oral Diseases, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Department of Dental Implant, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - 瑗 王
- 口腔疾病防治全国重点实验室 国家口腔医学中心 国家口腔疾病临床医学研究中心 四川大学华西口腔医院 种植科 (成都 610041)State Key Laboratory of Oral Diseases, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Department of Dental Implant, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - 泉 袁
- 口腔疾病防治全国重点实验室 国家口腔医学中心 国家口腔疾病临床医学研究中心 四川大学华西口腔医院 种植科 (成都 610041)State Key Laboratory of Oral Diseases, National Center for Stomatology, National Clinical Research Center for Oral Diseases, Department of Dental Implant, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
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Rahul R, Stinchcombe AR, Joseph JW, Ingalls B. Kinetic modelling of β-cell metabolism reveals control points in the insulin-regulating pyruvate cycling pathways. IET Syst Biol 2023; 17:303-315. [PMID: 37938890 PMCID: PMC10725709 DOI: 10.1049/syb2.12077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 11/10/2023] Open
Abstract
Insulin, a key hormone in the regulation of glucose homoeostasis, is secreted by pancreatic β-cells in response to elevated glucose levels. Insulin is released in a biphasic manner in response to glucose metabolism in β-cells. The first phase of insulin secretion is triggered by an increase in the ATP:ADP ratio; the second phase occurs in response to both a rise in ATP:ADP and other key metabolic signals, including a rise in the NADPH:NADP+ ratio. Experimental evidence indicates that pyruvate-cycling pathways play an important role in the elevation of the NADPH:NADP+ ratio in response to glucose. The authors developed a kinetic model for the tricarboxylic acid cycle and pyruvate cycling pathways. The authors successfully validated the model against experimental observations and performed a sensitivity analysis to identify key regulatory interactions in the system. The model predicts that the dicarboxylate carrier and the pyruvate transporter are the most important regulators of pyruvate cycling and NADPH production. In contrast, the analysis showed that variation in the pyruvate carboxylase flux was compensated by a response in the activity of mitochondrial isocitrate dehydrogenase (ICDm ) resulting in minimal effect on overall pyruvate cycling flux. The model predictions suggest starting points for further experimental investigation, as well as potential drug targets for the treatment of type 2 diabetes.
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Affiliation(s)
- Rahul Rahul
- Department of Applied MathematicsUniversity of WaterlooWaterlooOntarioCanada
| | | | - Jamie W. Joseph
- School of PharmacyUniversity of WaterlooWaterlooOntarioCanada
| | - Brian Ingalls
- Department of Applied MathematicsUniversity of WaterlooWaterlooOntarioCanada
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Hoang M, Jentz E, Janssen SM, Nasteska D, Cuozzo F, Hodson DJ, Tupling AR, Fong GH, Joseph JW. Isoform-specific Roles of Prolyl Hydroxylases in the Regulation of Pancreatic β-Cell Function. Endocrinology 2022; 163:6413706. [PMID: 34718519 PMCID: PMC8643417 DOI: 10.1210/endocr/bqab226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Indexed: 11/19/2022]
Abstract
Pancreatic β-cells can secrete insulin via 2 pathways characterized as KATP channel -dependent and -independent. The KATP channel-independent pathway is characterized by a rise in several potential metabolic signaling molecules, including the NADPH/NADP+ ratio and α-ketoglutarate (αKG). Prolyl hydroxylases (PHDs), which belong to the αKG-dependent dioxygenase superfamily, are known to regulate the stability of hypoxia-inducible factor α. In the current study, we assess the role of PHDs in vivo using the pharmacological inhibitor dimethyloxalylglycine (DMOG) and generated β-cell-specific knockout (KO) mice for all 3 isoforms of PHD (β-PHD1 KO, β-PHD2 KO, and β-PHD3 KO mice). DMOG inhibited in vivo insulin secretion in response to glucose challenge and inhibited the first phase of insulin secretion but enhanced the second phase of insulin secretion in isolated islets. None of the β-PHD KO mice showed any significant in vivo defects associated with glucose tolerance and insulin resistance except for β-PHD2 KO mice which had significantly increased plasma insulin during a glucose challenge. Islets from both β-PHD1 KO and β-PHD3 KO had elevated β-cell apoptosis and reduced β-cell mass. Isolated islets from β-PHD1 KO and β-PHD3 KO had impaired glucose-stimulated insulin secretion and glucose-stimulated increases in the ATP/ADP and NADPH/NADP+ ratio. All 3 PHD isoforms are expressed in β-cells, with PHD3 showing the most distinct expression pattern. The lack of each PHD protein did not significantly impair in vivo glucose homeostasis. However, β-PHD1 KO and β-PHD3 KO mice had defective β-cell mass and islet insulin secretion, suggesting that these mice may be predisposed to developing diabetes.
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Affiliation(s)
- Monica Hoang
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - Emelien Jentz
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - Sarah M Janssen
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
| | - Daniela Nasteska
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Federica Cuozzo
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - David J Hodson
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - A Russell Tupling
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Guo-Hua Fong
- Center for Vascular Biology, Department of Cell Biology, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - Jamie W Joseph
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
- Correspondence: Jamie W. Joseph, PhD, Health Science Campus Building A, Room 4008, University of Waterloo, 10A Victoria Street South, Kitchener, ON, Canada, N2G 1C5.
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Nasteska D, Cuozzo F, Viloria K, Johnson EM, Thakker A, Bany Bakar R, Westbrook RL, Barlow JP, Hoang M, Joseph JW, Lavery GG, Akerman I, Cantley J, Hodson L, Tennant DA, Hodson DJ. Prolyl-4-hydroxylase 3 maintains β cell glucose metabolism during fatty acid excess in mice. JCI Insight 2021; 6:e140288. [PMID: 34264866 PMCID: PMC8409982 DOI: 10.1172/jci.insight.140288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/14/2021] [Indexed: 02/06/2023] Open
Abstract
The α-ketoglutarate–dependent dioxygenase, prolyl-4-hydroxylase 3 (PHD3), is an HIF target that uses molecular oxygen to hydroxylate peptidyl prolyl residues. Although PHD3 has been reported to influence cancer cell metabolism and liver insulin sensitivity, relatively little is known about the effects of this highly conserved enzyme in insulin-secreting β cells in vivo. Here, we show that the deletion of PHD3 specifically in β cells (βPHD3KO) was associated with impaired glucose homeostasis in mice fed a high-fat diet. In the early stages of dietary fat excess, βPHD3KO islets energetically rewired, leading to defects in the management of pyruvate fate and a shift from glycolysis to increased fatty acid oxidation (FAO). However, under more prolonged metabolic stress, this switch to preferential FAO in βPHD3KO islets was associated with impaired glucose-stimulated ATP/ADP rises, Ca2+ fluxes, and insulin secretion. Thus, PHD3 might be a pivotal component of the β cell glucose metabolism machinery in mice by suppressing the use of fatty acids as a primary fuel source during the early phases of metabolic stress.
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Affiliation(s)
- Daniela Nasteska
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom.,Centre of Membrane Proteins and Receptors (COMPARE), University of Birmingham, Birmingham, United Kingdom
| | - Federica Cuozzo
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom.,Centre of Membrane Proteins and Receptors (COMPARE), University of Birmingham, Birmingham, United Kingdom
| | - Katrina Viloria
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom.,Centre of Membrane Proteins and Receptors (COMPARE), University of Birmingham, Birmingham, United Kingdom
| | - Elspeth M Johnson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom.,NIHR Oxford Biomedical Research Centre, Churchill Hospital, Oxford, United Kingdom
| | - Alpesh Thakker
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Rula Bany Bakar
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom
| | - Rebecca L Westbrook
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Jonathan P Barlow
- Mitochondrial Profiling Centre, School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Monica Hoang
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada
| | - Jamie W Joseph
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada
| | - Gareth G Lavery
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Ildem Akerman
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - James Cantley
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, United Kingdom.,Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Leanne Hodson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom.,NIHR Oxford Biomedical Research Centre, Churchill Hospital, Oxford, United Kingdom
| | - Daniel A Tennant
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - David J Hodson
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom.,Centre of Membrane Proteins and Receptors (COMPARE), University of Birmingham, Birmingham, United Kingdom
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Abstract
Hypoxia can be defined as a relative deficiency in the amount of oxygen reaching the tissues. Hypoxia-inducible factors (HIFs) are critical regulators of the mammalian response to hypoxia. In normal circumstances, HIF-1α protein turnover is rapid, and hyperglycemia further destabilizes the protein. In addition to their role in diabetes pathogenesis, HIFs are implicated in development of the microvascular and macrovascular complications of diabetes. Improving glucose control in people with diabetes increases HIF-1α protein and has wide-ranging benefits, some of which are at least partially mediated by HIF-1α. Nevertheless, most strategies to improve diabetes or its complications via regulation of HIF-1α have not currently proven to be clinically useful. The intersection of HIF biology with diabetes is a complex area in which many further questions remain, especially regarding the well-conducted studies clearly describing discrepant effects of different methods of increasing HIF-1α, even within the same tissues. This Review presents a brief overview of HIFs; discusses the range of evidence implicating HIFs in β cell dysfunction, diabetes pathogenesis, and diabetes complications; and examines the differing outcomes of HIF-targeting approaches in these conditions.
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Affiliation(s)
- Jenny E Gunton
- Centre for Diabetes, Obesity and Endocrinology, Westmead Institute for Medical Research, Westmead, New South Wales, Australia.,Westmead Hospital, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
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Abstract
Anaplerosis and the associated mitochondrial metabolite transporters generate unique cytosolic metabolic signaling molecules that can regulate insulin release from pancreatic β-cells. It has been shown that mitochondrial metabolites, transported by the citrate carrier (CIC), dicarboxylate carrier (DIC), oxoglutarate carrier (OGC), and mitochondrial pyruvate carrier (MPC) play a vital role in the regulation of glucose-stimulated insulin secretion (GSIS). Metabolomic studies on static and biphasic insulin secretion, suggests that several anaplerotic derived metabolites, including α-ketoglutarate (αKG), are strongly associated with nutrient regulated insulin secretion. Support for a role of αKG in the regulation of insulin secretion comes from studies looking at αKG dependent enzymes, including hypoxia-inducible factor-prolyl hydroxylases (PHDs) in clonal β-cells, and rodent and human islets. This review will focus on the possible link between defective anaplerotic-derived αKG, PHDs, and the development of type 2 diabetes (T2D).
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Affiliation(s)
- M. Hoang
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada
| | - J. W. Joseph
- School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada
- CONTACT J. W. Joseph School of Pharmacy, University of Waterloo, Kitchener, ONN2G1C5, Canada
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Eicosapentaenoic Acid (EPA) Modulates Glucose Metabolism by Targeting AMP-Activated Protein Kinase (AMPK) Pathway. Int J Mol Sci 2019; 20:ijms20194751. [PMID: 31557807 PMCID: PMC6801536 DOI: 10.3390/ijms20194751] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/20/2019] [Accepted: 09/24/2019] [Indexed: 11/17/2022] Open
Abstract
EPA, an omega-3 polyunsaturated fatty acid, exerts beneficial effects on human health. However, the molecular mechanisms underlying EPA function are poorly understood. The object was to illuminate molecular mechanism underlying EPA's role. Here, 1H-NMR-based metabolic analysis showed enhanced branched-chain amino acids (BCAAs) and lactate following EPA treatment in skeletal muscle cells. EPA regulated mitochondrial oxygen consumption rate. Furthermore, EPA induced calcium/calmodulin-dependent protein kinase kinase (CaMKK) through the generation of intracellular calcium. This induced the phosphorylation of AMP-activated protein kinase (AMPK) and p38 mitogen-activated protein kinase (p38 MAPK) that led to glucose uptake, and the translocation of glucose transporter type 4 (GLUT4) in muscles. In conclusion, EPA exerts benign effects on glucose through the activation of AMPK-p38 MAPK signaling pathways in skeletal muscles.
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Cluster-assembled zirconia substrates promote long-term differentiation and functioning of human islets of Langerhans. Sci Rep 2018; 8:9979. [PMID: 29967323 PMCID: PMC6028636 DOI: 10.1038/s41598-018-28019-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 06/07/2018] [Indexed: 12/19/2022] Open
Abstract
Ex vivo expansion and differentiation of human pancreatic β-cell are enabling steps of paramount importance for accelerating the development of therapies for diabetes. The success of regenerative strategies depends on their ability to reproduce the chemical and biophysical properties of the microenvironment in which β-cells develop, proliferate and function. In this paper we focus on the biophysical properties of the extracellular environment and exploit the cluster-assembled zirconia substrates with tailored roughness to mimic the nanotopography of the extracellular matrix. We demonstrate that β-cells can perceive nanoscale features of the substrate and can convert these stimuli into mechanotransductive processes which promote long-term in vitro human islet culture, thus preserving β-cell differentiation and function. Proteomic and quantitative immunofluorescence analyses demonstrate that the process is driven by nanoscale topography, via remodelling of the actin cytoskeleton and nuclear architecture. These modifications activate a transcriptional program which stimulates an adaptive metabolic glucose response. Engineered cluster-assembled substrates coupled with proteomic approaches may provide a useful strategy for identifying novel molecular targets for treating diabetes mellitus and for enhancing tissue engineering in order to improve the efficacy of islet cell transplantation therapies.
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Piperine regulates UCP1 through the AMPK pathway by generating intracellular lactate production in muscle cells. Sci Rep 2017; 7:41066. [PMID: 28117414 PMCID: PMC5259784 DOI: 10.1038/srep41066] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 12/14/2016] [Indexed: 12/19/2022] Open
Abstract
This study characterizes the human metabolic response to piperine, a curcumin extract, and the details of its underlying molecular mechanism. Using 1H-NMR-based metabolome analysis, we showed the metabolic effect of piperine on skeletal muscle and found that piperine increased the level of intracellular lactate, an important metabolic intermediate that controls expression of several genes involved in mitochondrial activity. Piperine also induced the phosphorylation of AMP-activated protein kinase (AMPK) and its downstream target, acetyl-CoA carboxylase (ACC), while additionally stimulating glucose uptake in an AMPK dependent manner. Piperine also stimulates the p38 mitogen-activated protein kinase (p38 MAPK), an effect that was reversed by pretreatment with compound C, an AMPK inhibitor. Inhibition of p38 MAPK resulted in no piperine-induced glucose uptake. Increased level of lactate resulted in increased expression of mitochondrial uncoupling protein 1 (UCP1), which regulates energy expenditure, thermogenesis, and fat browning. Knock-down of AMPK blocked piperine-induced UCP1 up-regulation, demonstrating the required role of AMPK in this effect. Taken together, these results suggest that piperine leads to benign metabolic effects by activating the AMPK-p38 MAPK signaling pathway and UCP1 expression by activating intracellular lactate production in skeletal muscle.
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Huang M, Paglialunga S, Wong JMK, Hoang M, Pillai R, Joseph JW. Role of prolyl hydroxylase domain proteins in the regulation of insulin secretion. Physiol Rep 2016; 4:4/5/e12722. [PMID: 26997627 PMCID: PMC4823601 DOI: 10.14814/phy2.12722] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Type 2 diabetes is associated with impaired nutrient‐regulated anaplerosis and insulin secretion in pancreatic β‐cells. One key anaplerotic substrate that may be involved in regulating insulin release is α‐ketoglutarate (αKG). Since prolyl hydroxylase domain proteins (PHDs) can metabolize cytosolic αKG, we sought to explore the role of this enzyme in the regulation of β‐cell function. The oxygen‐sensing PHDs regulate the stability of hypoxia‐inducible factor 1α (HIF1α) as well as other proline‐containing proteins by catalyzing the hydroxylation of proline residues. This reaction is dependent on sufficient levels of oxygen, iron, and αKG. In the present study, we utilized both pharmacological and genetic approaches to assess the impact of inhibiting PHD activity on β‐cell function. We demonstrate that ethyl‐3,4‐dihydroxybenzoate (EDHB), a PHD inhibitor, significantly blunted glucose‐stimulated insulin secretion (GSIS) from 832/13 clonal cells, rat, and human islets. EDHB reduced glucose utilization, ATP/ADP ratio, and key TCA cycle intermediates such as pyruvate, citrate, fumarate, and malate. siRNA‐mediated knockdown of PHD1 and PHD3 inhibited GSIS, whereas siRNA‐mediated knockdown of PHD2 had no effect on GSIS. Taken together, the current results demonstrate an important role for PHDs as mediators of islet insulin secretion.
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Affiliation(s)
- Mei Huang
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | | | - Julia M-K Wong
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Monica Hoang
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Renjitha Pillai
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Jamie W Joseph
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
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