Brain metabolism during fasting

Malnutrition in HIV infection

Malnutrition is a common complication of HIV infection and plays a significant and independent role in morbidity and mortality. Many studies have been conducted to assess the appropriate role of nutrition in the clinical management of HIV infection. The complex nature of AIDS wasting, however, requires individualized strategies when providing nutritional support. Algorithms to assist in the diagnosis and treatment of malnutrition in HIV infection serve as general guidelines.

Glutamate and potassium stimulation of hippocampal slices metabolizing glucose or glucose and pyruvate

Using 2-deoxyglucose phosphorylation as an index of glucose use and concentrations of selected intermediates to monitor metabolic pathways, responses of rat hippocampal slices to glutamate and K+ stimulation were examined. With glutamate, the glucose phosphorylation rate (GPR) increased, and the slices accumulated glutamate at a constant rate, for 10 min. The uptake rate at each glutamate level was matched, approximately, by the increase in GPR at that level, with 4 or 5 glutamate molecules accumulated for every glucose molecule phosphorylated. Phosphocreatine and ATP levels fell abruptly, and lactate rose, probably reflecting neuronal activity, found by others to be very brief in the presence of glutamate. K+ stimulation produced responses of phosphocreatine, ATP and lactate levels and of GPR similar to those due to glutamate. There were also prolonged changes in the levels of other metabolites: with both stimulants glucose 6-phosphate fell, and malate rose. The changes in malate may be the result of the participation of mitochondrial malate dehydrogenase in both citrate cycle and malate shuttle. Citrate and alpha-ketoglutarate rose only with K+. When pyruvate was added to the medium, resting GPR was reduced, but for both stimulants the relative increases in GPR with stimulation were the same as without pyruvate. The changes in metabolic intermediates in response to K+ were like those with glucose alone. But with glutamate, the rise in lactate was greatly diminished, and malate fell instead of rising. Glutamate interference with the transfer of both 3-carbon as well as 4- and 5-carbon intermediates from glia to neurons may explain these results. If so, this interference is greater with pyruvate supplementation than with glucose alone.

Effect of streptozotocin-induced maternal diabetes on fetal rat brain glucose transporters

Glucose, an essential substrate for brain oxidative metabolism, is transported across the blood-brain barrier and into neuronal and glial cells via Glut 1 and Glut 3 facilitative glucose transporter isoforms. To examine the effect of excessive circulating glucose on fetal brain glucose transporter expression, we investigated the effect of streptozotocin-induced maternal diabetes (SEVERE-D; n = 29) on the 20-d gestation fetal rat brain Glut 1 and Glut 3. We studied the effect of streptozotocin alone (STZ-ND; n = 12) in a nondiabetic state as well, along with vehicle injected controls (C; n = 24). In the presence of fetal hyperglycemia (12.63 +/- 0.82 nM-SEVERE-D versus 2.35 +/- 0.28-STZ-ND and 2.42 +/- 0.16-C; p < 0.001) and hypoinsulinemia (0.38 +/- 0.03 nM-SEVERE-D versus 0.50 +/- 0.07-STZ-ND and 0.55 +/- 0.06-C; p < 0.02), no detectable change in fetal brain Glut 1 and Glut 3 pretranslational expression (transcription/elongation rates and corresponding steady state mRNA levels) was noted when simultaneously compared with the STZ-ND and C groups. In contrast, a trend toward a decline in Glut 1 (approximately 25 to 30%, p = 0.05) and a substantive decrease in Glut 3 (approximately 35 to 50%, p = 0.0006) protein concentrations was present in both the STZ-ND and SEVERE-D groups when compared with the C group. These observations support a chemical effect of streptozotocin independent of maternal diabetes upon the translation or posttranslational processing of fetal brain glucose transporters. Maternal diabetes with fetal hyperglycemia, however, failed to substantively alter fetal brain glucose transporters independent of the streptozotocin effects upon neuroectodermally derived tissues. We conclude that maternal diabetes with associated overt fetal hyperglycemia does not significantly change fetal brain glucose transporter levels.

Hypoglycaemia of the newborn: a review

It is almost a century since hypoglycaemia (a reduction in the glucose concentration of circulating blood) was first described in children, and over 50 years since the condition was first recognized in infants. Nevertheless, controversy still surrounds the definition, significance, and management of neonatal hypoglycaemia. Technological developments such as bedside glucose monitoring have, paradoxically, exacerbated rather than eased the situation. This article reviews the literature on hypoglycaemia of the newborn, and covers the following: historical aspects; glucose homeostasis and metabolic adaptation at birth; the effect of low blood glucose levels on the central nervous system; the definition of hypoglycaemia; screening; prevention; treatment; research needs; and concludes with recommendations for prevention and management.

The effects of neurotransmitter antagonists and glucose on luteinizing hormone secretion in growth-restricted wethers

Chronic undernutrition results in reduced secretion of luteinizing hormone (LH). Two experiments were conducted in wethers whose LH secretion was suppressed by growth restriction caused by feeding a maintenance ration. The first study examined neurotransmitters that may be actively inhibiting LH secretion during growth restriction. The effects of various neurotransmitter antagonists were investigated: pimozide (PIM, dopamine), cyproheptadine (CYP, serotonin), pyrilamine (PYR, H1), cimetidine (CMT, H2) and propranolol (PRO, beta-adrenergic) in wethers specifically fed to maintain a body weight of 28 kg (GR, n = 7) and in full fed control wethers (n = 5). Blood samples were taken at 15 min intervals for 4 h before and after drug administration. Serum LH concentrations were determined by radioimmunoassay (RIA). Only PIM increased (P < 0.01) serum LH pulse frequency in the GR wethers (pre 0.5 +/- 0.2 pulses per 4 h vs. post 2.6 +/- 0.9 pulses per 4 h). None of the drugs tested had an effect on the control wethers. Experiment 2 examined the effect of glucose administration (50, 100, or 150 mg i.v.) on LH secretion in GR wethers. Only the 150 mg dose significantly (P < 0.05) increased LH pulse frequency compared to the pre-injection period (1.1 +/- 0.3 vs. 2.0 +/- 0.4 pulses per 4 h). After refeeding, LH pulse frequency and serum glucose concentrations increased. Proglumide, a cholecystokinin (CCK) antagonist, did not block this increase (2.1 +/- 0.4 vs. 2.2 +/- 0.3 pulses per 4 h). These data suggest that dopamine inhibits LH secretion in GR wethers and that increasing serum glucose concentrations increased LH secretion.

Extremely preterm infants (< 28 weeks) are capable of gluconeogenesis from glycerol on their first day of life

Extremely preterm infants have been shown capable of producing glucose at a rate comparable to that of term infants, but virtually no data are available on their capacity for lipolysis and gluconeogenesis. To address this issue, we studied the flux of glycerol and its gluconeogenic contribution to hepatic glucose output by determining the endogenous plasma appearance rate of glycerol (glycerol Ra) and its conversion to glucose in 10 newborn infants, 24-27 wk of gestational age. The study was performed during the 1st d of life by tracer dilution technique using [6,6-2H2]glucose and [2-13C]glycerol given as constant rate i.v. infusions. Plasma isotopic enrichments of the tracers were obtained by gas chromatography/mass spectrometry. Endogenous glycerol Ra ranged from 2.4 to 21.6 (median 5.0) mumol.kg-1.min-1, of which 31.5% (25.6-64.4%) was converted to glucose. The glucose production rate averaged 17.5 +/- 5.4 mumol.kg-1.min-1 (3.2 +/- 1.0 mg.kg-1.min-1), of which 5.0% (1.6-37.6%) was derived from glycerol. The results show that extremely preterm infants, despite limited fat stores, are capable of generating glycerol at a rate within the range reported for term and near term newborns. The infants were also capable of converting part of this glycerol to glucose, providing a contribution to hepatic glucose production comparable to that found in more mature newborns.

Acetate represents a major product of heptanoate and octanoate beta-oxidation in hepatocytes isolated from neonatal piglets

An experiment was conducted to explore the nature of the radiolabel distribution in acid-soluble products (ASPs) resulting from the oxidation of [1-14C]C7:0 or C8:0 by isolated piglet hepatocytes. The differences between odd and even chain-length and the impacts of valproate and malonate upon the rate of beta-oxidation and ASP characteristics were tested. A minor amount of fatty acid carboxyl carbon (< or = 10% of organic acids identified by radio-HPLC) accumulated in ketone bodies regardless of chain-length or inhibitor used. In all cases, acetate represented the major reservoir of carboxyl carbon, accounting for 60-70% of radiolabel in identified organic acids. Cells given [1-14C]C7:0 accumulated 85% more carboxyl carbon in Krebs cycle intermediates when compared with C8:0, while accumulation in acetate was unaffected. The results are consistent with the hypothesis that anaplerosis from odd-carbon fatty acids affects the oxidative fate of fatty acid carbon. The piglet appears unique in that non-ketogenic routes of fatty acid carbon flow (i.e. acetogenesis) predominate in the liver of this species.

Evaluation of the brain uptake properties of [1-11C]labeled hexanoate in anesthetized cats by means of positron emission tomography

Positron emission tomography (PET) was performed on the cat brain to characterize [1-11C]hexanoate and other [1-11C]labeled short and medium-chain fatty acids as a tracer of fatty acid oxidative metabolism. After an intravenous injection the brain uptake of [1-11C]hexanoate reached a peak followed by rapid washout until 2 min (first phase). Subsequently the total brain uptake was again increased and reached to a peak 7-10 min after tracer injection (second phase). The blood radioactivity of unmetabolized [1-11C]hexanoate was rapidly decreased and almost eliminated within the first 2 min, whereas the blood radioactivity of [11C]CO2/HCO3- was gradually increased and reached a peak approximately 5 min after tracer injection. As the effect of circulating [11C]CO2/HCO3- was examined by a bolus intravenous injection of [11C]CO2/HCO3-, the brain uptake of [11C]CO2/HCO3- was rapidly increased right after the injection and changed parallel to the blood level of [11C]CO2/HCO3-. These results suggest that, in contrast to the previous mouse data, the time-activity curve in the cat brain following intravenous injection of [1-11C]hexanoate has a biphasic pattern, the second phase being determined by peripherally originating [11C]CO2/HCO3-, and therefore does not reflect the metabolism of 11C-labeled fatty acid in the brain.

Total nutritional manipulation in humans: report of acancer patient

We report here on a patient requiring home total parenteral nutrition (TPN) for a huge intra-abdominal desmoid associated with chronic small bowel pseudo-obstruction who was kept on a special lipid-based calorie regimen for 5 months. The rationale was to attempt to feed the host with a minimal stimulation of tumour growth by using lipid as caloric substrate instead of glucose which is utilized by the tumour. Gluconeogenesis was tentatively inhibited at the level of phosphoenolpyruvate-carboxy-kinase through the oral intake of hydrazine sulphate. The regimen consisted of 28 non-protein lipid Kcal/kg/day plus 1.5 g amino acid per kg/day. Only a small amount of glucose (approx. 40 g/day) was allowed. Tolerance to the regimen was good and body weight maintained. Liver enzymes remained within the normal range and liver sonography was normal throughout the 5 months' therapy and there were no episodes of symptomatic hypoglycaemia. The tumour volume did not substantially change.

Diabetes and the nervous system

Hyperglycemia and its vascular complications affect the entire nervous system, contributing to increased morbidity and mortality. Chronic hyperglycemia is not only a known and major risk factor for cerebral vascular diseases but also the presence of hyperglycemia at the time of a cerebrovascular event may adversely influence the outcome. It also affects the treatment of some neurodegenerative disorders, and there are suggestions that diabetes may in fact suffer from a "chronic diabetic encephalopathy." Its varied effects on the peripheral nervous system result in several forms of diabetic neuropathies, the exact pathogenesis of which is still obscure. There is, however, some new information that may link metabolic and vascular hypotheses.

A brain uptake study of [1-(11)C]hexanoate in the mouse: the effect of hypoxia, starvation and substrate competition

We evaluated the potential of sodium [1-(11)C]hexanoate (11C-HA) as a radiopharmaceutical with which to assess oxidative metabolism of the brain by PET. 11C-HA, sodium [1-(14)C]acetate and [3H]deoxyglucose were simultaneously injected into mice under control, hypoxic and starving conditions. In the control, the brain uptake of 11C was maximal at 3 min (% ID/g = 2.2-2.5), being twice as high as that of 14C, followed by a gradual clearance. The time-radioactivity curve of 11C was similar to that of 14C. Hypoxia enhanced the brain uptake of 3H, but not of either 11C or 14C. Starvation enhanced the brain uptake of 3H and 11C. The clearance rate of 11C was not significantly affected by either condition. In the control brain at 3 min postinjection of HA, 65% of the total radioactivity was detected as labeled glutamate and glutamine, which was gradually decreased by 47% at 30 min. The brain to blood ratios of 11C-HA at 3 min were significantly reduced by butyrate, hexanoate and octanoate loading but not by that with other monocarboxylic acids or ketone bodies.

Carbohydrate metabolism and its regulatory hormones in anorexia nervosa

Findings of studies of carbohydrate metabolism in anorexia nervosa are reviewed. Topics covered included fasting blood sugar concentrations; serum insulin concentrations, insulin receptor binding activity, insulin sensitivity, and insulin resistance; plasma ketone bodies and free fatty acids; glucose tolerance tests; growth hormone, cortisol, intestinal hormones, and norepinephrine. Metabolic changes reported in anorexia nervosa are similar to those found in human and animal studies of states of caloric and carbohydrate restriction. Restoration of normal body weight is associated with normalization of virtually all measures. It is concluded that published studies offer no conclusive evidence for a syndrome-specific impairment in carbohydrate metabolism in anorexia nervosa.

Alternative epilepsy therapies: the ketogenic diet, immunoglobulins, and steroids

Despite the continued development and release of new antiepileptic drugs (AEDs), many children have seizures that do not respond to conventional therapy or have related side effects that preclude continued use. While some of these children are surgical candidates, the majority do not qualify for surgical resection. In these children alternative therapies are often considered by desperate physicians and parents. Three of the less conventional therapies which are currently used for intractable epilepsy are: the ketogenic diet, immunoglobulins, and steroids. None of these therapies has been adequately studied and it remains unclear which patients may benefit or be harmed by these therapies. Despite the lack of scientific vigor in evaluating these therapies, the television and print media has proclaimed these therapies as miraculous, yet grossly under-utilized by an ignorant medical community. The ketogenic diet has been demonstrated to reduce seizure frequency in some patients, but has an unclear mechanism of action, while immunoglobulins have both unknown efficacy and an unknown mechanism of action. While steroids are accepted as an effective therapy for infantile spasms, their role in the treatment of the Landau-Kleffner syndrome is far less clear. Although the ketogenic diet, immunoglobulins, and steroids may have a role in the treatment of severe childhood epilepsy, all three therapies need to be critically evaluated in regard to efficacy, mechanism of action, and safety.

Metabolic adaptations induced by long-term fasting in quails

After up to 21 days without food, adult male quails (Coturnix coturnix japonica) lost about 45% of the initial body weight (100-150 g). As in naturally fast-adapted and larger birds, three phases were identified during prolonged fasting in quails. Phase I lasted 2-3 days and was characterized by a rapid decrease in the rate of body weight loss and high fat mobilization. Phase II was longer and characterized by a slow and steady decline in the rates of body weight loss and of nitrogen excretion. The third (critical) period was marked by an abrupt increase in the rates of body weight loss and of nitrogen excretion. Despite their small size, the duration of phase II in quails was relatively long, a clear advantage for the study of the relationships between the several metabolic events that occur during this crucial adaptative period. Also, the beginning of phase III could be precisely determined. Changes in blood glucose, plasma FFA and triacylglycerols levels, as well as in liver and carcass lipid content were similar to those found in other species of birds. Therefore, quails seem to be a suitable model to investigate the biochemical mechanisms involved in the metabolic adjustments to prolonged food deprivation in non fasting-adapted birds.

Blood-brain barrier permeability of glucose and ketone bodies during short-term starvation in humans

The blood-brain barrier (BBB) permeability for glucose and beta-hydroxybutyrate (beta-OHB) was studied by the intravenous double-indicator method in nine healthy subjects before and after 3.5 days of starvation. In fasting, mean arterial plasma glucose decreased and arterial concentration of beta-OHB increased, whereas cerebral blood flow remained unchanged. The permeability-surface area product for BBB glucose transport from blood to brain (PS1) increased by 55 +/- 31%, whereas no significant change in the permeability from brain back to blood (PS2) was found. PS1 for beta-OHB remained constant during starvation. The expected increase in PS1 due to the lower plasma glucose concentration was calculated to be 22% using previous estimates of maximal transport velocity and Michaelis-Menten affinity constant for glucose transport. The determined increase was thus 33% higher than the expected increase and can only be partially explained by the decrease in plasma glucose. It is concluded that a modest upregulation of glucose transport across the BBB takes place after starvation. Brain transport of beta-OHB did not decrease as expected from the largely increased beta-OHB arterial level. This might be interpreted as an increase in brain transport of beta-OHB, which could be caused by induction mechanisms, but the large nonsaturable component of beta-OHB transport makes such a conclusion difficult. However, beta-OHB blood concentration and beta-OHB influx into the brain increased by > 10 times. This implies that the influx of ketone bodies into the brain is largely determined by the amount of ketones present in the blood, and any condition in which ketonemia occurs will lead to an increased ketone influx.

Organ fuel selection: brain

The brain's first choice for a metabolic fuel is glucose. In times of glucose lack, the brain can metabolize ketone bodies and lactate if they are available and by maintaining its metabolism, apparently, it also maintains its function. Brain metabolism of amino acid appears to be dictated by plasma levels, but the possibility that amino acids can support cerebral function during hypoglycaemia has not yet been investigated.

Synthesis and preliminary evaluation of [1-11C]hexanoate as a PET tracer of fatty acid metabolism

The potential of [1-11C]hexanoate (11C-HA) as a radiopharmaceutical assessing fatty acid metabolism of the myocardium and brain tissues by PET studies was evaluated. 11C-HA was synthesized by the Grignard reaction of pentylmagnesium bromide and 11CO2. 11C-HA, [1-14C]acetate and [3H]deoxyglucose were simultaneously injected i.v. into mice, and the tissue distribution of the three radionuclides was measured. In the heart, high uptake and rapid clearance of 11C and 14C was found. The brain uptake of 11C was twice as high as that of 14C, and both 11C and 14C decreased slowly compared to the heart. The level of 3H increased with time in both the heart and brain. In fasting conditions, the uptake of 11C by the heart was enhanced and the level of 3H decreased with time. The brain uptake of 11C and 3H was also enhanced. The fasting conditions did not affect the distribution of 14C. The radiation absorbed dose of 11C-HA was also estimated.

Progressive hippocampal loss of immunoreactive GLUT3, the neuron-specific glucose transporter, after global forebrain ischemia in the rat

Brain damage after global forebrain ischemia is worsened by prior hyperglycemia and ameliorated by antecedent hypoglycemia. To assess whether GLUT3, the neuron specific glucose transporter and its mRNA, are affected by cerebral ischemia, we investigated the hippocampal pattern of GLUT3 immunoreactivity and GLUT3 gene expression 1, 4 and 7 days after global forebrain ischemia in a rat 2-vessel occlusion model. We used a newly generated, specific, C-terminally directed polyclonal antiserum against GLUT3 to stain coronal frozen sections. Thionin staining and the microglial marker, OX42, indicated the extent of ischemic damage in hippocampus and correlated with GLUT3 loss. One day after ischemia, no significant change in hippocampal GLUT3 immunoreactivity was observed; by 4 days however, there was consistent and pronounced loss; and at 7 days the loss of GLUT3 staining was maximal. The greatest loss of GLUT3 staining was in the CA1 region, especially the strata oriens and radiatum of Ammon's horn. By contrast, GLUT3 staining was undiminished in the stratum lacunosum moleculare, in the mossy fibers of the lateral aspect of CA3 and in all but the inner-most portion of the molecular layer of the dentate gyrus, immediately adjacent to the granule cells. GLUT3 mRNA levels were not significantly altered at 24 hours and significantly declined at 4 and 7 days after ischemia in the CA1 pyramidal layer. These data are consistent with the pattern of neuronal loss and microglial activation in hippocampus. Loss of GLUT3 may affect the availability of glucose, and possibly the viability of ischemically damaged neurons.

Assessment of glucose metabolism in humans with the simultaneous use of indirect calorimetry and tracer techniques

Concomitant measurements of sytemic glucose delivery and carbohydrate oxidation are frequently performed in human investigations. Systemic glucose delivery (SGD) is usually determined using dilution of infused glucose tracers; net carbohydrate oxidation rate (net CHOOX) can be calculated from respiratory gas exchanges and urinary nitrogen excretion (indirect calorimetry); alternatively, glucose oxidation can be measured from labelled CO2 production during infusion of carbon-labelled glucose tracers. In this paper, the theory underlying the use of each of these techniques is briefly reviewed and qualitative differences are outlined. SGD represents the sum of hepatic glucogenolysis, gluconeogenesis from amino acids or glycerol, and, according to the glucose tracer used, glucose cycles (glucose-phosphate cycle, fructose-phosphate cycle, Cori and glucose-alanine cycles); systemic delivery of exogenous glucose after oral or i.v. glucose administration is also measured. Net CHOOX represents oxidation of glucose arising from hepatic or muscle glycogen or from exogenous glucose; it does not take into account oxidation of glucose formed from amino acids or glycerol, which is included in net protein or lipid oxidation. In contrast, isotopic determination of glucose oxidation corresponds to oxidation of glucose originating from hepatic glycogen breakdown, of exogenously administered glucose, and of glucose formed from amino acids and glycerol. Non-oxidative glucose disposal, calculated as SGD-net CHOOX, corresponds to the sum of gluconeogenesis from amino acids or glycerol (which are included in net protein and lipid oxidation), glucose cycles, and glycogen synthesis.

Effect of lipid infusion on postabsorptive glucose metabolism in non-insulin-dependent diabetic patients

The effect of a lipid infusion on postabsorptive glucose metabolism was investigated in non-insulin-dependent diabetes mellitus (NIDDM) patients. During a basal period, plasma free fatty acids (FFA) and triglycerides, postabsorptive glycemia and insulinemia, and glucose turnover and metabolic clearance rates (MCRs) were measured in 10 NIDDM patients. After the basal measurement, five patients received a lipid infusion, and the others received saline. Lipid infusion prevented the decrease in postabsorptive glycemia observed in the saline group (P < .01). The principal mechanism for this effect was a reduction in glucose MCR (30.8 +/- 5.7 v 47.2 +/- 3.4 mL/m2/min, P < .05), which was absent in control tests (50.4 +/- 8.1 v 47.9 +/- 4.7 mL/m2/min, NS). The absence of the compensatory insulin release observed in normal subjects may play a role in this response. The prolonged postabsorptive hyperglycemia induced by lipid infusion in NIDDM patients is further evidence for the detrimental effect of the lipid-carbohydrate interactions described by Randle.

Aminooxyacetic acid striatal lesions attenuated by 1,3-butanediol and coenzyme Q10

We previously showed that intrastriatal administration of aminooxyacetic acid (AOAA) produces striatal lesions by a secondary excitotoxic mechanism associated with impairment of oxidative phosphorylation. In the present study, we show that and the specific complex I inhibitor rotenone produces a similar neurochemical profile in the striatum, consistent with an effect of AOAA on energy metabolism. Lesions produced by AOAA were dose-dependently blocked by MK-801, with complete protection against GABA and substance P depletions at a dose of 3 mg/kg. AOAA lesions were significantly attenuated by pretreatment with either 1,3-butanediol or coenzyme Q10, two compounds which are thought to improve energy metabolism. These results provide further evidence that AOAA produces striatal excitotoxic lesions as a consequence of energy depletion and they suggest therapeutic strategies which may be useful in neurodegenerative diseases.

Carnitine-dependent changes of metabolic fuel consumption during long-term treatment with valproic acid

Energy metabolism was measured in children receiving long-term treatment with valproic acid. In 8 of 10 randomly selected subjects, the resting respiratory quotient was higher than in age- and sex-matched control subjects (0.91 +/- 0.01 vs 0.87 +/- 0.01; p < 0.05). A shift was observed in fuel consumption, and a significant reduction was found in the amount of fats oxidized (0.68 +/- 0.23 vs 1.18 +/- 0.18 gm.kg-1.day-1), which was accompanied by increased utilization of carbohydrates (5.31 +/- 0.79 vs 3.81 +/- 0.39 gm.kg-1.day-1) in comparison with the control subjects. The resting total energy expenditure was not affected by the treatment. The children with an altered energy consumption pattern (n = 8) received carnitine supplementation for a month; the respiratory quotient then decreased (0.87 +/- 0.02), the oxidation of fats increased (1.42 +/- 0.25), and the consumption of carbohydrates decreased (3.87 +/- 0.79), but no changes in resting energy expenditure were observed. We conclude that carnitine depletion, a known adverse effect of valproic acid administration, may result in inhibited fatty acid oxidation, leading to a shift of substrates utilized from fats to carbohydrates.

Effect of 1-week fasting on some blood values in man

Fifty-eight voluntary and healthy subjects (mean age 42.3 +/- 11.2 years) participated in 7-day supervised fasting trial during which only fruit and berry juices, tea and water were consumed. Venous blood was drawn before and after 1-week fasting and 3 months after the termination of the trial. The subjects' body weight and blood pressure values were also recorded. The results showed a statistically significant decrease in blood thrombocyte counts after 1-week fasting (p < 0.05), while a significant increase was observed in serum beta-hydroxybutyrate and alanine aminotransferase activities (p < 0.001). All other blood values, including glucose and creatinine, remained stable throughout the trial.

Gene expression of GLUT3 glucose transporter regulated by glucose in vivo in mouse brain and in vitro in neuronal cell cultures from rat embryos

This study was designed to determine whether glucose regulates the gene expression of glucose transporter GLUT3 in neurons. We examined the regulation of GLUT3 mRNA by glucose in vivo in mouse brain and in vitro by using neuronal cultures from rat embryos. Hypoglycaemia (< 30 mg/dl), produced by 72 h of starvation, increased GLUT3 mRNA in mouse brain by 2-fold. Hybridization studies in situ demonstrated that hypoglycaemia-induced increases in GLUT3 mRNA expression were observed selectively in brain regions including the hippocampus, dentate gyrus, cerebral cortex and piriform cortex, but not the cerebellum. Primary neuronal cultures from rat embryos deprived of glucose for 48 h also showed an increase (4-fold over control) in GLUT3 mRNA, indicating that glucose can directly regulate expression of GLUT3 mRNA. In contrast with hypoglycaemia, hyperglycaemia produced by streptozotocin did not alter the expression of GLUT3 mRNA. We also confirmed previous findings that hypoglycaemia increases GLUT1 mRNA expression in brain. The increase in GLUT1 expression was probably limited to the blood-brain barrier in vivo, since GLUT1 mRNA could not be detected in neurons of the mouse cerebrum. Thus we conclude that up-regulation of neuronal GLUT3 in response to glucose starvation represents a protective mechanism against energy depletion in neurons.

Glucagon-like peptide 1 enhances glucose tolerance both by stimulation of insulin release and by increasing insulin-independent glucose disposal

Glucagon-like peptide 1 [7-36 amide] (GLP-1) has been shown to enhance insulin secretion in healthy and type II diabetic humans, and to increase glucose disposal in type I diabetic patients. To further define its action on glucose kinetics, we studied six healthy subjects who received either GLP-1 (45 pmol/kg per h) or 150 mM saline on two mornings during which a modified intravenous glucose tolerance test was performed. Plasma insulin and glucose levels were analyzed using Bergman's minimal model of glucose kinetics to derive indices of insulin sensitivity (SI) and glucose effectiveness at basal insulin (SG), the latter a measure of glucose disposition independent of changes in insulin. In addition, basal insulin concentrations, the acute insulin response to glucose (AIRg), plasma glucagon levels, and the glucose disappearance constant (Kg) were measured on the days that subjects received GLP-1 or saline. Compared with saline infusions, GLP-1 increased the mean Kg from 1.61 +/- 0.20 to 2.65 +/- 0.25%/min (P = 0.022). The enhanced glucose disappearance seen with GLP-1 was in part the result of its insulinotropic effect, as indicated by a rise in AIRg from 240 +/- 48 to 400 +/- 78 pM (P = 0.013). However, there was also an increase in SG from 1.77 +/- 0.11 to 2.65 +/- 0.33 x 10(-2).min-1 (P = 0.038), which was accounted for primarily by insulin-independent processes, viz glucose effectiveness in the absence of insulin. There was no significant effect of GLP-1 on SI or basal insulin, and glucagon levels were not different during the glucose tolerance tests with or without GLP-1. Thus, GLP-1 improves glucose tolerance both through its insulinotropic action and by increasing glucose effectiveness. These findings suggest that GLP-1 has direct effects on tissues involved in glucose disposition. Furthermore, this peptide may be useful for studying the process of insulin-independent glucose disposal, and pharmacologic analogues may be beneficial for treating patients with diabetes mellitus.

Central nervous system disorders and possible brain type carnitine palmitoyltransferase II deficiency

We describe two male infants with central nervous system disorders, i.e. infantile spasms in one and athetotic quadriplegia in the other, and with recurrent attacks of high plasma creatine kinase levels induced by viral infections. Although carnitine palmitoyltransferase I (CPT I) activity in biopsied muscle was normal in both cases, that of carnitine palmitoyltransferase II (CPT II) was decreased to 37% and 25% of the control value, respectively. Meanwhile, to determine whether or not and how CPT exists in the central nervous system (CNS), we studied animal brain tissues. CPT activity was demonstrated in almost all regions, especially in the brainstem, cerebellum and spinal cord. Although CPT deficiency can be classified into hepatic (CPT I) and muscular (CPT II) presentations, these data suggest that another symptomatology of CPT II deficiency with CNS involvement (brain type?) might exist.

Protection by lactate of cerebral function during hypoglycaemia

Severe hypoglycaemia with brain dysfunction limits intensified therapy in patients with insulin-dependent diabetes mellitus, despite evidence that such therapy reduces the risk of chronic complications of the disease. We have investigated the effect of infusing lactate (a potential non-glucose fuel for brain metabolism) on protective, symptomatic neurohumoral responses and on brain function during hypoglycaemia in seven healthy men. Elevation of lactate (within a physiological range) substantially diminished catecholamines, growth hormone, cortisol, and symptomatic responses to hypoglycaemia and lowered the glucose level at which these responses began. Glucagon responses were unaffected. Lactate was also associated with a significant lowering of the glucose level at which brain function deteriorated, suggesting that brain function was protected during the hypoglycaemia. The defect in counter-regulation is similar to that seen in hypoglycaemia-prone diabetic patients. Initiation of the protective responses to hypoglycaemia (except glucagon) can be delayed by supporting metabolism with an alternative metabolic fuel. Cerebral cortical dysfunction of severe hypoglycaemia is also delayed. Our demonstration that higher brain function can be protected during hypoglycaemia may have therapeutic potential.

Brain metabolism during short-term starvation in humans

During prolonged starvation, brain energy requirements are covered in part by the metabolism of ketone bodies. It is unknown whether short-term starvation of a few days' duration may lead to reduced brain glucose metabolism due to the change toward ketone body consumption. In the present study we measured the cerebral metabolism of glucose and ketone bodies in nine healthy volunteers before and after 3.5 days of starvation. Regional glucose metabolism was measured by dynamic positron emission tomography using [18F]2-fluoro-2-deoxy-D-glucose. The mean value of K1* in gray and white matter increased by 12% (p < 0.05), whereas k2* and k3* were unchanged compared with control values. Regional glucose metabolism in cortical gray matter was reduced by 26% from 0.294 +/- 0.054 to 0.217 +/- 0.040 mumol g-1 min-1 (p < 0.001). White matter glucose metabolism decreased by 27% (p < 0.02). The decrease was uniform in gray and white matter with regional decreases ranging from 24 to 30%. A determination using Fick's principle confirmed the reduction in glucose metabolism yielding a decrease of 24% from 0.307 +/- 0.050 to 0.233 +/- 0.073 mumol g-1 min-1 (p < 0.05), whereas CBF did not change (0.57 +/- 0.07 vs. 0.57 +/- 0.06 ml g-1 min-1). The global net uptake of beta-hydroxybutyrate increased 13-fold from 0.012 +/- 0.024 to 0.155 +/- 0.140 mumol g-1 min-1 (p < 0.05). Net uptake of acetoacetate and net efflux of lactate and pyruvate did not change significantly during starvation. The present study shows that the human brain adapts to the changes in energy supply as early as 3 days following initiation of starvation, at which time ketone bodies account for approximately one-fourth of the cerebral energy requirements.

Expression of facilitative glucose transporter isoforms in human brain tumors

The expression of facilitative glucose transporter (GLUT) isoforms in human astrocytic tumors was examined. Reverse transcriptase-polymerase chain reaction of a surgically biopsied glioblastoma was carried out using the degenerative oligonucleotide primers corresponding to the sequences of the human facilitative glucose transporter family, and polymerase chain reaction products were hybridized with human GLUT1, GLUT2, GLUT3, GLUT4, and GLUT5 cDNA probes. The results showed that a biopsied glioblastoma expressed GLUT1, GLUT3, and GLUT4 glucose transporter genes. Northern blot analysis of total RNA (10 micrograms) from a biopsied glioblastoma showed the transcripts of only GLUT1 and GLUT3, suggesting that the expression of insulin-responsive glucose transporter GLUT4 mRNA is relatively low. Immunoblot analysis of biopsied glioblastoma tissues by polyclonal antibodies against the C-terminal synthetic peptides of GLUT1, GLUT3, and GLUT4 showed a single band of each polypeptide. However, elevated expression of GLUT1 and GLUT3 glucose transporters was not observed in the glioblastoma. Astrocytic tumor tissues (n = 14) were also examined immunohistochemically. Reactive products for GLUT1 were observed in the luminal surface of capillaries in all cases, whereas tumor cells were positive for GLUT1 in only two of 14 cases. GLUT3 was positive in astrocytic tumor cells in all cases. Three of 14 cases expressed the GLUT4 protein, which was localized in the cytoplasm of tumor cells. These results suggest that the facilitative glucose transport may be altered in astrocytic tumor cells and thus display a significant change in glucose metabolism.

Neuron-specific glucose transporter (NSGT): CNS distribution of GLUT3 rat glucose transporter (RGT3) in rat central neurons

The identity of the glucose transporters (GLUT) expressed in neurons in situ has yet to be fully established. In the present study we have isolated the GLUT3 (RGT3) cDNA and produced anti RGT3 polyclonal antibody allowing us to investigate the cellular localization and tissue distributions of RGT3 mRNA and protein in the central nervous system of the rat by the methods of in situ hybridization and immunohistochemistry. Here we demonstrate the direct evidence that RGT3 is present in neurons in adult rat brain. In situ hybridization showed the expression of RGT3 mRNA mostly in the regions of hippocampus, cerebral cortex, striatum, and the granule cell layer of the cerebellum, indicating that RGT3 mRNA is predominantly expressed within neurons. Immunohistochemistry showed that RGT3 protein is widely distributed in the rat brain, and concentrated on the plasma membrane of neurons. Double labeling studies with anti-RGT3, glial fibrillary acidic protein (GFAP), and neuron specific enolase (NSE) antibodies revealed the specific expression of RGT3 protein in neurons. Thus, RGT3 is indicated to be a neuron specific glucose transporter isoform (NSGT), and suggested to play a functionally significant role in rat central neurons.

Progressive alterations in lipid and glucose metabolism during short-term fasting in young adult men

Stable isotope tracers and indirect calorimetry were used to evaluate the progressive alterations in lipid and glucose metabolism after 12, 18, 24, 30, 42, 54, and 72 h of fasting in six healthy male volunteers. The rates of appearance (Ra) of glycerol and palmitic acid in plasma doubled from 2.08 +/- 0.22 and 1.63 +/- 0.20 mumol.kg-1 x min-1, respectively, after 12 h to 4.36 +/- 0.36 and 3.26 +/- 0.40 mumol.kg-1 x min-1, respectively, after 72 h of fasting (P < 0.01). Of the total increase in lipid kinetics, 60% occurred between 12 and 24 h of fasting; the greatest interval change occurred between 18 and 24 h of fasting. Glucose Ra and plasma concentration decreased by approximately 25% between 12 h (11.0 +/- 0.4 mumol.kg-1 x min-1 and 5.58 +/- 0.08 mmol/l, respectively) and 72 h (8.3 +/- 0.3 mumol.kg-1 x min-1 and 4.14 +/- 0.10 mmol/l, respectively) of fasting (P < 0.01), but no statistically significant changes occurred between 18 and 24 h of fasting. Plasma insulin decreased by approximately 50% between 12 h (64.6 +/- 12.9 pmol/l) and 72 h (30.1 +/- 7.9 pmol/l) of fasting (P < 0.001). Of the total decline in plasma insulin, 70% occurred within the first 24 h of fasting. These results demonstrate that the mobilization of adipose tissue triglycerides increases markedly between 18 and 24 h of fasting in young adult men. The early alterations in lipid metabolism are associated with a decline in circulating insulin but do not seem to be regulated by changes in glucose kinetics or plasma glucose concentrations.

Post-hypoglycaemic hyperketonaemia does not contribute to brain metabolism during insulin-induced hypoglycaemia in humans

It is controversial as to whether ketone bodies are utilized by the human brain as a fuel alternative to glucose during hypoglycaemia. To clarify the issue, we studied 10 normal volunteers during an experimental hypoglycaemia closely mimicking the clinical hypoglycaemia of patients with Type 1 (insulin-dependent) diabetes mellitus or insulinoma. Hypoglycaemia was induced by a continuous infusion of insulin (0.40 mU.kg-1.min-1 for 8 h, plasma insulin approximately 180 pmol/l) which decreased the plasma glucose concentration to approximately 3.1 mmol/l during the last 3 h of the studies. Subjects were studied on two occasions, i.e. spontaneous, counterregulatory-induced post-hypoglycaemic increase in 3-beta-hydroxybutyrate (from approximately 0.2 to approximately 1.1 mmol/l at 8 h), or prevention of post-hypoglycaemic hyperketonaemia (plasma beta-hydroxybutyrate approximately 0.1 mmol/l throughout the study) after administration of acipimox, a potent inhibitor of lipolysis. In the latter study, glucose was infused to match the hypoglycaemia observed in the former study. The glycaemic thresholds and overall responses of counterregulatory hormones, symptoms (both autonomic and neuroglycopenic), and deterioration of cognitive function (psychomotor tests) were superimposable in the control study in which ketones increased spontaneously after onset of hypoglycaemic counterregulation, as compared to the study in which ketones were suppressed (p = NS). The fact that responses of counterregulatory hormones, symptoms and deterioration in cognitive function were not exaggerated when posthypoglycaemic hyperketonaemia was prevented, indicate that during hypoglycaemia, the counterregulatory-induced endogenous hyperketonaemia does not provide the human brain with an alternative substrate to glucose. Thus, it is concluded that during hypoglycaemia, endogenous hyperketonaemia does not contribute to brain metabolism and function.

Control of glycaemia

Maintenance of plasma glucose concentrations within a narrow range despite wide fluctuations in the demand (e.g. vigorous exercise) and supply (e.g. large carbohydrate meals) of glucose results from coordination of factors that regulate glucose release into and removal from the circulation. On a moment-to-moment basis these processes are controlled mainly by insulin and glucagon, whose secretion is reciprocally influenced by the plasma glucose concentration. In the resting postabsorptive state, release of glucose from the liver (equally via glycogenolysis and gluconeogenesis) is the key regulated process. Glycogenolysis depends on the relative activities of glycogen synthase and phosphorylase, the latter being the more important. The activities of fructose-1,6-diphosphatase, phosphoenolpyruvate carboxylkinase and pyruvate dehydrogenase regulate gluconeogenesis, whose main precursors are lactate, glutamine and alanine. In the postprandial state, suppression of liver glucose output and stimulation of skeletal muscle glucose uptake are the most important factors. Glucose disposal by insulin-sensitive tissues is regulated initially at the transport step and the mainly by glycogen synthase, phosphofructokinase and pyruvate dehydrogenase. Hormonally induced changes in intracellular fructose 2,6-bisphosphate concentrations play a key role in muscle glycolytic flux and both glycolytic and gluconeogenic flux in the liver. Under stressful conditions (e.g. hypoglycaemia, trauma, vigorous exercise), increased secretion of other hormones such as adrenaline, cortisol and growth hormone, and increased activity of the sympathetic nervous system, come into play; their actions to increase hepatic glucose output and to suppress tissue glucose uptake are partly mediated by increases in tissue fatty acid oxidation. In diabetes, the most common disorder of glucose homeostasis, fasting hyperglycaemia, results primarily from excessive release of glucose by the liver due to increased gluconeogenesis; postprandial hyperglycaemia results from both impaired suppression of hepatic glucose release and impaired skeletal muscle glucose uptake. These abnormalities are usually due to the combination of impaired insulin secretion and tissue resistance to insulin, the causes of which remain to be determined.

Regional blood-brain lactate influx

Regional blood-to-brain lactate transport was studied in chloral hydrate anesthetized rats using the single pass, dual-label, indicator fractionation, right atrial injection method. Lactate influx was resolved into two components, a saturable, stereospecific (to the L-enantiomer) component and a non-saturable, non-stereospecific diffusional component. The saturable component was found to have a low efficiency and moderate capacity with transport affinity coefficients between 6 and 14 mM and transport maxima of 23-40 mumol/100 g/min in the various brain regions. Lactate transport was not inhibited by probenecid. The diffusional component was determined from D-lactate influx measurements and the regional linear diffusion coefficients ranged from 0.020 to 0.036 ml/g/min. At the usual levels of plasma lactate (1-1.5 mM) these two influx components were about equal. The relative contribution of the non-stereospecific diffusional component was increased at higher plasma lactate concentrations. Lactate clearance, estimated by the total apparent permeability x surface area products was between 6 and 8 ml/100 g/min.

Blood-brain glucose transfer in the mouse

The intracarotid injection method has been utilized to examine blood-brain barrier (BBB) glucose transport in normal mice, and after a 2-day fast. In anesthetized mice, cerebral blood flow (CBF) rates were reduced from 0.86 ml.min-1 x gm-1 in control to 0.80 ml.min-1 x gm-1 in fasted animals (p > 0.05). Brain Uptake Indices were significantly (p < 0.05) higher in fasted (plasma glucose = 4.7 mM) than control (plasma glucose = 6.5 mM) mice, while plasma glucose was significantly lower. The maximal velocity (Vmax) for glucose transport was 1562 +/- 303 nmoles.min-1 x g-1, and the half-saturation constant (Km =) 6.67 +/- 1.46 mM in normally fed mice. In fasted mice the Vmax was 2053 +/- 393 nmoles.min-1 x g-1 (p > 0.05), and the half-saturation constant (Km =) 7.40 +/- 1.60 mM (not significant, P > 0.05). A rabbit polyclonal antiserum to a synthetic peptide encoding the 13 C-terminal amino acids of the human erythrocyte glucose transporter (GLUT-1) immunocytochemically confirmed that the mouse brain capillary endothelial glucose transporter is a GLUT-1 transporter, and immunoreactivity was similar in brain endothelia from fed and fasted animals. In conclusion, after a 2-day fast in the mouse, we saw significant reductions in forebrain weight (7%), and plasma glucose levels (27%). Increased brain glucose extraction (25%, p < 0.05), and a 22% increase in the unsaturated permeability-surface area product (p < 0.05) was also observed.

Metabolic consequences of different perioperative fluid therapies in the neonatal period

Carbohydrate and fat metabolism during and after anaesthesia and surgery was studied in 14 neonates with major congenital non-cardiac anomalies. They were either given a glucose solution until surgery or starved for at least 4 h before surgery. Ringer-acetate alone or Ringer-acetate plus 10% glucose was used for the intraoperative fluid therapy. After anaesthesia all neonates were given a 10% glucose solution. Concentrations of glucose, free fatty acids, triglycerides, lactate, pyruvate, alanine, glycerol and 3-hydroxybutyrate were measured at predetermined intervals pre-, intra- and postoperatively. Blood glucose concentrations rose during surgery both in neonates given glucose before and during surgery (n = 6) and in neonates not given glucose before and during surgery (n = 6). Increased intraoperative levels of free fatty acids and 3-hydroxybutyrate were found in neonates not given glucose before and during surgery. The triglyceride levels were equal in both groups. In two neonates given glucose before surgery and Ringer-acetate during surgery increased levels of 3-hydroxybutyrate were found, particularly in one patient who became hypoglycaemic. In conclusion, starved neonates without intraoperative glucose supply mobilized fat and maintained blood glucose concentrations.

Effect of hypoglycemia on changes of brain lactic acid and intracellular pH produced by ischemia

Previous investigators have attributed the fall of brain intracellular pH (pHi) produced by ischemia to accumulation of lactic acid. The goal of the present experiments was to examine the hypothesis that the acidosis produced by cerebral ischemia is due to accumulation of lactic acid. The present experiments inhibited lactic acid production by lowering glucose availability using insulin-induced hypoglycemia. The adverse effects of hypoglycemia were prevented by the prior elevation of beta-hydroxybutyric acid and acetoacetic acid induced by a high lipid diet. Brain pHi and lactic acid were measured by 31P and 1H NMR. The results showed that insulin-induced hypoglycemia markedly inhibits production of lactic acid, but has no effect on brain pHi during ischemia. These findings suggest that, at least under some conditions, the acidosis produced by cerebral ischemia is not due to accumulation of lactic acid.

The expanding clinical spectrum of mitochondrial diseases

The mitochondrion is the only extranuclear organelle containing DNA (mtDNA). As such, genetically determined mitochondrial diseases may result from a molecular defect involving the mitochondrial or the nuclear genome. The first is characterized by maternal inheritance and the second by Mendelian inheritance. Ragged-red fibers (RRF) are commonly seen with primary lesions of mtDNA, but this association is not invariant. Conversely, RRF are seldom associated with primary lesions of nuclear DNA. Large-scale rearrangements (deletions and insertions) and point mutations of mtDNA are commonly associated with RRF and lactic acidosis, e.g. Kearns-Sayre syndrome (KSS) (major large-scale rearrangements), Pearson syndrome (large-scale rearrangements), myoclonus epilepsy with RRF (MERRF) (point mutation affecting tRNA(lys) gene), mitochondrial myopathy, lactic acidosis, and stroke-like episodes (MELAS) (two point mutations affecting tRNA(leu)(UUR) gene) and a maternally-inherited myopathy with cardiac involvement (MIMyCa) (point mutation affecting tRNA(leu)(UUR) gene). However, RRF and lactic acidosis are absent in Leber hereditary optic neuropathy (LHON) (one point mutation affecting ND4 gene, two point mutations affecting ND1 gene, and one point mutation affecting the apocytochrome b subunit of complex III), and the condition associated with maternally inherited sensory neuropathy (N), ataxia (A), retinitis pigmentosa (RP), developmental delay, dementia, seizures, and limb weakness (NARP) (point mutation affecting ATPase subunit 6 gene). The point mutations in MELAS, MIMyCa, and MERRF, and the large-scale mtDNA rearrangements in KSS and Pearson syndrome have a broader biochemical impact since these molecular defects involve the translational sequence of mitochondrial protein synthesis. The nuclear defects involving mitochondrial function generally are not associated with RRF. The biochemical classification of mitochondrial diseases principally catalogues these nuclear defects. This classification divides mitochondrial diseases into five categories. Primary and secondary deficiencies of carnitine are examples of a substrate transport defect. A lipid storage myopathy is often present. Disturbances of pyruvate or fatty acid metabolism are examples of substrate utilization defects. Only four defects of the Krebs cycle are known: fumarase deficiency, dihydrolipoyl dehydrogenase deficiency, alpha-ketoglutarate dehydrogenase deficiency, and combined defects of muscle succinate dehydrogenase and aconitase. Luft disease is the singular example of a defect in oxidation-phosphorylation coupling. Defects of respiratory chain function are manifold. Two clinical syndromes predominate, one involving limb weakness, and the other primarily affecting brain function. Leigh syndrome may result from different enzyme defects, most notably pyruvate dehydrogenase complex deficiency, cytochrome c oxidase deficiency, complex I deficiency, and complex V deficiency associated with the recently described NARP point mutation. A new group of mitochondrial diseases has emerged.(ABSTRACT TRUNCATED AT 400 WORDS)