Insulin effects on glucose and potassium metabolism in vivo: evidence for selective insulin resistance in humans

Observational study of the relative efficacy of insulin-glucose treatment for hyperkalaemia in patients with liver cirrhosis

OBJECTIVES

To determine if liver cirrhosis is associated with reduced efficacy of insulin-glucose treatment in moderate to severe hyperkalaemia.

DESIGN

Retrospective, cohort study.

SETTING

Two secondary and one tertiary care hospital at a large metropolitan healthcare network in Melbourne, Australia.

PARTICIPANTS

This study included 463 adults with a mean age of 68.7±15.8 years, comprising 79 patients with cirrhosis and 384 without cirrhosis as controls, who received standard insulin-glucose treatment for a serum potassium ≥6.0 mmol/L from October 2016 to March 2020. Patients were excluded if they received an insulin infusion, or if there was inadequate follow-up data for at least 6 hours after IDT due to death, lost to follow-up or inadequate biochemistry monitoring. The mean Model for End-stage Liver Disease score in patients with cirrhosis was 22.2±7.5, and the distribution of the Child-Pugh score for cirrhosis was: class A (24%), class B (46%), class C (30%).

OUTCOME MEASURES

The primary outcome was the degree of potassium lowering and the secondary outcome was the proportion of patients who achieved normokalaemia, within 6 hours of treatment.

RESULTS

The mean pretreatment potassium for the cohort was 6.57±0.52 mmol/L. After insulin-glucose treatment, mean potassium lowering was 0.84±0.58 mmol/L in patients with cirrhosis compared with 1.33±0.75 mmol/L for controls (p<0.001). The proportion of patients achieving normokalaemia was 33% for patients with cirrhosis, compared with 53% for controls (p=0.001). By multivariable regression, on average, liver cirrhosis was associated with a reduced potassium lowering effect of 0.42 mmol/L (95% CI 0.22 to 0.63 mmol/L, p<0.001) from insulin-glucose treatment, after adjusting for age, serum creatinine, cancer, pretreatment potassium level, β-blocker use and cotreatments (sodium polystyrene sulfonate, salbutamol, sodium bicarbonate).

CONCLUSIONS

Our observational data suggest reduced efficacy of insulin-glucose treatment for hyperkalaemia in patients with cirrhosis.

Do the Levels of Maternal Plasma Trace Elements Affect Fetal Nuchal Translucency Thickness?

OBJECTIVE

Fetal nuchal translucency (NT) thickness is an important marker for prenatal screening; however, studies focusing on the correlation between maternal trace element levels and NT thickness are limited. The aim of this study was to evaluate maternal trace element levels during the first trimester and to investigate the association between maternal trace element levels and fetal NT thickness.

METHODS

In total, 113 samples were obtained from singleton pregnant women. Maternal plasma samples were collected in the first trimester of gestation. Plasma trace element levels were measured using Inductively Coupled Plasma Mass Spectrometry (ICP-MS). Nuchal translucency thickness was measured using ultrasonography at 10-14 weeks of gestation.

RESULTS

We found that maternal plasma potassium (K) levels had a significant negative correlation with both NT (r = -0.230, p < 0.05) and NT Multiples of the Median (NT MoM) (r = -0.206, p < 0.05). After adjustment for potential confounders, log-transformed maternal plasma potassium levels in the first trimester were significantly associated with fetal NT (NT MoM: β = -0.68, p < 0.05; NT: β = -1.20, p < 0.01). Although not statistically significant, the As, Hg and Pb levels in maternal plasma were positively correlated with NT, and the Mg, Cu, Zn, Na and Ca levels were negatively correlated with NT.

CONCLUSION

Maternal plasma K levels during the first trimester appeared to be associated with NT thickness. The essential elements tended to decrease NT thickness, and non-essential elements tended to increase it.

A relationship between serum potassium concentration and insulin resistance in patients with type 2 diabetes mellitus

PURPOSE

In patients with type 2 diabetes mellitus (DM), insulin-stimulated glucose uptake is impaired. However, the relationship between serum potassium concentration and insulin resistance is poorly defined. This study aimed to investigate the association between serum potassium concentration and insulin resistance in these patients.

METHODS

Between April 2009 and October 2012, 180 patients with type 2 DM were analyzed. Insulin resistance was estimated using the homeostasis model and assessment (HOMA) index; resistance was defined as an index value of >2. The association between serum potassium concentration and insulin resistance was analyzed using linear regression methods. The incidence of hyperkalemia was also evaluated during follow-up.

RESULTS

Mean serum potassium concentration was 4.12 ± 0.47 mEq/l. The median HOMA index score was 2.1 (interquartile range 1.1-3.4). When the patients were compared based on insulin resistance, serum potassium concentration was higher in the patients with insulin resistance compared with the patients without (4.25 ± 0.48 vs. 4.09 ± 0.44 mEq/l, p = 0.015). The variables found to be the determinants of serum potassium concentration included female, renal function, serum sodium level, log aldosterone-to-plasma renin activity ratio, glycosylated hemoglobin, and log HOMA index. Over a mean follow-up period of 2.6 ± 1.1 years, 37 of 180 patients (21 %) experienced episodic hyperkalemia. Patients with insulin resistance experienced episodic hyperkalemia more frequently than those without.

CONCLUSIONS

Serum potassium concentration is likely to be increased in the patients with poorly controlled type 2 DM with insulin resistance than in those without insulin resistance.

Comparison of insulin action on glucose versus potassium uptake in humans

BACKGROUND AND OBJECTIVES

Insulin has several physiologic actions that include stimulation of cellular glucose and potassium uptake. The ability of insulin to induce glucose uptake by cells is impaired in type 2 diabetes mellitus, but whether potassium uptake is similarly impaired is not known. This study examines whether the cellular uptake of these molecules is regulated in concert or independently.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Thirty-two nondiabetic and 13 type 2 diabetic subjects with normal GFR were given a similar, constant metabolic diet for 8 days. On day 9, they were subjected to a hyperinsulinemic euglycemic clamp for 2 hours. Serum and urinary chemistry were obtained before and during the clamp. Glucose disposal rate was calculated from glucose infusion rate during hyperinsulinemic euglycemia. Intracellular potassium and phosphate uptake were calculated by the reduction of extracellular potassium or phosphate content corrected for urinary excretion.

RESULTS

Although glucose disposal rate tended to be lower in type 2 diabetics, cellular potassium uptake was similar between diabetics and nondiabetics. Additionally, although glucose disposal rate was lower with increasing body mass index (R² = 0.362), cellular potassium (R² = 0.052), and phosphate (R² = 0.002), uptake rates did not correlate with body mass index. There was also no correlation between glucose disposal rate and potassium (R² = 0.016) or phosphate uptake (R² = 0.053). Conclusions Insulin-stimulated intracellular uptake of glucose and potassium are independent of each other. In type 2 diabetes, potassium uptake is preserved despite impaired glucose disposal.

Metabolic effects of a corticosteroid-free immunosuppressive regimen in recipients of pancreatic transplant

BACKGROUND

A corticosteroid (CS)-free immunosuppressive regimen may be considered less diabetogenic than treatments including CSs principally after pancreas transplantation.

METHODS

To test whether a CS-free immunosuppressive treatment is metabolically superior to a regimen including CSs, we prospectively studied 19 CS-free simultaneous pancreas and kidney (SPK) transplant recipients (body mass index=22+/-1 kg/m2; cyclosporine dose=400+/-19 mg/kg/day; azathioprine dose=77+/-8 mg/day; basal plasma C-peptide=1.3+/-0.12 ng/mL) and 12 matched CS-treated SPK transplant recipients (prednisone dose=9+/-1 mg/day; basal C-peptide=2.2+/-0.2 ng/mL) by means of the 6,6-2H(2)-glucose infusion and the euglycemic insulin clamp (1 mU/kg/min, insulin infusion rate). In addition, six renal transplant recipients receiving a CS-free regimen were also studied as a control group.

RESULTS

In the postabsorptive state, CS-treated SPK transplant recipients demonstrated comparable plasma glucose levels but higher plasma insulin levels than CS-free SPK transplant recipients. Plasma triglyceride levels were significantly higher in CS-treated SPK patients than in CS-free SPK patients (1.16+/-0.16 mg/dL vs. 0.88+/-0.08; P<0.05). High-density lipoprotein and apoprotein A(1) levels were similar in both groups. No difference was observed in pyruvate, lactate, beta-OH-butyrate, and basal endogenous glucose production in all three groups of patients studied. During euglycemic hyperinsulinemia, the inhibition of endogenous glucose production and the stimulation of tissue glucose disposal were not statistically different among the three groups.

CONCLUSIONS

SPK recipients receiving chronic low-dose CS maintenance therapy do not present a lower glucose disposal than CS-free recipients. Nonetheless, this is obtained at the expense of a higher endogenous insulin secretion, which can cause an alteration of the triglyceride profile.

Independent regulation of in vivo insulin action on glucose versus K(+) uptake by dietary fat and K(+) content

Insulin stimulates both glucose and K(+) uptake, and high-fat feeding is known to decrease insulin-stimulated glucose uptake. The purpose of this study was to examine whether insulin's actions on glucose and K(+) uptake are similarly decreased by a high-fat diet. Wistar rats were fed a standard control (12.2% fat; n = 6) or high-fat (66.5% fat; n = 13) diet for 15 days. Because K(+) content was 1% in the control and 0.5% in the high-fat diet and because the rats ate less of the high-fat diet, we also compared the high-fat diet with 0.5% K(+) (HFD; n = 7) to a high-fat diet supplemented with 1.5% K(+) (HFD+K; n = 6). K(+) intake was matched between the control and HFD+K groups (246 +/- 8 vs. 224 +/- 2 mg/day), but was lower in the HFD group (78 +/- 10 mg/day; P < 0.05). Insulin-stimulated glucose and K(+) uptake were determined by hyperinsulinemic (5 mU.kg(-1).min(-1)) glucose and K(+) clamps. The HFD depressed both insulin-stimulated glucose uptake compared to the control (133 +/- 5 vs. 166 +/- 7 micromol.kg(-1).min(-1); P < 0.05) and K(+) uptake (5.5 +/- 0.9 vs. 8.9 +/- 1.0 micromol.kg(-1).min(-1); P < 0.05) compared to the control. However, insulin-stimulated K(+) uptake was unchanged in the HFD+K versus in the control group (10.0 +/- 0.6 vs. 8.9 +/- 1.0 micromol.kg(-1).min(-1); P > 0.05), whereas insulin-stimulated glucose uptake in the HFD+K group was decreased to a rate (137 +/- 9 micromol.kg(-1).min(-1)), similar to that of the HFD group. We concluded that the decrease in insulin-stimulated K(+) uptake during high-fat feeding was a result of decreased K(+) intake, and that insulin's actions on glucose uptake and K(+) uptake are independently regulated by dietary fat and K(+) content, respectively.

Hypokalemic periodic paralysis associated with hypophosphatemia in a patient with hyperinsulinemia

A 34-year-old man was admitted to the hospital because of acute quadriplegia. On admission, serum potassium was 2.1 mEq/L and serum inorganic phosphate was 1.4 mg/dL. Thyroid function was normal. Serum levels of aldosterone, cortisol, and intact parathyroid hormone were normal. Fasting plasma glucose was 109 mg/dL, and fasting serum insulin was 25.0 U/mL. Shortly after intravenous supplementation of potassium, muscle strength was normalized. Oral glucose tolerance test revealed impaired glucose tolerance and hyperresponse of insulin. During the oral glucose tolerance test, serum potassium and phosphate decreased significantly. These findings suggest that hyperinsulinemia and insulin-induced transmembrane shift of extracellular potassium and phosphate may have been involved in the abnormalities of serum electrolytes and development of hypokalemic periodic paralysis in the present patient.

Peripheral glucose metabolism in human hyperprolactinaemia

OBJECTIVE

Prolactin has important biological actions in several species which include metabolic control and water/electrolyte balance. However, human PRL has generally been characterized as a mammotrophic hormone and it is unknown whether PRL has any important metabolic actions. This study was thus conducted to evaluate the effect of hyperprolactinaemia on peripheral muscle glucose metabolism.

DESIGN

The study was designed to determine forearm muscle glucose uptake and utilization (oxidative and non-oxidative metabolism) in normal and hyperprolactinaemic subjects in the post-absorptive state and for 3 hours after the ingestion of 75 g of glucose. Peripheral glucose metabolism was analysed by the forearm technique to estimate muscle exchange of substrates combined with local indirect calorimetry.

PATIENTS

Eight hyperprolactinaemic patients (HP group, 6 females and 2 males) and ten normal subjects (N group, 7 females and 3 males) were studied. The hyperprolactinaemic patients showed no clinical or laboratory evidence of acromegaly or hypothyroidism and were not using any PRL releasing drugs.

MEASUREMENTS

Forearm blood flow was measured by capacitance plethysmography and arterial and venous blood samples were drawn simultaneously to determine plasma glucose, serum FFA, total blood CO2 and O2 and serum insulin in the post-absorptive state (0 time) and at 30, 60, 120 and 180 minutes after glucose ingestion.

RESULTS

No significant difference in glucose uptake by the forearm muscle tissue was observed between the N and HP groups (823 +/- 103 vs 828 +/- 110 mumol/100 ml forearm 3 h, respectively), nor were any significant differences observed in the intracellular utilization of glucose (oxidative and non-oxidative metabolism). However, the serum insulin levels after glucose ingestion were significantly higher in hyperprolactinaemic patients than in normal subjects, especially at 30 (N 283 +/- 46 vs HP 581 +/- 133 pmol/l) and 60 minutes (N 291 +/- 37 vs HP 544 +/- 61 pmol/l). Furthermore, after glucose ingestion the suppression of serum FFA levels was smaller in the hyperprolactinaemic patients than in normal subjects.

CONCLUSIONS

This study demonstrated that insulin resistance is associated with the presence of spontaneous human hyperprolactinaemia. The hyperinsulinaemia detected in the hyperprolactinaemic patients after the oral glucose stimulus did not determine a proportional increase in forearm glucose uptake and utilization, which were similar to the normal levels. The suppression of serum free fatty acid concentrations was also smaller in hyperprolactinaemic patients during the oral glucose challenge, suggesting an impaired antilipolytic effect of insulin.

Lymphocytic Na(+)-H+ exchange increases after an oral glucose challenge

The effects of oral glucose challenge on plasma glucose concentration, plasma insulin concentration, arterial blood pressure, cytosolic pH (pHi), cytosolic free Na+ concentration ([Na+]i), and cellular Na(+)-H+ exchange activity were investigated in 16 healthy subjects. The pHi, [Na+]i, and Na(+)-H+ exchange activity were measured in intact lymphocytes by using the fluorescent dye technique. The oral glucose challenge significantly increased plasma glucose, plasma insulin, and the lymphocytic Na(+)-H+ exchange activity, measured as change of pHi per second (control [0 hours], 5.20 +/- 0.53 x 10(-3) dpHi/s; 1 hour after glucose administration, 8.28 +/- 1.07 x 10(-3) dpHi/s; 2 hours after glucose administration, 8.15 +/- 1.18 x 10(-3) dpHi/s; P = .002). The lymphocytic Na(+)-H+ exchange was significantly correlated with plasma glucose concentration (r = .357, P = .041). During steady state euglycemic hyperinsulinemic clamp, the Na(+)-H+ exchange activity was not significantly changed compared with baseline values. The study shows that changes of blood glucose levels can induce an acute increase in Na(+)-H+ exchange activity. Systolic blood pressure and Na(+)-H+ exchange activity were significantly (P < .001) but weakly correlated during an oral glucose challenge.

Determination of endogenous ions in intercellular fluid using capillary ultrafiltration and microdialysis probes

Capillary ultrafiltration probes are novel sampling tools for continuously monitoring small molecules in the extracellular fluid of awake animals. Capillary ultrafiltration uses a vacuum applied to hydrophilic membrane fibres and extracts intercellular fluid and quantitatively recover many small hydrophilic molecules. The effects of continuously removing a small amount of fluid from the interstitial space are not known. The concentration of sodium, potassium, calcium and inorganic phosphorus were determined in the collected ultrafiltrates from subcutaneous tissue. These values were compared to literature values and to concentrations determined for the same animals using microdialysis. The concentrations of sodium, potassium, calcium and inorganic phosphorous were found to be 140 +/- 4, 3.7 +/- 0.1, 1.1 +/- 0.1 and 1.7 +/- 0.1 mM, respectively, in the subcutaneous ultrafiltrates obtained from rats. These corresponded very well with literature values and microdialysates, obtained, using pure water as the perfusate, in subcutaneous tissue. The concentration of sodium and potassium were determined to be 142 +/- 2 mM and 3.6 +/- 0.2 mM, respectively, for the dialysates. Hyperinsulinemic-induced decrease in intercellular potassium levels under a euglycemic clamp were monitored using capillary ultrafiltration probes in rats to further validate this technique for monitoring small molecule dynamics in the intercellular space. The intercellular level of potassium in rats decreased from 3.6 +/- 0.5 to 2.6 +/- 0.3 mM after an acute dose of pork insulin.