Hepatic steatosis and the elevated plasma insulin level in patients with endogenous hypertriglyceridemia

Among 31 nonobese or obese patients with endogenous hypertriglyceridemia, hepatic steatosis was found by histologic examination of the biopsied specimen in 17 patients, and it was severe in six patients. They had no history of excessive alcohol intake. Chemical analysis revealed that the lipid accumulated in the liver was triglyceride. The hypertriglyceridemic patients, with or without histologic steatosis, showed significantly increased responses of both plasma insulin and blood glucose to oral glucose load compared with control subjects. The responses were more exaggerated in the hypertriglyceridemic patients with steatosis than in the hypertriglyceridemic patients without steatosis. Analysis of correlations between five variables (liver triglyceride, plasma insulin, blood glucose, body weight index, and serum triglyceride) was done on 15 subjects whose liver triglyceride values were quantified, and highly significant correlations were found between liver triglyceride and plasma insulin, blood glucose, or body weight index. A stepwise multiple regression analysis performed on the five variables with liver triglyceride as the dependent variable revealed that the plasma insulin level was the most closely related variable, and the blood glucose level the next. The prediction equation for liver triglyceride as a function of plasma insulin and blood glucose levels (r = 0.91, p < 0.001) accounted for 84% of the total variance of liver triglyceride. It was shown that the decay of intravenously injected insulin in plasma was not delayed in the hypertriglyceridemic patients with steatosis, while the insulin sensitivity examined after intravenous insulin injection significantly decreased in the hypertriglyceridemic patients with or without steatosis, thus suggesting that the hyperinsulinemia in the hypertriglyceridemic patients was due to an increased insulin secretion associated with the decrease in the insulin sensitivity. Therefore, the elevated plasma insulin and blood glucose levels—or the insulin insensitivity by itself—might be the essential abnormalities in patients with endogenous hypertriglyceridemia, which, in extreme cases, might lead to massive triglyceride accumulation in the liver.     

Werner's syndrome: in vivo and in vitro characteristics as a model of aging.

Three patients who suffered from Werner's syndrome were studied to help to elucidate differences from and/or analogies to both clinical symptoms and biochemical changes in normal aging. Our patients commonly manifested graying of hair, atrophy and hyperkeratosis of the skin, cataracts and hypogonadism. Such alterations would appear to be analogous to normal aging phenomena. However, the types of cataracts, degree of skin changes and growth retardation in Werner's syndrome differed from the normal aging phenomena.Studies of endocrine functions in our patients did not show definite evidence of generalized hypopituitarism and impaired function of hormone secretion. Resistance to hormones human cholionic gonadotropin (hCG), luteinizing hormone-releasing hormone (LH-RH) and insulin was observed, suggesting a possible alteration of a diversity of proteins which may affect hormone receptors.Immunologic aspects were also studied, since the genetically programmed failure of thymic function could play a major role in the pathogenesis of aging and age-related diseases. Our results in three patients did not indicate any definite immunologic abnormalities.Culture studies showed that skin fibroblasts in Werner's syndrome exhibited more decreased potentials of in vitro clonal growth and elongation of newly synthesizing DMA as phenotypic expressions than did normal skin cells. Yet, in Werner's syndrome, cells repaired DNA damage normally. The relationship of these findings to the basic genetic defect of Werner's syndrome remains unknown.     

Altered insulin and glucagon secretion in treated genetic hyperlipemia: A mechanism of therapy?

The influence of Halofenate therapy on insulin and glucagon secretion was examined in the Zucker rat with genetic endogenous hyperlipemia. Coincident with the lipid lowering effects of Halofenate, the net change in the basal bihormonal axis favored glucagon, with the I/G molar ratio (Insulin/Glucagon) decreasing from 2.72 +/- 0.53 to 0.96 +/- 0.20 during treatment with this drug. Following arginine stimulation the I/G ratio remained reduced at 0.87 +/- 0.13 in Halofenate treated animals, contrasting with the statistically greater ratio of 2.5 +/- 0.55 in control animals. The Halofenate induced state of reduced insulin:glucagon was associated with hypolipemia, postarginine hyperglycemia, and hyperketonemia,-three metabolic parameters characteristic of glucagon excess relative to insulin. It is suggested that the lipid-lowering action of Halofenate in genetic hyperlipemia may reflect the altered bihormonal axis induced by the drug.     

Amino acid metabolism in parenteral nutrition: With special reference to the calorie: Nitrogen ratio and the blood urea nitrogen level

A clinical and experimental study was made on amino acid metabolism during parenteral nutrition with glucose and a synthetic amino acid solution. Good correlation was noted between the calorie: nitrogen ratio of the infusate and the blood urea nitrogen level, as well as between the calorie: nitrogen ratio and the amount of urinary excretion of urea nitrogen, nonprotein nitrogen, and amino nitrogen. Final results revealed that the extent to which amino acid is utilized for protein synthesis is directly proportional to the caloric supply, and for complete utilization of 1 g of nitrogen the required caloric intake is in the neighborhood of 450 total calories or 425 nonprotein calories. Blood urea nitrogen level can be used as a parameter of amino acid utilization during parenteral nutrition. Its level is influenced not only by renal function but also by calorie: nitrogen ratio of infusate.     

Effect of vasoactive intestinal polypeptide infused intrapancreatically on glucagon and insulin secretion

Synthetic vasoactive intestinal polypeptide (VIP) was infused at a dose of 50 ng/kg/min for 10 min into the cranial pancreaticoduodenal artery in anesthetized dogs. Both mean blood flow and plasma glucagon concentration in the cranial pancreaticoduodenal vein were significantly enhanced during the infusion, indicating a great augmentation in glucagon output. The pancreatic venous plasma concentration of insulin was not significantly raised, but its output increased during the infusion, again due to the increase in plasma flow. Plasma concentration of glucagon in the femoral artery was not significantly augmented, whereas that of insulin was enhanced during VIP infusion. Mean arterial plasma glucose levels rose gradually during the infusion. Intrapancreatic pretreatment with propranolol failed to exert any significant inhibiting effect upon the VIP-induced enhancement in plasma glucose, pancreatic venous blood flow, or bihormonal output. These results suggest that the vasoactive polypeptide of intestinal origin may regulate the function of the endocrine pancreas and that this effect may not be mediated mainly via the β-adrenergic receptor system.     

Incorporation of orally administered glucose-U-14C and fructose-U-14C into the triglyceride of liver, plasma, and adipose tissue of rats

Male rats, fasted for 5–6 hr, were given glucose-U-¹⁴C or fructose-U-¹⁴C, with their respective carrier, by intragastric instillation. Sequential radioactivity in plasma carbohydrates and in the triglyceride of the liver, plasma, and adipose tissue and plasma immunoreactive insulin and free fatty acids were measured. The validity of taking the triglyceride labeling rate as the triglyceride synthesis rate was tested by measuring the metabolic activity of endogenous glucose. Two or three times greater radioactivity was found in the liver and plasma triglycerides after fructose than after glucose while the reverse was true for adipose tissue. The greater radioactivity in triglyceride of the liver and plasma after fructose was mainly due to triglyceride-glycerol radioactivity. The greater radioactivity in adipose tissue triglyceride was due to the radioactivity of both triglyceride-fatty acids and triglyceride-glycerol. Three hours after glucose, 92% of the total radioactivity in triglyceride was in adipose tissue and 8% was in the liver. However, 3 hr after fructose, 57% of the radioactivity was in adipose tissue and 42% was in the liver. Daily repetition of such a pattern of fructose handling may lead to abnormal metabolism of endogenous triglyceride.     

Urinary excretion of carnitine in patients with hyperthyroidism and hypothyroidism: Augmentation by thyroid hormone

Urinary excretion of carnitine and serum concentrations of carnitine, triglyceride, and free fatty acids were measured in 54 hyperthyroid and 13 hypothyroid patients, and the results were compared with those of normal subjects. In hyperthyroid patients urinary excretion of carnitine was highly increased above that of the control subjects. On adequate treatment with antithyroid drug, carnitine excretion was reduced to the normal range, and serum lipids changed in parallel. In contrast, carnitine excretion was markedly reduced in hypothyroid patients. After substitution therapy with thyroid hormones the excretion increased in these patients. This change was associated with a marked reduction of serum triglyceride. There was an inverse correlation between urinary excretion of carnitine and serum triglyceride concentration. Carnitine excretion was significantly correlated with serum thyroxine concentration in hyper- and hypothyroid patients. The results suggest that thyroid hormones play an important role in carnitine metabolism, which in turn influences serum triglyceride metabolism.     

Permissive role of thyrotropin on thyroid radioiodine uptake during the recovery phase of subacute thyroiditis

Serial measurements of serum triiodothyronine (T₃), thyroxine (T₄), thyrotropin (TSH), and 4-hr thyroidal ¹³¹I uptake were carried out in nine patients with subacute thyroiditis. In the acute phase, suppressed TSH and ¹³¹I uptake were observed simultaneously with the elevations of T₃ and T₄. Thyrotropin-releasing hormone (TRH) failed to increase TSH in all patients studied. The mean value of an increment in serum TSH was only 1.8 μU/ml during the recovery phase when ¹³¹I uptake was normal or hyper-normal. In addition, and elevated ¹³¹I uptake was not necessarily associated with an immediate increase in the serum T₃ and T₄. These observations suggest that the resumption of the iodide pump may be more important than an increment in TSH in producing normal or hypernormal ¹³¹I uptake during the recovery phase. There appears to be a dissociation between the reestablishment of ¹³¹I uptake and the resumption of the mechanism of hormonal synthesis and secretion in the thyroid.     

Investigation of insulin resistance during diabetic ketoacidosis: role of counterregulatory substances and effect of insulin therapy.

It has been generally accepted that insulin resistance (IR) exists in diabetic subjects during episodes of ketoacidosis (DKA). However, little experimental data exist regarding this question. We have studied IR in nine untreated diabetic subjects (mean age 20 yr) both during their initial episode of DKA and after 2–7 wk of insulin therapy. The experimental protocol consisted of a 150-min intravenous infusion of glucose (6 mg/kg/min) and insulin (80 mU/min). Under these conditions steady-state plasma glucose (SSPG) and insulin (SSPI) levels were reached by 90 min and maintained for the duration of the study. Since all subjects achieved similar SSPI and all received the same glucose load, the SSPG could be used as a measure of an individual's IR. In addition, steady-state plasma levels of glucagon, cortisol, growth hormone, and free fatty acids were measured in an attempt to gain insight into their roles in the maintenance of IR during DKA. Although mean (± SE) SSPI levels were the same during both study periods (93 ± 4 versus 92 ± 4 μU/ml), there was a marked difference between the initial and posttherapy SSPG levels for the nine subjects 342 ± 32 versus 104 ± 16 mg/100 ml,p < .001). Mean steady-state plasma levels of growth hormone, corticol, and free fatty acids were significantly higher during the initial studies, but only cortisol and free fatty acid levels correlated significantly with their corresponding SSPG levels. Steady-state plasma glucagon levels were the same during both study periods, and individual levels did not correlate with associated SSPG levels. These studies demonstrate that significant IR was present in these subjects during DKA as compared to the posttherapy period. Furthermore, the results suggest that while increased plasma concentrations of cortisol and free fatty acids may be involved in the maintenance of IR during DKA, elevated levels of plasma growth hormone and glucagon are not necessary for this phenomenon.     

The glucagon receptor and adenylate cyclase.

Acidic phospholipids play a critical role in the hormone activation of adenylate cyclase. Solubilized myocardial adenylate cyclase is unresponsive to glucagon and the catecholamines, two of the hormones which activate the membrane-bound enzyme. Phosphatidylserine, purified from bovine brain restored glucagon responsiveness of the solubilized adenylate cyclase. Monophosphatidylinositol, also purified from bovine brain, restored catecholamine responsiveness. Solubilized preparations of myocardial adenylate cyclase bind 125-I-glucagon either in the presence of added phosphatidylserine, thereby providing a clear separation of the processes of activation and binding. Solubilized myocardial adenylate cyclase has a molecular weight of about 160,000. Sephadex G-100 chromatography of the solubilized enzyme following the binding of 125-I-glucagon to its myocardial receptor reveals two distinct peaks; one, having catalytic activity and a molecular weight greater than 100,000 and two, the binding material having no catalytic activity and a molecular weight of 24,000-28,000. These data are consistent with the presence of a dissociable glucagon receptor site. The role of this dissociation in the activation-inactivation of the enzyme remains to be explored. It is postulated that phospholipids induce the required configurational change in the catalytic site following the binding of hormone to its receptor, and by this means couples the receptor to the catalytic site. This model may be applicable to certain clinical situations. Cardiac adenylate cyclase is unresponsive to glucagon in chronic congestive heart failure. The defect may reside either in the binding of glucagon to its receptor site or in the metabolism of a specific acidic phospholipid such as phosphatidylserine.     

Urinary excretion of carnitine and serum concentrations of carnitine and lipids in patients with hypofunctional endocrine diseases: involvement of adrenocorticoid and thyroid hormones in ACTH-induced augmentation of carnitine and lipids metabolism.

The promoting effect of ACTH on carnitine and lipid metabolism was studied in patients with various endocrine hypofunctions. The results were compared with those of normal subjects. In adrenocortical insufficiency, hypothyroidism and hypopituitarism urinary excretion of carnitine was significantly lower than in normal subjects. On intramuscular injection of synthetic beta1-24 ACTH-Z urninary excretion of carnitine in normal subjects increased sixfold on the day of the injection and returned to the pretreatment level on the third day. Serum concentrations of carnitine and FFA increase in parallel with carnitine excretion, while serum triglyceride was lowered in response to ACTH administration. These responses were totally lacking or substantially suppressed in patients with the above endocrine insufficiencies. In hypothyroid and hypopituitary patients substitution therapy restored the responses to ACTH in the same fashion as those in normal subjects. These findings suggest that the promoting effect of ACTH on carnitine and lipid metabolism requires the presence of intact adrenocortical and thyroid functions.     

Exocrine and endocrine pancreatic function in rats treated with alpha-glucosidase inhibitor (acarbose)

Pancreatic exocrine and endocrine secretory dynamics were studied in the isolated perfused pancreata of rats fed a normal diet or a diet supplemented with the alpha-glucosidase inhibitor, acarbose (150 mg/100 g food). After 10 days, the body weight of acarbose-treated rats was slightly lower than that of the control rats despite a larger food intake. Pancreatic amylase levels were significantly decreased, trypsinogen levels were significantly increased, and lipase levels were unaltered in the treated group compared with the controls. Basal and caerulein-stimulated flow rates of pancreatic juice as well as basal amylase output were similar in both groups, whereas caerulein-stimulated amylase output was significantly lower in the acarbose-treated group. Secretory responsiveness of amylase in the treated group was, however, about twice as high as that in the control group when related to pancreatic amylase content. Insulin release in response to either glucose or cerulein was similar in both groups. These findings indicate that treatment with acarbose may alter pancreatic enzyme content without changing the secretory responsiveness of either the exocrine or endocrine pancreas.     

Effect of contraceptive steroids on arginine-stimulated glucagon and insulin secretion in women: I-Lipid physiology.

To evaluate the effect of contraceptive steroids on endogenous glucagon and insulin secretion, theta-arginine was infused intravenously in normal young women before and during selective steroid treatment. The effect of the combination of an estrogen derivative (mestranol), plus norethindrone (Norinyl, Syntex) was compared to the effect of ethinyl estradiol alone and to norethindrone alone. All three steroid schedules resulted in suppression of aminogenic insulin secretion. However, glucagon secretion was reduced only with ethinyl estradiol alone or the combination of mestranol plus norethindrone. In accordance with previous reports, treatment with an ethinyl estradiol derivative alone or in combination with norethindrone resulted in a tendency for elevated serum lipid concentration, while norethindrone alone resulted in a significant reduction in serum lipid concentration. These observations suggest an inverse relationship between aminogenic glucagon secretion and serum lipid concentration as influenced by contraceptive steroids. It is suggested that the metabolic effects of these steroids may be mediated in part by the associated alterations in pancreatic hormone secretory capacity.     

Effect of bombesin infused intrapancreatically on glucagon and insulin secretion

Synthetic bombesin was infused at a dose of 20 pmoles/kg/min for 10 min into the cranial pancreaticoduodenal artery of anesthetized dogs. Plasma immunoreactive glucagon concentrations in the cranial pancreaticoduodenal vein as well as in the femoral artery were concurrently and slowly elevated. However, the net release of glucagon from the pancreas did not increase significantly during infusion of bombesin. Plasma immunoreactive insulin concentrations in the pancreatic vein were transiently raised, and a delayed rise was noted in arterial plasma IRI. Net release of insulin was significantly augmented during infusion of the tetradecapeptide. Plasma glucose levels did not change after bombesin. These results indicate that the gastrointestinal tetradecapeptide may stimulate secretion of both insulin and gut glucagonlike immunoreactivity in the dog.     

Effect of clofibrate on arginine-stimulated glucagon and insulin secretion in man

Insulin and glucagon have been reported to have opposing effects upon the mechanisms regulating serum triglyceride concentration. Glucagon in excess of insulin will lower serum lipids in man. In the present studies, we have examined the possibility that a change in glucagon and insulin regulation might contribute to the hypolipemic action of the drug clofibrate. Control insulin and glucagon secretion were evaluated in 24 normal subjects by intravenous arginine infusion, which resulted in a prompt rise in both serum immunoreactive insulin and glucagon concentration. During the maximum rise in concentration of these hormones, plasma triglyceride concentration was acutely reduced from basal levels of $\text{104 ± 6}\text{mg}\text{100}\text{ml}$ to $\text{75 ± 5}\text{mg}\text{100}\text{ml}$ (p ≤ 0.001). Following 7 days of clofibrate therapy, basal plasma triglyceride concentration attained a new mean level of $\text{78 ± 5}\text{mg}\text{100}\text{ml}$, while basal insulin and glucagon concentrations remained unchanged. However, arginine infusion now resulted in a reduction of the insulin secretory response to 56% of the preclofibrate studies with an associated normal glucagon secretory response. Serum triglyceride concentration was further reduced during arginine infusion to $\text{46 ± 3}\text{mg}\text{100}\text{ml}$, demonstrating this minimum level as maximum plasma glucagon levels were attained, representing an excess of this hormone relative to the reduced insulin concentration. These observations are consistent with an effect of clofibrate on the hormonal regulation of triglyceride physiology in man. Glucose tolerance was unimpaired by clofibrate therapy in these normal subjects, in spite of an apparent reduction in glucose-stimulated insulin secretion.     

Effect of contraceptive steroids on arginine- stimulated glucagon and insulin secretion in women. II. Carbohydrate and lipid physiology in insulin-dependent diabetics.

The effect of contraceptive steroids on aminogenic glucagon secretion was studied in six insulin-dependent diabetic women. After 2 wk treatment with combined mestranol (80 mug) plus norethindrone (1 mg) daily, the mean peak plasma glucagon response to arginine infusion was suppressed to one-fourth of control levels. This was associated with a small but significant decrease in mean basal plasma cholesterol concentrations. There were no changes in basal plasma triglyceride, free fatty acid, glucose, insulin, or alpha-amino nitrogen concentrations or in daily insulin requirements during mestranol plus norethindrone treatment. These results confirm previous reports of no consistent changes in the insulin requirements of insulin-dependent diabetic women using contraceptive steroids and suggest that these women may not experience dramatic changes in their lipid metabolism during contraceptive therapy.     

Effects of ethanol ingestion on glucose tolerance and insulin secretion in normal and diabetic subjects

To investigate the effect of ethanol on carbohydrate homeostasis in circumstances in which food and ethanol are usually ingested, ethanol was administered hourly in the afternoon prior to the ingestion of a glucose load at 5:00 p.m. in a group of normal subjects and in mild diabetics. In both groups the blood glucose levels following the glucose load were $\text{30–80 mg}\text{100 ml}$ lower and the early insulin secretory response (15–45 min) was 35%–40% higher after ethanol ingestion. In contrast, ethanol intake had no effect on the glucagon response to glucose ingestion. These data suggest that ethanol enhances glucose-stimulated insulin secretion. The dampened blood glucose rise observed with ethanol may be related to the augmented insulin response or to decreased gastrointestinal absorption of glucose. In mild diabetic patients, moderate intake of ethanol is without acute deleterious effects on carbohydrate homeostasis and may in some instances improve the blood glucose response to ingested carbohydrate.     

Insulin and glucagon relationships during aging in man

To determine if the glucoregulatory hormones, insulin and glucagon, are altered with aging in man, 44 healthy volunteers, 22–81 yr of age, were evaluated by measurement of basal levels of glucose, insulin, and glucagon in relationship to their fat mass. In addition, the secretory capacities of the alpha and beta cells were assessed by measurement of the amounts of glucagon and insulin released after intravenous administration of glucose and arginine, respectively. Although no significant differences in weight could be distinguished longitudinally, the percentage adiposity was found to increase with age. Basal concentrations of glucose, glucagon, and insulin were not appreciably altered as a function of advancing years. After intravenous glucose, the glucose disappearance rate (K_g) was significantly slower in the elderly in comparison with the young, yet no differences in glucose-induced release were found. Similarly, insulin responses after arginine infusion between young and old were indistinguishable. The release of glucagon in response to arginine infusion was not perceptibly altered during aging. Thus, despite a decline in K_g with advancing age in this healthy population, gross changes in insulin and glucagon release were not apparent. We infer from these data that decreased carbohydrate tolerance accompanying aging in some populations may be due to factors other than abnormalities in secretion of insulin and glucagon.     

Effect of hypoglycemia on extracellular levels of cyclic AMP in man.

This study was designed to assess the response of cyclic AMP to "endogenous" hormonal stimulation resulting from insulin-induced hypoglycemia. Insulin was administered to four normal subjects and four adrenalectomized patients. Hypoglycemia resulted in four-fold increases in plasma cyclic AMP. This response is thought to be secondary to beta-adrenergic stimulation for the following reasons: (1) the response was absent in adrenalectomized, cortisol-treated subjects; (2) it was abolished by propranolol; and (3) urinary excretion of cyclic AMP did not reflect the rise in plasma cyclic AMP.