The effect of systemic venous drainage of the pancreas on insulin sensitivity in dogs.

To assess the metabolic consequences of the diversion of the pancreatic venous drainage to the systemic circulation, the pancreaticoduodenal and gastrosplenic veins were anastomosed to the inferior vena cava in nine normal dogs. This procedure maintained the integrity of the entire pancreas while shunting the hormonal output of the pancreas to the periphery. The metabolic effects were assessed from the sensitivity to insulin during a euglycemic hyperinsulinemic glucose clamp using an insulin infusion of 800 microU/kg per min. The studies were controlled by their duplication in seven dogs identically treated but with the pancreatic veins reanastomosed to the portal vein. No differences in systemic insulin levels or insulin sensitivity before and after surgery were seen under these circumstances. After diversion, however, basal insulin levels rose from 4.5 +/- 1.0 to 11.5 +/- 2.5 microU/ml. Basal glucose metabolic clearance rate (MCR) rose to 3.0 +/- 0.4 from 2.0 +/- 0.3 ml/kg per min. On insulin infusion, maximal stimulation of MCR within the 2-h infusion period was to 15.2 +/- 2.5 ml/kg per min preoperatively and to 7.2 +/- 0.8 ml/kg per min after diversion. Using ratios of MCR-to-insulin concentration as an index of insulin sensitivity, it was demonstrated that this index decreased by at least 50% after diversion. These data imply that portal venous drainage of the pancreas is an important factor in the determination of peripheral insulin sensitivity.

The effects of ingested and intravenous glucose on forearm uptake of glucose and glucogenic substrate in normal man.

The forearm uptake of glucose, lactate, and alanine was determined in overnight fasted man following both oral glucose loading and the intravenous (i.v.) infusion of glucose in an absorption pattern. Arterial glucose concentrations were lower following oral than following i.v. loading and forearm glucose uptake was 50% higher after oral glucose. Arterial insulin levels were higher in the first 2 h during oral loading. Forearm lactate and pyruvate production did not change significantly during glucose administration by either route so that the increased plasma levels are due to splanchnic production.

Effects of metformin on lactate uptake and gluconeogenesis in the perfused rat liver.

To directly assess the effects of the biguanide, metformin, on hepatic gluconeogenesis, it was added at high therapeutic levels (90 microg/ml) to the medium perfusing an isolated rat liver. Lactate (1 mg/min) was infused simultaneously along with [14C]lactate with or without [3H]lactate. [6-(3)H]glucose was added at the beginning of the perfusion in studies where [3H]lactate was not infused. Glucose levels decreased relative to control studies (metformin dose = 0) and lactate concentrations increased in this closed system. Quantitative analysis of the relationship between labeled glucose and lactate indicated that the flux of carbon from lactate to glucose and CO2 was halved, whereas reflux from glucose to lactate increased by approximately 80%. This was corroborated by measurement of labeled lactate extraction as well as glucose, CO2, and lactate production across the liver. Glycogen content of the liver fell by 60% relative to control and was greater for the gluconeogenic pathway. These data are consistent with an inhibitory action of metformin on gluconeogenesis, which is due to a primary inhibition of hepatic lactate uptake.

The effects of an alpha-glucoside hydrolase inhibitor on glycemia and the absorption of sucrose in man determined using a tracer method.

Acarbose, an alpha-glucosidase inhibitor, lowers the glycemic excursion following the ingestion of carbohydrates, in particular, sucrose. This was confirmed with increasing doses of acarbose (0, 50, and 100 mg) and the causes investigated. The absorption of the glucose moiety of sucrose was determined from plasma tracer concentrations when overnight-fasted normal subjects received a 100-g oral sucrose load labeled with sucrose [(1-14C]glucose and a simultaneous intravenous infusion of [3-3H]glucose. As the dose of acarbose given with the sucrose load was increased from 0 to 100 mg, the percentage of the load appearing in the peripheral circulation decreased from 90% to 62%. Malabsorption was confirmed by the appearance of breath hydrogen. Simultaneously, absorption time increased from 243 to 411 min. Maximal glycemic excursions were therefore lowered from 64 to 31 mg/dl. The plasma concentrations of gastric inhibitory polypeptide and insulin decreased with the acarbose dose so that the fractional disappearance rate of glucose also decreased. However, the concentrations of glucagon-like immunoreactivity (GLI) rose, confirming the ileal appearance of malabsorbed sucrose.

Galanin inhibits insulin secretion and induces hyperglycemia in dogs.

Intravenous administration of galanin into fasted conscious dogs produced a dose-dependent hyperglycemia accompanied by decreases in plasma insulin levels, but with no elevation of plasma glucagon levels. Galanin infusions produced greater parenteral glucose-induced rises in plasma glucose levels along with markedly blunted insulin responses compared with glucose and insulin responses to control glucose infusions. Immediately after cessation of the galanin infusions, elevation of plasma insulin levels occurred in the basal state and after parenteral glucose loading. These results suggest that galanin's hyperglycemic activity is predominantly mediated by a reversible inhibition of insulin secretion.

Bioavailability and bioeffectiveness of subcutaneous human insulin and two of its analogs--LysB28ProB29-human insulin and AspB10LysB28ProB29-human insulin--assessed in a conscious pig model.

In this study, human insulin was compared with two of its analogs--LysB28ProB29-human insulin and AspB10LysB28ProB29-human insulin-with respect to bioavailability and metabolic effectiveness. Absorption from the subcutaneous site was determined using kinetic parameters from the washout curve, following intravenous infusion of insulin or analog. Absorption was found to be more rapid for the two analogs, with 90% absorption by 100 min for the analogs and by 180 min for insulin. Total absorption was 97 +/- 10% for insulin, 99 +/- 7% for LysB28ProB29-human insulin, and 93 +/- 12% for AspB10LysB28ProB29-human insulin. Bioactivity was assessed from the glucose infusion and using tracer-determined metabolic clearance rates (MCRs) and glucose production rates. The fractional glucose requirements (relative to the total amount infused) increased more rapidly for the two analogs than for insulin, with 50% of the glucose infused by 105 min for both analogs vs. 145 min for insulin. The total amount of glucose required was, however, significantly less (19.7 +/- 1.5 mmol/kg) for AspB10LysB28ProB29-human insulin than for either LysB28ProB29-human insulin (25.9 +/- 3.0 mmol/kg) or human insulin (27.8 +/- 2.6 mmol/kg). The glucose requirements were reflected in a lower MCR for AspB10LysB28ProB29-human insulin but equivalent decreases in the rates of glucose production. Thus both analogs demonstrated more rapid rates of absorption, onset, and termination of action, but were not completely bioequivalent, with AspB10LysB28ProB29-human insulin demonstrating a 25% decrease in bioactivity.

Effect of acarbose on insulin sensitivity in elderly patients with diabetes.

OBJECTIVE: To study the effect of acarbose, an alpha-glucosidase inhibitor, on insulin release and insulin sensitivity in elderly patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: Elderly patients with type 2 diabetes were randomly treated in a double-blind fashion with placebo (n = 23) or acarbose (n = 22) for 12 months. Before and after randomization, subjects underwent a meal tolerance test and a hyperglycemic glucose clamp study designed to measure insulin release and sensitivity. RESULTS: After 12 months of therapy there was a significant difference in the change in fasting plasma glucose levels (0.2 +/- 0.3 vs. -0.5 +/- 0.2 mmol/l, placebo vs. acarbose group, respectively; P < 0.05) and in incremental postprandial glucose values (-0.4 +/- 0.6 vs. -3.5 +/- 0.6 mmol/l, placebo vs. acarbose group, P < 0.001) between groups. There was a significant difference in the change in HbA(1c) values in response to treatment (0.4 +/- 0.2 vs. -0.4 +/- 0.1%, placebo vs. acarbose group, P < 0.01). The change in fasting insulin in response to treatment (-2 +/- 2 vs. -13 +/- 4 pmol/l, placebo vs. acarbose group, P < 0.05) and incremental postprandial insulin responses (-89 +/- 26 vs. -271 +/- 59 pmol/l, placebo vs. acarbose group, P < 0.01) was also significantly different between groups. During the hyperglycemic clamps, glucose and insulin values were similar in both groups before and after therapy However, there was a significant difference in the change in insulin sensitivity in response to treatment between the placebo and the acarbose groups (0.001 +/- 0.001 vs. 0.004 +/- 0.001 mg/kg x min(-1) [pmol/l](-1), respectively, P < 0.05) CONCLUSIONS: Acarbose increases insulin sensitivity but not insulin release in elderly patients with diabetes.

Physicochemical basis for the rapid time-action of LysB28ProB29-insulin: dissociation of a protein-ligand complex.

The rate-limiting step for the absorption of insulin solutions after subcutaneous injection is considered to be the dissociation of self-associated hexamers to monomers. To accelerate this absorption process, insulin analogues have been designed that possess full biological activity and yet have greatly diminished tendencies to self-associate. Sedimentation velocity and static light scattering results show that the presence of zinc and phenolic ligands (m-cresol and/or phenol) cause one such insulin analogue, LysB28ProB29-human insulin (LysPro), to associate into a hexameric complex. Most importantly, this ligand-bound hexamer retains its rapid-acting pharmacokinetics and pharmacodynamics. The dissociation of the stabilized hexameric analogue has been studied in vitro using static light scattering as well as in vivo using a female pig pharmacodynamic model. Retention of rapid time-action is hypothesized to be due to altered subunit packing within the hexamer. Evidence for modified monomer-monomer interactions has been observed in the X-ray crystal structure of a zinc LysPro hexamer (Ciszak E et al., 1995, Structure 3:615-622). The solution state behavior of LysPro, reported here, has been interpreted with respect to the crystal structure results. In addition, the phenolic ligand binding differences between LysPro and insulin have been compared using isothermal titrating calorimetry and visible absorption spectroscopy of cobalt-containing hexamers. These studies establish that rapid-acting insulin analogues of this type can be stabilized in solution via the formation of hexamer complexes with altered dissociation properties.

Insulin sensitivity and its measurement: structural commonalities among the methods.

Insulin is the principal hormone of metabolic regulation. Reduced responses to insulin constitute an underlying feature of type 2 diabetes. It is, therefore, incumbent on those who work in this area (as well as many others) to characterize this response, in as simple and consistent a way as possible, so that this measure can be used both in the investigational and clinical setting. This type of approach, although eminently useful, is necessarily an oversimplification. Not only does insulin sensitivity change in pathological situations, but also in normal physiology. Tissue-specific, metabolite-specific, as well as process-specific responses may be expected to occur. Variations also occur in time-depending on the physiological state of the individual (e.g. pregnancy, aging) or following diurnal rhythms. It is perhaps remarkable that any consistent assessment of overall insulin sensitivity can be made. The observation that this can often be achieved has led to hypotheses suggesting that sensitivity to insulin is primarily determined at a single site (tissue, metabolite). At the same time, there are many discussions about the inconsistencies inherent in different approaches to the measurement of this parameter, suggesting that some of these variants, metabolic or otherwise, could lead to the low correlation between methods sometimes seen. Nevertheless, most methods used in the assessment of insulin sensitivity examine the response to insulin of a single metabolite, glucose, primarily in the muscle and liver, and under fasting conditions and should, therefore, demonstrate insulin sensitivity that is comparable among methods.

Comparison of the continuously calculated fractional splanchnic extraction of insulin with its fractional disappearance using a new double-tracer technique.

These studies were designed to calculate the fractional disappearance rate (FDR) and splanchnic extraction of insulin in response to an exogenous (intraperitoneal) input of insulin. A double-tracer technique using insulin tritiated on both the A1 and B1 positions was introduced for the measurement of hepatic extraction. The A1 tracer, not previously characterized in vivo, was compared in terms of its kinetics with H3-B1-insulin and unlabeled insulin. The metabolic clearance rates (MCR) of the three insulins were identical, as were the decay curves of the two tracers. To measure splanchnic insulin extraction, one tracer was infused systemically to evaluate the FDR of insulin, and the second was infused into the splanchnic circulation (superior mesenteric artery) and its peripheral appearance was calculated. Splanchnic extraction was determined from the difference between this rate of appearance and the rate of infusion of the mesenteric tracer. After intraperitoneal insulin injection, insulin levels increased to peaks of 549 +/- 93 microU/mL (portal vein) and 473 +/- 99 microU/mL (inferior vena cava) and decreased to basal levels over 3 hours. The FDR decreased from 0.295 +/- 0.051 min-1 to 0.125 +/- 0.026 min-1, and splanchnic extraction decreased from 0.534 +/- 0.06 to 0.232 +/- 0.088. The latter returned to near-basal values more rapidly than did the FDR. In conclusion, the kinetics of insulin both in and out of the steady state have been shown to be nonlinear through physiological insulin concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)

Initial splanchnic extraction of ingested glucose in normal man.

Estimates of initial splanchnic uptake of ingested glucose and the concomitant suppression of endogenous glucose production were obtained in man by validated tracer techniques for non--steady-state turnover measurement. Nine normal volunteers (18--44 yr old) fasted overnight received intravenous infusions of tracer (3-3H-glucose or 1-14C-glucose) and a low (45 +/- 1 g) or high (96 +/- 5 g) oral load of glucose labeled with an alternative tracer (1-14C-glucose or 2-2H-glucose). A two-compartment model was used to derive rates of peripheral appearance (Ra) of glucose from all sources (total) and the Ra of ingested glucose. Ra (total glucose) and Ra (ingested glucose) were integrated from the first appearance of ingested glucose until the basal Ra (total glucose) or 116 +/- 6 (SEM) mg/min was reattained. The total amount of glucose reaching the systemic pool in this time was 95 +/- 4 g and 46 +/- 3 g with high and low doses, respectively. Of these quantities 86 +/- 4 g and 40 +/- 3 g originated in the oral glucose, representing 90% +/- 4% of the administered glucose. The remainder (11% +/- 2% of the total) represented endogenous production, suppressed by 66% +/- 6% relative to basal. Sequestration of ingested glucose and subsequent release did not take place during the study since identical results were obtained with ingested 1-14C-glucose or 2-3H-glucose. The latter label would have been lost if the glucose had entered the hexose--phosphate pool. Thus, in normal man approximately 90% of an ingested glucose load is absorbed and passes through the liver to appear in the systemic pool.

Hyperglucagonemia in liver cirrhosis with portal-systemic venous anastomoses: responses of plasma glucagon and gastric inhibitory polypeptide to oral or intravenous glucose in cirrhotics with normal or elevated fasting plasma glucose levels.

Plasma immunoreactive glucagon (IRG) was examined in volunteers with biopsy-proven cirrhosis of the liver after recovery from surgical portal--caval anastomosis. A wide range of increased total plasma IRG concentrations was found after overnight fast in groups of cirrhotic subjects with and without fasting hyperglycemia. Gel filtration chromatography of plasma showed a major component in the 3500-mol wt fraction in all cases so studied. Administration of glucose i.v. caused rapid suppression of total plasma IRG in normoglycemic and non-insulin-dependent hyperglycemic cirrhotic subjects. After administration of oral glucose, total plasma IRG was suppressed rapidly in normoglycemic cirrhotic subjects, while non-insulin-dependent hyperglycemic cirrhotic subjects exhibited delayed but prolonged suppression. Chromatography of selected plasma with glucose-suppressed total IRG showed a major decrease in the 3500-mol wt component in every case. Exaggerated increments of plasma gastric inhibitory polypeptide were demonstrable in both groups of cirrhotic individuals after administration of oral glucose, and it is speculated that this peptide may contribute to stimulation of glucagon secretion in liver disease associated with insulin deficiency.

Glucose dynamics and gluconeogenesis during and after prolonged swimming in rats.

Glucose fluxes and, in particular, gluconeogenic rate were examined during and after prolonged submaximal exercise represented by a 4-h swim and 3-h recovery in 12-h-fasted previously catheterized rats. The metabolic clearance rate and production rate of glucose were measured using an infusion of [6-3H]glucose, and gluconeogenesis was assessed from the incorporation of 14C from [14C]bicarbonate into glucose. Immediately after exercise and after the 3-h recovery, liver glycogen was also determined. During exercise, euglycemia was maintained while glucose production and utilization doubled from 1.58 +/- 0.17 to 3.58 +/- 0.21 mg/min. During recovery, glucose concentrations increased to 131.0 +/- 5.8 vs. 110.8 +/- 5.1 mg/dl for controls (P < 0.05), because the decline in glucose production rate lagged behind the decline in metabolic clearance rate. The index of gluconeogenesis coupled with a metabolic correction factor indicates that gluconeogenesis was the primary source of glucose during swimming and recovery and that the principal substrates were at the level of pyruvate. CO2 production rates calculated using plasma CO2 and label concentrations doubled during exercise. Little repletion of liver glycogen was seen after exercise, indicating that the increased production of glucose after exercise is directed primarily toward the repletion of muscle glycogen. Swimming is therefore a useful model of low-intensity exercise easily implemented in untrained animals. [14C]bicarbonate can be used in the estimation of gluconeogenic rates during exercise.

A qualitative comparison of canine plasma gastroenteropancreatic hormone response to bombesin and the porcine gastrin-releasing peptide (GRP).

The effect on plasma gastroenteropancreatic hormone levels on infusing the porcine gastrin-releasing peptide and bombesin into dogs demonstrated no qualitative difference in the spectrum of activity of the two peptides. Sustained elevation in plasma immunoreactive gastrin, pancreatic polypeptide, enteroglucagon, gastric inhibitory polypeptide, pancreatic glucagon and transient elevations in plasma insulin were seen during infusions of both peptides. The similar spectrum of activities and the structural homology between the two peptides suggests that the porcine gastrin releasing peptide is the porcine counterpart of the amphibian peptide bombesin.

Differential effects of a graded selective suppression of insulin secretion with galanin on glucose production and removal in dogs.

The metabolic response to graded decreases in insulin concentration was evaluated by measuring the concentration, production, and metabolic clearance rate of glucose in response to the infusion of different galanin doses (1-12 micrograms/kg/h) in 18-h fasted dogs. Peripheral and portal concentrations of insulin and glucagon were measured simultaneously before, during, and after galanin infusions. No increases in portal or peripheral glucagon levels were seen at any dose of galanin infused but, in contrast, dose-dependent decreases of insulin levels occurred in both circulations. The metabolic clearance rate of glucose fell by approximately 25-30% at each dose of galanin infused; suggesting that the maximum effect was reached at the lowest dose. The rate of glucose production increased in a dose-dependent manner with integrated responses of 210 +/- 170, 620 +/- 80, 1,330 +/- 440, 1,920 +/- 310, 1,940 +/- 170, and 1,970 +/- 600 mg/kg at galanin doses of 1, 2, 4, 7, 10, and 12 micrograms/kg/h respectively; saturation of this response occurs at the 7 micrograms/kg/h dose of galanin. The changes in glucose production reflect most closely changes in the fractional decrease in insulin levels both in the portal and peripheral circulations. These changes appear to be mediated by insulin acting directly on the liver, because no alterations in the concentrations of the glucogenic substrates, lactate and glycerol, were seen.(ABSTRACT TRUNCATED AT 250 WORDS)

Mild acute renal failure potentiates metformin accumulation in the diabetic rat kidney without further impairment of renal function.

OBJECTIVES: To analyze, in acute renal failure (ARF) in diabetic rats, how moderate functional ARF would modify metformin (MET) pharmacokinetics and if plasma and renal tissue MET accumulation could aggravate renal insufficiency and/or elicit plasma lactate accumulation. METHODS: Streptozotocin-induced diabetic rats were allocated to four groups: control, MET, ARF, ARF-MET (6-7 rats per group). MET (100 mg/kg/day) was given per os for two weeks before ARF was induced by drinking restriction and enalapril treatment. The effects of MET and/or ARF were examined in vivo on renal function in conscious rats (metabolic cages) and ex vivo on renal vascular reactivity (isolated kidney). RESULTS: MET treatment (plasma level: 5.3 +/- 1.4 microg/ml, mean+/-SEM), resulted in biguanide accumulation in cortex and medulla (53 +/- 17 and 80 +/- 40 microg/g respectively). MET was devoid of any effect on creatinine clearance, mean blood pressure or renal vascular resistance, but moderately increased plasma lactate (3.8 +/- 0.5 vs 3.2 +/- 0.2 mM, P<0.05) and decreased angiotensin II-induced renal vasoconstriction. ARF, although mild, decreased renal MET clearance (0.29 +/- 0.05 vs 1.01 +/- 0.31 ml/min/100 g, P<0.05) and increased plasma and renal tissue MET levels (x 2-4). MET however did not worsen the fall in glomerular filtration rate, nor modify renal vascular reactivity. ARF did not change the MET-elicited moderate increase in plasma lactate. CONCLUSION: Despite the increase in MET plasma and renal tissue levels subsequent to moderate ARF, no harmful metabolic effect on plasma lactate and no further impairment of renal function was observed in MET-treated diabetic rats subjected to ARF.

Preparation of a microcrystalline suspension formulation of Lys(B28)Pro(B29)-human insulin with ultralente properties.

The monomeric analogue, Lys(B28)Pro(B29)-human insulin (LysPro), has been crystallized using similar conditions employed to prepare extended-acting insulin ultralente formulations. In the presence of zinc ions, sodium acetate and sodium chloride, but without phenolic preservative, LysPro surprisingly forms small rhombohedral crystals with similar morphology to human insulin ultralente crystals with a mean particle size of 20 +/- 1 microm. X-ray powder diffraction studies on the LysPro crystals prior to dilution in ultralente vehicle ([NaCl] = 1.2 M) revealed the presence of T(3)R(3)(f) hexamers. Consistent with human insulin ultralente preparations, LysPro crystals formulated as an ultralente suspension ([NaCl] = 0. 12 M) contain T(6) hexamers indicating that a conformational change occurs in the hexamer units of the crystals upon dilution of the salt concentration. The pharmacological properties of subcutaneously administered ultralente LysPro (ULP) were compared to ultralente human insulin (UHI) using a conscious dog model (n = 5) with glucose levels clamped at basal. There were no statistically significant differences between the kinetic and dynamic responses of ULP compared to UHI [C(max) (ng/mL): 3.58 +/- 0.76, ULP and 3.61 +/- 0. 66, UHI; T(max) (min): 226 +/- 30, ULP and 185 +/- 42, UHI; R(max) (mg/kg min): 11.2 +/- 1.9, ULP and 13.3 +/- 2.0, UHI; and T(Rmax) (min): 336 +/- 11, ULP and 285 +/- 57, UHI]. Although the Pro to Lys sequence inversion destabilizes insulin self-assembly and greatly alters the time action of soluble LysPro preparations, this modification has now been found neither to prevent the formation of ultralente crystals in the absence of phenolics nor to compromise the protracted activity of the insulin analogue suspension.

Preparation and characterization of a cocrystalline suspension of [LysB28,ProB29]-human insulin analogue.

Soluble preparations of [LysB28,ProB29]-human insulin analogue (LysPro) exhibit more rapid absorption than human insulin upon subcutaneous injection. Biphasic mixtures of LysPro and intermediate-acting insulin suspensions could provide advantages over current preparations for the treatment of diabetes. To prepare biphasic mixtures of LysPro, a suspension formulation of the analogue is required. We have devised a method for crystallizing LysPro with the basic peptide protamine yielding neutral protamine LysPro (NPL) suspension. The crystallization conditions are strongly dependent on the precipitation procedure and temperature. Using various techniques, the crystalline and suspension characteristics of NPL are found to be similar to human insulin (neutral protamine Hagedorn, NPH) (8:1 molar ratio insulin:protamine, rod-shaped crystals, particle size of 4.0-6.0 microns, and Point of Zero Charge at 6.0-7.0). Using a dog model with NPL or NPH injected subcutaneously and glucose levels clamped at basal, NPL was found to have kinetic and dynamic responses analogous to human insulin NPH [Cmax (maximal insulin or LysPro concentration, ng/mL) of 2.61 +/- 0.22, NPL; 2.58 +/- 0.36, NPH, attained at Tmax (min) of 93 +/- 22, NPL; 145 +/- 33 NPH, and Rmax (maximal rate of glucose infusion, mg/kg min) of 10.8 +/- 1.2, NPL; 13.2 +/- 1.9, NPH, attained at TRmax (min) of 277 +/- 58, NPL; 265 +/- 38, NPH]. There are no statistically significant differences between the insulin curves or the glucose responses. These results provide insight into the mechanism of action of NPH suspensions and the relationship to duration of action. Furthermore, the formulation of a suspension of LysPro having an intermediate time-action makes possible the preparation of stable biphasic mixtures containing LysPro and NPL.

The liver and glycogen metabolism.

It was shown that the liver is not the major site of removal of glucose after a carbohydrate meal in man. Fractional extractions varied from 5 to 10%. Alternative substrates for postprandial hepatic glycogen synthesis were therefore sought. It was demonstrated than, in man, about 60% of hepatic glycogen was formed from gluconeogenetic substrates. Since significant excursions occur only in plasma lactate after glucose loading, this was deemed the most likely substrate under these circumstances. By differential sampling across the liver and the gut in a conscious pig model, it was found that the liver takes up enough lactate (fractional extraction of 40-50%) to account for the gluconeogenetic production of glycogen. Forty percent of this arises from the gut. Muscle (as represented by the forearm in man) does not contribute lactate during glucose loading, suggesting that other tissues such as the skin are of importance. The gluconeogenetic process may be an important site for the obligatory tissue production of lactate.

An adaptive plasma glucose controller based on a nonlinear insulin/glucose model.

The design of plasma glucose controllers traditionally relies on linear approaches. The implementation of an appropriate nonlinear model of the insulin/glucose regulatory system into an adaptive controller should predict the insulin-dependent glucose removal more reliably and hence provide better control over a wide spectrum of insulin signals. A discretized form of the model leads to a two-step procedure. First, the measured plasma glucose levels associated with the exogenous glucose infusion rates are used in the estimation of the past removal rates which, in turn, can be expressed as a weighted sum of past insulin inputs and previous values of the removal rate. Parameters of the sum are adjusted on-line by a recursive method of estimation which features a prefiltering of data to account for a corrupting coloured process noise. The same equation is in turn used to predict the time course of the insulin-dependent fractional rate of glucose removal. The performance of the controller, tested in vivo in three pigs, is presented for various intravenous or subcutaneous rapid injections and staircase infusions of insulin. Plasma glucose is maintained at an average level of 99.9 +/- 8.7% of the target value (% set point +/- coefficient of variation). The controller reacts promptly to large and rapid variations in insulin action. Although control improves with the number of glucose measurements, the prediction of glucose removal allows for some flexibility in the monitoring of the plasma glucose. Sampling frequency varied from a 2 min interval during transient periods to 7 min as steady states were reached.