The danger of using inappropriate point-of-care glucose meters in patients on icodextrin dialysis.

AIMS: Icodextrin is a glucose polymer used to maintain an osmotic gradient in peritoneal dialysis. Metabolites of icodextrin are known to cause overestimation of blood glucose in glucose meters using glucose dehydrogenase/pyrroloquinolinequinone systems. The aim of this study is to determine the extent of icodextrin interference in glucose meters using the newer glucose dehydrogenase/NAD or glucose oxidase systems. This has not been established previously. METHODS: Fasting blood samples (n = 4) were spiked with either one icodextrin metabolite (maltose, maltotriose or maltotetraose) or a combination, at various blood concentrations expected during dialysis. Samples were tested in triplicate on: five glucose-meters, a Radiometer® (glucose oxidase/hydrogen peroxide) and laboratory (hexokinase) analysers. Each meter was also tested on blood from six patients undergoing dialysis. Accuracy was evaluated as % Bias = [(meter glucose - laboratory glucose)/laboratory glucose] × 100. RESULTS: A single icodextrin metabolite affected glucose measurements and, in combination, the interferences were additive in the two Accu-Chek® and Optium® Xceed meters by > 10%. Amongst these meters, the Optium Xceed 5-s machine was less affected. Meters using glucose oxidase were least affected by interference. A similar trend in interference was observed in vivo. CONCLUSION: While meters using glucose dehydrogenase/NAD are less affected by icodextrin metabolites, interference can still be demonstrated. The degree of interference can vary in different glucose meters using this enzyme/cofactor system, as seen in the Optium Xceed machines. Icodextrin is an important source of interference that sometimes even experienced professionals are unaware of and which leads to clinically significant errors in insulin dose adjustment. Awareness of this interference and selection of the most appropriate glucose meters are crucial to minimize this hazard.

Insulin inhibition of calcium binding by human placental membrane.

Insulin and its analogues displaced membrane-bound calcium within a physiological range of insulin concentration, in proportion to both biological potency and ability to displace porcine 125 I-labelled insulin from the insulin receptor. Mild tryptic digestion of the membrane reduced insulin binding but did not reduce specific calcium binding. Displacement of membrane-bound calcium by insulin was dependent on insulin binding to its intact receptor. These studies suggest that Ca2"ay exert a controlling influence on insulin-receptor binding in vivo.

Purification of the insulin receptor from human placental membranes.

Insulin receptors were purified from human placental microsomal membranes by solubilisation with Triton X-100 followed by Sepharose 6B chromatography, phosphate gradient elution from hydroxyapatite and affinity chromatography on concanavalin A-Sepharose. 2000-fold purification was achieved with 63% overall recovery. The purified receptor gave a single band on 3.75% polyacrylamide (0.1% Triton X-100) gel electrophoresis. On sodium dodecyl sulphate-polyacrylamide gel electrophoresis there was a major band at 75,000 and a minor band at 80,000 daltons. The purified receptor rechromatographed on Sepharose 6B with an apparent molecular weight of 300,000.

Control of insulin receptor affinity by a Ca2+-sensitive binding site.

Calcium (Ca2+) increased insulin-receptor binding in both membrane and solubilised receptor preparations. Ca2+ increased both receptor affinity and initial rate of association of [125I]insulin to the receptor preparations. Ca2+ had no effect on insulin receptor number in either receptor preparation. The effect of Ca2+ on affinity could be mimicked by ions with similar ionic radii and properties (e.g., Ba2+, Mg2+ and Sr2+). EDTA and oleic acid reduced insulin binding and receptor affinity and these effects were reversed by the addition of Ca2+. These studies suggest that Ca2+ and Ca2+-like ions may bind to a site on or near the receptor and may be responsible for a conformational change with a consequent increase in receptor affinity.

Differences in lipogenesis in tissues of control and gold-thioglucose obese mice after an isocaloric meal.

Lipogenesis was measured in 2 and 5 week gold-thioglucose (GTG) obese mice after a single meal of 0.5 g of standard chow. Compared to control mice the rate of lipogenesis in GTG obese mice, was 4-fold higher in liver and 10-fold higher in white adipose tissue (WAT). In brown adipose tissue (BAT) of GTG-injected mice the lipogenic rate was only 50% of that of controls. These results indicate that the increased lipid synthesis observed in GTG-injected mice is not due solely to hyperphagia and that some other stimuli, such as increased basal insulin levels and/or decreased thermogenesis and insulin resistance in BAT, contribute to the high rates of fat synthesis in this animal model of obesity.

Terbium, a fluorescent probe for insulin receptor binding. Evidence for a conformational change in the receptor protein due to insulin binding.

Terbium (Tb3+), an ion of the lanthanide series that has been used as a fluorescent probe for calcium (Ca2+) binding sites in proteins, binds to the proteins in both solubilized and purified human placental insulin receptor preparations. Tb3+ fluorescence was determined directly and the effect of insulin binding on Tb3+-enhanced fluorescence was studied without the need to separate bound and free ligands. Tb3+ behaved similarly to, but was more potent (50-fold) than, Ca2+ in increasing the insulin bound to its receptor. When insulin bound to its receptor, the Tb3+ fluorescence of the receptor preparation decreased. When various insulin analogues were tested, the decrease in Tb3+ fluorescence was proportional to the biologic activity of the insulin analogues. In addition, Tb3+ could be displaced from insulin-sensitive sites by Ca2+, indicating that there were Ca2+ (and Tb3+) binding sites on or near the insulin receptor. These sites, when filled, were responsible for the increased insulin receptor affinity. The decrease in Tb3+ fluorescence after insulin binding may be indicative of a conformational change in the insulin receptor precipitated by the binding of insulin. This conformational change may be related to the release of Ca2+ by insulin binding, is associated with a decrease in insulin receptor affinity, and suggests that an allosteric mechanism involving both Ca2+ and insulin binding sites may be responsible for the observed changes in insulin receptor affinity.

Insulin response in individual tissues of control and gold thioglucose-obese mice in vivo with [1-14C]2-deoxyglucose.

The dose-response characteristics of several glucose-utilizing tissues (brain, heart, white adipose tissue, brown adipose tissue, and quadriceps muscle) to a single injection of insulin have been compared in control mice and mice made obese with a single injection of gold thioglucose (GTG). Tissue content of [1-14C]2-deoxyglucose 6-phosphate and blood disappearance rate of [1-14C]2-deoxyglucose (2-DG) were measured at nine different insulin doses and used to calculate rates of 2-DG uptake and phosphorylation in tissues from control and obese mice. The insulin sensitivity of tissues reflected in the ED50 of insulin response varied widely, and brown adipose tissue was the most insulin-sensitive tissue studied. In GTG-obese mice, heart, quadriceps, and brown adipose tissue were insulin resistant (demonstrated by increased ED50), whereas in white adipose tissue, 2-DG phosphorylation was more sensitive to insulin. Brain 2-DG phosphorylation was insulin independent in control and obese animals. The largest decrease in insulin sensitivity in GTG-obese mice was observed in brown adipose tissue. The loss of diet-induced thermogenesis in brown adipose tissue as a result of the hypothalamic lesion in GTG-obese mice could be a major cause of insulin resistance in brown adipose tissue. Because brown adipose tissue can make a major contribution to whole-body glucose utilization, insulin resistance in this tissue may have a significant effect on whole-animal glucose homeostasis in GTG-obese mice.

Measurement of insulin binding by erythrocyte ghosts. A method that allows storage without loss of binding characteristics.

The insulin binding of red cell ghosts was studied and found to be similar to insulin binding of the original erythrocyte. Red cell ghosts were stable on storage, and serial samples can be measured in one assay, thus eliminating the problem of interassay variation. Erythrocyte ghosts may be preferable to whole red cells for long-term insulin receptor studies.

Results with combined kidney and paratopic segmental-pancreas transplantation.

Rehabilitation and quality of life after combined pancreas and kidney transplantation was assessed in 15 previously diabetic patients in renal failure and compared with 11 diabetic patients in renal failure transplanted with a kidney only. The paratopic segmental-pancreas-grafting technique, which allows physiologic insulin delivery into the portal venous system, was used in 13 patients; 2 patients received a heterotopic segmental-pancreas graft, resulting in systemic insulin delivery. A kidney was transplanted heterotopically in all cases. Mean age, duration of diabetes, retinopathy, neuropathy, mortality, infection rate, and immunosuppressive treatment did not differ significantly between the groups. Diabetic patients with only kidney transplants had difficulties adjusting to their diabetes, which may be partly due to the immunosuppressive treatment. The quality of life only marginally improved. In contrast, patients with a combined pancreas-kidney graft achieved full rehabilitation within a short time.

Renal chloride channel, CLCN5, mutations in Dent's disease.

Dent's disease is an X-linked renal tubular disorder characterized by low-molecular-weight proteinuria, hypercalciuria, nephrocalcinosis, nephrolithiasis, and renal failure. Patients with Dent's disease may also suffer from rickets and other features of the renal Fanconi Syndrome. Patients may have mutations in the X-linked renal chloride channel gene, CLCN5, which encodes a 746-amino-acid protein with 12-13 transmembrane domains. We have investigated the 11 coding exons of CLCN5 for mutations in eight unrelated patients with Dent's disease. Leukocyte DNA was used for the polymerase chain reaction amplification of CLCN5 and the products analyzed for single-stranded conformational polymorphisms (SSCPs). Abnormal SSCPs were sequenced and revealed eight mutations. These consisted of three nonsense mutations (Arg34Stop, Arg648Stop, Arg704Stop), four deletions involving codons 40, 86, 157, and 241, and one acceptor splice consensus sequence mutation tgcag --> tgaag. The mutations were confirmed either by restriction endonuclease or sequence-specific oligonucleotide hybridization analysis. In addition, an analysis of 110 alleles from 74 unrelated normal individuals demonstrated that the DNA sequence changes were not common polymorphisms. All of the mutations predict truncated chloride channels that are likely to result in a functional loss. Thus, our findings expand the spectrum of CLCN5 mutations associated with Dent's disease and the results will help to elucidate further the functional domains of this novel chloride channel.

High affinity insulin binding and insulin receptor-effector coupling: modulation by Ca2+.

Insulin binding and insulin stimulated amino acid and glucose uptake were determined in cultured HTC hepatoma cells in the presence of Ca2+ and ruthenium red (RR) in order to further characterise the putative calcium binding site on the receptor. These ions increased insulin receptor high affinity binding and the sensitivity of these responses to insulin. The insulin concentration required to half-maximally stimulate amino acid uptake decreased significantly from 26.9 +/- 5.8 ng/ml to 6.0 +/- 1.3 ng/ml in the presence of 10 mM Ca2+ and to 1.3 +/- 0.5 ng/ml in the presence of RR. The effect of Ca2+ and RR was more pronounced on insulin stimulated glucose uptake. These agents also increased receptor-effector coupling, reducing the percentage of occupied receptors required for maximal insulin stimulation of amino acid uptake from 10.8% in control cells to 3.4 and 1.4% in the presence of Ca2+ and RR respectively. The receptor occupancy required to produce maximal insulin responses on glucose uptake decreased from 20% (control) to 3.8% (Ca2+ and RR). We hypothesize that since Ca2+ and RR have similar effects, that occupation of Ca2+ binding sites on the receptor produces a conformational change in the insulin receptor which increases insulin receptor affinity, insulin sensitivity and acts on an early post-receptor event responsible for coupling binding to insulin action.

Cation-induced restoration of insulin action in insulin-desensitized HTC cells.

Insulin desensitization of amino acid uptake in HTC cells was induced by preincubation with 4 or 10 micrograms/ml insulin. Insulin binding after desensitisation was decreased by both insulin concentrations due to a 45-49% decrease in insulin receptor numbers. Desensitization with 4 micrograms/ml insulin increased the ED50 for half-maximal stimulation of amino acid uptake from 19.5 +/- 9.2 ng/ml in control cells to 84.0 +/- 8.3 ng/ml (P less than 0.0001). It also decreased the maximal insulin response of amino acid uptake from 1.40 +/- 0.10 to 1.14 +/- 0.10 nmol/mg protein, indicating the production of a mild postreceptor defect. Desensitization with 10 micrograms/ml insulin completely abolished this insulin response. When cellular receptors were down-regulated with 4 micrograms/ml insulin and restimulated with insulin in the presence of 0.03 mM ruthenium red (RR) or 10 mM Ca2+, both the insulin response and insulin binding were increased. Insulin binding was restored to levels comparable to those observed in control cells by an increase in receptor affinity. The ED50 of amino acid uptake decreased to 20.5 +/- 7.3 ng/ml insulin in the presence of RR and to 42.2 +/- 8.9 ng/ml in the presence of 10 mM Ca2+ (both P less than 0.0001 from down-regulated cells). In addition, the maximal insulin response increased from 1.14 +/- 0.10 to 1.40 +/- 0.10 and 1.45 +/- 0.10 nmol/mg protein, respectively. Preincubation with 10 micrograms/ml insulin prevented the effect of RR and Ca2+ on the recovery of insulin responses. These experiments suggest that insulin-desensitized cells undergo a progressive loss of their insulin response and that RR and Ca2+ provide useful reagents to investigate the mechanisms of this process because they can counteract the decrease in insulin response by increasing receptor affinity and receptor-effector coupling.

Familial hyperinsulinemia complicated by extreme insulin resistance during pregnancy: a probable postreceptor defect.

Detailed studies of a family with hyperinsulinemia are reported. The index patient, a 30-yr-old woman with polycystic ovary syndrome, presented with gestational diabetes which was completely resistant to insulin in the presence of severe endogenous hyperinsulinemia. Sensitivity to insulin was regained after delivery. Therapy with cyproterone acetate and ethinyl estradiol for hirsutism exacerbated the hyperinsulinemia toward the levels occurring in pregnancy, with a concomitant deterioration of glucose tolerance. Five other members of her family also were found to have hyperinsulinemia together with high concentrations of circulating C-peptide. Antibodies to insulin and to insulin receptors were not detected, insulin antagonists were not increased, and insulin degradation in the circulation was normal. Insulin extracted from the patient's serum was identical to normal insulin by the criteria of Sephadex chromatography, placental membrane insulin receptor binding, and stimulation of 2-deoxyglucose uptake in isolated rat adipocytes. Although [125I]insulin binding to erythrocytes of all family members and to the patient's placental membranes was markedly reduced, binding to fibroblast cultures from the patient was normal. Insulin-stimulated glucose transport in these fibroblasts also was normal, but there was a mild (20%) reduction in the concentration of cytochalasin B-binding sites in erythrocyte ghosts. Insulin resistance in this family may be due to a partial defect distal to the insulin receptor. This is asymptomatic unless metabolic stresses (pregnancy or steroid administration) are superimposed.

Fabrication and characterization of dipalmitoylphosphatidylcholine-attracting elastomeric material for joint replacements.

Wear debris associated with the polyethylene components of total joint replacements has been shown to induce bone resorption which contributes to implant loosening. In an effort to promote lubrication and reduce wear in artificial hip joints, the use of the cushion bearing concept has been proposed previously; however, an elastomeric material tested as a cushion bearing has been shown to have poor tribological properties during initiation of motion from rest. The goal of this project was to fabricate and characterize an elastomer that has the ability to attract to its surface naturally occurring boundary lubricants from an aqueous solution. The test elastomer and appropriate controls were characterized using fluorescence, electron spin resonance and X-ray photoelectron spectroscopy. The test elastomer was found to have an enhanced ability to attract dipalmitoylphosphatidylcholine, a known physiological boundary lubricant. A cushion bearing that also encourages boundary lubrication represents a potential improvement over currently existing orthopaedic implant-bearing materials.

Effects of glucose on matrix metalloproteinase and plasmin activities in mesangial cells: possible role in diabetic nephropathy.

Diabetic nephropathy is characterized by an accumulation of mesangium matrix that correlates well with the loss of kidney function. High glucose concentration is known to increase the synthesis of many matrix components. Recently, we have shown that degradation of matrix also decreases in diabetes. The major enzymes responsible for matrix degradation are the matrix metalloproteinases. The physiology of these enzymes is complex and their activity is tightly regulated at many levels. At the transcriptional level matrix metalloproteinase (MMP) expression is increased by protein kinase C (PKC) agonists, and some growth factors. In contrast transforming growth factor (TGF)-beta can decrease MMP expression. Once synthesized, MMPs are secreted as inactive pro-enzymes that are activated by other MMPs or plasmin. To effect this, plasmin must be liberated from plasminogen in the pericellular environment. In turn, activated MMPs can be inhibited by binding to specific inhibitors known as tissue inhibitor of metalloproteinases (TIMP). Cell culture and animal studies have shown that high glucose (HG) decreases expression of MMPs and increases expression of TIMPs. HG can also affect MMP activation by decreasing plasmin availability and reducing expression of a membrane-bound MMP called MT1-MMP. How HG induces these changes remains to be fully elucidated. One possibility is that HG can increase TGF-beta. which may in turn alter MMP promoter activity: this area is currently being studied in our laboratory.

The biochemical composition and metabolism of lipoproteins in type V hyperlipoproteinaemia.

The biochemical composition of lipoproteins in Type V hyperlipoproteinaemia was investigated with special reference to apolipoprotein-B. The in vivo metabolism of protein-labelled low density lipoprotein was also studied in five such patients (3 diabetic, 2 obese subjects). In association with pathologically elevated plasma levels of chylomicrons and very low density lipoproteins, low density lipoprotein concentration was significantly reduced. The proportions of triglyceride to apo-B and triglyceride to cholesterol were significantly increased in all lipoprotein classes, while the proportion of cholesterol to apo-B was significantly reduced. Disappearance of chylomicronaemia with treatment was associated with a prompt increase in low density lipoprotein concentration. The reduced low density lipoprotein concentration was accompanied by an accelerated fractional turnover rate, and by an absolute turnover rate which was subnormal. These results were interpreted as reduced synthesis of low density lipoprotein apoprotein and as a possible block in the conversion of very low density lipoprotein to low density lipoprotein in some Type V patients.

Effect of phorbol and glucose on insulin secretion from the human fetal pancreas.

It has been reported previously that 12-0-tetradecanoylphorbol-13-acetate is capable of stimulating the release of insulin from adult and neonatal pancreatic tissue. The data from this study show that this agent at a concentration of 1.3 uM, in the presence of 2.8 mM glucose, was unable to cause significant secretion of insulin from cultured human fetal pancreatic explants. By contrast 20 mM glucose was able to cause a small but significant immediate increase in secretion of insulin, but was unable to maintain this response beyond ten minutes. When the two agents were combined, a synergistic effect was seen throughout the entire 50 minute period of stimulation. The reason for this synergism is unclear since, whilst both secretagogues were able to cause a rise in the levels of diacylglycerol, together no extra effect was observed.

Hypoadrenal crisis caused by disseminated histoplasmosis.

We report a case of disseminated histoplasmosis presenting with acute renal impairment due to adrenal insufficiency. The finding of bilateral adrenal gland enlargement on abdominal ultrasound examination led to a diagnostic CT-guided adrenal biopsy. Prolonged therapy with amphotericin and itraconazole resulted in a clinical cure, although the patient still requires adrenal replacement therapy.

Dissociation of insulin binding from insulin stimulation of 2-deoxyglucose transport by ruthenium red.

Ruthenium red increased specific insulin binding to isolated adipocytes 5.4 fold and 2.6 fold over binding determined in the absence and presence of Ca2+ and Mg2+. The increase in insulin binding was not accompanied by an increase in insulin sensitivity. The lack of effect of ruthenium red on insulin action argued strongly against an increase in intracellular Ca2+ as a potential messenger/transducer of insulin action and suggested that the enhancing effect of Ca2+ on insulin action was a result of increased receptor affinity.

Restoration of muscle balance of the foot by transfer of the tibialis posterior.

A new technique of tibialis posterior transfer is described which has been used in a wide variety of conditions producing muscular imbalance in the foot. The results in eighty-five feet are reviewed in terms of range of motion, power and voluntary control of the transfer. The effect of the transfer on shoe wear, on the necessity for bracing and on the child's or his parents' assessment of the results are used to allocate an overall evaluation of the operation. Recommendations on the indications for the operation are given.