Fasting glucose production in the smaller of twins with epinephrine-deficient hypoglycemia

ABSTRACT

The possibility that insufficient glucose production or availability of gluconeogenic substrates could account for fasting hypoglycemia was investigated in three children with epinephrine deficiency. Each had been born the smaller of discordant identical twins, and the unaffected twins served as controls. Fasting plasma glucose production was measured by constant infusion of U-[13]C-glucose under steady-state conditions and was compared with availability of potential glucose sources estimated from respiratory calorimetry and excretory nitrogen. The average rate of glucose production was 2.6 mg/kg/min in the affected twins after they became symptomatic and 2.9 mg/kg/min in the control twins after comparable fasting. Plasma alanine was lower in the affected twins during this interval (average 0.11 mM versus 0.16 mM), but not earlier prior to decreased plasma glucose; alanine correlated with plasma glucose in a similar way in both groups (r = 0.77). Plasma urea production was 0.30 versus 0.15 mg urea N/kg/min. The calculated availability of potential gluconeogenic amino acids was 1.2 versus 0.6 mg/kg/min. Availability of glycerol, estimated from respiratory calorimetry was 0.4 mg/kg/min in both groups. In two of the twin pairs, net oxidation of carbohydrate (glycogen) was, by design, relatively small under these conditions (0.1 and 0.4 mg/kg/min in the affected and control twins, respectively). Gluconeogenesis therefore accounted for the majority of glucose production. The unaccounted remaining major gluconeogenic source is assumed to be recycled substrates from unoxidized pyruvate. Infusion of excess alanine in these two pairs increased plasma glucose and glucose production similarly in both the affected and control twins. This change was associated with an abnormally large increase in plasma alanine. In the third twin pair, net oxidation of carbohydrate was greater in the affected twin (1.8 versus 1.3 mg/kg/min) and possible glucose sources exceeded total glucose production during hypoglycemia. Earlier during fasting, net oxidation of carbohydrate in this twin was 5.8 mg/kg/min versus 3.1 mg/kg/min in the control. Plasma glucose production measured simultaneously was 4.3 versus 3.8 mg/kg/min, being less than the rate of carbohydrtae oxidation in the affected twin. It is concluded that the abnormal fasting metabolism observed in these children with decreased epinephrine was not primarily a consequence of deficient glucose production or lack of potential gluconeogenic substrates. Initial persistent oxidation of glycogen and subsequent increased utilization of protein during hypoglycemia indicate failure to conserve these limited net sources of pyruvate(AU)