The artificial pancreas: evaluating risk of hypoglycaemia following errors that can be expected with prolonged at-home use.

AIMS: Artificial pancreas systems show benefit in closely monitored at-home studies, but may not have sufficient power to assess safety during infrequent, but expected, system or user errors. The aim of this study was to assess the safety of an artificial pancreas system emulating the ß-cell when the glucose value used for control is improperly calibrated and participants forget to administer pre-meal insulin boluses. METHODS: Artificial pancreas control was performed in a clinic research centre on three separate occasions each lasting from 10 p.m. to 2 p.m. Sensor glucose values normally used for artificial pancreas control were replaced with scaled blood glucose values calculated to be 20% lower than, equal to or 33% higher than the true blood glucose. Safe control was defined as blood glucose between 3.9 and 8.3 mmol/l. RESULTS: Artificial pancreas control resulted in fasting scaled blood glucose values not different from target (6.67 mmol/l) at any scaling factor. Meal control with scaled blood glucose 33% higher than blood glucose resulted in supplemental carbohydrate to prevent hypoglycaemia in four of six participants during breakfast, and one participant during the night. In all instances, scaled blood glucose reported blood glucose as safe. CONCLUSIONS: Outpatient trials evaluating artificial pancreas performance based on sensor glucose may not detect hypoglycaemia when sensor glucose reads higher than blood glucose. Because these errors are expected to occur, in-hospital artificial pancreas studies using supplemental carbohydrate in anticipation of hypoglycaemia, which allow safety to be assessed in a controlled non-significant environment should be considered as an alternative. Inpatient studies provide a definitive alternative to model-based computer simulations and can be conducted in parallel with closely monitored outpatient artificial pancreas studies used to assess benefit.

Transendothelial insulin transport is not saturable in vivo. No evidence for a receptor-mediated process.

In vitro, insulin transport across endothelial cells has been reported to be saturable, suggesting that the transport process is receptor mediated. In the present study, the transport of insulin across capillary endothelial cells was investigated in vivo. Euglycemic glucose clamps were performed in anesthetized dogs (n = 16) in which insulin was infused to achieve concentrations in the physiological range (1.0 mU/kg per min + 5 mU/kg priming bolus; n = 8) or pharmacologic range (18 mU/kg per min + 325 mU/kg priming bolus; n = 8). Insulin concentrations were measured in plasma and hindlimb lymph derived from interstitial fluid (ISF) surrounding muscle. Basal plasma insulin concentrations were twice the basal ISF insulin concentrations and were not different between the physiologic and pharmacologic infusion groups (plasma/ISF ratio 2.05 +/- 0.22 vs 2.05 +/- 0.23; p = 0.0003). The plasma/ISF gradient was, however, significantly reduced at steady-state pharmacologic insulin concentrations (1.37 +/- 0.25 vs 1.98 +/- 0.21; P = 0.0003). The reduced gradient is opposite to that expected if transendothelial insulin transport were saturable. Insulin transport into muscle ISF tended to increase with pharmacologic compared with physiologic changes in insulin concentration (41% increase; 1.37 +/- 0.18 10(-2) to 1.93 +/- 0.24 10(-2) min-1; P = 0.088), while at the same time insulin clearance out of the muscle ISF compartment was unaltered (2.53 +/- 0.26 10(-2) vs 2.34 +/- 0.28 10(-2) min-1; P = 0.62). Thus, the reduced plasma/ISF gradient at pharmacologic insulin was due to enhanced transendothelial insulin transport rather than changes in ISF insulin clearance. We conclude that insulin transport is not saturable in vivo and thus not receptor mediated. The increase in transport efficiency with saturating insulin is likely due to an increase in diffusionary capacity resulting from capillary dilation or recruitment.

Causal linkage between insulin suppression of lipolysis and suppression of liver glucose output in dogs.

Suppression of hepatic glucose output (HGO) has been shown to be primarily mediated by peripheral rather than portal insulin concentrations; however, the mechanism by which peripheral insulin suppresses HGO has not yet been determined. Previous findings by our group indicated a strong correlation between free fatty acids (FFA) and HGO, suggesting that insulin suppression of HGO is mediated via suppression of lipolysis. To directly test the hypothesis that insulin suppression of HGO is causally linked to the suppression of adipose tissue lipolysis, we performed euglycemic-hyperinsulinemic glucose clamps in conscious dogs (n = 8) in which FFA were either allowed to fall or were prevented from falling with Liposyn plus heparin infusion (LI; 0.5 ml/min 20% Liposyn plus 25 U/min heparin with a 250 U prime). Endogenous insulin and glucagon were suppressed with somatostatin (1 microgram/min/kg), and insulin was infused at a rate of either 0.125 or 0.5 mU/min/kg. Two additional experiments were performed at the 0.5 mU/min/kg insulin dose: a double Liposyn infusion (2 x LI; 1.0 ml/min 20% Liposyn, heparin as above), and a glycerol infusion (19 mg/min). With the 0.125 mU/min/kg insulin infusion, FFA fell 40% and HGO fell 33%; preventing the fall in FFA with LI entirely prevented this decline in HGO. With 0.5 mU/min/kg insulin infusion, FFA levels fell 64% while HGO declined 62%. Preventing the fall in FFA at this higher insulin dose largely prevented the fall in HGO; however, steady state HGO still declined by 18%. Doubling the LI infusion did not further affect HGO, suggesting that the effect of FFA on HGO is saturable. Elevating plasma glycerol levels did not alter insulin's ability to suppress HGO. These data directly support the concept that insulin suppression of HGO is not direct, but rather is mediated via insulin suppression of adipose tissue lipolysis. Thus, resistance to insulin control of hepatic glucose production in obesity and/or non-insulin-dependent diabetes mellitus may reflect resistance of the adipocyte to insulin suppression of lipolysis.

Evidence for entry of plasma insulin into cerebrospinal fluid through an intermediate compartment in dogs. Quantitative aspects and implications for transport.

To study the route by which plasma insulin enters cerebrospinal fluid (CSF), the kinetics of uptake from plasma into cisternal CSF of both insulin and [14C]inulin were analyzed during intravenous infusion in anesthetized dogs. Four different mathematical models were used: three based on a two-compartment system (transport directly across the blood-CSF barrier by nonsaturable, saturable, or a combination of both mechanisms) and a fourth based on three compartments (uptake via an intermediate compartment). The kinetics of CSF uptake of [14C]inulin infused according to an "impulse" protocol were accurately accounted for only by the nonsaturable two-compartment model (determination coefficient [R2] = 0.879 +/- 0.044; mean +/- SEM; n = 5), consistent with uptake via diffusion across the blood-CSF barrier. When the same infusion protocol and model were used to analyze the kinetics of insulin uptake, the data fit (R2 = 0.671 +/- 0.037; n = 10) was significantly worse than that obtained with [14C]inulin (P = 0.02). Addition of a saturable component of uptake to the two-compartment model improved this fit, but was clearly inadequate for a subset of insulin infusion studies. In contrast, the three-compartment model accurately accounted for CSF insulin uptake in each study, regardless of infusion protocol (impulse infusion R2 = 0.947 +/- 0.026; n = 10; P less than 0.0001 vs. each two-compartment model; sustained infusion R2 = 0.981 +/- 0.003; n = 5). Thus, a model in which insulin passes through an intermediate compartment en route from plasma to CSF, as a part of a specialized transport system for the delivery of insulin to the brain, best accounts for the dynamics of this uptake process. This intermediate compartment could reside within the blood-CSF barrier or it may represent brain interstitial fluid, if CNS insulin uptake occurs preferentially across the blood-brain barrier.

Free fatty acid as a link in the regulation of hepatic glucose output by peripheral insulin.

Overproduction of glucose by the liver in the face of insulin resistance is a primary cause of hyperglycemia in non-insulin-dependent diabetes mellitus (NIDDM). However, mechanisms involved in control of hepatic glucose output (HGO) remain less than clear, even in normal individuals. Recent results have supported an indirect extrahepatic effect of insulin as the primary locus of insulin action to restrain HGO. One suggested extrahepatic site is the pancreatic alpha-cell. To examine whether insulin's extrahepatic site is independent of the alpha-cells, HGO suppression was examined independent of changes in glucagon secretion or insulin antagonism of glucagon action. Euglycemic glucose clamps (n = 40) with somatostatin infusion were performed in conscious dogs (n = 5). Paired experiments were conducted in which insulin was infused either portally (1.2, 3.0, 6.0 pmol.min-1.kg-1) or peripherally at half the portal infusion rate (0.6, 1.5, 3.0 pmol.min-1.kg-1). Additional zero and saturating portal-dose experiments (100 pmol.min-1.kg-1) were also performed. For the paired experiments, portal insulin infusion resulted in portal insulin concentrations approximately two to three times higher than in the corresponding peripheral insulin infusion experiments, while at the same time peripheral insulin concentrations were approximately matched. Equal peripheral insulin concentration resulted in equivalent HGO suppression irrespective of the portal concentrations. Thus, insulin affects a signal at a peripheral site, other than alpha-cell, that in turn suppresses hepatic glucose production. To investigate the nature of this signal, we measured alanine, lactate, and free fatty acids (FFAs).(ABSTRACT TRUNCATED AT 250 WORDS)

Repeatability of insulin sensitivity and glucose effectiveness from the minimal model. Implications for study design.

To determine the repeatability of insulin sensitivity measurements generated by the minimal model, we subjected 11 normal men to 3 frequently sampled intravenous glucose tolerance tests (FSIGTs) over the course of 12 days under conditions of fixed diet and limited physical activity. FSIGTs were analyzed by the minimal model using a full, 30-sample data set, as well as a reduced, 12-sample data set that has been proposed for population studies. Minimal model insulin sensitivity index (SI) calculated from the 30-sample data set averaged 0.8 +/- 0.083 x 10(-4) min-1.(pmol/l)-1 (range 0.10-1.64 x 10(-4) min-1.(pmol/l)-1 with an average interday coefficient of variation (CV) of 20.2 +/- 3.2% (range 6-44%). Glucose effectiveness (SG) was slightly less repeatable, with an average interday variability of 25.1 +/- 8.8%. The mean CVs for first-phase insulin secretion (20.1 +/- 3.5%) and total insulin secretion (21.4 +/- 3.2%) were similar to the CV for SI. Mean insulin sensitivity calculated from the 12-sample data set (0.82 +/- 0.08 x 10(-4) min-1.(pmol/l)-1 was not significantly different from the mean calculated from the full data set (P = 0.37, paired Student's t test). However, the mean CV of SI calculated from the reduced data set tended to be greater than that calculated from the full data set (27.7 +/- 5.4% vs. 20.2 +/- 3.2%).(ABSTRACT TRUNCATED AT 250 WORDS)

Reduced sample number for calculation of insulin sensitivity and glucose effectiveness from the minimal model. Suitability for use in population studies.

The FSIGT has been extensively applied to the minimal model of glucose kinetics to obtain noninvasive measures of Sl. The protocol has been modified by the addition of a bolus tolbutamide or insulin injection 20 min after glucose. Although the modified protocol has improved the Sl estimate, the method still requires a relatively large number of samples (n = 30). To reduce the total number of samples, we choose a sample schedule that minimizes the variance of the parameter estimates and the error in reconstructing the plasma insulin profile. With data from 10 subjects (BMI 30 +/- 7 kg/m2; Sl 0.9-10.2 x 10(-4) min-1.microU-1 x ml-1), a schedule consisting of 12 samples (0, 2, 4, 8, 19, 22, 30, 40, 50, 70, 90, and 180 min) was obtained. Estimates of Sl obtained from the reduced sampling schedule were then compared with those obtained with the full sampling schedule. In all 10 individuals, the Sl estimates were almost identical. A second, much larger data base consisting of 118 modified FSIGTs performed in 87 subjects (67 men, 20 women; BMI from 19.6 to 40 kg/m2 for men and 26.7 to 52.5 for women; Sl from 0.35 to 14.1 x 10(-4) min-1 x microU-1 x ml-1) was then used to independently assess the efficacy of the reduced sampling protocol. For this data base, the correlation between Sl, which was calculated from the full versus the reduced sampling schedule, was 0.95. The mean relative deviation was -1.5% (not significantly different from zero), and the SD of the relative deviation was 20.2%.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of portal insulin delivery in the disappearance of intravenous glucose and assessment of insulin sensitivity.

The contribution of portal insulin delivery to the disappearance of glucose administered intravenously was assessed in the present study. Paired insulin-modified intravenous glucose tolerance tests (IVGTTs) were performed in dogs in which insulin was administered into the portal vein or into a peripheral vein. Peripheral insulin levels were matched in the paired IVGTTs by adjusting the portal insulin dose in proportion to first-pass hepatic insulin extraction. Two sets of IVGTTs were performed. In the first set, hepatic insulin extraction was assumed to be 50% (insulin doses of 0.03 U/kg portal and 0.015 U/kg peripheral; n = 6); in the second set, the assumed extraction rate was reduced to 33% (0.0225 U/kg portal and 0.015 U/kg peripheral; n = 8). In the second set of experiments, a control "zero" dose (no insulin injection) was also performed. For these latter three IVGTTs, the exogenous glucose bolus was labeled with 3-[3H]glucose (25 microCi) to separately assess insulin's effects on the rate of glucose disappearance (Rd) and endogenous glucose production (EGP). For the paired IVGTT based on 33% extraction, the area under the insulin curves after the portal insulin injection was within 2% of that observed with peripheral insulin injection (1,820 +/- 711 vs. 1,791 +/- 661 microU/ml min; P = 0.79). For these conditions, neither the glucose profiles nor the minimal model estimate of insulin sensitivity (S(I)) was significantly influenced by the higher portal insulin delivery (S(I): 3.69 +/- 0.56 vs. 3.35 +/- 0.60 10(-4) min(-1) per microU/ml; portal vs. peripheral; P > 0.05). Analysis of the 3-[3H]glucose tracer dynamics failed to reveal any differences in the portal versus peripheral insulin effect on glucose disappearance or production. We conclude that portal insulin delivery per se does not significantly affect insulin's ability to normalize plasma glucose during acute glucose challenges.

Thoracic duct lymph. Relative contribution from splanchnic and muscle tissue.

We have shown previously that thoracic duct lymph insulin dynamics are well correlated with tracer-determined whole-body glucose uptake and have suggested that thoracic duct lymph insulin is representative of insulin concentration in muscle interstitial fluid. However, thoracic duct lymph is comprised of interstitial fluid from all sub-thoracic tissue beds. To investigate the relative contribution of muscle interstitial fluid to total thoracic duct lymph flow, the distribution and elimination of [14C]inulin was investigated in eight experiments with conscious dogs. Both plasma and thoracic duct lymph were measured, and a three-compartment model that was hypothesized to consist of plasma, splanchnic interstitial fluid, and muscle interstitial fluid was identified. Identifications were performed with either a bolus protocol (n = 4) or an infusion protocol (n = 4), and the predicted [14C]inulin dynamics in the splanchnic and muscle interstitial fluid compartments were compared with measured values in thoracic duct lymph. Neither compartment predicted the thoracic duct [14C]inulin dynamics; however, a model based on a percentage contribution from each tissue bed fit the thoracic data well. The relative contribution of splanchnic interstitial fluid to the total thoracic duct lymph flow averaged 78 +/- 5% for the bolus protocol and 54 +/- 5% for the infusion protocol. Thus, we conclude that in the conscious animal, approximately 25-50% of thoracic duct lymph originates from muscle interstitial fluid.

Insulin sensitivity accounts for glucose and lactate kinetics after intravenous glucose injection.

Mathematical modeling was used to explore the interaction between glucose, insulin, and lactate during the frequently sampled intravenous glucose tolerance test (FSIGTT). Insulin-modified FSIGTs were performed in 25 lean volunteers, and an additional 5 volunteers underwent FSIGTs with glucose injection alone to illustrate the effect of insulin on both glucose and lactate kinetics. The model chosen as the best representation of the system extended the minimal model of glucose kinetics (MM) by including a two-compartment model of lactate kinetics. The model accounted for both glucose and lactate kinetics, provided traditional MM parameters of insulin sensitivity and glucose effectiveness, and descriptive parameters of lactate kinetics. Modeling suggested that lactate production was limited by the rate of glucose disappearance, with no indication of direct effects of insulin on lactate. Inclusion of lactate kinetics had no adverse effect on MM parameters (SG: 0.023 +/- 0.009 vs. 0.023 +/- 0.010 min-1, SI: 1.01 +/- 0.70 vs. 1.03 +/- 0.71 x 10(4).min-1.pmol-1.1; P > 0.50, lactate model vs. MM), and indicated that approximately 1.2% min-1 of total glucose disappearance during the FSIGT is converted to lactate. An additional benefit of including lactate kinetics was the significant improvement in precision in MM parameter estimates as reflected by the fractional standard deviations (FSDs). This effect was most prominent for SG, in which a threefold improvement in parameter precision was observed (FSD: 13.5 +/- 3.1 vs. 42.5 +/- 48.5; means +/- SD).(ABSTRACT TRUNCATED AT 250 WORDS)

Dynamics of glucose production and uptake are more closely related to insulin in hindlimb lymph than in thoracic duct lymph.

We previously reported a striking similarity between the dynamics of both glucose turnover and thoracic duct lymph insulin during euglycemic clamps (J Clin Invest 84:1620, 1989), which suggested that transendothelial insulin transport (TET) is rate-limiting for insulin action in vivo. Thoracic duct lymph, however, is primarily derived from insulin-insensitive tissues, which raises questions as to the physiological significance of this relationship. The relationship between glucose turnover and TET was thus examined in insulin-sensitive tissues by the simultaneous measurement of insulin in plasma, thoracic duct lymph, and hindlimb lymph during euglycemic clamps in normal anesthetized dogs (n = 8). Clamps consisted of two 3-h phases: a 0.6 mU.min-1.kg-1 insulin infusion (activation phase) followed by termination of the insulin infusion (deactivation phase). Lymph insulin was less than plasma insulin during both phases (P < 0.01) with steady-state hindlimb (120 +/- 12 pM) and thoracic duct lymph insulin (138 +/- 12 pM) 38 and 45%, respectively, lower than steady-state plasma insulin (222 +/- 24 pM) at the end of the activation phase (P < 0.05). Also, the rate of increase of lymph insulin was slower than plasma insulin during hormone infusion; half-time to steady-state was 8.8 +/- 2.0 min for plasma insulin, but longer for thoracic (25.8 +/- 3.5) and hindlimb lymph insulin (40.7 +/- 5.7 min). A very close relationship was observed during activation between the rate of increase of glucose uptake (Rd) and the increase in hindlimb lymph insulin (r2 = 0.92); this relationship was weaker for thoracic lymph (r2 = 0.74) and much weaker between glucose uptake and plasma insulin (r2 = 0.35). These data support the concept that interstitial insulin (represented by hindlimb lymph) is the signal that determines glucose uptake by insulin-sensitive tissues and that the rate of increase of glucose uptake is determined by transendothelial insulin transport into insulin-sensitive tissue. Also, during activation, hindlimb lymph insulin was a very strong predictor of the rate of suppression of hepatic glucose output (HGO) (r2 = 0.96), and the correlation with HGO was stronger than that for thoracic lymph (r2 = 0.85). The evidence that the rate of increase of Rd and the rate of suppression of HGO during insulin infusion are very strongly predicted by the time course of insulin in hindlimb lymph is consistent with the single-gateway hypothesis: the insulin transport rate across endothelium in insulin-sensitive tissue (skeletal muscle) determines the rate of glucose utilization and the suppression of hepatic glucose output.(ABSTRACT TRUNCATED AT 400 WORDS)

Method of insulin administration has no effect on insulin sensitivity estimates from the insulin-modified minimal model protocol.

The effect of the method of insulin administration on insulin sensitivity estimates from the insulin modified minimal model (MINMOD) protocol was evaluated using the tolbutamide-boosted protocol as a reference. The study included 21 nondiabetic men ages 40 +/- 2 years (mean +/- SE) with a BMI of 26.6 +/- 1.1 kg/m2. Each subject underwent four frequently sampled intravenous glucose tolerance tests (FSIGTT), one with tolbutamide and three with the same insulin dosage (0.03 U/kg) given as a bolus or infusion over 5 or 10 min. The insulin sensitivity index (SI) of each subject was calculated from each FSIGTT with MINMOD. Insulin sensitivity indexes from the four FSIGTTs were highly correlated (r > 0.85, P < 0.001). SI(insulin) from the bolus and the 5- and 10-min infusion protocols were similar, but were 21 +/- 5, 29 +/- 5, and 23 +/- 4% lower than SI(tolbutamide), respectively. SG(tolbutamide) and SG(insulin) were not different among the four protocols and were significantly correlated (r > 0.55, P < 0.01). Thus the tolbutamide and insulin protocols must not be used interchangeably in any single cross-sectional or longitudinal study. When the same insulin dosage is used, the method of its administration has no bearing on insulin sensitivity estimates from the insulin-modified FSIGTT. The same method of insulin administration should be used, however, in any single study for purpose of standardization.

Differences between the tolbutamide-boosted and the insulin-modified minimal model protocols.

The insulin-modified frequently sampled intravenous glucose tolerance test (FSIGTT) with minimal model analysis (MINMOD) was compared with the tolbutamide protocol and the glucose clamp in 35 nondiabetic subjects (age 38 +/- 2 years [mean +/- SE], BMI 27.2 +/- 0.9 kg/m2). Each subject underwent two FSIGTTs, one with tolbutamide (300 mg) and the other with insulin (0.03 U/kg) and a euglycemic hyperinsulinemic clamp (40 mU x m(-2) x min(-1)). Insulin sensitivity was determined from each FSIGTT with MINMOD and from the clamp. Insulin sensitivity indexes (S(I)) from the two FSIGTTs were significantly correlated (r = 0.77, P < 0.001), but S(I(insulin)) was 29 +/- 4% lower than S(I(tolbutamide)). Both S(I(insulin)) and S(I(tolbutamide)) correlated significantly with S(I(clamp)) (r = 0.70 and 0.71, P < 0.001 for each). Expressed in the same units (dl/min per pU/ml), S(I(tolbutamide)) was on average 13 +/- 6% lower than S(I(clamp)) (4.51 +/- 0.40 vs. 5.36 +/- 0.36 x 10(-2), P = 0.009), whereas S(I(insulin)) was 44 +/- 4% lower. S(G(tolbutamide)) and S(G(insulin)) were not different (1.88 +/- 0.10 vs. 2.01 +/- 0.09 x 10(-2) min(-1), P = 0.167) and were significantly correlated (r = 0.50, P = 0.002). Thus, insulin sensitivity estimates from both protocols correlate significantly with each other and with the clamp. They are quantitatively discrepant, however, possibly due to differences in the route of insulin delivery, saturation of insulin action, and/or tolbutamide-induced proinsulin release. Data obtained from these two MINMOD protocols are not directly comparable, and the same protocol must be used in any single cross-sectional or longitudinal study.

Physiological insulinemia acutely modulates plasma leptin.

Whether insulin acutely regulates plasma leptin in humans is controversial. We examined the dosage-response and time-course characteristics of the effect of insulin on leptin in 10 men (age 42+/-2 years [mean+/-SE]; BMI 29.3+/-2.0 kg/m2). Each individual underwent four 9-h euglycemic clamps (insulin at 20, 40, 80, and 400 mU x m[-2] x min[-1) and a control saline infusion. Although plasma glucose and insulin levels remained constant, leptin diminished from 9.1+/-3.0 to 5.9+/-2.1 ng/ml (P < 0.001) by the end of the control experiment. Conversely, plasma leptin showed a dosage-dependent increase during the insulin infusions that was evident within 30-60 min. The insulin-induced increase in leptin was proportionately lower in obese insulin-resistant men. Free fatty acids (FFAs) decreased during insulin and did not change during saline infusions. ED50 (the dose producing half-maximal effect) for insulin's effect on leptin and FFA was similar (138+/-36 vs. 102+/-24 pmol/l, respectively; P=0.11). To further define the role of physiological insulinemia, we compared the effect of a very low dosage insulin infusion (10 mU x m[-2] x min[-1]) with that of a control saline infusion in another group of 10 men (mean age 39+/-3 years; BMI 27.1+/-1.0 kg/m2). Plasma leptin remained stable during that insulin infusion, but fell by 37+/-2% in the control experiment. Thus physiological insulinemia can acutely regulate plasma leptin. Insulin could mediate the effect of caloric intake on leptin and could be a determinant of its plasma concentration. Inadequate insulin-induced leptin production in obese and insulin-resistant subjects may contribute to the development or worsening of obesity.

Modeling insulin action for development of a closed-loop artificial pancreas.

Three models of glucose homeostasis are compared in terms of their steady-state dose-response characteristics, how they characterize glucose distribution kinetics, and how they characterize the dynamics of insulin action. The three models [minimal model, AIDA (Automated Insulin Dosage Advisor), and a model by Sorensen] are used to discuss a wider variety of questions related to metabolic modeling. Simulations are performed comparing each model's response to an intravenous glucose tolerance test, with and without incremental insulin responses, to existing data in individuals with type 1 diabetes mellitus. Predicted changes in blood glucose following a subcutaneous bolus of insulin or an incremental increase in basal insulin delivery are simulated. From these results, the models are evaluated as potential candidates for simulating changes in treatment and developing a closed-loop insulin delivery algorithm. While no consensus model is proposed, relevant issues needing to be addressed are highlighted.

Closed-loop insulin delivery-the path to physiological glucose control.

The development of an artificial pancreas for the treatment of insulin-dependent diabetes is a highly desired endeavor for patients, physicians, scientists, and engineers. Historical algorithms and recent progress in research and technology are reviewed in the present article, together with aspects of beta-cell physiology that lead to normal glucose tolerance. Algorithms are evaluated for their ability to deliver insulin as to recreate, as closely as possible, glucose and insulin profiles observed in healthy individuals. Emphasis is placed upon how the algorithms compare to the beta-cell's secretory response, specifically first-phase and second-phase insulin secretion. Experimental closed-loop data employing intravenous and subcutaneous glucose sensors and implanted and external insulin pumps (Medtronic MiniMed, Northridge CA) are presented.

Diurnal and ultradian rhythmicity of plasma leptin: effects of gender and adiposity.

Plasma leptin shows a nocturnal rise and a pulsatile pattern. This work was undertaken to determine the effects of gender and obesity on this pattern. Twenty-four-hour leptin profiles were evaluated in 31 subjects [17 male, 14 female; age: 36 +/- 2 yr (mean +/- SEM); body mass index: 27.5 +/- 1.0 kg/m2]. Plasma leptin profiles were higher in obese (body mass index > 27 kg/m2) than in lean subjects and higher in women than in men, regardless of fat mass. Leptin showed diurnal rhythmicity with peaks between 2200-0300 (median: 0120) and nadirs between 0800 and 1740 (median: 1033). Spectral analysis revealed 2 components (periodicities: 24 and 12 h) with higher relative amplitudes in lean than in obese subjects. The relative diurnal amplitude also was higher in men than in women, controlling for adiposity. Insulinemia, female sex, and age were negative determinants of diurnal rhythm relative amplitude. Pulse analysis revealed 3.6 +/- 0.3 pulses/24 h, occurring mostly 2-3 h after meals. Pulse frequency correlated negatively with fat mass and insulinemia (Spearman's r = -0.54 and -0.37, respectively; P < 0.05 for each). Thus, obesity is associated not only with higher leptin levels but also with blunted diurnal excursions and dampened pulsatility. This abnormal rhythmicity may contribute to leptin resistance in obesity. The significance of the sexual dimorphism in the diurnal amplitude is unclear, but it may be related to leptin's putative role as a metabolic signal to the reproductive axis.

Islets in alginate macrobeads reverse diabetes despite minimal acute insulin secretory responses.

BACKGROUND: Encapsulation of islets has been widely investigated as a treatment for diabetes. The characteristics and dynamics of insulin secretion by encapsulated islets in response to glucose and other secretagogues are not well understood. METHODS: In our study, macroencapsulated syngeneic islets at 3-4 wk after transplantation were studied for insulin release in response to i.v. glucose (hyperglycemic clamps at 250 or 350 mg/dl plasma glucose), arginine (i.v. bolus, 100 mg/kg), glucagon-like peptide-1 (i.v. infusion for 20 min, 2.2 pmol/kg/min), and meal challenge. Syngeneic islets (6000 islets) were encapsulated in alginate macrobeads (2-3 mm diameter) with or without poly-L-lysine coating and transplanted into the peritoneal cavity of STZ-diabetic Lewis rats. Normal (nontransplanted) and diabetic Lewis rats transplanted with "naked" islets under the kidney capsule served as controls. RESULTS: Animals transplanted with macrobeads displayed subnormal insulin responses to glucose, arginine, and glucagon-like peptide-1 despite achieving normoglycemia faster than animals with renal subcapsular islet transplants. Plasma insulin responses to meal challenges were blunted in animals with macrobeads resulting in increased plasma glucose excursions. CONCLUSIONS: We conclude that, after transplantation into diabetic Lewis rats, macroencapsulated islets have significantly impaired insulin secretion despite achieving normal fed glycemic levels.

Gene expression of VEGF and its receptors Flk-1/KDR and Flt-1 in cultured and transplanted rat islets.

BACKGROUND: Vascular endothelial growth factor (VEGF) and its two receptor tyrosine kinases, Flk-1/KDR and Flt-1, may play an important role in mediating the revascularization of transplanted pancreatic islets. METHODS: Using semiquantitative multiplex reverse-transcribed polymerase chain reaction we determined the gene expression of VEGF and its receptors in cultured and transplanted rat islets. RESULTS: After exposure of islet cells to hypoxia in vitro, increases were found in the gene expression of the VEGF120 and VEGF164 isoforms, with simultaneous increases in VE-cadherin, Flk-1/KDR, and Flt-1. In vivo studies consisted of analysis of islet grafts transplanted into both normal and diabetic recipients. Expression of both VEGF120 and VEGF164 in grafts was up-regulated for the first 2-3 days after transplantation, with the response being more prolonged in the diabetic rats. These increases were followed by reduced expression of VEGF on days 5, 7, and 9. Increases in the expression of VE-cadherin in islet grafts in normal and diabetic recipients tended to parallel VEGF expression, with the increases in both probably being caused by hypoxia. The early increases of VEGF expression were followed by a rise in the expression of VEGF receptors, which probably represents the early stages of angiogenesis. Graft expression of Flk-1/KDR and Flt-1 was enhanced at 3 and 5 days in the normoglycemic recipients, while in the diabetic recipients increases were found later on days 5, 7, and 14. CONCLUSIONS: The delayed expression of VEGF receptors in the diabetic recipients could reflect impaired angiogenesis caused by the diabetic milieu; this delay could contribute to the less outcomes of grafts transplanted into a hyperglycemic environment.

Beta-cell dysfunction in 48-hour glucose-infused rats is not a consequence of elevated plasma lipid or islet triglyceride levels.

The abnormal insulin secretion found in human diabetics and animal models of diabetes has been attributed to the deleterious effects of chronic hyperglycemia and/or elevated circulating levels of nonesterified fatty acids (NEFAs). In this study, abnormal glucose-induced insulin secretion (GIIS) was generated by a 48-hour infusion of glucose and assessed by the isolated perfused pancreas technique. In these hyperglycemic animals, abnormal GIIS is accompanied by a decrease in plasma NEFAs, while plasma and, more importantly, islet triglycerides remain at levels comparable to those in the controls. It is concluded that the abnormal insulin secretion in this glucose infusion model was likely caused by 48 hours of hyperglycemia and not by changes in circulating or islet lipids.