Peters A, Schweiger U, Frühwald-Schultes B, Born J, Fehm H L
Medical Clinic 1, Medical University of Luebeck, Germany.
Exp Clin Endocrinol Diabetes. 2002 Aug;110(5):199-211. doi: 10.1055/s-2002-33068.
Here we propose that glucose metabolism can be understood on the basis of three concept-derived axioms: (I) A hierarchy exists among the glucose-utilizing organs with the brain served first, followed by muscle and fat. (II) Tissue-specific glucose transporters allocate glucose among organs in order to maintain brain glucose concentrations. (III) Exogenous carbohydrate supply compensates for glucose alterations that can temporarily occur in muscle and fat. Derived from the control theory, the simplest solution of allocating supply to 2 organs, e.g. brain and muscle, is a "fishbone"-structured model. We reviewed the literature, searching for neuroendocrine and metabolic mechanisms that can fulfill control functions in such a model: The tissue-specific glucose transporters are differentially regulated. GLUT 1, carrying glucose across the blood-brain-barrier, is independent of insulin. Instead, this trans-endothelial glucose transporter is rather dependent on potent regulators of blood vessel function like vascular endothelial growth factor - a pituitary counterregulatory hormone. GLUT 4, carrying glucose across the membranes of muscle and fat cells, depends on insulin. Thereby, insulin allocates glucose to muscle and fat. The hypothalamus-pituitary-adrenal (HPA) axis, the sympathetic nervous system (SNS), and vascular endothelial growth factor allocate glucose to the brain. Multiple "sensors" (some of which have only recently been identified as ATP sensitive potassium channels) measure glucose or glucose equivalents at various sites of the body: the ventromedial hypothalamus, the lateral hypothalamus, portal vein, pancreatic beta cell, renal tubule, muscle and adipose tissue. Feedback pathways both from the brain and from muscle and fat are involved in regulating glucose allocation and exogenous glucose supply. The main feedback signal from the brain is found to be glucose, that from muscle and fat appears to be leptin. In fact, the literature search revealed two or more biological mechanisms for the function of each component in the model, finding glucose regulation highly redundant. This review focuses on "brain glucose" control. The concept of glucose allocation presented here challenges the common opinion of "blood glucose" being the main parameter controlled. According to the latter opinion, hyperglycemia in the metabolic syndrome is due to a putative defect located within the closed loop including the beta cell, muscle and fat cells. That traditional view leaves some peculiarities of e.g. the metabolic syndrome unexplained. The concept of glucose allocation, however, would predict that weight gain - with abundance of glucose in muscle and fat - increases feedback to the brain (via hyperleptinemia) which in turn results in HPA-axis and SNS overdrive, impaired insulin secretion, and insulin resistance. HPA-axis overdrive would account for metabolic abnormalities such as central adiposity, hyperglycemia, dyslipidemia, and hypertension, that are well known clinical aspects the metabolic syndrome. This novel viewpoint of "brain glucose" control may shed new light on the pathogenesis of the metabolic syndrome and type 2 diabetes.
在此,我们提出葡萄糖代谢可基于三个源自概念的公理来理解:(I)在利用葡萄糖的器官之间存在层级关系,大脑优先获得葡萄糖供应,其次是肌肉和脂肪。(II)组织特异性葡萄糖转运蛋白在各器官间分配葡萄糖,以维持大脑葡萄糖浓度。(III)外源性碳水化合物供应可补偿肌肉和脂肪中可能暂时出现的葡萄糖变化。源自控制理论,将供应分配给两个器官(如大脑和肌肉)的最简单解决方案是一个“鱼骨”结构模型。我们回顾了文献,寻找能在这样一个模型中发挥控制功能的神经内分泌和代谢机制:组织特异性葡萄糖转运蛋白受到不同调节。GLUT 1负责将葡萄糖转运过血脑屏障,它不依赖胰岛素。相反,这种跨内皮葡萄糖转运蛋白相当依赖血管功能的强效调节因子,如血管内皮生长因子——一种垂体反调节激素。GLUT 4负责将葡萄糖转运过肌肉和脂肪细胞的膜,它依赖胰岛素。因此,胰岛素将葡萄糖分配至肌肉和脂肪。下丘脑 - 垂体 - 肾上腺(HPA)轴、交感神经系统(SNS)以及血管内皮生长因子将葡萄糖分配至大脑。多个“传感器”(其中一些直到最近才被确定为ATP敏感钾通道)在身体的各个部位测量葡萄糖或葡萄糖等效物:腹内侧下丘脑、外侧下丘脑、门静脉、胰腺β细胞、肾小管、肌肉和脂肪组织。来自大脑以及肌肉和脂肪的反馈通路都参与调节葡萄糖分配和外源性葡萄糖供应。发现来自大脑的主要反馈信号是葡萄糖,来自肌肉和脂肪的似乎是瘦素。事实上,文献检索揭示了模型中每个组件功能的两种或更多种生物学机制,发现葡萄糖调节具有高度冗余性。本综述聚焦于“大脑葡萄糖”控制。此处提出的葡萄糖分配概念挑战了将“血糖”作为主要受控参数的普遍观点。根据后一种观点,代谢综合征中的高血糖是由于包括β细胞、肌肉和脂肪细胞在内的闭环内存在假定缺陷。那种传统观点无法解释例如代谢综合征的一些特殊情况。然而,葡萄糖分配概念预测体重增加——肌肉和脂肪中有大量葡萄糖——会增加对大脑的反馈(通过高瘦素血症),这反过来会导致HPA轴和SNS过度驱动、胰岛素分泌受损以及胰岛素抵抗。HPA轴过度驱动可解释代谢异常,如中心性肥胖、高血糖、血脂异常和高血压,这些都是代谢综合征众所周知的临床特征。这种“大脑葡萄糖”控制的新观点可能为代谢综合征和2型糖尿病的发病机制提供新的见解。
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