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肠道在糖尿病性高胰高血糖素血症中的作用

On the role of the gut in diabetic hyperglucagonaemia.

作者信息

Lund Asger

出版信息

Dan Med J. 2017 Apr;64(4).

Abstract

Patients with type 2 diabetes are characterised not only by compromised insulin secretion and action, but also by elevated plasma concentrations of the 29-amino acid peptide hormone glucagon, which generally is thought of as a pancreas-derived hormone (produced in and secreted from alpha cells in the islet of Langerhans). In patients with diabetes, circulating glucagon concentrations are elevated in the fasting state and fail to decrease appropriately or even increase in response to ingestion of nutrients. Glucagon is known to be a potent stimulator of hepatic glucose production, and, thus, the elevated glucagon concentrations in diabetes contribute decisively to the predominating trait of patients with diabetes namely hyperglycaemia. Interestingly, studies have shown that while oral intake of glucose results in inappropriately high plasma concentrations of glucagon in patients with diabetes, intravenous (iv) infusion of glucose does not. The mechanisms behind these differential glucagon responses to oral vs. iv glucose administration are currently unexplained. Three hypotheses were tested in the present thesis: 1) Could the inappropriate glucagon response to oral glucose ingestion in patients with diabetes be attributed to the release of glucagonotropic/glucagonostatic peptides secreted from the gut? 2) Could the inappropriate glucagon response to oral glucose ingestion in diabetes be a result of extrapancreatic glucagon secretion (possibly originating from the gut)? And 3) Does the differential glucagon responses between oral and iv glucose administration affect endogenous glucose production (EGP). The overall aim of this PhD thesis was, thus, to investigate the role of the gut in diabetic hyperglucagonaemia and hyperglycaemia. In Study I we examined the effect of the three gut-derived hormones glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptide-1 (GLP-1) and glucagon-like peptide-2 (GLP-2) on glucagon secretion in patients with type 2 diabetes. We applied a 50 g-oral glucose tolerance test (OGTT), and five isoglycaemic iv glucose infusions (IIGIs) with either saline, GIP, GLP-1, GLP-2 or a combination of the three hormones. We show that these gut-derived hormones affect glucagon secretion differently and that OGTT-induced secretion of these hormones may play a role in the inappropriate glucagon response to orally ingested glucose in patients with type 2 diabetes with especially GIP acting to increase glucagon secretion. In Study II we examined totally pancreatectomised patients and non-diabetic control subjects during a 75 g-OGTT and an IIGI. We applied sandwich enzyme-linked immunosorbent assay (ELISA) and mass spectrometry-based proteomics for plasma glucagon analysis and show that 29-amino acid glucagon circulates in patients without a pancreas and that glucose stimulation of the gut results in significant hyperglucagonemia in these patients - ultimately confirming the existence of extrapancreatic glucagon secretion in humans. In Study III we examined whether the different responses of insulin and glucagon, respectively, between oral and iv glucose administration translate into differences in EGP and glucose disappearance in patients with type 2 diabetes and non-diabetic control subjects. We applied glucose tracer methodology during a 75 g-OGTT, IIGI and IIGI + iv glucagon (to isolate the effect of glucagon) and show that EGP is less suppressed during OGTT than during IIGI in both patients with type 2 diabetes and non-diabetic control subjects.

摘要

2型糖尿病患者的特征不仅在于胰岛素分泌和作用受损,还在于血浆中29个氨基酸的肽类激素胰高血糖素浓度升高,该激素通常被认为是一种源自胰腺的激素(由胰岛的α细胞产生并分泌)。在糖尿病患者中,空腹状态下循环中的胰高血糖素浓度升高,并且在摄入营养物质后不能适当降低甚至升高。已知胰高血糖素是肝葡萄糖生成的有效刺激物,因此,糖尿病患者中升高的胰高血糖素浓度决定性地导致了糖尿病患者的主要特征,即高血糖症。有趣的是,研究表明,虽然糖尿病患者口服葡萄糖会导致血浆中胰高血糖素浓度异常升高,但静脉注射葡萄糖则不会。目前尚无法解释这些胰高血糖素对口服与静脉注射葡萄糖给药的不同反应背后的机制。本论文检验了三个假设:1)糖尿病患者对口服葡萄糖摄入的胰高血糖素反应不当是否可归因于肠道分泌的促胰高血糖素/抑胰高血糖素肽的释放?2)糖尿病患者对口服葡萄糖摄入的胰高血糖素反应不当是否是胰腺外胰高血糖素分泌(可能源自肠道)的结果?3)口服和静脉注射葡萄糖给药之间胰高血糖素的不同反应是否会影响内源性葡萄糖生成(EGP)?因此,本博士论文的总体目标是研究肠道在糖尿病性高胰高血糖素血症和高血糖症中的作用。在研究I中,我们研究了三种源自肠道的激素,即葡萄糖依赖性促胰岛素多肽(GIP)、胰高血糖素样肽-1(GLP-1)和胰高血糖素样肽-2(GLP-2)对2型糖尿病患者胰高血糖素分泌的影响。我们进行了一次50克口服葡萄糖耐量试验(OGTT),以及五次等血糖静脉注射葡萄糖输注(IIGI),分别使用生理盐水、GIP、GLP-1、GLP-2或这三种激素的组合。我们发现这些源自肠道的激素对胰高血糖素分泌的影响不同,并且OGTT诱导的这些激素分泌可能在2型糖尿病患者对口服葡萄糖的胰高血糖素反应不当中起作用,尤其是GIP会增加胰高血糖素分泌。在研究II中,我们在一次75克OGTT和一次IIGI期间对全胰腺切除患者和非糖尿病对照受试者进行了研究。我们应用夹心酶联免疫吸附测定(ELISA)和基于质谱的蛋白质组学进行血浆胰高血糖素分析,并表明在没有胰腺的患者中循环着29个氨基酸的胰高血糖素,并且肠道的葡萄糖刺激会导致这些患者出现显著的高胰高血糖素血症——最终证实了人类中存在胰腺外胰高血糖素分泌。在研究III中,我们研究了2型糖尿病患者和非糖尿病对照受试者口服和静脉注射葡萄糖给药后胰岛素和胰高血糖素的不同反应是否分别转化为EGP和葡萄糖消失的差异。我们在一次75克OGTT、IIGI和IIGI +静脉注射胰高血糖素(以分离胰高血糖素的作用)期间应用葡萄糖示踪方法,结果表明在2型糖尿病患者和非糖尿病对照受试者中OGTT期间EGP的抑制程度均低于IIGI期间。

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