Diabetes course notes (part 1)

1. Diabetes mellitus Whats in a name? 1. Diabetes: Marching through urine is produced incessantly 2. mellitus: honey-sweet as opposed to diabetes insipidus (insipid without avour) What does the adjective tell us about a traditional method of diagnosis? Notes: The traditional method of diagnosis was exactly as suggested by the nomenclature. It was eective, even if not entirely quantitative. For those of you who aspire to medical school, it may be comforting to know that it is no longer in use.

2. Forms of diabetes mellitus Type I, II, and secondary/symptomatic diabetes Type I and II are somewhat similar: Lack of insulin eect lack of the hormone (type I), or lack of functional response to the hormone (type II) Symptomatic diabetes dierent; insulin still present, but antagonistic hormones drive up glucose production. Typically acute clinical symptoms Notes: Type I diabetes is the form typically observed in the young, whereas the type II is more frequent overall and is typically observed in the elderly. MODY maturity type onset diabetes of the young is type II diabetes in young people. While the causation of diabetes type I is well understood and straightforward destruction of the insulin-producing -cells of the pancreatic isletsour understanding of type II diabetes is lagging behind. We will look at some recent science addressing this question. Symptomatic diabetes is diverse. A straightforward example is the excessive secretion of glucagon by a glucagonoma, that is a benign tumor derived from glucagonsecreting -cells in pancreatic islets. More commonly though it is caused by treatment with high dosages of glucocorticoid hormones in the treatment of auto-immune diseases.

3. Why is glucose lost through the kidneys? Stages of urine production in the kidneys: Filtration small molecules and ions are ltrated from the blood plasma at 150 liters/day Salts and major metabolites reabsorbed by specic transporters Capacity for glucose reuptake only slightly above the range of physiological blood glucose values elevated levels of blood glucose will result in overow

Kidney structure: Glomerulus and tubuli

4. Kidney tissue structure and function: Glomerulus and tubuli

Notes: The tissue slice shows a single glomerulus, and various tubular segments in cross- or longitudinal sections.

5. Primary ltration occurs in the glomerulus

Primary filtration in the glomerulus

Bowmans capsule

afferent arteriole

proximal tubule

efferent arteriole

Notes: The blood pressure remains high throughout the glomerulus, meaning that there is a driving force for ltration across the blood vessel walls. This explains the extraordinarily large ow rate of ltration. The ltration has a molecular weight cuto of about 10 kDa. Therefore, all small molecules and ions are ltrated, whereas large proteins such as proteins are retained in the blood plasma. The appearance in the urine of proteins in signicant amounts indicates that the ltration apparatus is damaged, as is the case in an autoimmune disease called glomerulonephritis.

6. Reuptake and secretion occur in the tubular segments

Active secretion of uric acid, organic acids, organic bases

Segments of the nephron and their functions

Reuptake of weak organic acids and bases

Filtration

Reuptake of glucose, amino acids, bicarbonate,

Reuptake / exchange of ions; reuptake of water

Notes: The bulk of the metabolites, including glucose, and most of the water are taken up again in the proximal tubule of the nephron. The distal segments are concerned with ne-tuning the concentration of the urine and the secretion or retention of salt ions and protons according to the metabolic situation.

7. The capacity for glucose reuptake is saturated slightly above the physiological Urine glucose secretion in diabetes mellitus plasma concentration range

Reabsorption maximum Amount filtrated Normal range Pathological range Amount excreted

Plasma glucose concentration

Notes: The normal range of glucose in the blood is approximately 48 mM. Glucose starts to appear in the urine when the plasma level exceeds 10 mM.

8. Types of glucose transporters

Active and facilitated transport of glucose

Na+ Glc

Na+ Glc

SGLUT

Glc

Glc

GLUT

Notes: The sodium-coupled SGLT transporter is an example of secondary active transport; it enables the uptake of glucose even against its concentration gradient. In the intestinal, the sodium is secreted by the pancreas and the glands underneath the mucosa of the small intestines. The simpler GLUT transporter enables facilitated diusion, which always occurs downhill the concentration gradient. In most tissues, a low intracellular glucose conSequential transport of glucose across the apical and centration is maintained through the phosphorylation of glucose by hexokinase.

basolateral membranes of the intestinal epithelia

gut lumen cytosol blood 9. SGLT occurs at the luminal side of intestinal and kidney epithelia

2 Na+ Glucose

2 Na+ Glucose SGLT1 Glucose GLUT2

Notes: The occurence of SGLT at the intestinal and kidney epithelia ensures a virtually complete uptake of glucose. 4

Modes of glucose transport

10. The role of insulin in glucose transport

Active transport Insulin-sensitive never

Facilitated transport Muscle Fat Most other tissues

Insulin-insensitive

Intestine Kidney tubules

Liver Brain Blood cells Lens and cornea of eye

Notes: The brain must keep working and can take up glucose with or without insulin. To preserve glucose when supply is low, its uptake into most other cell types occurs is restricted by its dependence on insulin. If blood glucose drops too low, a state called hypoglycemia, the brain will still experience shortages, and unconsciousness will result.

Insulin promotes sugar uptake by increasing the number 11. Insulin promotes sugar uptake by increasing the number of surface-exposed glucose transporters of surface-exposed glucose transporters
Glucose

Glucose transporter 4 exposed on cell surface

cytoplasmic membrane
High insulin Glucose Low insulin

Glucose transporter 4 stored intracellularly in vesicles

Notes: This scheme only applies to those cell types in which glucose uptake is insulindependent. As stated before, the brain and some other cell types are exempt.

12. Where does glucose come from, and where does it go? Sources: 1. Digested starch 2. Recovered from glycogen stores 3. Synthesized via gluconeogenesis 4. Converted from other carbohydrates: Fructose, galactose Destinations: 1. ATP production 2. Biosynthesis (amino acids, nucleotides, . . . ) 3. Glycogen synthesis 4. Triacylglycerol synthesis

13. Overview of glucose metabolism Starch, sugars Glucose glycolytic intermediates Amino acids NH3 UC Urea Pyruvate Acetyl-CoA TCA H2 H2 O ADP + P ATP Triacylglycerol Glycogen Ribulose-5-P

Notes: Looking at this slide is an opportunity for self-assessment. Do you understand it? Can you identify the pathways responsible for these conversions? If not, it is advisable to repeat them. If you lack a textbook for doing so, you may want to look at my Chem 333 metabolism course notes (available through the web).

14. Structure ofAmylose and amylopectin amylose/amylopectin

CH2OH

2OH

CH2OH O OH O O OH CH2OH O OH OH O OH

CH2OH O OH O OH CH2OH O OH O OH

CH2OH O OH O OH CH2OH O OH O OH OH O CH2 O OH CH2

O OH HO OH CH2OH O OH

O O OH

O OH

Amylopectin is polyglucose, (14) glycosidic bonds; branches formed by (14) glycosidic bonds. If no branches are present, the molecule is called amylose. Amylose and amylopectin are the two main components of starch, which is the major storage carbohydrate of plants.

Glucose and maltose

15. Digestion of amylose/amylopectin
CH2OH C H OH O CH H C OH OH

CH2OH HC HC OH H C OH O H C O HC

CH2OH HC OH C H H C OH O CH OH

HC

OH C H

OH C H

Glucose

Maltose

It is in turn cleaved by the brush-border enzyme Notes: In type II maltase. one therapeutic strategy is to inhibit the maltase enzyme diabetics,

Maltose: glucosyl-(14)- glucose Amylase cleaves amylose and amylopectin to the disaccharides maltose and isomaltose Maltose is produced by amylase cleaving amylose The brush border enzymes maltase and isomaltase produce monomeric glucose and amylopectin. Uptake occurs through the luminal SGLT transporter

with the drug acarbose, which results in a decreased rate of glucose uptake. Can you imagine what kind of side eects this would have? Think of lactose tolerance.

Villi and microvilli in the small intestine

16. The brush border of the small intestine

Notes: The rate of substrate uptake from the intestine is proportional to its surface. The surface is maximized at each level of organization: Length of the organ, folded surface, decorated with macro- and microvilli.

The portal circulation

17. The portal circulation

Systemic circulation Liver vein

Liver

Portal vein
Notes: The perfusion of the intestinal organs is organized dierently from most other organs, in that the blood drained from them is passed through the liver before being fed back into the general circulation. The liver plays a key role in metabolic regulation; it also protects the organism from ingested poisons.

18. Metabolic fates of glucose 1. Immediate utilization: Glycolysis, pentose phosphate shunt 2. Conversion for storage: Glycogen synthesis, triacylglycerol synthesis The distribution of glucose between these destinations depends on our metabolic state: If free glucose is plentiful, both immediate utilization and conversion for storage are enhanced. This is promoted by insulin If free glucose is in high demand, utilization is restricted to preferred customers, particularly the brain. This usage is promoted by glucagon and epinephrin

19. Glycolysis and gluconeogenesis

Gluconeogenesis uses the reversible reactions from glycolysis and bypasses the irreversible ones

Glucose Glucose-6-P Fructose-6-P Fructose-1,6-bis-P Dihydroxyacetone-P + Glyceraldehyde-P 1,3-Bis-P-glycerate

Glycolysis only Shared Gluconeogenesis only

Oxaloacetate

3-P-glycerate 2-P-glycerate P-enolpyruvate Pyruvate

20. Substrate sources for gluconeogenesis

Carbon sources for gluconeogenesis

P-enolpyruvate Pyruvate CO2 Acetyl-CoA

Glucose Lactate, amino acids

Oxaloacetate Malate

Citrate Isocitrate CO2 -Ketoglutarate CO2 Succinyl-CoA

Fumarate Succinate

Amino acids

Notes: Amino acids that are converted to pyruvate or TCA intermediates and therefore can serve as substrates for gluconeogenesis are called glucogenic. Leucine, lysine and the aromatic amino acids are degraded to acetyl-CoA and/or acetoacetate. Since the latter are, or Regulation of gluconeogenesis (1): Allosteric control of ketogenic. can be converted to ketone bodies, these amino acids are called

phosphofructokinase I and Fructose-bisphosphatase (1)

21. Glycolysis and gluconeogenesis: Allosteric regulation of key enzymes
Pi Fructose-6-P ATP

+
Fructose-1,6 bisphosphatase

ATP AMP

+ PFK 1

Fructose-2,6-bis-P + Fructose-1,6-bis-P ADP Glycolysis

H 2O Gluconeogenesis

Notes: The regulatory molecule fructose-2,6-bisphosphate is controlled by hormones (see below). Hormones communicate the metabolic demands of the entire organism (see below). In contrast, ATP and AMP reect the metabolic situation of the cell itself. Thus, the allosteric regulation of PFP-1 and fructose-1,6-bisphosphatase strikes a compromise between the needs of the individual cell and those of the organism as a whole.

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22. Fructose-bisphosphates compared

Fructose bisphosphates compared

O O OH O P O OH CH2 O H2C OH OH OH OH O HO P O O OH

O O P O OH CH2 O O H2C OH

P O

Fructose-1,6-bisphosphate

Fructose-2,6-bisphosphate

Notes: Fructose-2,6-bisphosphate is present at much lower levels than the 1,6bisphosphate and only exists for the purpose of regulation.

Regulation of gluconeogenesis (2): cAMP controls the level of PFK-2 / fructose-2,6-bisphosphatase 23. The level of Fructose-2,6-bisphosphate is under hormonal control
Epinephrin, glucagon + cAMP + Protein kinase A P PFK-2/bis-Pase PFK-2/bis-Pase Fructose-2,6-bis-P Glycolysis Fructose-6-P Gluconeogenesis Insulin

Notes: The phosphofructokinase 2 (PFK-2) and fructose-2,6-bisphosphatase enzyme activities are located on the same bifunctional enzyme molecule. The phosphorylation by protein kinase A activates the phosphatase activity and at the same time inhibits the kinase activity. Regulation by phosphorylation is best thought of as allosteric regulation, where the allosteric eector happens to be covalently bound to the enzyme.

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24. Glycogen metabolism Why store glucose in polymeric form? In the liver, glycogen accounts for up to 10% of wet weight, which corresponds to 600 mM of glucose. According to pV = nRT or p = n RT V

this would roughly triple the osmotic activity of the liver cytosol cells would swell and burst. Linking 2 (3, ..) molecules of glucose divides the osmotic eect by 2 (3, ..) and makes storage of large amounts of glucose compatible with physiological osmolarity. Notes: The proportionality of concentration and osmotic activity does not strictly apply at very large molecular weights.

25. Structure of glycogen

Structure of glycogen
Linear polymers of (14)-linked glucose residues, branched by (16)-glycosidic bonds

O CH2

O CH2 CH2 O O O

O-Tyr

Glycogenin

6-8 glc residues

total: > 105 glc residues

Notes: The structure of glycogen is essentially the same as that of amylopectin. However, the density of branches is greater, which means that a glycogen molecule has a greater number of free ends than an amylopectin molecule of the same molecular weight. The number of free ends determine the possible rates of synthesis and breakdown, and the higher density in glycogen reects the metabolic rate that is higher in humans than in plants.

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Glycogen synthesis (4): elongation

26. The glycogen synthase reaction
CH2OH O OH OH OH O

Tyr

Glycogenin

UDP-glc UDP-glc UDP-glc UDP-glc UDP-glc

HO

O-Tyr

Glycogenin

UDP

UDP

UDP

UDP

UDP

Notes: Glycogenin is a small protein that serves as the starter substrate for glycogen synthesis. This is just to remind you what glycogen synthase does nothing new here, move along. Glycogen degradation (1): Glycogen phosphorylase

successively cleaves single glucose subunits and converts them to glucose-1-phosphate 27. The glycogen phosphorylase reaction
Pi glcglcglcglcglcglcglcglc glc-1-P Pi glcglcglcglcglcglcglcglcglcglcglcglcglcglc glc-1-P glc-6-P glucose

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Regulation of glycogen metabolism (2): Allosteric regulation 28. Allosteric regulation of glycogen synthase and phosphorylase
Glycogen

glycogen synthase

Glc-6-P ATP AMP

phosphorylase

UDP-glucose Glucose-1-P Glucose-6-P

Notes: Glucose-1-phosphate is reversibly converted to glucose-6-phosphate by phosphoglucomutase. The conversion of glucose-1-phosphate to UDP-glucose by glucose-1phosphate uridyltransferase requires UTP and releases pyrophosphate.

29. Regulation of glycogen metabolism (2)

Regulation of glycogen metabolism (3): Regulation by phosphorylation in response to hormone action

ATP cAMP Protein Kinase A Insulin

Epinephrine, Glucagon

Glycogen synthase (active) Phosphorylase kinase (inactive)

Glycogen synthaseP (inactive) Phosphorylase kinaseP (active) Phosphorylase-P (active) Phosphorylase (inactive)

Notes: The upper part of this regulatory cascade is the same as in shown before for gluconeogenesis. Glycogen metabolism and gluconeogenesis are therefore regulated in parallel. In both cases, the eect of glucagon is to increase the rate of glucose synthesis and to reduce the rate of consumption, whereas the eect of insulin in both cases is the opposite.

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