Regulation of Brain Glucose Metabolism by Alternate Fuels in Type 1 Diabetes

描述（由申请人提供）：通过强化胰岛素治疗使血糖水平正常化，减少糖尿病并发症的发生率。然而，这种治疗方案的益处仍然受到频繁和严重低血糖发作的限制。这些发作降低了大脑检测低血糖和激活反调节防御的能力，进一步增加了随后低血糖的风险。因此，低血糖可以在没有任何征兆的情况下或在睡眠中发生，这强调了预防策略的必要性，并尽量减少其潜在的不良后果，如癫痫发作、昏迷和永久性损伤。这个问题在1型糖尿病（T1DM）中特别值得关注，最近的研究表明，在患者生命早期发生的严重和复发性低血糖可导致认知障碍和持久的脑损伤。先前我们发现，在T1DM和复发性低血糖大鼠模型中，醋酸一元羧酸的转运和代谢上调，表明增加的替代燃料消耗在低血糖无意识中起主要作用。然而，当我们研究更相关的替代燃料乳酸时，我们惊讶地发现乳酸运输的增强并不与乳酸利用率的增加密切相关，而是刺激了脑葡萄糖代谢。我们在啮齿类动物中的观察结果已经被最近对T1DM受试者的研究证实。这些发现支持了乳酸盐在T1DM患者低血糖过程中具有双重作用的概念，既是葡萄糖代谢的底物，也是葡萄糖代谢的激活剂。我们最近通过乳酸对神经元丙酮酸脱氢酶（PDH）复合物活性的影响，对乳酸悖论有了进一步的了解。我们的初步结果表明，PDH在低血糖时受到抑制，这种抑制可以通过血浆乳酸逆转。如果这个模型是正确的，T1DM中保存的葡萄糖代谢可能在低血糖无意识中起重要作用，这是由于转运升高，提高了脑乳酸水平，阻止了PDH的抑制。因此，本研究的总体目标是在反复低血糖的情况下确定脑乳酸和葡萄糖代谢的相互作用，以建立T1DM患者维持脑代谢（和功能）而不意识到低血糖的分子机制。我们将使用核磁共振波谱来确定13c标记的葡萄糖和乳酸对复发性低血糖的脑代谢的贡献。此外，我们将使用药理学和siRNA敲低方法来确定PDH抑制激酶在低血糖下抑制PDH通量中的作用。这些发现的人类相关性将通过核磁共振波谱在低血糖无意识的T1DM患者和使用13c -葡萄糖和乳酸盐的匹配对照中进行测试。

DESCRIPTION (provided by applicant): Normalization of blood glucose levels via intensive insulin therapy reduces the incidence of diabetic complications. However, the benefits of such treatment regimens remain limited by frequent and severe bouts of hypoglycemia. These episodes diminish the brain's capacity to detect hypoglycemia and to activate counterregulatory defenses, further increasing the risk of subsequent hypoglycemia. As a result, hypoglycemia can occur without warning symptoms or during sleep, underscoring the need for preventive strategies and of minimizing its potential adverse consequences like seizures, coma and permanent injury. This issue is of particular concern in type 1 diabetes (T1DM) where recent studies suggest that severe and recurrent hypoglycemia occurring early in a patient's life can result in cognitive impairment and lasting brain damage. Previously we found that transport and metabolism of the monocarboxylic acid acetate was upregulated in T1DM and in a recurrent hypoglycemia rat model indicating that enhanced alternate fuel consumption plays a major role in hypoglycemia unawareness. However, when we studied the more relevant alternate fuel lactate, we found to our surprise that enhanced lactate transport did not go hand in hand with increased lactate utilization, but stimulated brain glucose metabolism instead. Our observations in rodents have since been confirmed by a recent study in T1DM subjects. These findings support the concept of lactate having a dual role during hypoglycemia in T1DM, as both a substrate and as an activator of glucose metabolism. We have recently gained additional insight into this lactate paradox through its impact on neuronal pyruvate dehydrogenase (PDH) complex activity. Our preliminary results suggest that PDH is inhibited during hypoglycemia, and that this inhibition can be reversed by plasma lactate. If this model is correct the preserved glucose metabolism in T1DM, which may play an important role in hypoglycemia unawareness, is due to elevated transport raising brain lactate levels and preventing inhibition of PDH. Thus, the overall goal of this proposal is to define the interplay of brain lactate and glucose metabolism in the context of recurrent hypoglycemia to establish the molecular mechanism by which T1DM patients sustain brain metabolism (and function) and become unaware of hypoglycemia. We are going to use NMR spectroscopy to define the contributions of 13C-labeled glucose and lactate to brain metabolism in the setting of recurrent hypoglycemia. In addition we will use pharmacologic and siRNA knockdown approaches to determine the role of PDH inhibiting kinases in the suppression of PDH flux under hypoglycemia. The human relevance of these findings will be tested by NMR spectroscopy in T1DM patients with hypoglycemia unawareness and matched controls using 13C-glucose and lactate.