493 Horm. Me tab. Res 11 (1979) 493 -497

Effect of Metabolie Control on Urinary Exeretion and Plasma Levels of Cateeholamines in Diabeties G. Bolli, Maria G. Cartechini l , P. Compagnucci 1 , S. Malvicini, P. Oe Feo, F. Santeusanio 1, G. Angeletti and P. Brunetti Institute of Medical Pathology and lClinical Medicine, University of Perugia, Italy

Urinary excretion and plasma levels of catecholamines were determined in 20 normal and 39 diabetic subjects to evalu· ate the sympathetic aetivity. Diabetie patients were divided into 4 groups aecording to the metabolie eontro!. Sympathetie aetivity showed no differenees between normal and subjeets with ehemical diabetes (group I, n = 5). In insulintreated diabetics in good metabolie eontrol (group 11, n = 11) only urinary excretion of free norepinephrine was signifieantly higher than norm als (p < .05). In insulin-treated diabetics in poor metabolie eontrol (group III, n = 16) urinary excretion and plasma levels of norepinephrine showed a marked inerease over groups land 11 (p < .00 I). In insulintreated diabeties with ketosis (group IV, n = 7) urinary exeretion and plasma levels of both norepinephrine and epinephrine showed the highest values (p < .001 and < .1). Finally, in groups III and IV, after achieving improved metabolie control, a significant deerease of urinary exeretion and plasma levels of catecholamines was observed. The results confirm that there is an inereased rate of catecholamine release in poorly controlled diabeties and suggest a close correlation between sympathetic activity and metabolie derangement in diabetes. Key-Words: Diabetes - Catecholamines - Norepinephrine - Epinephrine - Sympathetic System

Introduction It is weil known that under physiological conditions the sympathetic nervous system interferes with glucose metabolism, mainly by constant contral of pancreatic secretion of insulin and glucagon (Porte, Graber, Kuzuya and Williams 1966; Robertson and Porte 1973; Gerich, Langlois, Noacco, Schneider and Forsham 1974). Therefore, the intolerance to carbohydrate which recurs in myocardial infarction, sepsis, bums, trauma, intensive physical exercise, all conditions which are notoriously associated with increased sympathetic activity (Lukomsky and Lorganov 1972; Rocha, Santeusanio, Raloona and Unger 1973; Wilmore, Lindsey, Moylan, Faloona, Pruitt and Unger 1974; Lindsey, Santeusanio, Braaten, Faloona and Unger 1974; Böttger, Faloona and Unger 1971), has been explained as a consequence of the insulin suppression and glucagon stimulation observed in these cases. Received: 14 Aug. 1978 0018-5043/79

0932-0493

Aecepted: 25 Jan. 1979 S 03.00

©

High plasma levels of norepinephrine and epinephrine have been observed during diabetic ketoacidosis (Christensen 1974), but not in the very early stages of this condition (Alberti, Christensen, [versen and (jJrskov 1975). Moreover, an abnormal increase in sympathetic activity in non-ketotic diabetics has been daimed by some (Robertson, Halter and Porte 1976), and denied by others (Cryer, Silverberg, Santiago and Shah 1976). In the present study, the evaluation of plasma levels and urinary excretion of norepinephrine and epinephrine has enabled us to demonstrate a dear correlation between the degree of metabolie contral and the increase of sympathetic activity in diabetic patients. Patients and Methods The study was carried out on 39 patients (21 males and 18 females) affeeted by diabetes mellitus aged from 16 to 71 years (45.5 ± 2.3 mean ± S.E.M.). The patients were divided into 4 groups depending on the degree of metabolie eontrol (see Table 1). Patients affeeted by diabetie neuropathy and by any stressful pathological condition other than diabetes (cardiac failure, respiratory insufficiency) were excluded. Endogenous creatinine clearanee was within the normal range in all patients examined. Group I. 5 patients affected by chemical diabetes, as diagnosed by OGTT, according to Fajans and Conn (1965). Group lI-IV. Diabetic patients on insulin treatment. The essential difference was the degree of metabolie control, as evaluated by blood glucose values determined on fasting and 90 minutes after lunch for 5 consecutive days before the study was started. In group IV kctonuria was present, but the pH was never lower than 7.30 and the plasma bicarbonate ne ver lower than 15 mEq/1. All patients in this group had clinical signs of deficient insulin supply, such as marked loss of weight, polydipsia, polyuria and asthenia. Patients of group 111 and IV were reinvestigated fot sympathetic activity 15 days after the initial examination, when good metabolie eontrol similar to that in group II patients had been obtained with a better adjusted insulin dose. 20 normal subjects served as controls. Great care was taken to avoid hypoglycemic reaction during the study. Daily urinary excretion and plasma norepinephrine and

1979 Georg Thieme Publ ishers

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Summary

494

G. Rolli, M.G. Cartechini, P. Compagnucci, S. Malvicini, P. Oe Feo, F. Santeusanio, G. Angeletti and P. Brunetti

Table I Metabolic parameters of subjects in the study. Oiabetics of group 111 and IV were examined be fore (B) and after (A) heUer adjustment of insulin treatment No of subjects

Group

M Control Oiabetic I II

Age

F

Glycosuria Blood glucose 90 min. after lunch g/24 h fasting mg/d1

Ouration of diabetes yr

yr

-

-~-~~-----~.~

--

43.5±4.29*

0

85 ± 3

110 ± 5

absent

absent

2

43.8±3.46

0

95 ± 3

149 ± 3

absent

absent

7

4 7.6±3. 73

11.2±1.72

132 ± 3

181 ± 6

6.7± J.7

absent

275 ± 5 171 ± 4

30.0±2.2 8. 7± 1.2

absent absent

333 ± 12 176 ± 6

60.0±5 9.8 ±I

presenl absent

10

10

3 4

B A

7

9

47.3±4.12

9.81±2.51

182 ± 3 129 ± 4

IV- B -A

4

3

34. 9±6. 91

5.71 ±1.86

244 ± 9 142 ± 5

IIIC

Ketonuria

*mean ± S.E.M. Table 2 Oaily urinary excretion and plasma levels (in supine position and after 3 minutes of standing) of norepinephrine (NE) and epinephrine (E) in 4 groups of diabetics and in controls. Oiabetics of groups III and IV were examined before (B) and after (A) beUer adjustment of insulin treatment Plasma (ng/I)

Control Oiabetic I II

Standing

Supine NE

E

NE 326 ± 6.9

23.4± 1.08

220±0.17

149 ± 2.7

50 ± 1.8

25.4± I. 98

2.00±0.79

152±4.6

56 ± J.7

35.1 ±1.61+ 2.64±0.22

182 ± 10

55 ± 1.8

E 52

±

1.8

309 ± 7.4

61

±

0.9

413 ± 20

60 ± 3.9

m/ B

51.2±3.14*

2.35±0.66

239 ± 10*

58 ± 2.7

505 ± 41 +

62

'A

329±1.66*

2.29±0.15

190 ±4.9°

59 ± I. 9

380 ± 15

60 ± 2.7

B IV/ ........... A

74.1 ±5.50*

4.52±0.79t

398 ± 30*

69 ± 5.7t

919 ± 91*

84 ± 7.3 0

37.4±3.90*

2.55±0.20

205

54 ± 3.4

399

62 ± 4.5

(values are mean ±S.E.M.). t p < .1;

+ P < .05;

0

±

17°

P < .01;

*

±

20

±

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Urine (",g/24 h) NE E

Group

4

p< .001.

Table 3 Significant correlations between catecholamines (urinary excretion; plasma levels in supine position and after 3 minutes standing) and blood glucose in 39 diabetics with different degrees of glycemic control ------

(Xl Blood glucose mg/dl 90' after lunch

fasting

= 0.77 = 0.75 r = 0.71

P < .0005

= 0.77 = 0.74 r = 0.67

P < .005

r

r

= 0.42 = 0.37

r

= 0.41

urinary excretion (Y) Norepinephrine/ . -........ plasma- ~upme ......... standing

r

P < .0005,

r

r

P < .0005

r

_ _ urinary excretion (Y) Epinephrine __ . -..... plasma- supme

r

"

standing

epinephrine levels were determined in patients and controls. Blood sampies were obtained by an indwelling catheter between 7 and 8 a.m., beforc morning insulin injcction, whilc the patient was fasting and had rested in bed for at least one hour, and again after 3 minu tes of standing. The blood was collected in iced test-tubes containing a film of heparin and 10 mg sodium metabisulphite, centrifuged immediately at + 2 °c at 3000 r.p.m. and the plasma stored at - 20 0l".

p< .0005 p< .0005 P < .0005 p< .0025

P < .01

= 0.46 r = 0.32

P < .005

r

= 0.41

P < .005

p< .025

Plasma and urinary catecholamines were determined according to a sensitive and specific tluorimetric method (Renzini, Brunori and Valori 1970), wh ich, despite the fact that the radiocnzymatic technique is considered superior, gives good results (Miura, Campese, De Quattro and Maijer 1977). Renal c1earance of catecholamines was calculated in all cases. Venous-blood and urinary glucose was determincd by mean' of a Beckman glucose Autoanalyzer.

Effect of Metabolie Control on Urinary Excretion and Plasma Levels of Catecholamines in Diabeties

495

0

( lIun

~

S.LII. )

•••

0

I

• P 4.01 •• P4 o~~Versus

...:10 """.... ...

-

.

/

normals (Schtlle - h stJ

• •• p4.001

•••

~

~o

-

~40

-

1

••

... ~

~

... 30

-

I

IX

C>

...

. .. 20

IX

11

11

111

IV

Fig. I Urinary excretion of free norepinephrinc and epinephrine in normals (N) and in 4 groups of diabetics (group I: chemie al diabetes; group 11: good metabolie control; group 11: good metabolie contro); group 1JI: poor metabolie controU; group IV: ketosis).

Fig. 2 Plasma levels of norepinephrine and epinephrinc (in supine position and after 3 minutes of standing) in normals (N) and in 4 groups of diabeties (group I: chemieal diabetes; group 11: good metabolie eontrol; group 1JI: poor metabolie control; group IV: ketosis)

Urinary ketone bodies were determined by the nitroprussidc method. The ANOV A (Scheffe test) was adopted for groups and the Student's t-test for paired groups for statistical analysis. Correlations between catecholamines levels (urinary excretion plasma values, in supine position and after 3 minutes of standing) and blood glucose (fasting and 90 minutes after lunch) were also calculated.

vels of norepinephrine (p < .001), but they were still higher than in the eontrols (urine p < .001; plasma p < .025). Urinary exeretion and plasma levels of epinephrine did not differ signifieantly from the normal mean.

Results The results are summarized in Tables 2, 3 and in Figures I, 2, 3, 4. In group I urinary and plasma catecholamines did not differ signifieantly from the normal mean.

In group IV urinary exeretion of free norepinephrine 'and epinephrine was eonsiderably higher than in any other group (p < .00 land < .1). Plasma levels of both eateeholamines were similarly inereased (norepinephrine p < .001); su pine epinephrine p < .1, standing p < .01). Reinvestigation after better adjustment of insulin treatment revealed a dreerease of norepinephrine (urine p < .001; plasma p < .005), and epinephrine (urine and plasma p < .05). Norepinephrine was, however, still lligher than in group I (urine and plasma p < .05). Neither urinary exeretion nor plasma levels of epinephrine differed signifieantly from the normal mean.

In group 11 urinary exeretion of free norepinephrine was s1ightly, but signifieantly, higher than in eontrols (p < .05). There were, however, no signifieant differenees in norepinephrine and epinephrine plasma levels nor in urinary exeretion of free epinephrine. Signifieant eorrelations (Table 3) wcre found beIn group III urinary exeretion of free norepinephrine tween cateeholamines (urinary exeretion and plasma was signifieantly lligher than in groups land 11 (p < levels of norepinephrine and epinephrine) and blood .00 I). Plasma levels of norepinephrine showed a simi- glucose values (both fasting and 90 minutes after lar inerease (supine p < .001; standing p < .05). Re- lunch) in all patients examined. lnvestigation after better adjusted insulin treatment Finally, there were no differenees between diabeties showed a markcd deerease of urinary and plasma le- and eontrols in the renal c1earance of norepinephrine

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10

496

G. Bolli, M.G. Carteehini, P. \ompagnueei, S. Malvicini, P. De Feo, F. Santeusanio, G. Angeletti and P. Brunetti 1010..-----------------,YI

9

100

[ IItu 80

8

I

..

""-.... ... 4 ......

/A renos B

JI

~

~

""

I

0

••

30

C>

,

:::: 20

I

l

... 4 "" ......

••

•• ,

•••

~

:=

IOD

1:

400

j

•

3 ~

...

...

!

0

1000

N

S.E.II. )

015-A IIIIUI

B

401

I

JOO

~

.011/

B" /A 111

.

-...... ...

200 .. :z:

A:

100 ...

500

900

o

UD ~

BOO

~

~

STANDING (3 min)

700

..':. 600

;

500

"" :z:

400

-... ....

200 _

:z:

....

~ 300

~ ~ 100

N

« .

I~:~llL~_~lI ~

0

( IInl .05~

SUPINE

:z:

2

... ""

700

.,« ,«

~IOO

6-

-50

100

~

-: 10

-

~

rt :

.P«.05, •• P« .001

o

5.E.II. )

~

öL IOD ....

z

IOD

N

Fig. 3 Urinary exeretion of free norepinephrine and epinephrine in 2 groups of diabeties with poor metabolie eontrol Oll) and ketosis (IV), before (B) and after (A) better adjusted insulin dose. (N = normals)

Fig.4 Plasma levels of norepinephrine and epinephrine (in supine position and after 3 minutes of standing) in 2 groups of diabeties with poor metabolie eontrol (111) and ketosis (IV), before (8) and after (A) better adjusted insulin dose. (N = normals)

and epinephrine, either before or after aehieving good metabolie eontrol.

In contrast, urinary and plasma epinephrine levels did not differ significantly from the normal mean in the diabetics and there was a marked increase only in ketotie patients. Owing to the different adrenergic mechanisms physiologically involved in norepinephrine and epinephrine release, the different behaviour of these two eatecholamines in the course of diabetes mellitus does not appear surprising.

Discussion Aeeording to our results the sympathetie aetivity, as evaluated by plasma levels and urinary exeretion of eateeholamines, is normal or inereased in diabeties, depending on the degree of metabolie eontrol. So in subjeets with ehemieal diabetes it does not differ in any way from normals, and in insulin-treated diabeties under good metabolie eontrol it is only slightly inereased. However, an exaggerated sympathetic aetivity has been demonstrated in diabeties with poor metabolie eontrol and it is even more exaggerated in ketotie patients. These data and the significant correlations found be· tween eateeholamines and blood glucose not only confirm a sympathetie neural hyperaetivity in ketotie patients (Christensen 1974), but also suggest that even a slight deterioration of g1yeemie eontrol can produce a significant increase in urinary excretion and plasma levels of norepinephrine in diabetics. Moreover, in the present investigation, when improved metabolie control was obtained with a better adjusted insulin schedule, the urinary cxcretion and plasma norepinephrine levels of diabetics in groups 111 and IV dropped to near those of group 11.

Urinary and, more particularly, norepinephrine levels, studied both in supine position and after 3 minutes of standing, are, perhaps, the more sensitive indices of sympathetic aetivity, while high epinephrine levels, which occur only in ketotic diabetics, reflect a more advanced stage of metabolie derangement. The results of investigations on sympathetic activity in diabetic patients are not always in agreement. Christen sen (1972) found lower than normal levels of plasma catecholamines in long-term diabeties affee ted by neuropathy, whereas Cryer, Silverberg, Santiago and Shah (1976) eould not confirm this result. Cryer, Silverberg, Santiago and Shah ( 1976), however, were able to detect a blunted or exaggerated plasma norepinephrine response to standing in individual diabeties with postural hypotension. More recently, Gun-

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ID

dersen and Christensen (1977) showed that intravenous injection of insulin in diabetics resulted in an enhanced plasma norepinephrine level. Dur result in blood collected from neuropathy-free diabetics before morning insulin injection strongly suggest that sympathetic hyperactivity is present in diabetics with poor metabolic control, even in the absence of ketosis. These conclusions agree weil with the recent report by Robertson, Halter and Porte (1976), who found high levels of me an total plasma catecholamine concentrations in 5 untreated nonketotic diabectics. Increased sympathetic nervous activity may playa role in diabetes mellitus, not only from the point of view of the well-known direct effects of catecholamines on carbohydrate, lipid, and, perhaps, protein metabolism, but also through the weil demonstrated sympathetic modulation of insular hormones secretion. A direct effect of catecholamines in insulin suppression (Porte, Graber, Kuzuya and Williams 1966; Johnson, Henry, Moss and Williams 1976) and glucagon release both in vitro (Leclercq-Meyer, Brisson and Malaisse 1971) and in vivo (Iversen 1973; Gerich, Karam and Forsham 1973; Gerich, Langlois, Noacco, Schneider and Forsham 1974), has been weil demonstrated. Therefore the exaggerated alpha-cell response to such stress as sepsis (Rocha, Santeusanio, Faloona and Unger 1973), trauma (Lindsey, Santeusanio, Braaten, Faloona and Unger 1974), bums (Willmore, Lindsey, Moylan, Faloona, Pruitt and Unger 1974), myocardial infarction (Willerson, Hutcheson, Leshin, FaIoona and Unger 1974), hypovolemic shock (Lindsey, Faloona and Unger 1975), exercise (Bättger, Faloona and Unger 1971) is presumed to be mainly mediated by sympathetic activity. It may be that not only hyperglucagonemia, but also catecholamine release, is responsible for the poor metabolic control and instability found in diabetics. Acknowledgements The authors are grateful to Prof. Enzo Bal/arori for his help in statistical analysis. Thanks are also due to Mr. Mario Fratte· giani for the excellent technical assistance during chromatographie isolation of catecholamines. This work was supported by grant N. 78.02009.04 from the Italian National Research Council.

References Alberti, K.G.M.M., N.J. Christensen, J. Iversen, H. (/Jrskov: Role of glucagon and other hormones in development of diabetic ketoacidosis. Lancet 1975/1, 1307 -1311 Böttger, 1., G.R. Faloona, R.H. Unger: The effect of intensive physical exercise on pancreatic glucagon secretion (Abstr.). Diabetes 20 (suppl. I): 339 (\ 971) Christensen, N.J.: Plasma catecholamines in long-term diabetics with and without neuropathy and in hypophysectomized subjects. J. ('Iin. Invest. 51: 779-787 (\ 972)

497

Christen sen, N.J.: Plasma norepinephrine and epinephrine in untreateu diabetics, du ring fasting. and after insulin administration. Diabetes 23: 1-8 (1974) Cryer, P.E., A. B. Silverberg, 1. V. Santiago, S.D. Shah: Plasma catecholamines in diabetes: The syndromes of hypoadrenergic and hyperadrenergic postural hypotension (Abstr.). Diabetes 25 (Suppt. 1): 347 (\ 976) Fajans, S.S., 1. W. Conn: Prcdiabctes, subclinical diabetes and latent c1inical diabetes: interpretation, diagnosis and treatment. In Leibei, B.S. and G.S. Wrenshall eds.: On the Nature and treatment of Diabetes. N.Y., Excerpta Medica F oundation, International Congress Series, 84: 641-656 (1965) Gerich, J.E., J.H. Karam, P.H. Forsham: Stimulation of glucagon secretion by epinephrine in man. J. Clin. Endocrinol. Metab. 37: 479-481 (1973) Gerich, J.E., M. Langlois, C. Noacco, V. Schneider, P.H. Forsham: Adrenergic modulation of pancreatic glucagon secretion in man. J. Clin. Invest. 53: 1441-1446 (\ 974) Gundersen, H.J.G., N.J. Christensen: Intravenous insulin causing 10~s of intravascular water and albumin and increased adrenergic nervous activity in diabetics. Diabetes 26: 551-557 (1977) Iversen, 1.: Adrenergic receptors and seeretion of glucagon and insulin from the isolated, perfused canine pancreas. J. Clin. Invest 52: 2102-2116 (1973) Johnson, D. G., D.P. Henry, 1. Moss, R.H. Williams: Inhibition of insulin release by scorpion toxin in rat pancreatic islet" Diabetes 25: 198- 20 I (1976) Leclercq·Meyer, v., G.R. Brisson, W.J. Malaisse: Effect of adrenaline and glucose on release 01' glucagon and insulin in vitro. Nature (New Bio!.) 231: 248-249 (\97\) Lindsey, CA., F. Santeusanio, J. Braaten, G.R. Faloona, R. H. Unger: Pancreatic alpha-ceH function in trauma. J. Am. Med. Assn. 227: 757-761 (1974) Lindsey, C.A., G.R. Faloona, R.H. Unger: Plasma glucagon levels during rapid exanguination with and without adrenergic blockade. Diabetes 24: 313 - 3 15 (\ 975) Lukomsky, P.E., R. G. Oganov: Blood plasma catecholamines and their urinary excretion in myocardial infarction. Am. Heart J. 83: 182-188 (\972) Miura, Y., V. Campese, V. De Quattro, D. Meijer: Plasma catecholamines via an improved fluorimetric assay: comparison with an cnzymatic method. J. Lab. Clin. Med. 89: 421-427 (1977) Porte, D. Jr., AL Graber, T. Kuzuya, R.H. Williams: The effect of epinephrine on immunoreactive insulin levels in man. 1. Clin. Invest. 45: 228-236 (1966) Renzini, v., C.A. Brunori, C Valori: A sensitive and specific fluorimetric method for the determination of noradrenalin and adrenalin in human plasma. Clin. C:him. Acta 30: 587-594 (\970) Robertson, R.P., D. Jr. Porte: Adrenergie modulation of basal insulin secretion in man. Diabetes 22: 1-8 (1973) Robertson, R.P., 1. B. Halter, D. Jr. Porte: A role for alphaadrenergic reeeptors in abnonnal insulin secretion in diabetes mellitus. J. CI in. Invest 57: 791-795 (1976) Rocha, D., F. Santeusanio, G.R. Faloona, R.H. Unger: Abnonnal pancreatic alpha-cell function in bacterial' infection. N. Engt. J. Med. 288: 700-703 (1973) Willerson, J. T., D. Hutcheson, S.J. Leshin, G.R. Faloona, R. H. Unger: Serum glucagon and insulin levels and their relationships to blood glucose values in patients with acute myocardial infarction. Am. J. Med. 57: 747-753 (\ 974) Wilmore, D. W., CA. Lindsey, J.A. Moylan, G.R. Faloona, B.A. Pruitt, R.H. Unger: Hyperglucagonemia after bums. Lancet 1974/1,73-75

Requests for reprints should be addressed to: Prof. Dr. Paolo Brunetti, Universita di Perugia, lstituto di Patologia Speciale Medica e Metodologia Clinica, Policlinico Monteluce, Perugia (Italy)

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Effect of Metabolie ('ontrol on Urinary Excretion and Plasma Levels of Catecholamines in Diabetics