CARBOHYDRATE METABOLISM TEXT (Supplementary material)

There are four major pathways of the carbohydrate metabolism, all of them either begin or
end with glucose. This fact indicates the significance of glucose in most of the living cells.
Essentially, all form of carbohydrates found in nature can be converted to glucose or produced
from glucose. In mammals, the carbohydrate metabolism is the metabolism of glucose or
glucose derivatives. It should be noted that the glucose is the only fuel used to any significant
extent by a few specialized cells. Furthermore, it is the major fuel used by the brain. The
carbohydrates are basic precursors in the synthesis of many biologically active compounds.

Oligo- and polysaccharides are composed of mono saccharides, attached to each other. Their
molecular weight may vary from few hundreds to several millions.

Carbohydrates are structural elements of many biologically active compounds as listed on the
lecture-slides (Fig. 5).

The main pathways indicate the significance of glucose in the carbohydrate metabolism (Fig.
8).

Photosynthesis in plants should also be considered as one the major pathway of the glucose
metabolism; not discussed here. However, it should be emphasized that all free energy
consumed by biological systems arises from solar energy that is trapped by the process of
photosynthesis.

Dietary carbohydrates are important sources of the daily caloric requirement. The daily
requirement of glucose for the human body is about 160 g, from which 120 g is utilized by the
brain. The normal blood glucose level is around 5 mM.

Only monosaccharides can be taken up by enterocytes; therefore the disaccharides (Fig. 10)
and polysaccharides must be hydrolyzed to monosaccharides. Disaccharides require the small
intestinal surface enzymes to be hydrolyzed (Fig. 10).

The polysaccharides are degraded first by salivary and pancreatic α-amylase (Fig. 11). The
products are further hydrolyzed by glucosidases localized on the small intestinal surface.

Starch is a plant polysaccharide with a molecular weight more than 100 000. It consists of a
mixture of linear chains of glucose molecules linked by α-1,4-glucosidic bonds (amylose) and
branched chains with branch points made up by α-1,6 linkages (amylopectin). In glycogen
much more branch points can be found than in amylopectin.

Amylopectin, amylose and glycogen are rapidly hydrolyzed by α-amylase (endosaccharidase)

producing maltose, maltotriose, α-limit dextrin (Fig. 11). The β-amylase, found in the malt, is
a exosaccharidase.

The oligo- and polysaccharides that are not hydrolyzed to monosaccharides cannot be
absorbed. They move to the lower tract of the intestine and will be utilized by bacterias
producing many more types of saccharidases.
Three major monosaccharides will be produced from the hydrolysis of di- and polysaccharids:
glucose, galactose and fructose and taken up by enterocytes by Na+ co-transport (glucose and
galactose) and by facilitated-diffusion (fructose; Fig. 12)

GLUT1 and GLUT3 can be found in nearly all mammalian cells. They responsible for the
basal uptake (KM= 1 mM) of glucose.

The GLUT1 is involved in the glucose uptake of red blood cells and brain cells. It also
transfers glucose into muscle and adipose tissue with an insulin independent process (Fig.
14,15).

GLUT2 is specific glucose transporter of the liver and pancreatic β cells, with a KM of 15-20
mM. Due to its high KM, this membrane protein works with full activity in case of high blood
glucose level. When the blood glucose level is low, glucose preferentially enters brain and
other tissues because their glucose transporters have a lower KM than that of liver.
GLUT4 is the glucose transporter of muscle and fat cells, with a KM of 5 mM. The activity of
GLUT4 depends on the presence of insulin (Fig. 16, 17)
GLUT5 is a transporter for fructose.

Fate of glucose in various cells

Red blood cells lack mitochondria; the end product of glycolysis is lactate (Fig 19). Therefore,
the blood always contains a small concentration of lactate (1.2 mM), released by the red blood
cells. In red blood cell about 20% of the glucose is converted to 2,3-bisphosphoglycerate,
which may be metabolized to form lactate (see later, Fig. 38). NADPH is produced by the
pentose phosphate pathway; NADPH is absolutely required for the reduction of oxidized
gluthatione. The NADPH, generated by the pentose phosphate pathway, will keep 5-10 mM
glutathione in reduced state. The reducing power of the high concentration of glutathione is
essential to remove the toxic H2O2 and protect the cell against oxidative damage.

In brain tissue cells the glucose is completely oxidized to serve as a source of energy (Fig.
20). The pentose phosphate pathway is also quite active, producing reducing power for the
cells.

In muscle cell the glucose uptake is insulin dependent. The glucose can be converted to
pyruvate (then AcetylCoA) or lactate depending the intensity of physical activity (Fig. 21).
The pentose phosphate pathway has a low activity, due to the low activity of of G-6-P
dehydrogenase, the first enzyme of this pathway. The muscle is able to synthesize glycogen, a
polysaccharide, the storage form of glucose.

In adipose tissue the glucose uptake is insulin dependent (Fig. 22). Small amount of glucose
is converted to glycogen. The fat synthesis and pentose phosphate pathway is active.

The liver (Fig. 23) is able to convert some non-carbohydrate material to glucose in the
gluconeogenesis. The high rate of glycogen synthesis and degradation is an important feature
of the liver. The pentose phosphate pathway and the synthesis of glucuronides are active. The
pyruvate, produced by the glycolytic pathway, may be converted to lactate or acetylCoA. The
acetylCoA can enter the citrate cycle or utilized in the synthesis of fatty acids.
The G-6-P mainly utilized by four pathways (Fig. 24). Their activity depends on the tissue
and physiological state of the cell.

GLYCOLYTIC PATHWAY

Glycolysis is the sequence of reactions that converts glucose into pyruvate (lactate) with the
concomitant production of ATP (Fig. 26).

Under aerobic conditions the glycolytic pathway is ended by pyruvate (two pyruvate/glucose)
which is converted to AcetylCoA (Fig. 27). It may be oxidized in the citric acid cycle or
utilized by various synthetic processes, mainly in fatty acid synthesis. The citrate cycle
produced NADH + H+ and FADH2 is oxidized in the electron-transport system yielding
energy in the form of ATP.

In the priming stage of the glycolysis (Fig. 28) two ATPs are lost, in the irreversible kinase
reactions, catalyzed by hexokinase/glucokinase and phosphofructokinase.

There are two enzymes catalyzing the phosphorylation of glucose: hexokinase and
glucokinase (Fig. 29). Hexokinase can be found in most of the cells, however, in liver
parenchimal cells and in pancreatic islet cells, this function is carried out by glucokinase.

Hexokinase is less specific, it is able to phosphorylate other hexoses (fructose, mannos) but a
much slower rate than glucose (the kinetic parameters are different for various hexoses).

The phosphohexose-isomerase catalyzes an aldose-ketose isomerization; readily reversible.

Glucokinase has a high KM (S0.5) compared to hexokinase. It works with full activity at high
concentration of glucose.

There are two reversible reactions in the splitting stage, catalyzed by aldolase and
triosephosphate-isomerase (Fig. 30).

The mammalian aldolases bind covalently the substrate forming a Schiff base between one of
the lysyl side chain and F-1,6-bisP. The Type B aldolase (liver aldolase) is able to use F-1-P
as substrate although it is not as good substrate as F-1,6-bisP.

In the oxidoreduction and phosphorylation stage, four ATPs and a two NADH is produced per
glucose molecule (Fig. 32, 33).

The glyceraldehyde 3-phosphate dehydrogenase (GAPDH) consists of four identical

polypeptides forming a tetramer. Each contains an essential –SH group (Fig. 32) involved in
the catalytic process (Fig. 36). The high energy linkage is produced in the internal-
oxidoreduction step.

The pyruvate is a branch point of the glycolysis. It can be converted to lactate or acetyl CoA
(Fig. 27) depending on the oxygen supply. If the oxygen supply is limited, for example in case
of very active physical work in muscle cells, the NADH, formed by the action of
glyceraldehyde 3-phosphate dehydrogenase (GAPDH) cannot be oxidized in the
mitochondria. Thus, the system is looking for a hydrogen acceptor to regenerate the NADH to
NAD+. The amount of NAD+ (oxidized!) in the cytosol is limited and it is a prerequisite of
glycolysis because the GAPDH catalyzed reaction requires NAD+ as a coenzyme. The
hydrogen acceptor can be the pyruvate, in the pyruvate lactate process, catalyzed by lactate
dehydrogenase. It should be noted, the energy produced by the glycolytic pathway (2ATPs
per glucose) under anaerobic condition is limited, because the concentration of lactate is
increasing. The maximal concentration of lactate, tolerated by the cell, is about 22 mM. The
lactic acid decreases the pH, slowing down the enzyme activities. The 22 mM limit cannot be
exceeded.

The phosphoglycerate kinase catalyzed step produces an ATP utilizing the high energy
linkage formed in the GAPDH reaction (1,3-bisphosphoglycerate; the phosphate attached to
C1 is high energy phosphate; Fig. 32).

The lactate dehydrogenase enzyme is composed of four subunits; there are two types of
subunits: muscle (M) and heart (H) type. All of the possible subunit combinations exist
yielding five lactate dehydrogenase isoenzymes.

How much energy can be produced without molecular oxygen? Two net ATPs and two mols
of NADH + H+ is produced per glucose in the glycolysis. Without oxygen the concentration
of lactate is increasing. The physiological limit of lactate in the muscle cell about 22 mM, as
mentioned above.

The 2,3-bisphosphoglycerate shunt is highly important in red blood cells (Fig. 38). The 2,3-
bisphosphoglycerate decreases the oxygen affinity of hemoglobin. This compound, in
catalytic amount, is also required for phosphoglycerate mutase reaction (Fig. 37).

The artificial inhibitors of the glycolytic pathway are valuable research materials (Fig. 39).
2-deoxyglucose is a substrate of hexokinase. The 2-deoxyglucose 6-phosphate is a potent
inhibitor of hexokinase. This compound is accumulated in the cell because it is not a substrate
of the isomerase catalyzing the next step of the glycolytic pathway.
Sulfhydryl reagents (like iodoacetate or mercury-containing compounds) can inhibit the
GAPDH enzyme reacting with the essential –SH group in the active center (Fig. 39).
Fluoride ion, in the presence of phosphate, forms a stable complex with Mg++, thus, the free
Mg++ concentration is very low, not enough to activate the enolase enzyme.
Arsenate ion is a structural analog of phosphate (HAsO42-) and is able to substitute for
inorganic phosphate in enzyme catalyzed reactions. In case of GAPDH a mixed anhydride is
formed between arsenic acid and the carboxyl group (carbon 1) of 3-phosphoglycerate. This
arseno-anhydride is unstable, undergoing spontaneous hydrolysis to give 3-phosphoglycerate
and inorganic arsenate. Thus, ATP is not produced in the next reaction, catalyzed by
phosphoglycerate kinase.

The NADH + H+, produced in the cytosol (Fig. 40, 41), must be reoxidized by the respiratory
chain (or under anaerobic conditions by lactate dehydrogenase), in order to keep going the
NAD+ requiring cytosolic processes, like GAPDH reaction (glycolytic pathway). There are
two shuttle pathways to transport reducing equivalents to mitochondria Glycerol Phosphate
shuttle and Malate-Aspartate shuttle (Fig 42, 43).

Recently, a new shuttle pathway was defined: the lactate shuttle. This pathway of NADH
transport is based on the cytosolic and mitochondrial activity of lactate dehydrogenase (Fig.
44, 45). Under aerobic conditions lactate is not accumulated, however, it is produced. It is
eliminated by gluconeogenesis in the liver and by the lactate shuttle, in the mitochondria. The
lactate can move freely between cell and tissue compartments, by the help of Mono-
Carboxylate-Transporters (MCT).

It was also shown that the sensation of chest pain caused by myocardial ischemia is mediated
by lactic acid. In case of myocardial ischemia (myocardial O2 limitation) a large amount of
lactate is produced, penetrating to the surrounding tissues by MTCs. The lactic acid opens the
Acid Sensing Iona Channel 3 (ASIC3) resulting in signals along cardiac sympathetic
afferents. To open the ASIC3 very low pH is required (6.8-7.0). The high intensity anaerobic
work will not produce such a low pH locally, consequently the ASIC3 will not be turned on,
therefore sensation of chest pain will not be developed during very intensive work.

In tumor cells the glycolytic pathway is highly active (Fig. 46).

GLUCONEOGENESIS

The net synthesis or formation of glucose from a large variety of non-carbohydrate substrates
is termed gluconeogenesis (Fig. 47-59). The peripherial tissues release alanine or lactate as
the end-products of glycolysis. These compounds are carried by the Cori’s and Glucose-
Alanine cycles to the site of gluconeogenesis, into the liver (Fig. 48 and 49). The three
irreversible steps of glycolysis is replaced by four enzymatic steps in the gluconeogenic
pathway (Fig. 52). The pyruvate kinase reaction converting PEP to pyruvate is replaced by
two enzymatic processes catalyzed by pyruvate carboxylase and PEP carboxykinase (Fig. 53-
55). The hexokinase and phosphofructokinase reactions are replaced by two specific
phosphatases (Fig. 57, 58).
The synthesis of 1 mol of glucose by gluconeogenesis, started from lactate, requires 6 ATPs.
Liver is the only organ which produces glucose for the blood by gluconeogenesis. The
gluconeogenesis is also active in the kidney. The gluconeogenic enzymes are active in the
muscle except that of G-6-P phosphatase.

REGULATION OF THE GLYCOLYTIC PATHWAY

Only nonequilibrium reactions of the glycolysis are suitable to control efficiently the process.
The equilibrium reactions are very sensitive to changes in the concentration of pathway-
intermediates and rapidly communicate any changes generated by the rate-determining steps.
The regulation is summarized in Fig. 63.
Because of the differences in isoenzyme distribution not all tissues of the body have all of the
regulatory mechanism.

Hexokinase could work at low glucose concentration (low KM), and inhibited by the product,
G-6-P (Fig. 64).

Glucokinase is indirectly regulated by F-6-P and F-1-P (Fig. 65). Insulin promotes the
transcription of glucokinase (Fig. 66).

The 6-phosphofructo-1-kinase (PFK-1) regulated by effectors (Fig. 67, 68). The Fructose 2,6-
bisphosphate is regulated by the hormonal status of the blood (Fig. 69-78).

The insulin/glucagon ratio in the blood affects the concentration of F-2,6-bisP in the cell. The
F-2,6-bisP is a potent activator of PFK-1. A summary of glucagon inhibition of liver
glycolysis is shown in Fig. 70, without details.
We have to answer the following questions to understand the hormonal regulation of PFK-1:
(1) how F-2,6-bisP is synthesized, (2) how its synthesis is regulated by glucagon, modifying
the cAMP level.

The cAMP system and protein phosphorylation

When the hormone, glucagon (or a few others) is attached to its receptor located on the outer
surface of the liver cell plasma membrane, the modification of the receptor protein
conformation by the hormone will activate an enzyme, adenylate cyclase, located on the inner
surface of the plasma membrane, catalyzing the synthesis of cAMP. There is another protein
between the receptor and enzyme called G protein, will be studied later. The adenylate-
cyclase synthesize cAMP from ATP (Fig. 71).

Protein kinase A is activated by cAMP. The active protein kinase phosphorylates a number of
proteins some of them activated some of them inactivated on phosphorylation (Fig. 71).

The PFK-2 is a bifunctional enzyme able to synthesize and degrade F-2,6-bisP. The kinase
and phosphatase activity of the enzyme depends on the phosphorylation status of the protein
(Fig. 72-74). The unphosphorylated form has high kinase activity. The phosphorylated form is
rather a phosphatese degrading F-2,6-bisP.

In muscle, the epinephrine can activate the adenylate cyclase through β adrenergic receptor.
The cAMP activated protein kinase could phosphorylate by PFK-2, which is converted to a
more active kinase and not inhibited as in liver cells (Fig. 76-77).

High insulin concentration in the blood accelerates the rate of hepatic glycolysis (Fig. 78).

Pyruvate kinase is also regulated by phosphorylation in the liver (Fig. 79).

The glycolysis and gluconeogenic enzyme activities are regulated reciprocally (Fig. 80-85).

The transcription of PEP carboxykinase is promoted by glucagon (Fig. 84) through the
activation of protein kinase A.

The glycolysis and gluconeogenic enzyme activities are also regulated by reversible
acetylation of the lysyl side chains (86-88).

GLYCOGENOLYSIS
The figures (Fig. 91-94) contains all of the necessary information.

GLYCOGENESIS
The figures (Fig. 95-96) contains all of the necessary information

Special features of glycogen metabolism (Fig. 97)

a. Why the glycogen is a better storage form of glucose?

The glucose is osmotically active, 400 mM stored glucose is equivalent with the stored
glycogen in an average liver cell (0.01 μM).
 b. Why not store our excess glucose calories entirely as fat, instead of glycogen?
The answer is at least threefold: (1) we do store fat, but fat cannot be mobilized as rapidly in
muscle as glycogen; (2) fat cannot be used as a source of energy in the absence of oxygen; (3)
fat cannot be converted to glucose by any pathway of the human body in order to maintain
blood glucose levels for use by tissues such as brain.

c. Why is glycogen a branched molecule?

There is only one reducing end in the glycogen molecule and a number of nonreducing ends.
Only the nonreducing ends are the sites for glycogen synthesis and degradation.

d. Primer is needed for glycogen synthesis! (Fig. 98, 99)

The glycogen synthase is not able to start the synthesis of glycogen. It needs a primer
molecule. A protein called glycogenin functions as a primer for glycogen synthesis.
Glycogenin is a self-glucosilating enzyme that uses UDP-glucose to glucosylate one of its
own tyrosine residues.

REGULATION OF GLYCOGENOLYSIS (Fig. 100)

Phosphorylase kinase (phosphorylated and activated by protein kinase A) is responsible for

the phosphorylation and activation of phosphorylase. Phosphorylase kinase is composed of 16
subunits α4β4γ4δ4, its molecular mass is 1.3 million Da. The δ subunit of phosphorylase kinase
is calmodulin, a calcium binding regulatory protein.

cAMP inhibits, insulin activates the phosphoprotein phosphatase (Fig. 100).

In liver cell the glucagon and epinephrine (when activates β adrenergic receptor) induce
cAMP stimulating glycogenolysis (Fig. 102).

In liver cell the epinephrine could activate Phospholipase C through α adrenergic receptor.
The Phospholipase C, acting on membrane phospholipids, produces inositol 1,4,5-
trisphosphate (IP3) and diacylglycerol (Fig. 103, 104). The IP3 induces Ca++ release from the
endoplasmic reticulum activating phosphorylase kinase. The diacylglycerol activates protein
kinase C.

In skeletal muscle the epinephrine and nerve impulse induce the same effect, activates
glycogen mobilization and inhibits glycogen synthesis (Fig. 105).

REGULATION OF GLYCOGEN SYNTHESIS

Phosphorylation of glycogen synthase results in inactivation rather than activation of the
enzyme (Fig. 106). Glycogen synthase is a tetramer (α4) with only one subunit type of mol wt
85 000. The subunits can be phosphorylated on at least nine different serine residues. The
phosphorylated, inactive, form of the enzyme can be partially activated by G-6-P.

Insulin activates glycogen synthesis both in muscle and liver cells (Fig. 107).

There is a wonderful agreement in the regulation of carbohydrate metabolism is various

tissues when a person is in danger (for example a big dog attacks you). The concentration of
epinephrine is increasing suddenly in the blood. It is attached to β and α adrenergic receptors
of the liver. Activation of β adrenergic receptor increases the cAMP level inducing an
elevated rate of glycogen mobilization (glycogenolyzis, Fig. 100, 102). The effect is similar
when it activates α adrenergic receptors of liver cells, the concentration of Ca++ is increasing
activating phosphorylase kinase, also inducing elevated rate of glycogen mobilization (Fig.
100). However, in the same time the glycolytic pathway is inhibited in the liver, because the
elevated level of cAMP decrease the concentration of F-2,6-bis-phosphate, a potent activator
of the PFK-1 (Fig. 70, 75). Is it logical? To produce large amount of substrate for glycolysis
by the activated glycogen mobilization and in the same time inhibiting the glycolysis which
could utilize the glycogen degradation product (both process is in the liver!). Yes! Because
the glucose formed by degradation of glycogen must not be used in the liver, it must be
released to the blood and utilized by the muscle. In the muscle cell the epinephrine also
induces elevated cAMP concentration, however, here, due to the different regulation of PFK-
2, more F-2,6-bis-phosphate is produced, activating the glycolysis (Fig. 76). The muscle could
work with high intensity.

The enzymes og glycogen synthesis and degradation are also regulated by reversible
acetylation (Fig. 108).

SPECIAL PATHWAYS OF CARBOHYDRATE METABOLISM

The pentose phosphate pathway
Summarized in Fig. 112-119. These figures contain all of the necessary information.

Fructose and galactose can enter the metabolism phosphorylating by specific enzymes on C1,
forming F-1-P and Gal-1-P. The Galactose 1-phosphate is converted to UDP-galactose, then
to UDP glucose (Fig. 121-123).

Lactose is synthesized in female mammals in lactating period by the action of lactose-

synthase (Fig. 124).

Fructose can be synthesized in mammalian tissue from glucose (Fig. 125).

The synthesis of UDP-glucuronic acid is highly active in the liver, involved in the
detoxification processes (Fig. 126); the glucuronic acid can be a precursor for synthesis of
vitamin C in most of the mammals (not in human) or can be converted to xylulose 5-
phosphate (in human, too) and utilized in the pentose phosphate pathway (Fig. 127).

Glycoproteins
The figures contain all of the most important information (Fig.129-133).

Glycogen-storage Diseases
The figures contain all of the most important information (Fig.134-135).

Brief summary of enzyme deficiencies listed in Fig. 136.

Lactose intolerancy
Defective enzyme: lactase. This is most common enzyme deficiency. About 20% of the
European population have lost the ability to synthesize the enzyme lactase in their adulthood.
Thus, for them excessive ingestion of milk may cause digestive problems because
unhydrolyzed lactose can pass into the lower intestine, where bacteria ferment it to organic
acids causing water retention a diarrhea. It is not a serious disease. The ability to digest
lactose in adulthood is evolved differently in the African and European population (Fig. 137).

Fructose intolerance
Defective enzyme: liver aldolase. Consumption of fructose by these patients results in the
accumulation of F-1-P and depletion of Pi and ATP in the liver.

Essential fructosuria
Defective enzyme: fructokinase. This disorder is benign usually asymptomatic metabolic
anomaly.

Pyruvate kinase and Hexokinase deficiency

Mature erythrocytes are absolutely dependent on glycolytic activity for ATP production. The
energy in the form of ATP is required for the proper activity of the ion pumps. Any enzyme
deficiencies in glycolytic pathway result hemolytic anemia. The enzyme deficiencies of the
glycolytic pathway are rare and never complete. The partial deficiencies of hexokinase and
pyruvate kinase modifies the intracellular concentration of 2,3-bisphosphoglycerate in red
blood cells, affecting the shape of oxygen-saturation curve of hemoglobin.

Glucose-6-phosphate dehydrogenase deficiency

Glucose-6-phosphate dehydrogenase (G6PD) is an important enzyme in red cell for the
maintenance of the red blood cell membrane. Over 100 G6PD mutations are known, several
of which occur with high incidence. For example, the so-called type A G6PD deficiency,
which exhibits about 10% of the normal G6PD activity, has an incidence of 11% among black
Americans. Such a decrease in G6PD activity usually enough to maintain the normal cell
metabolism (i.e., to keep the gluthathione in reduced state). However, a severe hemolytic
anemia will be resulted on administration of certain antimalarial drug (for example
Primaquine). Primaquine stimulates peroxide formation thereby increasing the demand for
NADPH to a level that mutant cells cannot meet. It should be noted that erythrocytes with
G6PD deficiency appear to be less suitable host for Plasmodia than normal cells because the
parasite requires the products of the pentose phosphate pathway and/or because the
erythrocyte is lysed before the parasite has had a chance to mature.

Galactosemia
Defective enzyme: galactokinase or galactiose-1-phosphate uridyltransferase.
Galactose cannot be converted to glucose. Its symptoms include failure to thrive, mental
retardation and, in some instances, death from liver damage. Most cases of galactosemia
involve a deficiency in galactose-1-phosphate uridyltransferase. The increased galactose
concentration in the blood results in a higher galactose concentration in the lens of trhe eye
where this sugar is reduced to galactitol. The presence of this sugar alcohol in the lens
eventually causes cataract formation. Galactosemia is treated by a galactose free diet.

Diabetes mellitus (Fig. 138)

Diabetes mellitus is a chronic disease effecting the carbohydrate, fat and protein metabolism.
Two major types of diabetes recognized clinically – the juvenile-onset or insulin dependent
type and the maturity-onset or noninsulin dependent type.
Insulin dependent diabetes mellitus. Insulin is absent or nearly absent in this desease because
of defective or absent β cells in the pancreas.
Noninsulin dependent diabetes mellitus. Insulin is present at normal to elevated levels in this
form of disease. The defect of these patients may be at the level of the insulin receptors
located in the plasma membranes of insulin-responsive cells.
Because the very complex nature of the diabetes mellitus, detailed description of this disease
cannot be completed at this stage of the study of the metabolism.