Clinical trial NCT04907721: Development and Evaluation of a Glucagon Sensitivity Test in Individuals With and Without Hepatic Steatosis
Official title: Development and Evaluation of a Glucagon Sensitivity Test in Individuals With and Without Hepatic Steatosis
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Non-Alcoholic Fatty Liver Disease
Glucagon Resistance
Type 1 Diabetes
Obesity
Lead sponsor: University of Copenhagen
Sponsor class: OTHER
Collaborators: name: Bispebjerg Hospital
name: Rigshospitalet, Denmark
First posted: 2021-06-01
Enrollment: 65
Sex: ALL
Minimum age (years): 25
Maximum age (years): 65
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: NA
Intervention model: SINGLE_GROUP
Primary purpose: BASIC_SCIENCE

Brief summary: Glucagon is secreted from pancreatic alpha-cells in response to protein-rich meals and during hypoglycemia. A physiological feedback system exists between the liver and the pancreatic alpha cells termed the liver-alpha cell axis and signifies the role between amino acid-stimulated glucagon secretion and glucagon-stimulated amino acid metabolism.

Individuals with non-alcoholic fatty liver disease have increased levels of glucagon (hyperglucagonemia) and amino acids (hyperaminoacidemia), which suggests that hepatic steatosis may uncouple glucagon's effect on amino acid metabolism (i.e. reduced glucagon sensitivity). Since hyperglucagonemia contributes to diabetes progression - due to its potentiating effects on hepatic glucose production - hepatic steatosis may create a diabetogenic circle. This study aims to develop and evaluate a test for measuring glucagon sensitivity in humans.

The investigators (Associate Prof. Nicolai J Wewer Albrechtsen and Prof. Jørgen Rungby) will investigate whether amino acid metabolism is attenuated in individuals with hepatic steatosis (assessed by magnetic resonance imaging) due to impaired hepatic glucagon sensitivity and if glucagon's effect on hepatic glucose production is intact compared to individuals without hepatic steatosis suggestive of biased signaling.

Detailed description: Amino acids administered orally or intravenously stimulate glucagon secretion from the pancreas and in turn, glucagon is a powerful stimulus for hepatic amino acid turnover through transcriptional (long-term) and non- transcriptional (acute) mechanisms. Several groups including the investigators have linked glucagon secretion to hepatic amino acid metabolism suggesting a mutual feedback cycle, termed the liver-alpha cell axis. A disruption of this axis, which has been shown both pharmacologically using glucagon receptor antagonists and genetically in glucagon receptor knockout mouse models, leads to increased glucagon (hyperglucagonemia) and amino acid (hyperaminoacidemia) concentrations. This phenotype is also evident in subjects with biopsy-verified metabolic dysfunction-associated steatotic liver disease (MASLD) independent of type 2 diabetes suggesting reduced hepatic glucagon sensitivity in the presence of hepatic steatosis. Glucagon increases amino acid catabolism by potentiating ureagenesis, a pathway exclusive to the liver, and hepatic accumulation of triglycerides may reduce glucagon's ability to augment amino acid turnover. Some amino acids are more potent in stimulating glucagon secretion (glucagonotropic amino acids), including alanine, and the glucagon-alanine index is currently used as a surrogate marker for the hepatic actions of glucagon on ureagenesis. The fate of amino acid turnover depends on both glucagon and insulin dynamics by stimulating amino acid catabolism and synthesis, respectively. Studying the effects of glucagon in individuals with type 1 diabetes will allow one to differentiate between the combined effects of glucagon and insulin compared to the effects of glucagon alone.

This study aims to explore hepatic glucagon sensitivity towards amino acid metabolism in individuals with and without hepatic steatosis (based on magnetic resonance imaging (MRI)).

The investigators hypothesize that the effect of endogenous and exogenous glucagon on plasma amino acid levels are impaired in individuals with MASLD (based on hepatic steatosis measured by MRI) compared to controls.

The nomenclature for MASLD has recently been updated from non-alcoholic fatty liver disease (NAFLD) (https://pubmed.ncbi.nlm.nih.gov/37363821/).

Eligibility criteria: Group 1 (lean controls)

Inclusion Criteria:

* BMI = 18.6-25 kg/m2
* Male or female
* 25-65 years of age

Exclusion Criteria:

* Diabetes (ADA criteria)
* Significant alcohol/drug abuse as per investigators judgement
* Amino acid-related diseases such as phenylketonuria
* Kidney disease
* Cardiac problems
* Cancer within the past 1 year
* Severe claustrophobia
* Pacemaker or other non-MR-compatible devices
* Pregnancy or breastfeeding.
* Fib4 score \> 3.25.
* Any medicine, acute illness (within the last two weeks) or other circumstances that in the opinion of the investigator might endanger the participants' safety or compliance with the protocol

Group 2 (overweight and obese individuals)

Inclusion Criteria:

* BMI = 25-40 kg/m2
* Male or female
* 25-65 years of age

Exclusion Criteria:

* Diabetes (ADA criteria)
* Significant alcohol/drug abuse as per investigators judgement
* Amino acid-related diseases such as phenylketonuria
* Kidney disease
* Cardiac problems
* Cancer within the past 1 year
* Severe claustrophobia
* Pacemaker or other non-MR-compatible devices
* Pregnancy or breastfeeding
* Abdominal diameter \>70 cm
* Fib4 score \> 3.25.
* Any medicine, acute illness (within the last two weeks) or other circumstances that in the opinion of the investigator might endanger the participants' safety or compliance with the protocol

Group 3 (individuals with type 1 diabetes)

Inclusion Criteria:

* BMI = 18.6-40 kg/m2
* Male or female
* C-peptide negative
* Insulin pump user
* 25-65 years of age

Exclusion Criteria:

* Type 2 diabetes
* Closed loop user
* Microalbuminuria (30-300 mg/g)
* Significant alcohol/drug abuse as per investigators judgement
* Amino acid-related diseases such as phenylketonuria
* Kidney disease
* Cardiac problems
* Cancer within the past 1 year
* Severe claustrophobia
* Pacemaker or other non-MR-compatible devices
* Pregnancy or breastfeeding
* Abdominal diameter \>70 cm
* Fib4 score \> 3.25.
* Any medicine, acute illness (within the last two weeks) or other circumstances that in the opinion of the investigator might endanger the participants' safety or compliance with the protocol

Following inclusion and study completion, our two groups of lean individuals (n=20) and overweight and obese individuals (n=30) will be stratified into two groups based on liver fat content assessed by the magnetic resonance imaging scan. Individuals with \<5.6% hepatic steatosis will be allocated to the control group and individuals with ≥5.6% hepatic steatosis to the MASLD group.

Primary outcomes:
measure: Differences in the calculated GLUSENTIC index between individuals with or without MASLD without diabetes
timeFrame: Time from the first blood sample (at time -10 minutes, following an overnight fast) until the amino acid infusion stops (45 minutes)
Secondary outcomes:
measure: Simple linear regression between hepatic steatosis (%) and the GLUSENTIC index
timeFrame: Time from the first blood sample (at time -10 minutes, following an overnight fast) until the amino acid infusion stops (45 minutes)
measure: ROC curve analysis to evaluate cut-off value for GLUSENTIC index
timeFrame: Time from the first blood sample (at time -10 minutes, following an overnight fast) until the amino acid infusion stops (45 minutes)
measure: Differences in the glucagon-alanine index
timeFrame: The index will be measured on samples collected after an overnight fast (12 hours)
measure: Differences in plasma levels of amino acids during the amino acid tolerance test (determined by baseline corrected AUC)
timeFrame: Time from the start of infusion (0 minutes) until time 60 minutes.
measure: Glucagon's ability (exogenous glucagon) to increase amino acid disappearance (determined by baseline corrected AUC or delta) for total amino acid levels and the individual amino acids.
timeFrame: Time from the glucagon injection (time 0 minutes) until time 20 minutes.
measure: Differences in plasma levels of total amino acids and alanine following an overnight fast.
timeFrame: Measured on samples collected after an overnight fast (12 hours)
measure: Baseline corrected AUC for glucagon after a bolus injection of glucagon.
timeFrame: Time from the glucagon injection (time 0 minutes) until time 120 minutes.
measure: Baseline corrected AUC for glucagon during and after the amino acid tolerance test.
timeFrame: Time from the amino acid infusion starts (time 0 minutes) until time 180 minutes.
measure: Differences in plasma levels of glucagon following an overnight fast.
timeFrame: Measured on samples collected after an overnight fast (12 hours)
measure: Baseline corrected AUC for glucose after a bolus injection of glucagon.
timeFrame: Time from the glucagon injection (time 0 minutes) until time 120 minutes.
measure: Baseline corrected AUC for insulin after a bolus injection of glucagon.
timeFrame: Time from the glucagon injection (time 0 minutes) until time 120 minutes.
measure: Baseline corrected AUC for C-peptide after a bolus injection of glucagon.
timeFrame: Time from the glucagon injection (time 0 minutes) until time 120 minutes.
measure: Baseline corrected AUC for urea after a bolus injection of glucagon.
timeFrame: Time from the glucagon injection (time 0 minutes) until time 120 minutes.
measure: Baseline corrected AUC for triglycerides after a bolus injection of glucagon.
timeFrame: Time from the glucagon injection (time 0 minutes) until time 120 minutes.
measure: Baseline corrected AUC for glucose during and after the amino acid tolerance test.
timeFrame: Time from the amino acid infusion starts (time 0 minutes) until time 180 minutes.
measure: Baseline corrected AUC for insulin during and after the amino acid tolerance test.
timeFrame: Time from the amino acid infusion starts (time 0 minutes) until time 180 minutes.
measure: Baseline corrected AUC for C-peptide during and after the amino acid tolerance test.
timeFrame: Time from the amino acid infusion starts (time 0 minutes) until time 180 minutes.
measure: Baseline corrected AUC for urea during and after the amino acid tolerance test.
timeFrame: Time from the amino acid infusion starts (time 0 minutes) until time 180 minutes.
measure: Baseline corrected AUC for triglycerides during and after the amino acid tolerance test.
timeFrame: Time from the amino acid infusion starts (time 0 minutes) until time 180 minutes.
measure: Differences in the formula (plasma urea/plasma amino acids) after the amino acid tolerance test.
timeFrame: Time from the amino acid infusion stops (time 45 minutes) until time 180 minutes.
measure: Differences in total and individual amino acids between individuals with overweight or obesity without hepatic steatosis who have been BMI-matched to individuals with hepatic steatosis.
timeFrame: Time 0-120 minutes on the day of the glucagon injection and time 0-180 minutes on the day of the amino acid tolerance test.
measure: Differences in glucagon between individuals with overweight or obesity without hepatic steatosis who have been BMI-matched to individuals with hepatic steatosis.
timeFrame: Time time 0-180 minutes on the day of the amino acid tolerance test.
measure: Simple linear regression between the variables, pancreatic steatosis and amino acid stimulated glucagon or insulin levels in individuals without diabetes.
timeFrame: Pancreatic steatosis and time point 30 minutes on the day of the amino acid tolerance test will be used.
Other outcomes:
measure: Differences in FGF-21
timeFrame: From time -10 to 120 minutes on the day of the glucagon bolus infusion and from time -10 to 180 minuteson the day of the amino acid infusion.
measure: Differences in GLP-1
timeFrame: From time -10 to 120 minutes on the day of the glucagon bolus infusion and from time -10 to 180 minutes on the day of the amino acid infusion.
measure: Differences in GIP
timeFrame: From time -10 to 120 minutes on the day of the glucagon bolus infusion and from time -10 to 180 minutes on the day of the amino acid infusion.
measure: Differences in GDF-15
timeFrame: From time -10 to 120 minutes on the day of the glucagon bolus infusion and from time -10 to 180 minutes on the day of the amino acid infusion.
measure: Differences in focused genotyping (PNPLA3; MBOAT7; GCKR; TNF; TM6SF2).
timeFrame: From time -10 to 120 minutes on the day of the glucagon bolus infusion and from time -10 to 180 minutes on the day of the amino acid infusion.
measure: Differences in follistatin
timeFrame: From time -10 to 120 minutes on the day of the glucagon bolus infusion and from time -10 to 180 minuteson the day of the amino acid infusion.
measure: Differences in fetuin-B
timeFrame: From time -10 to 120 minutes on the day of the glucagon bolus infusion and from time -10 to 180 minuteson the day of the amino acid infusion.
Locations:
city: Copenhagen
country: Denmark
facility: Bispebjerg University Hospital
Study officials:
References: