Sarah A. Lattimer

Regeneration and Repair of Myelinated Fibers in Sural-Nerve Biopsy Specimens from Patients with Diabetic Neuropathy Treated with Sorbinil

There is reason to believe that diabetic neuropathy may be related to the accumulation of sorbitol in nerve tissue through an aldose reductase pathway from glucose. Short-term treatment with aldose reductase inhibitors improves nerve conduction in subjects with diabetes, but the effects of long-term treatment on the neuropathologic changes of diabetic neuropathy are unknown. To determine whether more prolonged aldose reductase inhibition reverses the underlying lesions that accompany symptomatic diabetic peripheral polyneuropathy, we performed a randomized, placebo-controlled, double-blind trial of the investigational aldose reductase inhibitor sorbinil (250 mg per day). Sural-nerve biopsy specimens obtained at base line and after one year from 16 diabetic patients with neuropathy were analyzed morphometrically in detail and compared with selected electrophysiologic and clinical indexes. In contrast to patients who received placebo, the 10 sorbinil-treated patients had a decrease of 41.8 +/- 8.0 percent in nerve sorbitol content (P less than 0.01) and a 3.8-fold increase in the percentage of regenerating myelinated nerve fibers (P less than 0.001), reflected by a 33 percent increase in the number of myelinated fibers per unit of cross-sectional area of nerve (P = 0.04). They also had quantitative improvement in terms of the degree of paranodal demyelination, segmental demyelination, and myelin wrinkling. The increase in the number of fibers was accompanied by electrophysiologic and clinical evidence of improved nerve function. We conclude that sorbinil, as a metabolic intervention targeted against a specific biochemical consequence of hyperglycemia, can improve the neuropathologic lesions of diabetic neuropathy.

Glucose-induced Alterations in Nerve Metabolism: Current Perspective on the Pathogenesis of Diabetic Neuropathy and Future Directions for Research and Therapy

Recent animal and in vitro studies have identified several interrelated metabolic abnormalities in diabetic nerve that are attributable to elevated ambient glucose concentrations. In combination, these metabolic changes may induce a variety of biochemical and biophysical alterations in peripheral nerve that are highly relevant to the pathogenesis of diabetic neuropathy. This article reviews the current status of several of these metabolic defects and describes ways in which their interaction could lead to pathogenetically important changes in nerve metabolism, function, and structure. Areas of related future research are also discussed.

Are Disturbances of Sorbitol, Phosphoinositide, and Na+-K+-ATPase Regulation Involved in Pathogenesis of Diabetic Neuropathy?

Alterations in myo-inositol and phosphoinositide metabolism, induced by hyperglycemia and prevented by aldose reductase inhibitors, are implicated in impaired Na+-K+-ATPase regulation in peripheral nerve and other tissues prone to diabetic complications by an increasing range of scientific observations. However, the precise role of these related metabolic derangements in various stages of clinical complications is complex. For instance, it appears that these biochemical defects may play a role not only in the initiation of diabetic neuropathy but also in its later progression. Therefore, full appreciation of the potential pathogenetic role of altered phosphoinositide metabolism in diabetic complications requires detailed studies of both the earliest and the more mature stages of these disease processes.

Action of Sorbinil in Diabetic Peripheral Nerve: Relationship of Polyol (Sorbitol) Pathway Inhibition to a myo-Inositol-mediated Defect in Sodium-Potassium ATPase Activity

The small, but statistically significant, improvement in nerve conduction after treatment of diabetic patients with the aldose reductase inhibitor, sorbinil, suggests that increased polyol (sorbitol) pathway activity may contribute to diabetic nerve conduction slowing. Although classically viewed solely in terms of sorbitol-induced osmotic swelling, polyol pathway inhibition is now speculated to influence a concomitant myo-inositol-mediated alteration in nerve sodium-potassium ATPase activity in diabetic nerve. Therefore, we directly examined the effect of sorbinil treatment on sodium-potassium ATPase activity in crude homogenates of sciatic nerve from streptozotocin-diabetic and non-diabetic rats. We demonstrate that sorbinil treatment, which preserves normal nerve myo-inositol content, prevents the fall in nerve sodium-potassium ATPase activity that has been linked to conduction slowing in the diabetic rat.

Polyol Pathway Activity and Myo-Inositol Metabolism: A Suggested Relationship in the Pathogenesis of Diabetic Neuropathy

Two major metabolic perturbations, increased polyol (sorbitol) pathway activity and reduced tissue myo-inositol content, are induced in peripheral nerve by hyperglycemie. Although they are commonly invoked as alternative biochemical pathogenetic mechanisms for diabetic neuropathy, their possible interrelationship has never been adequately explored. Therefore, we studied the effect of polyol pathway blockade with sorbinil, a specific inhibitor of aldose reductase, on nerve myo-inositol content in acutely streptozotocin-diabetic rats. Sorbinil administration completely prevented the fall in nerve myo-inositol, thereby implicating increased polyol pathway activity as a likely factor in the fall in nerve myo-inositol content in experimental diabetes.

Protein Kinase C Agonists Acutely Normalize Decreased Ouabain-inhibitable Respiration in Diabetic Rabbit Nerve: Implications for (Na,K)-ATPase Regulation and Diabetic Complications

Diminished (Na,K)-ATPase activity in diabetic peripheral nerve is attributed to an underlying depletion of free myo-inositol, but no biochemical mechanism linking myo-inositol metabolism and (Na,K)-ATPase has emerged. Since inositol phospholipid turnover releases inositol-(1,4,5)-tris-phosphate and diacylglycerol, two putative “second messengers” that modulate protein kinase C, the effect of protein kinase C agonists on (Na,K)-ATPase activity was examined in diabetic nerve. Phorbol myristate acetate or the diacylglycerol sn-1,2-dioctanoylglycerol acutely normalized depressed ouabain-inhibitable respiration [a measure of (Na,K)-ATP-ase activity], suggesting that myo-inositol metabolism modulates (Na,K)-ATPase activity via protein kinase C, and that reduced myo-inositol impairs (Na,K)-ATPase activity in diabetic nerve by this mechanism.

Selective Effects of Myo -inositol Administration on Sciatic and Tibial Motor Nerve Conduction Parameters in the Streptozocin-Diabetic Rat

Time-dependent effects of experimental diabetes and dietary myo-inositol supplementation on motor nerve conduction velocity (MNCV) were assessed in two populations of motor nerve fibers in the rat hind limb. These two populations of large myelinated motor fibers, which innervate the musculature of the calf and the foot, were differentially affected by growth, experimental diabetes, and dietary myo-inositol. Dietary myo-inositol supplementation ameliorated the diabetes-induced MNCV impairment in both nerve fiber populations but with different time courses. These observations suggest metabolic or physiologic heterogeneity among populations of large myelinated motor fibers which may partially explain published discrepancies regarding the efficacy of dietary myo-inositol supplementation in improving slowed MNCV in the streptozocin-diabetic rat.

Reduced Motor Nerve Conduction Velocity and Na + -K + -ATPase Activity in Rats Maintained on L-Fucose Diet: Reversal by myo -Inositol Supplementation

L-Fucose is a monosaccharide that occurs in low concentrations in normal serum but has been shown to be increased in diabetic individuals. In cultured mammalian cells, L-fucose is a potent competitive inhibitor of myo-inositol transport. Abnormal myo-inositol metabolism has been proposed to be a factor in the development of diabetic complications. To test the hypothesis that myo-inositol deficiency may be responsible for the electrophysiological and biological defects in diabetic neuropathy, rats were fed a diet containing 10 or 20% L-fucose for a period of 6 wk. After 3 wk, the L-fucose diets in two groups of rats were supplemented with 1% myo-inositol. At the end of the study protocol, motor nerve conduction velocity, sciatic nerve tissue Na+-K+-ATPase activity, and myo-inositol content were determined. These results were compared with those of STZ-induced diabetic rats fed either a normal diet or a diet containing 1% myo-inositol or with those given 450 mg/kg body wt of sorbinil. Serum L-fucose levels were significantly increased in rats fed a diet containing 10 or 20% L-fucose. In comparison, the serum L-fucose levels in the diabetic rats were increased to a lesser extent. Motor nerve conduction velocity was significantly slower in rats fed a 10 or 20% L-fucose diet. Sciatic nerve composite and ouabain-sensitive Na+-K+-ATPase activity and myo-inositol content was also significantly decreased. Supplementation of 1% myo-inositol to the L-fucose-containing diet restored nerve myo-inositol levels and significantly improved Na+-K+-ATPase activity and motor nerve conduction velocity. In diabetic rats, similar changes were prevented by treatment with myo-inositol or sorbinil. These observations suggest that myo-inositol deficiency may be a major factor in the development of neural defects associated with acute diabetic neuropathy.

Recent advances in the therapy of diabetic peripheral neuropathy by means of an aldose reductase inhibitor

Nerve conduction slowing, a hallmark of both experimental and human diabetic neuropathy, is improved or corrected by administration of aldose reductase inhibitors such as sorbinil. Recent experiments in animals attribute acutely reversible nerve conduction slowing in diabetes to a myo-inositol-related defect in nerve sodium-potassium adenosinetriphosphatase, which generates the transmembrane sodium and potassium potentials necessary for nerve impulse conduction and the sodium gradient necessary for sodium-dependent uptake of substrates. This myo-inositol-related abnormality in sodium-potassium adenosinetriphosphatase function is currently viewed as a cyclic metabolic defect involving sequential alteration of sodium-dependent myo-inositol uptake, myo-inositol content, myo-inositol incorporation into membrane phospholipids, and phospholipid-dependent sodium-potassium adenosinetriphosphatase function in peripheral nerve. Aldose reductase inhibitors have been shown to normalize both nerve myo-inositol content and nerve sodium-potassium adenosinetriphosphatase activity. These observations suggest that the acute effects of aldose reductase inhibitors on nerve conduction in both animals and humans with diabetes may be mediated by correction of an underlying myo-inositol-related nerve sodium-potassium adenosinetriphosphatase defect. Furthermore, this sorbinil-corrected sodium-potassium adenosinetriphosphatase defect in diabetic nerve may contribute to other biochemical, functional, and structural abnormalities present in diabetic peripheral neuropathy.

Altered Nerve Myo-Inositol Metabolism in Experimental Diabetes and Its Relationship to Nerve Function

The following picture of altered myo-inositol metabolism in diabetic peripheral nerve has recently emerged. Hyperglycemia, through competitive inhibition of sodium-dependent myo-inositol uptake and/or increased polyol (sorbitol) pathway activity, reduces nerve myo-inositol content, secondarily altering nerve phosphoinositide metabolism and impairing the function of the membrane-bound sodium-potassium ATPase. The resulting reduction in the transmembrane sodium gradient impairs nerve conduction and further reduces sodium gradient-dependent myo-inositol uptake, creating a self-reinforcing metabolic defect in diabetic peripheral nerve. Other sodium-gradient dependent processes such as amino acid uptake and intracellular water and electrolyte homeostasis may also be secondarily altered. These abnormalities may have potentially widespread pathophysiological implications, possibly leading to the later structural defects in diabetic peripheral nerve, which are thought to underlie neurological deficits in diabetic neuropathy.