Glycine N-methyltransferase deficiency in female mice impairs insulin signaling and promotes gluconeogenesis by modulating the PI3K/Akt pathway in the liver
© The Author(s). 2016
Received: 1 April 2016
Accepted: 30 July 2016
Published: 4 October 2016
Glycine N-methyltransferase (GNMT) is abundantly expressed in the normal liver but is down-regulated in liver cancer tissues. GNMT knockout (Gnmt−/−) mice can spontaneously develop chronic hepatitis, fatty liver, and liver cancer. We previously demonstrated that hepatic GNMT is decreased in high-fat-diet-induced type 2 diabetes mellitus, but its contribution to metabolic syndrome is unclear. Here we show that GNMT modulates key aspects of metabolic syndrome in mice.
Eleven-week-old Gnmt−/− and wild-type (WT) mice with a C57BL/6 genetic background were used in this study. The metabolic defects of GNMT deficiency were measured by glucose and insulin tolerance tests, lipid homeostasis, gluconeogenesis, and insulin signaling.
Gnmt−/− mice, especially females, exhibited glucose intolerance and insulin resistance. However, their body fat and lean mass, food and water intakes, and energy expenditure did not differ from those of WT mice. In addition, glucose-stimulated insulin secretion and insulin-stimulated glucagon secretion were normal in the serum and pancreatic islets of Gnmt−/− mice. Importantly, we found that GNMT deficiency increased lipogenesis and triglycerides in the liver. The elevated triglycerides disrupted the ability of insulin to induce Akt and S6 ribosomal protein phosphorylation, and then triggered insulin resistance and gluconeogenesis in female Gnmt−/− mice.
Our data indicate that hepatic GNMT regulates lipid and glucose homeostasis, and provide insight into the development of insulin resistance through modulating the PI3K/Akt pathway.
KeywordsGlycine N-methyltransferase Triglycerides Insulin signaling PI3K/Akt pathway Liver
Metabolic syndrome is a constellation of interrelated disorders that include type 2 diabetes mellitus (T2DM), insulin resistance, dyslipidemia, fatty liver, and atherosclerosis . The pathogenesis of metabolic syndrome is multifactorial, but lipids, glucose, and inflammation manifested as insulin resistance appear to be crucial features . T2DM has reached epidemic proportions worldwide . The rapid increase in the prevalence of T2DM in recent decades is due to the interaction of genetic susceptibility and environmental factors such as inappropriate diet and sedentary lifestyles [4–6]. Insulin resistance is correlated with dyslipidemia and nonalcoholic fatty liver disease , which is the most common type of liver disease worldwide.
Glycine N-methyltransferase (GNMT) catalyzes the synthesis of sarcosine from glycine using S-adenosylmethionine (SAM) as the methyl donor, and plays an important role in the regulation of the hepatic SAM pool . GNMT also functions as a folate-binding protein and cytosolic receptor for clearing environmental carcinogens by regulating hepatic detoxification pathways [9, 10]. There is increasing evidence that GNMT plays a crucial role in the pathophysiological features of liver diseases, including chronic hepatitis, glycogen storage, hypercholesterolemia, fatty nodules, and liver cancer [11–15]. In addition, a lack of SAM (in a methyl-deficient diet) also causes liver cancer and steatohepatitis in rodents [16, 17]. A particularly important finding in both our own studies and those of others is that hepatic GNMT is down-regulated in dietary models (e.g., methionine/choline-deficient, high-cholesterol, and high-fat diets) of induced T2DM but not in genetic model (e.g., ob/ob mice) [18, 19]. Hepatic GNMT is reported elevated in streptozotocin-treated rats , a missense mutation (fatty, fa) in the leptin receptor gene (ZFD) rats , and retinoic acid/dexamethasone-treated rats , suggesting that the regulatory mechanisms of GNMT in the liver differ between type 1 diabetes and T2DM, and between dietary and genetic models. Since GNMT is also found in pancreatic tissue , whether GNMT is involved in the regulation of insulin signaling and T2DM is largely unknown.
In this study we investigated the role of hepatic GNMT in insulin signaling and the underlying molecular mechanisms. Genetic deletion of GNMT impaired glucose tolerance and insulin sensitivity via the accumulation of triglycerides and deregulation of insulin-stimulated Akt activation and gluconeogenesis in the liver.
Animals and diet
Eleven-week-old wild-type (WT) and GNMT knockout (Gnmt−/−) mice [11, 12] with a C57BL/6 genetic background were used in this study. All mice were maintained on standard chow (5001, LabDiet, St Louis, MO, USA) and housed in a 12-/12-h light/dark cycle. The experimental protocols were approved by the Institutional Animal Care and Use Committee of Taipei Medical University.
Glucose and insulin tolerance tests
For glucose-tolerance tests, the mice (n = 8–10 per group) were fasted overnight for 16 h. After measuring the fasted blood glucose level, each mouse received intraperitoneal (i.p.) injection of 20 % glucose at 2 g/kg body weight (Delta Select, Dreieich, Germany). Blood glucose levels were then measured after 15, 30, 60, 90, and 120 min. For insulin-tolerance tests, the blood glucose levels were measured after mice had fasted for 3 h. Each mouse received an i.p. insulin injection at 0.75 U/kg body weight (Actrapid, Novo Nordisk, Bagsvaerd, Denmark), and the blood glucose levels were then measured after 15, 30, 45, and 60 min.
Physiological metabolic analyses
The metabolic rate, food and water intakes and body fat and lean mass of WT and Gnmt−/− mice (n = 3 or 4 per group) were analyzed using the LabMaster Calorimetry Module (TSE Systems, Bad Homburg, Germany), Tecniplast® device, and Skyscan 1076 device, respectively.
Glucagon and insulin secretion
All animals (n = 4–7 per group) received an i.p. injection with insulin (100 IU/ml, Actrapid, Novo Nordisk, Bagsvaerd, Denmark) at 0.75 U/kg body weight or 20 % glucose at 2 g/kg body weight. After 20 min, the pancreatic and blood samples were collected for immunohistochemistry (IHC) staining and ELISA analyses.
IHC and ELISA
Paraffin-embedded pancreatic sections were incubated with the antibodies against glucagon (1:200 dilution, Lot No. #8233) and insulin (1:100 dilution, Lot No. #4590) (Cell Signaling, Beverly, MA, USA) and detected using the Universal LSABTM2 kit (DakoCytomation Carpinteria, CA, USA) according to the manufacturer’s instructions. The serum insulin levels were measured using mouse insulin ELISA kit (Cat. #EZRMI-13 K, Millipore, Billerica, MA) in accordance with the manufacturer’s instructions. The whole blood samples were directly drawn into a centrifuge tube without anti-coagulant. Let blood clot at room temperature for 30 min. Centrifuge the clotted blood at 2,000 to 3,000 × g for 15 min at 4 °C and the serum samples were subjected to insulin quantification.
Liver tissues were lysed using a lysis buffer supplemented with protease and phosphatase inhibitors . Proteins (50 μg) were separated using an 8-12 % SDS gel. The following antibodies (1:1000 dilution) used in this study were purchased from Cell Signaling: phospho-Akt (Ser-473, Lot No. #4060), total-Akt (Lot No. #4691), phospho-S6 ribosomal protein (Ser240/244, Lot No. #4858; and Ser235/236, Lot No. #5364) and total-S6 ribosomal protein (Lot No.#2317), and phospho-insulin receptor β (IR-β, Tyr1150/1151, Lot No. #3024). Total-IR-β (Lot No. sc-711) was purchased from Santa Cruz Biotechnology. Immunoblotting signals were normalized to those for α-tubulin (1:5000 dilution, Lot No. T9026, Sigma-Aldrich), and quantified by densitometric scanning.
Gene expression analysis
Total RNA was isolated from mouse liver using TRIzol Reagent (Ambion, Carlsbad, CA, USA), according to the manufacturer’s protocol. Complementary DNA was produced from RNA (2 μg) using a SuperScript II RNase H-Reverse Transcriptase Kit (Invitrogen, Carlsbad, CA, USA). The real-time PCR reactions using SYBR Green (Applied Biosystems, Foster City, CA, USA) were assayed using an Applied Biosystems Prism 7700 sequence detection system. The specific primer sequences are listed in Additional file 1: Table S1. Predicted cycle threshold (CT) values were exported into Microsoft Excel worksheets for analysis. Comparative CT methods were used to determine the differences in gene expression relative to GAPDH. Relative amounts of mRNA level in Gnmt−/− mice were determined by calculating the ratio relative to the WT mice separately for each sex.
Statistical analyses were performed using SPSS version 13 (SPSS, Chicago, IL, USA). Student’s t-test was used to compare groups. A probability value of p < 0.05 was considered to indicate statistical significance.
GNMT deficiency impaired glucose tolerance, especially in female mice
GNMT deficiency did not impair the metabolic effects
GNMT deficiency did not impair the secretion function of pancreatic islets
Increased lipogenesis and accumulated triglycerides in the liver of Gnmt−/− mice
Dysregulation of insulin-stimulated Akt activation in the liver of female Gnmt−/− mice
GNMT knockdown is associated with increased expression of liver gluconeogenesis genes in female mice
Discussion and conclusion
The liver plays a critical role in the systemic response to insulin, controlling the metabolism of both glucose and lipids [27, 28]. Hepatic lipogenesis includes the de novo synthesis of fatty acids from acetyl-CoA and malonyl-CoA and further processing into triglycerides. The produced triglycerides are then either stored in lipid droplets or packed into VLDL and exported into the blood . In our study we found that the increased de novo lipogenesis and inhibition of hepatic triglycerides exported via VLDL contribute to lipid accumulation in the liver of Gnmt−/− mice (Fig. 4). Triglycerides, which are the main lipids stored in the liver of nonalcoholic fatty liver disease patients, are associated with the development of steatohepatitis and insulin resistance [7, 25, 29]. Indeed, hepatic inflammatory infiltration  as well as inflammatory genes (IL-6, TNF-α and IL1-β) were increased in Gnmt−/− mice (data not shown). The impairment of PI3K/Akt activation is involved in the triglycerides accumulation induced hepatic insulin resistance [7, 30]. Our study has revealed impaired insulin-stimulated Akt phosphorylation in Gnmt−/− mice (Fig. 5).
Our previous studies suggested that the rate of tumorigenesis in HCC was significantly higher in female Gnmt−/− mice [10-12, 31]. Moreover, the retinoids that induce the activation of GNMT are sex-specific . In the present study we observed that female Gnmt−/− mice express a glucose intolerance phenotype (Fig. 1). The activation of the PI3K/Akt pathway is responsible for glucose metabolism, including glycogen synthesis and gluconeogenesis . We found that the gluconeogenesis genes (Pepck, Foxo1, and G6pase) were up-regulated only in female Gnmt−/− mice (Fig. 6). Foxo1 stimulates hepatic gluconeogenic gene expression and is directly phosphorylated and inhibited by Akt [34, 35]. Indeed, the level of insulin-stimulated Akt phosphorylation was lower in female Gnmt−/− mice (Fig. 5b). In addition, a twofold increase in hepatic triglycerides was observed in Gnmt−/− mice of either sex, but the lipogenesis and gluconeogenesis were elevated in female Gnmt−/− mice. Although the detailed underlying mechanism is unclear, this discrepancy may due to different roles of estrogen and androgen in Gnmt−/− mice.
Previously, we reported that GNMT regulates liver cancer growth in part via interacting with the DEP domain containing mTOR-interacting protein (DEPTOR) and modulating the mTOR signaling pathway . DEPTOR is an mTOR inhibitor that interacts with mTOR directly. Overexpression of DEPTOR activates Akt via the inhibition of a negative feedback loop from S6 to PI3K . The phosphorylation of IR-β is able to recruit and phosphorylate IR substrate proteins after ligand binding, leading to activation of the PI3K/Akt pathway [37, 38]. However, the difference of insulin-stimulated pIR-β was observed between male and female Gnmt−/− mice (Fig. 5). Although the detailed underlying mechanism is unclear, this sex discrepancy may due to different feedback controls of hepatic glucose metabolism , methylation  or hormone  in Gnmt−/− mice.
GNMT is expressed predominantly in the liver, with moderate levels in proximal kidney tubules and exocrine tissue of the pancreas [8, 23]. However, GNMT deficiency does not affect the insulin and glucagon secretion of pancreatic islets (Fig. 3), implying that the dysregulation of glucose metabolism in Gnmt−/− mice may arise primarily from hepatic insulin resistance rather than impaired insulin secretion due to β-cell dysfunction. In addition to the liver, skeletal muscle and adipocytes are the main insulin-responsive tissues and are associated with the pathogenesis of T2DM . Although we did not detect GNMT in adipocytes using Western blotting and Q-PCR, weak expressions of GNMT in both mRNA and protein levels were observed in the skeletal soleus muscle (data not shown). Therefore, the role of GNMT in these insulin target organs is yet to be elucidated, especially in skeletal muscle.
In conclusion, our findings indicate that GNMT deficiency exacerbates lipogenesis and the accumulation of triglycerides in the liver, further impairing insulin signaling and gluconeogenesis. GNMT may therefore be a suitable therapeutic target when treating not only dyslipidemia but also broader aspects of metabolic diseases.
Acc, acetyl-CoA carboxylase; Ascl4, long-chain fatty-acid-CoA ligase-4; DEPTOR, DEP domain containing mTOR-interacting protein; Fasn, fatty acid synthase; GNMT, glycine N-methyltransferase; Gnmt−/−, GNMT knockout; IR-β, insulin receptor β; Mttp, microsomal triglyceride transfer protein; PPARγ, peroxisome proliferator-activated receptor-γ; SAM, s-adenosylmethionine; Scd1, stearoyl-CoA desaturase 1; Srebp1c, sterol-regulatory element-binding protein 1c; T2DM, type 2 diabetes mellitus; WT, wild-type.
We thank the Taiwan Mouse Clinic (MOST 103-2325-B-001-015) which is funded by the National Research Program for Biopharmaceuticals (NRPB) at the Ministry of Science and Technology (MOST) of Taiwan for technical support in physiological metabolic experiments. We also thank Yuan-Hsi Wang for support in Q-PCR experiments.
This study was partially supported by Ministry of Science and Technology of the Republic of China (MOST104-2632-B-037-001 and MOST103-2320-B-038-044) and Kaohsiung Medical University (KMU-TP104E11).
Availability of data and materials
Conception and design: YJL, YMC. Analysis and interpretation of data: YJL, TSL, YCT, CPY. Administrative, technical, or material support: SMH, CKW, YCL. Wrote the manuscript: YJL. All authors read and approved the final manuscript.
The authors have no conflicts of interest.
Consent for publication
Ethics approval and consent to participate
The experimental protocols were approved by the Institutional Animal Care and Use Committee of Taipei Medical University (LAC-2013-0277).
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Gaggini M, Morelli M, Buzzigoli E, DeFronzo RA, Bugianesi E, Gastaldelli A. Non-alcoholic fatty liver disease (NAFLD) and its connection with insulin resistance, dyslipidemia, atherosclerosis and coronary heart disease. Nutrients. 2013;5:1544–60.View ArticlePubMedPubMed CentralGoogle Scholar
- Medina-Santillan R, Lopez-Velazquez JA, Chavez-Tapia N, Torres-Villalobos G, Uribe M, Mendez-Sanchez N. Hepatic manifestations of metabolic syndrome. Diabetes/metabolism research and reviews. 2013. doi: https://doi.org/10.1002/dmrr.2410.
- Shaw JE, Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2013;87:4–14.View ArticleGoogle Scholar
- Diamant M, Blaak EE, de Vos WM. Do nutrient-gut-microbiota interactions play a role in human obesity, insulin resistance and type 2 diabetes? Obes Rev. 2011;12:272–81.View ArticlePubMedGoogle Scholar
- Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ, et al. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. Lancet. 2013;378:31–40.View ArticleGoogle Scholar
- Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract. 2013;94:311–21.View ArticleGoogle Scholar
- Birkenfeld AL, Shulman GI. Nonalcoholic fatty liver disease, hepatic insulin resistance, and type 2 diabetes. Hepatology. 2014;59:713–23.View ArticlePubMedPubMed CentralGoogle Scholar
- Kerr SJ. Competing methyltransferase systems. J Biol Chem. 1972;247:4248–52.PubMedGoogle Scholar
- Cook RJ, Wagner C. Glycine N-methyltransferase is a folate binding protein of rat liver cytosol. Proc Natl Acad Sci U S A. 1984;81:3631–4.View ArticlePubMedPubMed CentralGoogle Scholar
- Liao YJ, Chen KH, Huang SF, Chen TL, Wang CK, Chien CH, et al. Deficiency of glycine N-methyltransferase results in deterioration of cellular defense to stress in mouse liver. Proteomics Clin Appl. 2010;4:394–406.View ArticlePubMedGoogle Scholar
- Liao YJ, Liu SP, Lee CM, Yen CH, Chuang PC, Chen CY, et al. Characterization of a glycine N-methyltransferase gene knockout mouse model for hepatocellular carcinoma: Implications of the gender disparity in liver cancer susceptibility. Int J Cancer. 2009;124:816–26.View ArticlePubMedGoogle Scholar
- Liu SP, Li YS, Chen YJ, Chiang EP, Li AF, Lee YH, et al. Glycine N-methyltransferase−/− mice develop chronic hepatitis and glycogen storage disease in the liver. Hepatology. 2007;46:1413–25.View ArticlePubMedGoogle Scholar
- Chen YM, Shiu JY, Tzeng SJ, Shih LS, Chen YJ, Lui WY, et al. Characterization of glycine-N-methyltransferase-gene expression in human hepatocellular carcinoma. Int J Cancer. 1998;75:787–93.View ArticlePubMedGoogle Scholar
- Liu HH, Chen KH, Shih YP, Lui WY, Wong FH, Chen YM. Characterization of reduced expression of glycine N-methyltransferase in cancerous hepatic tissues using two newly developed monoclonal antibodies. J Biomed Sci. 2003;10:87–97.View ArticlePubMedGoogle Scholar
- Martinez-Chantar ML, Vazquez-Chantada M, Ariz U, Martinez N, Varela M, Luka Z, et al. Loss of the glycine N-methyltransferase gene leads to steatosis and hepatocellular carcinoma in mice. Hepatology. 2008;47:1191–9.View ArticlePubMedGoogle Scholar
- Pogribny IP, James SJ, Beland FA. Molecular alterations in hepatocarcinogenesis induced by dietary methyl deficiency. Mol Nutr Food Res. 2012;56:116–25.View ArticlePubMedGoogle Scholar
- Mato JM, Lu SC. The hepatocarcinogenic effect of methionine and choline deficient diets: an adaptation to the Warburg effect? Alcohol Clin Exp Res. 2011;35:811–4.View ArticlePubMedPubMed CentralGoogle Scholar
- Pacana T, Cazanave S, Verdianelli A, Patel V, Min HK, Mirshahi F, et al. Dysregulated hepatic methionine metabolism drives homocysteine elevation in diet-induced nonalcoholic fatty liver disease. PloS One. 2015;10:e0136822.View ArticlePubMedPubMed CentralGoogle Scholar
- Liao YJ, Chen TL, Lee TS, Wang HA, Wang CK, Liao LY, et al. Glycine N-methyltransferase deficiency affects Niemann-Pick type C2 protein stability and regulates hepatic cholesterol homeostasis. Mol Med. 2012;18:412–22.PubMedGoogle Scholar
- Nieman KM, Schalinske KL. Insulin administration abrogates perturbation of methyl group and homocysteine metabolism in streptozotocin-treated type 1 diabetic rats. Am J Physiol Endocrinol Metab. 2011;301:E560–565.View ArticlePubMedGoogle Scholar
- Williams KT, Schalinske KL. Tissue-specific alterations of methyl group metabolism with DNA hypermethylation in the Zucker (type 2) diabetic fatty rat. Diabetes Metab Res Rev. 2012;28:123–31.View ArticlePubMedGoogle Scholar
- Rowling MJ, Schalinske KL. Retinoic acid and glucocorticoid treatment induce hepatic glycine N-methyltransferase and lower plasma homocysteine concentrations in rats and rat hepatoma cells. J Nutr. 2003;133:3392–8.PubMedGoogle Scholar
- Yeo EJ, Wagner C. Tissue distribution of glycine N-methyltransferase, a major folate-binding protein of liver. Proc Natl Acad Sci U S A. 1994;91:210–4.View ArticlePubMedPubMed CentralGoogle Scholar
- Yen CH, Lu YC, Li CH, Lee CM, Chen CY, Cheng MY, et al. Functional characterization of glycine N-methyltransferase and its interactive protein DEPDC6/DEPTOR in hepatocellular carcinoma. Mol Med. 2012;18:286–96.View ArticlePubMedGoogle Scholar
- Tilg H, Moschen AR. Insulin resistance, inflammation, and non-alcoholic fatty liver disease. Trends Endocrinol Metab. 2008;19:371–9.View ArticlePubMedGoogle Scholar
- Martinez-Una M, Varela-Rey M, Mestre D, Fernandez-Ares L, Fresnedo O, Fernandez-Ramos D, et al. S-Adenosylmethionine increases circulating very-low density lipoprotein clearance in non-alcoholic fatty liver disease. J Hepatol. 2015;62:673–81.View ArticlePubMedGoogle Scholar
- Maxfield FR, Tabas I. Role of cholesterol and lipid organization in disease. Nature. 2005;438:612–21.View ArticlePubMedGoogle Scholar
- Bechmann LP, Hannivoort RA, Gerken G, Hotamisligil GS, Trauner M, Canbay A. The interaction of hepatic lipid and glucose metabolism in liver diseases. J Hepatol. 2012;56:952–64.View ArticlePubMedGoogle Scholar
- Asrih M, Jornayvaz FR. Metabolic syndrome and nonalcoholic fatty liver disease: Is insulin resistance the link? Mol Cell Endocrinol. 2015;418:55–65.View ArticlePubMedGoogle Scholar
- Samuel VT, Shulman GI. Mechanisms for insulin resistance: common threads and missing links. Cell. 2012;148:852–71.View ArticlePubMedPubMed CentralGoogle Scholar
- Liu SP, Li YS, Lee CM, Yen CH, Liao YJ, Huang SF, et al. Higher susceptibility to aflatoxin B(1)-related hepatocellular carcinoma in glycine N-methyltransferase knockout mice. Int J Cancer. 2010;128:511–23.View ArticleGoogle Scholar
- McMullen MH, Rowling MJ, Ozias MK, Schalinske KL. Activation and induction of glycine N-methyltransferase by retinoids are tissue- and gender-specific. Archives of biochemistry and biophysics. 2002;401:73–80.View ArticlePubMedGoogle Scholar
- Perry RJ, Samuel VT, Petersen KF, Shulman GI. The role of hepatic lipids in hepatic insulin resistance and type 2 diabetes. Nature. 2014;510:84–91.View ArticlePubMedPubMed CentralGoogle Scholar
- Gross DN, Wan M, Birnbaum MJ. The role of FOXO in the regulation of metabolism. Curr Diab Rep. 2009;9:208–14.View ArticlePubMedGoogle Scholar
- Lu M, Wan M, Leavens KF, Chu Q, Monks BR, Fernandez S, et al. Insulin regulates liver metabolism in vivo in the absence of hepatic Akt and Foxo1. Nat Med. 2012;18:388–95.View ArticlePubMedPubMed CentralGoogle Scholar
- Peterson TR, Laplante M, Thoreen CC, Sancak Y, Kang SA, Kuehl WM, et al. DEPTOR is an mTOR inhibitor frequently overexpressed in multiple myeloma cells and required for their survival. Cell. 2009;137:873–86.View ArticlePubMedPubMed CentralGoogle Scholar
- Biddinger SB, Kahn CR. From mice to men: insights into the insulin resistance syndromes. Annu Rev Physiol. 2006;68:123–58.View ArticlePubMedGoogle Scholar
- Sun XJ, Rothenberg P, Kahn CR, Backer JM, Araki E, Wilden PA, et al. Structure of the insulin receptor substrate IRS-1 defines a unique signal transduction protein. Nature. 1991;352:73–7.View ArticlePubMedGoogle Scholar