Casper G. Schalkwijk, Coen D. A. Stehouwer, Victor W. M. van Hinsbergh
The Maillard reaction is a process in which reducing sugars react spontaneously with amino groups in proteins to advanced glycation endproducts (AGEs). Although an elevated level of glucose had been thought to play a primary role in the Maillard reaction, on a molecular basis, glucose is among the least reactive sugars within biological systems. The formation of AGEs is now also known to result from the action of various metabolites other than glucose, which are primarily located intracellularly and participate in the non-enzymatic glycation reaction at a much faster rate, such as fructose, trioses and dicarbonyl compounds. In this review, we considered the glycation reaction with particular attention to the potential role of fructose and fructose metabolites. The two sources for fructose are an exogenous supply from the diet and the endogenous formation from glucose through the aldose reductase pathway. Despite its ∼eightfold higher reactivity, the contribution of extracellular glycation by fructose is considerably less than that by glucose, because of the low plasma concentration of fructose (5 mmol/L glucose vs 35 μmol/L fructose). Intracellularly, fructose is elevated in a number of tissues of diabetic patients in which the polyol pathway is active. In the cells of these tissues, the concentrations of fructose and glucose are of the same magnitude. Although direct evidence is not yet available, it is likely that the high reactivity of fructose and its metabolites may substantially contribute to the formation of intracellular AGEs and may contribute to alterations of cellular proteins, dysfunction of cells and, subsequently, to vascular complications.