SummaryTo assess the relative contributions of gluconeogenesis and glycogenolysis to overall hepatic glucose output in postabsorptive normal humans and those of the indirect and direct pathways for glycogen synthesis, we studied six normal volunteers, who had been fasted for 16 h to reduce their hepatic glycogen stores, and then ingested glucose (250 g over 10 h) enriched with [6-3H] glucose to replenish and label their hepatic glycogen. After a 10-h overnight fast, release of the [6-3H] glucose into the circulation was traced with [2-3H] glucose to estimate breakdown of glycogen that had been formed via the direct pathway while gluconeogenesis was simultaneously estimated by incorporation of infused [14C] lactate into plasma glucose. We found that release of [6-3H] glucose into plasma (6.79 _+ 0.69 gmol. kg -1. min -~) accounted for 46 + 5 % of hepatic glucose output (15.0+0.7gmol.kg -1. min -~) while glucose formed from lactate (2.71+ 0.28 gmol-kg -1 -min -~) accounted for 19 + 2% of hepatic glucose output. Since these determinations underestimate direct pathway glycogenolysis and overall gluconeogenesis, a maximal estimate for the contribution of indirect pathway glycogenolysis to hepatic glucose output is obtained by subtracting the sum of direct pathway glycogenolysis and lactate gluconeogenesis from hepatic glucose output. This amounted to a maximum of 36 + 5 % of hepatic glucose output and 44 + 6 % of overall glycogenolysis. Assuming that the relative proportions of direct and indirect pathway glycogen breakdown would reflect the relative contributions of these pathways to glycogen formation, we conclude that under our experimental conditions the direct pathway is the predominant route for glycogen formation in man and that in overnight fasted humans, hepatic glucose output is mainly the result of glycogenolysis. [Diabetologia (1994) 37: 697-702] Key words Glycogen, gluconeogenesis, glycogenolysis, hepatic glucose output.In overnight fasted humans, the liver is essentially the only organ supplying glucose to the systemic circulation. It does this via two processes: glycogenolysis (via release of glucose previously stored as glycogen) and gluconeogenesis (via release of glucose newly synthesized from precursors such as lactate, glycerol and amino acids). The relative contributions of these two processes is currently unclear. Splanchnic balance Received: 23 August 1993 and in revised form: 14 January 1994Corresponding author: Dr. J. E. Gerich, University of Rochester Medical Center 601 Elmwood Ave, MED/CRC, Rochester NY 14642, USA [1,2], isotope dilution [3,4] and serial liver biopsy studies [5] have generally indicated that glycogenolysis is the predominant process, accounting for 50-70 % of hepatic glucose output. On the other hand, recent studies using nuclear magnetic resonance to measure the depletion of 13C in hepatic glycogen [6,7] have suggested that gluconeogenesis is the predominant process, accounting for at least two-thirds of hepatic glucose output.Another currently unresolved issue is the...