1
|
Fragkos KC, Forbes A. Citrulline as a marker of intestinal function and absorption in clinical settings: A systematic review and meta-analysis. United European Gastroenterol J 2017; 6:181-191. [PMID: 29511548 DOI: 10.1177/2050640617737632] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 09/26/2017] [Indexed: 12/15/2022] Open
Abstract
Background Citrulline has been described as a marker of intestinal function or absorption but evidence varies according to clinical settings. Objective The objective of this article is to examine the evidence of plasma citrulline as a marker of intestinal function and absorption in various clinical settings. Methods Studies were examined for p values, means and standard deviations, correlation coefficients or other metrics depicting the association of citrulline with intestinal function. A random effects model was used to produce a pooled estimate. A hierarchical summary receiver operating curve model was fitted for diagnostic accuracy measures. Results Citrulline levels are correlated strongly with small bowel length in short bowel syndrome patients (r = 0.67). Citrulline is strongly negatively correlated (r = -0.56) with intestinal disease severity with regards to enteropathies (coeliac disease, tropical enteropathy, Crohn's disease, mucositis, acute rejection in intestinal transplantation). Citrulline cut-off levels have an overall sensitivity and specificity of 80% and 84% respectively. Citrulline levels in untreated coeliac patients compared to controls were reduced by 10 µmol/l. Citrulline levels increase with gluten-free diet and with improvement of enteropathy. Citrulline is decreased in critical illness and sepsis. Conclusion These findings allow us to advocate quite reasonably that citrulline is a marker of acute and chronic intestinal insufficiency.
Collapse
Affiliation(s)
| | - Alastair Forbes
- University of East Anglia, Norwich and Norfolk Medical School, Norwich, UK
| |
Collapse
|
2
|
Intestinal transplantation: current improvements and perspectives. Curr Opin Organ Transplant 2017; 12:265-270. [PMID: 27711016 DOI: 10.1097/mot.0b013e32814a5a3b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the most recent relevant knowledge in clinical practice in the field of intestinal transplantation. RECENT FINDINGS Three important factors that have allowed improving results during the last few years are reviewed here. The first relates to the development of a different approach to tackle the underlying cause of intestinal failure and to the patient's characteristics in terms of liver function, age, and body size. The second involves immune modulation and especially the immunosuppressive regimen at induction. The third refers to posttransplantation monitoring, in particular the diagnosis and treatment of intestinal graft rejection and lymphoproliferative disorders. Patient status and referral for intestinal transplantation remain debated. The Intestinal Transplant Registry and a report from an individual program have demonstrated the relationship between a patient's pretransplant status and outcome. Candidacy for intestinal transplantation was analysed in a European survey of home parenteral nutrition patients. Early referral and listing are important for successful outcomes after intestinal grafting. SUMMARY Patient management should include therapies adapted to each stage of intestinal failure based on a multidisciplinary approach in centers involving surgery, gastroenterology, parenteral nutrition expertise, home parenteral nutrition programs, and liver-intestinal transplantation experience. Timing for referral of patients in specialized centers remains a crucial issue.
Collapse
|
3
|
Abstract
PURPOSE OF REVIEW The purpose of this article is to review the existing literature on the current indications, surgical techniques, immunosuppressive therapy and outcomes following intestinal transplantation (ITx). RECENT FINDINGS Over recent years, ITx has become a more common operation with approximately 2500 procedures carried out worldwide by 2014. It is reserved for patients with intestinal failure and who have developed complications of home parenteral nutrition or who have a high risk of dying from their underlying disease. Recent advances such as the improvement in survival rates, not only for isolated small bowel transplants but also following inclusion of a liver graft in combined liver-small bowel transplant, and the utility of citrulline as a noninvasive biomarker to appreciate acute rejection herald an exciting shift in the field of ITx. SUMMARY With advancements in immunosuppressive drugs, induction regimens, standardization of surgical techniques and improved postoperative care, survival is increasing. In due course, it will most likely become as good as remaining on home parenteral nutrition and as such could become a viable first-line option.
Collapse
|
4
|
Abstract
Nutrition therapy after small bowel or combined liver/small bowel transplantation is challenging. The objective is to restore enteral autonomy to a patient with a complex past surgical history and equally complex posttransplant immunosuppressive regimen in the context of a newly created surgical anatomy. Improved surgical techniques and immunosuppressive regimens have led to superior outcomes. Accompanying these advances is a range of nutrition issues that require specific management strategies. This review outlines the current clinical practice and decision making used to create individualized nutrition regimens for small bowel or combined liver/small bowel transplant recipients. Successful small bowel transplant outcomes require a coordinated effort from a transplant team to restore nutritional autonomy to transplant recipients and free them from parenteral nutrition.
Collapse
Affiliation(s)
- Rebecca A Weseman
- Intestinal Rehabilitation and Transplant Programs, 983285 Nebraska Medical Center, Omaha, NE 68198-3285, USA.
| | | |
Collapse
|
5
|
Flynn B, Park BK, Bond G, McGhee W, Mazariegos G, Sindhi R, Reyes J, Abu-Elmagd K. Immunosuppressant Strategies for Intestinal Transplantation: A Review of a Tolerogenic Regimen. Prog Transplant 2016; 15:60-4. [PMID: 15839373 DOI: 10.1177/152692480501500110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intestinal, combined liver-intestinal, and multivisceral transplantation are now considered the standard of care for children and adults with permanent intestinal failure. Early attempts at intestinal transplantation were discouraging because of the high incidence of technical complications, rejection, and infection. Advances in the field of transplantation, including the introduction of tacrolimus, improved surgical techniques, and improvements in postoperative care, have led to a renewed interest in intestinal transplantation since 1990. The most significant achievement, however, has been the effective control of rejection and life-threatening infections. This article focuses on the experience to date of innovative strategies that induce lymphocyte depletion and reduction in the incidence of rejection. In this setting, low-maintenance immunosuppression is clinically achievable with an acceptable rate of allograft rejection. Subsequently, the long-term complications of immunosuppression are significantly reduced with achievement of better long-term survival, and an overall improvement in the quality of life.
Collapse
Affiliation(s)
- Bridget Flynn
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | | | | | | | | | | |
Collapse
|
6
|
|
7
|
Sequeira IR, Lentle RG, Kruger MC, Hurst RD. Assessment of the Effect of Intestinal Permeability Probes (Lactulose And Mannitol) and Other Liquids on Digesta Residence Times in Various Segments of the Gut Determined by Wireless Motility Capsule: A Randomised Controlled Trial. PLoS One 2015; 10:e0143690. [PMID: 26629926 PMCID: PMC4667890 DOI: 10.1371/journal.pone.0143690] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 11/07/2015] [Indexed: 12/11/2022] Open
Abstract
Background Whilst the use of the mannitol/lactulose test for intestinal permeability has been long established it is not known whether the doses of these sugars modify transit time Similarly it is not known whether substances such as aspirin that are known to increase intestinal permeability to lactulose and mannitol and those such as ascorbic acid which are stated to be beneficial to gastrointestinal health also influence intestinal transit time. Methods Gastric and intestinal transit times were determined with a SmartPill following consumption of either a lactulose mannitol solution, a solution containing 600 mg aspirin, a solution containing 500 mg of ascorbic acid or an extract of blackcurrant, and compared by doubly repeated measures ANOVA with those following consumption of the same volume of a control in a cross-over study in six healthy female volunteers. The dominant frequencies of cyclic variations in gastric pressure recorded by the Smartpill were determined by fast Fourier transforms. Results The gastric transit times of lactulose mannitol solutions, of aspirin solutions and of blackcurrant juice did not differ from those of the control. The gastric transit times of the ascorbic acid solutions were significantly shorter than those of the other solutions. There were no significant differences between the various solutions either in the total small intestinal or colonic transit times. The intraluminal pHs during the initial quartiles of the small intestinal transit times were lower than those in the succeeding quartiles. This pattern did not vary with the solution that was consumed. The power of the frequencies of cyclic variation in intragastric pressure recorded by the Smartpill declined exponentially with increase in frequency and did not peak at the reported physiological frequencies of gastric contractile activity. Conclusions Whilst the segmental residence times were broadly similar to those using other methods, the high degree of variation between subjects generally precluded the identification of all but gross variation between treatments. The lack of any differences between treatments in either total small or large intestinal transit times indicates that the solutions administered in the lactulose mannitol test of permeability had no consistent influence on the temporal pattern of absorption. The negatively exponential profile and lack of any peaks in the frequency spectra of cyclic variation in gastric intraluminal pressure that were consistent with reported physiological frequencies of contractile activity profile suggests that the principal source of this variation is stochastic likely resulting from the effects of external events occasioned by normal daily activities on intra-abdominal pressure. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12615000596505
Collapse
Affiliation(s)
- Ivana R. Sequeira
- School of Food and Nutrition, Massey University, Private Bag 11222, Palmerston North, New Zealand
| | - Roger G. Lentle
- School of Food and Nutrition, Massey University, Private Bag 11222, Palmerston North, New Zealand
- * E-mail:
| | - Marlena C. Kruger
- School of Food and Nutrition, Massey University, Private Bag 11222, Palmerston North, New Zealand
| | - Roger D. Hurst
- The New Zealand Institute for Plant & Food Research Ltd, Palmerston North, New Zealand
| |
Collapse
|
8
|
Jones JW, Tudor G, Li F, Tong Y, Katz B, Farese AM, MacVittie TJ, Booth C, Kane MA. Citrulline as a Biomarker in the Murine Total-Body Irradiation Model: Correlation of Circulating and Tissue Citrulline to Small Intestine Epithelial Histopathology. HEALTH PHYSICS 2015; 109:452-65. [PMID: 26425905 PMCID: PMC4727745 DOI: 10.1097/hp.0000000000000346] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
The use of plasma citrulline as a biomarker for gastrointestinal acute radiation syndrome via exposure to total-body irradiation in a murine model was investigated. The radiation exposure covered lethal, mid-lethal, and sub-lethal gastrointestinal acute radiation syndrome. Plasma citrulline profiles were generated over the first 6 d following total-body irradiation exposure of 6-15 Gy. In addition, plasma citrulline was comprehensively evaluated in the context of matching small intestine citrulline and histopathology. Higher plasma citrulline was significantly associated with lower irradiation doses over the first 6 d following the irradiation insult. Furthermore, higher plasma citrulline was significantly associated with higher crypt survival. The correlation of the plasma citrulline to crypt survival was more robust for higher irradiation doses and for later time points. The data suggested plasma citrulline was most informative for reflecting gastrointestinal injury resulting from exposure to 9-15 Gy total-body irradiation covering time-points 2-5 d post the irradiation insult.
Collapse
Affiliation(s)
- Jace W. Jones
- University of Maryland, School of Pharmacy, Department of Pharmaceutical Sciences, Baltimore, MD
| | | | - Fei Li
- University of Maryland, School of Pharmacy, Department of Pharmaceutical Sciences, Baltimore, MD
| | - Yan Tong
- Indiana University, School of Medicine and Richard M. Fairbanks School of Public Health, Department of Biostatistics, Indianapolis, IN
| | - Barry Katz
- Indiana University, School of Medicine and Richard M. Fairbanks School of Public Health, Department of Biostatistics, Indianapolis, IN
| | - Ann M. Farese
- University of Maryland, School of Medicine, Department of Radiation Oncology, Baltimore, MD
| | - Thomas J. MacVittie
- University of Maryland, School of Medicine, Department of Radiation Oncology, Baltimore, MD
| | | | - Maureen A. Kane
- University of Maryland, School of Pharmacy, Department of Pharmaceutical Sciences, Baltimore, MD
| |
Collapse
|
9
|
Development and validation of a LC-MS/MS assay for quantitation of plasma citrulline for application to animal models of the acute radiation syndrome across multiple species. Anal Bioanal Chem 2014; 406:4663-75. [DOI: 10.1007/s00216-014-7870-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 04/24/2014] [Accepted: 04/29/2014] [Indexed: 10/25/2022]
|
10
|
Jones JW, Scott AJ, Tudor G, Xu PT, Jackson IL, Vujaskovic Z, Booth C, MacVittie TJ, Ernst RK, Kane MA. Identification and quantitation of biomarkers for radiation-induced injury via mass spectrometry. HEALTH PHYSICS 2014; 106:106-19. [PMID: 24276554 PMCID: PMC3843144 DOI: 10.1097/hp.0b013e3182a4ed3b] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Biomarker identification and validation for radiation exposure is a rapidly expanding field encompassing the need for well defined animal models and advanced analytical techniques. The resources within the consortium, Medical Countermeasures Against Radiological Threats (MCART), provide a unique opportunity for accessing well defined animal models that simulate the key sequelae of the acute radiation syndrome and the delayed effects of acute radiation exposure. Likewise, the use of mass spectrometry-based analytical techniques for biomarker discovery and validation enables a robust analytical platform that is amenable to a variety of sample matrices and considered the benchmark for biomolecular identification and quantitation. Herein, the authors demonstrate the use of two targeted mass spectrometry approaches to link established MCART animal models to identified metabolite biomarkers. Circulating citrulline concentration was correlated to gross histological gastrointestinal tissue damage, and retinoic acid production in lung tissue was established to be reduced at early and late time points post high dose irradiation. Going forward, the use of mass spectrometry-based metabolomics coupled to well defined animal models provides the unique opportunity for comprehensive biomarker discovery.
Collapse
Affiliation(s)
- Jace W. Jones
- University of Maryland, School of Pharmacy, Department of Pharmaceutical Sciences, Baltimore, MD
| | - Alison J. Scott
- University of Maryland, School of Dentistry, Department of Microbial Pathogenesis, Baltimore, MD
| | | | - Pu-Ting Xu
- University of Maryland, School of Medicine, Department of Radiation Oncology, Baltimore, MD
| | - Isabel L. Jackson
- University of Maryland, School of Medicine, Department of Radiation Oncology, Baltimore, MD
| | - Zeljko Vujaskovic
- University of Maryland, School of Medicine, Department of Radiation Oncology, Baltimore, MD
| | | | - Thomas J. MacVittie
- University of Maryland, School of Medicine, Department of Radiation Oncology, Baltimore, MD
| | - Robert K. Ernst
- University of Maryland, School of Dentistry, Department of Microbial Pathogenesis, Baltimore, MD
| | - Maureen A. Kane
- University of Maryland, School of Pharmacy, Department of Pharmaceutical Sciences, Baltimore, MD
| |
Collapse
|
11
|
Association between donor-specific antibodies and acute rejection and resolution in small bowel and multivisceral transplantation. Transplantation 2011; 92:709-15. [PMID: 21804443 DOI: 10.1097/tp.0b013e318229f752] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Donor-specific antibodies (DSA) are associated with acute kidney graft rejection, but their role in small bowel/multivisceral allograft remains unclear. We carried out a prospective study to understand the impact of DSA in the setting of intestinal allograft rejection. METHODS Thirteen patients (15 grafts) were serially evaluated for DSA levels pre- and posttransplant. DSA was determined by Luminex and the results were interpreted as fluorescence intensity (FI), with FI more than 3000 considered positive. RESULTS The clinical rejection episodes in allografts were significantly associated with the presence of DSA (P=0.041).We obtained 291 biopsy samples from graft ileum and date-matched DSA assay reports. Sixty-three (21.65%) of the biopsies showed acute rejection. The appearance of DSA were preformed (n=5, anti-human leukocyte antigen class II=3, anti-class I and II=2), de novo (n=4, 15.25±4.72 days after transplantation, anti-class II=1, and anti-class I and II=3) and never (n=6). Among the 63 biopsies, 30(47.6%) had significant correlations with positive DSA (kappa=0.30, P<0.001) and manifested severe rejection grade (P=0.009). CONCLUSIONS In this cohort of small bowel/multivisceral transplantation patients, there was a high incidence of DSA. The presence of DSA should alert the clinical team of a higher risk of rejection, and reduction of the FI is clinically associated with resolution. Serial endoscopy guided biopsies combined with simultaneous DSA measurement in postintestinal transplantation follow-up is an effective means of screening for cellular and humoral-based forms of acute rejection.
Collapse
|
12
|
Hot topics in postsmall bowel transplantation: noninvasive graft monitoring including stool calprotectin and plasma citrulline. Curr Opin Organ Transplant 2011; 16:316-22. [DOI: 10.1097/mot.0b013e3283467115] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
13
|
Papadia C, Kelly P, Caini S, Roberto Corazza G, Shawa T, Franzè A, Forbes A, Di Sabatino A. Plasma citrulline as a quantitative biomarker of HIV-associated villous atrophy in a tropical enteropathy population. Clin Nutr 2010; 29:795-800. [DOI: 10.1016/j.clnu.2010.04.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 03/21/2010] [Accepted: 04/13/2010] [Indexed: 10/19/2022]
|
14
|
Siqueira LT, Ferraz ÁAB, Campos JM, De Lima Filho JL, Albuquerque MC, de Lima Aires A, Ribeiro MHML, Cavalcanti MTH, De Lima B. Cavalcanti C, Ferraz EM. Analysis of Plasma Citrulline and Intestinal Morphometry in Mice with Hepatosplenic Schistosomiasis. Surg Infect (Larchmt) 2010; 11:419-26. [DOI: 10.1089/sur.2009.066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Luciana T. Siqueira
- General Surgery Service, University Hospital of the Universidade Federal de Pernambuco, Recife, Brazil
| | - Álvaro Antônio B. Ferraz
- General Surgery Service, University Hospital of the Universidade Federal de Pernambuco, Recife, Brazil
| | - Josemberg M. Campos
- General Surgery Service, University Hospital of the Universidade Federal de Pernambuco, Recife, Brazil
| | | | | | | | | | | | | | - Edmundo Machado Ferraz
- General Surgery Service, University Hospital of the Universidade Federal de Pernambuco, Recife, Brazil
| |
Collapse
|
15
|
Ruiz P, Tryphonopoulos P, Island E, Selvaggi G, Nishida S, Moon J, Berlanga A, Defranc T, Levi D, Tekin A, Tzakis AG. Citrulline evaluation in bowel transplantation. Transplant Proc 2010; 42:54-6. [PMID: 20172280 DOI: 10.1016/j.transproceed.2009.12.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate the correlation of plasma citrulline and rejection episodes in intestinal transplantation. METHODS From January 2007 until present, we performed citrulline assays on our small bowel patients. We investigated the correlation of these assays with the rejection status of the patients. The rejection status of the graft was defined based on graft biopsies. RESULTS Of 5195 citrulline samples, average serum citrulline levels decreased significantly when the patients presented a rejection episode. We found the following: no rejection, 17.38 microm/L; mild rejection, 13.05 microm/L; moderate rejection, 7.98 microm/L; and severe rejection, 6.05 microm/L. Our current emphasis is to determine the predictive power of citrulline with other biomarkers versus as a separate and isolated measurement. CONCLUSIONS In our study, citrulline levels correlated significantly with the rejection status of the graft. Serial follow-up of the patients using this assay may alert us to the possibility of increased alloreactivity and rejection episodes.
Collapse
Affiliation(s)
- P Ruiz
- Department of Surgery, University of Miami School of Medicine, Miami, Florida, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Tolerance and Long-Lasting Peripheral Chimerism After Allogeneic Intestinal Transplantation in MGH Miniature Swine. Transplantation 2010; 89:417-26. [DOI: 10.1097/tp.0b013e3181ca8848] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
17
|
Yuan-Xin L, Ning L, You-Sheng L, Xiao-Dong N, Ming L, Jian W, Jie-Shou L. Preliminary Experience With Alemtuzumab Induction Therapy Combined With Maintenance Low-Dose Tacrolimus Monotherapy in Small-Bowel Transplantation in China. Transplant Proc 2010; 42:29-34. [DOI: 10.1016/j.transproceed.2009.12.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
18
|
Crenn P, De Truchis P, Neveux N, Galpérine T, Cynober L, Melchior JC. Plasma citrulline is a biomarker of enterocyte mass and an indicator of parenteral nutrition in HIV-infected patients. Am J Clin Nutr 2009; 90:587-94. [PMID: 19587086 DOI: 10.3945/ajcn.2009.27448] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Plasma citrulline is a biomarker of enterocyte mass and function in humans. OBJECTIVE We evaluated citrulline in the reemerging context of diarrhea in HIV-infected patients receiving highly active antiretroviral therapy. DESIGN This study prospectively measured citrulline in 6 groups of HIV-1 patients (n = 115): 1) undetectable viral load without chronic diarrhea (a; n = 40) and with protease inhibitor-associated toxic chronic diarrhea (b; n = 26), 2) detectable viral load and CD4 > 200/mm(3) without (a; n = 6) and with (b; n = 11) chronic diarrhea, and 3) detectable viral load and CD4 <200/mm(3) without chronic diarrhea (a; n = 7) and with opportunistic intestinal infections or HIV enteropathy (b; n = 25). The influence of diarrhea on citrulline was assessed by comparing the a and b subgroups with healthy control subjects (n = 100). RESULTS Citrulline was slightly decreased (22-30 micromol/L) in groups 1b and 2b and was <22 micromol/L in 19 of 25 patients in group 3b. In group 3b, a citrulline concentration <10 micromol/L was associated with a clinical indication for parenteral nutrition (n = 6 of 8 compared with 2 of 17 if the citrulline concentration was >10 micromol/L; P < 0.05). Citrulline correlated positively with albumin (P < 0.01) and BMI (P < 0.05) and negatively with C-reactive protein (P < 0.01). When antiinfectious and nutritional therapies were successful (n = 18 of 25), citrulline normalized in 2-12 wk. Neither chronic hepatic or pancreatic disease nor lipodystrophy and the metabolic syndrome affected citrulline. Compared with control subjects (38 +/- 8 micromol/L), patients without chronic diarrhea (groups 1a, 2a, and 3a) had normal citrulline concentrations (36 +/- 6 micromol/L). CONCLUSIONS Plasma citrulline is a reliable biomarker of enterocyte functional mass in HIV patients. Citrulline does not allow the etiologic diagnosis of enteropathy, but it can discriminate between protease inhibitor toxic diarrhea and infectious enteropathy and quantify the functional consequences, which makes it an objective tool for indicating the need for parenteral nutrition.
Collapse
Affiliation(s)
- Pascal Crenn
- Département de Médecine, Hôpital Raymond Poincaré, AP-HP, Université de Versailles-Saint Quentin en Yvelines, Garches, France.
| | | | | | | | | | | |
Collapse
|
19
|
|
20
|
Crenn P, Messing B, Cynober L. Citrulline as a biomarker of intestinal failure due to enterocyte mass reduction. Clin Nutr 2008; 27:328-39. [PMID: 18440672 DOI: 10.1016/j.clnu.2008.02.005] [Citation(s) in RCA: 285] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Revised: 02/12/2008] [Accepted: 02/22/2008] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS In human, citrulline (plasma concentration about 40 micromol/L) is an amino acid involved in intermediary metabolism and that is not incorporated in proteins. Circulating citrulline is mainly produced by enterocytes of the small bowel. For this reason plasma or serum citrulline concentration has been proposed as a biomarker of remnant small bowel mass and function. This article reviews this concept and its metabolic basis. METHODS Conditions in which there is a significantly reduced small bowel enterocyte mass and function and a plasma or serum citrulline were measured in adults and children. These studies included patients with a short bowel syndrome, villous atrophy states, Crohn's disease, during monitoring of digestive toxicity of chemotherapy and radiotherapy or follow-up of patients after small bowel transplantation. RESULTS In all these situations, with more than 500 studied patients a decreased level of plasma citrulline correlated with the reduced enterocyte mass independently of nutritional and inflammatory status. A close correlation between small bowel remnant length and citrullinemia was found. In addition, diagnosis of intestinal failure was assessed through plasma citrulline levels in severe small bowel diseases in which there is a marked enterocyte mass reduction. DISCUSSION The threshold for establishing a diagnosis of intestinal failure is lower in villous atrophy disease (10mumol/L) than in short bowel syndrome (20mumol/L). Compromised renal function is an important factor when considering plasma citrulline levels as a marker of intestinal failure as this potentially can increase circulating citrulline values. CONCLUSIONS Reduced plasma citrulline levels are an innovative quantitative biomarker of significantly reduced enterocyte mass and function in different disease states in humans.
Collapse
Affiliation(s)
- Pascal Crenn
- Département de Médecine, Hôpital Raymond Poincaré, Assistance Publique-Hôpitaux de Paris, Université de Versailles Saint-Quentin-en-Yvelines, Garches, France.
| | | | | |
Collapse
|
21
|
Blood Citrulline Level Is an Exclusionary Marker for Significant Acute Rejection After Intestinal Transplantation. Transplantation 2007; 84:1077-81. [DOI: 10.1097/01.tp.0000287186.04342.82] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
22
|
Matsuura T, Taguchi T, Hayashida M, Ogita K, Takada N, Nishimoto Y, Taguchi S, Uesugi T, Kondo T, Hirose R, Suita S. The influence of rejection on graft motility after intestinal transplantation in swine: the possibility of using this method for the real-time monitoring of acute cellular rejection. J Pediatr Surg 2007; 42:1377-85. [PMID: 17706500 DOI: 10.1016/j.jpedsurg.2007.03.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND We have previously reported that rejected allografts show dysmotility, which can be detected by real-time monitoring in swine. We examined the correlation between the motility and the mucosal histology to detect rejection at an early stage by real-time monitoring. METHODS Intestinal transplantation was performed orthotopically using FK506. The distal segment of the allograft measuring about 20 cm was isolated and exteriorized as "Thiry-Vella" stoma for biopsies. Strain-gage force transducers were attached on a graft for the real-time monitoring of graft motility. The pigs without intestinal transplantation were used as controls (C). The rejection was classified into 4 groups based on the histologic findings: nonrejection, mild rejection, moderate rejection, and severe rejection. Migrating motor complex (MMC) phase 3 was estimated by the following parameters: duration, amplitude, interval, motility index, velocity, and frequency of the propagation. RESULTS In the nonrejection group, all parameters were almost the same as in C group. In contrast, in the moderate rejection and severe rejection groups, most of the parameters were significantly lower than those in the C group. In the mild rejection group, the contractility of the MMC was not significantly altered, but the frequency of the propagation decreased significantly. CONCLUSIONS The graft motility detected by the real-time strain-gage method correlated closely to the grade of mucosal histology. This method is therefore considered to be useful for detecting rejection at an early stage by examining the frequency of MMC propagation.
Collapse
Affiliation(s)
- Toshiharu Matsuura
- Department of Pediatric Surgery, Reproductive and Developmental Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Papadia C, Sherwood RA, Kalantzis C, Wallis K, Volta U, Fiorini E, Forbes A. Plasma citrulline concentration: a reliable marker of small bowel absorptive capacity independent of intestinal inflammation. Am J Gastroenterol 2007; 102:1474-82. [PMID: 17459021 DOI: 10.1111/j.1572-0241.2007.01239.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Postabsorptive plasma citrulline concentration has been proposed as a reliable marker of small bowel absorptive capacity in short bowel patients. The aim of this study was to address the potentially confounding impact of intestinal inflammation. METHODS Fifty-five patients were selected according to diagnosis, small bowel length, and degree of bowel inflammation. (a) Crohn's disease (CD) with massive small bowel resection leaving </=50 cm (N = 6), (b) CD with 50-150 cm remaining (N = 9), (c) CD with no resection but active inflammation (high C-reactive protein [CRP] and Crohn's Disease Activity Index [CDAI] >220) (N = 7), (d) CD without resection or active inflammation (normal CRP and CDAI <150) (N = 9), (e) mesenteric infarction (MI) with resection leaving </=50 cm (N = 6), (f) MI leaving 50-150 cm (N = 6), (g) active celiac disease (N = 6), (h) healthy volunteers (N = 6). Postabsorptive fasting plasma citrulline was measured using reverse-phase, high performance liquid chromatography. Absorptive capacity and permeability were also measured after oral sugar-mix ingestion (5 g lactulose, 1 g L-rhamnose, 0.5 g D-xylose). RESULTS The plasma citrulline strongly correlated with small bowel length (P < 0.0001) and xylose absorption (P < 0.001). No correlation was found with CDAI, permeability, CRP, albumin, sedimentation rate, white cell count, or platelet count. Citrulline was significantly higher (P < 0.0004) in CD and MI patients with a remnant small bowel length of 50-150 cm (mean 21.0 micromol/L) than in those with length </=50 cm (mean 9.2 micromol/L). CONCLUSIONS Plasma citrulline concentration is a simple and reliable surrogate for small bowel absorptive capacity and is not influenced by intestinal inflammation.
Collapse
Affiliation(s)
- Cinzia Papadia
- Department of Gastroenterology, University College Hospital, London, United Kingdom
| | | | | | | | | | | | | |
Collapse
|
24
|
Yamayoshi Y, Watanabe T, Tanabe M, Hoshino K, Matsumoto K, Morikawa Y, Shimadzu M, Kitajima M, Tanigawara Y. Novel application of ProteinChip technology exploring acute rejection markers of rat small bowel transplantation. Transplantation 2006; 82:320-6. [PMID: 16906028 DOI: 10.1097/01.tp.0000228909.49640.08] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Because no biomarker that reflects small bowel allograft rejection is available, we applied surface-enhanced laser desorption/ionization time-of-flight mass spectrometry (SELDI-TOF MS) to develop noninvasive markers required for routine diagnosis. METHODS Heterotopic small bowel transplantation (SBT) was performed in rats, and they were divided into four experimental groups: sham-operated rats (sham), syngeneic transplants (syngeneic), allogeneic transplants (allogeneic), allogeneic transplants received FK506 (allo+FK). Plasma samples were analyzed with SELDI ProteinChip arrays to detect peaks that predominated in the allogeneic model. Possible biomarkers were identified in combination with SELDI retentate chromatography mass spectrometry (RCMS) and matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS). The identified protein was further analyzed by immunohistochemistry. RESULTS An increase in the level of a 14.8-kDa protein, identified as lysozyme, was observed specifically in the plasma of the allogeneic group; the levels of this protein remained unchanged in the plasma of the other groups. On the other hand, the levels of a 10.1-kDa and a 13.0-kDa protein, identified as migration inhibitory factor-related proteins (MRP), MRP-8 and MRP-14, respectively, began to increase from an early stage of acute rejection. We also observed that lysozyme-positive macrophages had strongly infiltrated the lamina propria during acute rejection. CONCLUSIONS We identified three plasma proteins-MRP-8, MRP-14, and lysozyme-that increased during small bowel allograft rejection. The identified proteins appeared to be markers for inflammation associated with allograft rejection. This proteomic approach will be useful for the identification of candidate biomarkers.
Collapse
Affiliation(s)
- Yasuko Yamayoshi
- Department of Hospital Pharmacy, School of Medicine, Keio University, Tokyo, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Abstract
PURPOSE OF REVIEW This review summarizes recent knowledge and clinical practice for pediatric patients suffering extensive intestinal resection causing short bowel syndrome. This condition requires the use of parenteral nutrition, as long as intestinal failure persists, and may be, in some selected cases, an indication for intestinal transplantation. RECENT FINDINGS Biological evaluation of intestinal failure is becoming possible with the use of plasma citrulline as a marker of intestinal mass. Few epidemiological data are available; some indicate an increased incidence of short bowel syndrome-related gastroschisis and persistent high incidence of necrotizing enterocolitis. Morbidity and mortality data in pediatric patients with short bowel syndrome are limited, while long-term outcome is better documented from recently reported cohorts. Non-transplant surgery is one of the best options for patients with unadapted short bowel syndrome. Isolated liver transplantation may be avoided. The use of trophic factors for enhancing mucosal hyperplasia still remains disappointing. SUMMARY The management should include therapies adapted to each stage of intestinal failure, based on a multidisciplinary approach in centers involving pediatric surgery, pediatric gastroenterology, parenteral nutrition expertise, home-parenteral nutrition program, and liver-intestinal transplantation experience. If managed appropriately, the prognosis of short bowel syndrome is excellent, with limited indications for intestinal and/or liver transplantation. Timing for patient referral in specialized centers remains an issue.
Collapse
Affiliation(s)
- Olivier Goulet
- Integrated Program of Intestinal Failure, Home Parenteral Nutrition, and Intestinal Transplantation, National Reference Center for Rare Digestive Diseases, Necker Hospital for Sick Children, University of Paris, France.
| | | |
Collapse
|
26
|
Goulet O, Ruemmele F. Causes and management of intestinal failure in children. Gastroenterology 2006; 130:S16-28. [PMID: 16473066 DOI: 10.1053/j.gastro.2005.12.002] [Citation(s) in RCA: 236] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2004] [Accepted: 06/06/2005] [Indexed: 12/28/2022]
Abstract
Intestinal failure is a condition requiring the use of parenteral nutrition as long as it persists. Causes of severe protracted intestinal failure include short bowel syndrome, congenital diseases of enterocyte development, and severe motility disorders (total or subtotal aganglionosis or chronic intestinal pseudo-obstruction syndrome). Intestinal failure may be irreversible in some patients, thus requiring permanent parenteral nutrition. Liver disease may develop with subsequent end-stage liver cirrhosis in patients with intestinal failure as a consequence of both underlying digestive disease and unadapted parenteral nutrition. Death will occur if combined liver-intestine transplantation is not performed. Catheter-related sepsis and/or extensive vascular thrombosis may impede the continuation of a safe and efficient parenteral nutrition and may also require intestinal transplantation in some selected cases. Thus management of patients with intestinal failure requires an early recognition of the condition and the analysis of its risk of irreversibility. Timing of referral for intestinal transplantation remains a crucial issue. As a consequence, management should include therapies adapted to each stage of intestinal failure based on a multidisciplinary approach in centers involving pediatric gastroenterology, parenteral nutrition expertise, home parenteral nutrition program, pediatric surgery, and liver intestinal transplantation program.
Collapse
Affiliation(s)
- Olivier Goulet
- Integrated Program of Intestinal Failure, Home Parenteral Nutrition and Intestinal Transplantation, National Reference Center for Rare Digestive Disease, Hôpital Necker-Enfants Malades, Université Reni Descartes, Paris, France.
| | | |
Collapse
|
27
|
Yu HC, Tuteja S, Moon JI, Kleiner GI, Conanan L, Gaynor JJ, Kato T, Levi DM, Nishida S, Selvaggi G, Gandia C, Weppler D, Esquenazi V, Ruiz P, Miller J, Tzakis AG. Utilization of Dried Blood Spot Citrulline Level as a Noninvasive Method for Monitoring Graft Function Following Intestinal Transplantation. Transplantation 2005; 80:1729-33. [PMID: 16378068 DOI: 10.1097/01.tp.0000188168.45003.63] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Citrulline concentrations have been proposed as a marker for intestinal allograft rejection. We instituted dried blood spot (DBS) specimen monitoring of citrulline to simplify sample collection posttransplant. This study demonstrates the correlation between plasma and dried blood spot specimen citrulline concentrations after intestinal transplantation. METHODS Plasma and DBS samples were analyzed by hydrophilic interaction chromatography tandem mass spectrometry. Comparison of the strength of linear correlation was made according to the type of surgery, sonication time, DBS citrulline levels, and the time interval between the blood sample collection and the assay date. RESULTS A very strong linear correlation exists between the plasma and DBS citrulline concentrations (r=0.87; P<0.001). The correlation between plasma and DBS citrulline concentrations was maintained when evaluating only the intestinal transplant recipients. There was no significant difference in the strength of linear correlation according to sonication time, cirtrulline concentrations, or length of time to assay date. CONCLUSIONS DBS citrulline monitoring will ease sample collection following intestinal transplantation and improve the ability to detect intestinal dysfunction and rejection by a noninvasive means.
Collapse
Affiliation(s)
- Hee Chul Yu
- Department of Surgery, Division of Transplantation, University of Miami School of Medicine, Miami, FL 33136, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Tzakis AG, Kato T, Levi DM, Defaria W, Selvaggi G, Weppler D, Nishida S, Moon J, Madariaga JR, David AI, Gaynor JJ, Thompson J, Hernandez E, Martinez E, Cantwell GP, Augenstein JS, Gyamfi A, Pretto EA, Dowdy L, Tryphonopoulos P, Ruiz P. 100 multivisceral transplants at a single center. Ann Surg 2005; 242:480-90; discussion 491-3. [PMID: 16192808 PMCID: PMC1402343 DOI: 10.1097/01.sla.0000183347.61361.7a] [Citation(s) in RCA: 203] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The objective of this study was to summarize the evolution of multivisceral transplantation over a decade of experience and evaluate its current status. SUMMARY BACKGROUND DATA Multivisceral transplantation can be valuable for the treatment of patients with massive abdominal catastrophes. Its major limitations have been technical and rejection of the intestinal graft. METHODS This study consisted of an outcome analysis of 98 consecutive patients who received multivisceral transplantation at our institution. This represents the largest single center experience to date. RESULTS The most common diseases in our population before transplant were intestinal gastroschisis and intestinal dysmotility syndromes in children, and mesenteric thrombosis and trauma in adults. Kaplan Meier estimated patient and graft survivals for all cases were 65% and 63% at 1 year, 49% and 47% at 3 years, and 49% and 47% at 5 years. Factors that adversely influenced patient survival included transplant before 1998 (P = 0.01), being hospitalized at the time of transplant (P = 0.05), and being a child who received Campath-1H induction (P = 0.03). Among 37 patients who had none of these 3 factors (15 adults and 22 children), estimated 1- and 3-year survivals were 89% and 71%, respectively. Patients transplanted since 2001 had significantly less moderate and severe rejections (31.6% vs 67.6%, P = 0.0005) with almost half of these patients never developing rejection. CONCLUSIONS Multivisceral transplantation is now an effective treatment of patients with complex abdominal pathology. The incidences of serious acute rejection and patient survival have improved in the most recent experience. Our results show that the multivisceral graft seems to facilitate engraftment of transplanted organs and raises the possibility that there is a degree of immunologic protection afforded by this procedure.
Collapse
Affiliation(s)
- Andreas G Tzakis
- Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida 33136, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Jianfeng G, Weiming Z, Ning L, Fangnan L, Li T, Nan L, Jieshou L. Serum citrulline is a simple quantitative marker for small intestinal enterocytes mass and absorption function in short bowel patients. J Surg Res 2005; 127:177-82. [PMID: 15921697 DOI: 10.1016/j.jss.2005.04.004] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2004] [Revised: 03/10/2005] [Accepted: 04/02/2005] [Indexed: 01/08/2023]
Abstract
BACKGROUND To investigate the clinical significance of serum citrulline in evaluating the remnant small bowel enterocytes mass and absorptive function in short bowel (SB) patients. MATERIALS AND METHODS Serum citrulline concentrations were determined using high-performance liquid chromatography (HPLC) in 22 SBS patients and 33 healthy controls. Five-hour urine D-xylose excretion and digestive protein absorption were measured using HPLC and micro-Kjeldahl method, respectively. Small bowel length and surface area were assessed on X-ray radiograph. Correlations between serum citrulline levels and small bowel length, small bowel surface, and nutritional substrate digestive absorption percentage were analyzed. For six patients receiving bowel rehabilitation therapy, serum citrulline, D-xylose excretion, and intestinal protein absorption were measured pre- and immediately postmanagement, and their correlations were analyzed. RESULTS Serum citrulline levels were significantly lower in SB patients compared with healthy controls. In SB patients, they correlated well with remnant small bowel length (r = 0.82, P < 0.001), surface area (r = 0.86, P < 0.001), 5-h urine D-xylose excretion (r = 0.56, P = 0.007), and digestive protein absorption (r = 0.48, P = 0.046). The increased percentage of serum citrulline level in six patients receiving rehabilitation therapy followed a trend of correlating with that of intestinal protein absorption (r = 0.79, P = 0.063) and urine D-xylose excretion (r = 0.81, P = 0.053). CONCLUSIONS In patients with short bowel syndrome, serum citrulline is a simple and accurate biomarker for the severity of intestinal failure and may be a candidate marker for the gut-trophic effects of bowel rehabilitation therapies.
Collapse
Affiliation(s)
- Gong Jianfeng
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, P.R. China
| | | | | | | | | | | | | |
Collapse
|
30
|
Sudan D. Small bowel transplantation: current status and new developments in allograft monitoring. Curr Opin Organ Transplant 2005. [DOI: 10.1097/01.mot.0000163040.48954.8c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
31
|
Flynn B, Park B, Bond G, McGhee W, Mazariegos G, Sindhi R, Reyes J, Abu-Elmagd K. Immunosuppressant strategies for intestinal transplantation: a review of a tolerogenic regimen. Prog Transplant 2005. [DOI: 10.7182/prtr.15.1.c43t80h754715g32] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
32
|
Baumgartner MR, Rabier D, Nassogne MC, Dufier JL, Padovani JP, Kamoun P, Valle D, Saudubray JM. Delta1-pyrroline-5-carboxylate synthase deficiency: neurodegeneration, cataracts and connective tissue manifestations combined with hyperammonaemia and reduced ornithine, citrulline, arginine and proline. Eur J Pediatr 2005; 164:31-6. [PMID: 15517380 DOI: 10.1007/s00431-004-1545-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2004] [Accepted: 08/25/2004] [Indexed: 10/26/2022]
Abstract
UNLABELLED Delta1-pyrroline-5-carboxylate synthase (P5CS) catalyses the reduction of glutamate to Delta1-pyrroline-5-carboxylate, a critical step in the biosynthesis of proline, ornithine and arginine. Recently, we reported a newly recognised inborn error due to deficiency of P5CS in two sibs, one presenting at birth with hypotonia, dysmorphic signs, pes planus and clonic seizures. Both developed progressive neurodegeneration and peripheral neuropathy, joint laxity, skin hyperelasticity and bilateral subcapsular cataracts. Their metabolic phenotype includes mild hyperammonaemia, hypo-ornithinaemia, hypocitrullinaemia, hypo-argininaemia and hypoprolinaemia. Incorporation of 3H-proline into protein was deficient in fibroblasts incubated with 3H-glutamate. Both patients are homozygous for the missense mutation R84Q in P5CS. Here, we describe the clinical phenotype of the sibs in detail and show that a relative deficiency of urea cycle intermediates (ornithine, citrulline and arginine) during fasting periods results in a paradoxical hyperammonaemia. Furthermore, we show the results of ornithine loading tests and indirect enzyme studies corroborating the biological significance of the defect in P5CS in vivo. CONCLUSION The metabolic phenotype of Delta1-pyrroline-5-carboxylate synthase deficiency is easily missed. The combination of low levels of ornithine, citrulline, arginine and proline plus a tendency to hyperammonaemia or one of the above together with a clinical phenotype of neurodegeneration with peripheral neuropathy and/or cataracts and connective tissue manifestations should suggest this disorder. Early recognition would allow a therapeutic trial with citrulline and proline.
Collapse
Affiliation(s)
- Matthias R Baumgartner
- Division of Metabolism and Molecular Paediatrics, University Children's Hospital, Zurich, Switzerland
| | | | | | | | | | | | | | | |
Collapse
|
33
|
Bond GJ, Mazariegos GV, Sindhi R, Abu-Elmagd KM, Reyes J. Evolutionary experience with immunosuppression in pediatric intestinal transplantation. J Pediatr Surg 2005; 40:274-9; discussion 279-80. [PMID: 15868597 DOI: 10.1016/j.jpedsurg.2004.09.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE Intestinal transplantation has developed to become the standard of care for patients with irreversible intestinal failure who are not responding to total parenteral nutrition. Once considered experimental, it has taken time and much effort for the procedure to become a clinical reality, with final acceptance primarily because of the vastly improved outcomes. Advances and novel modifications in immunosuppression have been at the forefront of these improvements. The authors review their evolutionary experience with intestinal transplantation, particularly relating changes in immunosuppression protocols to improved outcomes. METHODS From July 1990 to December 2003, 122 children received 129 intestinal containing allografts (70 liver/intestine, 42 isolated intestine, 17 multivisceral). Mean age was 5.3 +/- 5.2 years, and 55% were boys. Indications for transplantation were mostly short gut syndrome. The allografts were cadaveric, ABO identical (except one), with no immunomodulation. Bone marrow augmentation was used in 29% of the recipients since 1995. T-cell lymphoctytotoxic crossmatch was positive in 24% cases. Immunosuppression protocols can be divided into 3 categories: (i) maintenance tacrolimus and steroids (n = 52, 1990-1995, 1997-1998); (ii) addition of induction therapy with cyclophosphamide (n = 16, 1995-1997) then daclizumab (n = 24, 1998-2001). A third immunosuppressive agent was added in either group where increased immunosuppression was indicated; (iii) pretreatment/induction with antilymphocyte conditioning and steroid-free posttransplantation tacrolimus monotherapy (n = 37, 2002-2003). In this later group, if clinically stable at 60 to 90 days posttransplantation, and no recent rejection, the tacrolimus was weaned by decreasing frequency of dosing. RESULTS The overall Kaplan-Meier patient/graft survival was 81%/76% at 1 year, 62%/60% at 3 years, and 61%/51% at 5 years. Survival continues to improve, with 1-year patient/graft survival being 71%/62%, 77%/75%, and 100%/100% for groups (i), (ii), and (iii), respectively. Acute intestinal allograft rejection has decreased markedly in group (iii). The rate of infectious diseases, such as cytomegalovirus and Epstein-Barr virus, is lowest in group (iii). Graft-versus-host disease has not significantly increased with the latest protocol. Most importantly, the overall level of immunosuppression requirements has decreased markedly, with most patients in group (iii) being on monotherapy. Of these, most had their monotherapy weaned down to spaced doses, something never systematically attempted or achieved in pediatric intestinal transplantation. CONCLUSIONS Intestinal transplantation has progressed markedly over the last 13 years. Although there have been modifications in all aspects of the procedure, the story of intestinal transplantation has been the evolution of successful immunosuppression regimens. Our latest pretreatment/induction conditioning and posttransplantation monotherapy strategy improves graft acceptance and lowers subsequent immunosuppression dosing requirements. It is expected this will overcome many of the complications related to the previously high immunosuppression requirements. Minimization of immunosuppression with avoidance of steroid therapy offers profound long-term benefits, especially in the pediatric population. The patients still remain challenging and complex in every aspect; however, these advances offer significant hope to both patients and caregivers alike.
Collapse
Affiliation(s)
- Geoffrey J Bond
- Thomas E Starzl Transplantation Institute, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | | | | | | | | |
Collapse
|
34
|
|
35
|
Pappas PA, Tzakis AG, Saudubray JM, Gaynor JJ, Carreno MR, Huijing F, Kleiner G, Rabier D, Kato T, Levi DM, Nishida S, Gelman B, Thompson JF, Mittal N, Ruiz P. Trends in serum citrulline and acute rejection among recipients of small bowel transplants. Transplant Proc 2004; 36:345-7. [PMID: 15050154 DOI: 10.1016/j.transproceed.2003.12.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A test for detecting acute cellular rejection (ACR) of small intestinal transplants (ITx) would be a major advance. Small preliminary studies suggest that serum citrulline levels correlate with ACR. The results for a group of 26 isolated intestinal and multivisceral transplant recipients are summarized here. Serum citrulline concentrations were determined by ion exchange chromatography and compared to biopsy-based grade of ACR. Other factors considered included patient and donor age and sex, ischemia time, and serum creatinine. Straight-line fits were employed to describe how each patient's citrulline levels changed over time. Estimated times to achieve normal citrulline (>or=30 micromol/L) ranged from 1 to 730 days posttransplant for 21 patients demonstrating increasing citrulline levels over time. Using stepwise linear regression, patients' ranks for time required to achieve normal citrulline levels were the only independent predictors of both maximum ACR (P <.0001) and average ACR (P =.0059) after 14 days posttransplant. The rate and direction of change in citrulline over time may be an indicator of the risk of acute rejection. We plan to further examine the use of citrulline as a marker for rejection in larger prospective studies.
Collapse
Affiliation(s)
- P A Pappas
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida 33136, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
D'Errico A, Corti B, Pinna AD, Altimari A, Gruppioni E, Gabusi E, Fiorentino M, Bagni A, Grigioni WF. Granzyme B and perforin as predictive markers for acute rejection in human intestinal transplantation. Transplant Proc 2004; 35:3061-5. [PMID: 14697980 DOI: 10.1016/j.transproceed.2003.10.073] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In human heart and kidney transplantations, granzyme B (GrB) and perforin have both been shown to be predictive markers for acute cellular rejection (ACR). We investigated the tissue expression and possible relationship of GrB and perforin to the clinical outcome, histopathology, and function of intestinal transplants. In 13 consecutive patients undergoing small intestine transplantation, histologic/immunohistochemical rejection monitoring was performed together with GrB and perforin immunostaining (score "0", 0%-10% positive lymphocytes; "1", 10%-25%; "2", 25%-50%; "3", >50%). Eleven patients are currently alive and well. All 11 had at least one episode of ACR: one patient had 6 episodes of severe ACR requiring retransplantation; the remaining 10 experienced only mild or moderate rejection. Both GrB and perforin were always co-expressed. A highly significant correlation was observed between GrB/perforin scores and histological severity of ACR (Pearson's coefficient, R < 0.0009). Interestingly, score 3 GrB/perforin immunostaining was recorded only in the context of severe ACR; all the histologically negative or "indeterminate" biopsies (n = 6) taken from a single affected patient showed GrB/perforin scores of 1 or 2. By contrast, none of the other tested histologically negative/"indeterminate" biopsies (n = 350), including those performed during graft stabilization, had raised GrB or perforin scores. We conclude that in intestinal transplantation recipients, a direct correlation seems to exist between histologically confirmed ACR and raised GrB/perforin immunohistochemical scores. Our findings suggest the need to investigate the possibility of predicting ACR by routine serum polymerase chain reaction (PCR) monitoring, which would reduce discomfort to patients.
Collapse
Affiliation(s)
- A D'Errico
- Policlinico S. Orsola-Malpighi, Instituto Felice Addarii, Viale Ercolani 4/2, Bologna 40138, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Pappas PA, G Tzakis A, Gaynor JJ, Carreno MR, Ruiz P, Huijing F, Kleiner G, Rabier D, Kato T, Levi DM, Nishida S, Gelman B, Thompson JF, Mittal N, Saudubray JM. An analysis of the association between serum citrulline and acute rejection among 26 recipients of intestinal transplant. Am J Transplant 2004; 4:1124-32. [PMID: 15196071 DOI: 10.1111/j.1600-6143.2004.00469.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Small preliminary studies suggest that serum citrulline levels may act as a marker for acute cellular rejection in small intestinal transplant recipients. The results comparing serum citrulline concentrations with biopsy-based grades of rejection are summarized here for an expanded group of 26 isolated intestinal and multivisceral transplant recipients. Other factors considered included patient and donor age and sex, ischemia time, serum creatinine, and type of transplant. Straight-line fits reasonably described how each patient's citrulline levels changed over time. Among 21 patients who demonstrated increasing citrulline levels over time, the estimated median time-to-achieve normal citrulline (>or=30 micromol/L) was 79 days post-transplant. Using stepwise linear regression, two characteristics were associated with a significantly higher maximum grade of rejection after 14 d post-transplant: longer time-to-achieve normal citrulline (using ranks, p < 0.00001) and the patient not receiving a multivisceral transplant (p = 0.0005). Only the latter characteristic was significantly associated with maximum grade of rejection during the first 14 d post-transplant (p = 0.01). Clearly, time-to-normalization of citrulline was delayed by the incidence of rejection, and in some cases with moderate-to-severe rejection, normalization of citrulline levels never occurred. We plan to further examine the use of citrulline as a marker for rejection in larger prospective studies.
Collapse
Affiliation(s)
- Peter A Pappas
- University of Miami/Jackson Memorial Hospital, Department of Surgery, Division of Transplantation, Miami, FL USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
|
39
|
Abstract
Intestinal transplantation has become the treatment of choice for patients who are experiencing life-threatening complications of intestinal failure. Early attempts with intestinal transplantation were unsuccessful as a consequence of both technical and immunologic failures. The introduction of tacrolimus provided the immunologic foundation needed for the field to advance. Guidelines for patient selection combined with standardization of operative procedures and postoperative management has allowed for improved patient and graft survival. There has been a gradual improvement in patient survival over the past 10 years, most notably in the past 3 years. Nutritional autonomy has been achieved in hundreds of patients worldwide. Further advancements in the understanding of the immune response to the transplanted intestine are still needed and will allow the use of new antirejection medications, resulting in improved outcomes.
Collapse
Affiliation(s)
- Alan N Langnas
- Section of Transplantation Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE 68198, USA
| |
Collapse
|
40
|
Abstract
Despite the reported high survival with total parenteral nutrition (TPN) therapy for patients with intestinal failure, a considerable number of patients do not escape the potential risks of TPN-associated complications, including hepatic failure, vanishing of central venous access and line sepsis. Thus, intestinal, liver-intestinal and multivisceral transplantation have recently emerged to rescue those who can no longer be maintained on TPN. Before this development, and for nearly three decades, small-bowel transplantation was plagued with uncontrolled rejection, graft v. host disease and fatal infection. These barriers stemmed from the large gut lymphoid mass and heavy microbial load contained in the intestinal lumen. The recent improvement in survival after the clinical introduction of tacrolimus with achievement of full enteric nutritional autonomy qualified the procedure by the US Health Care Financing Administration as the standard of care for patients with intestinal and TPN failure. The decision was supported by a decade of clinical experience with cumulative improvement in patient and graft survival. In addition, the introduction of new effective immunoprophylactic agents and novel therapeutic approaches has contributed to a further increase in the therapeutic advantages of the procedure. The present review article outlines the current clinical practice of intestinal transplantation and defines new management strategies with the aim of raising the level of the procedure to be a better alternative therapy for TPN-dependent patients.
Collapse
Affiliation(s)
- Kareem Abu-Elmagd
- Intestinal Rehabilitation and Transplantation Center, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
| | | |
Collapse
|
41
|
Abstract
Intestinal failure (IF) can be defined as the reduction of functional gut mass below the minimal amount necessary for digestion and absorption adequate to satisfy the nutrient and fluid requirements for maintenance in adults or growth in children. In developed countries, IF mainly includes individuals with the congenital or early onset of conditions requiring protracted or indefinite parenteral nutrition (PN). Short bowel syndrome was the first commonly recognized cause of protracted IF. The normal physiologic process of intestinal adaptation after extensive resection usually allows for recovery of sufficient intestinal function within weeks to months. During this time, patients can be sustained on parenteral nutrition. Only a few children have permanent intestinal insufficiency and life-long dependency on PN. Non-transplant surgery including small bowel tapering and lengthening may allow weaning from PN in some cases. Hormonal therapy with recombinant human growth hormone has produced poor results while therapy with glucagon-like peptide-2 holds promise. Congenital diseases of enterocyte development such as microvillus inclusion disease or intestinal epithelial dysplasia cause permanent IF for which no curative medical treatment is currently available. Severe and extensive motility disorders such as total or subtotal intestinal aganglionosis (long segment Hirschsprung disease) or chronic intestinal pseudo-obstruction syndrome may also cause permanent IF. PN and home-PN remain are the mainstays of therapy regardless of the cause of IF. Some patients develop complications while receiving long-term PN for IF especially catheter related complications (thrombosis, sepsis) and liver disease. These patients may be candidates for intestinal transplantation. This review discusses the causes of irreversible IF and emphasizes the specific medico-surgical strategies for prevention and treatment of these conditions at several stages of IF.
Collapse
Affiliation(s)
- Olivier Goulet
- Département de Gastroentérologie, Hépatologie et Nutrition Pédiatriques, Hôpital Necker- Infants Malades and INSERM, Faculté de Necker, Paris, France.
| | | | | | | |
Collapse
|
42
|
Mittal NK, Tzakis AG, Kato T, Thompson JF. Current status of small bowel transplantation in children: update 2003. Pediatr Clin North Am 2003; 50:1419-33, ix. [PMID: 14710785 DOI: 10.1016/s0031-3955(03)00124-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
This article reviews the current indications for intestinal transplantation and advances in immunosuppression and postoperative care, which help to improve the outcome results of intestinal transplantation. Major current controversies and future trends are discussed briefly.
Collapse
Affiliation(s)
- Naveen K Mittal
- Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, 1601 NW 12th Avenue (D-820), University of Miami, Miami, FL 33136, USA.
| | | | | | | |
Collapse
|
43
|
Klaus A, Weiss H, Nguyen JH, Margreiter R, Obrist P, Schwelberger HG. Histamine-degrading enzymes as cellular markers of acute small bowel allograft rejection. Transpl Int 2003. [DOI: 10.1111/j.1432-2277.2003.tb00351.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
44
|
Affiliation(s)
- Thomas M Fishbein
- Department of Surgery, Mount Sinai School of Medicine, New York, New York 10029, USA.
| | | | | |
Collapse
|
45
|
Pappas PA, Saudubray JM, Tzakis AG, Rabier D, Carreno MR, Gomez-Marin O, Huijing F, Gelman B, Levi DM, Nery JR, Kato T, Mittal N, Nishida S, Thompson JF, Ruiz P. Serum citrulline as a marker of acute cellular rejection for intestinal transplantation. Transplant Proc 2002; 34:915-7. [PMID: 12034237 DOI: 10.1016/s0041-1345(02)02668-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- P A Pappas
- Department of Surgery, Division of Transplantation, University of Miami, Florida 33136, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Abstract
The small intestine is the portal of entry of virtually all nutrients and is also the site of diverse inflammatory and neoplastic diseases. This field has recently attracted intense excitement as a result of novel clinical and experimental techniques, combined modality therapies, and basic science applications. This review will highlight important clinical advances in surgery for Crohn disease, short bowel syndrome, transplantation, trauma, and polyposis. Promising experimental approaches, novel methods of clinical assessment, and multimodality treatment will also be considered.
Collapse
Affiliation(s)
- Kourosh Khosraviani
- Department of Surgery, Queen's University of Belfast, Belfast, United Kingdom
| | | |
Collapse
|