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Fourati S, Hamon A, Daclat R, Salem JE, Peoc’h K, Le Beyec J, Joly F, Lacorte JM. Circulating Apolipoprotein B-48 as a Biomarker of Parenteral Nutrition Dependence in Adult Patients with Short Bowel Syndrome. Nutrients 2023; 15:3982. [PMID: 37764766 PMCID: PMC10536633 DOI: 10.3390/nu15183982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
Short bowel syndrome (SBS) is a rare but serious condition that may lead to chronic intestinal failure. Citrulline concentrations are currently used to reflect the residual intestinal mass in patients with SBS, although this method has several limitations. In a cohort of patients with SBS, we quantified apolipoprotein B-48 (ApoB-48), which is exclusively synthesized by enterocytes and secreted associated with dietary lipids and investigated the relationship between ApoB-48 and clinical and biological data as well as PN dependence. A total of 51 adult patients were included, 36 of whom were PN-dependent. We found a robust positive correlation between circulating ApoB-48 and residual small bowel length, which was also found in the subgroup of patients with jejunocolic anastomosis. Fasting ApoB-48 levels were significantly lower in PN-dependent patients than in PN-weaned patients and negatively correlated with parenteral nutrition dependence. Our results suggest that ApoB-48 could be proposed as a marker of intestinal absorptive function and could be an interesting follow-up marker in patients with SBS.
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Affiliation(s)
- Salma Fourati
- Service de Biochimie Endocrinienne et Oncologique, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, UMR-S 1149 Centre de Recherche sur l’Inflammation Inserm, Paris Cité University, 75013 Paris, France
| | - Annick Hamon
- Department of Gastroenterology, IBD and Nutrition Support, CRMR MarDi, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, 92110 Clichy, France
| | - Rita Daclat
- UMR_S1166, Research Institute of Cardiovascular Disease, Metabolism and Nutrition Inserm, Pitié-Salpêtrière Hospital, Sorbonne University, 75013 Paris, France
| | - Joe-Elie Salem
- Department of Pharmacology and Clinical Investigation Centre (CIC-1901), Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, INSERM, 75013 Paris, France
| | - Katell Peoc’h
- Department of Biochemistry, CRI INSERM UMR1149, HUPNVS, Assistance Publique-Hôpitaux de Paris, Paris Cité University, 75018 Paris, France
| | - Johanne Le Beyec
- Service de Biochimie Endocrinienne et Oncologique, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, UMR-S 1149 Centre de Recherche sur l’Inflammation Inserm, Sorbonne University, 75013 Paris, France;
| | - Francisca Joly
- Department of Gastroenterology, IBD and Nutrition Support, CRMR MarDi, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris, 92110 Clichy, UMR-S 1149 Centre de Recherche sur l’Inflammation Inserm, Université Paris Cité, 75018 Paris, France;
| | - Jean-Marc Lacorte
- Service de Biochimie Endocrinienne et Oncologique, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Research Unit on Cardiovascular and Metabolic Disease, UMR ICAN, Sorbonne University, Inserm, 75013 Paris, France;
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Citrulline, Biomarker of Enterocyte Functional Mass and Dietary Supplement. Metabolism, Transport, and Current Evidence for Clinical Use. Nutrients 2021; 13:nu13082794. [PMID: 34444954 PMCID: PMC8398474 DOI: 10.3390/nu13082794] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 12/25/2022] Open
Abstract
L-Citrulline is a non-essential but still important amino acid that is released from enterocytes. Because plasma levels are reduced in case of impaired intestinal function, it has become a biomarker to monitor intestinal integrity. Moreover, oxidative stress induces protein citrullination, and antibodies against anti-citrullinated proteins are useful to monitor rheumatoid diseases. Citrullinated histones, however, may even predict a worse outcome in cancer patients. Supplementation of citrulline is better tolerated compared to arginine and might be useful to slightly improve muscle strength or protein balance. The following article shall provide an overview of L-citrulline properties and functions, as well as the current evidence for its use as a biomarker or as a therapeutic supplement.
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Abstract
OBJECTIVES The aim of the study was to describe the experience with teduglutide of several Spanish hospitals in pediatric patients with SBS (SBS). METHODS Seventeen pediatric patients with intestinal failure associated with SBS were treated with teduglutide. Patients received 0.05 mg · kg · day of subcutaneous teduglutide. Patients' demographics and changes in parenteral nutrition (PN) needs, fecal losses, and citrulline level initially and at 3, 6, and 12 months were collected, as well as any adverse events. RESULTS Patients were receiving 55 ml · kg · day and 33 kcal · kg · day of parenteral supplementation on average at baseline (2 patients received only hydroelectrolytic solution). A total of 12/17 patients achieved parenteral independence: 3 patients after 3 months of treatment, 4 patients at 6 months, and 5 after 12 months. One patient discontinued treatment 1 year after the beginning as no changes in parenteral support or fecal losses were obtained. All others decreased their intravenous requirements by 50%. One patient suffered an episode of cholecystitis, and another one with a pre-existing cardiac disease, developed a cardiac decompensation. CONCLUSIONS Teduglutide seems to be a safe and effective treatment in the pediatric SBS population with better results than in the pivotal study as well as in the adult population.
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Pellino G, Keller DS, Sampietro GM, Annese V, Carvello M, Celentano V, Coco C, Colombo F, Cracco N, Di Candido F, Franceschi M, Laureti S, Mattioli G, Pio L, Sciaudone G, Sica G, Villanacci V, Zinicola R, Leone S, Danese S, Spinelli A, Delaini G, Selvaggi F. Inflammatory bowel disease (IBD) position statement of the Italian Society of Colorectal Surgery (SICCR): general principles of IBD management. Tech Coloproctol 2020; 24:105-126. [PMID: 31983044 DOI: 10.1007/s10151-019-02145-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 12/23/2019] [Indexed: 02/08/2023]
Abstract
The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a Position Statement of Italian colorectal surgeons to address the surgical aspects of inflammatory bowel disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the general principles of surgical treatment of inflammatory bowel disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.
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Affiliation(s)
- G Pellino
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy.
| | - D S Keller
- Division of Colon and Rectal Surgery, Department of Surgery, NewYork-Presbyterian, Columbia University Medical Center, New York, USA
| | | | - V Annese
- Gastroenterology Unit, DEA-Medicina E Chirurgia Generale E D'Urgenza, University Hospital Careggi, Firenze, Italy
| | - M Carvello
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - V Celentano
- Portsmouth Hospitals NHS Trust, Portsmouth, UK
- University of Portsmouth, Portsmouth, UK
| | - C Coco
- UOC Chirurgia Generale 2, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
| | - F Colombo
- L. Sacco University Hospital Milano, Milan, Italy
| | - N Cracco
- Department of General Surgery, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - F Di Candido
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - M Franceschi
- IBD Surgery, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - S Laureti
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - G Mattioli
- Pediatric Surgery Unit, Istituto Giannina Gaslini, and Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - L Pio
- Pediatric Surgery Department, Hôpital Robert-Debré and Université de Paris, Paris, France
| | - G Sciaudone
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
| | - G Sica
- Minimally Invasive and Gastro-Intestinal Unit, Department of Surgery, Policlinico Tor Vergata, Rome, Italy
| | - V Villanacci
- Institute of Pathology, Spedali Civili Brescia, Brescia, Italy
| | - R Zinicola
- Department of Emergency Surgery, University Hospital Parma, Parma, Italy
| | - S Leone
- CEO, Associazione Nazionale Per Le Malattie Infiammatorie Croniche Dell'Intestino "A.M.I.C.I. Onlus", Milan, Italy
| | - S Danese
- Division of Gastroenterology, IBD Center, Humanitas University, Rozzano, Milan, Italy
| | - A Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - G Delaini
- Department of Surgery, "Pederzoli" Hospital, Peschiera del Garda, Verona, Italy
| | - F Selvaggi
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
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Jeppesen PB, Gabe SM, Seidner DL, Lee HM, Olivier C. Citrulline correlations in short bowel syndrome-intestinal failure by patient stratification: Analysis of 24 weeks of teduglutide treatment from a randomized controlled study. Clin Nutr 2019; 39:2479-2486. [PMID: 31784300 DOI: 10.1016/j.clnu.2019.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 10/29/2019] [Accepted: 11/01/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND & AIMS Disease-associated factors influence parenteral support (PS) reduction in response to teduglutide in patients with intestinal failure associated-short bowel syndrome (SBS-IF). We sought to determine correlative relationships between plasma citrulline levels, small bowel length, and PS volume. METHODS A post hoc analysis of plasma citrulline levels from patients in the STEPS 24-week study of teduglutide in patients with SBS-IF. Plasma citrulline was assessed in all patients; patients were stratified 3 times into subgroups based on bowel anatomy, cause of SBS-IF, and baseline PS volumes. Correlation analyses used simple linear regression models. Statistical comparisons between study groups were conducted using 2-sided t tests for 2 independent mean differences. RESULTS Baseline plasma citrulline correlated with remnant small bowel length (r = 0.355, P = 0.002), but not with baseline PS volume (r = -0.167, P = 0.14), in the overall population. There was a robust correlation between the baseline and Week 24 citrulline (r = 0.705, P < 0.0001), and an inverse correlation between change from baseline in citrulline and PS volume from baseline to Week 24 (r = -0.359, P = 0.001). In all subgroups, patients treated with teduglutide showed numerically greater increases in plasma citrulline at Week 24 compared with placebo. CONCLUSION Baseline plasma citrulline showed significant correlations with small bowel length in patients with ≥50% colon remaining/no stoma/colon-in-continuity, and patients with SBS-IF causes other than IBD/vascular disease. Citrulline levels may correlate with PS changes in response to teduglutide and more research may reveal a relationship between citrulline levels within the heterogeneous population of patients with SBS-IF. ClinicalTrials.gov NCT00798967, ClinicalTrialsRegister.eu 2008-006193-15.
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Affiliation(s)
| | - Simon M Gabe
- Lennard Jones Intestinal Failure Unit, St. Mark's Hospital, Northwick Park, London, UK
| | - Douglas L Seidner
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hak-Myung Lee
- Shire Human Genetic Therapies, Inc., Lexington, MA, USA
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Plasma citrulline is not a biomarker for intestinal adaptation in short bowel syndrome, studied in piglets: a model for human neonates. Pediatr Surg Int 2019; 35:657-663. [PMID: 30937511 DOI: 10.1007/s00383-019-04475-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND There are no in vivo methods to measure adaptation in neonatal short bowel syndrome (SBS). We evaluated citrulline (Cit) levels in neonatal piglet surgical models of SBS. METHODS Piglets underwent 75% mid-intestinal resection with jejunoileal anastomosis (JI), 75% distal resection of ileum with jejunocolic anastomosis (JC) or sham surgery. Jugular and gastric catheters were inserted for parenteral and enteral nutrition. On D7, small intestine length and weight were measured, jejunum collected for histopathology and Cit level determined. RESULTS JI (n = 5) compared to JC (n = 5) had increased small intestinal length (JC - 17.5 cm; JI +22.0 cm; p = 0.02) and mass (JC 43.1 mg/cm/kg; JI 51.3 mg/cm/kg; p = 0.02), while Cit did not differ (JI 801.0 µM; JC 677.7 µM; p = 0.90). Including non-resected shams (n = 4), Cit correlated with length (R2 = 0.48; p = 0.006), but not for SBS alone (R2 = 0.11; p = 0.4), mass (R2 = 0.05; p = 0.5). A second experiment compared change in Cit levels from baseline to D7. Levels declined in sham (n = 8) and JC (n = 10) (sham - 110.1 µM; JC - 56.6 µM; p = 0.17), regardless of intestinal lengthening (sham 29.9 cm; JC - 10.4 cm; p = 0.002). CONCLUSION Citrulline levels predict large differences in intestinal length and 'identify' SBS. However, citrulline cannot discriminate between adaptation in JI and JC, nor predict intestinal lengthening.
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Park CJ, Shaughnessy MP, Armenia SJ, Cowles RA. Serum Citrulline Levels Exhibit Circadian Variation and Fluctuations in Relation to Food Intake in Mice. Gastroenterology Res 2019; 12:88-92. [PMID: 31019618 PMCID: PMC6469904 DOI: 10.14740/gr1146] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 02/15/2019] [Indexed: 12/23/2022] Open
Abstract
Background Plasma citrulline is a nonessential amino acid synthesized almost exclusively by enterocytes of the small intestine. Correlation between post-operative plasma citrulline levels and remnant small bowel mass and function has led to its use as a simple biomarker of functional intestinal mass in adults and children, with a proposed prognostic value for achieving enteral autonomy in the setting of intestinal failure. While it is standard to measure fasting levels in humans, the optimal timing of blood draws in relation to food intake and time of day has not been standardized and is poorly studied in animal models. We hypothesize that serum citrulline levels vary both throughout the day and with relation to food intake in mice. Methods Serum citrulline levels were measured from 12 C57BL/6 mice (6 - 9 weeks old) in the mornings and evenings, either after ad libitum food intake or after 8 - 12 h of access to water only. Blood draws for each experimental set-up were performed 1 week apart according to our Institutional Animal Care and Use Committee (IACUC) guidelines for acceptable blood collection volumes for survival procedures. At the end of the experiment, mice were euthanized and small intestine was harvested for morphometric measurements. Group means were compared using Student’s t-test with significance assumed for P < 0.05. Results After withholding chow for 8 - 12 h, serum citrulline levels were significantly greater in the morning compared to levels drawn in the evening. When mice were allowed ad libitum chow, there was no significant difference in serum citrulline levels drawn in the morning compared to the evening. There was no difference detected in villus height across the different experimental conditions. Conclusions Serum citrulline levels exhibit circadian variation and fluctuations in relation to food intake in mice, without apparent concurrent changes in enterocyte mass. There was no diurnal variation of serum citrulline levels in fed mice whereas fasted mice had significantly higher levels of serum citrulline in the morning compared to the evening. These findings underscore the paramount importance of consistent sample collection strategies in the setting of translational research.
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Affiliation(s)
- Christine J Park
- Department of Surgery, Section of Pediatric Surgery, Yale School of Medicine, 333 Cedar Street, FMB 131, New Haven, CT 06510, USA
| | - Matthew P Shaughnessy
- Department of Surgery, Section of Pediatric Surgery, Yale School of Medicine, 333 Cedar Street, FMB 131, New Haven, CT 06510, USA
| | - Sarah J Armenia
- Department of Surgery, Section of Pediatric Surgery, Yale School of Medicine, 333 Cedar Street, FMB 131, New Haven, CT 06510, USA
| | - Robert A Cowles
- Department of Surgery, Section of Pediatric Surgery, Yale School of Medicine, 333 Cedar Street, FMB 131, New Haven, CT 06510, USA
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Sigall-Boneh R, Levine A, Lomer M, Wierdsma N, Allan P, Fiorino G, Gatti S, Jonkers D, Kierkus J, Katsanos KH, Melgar S, Yuksel ES, Whelan K, Wine E, Gerasimidis K. Research Gaps in Diet and Nutrition in Inflammatory Bowel Disease. A Topical Review by D-ECCO Working Group [Dietitians of ECCO]. J Crohns Colitis 2017; 11:1407-1419. [PMID: 28961811 DOI: 10.1093/ecco-jcc/jjx109] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 08/04/2017] [Indexed: 02/06/2023]
Abstract
Although the current doctrine of IBD pathogenesis proposes an interaction between environmental factors and gut microbiota in genetically susceptible individuals, dietary exposures have attracted recent interest and are, at least in part, likely to explain the rapid rise in disease incidence and prevalence. The D-ECCO working group along with other ECCO experts with expertise in nutrition, microbiology, physiology, and medicine reviewed the evidence investigating the role of diet and nutritional therapy in the onset, perpetuation, and management of IBD. A narrative topical review is presented where evidence pertinent to the topic is summarised collectively under three main thematic domains: i] the role of diet as an environmental factor in IBD aetiology; ii] the role of diet as induction and maintenance therapy in IBD; and iii] assessment of nutritional status and supportive nutritional therapy in IBD. A summary of research gaps for each of these thematic domains is proposed, which is anticipated to be agenda-setting for future research in the area of diet and nutrition in IBD.
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Affiliation(s)
- Rotem Sigall-Boneh
- PIBD Research Center, Pediatric Gastroenterology and Nutrition Unit, Edith Wolfson Medical Center, Israel
| | - Arie Levine
- Paediatric Gastroenterology & Nutrition Unit, Wolfson Medical Center, Tel Aviv University, Israel
| | - Miranda Lomer
- Department of Nutrition and Dietetics, Guy's and St Thomas' NHS Foundation Trust and King's College London, UK
| | - Nicolette Wierdsma
- Department of Nutrition and Dietetics, VU University Medical Centre, The Netherlands
| | - Philip Allan
- Department of Translational Gastroenterology, John Radcliffe Hospital, UK
| | - Gionata Fiorino
- Department of Gastroenterology, IBD Center, Humanitas Research Hospital, Italy
| | - Simona Gatti
- Department of Paediatrics, Polytechnic University of Marche, Italy
| | - Daisy Jonkers
- Division Gastroenterology-Hepatology, Department of Internal Medicine, NUTRIM School for Nutrition and Translational Research in Metabolism, The Netherlands
| | - Jaroslaw Kierkus
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, Children's Memorial Health Institute, Poland
| | - Konstantinos H Katsanos
- Department of Gastroenterology and Hepatology, University and Medical School of Ioannina, Greece
| | - Silvia Melgar
- APC Microbiome Institute, University College Cork, Ireland
| | - Elif Saritas Yuksel
- Department of Gastroenterology, Izmir Katip Celebi University Ataturk Teaching and Research Hospital, Turkey
| | - Kevin Whelan
- King's College London, Division of Diabetes and Nutritional Sciences, UK
| | - Eytan Wine
- Division of Paediatric Gastroenterology and Nutrition, Departments of Paediatrics and Physiology, University of Alberta, Canada
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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.
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Affiliation(s)
| | - Alastair Forbes
- University of East Anglia, Norwich and Norfolk Medical School, Norwich, UK
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Morris CR, Hamilton-Reeves J, Martindale RG, Sarav M, Ochoa Gautier JB. Acquired Amino Acid Deficiencies: A Focus on Arginine and Glutamine. Nutr Clin Pract 2017; 32:30S-47S. [PMID: 28388380 DOI: 10.1177/0884533617691250] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Nonessential amino acids are synthesized de novo and therefore not diet dependent. In contrast, essential amino acids must be obtained through nutrition since they cannot be synthesized internally. Several nonessential amino acids may become essential under conditions of stress and catabolic states when the capacity of endogenous amino acid synthesis is exceeded. Arginine and glutamine are 2 such conditionally essential amino acids and are the focus of this review. Low arginine bioavailability plays a pivotal role in the pathogenesis of a growing number of varied diseases, including sickle cell disease, thalassemia, malaria, acute asthma, cystic fibrosis, pulmonary hypertension, cardiovascular disease, certain cancers, and trauma, among others. Catabolism of arginine by arginase enzymes is the most common cause of an acquired arginine deficiency syndrome, frequently contributing to endothelial dysfunction and/or T-cell dysfunction, depending on the clinical scenario and disease state. Glutamine, an arginine precursor, is one of the most abundant amino acids in the body and, like arginine, becomes deficient in several conditions of stress, including critical illness, trauma, infection, cancer, and gastrointestinal disorders. At-risk populations are discussed together with therapeutic options that target these specific acquired amino acid deficiencies.
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Affiliation(s)
- Claudia R Morris
- 1 Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory-Children's Center for Cystic Fibrosis and Airways Disease Research, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jill Hamilton-Reeves
- 2 Department of Dietetics and Nutrition, University of Kansas, Kansas City, Kansas, USA
| | - Robert G Martindale
- 3 Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Menaka Sarav
- 4 Department of Medicine, Division of Nephrology, Northshore University Health System, University of Chicago, Chicago, Illinois, USA
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Fjermestad H, Hvistendahl M, Jeppesen PB. Fasting and Postprandial Plasma Citrulline and the Correlation to Intestinal Function Evaluated by 72-Hour Metabolic Balance Studies in Short Bowel Jejunostomy Patients With Intestinal Failure. JPEN J Parenter Enteral Nutr 2017; 42:418-426. [DOI: 10.1177/0148607116687497] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/10/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Hilde Fjermestad
- Department of Medical Gastroenterology CA 2121, Rigshospitalet, Copenhagen, Denmark
| | - Mark Hvistendahl
- Department of Medical Gastroenterology CA 2121, Rigshospitalet, Copenhagen, Denmark
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López-Tejero MD, Virgili N, Targarona J, Ruiz J, García N, Oró D, García-Villoria J, Creus G, Pita AM. Apo AIV and Citrulline Plasma Concentrations in Short Bowel Syndrome Patients: The Influence of Short Bowel Anatomy. PLoS One 2016; 11:e0163762. [PMID: 27689355 PMCID: PMC5045203 DOI: 10.1371/journal.pone.0163762] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 08/25/2016] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Parenteral nutrition (PN) dependence in short bowel syndrome (SBS) patients is linked to the functionality of the remnant small bowel (RSB). Patients may wean off PN following a period of intestinal adaptation that restores this functionality. Currently, plasma citrulline is the standard biomarker for monitoring intestinal functionality and adaptation. However, available studies reveal that the relationship the biomarker with the length and function of the RSB is arguable. Thus, having additional biomarkers would improve pointing out PN weaning. AIM By measuring concomitant changes in citrulline and the novel biomarker apolipoprotein AIV (Apo AIV), as well as taking into account the anatomy of the RSB, this exploratory study aims to a better understanding of the intestinal adaptation process and characterization of the SBS patients under PN. METHODS Thirty four adult SBS patients were selected and assigned to adapted (aSBS) and non-adapted (nSBS) groups after reconstructive surgeries. Remaining jejunum and ileum lengths were recorded. The aSBS patients were either on an oral diet (ORAL group), those with intestinal insufficiency, or on oral and home parenteral nutrition (HPN group), those with chronic intestinal failure. Apo AIV and citrulline were analyzed in plasma samples after overnight fasting. An exploratory ROC analysis using citrulline as gold standard was performed. RESULTS Biomarkers, Apo AIV and citrulline showed a significant correlation with RSBL in aSBS patients. In jejuno-ileocolic patients, only Apo AIV correlated with RSBL (rb = 0.54) and with ileum length (rb = 0.84). In patients without ileum neither biomarker showed any correlation with RSBL. ROC analysis indicated the Apo AIV cut-off value to be 4.6 mg /100 mL for differentiating between the aSBS HPN and ORAL groups. CONCLUSIONS Therefore, in addition to citrulline, Apo AIV can be set as a biomarker to monitor intestinal adaptation in SBS patients. As short bowel anatomy is shown to influence citrulline and Apo AIV plasma values, both biomarkers complement each other furnishing a new insight to manage PN dependence.
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Affiliation(s)
- M. Dolores López-Tejero
- Departament de Bioquimica i Biomedicina Molecular, Facultat de Biologia, Universitat de Barcelona, Barcelona, Spain
- * E-mail:
| | - Núria Virgili
- Unitat de Nutrició i Dietètica, Servei d’Endocrinologia i Nutrició, Hospital Universitari de Bellvitge (HUB), IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Targarona
- Departament de Bioquimica i Biomedicina Molecular, Facultat de Biologia, Universitat de Barcelona, Barcelona, Spain
| | | | - Natalia García
- Departament de Bioquimica i Biomedicina Molecular, Facultat de Biologia, Universitat de Barcelona, Barcelona, Spain
| | - Denise Oró
- Departament de Bioquimica i Biomedicina Molecular, Facultat de Biologia, Universitat de Barcelona, Barcelona, Spain
| | - Judit García-Villoria
- Sección de Errores Congénitos del Metabolismo-IBC, Servicio de Bioquímica y Genética Molecular, Hospital Clínic de Barcelona, CIBERER, IDIBAPS, Barcelona, Spain
| | - Gloria Creus
- Unitat de Nutrició i Dietètica, Servei d’Endocrinologia i Nutrició, Hospital Universitari de Bellvitge (HUB), IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Ana M. Pita
- Unitat de Nutrició i Dietètica, Servei d’Endocrinologia i Nutrició, Hospital Universitari de Bellvitge (HUB), IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
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Lai CH, Lee CH, Hung CY, Lo HC. Oral Citrulline Mitigates Inflammation and Jejunal Damage via the Inactivation of Neuronal Nitric Oxide Synthase and Nuclear Factor-κB in Intestinal Ischemia and Reperfusion. JPEN J Parenter Enteral Nutr 2016; 41:422-435. [PMID: 26129897 DOI: 10.1177/0148607115590661] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intestinal ischemia and reperfusion (I/R) is a life-threatening emergency accompanied by inflammation and organ damage. We compared the mechanisms and the effects of arginine, citrulline, and glutamine on inflammation and intestinal damage. MATERIALS AND METHODS Male Wistar rats underwent 60 minutes of superior mesenteric artery occlusion and either 3 (I/R3) or 24 (I/R24) hours of reperfusion and were orally administered vehicle, arginine, citrulline, or glutamine 15 minutes before reperfusion and at 3, 9, and 21 hours of reperfusion. RESULTS I/R3 rats experienced jejunal damage and apoptosis, and I/R24 rats had liver dysfunction compared with normal rats (one-way ANOVA, P < .05). Arginine and citrulline administrations improved jejunal morphology, and citrulline and glutamine administrations alleviated the loss of jejunal mass in I/R3 rats. I/R3-increased circulating nitrate/nitrite (NOx), tumor necrosis factor-α, and interleukin-6 were significantly decreased by citrulline, glutamine and citrulline, and arginine, glutamine, and citrulline, respectively. These amino acids decreased plasma NOx and interferon-γ in I/R24, decreased jejunal neuronal nitric oxide synthase (NOS) protein in I/R3 rats, and alleviated jejunal apoptosis in I/R3 and I/R24 rats. In addition, the jejunal phosphorylated to total nuclear factor-κB (NF-κB) ratio was decreased by arginine and citrulline in I/R24 rats. CONCLUSION Oral administration of arginine, citrulline, and glutamine may alleviate systemic inflammation, jejunal apoptosis, and neuronal NOS in intestinal I/R. Citrulline may further attenuate jejunal damage by preserving jejunal mass, partially via the inactivation of NOS and the NF-κB pathway. In conclusion, oral citrulline may have more benefits than arginine and glutamine in mitigating intestinal ischemia and reperfusion-induced adverse effects.
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Affiliation(s)
- Chun-Hong Lai
- 1 Department of Nutrition, Chi-Mei Medical Center, Tainan, Taiwan
| | - Chien-Hsing Lee
- 2 Division of Pediatric Surgery, Department of Surgery, Children's Hospital of China Medical University, Taichung, Taiwan.,3 Graduate Institute of Medical Sciences, Chang Jung Christian University, Tainan, Taiwan
| | - Ching-Yi Hung
- 2 Division of Pediatric Surgery, Department of Surgery, Children's Hospital of China Medical University, Taichung, Taiwan
| | - Hui-Chen Lo
- 4 Department of Nutritional Science, Fu Jen Catholic University, New Taipei City, Taiwan
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Seidner DL, Joly F, Youssef NN. Effect of Teduglutide, a Glucagon-like Peptide 2 Analog, on Citrulline Levels in Patients With Short Bowel Syndrome in Two Phase III Randomized Trials. Clin Transl Gastroenterol 2015; 6:e93. [PMID: 26111125 PMCID: PMC4816243 DOI: 10.1038/ctg.2015.15] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2015] [Indexed: 12/15/2022] Open
Abstract
Objectives: In clinical trials, treatment with the glucagon-like peptide 2 analog teduglutide was associated with improved fluid and nutrient absorption and increased intestinal villus height and crypt depth in patients with short bowel syndrome (SBS). Plasma citrulline, an amino acid produced by enterocytes, is considered a measure of enterocyte mass. This analysis assessed changes in plasma citrulline levels in patients with SBS in 2 phase III clinical studies of teduglutide. Methods: Both teduglutide studies (0.05 or 0.10 mg/kg/day in CL0600-004 and 0.05 mg/kg/day in CL0600-020) were phase III, 24-week, double-blind, and placebo controlled. Plasma citrulline levels were analyzed and validated by liquid chromatography coupled to tandem mass spectrometry. Results: In both the CL0600-004 and CL0600-020 studies, change in mean plasma citrulline concentrations at Week 24 vs. baseline was significantly greater with teduglutide compared with placebo (10.9 (0.05-mg/kg/day dose) and 15.7 (0.10-mg/kg/day dose) vs. 2.0 μmol/L and 20.6 vs. 0.7 μmol/L, respectively, for each study (P≤0.0001 for each comparison with placebo)). Teduglutide treatment was associated with reductions from baseline in PS (parenteral support) volume requirements; however, a significant correlation between PS reduction and increase in plasma citrulline at Week 24 was observed in only one out of the three teduglutide treatment groups. Conclusions: In 2 phase III studies, patients receiving teduglutide had significant increases in plasma citrulline at Week 24 compared with patients receiving placebo. Increases in plasma citrulline concentrations likely reflect enterocyte mass expansion, but no clear correlation was detected between change in plasma citrulline and change in weekly PS volume.
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Affiliation(s)
- Douglas L Seidner
- 1] Vanderbilt Center for Human Nutrition, Nashville, TN, USA [2] Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Francisca Joly
- Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies, Inserm UMR 1149, Centre de Recherche sur l'Inflammation Paris Montmartre UFR de Médecine Paris Diderot, Paris, France
| | - Nader N Youssef
- Clinical Research and Development, NPS Pharmaceuticals, Bedminster, NJ, USA
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Frongia G, Weih S, Romero P, Mehrabi A, Holland-Cunz S, Günther P. Surgical intervention does not affect short-term plasma citrulline levels in infants: implications for citrulline as a marker of postoperative intestinal complications. Eur Surg 2015. [DOI: 10.1007/s10353-015-0312-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Poole A, Deane A, Summers M, Fletcher J, Chapman M. The relationship between fasting plasma citrulline concentration and small intestinal function in the critically ill. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:16. [PMID: 25599966 PMCID: PMC4355456 DOI: 10.1186/s13054-014-0725-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 12/18/2014] [Indexed: 01/21/2023]
Abstract
Introduction In this study, we aimed to evaluate whether fasting plasma citrulline concentration predicts subsequent glucose absorption in critically ill patients. Methods In a prospective observational study involving 15 healthy and 20 critically ill subjects, fasting plasma citrulline concentrations were assayed in blood samples immediately prior to the administration of a liquid test meal (1 kcal/ml; containing 3 g of 3-O-methylglucose (3-OMG)) that was infused directly into the small intestine. Serum 3-OMG concentrations were measured over the following 4 hours, with the area under the 3-OMG concentration curve (AUC) calculated as an index of glucose absorption. Results The groups were well matched in terms of age, sex and body mass index (BMI) (healthy subjects versus patients, mean (range) values: age, 47 (18 to 88) versus 49 (21 to 77) years; sex ratio, 60% versus 80% male; BMI, 25.2 (18.8 to 30.0) versus 25.5 (19.4 to 32.2) kg/m2). Compared to the healthy subjects, patients who were critically ill had reduced fasting citrulline concentration (26.5 (13.9 to 43.0) versus 15.2 (5.7 to 28.6) μmol/L; P < 0.01) and glucose absorption (3-OMG AUC, 79.7 (28.6 to 117.8) versus 61.0 (4.5 to 97.1) mmol/L/240 min; P = 0.05). There was no relationship between fasting citrulline concentration and subsequent glucose absorption (r = 0.28; P = 0.12). Conclusions Whereas both plasma citrulline concentrations and glucose absorption were reduced in critical illness, fasting plasma citrulline concentrations were not predictive of subsequent glucose absorption. These data suggest that fasting citrulline concentration does not appear to be a marker of small intestinal absorptive function in patients who are critically ill.
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Affiliation(s)
- Alexis Poole
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia
| | - Adam Deane
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Frome Road, Adelaide, South Australia, 5000, Australia
| | - Matthew Summers
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Frome Road, Adelaide, South Australia, 5000, Australia
| | - Janice Fletcher
- Genetics and Molecular Pathology, SA Pathology, Frome Road, Adelaide, South Australia, 5000, Australia
| | - Marianne Chapman
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia. .,Discipline of Acute Care Medicine, University of Adelaide, Frome Road, Adelaide, South Australia, 5000, Australia.
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Gutierrez IM, Fisher JG, Ben-Ishay O, Jones BA, Kang KH, Hull MA, Shillingford N, Zurakowski D, Modi BP, Jaksic T. Citrulline levels following proximal versus distal small bowel resection. J Pediatr Surg 2014; 49:741-4. [PMID: 24851760 DOI: 10.1016/j.jpedsurg.2014.02.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 02/13/2014] [Indexed: 01/17/2023]
Abstract
PURPOSE Citrulline, a nonprotein amino acid synthesized by enterocytes, is a biomarker of bowel length and the capacity to wean from parenteral nutrition. However, the potentially variant effect of jejunal versus ileal excision on plasma citrulline concentration [CIT] has not been studied. This investigation compared serial serum [CIT] and mucosal adaptive potential after proximal versus distal small bowel resection. METHODS Enterally fed Sprague-Dawley rats underwent sham operation or 50% small bowel resection, either proximal (PR) or distal (DR). [CIT] was measured at operation and weekly for 8 weeks. At necropsy, histologic features reflecting bowel adaptation were evaluated. RESULTS By weeks 6-7, [CIT] in both resection groups significantly decreased from baseline (P<0.05) and was significantly lower than the concentration in sham animals (P<0.05). There was no difference in [CIT] between PR and DR at any point. Villus height and crypt density were higher in the PR than in the DR group (P≤0.02). CONCLUSION [CIT] effectively differentiates animals undergoing major bowel resection from those with preserved intestinal length. The region of intestinal resection was not a determinant of [CIT]. The remaining bowel in the PR group demonstrated greater adaptive potential histologically. [CIT] is a robust biomarker for intestinal length, irrespective of location of small intestine lost.
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Affiliation(s)
- Ivan M Gutierrez
- Center for Advanced Intestinal Rehabilitation (CAIR), Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Jeremy G Fisher
- Center for Advanced Intestinal Rehabilitation (CAIR), Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Offir Ben-Ishay
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Brian A Jones
- Center for Advanced Intestinal Rehabilitation (CAIR), Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Kuang Horng Kang
- Center for Advanced Intestinal Rehabilitation (CAIR), Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Melissa A Hull
- Center for Advanced Intestinal Rehabilitation (CAIR), Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Nick Shillingford
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Biren P Modi
- Center for Advanced Intestinal Rehabilitation (CAIR), Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation (CAIR), Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA.
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Abstract
Intestinal adaptation is a natural compensatory process that occurs following extensive intestinal resection, whereby structural and functional changes in the intestine improve nutrient and fluid absorption in the remnant bowel. In animal studies, postresection structural adaptations include bowel lengthening and thickening and increases in villus height and crypt depth. Functional changes include increased nutrient transporter expression, accelerated crypt cell differentiation, and slowed transit time. In adult humans, data regarding adaptive changes are sparse, and the mechanisms underlying intestinal adaptation remain to be fully elucidated. Several factors influence the degree of intestinal adaptation that occurs post resection, including site and extent of resection, luminal stimulation with enteral nutrients, and intestinotrophic factors. Two intestinotrophic growth factors, the glucagon-like peptide 2 analog teduglutide and recombinant growth hormone (somatropin), are now approved for clinical use in patients with short bowel syndrome (SBS). Both agents enhance fluid absorption and decrease requirements for parenteral nutrition (PN) and/or intravenous fluid. Intestinal adaptation has been thought to be limited to the first 1-2 years following resection in humans. However, recent data suggest that a significant proportion of adult patients with SBS can achieve enteral autonomy, even after many years of PN dependence, particularly with trophic stimulation.
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Affiliation(s)
- Kelly A Tappenden
- Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign, Urbana, Illinois
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Vecino López R, Andrés Moreno AM, Ramos Boluda E, Martinez-Ojinaga Nodal E, Hernanz Macías A, Prieto Bozano G, Lopez Santamaria M, Tovar Larrucea JA. [Plasma citrulline concentration as a biomarker of intestinal function in short bowel syndrome and in intestinal transplant]. An Pediatr (Barc) 2013; 79:218-23. [PMID: 23528708 DOI: 10.1016/j.anpedi.2013.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 01/28/2013] [Accepted: 02/08/2013] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Citrulline is a non-essential amino acid produced solely in the enterocyte. The aim of this study was to analyse the role of serum citrulline as a biomarker of enterocyte load in children with intestinal failure due to short bowel syndrome (SBS) and its relationship to enteral adaptation. MATERIAL AND METHODS Plasma citrulline concentration was determined by chromatography (normal value>15 μmol/L) in 57 patients (age 0.5-18 years) admitted to our Intestinal Rehabilitation Unit with intestinal failure. Those who were dehydrated, with renal insufficiency, or other conditions able to modify the results were excluded. Patients were divided into 4 groups: group i: SBS totally dependent on parenteral nutrition (PN); group ii: SBS under mixed enteral-parenteral nutrition; group iii: IF weaned from PN after a rehabilitation period; group iv: small bowel transplanted patients weaned from PN and taking a normal diet. RESULTS The mean ± SD plasma citrulline values were: group i (n=15): 7.1 ± 4.1; group ii (n=11): 15.8 ± 8.9; group iii (n=13): 20.6 ± 7.5; group iv (n=25): 28.8 ± 10.1. Values were significantly lower in group i in comparison with groups ii-iii-iv (P<.001), and in group ii in comparison with groups iii-iv (P<.001). A low citrulline was associated with remnant small bowel length (P<.001, r=0.85). In group iv citrulline levels decreased >50% in 3 patients who developed moderate-severe rejection, and in one patient who developed viral enteritis. CONCLUSIONS 1. Plasma citrulline could be a sensitive and specific biomarker of the residual functional enterocyte load. 2. It is related to enteral feeding tolerance. 3. Its prognostic value in the process of intestinal adaptation and as a rejection marker in small bowel transplanted patients needs to be confirmed.
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Affiliation(s)
- R Vecino López
- Servicio de Gastroenterología Infantil, Hospital Infantil La Paz, Madrid, España.
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Jeppesen PB. Teduglutide, a novel glucagon-like peptide 2 analog, in the treatment of patients with short bowel syndrome. Therap Adv Gastroenterol 2012; 5:159-71. [PMID: 22570676 PMCID: PMC3342570 DOI: 10.1177/1756283x11436318] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Short bowel syndrome results from surgical resection, congenital defect or disease-associated loss of absorption. Parenteral support (PS) is lifesaving in patients with short bowel syndrome and intestinal failure who are unable to compensate for their malabsorption by metabolic or pharmacologic adaptation. Together, the symptoms of short bowel syndrome and the inconvenience and complications in relation to PS (e.g. catheter-related blood steam infections, central thrombosis and intestinal failure associated liver disease) may impair the quality of life of patients. The aim of treatment is to maximize intestinal absorption, minimize the inconvenience of diarrhea, and avoid, reduce or eliminate the need for PS to achieve the best possible quality of life for the patient. Conventional treatments include dietary manipulations, oral rehydration solutions, and antidiarrheal and antisecretory treatments. However, the evidence base for these interventions is limited and treatments that improve the structural and functional integrity of the remaining intestine are needed. Teduglutide, an analog of glucagon-like peptide 2, improves intestinal rehabilitation by promoting mucosal growth and possibly by restoring gastric emptying and secretion, thereby reducing intestinal losses and promoting intestinal absorption. In a 3-week, phase II balance study, teduglutide reduced diarrhea by around 700 g/day and fecal energy losses by around 0.8 MJ/day. In two randomized, placebo-controlled, 24-week, phase III studies, similar findings were obtained when evaluating the fluid composite effect, which is the sum of the beneficial effects of teduglutide - reduction in the need for PS, increase in urine production and reduction in oral fluid intake. The fluid composite effect reflects the increase in intestinal fluid absorption (and the concomitant reduction in diarrhea) and may be used in studies in which metabolic balance assessments are not performed. In studies of up to 24 weeks' duration, teduglutide appears to be safe and well tolerated. Treatment with teduglutide was associated with enhancement or restoration of the structural and functional integrity of the remaining intestine with significant intestinotrophic and proabsorptive effects, facilitating a reduction in diarrhea and an equivalent reduction in the need for PS in patients with short bowel syndrome and intestinal failure.
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Affiliation(s)
- Palle Bekker Jeppesen
- Department of Medicine CA-2121, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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22
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Thompson JS, Rochling FA, Weseman RA, Mercer DF. Current management of short bowel syndrome. Curr Probl Surg 2012; 49:52-115. [PMID: 22244264 DOI: 10.1067/j.cpsurg.2011.10.002] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Jon S Thompson
- University of Nebraska Medical Center, Omaha, Nebraska, USA
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Peterson J, Kerner JA. New advances in the management of children with intestinal failure. JPEN J Parenter Enteral Nutr 2011; 36:36S-42S. [PMID: 22190603 DOI: 10.1177/0148607111422069] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Johann Peterson
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucile Packard Children's Hospital, Stanford University Medical Center, Palo Alto, California 94304, USA.
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Plasma citrulline as marker of bowel adaptation in children with short bowel syndrome. Langenbecks Arch Surg 2011; 396:1041-6. [DOI: 10.1007/s00423-011-0813-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Accepted: 05/18/2011] [Indexed: 01/13/2023]
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Peters J, Beishuizen A, Keur M, Dobrowolski L, Wierdsma N, van Bodegraven A. Assessment of Small Bowel Function in Critical Illness: Potential Role of Citrulline Metabolism. J Intensive Care Med 2011; 26:105-10. [DOI: 10.1177/0885066610387998] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Small intestinal function in critically ill patients should ideally be assessed in order to determine the preferred feeding route, timing, and composition of enteral nutrition. Additionally, evaluation of small bowel function may lead to new insights aimed to maintain enterocyte integrity. Critically ill patients are likely to have impaired enterocyte function mainly as a consequence of diminished splanchnic blood flow associated with mucosal hyperpermeability and bacterial translocation, a pathological state believed to be pivotal in the development of sepsis and multiple organ dysfunction syndrome (MODS). However, feasible and validated clinical tools to reliably assess enterocyte function are lacking. This explorative review discusses the promising role of citrulline, a nonprotein amino acid almost exclusively generated by the enterocyte, as a biomarker reflecting enterocyte function in critically ill patients. Citrulline metabolism, its potential as enterocyte biomarker, and literature on citrulline in critically illness will be discussed. Finally, a novel test for enterocyte function, the citrulline generation test (enterocytic citrulline production upon stimulation with enteral or intravenous glutamine) will be considered briefly.
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Affiliation(s)
- J.H.C. Peters
- Department of Gastroenterology, Red Cross Hospital, Beverwijk, Netherlands,
| | - A. Beishuizen
- Intensive Care Unit, VU University Medical Center, Amsterdam, Netherlands
| | - M.B. Keur
- Intensive Care Unit, VU University Medical Center, Amsterdam, Netherlands
| | - L. Dobrowolski
- Intensive Care Unit, VU University Medical Center, Amsterdam, Netherlands
| | - N.J. Wierdsma
- Department of Nutrition and Dietetics, VU University Medical Center, Amsterdam, Netherlands
| | - A.A. van Bodegraven
- Department of Gastroenterology, VU University Medical Center, Amsterdam, Netherlands
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Goulet O, Dabbas-Tyan M, Talbotec C, Kapel N, Rosilio M, Souberbielle JC, Corriol O, Ricour C, Colomb V. Effect of recombinant human growth hormone on intestinal absorption and body composition in children with short bowel syndrome. JPEN J Parenter Enteral Nutr 2011; 34:513-20. [PMID: 20852179 DOI: 10.1177/0148607110362585] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This prospective study aimed to establish the effect of recombinant human growth hormone (rhGH) on intestinal function in children with short bowel syndrome (SBS). Eight children with neonatal SBS were included. All were dependent on parenteral nutrition (PN) for >3 years (range, 3.8-11.6 years), with PN providing >50% of recommended dietary allowance for age (range, 50%-65%). The subjects received rhGH (Humatrope) 0.13 mg/kg/d subcutaneously over a 12-week period. The follow-up was continued over a 12-month period after rhGH discontinuation. Clinical and biological assessments were performed at baseline, at the end of the treatment period, and 12 months after the end of treatment. No side effects related to rhGH were observed. PN requirements were decreased in all children during the course of rhGH treatment. Between baseline and the end of treatment, significant increases were observed in concentrations (mean ± standard deviation) of serum insulin-like growth factor 1 (103.1 ± 49.9 µg/L vs 153.5 ± 82.2 µg/L; P < .01), serum insulin-like growth factor-binding protein 3 (1.7 ± 0.6 mg/L vs 2.5 ± 0.9 mg/L; P < .001), and plasma citrulline (16.5 ± 14.8 µmol/L vs 25.2 ± 18.3 µmol/L; P < .05). A median 54% increase in enteral intake (range, 10%-244%) was observed (P < .001) and net energy balance improved significantly (P < .002). It was necessary for 6 children to be maintained on PN or restarted after discontinuation of rhGH treatment, and they remained on PN until the end of the follow-up period. A 12-week high-dose rhGH treatment allowed patients to decrease PN, but only 2 patients could be definitively weaned from PN. Indications and cost-effectiveness of rhGH treatment for SBS pediatric patients need further evaluation.
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Affiliation(s)
- Olivier Goulet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Hospital Necker-Enfants Malades, University of Paris-René Descartes, Paris, France.
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Dossin O, Rupassara S, Weng HY, Williams D, Garlick P, Schoeman J. Effect of Parvoviral Enteritis on Plasma Citrulline Concentration in Dogs. J Vet Intern Med 2011; 25:215-21. [DOI: 10.1111/j.1939-1676.2010.0671.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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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]
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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
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Marini JC, Didelija IC, Castillo L, Lee B. Plasma arginine and ornithine are the main citrulline precursors in mice infused with arginine-free diets. J Nutr 2010; 140:1432-7. [PMID: 20573946 PMCID: PMC2903302 DOI: 10.3945/jn.110.125377] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Dietary arginine is the main dietary precursor for citrulline synthesis, but it is not known if other precursors can compensate when arginine is absent in the diet. To address this question, the contributions of plasma and dietary precursors were determined by using multitracer protocols in conscious mice infused i.g. either an arginine-sufficient diet [Arg(+)] or an arginine-free diet [Arg(-)]. The plasma entry rate of citrulline and arginine did not differ between the 2 diet groups (156 +/- 6 and 564 +/- 30 micromol kg(-1) h(-1), respectively); however, the entry rate of ornithine was greater in the mice fed the Arg(+) than the Arg(-) diet (332 +/- 33 vs. 180 +/- 16 micromol kg(-1) h(-1)). There was a greater utilization of plasma ornithine for the synthesis of citrulline (49 +/- 4 vs. 36 +/- 3 micromol kg(-1) h(-1), 30 +/- 3% vs. 24 +/- 2% of citrulline entry rate) in the mice fed the Arg(-) diet than the Arg(+) diet. The utilization of plasma arginine did not differ between the 2 diet groups for citrulline synthesis, either through plasma ornithine (approximately 29 +/- 3 micromol kg(-1) h(-1)) or at the site of citrulline synthesis (approximately 12 +/- 3 micromol kg(-1) h(-1)). The contribution of dietary proline to the synthesis of citrulline was mainly at the site of citrulline production (17 +/- 1 micromol kg(-1) h(-1)), rather than through plasma ornithine (5 +/- 0.4 micromol kg(-1) h(-1)). Dietary glutamine was utilized only at the site of citrulline synthesis (4 +/- 0.2 micromol kg(-1) h(-1)). Dietary glutamine and proline made a greater contribution to the synthesis of citrulline in mice fed the Arg(-) diet but remained minor sources for citrulline production. Plasma arginine and ornithine are able to support citrulline synthesis during arginine-free feeding.
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Affiliation(s)
- Juan C. Marini
- USDA/Agricultural Research Service Children's Nutrition Research Center, Department of Pediatrics and Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030; and Howard Hughes Medical Institute, Houston, TX 77030,To whom correspondence should be addressed. E-mail:
| | - Inka Cajo Didelija
- USDA/Agricultural Research Service Children's Nutrition Research Center, Department of Pediatrics and Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030; and Howard Hughes Medical Institute, Houston, TX 77030
| | - Leticia Castillo
- USDA/Agricultural Research Service Children's Nutrition Research Center, Department of Pediatrics and Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030; and Howard Hughes Medical Institute, Houston, TX 77030
| | - Brendan Lee
- USDA/Agricultural Research Service Children's Nutrition Research Center, Department of Pediatrics and Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030; and Howard Hughes Medical Institute, Houston, TX 77030
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Plasma citrulline is a marker of absorptive small bowel length in patients with transient enterostomy and acute intestinal failure. Clin Nutr 2010; 29:235-42. [DOI: 10.1016/j.clnu.2009.08.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Revised: 08/03/2009] [Accepted: 08/14/2009] [Indexed: 11/20/2022]
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Parenteral Nutrition Independence in a Patient Left with 25 cm of Ileum and Jejunum: A Case Report. Obes Surg 2010; 20:666-71. [DOI: 10.1007/s11695-010-0098-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 01/28/2010] [Indexed: 12/14/2022]
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Sigalet DL, Lam V, Boctor D. The assessment, and glucagon-like peptide-2 modulation, of intestinal absorption and function. Semin Pediatr Surg 2010; 19:44-9. [PMID: 20123273 DOI: 10.1053/j.sempedsurg.2009.11.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The treatment of patients with short bowel syndrome is hampered by a lack of treatment and measurement methods. This article reviews our evolving understanding of the role of glucagon-like peptide 2 (GLP-2) in controlling the adaptive process. The ability of the remnant intestine to produce GLP-2 appears to be predictive of the adaptive process; exogenous GLP-2 may be a therapy to augment adaptation. Strategies for monitoring patients, including conventional means, such as anthropomorphic measurements, plasma levels of specific nutrients, and vitamins and radiological contrast studies are reviewed. Investigational methods, such as nutrient balance studies, plasma citrulline levels, and the absorption of inert sugars (3-0 methyl glucose, mannitol, and lactulose) are discussed with the evidence to support their use.
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Affiliation(s)
- David L Sigalet
- Alberta Children's Hospital Intestinal Rehabilitation Program, Alberta Children's Hospital and University of Calgary, Calgary, Alberta, Canada.
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Keur MB, Beishuizen A, van Bodegraven AA. Diagnosing malabsorption in the intensive care unit. F1000 MEDICINE REPORTS 2010; 2. [PMID: 20948831 PMCID: PMC2948382 DOI: 10.3410/m2-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Malabsorption as a result of decreased intestinal function is a frequently occurring problem in intensive care units. Small bowel dysfunction may lead to malnutrition and may predispose patients to infectious complications (sepsis) and may be linked to increased hospitalization duration, morbidity and mortality. There are several small bowel function tests, such as faecal fat excretion and sugar absorption tests, but data specifically applicable to the intensive care setting are limited. Moreover, there are multiple confounders such as altered intestinal permeability, changed transit time and renal dysfunction. A more specific test, fasting plasma citrulline concentration, has poor test characteristics for detection of decreased intestinal function in patients with dysfunctional enterocytes. Therefore, a citrulline generation test was recently developed in order to measure the conversion of glutamine (administered either enterally or intravenously) into citrulline. This conversion takes place exclusively in a properly functioning enterocyte; therefore, citrulline generation upon glutamine stimulation may be a promising biomarker for assessment of the small bowel function.
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Affiliation(s)
- Martijn B Keur
- Departments of Intensive Care and Gastroenterology, VU University Medical Center Amsterdam De Boelelaan 1117, 1081 HV Amsterdam The Netherlands
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35
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Bailly-Botuha C, Colomb V, Thioulouse E, Berthe MC, Garcette K, Dubern B, Goulet O, Couderc R, Girardet JP. Plasma citrulline concentration reflects enterocyte mass in children with short bowel syndrome. Pediatr Res 2009; 65:559-63. [PMID: 19127207 DOI: 10.1203/pdr.0b013e31819986da] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Plasma citrulline was recently shown to reflect the residual functional enterocyte mass in various situations characterized by intestinal failure. However, few data are available in children with short bowel syndrome. The objective of this study was to assess the value of citrulline assays in this situation. Prospective plasma citrulline assays were performed in 31 children with short bowel syndrome. Median age was 16 mo (range, 1 mo to 15 y), and median follow-up was 14 mo (6-40 mo). The energy supplied by parenteral nutrition (PN), served to assess intestinal failure severity. Plasma citrulline at inclusion showed a positive correlation with residual short bowel length. Subsequent values correlated negatively with intestinal failure severity. Plasma citrulline increased over time during or after weaning from PN (from 15.8 +/- 11.5 microM to 19.3 +/- 3.8 microM) but remained stable and low in patients who continued to need PN (6.5 +/- 3.0 microM at inclusion and 7.7 +/- 6.0 microM at last follow-up). No weaned patients had a residual short bowel length less than 40 cm and plasma citrulline less than 11 microM. Our findings constitute the first evidence that serial plasma citrulline assays help to monitor residual small bowel adaptation in children.
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Affiliation(s)
- Céline Bailly-Botuha
- Gastroentérologie et Nutrition Pédiatriques, Hôpital Armand-Trousseau, APHP, Paris 75012, France
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Luo M, Estívariz CF, Schleicher RL, Bazargan N, Leader LM, Galloway JR, Ziegler TR. Prospective analysis of serum carotenoids, vitamin A, and tocopherols in adults with short bowel syndrome undergoing intestinal rehabilitation. Nutrition 2008; 25:400-7. [PMID: 19081706 DOI: 10.1016/j.nut.2008.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Revised: 08/15/2008] [Accepted: 10/03/2008] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Carotenoids, vitamin A, and tocopherols serve important roles in many key body functions. However, availability of these compounds may be decreased in patients with short bowel syndrome (SBS) due to decreased oral intake of fruits and vegetables and/or decreased intestinal absorption. Little information is available on serum concentrations of carotenoids, vitamin A, and tocopherols during chronic parenteral nutrition (PN) or during PN weaning. The aim of this study was to prospectively examine serum concentrations of a wide variety of carotenoids, vitamin A, and tocopherols in patients with SBS undergoing an intensive 12-wk intestinal rehabilitation program. METHODS Twenty-one PN-dependent adult patients with SBS were enrolled in a 12-wk intestinal rehabilitation program, which included individualized dietary modification, multivitamin supplementation, and randomization to receive subcutaneous placebo (n = 9) or human growth hormone (0.1 mg . kg(-1) . d(-1); n = 12). PN weaning was initiated after week 4 and advanced as tolerated. Serum concentrations of carotenoids, vitamin A, and tocopherols were determined at baseline and at weeks 4 and 12. RESULTS A significant percentage of subjects exhibited low serum concentrations for carotenoids and alpha-tocopherol at study entry, and a few subjects had low concentrations of retinol (5%). Carotenoid and vitamin A valves did not improve over time, while alpha-tocopherol levels rose. Serum alpha-tocopherol concentration was negatively associated with PN lipid dose (r = -0.34, P < 0.008). CONCLUSION Patients with SBS are depleted in diet-derived carotenoids despite oral and intravenous multivitamin supplementation and dietary adjustment during intestinal rehabilitation and PN weaning. Reduction of PN lipid infusion may improve serum alpha-tocopherol concentrations.
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Affiliation(s)
- Menghua Luo
- Nutrition and Health Science Program, Graduate School of Arts and Sciences, Emory University, Atlanta, Georgia, USA
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Peters JHC, Wierdsma NJ, Teerlink T, van Leeuwen PAM, Mulder CJJ, van Bodegraven AA. The citrulline generation test: proposal for a new enterocyte function test. Aliment Pharmacol Ther 2008; 27:1300-10. [PMID: 18331613 DOI: 10.1111/j.1365-2036.2008.03678.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The amino acid citrulline is mainly produced by enterocytes from conversion of glutamine. As fasting plasma citrulline proved disappointing as a biomarker for enterocyte dysfunction in clinical practice, we propose a citrulline generation test (CGT) to assess enterocyte function. AIM To assess the feasibility of a CGT in healthy subjects and patients with decreased enterocyte mass. METHODS Nineteen healthy subjects, 16 patients with intestinal villous atrophy and nine patients with short bowel syndrome (SBS) were given an oral bolus of 20 g of the dipeptide alanine-glutamine. Subsequent changes in plasma citrulline and other amino acid concentrations were determined using reverse-phase high-performance liquid chromatography. RESULTS Following the oral bolus of alanine-glutamine, plasma citrulline concentrations showed a time dependent rise in healthy subjects of 44 +/- 13% (38-55 micromol/L, P < 0.0001). The slope from baseline plasma citrulline to peak concentrations was 0.22 +/- 0.08, 0.13 +/- 0.04 and 0.09 +/- 0.04 micromol/L/min in healthy subjects, patients with coeliac disease (CeD) and refractory CeD, respectively (healthy subjects vs. CeD P < 0.05, healthy subjects vs. refractory CeD P < 0.001). In patients with SBS, the CGT was able to distinguish between non-adapted and adapted SBS by means of the incremental area under the CGT curve till 90 min (iAUC T90). The iAUC T90 was 447 +/- 179 and 1039 +/- 178 micromol/L/min in non-adapted and adapted SBS, respectively (P = 0.04). CONCLUSION An oral bolus of alanine-glutamine induces a time-dependent rise in plasma citrulline concentration to an extent dependent on the existence of villous atrophy or enterocyte hyperplasia in CeD, and adapted SBS, respectively.
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Affiliation(s)
- J H C Peters
- Small Bowel Diseases Unit, Department of Gastroenterology and Hepatology, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands.
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Peters JHC, Mulder CJJ, van Bodegraven AA. Letters to the Editor. JPEN J Parenter Enteral Nutr 2008; 32:288; author reply 289. [DOI: 10.1177/0148607108316186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Job H. C. Peters
- Department of Gastroenterology & Hepatology, Small Bowel Unit VU
University Medical Center, Amsterdam, the Netherlands
| | - Chris J. J. Mulder
- Department of Gastroenterology & Hepatology, Small Bowel Unit VU
University Medical Center, Amsterdam, the Netherlands
| | - Ad A. van Bodegraven
- Department of Gastroenterology & Hepatology, Small Bowel Unit VU
University Medical Center, Amsterdam, the Netherlands
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Ziegler TR, Luo M. Response. JPEN J Parenter Enteral Nutr 2008; 32:289. [DOI: 10.1177/0148607108316199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thomas R. Ziegler
- Department of Medicine and Center for Clinical and Molecular Nutrition
Emory University School of Medicine, Atlanta, GA
| | - Menghua Luo
- Department of Medicine and Center for Clinical and Molecular Nutrition
Emory University School of Medicine, Atlanta, GA
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40
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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.
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Affiliation(s)
- Pascal Crenn
- Département de Médecine, Hôpital Raymond Poincaré, Assistance Publique-Hôpitaux de Paris, Université de Versailles Saint-Quentin-en-Yvelines, Garches, France.
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Kang W, Kudsk KA, Sano Y, Lan J, Yang-Xin F, Gomez FE, Maeshima Y. Effects of lymphotoxin beta receptor blockade on intestinal mucosal immunity. JPEN J Parenter Enteral Nutr 2007; 31:358-64; discussion 364-5. [PMID: 17712143 DOI: 10.1177/0148607107031005358] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mucosal addressin cellular adhesion molecule-1 (MAdCAM-1) directs lymphocyte migration into gut-associated lymphoid tissue (GALT) through Peyer's patches (PPs). Parenteral nutrition (PN) impairs mucosal immunity by reducing PPs MAdCAM-1 expression, T and B cells in GALT, and intestinal and respiratory immunoglobulin (Ig) A levels. We previously showed that PN reduces lymphotoxin beta receptor blockade (LTbetaR) in PPs and intestine, and that stimulation with LTbetaR agonist antibodies reverses these defects. To confirm that LTbetaR regulates transcription of MAdCAM-1 message and more fully understand the effects of LTbetaR on MAdCAM-1 function within the mucosal immune system, we studied the effect of LTbetaR blockade with a chimeric LTbetaR Ig-fusion protein on MAdCAM-1 mRNA levels, PP lymphocyte mass and IgA levels in the intestinal and respiratory tracts. METHODS Mice were cannulated and killed 3 days after receiving chow + control Ig, chow + LTbetaR-Ig fusion protein (100 microg IV), or PN + control Ig. The PPs of half of the animals were processed for lymphocyte count, and the other half were processed for complementary DNA and subsequent polymerase chain reaction (PCR). mRNA levels of MAdCAM-1 were determined by real-time PCR; intestinal and respiratory IgA levels were measured by ELISA. RESULTS PN significantly reduced PP lymphocyte mass, MAdCAM-1 mRNA, and intestinal IgA. As anticipated, LTbetaR blockade significantly decreased PP cells and MAdCAM-1 mRNA, but not intestinal IgA because chow feeding was maintained. Both LTbetaR blockade and PN decreased nasal IgA, but not significantly. CONCLUSIONS LTbetaR blockade in chow animals significantly reduces transcription of MAdCAM-1 gene and PPs lymphocyte mass. These data implicate inadequate LTbetaR signaling as a major mechanism for decreased GALT cells with lack of enteral stimulation, and further establish the role of LTbetaR in the mucosal immune system.
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Affiliation(s)
- Woodae Kang
- Department of Surgery, University of Wisconsin-Madison College of Medicine and Public Health, Madison, Wisconsin, USA
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Abstract
PURPOSE OF REVIEW Citrulline, a nonprotein amino acid, is an important source of endogenous arginine. The gut is the main source of citrulline in humans. Hence, citrulline is a potential biomarker of short bowel function. Conversely, citrulline uptake by the gut is important for an oral supply of this amino acid as an alternative to arginine. This review discusses these two aspects of citrulline, as well as the recent developments in the understanding of its metabolism. RECENT FINDINGS Citrullinemia is such an efficient marker when the active mass of the bowel is affected that it can be used as a prognostic marker for parenteral nutrition weaning (if citrullinemia is >20 micromol/l) and as a factor for deciding between parenteral and enteral nutrition (as long as the pathology is considered). Citrullinemia should be used with care as a marker either of the intestinal absorption or following small bowel transplantation. SUMMARY Citrulline is easily taken up by the gut, with a broad set of transporters that can remove it from the lumen in the enterocytes. This is confirmed by pharmacokinetic studies and the efficacy is so great that oral complementation with citrulline seems more efficient than complementation with arginine to provide arginine.
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Affiliation(s)
- Emmanuel Curis
- Laboratoire de Biomathématiques, Faculté de Pharmacie, Université Paris Descartes, Paris, France.
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