An analysis of the association between serum citrulline and acute rejection among 26 recipients of intestinal transplant

Application of Intestinal Barrier Molecules in the Diagnosis of Acute Cellular Rejection After Intestinal Transplantation

Diagnosing acute rejection after intestinal transplantation currently heavily relies on histopathological analysis of graft biopsies. However, the invasive risks associated with ileoscopic examination and the inaccessibility for biopsy after ileostomy closure hinder real-time detection of rejection responses. Molecules comprising the intestinal barrier have been identified as physiological and molecular biomarkers for various bowel conditions and systemic diseases. To investigate the potential of barrier function-related molecules in diagnosing rejection after intestinal transplantation, plasma samples were collected longitudinally from transplant recipients. The samples were categorized into "indeterminate for rejection (IND)" and "acute rejection (AR)" groups based on clinical diagnoses at each time point. The longitudinal association between plasma levels of these barrier function-related molecules and acute rejection was analyzed using the generalized estimating equations (GEE) method. Logistic GEE models revealed that plasma levels of claudin-3, occludin, sIgA, and zonulin were independent variables correlated with the clinical diagnosis of acute rejection. The subsequent prediction model demonstrated moderate ability in discriminating between IND and AR samples, with a sensitivity of 76.0%, specificity of 89.2%, and accuracy of 84.6%. In conclusion, monitoring plasma levels of claudin-3, occludin, sIgA, and zonulin shows great potential in aiding the diagnosis of acute rejection after intestinal transplantation.

Dried blood spot reference intervals for 18 amino acids in a 1 to 6 years old pediatric cohort

OBJECTIVES

Reference intervals are indispensable for the accurate clinical interpretation of clinical laboratory tests. The reference intervals of amino acids in dried blood spots (DBS) from nonnewborn children are limited. In this study, we aim to establish the pediatric reference intervals for amino acids in DBS from healthy Chinese children aged from 1 to 6 years and to investigate the effect of sex and age.

DESIGN AND METHODS

In 301 healthy subjects aged from 1 to 6 years old, eighteen DBS amino acids were determined using ultra-performance chromatography-tandem mass spectrometry method. Amino acid concentrations were examined in relation to sex and age. Reference intervals were established according to the CLSI C28-A3 guidelines.

RESULTS

Reference intervals of 18 amino acids bounded by the 2.5 and 97.5 percentiles were calculated in DBS specimen. No significant influence of age was observed for all the target amino acid concentrations in 1- to 6-year-olds. Sex differences were found in leucine and aspartic acid.

CONCLUSIONS

The RIs established in the present study added value for diagnosing and managing the amino acid-related diseases in the pediatric population.

Intestinal Transplant Immunology and Intestinal Graft Rejection: From Basic Mechanisms to Potential Biomarkers

Intestinal transplantation (ITx) remains a lifesaving option for patients suffering from irreversible intestinal failure and complications from total parenteral nutrition. Since its inception, it became obvious that intestinal grafts are highly immunogenic, due to their high lymphoid load, the abundance in epithelial cells and constant exposure to external antigens and microbiota. This combination of factors and several redundant effector pathways makes ITx immunobiology unique. To this complex immunologic situation, which leads to the highest rate of rejection among solid organs (>40%), there is added the lack of reliable non-invasive biomarkers, which would allow for frequent, convenient and reliable rejection surveillance. Numerous assays, of which several were previously used in inflammatory bowel disease, have been tested after ITx, but none have shown sufficient sensibility and/or specificity to be used alone for diagnosing acute rejection. Herein, we review and integrate the mechanistic aspects of graft rejection with the current knowledge of ITx immunobiology and summarize the quest for a noninvasive biomarker of rejection.

Citrulline, Biomarker of Enterocyte Functional Mass and Dietary Supplement. Metabolism, Transport, and Current Evidence for Clinical Use

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.

Graft assessment for acute rejection after intestinal transplantation: current status and future perspective

Intestinal transplantation has since its inception evolved as a lifesaving treatment option for patients with irreversible intestinal failure who can no longer be sustained on parenteral nutrition. Improvement in short-term survival after transplantation has also justified the expansion of treatment indications. Unfortunately, success is somewhat limited by a plateau observed in long-term survival. The reason for this sub-optimal long-term result experienced in this cohort may in part be attributed to the intestinal graft with the lymphoid content it carries inflicting the host with multiple complications where acute cellular rejection is one of the most common causes for graft loss. Graft monitoring is for this reason of paramount importance and detection of rejection at an early stage essential to enable early instigation of treatment and successful reversal of the pathology. Due to the challenges in diagnosing acute rejection with a noninvasive marker we are still limited to a surveillance protocol using endoscopy and biopsies for the diagnosis of rejection. The purpose of our paper is to review the adequacy of different methods in monitoring the graft for acute rejection using biomarkers, endoscopy and imaging. In conclusion, the evidence base continues to support the use of histology for the diagnosis of acute rejection. The role of biomarkers are still debatable, although markers such as calprotectin might be beneficial in excluding an ongoing process.

Citrulline as a marker of intestinal function and absorption in clinical settings: A systematic review and meta-analysis

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.

Long-term endoscopic follow-up in small bowel transplant recipients: single-center series

BACKGROUND

The reliability of endoscopic findings after adult intestinal transplantation on short-term follow-up has been shown. The aim of this study was to evaluate in a long-term follow-up the diagnostic value of endoscopies compared with the biopsy value.

METHODS

We evaluated 52 endoscopies over a period of 2 years (2 in each patient in 2010 and 1 in each patient in 2011, plus 1 endoscopy for suspected post-transplant lymphoproliferative disease [PTLD]) on 17 recipients transplanted between the years 2000 and 2006 (more than 5 years of follow-up).

RESULTS

All the 52 endoscopic findings were comparable to biopsy definitive results: only 1 case of mild enteritis and 1 case of Epstein-Barr virus (EBV) chronic infection at biopsy were not diagnosed by endoscopy. One case of rectal PTLD and 1 of EBV-related enteritis were diagnosed by use of both procedures. Specificity was 98%: we did not calculate sensitivity because no episodes of rejection were diagnosed because recipients were stable in long-term follow-up.

CONCLUSIONS

Endoscopy is a reliable procedure even on a long-term follow-up after intestinal transplantation, allowing a support to biopsy for diagnosis on adult recipients, especially for EBV infections and PTLD surveillance.

Updates on acute and chronic rejection in small bowel and multivisceral allografts

PURPOSE OF REVIEW

The surgical management of short bowel syndrome now includes intestinal (ITx) and multivisceral transplantation (MVTx), which has advanced and is now a sustainable option for the treatment of intestinal failure. Improvements in immunosuppressive therapies, excellence in surgical and medical management and enhanced post-transplant monitoring have all contributed to optimizing this solid organ transplant as a means of supplanting the diseased native bowel and alimentary tract with a functional alternative.

RECENT FINDINGS

Post-transplant management is a critical and challenging phase of gastrointestinal transplantation, and the transplant pathologist is an essential member of the transplant team who identifies many of the early and late complications after ITx and MVTx. Among the most injurious and common complications of ITx and MVTx is acute rejection and, to a lesser degree, chronic rejection. Both of these broad categories of rejection are principally identified by histopathological changes in the allograft; however, biomarkers and other laboratory analytes are rapidly evolving into critical ancillary tools in identifying and further characterizing the rejection process. Thus, the transplant pathologist must also be able to utilize numerous other laboratory tests and panels of molecular biomarkers that provide supplementary information to accompany the biopsy interpretation and clinical suspicion of rejection.

SUMMARY

Using biopsies and an assortment of additional approaches, the transplant pathologist is now able to provide swift and detailed information regarding the rejection process in the gastrointestinal transplant. This enables the clinical team to properly and successfully intercede, contributing to enhanced patient and graft survival.

Reduced plasma citrulline levels in low birth weight infants with necrotizing enterocolitis

BACKGROUND

Citrulline, a nonprotein amino acid, is an intermediate of the urea cycle and synthesized in small intestine. Lower plasma citrulline levels were associated with reduced function of enterocytes. Necrotizing enterocolitis (NEC) causes high morbidity and mortality, and leads impaired intestinal functions.

METHODS

Plasma citrulline levels of neonates with a gestational age <32 weeks and ≤1,500 gm who developed NEC stage II/III were measured by high-performance liquid chromatography.

RESULTS

We enrolled 36 preterm infants including 20 with NEC and 16 controls. Median citrulline levels of NEC and control groups were 8.6 and 20.18 μmol/l (P < 0.05), and cut off level of citrulline was 13.15 μmol/l with a sensitivity of 80% and a specificity of 82%. Median arginine levels of NEC and control groups were 22.02 and 39.89 μmol/l (P < 0.05), and cut off level of arginine was 28.52 μmol/l with a sensitivity of 70% and a specificity of 75%. Blood sampling day, gender, parenteral, and enteral nutrition did not affect the amino acid levels.

CONCLUSION

We found lower plasma citrulline and arginine levels in preterm infants with NEC. Further studies are needed to determine most appropriate levels to predict recovery and prognosis of NEC, and treatment options with these amino acids in preterm infants.

Clinical practice guidelines--Nursing management for pediatric patients with small bowel or multivisceral transplant

PURPOSE

Small bowel or multivisceral transplant is a relatively new treatment for irreversible intestinal damage, and no published practice guidelines exist. The purpose of this article is to report evidence regarding the best plan of care to achieve adequate nutrition and appropriate development for children.

DESIGN AND METHODS

An integrative review was conducted with 54 articles related to management of this transplant population. A nine-member nursing team integrated the findings.

PRACTICE IMPLICATIONS

This resulting guideline represents the best research and best practices on which to base staff education and competency validations to manage this medically fragile patient population.

Endoscopic evaluation of small intestine transplant grafts

BACKGROUND

The management of small bowel transplantation is unique because signs of rejection can be obtained visually by endoscopy. The aim of this study was to evaluate the accuracy of endoscopic appearance in assessing histologic evidence of acute cellular rejection (ACR).

METHODS

Endoscopies were performed in 66 asymptomatic "surveillance" small bowel transplant recipients and 71 symptomatic recipients from a single center. For surveillance patients, 125 ileoscopies were performed to collect 590 biopsies, and for the symptomatic group, 229 ileoscopies and jejunoscopies were conducted to obtain 434 biopsies.

RESULTS

The sensitivity and specificity of endoscopic visualization in detecting ACR was 50% and 91.5% for the surveillance group and 43% and 67% for the symptomatic patients. In surveillance, visual impression alone would have missed three cases of moderate and no cases of severe ACR, whereas in the symptomatic group, visual inspection alone would have missed 20 cases of moderate ACR, and findings from visual inspection of the chimney were normal in 55% of cases with proximal ACR. However, chimney biopsy was generally representative of biopsy findings in the proximal graft but would have missed moderate to severe rejection in three patients (1%). In a subset of 23 endoscopies, zoom endoscopy did not improve visual discrimination. The only complication was a biopsy-related non-life-threatening bleed.

CONCLUSIONS

In symptomatic patients, visual inspection detected all cases of severe rejection but would have missed patients with early readily treatable rejection and thus making biopsy mandatory in clinical practice. Our results support the current practice of ileoscopic biopsy alone for graft surveillance in asymptomatic patients.

Citrulline level is a potent indicator of acute rejection in the long term following pediatric intestinal/multivisceral transplantation

Citrulline has been advocated as a marker for acute cellular rejection (ACR) in intestinal transplantation; however, its significance as a forewarning in the long-term follow-up remains unknown. This study aimed to investigate the association between citrulline levels and the grading of ACR to establish a cutoff point that accurately predicts ACR beyond 3 months posttransplant in the pediatric patient population. During a 16-year period (1995-2011), a total of 13 499 citrulline samples were prospectively collected from 111 consecutive pediatric intestinal/multivisceral transplant recipients: 2155 were obtained concurrently with intestinal biopsies. There were 185 ACR episodes observed among 74/111 (67%) patients (median follow-up: 4.4 years). Citrulline levels were inversely proportional to the severity of ACR. Negative predictive values for any type of ACR (cutoff, 20 μmol/L) and moderate/severe ACR (cutoff, 10 μmol/L) were 95% and 99%, respectively. When patients were divided according to graft size, diagnostic accuracy using the same cutoff was identical. Similarly, subgroup analysis by the timing of citrulline measurement prior to biopsy varying from 1 to 7 days demonstrated comparable results. Citrulline is a potent indicator as a danger signal for ACR, being an exclusionary, noninvasive biomarker with excellent negative predictive values in the long term after pediatric intestinal/multivisceral transplant.

Plasma citrulline concentration as a marker for disease activity in patients with Crohn's disease

BACKGROUND

Citrulline is a nitrogen end product produced from the intermediary metabolism of glutamine through the enzymatically mediated urea cycle, almost exclusively in the enterocytes of small intestinal epithelium, with some synthesis in colonocytes. Intestinal dysfunction resulting from intestinal diseases or injuries affects intermediary metabolism, which includes citrulline synthesis. We sought to determine whether plasma citrulline was a biomarker for disease activity in patients with Crohn's disease with the hypothesis that citrulline concentration would be reduced during active disease.

METHODS

A total of 81 outpatients aged 18 to 65 years (mean, 40.6±15.4 y) with a known history of Crohn's disease were studied prospectively. Patients with prior small intestinal resection, or renal or hepatic insufficiency were excluded. Crohn's disease activity was measured by Harvey-Bradshaw Index (HBI) and was correlated to the plasma citrulline concentration measured simultaneously (ion chromatography). Spearman correlation coefficients were used to assess for an association between the 2 variables. Subgroup analyses of patients with isolated small intestinal disease and endoscopically or radiologic verified disease activity were also performed.

RESULTS

Twenty-two patients had isolated colonic disease and 59 had small intestinal involvement. Twenty-six of these patients had concurrent endoscopy and/or computed tomography or magnetic resonance imaging. On the basis of HBI scores, 32 patients had active disease (HBI ≥5) and 49 patients had inactive disease. The mean HBI scores were 4.8±5.5. The mean plasma citrulline concentration was normal, although was below normal in some patients. However, it failed to distinguish between active and inactive patients based on the HBI (active 27.8±8.8 μmol/L, inactive 27.8±11.1 μmol/L, P=0.991). There was no significant linear association between the ranks of citrulline and ranks of HBI (rs=0.012, P=0.915). Of the 59 patients with isolated small intestinal disease, there was no association between plasma citrulline concentration and the HBI (Spearman correlation coefficient, 0.073; P=0.583). There was no difference in plasma citrulline concentrations among those with confirmed inflammation by imaging or endoscopy (confirmed, 26.2±11.8; negative, 28.0±10.0; independent t test P=0.583).

CONCLUSIONS

Plasma citrulline concentration was not a marker of disease activity in patients with Crohn's disease. However, all patients studied were outpatients and it is possible that plasma citrulline concentration may be depressed only in patients with more severe disease or extensive small bowel involvement. In addition, plasma citrulline may be increased in the postabsorptional state, and for the most part, our patients were nonfasting. More studies are needed to further elucidate the role of citrulline as a marker of disease activity in patients with Crohn's disease. The possibility also exists that citrulline may be a better marker in patients with previous resection, and this group will require specific evaluation.

Characterization of the ileal microbiota in rejecting and nonrejecting recipients of small bowel transplants

Small bowel transplantation can be a life-preserving procedure for patients with irreversible intestinal failure. Allograft rejection remains a major source of morbidity and mortality and its accurate diagnosis and treatment are critical. In this study, we used pyrosequencing of 16S ribosomal RNA gene tags to compare the composition of the ileal microbiota present during nonrejection, prerejection and active rejection states in small bowel transplant patients. During episodes of rejection, the proportions of phylum Firmicutes (p < 0.001) and the order Lactobacillales (p < 0.01) were significantly decreased, while those of the phylum Proteobacteria, especially the family Enterobacteriaceae, were significantly increased (p < 0.005). Receiver-operating characteristic analysis revealed that relative proportions of several bacterial taxa in ileal effluents and especially Firmicutes, could be used to discriminate between nonrejection and active rejection. In conclusion, the findings obtained during this study suggest that small bowel transplant rejection is associated with changes in the microbial populations in ileal effluents and support microbiota profiling as a potential diagnostic biomarker of rejection. Future studies should investigate if the dysbiosis that we observed is a cause or a consequence of the rejection process.

Plasma citrulline as surrogate marker of intestinal inflammation in pediatric and adolescent with Crohn's disease: preliminary report

PURPOSE

Several researchers have found that plasma citrulline could be a marker of reduced enterocyte mass. The aim of this study was to assess the relationship between plasma citrulline and bowel inflammation and/or disease location in pediatric and adolescent Crohn's disease (CD) patients.

METHODS

Between January 2008 and January 2010, 31 CD patients and 44 controls were included in our study, and 15 out of the 31 CD patients continued a prospective survey. We evaluated the differences between groups, at baseline, in plasma citrulline and glutamine and between their baseline and final values during the prospective survey, and correlation between baseline values of citrulline and duration of disease, C-reactive protein, and fecal calprotectin.

RESULTS

Mean citrulline value was 33.0 ± 7.5 μmol/L in controls and 23.5 ± 8.4 μmol/L in CD patients (P < 0.0001). Plasma citrulline was significantly lower in patients with small bowel (SB) location than in patient with only ileo-colon disease (14.2 ± 5.5 and 24.7 ± 8.0, respectively; P = 0.0037). Citrulline ≤22 μmol/L reached sensitivity of 100% (95% confidence interval (CI) 54-100) and specificity of 98% (CI 89-99) in differentiating control subjects from CD with SB location.

CONCLUSIONS

CD patients have reduced concentration of plasma citrulline than controls. Intestinal damage rather than inflammation seems to be responsible for the reduced biosynthesis of citrulline, which decreases particularly in CD patients with SB location. This finding suggests the potential role of citrulline as marker of disease location, but future works will be needed to confirm this suggestion.

Biomarkers of immunosuppressant organ toxicity after transplantation: status, concepts and misconceptions

INTRODUCTION

A major challenge in transplantation is improving long-term organ transplant and patient survival. Immunosuppressants protect the transplant organ from alloimmune reactions, but sometimes also exhibit limiting side effects. The key to improving long-term outcome following transplantation is the selection of the correct immunosuppressive regimen for an individual patient for minimizing toxicity while maintaining immunosuppressive efficacy.

AREAS COVERED

Proteomics and metabolomics have the potential to develop sensitive and specific diagnostic tools for monitoring early changes in cell signal transduction, regulation and biochemical pathways. Here, we review the steps required for the development of molecular markers from discovery, mechanistic and clinical qualification to regulatory approval, and present a critical discussion of the current status of molecular marker development as relevant for the management and individualization of immunosuppressive drug regimens.

EXPERT OPINION

Although metabolomics and proteomics-based studies have yielded several candidate molecular markers, most published studies are poorly designed, statistically underpowered and/or often have not gone beyond the discovery stage. Most molecular marker candidates are still at an early stage. Due to the high complexity of and the resources required for diagnostic marker development, initiatives and consortia organized and supported by funding agencies and regulatory agencies will be critical.

[Small intestine, pancreas and islet cell transplantation]

The past decade has seen substantial improvements in patient and graft survival after intestinal transplantation. This improvement has been achieved by advances in donor and recipient selection, patient management, immunosuppression and surgical techniques. Intestinal transplantation is therefore considered a therapeutic option in the treatment of short bowel syndrome. Mile stones include the development of the calcineurin inhibitor Tacrolimus for immunosuppression as well as induction therapy using immune modulating substances like interleukin-2 receptor antagonists and antilymphocyte preparations. In addition to improvements in immunosuppression, antimicrobial prophylaxis and diagnosis of rejection, advances in surgical techniques have been crucial to achieving increased graft survival. Pancreas transplantation, generally with simultaneous kidney transplantation, is now available as a treatment option for patients with labile diabetes mellitus (usually type 1). Allogeneic islet transplantation was developed in the 1990s as a minimally invasive alternative to pancreas transplantation. Pancreatic islets are isolated enzymatically from the donor pancreas, in most cases infused into the portal vein and thus engrafted into the liver. Currently, technical and medical problems as well as high costs prevent the application of islet transplantation as a therapeutic option for a larger number of patients with diabetes mellitus.

Serum markers and intestinal mucosal injury in chronic gastrointestinal ischemia

BACKGROUND

Diagnosing chronic gastrointestinal ischemia (CGI) is a challenging problem in clinical practice. Serum markers for CGI would be of great diagnostic value as a non-invasive test method.

AIMS

This study investigated serum markers in patients with well-defined ischemia. Furthermore, intestinal mucosal injury was also evaluated in CGI patients.

METHODS

Consecutive patients suspected of CGI were prospectively enrolled and underwent a diagnostic work-up consisting of gastrointestinal tonometry and either CT or MR angiography. Blood samples for analysis of intestinal fatty acid-binding protein (I-FABP), D-dimer, lactate dehydrogenase (LDH), leucocyte counts, C-reactive protein (CRP), and L-lactate were drawn before and after a standard meal. Intestinal mucosal injury was assessed with glutamine, citrulline and arginine in blood samples and compared to a sugar absorption test (SAT). Test reproducibility was validated in healthy subjects.

RESULTS

Forty patients and nine healthy subjects were included. Ischemia was diagnosed in 32 patients (80%). I-FABP, leucocyte counts, LDH, CRP, glutamine, citrulline, arginine and SAT levels did not differ between patients with and without ischemia. L-lactate concentration showed a significant elevation in ischemia patients as compared to non-ischemia patients. In ischemia patients, D-dimer levels showed a significant elevation postprandially as compared to D-dimer levels at baseline. However, these ischemia patients did not show intestinal mucosal injury.

CONCLUSIONS

I-FABP, leucocyte counts, LDH and CRP levels are not clinically useful for the diagnosis of CGI. However, postprandial rises in L-lactate and D-dimer serum levels can serve as non-invasive indicators of CGI.

Citrulline levels in a paediatric age group: does measurement on dried blood spots have additional value?

BACKGROUND

Citrulline is considered to be a marker of absorptive enterocyte mass. Citrulline levels can be measured in plasma or dried blood spot (DBS) samples. The purpose of this study is to calculate reference intervals for plasma and DBS citrulline concentrations in children and to examine the effect of age and gender.

METHODS

In 151 healthy subjects ranging from 1 month to 20 years of age, plasma and DBS citrulline concentration were determined by using Liquid Chromatography-tandem Mass Spectrometry. Citrulline concentrations were examined in relation to age and gender. Reference values were calculated according to the guidelines of the International Federation of Clinical Chemistry and the National Committee on Clinical Laboratory Standards.

RESULTS

No significant influence of age and gender could be discerned on plasma or DBS citrulline concentration. In children, the reference intervals for citrulline bounded by the 2.5 and 97.5 percentiles are 13.31-69.05 μmol/L and 23.70-49.04 μmol/L for plasma and DBS samples respectively.

CONCLUSIONS

The reference intervals for citrulline levels in healthy children are widely dispersed. Measuring citrulline concentrations in dried blood spots delivers no additional value to plasma measurements for the calculation of reference intervals in children.

Intestine transplantation in children: update 2010

This article reviews the current status of pediatric intestinal transplantation, focusing on referral and listing criteria, surgical techniques, patient management, monitoring, complications after transplant, and short- and long-term patient outcome. Intestine transplantation has become the standard of care for children who develop life-threatening complications associated with intestinal failure. The results of intestinal failure treatment have significantly improved in the last decade following the establishment of gut rehabilitation programs and advances in transplant immunosuppressive protocols, surgical techniques, and posttransplant monitoring. The 1-year patient survival is now 80% and more than 80% of the children who survive the transplant are weaned off parenteral nutrition. Early referral for pretransplant assessment and careful follow-up after transplant with prompt recognition and treatment of transplant-related complications are key factors contributing to superior patient outcomes and survival. The best results are being obtained at high-volume centers with survival rates of up to 75% at 5 years.

The citrulline generation test: proposal for a new enterocyte function test

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.

Correlation of motility and neuronal integrity with a focus on the grade of intestinal allograft rejection

Intestinal graft motility after small bowel transplantation (SBT) is poorly characterized. The aim of this study was to compare motor patterns with myenteric neuronal cell population as a parameter of graft viability at various degrees of acute cellular rejection (ACR). Three grades of ACR were achieved in orthotopic allografts. Syngeneic transplants and allografts with immunosuppression served as controls. Motor activities were recorded using strain gauge force transducers and analyzed visually. Quantifications of myenteric neurons in whole mounts of intestinal grafts were used to evaluate neuronal population. A typical migrating motor complex (MMC) was found in syngeneic and allogenic transplants with immunosuppression. A high prevalence of discrete clustered contractions (DCC) and nonpropagating contractions (NPC) without MMC was seen in moderately and severely rejected allografts. Neuronal cell loss in the allografts, which could be one of the causes of motor dysfunction, was noted in moderate rejection (19.3%) and progressed until severe rejection (60.1%). Monitoring motility patterns in SBT could be an effective tool for assessing intestinal rejection. Allograft dysmotility, such as absence of MMC and high prevalence of DCC or NPC, could be useful markers of progression of acute rejection and help guide treatment decisions.

Present status and future perspectives of intestinal transplantation

Intestinal transplantation (ITx) is the only definitive therapy for irreversible intestinal failure. Owing to the limited short- and long-term graft survival over the years, ITx has been a complementary treatment to home parenteral nutrition. However, the development of intestinal and multivisceral transplantation has been significant over the past 15-20 years owing to the progress in immunosuppressive therapy, refinement of surgical techniques, post-transplant care, intestinal immunology, and immunological as well as anti-infectious monitoring. The improvement of patient- and graft survival over the last few years together with data on the cost effectiveness of ITx, following 2 years after transplantation, may require a redefinition of the indication for ITx.

Critical sample pretreatment in monitoring dried blood spot citrulline

BACKGROUND

Plasma Citrulline concentration has been correlated to functional enterocyte mass. Dried blood spot (DBS) analysis using LC-MSMS reduces sample amount needed. We optimized DBS elution to increase precision and accuracy of DBS LC-MSMS analysis.

METHOD

DBS control samples were eluted in varying pH (2.2-7.0) and for varying times (15-75 min) and Cit, Arg and Orn were analyzed using LC-MSMS, with and without derivatization. In 20 volunteers, the DBS LC-MSMS assay was correlated with a plasma ion exchange HPLC method.

RESULTS

For Citrulline an extraction optimum was obtained at pH 2.6, whereas lower Arginine concentrations were found using low extraction pH. Increasing elution times lead to increased concentrations. Within-run CV was higher with, compared to without derivatization. No close association could be found between plasma HPLC and DBS LC-MSMS concentrations.

CONCLUSION

Analysis of amino acids on DBS using LC-MSMS should be optimized regarding the purpose of the assay. In our study, most optimal results were obtained without derivatization and elution in pH 2.6 for 45 min. Cellular amino acids in DBS might influence the correlation of Cit with severity of enteral disorders. Therefore, further evaluation of DBS Cit as a marker for enteral disorders is warranted.

Calprotectin: a novel noninvasive marker for intestinal allograft monitoring

OBJECTIVE

To identify a noninvasive screening test for intestinal allograft monitoring.

SUMMARY BACKGROUND DATA

Intestinal allograft rejection is difficult to distinguish from other causes of diarrhea and can rapidly lead to severe exfoliation or death. Protocol biopsies are standard for allograft monitoring but may cause serious complications. No noninvasive test has shown clinical utility for monitoring of the intestinal allograft.

METHODS

Calprotectin levels (n = 68) were measured in this pilot study from ileostomy effluent in patients with histologic evidence of acute rejection (n = 12), viral enteritis (n = 5), and nonspecific inflammation (n = 16) and compared with those with normal allograft histology (n = 35).

RESULTS

Median stool calprotectin levels from patients with rejection were significantly higher than those from patients with viral enteritis or normal biopsies [198 mg/kg compared with 7 and 19 mg/kg, respectively (P = 0.0002)]. Receiver operator characteristics suggest the optimal cut-off level to distinguish rejection from other diagnoses is 92 mg/kg with specificity of 77% and sensitivity of 83%. Although false-positive results occurred in 26% of patients with normal biopsies and 30% with nonspecific changes, no treated episode of acute rejection was below the cutoff. In addition, in 2 patients with serial levels, elevations in the calprotectin levels preceded histologic changes by 6 to 18 days.

CONCLUSIONS

Low stool calprotectin levels correlate well with a low risk for intestinal allograft rejection. If confirmed, biopsies may be reserved in the future for confirmation of rejection, eliminating protocol biopsies, and immunosuppressive changes could potentially be made before allograft injury.

Plasma citrulline concentration: a reliable marker of small bowel absorptive capacity independent of intestinal inflammation

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.

Biomarkers for radiation-induced small bowel epithelial damage: An emerging role for plasma Citrulline

Reduction of cancer treatment-induced mucosal injury has been recognized as an important target for improving the therapeutic ratio as well as reducing the economic burden associated with these treatment related sequellae. Clinical studies addressing this issue are hampered by the fact that specific objective parameters, which enable monitoring of damage in routine clinical practice, are lacking. This review summarizes pros and cons of currently available endpoints for intestinal injury. The metabolic background and characteristics of plasma citrulline, a recently investigated biomarker specifically for small intestinal injury, are discussed in more detail.

Citrulline: a new player in the control of nitrogen homeostasis

Citrulline (CIT) is an amino acid that is not involved in protein synthesis but that is tightly linked to arginine (ARG) metabolism. CIT displays a very specific metabolism: In the 1980s, Windmuller demonstrated that the small intestine releases CIT, which is mainly taken up by the kidney and metabolized into ARG. Because CIT is not taken up by the liver, this ARG-CIT-ARG cycle can be seen as a means of protecting dietary ARG from liver degradation and of sustaining protein homeostasis. These observations have led to the concept that plasma CIT concentration would be a good marker of intestinal failure in short bowel syndrome. Hence, in massive intestinal resection, citrullinemia is greatly reduced, and this is proportional to the severity of the intestinal disease. This concept was then extended to other situations in which the intestinal function is compromised. The data strongly suggest that CIT may be a conditionally essential amino acid in situations where the intestinal function is compromised. Recent data support this idea. Thus, CIT supplementation is able to restore nitrogen balance, generate large amounts of ARG in rats with short bowel syndrome, and increase muscle protein content (+20%) as well as muscle protein synthesis (+90%) in elderly malnourished rats. Finally, recent data indicate that CIT per se could be able to stimulate muscle protein synthesis. Hence, CIT could play a pivotal role in maintaining protein homeostasis, and the determination of the underlying mechanisms involved in its action should be important for the development of new nutritional strategies in malnourished patients with compromised intestinal functions.

Current status of transplantation of the small intestine

The evolution of small bowel transplantation has been significant over the past 20 years to the point at which it can now be considered a viable and often successful option in the treatment of many forms of short bowel syndrome. A refinement of surgical techniques, improved immunosuppression, enhanced understanding of gut immunology, and better treatment and prevention of complications have contributed to a marked improvement in graft and patient survival. Whereas this transplant population is still beset with many potential complications after isolated bowel or multivisceral transplantation and long-term graft survival (like with other solid organ transplants) remains a challenge, the future holds promise for a continuation of the current positive trend of improvement in several areas.

The value of plasma citrulline to predict mucosal injury in intestinal allografts

Diagnosis of intestinal transplant rejection depends on clinical assessment, endoscopy and most importantly, histology of intestinal biopsies. Plasma citrulline levels (P-Cit) reflect functional enterocyte mass in nontransplant patients and have been evaluated in two small series after transplant. This study was designed to determine the sensitivity and specificity of P-Cit as diagnostic tool for allograft injury, especially to distinguish between viral enteritis and rejection. We prospectively collected 403 P-Cit samples within 24 h of intestinal biopsy in 49 patients. P-Cit levels were correlated with the mucosal damage and histopathological diagnoses. P-Cit levels in bowels with significant mucosal damage (i.e. moderate or severe rejection, viral enteritis, PTLD, ischemia reperfusion injury, allergic enteritis) were significantly lower than in intestines with no or mild injury (i.e. indeterminate or mild rejection, nonspecific enteritis): 22.9 +/- 15.4 versus 38 +/- 23.2 nmol/mL (p < 0.0001). Sensitivity and specificity of the test were 80% and 58.1% for rejection, and 56.5% and 66% for viral enteritis, thereby unable to distinguish between both entities. In conclusion, P-Cit reflects the extent of mucosal injury regardless of the etiology, but does not seem to be a predictive marker for rejection or viral enteritis, as its values may decline only when diffuse mucosal damage has occurred.

An association of lower serum citrulline levels within 30 days of acute rejection in patients following small intestine transplantation

INTRODUCTION

In a prospective protocol we studied whether serum citrulline level within 30 days of an acute rejection was predictive of the episode.

METHODS

An acute rejection episode was defined as the date of occurrence of any biopsy-proven rejection in which treatment was initiated until two successive biopsies showed no further rejection. We compared the mean citrulline level based on values determined within 30 days of the start of an acute rejection episode with the mean citrulline level measured on the same patient during a rejection-free period. Serum citrulline measurements were available immediately prior to the occurrence of rejection for 22 patients who experienced 37 episodes.

RESULTS

For the 12 episodes of mild rejection, the mean serum citrulline level +/- SE (standard error) was 15.0 + 2.3 micromol/L prior to rejection and 18.8 +/- 2.4 micromol/L during the rejection-free periods. A paired t test of the mean differences was not significant (P = 17). For the 25 episodes of moderate or severe rejection, the mean serum citrulline level was 12.4 +/- 1.1 micromol/L before rejection and 18.8 +/- 2.0 micromol/L during the rejection-free periods. A paired t test of the mean difference was statistically significant (P = .002).

CONCLUSIONS

Although further study of citrulline as a marker for the early detection of acute rejection episodes is needed, our hope is that its use will help to prevent some of these early episodes from evolving into full-blown moderate or severe grades of rejection.

Combined liver transplants: main characteristics from the standpoint of anesthesia and support in intensive care

Combined transplants with the liver represent a small number of associated pathologies with little chance of resolving with a single transplant. The small case number prevents us from establishing homogeneous criteria for the procedure. The insertion of the Model for End-Stage Liver Disease in the preoperative evaluation of the patients awaiting liver transplant has definitely increased the number of combined liver-kidney transplants, which have reached more significant numbers. The number of heart-liver transplants is still too low to establish the efficacy of the measure. The multiorgan transplant with the liver represents a rare event entrusted to a series of case reports, each one of which has a history unto itself. Our experience in this field includes 14 combined liver-kidney, six combined heart-liver, and two multiorgan transplants with liver among 36 intestine transplants. We have examined the main pre-, intra-, and postsurgical problems for each one of these transplants, particularly relating to the anesthetic and intensive-care aspects.

Zoom endoscopic monitoring of small bowel allograft rejection

BACKGROUND

The small bowel has been successfully transplanted in patients with irreversible intestinal failure. This report aims to describe endoscopic monitoring of small bowel rejection.

METHODS

A magnification endoscope (zoom endoscope) was used in this study. In the first part of the study (October 1998 to March 2000, 271 endoscopy sessions), the specific endoscopic findings that correlated with rejection were determined. An analysis then was performed on data from the second period (March 2001 to November 2002, 499 sessions) to evaluate the zoom endoscope's accuracy in monitoring rejection.

RESULTS

Specific endoscopic findings of rejection found in the first period included background erythema, villous congestion, blunted villous tip, and shortened villous height. When the rejection was successfully treated, endoscopic appearance returned to normal. On the basis of these findings, five endoscopic criteria (villous shortening, villous blunting, background erythema, villous congestion, and mucosal friability) were used to score endoscopic sessions in the second period. Endoscopic diagnosis of rejection was compared with histology. Adult patients showed a sensitivity of 45%, a specificity of 98%, a positive predictive value of 82%, and a negative predictive value of 88%. In pediatric patients, these values were, respectively, 61%, 84%, 57%, and 86%. On 59 distinct occasions (30 in period 1 and 29 in period 2) in which the results were endoscopy negative yet biopsy positive (mild) for rejection, we elected not to treat these rejections on the basis of clinical evaluation, and 58 (98%) resolved without further therapy.

CONCLUSIONS

With the use of magnification, endoscopy is a useful tool for monitoring acute rejection in the small bowel allograft.

Utilization of Dried Blood Spot Citrulline Level as a Noninvasive Method for Monitoring Graft Function Following Intestinal Transplantation

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.

Potential of Real-Time PCR Assessment of Granzyme B and Perforin Up-Regulation for Rejection Monitoring in Intestinal Transplant Recipients

Granzyme B (GrB) and perforin are promising markers to predict acute rejection episodes of transplanted organs. Having recently reported that immunohistochemical expression of GrB/perforin correlates with histologically assessed acute cellular rejection (ACR) episodes in intestinal transplantation recipients, herein we have additionally explored the potential of real-time polymerase chain reaction (PCR) assessment of GrB/perforin gene up-regulation in peripheral blood mononuclear cells. Both immunohistochemical evaluation of GrB/perforin expression and real-time PCR assessment of up-regulation, which was defined as a 2-fold increase with respect to "basal" levels during maintenance immunosuppressive protocols, were performed among a population of 23 intestinal transplant recipients under routine surveillance, in addition to histological analysis of ACR. The ACR scores showed direct relationships both with GrB/perforin immunohistochemistry (IHC) scores (P < .001) and with gene up-regulation by real-time PCR (P = .004). Furthermore, real-time PCR upregulation was associated with the IHC score (P < .001). A preliminary analysis of diagnostic accuracy-performed to gain information to plan future studies-indicated that when using histological assessment as the reference technique, our current definition of PCR up-regulation provided good specificity (84%) but insufficient sensitivity (44%) for a noninvasive prediction of ACR. The results of this pilot study suggested that real-time PCR analysis of GrB/perforin upregulation may help therapeutic decision making, and have the potential for detection of presymptomatic rejection. More extensive studies must investigate strategies to improve the sensitivity of the analyses of GrB/perforin up-regulation.