Glucose absorption kinetics in Zambian African patients with and without systemic bacterial infections

Direct In Vivo Human Intestinal Permeability (Peff ) Determined with Different Clinical Perfusion and Intubation Methods

Regional in vivo human intestinal effective permeability (Peff ) is calculated by measuring the disappearance rate of substances during intestinal perfusion. Peff is the most relevant parameter in the prediction of rate and extent of drug absorption from all parts of the intestine. Today, human intestinal perfusions are not performed on a routine basis in drug development. Therefore, it would be beneficial to increase the accuracy of the in vitro and in silico tools used to evaluate the intestinal Peff of novel drugs. This review compiles historical Peff data from 273 individual measurements of 80 substances from 61 studies performed in all parts of the human intestinal tract. These substances include: drugs, monosaccharaides, amino acids, dipeptides, vitamins, steroids, bile acids, ions, fatty acids, and water. The review also discusses the determination and prediction of Peff using in vitro and in silico methods such as quantitative structure-activity relationship, Caco-2, Ussing chamber, animal intestinal perfusion, and physiologically based pharmacokinetic (PBPK) modeling. Finally, we briefly outline how to acquire accurate human intestinal Peff data by deconvolution of plasma concentration-time profiles following regional intestinal bolus dosing.

Jejunal absorption rates of glucose and glycine in post-infective tropical malabsorption

In a prospective study jejunal absorption rates of glucose (from a 200 mmol 1-1 solution) and glycine (from a 100 mmol 1-1 solution) were measured, using a perfusion technique, in nine patients with clinical evidence of post-infective tropical malabsorption (TM group) and in 10 others with trivial symptoms who had also visited the tropics (control group); all were of northern European origin. Seven and one in the two groups, respectively, had Giardia lamblia infections. Mean glucose absorption rate was significantly impaired by TM (P less than 0.01); mean rate for glycine was also depressed but not significantly. Presence of G. lamblia did not affect the severity of malabsorption although numbers studied were small.

Rates and mechanisms of glucose, galactose, and xylose absorption in man in vivo

Jejunal absorption-rates of glucose, galactose, and xylose were determined consecutively, using a double-lumen tube perfusion technique, in 6 Arab subjects in vivo; perfusion solutions contained 200 mmol/l of each monosaccharide. Mean xylose absorption rate was significantly lower than that for glucose (P less than 0.001) and galactose (P less than 0.001). In order to investigate evidence that glucose and xylose share the same jejunal transfer mechanism, their absorption-rates when given alone and together, at high concentrations, were determined in 6 other Arabs; perfusion solutions contained (1) 200 mmol/l glucose, (2) 100 mmol/l xylose, and (3) 200 mmol/l glucose + 100 mmol/l xylose. Rates of glucose and xylose absorption were not significantly influenced by the other monosaccharide. This study does not therefore confirm existence of a common transfer mechanism. A significant correlation between absorption rate of glucose and weight of xylose excreted after a 25 g oral load (P less than 0.05) was demonstrated.

Absorption of xylose, glucose, glycine, and folic (pteroylglutamic) acid in Zambian Africans with anaemia

Rates of glucose, glycine, and folic (pteroylglutamic) acid absorption were determined for a 30 cm jejunal segment in vivo, with a double-lumen tube perfusion system, in 10 Zambian African women with a mean haemoglobin concentration of 5-1 (3-5-9-2) g/dl. In four the anaemia was megaloblastic (due to folate deficiency) and in six hypochromic. Perfusion solutions contained (1) glucose 200 mmol/1, (2) glycine 100 mmol/1, and (3) folic acid 250 mug/1. D-xylose absorption after a 25 g oral load was determined in them, and also in 18 additional patients (11 had megaloblastic and seven either hypochromic or haemolytic anaemia). Xylose absorption tests were significantly impaired in the patients with megaloblastic compared with hypochromic or haemolytic anaemia (P less than 0-001); those with untreated megaloblastic anaemia had a greater abnormality than those who had started treatment. Mean glucose, glycine, and folic acid absorption rates were similar to those in controls, and the rates in patients with megaloblastic and hypochromic anaemia were not significantly different. Correlation between glucose absorption rate and xylose excretion was, however, significantly (P less than 0-02). If more patients had been studied it seems likely therefore that a significant impairment of glucose absorption rate in the presence of megaloblastic anaemia would also have been demonstrated. In this investigation anaemia per se did not affect glucose, glycine, or folic acid absorption rates or xylose absorption, but xylose absorption was reduced in patients with megaloblastic anaemia. That abnormality was probably related to folate deficiency, and the underlying mechanism seems to be different from that causing impairment of monosaccharide absorption in patients with systemic bacterial infections. Mean glycine and folic acid absorption rates were not altered by megaloblastic anaemia, indicating that folate deficiency does not cause a general depression of absorption.

Relation between malaria serum gamma-globulin concentration and the D-xylose absorption test

D-xylose excretion after a 25 g. oral load was determined in 15 African subjects suffering from malaria. Nine of them were re-investigated after the malaria had been or was being treated. Malarial parasitaemia and pyrexia did not significantly influence results of the D-xylose test. However, in the untreated subjects, there was a significant inverse correlation between the weight of D-xylose excreted and the serum gamma-globulin concentrations. The observation may have a nutritional importance.

Jejunal absorption rates of glucose, glycine and glycylglycine in Zambian African adults with malnutrition

1. Absorption rates of glucose (from a 200 mM solution), glycine (from a 100 mM solution), and glycylglycine (from a 50 mM solution) have been estimated in six Zambian African adults with clinical evidence of malnutrition. A double-lumen tube technique was used to determine absorption rates from a 300 mm section of jejunum in vivo.

2. Two of the subjects had ileal tuberculosis and Kaposi's sarcoma respectively. A third probably had abdominal tuberculosis. Three of them had pellagra. Mean serum albumin concentration was 24 (14–43) g/l. Absorption rates have been compared with those in Zambian Africans (control subjects), previously studied, who had no clinical evidence of malnutrition, systemic infection or of gastrointestinal disease.

3. Mean glucose, glycine and glycylglycine absorption rates in the malnourished subjects were not significantly different from those in the control subjects. Mean net water absorption rate from the glucose solution was similar in the malnourished subjects and controls; during the glycine and glycylglycine perfusions the mean net absorption rate was, however, significantly lower in the malnourished subjects (P < 0.01 and P < 0.05 respectively); mean net water transfer during the glycine perfusions was towards the jejunal lumen in the malnourished subjects. One subject with pellagra had an abnormal excretion of D-xylose after a 25 g oral load; all other tests were normal.

4. It seems probable that malnutrition must be very severe, with jejunal mucosal abnormalities, before absorption rates of glucose, glycine and glycylglycine are significantly altered. The present study does not support the view that subclinical malnutrition is important in producing malabsorption of dietary components in Zambian African subjects. Systemic bacterial infections, and raised serum γ-globulin and immunoglobulin IgG concentrations have previously been associated with an impairment of glucose absorption rate in Zambian African subjects; those factors seem much more likely than subclinical malnutrition to be relevant, in the context of absorption, in the pathogenesis of overt malnutrition.

Inverse relation between serum IgG concentration and glucose and xylose absorption in Zambian African adults

In three separate investigations in Zambian African adults in Lusaka an inverse association has been shown between serum IgG concentration and either glucose absorption rate from the jejunum (from a 200-mM solution) or xylose absorption (from a 25-g oral load). In developing areas of the world, where serum IgG concentrations are often high, this finding may have widespread nutritional implications.

Reaction of human small intestine to an intraluminal tube and its importance in jejunal perfusion studies

A double-lumen tube with a mercury weight attached to its distal end was positioned in the small intestine of six subjects who were to undergo an elective laparotomy. The tube and the technique for its localization were exactly similar to those used in previous intestinal perfusion experiments. Marked ;concertinaing', or gathering of the small intestine proximal to the mercury weight, was seen at laparotomy in all six subjects. The ratio between the mean intestinal length from the mercury weight to the ligament of Treitz after removal of the tube to that with the tube in situ was 3.0 (2.5-3.8). Mean total jejuno-ileal length was 421 (320-521) cm. In five of the six subjects the distal end of the tube was more than half way between the ligament of Treitz and the ileo-caecal valve although it was only 100-120 (mean 108) cm from the incisor teeth. Segmental perfusion studies of the human jejunum involve a much longer length of small intestine than is generally assumed-by a factor of approximately 3. Such studies assess absorption rates over a substantial proportion of the small intestine and are not confined to a short segment of proximal jejunum. The nutritional significance of such studies in which amino acids, peptides, and carbohydrates are investigated is increased. Studies designed to measure absorption rates from the ileum should be treated with caution as part or all of the perfusion segment may be past the ileo-caecal valve.

Lactose absorption kinetics in Zambian African subjects

1. Using a double-lumen tube perfusion system, solutions of lactose (50, 125 and 250 mmol/l) were introduced into the upper jejunum of six Zambian African subjects. By reference to a non-absorbable marker, polyethylene glycol, mol. wt 4000, the rates of absorption of lactose from each solution were calculated for a 300 mm jejunal segment.

2. In three subjects total lactase activity of the jejunal mucosa and brush-border lactase and other disaccharidase activities were estimated. The jejunal total and brush-border lactase activities were low. Jejunal morphology was normal for African subjects.

3. All subjects suffered abdominal colic and diarrhoea during and after the lactose perfusions. The kinetic curves for lactose were very shallow, and with all perfused solutions, there was a net movement of water into the jejunal lumen. The limited number of subjects, and the low and narrow range of enzyme activity, did not permit correlation between lactose absorption rate and lactase activity.

4. In Zambian African subjects with adult hypolactasia, the jejunal mucosa absorbs a very small proportion of the perfused lactose.

Increased glycine absorption rate associated with acute bacterial infections in man

1. Glycine absorption rate from a 300 mm jejunal segment was determined in vivo in four Zambian African subjects with acute, and four with chronic, respiratory infections. Glycine solutions (100, 150 and 250 mmol/l) were perfused, by means of a double-lumen tube technique. The results were compared with those for four relatively normal Zambian African subjects (‘reference’ group) previously studied. The group with acute-infections had a significantly higher mean absorption rate than the reference or chronic-infection group.

2. Glycine absorption results from a 100 mmol/l glycine solution in an additional twenty-four Zambian African subjects have also been analysed. When results for the thirty-six subjects were combined, those with acute bacterial infections had a significantly higher mean absorption rate than the normal subjects or those with chronic infections. For the twenty-one normal subjects there was a significant positive correlation between the individual absorption rates and serum total globulin and γ-globulin concentrations.

3. It seems likely that the rapid catabolism of protein associated with infection is counteracted by an increase in amino acid absorption rate. In subjects on a low-protein diet that mechanism would be limited. The deterioration in nutritional status during infections in developing countries could therefore be partly explained by the present observation.