Biochemical and genetic studies in cystinuria: observations on double heterozygotes of genotype I-II

The antioxidant l-Ergothioneine prevents cystine lithiasis in the Slc7a9-/- mouse model of cystinuria

The high recurrence rate of cystine lithiasis observed in cystinuria patients highlights the need for new therapeutic options to address this chronic disease. There is growing evidence of an antioxidant defect in cystinuria, which has led to test antioxidant molecules as new therapeutic approaches. In this study, the antioxidant l-Ergothioneine was evaluated, at two different doses, as a preventive and long-term treatment for cystinuria in the Slc7a9-/- mouse model. l-Ergothioneine treatments decreased the rate of stone formation by more than 60% and delayed its onset in those mice that still developed calculi. Although there were no differences in metabolic parameters or urinary cystine concentration between control and treated mice, cystine solubility was increased by 50% in the urines of treated mice. We also demonstrate that l-Ergothioneine needs to be internalized by its transporter OCTN1 (Slc22a4) to be effective, as when administrated to the double mutant Slc7a9-/-Slc22a4-/- mouse model, no effect on the lithiasis phenotype was observed. In kidneys, we detected a decrease in GSH levels and an impairment of maximal mitochondrial respiratory capacity in cystinuric mice that l-Ergothioneine treatment was able to restore. Thus, l-Ergothioneine administration prevented cystine lithiasis in the Slc7a9-/- mouse model by increasing urinary cystine solubility and recovered renal GSH metabolism and mitochondrial function. These results support the need for clinical trials to test l-Ergothioneine as a new treatment for cystinuria.

Environmental cystine drives glutamine anaplerosis and sensitizes cancer cells to glutaminase inhibition

Many mammalian cancer cell lines depend on glutamine as a major tri-carboxylic acid (TCA) cycle anaplerotic substrate to support proliferation. However, some cell lines that depend on glutamine anaplerosis in culture rely less on glutamine catabolism to proliferate in vivo. We sought to understand the environmental differences that cause differential dependence on glutamine for anaplerosis. We find that cells cultured in adult bovine serum, which better reflects nutrients available to cells in vivo, exhibit decreased glutamine catabolism and reduced reliance on glutamine anaplerosis compared to cells cultured in standard tissue culture conditions. We find that levels of a single nutrient, cystine, accounts for the differential dependence on glutamine in these different environmental contexts. Further, we show that cystine levels dictate glutamine dependence via the cystine/glutamate antiporter xCT/SLC7A11. Thus, xCT/SLC7A11 expression, in conjunction with environmental cystine, is necessary and sufficient to increase glutamine catabolism, defining important determinants of glutamine anaplerosis and glutaminase dependence in cancer.

Cancer cells need to consume certain nutrients in order to grow, and some cancer drugs work by affecting the ability of the cells to use these nutrients. For decades researchers have grown cancer cells in petri dishes with standard nutrient formulations (also known as tissue culture), but the nutrients available to cancer cells in tissue culture are not the same as those found in the body.

Cancer cells growing in tissue culture consume large amounts of a nutrient called glutamine. These cells die when exposed to a class of drugs called glutaminase inhibitors that prevent them from processing glutamine. However, when these same cancer cells grow as tumors in animals, they process less glutamine and are not affected by glutaminase inhibitors. So what differences are there between growing cancer cells in tumors and tissue culture that explain this different reliance on glutamine?

Muir et al. reasoned that changing the levels of nutrients available to cancer cells might change what these cells consume, and so grew human cancer cells in cow serum (which has a similar nutrient content to blood in humans and other mammals). Indeed, these cells consumed less glutamine and responded to glutaminase inhibitors in a way that is similar to how tumors in the body respond to these drugs. Comparing the nutrient content of cow serum and typical tissue culture formulations revealed that high levels of the nutrient cystine cause the cells to rely more on glutamine.

The results presented by Muir et al. suggest that cancer cells in tumors could be made to consume more glutamine and that this would make them sensitive to glutaminase inhibitors – a possibility that will be studied in future work. Exposing cultured cancer cells to nutrient levels closer to those found in the body may also better predict how tumor cells use nutrients and respond to some treatments.

Lysinuric protein intolerance: mechanisms of pathophysiology

Heteromeric amino acid transporters (HATs) are composed of two subunits, a polytopic membrane protein (the light subunit) and a disulfide-linked type II membrane glycoprotein (the heavy subunit). HATs represent several of the classic mammalian amino acid transport systems (e.g., L isoforms, y(+)L isoforms, asc, xc-, and b(0,+)). The light subunits confer the amino acid transport specificity to the HAT. Two transporters of this family are relevant for inherited aminoacidurias. Mutations in any of the two genes coding for the subunits of system b(0,+) (rBAT and b(0,+)AT) lead to cystinuria (MIM 220100). Transport defects in a system y(+)L isoform, composed of 4F2hc and y(+)LAT-1, result in lysinuric protein intolerance (LPI) (MIM 222700). In this case, only mutations in the light subunit y(+)LAT-1, but not in the heavy chain 4F2hc, cause the disease. LPI, in addition to affecting intestinal and renal reabsorption of amino acids, is a multisystemic disease affecting the urea cycle and presents also with symptoms related to the immune system. The pathogenesis of these alterations is less well, or not understood at all.

Pilot screening programme for cystinuria in the Valencian community

Cystinuria is an autosomal recessive disorder of the kidneys and small intestine, affecting a luminal transport mechanism shared by cystine, ornithine, arginine and lysine. When cystine exceeds its solubility at low pH, the risk of stone formation increases. The data reported in the literature show a variation for the incidence of cystinuria, from 1 in 600 to 1 in 17,000, depending on the definition of cystinuria and the method used for screening the population. We set up a pilot screening programme to determine the incidence of cystinuria in the population of the Valencian Community. Urine filter paper samples submitted for the neonatal screening programme from 33,995 newborns (5-10 days old) were used for the study. Thin layer chromatography (TLC) was performed to screen cystinuric patients. To confirm positive filter paper samples, liquid samples were requested and TLC as well as the cyanide-nitroprusside test (CNT) were performed. Final diagnosis was achieved by quantifying cystine, lysine, ornithine and arginine using high-performance liquid chromatography (HPLC) in children's urine samples which remained positive for TLC and CNT for more than 1 year. We conclude that the incidence of subjects at risk for cystine stones in the Valencian Community is 1:1887. TLC is shown as a reliable method to perform newborn screening in large population to detect cystinuric subjects. Additional studies, including characterization of appropriate haplotypes, should be carried out for a more precise identification of the frequency of the different types of cystinuria in our population.

Reference values of urinary excretion of cystine and dibasic aminoacids: classification of patients with cystinuria in the Valencian Community, Spain

OBJECTIVE

Cystinuria is an autosomal-recessive disorder of the kidneys and small intestine affecting a luminal transport mechanism shared by cystine, ornithine, arginine, and lysine. Three different types of cystinuria can be distinguished according to the excretion of these amino acids in urine samples. We propose cutoff values from our population as references and we present a classification of cystinuric patients using quantitative amino acid chromatography in first morning urine samples.

DESIGN AND METHODS

A random sample of forty healthy subjects belonging to general population of the Valencian Community were selected as control subjects. Cystine, lysine, arginine, and ornithine were quantified by reverse-phase HPLC. Seventy-two subjects, diagnosed previously as cystinuric by the cyanide-nitroprusside test were classified. Probands excreting more than 113.12 micromol cystine per mmol of creatinine (i.e., 1,000 micromol cystine per gram of creatinine) were classified as homozygotes. Parents of homozygotes in whom excretion of amino acids were normal were classified as heterozygotes type I. Those probands showing the excretion of at least one amino acid and the sum of urinary cystine plus the basic amino acids higher than the corresponding references ranges in our population were classified as heterozygotes type II or type III (heterozygotes non-type 1).

RESULTS

We identified 24 homozygotes, 39 non-type I heterozygotes and 3 type I heterozygotes. The remaining 6 probands could not be classified. Means for cystine, lysine, arginine ornithine and their sum in homozygotes and heterozygotes non-type I were significantly (p < 0.001) in excess of the respective reference ranges. Moreover, means values in homozygotes were statistically different (p < 0.001) from heterozygotes non-type I.

CONCLUSION

Urinary excretion of cystine per mmol creatinine allow us to distinguish heterozygotes from homozygotes. However, the best discriminator to distinguish non-type I heterozygotes from normal population might be the excretion of lysine per mmol creatinine. Additional studies including characterization of appropriate haplotypes should be carried out for a more precise identification of types of cystinuria.

Molecular biology of mammalian plasma membrane amino acid transporters

Molecular biology entered the field of mammalian amino acid transporters in 1990-1991 with the cloning of the first GABA and cationic amino acid transporters. Since then, cDNA have been isolated for more than 20 mammalian amino acid transporters. All of them belong to four protein families. Here we describe the tissue expression, transport characteristics, structure-function relationship, and the putative physiological roles of these transporters. Wherever possible, the ascription of these transporters to known amino acid transport systems is suggested. Significant contributions have been made to the molecular biology of amino acid transport in mammals in the last 3 years, such as the construction of knockouts for the CAT-1 cationic amino acid transporter and the EAAT2 and EAAT3 glutamate transporters, as well as a growing number of studies aimed to elucidate the structure-function relationship of the amino acid transporter. In addition, the first gene (rBAT) responsible for an inherited disease of amino acid transport (cystinuria) has been identified. Identifying the molecular structure of amino acid transport systems of high physiological relevance (e.g., system A, L, N, and x(c)- and of the genes responsible for other aminoacidurias as well as revealing the key molecular mechanisms of the amino acid transporters are the main challenges of the future in this field.

Decreased uptake of L-cystine by duodenal brush border membrane vesicles from patients with cystinuria

BACKGROUND

The pathophysiology of cystinuria remains unclear. Decreased absorption of L-cystine across brush border membranes of small intestinal and renal proximal tubular epithelial cells is likely but has not been directly demonstrated.

AIMS

To compare the rates of L-cystine transport by isolated duodenal brush border membranes of normal individuals and patients with cystinuria.

METHODS

Distal duodenal biopsies were taken from normal individuals and patients with cystinuria. Brush border membrane vesicles (BBMV) were prepared using magnesium aggregation and differential centrifugation and the rates of L-cystine transport into the vesicles measured using a rapid filtration technique.

RESULTS

Rates of L-cystine transport by BBMV from patients with cystinuria were reduced at 5 minute (p = 0.003) and 30 minute (p = 0.053). Time points, indicating that L-cystine absorption across brush border membranes is abnormal in cystinuria.

Balanced translocation (14;20) in a mentally handicapped child with cystinuria

A mentally handicapped 3 year old child with cystinuria is presented. Routine chromosomal analysis showed an apparently balanced de novo translocation in the child with breakpoints 14q22 and 20p13. Family studies suggested that the child is a type I/type II compound heterozygote for cystinuria. This translocation may indicate a possible locus for the gene for cystinuria.

Long-term followup in patients with cystine urinary calculi treated by percutaneous ultrasonic lithotripsy

From February 1983 through 1986, 15 patients (17 renal units) with cystine urinary lithiasis were treated by percutaneous ultrasonic lithotripsy. Three patients were lost to followup. Of the 13 renal units in the remaining 12 patients 7 (54 per cent) had retained stone fragments and 6 (46 per cent) were free of stones. While on medical management 7 of the 13 renal units (54 per cent) had new stones, 5 (38 per cent) remained unchanged and in 1 (8 per cent) the retained stones dissolved. The rate for reoperations was 43 per cent for the group with retained stones (3 of 7) and 17 per cent for the group that was free of calculi after percutaneous ultrasonic lithotripsy (1 of 6). Our study suggests that the optimal treatment with percutaneous ultrasonic lithotripsy should result in a patient who is free of stones.

Cystinuria

Cystinuria is an inherited metabolic disease resulting in renal stone formation. An incidence of 1 in 7000 makes it a relatively common genetic disease. The biochemical defect is a carrier protein in the epithelial cells of certain organs. This carrier protein is responsible for the transport of cystine and the dibasic amino acids. Cystine is a poorly soluble compound which precipitates in acid urine and results in renal calculi. Cystine stones account for 1 to 2% of all renal calculi. Homozygotes are detected by the high concentration of cystine in their urine. Treatment consists of sulfhydryl compounds that form more soluble compounds with cystine through sulfhydryl exchange as well as alkalinization of urine and hydration to make cystine more soluble.

Ontogeny modifies manifestations of cystinuria genes: implications for counseling

Among 339,868 newborn infants screened at 3 weeks of age (91% compliance rate), 730 had elevated rates of excretion of cystine and the dibasic amino acids lysine, ornithine, and arginine; 191 infants had persistent "infantile cystinuria" on follow-up screening (100% compliance). Apparent incidence of the phenotype was 562 per million infants; this rate is seven times higher than for classic cystinuria in the adult segment of the Quebec population. We studied longitudinally 26 probands 2 to 4 months of age. Initially, each excreted cystine and dibasic amino acids at much higher levels than did normal infants or either parent. From parental phenotypes (heterozygous or homozygous normal) and urine amino acid excretion values at 6 months of age in probands, the infants were classified as either heterozygous for the various classic cystinuria genotypes--type I ("silent"), eight infants; type II (high excretor), three; type III (moderate excretor), nine--or homozygous (and genetic compound), six. Urine amino acid excretion diminished steadily with age, to reach the variant parental value in heterozygous infants but not in homozygotes. Cystinuria heterozygotes, with the possible exception of some type I individuals, could not be distinguished reliably from homozygotes in early infancy, although homozygotes had significantly higher excretion values as a group. We deduce that renal ontogeny amplifies phenotypic expression of cystinuria alleles, thus influencing correct classification of genotype (heterozygote vs homozygote, and type of allele). These findings have implications for counseling and the need for follow-up of infantile cystinuria.

Renal tubule reabsorption of amino acids after lysine loading of cystinuric dogs

The renal reabsorption of cystine, lysine, arginine, and ornithine as well as other amino acids has been determined before and after lysine infusion in four normal and five cystinuric dogs. The large filtered load of lysine caused defective reabsorption of cystine in three of four normals and augmented the basal defect in all of the cystinuric dogs. Two of the cystinuric dogs responded with cystine clearances in excess of the glomerular filtration rate. The magnitude of increase of the reabsorptive defect for cystine observed after lysine infusion into the cystinuric dogs was unrelated to the extent of the basal defect. Two of the normal dogs and four of the five cystinuric dogs demonstrated defective arginine reabsorption after lysine loading, one of the cystinuric dogs having greater arginine excretion than the filtered load. Although normal dogs showed a moderate inability to reabsorb the large filtered load of lysine, three of the cystinuric dogs exhibited a -60 to -70% reabsorption, consistent with lysine secretion. Both normal and cystinuric dogs showed defective glycine absorption after lysine loading, but only cystinuric dogs showed variable defects in threonine, serine, histidine, methionine, and tyrosine when the basic amino acid was infused. Each cystinuric dog responded to lysine infusion in a different way, and the overall pattern of response differed from the normal, with evidence of induced secretion of cystine, lysine, and arginine in the affected dogs.

Transport of L-cystine in isolated perfused proximal straight tubules

Unidirectional fluxes of L-35S-cystine and intracellular 35S activity were measured in isolated perfused segments of rabbit proximal straight tubule. The absorptive (lumen-to-both) flux of L-35S-cysteine showed a tendency toward saturation within the concentration limits imposed by the low solubility of cystine (0.3 mmol . l-1). In contrast, for the bath-to-lumen fluxes, there was a linear relation between the bathing solution concentration of L-35S-cystine and the rate of 35S appearance in the lumen. Nonlinear fitting of both sets of unidirectional flux data gave a maximal cystine transport rate (Jmax) of 1.45 +/- 0.27 (SEM) pmol min-1 mm-1, a Michaelis constant (Km) of 0.20 +/- 0.07 mmol . l-1, and an apparent permeability coefficient of 0.27 +/- 0.11 pmol min-1 mm-1 (mmol . l-1)-1 (approximately 0.06 micrometer/s). The 35S concentration in the cell exceeded that in the lumen by almost 60-fold during the lumen-to-bath flux, and exceeded the bathing solution concentration by 4.7-fold during the bath-to-lumen flux. Thus cystine was accumulated by the cells across either membrane, but over 77% of the intracellular activity was in the form of cysteine. Although the presence of luminal L-lysine or cycloleucine inhibited the absorptive flux of cystine, neither amino acid affected the bath-to-lumen flux.

Renal transport of lysine and arginine in lysinuric protein intolerance

In a patient with lysinuric protein intolerance, renal handling of lysine and arginine was examined to study the renal transport mechanism of this disease. The tubular reabsorption of lysine or arginine of the patient, when the filtered load of amino acid was increased by intravenous infusion, was not raised as much as that of control subjects at low filtered loads, but the ability for amino acid reabsorption seemed to exist under these conditions. However, when the filtered load was greatly increased, instead of a net reabsorption, a net secretion of amino acid was obtained. This seems to mean that at low filtered loads the amino acid in the tubular lumen is accumulated by the tubular cell across the intact luminal membrane, leading to a small amino acid excretion in the urine. With a great increase of the filtered load the saturated intracellular amino acid, which is not transported to the capillary because of a transport defect of the basolateral membrane, is assumed to leak back into the lumen. This causes a marked urinary amino acid loss exceeding filtered load at high tubular loads. The intravenous load of lysine depressed the percentage of arginine reabsorption and arginine load depressed lysine reabsorption. The percentage of the depressed amino acid reabsorption of the patient decreased almost linearly with increases of the inhibitor load.

Cystine crystalluria and urinary saturation in cystine and non-cystine stone formers

It has been suggested recently that the first step in the formation of calcium oxalate stones appears to be crystallisation. This step is said to depend on the state of saturation of the urine. This hypothesis was checked in cystine stone formers. Cystine crystalluria was found in 83% of 24 urine samples from cystine stone formers (CSF) but in one of the 400 control samples and appears to be a good guide in the diagnosis of cystine lithiasis. Urinary cystine saturation was constantly higher in CSF than in non-cystine stone formers (NCSF) who exhibited undersaturated urine with respect to cystine. There was almost no overlap between these 2 groups. Crystals were never found in undersaturated urine and were always present when the saturation was above 1. There appears to be a good correlation between the level of urinary saturation and the presence of crystalluria and there is no need for any additional factor such as a defective inhibitor. The study underlines the limits of a therapeutic regimen of a high fluid intake and alkalinisation of the urine.

Transport interactions of cystine and dibasic amino acids in isolated rat renal tubules

Isolated renal cortical tubules prepared from adult male Sprague-Dawley rats were used to study the nature of cystine entry into tubule cells and its transport interactions with dibastic amino acids. The uptake of cystine over time was progressive, reaching a steady-state after 60 min of incubation. Analysis of the intracellular pool after incubation revealed that a significant fraction of the transported cystine was reduced to cysteine. A kinetic analysis of uptake demonstrated that two systems for cellular entry of cystine existed with a Km1 of 0.012 mM and Km2 of 0.55 mM. Cystine uptake was sodium dependent with an apparent Km for sodium of 36 mEq/liter. Lysine inhibited cystine uptake via the low Km system, but appeared not to inhibit cystine uptake via the high Km system. Ornithine, leucine, and isoleucine each inhibited cystine uptake via the low Km system. Arginine appeared to affect both systems for cystine uptake. Cystine inhibited the uptake of lysine by isolated renal tubules. The data suggest that cystine at physiologic concentrations is transported into renal tubule cells nearly equally by two systems, of which, the low Km system is shared with the dibasic amino acids. A defective low Km system could in part explain human cystinuria.

Heterozygous cystinuria and calcium oxalate urolithiasis

Many variables are known to be associated with the formation of calcium oxalate urolithiasis but none is essential for the initiation or growth of stones. It is likely that the predisposition to stone formation is related to multiple factors. We herein describe still another metabolic state that seems to predispose to calcium oxalate stone disease, namely heterozygosity for cystinuria. Cystine screening tests were done on 24-hour urine specimens obtained from 126 patients in whom recurrent calcium oxalate stones form and 84 controls and quantitative amino acid determinations were done on all positive specimens. Of those studied 17 of 126 stone patients and 1 of 84 controls were heterozygous cystinurics. A test of the differences between the relative frequencies of cystinuria heterozygotes in the 2 groups with Fisher's exact test revealed them to be highly significant (p less than 0.001). Our study indicates that carrier status for 1 of the cystinuria genes predisposes to calcium oxalate stone formation but, like other factors related to urolithiasis, it is not a necessary cause of stone disease.

Cystinuria genotypes predicted from excretion patterns

Genotypes of 17 patients with cystinuria were predicted from data based on excretion rates of the families' obligate carriers. The methodology differed from that used by other investigators as it did not employ intestinal biopsy studies or loading dose measurements. The Type I form was more common than either Type II or Type III and frequently occurred in combination to give compound heterozygous genotypes with the Type III form.

Transport interaction of cystine and dibasic amino acids in renal brush border vesicles

The uptake of cystine by vesicles prepared from rat kidney brush borders occurs by two distinct transport systems. The higher affinity system is inhibited by the dibasic amino acids lysine, arginine, and ornithine. The lower affinity system, unaffected by dibasic amino acids, appears to correspond to that observed by studying uptake of cystine by kidney slices.

Small bowel mucosal dysfunction in patients with cystic fibrosis

Jejunal biopsies were obtained from 37 children with cystic fibrosis, 16 with gluten-induced enteropathy, and 18 control subjects for the following studies: (1) disaccharidase activity, (2) L-ALA-L-Phe hydrolase activity, and (3) intestinal uptake of three 14C-labeled amino acids. Values were significantly reduced in the three determinations in patients with gluten-induced enteropathy as compared to control subjects. Lactase and L-ALA-L-Phe hydrolase activities were significantly reduced (p less than 0.01) in CF patients as compared to control subjects. Definite hypolactasia was also observed in 23% of the children with CF. Uptake of lysine was normal in CF patients whereas that of phenylalanine and cycloleucine was reduced as compared to control subjects. This study suggests an intestinal component to the malabsorption of patients with CF.

Cystinuric heterozygotes and cystine-loading

During routine screening procedures for amino acid disorders by thin layer chromatography, performed in a children's psychiatric hospital, we detected 6 children who excreted excessive amounts of dibasic amino acids. The probands, their siblings and parents and 11 controls (29 subjects in all) were loaded with cystine. On the basis of the urinary excretion after the loading we distinguished normal subjects from cystinuric heterozygotes, which we further subdivided in heterozygotes type II and III by the corresponding serum response.

Lysinuric protein intolerance

Lysinuric protein intolerance (LPI), an autosomal recessive defect of diamino acid transport, is characterized chemically by renal hyperdiaminoaciduria, especially lysinuria, and by impaired formation of urea with hyperammonemia after protein ingestion. Our 20 patients thrived during breast-feeding, but ingestion of cow's milk caused diarrhea and vomiting. When able to select their diet, they rejected all protein-rich foods. They were short staturated and had weak atrophic muscles, osteoporosis, hepatomegaly and often splenomegaly. Four patients were mentally retarded. Fifteen patients had leukocyte counts below 4,000/mm3, and 17 patients had platelet counts below 150,000/mm3. Serum lactate dehydrogenase activity was constantly increased, and transaminase and aldolase activities were often increased. In the infants' livers, changes were only revealed by electron microscopy: increased and vesicular smooth endoplasmic reticulum, and abundance of glycogen particles in the hepatocytes. In the older patients, light microscopy demonstrated clearly limited areas where hepatocytes had large pale cytoplasm and small pyknotic nuclei. The diamino acids lysine, arginine and ornithine had plasma concentrations only one-third to one-half the normal mean; the renal clearances were clearly increased. Oral diamino acid loading tests suggested impaired intestinal absorption. Urea is built in the liver through transformation of ornithine to arginine, and cleavage of arginine to ornithine and urea. The addition of ornithine to an intravenous I-alanine loading prevented the hyperammonemia and normalized the urea production. Therefore, the diet has been supplemented with arginine, and more protein has been added. This therapy has lead to a remarkable catch-up growth in some patients. The pathophysiology of LPI is explained. Because of defective intestinal absorption and incrased renal loss, the diamino acids have a low plasma concentration. Their transport from plasma to hepatocytes is also impaired, and the liver becomes deficient in ornithine. This retards the urea cycle, and leads to postprandial hyperammonemia and protein aversion. The presence of the transport defect in the hepatocytes distinguishes LPI from other hyperdibasicaminoacidurias.

A study of the renal handling and intestinal absorption of dibasic amino acids in a patient with genotype +/11 heterozygous cystinuria and idiopathic hypercalcuria

A case is reported of a patient with idiopathic hypercalcuria who was referred for investigation of renal calculi. Studies of urinary amino acid excretion in the patient and all living members of his family, as well as studies of endogenous renal clearances of dibasic amino acids and cystine in the patient and his daughter, indicated that the patient had genotype +/11 heterozygous cystinuria. Intestinal perfusion studies showed however that the patient was able to absorb L-lysine, L-arginine normally from the jejunum and ileum. This suggests that a difference exists between renal and intestinal handling of lysine and arginine in cystinuria.