Gastroenterology

Gastroenterology

Volume 119, Issue 6, December 2000, Pages 1496-1505
Gastroenterology

Alimentary Tract
Postabsorptive plasma citrulline concentration is a marker of absorptive enterocyte mass and intestinal failure in humans

Presented in part at the 5th International Symposium on Intestinal Transplantation (1997) and published in abstract form (Transplant Proc 1998;30:2528).
https://doi.org/10.1053/gast.2000.20227Get rights and content

Abstract

Background & Aims: No blood marker assessing the functional absorptive bowel length has been identified. Plasma citrulline, a nonprotein amino acid produced by intestinal mucosa, is one candidate. We tested this hypothesis in adult patients with the short-bowel syndrome, whose condition can lead to intestinal failure. Methods: In 57 patients, after a minimal follow-up of 2 years subsequent to final digestive circuit modification, postabsorptive citrulline concentration was measured and parenteral nutrition dependence was used to define permanent (n = 37) and transient (n = 20) intestinal failure. Absorptive function, studied over a 3-day period, was evaluated by net digestive absorption for protein and fat (n = 51). Relations between quantitative values were assessed by linear regression analysis and cutoff citrulline threshold, for a diagnosis of intestinal failure by linear discriminant analysis. Cox model was used to compare citrulline threshold and anatomic variables of the short bowel as indicators of transient as opposed to permanent intestinal failure. Results: In patients with short-bowel syndrome, citrulline levels were lower than in controls (n = 51): 20 ± 13 vs. 40 ± 10 μmol/L (mean ± SD), respectively (P < 0.001). After multivariate analysis, citrullinemia was correlated to small bowel length (P < 0.0001, r = 0.86) and to net digestive absorption of fat, but to neither body mass index nor creatinine clearance. A 20-μmol/L threshold citrullinemia, (1) classified short bowel patients with permanent intestinal failure with high sensitivity (92%), specificity (90%), positive predictive value (95%), and negative value (86%); and (2) was a more reliable indicator (odds ratio, 20.0; 95% confidence interval, 1.9–206.1) than anatomic variables (odds ratio, 2.9; 95% confidence interval, 0.5–15.8) to separate transient as opposed to permanent intestinal failure. Conclusions: In patients with short-bowel syndrome, postabsorptive plasma citrulline concentration is a marker of functional absorptive bowel length and, past the 2-year adaptive period, a powerful independent indicator allowing distinction of transient from permanent intestinal failure.

GASTROENTEROLOGY 2000;119:1496-1505

Section snippets

Patients

All consecutive adult patients with nonmalignant short-bowel syndrome, as defined by a postduodenal remnant small bowel length of less than 200 cm (n = 82), followed up between November 1992 and November 1996 at Lariboisière-Saint Lazare Hospital in Paris, France, were considered for inclusion in this study. This hospital is the only authorized French HPN center for adults in the Ile-de-France region.

To separate transient from permanent intestinal failure, criterium for inclusion of short

Patient characteristics

Characteristics of the patients (median age, 49; range, 22–78) are shown in Tables 1 and 2.

. Characteristics of 57 adult patients with short-bowel syndrome

CharacteristicsNo. of patients (%)
Sex
 Male31 (54)
 Female26 (46)
Cause of bowel resection
 Mesenteric infarction21 (37)
 Radiation enteritis20 (35)
 Crohn's disease4 (7)
 Miscellaneous12 (21)
Digestive circuit type of anastomosis
 End-enterostomy10 (17)
 Jejunocolic anastomosis38 (67)
 Jejunoileocolic anastomosis9 (16)
Abnormal radiographic pattern of remnant

Discussion

In this study we show that postabsorptive plasma citrulline, an intermediary product of amino acid metabolism, is able to assess the absorptive functioning small bowel length and to diagnose intestinal failure severity in patients with nonmalignant short-bowel syndrome.2, 5, 6 In addition, plasma citrulline concentration gives a better classification for diagnosis of permanent intestinal failure than the clinical anatomic model shown previously.6 Plasma postheparin diamine oxidase was proposed

Acknowledgements

The authors thank Dr. M. C. Boutron-Ruault for statistical advice, M. C. Morin for dietary inquiry, and J. Arsham for careful review of the English style of the manuscript.

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    Address requests for reprints to: Bernard Messing, M.D., Hôpital Lariboisière, 2 rue Ambroise Paré, 75475 Paris, France. e-mail: [email protected]; fax: (33) 1-49-95-25-44.

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