Apo AIV and Citrulline Plasma Concentrations in Short Bowel Syndrome Patients: The Influence of Short Bowel Anatomy

Abstract

IntroductionParenteral nutrition (PN) dependence in short bowel syndrome (SBS) patients is linked to the functionality of the remnant small bowel (RSB). Patients may wean off PN following a period of intestinal adaptation that restores this functionality. Currently, plasma citrulline is the standard biomarker for monitoring intestinal functionality and adaptation. However, available studies reveal that the relationship the biomarker with the length and function of the RSB is arguable. Thus, having additional biomarkers would improve pointing out PN weaning.AimBy measuring concomitant changes in citrulline and the novel biomarker apolipoprotein AIV (Apo AIV), as well as taking into account the anatomy of the RSB, this exploratory study aims to a better understanding of the intestinal adaptation process and characterization of the SBS patients under PN.MethodsThirty four adult SBS patients were selected and assigned to adapted (aSBS) and non-adapted (nSBS) groups after reconstructive surgeries. Remaining jejunum and ileum lengths were recorded. The aSBS patients were either on an oral diet (ORAL group), those with intestinal insufficiency, or on oral and home parenteral nutrition (HPN group), those with chronic intestinal failure. Apo AIV and citrulline were analyzed in plasma samples after overnight fasting. An exploratory ROC analysis using citrulline as gold standard was performed.ResultsBiomarkers, Apo AIV and citrulline showed a significant correlation with RSBL in aSBS patients. In jejuno-ileocolic patients, only Apo AIV correlated with RSBL (rb = 0.54) and with ileum length (rb = 0.84). In patients without ileum neither biomarker showed any correlation with RSBL. ROC analysis indicated the Apo AIV cut-off value to be 4.6 mg /100 mL for differentiating between the aSBS HPN and ORAL groups.ConclusionsTherefore, in addition to citrulline, Apo AIV can be set as a biomarker to monitor intestinal adaptation in SBS patients. As short bowel anatomy is shown to influence citrulline and Apo AIV plasma values, both biomarkers complement each other furnishing a new insight to manage PN dependence.

Fasting and Postprandial Plasma Citrulline and the Correlation to Intestinal Function Evaluated by 72‐Hour Metabolic Balance Studies in Short Bowel Jejunostomy Patients With Intestinal Failure

“…Researchers have found inconsistent correlations between citrullinemia and energy, macronutrient, wet weight, and electrolyte absorption, and this probably reflects the complex nature of absorptive function in patients with SBS‐IF. Although a recently published study showed that short bowel anatomy might influence p‐citrulline values, no correlation between p‐citrulline and remnant bowel length was found in patients with SBS without ileum . Thus, the large patient heterogeneity and consequent heterogeneity in the pathophysiological manifestations of SBS may explain the variable results regarding correlations between p‐citrulline and intestinal length and function.…”

Biomarcadores para la insuficiencia intestinal en Síndrome de intestino corto: ¿Una nueva era en la rehabilitación gastrointestinal?

“…In intestinal failure and short bowel syndrome with a significant mass reduction in the intestinal anatomy, levels can decrease to 20 mcmol/L and in villous atrophic intestinal disease levels reach 10 mcmol/L [14][15][16] . When serum levels reach 20 mcmol/L in the context of short bowel syndrome, permanent intestinal failure is predicted with a sensitivity of 92% and specificity of 90% [15][16][17] . In prolonged starvation, serum levels can also drop by 30%.…”

“…Two primary factors which may cause false negatives in patients with short bowel syndrome are age and renal failure; in both of these conditions serum levels may rise confusing the clinician. Between 140 cm and 160 cm of small intestine, serum Citrulline levels average 30-40 mcmol/L, whereas remnant lengths of 20-40 cm average 10-20 mcmol/L [14][15][16][17] .…”

“…APO IVA travels on chylomicron membranes and is released into plasma providing a normal serum level of 4.6 mg/100ml or 32 AU. Using a Western blot technique, APO IVA levels can be compared between healthy patients and those with short bowel syndrome [14][15][16][17] . A cut-off value 4.6 mg/100ml gives a predictive value of intestinal rehabilitation and sets a score between patients who attain oral feeding vs those who remain on parenteral nutrition.…”

“…A cut-off value 4.6 mg/100ml gives a predictive value of intestinal rehabilitation and sets a score between patients who attain oral feeding vs those who remain on parenteral nutrition. Patients with approximately 150 cm of small intestine average serum APO IVA levels between 30 to 50 AU and those with small bowel remnants of less than 50 cm average serum APO IVA levels of 10 AU [14][15][16][17] .…”