GLP-2 Induces Intestinal Adaptation in Jejunal Remnant Osama Bawazir FRCSI, FRCS(Ed), FRCS (glas), FRCSC. G.R. Martin, L.E. Wallace and D.L. Sigalet. Gastrointestinal Research Group, University of Calgary, Calgary, AB
INTRODUCTION Resection > 50 % of small bowel → Short Bowel Syndrome (SBS). SBS → severe diarrhea, dehydration, nutrient malabsorption, electrolyte imbalance, micronutrient deficiencies, weight loss, long- term dependence on parenteral nutrition. In the pediatric population, total parenteral nutrition (TPN) → sepsis, secondary liver failure, morbidity.
NEC in preterm baby. Midgut volvulus with Malrotation Small bowel atresia
Distal small bowel resection is the most common clinical scenario In SBS We try to create module similar to the common clinical presentation of SBS
Adaptation: Mechanisms Adaptation as process of ↑ in absorptive capacity of the bowel & ↑ in the surface area. Increase in villous height/crypt depth CCPR ? crypt apoptosis nutrient absorption ↑ permeability Control
We have previously shown that GLP-2 stimulates intestinal adaptation in the terminal ileum. GLP-2 is an intestinal trophic hormone ↑ crypt cell proliferation → increase in absorptive surface area. GLP-2 release following resection is correlated with the adaptive up-regulation of nutrient transport. We hypothesized that GLP-2 would stimulate intestinal adaptation in jejunal remnant following massive intestinal resection.
GLP-2 GLP-2R Nutrient {FAT} L-cells Dipeptidyl peptidase IV GLP >> GLP Trophic less trophic 33 amino acid peptide 7 minute ½ life PACAP / glucagon super family GLP-2 Background ↑ satiety ↓motility
TPN Bowel resection Line insertion 5 mL vial mL vial 2 = 10 Multi-XII vitamins 1.8Magnisium sulfate 36Calcium gluconate 10KCl (2meq/mL) 16NaCl (23.4% solution) % dextrose solution 28010% Travasol solution Volume in 500 mL bag (mLs) Ingredient + Intralipid (20 %) isocaloric / isonitroge nous 75.5 kcal, 11.4 g CHO, 2.8 g protein, 2.0 g fat /Day TPN + GLP2 GLP-2 Infusion 10 µg/kg/hr METHODS
Body weight changes were monitored over the 8 day study Serum GLP-2 levels: ELIZA N-terminus of native GLP-2(1-33) Intestinal Permeability: 20-hr urinary recovery of gavaged carbohydrate probes (3-0 methyl- glucose, lactulose, and mannitol)
Day 8 →pulsed with BRDU (lables active dividing cell), euthanized. Tissues processed for morphology,crypt cell proliferation rates Apoptosis was assessed by activated caspase-3 expression using immuno- histochemical staining Nutritional transport capacity was assessed by mucosal expression of Na+-dependent glucose co-transporter-1 (SGLT-1) and Glut-5 (Western blot)Endpoints
Intestinal Permeability
groupBody weight (% change) Small bowel weight (g) Small bowel % BWT Small bowel Length (cm) Small bowel Width (cm) TPN6.52±5.11.3±0.30.5± ± ± GLP-2 * 8.33± 2.9 * 2.7±0.4 * 1.0± ± ± Gross Morphology * P<0.05. Data expressed as mean ± SEM.
Morphology *P<0.05. Data expressed as mean ± SEM. Representative photos visualized at 10x. TPNTPN + GLP-2 groupVillus ht (um) Crypt depth (um) Villus density C/V ratiovilli surface area um² TPN534 ± 58157± ± ± /-11 TPN+GLP2 * 808 ± 27 * 207 ± ± ± 0.03 * /-15
GroupMicro Villus height Micro Villus width Micro Villius density Micro Villus surface area TPN1.9 ± ± ± ± 0.2 TPN+GLP2*2.3 ± ± 0.1*17.4 ± 0.6*4.7 ±-0.4 Ultra-structural Morphology TPNTPN + GLP-2 * P<0.05. Data expressed as mean ± SEM.
Crypt Cell Proliferation { Brdu +ve cell / Crypt} Crypt BRDU immunoreactivity
Apoptosis {Activated Caspase-3 +ve cell / Crypt}
Transporter Protein Expression SGLT1 = Active transport GLUT-5 = Passive transport
Serum GLP-2 Levels Basal serum GLP-2 levels. Blood sampled on day 8 in the a.m. Data expressed as mean ± SEM. *P<0.02 versus TPN group
SUMMARY GLP-2 ↓ intestinal permeability ↑ crypt cell proliferation, small bowel weight, and morphological measures of adaptation in jejunum GLP-2 treatment did not change the expression of the active nutrient transporter SGLT-1.(?! May be SGLT-1 at maximum up- regulation) There were significant changes in apoptosis (↑) as assessed by activated caspase-3 expression.
These findings differ from the effects of GLP-2 on residual ileum noted in our previous studies, showing that different segment of bowel had different reaction and variable adaptation to the GLP2. This study supports the use of GLP-2 in TPN maintained patients following intestinal resection. Further studies to determine the optimal timing, dosing, and latency period are required.
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