title: [Critical value of citrulline for complications of intestinal transplant graft].
abstract: OBJECTIVE
  A biochemical marker for detection of acute cellular rejection following small intestine transplantation has been sought. Citrulline, a non- protein amino acid synthesized mainly by functioning enterocytes, has been proposed. Trial sensitivity has been reportedly high but with low specificity. Thus, the goal was to determine, in a sufficiently large analysis, the significant value of citrulline level in the post-transplant setting, which would correlate with complications such as rejection and infection.
  
  
  METHODS
  Since March, 2004 2,135 dried blood spot (DBS) citrulline samples were obtained from 57 small intestine transplant recipients three months or more after post-transplant, i.e., once the expected period of recovery in the citrulline levels had occurred.
  
  
  RESULTS
  Using a <13 vs. > 13 micromoles/L cut off point, sensitivity of DBS citrulline for the detection of moderate or severe ACR was extremely high (96.4%). Furthermore, specificity estimates (given the absence of ACR and these particular infections), while controlling for time-to-DBS sample were reasonably high (54%-74% in children and 83%-88% in adults), and the negative predictive value (NPV) was >99%.
  
  
  CONCLUSIONS
  Citrulline is a non-invasive marker to evaluate problems of the intestinal graft after three months post-transplant. Due to the high NPV, a moderate or severe ACR can be ruled out, based exclusively on knowledge of a high value for DBS citrulline.
authors.affiliation: Departamento de Cirurgia da Irmandade, Santa Casa de Misericórdia de São Paulo, SP. drandredavid@terra.com.br
authors.forename: André Ibrahim
authors.initials: AI
authors.lastname: David
authors.forename: Luiz Arnaldo
authors.initials: LA
authors.lastname: Szutan
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Gaynor
authors.forename: Phillip
authors.initials: P
authors.lastname: Ruiz
authors.forename: Gennaro
authors.initials: G
authors.lastname: Selvaggi
authors.forename: Panagiotis
authors.initials: P
authors.lastname: Tryphonopoulos
authors.forename: Gary
authors.initials: G
authors.lastname: Kleiner
authors.forename: Jang I
authors.initials: JI
authors.lastname: Moon
authors.forename: Seigo
authors.initials: S
authors.lastname: Nishida
authors.forename: Debbie
authors.initials: D
authors.lastname: Weppler
authors.forename: Violet
authors.initials: V
authors.lastname: Squenazi
authors.forename: Lobella
authors.initials: L
authors.lastname: Conanan
authors.forename: David M
authors.initials: DM
authors.lastname: Levi
authors.forename: Tomoaki
authors.initials: T
authors.lastname: Kato
authors.forename: Andreas G
authors.initials: AG
authors.lastname: Tzakis
mesh_terms: D000328:Adult; D015415:Biomarkers / Q000097:blood; D002648:Child; D002956:Citrulline / Q000097:blood*; D006084:Graft Rejection / Q000097:blood / Q000175:diagnosis*; D006801:Humans; D007422:Intestines / Q000637:transplantation*; D011237:Predictive Value of Tests; D012016:Reference Values
chemical_list: D015415:Biomarkers; D002956:Citrulline