Research Article: Blood Trimethylamine-N-Oxide Originates from Microbiota Mediated Breakdown of Phosphatidylcholine and Absorption from Small Intestine

Date Published: January 27, 2017

Publisher: Public Library of Science

Author(s): Wolfgang Stremmel, Kathrin V. Schmidt, Vera Schuhmann, Frank Kratzer, Sven F. Garbade, Claus-Dieter Langhans, Gert Fricker, Jürgen G. Okun, Pratibha V. Nerurkar.


Elevated serum trimethylamine-N-oxide (TMAO) was previously reported to be associated with an elevated risk for cardiovascular events. TMAO originates from the microbiota-dependent breakdown of food-derived phosphatidylcholine (PC) to trimethylamine (TMA), which is oxidized by hepatic flavin-containing monooxygenases to TMAO. Our aim was to investigate the predominant site of absorption of the bacterial PC-breakdown product TMA. A healthy human proband was exposed to 6.9 g native phosphatidylcholine, either without concomitant treatment or during application with the topical antibiotic rifaximin, or exposed only to 6.9 g of a delayed-release PC formulation. Plasma and urine concentrations of TMA and TMAO were determined by electrospray ionization tandem mass spectrometry (plasma) and gas chromatography-mass spectrometry (urine). Native PC administration without concomitant treatment resulted in peak plasma TMAO levels of 43 ± 8 μM at 12 h post-ingestion, which was reduced by concomitant rifaximin treatment to 22 ± 8 μM (p < 0.05). TMAO levels observed after delayed-release PC administration were 20 ± 3 μM (p < 0.001). Accordingly, the peak urinary concentration at 24 h post-exposure dropped from 252 ± 33 to 185 ± 31 mmol/mmol creatinine after rifaximin treatment. In contrast, delayed-release PC resulted in even more suppressed urinary TMAO levels after the initial 12-h observation period (143 ± 18 mmol/mmol creatinine) and thereafter remained within the control range (24 h: 97 ± 9 mmol/mmol creatinine, p < 0.001 24 h vs. 12 h), indicating a lack of substrate absorption in distal intestine and large bowel. Our results showed that the microbiota in the small intestine generated the PC breakdown product TMA. The resulting TMAO, as a cardiovascular risk factor, was suppressed by topical-acting antibiotics or when PC was presented in an intestinally delayed release preparation.

Partial Text

The small intestine is the main site of substrate absorption, whereas the colon absorbs mainly water and electrolytes (thereby promoting stool consolidation) and short-chain, microbiota-produced fatty acids as additional nutrients for mucosal epithelial cells. In addition to fibres and biliary dyes, the stool contains one trillion bacteria per gram for release from the body. Whether it has in addition other functions is at present in discussion. The biodiversity of the colonic microbiome is very high, particularly under healthy conditions, and includes multiple pathogens [1]. A protective mucosal barrier constrains bacteria and their toxic bacterial metabolites to the lumen. Although the concentrations and diversity of microbiota in small intestine is lower than in the large intestine, it may still suffice to express metabolic activity with potential impact for the host. Moreover, the compositions of the small and large intestinal microbiota are different, which may also impact on metabolism [1]. This is due to the proximity of the various bacterial species and their interaction in consolidated stool, the impact of the different metabolic milieu, the presence of bile acids in the small intestine (but not in colon), and potential secretory factors of the host small intestine. The microbiome of the small intestine fulfils specific metabolic functions that are different from their effects observed in the large intestine where absorption is negligible. Therefore, we postulated that the small intestinal microbiota produces bacterial breakdown products from food constituents, which are absorbed there. They may serve normal physiological functions in controlling metabolism, or cause harm in case of pathological conditions. The latter consideration is of significance in decompensated liver cirrhosis, where the commensal small intestinal microbiota generates ammonium from amino acids, which after absorption cannot be cleared by the liver due to functional failure or portocaval shunts, thus inducing hepatic encephalopathy. This is likely a small intestinal event because of the physiology of absorption, as no non-absorbed amino acids are left over in the colonic lumen, available for ammonium production and consequent absorption. However, this simple assumption that absorption occurs only in the small intestine is often neglected and textbooks still propose the colon as an absorptive organ, also for ammonium.

After the application of each of the PC preparations (dose of 6.9 g), plasma and urinary TMA concentrations were not detectable in the plasma or were low (<9 mmol/mol creatinine, N-oxidation capacity > 90), respectively, and not statistically different between the examined conditions, indicating that TMA was rapidly oxidized to TMAO by the liver with normal FMO3 enzymatic activity [6]. The determined TMAO and TMA levels are summarized in Table 1.

In the present investigation, we addressed whether the absorption of bacterial breakdown products occurs in the small or large intestine, as well as the consequences for metabolism. Thus, we evaluated the generation of the PC-breakdown products TMA and its oxidized form TMAO after oral PC loading under different conditions.




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