Creatine metabolism is dysregulated in necrotizing enterocolitis

BACKGROUND: Necrotizing enterocolitis (NEC) remains a leading cause of morbidity and mortality in preterm infants, yet effective preventive or therapeutic strategies are lacking. Emerging evidence implicates metabolic dysfunction in NEC pathogenesis. We hypothesized metabolism of creatine (Cr), a key regulator of cellular energy homeostasis that supports adenosine triphosphate (ATP) buffering, oxidative phosphorylation, and protection against hypoxic injury, may be dysfunctional in NEC. METHODS: Enterocyte scratch wound healing assays, Seahorse metabolic assays, and hypoxia-induced apoptosis assays in human preterm ileal enteroids were performed. Human NEC bulk and single-cell RNA-sequencing datasets were analyzed to characterize intestinal Cr metabolism, and targeted metabolomics was performed on longitudinal urine samples from preterm infants, before and at NEC diagnosis. RESULTS: Cr (1-10 mM) enhanced enterocyte wound healing, increased mitochondrial and glycolytic ATP production, and protected enteroids from hypoxia-induced apoptosis. NEC transcriptomic analyses demonstrated downregulation of Cr metabolism genes across bulk and epithelial cell populations. Targeted metabolomics indicated urinary Cr, but not related metabolites, declined significantly from baseline to NEC diagnosis, indicating a specific disruption in Cr homeostasis. CONCLUSIONS: Cr depletion represents a previously unrecognized metabolic vulnerability in NEC, supporting Cr supplementation as a safe, practical, and potentially effective strategy for NEC prevention. IMPACT: This study identifies dysregulated metabolism of creatine, an organic acid generated from glycine and arginine, in intestinal NEC tissue, with significant downregulation of key creatine transport and synthesis proteins compared with tissue of age-matched controls. This study is the first to demonstrate an abrupt decline in preterm urinary creatine at NEC diagnosis, establishing creatine depletion as a novel and modifiable metabolic vulnerability in NEC. Creatine supplementation accelerates intestinal epithelial wound healing, improves bioenergetic capacity, and protects against hypoxia-associated apoptosis, all physiological tenets of NEC. These findings support investigation of creatine repletion as a potential NEC preventative strategy in preterm infants.