Exogenous arginine in sepsis

Yvette C. Luiking, PhD; Nicolaas E. P. Deutz, MD, PhD

Sepsis is a severe condition in critically ill patients and is considered an arginine deciency state. The rationale for arginine deciency in sepsis is mainly based on the reduced arginine levels in sepsis that are associated with the specic changes in arginine metabolism related to endothelial dysfunction, severe catabolism, and worse outcome. Exogenous arginine supplementation in sepsis shows controversial results with only limited data in humans and variable results in animal models of sepsis. Since in these studies the severity of sepsis varies but also the route, timing, and dose of arginine, it is difcult to draw a denitive conclusion for sepsis in general without considering the inuence of these factors. Enhanced nitric oxide production in sepsis is related to suggested detrimental effects on hemodynamic instability and

enhanced oxidative stress. Potential mechanisms for benecial effects of exogenous arginine in sepsis include enhanced (protein) metabolism, improved microcirculation and organ function, effects on immune function and antibacterial effects, improved gut function, and an antioxidant role of arginine. We recently performed a study indicating that arginine can be given to septic patients without major effects on hemodynamics, suggesting that more studies can be conducted on the effects of arginine supplementation in septic patients. (Crit Care Med 2007; 35[Suppl.]:S557S563) KEY WORDS: arginine; sepsis; supplementation; critically ill; nitric oxide; citrulline; nutrition; metabolism; amino acid; protein

epsis is a major complication of an acute infection, triggered by a systemic inammatory reaction. According to its progressive injury process, the sepsis syndrome can be classied as mild or severe sepsis or septic shock. Severe sepsis coincides with multiple organ failure, while septic shock is characterized by additional cardiovascular failure and the need for blood pressure supportive therapy (1). Sepsis is a highly frequent condition in the intensive care unit with a high morbidity and mortality rate, the latter varying between 20% and 50% within the rst month of disease (2, 3), still further increasing thereafter (4). Risk factors for

From the Center for Translational Research on Aging & Longevity, Donald W. Reynolds Institute on Aging, University of Arkansas for Medical Sciences, Little Rock, AR. Supported, in part, by Novartis Consumer Health, St. Louis Park, MN. The authors have not disclosed any potential conicts of interest. Address requests for reprint to: N. E. P. Deutz, MD, PhD, Center for Translational Research on Aging & Longevity, Room 3.121, Donald W. Reynolds Institute on Aging, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Slot 806, Little Rock, AR. E-mail: deutzNEP@uams.edu Copyright 2007 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/01.CCM.0000279191.44730.A2

sepsis are age (70% of patients are 60 yrs), gender (63% male vs. 37% female), and comorbidities like malignancies, respiratory failure, and diabetes (70% of all patients) (25). Most common sites of infection are the lungs (47%) and the abdomen (34%) (5). Arginine is considered a conditionally essential amino acid: not essential under normal healthy conditions but essential in disease states like sepsis (6 8). This is partly because arginine is a key amino acid in several metabolic pathways of which synthesis of nitric oxide is considered of main importance during disease (for recent reviews, see Refs. 9 14). This review focuses on arginine metabolism in sepsis and implications for arginine availability and related functions, arginine and arginine-related therapies, and potential mechanisms by which exogenous arginine may improve the condition of the patient with sepsis/multiple organ failure.

Arginine Deciency in Sepsis: Rationale

A deciency of arginine can be considered from changes in arginine metabolism that may compromise the availability of arginine with functional consequences. Both are described in detail later. For extensive information on arginine metab-

olism in normal health, we refer to existing reviews (9, 10, 1214). Changes in Arginine Metabolism in Sepsis. Sepsis is characterized by a reduction in plasma and tissue arginine levels compared with healthy individuals or nonseptic critically ill patients (1518). In addition, plasma amino acid levels are in general lower during sepsis, which is partly related to starvation due to limited nutritional protein supply as well as to increased amino acid clearance (17) through gluconeogenesis, oxidation for energy supply, and protein synthesis in especially the liver and immune cells (19 21). This negative amino acid balance apparently cannot be compensated for by the excessive protein catabolism (protein breakdown is increased by 50% in septic patients (YC Luiking, unpublished data), mainly from muscle but also from the gut (21). In addition, recent evidence suggests that arginine metabolism in sepsis is disturbed in various aspects, probably related to the severity of the inammatory response and induced by inammatory mediators. In sepsis, de novo arginine production, that is, the endogenous synthesis of arginine from the amino acid citrulline (2226), is reduced to one third of the normal level (18). Studies in an animal model of sepsis demonstrated accordingly that impaired de novo arginine
S557

Crit Care Med 2007 Vol. 35, No. 9 (Suppl.)

synthesis in the kidney is a major factor responsible for the rapid decrease in extracellular arginine content after lipopolysaccharide injection (27). Another metabolic change in sepsis is the fourfold increase in arginase activity (YC Luiking, unpublished data), that is, the catabolism of arginine to urea and ornithine, probably through up-regulation of arginase I activity in macrophages by cytokines (interleukin-4, interleukin-10, and transforming growth factor ) secreted by T-helper lymphocyte cells (28). Changes in arginine metabolism can subsequently affect availability of arginine for nitric oxide (NO) synthase (NOS) and therefore NO production. NO production is essential for smooth muscle relaxation and vasodilation via NOS-3 (or eNOS) and as a neurotransmitter via NOS-1 (or nNOS) (29, 30), and NO production is stimulated by inammatory mediators through induction of NOS-2 (or iNOS) (10). Besides arginine availability, other factors that probably affect NO production in sepsis are 1) coupling of NOS with other enzymes involved in arginine metabolism (3133); 2) the effects of bacterial endotoxins and host cytokines on intracellular cationic transport systems (34, 35); and 3) increased presence of endogenous NOS inhibitors like asymmetric dimethylarginine, a byproduct of protein breakdown (36). Although dramatic increases in NO production have been suggested in sepsis and are ascribed to stimulation of NOS-2 by cytokines (interleukin-1, interleukin-2, tumor necrosis factor, and -interferon) produced by T-helper 1 cells (28), evidence was mainly based on reported increases in plasma nitrate levels and increased NOS gene expression (increased NOS-2, but unchanged or even lowered NOS-1 and NOS-3) (37 45). Stable isotope studies could, however, not conrm this dramatic increase in NO production in septic animal models (46 48) and humans (49) (YC Luiking, unpublished data). The discrepancy in measures of NO in sepsis may be due partly to an effect of renal failure on plasma nitrate levels (39), since nitrate is excreted via the urine (50) and its concentration correlates with the glomerular ltration rate in septic patients (49). However, timespecic changes in NOS enzyme activity in sepsis may also play a role (32, 5153), as well as diversity of the septic population related to, for example, the initial presence of trauma (42).
S558

Figure 1. Hypothesis: Time-related changes in arginine availability and arginine metabolism in sepsis (1) or sepsis with optimal nutritional supply (2) with functional consequences. This time-related mechanism in sepsis is represented by an early phase with adaptive changes in activity of metabolic pathways to preserve amino acids and a late adaptive phase aimed at cell survival with enhanced protein breakdown before the onset of arginine deciency when all adaptive mechanisms are exhausted. Optimal nutritional supply may preserve metabolism and function.

The previously described changes in arginine availability and arginine metabolism in sepsis therefore make sepsis an arginine deciency disease with functional consequences. It can be hypothesized that this is a time-related mechanism represented by an early phase with adaptive changes in activity of metabolic pathways to preserve amino acids and a late adaptive phase aimed at cell survival with enhanced protein breakdown before the onset of arginine deciency when all adaptive mechanisms are exhausted (Fig. 1). Functional Consequences of Arginine Deciency. Changes in arginine metabolism in sepsis have mainly focused on NO production. The presumed excessive NO production in sepsis related to enhanced NOS-2 activity is thought to contribute to the systemic hypotension and vascular hyporeactivity in sepsis (42, 54, 55). However, inhibition of NOS turned out to be detrimental also in terms of diminished blood ow (56), and, although resolution from shock was promoted (57), mortality and especially cardiovascular deaths were higher in patients treated with a nonselective NOS inhibitor in a multicenter trial (58). On the other hand, basal NO production (by endothelial NOS or NOS-3) is limited due to endotoxemia (59) and related to diminished vasodilation as observed in aortic rings (60) but probably also in the microcirculation. This latter hypothesis is supported by the observation that administration of the

NO donor nitroglycerin in septic patients improves the microcirculation (61). A relation between de novo synthesis of arginine in the kidneys and renal perfusion was observed in an animal model of sepsis (27) and suggests a functional relation between de novo arginine synthesis and NOS-3 activity, which was also demonstrated by the colocalization of the enzymatic pathways involved (33). Other metabolic changes in sepsis with functional consequences are the severe catabolic state of sepsis. This catabolic state is related to impaired protein synthesis and increased protein breakdown and may result in loss of muscle mass and function and impaired recovery (62). Besides diminished substrate supply due to impaired (microvascular) ow, other factors like cytokines and hormones probably affect protein turnover in sepsis (62). Loss of skeletal muscle mass can result in fatigue and reduced quality of life after recovery, but loss of muscle mass from the diaphragm may also affect respiratory muscle during sepsis (63). On the other hand, however, muscle fatigue has also been associated with the formation of peroxynitrite due to access of NO (64). Muscle catabolism is not specic for lack of arginine (62), as muscle protein comprises other amino acids besides arginine in larger amounts (65). Besides, it has been demonstrated that for the synthesis of acute phase protein, which is greatly elevated in sepsis, an estimated double amount of muscle protein has to
Crit Care Med 2007 Vol. 35, No. 9 (Suppl.)

be broken down to supply aromatic amino acids in adequate amounts (66). Regarding the role of arginine in wound healing (67), which seems to occur via enhanced ornithine and subsequent collagen formation (68) or via a NO-mediated mechanism (69), it is feasible that arginine deciency may impair wound healing, if present, in sepsis. Finally, lower plasma arginine levels also correlated with a poorer prognosis and higher mortality rate from sepsis (15). In summary, the rationale for arginine deciency in sepsis is mainly based on the reduced arginine levels in sepsis that reect the specic changes in arginine metabolism with functional consequences regarding endothelial dysfunction, severe catabolism, impaired wound healing, and worse outcome. However, we need to mention that direct effects of cytokines and hormones are also involved in these pathophysiological processes and that other amino acids may also be present in inadequate amounts (70).

Exogenous Arginine Supplementation in Sepsis: Where Do We Stand and Is It Safe?

Arginine has been supplied in various forms, of which incorporation into the so-called immunonutrition has been most widely used and described. Only a few studies supplied exogenous arginine as a monotherapy. Moreover, the dose and route of exogenous arginine supply (i.e., intravenous or enteral) vary. This section gives an overview of arginine supplementation in patients with sepsis, which is still subject of debate regarding harm or benet (7173). Immunonutrition Containing Arginine in Sepsis. Immunonutrition containing arginine has been investigated in several clinical trials (74 79). In addition, several published meta-analyses, reviews, and opinion papers have focused on arginine-containing immunonutrition in sepsis (80 87). Despite apparent benets of immunonutrition on infection rate and length of hospital stay, metaanalyses identied no benecial effect on mortality rate (84) or even suggested a higher mortality rate with immunonutrition (80). However, benets of immunonutrition were considered most marked in surgical patients (84). Especially these outcomes caused the greatest controversy and discussion, which also resulted in a recommendation by the Canadian
Crit Care Med 2007 Vol. 35, No. 9 (Suppl.)

Clinical Practice Guidelines against supplemental arginine in critically ill adults and especially nonsurgical patients with sepsis (82). Immune-enhancing nutrients have as their principal components several nutrients with putative benets. Besides arginine, these include omega-3 fatty acids and nucleotides, and some contain also glutamine. Although all these components are considered benecial, adequate evaluation of individual effects of components and possible mechanisms of (combined) action are largely missing. Concerning the latter, counterregulating effects of other components in immunonutrition on the efcacy of arginine have been considered but not yet identied (88). Animal Studies in Septic Models. Various animal models of sepsis are available, using different animals as well as different challenges to induce sepsis. Moreover, the route of arginine supply (i.e., intravenous or enteral) also varies. The effects of arginine supplementation on survival are not homogeneous in animal models of sepsis. While some studies reported improved survival (89, 90), others showed no effect (91) or even reported increased mortality (92, 93). In the latter study, this coincided with increased plasma ornithine and serum levels of nitrate and nitrite, a lowered mean arterial pressure, and worsened organ injury (93). In septic sheep, arginine supplementation also resulted in decreased blood pressure (94). A reduction of the production of inamma-

tory mediators at the site of infection (91), as well as an increase in albumin, histone, and liver protein synthesis (95), was observed with intravenous arginine in septic rats. In a hyperdynamic pig model of sepsis, arginine supplementation increased organ NO production (47, 96), with decreased liver protein turnover and increased muscle protein turnover (97). Arginine supplementation nonspecically (i.e., no difference between L-arginine and D-arginine) prevented endothelial dysfunction by restoring endothelial histologic injury in rabbit endotoxic shock, while it did not affect acidosis, coagulation, or monocyte tissue factor expression (98). From this study it was questionable whether the action of arginine supplementation was via enhanced NO synthesis or otherwise. Exogenous Arginine Supplementation as a Monotherapy in Human Sepsis. Only a few studies have investigated the effects of arginine per se in patients with sepsis. Lorente et al. (99) supplied seven septic shock patients with 200 mg/kg L-arginine as an intravenous bolus, which resulted in immediate but transient hemodynamic changes consistent with systemic and pulmonary vasodilation. In a doseresponse pilot study in eight patients with septic shock (100), intravenous Larginine infusion in doses increasing from 0.6 to 1.8 mol/kgmin (each dose for 2 hrs, equal to 1133 g daily for a 75-kg adult) resulted in plasma arginine levels of four times baseline at the highest dose. No changes in systemic blood

Figure 2. Dose-response pilot study of intravenous L-arginine supplementation in septic shock patients (n 8). Each dose was supplied for 2 hrs in a stepwise increasing order. No signicant effect on systemic blood pressure was observed. BP, blood pressure; MAP, mean arterial pressure. Adapted from Luiking et al (100).

S559

pressure or use of vasopressive medication were observed with any dose, but stroke volume increased (Fig. 2) (100). In addition, a recent randomized controlled trial with 3-day intravenous continuous arginine supplementation at 1.2 mol/ kgmin also could not demonstrate an effect on hemodynamic parameters (101). Factors That Potentially Affect the Effectiveness of Exogenous Arginine. First, differences between enteral and intravenous supply of exogenous arginine may inuence the outcome of treatment. Continuous supply of arginine via the enteral route will result in a high rst-pass uptake of arginine in the gut mucosa and the liver, regarding the 40% splanchnic extraction that is reported in healthy subjects using stable isotope techniques (102). Intravenous arginine supplementation, on the other hand, bypasses the large rst-pass extraction of arginine in the splanchnic area. In addition, the impaired absorptive gut function in sepsis (103, 104) may further negatively affect bioavailability of enteral arginine. This was also demonstrated in a peritonitis rat model, in which oral arginine supplementation did not increase plasma arginine levels and survival, whereas intravenous arginine improved survival when administered after initiation of sepsis (90). In addition, differences in argininestimulated NO production between intravenous (105) and dietary arginine supplementation (106) in healthy subjects suggest that the route of arginine administration is probably also important for the NO-stimulating effect of arginine. Second, it is well possible that bolus administration of arginine differs from continuous administration with regard to bioavailability. After an oral bolus of arginine (10 g), a bioavailability of about 20% in healthy subjects has been reported (107), which is substantially lower than the 60% availability to the peripheral circulation after continuous intragastric arginine supply (102). Intravenous bolus arginine supply (30 g in 30 mins) that causes a rapid peak in plasma arginine of 8 mmol/L results in urinary excretion of arginine, as the threshold for renal reabsorption probably is exceeded (107). Intravenous arginine supply as a bolus in sepsis, like 200 mg/kg (about 15 g) arginine administered in the study by Lorente et al. (99), caused transient hypotension, while continuous arginine supplementation at 12.5 mg/kghr (reaching plasma levels of about 300 mol/L) did not
S560

affect blood pressure in septic patients (101). Third, most of the survival benets of immunotherapy occurred in groups with the lowest Acute Physiology and Chronic Health Evaluation II scores (10 15), reecting moderate severity of illness, with little difference in outcome in the more severely ill (74, 84). This suggests that subgroups of septic patients may benet from arginine supplementation while others do not. In summary, exogenous arginine supplementation in sepsis shows controversial results with only limited data in humans and various results in animal models of sepsis. Since the severity of sepsis varies, and the route, timing, and dose of arginine differ between studies, it is difcult to draw a denitive conclusion for the effect of exogenous arginine supplementation in sepsis in general without considering these factors.

Possible Risks and Benets of Exogenous Arginine in Sepsis

Although mechanistic studies on arginine supplementation in septic patients are scarce, major risks of exogenous arginine are ascribed to the suggested increase of NO synthesis. Stimulated NO production is related to reduced blood pressure (105, 108) and is suggested to impair cardiac contractility, induce liver damage, and increase vascular permeability and bacterial translocation from the intestine (109). In addition, oxidative stress (through production of peroxynitrite, a harmful metabolite formed from NO and superoxide that nitrates the tyrosine residues in proteins to nitrotyrosine) (110) and mitochondrial dysfunction (111) are considered further risk factors of increased NO and, therefore, indirect results of exogenous arginine supply. However, in a recent placebo-controlled study in septic patients, we could not demonstrate an effect of 3-day arginine supplementation on plasma nitrotyrosine in patients with severe sepsis (101). Besides the suggested detrimental effects of NO, benets of exogenous arginine can also be considered. First, from a metabolic point of view, exogenous arginine could compensate for the increased arginine need and could diminish the need for endogenous arginine sources like body protein and, thereby, potentially reduce catabolism. Exogenous arginine supply indeed reduced protein breakdown in a pilot study in septic

patients (YC Luiking et al., unpublished data). Moreover, exogenous arginine enhanced protein synthesis and degradation across the hindquarter and simultaneously reduced protein synthesis and degradation in the liver at equal rates in a pig sepsis model (97). A second mechanism is related to the importance of NOS-3 in the regulation of the microcirculation and endothelial function, as demonstrated for arginine supplementation in other vascular diseases (112118). Stimulation of NOS-3mediated NO production may be benecial, specically regarding the fact that NOS-3 is down-regulated in sepsis (44, 45). In vitro studies also conrm that NO production by NOS-3 can be stimulated by exogenous arginine, but this occurred only when L-arginine stores were depleted (119). The mechanism for impaired microcirculation in sepsis is, however, multifactorial, and other factors like mechanic capillary occlusion through extensive edema, occlusion from leukocytes, and impaired mitochondrial function may be involved. Improvement of the microcirculation and local vasodilation may contribute to restoration of organ function in sepsis (multiple organ failure). Arginine may also affect the immune response in sepsis (120, 121) with an aggravated inammatory reaction and increased tissue neutrophil inltration (121). In addition, restored intestinal motility was observed with arginine supplementation in a pig model of sepsis (96). Finally, under conditions of impaired substrate (arginine) availability, the endothelial NOS-3 may undergo structural disarrangement, resulting in the conversion of this enzyme from a NO synthesizer into a generator of superoxide anion (122). This uncoupled reaction can be antagonized by excess L-arginine, as was demonstrated in a rabbit model of hypercholesterolemia (123) and in cells in vitro (124). It may, therefore, be suggested that patients with sepsis lack antioxidant defense strategies, which may contribute to compromised NO availability, with arginine acting as an antioxidant. While enhanced NO production in sepsis is related to suggested detrimental effects of hemodynamic instability and enhanced oxidative stress, potential mechanisms for benecial effects of exogenous arginine supplementation in sepsis include enhanced (protein) metabolism, improved (micro)circulation and organ function, effects on immune function and
Crit Care Med 2007 Vol. 35, No. 9 (Suppl.)

antibacterial effects, improved gut function, and an antioxidant role of arginine.

14.

CONCLUSION
Sepsis is considered an arginine deciency state with reduced arginine levels and specic changes in arginine metabolism related to endothelial dysfunction, severe catabolism, and worse outcome. Regarding the multiple pathways that may benet from arginine supplementation and taking into account our recent study indicating that arginine can be given to septic patients without major effects on hemodynamics, we recommend more studies on the effects of arginine supplementation in septic patients.
15.

16.

17.

18.

REFERENCES
1. Levy MM, Fink MP, Marshall JC, et al: 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Denitions Conference. Crit Care Med 2003; 31:1250 1256 2. Angus DC, Linde-Zwirble WT, Lidicker J, et al: Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29:13031310 3. Friedman G, Silva E, Vincent JL: Has the mortality of septic shock changed with time? Crit Care Med 1998; 26:2078 2086 4. Weycker D, Akhras KS, Edelsberg J, et al: Long-term mortality and medical care charges in patients with severe sepsis. Crit Care Med 2003; 31:2316 2323 5. van Gestel A, Bakker J, Veraart CP, et al: Prevalence and incidence of severe sepsis in Dutch intensive care units. Crit Care 2004; 8:R153R162 6. Luiking YC, Poeze M, Dejong CH, et al: Sepsis: An arginine deciency state? Crit Care Med 2004; 32:21352145 7. Castillo L, Chapman TE, Sanchez M, et al: Plasma arginine and citrulline kinetics in adults given adequate and arginine-free diets. Proc Natl Acad Sci U S A 1993; 90: 7749 7753 8. Wu G, Meininger CJ, Knabe DA, et al: Arginine nutrition in development, health and disease. Curr Opin Clin Nutr Metab Care 2000; 3:59 66 9. Morris SM Jr: Regulation of enzymes of the urea cycle and arginine metabolism. Annu Rev Nutr 2002; 22:87105 10. Kelm M: Nitric oxide metabolism and breakdown. Biochim Biophys Acta 1999; 1411:273289 11. Boger RH, Bode-Boger SM: The clinical pharmacology of L-arginine. Annu Rev Pharmacol Toxicol 2001; 41:79 99 12. Wu G, Morris SM Jr: Arginine metabolism: nitric oxide and beyond. Biochem J 1998; 336:117 13. Cynober L, Le Boucher J, Vasson M-P: Ar-

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

ginine metabolism in mammals. Nutr Biochem 1995; 6:402 413 Flynn NE, Meininger CJ, Haynes TE, et al: The metabolic basis of arginine nutrition and pharmacotherapy. Biomed Pharmacother 2002; 56:427 438 Freund H, Atamian S, Holroyde J, et al: Plasma amino acids as predictors of the severity and outcome of sepsis. Ann Surg 1979; 190:571576 Milewski PJ, Threlfall CJ, Heath DF, et al: Intracellular free amino acids in undernourished patients with or without sepsis. Clin Sci (Lond) 1982; 62:8391 Druml W, Heinzel G, Kleinberger G: Amino acid kinetics in patients with sepsis. Am J Clin Nutr 2001; 73:908 913 Luiking YC, Steens L, Poeze M, et al: Low plasma arginine concentration in septic patients is related to diminished de novo arginine production from citrulline. Clin Nutr 2003; 22(Suppl 1):S26 Sax HC, Hasselgren PO, Talamini MA, et al: Amino acid uptake in isolated, perfused liver: Effect of trauma and sepsis. J Surg Res 1988; 45:50 55 Bruins MJ, Deutz NE, Soeters PB: Aspects of organ protein, amino acid and glucose metabolism in a porcine model of hypermetabolic sepsis. Clin Sci (Lond) 2003; 104: 127141 Bruins MJ, Soeters PB, Deutz NE: Endotoxemia affects organ protein metabolism differently during prolonged feeding in pigs. J Nutr 2000; 130:30033013 Tizianello A, De Ferrari G, Garibotto G, et al: Renal metabolism of amino acids and ammonia in subjects with normal renal function and in patients with chronic renal insufciency. J Clin Invest 1980; 65: 11621173 Windmueller HG, Spaeth AE: Source and fate of circulating citrulline. Am J Physiol 1981; 241:E473E480 Featherston WR, Rogers QR, Freedland RA: Relative importance of kidney and liver in synthesis of arginine by the rat. Am J Physiol 1973; 224:127129 Yu YM, Burke JF, Tompkins RG, et al: Quantitative aspects of interorgan relationships among arginine and citrulline metabolism. Am J Physiol 1996; 271: E1098 E1109 Dhanakoti SN, Brosnan JT, Herzberg GR, et al: Renal arginine synthesis: Studies in vitro and in vivo. Am J Physiol 1990; 259: E437E442 Lortie MJ, Satriano J, Gabbai FB, et al: Production of arginine by the kidney is impaired in a model of sepsis: Early events following LPS. Am J Physiol Regul Integr Comp Physiol 2004; 287:R1434 R1440 Bansal V, Ochoa JB: Arginine availability, arginase, and the immune response. Curr Opin Clin Nutr Metab Care 2003; 6:223228 Knowles RG, Moncada S: Nitric oxide synthases in mammals. Biochem J 1994; 298: 249 258

30. Bachmann S, Bosse HM, Mundel P: Topography of nitric oxide synthesis by localizing constitutive NO synthases in mammalian kidney. Am J Physiol 1995; 268:F885F898 31. Shen LJ, Beloussow K, Shen WC: Accessibility of endothelial and inducible nitric oxide synthase to the intracellular citrullinearginine regeneration pathway. Biochem Pharmacol 2005; 69:97104 32. Salimuddin, Nagasaki A, Gotoh T, et al: Regulation of the genes for arginase isoforms and related enzymes in mouse macrophages by lipopolysaccharide. Am J Physiol 1999; 277:E110 E117 33. Flam BR, Hartmann PJ, Harrell-Booth M, et al: Caveolar localization of arginine regeneration enzymes, argininosuccinate synthase, and lyase, with endothelial nitric oxide synthase. Nitric Oxide 2001; 5:187197 34. Reade MC, Clark MF, Young JD, et al: Increased cationic amino acid ux through a newly expressed transporter in cells overproducing nitric oxide from patients with septic shock. Clin Sci (Lond) 2002; 102: 645 650 35. Schwartz D, Schwartz IF, Gnessin E, et al: Differential regulation of glomerular arginine transporters (CAT-1 and CAT-2) in lipopolysaccharide-treated rats. Am J Physiol Renal Physiol 2003; 284:F788 F795 36. Nijveldt RJ, Teerlink T, Van Der Hoven B, et al: Asymmetrical dimethylarginine (ADMA) in critically ill patients: High plasma ADMA concentration is an independent risk factor of ICU mortality. Clin Nutr 2003; 22:2330 37. MacKenzie IM, Garrard CS, Young JD: Indices of nitric oxide synthesis and outcome in critically ill patients. Anaesthesia 2001; 56:326 330 38. Gomez-Jimenez J, Salgado A, Mourelle M, et al: L-arginine: Nitric oxide pathway in endotoxemia and human septic shock. Crit Care Med 1995; 23:253258 39. Groeneveld PH, Kwappenberg KM, Langermans JA, et al: Nitric oxide (NO) production correlates with renal insufciency and multiple organ dysfunction syndrome in severe sepsis. Intensive Care Med 1996; 22:11971202 40. Endo S, Inada K, Nakae H, et al: Nitrite/ nitrate oxide (NOx) and cytokine levels in patients with septic shock. Res Commun Mol Pathol Pharmacol 1996; 91:347356 41. de Werra I, Jaccard C, Corradin SB, et al: Cytokines, nitrite/nitrate, soluble tumor necrosis factor receptors, and procalcitonin concentrations: Comparisons in patients with septic shock, cardiogenic shock, and bacterial pneumonia. Crit Care Med 1997; 25:607 613 42. Ochoa JB, Udekwu AO, Billiar TR, et al: Nitrogen oxide levels in patients after trauma and during sepsis. Ann Surg 1991; 214:621 626 43. Lanone S, Mebazaa A, Heymes C, et al: Sepsis is associated with reciprocal expressional modications of constitutive nitric oxide synthase (NOS) in human skeletal

Crit Care Med 2007 Vol. 35, No. 9 (Suppl.)

S561

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

muscle: Down-regulation of NOS1 and upregulation of NOS3. Crit Care Med 2001; 29:1720 1725 Beach PK, Spain DA, Kawabe T, et al: Sepsis increases NOS-2 activity and decreases nonNOS-mediated acetylcholine-induced dilation in rat aorta. J Surg Res 2001; 96:1722 Hallemeesch MM, Janssen BJA, De Jonge WJ, et al: NO production by cNOS and iNOS reects blood pressure changes in LPSchallenged mice. Am J Physiol Endocrinol Metab 2003; 285:E871E875 Hallemeesch MM, Soeters PB, Deutz NE: Renal arginine and protein synthesis are increased during early endotoxemia in mice. Am J Physiol Renal Physiol 2002; 282:F316 F323 Bruins MJ, Soeters PB, Lamers WH, et al: L-arginine supplementation in hyperdynamic endotoxemic pigs: Effect on nitric oxide synthesis by the different organs. Crit Care Med 2002; 30:508 517 Bruins MJ, Lamers WH, Meijer AJ, et al: In vivo measurement of nitric oxide production in porcine gut, liver and muscle during hyperdynamic endotoxaemia. Br J Pharmacol 2002; 137:12251236 Villalpando S, Gopal J, Balasubramanyam A, et al: In vivo arginine production and intravascular nitric oxide synthesis in hypotensive sepsis. Am J Clin Nutr 2006; 84: 197203 Kirkeboen KA, Strand OA: The role of nitric oxide in sepsisAn overview. Acta Anaesthesiol 1999; 43:275288 Tabuchi S, Gotoh T, Miyanaka K, et al: Regulation of genes for inducible nitric oxide synthase and urea cycle enzymes in rat liver in endotoxin shock. Biochem Biophys Res Commun 2000; 268:221224 Sade K, Schwartz D, Wolman Y, et al: Time course of lipopolysaccharide-induced nitric oxide synthase mRNA expression in rat glomeruli. J Lab Clin Med 1999; 134:471 477 Braulio VB, Ten Have GA, Vissers YL, et al: Time course of nitric oxide production after endotoxin challenge in mice. Am J Physiol Endocrinol Metab 2004; 287:E912E918 Evans T, Carpenter A, Kinderman H, et al: Evidence of increased nitric oxide production in patients with the sepsis syndrome. Circ Shock 1993; 41:77 81 Morris SM Jr, Billiar TR: New insights into the regulation of inducible nitric oxide synthesis. Am J Physiol 1994; 266:E829 E839 Pastor C, Teisseire B, Vicaut E, et al: Effects of L-arginine and L-nitro-arginine treatment on blood pressure and cardiac output in a rabbit endotoxin shock model. Crit Care Med 1994; 22:465 469 Bakker J, Grover R, McLuckie A, et al: Administration of the nitric oxide synthase inhibitor NG-methyl-L-arginine hydrochloride (546C88) by intravenous infusion for up to 72 hours can promote the resolution of shock in patients with severe sepsis: Results of a randomized, double-blind, place-

58.

59.

60.

61.

62.

63.

64.

65.

66.

67.

68.

69.

70.

71.

72.

73.

74.

bo-controlled multicenter study (study no. 144-002). Crit Care Med 2004; 32:112 Lopez A, Lorente JA, Steingrub J, et al: Multiple-center, randomized, placebocontrolled, double-blind study of the nitric oxide synthase inhibitor 546C88: Effect on survival in patients with septic shock. Crit Care Med 2004; 32:2130 Parker JL, Myers PR, Zhong Q, et al: Inhibition of endothelium-dependent vasodilation by Escherichia coli endotoxemia. Shock 1994; 2:451 458 Myers PR, Zhong Q, Jones JJ, et al: Release of EDRF and NO in ex vivo perfused aorta: Inhibition by in vivo E. coli endotoxemia. Am J Physiol 1995; 268:H955H961 Spronk PE, Ince C, Gardien MJ, et al: Nitroglycerin in septic shock after intravascular volume resuscitation. Lancet 2002; 360: 13951396 Vary TC: Regulation of skeletal muscle protein turnover during sepsis. Curr Opin Clin Nutr Metab Care 1998; 1:217224 Lanone S, Taille C, Boczkowski J, et al: Diaphragmatic fatigue during sepsis and septic shock. Intensive Care Med 2005; 31: 16111617 Lanone S, Mebazaa A, Heymes C, et al: Muscular contractile failure in septic patients: Role of the inducible nitric oxide synthase pathway. Am J Respir Crit Care Med 2000; 162:2308 2315 Smith K, Rennie MJ: Protein turnover and amino acid metabolism in human skeletal muscle. Baillieres Clin Endocrinol Metab 1990; 4:461 498 Reeds PJ, Fjeld CR, Jahoor F: Do the differences between the amino acid compositions of acute-phase and muscle proteins have a bearing on nitrogen loss in traumatic states? J Nutr 1994; 124:906 910 Barbul A, Lazarou SA, Efron DT, et al: Arginine enhances wound healing and lymphocyte immune responses in humans. Surgery 108:331336, 1990 Shi HP, Fishel RS, Efron DT, et al: Effect of supplemental ornithine on wound healing. J Surg Res 2002; 106:299 302 Witte MB, Barbul A: Role of nitric oxide in wound repair. Am J Surg 2002; 183: 406 412 Chiarla C, Giovannini I, Siegel JH: Plasma arginine correlations in trauma and sepsis. Amino Acids 2006; 30:81 86 Kalil AC, Danner RL: L-Arginine supplementation in sepsis: Benecial or harmful? Curr Opin Crit Care 2006; 12:303308 Zaloga GP, Siddiqui R, Terry C, et al: Arginine: Mediator or modulator of sepsis? Nutr Clin Pract 2004; 19:201215 Suchner U, Heyland DK, Peter K: Immunemodulatory actions of arginine in the critically ill. Br J Nutr 2002; 87(Suppl 1): S121S132 Galban C, Montejo JC, Mesejo A, et al: An immune-enhancing enteral diet reduces mortality rate and episodes of bacteremia in

75.

76.

77.

78.

79.

80.

81.

82.

83.

84.

85.

86. 87.

88.

89.

septic intensive care unit patients. Crit Care Med 2000; 28:643 648 Atkinson S, Sieffert E, Bihari D: A prospective, randomized, double-blind, controlled clinical trial of enteral immunonutrition in the critically ill. Guys Hospital Intensive Care Group. Crit Care Med 1998; 26: 1164 1172 Bower RH, Cerra FB, Bershadsky B, et al: Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and sh oil in intensive care unit patients: Results of a multicenter, prospective, randomized, clinical trial. Crit Care Med 1995; 23:436 449 Caparros T, Lopez J, Grau T: Early enteral nutrition in critically ill patients with a high-protein diet enriched with arginine, ber, and antioxidants compared with a standard high-protein diet: The effect on nosocomial infections and outcome. JPEN J Parenter Enteral Nutr 2001; 25:299 308 Bertolini G, Iapichino G, Radrizzani D, et al: Early enteral immunonutrition in patients with severe sepsis: Results of an interim analysis of a randomized multicentre clinical trial. Intensive Care Med 2003; 29: 834 840 Kieft H, Roos AN, van Drunen JD, et al: Clinical outcome of immunonutrition in a heterogeneous intensive care population. Intensive Care Med 2005; 31:524 532 Heyland DK, Novak F, Drover JW, et al: Should immunonutrition become routine in critically ill patients? A systematic review of the evidence. JAMA 2001; 286:944 953 Heyland DK, Samis A: Does immunonutrition in patients with sepsis do more harm than good? Intensive Care Med 2003; 29: 669 671 Heyland DK, Dhaliwal R, Drover JW, et al: Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 2003; 27:355373 McCowen KC, Bistrian BR: Immunonutrition: Problematic or problem solving? Am J Clin Nutr 2003; 77:764 770 Beale RJ, Bryg DJ, Bihari DJ: Immunonutrition in the critically ill: A systematic review of clinical outcome. Crit Care Med 1999; 27:2799 2805 Bistrian BR: Practical recommendations for immune-enhancing diets. J Nutr 2004; 134: 2868S2872S. Calder PC: Immunonutrition. BMJ 2003; 327:117118 Ochoa JB, Makarenkova V, Bansal V: A rational use of immune enhancing diets: When should we use dietary arginine supplementation? Nutr Clin Pract 2004; 19: 216 225 Kuhn M, Hamani D, Moinard C, et al: Differentiation of the effects of arginine and n-3 polyunsaturated fatty acids within and immune-enhancing diet (IED). e-SPEN 2006; 1:48 Gianotti L, Alexander JW, Pyles T, et al:

S562

Crit Care Med 2007 Vol. 35, No. 9 (Suppl.)

90.

91.

92.

93.

94.

95.

96.

97.

98.

99.

100.

Arginine-supplemented diets improve survival in gut-derived sepsis and peritonitis by modulating bacterial clearance: The role of nitric oxide. Ann Surg 1993; 217:644 653 Madden HP, Breslin RJ, Wasserkrug HL, et al: Stimulation of T cell immunity by arginine enhances survival in peritonitis. J Surg Res 1988; 44:658 663 Yeh CL, Yeh SL, Lin MT, et al: Effects of arginine-enriched total parenteral nutrition on inammatory-related mediator and Tcell population in septic rats. Nutrition 2002; 18:631 635 Gonce SJ, Peck MD, Alexander JW, et al: Arginine supplementation and its effect on established peritonitis in guinea pigs. JPEN J Parenter Enteral Nutr 1990; 14:237244 Kalil AC, Sevransky JE, Myers DE, et al: Preclinical trial of l-arginine monotherapy alone or with N-acetylcysteine in septic shock. Crit Care Med 2006; 34:2719 2728 Lorente JA, Delgado MA, Tejedor C, et al: Modulation of systemic hemodynamics by exogenous L-arginine in normal and bacteremic sheep. Crit Care Med 1999; 27: 2474 2479 Leon P, Redmond HP, Stein TP, et al: Harry M. Vars Research Award. Arginine supplementation improves histone and acutephase protein synthesis during Gramnegative sepsis in the rat. JPEN J Parenter Enteral Nutr 1991; 15:503508 Bruins MJ, Luiking YC, Soeters PB, et al: Effects of long-term intravenous and intragastric L-arginine intervention on jejunal motility and visceral nitric oxide production in the hyperdynamic compensated endotoxaemic pig. Neurogastroenterol Motil 2004; 16:819 828 Bruins MJ, Soeters PB, Lamers WH, et al: L-arginine supplementation in pigs decreases liver protein turnover and increases hindquarter protein turnover both during and after endotoxemia. Am J Clin Nutr 2002; 75:10311044 Wiel E, Pu Q, Corseaux D, et al: Effect of L-arginine on endothelial injury and hemostasis in rabbit endotoxin shock. J Appl Physiol 2000; 89:18111818 Lorente JA, Landin L, De Pablo R, et al: L-arginine pathway in the sepsis syndrome. Crit Care Med 1993; 21:12871295 Luiking YC, Poeze M, Hendrikx M, et al: Continuous L-arginine infusion does not deteriorate the haemodyamic condition in patients with severe sepsis. Clin Nutr 2005; 24:612 613

101. Luiking YC, Poeze M, Preiser J, et al: Larginine infusion in severely septic patients does not enhance protein nitrosylation or haemodynamic instability. e-SPEN 2006; 1:14 15 102. Castillo L, Chapman TE, Yu YM, et al: Dietary arginine uptake by the splanchnic region in adult humans. Am J Physiol 1993; 265:E532E539 103. Sodeyama M, Gardiner KR, Regan MC, et al: Sepsis impairs gut amino acid absorption. Am J Surg 1993; 165:150 154 104. Gardiner KR, Gardiner RE, Barbul A: Reduced intestinal absorption of arginine during sepsis. Crit Care Med 1995; 23: 12271232 105. Mehta S, Stewart DJ, Levy RD: The hypotensive effect of L-arginine is associated with increased expired nitric oxide in humans. Chest 1996; 109:1550 1555 106. Beaumier L, Castillo L, Ajami AM, et al: Urea cycle intermediate kinetics and nitrate excretion at normal and therapeutic intakes of arginine in humans. Am J Physiol 1995; 269:E884 E896 107. Tangphao O, Grossmann M, Chalon S, et al: Pharmacokinetics of intravenous and oral L-arginine in normal volunteers. Br J Clin Pharmacol 1999; 47:261266 108. Castejon AM, Hoffmann IS, Jimenez E, et al: Differential blood pressure effects of oral glucose and intravenous L-arginine in healthy lean normotensive and obese hypertensive subjects. J Hum Hypertens 2002; 16(Suppl 1):S133S136 109. Fink MP: Modulating the L-arginine-nitric oxide pathway in septic shock: Choosing the proper point of attack. Crit Care Med 1999; 27:2019 2022 110. Ischiropoulos H: Biological tyrosine nitration: A pathophysiological function of nitric oxide and reactive oxygen species. Arch Biochem Biophys 1998; 356:111 111. Singer M, Brealey D: Mitochondrial dysfunction in sepsis. Biochem Soc Symp 1999; 66:149 166 112. Lerman A, Burnett JC Jr, Higano ST, et al: Long-term L-arginine supplementation improves small-vessel coronary endothelial function in humans. Circulation 1998; 97: 21232128 113. Creager MA, Gallagher SJ, Girerd XJ, et al: L-arginine improves endothelium-dependent vasodilation in hypercholesterolemic humans. J Clin Invest 1992; 90:1248 1253 114. Drexler H, Zeiher AM, Meinzer K, et al: Correction of endothelial dysfunction in

115.

116.

117.

118.

119.

120.

121.

122.

123.

124.

coronary microcirculation of hypercholesterolaemic patients by L-arginine. Lancet 1991; 338:1546 1550 Rector TS, Bank AJ, Mullen KA, et al: Randomized, double-blind, placebo-controlled study of supplemental oral L-arginine in patients with heart failure. Circulation 1996; 93:21352141 Boger RH, Bode-Boger SM, Thiele W, et al: Restoring vascular nitric oxide formation by L-arginine improves the symptoms of intermittent claudication in patients with peripheral arterial occlusive disease. J Am Coll Cardiol 1998; 32:1336 1344 Oka RK, Szuba A, Giacomini JC, et al: A pilot study of L-arginine supplementation on functional capacity in peripheral arterial disease. Vasc Med 2005; 10:265274 Schellong SM, Boger RH, Burchert W, et al: Dose-related effect of intravenous Larginine on muscular blood ow of the calf in patients with peripheral vascular disease: A H215O positron emission tomography study. Clin Sci (Lond) 1997; 93:159 165 Arnal JF, Munzel T, Venema RC, et al: Interactions between L-arginine and Lglutamine change endothelial NO production: An effect independent of NO synthase substrate availability. J Clin Invest 1995; 95:25652572 Shang HF, Hsu CS, Yeh CL, et al: Effects of arginine supplementation on splenocyte cytokine mRNA expression in rats with gutderived sepsis. World J Gastroenterol 2005; 11:70917096 Yeh CL, Hsu CS, Chiu WC, et al: Dietary arginine enhances adhesion molecule and T helper 2 cytokine expression in mice with gut-derived sepsis. Shock 2006; 25:155 160 Forstermann U: Endothelial NO synthase as a source of NO and superoxide. Eur J Clin Pharmacol 2006; 62(Suppl 13):512 Boger RH, Bode-Boger SM, Mugge A, et al: Supplementation of hypercholesterolaemic rabbits with L-arginine reduces the vascular release of superoxide anions and restores NO production. Atherosclerosis 1995; 117: 273284 Xia Y, Dawson VL, Dawson TM, et al: Nitric oxide synthase generates superoxide and nitric oxide in arginine-depleted cells leading to peroxynitrite-mediated cellular injury. Proc Natl Acad Sci U S A 1996; 93: 6770 6774

Crit Care Med 2007 Vol. 35, No. 9 (Suppl.)

S563