Exogenous arginine in sepsis

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

S
epsis is a major complication
of an acute infection, triggered
by a systemic inammatory re-
action. According to its pro-
gressive injury process, the sepsis syn-
drome can be classied as mild or severe
sepsis or septic shock. Severe sepsis co-
incides with multiple organ failure, while
septic shock is characterized by addi-
tional 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 mor-
bidity and mortality rate, the latter vary-
ing between 20% and 50% within the
rst month of disease (2, 3), still further
increasing thereafter (4). Risk factors for
sepsis are age (70% of patients are 60
yrs), gender (63% male vs. 37% female),
and comorbidities like malignancies, re-
spiratory 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 (68). This is
partly because arginine is a key amino
acid in several metabolic pathways of
which synthesis of nitric oxide is consid-
ered of main importance during disease
(for recent reviews, see Refs. 914). This
review focuses on arginine metabolism in
sepsis and implications for arginine avail-
ability and related functions, arginine
and arginine-related therapies, and po-
tential 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 consid-
ered 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 exist-
ing reviews (9, 10, 1214).
Changes in Arginine Metabolism in
Sepsis. Sepsis is characterized by a reduc-
tion 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
(1921). This negative amino acid bal-
ance apparently cannot be compensated
for by the excessive protein catabolism
(protein breakdown is increased by 50%
in septic patients (YC Luiking, unpub-
lished data), mainly from muscle but also
from the gut (21).
In addition, recent evidence suggests
that arginine metabolism in sepsis is dis-
turbed in various aspects, probably re-
lated to the severity of the inammatory
response and induced by inammatory
mediators. In sepsis, de novo arginine
production, that is, the endogenous syn-
thesis 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 ac-
cordingly that impaired de novo arginine
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 con-
icts 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 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 con-
troversial 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, sug-
gesting 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; pro-
tein
S557 Crit Care Med 2007 Vol. 35, No. 9 (Suppl.)
synthesis in the kidney is a major factor
responsible for the rapid decrease in ex-
tracellular arginine content after lipo-
polysaccharide injection (27). Another
metabolic change in sepsis is the four-
fold increase in arginase activity (YC Lu-
iking, unpublished data), that is, the
catabolism of arginine to urea and orni-
thine, probably through up-regulation of
arginase I activity in macrophages by cy-
tokines (interleukin-4, interleukin-10,
and transforming growth factor ) se-
creted by T-helper lymphocyte cells (28).
Changes in arginine metabolism can sub-
sequently 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 produc-
tion in sepsis are 1) coupling of NOS
with other enzymes involved in argi-
nine metabolism (3133); 2) the effects
of bacterial endotoxins and host cyto-
kines on intracellular cationic trans-
port systems (34, 35); and 3) increased
presence of endogenous NOS inhibitors
like asymmetric dimethylarginine, a by-
product of protein breakdown (36). Al-
though dramatic increases in NO pro-
duction have been suggested in sepsis
and are ascribed to stimulation of
NOS-2 by cytokines (interleukin-1, in-
terleukin-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 expres-
sion (increased NOS-2, but unchanged
or even lowered NOS-1 and NOS-3)
(3745). Stable isotope studies could,
however, not conrm this dramatic in-
crease in NO production in septic ani-
mal models (4648) 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, time-
specic changes in NOS enzyme activ-
ity 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).
The previously described changes in
arginine availability and arginine me-
tabolism in sepsis therefore make sepsis
an arginine deciency disease with
functional consequences. It can be hy-
pothesized 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 metabo-
lism 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). How-
ever, 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 nonse-
lective 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 vasodila-
tion 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 re-
lation between de novo synthesis of argi-
nine 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 demon-
strated by the colocalization of the enzy-
matic pathways involved (33).
Other metabolic changes in sepsis
with functional consequences are the se-
vere catabolic state of sepsis. This cata-
bolic state is related to impaired protein
synthesis and increased protein break-
down 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 hor-
mones 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 forma-
tion 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 ar-
ginine in larger amounts (65). Besides, it
has been demonstrated that for the syn-
thesis of acute phase protein, which is
greatly elevated in sepsis, an estimated
double amount of muscle protein has to
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 ex-
hausted. Optimal nutritional supply may preserve metabolism and function.
S558 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 oc-
cur via enhanced ornithine and subse-
quent collagen formation (68) or via a
NO-mediated mechanism (69), it is feasi-
ble that arginine deciency may impair
wound healing, if present, in sepsis. Fi-
nally, 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 re-
ect the specic changes in arginine me-
tabolism 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 sup-
plementation in patients with sepsis,
which is still subject of debate regarding
harm or benet (7173).
Immunonutrition Containing Argi-
nine in Sepsis. Immunonutrition con-
taining arginine has been investigated in
several clinical trials (7479). In addi-
tion, several published meta-analyses, re-
views, and opinion papers have focused
on arginine-containing immunonutrition
in sepsis (8087). Despite apparent ben-
ets of immunonutrition on infection
rate and length of hospital stay, meta-
analyses identied no benecial effect on
mortality rate (84) or even suggested a
higher mortality rate with immunonutri-
tion (80). However, benets of immunonu-
trition were considered most marked in
surgical patients (84). Especially these
outcomes caused the greatest contro-
versy and discussion, which also resulted
in a recommendation by the Canadian
Clinical Practice Guidelines against sup-
plemental arginine in critically ill adults
and especially nonsurgical patients with
sepsis (82).
Immune-enhancing nutrients have as
their principal components several nutri-
ents with putative benets. Besides argi-
nine, these include omega-3 fatty acids and
nucleotides, and some contain also glu-
tamine. 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 compo-
nents in immunonutrition on the efcacy
of arginine have been considered but not
yet identied (88).
Animal Studies in Septic Models. Var-
ious animal models of sepsis are avail-
able, 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 re-
ported improved survival (89, 90), others
showed no effect (91) or even reported in-
creased 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 re-
sulted 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 ob-
served 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 mus-
cle protein turnover (97). Arginine supple-
mentation nonspecically (i.e., no differ-
ence between L-arginine and D-arginine)
prevented endothelial dysfunction by re-
storing endothelial histologic injury in rab-
bit 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 ar-
ginine 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 dose-
response pilot study in eight patients
with septic shock (100), intravenous L-
arginine 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 high-
est 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 Crit Care Med 2007 Vol. 35, No. 9 (Suppl.)
pressure or use of vasopressive medica-
tion 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 in-
travenous supply of exogenous arginine
may inuence the outcome of treatment.
Continuous supply of arginine via the en-
teral 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 sub-
jects using stable isotope techniques
(102). Intravenous arginine supplemen-
tation, on the other hand, bypasses the
large rst-pass extraction of arginine in
the splanchnic area. In addition, the im-
paired 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 supple-
mentation did not increase plasma argi-
nine levels and survival, whereas intrave-
nous arginine improved survival when
administered after initiation of sepsis
(90). In addition, differences in arginine-
stimulated NO production between intra-
venous (105) and dietary arginine supple-
mentation (106) in healthy subjects
suggest that the route of arginine admin-
istration 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 ar-
ginine (10 g), a bioavailability of about
20% in healthy subjects has been re-
ported (107), which is substantially lower
than the 60% availability to the periph-
eral circulation after continuous intra-
gastric arginine supply (102). Intrave-
nous 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 hy-
potension, while continuous arginine sup-
plementation at 12.5 mg/kghr (reaching
plasma levels of about 300 mol/L) did not
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 (1015), re-
ecting 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 sup-
plementation in sepsis shows controver-
sial results with only limited data in hu-
mans 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 sup-
plementation in sepsis in general without
considering these factors.
Possible Risks and Benets of
Exogenous Arginine in Sepsis
Although mechanistic studies on argi-
nine supplementation in septic patients
are scarce, major risks of exogenous ar-
ginine are ascribed to the suggested in-
crease 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 permeabil-
ity and bacterial translocation from the
intestine (109). In addition, oxidative
stress (through production of peroxyni-
trite, a harmful metabolite formed from
NO and superoxide that nitrates the ty-
rosine residues in proteins to nitroty-
rosine) (110) and mitochondrial dysfunc-
tion (111) are considered further risk
factors of increased NO and, therefore,
indirect results of exogenous arginine sup-
ply. However, in a recent placebo-con-
trolled 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 ef-
fects of NO, benets of exogenous argi-
nine can also be considered. First, from a
metabolic point of view, exogenous argi-
nine could compensate for the increased
arginine need and could diminish the
need for endogenous arginine sources
like body protein and, thereby, poten-
tially reduce catabolism. Exogenous ar-
ginine 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 degra-
dation across the hindquarter and si-
multaneously 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 dis-
eases (112118). Stimulation of NOS-3-
mediated NO production may be bene-
cial, 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 de-
pleted (119). The mechanism for im-
paired microcirculation in sepsis is, how-
ever, multifactorial, and other factors like
mechanic capillary occlusion through ex-
tensive edema, occlusion from leuko-
cytes, and impaired mitochondrial func-
tion may be involved. Improvement of
the microcirculation and local vasodila-
tion may contribute to restoration of or-
gan function in sepsis (multiple organ
failure).
Arginine may also affect the immune
response in sepsis (120, 121) with an ag-
gravated inammatory reaction and in-
creased tissue neutrophil inltration
(121). In addition, restored intestinal mo-
tility was observed with arginine supple-
mentation in a pig model of sepsis (96).
Finally, under conditions of impaired
substrate (arginine) availability, the en-
dothelial NOS-3 may undergo structural
disarrangement, resulting in the conver-
sion of this enzyme from a NO synthe-
sizer 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 hyper-
cholesterolemia (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 ar-
ginine 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 exog-
enous arginine supplementation in sepsis
include enhanced (protein) metabolism,
improved (micro)circulation and organ
function, effects on immune function and
S560 Crit Care Med 2007 Vol. 35, No. 9 (Suppl.)
antibacterial effects, improved gut func-
tion, and an antioxidant role of arginine.
CONCLUSION
Sepsis is considered an arginine de-
ciency state with reduced arginine levels
and specic changes in arginine metabo-
lism related to endothelial dysfunction,
severe catabolism, and worse outcome.
Regarding the multiple pathways that
may benet from arginine supplementa-
tion and taking into account our recent
study indicating that arginine can be
given to septic patients without major
effects on hemodynamics, we recom-
mend more studies on the effects of argi-
nine supplementation in septic patients.
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