Urea inhibits inducible nitric oxide synthase in macrophage cell line

The roles of arginases and arginine in immunity

Arginase activity and arginine metabolism in immune cells have important consequences for health and disease. Their dysregulation is commonly observed in cancer, autoimmune disorders and infectious diseases. Following the initial description of a role for arginase in the dysfunction of T cells mounting an antitumour response, numerous studies have broadened our understanding of the regulation and expression of arginases and their integration with other metabolic pathways. Here, we highlight the differences in arginase compartmentalization and storage between humans and rodents that should be taken into consideration when assessing the effects of arginase activity. We detail the roles of arginases, arginine and its metabolites in immune cells and their effects in the context of cancer, autoimmunity and infectious disease. Finally, we explore potential therapeutic strategies targeting arginases and arginine.

Arginase: Biological and Therapeutic Implications in Diabetes Mellitus and Its Complications

Arginase is a ubiquitous enzyme in the urea cycle (UC) that hydrolyzes L-arginine to urea and L-ornithine. Two mammalian arginase isoforms, arginase1 (ARG1) and arginase2 (ARG2), play a vital role in the regulation of β-cell functions, insulin resistance (IR), and vascular complications via modulating L-arginine metabolism, nitric oxide (NO) production, and inflammatory responses as well as oxidative stress. Basic and clinical studies reveal that abnormal alterations of arginase expression and activity are strongly associated with the onset and development of diabetes mellitus (DM) and its complications. As a result, targeting arginase may be a novel and promising approach for DM treatment. An increasing number of arginase inhibitors, including chemical and natural inhibitors, have been developed and shown to protect against the development of DM and its complications. In this review, we discuss the fundamental features of arginase. Next, the regulatory roles and underlying mechanisms of arginase in the pathogenesis and progression of DM and its complications are explored. Furthermore, we review the development and discuss the challenges of arginase inhibitors in treating DM and its related pathologies.

Multistability in Macrophage Activation Pathways and Metabolic Implications

Macrophages are innate immune cells with a dynamic range of reversible activation states including the classical pro-inflammatory (M1) and alternative anti-inflammatory (M2) states. Deciphering how macrophages regulate their transition from one state to the other is key for a deeper understanding of inflammatory diseases and relevant therapies. Common regulatory motifs reported for macrophage transitions, such as positive or double-negative feedback loops, exhibit a switchlike behavior, suggesting the bistability of the system. In this review, we explore the evidence for multistability (including bistability) in macrophage activation pathways at four molecular levels. First, a decision-making module in signal transduction includes mutual inhibitory interactions between M1 (STAT1, NF-KB/p50-p65) and M2 (STAT3, NF-KB/p50-p50) signaling pathways. Second, a switchlike behavior at the gene expression level includes complex network motifs of transcription factors and miRNAs. Third, these changes impact metabolic gene expression, leading to switches in energy production, NADPH and ROS production, TCA cycle functionality, biosynthesis, and nitrogen metabolism. Fourth, metabolic changes are monitored by metabolic sensors coupled to AMPK and mTOR activity to provide stability by maintaining signals promoting M1 or M2 activation. In conclusion, we identify bistability hubs as promising therapeutic targets for reverting or blocking macrophage transitions through modulation of the metabolic environment.

Cyst(e)ine fortification in low crude protein diet improves growth performance of broilers by modulating serum metabolite profile

This study was aimed to explore the metabolomical mechanisms for the potentially ameliorative effect of cyst(e)ine (Cys) fortification on growth performance of broilers fed low crude protein (CP) diet. A total of 432 1-d-old broilers were randomly divided into 6 groups, each of which received one of the following diets: normal-CP diet (positive control, PC), low-CP diet (negative control, NC), NC diet fortified with 0.05%, 0.1%, 0.15% or 0.2% of Cys. Samples were collected on d 42. Results showed that increasing Cys fortification quadratically elevated (P < 0.05) the accumulative growth performance and leg muscle yield of broilers fed NC diet, with 0.1% being the optimal dose. Thus, samples from PC, NC and NC plus 0.1% Cys (NCC) groups were selected for further analysis. Both dietary CP reduction and fortification of 0.1% Cys in NC diet caused complex changes (P < 0.05) in serum amino acids and some other metabolites primarily involved in lipid metabolism. Multiple lipogenesis-related pathways were regulated (P < 0.05) following Cys fortification in NC diet, which could at least partially interpret the benefit of Cys fortification in NC diet on broiler performance. In conclusion, fortifying low-CP diet with 0.1% Cys promoted the growth performance of broilers probably through modulating serum metabolite profile.

Characteris Tics and Causes of Immune Dysfunction Related to Uremia and Dialysis

From the immunologic viewpoint, chronic kidney disease (CKD) is characterized by disorders of both the innate and adaptive systems, generating a complex and still not fully understood immune dysfunction. Markers of a chronically activated immune system are closely linked to several complications of CKD and represent powerful predictors for mortality in the CKD population. On the other hand, CKD patients respond poorly to vaccination and to challenges such as bacterial infection. Interestingly, the main causes of death in patients with CKD are cardiovascular and infectious diseases, both being pathologic processes closely linked to immune function. Therefore, accelerated tissue degeneration (as a consequence of chronic inflammation) and increased rate of sepsis (because of a poorly orchestrated immune response) represent the most important targets for interventions aiming to reduce mortality in CKD patients. Understanding the mechanisms behind the immune dysfunction that is peculiar to CKD generates a perspective to improve outcomes in this group of patients.

UT-A1/A3 knockout mice show reduced fibrosis following unilateral ureteral obstruction

Renal fibrosis is a major contributor to the development and progression of chronic kidney disease. A low-protein diet can reduce the progression of chronic kidney disease and reduce the development of renal fibrosis, although the mechanism is not well understood. Urea reabsorption into the inner medulla is regulated by inner medullary urea transporter (UT)-A1 and UT-A3. Inhibition or knockout of UT-A1/A3 will reduce interstitial urea accumulation, which may be beneficial in reducing renal fibrosis. To test this hypothesis, the effect of unilateral ureteral obstruction (UUO) was compared in wild-type (WT) and UT-A1/A3 knockout mice. UUO causes increased extracellular matrix associated with increases in transforming growth factor-β, vimentin, and α-smooth muscle actin (α-SMA). In WT mice, UUO increased the abundance of three markers of fibrosis: transforming growth factor-β, vimentin, and α-SMA. In contrast, in UT-A1/A3 knockout mice, the increase following UUO was significantly reduced. Consistent with the Western blot results, immunohistochemical staining showed that the levels of vimentin and α-SMA were increased in WT mice with UUO and that the increase was reduced in UT-A1/A3 knockout mice with UUO. Masson's trichrome staining showed increased collagen in WT mice with UUO, which was reduced in UT-A1/A3 knockout mice with UUO. We conclude that reduced UT activity reduces the severity of renal fibrosis following UUO.

The role of S-methylisothiourea hemisulfate as inducible nitric oxide synthase inhibitor against kidney iron deposition in iron overload rats

Background:

Iron dextran is in common use to maintain iron stores. However, it is potentially toxic and may lead to iron deposition (ID) and impair functions of organs. Iron overload can regulate the expression of inducible nitric oxide synthase (iNOS) in some cells that has an important role in tissue destruction. S-methylisothiourea hemisulfate (SMT) is a direct inhibitor of iNOS, and this study was designed to investigate the effect of SMT against kidney ID in iron overload rats.

Materials and Methods:

24 Wistar rats (male and female) were randomly assigned to two groups. Iron overloading was performed by iron dextran 100 mg/kg/day every other day for 2 weeks. In addition, during the study, groups 1 and 2 received vehicle and SMT (10 mg/kg, ip), respectively. Finally, blood samples were obtained, and the kidneys were prepared for histopathological procedures.

Results:

SMT significantly reduced the serum levels of creatinine and blood urea nitrogen. However, SMT did not alter the serum levels of iron and nitrite, and the kidney tissue level of nitrite. Co-administration of SMT with iron dextran did not attenuate the ID in the kidney.

Conclusion:

SMT, as a specific iNOS inhibitor, could not protect the kidney from ID while it attenuated the serum levels of kidney function biomarkers.

Urea transporter UT-B deletion induces DNA damage and apoptosis in mouse bladder urothelium

BACKGROUND

Previous studies found that urea transporter UT-B is abundantly expressed in bladder urothelium. However, the dynamic role of UT-B in bladder urothelial cells remains unclear. The objective of this study is to evaluate the physiological roles of UT-B in bladder urothelium using UT-B knockout mouse model and T24 cell line.

METHODOLOGY/PRINCIPAL FINDINGS

Urea and NO measurement, mRNA expression micro-array analysis, light and transmission electron microscopy, apoptosis assays, DNA damage and repair determination, and intracellular signaling examination were performed in UT-B null bladders vs wild-type bladders and in vitro T24 epithelial cells. UT-B was highly expressed in mouse bladder urothelium. The genes, Dcaf11, MCM2-4, Uch-L1, Bnip3 and 45 S pre rRNA, related to DNA damage and apoptosis were significantly regulated in UT-B null urothelium. DNA damage and apoptosis highly occurred in UT-B null urothelium. Urea and NO levels were significantly higher in UT-B null urothelium than that in wild-type, which may affect L-arginine metabolism and the intracellular signals related to DNA damage and apoptosis. These findings were consistent with the in vitro study in T24 cells that, after urea loading, exhibited cell cycle delay and apoptosis.

CONCLUSIONS/SIGNIFICANCE

UT-B may play an important role in protecting bladder urothelium by balancing intracellular urea concentration. Disruption of UT-B function induces DNA damage and apoptosis in bladder, which can result in bladder disorders.

Novel biomarkers for early diagnosis of acute kidney injury

BACKGROUND

Acute kidney injury (AKI) is a common and serious problem in critically ill patients. Tests currently used to detect AKI (i.e., serum creatinine, serum urea and various urinary indices) often result in serious delays in detection of clinically relevant injury. This delayed detection translates into a potential missed opportunity for therapeutic interventions at a time when kidney damage may be limitable or reversible. This is also recognized as a potential reason for the poor clinical outcomes often associated with AKI.

OBJECTIVES

To appraise the recent literature characterizing several novel serum and urinary biomarkers, including neutrophil gelatinase-associated lipocalin, IL-18 and kidney injury molecule-1, which are capable of detecting AKI at an earlier phase of injury. Also to discuss the pitfalls of current conventional testing in kidney injury.

METHOD

Narrative literature review.

CONCLUSIONS

These novel biomarkers can detect injury when damage may still be reversible, allow for early risk stratification and/or prognostication, and are associated in early clinical studies with important outcomes such as severity of AKI, need for renal replacement therapy and survival. There is optimism that these novel biomarkers will discriminate the underlying pathophysiology of AKI (i.e., ischemia, sepsis, toxins or multifactorial), discriminate AKI from other renal disease (i.e., chronic kidney disease) and aid in localizing the site of acute injury in the kidney. As such, the future may entail development of an 'AKI biomarker panel' (i.e., analogous to a cardiac or liver enzyme panel) for use in clinical practice.

Introduction of a lysine residue promotes aggregation of temporin L in lipopolysaccharides and augmentation of its antiendotoxin property

Temporin L (TempL) is a 13-residue frog antimicrobial peptide that shows moderate bactericidal activity and antiendotoxin properties in macrophages. We envisioned that, due to its very hydrophobic nature, the peptide might fail to show its desired biological properties. It was predicted by employing the available algorithms that the replacement of a glutamine by lysine at position 3 could appreciably reduce its aggregation propensity in an aqueous environment. In order to investigate the structural, functional, and biological consequences of replacement of glutamine by lysine at its third position, TempL and the corresponding analog, Q3K-TempL, was synthesized and characterized. Introduction of the lysine residue significantly promoted the self-assembly and oligomeric state of TempL in lipopolysaccharide (LPS). Q3K-TempL exhibited augmented binding to LPS and also dissociated LPS aggregates with greater efficacy than TempL. Further, Q3K-TempL inhibited the LPS-induced proinflammatory cytokines in rat primary macrophages in vitro and in vivo in BALB/c mice with greater efficacy than TempL. The results showed that a simple amino acid substitution in a short hydrophobic antimicrobial peptide, TempL, enhanced its antiendotoxin properties and illustrate a plausible correlation between its aggregation properties in LPS and LPS detoxification activity.

Model-driven multi-omic data analysis elucidates metabolic immunomodulators of macrophage activation

Macrophages are central players in immune response, manifesting divergent phenotypes to control inflammation and innate immunity through release of cytokines and other signaling factors. Recently, the focus on metabolism has been reemphasized as critical signaling and regulatory pathways of human pathophysiology, ranging from cancer to aging, often converge on metabolic responses. Here, we used genome-scale modeling and multi-omics (transcriptomics, proteomics, and metabolomics) analysis to assess metabolic features that are critical for macrophage activation. We constructed a genome-scale metabolic network for the RAW 264.7 cell line to determine metabolic modulators of activation. Metabolites well-known to be associated with immunoactivation (glucose and arginine) and immunosuppression (tryptophan and vitamin D3) were among the most critical effectors. Intracellular metabolic mechanisms were assessed, identifying a suppressive role for de-novo nucleotide synthesis. Finally, underlying metabolic mechanisms of macrophage activation are identified by analyzing multi-omic data obtained from LPS-stimulated RAW cells in the context of our flux-based predictions. Our study demonstrates metabolism's role in regulating activation may be greater than previously anticipated and elucidates underlying connections between activation and metabolic effectors.

SPA0355, a thiourea analogue, inhibits inflammatory responses and joint destruction in fibroblast-like synoviocytes and mice with collagen-induced arthritis

BACKGROUND AND PURPOSE

NF-κB has been implicated as a therapeutic target for the treatment of rheumatoid arthritis. We previously synthesized a thiourea analogue, SPA0355, which suppressed NF-κB activity. Here we have assessed the anti-inflammatory and anti-arthritic effects of SPA0355.

EXPERIMENTAL APPROACH

We evaluated the effects of SPA0355 on human rheumatoid fibroblast-like synoviocytes in vitro and on collagen-induced arthritis (CIA) in mice in vivo.

KEY RESULTS

In vitro experiments demonstrated that SPA0355 suppressed chemokine production, matrix metalloproteinase secretion and cell proliferation induced by TNF-α in rheumatoid fibroblast-like synoviocytes. In addition, SPA0355 inhibited osteoclast differentiation induced by macrophage colony-stimulating factor and the receptor activator of NF-κB ligand, in bone marrow macrophages. Mice with CIA that were pretreated with SPA0355 had a lower cumulative disease incidence and severity of arthritis, based on hind paw thickness, radiological and histopathological findings, and inflammatory cytokine levels, than mice treated with vehicle. Mice treated with SPA0355, after the onset of CIA, also showed significantly decreased disease incidence and joint oedema. The in vitro and in vivo protective effects of SPA0355 were mediated by inhibition of the NF-κB signalling pathway.

CONCLUSION AND IMPLICATIONS

Taken together, these results suggested that using SPA0355 to block the NF-κB pathway in rheumatoid joints reduced both the inflammatory responses and tissue destruction. Therefore, SPA0355 may have therapeutic value in preventing or delaying joint destruction in patients with rheumatoid arthritis.

Synthesis of phenylisothiourea derivatives as inhibitors of NO production in LPS activated macrophages

A series of phenylisothioureas were synthesized as inhibitors of NO production in lipopolysaccharide-activated macrophages. We investigated the effect of lipophilic moiety and N- or S-substituents of the phenylisothioureas on the activity. Inhibitory activities of carbazole-linked phenylisothioureas were superior to the corresponding simple phenylisothiourea derivatives. Among these compounds, 12b having N-ethyl and S-isopropyl groups on phenylisothiourea moiety was the most potent in the inhibition of NO production. They inhibited NO production through the suppression of the LPS-induced translocation of p65 subunit of NF-kappaB and the followed suppression of the iNOS protein and mRNA expression.

Early diagnosis of acute kidney injury in critically ill patients

Acute kidney injury (AKI) is a common and serious problem in critically ill patients. Tests currently used to detect AKI (i.e., serum creatinine, serum urea and various urinary indices) often result in delayed detection of injury--becoming abnormal at 48-72 h after the initial insult. This delayed detection translates into a potential missed opportunity for therapeutic interventions at a time when kidney damage may be limitable or reversible. This may also, in particular, account for the poor clinical outcomes commonly associated with AKI. The development of novel serum and urinary biomarkers capable of detecting AKI at an earlier phase of illness is therefore vital. This article will review the pitfalls of current conventional testing in kidney injury and discuss the emergence of novel biomarkers with the potential to revolutionize the field of critical care nephrology.

Conventional markers of kidney function

Acute kidney injury remains a serious clinical problem for intensive care unit patients, and its incidence is rising. The detection and diagnosis of acute kidney injury in the intensive care unit currently require use of conventional markers of kidney function, specifically, serum creatinine and urea levels and, less frequently, other urinary tests. These conventional markers are familiar to clinicians and have long been used at the bedside. However, these markers are clearly not ideal, each has limitations, and none reflect real-time changes in glomerular filtration rate or a genuine acute injurious process to the kidney. More importantly, these conventional markers can contribute to delays in recognition of acute kidney injury and, hence, delays to appropriate supportive and therapeutic interventions. The early detection and diagnosis of acute kidney injury should be a clinical priority. A diagnostic test or panel of tests that are capable of evaluating aspects both of kidney function and acute injury are desperately needed in critical care nephrology. Cystatin C has been shown superior to conventional markers and may assume a greater role in intensive care unit patients for detecting both early changes in glomerular filtration rate and evidence of acute injury. Other newly characterized markers of kidney function or acute injury have the potential to revolutionized the field of critical care nephrology and greatly improve the supportive and therapeutic management of intensive care unit patients with acute kidney injury.

Arginase: a critical regulator of nitric oxide synthesis and vascular function

1. Arginase is the focal enzyme of the urea cycle hydrolysing L-arginine to urea and L-ornithine. Emerging studies have identified arginase in the vasculature and have implicated this enzyme in the regulation of nitric oxide (NO) synthesis and the development of vascular disease. 2. Arginase inhibits the production of NO via several potential mechanisms, including competition with NO synthase (NOS) for the substrate L-arginine, uncoupling of NOS resulting in the generation of the NO scavenger, superoxide and peroxynitrite, repression of the translation and stability of inducible NOS protein, inhibition of inducible NOS activity via the generation of urea and by sensitization of NOS to its endogenous inhibitor asymmetric dimethyl-L-arginine. 3. Upregulation of arginase inhibits endothelial NOS-mediated NO synthesis and may contribute to endothelial dysfunction in hypertension, ageing, ischaemia-reperfusion and diabetes. 4. Arginase also redirects the metabolism of L-arginine to L-ornithine and the formation of polyamines and L-proline, which are essential for smooth muscle cell growth and collagen synthesis. Therefore, the induction of arginase may also promote aberrant vessel wall remodelling and neointima formation. 5. Arginase represents a promising novel therapeutic target that may reverse endothelial and smooth muscle cell dysfunction and prevent vascular disease.

Design and synthesis of urea and thiourea derivatives and their inhibitory activities on lipopolysaccharide-induced NO production

Series of ureas and thioureas were designed and synthesized, and their inhibitory activities of NO production in lipopolysaccharide-activated macrophages were evaluated. We found several essential moieties in the structure of the prepared compounds for the activity. Thiourea derivatives revealed higher inhibitory activity than the corresponding urea derivatives. Among these compounds, 7e having carboxymethyl group at N3 position of thiourea was the most potent in the inhibition of NO production. They inhibited NO production through the suppression of iNOS protein and mRNA expression.

Biological fate and clinical implications of arginine metabolism in tissue healing

Since its discovery in 1987, many biological roles (including wound healing) have been identified for nitric oxide (NO). The gas is produced by NO synthase using the dibasic amino acid L-arginine as a substrate. It has been established that a lack of dietary L-arginine delays experimental wound healing. Arginine can also be metabolized to urea and ornithine by arginase-1, a pathway that generates L-proline, a substrate for collagen synthesis, and polyamines, which stimulate cellular proliferation. Herein, we review subjects of interest in arginine metabolism, with emphasis on the biochemistry of wound NO production, relative NO synthase isoform activity in healing wounds, cellular contributions to NO production, and NO effects and mechanisms of action in wound healing.

Inhibition of inducible nitric oxide synthesis by azathioprine in a macrophage cell line

Azathioprine is used as an anti-inflammatory agent. Although there are numerous data demonstrating cytotoxic and immunosuppressive properties of azathioprine and its metabolite 6-mercaptopurine, the mechanism of the anti-inflammatory action of azathioprine has not yet been fully clarified. During our study, we investigated the effects of azathioprine on the inducible nitric oxide synthase (iNOS) in lipopolysaccharide stimulated murine macrophages (RAW 264.7) by measurement of iNOS protein (immunoblotting), iNOS mRNA (semiquantitative competitive RT-PCR), and NO production (nitrite levels). Azathioprine (0-210 muM) induces a concentration dependent inhibition of inducible nitric oxide synthesis (IC50: 33.5 muM). iNOS protein expression showed a concentration dependent reduction as revealed by immunoblotting when cells were incubated with increasing amounts of azathioprine. Azathioprine decreases iNOS mRNA levels as shown by semiquantitative competitive RT-PCR. In contrast, 6-mercaptopurine showed no inhibition of inducible nitric oxide synthesis. Azathioprine did not reduce iNOS mRNA stability after the addition of actinomycin D. Enzymatic activity assays with increasing concentrations of azathioprine (0-210 muM) showed no statistically significant inhibition of iNOS enzyme activity compared to cell lysates without azathioprine. Nuclear translocation of NF-kappaB p65 subunit and binding of NF-kappaB p50 subunit from nuclear extracts to a biotinylated-consensus sequence was unaffected by azathioprine treatment. iNOS inhibition by azathioprine was associated with a decreased expression of IRF-1 (interferon regulatory factor 1) and IFN-beta (beta-interferon) mRNA. Azathioprine induced iNOS inhibition seems to be associated with an action of the methylnitroimidazolyl substituent. This suggests a route to the rational design of nontoxic anti-inflammatory agents by replacing the 6-mercaptopurine component of azathioprine with other substituents. The inhibition of inducible nitric oxide synthesis might contribute to the anti-inflammatory activities of azathioprine.

Endothelin-Induced Increased Nitric Oxide Mediates Augmented Distal Nephron Acidification as a Result of Dietary Protein

Tested was the hypothesis that enhanced nitric oxide (NO) production that is stimulated by increased renal endothelin activity mediates decreased distal nephron HCO(3) secretion that is induced by dietary protein. Munich-Wistar rats that ate minimum electrolyte diets with 50% casein-provided protein (HiPro) compared with controls that ate 20% protein for 3 wk had higher urine excretion of endothelin-1 (80 +/- 15.7 versus 29 +/- 3.9 fmol/kg body wt per d; P < 0.02) and of the NO metabolites NO(2)/NO(3) (21.2 +/- 1.9 versus 14.9 +/- 0.8 mumol/kg body wt per d; P < 0.03). Bosentan, an endothelin A/B receptor antagonist, reduced HiPro rats' urine excretion of net acid (5859 +/- 654 versus 8017 +/- 1103 micromol/d; P < 0.03, paired t test) and NO(2)/NO(3) (18.1 +/- 1.1 versus 22.9 +/- 2.0 micromol/kg body wt per d; P < 0.05, paired t test). N-nitro-l-arginine methyl ester (L-NAME), an NO synthase inhibitor, also decreased urine net acid excretion (6621 +/- 717 versus 8449 +/- 1086 micromol/d; P < 0.05, paired t test) but was not additive to bosentan. L-NAME increased in situ late distal nephron HCO(3) delivery in HiPro rats (18.8 +/- 1.7 versus 9.6 +/- 1.4 pmol/mm per min; P < 0.001) that was mediated by increased distal nephron HCO(3) secretion (-7.2 +/- 0.7 versus -3.5 +/- 0.4 pmol/mm per min; P < 0.001) without changes in distal nephron transtubule HCO(3) permeability or H(+) secretion. Bosentan decreased H(+) secretion and increased HCO(3) secretion in the distal nephron of HiPro rats, but L-NAME had no additive effect on either component. The data support that dietary protein augments distal nephron acidification through decreased HCO(3) secretion that is mediated through endothelin-stimulated NO.

CELL SURVIVAL IN THE HOSTILE ENVIRONMENT OF THE RENAL MEDULLA

The countercurrent system in the medulla of the mammalian kidney provides the basis for the production of urine of widely varying osmolalities, but necessarily entails extreme conditions for medullary cells, i.e., high concentrations of solutes (mainly NaCl and urea) in antidiuresis, massive changes in extracellular solute concentrations during the transitions from antidiuresis to diuresis and vice versa, and low oxygen tension. The strategies used by medullary cells to survive in this hostile milieu include accumulation of organic osmolytes and heat shock proteins, the extensive use of the glycolysis for energy production, and a well-orchestrated network of signaling pathways coordinating medullary circulation and tubular work.

Nitric oxide release by hemocytes of the mussel Mytilus galloprovincialis Lmk was provoked by interleukin-2 but not by lipopolysaccharide

As other marine and land mollusks, mussels have special cells in charge of the immune function called hemocytes. The activation of these cells leads to a series of events that end up in phagocytosis and in secretion of digestive enzymes that eliminate the pathogen. The production of nitric oxide is among the early activation processes. Contrary to what happens in cells of vertebrates and of other species of mollusks, in hemocytes of Mytilus galloprovincialis, LPS did not induce secretion of NO to the medium. However, human IL-2 provoked an important increase in NO production. The maximal synthesis of NO was detected after the hemocytes were incubated with the cytokine for 24h. In both stimulated and non-stimulated cells, Western blotting showed the presence of a protein of 130kDa, recognized by anti-mouse iNOS. Therefore, the higher production of NO can only be explained as a direct action of some effector upon the nitric oxide synthetase. NO production decreased by the action of H-89, a powerful inhibitor of the cAMP-dependent protein kinase (PKA). This suggests the involvement of PKA in the pathway of NO synthesis.

Low water-soluble uremic toxins

The uremic syndrome is the result of the retention of solutes, which under normal conditions are cleared by the healthy kidneys. Uremic retention products are arbitrarily subdivided according to their molecular weight. Low-molecular-weight molecules are characterized by a molecular weight below 500 D. The purpose of the present publication is to review the main water soluble, nonprotein bound uremic retention solutes, together with their main toxic effects. We will consecutively discuss creatinine, glomerulopressin, the guanidines, the methylamines, myo-inositol, oxalate, phenylacetyl-glutamine, phosphate, the polyamines, pseudouridine, the purines, the trihalomethanes, and urea per se.

Basic Science and Dialysis: Nitric Oxide and Hemodialysis

Nitric oxide (NO), previously thought of as a noxious gas, is now recognized as an important mediator of vascular responsiveness. Soon after its discovery, it was realized that the actions of NO are similar to the previously described endothelium-derived relaxing factor (EDRF). It is synthesized in the vascular endothelium utilizing the enzyme nitric oxide synthase (NOS) and diffuses in the adjacent vascular media, where it has a vasodilatory action. Opposing actions of NO and vasoconstrictor agents (such as endothelin-1, angiotensin IotaIota, and others) maintain the vascular tone of the renal arteries. The same balance at the level of the macula densa maintains glomerular filtration rate (GFR) during varying levels of salt excretion. Lack of NO can result in disruption of this fine balance, with resultant vasoconstriction and disease progression, hypertension, and accelerated atherosclerosis. In addition, hypertension may result from positive salt balance that occurs when macula densa NOS is inhibited. While most investigators report low levels of NO in uremic subjects, the levels in hemodialysis (HD) patients have not been characterized adequately. This is primarily because HD patients are exposed to both stimulatory and inhibitory factors for NO synthesis. Retention of inhibitors of NOS tends to decrease NO levels, whereas production of NO will be increased by cytokines generated during blood-dialyzer interaction. There is less disagreement, however, over the finding of elevated levels in those with dialyzer reactions and dialysis-induced hypotension. Recent developments in the isolation of inducible and constitutive forms of NOS makes understanding of its pathophysiologic effects more complete. Newer treatment directed at inhibiting only the inducible forms of NOS (sparing the constitutive forms) may soon be found useful for the treatment and prevention of hypotension and dialyzer reactions in HD patients.

Nitric oxide and wound healing

Nitric oxide is a short-lived free radical that acts at the molecular, cellular, and physiologic level. Since its discovery almost 20 years ago it has proven itself as an important element in wound healing. This review highlights many of the important aspects of nitric oxide in wound healing, including a review of the basic biology of nitric oxide, its role as part of the cytokine cascade and as a promoter of angiogenesis, as well as its more recently elucidated role in apoptosis.

Vaccinia virus-induced inhibition of nitric oxide production

BACKGROUND

The role of nitric oxide (NO) in the host defense against viruses has not been well defined. Several studies have implicated NO as responsible for the destruction of a variety of viruses. However, others have reported that certain viruses can impair the ability of macrophages to produce NO. This study was initiated to determine the ability of macrophages to produce NO in response to vaccinia virus infection.

METHODS

RAW 264.7 murine macrophages in minimum essential medium were exposed to virus-containing supernatants for 1 h before stimulation with Escherichia coli lipopolysaccharide (LPS, 0.001 and 1.0 microg/ml). After further 24-h incubations, nitrite concentration, cell viability, and inducible nitric oxide synthase (iNOS) were quantitated.

RESULTS

The viral preparation alone did not stimulate nitric oxide synthesis (measured as nitrite) by macrophages. However, macrophages exposed to 0.001 and 1.0 microg/ml LPS produced 7.7 +/- 0.6 and 16.6 +/- 0.8 nmole/1.1 x 10(6) cells/24-h nitrite, respectively. Production of nitrite caused cell death. Macrophages incubated with vaccinia virus prior to exposure to LPS resulted in a dose-dependent decrease in nitrite production. An 80% inhibition of nitrite was noted when macrophages were exposed to vaccinia virus (m.o.i. 10(-4)) plus LPS (1.0 microg/ml) (P < 0.05). Further study showed that this inhibition was not associated with changes in cell viability or substrate availability, but was associated with a marked reduction in iNOS protein. When the virus was inactivated with UV-irradiation, the same incubation caused a 46% inhibition of nitrite production (P < 0.05 vs active virus). However, this effect occurred without altering the quantity of iNOS protein.

CONCLUSION

These results indicate that active vaccinia virus inhibits the ability of stimulated macrophages to produce NO by hindering iNOS protein expression. Because live viral particles were not entirely required for this inhibition, it is possible that by products of viral infection, such as soluble viral proteins, may also be responsible for this effect.

Urea percentiles in children with chronic renal failure. Data from the ItalKid project

In chronic renal failure high serum urea levels (sUrea) are correlated with the onset of uremic symptoms. Urea has generally been considered relatively non-toxic, functioning more as a surrogate for other toxic solutes; however, it has been recently reported that it can contribute to uremic toxicity. Clinically sUrea are often difficult to interpret because of the wide range of kidney functions. To obtain a practical and easily accessible tool to evaluate sUrea, we have produced percentile curves for different ranges of chronic renal failure, defined with creatinine clearance ( C(Cr)) obtained with the Schwartz formula. Data were obtained from the Italian Pediatric Registry of Chronic Renal Failure (ItalKid); its inclusion criteria are: (1) C(Cr )<75 ml/min per 1.73 m(2), (2) age <20 years at time of registration, and (3) conservative treatment. To obtain the percentiles, the following patients were excluded: patients with an underlying disease, a concomitant treatment, or a disorder that could affect urea metabolism, per se, and/or food intake, and patients aged <2 years. The study group included 690 subjects (mean age 9.56+/-4.54 years, 485 males). In total, 2,085 observations (C(Cr )and sUrea) were available for the construction of the percentile curves. A median of 258 (range 99-380) observations was obtained for each of the eight different categories of C(Cr )(intervals of 10 ml/min per 1.73 m(2)). The 10th, 25th, 50th, 75th, and 90th percentiles were calculated and a graph was produced. Patients with the highest urea percentiles showed significantly higher plasma levels of phosphorus and parathyroid hormone and significantly lower hemoglobin concentrations and bicarbonate levels. Our percentile curves may help to identify subjects with inappropriate sUrea for a given C(Cr).

Evolution of oxidative stress and inflammation during hemodialysis and their contribution to cardiovascular disease

End-stage renal disease patients have increased cardiovascular morbidity and mortality. These patients have many unique risk factors, such as an accumulation of uremic toxins, electrolyte imbalances, metabolic disturbances, anemia, chronic inflammation, and thrombogenic disturbances. Oxidative stress has been implicated in many of these disturbances. This review will focus on some of the factors that may accelerate cardiovascular disease in uremic patients, with an emphasis on mechanisms and interactions of various components of oxidative stress and inflammation. Understanding the mechanisms of these pathways may be useful in developing effective prevention and treatment strategies.

Inhibition of mesangial iNOS by reduced extracellular pH is associated with uncoupling of NADPH oxidation

BACKGROUND

Since chronic renal failure is associated with metabolic acidosis and down-regulation of intrarenal nitric oxide (NO) synthesis, I tested the hypothesis that acidosis may impair the intrarenal NO synthesis. The effects of alterations in extracellular pH were examined on inducible NO synthesis in murine mesangial cells (MMC) in culture.

METHODS

NO synthesis was induced in MMC by bacterial lipopolysaccharide and tumor necrosis factor-alpha and assayed by an NO analyzer that measured nitrites and nitrates (NOx). The activity of inducible NO synthase (iNOS) enzyme was assayed by conversion of [3H]-arginine to [3H]-citrulline. Experimental groups included cells cultured with a pH of 7.3 (normal), or 7.0 (low) or 7.6 (high), and the assigned pH values were maintained by HEPES and Tris.

RESULTS

NOx was decreased in MMC exposed to the reduced pH compared to other groups. [3H]-citrulline assay showed an 80% reduction in iNOS activity in stimulated MMC exposed to a reduced pH versus control pH (P < 0.01). iNOS mRNA and protein expression were similar in control and low pH cells. The iNOS inhibition was not reversed by supplementation of MMC with either l-arginine or tetrahydrobiopterin, a major co-factor for NOS enzyme. MMC re-incubated in control pH after being exposed to the low pH demonstrated re-inducibility of NOS activity. Furthermore, MMC exposed to low pH were associated with a higher NADP+/+[H]-citrulline ratio (3.2) compared to standard pH (1.7), indicating an increase in NADP+/+[H]-citrulline stoichiometries and uncoupling of nicotinamide adenine dinucleotide phosphate (NADPH) oxidation. In contrast, macrophages exposed to the reduced pH did not demonstrate uncoupling of NADPH oxidation.

CONCLUSION

Acidosis impairs iNOS activity in MMC by a post-translational mechanism that involves uncoupling of NADPH oxidation.

Role of nitric oxide in wound repair

After injury, wound healing is essential for recovery of the integrity of the body. It is a complex, sequential cascade of events. Nitric oxide (NO) is a small radical, formed from the amino acid L-arginine by three distinct isoforms of nitric oxide synthase. The inducible isoform (iNOS) is synthesized in the early phase of wound healing by inflammatory cells, mainly macrophages. However many cells participate in NO synthesis during the proliferative phase after wounding. NO released through iNOS regulates collagen formation, cell proliferation and wound contraction in distinct ways in animal models of wound healing. Although iNOS gene deletion delays, and arginine and NO administration improve healing, the exact mechanisms of action of NO on wound healing parameters are still unknown. The current review summarizes what is known about the role of NO in wound healing and points out path for further research.

Arginase in glomerulonephritis

l-Arginine is converted to nitric oxide and citrulline by the enzyme nitric oxide synthase (NOS). Its in vivo inhibition has led to the revelation of a multitude of diverse, often conflicting functions in the inflammatory melee. l-Arginine is also converted to ornithine and urea by the enzyme arginase as a part of the hepatic urea cycle. However, a more holistic interpretation of the two pathways and the associated metabolism (summarized in Fig. 1) has led to its reassessment as a pathologically significant enzyme. This is reflected by the continued increase over the past five years of the number of publications discussing both nitric oxide and arginase. The strong association between inflammation and high arginase and NOS activity is epitomized by immune complex-induced glomerulonephritis and other glomerulonephritides. Arginase is encoded by two recently discovered genes (Arginase I and Arginase II). There is now substantial evidence for an interaction between both arginase isoforms and all three NOS isoforms in pathological situations. This review considers the relationship between Arginases I and II and the inflammation-associated isoform of NOS called NOS II. In particular, it consolidates the current understanding of arginase and associated metabolic pathways, and highlights some of the issues that are often overlooked in such studies.

Tetrahydrobiopterin reverses the inhibition of nitric oxide by high glucose in cultured murine mesangial cells

Alterations of intrarenal nitric oxide (NO) synthesis play an important role in the pathogenesis and progression of diabetic nephropathy. We tested the hypothesis that hyperglycemia modulates intrarenal NO synthesis, which might mediate the mesangial cell proliferation and matrix production. Murine mesangial cells were grown in media containing varying glucose concentrations, and cytokine-induced NO synthesis was assayed by chemiluminescence using an NO analyzer. High media glucose (25 mM) inhibited NO synthesis in a time-dependent fashion. This inhibition was posttranslational as revealed by analysis of inducible nitric oxide synthase (iNOS) gene and protein expression. L-Arginine supplementation partially reversed the inhibition whereas addition of tetrahydrobiopterin (BH4), a cofactor for NOS, restored the inducibility of NO synthesis. The in vitro [3H]citrulline assay for iNOS activity indicated that high glucose decreased BH4 availability whereas examination of the BH4 synthetic pathway suggested decreased BH4 stability rather than synthesis, a defect that was corrected by ascorbic acid. We conclude that hyperglycemia inhibits NO synthesis in mesangial cells by a posttranslational defect that might involve the stability and hence availability of BH4.

Uremic levels of BUN do not cause nitric oxide deficiency in rats with normal renal function

In vitro, 7 days of high blood urea nitrogen (BUN) inhibits endothelial L-arginine transport and nitric oxide synthase (NOS) activity. The present study investigates whether 7 days of high BUN in vivo influences renal hemodynamics, blood pressure (BP), and/or the nitric oxide (NO) system. Normal rats were fed low-nitrate food containing 30% urea for 7 days, which increased BUN (15 +/- 1 to 69 +/- 4 mg/100 ml, P < 0.001). High BUN did not reduce 24-hour urinary nitrite/nitrate excretion (a measure of total NO production). Baseline BP and renal hemodynamics were unaffected by high BUN as were the pressor and renal vasoconstrictor responses to acute NOS inhibition with N(G)-nitro-L-arginine-methyl ester. In addition, high BUN had no impact on renal cortical L-arginine concentration, density of either endothelial NOS or neuronal NOS protein, or renal cortical NOS activity. NOS activity in the brain cerebellum was also unaffected. In conclusion, high BUN did not lead to vasoconstriction or NO deficiency in rats with normal renal function. Further studies are needed to evaluate the effect of high BUN on the NO system in rats with progressive renal functional insufficiency.

Uremic levels of urea inhibit L-arginine transport in cultured endothelial cells

Hypertension in end-stage renal disease (ESRD) may involve lack of endothelial nitric oxide (NO), as suggested by reduced total NO synthase (NOS) in dialysis patients. One reason might be due to substrate deficiency. To test the hypothesis that uremia is a state of intracellular L-arginine deficiency, uremic plasma was obtained from dialysis patients, and its effect was tested on arginine transport in cultured vascular endothelial cells. L-arginine transport (P < 0.01) was reduced in human dermal microvascular endothelial cells (HDMEC) incubated for 6 h with 20% uremic plasma from peritoneal dialysis and hemodialysis patients obtained immediately predialysis. Similar transport inhibition was seen with ESRD plasma in human glomerular capillary and bovine aortic endothelial cells. Hemodialysis partially reversed inhibition of L-arginine transport. HDMECs incubated for 6 h with synthetic media containing high (uremic) urea concentrations showed inhibition of L-arginine transport, but this was not competitive because acute exposure to urea had no impact on L-arginine transport. Over a 6-h period, urea-induced inhibition of L-arginine transport was not sufficient to inhibit NOS activity, but after 7 days NOS activity was reduced. These cellular findings suggest that substrate delivery may be lowered, thus reducing endothelial NOS activity and contributing to hypertension in ESRD patients.

Plasma levels of arginine, ornithine, and urea and growth performance of broilers fed supplemental L-arginine during cool temperature exposure

Two experiments (Experiment 1 and 2) were conducted to evaluate growth performance, ascites mortality, and concentrations of plasma Arg, urea, and ornithine in male broilers raised in floor pens (2 x 4 factorial experiment, six pens for treatment) and exposed to cool temperatures averaging 16 C after 21 d of age. Broilers were fed low- or high-CP diets in both Experiments. In Experiment 1, Arg treatments consisted of control (no supplemental Arg); 0.15 or 0.3% supplemental Arg in the diet (low- and medium-Arg feed, respectively); and 0.3% supplemental Arg in the drinking water (Arg-water). Arginine levels were increased in Experiment 2 and consisted of the following: control (no supplemental Arg); 0.3 or 0.85% supplemental Arg in the diet (medium- and high-Arg feed, respectively); and 0.6% supplemental Arg in the drinking water (Arg-water). The water treatment followed a 3-d cyclic regimen, with supplemental Arg being provided for 24 h, followed by tap water for 48 h. When the broilers reached 37 d of age and all groups had consumed tap water for the previous 48 h, blood samples were collected from one bird per pen (Time 0, 0700 h); then supplemental Arg was provided in the Arg-water group, and additional blood samples were collected from the control and Arg-water groups at 3, 6, 12, and 36 h after Time 0. Plasma amino acids were analyzed using HPLC. Birds fed the high-CP diet were heavier at 49 d than birds fed the low-CP diet in Experiment 1, but not in Experiment 2. No differences were found in feed conversion or ascites mortality due to CP or Arg treatments in either experiment. In both experiments, plasma Arg was similar for all groups at Time 0, but increased in the Arg-water group at 3, 6, and 12 h after Arg was provided in the water. Within 12 h after returning to tap water, plasma Arg levels of the Arg-water group did not differ from the control group. Plasma urea and ornithine were parallel to plasma Arg concentrations, and the high-CP diets resulted in higher plasma levels of urea and ornithine compared with low-CP diets. These results indicate that kidney arginase was readily activated by Arg provided in the water, resulting in an immediate increase in plasma urea and ornithine. Plasma Arg was increased significantly, but no effects were observed in ascites mortality.

Urea-induced inducible nitric oxide synthase inhibition and macrophage proliferation

BACKGROUND

Atherosclerosis is a major cause of morbidity and mortality in chronic renal failure and is associated with the proliferation of macrophages within atherosclerotic lesions.

METHODS

Because the progression of atherosclerosis as a consequence of decreased nitric oxide (NO) synthesis has been described, we investigated the correlation between the inhibition of inducible NO synthase (iNOS) by urea, macrophage proliferation as assayed by cell counting, tritiated-thymidine incorporation and measurement of cell protein, and macrophage apoptosis.

RESULTS

Urea induces a dose-dependent inhibition of inducible NO synthesis in lipopolysaccharide-stimulated mouse macrophages (RAW 264.7) with concomitant macrophage proliferation. Macrophage proliferation as determined by cell counting became statistically significant at 60 mmol/L urea corresponding to a blood urea nitrogen level of 180 mg/100 mL, concentrations seen in uremic patients. iNOS protein expression showed a dose-dependent reduction, as revealed by immunoblotting when cells were incubated with increasing amounts of urea. The decrease of cytosolic DNA fragments in stimulated macrophages incubated with urea shows that the proliferative actions of urea are associated with a decrease of diminished NO-mediated apoptosis.

CONCLUSIONS

These data demonstrate that inhibition of iNOS-dependent NO production caused by urea enhances macrophage proliferation as a consequence of diminished NO-mediated apoptosis. This fact may be important for the development of atherosclerotic lesions during chronic renal failure and is in accordance with recently published studies showing that under conditions with decreased constitutive NOS activity, iNOS might substitute the synthesis of NO. iNOS expression in vascular smooth muscle cells and macrophages is supposed to prevent restenosis following angioplasty or heart transplant vasculopathy. This is supported by the fact that specific inhibition of endogenous iNOS activity with L-N6-(1-iminoethly)-lysine accelerates the progression of vasculopathy in transplantation atherosclerosis.

Inhibition of inducible nitric oxide synthesis by the herbal preparation Padma 28 in macrophage cell line

Padma 28 is a mixture of herbs used in traditional Tibetan medicine with anti-inflammatory activities. We investigated the effects of Padma 28 on nitric oxide (NO) production by the inducible nitric oxide synthase (iNOS) in lipopolysaccharide stimulated mouse macrophages (RAW 264.7). Padma 28 (0-900 µg/mL) induced a concentration dependent inhibition of inducible nitric oxide synthesis. iNOS protein expression showed a concentration dependent reduction as revealed by immunoblotting when cells were incubated with increasing amounts of Padma 28. Padma 28 decreased iNOS mRNA levels as shown by RT-PCR. Aqueous extracts from costi amari radix (costus root, the dried root of Saussurea lappa) and the outer cover of myrobalani fructus (the dried fruit of Terminalia chebula), constituents of the complex herb preparation Padma 28, were found to inhibit inducible nitric oxide synthesis by decreasing iNOS protein and iNOS mRNA levels. The inhibition of inducible nitric oxide synthesis might contribute to the anti-inflammatory activities of Padma 28.Key words: inducible nitric oxide synthase, mouse macrophages, myrobalans, radix costae.

Novel cardiac protective effects of urea: from shark to rat

1. This study was carried out to investigate novel cardioprotective effects of urea and the underlying mechanisms. The cardiac functions under oxidative stress were evaluated using Langendorff perfused isolated heart. 2. Isolated dogfish shark hearts tolerated the oxidative stress generated by electrolysis (10 mA, 1 min) of the perfusion solution (n=4), and also showed normal cardiac functions during post-ischaemia reperfusion (n=4). The high concentration of urea (350 mM) in the heart perfusate was indispensable for maintaining the normal cardiac functions of the shark heart. 3. Urea at 3 - 300 mM (n=4 for each group) protected the isolated rat heart against both electrolysis-induced heart damage and post-ischaemia reperfusion-induced cardiac injury. 4. A concentration-dependent scavenging effect of urea (3 - 300 mM, n=4 for each group) against electrolysis-induced reactive oxygen species was also demonstrated in vitro. 5. Urea derivatives as hydroxyurea, dimethylurea, and thiourea had antioxidant cardioprotective effect against the electrolysis-induced cardiac dysfunction of rat heart, but were not as effective as urea in suppressing the post-ischaemia reperfusion injury. 6. Our results suggest that urea and its derivatives are potential antioxidant cardioprotective agents against oxidative stress-induced myocardium damage including the post-ischaemia reperfusion-induced injury.

Urea induces macrophage proliferation by inhibition of inducible nitric oxide synthesis

BACKGROUND

Atherosclerosis is a major cause of morbidity and mortality in chronic renal failure and is associated with the proliferation of macrophages within atherosclerotic lesions.

METHODS

Because the progression of atherosclerosis as a consequence of decreased nitric oxide synthesis has been described, we investigated the correlation between the inhibition of inducible nitric oxide synthase (iNOS) by urea, macrophage proliferation as assayed by cell counting, tritiated thymidine incorporation and measurement of cell protein, and macrophage apoptosis.

RESULTS

Urea induces a dose-dependent inhibition of inducible nitric oxide synthesis in lipopolysaccharide-stimulated mouse macrophages (RAW 264.7) with concomitant macrophage proliferation. Macrophage proliferation, as determined by cell counting, became statistically significant at 60 mM urea, corresponding to a blood urea nitrogen level of 180 mg/100 ml, concentrations seen in uremic patients. iNOS protein expression showed a dose-dependent reduction, as revealed by immunoblotting when cells were incubated with increasing amounts of urea. The decrease of cytosolic DNA fragments in stimulated macrophages incubated with urea shows that the proliferative actions of urea are associated with a decrease of NO-induced apoptosis.

CONCLUSIONS

Our data demonstrate that the inhibition of iNOS-dependent NO production caused by urea enhances macrophage proliferation as a consequence of diminished NO-mediated apoptosis.

Decreased activity of the L-arginine-nitric oxide metabolic pathway in patients with congestive heart failure

BACKGROUND

Impaired endothelium-dependent, nitric oxide (NO)-mediated vasodilation may contribute to increased vasomotor tone in patients with heart failure. Whether decreased endothelium-dependent, NO-mediated vasodilation in patients with heart failure is due to decreased synthesis or increased degradation of NO is unknown.

METHODS AND RESULTS

To specifically assess the synthetic activity of the L-arginine-NO metabolic pathway, urinary excretion of [15N]nitrates and [15N]urea was determined after a primed continuous intravenous infusion of L-[15N]arginine (40 micromol/kg) in 16 patients with congestive heart failure and 9 age-matched normal control subjects at rest and during submaximal treadmill exercise. After infusion of L-[15N]arginine, 24-hour urinary excretion of [15N]nitrates was decreased in patients with congestive heart failure at rest (2.2+/-0.5 versus 8.0+/-2.3 micromol/24 h) and during submaximal exercise (2.4+/-1.2 versus 11. 4+/-4.0 micromol/24 h) compared with control subjects (both P<0.01). After infusion of L-[15N]arginine, 24-hour urinary excretions of [15N]urea at rest in patients with congestive heart failure and control subjects were not different (1.1+/-0.3 versus 1.2+/-0.2 mmol/24 h, P>0.20).

CONCLUSIONS

A specific decrease in synthetic activity of the L-arginine-NO metabolic pathway contributes to decreased endothelium-dependent vasodilation in patients with congestive heart failure.