Brief Review |
From the Division of Cardiovascular Medicine, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, Calif.
Correspondence to John P. Cooke, MD, PhD, Associate Professor and Director, Section of Vascular Medicine, Division of Cardiovascular Medicine, CVRC, Falk Cardiovascular Research Center, Stanford University School of Medicine, 300 Pasteur Dr, Stanford, CA 94305-5406. E-mail john.cooke{at}stanford.edu
| Abstract |
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Key Words: arginine nitric oxide atherosclerosis vasodilation
| NO and Vascular Homeostasis |
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Vascular NO also influences vascular structure. NO suppresses the proliferation of vascular smooth muscle.12 A chronic deficiency or loss of NO activity may contribute to medial thickening and/or myointimal hyperplasia.13 14 Conversely, treatment with NO donors or gene therapy with NOS reduces lesion formation after vascular injury in animal models.15 16 Furthermore, NO inhibits the interaction of circulating blood elements with the vessel wall. Platelet aggregation and leukocyte adherence are unlikely when the endothelium is healthy.17 18 19 The loss of NO activity accelerates the development of vascular lesions.20 21 A loss of NO activity occurs early in the course of human vascular disease22 23 and is a contributing factor to abnormal vasomotion and ischemic symptoms.10 11 In addition, there is accumulating evidence that the deficit of NO participates in the initiation and progression of atherosclerosis. Intriguingly, very recent data indicate that defective endothelial vasodilator function is predictive of vascular events.24 Accordingly, there is a compelling clinical rationale to understand the mechanisms of endothelial dysfunction.
| Endothelial Dysfunction Is Multifactorial |
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Increased vascular elaboration of superoxide anion is an abnormality commonly associated with atherosclerosis and its risk factors.25 The half-life of NO is reduced under conditions of oxidative stress.26 The attendant formation of peroxynitrite anion produces lipid peroxidation and nitrosation of tyrosine moieties, thereby disrupting cell membranes, cell signaling, and cell survival.27 Conversely, antioxidant strategies lengthen NO half-life, increase NOS expression, and restore endothelial vasodilator function.28 29 30 The oxidative enzymes responsible for increased oxidative stress in the vessel wall include NAD(P)H oxidase, xanthine oxidase, and NOS itself. Under conditions of reduced availability of L-arginine (the NO precursor) or tetrahydrobiopterin (an NOS cofactor), the preferred substrate of the monomer is oxygen, producing superoxide anion.31 32 33 34 35 Antioxidants may enhance the activity of NOS by preserving tetrahydrobiopterin.36
In the later stages of atherosclerosis, reduced sensitivity to endogenous and exogenous NO is observed, possibly due to oxidative inactivation of NO and/or soluble guanylate cyclase. In addition, in advanced atherosclerosis, reduced expression of the endothelial isoform of the NOS enzyme is observed, possibly due to cytokine- or lipid-induced instability and/or reduced transcription of NOS mRNA.37 38 Additionally, certain polymorphisms of the NOS gene may be associated with functional alterations in the enzyme and vascular disease.39 Finally, a growing body of data indicates that endogenous inhibitors of NOS may be responsible for endothelial vasodilator dysfunction in many individuals with coronary and peripheral arterial diseases and in those with their risk factors, particularly hypercholesterolemia, hyperhomocysteinemia, tobacco use, and aging. The endogenous inhibitors are asymmetric dimethylarginine (ADMA) and N-monomethylarginine (NMA). Because the former is the predominant species (plasma levels of ADMA are 10-fold greater than those of NMA), further discussion will focus on ADMA.
| ADMA Is an Endogenous Inhibitor of NOS |
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Subsequently, plasma ADMA has been found to be elevated in patients with vascular disease, as well as in the setting of risk factors for vascular disease.44 45 46 47 48 49 Hypercholesterolemic animals and humans manifest an impairment of endothelium-dependent vasodilation.49 50 51 In these individuals, plasma ADMA levels are better correlated with endothelial dysfunction than are LDL cholesterol levels.49 Furthermore, the endothelial vasodilator dysfunction associated with an elevated plasma ADMA level is reversible by administration of L-arginine, consistent with the notion that ADMA is a competitive inhibitor.49
Intriguingly, plasma levels of ADMA appear to be dynamically regulated and can be correlated with measures of NO synthesis. In the Dahl salt-sensitive rat, a high-salt diet is associated with an increase in urinary ADMA excretion and an increase in blood pressure.52 In humans with salt-sensitive hypertension, administration of a high-salt diet increases plasma ADMA levels and blood pressure and reduces urinary NOx; a low-salt diet reverses these abnormalities.46 Preliminary studies indicate that plasma ADMA also increases with administration of a high-fat diet, which is associated with a temporally related impairment in endothelial vasodilator dysfunction.53 The mechanisms by which ADMA becomes elevated under these conditions require an understanding of its origin and metabolic fate.
Origin and Fate of ADMA
ADMA is not derived from the methylation of free
L-arginine. Rather, ADMA is derived from the catabolism of
proteins containing methylated arginine residues (Figure 1
). These proteins are largely
found in the nucleus and appear to be involved in RNA processing and
transcriptional control.55 There are 2 types of enzymes
that methylate arginine residues. These are protein arginine
methyltransferase types I and II (PRMT I and PRMT
II).56 57 PRMT type I forms ADMA and NMA, whereas PRMT
type II forms symmetric dimethylarginine (SDMA) and NMA. SDMA does not
inhibit NOS. There are a number of type I PRMTs, with specificity for
different proteins.55 By contrast, the only known
substrate for type II PRMT is myelin basic protein.
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When these proteins undergo hydrolysis, their methylated arginine residues are released. Methylated arginines are excreted in the urine.40 This explains the increase in plasma ADMA levels in patients with renal insufficiency. Methylated arginines may also be metabolized. A minor source of metabolism occurs via dimethylarginine pyruvate transferase in the kidney and possibly, via acetylation in the liver. However, the major metabolic pathway for NMA and ADMA is the enzyme dimethylarginine dimethylaminohydrolase (DDAH).58 Two isoforms of DDAH are known, I and II. Either or both isoforms have been found in every cell type examined. DDAH I is typically found in tissues expressing neuronal NOS, whereas DDAH II predominates in tissues containing the endothelial isoform of NOS.59
| Dysregulation of DDAH: A Novel Mechanism of Endothelial Dysfunction |
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Additional evidence that DDAH is a critical regulator of ADMA levels comes from observations of the effects of the DDAH inhibitor 4124W. Addition of 4124W to an isolated vascular segment induces gradual vasoconstriction, which is reversed by addition of L-arginine to the medium.62 This finding is most consistent with the view that ADMA is constantly being produced in the course of normal protein turnover. The production of ADMA is balanced by its metabolism by DDAH. Accordingly, inhibition of DDAH activity will cause a gradual accumulation of ADMA, sufficient to induce vasoconstriction.
Recent data from our laboratory indicate that hypercholesterolemia may cause a decline in DDAH activity. The accumulation of ADMA that ensues may contribute to lipid-induced endothelial vasodilator dysfunction. We found that when cultured endothelial cells were exposed to oxidized LDL cholesterol, ADMA accumulated in the medium at a faster rate than when cells were treated with vehicle or native LDL cholesterol.63 The accelerated accumulation of ADMA was associated with a temporally related decline in DDAH activity. Similarly, the activity of DDAH is reduced in both vascular and nonvascular tissues of hypercholesterolemic rabbits (in which the animals plasma ADMA levels are known to be elevated).63 More recently, we have made similar observations in vitro and in vivo regarding the adverse effect of hyperglycemia to reduce DDAH activity and to increase ADMA accumulation (J.P.C. et al, unpublished observations, 2000). Furthermore, the decline in DDAH activity appears to be related to oxidative stress and can be prevented by the use of antioxidants.
| Does ADMA Explain the Arginine Paradox? |
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The elevation of plasma ADMA provides a possible explanation for the
benefits of supplemental L-arginine in these patients. The
plasma level of ADMA is normally
1 µmol/L, is typically
increased 2-fold in subjects with risk factors for vascular disease,
and is increased even further (up to 10-fold) in patients with clinical
atherosclerosis. But with circulating
L-arginine levels at
50 µmol/L, is this elevation
in ADMA sufficient to have an effect on NOS? Perhaps the sensitivity to
ADMA could be explained by the fact that it also competes with
L-arginine for uptake by the y+ transporter. Furthermore,
the y+ transporter and endothelial NOS are physically
associated in the caveolae of endothelial
cells.72 The arginine interventions discussed above
certainly support the view that NO synthesis is sensitive to changes in
extracellular arginine availability. Furthermore, Faraci and
colleagues73 have shown that the
Km of NOS isolated from the cerebellum
(largely neuronal NOS) is 2.8 µmol/L. Also, concentrations of 1
to 10 µmol/L ADMA were sufficient to cause modest contractions
of cerebral vessels in situ.
Intravenous infusion of ADMA sufficient to increase plasma
concentrations 9-fold increased systolic blood pressure by 15%
in anesthetized guinea pigs.41
Intra-arterial infusion of ADMA (8 µmol/min) reduced
forearm blood flow by
30% in healthy volunteers.41
Finally, we have observed intriguing changes in
endothelial behavior when cultured cells are
chronically exposed to concentrations of ADMA and
L-arginine similar to those found in the plasma of
hypercholesterolemic individuals. ADMA-exposed cells
increase the adhesiveness of monocytes in coculture.74
Furthermore, monocytes and T lymphocytes derived from
hypercholesterolemic individuals are hyperadhesive, an
abnormality that is reversed by several weeks of oral administration of
L-arginine.74 This finding is
consistent with previous observations in
hypercholesterolemic animal models and humans that
administration of the NO precursor inhibits
endothelial-monocyte interaction.18 75 76
These observations raise the following question.
| Is ADMA a Risk Factor for Vascular Disease? |
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Intriguingly, in animal models and in humans, endogenous ADMA levels may be predictive of vascular lesion formation. After balloon injury, the regenerating endothelial cells manifest higher intracellular levels of ADMA and impaired endothelium-dependent vasodilation.87 88 89 The severity of the endothelial dysfunction and the intracellular levels of ADMA are directly related to the intimal thickness of the injured vessel.87 89 There are similar data for humans. In 120 Japanese individuals with varying levels of risk, intimal-medial thickness of the carotid artery was measured by ultrasound and was correlated with blood pressure, lipid profile, smoking history, blood sugar, age, and ADMA. A multivariate analysis revealed that ADMA and age were the only independent predictors in these patients.90
Finally, 3 groups have independently offered evidence that endothelial vasodilator dysfunction is an independent predictor of vascular events.24 91 92 Impaired coronary blood flow response to acetylcholine or reduced brachial artery response to flow was predictive of vascular morbidity and mortality. To the extent that ADMA is responsible for the impairment of endothelial vasodilator dysfunction in these patients, it may be a predictor for vascular events.
| Future Directions |
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The regulation of DDAH is just beginning to be understood, and modulators of its expression are being defined. Structure-function studies and novel drug discovery will be enhanced by obtaining its crystal structure. Genetically engineered animals that overexpress or are deficient in DDAH are being created and will provide new insights into the developmental and physiological actions of DDAH. Other enzymes along the metabolic pathway of ADMA deserve further scrutiny; for example, can increased methylation of specific proteins or increased catabolism of these proteins be involved in elevation of plasma ADMA?
Other interesting biological questions remain to be answered. Does ADMA play an important regulatory role in inflammation or infection (ie, as a "brake" on the action of inducible NOS)? Does ADMA have a role in the central or peripheral nervous system? Are other processes that are modulated by NO (eg, angiogenesis) affected by endogenous ADMA? There are many unanswered questions, but it seems certain that endogenous NOS inhibitors represent an important new class of biological mediators. An understanding of their physiological and pathological roles and their regulation may lead to new therapeutic avenues.
| Acknowledgments |
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Received May 5, 2000; accepted June 1, 2000.
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M. Knipp, O. Braun, P. M. Gehrig, R. Sack, and M. Vasak Zn(II)-free Dimethylargininase-1 (DDAH-1) Is Inhibited upon Specific Cys-S-Nitrosylation J. Biol. Chem., January 24, 2003; 278(5): 3410 - 3416. [Abstract] [Full Text] [PDF] |
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T. Maeda, T. Yoshimura, and H. Okamura Asymmetric Dimethylarginine, an Endogenous Inhibitor of Nitric Oxide Synthase, in Maternal and Fetal Circulation Reproductive Sciences, January 1, 2003; 10(1): 2 - 4. [Abstract] [PDF] |
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G. E. Mann, D. L. Yudilevich, and L. Sobrevia Regulation of Amino Acid and Glucose Transporters in Endothelial and Smooth Muscle Cells Physiol Rev, January 1, 2003; 83(1): 183 - 252. [Abstract] [Full Text] [PDF] |
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V. Schachinger and A. M. Zeiher Atherogenesis--recent insights into basic mechanisms and their clinical impact Nephrol. Dial. Transplant., December 1, 2002; 17(12): 2055 - 2064. [Full Text] [PDF] |
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A. J. Cardounel and J. L. Zweier Endogenous Methylarginines Regulate Neuronal Nitric-oxide Synthase and Prevent Excitotoxic Injury J. Biol. Chem., September 6, 2002; 277(37): 33995 - 34002. [Abstract] [Full Text] [PDF] |
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D. Tousoulis, C. Antoniades, C. Tentolouris, G. Goumas, C. Stefanadis, and P. Toutouzas L-Arginine in cardiovascular disease: dream or reality? Vascular Medicine, August 1, 2002; 7(3): 203 - 211. [Abstract] [PDF] |
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T.-H. Hung, J. N. Skepper, D. S. Charnock-Jones, and G. J. Burton Hypoxia-Reoxygenation: A Potent Inducer of Apoptotic Changes in the Human Placenta and Possible Etiological Factor in Preeclampsia Circ. Res., June 28, 2002; 90(12): 1274 - 1281. [Abstract] [Full Text] [PDF] |
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J. P. Cooke and D. W. Losordo Nitric Oxide and Angiogenesis Circulation, May 7, 2002; 105(18): 2133 - 2135. [Full Text] [PDF] |
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D. T. Nash Insulin Resistance, ADMA Levels, and Cardiovascular Disease JAMA, March 20, 2002; 287(11): 1451 - 1452. [Full Text] [PDF] |
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J. T. Kielstein, R. H. Boger, S. M. Bode-Boger, J. C. Frolich, H. Haller, E. Ritz, and D. Fliser Marked Increase of Asymmetric Dimethylarginine in Patients with Incipient Primary Chronic Renal Disease J. Am. Soc. Nephrol., January 1, 2002; 13(1): 170 - 176. [Abstract] [Full Text] [PDF] |
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E. R. Edelman On Causes: Hippocrates, Aristotle, Robert Koch, and the Dread Pirate Roberts Circulation, November 20, 2001; 104(21): 2509 - 2512. [Full Text] [PDF] |
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M. C. Stuhlinger, P. S. Tsao, J.-H. Her, M. Kimoto, R. F. Balint, and J. P. Cooke Homocysteine Impairs the Nitric Oxide Synthase Pathway: Role of Asymmetric Dimethylarginine Circulation, November 20, 2001; 104(21): 2569 - 2575. [Abstract] [Full Text] [PDF] |
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P. Vermeersch, Z. Nong, E. Stabile, O. Varenne, H. Gillijns, M. Pellens, N. Van Pelt, M. Hoylaerts, I. De Scheerder, D. Collen, et al. L-Arginine Administration Reduces Neointima Formation After Stent Injury in Rats by a Nitric Oxide-Mediated Mechanism Arterioscler Thromb Vasc Biol, October 1, 2001; 21(10): 1604 - 1609. [Abstract] [Full Text] [PDF] |
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J. T. Kielstein, J. C. Frolich, H. Haller, and D. Fliser ADMA (asymmetric dimethylarginine): an atherosclerotic disease mediating agent in patients with renal disease? Nephrol. Dial. Transplant., September 1, 2001; 16(9): 1742 - 1745. [Full Text] [PDF] |
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P. Lundman, M. J. Eriksson, M. Stuhlinger, J. P. Cooke, A. Hamsten, and P. Tornvall Mild-to-moderate hypertriglyceridemia in young men is associated with endothelial dysfunction and increased plasma concentrations of asymmetric dimethylarginine J. Am. Coll. Cardiol., July 1, 2001; 38(1): 111 - 116. [Abstract] [Full Text] [PDF] |
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M. Knipp, J. M. Charnock, C. D. Garner, and M. Vasak Structural and Functional Characterization of the Zn(II) Site in Dimethylargininase-1 (DDAH-1) from Bovine Brain. Zn(II) RELEASE ACTIVATES DDAH-1 J. Biol. Chem., October 26, 2001; 276(44): 40449 - 40456. [Abstract] [Full Text] [PDF] |
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