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  • Clinical Research Article
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Arginine-NO metabolites are associated with morbidity in single ventricle infants undergoing stage 2 palliation

Pediatric Research (2024)Cite this article

Abstract

Background

Infants with single ventricle heart disease (SVHD) suffer morbidity from insufficient pulmonary blood flow, which may be related to impaired arginine metabolism. No prior study has reported quantitative mapping of arginine metabolites to evaluate the relationship between circulating metabolite levels and outcomes.

Methods

Prospective cohort study of 75 SVHD cases peri-Stage 2 and 50 healthy controls. We targeted pre- and post-op absolute serum quantification of 9 key members of the arginine metabolism pathway by tandem mass spectrometry. Primary outcomes were length of stay (LOS) and post-Stage 2 hypoxemia.

Results

Pre-op cases showed alteration in 6 metabolites including decreased arginine and increased asymmetric dimethyl arginine (ADMA) levels compared to controls. Post-op cases demonstrated decreased arginine and citrulline levels persisting through 48 h. Adjusting for clinical variables, lower pre-op and 2 h post-op concentrations of multiple metabolites, including arginine and citrulline, were associated with longer post-op LOS (p < 0.01). Increased ADMA at 24 h was associated with greater post-op hypoxemia burden (p < 0.05).

Conclusion

Arginine metabolism is impaired in interstage SVHD infants and is further deranged following Stage 2 palliation. Patients with greater metabolite alterations experience greater post-op morbidity. Decreased arginine metabolism may be an important driver of pathology in SVHD.

Impact

  • Interstage infants with SVHD have significantly altered arginine-nitric oxide metabolism compared to healthy children with deficiency of multiple pathway intermediates persisting through 48 h post-Stage 2 palliation.

  • After controlling for clinical covariates and classic catheterization-derived predictors of Stage 2 readiness, both lower pre-operation and lower post-operation circulating metabolite levels were associated with longer post-Stage 2 LOS while increased post-Stage 2 ADMA concentration was associated with greater post-op hypoxemia.

  • Arginine metabolism mapping offers potential for development using personalized medicine strategies as a biomarker of Stage 2 readiness and therapeutic target to improve pulmonary vascular health in infants with SVHD.

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Fig. 1: Case control analysis.
Fig. 2: Time series analysis.

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Data availability

The datasets analyzed during the current study are available from the corresponding author on reasonable request.

References

  1. Hoffman, J. I. E. & Kaplan, S. The incidence of congenital heart disease. J. Am. Coll. Cardiol. 39, 1890–1900 (2002).

    Article  PubMed  Google Scholar 

  2. Ohye, R. G., Schranz, D. & D’Udekem, Y. Current therapy for hypoplastic left heart syndrome and related single ventricle lesions. Circulation 134, 1265–1279 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  3. Caspi, J., Pettitt, T. W., Mulder, T. & Stopa, A. Development of the pulmonary arteries after the Norwood procedure: comparison between Blalock-Taussig shunt and right ventricular-pulmonary artery conduit. Ann. Thorac. Surg. 86, 1299–1304 (2008).

    Article  PubMed  Google Scholar 

  4. Huffmyer, J. L. & Groves, D. S. Pulmonary complications of cardiopulmonary bypass. Best. Pr. Res Clin. Anaesthesiol. 29, 163–175 (2015).

    Article  Google Scholar 

  5. Kogon, B. E. et al. The bidirectional Glenn operation: A risk factor analysis for morbidity and mortality. J. Thorac. Cardiovasc Surg. 136, 1237–1242 (2008).

    Article  PubMed  Google Scholar 

  6. Brown, D. W. et al. Cardiac magnetic resonance versus routine cardiac catheterization before bidirectional Glenn anastomosis: long-term follow-up of a prospective randomized trial. J. Thorac. Cardiovasc Surg. 146, 1172–1178 (2013).

    Article  PubMed  Google Scholar 

  7. Lee, T. M. et al. Risk factor analysis for second-stage palliation of single ventricle anatomy. Ann. Thorac. Surg. 93, 614–618 (2012).

    Article  PubMed  Google Scholar 

  8. Malhotra, S. P. et al. Performance of cavopulmonary palliation at elevated altitude: midterm outcomes and risk factors for failure. Circulation 118, S177–S181 (2008).

    Article  PubMed  PubMed Central  Google Scholar 

  9. Rashid, J. et al. Therapeutic potential of citrulline as an arginine supplement: A clinical pharmacology review. Paediatr. Drugs 22, 279–293 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  10. Lewis, G. D. et al. Metabolic profiling of right ventricular-pulmonary vascular function reveals circulating biomarkers of pulmonary hypertension. J. Am. Coll. Cardiol. 67, 174–189 (2016).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Chao, Y. K. et al. Pulmonary perfusion with L-arginine ameliorates post-cardiopulmonary bypass lung injury in a rabbit model. J. Surg. Res. 167, e77–e83 (2011).

    Article  CAS  PubMed  Google Scholar 

  12. Barr, F. E. et al. Pharmacokinetics and safety of intravenously administered citrulline in children undergoing congenital heart surgery: potential therapy for postoperative pulmonary hypertension. J. Thorac. Cardiovasc Surg. 134, 319–326 (2007).

    Article  CAS  PubMed  Google Scholar 

  13. Hassinger, A. B. et al. Elevated preoperative serum asymmetrical dimethylarginine (ADMA) is associated with poor outcomes after pediatric cardiac surgery. Intensive Care Med 38, 1697–1704 (2012).

    Article  CAS  PubMed  Google Scholar 

  14. Navaei, A. H. et al. Derangement of arginine and related amino acids in children undergoing surgery for congenital heart disease with cardiopulmonary bypass. Crit. Care Explor 2, e0150 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  15. Frank B. S. et al. Interstage single ventricle heart disease infants show dysregulation in multiple metabolic pathways: Targeted metabolomics analysis. JACC Adv. 2, 100169 (2023).

  16. Frank, B. S. et al. Proteomic profiling identifies key differences between inter-stage infants with single ventricle heart disease and healthy controls. Transl. Res. 229, 24–37 (2021).

    Article  CAS  PubMed  Google Scholar 

  17. Klepacki, J., Klawitter, J., Klawitter, J., Thurman, J. M. & Christians, U. A high-performance liquid chromatography-tandem mass spectrometry-based targeted metabolomics kidney dysfunction marker panel in human urine. Clin. Chim. Acta 446, 43–53 (2015).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Benjamini, Y. & Hochberg, Y. Controlling the false discovery rate: A practical and powerful approach ot multiple testing. J. R. Stat. Soc. 57, 289–300 (1995).

    Google Scholar 

  19. Wu, G. & Morris, S. Arginine metabolism: Nitric oxide and beyond. J. Biochem 336, 1–17 (1998).

    Article  CAS  Google Scholar 

  20. Zuckerbraun, B. S., George, P. & Gladwin, M. T. Nitrite in pulmonary arterial hypertension: therapeutic avenues in the setting of dysregulated arginine/nitric oxide synthase signalling. Cardiovasc. Res. 89, 542–552 (2011).

    Article  CAS  PubMed  Google Scholar 

  21. Lavallee, M. et al. Crosstalk between endothelin and nitric oxide in the control of vascular tone. Heart Fail. Rev. 6, 265–276 (2011).

    Article  Google Scholar 

  22. Xia, Y. & Zweier, J. Superoxide and peroxynitrite generation from inducible nitric oxide synthase. Macrophages. PNAS 94, 6954–6958 (1997).

    Article  CAS  PubMed  Google Scholar 

  23. Murakami, K. et al. L-arginine attenuates acute lung injury after smoke inhalation and burn injury in sheep. Shock 28, 477–483 (2007).

    Article  CAS  PubMed  Google Scholar 

  24. Kielstein, J. T. et al. Asymmetrical dimethylarginine in idiopathic pulmonary arterial hypertension. Arterioscler Thromb. Vasc. Biol. 25, 1414–1418 (2005).

    Article  CAS  PubMed  Google Scholar 

  25. Pearson, D. et al. Urea-cycle intermediates, nitric oxide production, and carbamoyl-phosphate synthetase function. N. Engl. J. Med. 344, 1832–1838 (2001).

    Article  CAS  PubMed  Google Scholar 

  26. Xu, W. et al. Integrative proteomics and phosphoproteomics in pulmonary arterial hypertension. Sci. Rep. 9, 18623 (2019).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Luneburg, N., Harbaum, L. & Hennigs, J. K. Low plasma citrulline levels are associated with acute respiratory distress syndrome in patients with severe sepsis. Crit. Care 17, 1–8 (2013).

    Google Scholar 

  28. O’Connor, M. G. et al. Pulmonary hypertension in the premature infant population: Analysis of echocardiographic findings and biomarkers. Pediatr. Pulmonol. 53, 302–309 (2018).

    Article  PubMed  Google Scholar 

  29. Motoki, N. et al. Identification of metabolomic profile related to adult Fontan pathophysiology. Int J. Cardiol. Heart Vasc. 37, 100921 (2021).

    PubMed  PubMed Central  Google Scholar 

  30. Barr, F. E. et al. Effect of cardiopulmonary bypass on urea cycle intermediates and nitric oxide levels after congenital heart surgery. J. Pediatr. 142, 26–30 (2003).

    Article  CAS  PubMed  Google Scholar 

  31. Trittmann, J. K. et al. Plasma asymmetric dimethylarginine levels are increased in neonates with bronchopulmonary dysplasia-associated pulmonary hypertension. J. Pediatr. 166, 230–233 (2015).

    Article  CAS  PubMed  Google Scholar 

  32. Fang, Z. F. et al. Asymmetric dimethyl-l-arginine is a biomarker for disease stage and follow-up of pulmonary hypertension associated with congenital heart disease. Pediatr. Cardiol. 36, 1062–1069 (2015).

    Article  CAS  PubMed  Google Scholar 

  33. Dimitroulas, T. et al. Asymmetrical dimethylarginine in systemic sclerosis-related pulmonary arterial hypertension. Rheumatol. (Oxf.) 47, 1682–1685 (2008).

    Article  CAS  Google Scholar 

  34. Goldberg, D. J. et al. Results of the FUEL trial. Circulation 141, 641–651 (2020).

    Article  PubMed  Google Scholar 

  35. Goldberg, D. J. et al. Impact of oral sildenafil on exercise performance in children and young adults after the fontan operation: a randomized, double-blind, placebo-controlled, crossover trial. Circulation 123, 1185–1193 (2011).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Goldberg, D. J. et al. Results of a phase I/II multi-center investigation of udenafil in adolescents after fontan palliation. Am. Heart J. 188, 42–52 (2017).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Rosenkranz, S. et al. Riociguat for pulmonary arterial hypertension associated with congenital heart disease. Heart 101, 1792–1799 (2015).

    Article  CAS  PubMed  Google Scholar 

  38. Ghofrani, H. A. et al. Riociguat for the treatment of pulmonary arterial hypertension. N. Engl. J. Med. 369, 330–340 (2013).

    Article  CAS  PubMed  Google Scholar 

  39. Smith, H. A. et al. Nitric oxide precursors and congenital heart surgery: a randomized controlled trial of oral citrulline. J. Thorac. Cardiovasc. Surg. 132, 58–65 (2006).

    Article  CAS  PubMed  Google Scholar 

  40. Douglass, M. et al. Folic acid, either solely or combined with L-citrulline, improves NO signaling and ameliorates chronic hypoxia-induced pulmonary hypertension in newborn pigs. Physiol. Rep. 9, e15096 (2021).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Dikalova, A. et al. Combined l-citrulline and tetrahydrobiopterin therapy improves NO signaling and ameliorates chronic hypoxia-induced pulmonary hypertension in newborn pigs. Am. J. Physiol. Lung Cell Mol. Physiol. 318, L762–L772 (2020).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Douglass, M. S., Zhang, Y., Kaplowitz, M. R. & Fike, C. D. L-citrulline increases arginase II protein levels and arginase activity in hypoxic piglet pulmonary artery endothelial cells. Pulm. Circ. 11, 20458940211006289 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  43. Vadivel, A. et al. L-citrulline attenuates arrested alveolar growth and pulmonary hypertension in oxygen-induced lung injury in newborn rats. Pediatr. Res. 68, 519–525 (2010).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Fike, C. D. et al. Rescue treatment with L-citrulline inhibits hypoxia-induced pulmonary hypertension in newborn pigs. Am. J. Respir. Cell Mol. Biol. 53, 255–264 (2015).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Funding

Funding

This study was supported by the American Heart Association - AHA 20CDA35310498 (Frank) and AHA18IPA34170070 (Davidson), the National Institutes of Health - NIH/NCATS Colorado CTSA, No. UL1 TR001082 and UL1 TR002535, NIH/NHLBI K23HL123634 (Frank), and R01HL156936 (Davidson), and the Jayden DeLuca Foundation. There was no relationship with industry associated with this manuscript.

Author information

Author notes

  1. These authors jointly supervised this work: Jelena Klawitter, Jesse A. Davidson.

Authors and Affiliations

  1. University of Colorado Department of Pediatrics, Section of Cardiology, Denver, CO, USA

    Benjamin S. Frank, Ludmila Khailova, Tanner Lehmann, Gareth J. Morgan, Michael V. DiMaria & Jesse A. Davidson

  2. University of Colorado Department of Biostatistics and Informatics, Denver, CO, USA

    Sierra Niemiec & Christopher A. Mancuso

  3. University of Colorado Department of Surgery, Denver, CO, USA

    Max B. Mitchell

  4. University of Colorado Department of Anesthesiology, Denver, CO, USA

    Mark Twite & Jelena Klawitter

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  1. Benjamin S. Frank
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Contributions

B.F. wrote the first draft. B.F. and J.D. created the original study design. D.N. performed the statistical analysis. D.N., L.K., M.M., G.M., M.T., M.D. and J.D. assisted with study operations, analyzed the data, and edited the manuscript. All authors have approved the final version and agree to take accountability for the submission.

Corresponding author

Correspondence to Benjamin S. Frank.

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The authors declare no competing interests.

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Written informed consent was obtained from the study subjects’ parents in all cases.

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Frank, B.S., Niemiec, S., Khailova, L. et al. Arginine-NO metabolites are associated with morbidity in single ventricle infants undergoing stage 2 palliation. Pediatr Res (2024). https://doi.org/10.1038/s41390-024-03162-y

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