Nitric Oxide: Introduction

Nitric oxide (NO) is a gaseous signaling molecule that readily diffuses across cell membranes and regulates a wide range of physiologic and pathophysiologic processes including cardiovascular, inflammation, immune, and neuronal functions. Nitric oxide should not be confused with nitrous oxide (N₂O), an anesthetic gas, nor with nitrogen dioxide (NO₂), a toxic pulmonary irritant gas.

*The author acknowledges the contribution of the previous authors of this chapter, George Thomas, PhD, & Peter Ramwell, PhD.

Discovery of Endogenously Generated Nitric Oxide

The first indication that NO is generated in cells came from studies of cultured macrophages, which showed that treatment with inflammatory mediators, such as bacterial endotoxin, resulted in the release of nitrate and nitrite, molecules that can form from the breakdown of NO. Similarly, injection of endotoxin in animals elevated urinary nitrite and nitrate.

The second indication came from studies of vascular regulation. Several molecules, such as acetylcholine, were known to cause relaxation of blood vessels. This effect occurred only when the vessels were prepared so that the luminal endothelial cells covering the smooth muscle of the vessel wall were retained. Subsequent studies showed that endothelial cells respond to these vasorelaxants by releasing a soluble endothelial-derived relaxing factor (EDRF). EDRF acts on vascular muscle to elicit relaxation. These findings prompted an intense search for the identity of EDRF.

Exogenous application of NO or organic nitrates, which are metabolized to NO, were known to elicit a variety of cellular effects including inhibition of platelet aggregation and vasorelaxation. The cellular effects of NO were particularly intriguing, since they appeared to induce the activation of highly specific physiologic responses, rather than more general cytotoxic responses. Comparison of the biochemical and pharmacological properties of EDRF and NO led to the conclusion that NO is the major bioactive component of EDRF. These findings made it clear that exogenously applied NO and NO-releasing compounds (nitrates, nitrites, nitroprusside; see Chapters 11 and 12) elicited their effects by recruiting physiologic signaling pathways that respond to endogenously generated NO. NO was subsequently found to be synthesized and have signaling roles in other tissues in addition to endothelial cells, notably neurons, immune system cells, and skeletal muscle.

Nitric Oxide Synthesis, Signaling Mechanisms, & Inactivation

Synthesis

NO, written as NO^·  to indicate an unpaired electron in its chemical structure, or simply NO, is a highly reactive signaling molecule that is made by one or more of three closely related NO synthase (NOS, EC 1.14.13.49) isoenzymes, each of which is encoded by a separate gene and named for the initial cell type from which it was isolated (Table 19–1). These enzymes, neuronal NOS (nNOS or NOS-1), macrophage or inducible NOS (iNOS or NOS-2), and endothelial NOS (eNOS or NOS-3), despite their names, are each expressed in a wide variety of cell types, often with an overlapping distribution. These isoforms generate NO from the amino acid L -arginine in an O₂- and NADPH-dependent reaction (Figure 19–1). This enzymatic reaction involves enzyme-bound cofactors, including heme, tetrahydrobiopterin, and flavin adenine dinucleotide (FAD). In the case of nNOS and eNOS, NO synthesis is triggered by agents and processes that increase cytosolic calcium concentrations. Cytosolic calcium forms complexes with calmodulin, an abundant calcium-binding protein, which then binds and activates eNOS and nNOS. On the other hand, iNOS is not regulated by calcium, but is constitutively active. In macrophages and several other cell types, inflammatory mediators induce the transcriptional activation of the iNOS gene, resulting in accumulation of iNOS and generation of increased quantities of NO.

Signaling Mechanisms

NO mediates its effects by covalent modification of proteins. There are three major effector targets of NO (Figure 19–1):

Metalloproteins

NO interacts with metals, especially iron in heme. The major target of NO is soluble guanylyl cyclase (sGC), an enzyme that generates cyclic GMP from guanosine triphosphate (GTP). sGC contains heme, which readily binds NO, resulting in enzyme activation and elevation in intracellular cGMP levels. cGMP activates protein kinase G (PKG), which phosphorylates specific proteins. In blood vessels, NO-dependent elevations in cGMP and PKG activity result in the phosphorylation of proteins that lead to reduced cytosolic calcium levels and subsequently reduced contraction of vascular smooth muscle. NO also has cytotoxic effects when synthesized in large quantities, eg, by activated macrophages. For example, NO inhibits metalloproteins involved in cellular respiration, such as the citric acid cycle enzyme aconitase and the electron transport chain protein cytochrome oxidase. Inhibition of the heme-containing cytochrome P450 enzymes by NO is a major pathogenic mechanism in inflammatory liver disease.

Thiols

NO reacts with thiols (compounds containing the –SH group) to form nitrosothiols. In proteins, the thiol moiety is found in the amino acid cysteine. Upon exposure to NO, certain proteins are found to accumulate nitrosothiols, which can activate or inhibit the activity of these proteins. This post-translational modification, termed S-nitrosylation or S-nitrosation, requires either metals or oxygen to catalyze the formation of the nitrosothiol adduct. Indeed, NO undergoes both oxidative and reductive reactions, resulting in the formation of a variety of oxides of nitrogen that can nitrosylate thiols, nitrate tyrosines (below), or which are stable oxidation products (Table 19–2). Although the physiologic roles of protein nitrosylation are not fully established, major targets of S-nitrosylation are H-ras, a regulator of cell proliferation that is activated by S-nitrosylation, and the metabolic enzyme glyceraldehyde-3-phosphate dehydrogenase, which is inhibited when it is S-nitrosylated. Denitrosylation of proteins is poorly understood but may involve enzymes, such as thioredoxin, or chemical reduction by intracellular reducing agents. Glutathione, a major intracellular sulfhydryl-containing compound, can also be S-nitrosylated under physiologic conditions to generate S-nitrosoglutathione. Nitrosoglutathione may serve as an endogenous long-lived adduct or carrier of NO. Vascular glutathione is decreased in diabetes mellitus and atherosclerosis, and the resulting deficiency of S-nitrosoglutathione may account for the increased incidence of cardiovascular complications in these conditions.

Tyrosine Nitration

NO reacts very efficiently with superoxide to form peroxynitrite (ONOO^–), a highly reactive oxidant that leads to DNA damage, nitration of tyrosine, and oxidation of cysteine to disulfides or to various sulfur oxides (SO_x). Several cellular enzymes synthesize superoxide, and the activity of these enzymes, as well as NO synthesis, is increased in numerous inflammatory and degenerative diseases, resulting in an increase in peroxynitrite levels. Numerous proteins have been found to be susceptible to peroxynitrite-catalyzed tyrosine nitration, and this irreversible modification can be associated with either activation or inhibition of protein function. The presence of tyrosine nitration in tissue correlates with tissue damage, although a direct causal role of tyrosine nitration in the pathogenesis of any disease has not been definitively established. Protein tyrosine nitration is also used as a marker for the presence of oxidative and nitrosative stress. Peroxynitrite-mediated protein modification is regulated by intracellular levels of glutathione, which can protect against tissue damage by scavenging peroxynitrite. Factors that regulate the biosynthesis and decomposition of glutathione may have important consequences on the toxicity of NO.

Inactivation

The lability of NO is related to its rapid reactions with metals and reactive oxygen species. Thus, NO reacts with heme and hemoproteins, including oxyhemoglobin, which catalyze NO oxidation to nitrate. NO reactions with hemoglobin may also result in partial S-nitrosylation of hemoglobin, resulting in transport of NO throughout the vasculature. NO is also inactivated by superoxide, and scavengers of superoxide anion such as superoxide dismutase may protect NO, enhancing its potency and prolonging its duration of action.

Pharmacologic Manipulation of Nitric Oxide

Inhibitors of Nitric Oxide Synthesis

The primary strategy to reduce NO generation in cells is to use NOS inhibitors. The majority of these inhibitors are arginine analogs that bind to the NOS arginine-binding site. Since each of the NOS isoforms has high sequence similarity, most of these inhibitors do not exhibit selectivity for any of the NOS isoforms. In inflammatory disorders and sepsis (see below), inhibition of the iNOS isoform is potentially beneficial, whereas in neurodegenerative conditions, nNOS-specific inhibitors are needed. However, administration of nonselective NOS inhibitors leads to concurrent inhibition of eNOS, which impairs its homeostatic signaling and also results in vasoconstriction and potential ischemic damage. Thus, newer NOS isoform-selective inhibitors are being designed that exploit subtle differences in substrate binding sites between the isoforms, as well as newer inhibitors that prevent NOS dimerization, the conformation required for enzymatic activity. The efficacy of NOS isoform-selective inhibitors in medical conditions is under investigation.

Nitric Oxide Donors

NO donors, which release NO or related NO species, are used to elicit smooth muscle relaxation. Different classes of NO donors have differing biologic properties, related to the nature of the NO species that is released and the mechanism that relates to their release.

Organic Nitrates

Nitroglycerin, which dilates veins and coronary arteries, is metabolized to NO by mitochondrial aldehyde reductase, an enzyme enriched in venous smooth muscle, accounting for the potent venodilating activity of this molecule. Other organic nitrates, such as isosorbide dinitrate are metabolized to a NO-releasing species through a currently unidentified enzymatic pathway. Unlike NO, organic nitrates have less significant effects on aggregation of platelets, which appear to lack the enzymatic pathways necessary for rapid metabolic activation. Organic nitrates exhibit tolerance during continuous administration. This nitrate tolerance may derive from NO-mediated inhibition of mitochondrial aldehyde reductase.

Organic Nitrites

Organic nitrites, such as the volatile antianginal amyl nitrite, also require metabolic activation to elicit vasorelaxation, although the responsible enzyme has not been identified. Nitrites are arterial vasodilators and do not exhibit the rapid tolerance seen with nitrates.

Sodium Nitroprusside

Sodium nitroprusside, which is used for rapid pressure reduction in arterial hypertension, generates NO in response to light as well as chemical or enzymatic mechanisms in cell membranes. See Chapter 11 for additional details.

No Gas Inhalation

NO itself can be used therapeutically. Inhalation of NO results in reduced pulmonary artery pressure and improved perfusion of ventilated areas of the lung. Inhaled NO is used for pulmonary hypertension, acute hypoxemia, and cardiopulmonary resuscitation, and there is evidence of short-term improvements in pulmonary function.

Alternate Strategies

Another mechanism to increase NO signaling is to enhance the downstream NO signaling pathway. Inhibitors of type 5 phosphodiesterase such as sildenafil result in prolongation of the duration of NO-induced cGMP elevations in a variety of tissues (see Chapter 12).

Nitric Oxide in Disease

Vascular Effects

NO has a significant effect on vascular smooth muscle tone and blood pressure. Numerous endothelium-dependent vasodilators, such as acetylcholine and bradykinin, act by increasing intracellular calcium levels, which induces NO synthesis (Figure 19–2). Mice with a knockout mutation in the eNOS gene display increased vascular tone and elevated mean arterial pressure, indicating that eNOS is a fundamental regulator of blood pressure. The effects of vasopressor drugs are increased by inhibition of NOS.

Apart from being a vasodilator, NO protects against thrombosis and atherogenesis through several mechanisms. A major mechanism involves the inhibition of proliferation and migration of vascular smooth muscle. In animal models, myointimal proliferation following angioplasty can be blocked by NO donors, by NOS gene transfer, and by NO inhalation.

The antithrombotic effects of NO are also mediated by NO-dependent inhibition of platelet aggregation. Both endothelial cells and platelets contain eNOS, which acts to regulate thrombus formation. Thus, endothelial dysfunction and the associated decrease in NO generation may result in abnormal platelet function. As in vascular smooth muscle, cGMP mediates the effect of NO in platelets. NO may have an additional inhibitory effect on blood coagulation by enhancing fibrinolysis via an effect on plasminogen.

NO also reduces endothelial adhesion of monocytes and leukocytes, key features of the early development of atheromatous plaques. This effect is due to the inhibitory effect of NO on the expression of adhesion molecules on the endothelial surface. In addition, NO may act as an antioxidant, blocking the oxidation of low-density lipoproteins and thus preventing or reducing the formation of foam cells in the vascular wall. Plaque formation is also affected by NO-dependent reduction in endothelial cell permeability to lipoproteins. The importance of eNOS in cardiovascular disease is supported by experiments showing increased atherosclerosis in animals deficient in eNOS by pharmacologic inhibition. Atherosclerosis risk factors, such as smoking, hyperlipidemia, diabetes, and hypertension, are associated with decreased endothelial NO production, and thus enhance atherogenesis.

Septic Shock

Sepsis is a systemic inflammatory response caused by infection. Endotoxin components from the bacterial wall along with endogenously generated tumor necrosis factor- and other cytokines induce synthesis of iNOS in macrophages, neutrophils, and T cells, as well as hepatocytes, smooth muscle cells, endothelial cells, and fibroblasts. This widespread generation of NO results in exaggerated hypotension, shock, and, in some cases, death. This hypotension is reversed by NOS inhibitors in humans as well as in animal models (Table 19–3). A similar reversal of hypotension is produced by compounds that prevent the action of NO (such as the sGC inhibitor methylene blue), as well as by scavengers of NO (eg, hemoglobin). Furthermore, knockout mice lacking a functional iNOS gene are more resistant to endotoxin than wild-type mice. However, thus far there has been no correlation between the hemodynamic effects of relatively nonselective NOS inhibitors and survival rate in gram-negative sepsis in humans. The absence of benefit may reflect the inability of the NOS inhibitors to differentiate between NOS isoforms or may reflect concurrent inhibition of beneficial aspects of iNOS signaling.

Inflammation

The host response to infection or injury involves the recruitment of leukocytes and the release of inflammatory mediators, such as tumor necrosis factor and interleukin-1. This leads to induction of iNOS in leukocytes, fibroblasts, and other cell types, resulting in enhanced levels of NO. NO, along with peroxynitrite that forms from its interaction with superoxide, is an important microbicide and may have significant roles in tissue adapting to inflammatory states. Recent studies have shown that NO stimulates the synthesis of inflammatory prostaglandins by activating cyclooxygenase isoenzyme 2 (COX-2). In addition, NO generated during inflammation is involved in the vasodilation, vascular permeability, and subsequent edema associated with acute inflammation. However, in both acute and chronic inflammatory conditions, prolonged or excessive NO production may exacerbate tissue injury. Excessive NO production has a detrimental effect in chronic models of arthritis; dietary L-arginine supplementation exacerbates arthritis, whereas protection is seen with iNOS inhibitors. Synovial fluid from patients with arthritis contains increased oxidation products of NO, particularly peroxynitrite. Psoriasis lesions, airway epithelium in asthma, and inflammatory bowel lesions in humans all demonstrate elevated levels of NO and iNOS. Thus, inhibition of the NO pathway may have a beneficial effect on a variety of acute and chronic inflammatory diseases.

However, NO also appears to play an important protective role in the body via immune cell function. When challenged with foreign antigens, TH 1 cells (see Chapter 55) respond by synthesizing NO. Inhibition of NOS and knockout of the iNOS gene can markedly impair the protective response to injected parasites in animal models.

The Central Nervous System

NO has a major role in the central nervous system as a neurotransmitter. Unlike classic transmitters such as glutamate or dopamine, which are stored in synaptic vesicles and released in the synaptic cleft upon vesicle fusion, NO is not stored, but synthesized on demand and immediately diffuses to neighboring cells. NO synthesis is induced at postsynaptic sites in neurons, most commonly upon activation of the NMDA subtype of glutamate receptor, which results in calcium influx and activation of nNOS. In several neuronal subtypes, eNOS is also present and activated by neurotransmitter pathways that lead to calcium influx. NO synthesized postsynaptically may function as a retrograde messenger and diffuse to the presynaptic terminal to enhance the efficiency of neurotransmitter release through a cGMP or S-nitrosylation-dependent mechanism. It has been suggested that a major role for NO is in the regulation of synaptic plasticity, the process of synapse strengthening that underlies learning and memory.

The Peripheral Nervous System

Nonadrenergic, noncholinergic (NANC) neurons are widely distributed in peripheral tissues, especially the gastrointestinal and reproductive tracts (see Chapter 6). Considerable evidence implicates NO as a mediator of certain NANC actions, and some NANC neurons appear to release NO. Penile erection is thought to be caused by the release of NO from NANC neurons; it is well documented that NO promotes relaxation of the smooth muscle in the corpora cavernosa—the initiating factor in penile erection—and inhibitors of NOS have been shown to prevent erection caused by pelvic nerve stimulation in the rat. Thus, impotence is a possible clinical indication for the use of a NO donor, and trials have been carried out with nitroglycerin ointment and the nitroglycerin patch. An established approach is to inhibit the breakdown of cGMP by the phosphodiesterase (PDE isoform 5) present in the smooth muscle of the corpora cavernosa with drugs such as sildenafil, tadalafil, and vardenafil (see Chapter 12).

Respiratory Disorders

NO is administered by inhalation (see Preparations Available) to newborns with hypoxic respiratory failure associated with pulmonary hypertension. The current treatment for severely defective gas exchange in the newborn is with extracorporeal membrane oxygenation (ECMO), which does not directly affect pulmonary vascular pressures. NO inhalation dilates pulmonary vessels, resulting in decreased pulmonary vascular resistance and reduced pulmonary artery pressure. Inhaled NO also improves oxygenation by reducing mismatch of ventilation and perfusion in the lung. Inhalation of NO results in dilation of pulmonary vessels in areas of the lung with better ventilation, thereby redistributing pulmonary blood flow away from poorly ventilated areas. NO inhalation does not typically exert pronounced effects on the systemic circulation. Inhaled NO has also been shown to improve cardiopulmonary function in adult patients with pulmonary artery hypertension.

Summary: Nitric Oxide

Preparations Available

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