Use of exogenous arginine in multiple organ dysfunction syndrome and sepsis

Given the multiple biological, metabolic, and pharmacologic effects of supplemental arginine, much effort has been devoted to defining its role in numerous clinical conditions. Herein, we review the multiple pathways of arginine metabolism with its various enzyme systems; the effect of arginine on nutrition, healing, and immune system; and its clinical use. Sepsis has been postulated to be an arginine-deficient state and/or a syndrome with elevated levels of nitric oxide. So-called immunonutritional formulations containing various nutritional components have been used most often, yet the effects often are attributed to arginine alone. Such conclusions led to guidelines recommending against the use of arginine-supplemented diets in critically ill patients. While caution in the face of a lack of evidence for benefit in sepsis is commended, well-defined studies examining arginine monotherapy in the context of full nutritional support should be carried out so as to define the possible clinical uses of arginine in critically ill and septic patients.