Cited by 186Nitric Oxide and Endothelin EffectsOral microbiology and periodontitis researchGut microbiota and health

The DOI matches its Crossref record; 455 of the 460 references it cites were found in a registry or an index, and 1 are not checked yet; 35 of the 549 sources its claims cite were checked for support.

Enterosalivary nitrate metabolism and the microbiome: Intersection of microbial metabolism, nitric oxide and diet in cardiac and pulmonary vascular health

Open access
Koch, Carl D., Gladwin, Mark T., Freeman, Bruce A., Lundberg, Jon O., Weitzberg, Eddie, Morris, Alison·2017·Free Radical Biology and Medicine

Abstract

Abstract Recent insights into the bioactivation and signaling actions of inorganic, dietary nitrate and nitrite now suggest a critical role for the microbiome in the development of cardiac and pulmonary vascular diseases. Once thought to be the inert, end‐products of endothelial‐derived nitric oxide (NO) heme‐oxidation, nitrate and nitrite are now considered major sources of exogenous NO that exhibit enhanced vasoactive signaling activity under conditions of hypoxia and stress. The bioavailability of nitrate and nitrite depend on the enzymatic reduction of nitrate to nitrite by a unique set of bacterial nitrate reductase enzymes possessed by specific bacterial populations in the mammalian mouth and gut. The pathogenesis of pulmonary hypertension (PH), obesity, hypertension and CVD are linked to defects in NO signaling, suggesting a role for commensal oral bacteria to shape the development of PH through the formation of nitrite, NO and other bioactive nitrogen oxides. Oral supplementation with inorganic nitrate or nitrate‐containing foods exert pleiotropic, beneficial vascular effects in the setting of inflammation, endothelial dysfunction, ischemia‐reperfusion injury and in pre‐clinical models of PH, while traditional high‐nitrate dietary patterns are associated with beneficial outcomes in hypertension, obesity and CVD. These observations highlight the potential of the microbiome in the development of novel nitrate‐ and nitrite‐based therapeutics for PH, CVD and their risk factors. Graphical abstract Figure. No caption available. HighlightsThe microbiome may influence pulmonary hypertension via nitrogen oxide signaling.Oral microbiota are necessary for nitrate reduction to vasoactive nitrogen oxides.Dietary nitrate and nitrite are major sources of exogenous nitrogen oxides.Dietary nitrate in vegetables exerts pleiotropic, beneficial nitrogen oxide effects.Diet and probiotic therapy can alter beneficial nitrate and fatty acid metabolism.

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Overview

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Written from the paper’s full text.

TL;DR

This review argues that dietary nitrate and nitrite are bioactivated by oral and gut microbial nitrate reductases to nitrite, nitric oxide, and other bioactive nitrogen oxides that support cardiac and pulmonary vascular health. It synthesizes preclinical and clinical evidence linking this enterosalivary pathway to blood pressure, endothelial function, exercise capacity, and pulmonary hypertension, while noting that no studies directly link the microbiome, nitrate bioavailability, and PH.

Key findings

  • In the enterosalivary nitrate circulation, approximately 25% of circulating nitrate is sequestered into salivary glands and concentrated in saliva up to 20 times plasma levels; oral bacteria reduce nitrate to nitrite. Chlorhexidine mouthwash decreased oral nitrite by 90% (p<0.001), plasma nitrite by 25% (p=0.001), and increased blood pressure by 2–3.5 mmHg in proportion to decreased plasma nitrite (R2=0.56, p=0.002) in humans.
  • At least 19 studies in hypertensive, overweight, and other patient populations showed blood pressure reduction with nitrate supplementation; nitrate/nitrite prevented or reversed endothelial dysfunction in mice and in healthy, hypertensive, obese, hypercholesterolemic, and peripheral arterial disease individuals. In HFpEF, a single dose of beetroot juice (12.9 mmol nitrate) increased cardiopulmonary exercise testing performance by 14% in 17 patients, and 1 week of daily beetroot juice (6.1 mmol nitrate) improved submaximal aerobic endurance by 24%.
  • No human clinical studies have tested oral nitrate or nitrite in PH, but animal data show nitrite is a selective pulmonary vasodilator, inhibits hypoxia- and monocrotaline-induced PH in rats, and dietary nitrate prevented pulmonary vascular remodeling and right ventricular hypertrophy in wild-type and endothelial NOS-deficient mice.
  • The oral cavity contains an estimated 50–100 billion bacteria and nearly 700 identified species; high nitrate reducers include Firmicutes (Staphylococcus, Streptococcus, Veillonella) and Actinobacteria (Actinomyces). Periodontal disease, xerostomia, and gut Firmicutes:Bacteroidetes shifts are associated with inflammation and altered NO signaling, but no studies directly link oral/gut microbial community features, nitrate bioavailability, and PH development.

Methods

  • Narrative review, not a systematic review, synthesizing preclinical and clinical literature on the nitrate-nitrite-NO pathway, oral and gut microbiome, pulmonary hypertension, cardiovascular disease, diet, probiotics, and antimicrobials.
  • Discusses bacterial nitrate reductase pathways (respiratory denitrification via nar/nap, dissimilatory nitrate reduction to ammonia, assimilatory nitrate reduction), nitrate transport (NarK/NarU), and regulation by oxygen, nitrate, pH, and oral/gut oxygen gradients.
  • Reviews dietary nitrate sources and intakes: DASH-related nitrate blood pressure effects began at about 160 mg/day vegetable nitrate; DASH-compliant diets estimated 174–1222 mg/day; average U.S. intake 40–100 mg/day, Europe 30–180 mg/day, and traditional Japanese diet >1100 mg/day for a 60 kg person.

Limitations

  • Stated: there have been no human clinical studies testing oral nitrate or nitrite in PH; no studies directly link oral/gut microbial community features, nitrate bioavailability, and PH development; mechanisms of microbial nitrate reduction and contributions to enterosalivary nitrite/NO remain uncertain; identification of major nitrate-reducing bacteria varies with methodological factors.
  • Stated: safety of brief and chronic supplemental nitrate/nitrite in PH and dysfunctional NO signaling must be ascertained; carcinogenic potential of nitrite is contextual, depending on interactions with amines/amides versus plant polyphenols and ascorbate.
  • Evident from the text: the review is narrative and largely synthesizes animal/preclinical and associative human data; proposed prebiotic, probiotic, and targeted antimicrobial strategies for PH are speculative and not directly tested in PH.

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Integrity signals

Registry

Crossref · 10.1016/j.freeradbiomed.2016.12.015

Cites

455 of 456 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Verification

Claims the paper makes

173 Not checked yet · 35 Own interpretation · 18 No basis given · 7 Partly supported · 3 Supported so far · 1 Supported · 1 Mixed support · accuracy not yet measured

Verify all 514 references — free account

Show all 138 claims

  • It may state two separate claims as one. 71
  • Probably not a substantial claim. 42
100 of 100
  • The paper relies on this without support.

    Animal model findings of nitrate/nitrite benefit in pulmonary hypertension are predictive of human pulmonary hypertension.

    “though animal model data support a therapeutic role”
  • The paper relies on this without support.

    The enterosalivary nitrate-nitrite-NO pathway operates similarly in humans and rodents.

    “Studies in Sprague-Dawley rats[78] and normal human volunteers[106] showed that depletion of oral bacterial nitrate reductases by chlorhexidine mouthwash correlated with a 90% decrease in oral nitrite levels (p<0.001) in humans”
  • The paper relies on this without support.

    The oral microbiome's nitrate-reducing capacity is critical for systemic NO bioavailability in humans.

    “These data also support the concept that an intricate and dependent relationship exists between mammals and commensal, oral, nitrate-reducing microbiota in maintaining adequate NO signaling.”
  • The paper relies on this without support.

    The vast majority of oral and GI nitrate reducers are facultative anaerobes.

    “The vast majority of oral and GI nitrate reducers are facultative anaerobes.”
  • The paper relies on this without support.

    Nitrite is the common early intermediate in all bacterial nitrate-reductive pathways.

    “Nitrite is the common early intermediate in all bacterial nitrate-reductive pathways, but it is unlikely that all three mechanisms contribute in equal amounts.”
  • The authors state this as an assumption.

    In a healthy mouth, ATP-generating respiration would predominate.

    “The logical assumption would be that in a healthy mouth, ATP-generating respiration would predominate.”
  • The paper relies on this without support.

    To date, there are no studies that directly link microbial community features of the oral and gut microbiome, nitrate bioavailability, and the development of PH.

    “To date, there are no studies that directly link microbial community features of the oral and gut microbiome, nitrate bioavailability, and the development of PH.”
  • The paper relies on this without support.

    There are no studies that directly investigate an association between the gut microbiome, nitrate, and PH.

    “There are no studies that directly investigate an association between the gut microbiome, nitrate, and PH.”
  • The paper relies on this without support.

    There is no conclusive link between dysregulated salivary flow, altered oral microbial populations, and PH.

    “While there is no conclusive link between these factors, these associations offer a potentially novel line of investigation.”
  • The paper relies on this without support.

    Relationships of the microbiome to PH have never been directly examined.

    “Relationships of the microbiome to PH have never been directly examined, but represent a novel testable and modifiable factor in disease pathogenesis.”
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Citations

Cites

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Research works printed but not linked: 3

  1. Gilbert, 1889, Arterites infectieuses experimentales, C. R. Hebd. Des. Séances Mémoires De. La Soc. Biol., 6, 583
  2. Sun, 2016, The role of intestinal microflora and its possible mechanisms in hypertension, Lipid Cardiovasc. Res.
  3. Nadtochiy, 2015, Nitroalkenes confer acute Cardioprot. via Aden. Nucleotide translocase, 1

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Metadata

Authors
Koch, C. D., Gladwin, M. T., Freeman, B. A., Lundberg, J. O., Weitzberg, E., & Morris, A.
Affiliations
  • University of Pittsburgh Medical Center (US)
  • University of Pittsburgh (US)
  • Karolinska Institutet (SE)
Corresponding author
Koch, Carl D.
Venue
Free Radical Biology and Medicine
Publisher
Elsevier BV
Published
2017-04
Volume
105
Pages
48-67
ISSN
0891-5849 (ISSN-L)
OpenAlex
W2563427802
Cited by
186
References
460
Citations by year
2026: 18 · 2025: 17 · 2024: 24 · 2023: 23 · 2022: 27 · 2021: 19 · 2020: 20 · 2019: 20 · 2018: 9 · 2017: 9
FWCI
1.49
Type
journal article
Language
en
Open access
Locations
  • Free Radical Biology and Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health
  • National Heart, Lung, and Blood Institute
  • Swedish Heart and Lung Foundation
Topics
  • Health Sciences › Medicine › Physiology (medical) › Nitric Oxide and Endothelin Effects
  • Health Sciences › Dentistry › Periodontics › Oral microbiology and periodontitis research
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Gut microbiota and health
Keywords
dietary nitrate, nitrite, oral microbiota, gut microbiota, nitric oxide signaling, pulmonary hypertension, cardiovascular disease, hypertension, obesity, nitrate reductase, endothelial dysfunction, ischemia-reperfusion injury, inorganic nitrate supplementation, hypoxia, cardiovascular therapeutics
MeSH terms
Animals, Cardiovascular Diseases, Fatty Acids, Humans, Mouth, Nitrates, Nitric Oxide, Pulmonary Circulation, Signal Transduction, Microbiota

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