Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp itric oxide (NO), a potent vasodilator, regulates systemic blood pressure (BP) and local blood flow. A deficiency of NO can lead to vasoconstriction and cause diseases including hypertension and chronic kidney disease (CKD). 1-3 Reduced l-arginine (ARG) bioavailability and increased asymmetric dimethylarginine (ADMA) both contribute to NO deficiency. 3 ARG is a substrate for the synthesis of NO and this constitutes the rationale for manipulating ARG metabolism as a therapeutic approach for kidney disease and hypertension. 4 Because ARG is involved in multiple metabolic pathways, 5 there are discrepant findings in the literature according to the plasma level of ARG in patients with CKD and hypertension. 6-8 ARG can be metabolized by arginase to generate ornithine, which can be further converted to l-citrulline (CIT). In contrast, the body can use CIT to make ARG via the argininosuccinate (AS) pathway involving AS synthetase and lyase. 9 In human and experimental CKD, renal CIT uptake is diminished, the amount of CIT converted to ARG in the kidney is reduced, and plasma CIT levels and turnover are elevated. 6-8,10,11 We and others demonstrated that reduced renal ARG availability precedes hypertension in the young spontaneously hypertensive rat (SHR). 12, 13 We also found that restoration of renal ARG availability is associated with lowering BP in young SHR. 12 Renal ARG level, however, is not correlated with the levels of ARG and dimethylarginine in the plasma. 14 These findings suggest that decreased renal ARG level could develop in early CKD causing BP abnormalities, which might be predicted by plasma CIT level and CIT-to-ARG ratio.ADMA can compete with ARG for NO synthase (NOS) to generate NO and CIT. 15,16 Therefore, the ARG-to-ADMA ratio is considered to represent NO bioavailability. 17 ADMA is mainly metabolized by dimethylarginine dimethylaminohydrolase (DDAH) in the kidney. Unlike ADMA, another structural Background: Nitric oxide (NO) is involved in hypertension and chronic kidney disease (CKD). NO synthase can metabolize l-arginine (ARG) to generate NO and l-citrulline (CIT). Two methylated ARG derivatives, asymmetric and symmetric dimethylarginine, are also involved in NO deficiency. Thus it was hypothesized that their combined ratios relate to blood pressure (BP) abnormalities in children with early CKD.