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Connolly JM, McClary JD, Desai R, Sundaram A, Neudecker M, Nock ML, Ryan RM, Marasch JL. Efficacy of recombinant erythropoietin for the late treatment of anemia of prematurity in a level IV neonatal intensive care unit: a retrospective single-center cohort study. J Perinatol 2024; 44:892-896. [PMID: 38773216 DOI: 10.1038/s41372-024-02001-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/30/2024] [Accepted: 05/07/2024] [Indexed: 05/23/2024]
Abstract
OBJECTIVE To describe the population to which we administered recombinant erythropoietin and to determine the effectiveness of this treatment as quantified by the change in hematocrit. STUDY DESIGN This retrospective chart review study included infants who received erythropoietin for the treatment of anemia of prematurity. RESULTS There were 132 infants representing 162 unique treatment courses included in the study. The average duration of therapy was 9 days (±7) and 6 doses (±2). The average change in hematocrit (Hct) was 6.2% (SD 3.9%, p < 0.001). Rise in Hct was associated with a higher number of rEPO doses (p < 0.001) and higher postmenstrual age (p < 0.001). In our small cohort we did not find an association between the number of rEPO doses and retinopathy of prematurity (ROP) requiring treatment. CONCLUSION Erythropoietin is safe and effective at treating anemia of prematurity as evidenced by a clinically and statistically significant increase in Hct from baseline.
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Affiliation(s)
- Jillian M Connolly
- UH Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
| | - Jacquelyn D McClary
- UH Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Riddhi Desai
- UH Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Anupama Sundaram
- UH Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Mandy Neudecker
- UH Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Mary L Nock
- UH Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Rita M Ryan
- UH Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Jaime L Marasch
- UH Rainbow Babies & Children's Hospital, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
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2
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Fukui K, Ito Y, Kokubo M, Nakanishi H, Hirano S, Kusuda S, Ito S, Isayama T. Erythropoietin and retinopathy of prematurity: a retrospective cohort study in Japan, 2008-2018. J Perinatol 2024; 44:886-891. [PMID: 38514743 DOI: 10.1038/s41372-024-01929-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 02/20/2024] [Accepted: 03/04/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Erythropoietin has an angiogenic effect on the retina and might increase the risk of retinopathy of prematurity (ROP). METHODS This retrospective cohort study included infants born at 22 to 27 weeks' gestation between 2008 and 2018 who were admitted to neonatal intensive care units (NICUs). We compared mortality and morbidities between infants who received erythropoietin and those who did not. RESULTS Among 18,955 livebirth infants, this study included 16,031 infants, among which 14,373 infants received erythropoietin. The risk of ROP requiring treatment was significantly higher in the erythropoietin group than in the control group (33% vs. 26%; aOR 1.50 [95% CI 1.28-1.76]). On the other hand, the erythropoietin group had lower risks of death and necrotizing enterocolitis. CONCLUSIONS This study with a large sample size found that erythropoietin use was associated with increased risk of ROP requiring treatment, while being associated with reductions in deaths and NEC.
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Affiliation(s)
- Kana Fukui
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Yushi Ito
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
| | - Masayo Kokubo
- Division of Neonatology, Nagano Children's Hospital, Nagano, Japan
| | - Hidehiko Nakanishi
- Research and Development Center for New Medical Frontiers, Division of Neonatal Intensive Care Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Shinya Hirano
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Satoshi Kusuda
- Department of Pediatrics, Kyorin University, Tokyo, Japan
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Tetsuya Isayama
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan.
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan.
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Fung C, Cung T, Nelson C, Wang H, Bretz C, Ramshekar A, Brown A, Stoddard GJ, Hartnett ME. Retinopathy of prematurity protection conferred by uteroplacental insufficiency through erythropoietin signaling in an experimental Murine Model. Pediatr Res 2023; 94:950-955. [PMID: 37016003 PMCID: PMC10444624 DOI: 10.1038/s41390-023-02568-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/23/2023] [Accepted: 03/04/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Recent clinical studies suggest that preeclampsia, characterized by uteroplacental insufficiency (UPI) and infant intrauterine growth restriction (IUGR), may be protective against retinopathy of prematurity (ROP) in preterm infants. Experimental models of UPI/IUGR have found an association of erythropoietin (EPO) with less severe oxygen-induced retinopathy (OIR); however, it is unclear if EPO/EPO receptor (EPOR) signaling was involved. We hypothesized that maternal UPI and resultant infant IUGR would protect against features of ROP through EPO/EPOR signaling. METHODS We compared transgenic mice with hypoactive EPOR signaling (hWtEPOR) to littermate wild-type mice (mWtEpoR) in a novel combined model of IUGR and ROP. Thromboxane A2 (TXA2) was infused into pregnant C57Bl/6J dams to produce UPI/IUGR; postnatal pups and their foster dams were subjected to a murine OIR model. RESULTS Following hyperoxia, hematocrits were similar between littermate wild-type (mWtEpoR) TXA2/OIR and vehicle/OIR pups. mWtEpoR TXA2/OIR had increased serum EPO, retinal EPO and VEGF, and decreased avascular retinal area (AVA) compared to vehicle/OIR pups. In comparison to the mWtEpoR TXA2/OIR pups, AVA was not reduced in hWtEPOR TXA2/OIR pups. CONCLUSION Our findings provide biologic evidence that UPI/OIR-induced endogenous EPOR signaling confers protection against hyperoxia-induced vascular damage that may be related to pathophysiology in ROP. IMPACT Maternal preeclampsia and infant growth restriction confer retinovascular protection against high oxygen-induced damage through endogenous erythropoietin signaling.
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Affiliation(s)
- Camille Fung
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Thaonhi Cung
- Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Caroline Nelson
- Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Haibo Wang
- Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Colin Bretz
- Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | | | - Ashley Brown
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Gregory J Stoddard
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - M Elizabeth Hartnett
- Moran Eye Center, University of Utah, Salt Lake City, UT, USA.
- Byers Eye Institute at Stanford University, 2452 Watson Court, Palo Alto, CA 94303, USA.
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Fischer HS, Reibel NJ, Bührer C, Dame C. Effect of Early Erythropoietin on Retinopathy of Prematurity: A Stratified Meta-Analysis. Neonatology 2023; 120:566-576. [PMID: 37369177 DOI: 10.1159/000530126] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/07/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Recombinant human erythropoietin (rhEPO) lost its role in minimizing red blood cell transfusion in very preterm infants after it had been associated with severe retinopathy of prematurity (ROP). Previous systematic reviews did not stratify ROP by gestation and birth weight (BW). OBJECTIVES The aim of this study was to investigate the effect of early prophylactic rhEPO on ROP in a stratified meta-analysis of randomized controlled trials (RCTs). METHODS The databases EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched in January 2022 and complemented by citation searching. RCTs comparing early rhEPO treatment with no treatment or placebo were selected if they were published in a peer-reviewed journal and reported ROP outcomes. Previously unpublished data were requested from the study authors to allow stratified analyses by gestational age (GA) and BW. Data were extracted and analyzed using the standard methods of the Cochrane Neonatal Review Group. Pre-specified outcomes were "ROP stage ≥3" (primary outcome) and "any ROP." RESULTS Fourteen RCTs, comprising 2,040 infants of <29 weeks of GA, were included for meta-analysis. Data syntheses showed no effects of rhEPO on ROP stage ≥3 or on any ROP, neither in infants of <29 weeks GA, nor in infants of <1,000 g BW, nor in any GA strata. The risk ratio (95% confidence interval) for ROP stage ≥3 in infants of <29 weeks of GA was 1.13 (0.84, 1.53), p = 0.41 (quality of evidence: moderate). CONCLUSIONS The present meta-analysis detected no effects of early rhEPO on ROP in any comparison, but most stratified analyses were limited by low statistical power.
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Affiliation(s)
- Hendrik S Fischer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nora J Reibel
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christof Dame
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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5
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Odom TL, Eubanks J, Redpath N, Davenport E, Tumin D, Akpan US. Development of necrotizing enterocolitis after blood transfusion in very premature neonates. World J Pediatr 2023; 19:68-75. [PMID: 36227506 DOI: 10.1007/s12519-022-00627-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 09/21/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Prior studies report conflicting evidence on the association between packed red blood cell (PRBC) transfusions and necrotizing enterocolitis (NEC), especially in early weeks of life where transfusions are frequent and spontaneous intestinal perforation can mimic NEC. The primary objective of this study was to evaluate the association between PRBC transfusions and NEC after day of life (DOL) 14 in very premature neonates. METHODS A retrospective cohort analysis of very premature neonates was conducted to investigate association between PRBC transfusions and NEC after DOL 14. Primary endpoints were PRBC transfusions after DOL 14 until the date of NEC diagnosis, discharge, or death. Wilcoxon ranked-sum and Fisher's exact tests, Cox proportional hazards regression, and Kaplan-Meier curves were used to analyze data. RESULTS Of 549 premature neonates, 186 (34%) received transfusions after DOL 14 and nine (2%) developed NEC (median DOL = 38; interquartile range = 32-46). Of the nine with NEC after DOL 14, all were previously transfused (P < 0.001); therefore, hazard of NEC could not be estimated. Post hoc analysis of patients from DOL 10 onward included five additional patients who developed NEC between DOL 10 and DOL 14, and the hazard of NEC increased by a factor of nearly six after PRBC transfusion (hazard ratio = 5.76, 95% confidence interval = 1.02-32.7; P = 0.048). CONCLUSIONS Transfusions were strongly associated with NEC after DOL 14. Prospective studies are needed to determine if restrictive transfusion practices can decrease incidence of NEC after DOL 14.
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Affiliation(s)
- Travis L Odom
- Department of Pediatrics, University of Texas Health Sciences Campus, 7703 Floyd Curl Drive, San Antonio, TX, 78229-3900, USA. .,Department of Pediatrics, Brody School of Medicine at East, Carolina University, Greenville, NC, USA. .,ECU Health Medical Center, Greenville, NC, USA.
| | - Jessica Eubanks
- Department of Pediatrics, Brody School of Medicine at East, Carolina University, Greenville, NC, USA.,ECU Health Medical Center, Greenville, NC, USA
| | - Nusiebeh Redpath
- Department of Pediatrics, Brody School of Medicine at East, Carolina University, Greenville, NC, USA.,ECU Health Medical Center, Greenville, NC, USA
| | - Erica Davenport
- Department of Pediatrics, Brody School of Medicine at East, Carolina University, Greenville, NC, USA.,ECU Health Medical Center, Greenville, NC, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
| | - Uduak S Akpan
- Department of Pediatrics, Brody School of Medicine at East, Carolina University, Greenville, NC, USA
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Chung Y, Desiraju S, Namachivayam K, Guzman P, He L, MohanKumar K. Hematological changes in neonatal mice with phlebotomy-induced anemia. Pediatr Res 2022; 92:1575-1579. [PMID: 35322186 PMCID: PMC9500113 DOI: 10.1038/s41390-022-02023-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/18/2021] [Accepted: 03/06/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Anemia is a nearly universal diagnosis in preterm infants, caused by phlebotomy, and exacerbated by the underlying erythropoietic immaturity. Newborn infants are exposed to the unique stressor of fetal-to-neonatal transition, which requires significant adaptation ex utero. Accordingly, the preterm infant's response to anemia may alter the ability to confront underlying illness. This study utilized our preclinical mouse model of phlebotomy-induced anemia (PIA) to comprehensively investigate associated hematological changes. METHODS C57BL/6 mice were subjected to timed phlebotomy between postnatal days 2--10 to induce severe anemia. Complete blood counts were determined by the Sysmex XT-2000iV analyzer. RESULTS Anemic pups showed a gradual reduction of RBC and hemoglobin (Hb) and increased reticulocyte (RET) counts and red cell distribution width (RDW), however, with reduced RET-Hb from postnatal day (P) of 4 onwards. Elevated levels of high fluorescent RET and immature reticulocyte fraction (IRF) were noted in anemic mouse pups, but low and medium fluorescent RET were reduced. Also, the reduction of mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) were noted in anemic pups. No changes were seen in lymphocytes, but monocytes and neutrophils were significantly elevated from P4-P6. CONCLUSIONS PIA in mouse pups is associated with hematological changes that may be exacerbating factors in neonatal diseases. IMPACT Anemia is common and often severe in premature infants. Investigation of hematological parameters in settings of preclinical anemia may be an index of therapeutic strategies. Preclinical model evaluating the effects of neonatal anemia on the remainder of complete blood count. Detailed time kinetic phlebotomy-induced anemic mice enable us to study the impact on developmental delays in erythropoiesis and possible strategic intervention. Hematological effects of severe anemia in mice might provide insight on how best to investigate anemia in preterm infants.
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Affiliation(s)
- Yerin Chung
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Suneetha Desiraju
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | | | - Pierre Guzman
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Ling He
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
- Department of Pharmacology & Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Krishnan MohanKumar
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.
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Ma Y, Zhou Z, Yang GY, Ding J, Wang X. The Effect of Erythropoietin and Its Derivatives on Ischemic Stroke Therapy: A Comprehensive Review. Front Pharmacol 2022; 13:743926. [PMID: 35250554 PMCID: PMC8892214 DOI: 10.3389/fphar.2022.743926] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 01/19/2022] [Indexed: 12/17/2022] Open
Abstract
Numerous studies explored the therapeutic effects of erythropoietin (EPO) on neurodegenerative diseases. Few studies provided comprehensive and latest knowledge of EPO treatment for ischemic stroke. In the present review, we introduced the structure, expression, function of EPO, and its receptors in the central nervous system. Furthermore, we comprehensively discussed EPO treatment in pre-clinical studies, clinical trials, and its therapeutic mechanisms including suppressing inflammation. Finally, advanced studies of the therapy of EPO derivatives in ischemic stroke were also discussed. We wish to provide valuable information on EPO and EPO derivatives’ treatment for ischemic stroke for basic researchers and clinicians to accelerate the process of their clinical applications.
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Affiliation(s)
- Yuanyuan Ma
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhiyuan Zhou
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Yuan Yang
- Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Guo-Yuan Yang, ; Jing Ding,
| | - Jing Ding
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
- *Correspondence: Guo-Yuan Yang, ; Jing Ding,
| | - Xin Wang
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of The State Key Laboratory of Medical Neurobiology, The Institutes of Brain Science and the Collaborative Innovation Center for Brain Science, Fudan University, Shanghai, China
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Ottolenghi S, Milano G, Cas MD, Findley TO, Paroni R, Corno AF. Can Erythropoietin Reduce Hypoxemic Neurological Damages in Neonates With Congenital Heart Defects? Front Pharmacol 2021; 12:770590. [PMID: 34912224 PMCID: PMC8666450 DOI: 10.3389/fphar.2021.770590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 11/11/2021] [Indexed: 11/21/2022] Open
Abstract
Congenital heart defects (CHD), the most common cause of birth defects with increasing birth prevalence, affect nearly 1% of live births worldwide. Cyanotic CHD are characterized by hypoxemia, with subsequent reduced oxygen delivery to the brain, especially critical during brain development, beginning in the fetus and continuing through the neonatal period. Therefore, neonates with CHD carry a high risk for neurological comorbidities, even more frequently when there are associated underlying genetic disorders. We review the currently available knowledge on potential prevention strategies to reduce brain damage induced by hypoxemia during fetal development and immediately after birth, and the role of erythropoietin (EPO) as a potential adjunctive treatment. Maternal hyper-oxygenation had been studied as a potential therapeutic to improve fetal oxygenation. Despite demonstrating some effectiveness, maternal hyper-oxygenation has proven to be impractical for extensive clinical application, thus prompting the investigation of specific pathways for pharmacological intervention. Among those, the role of antioxidant pathways and Hypoxia Inducible Factors (HIF) have been studied for their involvement in the protective response to hypoxic injury. One of the proteins induced by HIF, EPO, has properties of being anti-apoptotic, antioxidant, and protective for neurons, astrocytes, and oligodendrocytes. In human trials, EPO administration in neonates with hypoxic ischemic encephalopathy (HIE) significantly reduced the neurological hypoxemic damages in several reported studies. Currently, it is unknown if the mechanisms of pathophysiology of cyanotic CHD are like HIE. Neonates with cyanotic CHD are exposed to both chronic hypoxemia and episodes of acute ischemia-reperfusion injury when undergo cardiopulmonary bypass surgery requiring aortic cross-clamp and general anesthesia. Our review supports future trials to evaluate the potential efficiency of EPO in reducing the hypoxemic neurologic damages in neonates with CHD. Furthermore, it suggests the need to identify early biomarkers of hypoxia-induced neurological damage, which must be sensitive to the neuroprotective effects of EPO.
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Affiliation(s)
- Sara Ottolenghi
- Department of Health Science, University of Milan, Milan, Italy.,Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
| | - Giuseppina Milano
- Department Cœur-Vaisseaux, Cardiac Surgery Center, University Hospital of Lausanne, Lausanne, Switzerland
| | - Michele Dei Cas
- Department of Health Science, University of Milan, Milan, Italy
| | - Tina O Findley
- Department of Pediatrics, Children's Heart Institute, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Rita Paroni
- Department of Health Science, University of Milan, Milan, Italy
| | - Antonio F Corno
- Department of Pediatrics, Children's Heart Institute, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, United States
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Jassem-Bobowicz JM, Klasa-Mazurkiewicz D, Żawrocki A, Stefańska K, Domżalska-Popadiuk I, Kwiatkowski S, Preis K. Prediction Model for Bronchopulmonary Dysplasia in Preterm Newborns. CHILDREN-BASEL 2021; 8:children8100886. [PMID: 34682151 PMCID: PMC8534367 DOI: 10.3390/children8100886] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/27/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE: To develop a multifactorial model that allows the prediction of bronchopulmonary dysplasia (BPD) in preterm newborns. MATERIALS AND METHODS: A single-center retrospective study of infants born below 32 + 0 weeks gestational age. We created a receiver operating characteristic curve to assess the multifactorial BPD risk and calculate the BPD risk accuracy using the area under the curve (AUC). BPD risk was categorized using a multifactorial predictive model based on the weight of the evidence. RESULTS: Of the 278 analyzed preterm newborns, 127 (46%) developed BPD. The significant risk factors for BPD in the multivariate analysis were gestational age, number of red blood cell concentrate transfusions, number of surfactant administrations, and hemodynamically significant patent ductus arteriosus. The combination of these factors determined the risk of developing BPD, with an AUC value of 0.932. A multifactorial predictive model based on these factors, weighted by their odds ratios, identified four categories of newborns with mean BPD risks of 9%, 59%, 82%, and 100%. CONCLUSION: A multifactorial model based on easily available clinical factors can predict BPD risk in preterm newborns and inform potential preventive measures.
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Affiliation(s)
- Joanna Maria Jassem-Bobowicz
- Department of Neonatology, Medical University of Gdańsk, 80-214 Gdańsk, Poland;
- Correspondence: ; Tel.: +48-58-584-41-48
| | - Dagmara Klasa-Mazurkiewicz
- Department of Gynaecology and Oncological Gynaecology, Medical University of Gdańsk, 80-214 Gdańsk, Poland;
| | - Anton Żawrocki
- Department of Pathology, Specialist Hospital in Wejherowo, 84-200 Wejherowo, Poland;
| | - Katarzyna Stefańska
- Department of Obstetrics, Medical University of Gdańsk, 80-214 Gdańsk, Poland; (K.S.); (K.P.)
| | | | - Sebastian Kwiatkowski
- Department of Obstetrics and Gynecology, Pomeranian Medical University of Szczecin, 70-111 Szczecin, Poland;
| | - Krzysztof Preis
- Department of Obstetrics, Medical University of Gdańsk, 80-214 Gdańsk, Poland; (K.S.); (K.P.)
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10
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Zhang JY, Wu XW, Wang X, Wang R, Liu WT. Can combination of CEA, CA 19-9, and CA242 improve diagnostic sensitivity and diagnostic value for colorectal cancer? A Meta-analysis. Shijie Huaren Xiaohua Zazhi 2021; 29:825-834. [DOI: 10.11569/wcjd.v29.i14.825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In this study, the combination of CEA, CA19-9, and CA242 in the diagnosis of colorectal cancer (CRC) was analyzed by Meta-analysis, and the clinical value of combined CEA, CA19-9, and CA242 in the diagnosis of CRC was discussed.
AIM To investigate whether combined detection of CEA, CA 19-9, and CA242 can improve detection rate and diagnostic value compared to single biomarkers for CRC.
METHODS We searched PubMed, Embase, Cochrane Library, CNKI, Wanfang database and Sinomed up to October 25, 2019. Diagnostic tests on CEA, CA 19-9, and CA242 used for CRC were included in this Meta-analysis. Two reviewers finished data extraction and quality assessment on the basis of Diagnostic Accuracy Studies 2. By using bivariate regression model, we analyzed the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), area under the curve (AUC), and corresponding 95% credible interval (CI). Meta-regression and subgroup analyses were employed to explore possible source of heterogeneity.
RESULTS Eighteen studies (3534 patients) were included. For single biomarkers, the pooled sensitivity of CA 19-9 [0.37(0.32, 0.43)] was lower than that of CEA [0.50 (0.46, 0.55)] and the pooled AUC of CEA [0.73 (0.68, 0.76)] was lower than that of CA 19-9 [0.82 (0.78, 0.85)] and CA242 [0.87 (0.83, 0.89)]. For biomarker combination, the sensitivity of any two or three biomarkers was greater than that of any single biomarker. For AUC, there was no statistically significant difference between biomarker combinations and single biomarkers but CEA. The result of heterogeneity exploration showed that subject number was the heterogeneity source of CEA and CA 19-9 while cut-off value was the heterogeneity source of CA242.
CONCLUSION Combination of CEA, CA 19-9, and CA242 can remarkably improve the diagnostic sensitivity for CRC compared to single biomarkers. There is no discernable differences between biomarker combinations and single biomarkers except CEA in diagnostic value for CRC.
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Affiliation(s)
- Jing-Yu Zhang
- Department of Gastroenterology, the General Hospital of Tianjin Medical University, Tianjin 300052, China
| | - Xiao-Wei Wu
- Department of Gastroenterology, the General Hospital of Tianjin Medical University, Tianjin 300052, China
| | - Xu Wang
- Department of Gastroenterology, the General Hospital of Tianjin Medical University, Tianjin 300052, China
| | - Rui Wang
- Department of Gastroenterology, the General Hospital of Tianjin Medical University, Tianjin 300052, China
| | - Wen-Tian Liu
- Department of Gastroenterology, the General Hospital of Tianjin Medical University, Tianjin 300052, China
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11
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He F, Huang T, Liao B, Huang Q, Peng X, Zhong X. Analysis of subjective and objective safety risks in nursing care of pediatric hematologic diseases. Am J Transl Res 2021; 13:7730-7742. [PMID: 34377250 PMCID: PMC8340258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/23/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To explore safety risks in the common nursing care of pediatric hematologic diseases. METHODS A total of 100 children with hematologic diseases treated in our hospital were included and randomly divided into a control group (n = 49) and an observation group (n = 51). Children in the control group received routine nursing according to previous practice, while children in the observation group received special environmental nursing with a large number of nurses who had received professional nursing education. After a period of time, the related satisfaction of the two groups of patients was investigated and compared. RESULTS There were significant differences in nursing environment, the quantity of nursing staff, and the nursing level between the control group and the observation group. The proportion of patients with treatment compliance and accident incidence in the observation group was significantly different from that in the control group, indicating some safety risks in the nursing care of pediatric hematologic diseases. CONCLUSION Reducing the probability of various risks in the process of nursing care can create a high-quality and comfortable rehabilitation environment for patients, so as to improve the patients' satisfaction with the service of medical staffs.
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Affiliation(s)
- Fuyu He
- Department of Pediatric Digestive and Hematology, Ganzhou Maternal and Child Health Care Hospital Ganzhou 341000, Jiangxi Province, China
| | - Ting Huang
- Department of Pediatric Digestive and Hematology, Ganzhou Maternal and Child Health Care Hospital Ganzhou 341000, Jiangxi Province, China
| | - Binbin Liao
- Department of Pediatric Digestive and Hematology, Ganzhou Maternal and Child Health Care Hospital Ganzhou 341000, Jiangxi Province, China
| | - Qun Huang
- Department of Pediatric Digestive and Hematology, Ganzhou Maternal and Child Health Care Hospital Ganzhou 341000, Jiangxi Province, China
| | - Xiaoyan Peng
- Department of Pediatric Digestive and Hematology, Ganzhou Maternal and Child Health Care Hospital Ganzhou 341000, Jiangxi Province, China
| | - Xiaoyan Zhong
- Department of Pediatric Digestive and Hematology, Ganzhou Maternal and Child Health Care Hospital Ganzhou 341000, Jiangxi Province, China
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12
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Hoyos AB, Vasquez-Hoyos P. Transfusion prevention using erythropoietin, parenteral sucrose iron, and fewer phlebotomies in infants born at ≤30 weeks gestation at a high altitude center: a 10-year experience. J Perinatol 2021; 41:1403-1411. [PMID: 33568772 DOI: 10.1038/s41372-021-00945-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/11/2020] [Accepted: 01/19/2021] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Red blood cell transfusions in infants born at ≤30 weeks gestation are frequent. Erythropoietin therapy reduces transfusions. An increase in hematocrit is an adaptive response at high altitudes but a guaranteed source of iron is necessary for adequate erythropoiesis. METHODS A retrospective cohort study was done to compare red blood cell transfusion practices of the 2019 EpicLatino (EPIC) Latin America network database with a single unit at 2650 m above sea level (LOCAL). The data from LOCAL for three time periods were compared over 10 years based on changes in erythropoietin dose and fewer phlebotomies. The number of cases that received transfusions and the total number of transfusions required were compared. Adjustments were made for known risk factors using a multivariate regression analysis. RESULTS Two hundred and twenty-one cases in LOCAL and 382 cases from EPIC were included. Overall basic demographic characteristics were similar. In EPIC a significantly higher rate of infection (28% vs. 15%) and outborn (10% vs. 1%) was found, but less necrotizing enterocolitis (9% vs. 15%) and use of prenatal steroids (62% vs. 93%) than LOCAL (p < 0.05). EPIC patients received more transfusions (2.6 ± 3 vs. 0.6 ± 1 times) than LOCAL (p < 0.001) and received them significantly more frequently (61% vs. 25%). Within the LOCAL time periods, no statistically significant differences were found other than the need for transfusions (1st 32%, 2nd 28%, 3rd 9%, p = 0.005) and the average number of transfusions (1st 0.8 ± 1.6, 2nd 0.7 ± 1.3, 3rd 0.1 ± 0.3, p = 0.004). These differences remained significant after multivariate regression analysis and adjusting for risk variables. CONCLUSION The combination of erythropoietin, parenteral sucrose iron, fewer phlebotomies during the first 72 h, and delayed umbilical cord clamping seem to reduce red blood cell transfusion needs. This can be extremely important in high altitude units where higher hematocrit is desirable but may also be valuable at sea level.
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Affiliation(s)
- Angela B Hoyos
- Division of Neonatology, Clínica del Country, Bogota, DC, Colombia. .,Universidad El Bosque, Bogota, Colombia.
| | - Pablo Vasquez-Hoyos
- Sociedad de Cirugía Hospital de San José, Bogota, Colombia.,Department of Pediatrics, Universidad Nacional de Colombia, Bogota, Colombia.,Department of Pediatrics, Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia
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13
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Cibulskis CC, Maheshwari A, Rao R, Mathur AM. Anemia of prematurity: how low is too low? J Perinatol 2021; 41:1244-1257. [PMID: 33664467 DOI: 10.1038/s41372-021-00992-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 01/20/2021] [Accepted: 02/04/2021] [Indexed: 12/11/2022]
Abstract
Anemia of prematurity (AOP) is a common condition with a well-described chronology, nadir hemoglobin levels, and timeline of recovery. However, the underlying pathophysiology and impact of prolonged exposure of the developing infant to low levels of hemoglobin remains unclear. Phlebotomy losses exacerbate the gradual decline of hemoglobin levels which is insidious in presentation, often without any clinical signs. Progressive anemia in preterm infants is associated with poor weight gain, inability to take oral feeds, tachycardia and exacerbation of apneic, and bradycardic events. There remains a lack of consensus on treatment thresholds for RBC transfusion which vary considerably. This review elaborates on the current state of the problem, its implication for the premature infant including association with subphysiologic cerebral tissue oxygenation, necrotizing enterocolitis, and retinopathy of prematurity. It outlines the impact of prophylaxis and treatment of anemia of prematurity and offers suggestions on improving monitoring and management of the condition.
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Affiliation(s)
- Catherine C Cibulskis
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Akhil Maheshwari
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rakesh Rao
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Amit M Mathur
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA.
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14
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Ma X, Shi Y. Whether erythropoietin can be a neuroprotective agent against premature brain injury: cellular mechanisms and clinical efficacy. Curr Neuropharmacol 2021; 20:611-629. [PMID: 34030616 DOI: 10.2174/1570159x19666210524154519] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/27/2021] [Accepted: 05/08/2021] [Indexed: 11/22/2022] Open
Abstract
Preterm infants are at high risk of brain injury. With more understanding of the preterm brain injury's pathogenesis, neuroscientists are looking for more effective methods to prevent and treat it, among which erythropoietin (Epo) is considered as a prime candidate. This review tries to clarify the possible mechanisms of Epo in preterm neuroprotection and summarize updated evidence considering Epo as a pharmacological neuroprotective strategy in animal models and clinical trials. To date, various animal models have validated that Epo is an anti-apoptotic, anti-inflammatory, anti-oxidant, anti-excitotoxic, neurogenetic, erythropoietic, angiogenetic, and neurotrophic agent, thus preventing preterm brain injury. However, although the scientific rationale and preclinical data for Epo's neuroprotective effect are promising, when translated to bedside, the results vary in different studies, especially in its long-term efficacy. Based on existing evidence, it is still too early to recommend Epo as the standard treatment for preterm brain injury.
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Affiliation(s)
- Xueling Ma
- Department of Neonatology, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing 400014, China
| | - Yuan Shi
- Department of Neonatology, Children's Hospital of Chongqing Medical University; National Clinical Research Center for Child Health and Disorders; Ministry of Education Key Laboratory of Child Development and Disorders; Chongqing 400014, China
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15
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Balasubramanian H, Atyalgade M, Garg B, Srinivasan L, Kabra NS, Khapekar S. Effects of blood sampling stewardship and erythropoietin administration in extremely low birth weight infants-a quality improvement non-controlled before-and-after retrospective study. Eur J Pediatr 2021; 180:1617-1626. [PMID: 33464366 DOI: 10.1007/s00431-020-03925-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/24/2020] [Accepted: 12/29/2020] [Indexed: 11/26/2022]
Abstract
The majority of extremely low birth weight (ELBW) neonates receive red blood cell (RBC) transfusions; at least 50% receive multiple transfusions. Anemia care bundles could be the most effective approach to reduce transfusion rates. We conducted a quality improvement non-controlled before-and-after retrospective study involving 345 ELBW infants admitted over a 5-year period in two consecutive epochs before and after implementation of an anemia care bundle in January 2017. Bundle components included (a) prophylactic subcutaneous erythropoietin twice each week (600 IU/kg/week) from day 7 through 8 weeks of age and (b) blood sampling stewardship in the first five postnatal weeks. Early postnatal blood sampling losses were significantly reduced following the implementation of the care bundle (21.2 ml/kg vs 25 ml/kg, P < 0.001). We found a 50% reduction in the rate of multiple RBC transfusions (adjusted RR 0.45, 95% CI: 0.34-0.59) and a reduced odds of necrotizing enterocolitis (NEC) (4% vs 10%, adjusted OR 0.38 (95% CI: 0.15-0.78)) among infants that received the anemia care bundle (n = 182 infants). The overall transfusion rate, number and volume of transfusions, and multiple donor exposures were also significantly reduced.Conclusion: The combination of extended subcutaneous erythropoietin administration and reduced early postnatal blood sampling was associated with a significant reduction in the rate of multiple erythrocyte transfusions and NEC in ELBW neonates. What is known: • The majority of extremely low birth weight neonates continue to require blood transfusions despite advances in standardized transfusion practices; at least 50% require multiple transfusions. • Anemia care bundles, employing a combination of anemia prevention strategies, can effectively reduce the RBC transfusion rates in ELBW infants. What is new: • A combination of extended subcutaneous erythropoietin supplementation and blood sampling stewardship practices reduced the rate of multiple RBC transfusions in ELBW neonates by 50%. • Implementation of the anemia care bundle was associated with a significant reduction in the rates of necrotizing enterocolitis.
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Affiliation(s)
| | - Mukesh Atyalgade
- Surya Children's Hospital, SV Road, Santacruz West, Mumbai, Maharashtra, 400054, India
| | - Bhawandeep Garg
- Surya Children's Hospital, SV Road, Santacruz West, Mumbai, Maharashtra, 400054, India
| | - Lakshmi Srinivasan
- The Children's Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, PA, USA
| | - Nandkishor S Kabra
- Surya Children's Hospital, SV Road, Santacruz West, Mumbai, Maharashtra, 400054, India
| | - Swati Khapekar
- Surya Children's Hospital, SV Road, Santacruz West, Mumbai, Maharashtra, 400054, India
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16
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Can cord blood sampling delay the first packed red blood cell transfusion? J Perinatol 2021; 41:644-647. [PMID: 33221814 DOI: 10.1038/s41372-020-00872-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/27/2020] [Accepted: 11/04/2020] [Indexed: 11/09/2022]
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17
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Song J, Wang Y, Xu F, Sun H, Zhang X, Xia L, Zhang S, Li K, Peng X, Li B, Zhang Y, Kang W, Wang X, Zhu C. Erythropoietin Improves Poor Outcomes in Preterm Infants with Intraventricular Hemorrhage. CNS Drugs 2021; 35:681-690. [PMID: 33959935 PMCID: PMC8219571 DOI: 10.1007/s40263-021-00817-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Intraventricular hemorrhage (IVH) is a common complication in preterm infants that has poor outcomes, especially in severe cases, and there are currently no widely accepted effective treatments. Erythropoietin has been shown to be neuroprotective in neonatal brain injury. OBJECTIVE The objective of this study was to evaluate the protective effect of repeated low-dose recombinant human erythropoietin (rhEPO) in preterm infants with IVH. METHODS This was a single-blinded prospective randomized controlled trial. Preterm infants ≤ 32 weeks gestational age who were diagnosed with IVH within 72 h after birth were randomized to receive rhEPO 500 IU/kg or placebo (equivalent volume of saline) every other day for 2 weeks. The primary outcome was death or neurological disability assessed at 18 months of corrected age. RESULTS A total of 316 eligible infants were included in the study, with 157 in the rhEPO group and 159 in the placebo group. Although no significant differences in mortality (p = 0.176) or incidence of neurological disability (p = 0.055) separately at 18 months of corrected age were seen between the rhEPO and placebo groups, significantly fewer infants had poor outcomes (death and neurological disability) in the rhEPO group: 14.9 vs. 26.4%; odds ratio (OR) 0.398; 95% confidence interval (CI) 0.199-0.796; p = 0.009. In addition, the incidence of Mental Development Index scores of < 70 was lower in the rhEPO group than in the placebo group: 7.2 vs. 15.3%; OR 0.326; 95% CI 0.122-0.875; p = 0.026. CONCLUSIONS Treatment with repeated low-dose rhEPO improved outcomes in preterm infants with IVH. TRIAL REGISTRATION The study was retrospectively registered on ClinicalTrials.gov on 16 April 2019 (NCT03914690).
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Affiliation(s)
- Juan Song
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Yong Wang
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Falin Xu
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Huiqing Sun
- Department of Neonatology, Children’s Hospital of Zhengzhou University, Zhengzhou, 450018 China
| | - Xiaoli Zhang
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Lei Xia
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Shan Zhang
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Kenan Li
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Xirui Peng
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Bingbing Li
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China
| | - Yaodong Zhang
- Department of Neonatology, Children’s Hospital of Zhengzhou University, Zhengzhou, 450018 China
| | - Wenqing Kang
- Department of Neonatology, Children’s Hospital of Zhengzhou University, Zhengzhou, 450018 China
| | - Xiaoyang Wang
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 China ,Center for Perinatal Medicine and Health, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, 40530 Gothenburg, Sweden
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury and Henan Pediatric Clinical Research Center, Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China. .,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, 40530, Gothenburg, Sweden. .,Department of Women's and Children's Health, Karolinska Institutet, 17176, Stockholm, Sweden.
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18
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Sun H, Song J, Kang W, Wang Y, Sun X, Zhou C, Xiong H, Xu F, Li M, Zhang X, Yu Z, Peng X, Li B, Xu Y, Xing S, Wang X, Zhu C. Effect of early prophylactic low-dose recombinant human erythropoietin on retinopathy of prematurity in very preterm infants. J Transl Med 2020; 18:397. [PMID: 33076939 PMCID: PMC7574422 DOI: 10.1186/s12967-020-02562-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/03/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Very preterm infants are at risk of developing retinopathy of prematurity (ROP). Recombinant human erythropoietin (rhEPO) is routinely used to prevent anemia in preterm infants; however, the effect of rhEPO on ROP development is still controversial. The purpose of this study was to evaluate the effect of early prophylactic low-dose rhEPO administration on ROP development in very preterm infants. METHODS A total of 1898 preterm infants born before 32 weeks of gestation were included. Preterm infants received rhEPO (n = 950; 500 U/kg, rhEPO group) or saline (n = 948, control group) intravenously within 72 h of birth and then once every other day for 2 weeks. RESULTS The total incidence of ROP was not significantly different between the two groups (10.2% vs. 13.2%, p = 0.055). Further analysis showed that rhEPO group had lower rates of type 2 ROP than the control group (2.2% vs. 4.1%, RR 0.98; 95% CI 0.96-1.00; p = 0.021). Subgroup analysis found that rhEPO treatment significantly decreased the incidence of type 2 ROP in infant boys (1.8% vs. 4.3%, p = 0.021) and in those with a gestational age of 28-296/7 weeks (1.1% vs. 4.9%, p = 0.002) and birth weight of 1000-1499 g (1.2% vs. 4.2%, p = 0.002). There was a small increasing tendency for the incidence of ROP in infants with a gestational age of < 28 weeks after rhEPO treatment. CONCLUSIONS Repeated low-dose rhEPO administration has no significant influence on the development of ROP; however, it may be effective for type 2 ROP in infant boys or in infants with gestational age > 28 weeks and birth weight > 1500 g. Trial registration The data of this study were retrieved from two clinical studies registered ClinicalTrials.gov (NCT02036073) on January 14, 2014, https://clinicaltrials.gov/ct2/show/NCT02036073 ; and (NCT03919500) on April 18, 2019. https://clinicaltrials.gov/ct2/show/NCT03919500 .
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Affiliation(s)
- Huiqing Sun
- Department of Neonatology, Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, China
| | - Juan Song
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Wenqing Kang
- Department of Neonatology, Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, China
| | - Yong Wang
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Xiantao Sun
- Department of Ophthalmology, Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou, China
| | - Chongchen Zhou
- Key Laboratories of Children's Genetic Metabolic Diseases, Henan Province, Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou, China
| | - Hong Xiong
- Department of Neonatology, Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, China
| | - Falin Xu
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Mingchao Li
- Department of Neonatology, Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, China
| | - Xiaoli Zhang
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Zengyuan Yu
- Department of Neonatology, Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, China
| | - Xirui Peng
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Bingbing Li
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Yiran Xu
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China
| | - Shan Xing
- Department of Neonatology, Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, China
| | - Xiaoyang Wang
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China.,Centre of Perinatal Medicine and Health, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Changlian Zhu
- Henan Key Laboratory of Child Brain Injury, Institute of Neuroscience and Third Affiliated Hospital, Zhengzhou University, Zhengzhou, 450052, China. .,Center for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden. .,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
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Hierro-Bujalance C, Infante-Garcia C, Sanchez-Sotano D, del Marco A, Casado-Revuelta A, Mengual-Gonzalez CM, Lucena-Porras C, Bernal-Martin M, Benavente-Fernandez I, Lubian-Lopez S, Garcia-Alloza M. Erythropoietin Improves Atrophy, Bleeding and Cognition in the Newborn Intraventricular Hemorrhage. Front Cell Dev Biol 2020; 8:571258. [PMID: 33043002 PMCID: PMC7525073 DOI: 10.3389/fcell.2020.571258] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/18/2020] [Indexed: 12/22/2022] Open
Abstract
The germinal matrix-intraventricular hemorrhage (GM-IVH) is one of the most devastating complications of prematurity. The short- and long-term neurodevelopmental consequences after severe GM-IVH are a major concern for neonatologists. These kids are at high risk of psychomotor alterations and cerebral palsy; however, therapeutic approaches are limited. Erythropoietin (EPO) has been previously used to treat several central nervous system complications due to its role in angiogenesis, neurogenesis and as growth factor. In addition, EPO is regularly used to reduce the number of transfusions in the preterm infant. Moreover, EPO crosses the blood-brain barrier and EPO receptors are expressed in the human brain throughout development. To analyze the role of EPO in the GM-IVH, we have administered intraventricular collagenase (Col) to P7 mice, as a model of GM-IVH of the preterm infant. After EPO treatment, we have characterized our animals in the short (14 days) and the long (70 days) term. In our hands, EPO treatment significantly limited brain atrophy and ventricle enlargement. EPO also restored neuronal density and ameliorated dendritic spine loss. Likewise, inflammation and small vessel bleeding were also reduced, resulting in the preservation of learning and memory abilities. Moreover, plasma gelsolin levels, as a feasible peripheral marker of GM-IVH-induced damage, recovered after EPO treatment. Altogether, our data support the positive effect of EPO treatment in our preclinical model of GM-IVH, both in the short and the long term.
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Affiliation(s)
- Carmen Hierro-Bujalance
- Division of Physiology, School of Medicine, Universidadde Cádiz, Cádiz, Spain
- Instituto de Investigacion e Innovacion en Ciencias Biomedicas de la Provincia de Cádiz (INiBICA), Cádiz, Spain
| | - Carmen Infante-Garcia
- Division of Physiology, School of Medicine, Universidadde Cádiz, Cádiz, Spain
- Instituto de Investigacion e Innovacion en Ciencias Biomedicas de la Provincia de Cádiz (INiBICA), Cádiz, Spain
| | | | - Angel del Marco
- Division of Physiology, School of Medicine, Universidadde Cádiz, Cádiz, Spain
- Instituto de Investigacion e Innovacion en Ciencias Biomedicas de la Provincia de Cádiz (INiBICA), Cádiz, Spain
| | - Ana Casado-Revuelta
- Division of Physiology, School of Medicine, Universidadde Cádiz, Cádiz, Spain
| | | | | | | | - Isabel Benavente-Fernandez
- Instituto de Investigacion e Innovacion en Ciencias Biomedicas de la Provincia de Cádiz (INiBICA), Cádiz, Spain
- Division of Paediatrics, Section of Neonatology, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Simon Lubian-Lopez
- Instituto de Investigacion e Innovacion en Ciencias Biomedicas de la Provincia de Cádiz (INiBICA), Cádiz, Spain
- Division of Paediatrics, Section of Neonatology, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Monica Garcia-Alloza
- Division of Physiology, School of Medicine, Universidadde Cádiz, Cádiz, Spain
- Instituto de Investigacion e Innovacion en Ciencias Biomedicas de la Provincia de Cádiz (INiBICA), Cádiz, Spain
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20
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Ophelders DR, Gussenhoven R, Klein L, Jellema RK, Westerlaken RJ, Hütten MC, Vermeulen J, Wassink G, Gunn AJ, Wolfs TG. Preterm Brain Injury, Antenatal Triggers, and Therapeutics: Timing Is Key. Cells 2020; 9:E1871. [PMID: 32785181 PMCID: PMC7464163 DOI: 10.3390/cells9081871] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/31/2020] [Accepted: 08/05/2020] [Indexed: 02/08/2023] Open
Abstract
With a worldwide incidence of 15 million cases, preterm birth is a major contributor to neonatal mortality and morbidity, and concomitant social and economic burden Preterm infants are predisposed to life-long neurological disorders due to the immaturity of the brain. The risks are inversely proportional to maturity at birth. In the majority of extremely preterm infants (<28 weeks' gestation), perinatal brain injury is associated with exposure to multiple inflammatory perinatal triggers that include antenatal infection (i.e., chorioamnionitis), hypoxia-ischemia, and various postnatal injurious triggers (i.e., oxidative stress, sepsis, mechanical ventilation, hemodynamic instability). These perinatal insults cause a self-perpetuating cascade of peripheral and cerebral inflammation that plays a critical role in the etiology of diffuse white and grey matter injuries that underlies a spectrum of connectivity deficits in survivors from extremely preterm birth. This review focuses on chorioamnionitis and hypoxia-ischemia, which are two important antenatal risk factors for preterm brain injury, and highlights the latest insights on its pathophysiology, potential treatment, and future perspectives to narrow the translational gap between preclinical research and clinical applications.
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Affiliation(s)
- Daan R.M.G. Ophelders
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Ruth Gussenhoven
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
| | - Luise Klein
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Reint K. Jellema
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
| | - Rob J.J. Westerlaken
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Matthias C. Hütten
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Jeroen Vermeulen
- Department of Pediatric Neurology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands;
| | - Guido Wassink
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Private bag 92019, Auckland 1023, New Zealand; (G.W.); (A.J.G.)
| | - Alistair J. Gunn
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Private bag 92019, Auckland 1023, New Zealand; (G.W.); (A.J.G.)
| | - Tim G.A.M. Wolfs
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
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Are single-donor red blood cell transfusions still relevant for preterm infants? J Perinatol 2020; 40:1075-1082. [PMID: 32346131 DOI: 10.1038/s41372-020-0670-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/13/2020] [Accepted: 04/09/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To explore the worth of a single-donor program for preterm infants through the recipient profile and the impact on donor exposure, red blood cell (RBC) pack waste, storage duration, and transfusion performance. STUDY DESIGN Patients and transfusion characteristics were collected for 3 years (2015-2017) in preterm infants according to single-donor program prescription in a unit not practicing placental transfusion or erythropoietin supplementation. RESULTS Among 1048 eligible preterm infants, 161 met the inclusion criteria, and 51 received single-donor packs. Our single-donor program induced a donor number reduction (34% less than the transfusion number) and an extension of storage duration (median: 9 versus 7 days, p < 0.0001) without altering the transfusion performance. However, 41% of small packs were not used. CONCLUSION A single-donor program partially reduced donor exposure but led to drastic RBC pack waste. Optimization of transfusion alternatives may increase this phenomenon, calling into question the rationale of this practice.
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Aher SM, Ohlsson A. Late erythropoiesis-stimulating agents to prevent red blood cell transfusion in preterm or low birth weight infants. Cochrane Database Syst Rev 2020; 1:CD004868. [PMID: 31990982 PMCID: PMC6986694 DOI: 10.1002/14651858.cd004868.pub6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Preterm infants have low plasma levels of erythropoietin (EPO), providing a rationale for the use of erythropoiesis-stimulating agents (ESAs) to prevent or treat anaemia. Darbepoetin (Darbe) and EPO are currently available ESAs. OBJECTIVES To assess the effectiveness and safety of late initiation of ESAs, between eight and 28 days after birth, in reducing the use of red blood cell (RBC) transfusions in preterm or low birth weight infants. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 5 June 2018), Embase (1980 to 5 June 2018), and CINAHL (1982 to 5 June 2018). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised or quasi-randomised controlled trials of late initiation of EPO treatment (started at ≥ eight days of age) versus placebo or no intervention in preterm (< 37 weeks) or low birth weight (< 2500 grams) neonates. DATA COLLECTION AND ANALYSIS We performed data collection and analyses in accordance with the methods of the Cochrane Neonatal Review Group. We used the GRADE approach to assess the quality of the evidence. MAIN RESULTS We include 31 studies (32 comparisons) randomising 1651 preterm infants. Literature searches in 2018 identified one new study for inclusion. No new on-going trials were identified and no studies used darbepoetin. Most included trials were of small sample size. The meta-analysis showed a significant effect on the use of one or more RBC transfusions (21 studies (n = 1202); typical risk ratio (RR) 0.72, 95% confidence interval (CI) 0.65 to 0.79; typical risk difference (RD) -0.17, 95% CI -0.22 to -0.12; typical number needed to treat for an additional beneficial outcome (NNTB) 6, 95% CI 5 to 8). There was moderate heterogeneity for this outcome (RR I² = 66%; RD I² = 58%). The quality of the evidence was very low. We obtained similar results in secondary analyses based on different combinations of high/low doses of EPO and iron supplementation. There was no significant reduction in the total volume (mL/kg) of blood transfused per infant (typical mean difference (MD) -1.6 mL/kg, 95% CI -5.8 to 2.6); 5 studies, 197 infants). There was high heterogeneity for this outcome (I² = 92%). There was a significant reduction in the number of transfusions per infant (11 studies enrolling 817 infants; typical MD -0.22, 95% CI -0.38 to -0.06). There was high heterogeneity for this outcome (I² = 94%). Three studies including 404 infants reported on retinopathy of prematurity (ROP) (all stages or stage not reported), with a typical RR 1.27 (95% CI 0.99 to 1.64) and a typical RD of 0.09 (95% CI -0.00 to 0.18). There was high heterogeneity for this outcome for both RR (I² = 83%) and RD (I² = 82%). The quality of the evidence was very low.Three trials enrolling 442 infants reported on ROP (stage ≥ 3). The typical RR was 1.73 (95% CI 0.92 to 3.24) and the typical RD was 0.05 (95% CI -0.01 to 0.10). There was no heterogeneity for this outcome for RR (I² = 18%) but high heterogeneity for RD (I² = 79%). The quality of the evidence was very low.There were no significant differences in other clinical outcomes including mortality and necrotising enterocolitis. For the outcomes of mortality and necrotising enterocolitis, the quality of the evidence was moderate. Long-term neurodevelopmental outcomes were not reported. AUTHORS' CONCLUSIONS Late administration of EPO reduces the use of one or more RBC transfusions, the number of RBC transfusions per infant (< 1 transfusion per infant) but not the total volume (mL/kg) of RBCs transfused per infant. Any donor exposure is likely not avoided as most studies included infants who had received RBC transfusions prior to trial entry. Late EPO does not significantly reduce or increase any clinically important adverse outcomes except for a trend in increased risk for ROP. Further research of the use of late EPO treatment, to prevent donor exposure, is not indicated. Research efforts should focus on limiting donor exposure during the first few days of life in sick neonates, when RBC requirements are most likely to be required and cannot be prevented by late EPO treatment. The use of satellite packs (dividing one unit of donor blood into many smaller aliquots) may reduce donor exposure.
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Affiliation(s)
- Sanjay M Aher
- Neocare HospitalNeonatal Intensive Care UnitMumbai NakaNashikMaharashtraIndia422002
| | - Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and EvaluationTorontoCanada
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Juul SE, Comstock BA, Wadhawan R, Mayock DE, Courtney SE, Robinson T, Ahmad KA, Bendel-Stenzel E, Baserga M, LaGamma EF, Downey LC, Rao R, Fahim N, Lampland A, Frantz ID, Khan JY, Weiss M, Gilmore MM, Ohls RK, Srinivasan N, Perez JE, McKay V, Vu PT, Lowe J, Kuban K, O'Shea TM, Hartman AL, Heagerty PJ. A Randomized Trial of Erythropoietin for Neuroprotection in Preterm Infants. N Engl J Med 2020; 382:233-243. [PMID: 31940698 PMCID: PMC7060076 DOI: 10.1056/nejmoa1907423] [Citation(s) in RCA: 187] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND High-dose erythropoietin has been shown to have a neuroprotective effect in preclinical models of neonatal brain injury, and phase 2 trials have suggested possible efficacy; however, the benefits and safety of this therapy in extremely preterm infants have not been established. METHODS In this multicenter, randomized, double-blind trial of high-dose erythropoietin, we assigned 941 infants who were born at 24 weeks 0 days to 27 weeks 6 days of gestation to receive erythropoietin or placebo within 24 hours after birth. Erythropoietin was administered intravenously at a dose of 1000 U per kilogram of body weight every 48 hours for a total of six doses, followed by a maintenance dose of 400 U per kilogram three times per week by subcutaneous injection through 32 completed weeks of postmenstrual age. Placebo was administered as intravenous saline followed by sham injections. The primary outcome was death or severe neurodevelopmental impairment at 22 to 26 months of postmenstrual age. Severe neurodevelopmental impairment was defined as severe cerebral palsy or a composite motor or composite cognitive score of less than 70 (which corresponds to 2 SD below the mean, with higher scores indicating better performance) on the Bayley Scales of Infant and Toddler Development, third edition. RESULTS A total of 741 infants were included in the per-protocol efficacy analysis: 376 received erythropoietin and 365 received placebo. There was no significant difference between the erythropoietin group and the placebo group in the incidence of death or severe neurodevelopmental impairment at 2 years of age (97 children [26%] vs. 94 children [26%]; relative risk, 1.03; 95% confidence interval, 0.81 to 1.32; P = 0.80). There were no significant differences between the groups in the rates of retinopathy of prematurity, intracranial hemorrhage, sepsis, necrotizing enterocolitis, bronchopulmonary dysplasia, or death or in the frequency of serious adverse events. CONCLUSIONS High-dose erythropoietin treatment administered to extremely preterm infants from 24 hours after birth through 32 weeks of postmenstrual age did not result in a lower risk of severe neurodevelopmental impairment or death at 2 years of age. (Funded by the National Institute of Neurological Disorders and Stroke; PENUT ClinicalTrials.gov number, NCT01378273.).
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Affiliation(s)
- Sandra E Juul
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Bryan A Comstock
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Rajan Wadhawan
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Dennis E Mayock
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Sherry E Courtney
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Tonya Robinson
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Kaashif A Ahmad
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Ellen Bendel-Stenzel
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Mariana Baserga
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Edmund F LaGamma
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - L Corbin Downey
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Raghavendra Rao
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Nancy Fahim
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Andrea Lampland
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Ivan D Frantz
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Janine Y Khan
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Michael Weiss
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Maureen M Gilmore
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Robin K Ohls
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Nishant Srinivasan
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Jorge E Perez
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Victor McKay
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Phuong T Vu
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Jean Lowe
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Karl Kuban
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - T Michael O'Shea
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Adam L Hartman
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
| | - Patrick J Heagerty
- From the University of Washington, Seattle (S.E.J., B.A.C., D.E.M., P.T.V., P.J.H.); Florida Hospital Orlando, Orlando (R.W.), the University of Florida, Gainesville (M.W.), South Miami Hospital, South Miami (J.E.P.), and Johns Hopkins All Children's Hospital, St. Petersburg (V.M.) - all in Florida; the University of Arkansas for Medical Sciences, Little Rock (S.E.C.); the University of Louisville, Louisville, KY (T.R.); Methodist Children's Hospital, San Antonio, TX (K.A.A.); Children's Hospital and Clinics of Minnesota (E.B.-S.) and University of Minnesota Masonic Children's Hospital (R.R., N.F.), Minneapolis, and Children's Minnesota, St. Paul (A.L.) - all in Minnesota; the University of Utah, Salt Lake City (M.B.); Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY (E.F.L.); Wake Forest School of Medicine, Winston-Salem (L.C.D.), and the University of North Carolina, Chapel Hill (T.M.O.) - both in North Carolina; Beth Israel Deaconess Medical Center (I.D.F.) and Boston University (K.K.) - both in Boston; Prentice Women's Hospital (J.Y.K.) and Children's Hospital of the University of Illinois (N.S.) - both in Chicago; Johns Hopkins University, Baltimore (M.M.G.), and the National Institute of Neurological Disorders and Stroke, Bethesda (A.L.H.) - both in Maryland; and the University of New Mexico, Albuquerque (R.K.O., J.L.)
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Mayock DE, Xie Z, Comstock BA, Heagerty PJ, Juul SE. High-Dose Erythropoietin in Extremely Low Gestational Age Neonates Does Not Alter Risk of Retinopathy of Prematurity. Neonatology 2020; 117:650-657. [PMID: 33113526 PMCID: PMC7855231 DOI: 10.1159/000511262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/25/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The Preterm Erythropoietin (Epo) Neuroprotection (PENUT) Trial sought to determine the safety and efficacy of early high-dose Epo as a potential neuroprotective treatment. We hypothesized that Epo would not increase the incidence or severity of retinopathy of prematurity (ROP). METHODS A total of 941 infants born between 24-0/7 and 27-6/7 weeks' gestation were randomized to 1,000 U/kg Epo or placebo intravenously for 6 doses, followed by subcutaneous or sham injections of 400 U/kg Epo 3 times a week through 32 weeks post-menstrual age. In this secondary analysis of PENUT trial data, survivors were evaluated for ROP. A modified intention-to-treat approach was used to compare treatment groups. In addition, risk factors for ROP were evaluated using regression methods that account for multiples and allow for adjustment for treatment and gestational age at birth. RESULTS Of 845 subjects who underwent ROP examination, 503 were diagnosed with ROP with similar incidence and severity between treatment groups. Gestational age at birth, birth weight, prenatal magnesium sulfate, maternal antibiotic exposure, and presence of heart murmur at 2 weeks predicted the development of any ROP, while being on high-frequency oscillator or high-frequency jet ventilation (HFOV/HFJV) at 2 weeks predicted severe ROP. CONCLUSION Early high-dose Epo followed by maintenance dosing through 32 weeks does not increase the risk of any or severe ROP in extremely low gestational age neonates. Gestational age, birth weight, maternal treatment with magnesium sulfate, antibiotic use during pregnancy, and presence of a heart murmur at 2 weeks were associated with increased risk of any ROP. Treatment with HFOV/HFJV was associated with an increased risk of severe ROP.
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Affiliation(s)
- Dennis E Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA,
| | - Zimeng Xie
- Division of Biomedical Statistics, Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Bryan A Comstock
- Division of Biomedical Statistics, Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Patrick J Heagerty
- Division of Biomedical Statistics, Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
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Abstract
Perinatal brain injury is a major cause of neurological disability in both premature and term infants. In this review, we summarize the evidence behind some established neuroprotective practices such as administration of antenatal steroids, intrapartum magnesium for preterm delivery, and therapeutic hypothermia. In addition, we examine emerging practices such as delayed cord clamping, postnatal magnesium administration, recombinant erythropoietin, and non-steroidal anti-inflammatory agents and finally inform the reader about novel interventions, some of which are currently in trials, such as xenon, melatonin, topiramate, allopurinol, creatine, and autologous cord cell therapy.
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Affiliation(s)
- Samata Singhi
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland, 21205, USA
- Department of Pediatric Neurology, Johns Hopkins Medicine, Baltimore, MD, 21287, USA
| | - Michael Johnston
- Department of Neurology, Kennedy Krieger Institute, Baltimore, Maryland, 21205, USA
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Lundgren P, Hellgren G, Pivodic A, Sävman K, Smith LEH, Hellström A. Erythropoietin serum levels, versus anaemia as risk factors for severe retinopathy of prematurity. Pediatr Res 2019; 86:276-282. [PMID: 30297879 PMCID: PMC6422731 DOI: 10.1038/s41390-018-0186-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/28/2018] [Accepted: 09/04/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Preterm infants with anaemia are treated with recombinant human erythropoietin (rhEPO). It is debated whether rhEPO treatment is a risk factor for retinopathy of prematurity (ROP). We evaluated longitudinal EPO and haemoglobin levels, blood transfusions and neonatal morbidities as risk factors for severe ROP. METHOD This prospective study included 78 Swedish infants, born <28 weeks gestational age (GA), screened for ROP. We tested serum EPO levels on postnatal days 1, 7, 14 and 28 and at postmenstrual ages 32, 36 and 40 weeks. Haemoglobin levels and blood transfusions were recorded during postnatal weeks 1-4. Anaemia was defined as haemoglobin ≤110 g/L. RESULTS During postnatal week 1, infants with severe ROP requiring treatment (28%) more frequently developed anaemia (42.9% versus 8.0%, P = 0.003) and had higher mean EPO levels (postnatal day 7: 14.2 versus 10.8 mIU/mL, P = 0.003) compared to infants with no or less severe ROP not requiring treatment. In multivariable analyses, GA and anaemia during week 1 remained significant risk factors, but elevated EPO level postnatal day 7 was no longer significant. CONCLUSIONS Among infants born <28 weeks GA, anaemia during week 1 was a significant risk factor for severe ROP requiring treatment but not elevated EPO levels.
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Affiliation(s)
- Pia Lundgren
- Section for Ophthalmology, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Gunnel Hellgren
- Department of Clinical Neuroscience, Section for Ophthalmology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Karin Sävman
- Department of Paediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lois E. H. Smith
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ann Hellström
- Department of Clinical Neuroscience, Section for Ophthalmology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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van Bel F, Vaes J, Groenendaal F. Prevention, Reduction and Repair of Brain Injury of the Preterm Infant. Front Physiol 2019; 10:181. [PMID: 30949060 PMCID: PMC6435588 DOI: 10.3389/fphys.2019.00181] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 02/14/2019] [Indexed: 12/15/2022] Open
Affiliation(s)
- Frank van Bel
- Department of Neonatology, Wilhelmina Children’s Hospital and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Josine Vaes
- Laboratory of Neuroimmunology and Developmental Origins of Disease, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children’s Hospital and Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Saroha V, Josephson CD, Patel RM. Epidemiology of Necrotizing Enterocolitis: New Considerations Regarding the Influence of Red Blood Cell Transfusions and Anemia. Clin Perinatol 2019; 46:101-117. [PMID: 30771812 PMCID: PMC6383803 DOI: 10.1016/j.clp.2018.09.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
This article summarizes available evidence on the relationship between red blood cell transfusion and anemia, and necrotizing enterocolitis (NEC). We review recent studies that highlight the uncertainty of the effect of red blood cell transfusion on NEC and the potential role of anemia. We also discuss potential pathophysiologic effects of both red blood cell transfusion and anemia and highlight strategies to prevent anemia and red blood cell transfusion. We also discuss ongoing randomized trials that are likely to provide important new evidence to guide red blood cell transfusion practices.
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Affiliation(s)
- Vivek Saroha
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, 2015 Uppergate Dr. NE, 3 floor, Atlanta, GA 30322. Tel 404-727-3236.
| | - Cassandra D. Josephson
- Center for Transfusion and Cellular Therapies, Departments of Pathology and Laboratory Medicine and Pediatrics, Emory University School of Medicine, 101 Woodruff Cir, Atlanta, GA 30322. Tel 404-785-4553.
| | - Ravi Mangal Patel
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, 2015 Uppergate Dr. NE, 3 floor, Atlanta, GA 30322. Tel 404-727-3236.
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29
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Aher SM, Ohlsson A. Late erythropoiesis-stimulating agents to prevent red blood cell transfusion in preterm or low birth weight infants. Cochrane Database Syst Rev 2019; 2:CD004868. [PMID: 30776084 PMCID: PMC6378929 DOI: 10.1002/14651858.cd004868.pub5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Preterm infants have low plasma levels of erythropoietin (EPO), providing a rationale for the use of erythropoiesis-stimulating agents (ESAs) to prevent or treat anaemia. Darbepoetin (Darbe) and EPO are currently available ESAs. OBJECTIVES To assess the effectiveness and safety of late initiation of ESAs, between eight and 28 days after birth, in reducing the use of red blood cell (RBC) transfusions in preterm or low birth weight infants. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 5 June 2018), Embase (1980 to 5 June 2018), and CINAHL (1982 to 5 June 2018). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised or quasi-randomised controlled trials of late initiation of EPO treatment (started at ≥ eight days of age) versus placebo or no intervention in preterm (< 37 weeks) or low birth weight (< 2500 grams) neonates. DATA COLLECTION AND ANALYSIS We performed data collection and analyses in accordance with the methods of the Cochrane Neonatal Review Group. We used the GRADE approach to assess the quality of the evidence. MAIN RESULTS We include 31 studies (32 comparisons) randomising 1651 preterm infants. Literature searches in 2018 identified one new study for inclusion. No new on-going trials were identified and no studies used darbepoetin.Most included trials were of small sample size. The meta-analysis showed a significant effect on the use of one or more RBC transfusions (21 studies (n = 1202); typical risk ratio (RR) 0.72, 95% confidence interval (CI) 0.65 to 0.79; typical risk difference (RD) -0.17, 95% CI -0.22 to -0.12; typical number needed to treat for an additional beneficial outcome (NNTB) 6, 95% CI 5 to 8). There was moderate heterogeneity for this outcome (RR I² = 66%; RD I² = 58%). The quality of the evidence was very low. We obtained similar results in secondary analyses based on different combinations of high/low doses of EPO and iron supplementation. There was no significant reduction in the total volume (mL/kg) of blood transfused per infant (typical mean difference (MD) -1.6 mL/kg, 95% CI -5.8 to 2.6); 5 studies, 197 infants). There was high heterogeneity for this outcome (I² = 92%). There was a significant reduction in the number of transfusions per infant (11 studies enrolling 817 infants; typical MD -0.22, 95% CI -0.38 to -0.06). There was high heterogeneity for this outcome (I² = 94%).Three studies including 404 infants reported on retinopathy of prematurity (ROP) (all stages or stage not reported), with a typical RR 1.27 (95% CI 0.99 to 1.64) and a typical RD of 0.09 (95% CI -0.00 to 0.18). There was high heterogeneity for this outcome for both RR (I² = 83%) and RD (I² = 82%). The quality of the evidence was very low.Three trials enrolling 442 infants reported on ROP (stage ≥ 3). The typical RR was 1.73 (95% CI 0.92 to 3.24) and the typical RD was 0.05 (95% CI -0.01 to 0.10). There was no heterogeneity for this outcome for RR (I² = 18%) but high heterogeneity for RD (I² = 79%). The quality of the evidence was very low.There were no significant differences in other clinical outcomes including mortality and necrotising enterocolitis. For the outcomes of mortality and necrotising enterocolitis, the quality of the evidence was moderate. Long-term neurodevelopmental outcomes were not reported. AUTHORS' CONCLUSIONS Late administration of EPO reduces the use of one or more RBC transfusions, the number of RBC transfusions per infant (< 1 transfusion per infant) but not the total volume (mL/kg) of RBCs transfused per infant. Any donor exposure is likely not avoided as most studies included infants who had received RBC transfusions prior to trial entry. Late EPO does not significantly reduce or increase any clinically important adverse outcomes except for a trend in increased risk for ROP. Further research of the use of late EPO treatment, to prevent donor exposure, is not indicated. Research efforts should focus on limiting donor exposure during the first few days of life in sick neonates, when RBC requirements are most likely to be required and cannot be prevented by late EPO treatment. The use of satellite packs (dividing one unit of donor blood into many smaller aliquots) may reduce donor exposure.
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Affiliation(s)
- Sanjay M Aher
- Neocare HospitalNeonatal Intensive Care UnitMumbai NakaNashikIndia422002
| | - Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoCanadaM5G 1X5
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Michael Z, Spyropoulos F, Ghanta S, Christou H. Bronchopulmonary Dysplasia: An Update of Current Pharmacologic Therapies and New Approaches. Clin Med Insights Pediatr 2018; 12:1179556518817322. [PMID: 30574005 PMCID: PMC6295761 DOI: 10.1177/1179556518817322] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/03/2018] [Indexed: 12/21/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) remains the most prevalent long-term morbidity of surviving extremely preterm infants and is associated with significant health care utilization in infancy and beyond. Recent advances in neonatal care have resulted in improved survival of extremely low birth weight (ELBW) infants; however, the incidence of BPD has not been substantially impacted by novel interventions in this vulnerable population. The multifactorial cause of BPD requires a multi-pronged approach for prevention and treatment. New approaches in assisted ventilation, optimal nutrition, and pharmacologic interventions are currently being evaluated. The focus of this review is the current state of the evidence for pharmacotherapy in BPD. Promising future approaches in need of further study will also be reviewed.
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Affiliation(s)
- Zoe Michael
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Fotios Spyropoulos
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Sailaja Ghanta
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Helen Christou
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA, USA
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31
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Abstract
Necrotizing enterocolitis (NEC) is the most common serious gastrointestinal morbidity in preterm infants. A number of risk factors for NEC have been reported in the literature. With the exception of decreasing gestational age, decreasing birth weight and formula feeding, there is disagreement on the importance of reported risk factors with uncertain causality. Causal risk factors may be observed at any time before the onset of NEC, including prior to an infant's birth. The purpose of this review is to examine the existing literature and summarize risk factors for NEC. This review may be helpful in understanding the epidemiology of NEC and inform the measurement and assessment of risks factors for NEC in research studies and quality improvement projects.
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Affiliation(s)
- Allison Thomas Rose
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Ravi Mangal Patel
- Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
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32
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Libudzic-Nowak AM, Cachat F, Pascual M, Chehade H. Darbepoetin Alfa in Young Infants With Renal Failure: Single Center Experience, a Case Series and Review of the Literature. Front Pediatr 2018; 6:398. [PMID: 30619793 PMCID: PMC6305342 DOI: 10.3389/fped.2018.00398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 11/30/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Anemia treatment in infants with advanced or chronic kidney disease (CKD) represents an important challenge to nephrologists. The use of darbepoetin alfa, a novel erythropoiesis stimulating agent, has largely replaced recombinant human erythropoietin in older children and in adults with CKD. However, studies reporting the use of darbepoetin alfa in infants below 1 year of age are rare. Case presentation: We report the data of three infants with advanced stage kidney failure, aged 1, 4, and 7 months, who were treated with darbepoetin alfa and followed for 18-41 months. Hemoglobin levels increased in all three patients, reaching the target levels of 10.7-12 g/dl by 11, 19, and 22 weeks respectively, without any documented adverse effects. Patients younger than 1 year of age required a larger darbepoetin alfa dosage (ranged from 1.2 to 2.9 μg/kg per month) as compared to older children. A review of the literature found only three studies using darbepoetin alfa successfully in such young infants, with similar dosage and clinical success. Conclusion: In these three patients with advanced kidney disease, darbepoetin alfa was effective in correcting anemia with no observed side effects. It reinforces its potential use in very young patients with advanced CKD.
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Affiliation(s)
- Anna Maria Libudzic-Nowak
- Pediatric Nephrology Unit, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Transplantation Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Francois Cachat
- Pediatric Nephrology Unit, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Manuel Pascual
- Transplantation Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Hassib Chehade
- Pediatric Nephrology Unit, Lausanne University Hospital (CHUV), Lausanne, Switzerland
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33
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Panfoli I, Candiano G, Malova M, De Angelis L, Cardiello V, Buonocore G, Ramenghi LA. Oxidative Stress as a Primary Risk Factor for Brain Damage in Preterm Newborns. Front Pediatr 2018; 6:369. [PMID: 30555809 PMCID: PMC6281966 DOI: 10.3389/fped.2018.00369] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 11/12/2018] [Indexed: 12/28/2022] Open
Abstract
The risk of oxidative stress is high in preterm newborns. Room air exposure of an organism primed to develop in a hypoxic environment, lacking antioxidant defenses, and subjected to hyperoxia, hypoxia, and ischemia challenges the newborn with oxidative stress production. Free radicals can be generated by a multitude of other mechanisms, such as glutamate excitotoxicity, excess free iron, inflammation, and immune reactions. Free radical-induced damage caused by oxidative stress appears to be the major candidate for the pathogenesis of most of the complications of prematurity, brain being especially at risk, with short to long-term consequences. We review the role of free radical oxidative damage to the newborn brain and propose a mechanism of oxidative injury, taking into consideration the particular maturation-dependent vulnerability of the oligodendrocyte precursors. Prompted by our observation of an increase in plasma Adenosine concentrations significantly associated with brain white matter lesions in some premature infants, we discuss a possible bioenergetics hypothesis, correlated to the oxidative challenge of the premature infant. We aim at explaining both the oxidative stress generation and the mechanism promoting the myelination disturbances. Being white matter abnormalities among the most common lesions of prematurity, the use of Adenosine as a biomarker of brain damage appears promising in order to design neuroprotective strategies.
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Affiliation(s)
| | - Giovanni Candiano
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Mariya Malova
- Neonatal Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Laura De Angelis
- Neonatal Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Valentina Cardiello
- Neonatal Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giuseppe Buonocore
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Luca A Ramenghi
- Neonatal Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
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