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Maxwell JR, Ohls RK. Update on Erythropoiesis-Stimulating Agents Administered to Neonates for Neuroprotection. Neoreviews 2020; 20:e622-e635. [PMID: 31676737 DOI: 10.1542/neo.20-11-e622] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Erythropoiesis-stimulating agents (ESAs) such as erythropoietin and darbepoetin have been studied as red blood cell growth factors in preterm and term infants for more than 30 years. Recently, studies have focused on the potential neuroprotective effects of ESAs. In this review, we summarize preclinical animal models and recent clinical trials that provide evidence for ESAs as potential treatments to improve neurodevelopmental outcomes in preterm and term infants.
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Affiliation(s)
- Jessie R Maxwell
- Department of Pediatrics, University of New Mexico, Albuquerque, NM
| | - Robin K Ohls
- Department of Pediatrics, University of Utah, Salt Lake City, UT
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Dhillon SK, Lear CA, Galinsky R, Wassink G, Davidson JO, Juul S, Robertson NJ, Gunn AJ, Bennet L. The fetus at the tipping point: modifying the outcome of fetal asphyxia. J Physiol 2018; 596:5571-5592. [PMID: 29774532 DOI: 10.1113/jp274949] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/13/2018] [Indexed: 12/13/2022] Open
Abstract
Brain injury around birth is associated with nearly half of all cases of cerebral palsy. Although brain injury is multifactorial, particularly after preterm birth, acute hypoxia-ischaemia is a major contributor to injury. It is now well established that the severity of injury after hypoxia-ischaemia is determined by a dynamic balance between injurious and protective processes. In addition, mothers who are at risk of premature delivery have high rates of diabetes and antepartum infection/inflammation and are almost universally given treatments such as antenatal glucocorticoids and magnesium sulphate to reduce the risk of death and complications after preterm birth. We review evidence that these common factors affect responses to fetal asphyxia, often in unexpected ways. For example, glucocorticoid exposure dramatically increases delayed cell loss after acute hypoxia-ischaemia, largely through secondary hyperglycaemia. This critical new information is important to understand the effects of clinical treatments of women whose fetuses are at risk of perinatal asphyxia.
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Affiliation(s)
| | - Christopher A Lear
- The Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Robert Galinsky
- The Department of Physiology, University of Auckland, Auckland, New Zealand.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Guido Wassink
- The Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Joanne O Davidson
- The Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Sandra Juul
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | | | - Alistair J Gunn
- The Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- The Department of Physiology, University of Auckland, Auckland, New Zealand
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Fischer HS, Reibel NJ, Bührer C, Dame C. Prophylactic Early Erythropoietin for Neuroprotection in Preterm Infants: A Meta-analysis. Pediatrics 2017; 139:peds.2016-4317. [PMID: 28557760 DOI: 10.1542/peds.2016-4317] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2017] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Recombinant human erythropoietin (rhEPO) is a promising pharmacological agent for neuroprotection in neonates. OBJECTIVE To investigate whether prophylactic rhEPO administration in very preterm infants improves neurodevelopmental outcomes in a meta-analysis of randomized controlled trials (RCTs). DATA SOURCES Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched in December 2016 and complemented by other sources. STUDY SELECTION RCTs investigating the use of rhEPO in preterm infants versus a control group were selected if they were published in a peer-reviewed journal and reported neurodevelopmental outcomes at 18 to 24 months' corrected age. DATA EXTRACTION Data extraction and analysis followed the standard methods of the Cochrane Neonatal Review Group. The primary outcome was the number of infants with a Mental Developmental Index (MDI) <70 on the Bayley Scales of Infant Development. Secondary outcomes included a Psychomotor Development Index <70, cerebral palsy, visual impairment, and hearing impairment. RESULTS Four RCTs, comprising 1133 infants, were included in the meta-analysis. Prophylactic rhEPO administration reduced the incidence of children with an MDI <70, with an odds ratio (95% confidence interval) of 0.51 (0.31-0.81), P < .005. The number needed to treat was 14. There was no statistically significant effect on any secondary outcome. CONCLUSIONS Prophylactic rhEPO improved the cognitive development of very preterm infants, as assessed by the MDI at a corrected age of 18 to 24 months, without affecting other neurodevelopmental outcomes. Current and future RCTs should investigate optimal dosing and timing of prophylactic rhEPO and plan for long-term neurodevelopmental follow-up.
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Affiliation(s)
- Hendrik S Fischer
- Department of Neonatology, Charité University Medical Center, Berlin, Germany
| | - Nora J Reibel
- Department of Neonatology, Charité University Medical Center, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité University Medical Center, Berlin, Germany
| | - Christof Dame
- Department of Neonatology, Charité University Medical Center, Berlin, Germany
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D’Souza A, Algotar A, Pan L, Schwarz SM, Treem WR, Valencia G, Rabinowitz SS. Packed red blood cell transfusions as a risk factor for parenteral nutrition associated liver disease in premature infants. World J Clin Pediatr 2016; 5:365-369. [PMID: 27872824 PMCID: PMC5099588 DOI: 10.5409/wjcp.v5.i4.365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/13/2016] [Accepted: 10/24/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To determine if packed red blood cell transfusions contribute to the development of parenteral nutrition associated liver disease.
METHODS A retrospective chart review of 49 premature infants on parenteral nutrition for > 30 d who received packed red blood cell (PRBC) transfusions was performed. Parenteral nutrition associated liver disease was primarily defined by direct bilirubin (db) > 2.0 mg/dL. A high transfusion cohort was defined as receiving > 75 mL packed red blood cells (the median value). Kaplan-Meier plots estimated the median volume of packed red blood cells received in order to develop parenteral nutrition associated liver disease.
RESULTS Parenteral nutritional associated liver disease (PNALD) was noted in 21 (43%) infants based on db. Among the 27 high transfusion infants, PNALD was present in 17 (64%) based on elevated direct bilirubin which was significantly greater than the low transfusion recipients. About 50% of the infants, who were transfused 101-125 mL packed red blood cells, developed PNALD based on elevation of direct bilirubin. All infants who were transfused more than 200 mL of packed red blood cells developed PNALD. Similar results were seen when using elevation of aspartate transaminase or alanine transaminase to define PNALD.
CONCLUSION In this retrospective, pilot study there was a statistically significant correlation between the volume of PRBC transfusions received by premature infants and the development of PNALD.
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Wu YW, Mathur AM, Chang T, McKinstry RC, Mulkey SB, Mayock DE, Van Meurs KP, Rogers EE, Gonzalez FF, Comstock BA, Juul SE, Msall ME, Bonifacio SL, Glass HC, Massaro AN, Dong L, Tan KW, Heagerty PJ, Ballard RA. High-Dose Erythropoietin and Hypothermia for Hypoxic-Ischemic Encephalopathy: A Phase II Trial. Pediatrics 2016; 137:peds.2016-0191. [PMID: 27244862 DOI: 10.1542/peds.2016-0191] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine if multiple doses of erythropoietin (Epo) administered with hypothermia improve neuroradiographic and short-term outcomes of newborns with hypoxic-ischemic encephalopathy. METHODS In a phase II double-blinded, placebo-controlled trial, we randomized newborns to receive Epo (1000 U/kg intravenously; n = 24) or placebo (n = 26) at 1, 2, 3, 5, and 7 days of age. All infants had moderate/severe encephalopathy; perinatal depression (10 minute Apgar <5, pH <7.00 or base deficit ≥15, or resuscitation at 10 minutes); and received hypothermia. Primary outcome was neurodevelopment at 12 months assessed by the Alberta Infant Motor Scale and Warner Initial Developmental Evaluation. Two independent observers rated MRI brain injury severity by using an established scoring system. RESULTS The mean age at first study drug was 16.5 hours (SD, 5.9). Neonatal deaths did not significantly differ between Epo and placebo groups (8% vs 19%, P = .42). Brain MRI at mean 5.1 days (SD, 2.3) showed a lower global brain injury score in Epo-treated infants (median, 2 vs 11, P = .01). Moderate/severe brain injury (4% vs 44%, P = .002), subcortical (30% vs 68%, P = .02), and cerebellar injury (0% vs 20%, P = .05) were less frequent in the Epo than placebo group. At mean age 12.7 months (SD, 0.9), motor performance in Epo-treated (n = 21) versus placebo-treated (n = 20) infants were as follows: Alberta Infant Motor Scale (53.2 vs 42.8, P = .03); Warner Initial Developmental Evaluation (28.6 vs 23.8, P = .05). CONCLUSIONS High doses of Epo given with hypothermia for hypoxic-ischemic encephalopathy may result in less MRI brain injury and improved 1-year motor function.
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Affiliation(s)
| | | | - Taeun Chang
- Departments of Neurology and Neonatology, Children's National Health Systems, Washington, District of Columbia
| | | | - Sarah B Mulkey
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Krisa P Van Meurs
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | | | | | | | | | - Michael E Msall
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, University of Chicago Medicine, Comer Children's Hospital, Chicago, Illinois; and
| | - Sonia L Bonifacio
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Hannah C Glass
- Departments of Neurology, Pediatrics, and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - An N Massaro
- Neonatology, Children's National Health Systems, Washington, District of Columbia
| | - Lawrence Dong
- Department of Pediatrics, Kaiser Permanente Santa Clara, Santa Clara, California
| | - Katherine W Tan
- Biostatistics, University of Washington, Seattle, Washington
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Juul SE, Mayock DE, Comstock BA, Heagerty PJ. Neuroprotective potential of erythropoietin in neonates; design of a randomized trial. Matern Health Neonatol Perinatol 2015; 1:27. [PMID: 27057344 PMCID: PMC4823689 DOI: 10.1186/s40748-015-0028-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 10/26/2015] [Indexed: 11/12/2022] Open
Abstract
Background In 2013, nearly four million babies were born in the U.S., among whom 447,875 were born preterm. Approximately 30,000 of these infants were born before 28 weeks of gestation. These infants, termed Extremely Low Gestational Age Neonates (ELGANs), experience high morbidity and mortality despite modern therapies: approximately 20 % of ELGANs admitted to an NICU die before discharge, 20 % of survivors have severe, and 20 % moderate neurodevelopmental impairment (NDI). New approaches are needed to improve neonatal outcomes. Recombinant erythropoietin (Epo) is a promising neuroprotective agent that is widely available, affordable, and has been used safely in neonates to stimulate erythropoiesis. There are extensive preclinical data to support its use as a neuroprotective intervention: Epo promotes normal brain maturation by increasing neurogenesis, angiogenesis, and by protecting oligodendrocytes. Epo also decreases acute brain injury following hypoxia ischemia by decreasing inflammation, oxidative and excitotoxic injury, resulting in decreased apoptosis. Despite the availability of both preclinical and safety data there has not been a definitive clinical evaluation of the benefit of Epo, and a large phase III trial is necessary to provide evidence to support potential changes in practice guidelines. Findings We first review the preclinical data motivating further clinical trials, and then describe in detail the design of the PENUT study (Preterm Epo Neuroprotection). PENUT is a phase III study evaluating the effect of neonatal Epo treatment on the combined outcome of death or severe NDI among ELGANS. 940 subjects will be randomized to determine: 1) whether Epo decreases the combined outcome of death or NDI at 22–26 months corrected age; 2) the safety of high dose Epo administration to ELGANs; 3) whether Epo treatment decreases serial measures of circulating inflammatory mediators, and improves biomarkers of brain injury; and 4) whether Epo treatment improves brain structure at 36 weeks postmenstrual age as measured by MRI. Conclusions Epo neuroprotection is an exciting new approach to preterm neuroprotection, and if efficacious, will provide a much-needed therapy for this group of vulnerable infants.
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Affiliation(s)
- Sandra E Juul
- Department of Pediatrics, Division of Neonatology, University of Washington, 1959 Pacific Ave NE, Box 356320, Seattle, WA 98195-6320 USA
| | - Dennis E Mayock
- Department of Pediatrics, Division of Neonatology, University of Washington, 1959 Pacific Ave NE, Box 356320, Seattle, WA 98195-6320 USA
| | - Bryan A Comstock
- Department of Biostatistics, University of Washington, 4333 Brooklyn Avenue NE, Box 359461, Seattle, WA 98195-9461 USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, 4333 Brooklyn Avenue NE, Box 359461, Seattle, WA 98195-9461 USA
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