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van Kammen CM, Taal SEL, Wever KE, Granger JP, Lely AT, Terstappen F. Reduced uterine perfusion pressure as a model for preeclampsia and fetal growth restriction in murine: a systematic review and meta-analysis. Am J Physiol Heart Circ Physiol 2024; 327:H89-H107. [PMID: 38758122 DOI: 10.1152/ajpheart.00056.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/18/2024]
Abstract
The reduced uterine perfusion pressure (RUPP) model is frequently used to study preeclampsia and fetal growth restriction. An improved understanding of influential factors might improve reproducibility and reduce animal use considering the variability in RUPP phenotype. We performed a systematic review and meta-analysis by searching Medline and Embase (until 28 March, 2023) for RUPP studies in murine. Primary outcomes included maternal blood pressure (BP) or proteinuria, fetal weight or crown-rump length, fetal reabsorptions, or antiangiogenic factors. We aimed to identify influential factors by meta-regression analysis. We included 155 studies. Our meta-analysis showed that the RUPP procedure results in significantly higher BP (MD = 24.1 mmHg; [22.6; 25.7]; n = 148), proteinuria (SMD = 2.3; [0.9; 3.8]; n = 28), fetal reabsorptions (MD = 50.4%; [45.5; 55.2]; n = 42), circulating soluble FMS-like tyrosine kinase-1 (sFlt-1) (SMD = 2.6; [1.7; 3.4]; n = 34), and lower fetal weight (MD = -0.4 g; [-0.47; -0.34]; n = 113. The heterogeneity (variability between studies) in primary outcomes appeared ≥90%. Our meta-regression identified influential factors in the method and time point of BP measurement, randomization in fetal weight, and type of control group in sFlt-1. The RUPP is a robust model considering the evident differences in maternal and fetal outcomes. The high heterogeneity reflects the observed variability in phenotype. Because of underreporting, we observed reporting bias and a high risk of bias. We recommend standardizing study design by optimal time point and method chosen for readout measures to limit the variability. This contributes to improved reproducibility and thereby eventually improves the translational value of the RUPP model.
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Affiliation(s)
- Caren M van Kammen
- Division of Nanomedicine, Department CDL Research, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Seija E L Taal
- Department of Woman and Baby, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Kimberley E Wever
- Department of Anesthesiology, Pain, and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joey P Granger
- Department of Physiology and Biophysics, Cardiovascular-Renal Research Center, University of Mississippi Medical Center, Jackson, Mississippi, United States
| | - A Titia Lely
- Department of Woman and Baby, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Fieke Terstappen
- Department of Woman and Baby, University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
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2
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David M, Singh S, Naicker T. Is the central complement component C3 altered in the synergy of HIV infection and preeclampsia? Eur J Obstet Gynecol Reprod Biol X 2023; 20:100257. [PMID: 37885814 PMCID: PMC10598405 DOI: 10.1016/j.eurox.2023.100257] [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: 05/04/2023] [Revised: 09/26/2023] [Accepted: 10/17/2023] [Indexed: 10/28/2023] Open
Abstract
Objective In light of complement activation in preeclampsia and HIV infection, this study evaluates the concentration of complement component 3 (C3) in HIV-associated preeclampsia. Method The study population (n = 76) was equally stratified by pregnancy type (normotensive pregnant and preeclampsia) and by HIV status (HIV positive and HIV negative). The plasma concentration of C3 was determined using a Bioplex immunoassay procedure. Results We report a significant increase in C3 concentration in the HIV-negative versus the HIV-positive groups (p < 0.05), regardless of pregnancy type. However, based on pregnancy type and irrespective of HIV status, C3 concentration was similar between normotensive versus preeclampsia. Concentration of C3 was significantly increased in the HIV-positive preeclamptic compared HIV-negative preeclamptic groups (p = 0.04). The correlation of C3 with all study groups was non-significant. Conclusion This study demonstrates that C3 was upregulated in HIV-associated PE compared to HIV- associated normotensive pregnancies. The dysregulation of C3 expression by HIV infection may be attributed to antiretroviral therapy.
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Affiliation(s)
- Mikyle David
- Optics and Imaging Centre, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Shoohana Singh
- Optics and Imaging Centre, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Thajasvarie Naicker
- Optics and Imaging Centre, Doris Duke Medical Research Institute, Nelson R. Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
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Deer E, Herrock O, Campbell N, Cornelius D, Fitzgerald S, Amaral LM, LaMarca B. The role of immune cells and mediators in preeclampsia. Nat Rev Nephrol 2023; 19:257-270. [PMID: 36635411 PMCID: PMC10038936 DOI: 10.1038/s41581-022-00670-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 01/14/2023]
Abstract
Preeclampsia is a hypertensive disorder of major concern in pregnancy than can lead to intrauterine growth restriction, placental abruption and stillbirth. The pathophysiology of preeclampsia is multifactorial, including not only kidney dysfunction but also endothelial dysfunction, as the maternal endothelium becomes exposed to placental factors that are released into the circulation and increase systemic levels of vasoconstrictors, oxidative stress, anti-angiogenic factors and inflammatory mediators. Importantly, inflammation can lead to insufficient placental perfusion and low birthweight in offspring. Various innate and adaptive immune cells and mediators have been implicated in the development of preeclampsia, in which oxidative stress is associated with activation of the maternal inflammatory response. Immune cells such as regulatory T cells, macrophages, natural killer cells, and neutrophils are known to have major causative roles in the pathology of preeclampsia, but the contributions of additional immune cells such as B cells, inflammatory cytokines and anti-angiotensin II type 1 receptor autoantibodies are also now recognized. Immunological interventions, therefore, have therapeutic potential in this disease. Here, we provide an overview of the immune responses that are involved in the pathogenesis of preeclampsia, including the role of innate and adaptive immune cells and mediators.
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Affiliation(s)
- Evangeline Deer
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Owen Herrock
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Nathan Campbell
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Denise Cornelius
- Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Sarah Fitzgerald
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Lorena M Amaral
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Babbette LaMarca
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS, USA.
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, USA.
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4
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Smith-Jackson K, Harrison RA. Alternative pathway activation in pregnancy, a measured amount "complements" a successful pregnancy, too much results in adverse events. Immunol Rev 2023; 313:298-319. [PMID: 36377667 PMCID: PMC10100418 DOI: 10.1111/imr.13169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
During pregnancy, the maternal host must adapt in order to enable growth of the fetus. These changes affect all organ systems and are designed both to protect the fetus and to minimize risk to the mother. One of the most prominent adaptations involves the immune system. The semi-allogenic fetoplacental unit has non-self components and must be protected against attack from the host. This requires both attenuation of adaptive immunity and protection from innate immune defense mechanisms. One of the key innate immune players is complement, and it is important that the fetoplacental unit is not identified as non-self and subjected to complement attack. Adaptation of the complement response must, however, be managed in such a way that maternal protection against infection is not compromised. As the complement system also plays a significant facilitating role in many of the stages of a normal pregnancy, it is also important that any necessary adaptation to accommodate the semi-allogenic aspects of the fetoplacental unit does not compromise this. In this review, both the physiological role of the alternative pathway of complement in facilitating a normal pregnancy, and its detrimental participation in pregnancy-specific disorders, are discussed.
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Affiliation(s)
- Kate Smith-Jackson
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Faculty of Medical Science, Newcastle University, Newcastle-upon-Tyne, UK.,The National Renal Complement Therapeutics Centre (NRCTC), Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
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5
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Root KM, Akhaphong B, Cedars MA, Molin AM, Huchthausen ME, Laule CF, Regal RR, Alejandro EU, Regal JF. Critical Role for Macrophages in the Developmental Programming of Pancreatic β-Cell Area in Offspring of Hypertensive Pregnancies. Diabetes 2022; 71:2597-2611. [PMID: 36125850 PMCID: PMC9750952 DOI: 10.2337/db22-0404] [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: 04/29/2022] [Accepted: 09/06/2022] [Indexed: 01/11/2023]
Abstract
Preeclampsia is a pregnancy-specific complication with long-term negative outcomes for offspring, including increased susceptibility to type 2 diabetes (T2D) in adulthood. In a rat reduced uteroplacental perfusion pressure (RUPP) model of chronic placental ischemia, maternal hypertension in conjunction with intrauterine growth restriction mimicked aspects of preeclampsia and resulted in female embryonic day 19 (e19) offspring with reduced β-cell area and increased β-cell apoptosis compared with offspring of sham pregnancies. Decreased pancreatic β-cell area persisted to postnatal day 13 (PD13) in females and could influence whether T2D developed in adulthood. Macrophage changes also occurred in islets in T2D. Therefore, we hypothesized that macrophages are crucial to reduction in pancreatic β-cell area in female offspring after chronic placental ischemia. Macrophage marker CD68 mRNA expression was significantly elevated in e19 and PD13 islets isolated from female RUPP offspring compared with sham. Postnatal injections of clodronate liposomes into female RUPP and sham offspring on PD2 and PD9 significantly depleted macrophages compared with injections of control liposomes. Depletion of macrophages rescued reduced β-cell area and increased β-cell proliferation and size in RUPP offspring. Our studies suggest that the presence of macrophages is important for reduced β-cell area in female RUPP offspring and changes in macrophages could contribute to development of T2D in adulthood.
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Affiliation(s)
- Kate M. Root
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth, MN
| | - Brian Akhaphong
- Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis, MN
| | - Melissa A. Cedars
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth, MN
| | - Alexa M. Molin
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth, MN
| | | | - Connor F. Laule
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth, MN
- Department of Neuroscience and Pharmacology, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Ronald R. Regal
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth, MN
| | - Emilyn U. Alejandro
- Department of Integrative Biology and Physiology, University of Minnesota Medical School, Minneapolis, MN
| | - Jean F. Regal
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth, MN
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Taylor EB, George EM. Animal Models of Preeclampsia: Mechanistic Insights and Promising Therapeutics. Endocrinology 2022; 163:6623845. [PMID: 35772781 PMCID: PMC9262036 DOI: 10.1210/endocr/bqac096] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Indexed: 11/19/2022]
Abstract
Preeclampsia (PE) is a common pregnancy-specific disorder that is a major cause of both maternal and fetal morbidity and mortality. Central to the pathogenesis of PE is the production of antiangiogenic and inflammatory factors by the hypoxic placenta, leading to the downstream manifestations of the disease, including hypertension and end-organ damage. Currently, effective treatments are limited for PE; however, the development of preclinical animal models has helped in the development and evaluation of new therapeutics. In this review, we will summarize some of the more commonly used models of PE and highlight their similarities to the human syndrome, as well as the therapeutics tested in each model.
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Affiliation(s)
- Erin B Taylor
- Correspondence: Erin B. Taylor, PhD, Department of Physiology and Biophysics, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216-4505, USA.
| | - Eric M George
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, Mississippi 39216-4505, USA
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7
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Bakrania BA, George EM, Granger JP. Animal models of preeclampsia: investigating pathophysiology and therapeutic targets. Am J Obstet Gynecol 2022; 226:S973-S987. [PMID: 33722383 PMCID: PMC8141071 DOI: 10.1016/j.ajog.2020.10.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 10/01/2020] [Accepted: 10/19/2020] [Indexed: 02/03/2023]
Abstract
Animal models have been critical in investigating the pathogenesis, mediators, and even therapeutic options for a number of diseases, including preeclampsia. Preeclampsia is the leading cause of maternal and fetal morbidity and mortality worldwide. The placenta is thought to play a central role in the pathogenesis of this disease because it releases antiangiogenic and proinflammatory factors into the maternal circulation, resulting in the maternal syndrome. Despite the deleterious effects preeclampsia has been shown to have on the mother and baby during pregnancy and postpartum, there is still no effective treatment for this disease. Although clinical studies in patients are crucial to identify the involvement of pathogenic factors in preeclampsia, there are obvious limitations that prevent detailed investigation of the quantitative importance of time-dependent mechanisms involved in this syndrome. Animal models allow investigators to perform proof-of-concept studies and examine whether certain factors found in women with preeclampsia mediate hypertension and other manifestations of this disease. In this brief review, we summarize some of the more widely studied models used to investigate pathophysiological mechanisms that are thought to be involved in preeclampsia. These include models of placental ischemia, angiogenic imbalance, and maternal immune activation. Infusion of preeclampsia-related factors into animals has been widely studied to understand the specific mediators of this disease. These models have been included, in addition to a number of genetic models involved in overexpression of the renin-angiotensin system, complement activation, and trophoblast differentiation. Together, these models cover multiple mechanisms of preeclampsia from trophoblast dysfunction and impaired placental vascularization to the excess circulating placental factors and clinical manifestation of this disease. Most animal studies have been performed in rats and mice; however, we have also incorporated nonhuman primate models in this review. Preclinical animal models not only have been instrumental in understanding the pathophysiology of preeclampsia but also continue to be important tools in the search for novel therapeutic options for the treatment of this disease.
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Affiliation(s)
- Bhavisha A Bakrania
- Cardiovascular-Renal Research Center, Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS
| | - Eric M George
- Cardiovascular-Renal Research Center, Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS
| | - Joey P Granger
- Cardiovascular-Renal Research Center, Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS.
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8
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Palei AC, Granger JP, Spradley FT. Placental Ischemia Says "NO" to Proper NOS-Mediated Control of Vascular Tone and Blood Pressure in Preeclampsia. Int J Mol Sci 2021; 22:ijms222011261. [PMID: 34681920 PMCID: PMC8541176 DOI: 10.3390/ijms222011261] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/18/2021] [Indexed: 12/15/2022] Open
Abstract
In this review, we first provide a brief overview of the nitric oxide synthase (NOS) isoforms and biochemistry. This is followed by describing what is known about NOS-mediated blood pressure control during normal pregnancy. Circulating nitric oxide (NO) bioavailability has been assessed by measuring its metabolites, nitrite (NO2) and/or nitrate (NO3), and shown to rise throughout normal pregnancy in humans and rats and decline postpartum. In contrast, placental malperfusion/ischemia leads to systemic reductions in NO bioavailability leading to maternal endothelial and vascular dysfunction with subsequent development of hypertension in PE. We end this article by describing emergent risk factors for placental malperfusion and ischemic disease and discussing strategies to target the NOS system therapeutically to increase NO bioavailability in preeclamptic patients. Throughout this discussion, we highlight the critical importance that experimental animal studies have played in our current understanding of NOS biology in normal pregnancy and their use in finding novel ways to preserve this signaling pathway to prevent the development, treat symptoms, or reduce the severity of PE.
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Affiliation(s)
- Ana C. Palei
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Joey P. Granger
- Department of Physiology & Biophysics, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Frank T. Spradley
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS 39216, USA;
- Department of Physiology & Biophysics, University of Mississippi Medical Center, Jackson, MS 39216, USA;
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS 39216, USA
- Correspondence:
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9
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Plasma CD59 concentrations are increased in preeclampsia with severe features and correlate with laboratory measures of end-organ injury. Pregnancy Hypertens 2020; 22:204-209. [PMID: 33091682 DOI: 10.1016/j.preghy.2020.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/08/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Dysregulation of CD59 may lead to increased complement-mediated end-organ injury in preeclampsia. We sought to determine if soluble CD59 concentrations are altered in preeclampsia with severe features. STUDY DESIGN Observational case-control study, which enrolled subjects prospectively from six centers in Colombia from 2015 to 2016. Cases had preeclampsia with severe features and controls were either healthy or had chronic hypertension, gestational hypertension, or preeclampsia without severe features. Trained coordinators collected clinical data, blood and urine. Analyses were by test of medians and Spearman's correlation. MAIN OUTCOME MEASURES Soluble CD59 concentration in plasma and urine, using enzyme linked immunosorbent assays. RESULTS In total, 352 subjects were enrolled (104 cases; 248 controls). Compared to healthy women or those with other hypertensive disorders of pregnancy, women with preeclampsia with severe features had increased concentration of CD59 in plasma (P < 0.001) and decreased CD59 in urine (P = 0.01). In sub-group analyses, plasma CD59 concentrations were increased in preeclampsia with severe features compared to healthy controls (P < 0.001) or controls with either chronic hypertension (P = 0.002) or gestational hypertension (P = 0.02). Increased plasma CD59 concentrations correlated with decreased platelet count and increased lactate dehydrogenase, creatinine, aspartate transaminase, urine protein/creatinine ratio, systolic blood pressure and diastolic blood pressure (P < 0.01, all correlations). CONCLUSION In women with preeclampsia with severe features, soluble CD59 concentrations were increased in plasma and decreased in urine, and plasma levels correlated with increased blood pressure and end-organ injury. Soluble CD59 concentrations may help identify a subset of women with preeclampsia that have altered regulation of terminal complement proteins.
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10
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Qu H, Khalil RA. Vascular mechanisms and molecular targets in hypertensive pregnancy and preeclampsia. Am J Physiol Heart Circ Physiol 2020; 319:H661-H681. [PMID: 32762557 DOI: 10.1152/ajpheart.00202.2020] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Preeclampsia is a major complication of pregnancy manifested as hypertension and often intrauterine growth restriction, but the underlying pathophysiological mechanisms are unclear. Predisposing genetic and environmental factors cause placental maladaptations leading to defective placentation, apoptosis of invasive cytotrophoblasts, inadequate expansive remodeling of the spiral arteries, reduced uteroplacental perfusion pressure, and placental ischemia. Placental ischemia promotes the release of bioactive factors into the maternal circulation, causing an imbalance between antiangiogenic soluble fms-like tyrosine kinase-1 and soluble endoglin and proangiogenic vascular endothelial growth factor, placental growth factor, and transforming growth factor-β. Placental ischemia also stimulates the release of proinflammatory cytokines, hypoxia-inducible factor, reactive oxygen species, and angiotensin type 1 receptor agonistic autoantibodies. These circulating factors target the vascular endothelium, causing generalized endotheliosis in systemic, renal, cerebral, and hepatic vessels, leading to decreases in endothelium-derived vasodilators such as nitric oxide, prostacyclin, and hyperpolarization factor and increases in vasoconstrictors such as endothelin-1 and thromboxane A2. The bioactive factors also target vascular smooth muscle and enhance the mechanisms of vascular contraction, including cytosolic Ca2+, protein kinase C, and Rho-kinase. The bioactive factors could also target matrix metalloproteinases and the extracellular matrix, causing inadequate vascular remodeling, increased arterial stiffening, and further increases in vascular resistance and hypertension. As therapeutic options are limited, understanding the underlying vascular mechanisms and molecular targets should help design new tools for the detection and management of hypertension in pregnancy and preeclampsia.
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Affiliation(s)
- Hongmei Qu
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Raouf A Khalil
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
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11
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Dong N, Gu H, Liu D, Wei X, Ma W, Ma L, Liu Y, Wang Y, Jia S, Huang J, Wang C, He X, Huang T, He Y, Zhang Q, An D, Bai Y, Yuan Z. Complement factors and alpha-fetoprotein as biomarkers for noninvasive prenatal diagnosis of neural tube defects. Ann N Y Acad Sci 2020; 1478:75-91. [PMID: 32761624 DOI: 10.1111/nyas.14443] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 05/30/2020] [Accepted: 06/29/2020] [Indexed: 12/23/2022]
Abstract
Neural tube defects (NTDs) are serious congenital malformations. In this study, we aimed to identify more specific and sensitive maternal serum biomarkers for noninvasive NTD screenings. We collected serum from 37 pregnant women carrying fetuses with NTDs and 38 pregnant women carrying normal fetuses. Isobaric tags for relative and absolute quantitation were conducted for differential proteomic analysis, and an enzyme-linked immunosorbent assay was used to validate the results. We then used a support vector machine (SVM) classifier to establish a disease prediction model for NTD diagnosis. We identified 113 differentially expressed proteins; of these, 23 were either up- or downregulated 1.5-fold or more, including five complement proteins (C1QA, C1S, C1R, C9, and C3); C3 and C9 were downregulated significantly in NTD groups. The accuracy rate of the SVM model of the complement factors (including C1QA, C1S, and C3) was 62.5%, with 60% sensitivity and 67% specificity, while the accuracy rate of the SVM model of alpha-fetoprotein (AFP, an established biomarker for NTDs) was 62.5%, with 75% sensitivity and 50% specificity. Combination of the complement factor and AFP data resulted in the SVM model accuracy of 75%, and receiver operating characteristic curve analysis showed 75% sensitivity and 75% specificity. These data suggest that a disease prediction model based on combined complement factor and AFP data could serve as a more accurate method of noninvasive prenatal NTD diagnosis.
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Affiliation(s)
- Naixuan Dong
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China.,School of Sino-Dutch Biomedical & Information Engineering, Northeastern University, Shenyang, China
| | - Hui Gu
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Dan Liu
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Xiaowei Wei
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Wei Ma
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Ling Ma
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Yusi Liu
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Yanfu Wang
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Shanshan Jia
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Jieting Huang
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Chenfei Wang
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Xuan He
- School of Sino-Dutch Biomedical & Information Engineering, Northeastern University, Shenyang, China
| | - Tianchu Huang
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Yiwen He
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
| | - Qiang Zhang
- Second Respiratory Department, Shengjing Hospital, China Medical University, Shenyang, China
| | - Dong An
- Pediatric Department, The First Hospital of China Medical University, Shenyang, China
| | - Yuzuo Bai
- Department of Pediatric Surgery, Shengjing Hospital, China Medical University, Shenyang, China
| | - Zhengwei Yuan
- Key Laboratory of Health Ministry for Congenital Malformation, Shengjing Hospital, China Medical University, Shenyang, China
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12
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Girardi G, Lingo JJ, Fleming SD, Regal JF. Essential Role of Complement in Pregnancy: From Implantation to Parturition and Beyond. Front Immunol 2020; 11:1681. [PMID: 32849586 PMCID: PMC7411130 DOI: 10.3389/fimmu.2020.01681] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/23/2020] [Indexed: 12/12/2022] Open
Abstract
The complement cascade was identified over 100 years ago, yet investigation of its role in pregnancy remains an area of intense research. Complement inhibitors at the maternal-fetal interface prevent inappropriate complement activation to protect the fetus. However, this versatile proteolytic cascade also favorably influences numerous stages of pregnancy, including implantation, fetal development, and labor. Inappropriate complement activation in pregnancy can have adverse lifelong sequelae for both mother and child. This review summarizes the current understanding of complement activation during all stages of pregnancy. In addition, consequences of complement dysregulation during adverse pregnancy outcomes from miscarriage, preeclampsia, and pre-term birth are examined. Finally, future research directions into complement activation during pregnancy are considered.
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Affiliation(s)
- Guillermina Girardi
- Department of Basic Medical Sciences, College of Medicine, Member of QU Health, Qatar University, Doha, Qatar
| | - Joshua J Lingo
- Division of Biology, Kansas State University, Manhattan, KS, United States
| | - Sherry D Fleming
- Division of Biology, Kansas State University, Manhattan, KS, United States
| | - Jean F Regal
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth, MN, United States
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13
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He YD, Xu BN, Wang ML, Wang YQ, Yu F, Chen Q, Zhao MH. Dysregulation of complement system during pregnancy in patients with preeclampsia: A prospective study. Mol Immunol 2020; 122:69-79. [PMID: 32305690 DOI: 10.1016/j.molimm.2020.03.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 03/19/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023]
Abstract
Recent studies have shown that aberrant activation of the complement system plays an important role in the pathogenesis of preeclampsia. There is evidence to suggest that aberrant activation of the complement system may already be present during the first trimester. Here, we performed a prospective study in which peripheral blood samples were collected from 500 women during pregnancy. Twenty-one patients (41 specimens) suffering from preeclampsia later in pregnancy were classified into the study group, and sixty-three gravidas with normal pregnancies (136 specimens) were selected as the control group. The plasma concentrations of complement factor B (CFB), C1q, complement factor H (CFH), C3c, C4, C3a, C5a and soluble C5b-9 (sC5b-9) were measured. The levels of CFB (P = 0.004), CFH (P = 0.002), C1q (P = 0.044), C3c (P = 0.032) and C4 (P = 0.015) were significantly higher in preeclampsia than in normal pregnancy during the first trimester, and these levels became similar to those in normal pregnancy thereafter. Before the onset of preeclampsia, the levels of C3a, C5a and sC5b-9 in the preeclampsia group were similar to those in control group even in late pregnancy. C3a levels showed a significant positive correlation with C5a in normal pregnancy (r=0.658, P<0.01) but not in preeclampsia (r = 0.001, P = 1).Thus, we found that aberrant activation of the complement system in patients with preeclampsia was initiated during the first trimester but returned to normal pregnancy levels in the second trimester. At the same time, there is aberrant regulation of complement activation at the C3a-C5a level in preeclampsia during pregnancy.
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Affiliation(s)
- Ying-Dong He
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, PR China
| | - Bing-Ning Xu
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, PR China
| | - Meng-Lu Wang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, PR China
| | - Ya-Qin Wang
- Key Laboratory of Renal Disease, Ministry of Health of China, Renal Division, Department of Medicine, Peking University First Hospital, PR China
| | - Feng Yu
- Key Laboratory of Renal Disease, Ministry of Health of China, Renal Division, Department of Medicine, Peking University First Hospital, PR China
| | - Qian Chen
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, PR China.
| | - Ming-Hui Zhao
- Key Laboratory of Renal Disease, Ministry of Health of China, Renal Division, Department of Medicine, Peking University First Hospital, PR China; Peking-Tsinghua Center for Life Sciences, Beijing, PR China
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14
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Pierik E, Prins JR, van Goor H, Dekker GA, Daha MR, Seelen MAJ, Scherjon SA. Dysregulation of Complement Activation and Placental Dysfunction: A Potential Target to Treat Preeclampsia? Front Immunol 2020; 10:3098. [PMID: 32010144 PMCID: PMC6974484 DOI: 10.3389/fimmu.2019.03098] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/18/2019] [Indexed: 12/16/2022] Open
Abstract
Preeclampsia is one of the leading causes of maternal and neonatal mortality and morbidity worldwide, affecting 2–8% of all pregnancies. Studies suggest a link between complement activation and preeclampsia. The complement system plays an essential role in the innate immunity, leading to opsonization, inflammation, and elimination of potential pathogens. The complement system also provides a link between innate and adaptive immunity and clearance of immune complexes and apoptotic cells. During pregnancy there is increased activity of the complement system systemically. However, locally at the placenta, complement inhibition is crucial for the maintenance of a normal pregnancy. Inappropriate or excessive activation of the complement system at the placenta is likely involved in placental dysfunction, and is in turn associated with pregnancy complications like preeclampsia. Therefore, modulation of the complement system could be a potential therapeutic target to prevent pregnancy complications such as preeclampsia. This review, based on a systematic literature search, gives an overview of the complement system and its activation locally in the placenta and systemically during healthy pregnancies and during complicated pregnancies, with a focus on preeclampsia. Furthermore, this review describes results of animal and human studies with a focus on the complement system in pregnancy, and the role of the complement system in placental dysfunction. Various clinical and animal studies provide evidence that dysregulation of the complement system is associated with placental dysfunction and therefore with preeclampsia. Several drugs are used for prevention and treatment of preeclampsia in humans and animal models, and some of these drugs work through complement modulation. Therefore, this review further discusses these studies examining pharmaceutical interventions as treatment for preeclampsia. These observations will help direct research to generate new target options for prevention and treatment of preeclampsia, which include direct and indirect modulation of the complement system.
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Affiliation(s)
- E Pierik
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jelmer R Prins
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Harry van Goor
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Gustaaf A Dekker
- Department of Obstetrics and Gynecology, Lyell McEwin Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Mohamed R Daha
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen and University of Groningen, Groningen, Netherlands
| | - Marc A J Seelen
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen and University of Groningen, Groningen, Netherlands
| | - Sicco A Scherjon
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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15
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Laule CF, Odean EJ, Wing CR, Root KM, Towner KJ, Hamm CM, Gilbert JS, Fleming SD, Regal JF. Role of B1 and B2 lymphocytes in placental ischemia-induced hypertension. Am J Physiol Heart Circ Physiol 2019; 317:H732-H742. [PMID: 31397167 DOI: 10.1152/ajpheart.00132.2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Preeclampsia is a prevalent pregnancy complication characterized by new-onset maternal hypertension and inflammation, with placental ischemia as the initiating event. Studies of others have provided evidence for the importance of lymphocytes in placental ischemia-induced hypertension; however, the contributions of B1 versus B2 lymphocytes are unknown. We hypothesized that peritoneal B1 lymphocytes are important for placental ischemia-induced hypertension. As an initial test of this hypothesis, the effect of anti-CD20 depletion on both B-cell populations was determined in a reduced utero-placental perfusion pressure (RUPP) model of preeclampsia. Anti-murine CD20 monoclonal antibody (5 mg/kg, Clone 5D2) or corresponding mu IgG2a isotype control was administered intraperitoneally to timed pregnant Sprague-Dawley rats on gestation day (GD)10 and 13. RUPP or sham control surgeries were performed on GD14, and mean arterial pressure (MAP) was measured on GD19 from a carotid catheter. As anticipated, RUPP surgery increased MAP and heart rate and decreased mean fetal and placental weight. However, anti-CD20 treatment did not affect these responses. On GD19, B-cell populations were enumerated in the blood, peritoneal cavity, spleen, and placenta with flow cytometry. B1 and B2 cells were not significantly increased following RUPP. Anti-CD20 depleted B1 and B2 cells in peritoneum and circulation but depleted only B2 lymphocytes in spleen and placenta, with no effect on circulating or peritoneal IgM. Overall, these data do not exclude a role for antibodies produced by B cells before depletion but indicate the presence of B lymphocytes in the last trimester of pregnancy is not critical for placental ischemia-induced hypertension.NEW & NOTEWORTHY The adaptive and innate immune systems are implicated in hypertension, including the pregnancy-specific hypertensive condition preeclampsia. However, the mechanism of immune system dysfunction leading to pregnancy-induced hypertension is unresolved. In contrast to previous reports, this study reveals that the presence of classic B2 lymphocytes and peritoneal and circulating B1 lymphocytes is not required for development of hypertension following third trimester placental ischemia in a rat model of pregnancy-induced hypertension.
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Affiliation(s)
- Connor F Laule
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
| | - Evan J Odean
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
| | - Cameron R Wing
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
| | - Kate M Root
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
| | - Kendra J Towner
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
| | - Cassandra M Hamm
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
| | - Jeffrey S Gilbert
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
| | | | - Jean F Regal
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
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16
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Regal JF, Lund JM, Wing CR, Root KM, McCutcheon L, Bemis LT, Gilbert JS, Fleming SD. Interactions between the complement and endothelin systems in normal pregnancy and following placental ischemia. Mol Immunol 2019; 114:10-18. [PMID: 31326653 DOI: 10.1016/j.molimm.2019.06.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/22/2019] [Accepted: 06/23/2019] [Indexed: 01/01/2023]
Abstract
Preeclampsia is characterized by new onset hypertension and fetal growth restriction and is associated with aberrant activation of the innate immune complement system and stressed or ischemic placenta. Previous studies have suggested a role for both endothelin and complement system activation products in new onset hypertension in pregnancy, but inter-relationships of the pathways are unclear. We hypothesized that complement activation following placental ischemia stimulates the endothelin pathway to cause hypertension and impair fetal growth. The Reduced Uterine Perfusion Pressure (RUPP) model results in hypertension and fetal growth restriction in a pregnant rat due to placental ischemia caused by mechanical obstruction of blood flow to uterus and placenta. The effect of inhibitor of complement activation soluble Complement Receptor 1 (sCR1) and endothelin A receptor (ETA) antagonist atrasentan on hypertension, fetal weight, complement activation (systemic circulating C3a and local C3 placental deposition) and endothelin [circulating endothelin and message for preproendothelin (PPE), ETA and endothelin B receptor (ETB) in placenta] in the RUPP rat model were determined. Following placental ischemia, sCR1 attenuated hypertension but increased message for PPE and ETA in placenta, suggesting complement activation causes hypertension via an endothelin independent pathway. With ETA antagonism the placental ischemia-induced increase in circulating C3a was unaffected despite inhibition of hypertension, indicating systemic C3a alone is not sufficient. In normal pregnancy, inhibiting complement activation increased plasma endothelin but not placental PPE message. Atrasentan treatment increased fetal weight, circulating endothelin and placental ETA message, and unexpectedly increased local complement activation in placenta (C3 deposition) but not C3a in circulation, suggesting endothelin controls local placental complement activation in normal pregnancy. Atrasentan also significantly decreased message for endogenous complement regulators Crry and CD55 in placenta and kidney in normal pregnancy. Results of our study indicate that complement/endothelin interactions differ in pregnancies complicated with placental ischemia vs normal pregnancy, as well as locally vs systemically. These data clearly illustrate the complex interplay between complement and endothelin indicating that perturbations of either pathway may affect pregnancy outcomes.
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Affiliation(s)
- Jean F Regal
- Department of Biomedical Sciences, 1035 University Dr., University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota, 55812, USA.
| | - Jenna M Lund
- Department of Biomedical Sciences, 1035 University Dr., University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota, 55812, USA.
| | - Cameron R Wing
- Department of Biomedical Sciences, 1035 University Dr., University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota, 55812, USA.
| | - Kate M Root
- Department of Biomedical Sciences, 1035 University Dr., University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota, 55812, USA.
| | - Luke McCutcheon
- Department of Biomedical Sciences, 1035 University Dr., University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota, 55812, USA.
| | - Lynne T Bemis
- Department of Biomedical Sciences, 1035 University Dr., University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota, 55812, USA.
| | - Jeffrey S Gilbert
- Department of Biomedical Sciences, 1035 University Dr., University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota, 55812, USA.
| | - Sherry D Fleming
- Division of Biology, 18 Ackert, Kansas State University, 1717 Claflin Rd, Manhattan, Kansas, 66506, USA.
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17
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Morton JS, Levasseur J, Ganguly E, Quon A, Kirschenman R, Dyck JRB, Fraser GM, Davidge ST. Characterisation of the Selective Reduced Uteroplacental Perfusion (sRUPP) Model of Preeclampsia. Sci Rep 2019; 9:9565. [PMID: 31266978 PMCID: PMC6606748 DOI: 10.1038/s41598-019-45959-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 06/20/2019] [Indexed: 12/03/2022] Open
Abstract
Preeclampsia is a complication of pregnancy characterised by gestational hypertension, proteinuria and/or end organ disease. The reduced uteroplacental perfusion (RUPP) model, via partial occlusion of the lower abdominal aorta, mimics insufficient placental perfusion as a primary causal characteristic of preeclampsia. However, a major limitation of the RUPP model is that perfusion is reduced to the entire hindquarters of the rat resulting in hindlimb ischemia. We hypothesised that clipping the uterine and ovarian arteries in the selective (s)RUPP model would provoke signs of preeclampsia while avoiding systemic ischemia. Sham, RUPP or sRUPP procedures were performed in pregnant Sprague Dawley rats on gestational day (GD)14. On GD21 uterine blood flow was significantly reduced in both the RUPP and sRUPP models while aortic flow was reduced only in RUPP. Both models resulted in increased MAP, increased vascular oxidative stress (superoxide generation), increased pro-inflammatory (RANTES) and reduced pro-angiogenic (endoglin) mediators. Vascular compliance and constriction were unaltered in either RUPP or sRUPP groups. In summary, refinements to the RUPP model simultaneously maintain the characteristic phenotype of preeclampsia and avoid peripheral ischemia; providing a useful tool which may be used to increase our knowledge and bring us closer to a solution for women affected by preeclampsia.
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Affiliation(s)
- J S Morton
- Faculty of Medicine and Dentistry, Dept. of Ob/Gyn, University of Alberta, Edmonton, AB, T6G 2S2, Canada.,Women and Children's Health Research Institute, Edmonton, AB, T6G 2R3, Canada
| | - J Levasseur
- Faculty of Medicine and Dentistry, Dept. of Pediatrics, University of Alberta, Edmonton, AB, T6G 2S2, Canada
| | - E Ganguly
- Faculty of Medicine and Dentistry, Dept. of Ob/Gyn, University of Alberta, Edmonton, AB, T6G 2S2, Canada.,Faculty of Medicine and Dentistry, Dept. of Physiology, University of Alberta, Edmonton, AB, T6G 2H7, Canada.,Women and Children's Health Research Institute, Edmonton, AB, T6G 2R3, Canada
| | - A Quon
- Faculty of Medicine and Dentistry, Dept. of Ob/Gyn, University of Alberta, Edmonton, AB, T6G 2S2, Canada.,Women and Children's Health Research Institute, Edmonton, AB, T6G 2R3, Canada
| | - R Kirschenman
- Faculty of Medicine and Dentistry, Dept. of Ob/Gyn, University of Alberta, Edmonton, AB, T6G 2S2, Canada.,Women and Children's Health Research Institute, Edmonton, AB, T6G 2R3, Canada
| | - J R B Dyck
- Faculty of Medicine and Dentistry, Dept. of Pediatrics, University of Alberta, Edmonton, AB, T6G 2S2, Canada
| | - G M Fraser
- Division of Biomedical Sciences, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, A1B 3V6, Canada
| | - S T Davidge
- Faculty of Medicine and Dentistry, Dept. of Ob/Gyn, University of Alberta, Edmonton, AB, T6G 2S2, Canada. .,Faculty of Medicine and Dentistry, Dept. of Physiology, University of Alberta, Edmonton, AB, T6G 2H7, Canada. .,Women and Children's Health Research Institute, Edmonton, AB, T6G 2R3, Canada.
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18
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Pillay Y, Moodley J, Naicker T. The role of the complement system in HIV infection and preeclampsia. Inflamm Res 2019; 68:459-469. [PMID: 31028431 DOI: 10.1007/s00011-019-01240-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/18/2019] [Accepted: 04/22/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The complement system is a key component of the innate immune system that plays a vital role in host defense, maintains homeostasis and acts as a mediator of the adaptive immune response. The complement system could possibly play a role in the pathogenesis of HIV infection and preeclampsia (PE), both of which represent major causes of maternal death in South Africa. RECENT FINDINGS The relationship between PE and HIV infection is unclear as PE represents an exaggerated immune response, while HIV infection is associated with a decline in immune activity. Although the complement system works to clear and neutralize HIV, it could also enhance the infectivity of HIV by various other mechanisms. It has been suggested that the dysregulation of the complement system is associated with the development of PE. CONCLUSION There is currently a paucity of information on the combined effect of the complement system in HIV-associated PE. This review highlights the role of the complement system in the duality of HIV infection and PE and provides new insights into this relationship whilst also elucidating potential therapeutic targets.
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Affiliation(s)
- Yazira Pillay
- Optics and Imaging Centre, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa.
| | - Jagidesa Moodley
- Women's Health and HIV Research Group, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Thajasvarie Naicker
- Optics and Imaging Centre, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
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19
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Regal JF, Laule CF, McCutcheon L, Root KM, Lund H, Hashmat S, Mattson DL. The complement system in hypertension and renal damage in the Dahl SS rat. Physiol Rep 2019; 6:e13655. [PMID: 29595916 PMCID: PMC5875537 DOI: 10.14814/phy2.13655] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 02/25/2018] [Accepted: 02/26/2018] [Indexed: 11/24/2022] Open
Abstract
Evidence indicates the immune system is important in development of hypertension and kidney disease. In the Dahl Salt-Sensitive (SS) rat model, lymphocytes play a role in development of hypertension and kidney damage after increased sodium intake. Recent transcriptomic analyses demonstrate upregulation of the innate immune complement system in the kidney of Dahl SS rat fed a high-salt diet, leading us to hypothesize that inhibition of complement activation would attenuate development of hypertension and kidney damage. Male Dahl SS rats on a low salt (0.4% NaCl) diet were instrumented with telemeters for continuous monitoring of arterial blood pressure. Animals received saline vehicle (Control) or sCR1, a soluble form of endogenous Complement Receptor 1 (CR1; CD35) that inhibits complement activation. At Day 0, rats were switched to high salt (4.0% NaCl) diet and assigned to sCR1 (15 mg/kg per day) or Control groups with daily ip injections either days 1-7 or days 14-18. Urine was collected overnight for determination of albumin excretion. Treatment with sCR1, either immediately after high-salt diet was initiated, or at days 14-18, did not alter development of hypertension or albuminuria. The sCR1 dose effectively inhibited total hemolytic complement activity as well as C3a generation. High salt caused an increase in message for complement regulator Cd59, with minimal change in Crry that controls the C3 convertase. Thus, innate immune complement activation in the circulation is not critical for development of hypertension and kidney damage due to increased sodium intake, and therapeutic manipulation of the complement system is not indicated in salt-sensitive hypertension.
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Affiliation(s)
- Jean F Regal
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
| | - Connor F Laule
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
| | - Luke McCutcheon
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
| | - Kate M Root
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
| | - Hayley Lund
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Shireen Hashmat
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David L Mattson
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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20
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Lokki AI, Heikkinen-Eloranta JK, Laivuori H. The Immunogenetic Conundrum of Preeclampsia. Front Immunol 2018; 9:2630. [PMID: 30483272 PMCID: PMC6243043 DOI: 10.3389/fimmu.2018.02630] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/25/2018] [Indexed: 12/12/2022] Open
Abstract
Pregnancy is an immunological challenge to the mother. The fetal tissues including the placenta must be protected from activation of the maternal immune system. On the other hand, the placental tissue sheds into the maternal circulation and must be adequately identified and phagocytized by the maternal immune system. During a healthy pregnancy, numerous immunosuppressive processes take place that allow the allograft fetus to thrive under exposure to humoral and cellular components of the maternal immune system. Breakdown of immune tolerance may result in sterile inflammation and cause adverse pregnancy outcomes such as preeclampsia, a vascular disease of the pregnancy with unpredictable course and symptoms from several organs. Immunological incompatibility between mother and fetus is strongly indicated in preeclampsia. Recently, genetic factors linking immunological pathways to predisposition to preeclampsia have been identified. In this mini-review genetic variation in immunological factors are discussed in the context of preeclampsia. Specifically, we explore immunogenetic and immunomodulary mechanisms contributing to loss of tolerance, inflammation, and autoimmunity in preeclampsia.
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Affiliation(s)
- A Inkeri Lokki
- Research Programs Unit, Immunobiology Research Program, University of Helsinki, Helsinki, Finland.,Bacteriology and Immunology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Hannele Laivuori
- Medical and Clinical genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland.,Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
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21
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Yu W, Gao W, Rong D, Wu Z, Khalil RA. Molecular determinants of microvascular dysfunction in hypertensive pregnancy and preeclampsia. Microcirculation 2018; 26:e12508. [PMID: 30338879 PMCID: PMC6474836 DOI: 10.1111/micc.12508] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 10/05/2018] [Accepted: 10/15/2018] [Indexed: 12/16/2022]
Abstract
Preeclampsia is a pregnancy-related disorder characterized by hypertension and often fetal intrauterine growth restriction, but the underlying mechanisms are unclear. Defective placentation and apoptosis of invasive cytotrophoblasts cause inadequate remodeling of spiral arteries, placental ischemia, and reduced uterine perfusion pressure (RUPP). RUPP causes imbalance between the anti-angiogenic factors soluble fms-like tyrosine kinase-1 and soluble endoglin and the pro-angiogenic vascular endothelial growth factor and placental growth factor, and stimulates the release of proinflammatory cytokines, hypoxia-inducible factor, reactive oxygen species, and angiotensin AT1 receptor agonistic autoantibodies. These circulating factors target the vascular endothelium, smooth muscle and various components of the extracellular matrix. Generalized endotheliosis in systemic, renal, cerebral, and hepatic vessels causes decreases in endothelium-derived vasodilators such as nitric oxide, prostacyclin and hyperpolarization factor, and increases in vasoconstrictors such as endothelin-1 and thromboxane A2. Enhanced mechanisms of vascular smooth muscle contraction, such as intracellular Ca2+ , protein kinase C, and Rho-kinase cause further increases in vasoconstriction. Changes in matrix metalloproteinases and extracellular matrix cause inadequate vascular remodeling and increased arterial stiffening, leading to further increases in vascular resistance and hypertension. Therapeutic options are currently limited, but understanding the molecular determinants of microvascular dysfunction could help in the design of new approaches for the prediction and management of preeclampsia.
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Affiliation(s)
- Wentao Yu
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Wei Gao
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dan Rong
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zhixian Wu
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Raouf A Khalil
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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22
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Akhaphong B, Lockridge A, Jo S, Mohan R, Wilcox JA, Wing CR, Regal JF, Alejandro EU. Reduced uterine perfusion pressure causes loss of pancreatic β-cell area but normal function in fetal rat offspring. Am J Physiol Regul Integr Comp Physiol 2018; 315:R1220-R1231. [PMID: 30303709 DOI: 10.1152/ajpregu.00458.2017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Maternal hypertension during pregnancy is a major risk factor for intrauterine growth restriction (IUGR), which increases susceptibility to cardiovascular and metabolic disease in adulthood through unclear mechanisms. The aim of this study was to characterize the pancreatic β-cell area and function in the fetal rat offspring of a reduced uterine perfusion pressure (RUPP) model of gestational hypertension. At embryonic day 19.5, RUPP dams exhibited lower body weight, elevated mean blood pressure, reduced litter size, and higher blood glucose compared with sham-operated controls. In RUPP placental lysates, a nonsignificant change in mammalian target of rapamycin (mTOR) activity markers, phosphorylated S6 at serine 240, and phosphorylated AKT (at S473) was observed. RUPP offspring showed significantly reduced β-cell-to-pancreas area and increased β-cell death but normal insulin levels in serum. Isolated islets had normal insulin content and secretory function in response to glucose and palmitate. Fetal pancreatic lysates showed a tendency for reduced insulin levels, with a significant reduction in total mTOR protein with RUPP surgery. In addition, its downstream complex 2 targets phosphorylation of AKT at S473, and pAKT at Thr308 tended to be reduced in the fetal RUPP pancreas. Altogether, these data show that RUPP offspring demonstrated increased β-cell death, reduced β-cell area, and altered nutrient-sensor mTOR protein level in the pancreas. This could represent a mechanistic foundation in IUGR offspring's risk for enhanced susceptibility to type 2 diabetes and other metabolic vulnerabilities seen in adulthood.
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Affiliation(s)
- Brian Akhaphong
- Department of Integrative Biology & Physiology, University of Minnesota: Twin Cities, Minnesota
| | - Amber Lockridge
- Department of Integrative Biology & Physiology, University of Minnesota: Twin Cities, Minnesota
| | - Seokwon Jo
- Department of Integrative Biology & Physiology, University of Minnesota: Twin Cities, Minnesota
| | - Ramkumar Mohan
- Department of Integrative Biology & Physiology, University of Minnesota: Twin Cities, Minnesota
| | - Jacob A Wilcox
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
| | - Cameron R Wing
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
| | - Jean F Regal
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, Duluth, Minnesota
| | - Emilyn U Alejandro
- Department of Integrative Biology & Physiology, University of Minnesota: Twin Cities, Minnesota
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23
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Laule CF, Wing CR, Odean EJ, Wilcox JA, Gilbert JS, Regal JF. Effect of nicotine on placental ischemia-induced complement activation and hypertension in the rat. J Immunotoxicol 2018; 14:235-240. [PMID: 29185370 DOI: 10.1080/1547691x.2017.1394934] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Preeclampsia is a pregnancy-specific condition manifested by new-onset maternal hypertension with systemic inflammation, including increased innate immune system complement activation. While exact pathophysiology is unknown, evidence suggests that inadequate spiral artery invasion and resulting utero-placental insufficiency is the initiating event. Cigarette smoking during pregnancy decreases the risk of preeclampsia. Nicotine, a major component of cigarettes, stimulates the efferent cholinergic anti-inflammatory pathway through peripherally expressed nicotinic acetylcholine receptors (nAChR) and is known to attenuate ischemia-reperfusion injury in kidney and liver. Prior studies indicated that complement activation was critical for placental ischemia-induced hypertension in a rat model. Thus, it was hypothesized here that nicotine was responsible for the protective effect of cigarette smoking in preeclampsia and would attenuate placental ischemia-induced systemic complement activation and hypertension. The Reduced Utero-placental Perfusion Pressure (RUPP) model in the pregnant rat was employed to induce placental ischemia, resulting in complement activation, fetal resorptions, and hypertension. On gestation day (GD)14, nicotine (1 mg/kg) or saline was administered via subcutaneous injection prior to RUPP surgery and daily through GD18. On GD19, placental ischemia significantly increased mean arterial pressure (MAP) in saline injected animals. However, the placental ischemia-induced increase in blood pressure was not evident in nicotine-treated animals and nicotine treatment significantly increased MAP variability. Circulating C3a was measured as an indicator of complement activation and increased C3a in RUPP compared to Sham persisted with nicotine treatment, as did fetal resorptions. These data suggested to us that nicotine may contribute to the decreased risk of preeclampsia with cigarette smoking, but this protective effect was confounded by additional effects of nicotine on the cardiovascular system.
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Affiliation(s)
- Connor F Laule
- a Department of Biomedical Sciences , University of Minnesota, Medical School , Duluth , MN , USA
| | - Cameron R Wing
- a Department of Biomedical Sciences , University of Minnesota, Medical School , Duluth , MN , USA
| | - Evan J Odean
- a Department of Biomedical Sciences , University of Minnesota, Medical School , Duluth , MN , USA
| | - Jacob A Wilcox
- a Department of Biomedical Sciences , University of Minnesota, Medical School , Duluth , MN , USA
| | - Jeffrey S Gilbert
- a Department of Biomedical Sciences , University of Minnesota, Medical School , Duluth , MN , USA
| | - Jean F Regal
- a Department of Biomedical Sciences , University of Minnesota, Medical School , Duluth , MN , USA
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24
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Abstract
PURPOSE OF REVIEW Preeclampsia affects 3-4% of pregnancies with few treatment options to reduce maternal and fetal harm. Recent evidence that targeting the complement system may be an effective therapeutic strategy in prevention or treatment of preeclampsia will be reviewed. RECENT FINDINGS Studies in humans confirm the safety and efficacy of C5 blockade in complement-mediated disorders of pregnancy, including preeclampsia. Animal models mimic the placental abnormalities and/or the maternal symptoms which characterize preeclampsia. These models in mouse and rat have defined a role for complement and its regulators in placental dysfunction, hypertension, proteinuria, endothelial dysfunction, fetal growth restriction, and angiogenic imbalance, thus informing future human studies. Targeting excessive complement activation, particularly the terminal complement complex (C5b-9) and C5a may be an effective strategy to prolong pregnancy in women with preeclampsia. Continued research is needed to identify the initiator(s) of activation, the pathways involved, and the key component(s) in the pathophysiology to allow development of safe and effective therapeutics to target complement without compromising its role in homeostasis and host defense.
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Affiliation(s)
- Jean F Regal
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth Campus, 1035 University Dr., Duluth, MN, 55812, USA.
| | - Richard M Burwick
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sherry D Fleming
- Division of Biology, Kansas State University, Manhattan, KS, USA
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25
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Lokki AI, Kaartokallio T, Holmberg V, Onkamo P, Koskinen LLE, Saavalainen P, Heinonen S, Kajantie E, Kere J, Kivinen K, Pouta A, Villa PM, Hiltunen L, Laivuori H, Meri S. Analysis of Complement C3 Gene Reveals Susceptibility to Severe Preeclampsia. Front Immunol 2017; 8:589. [PMID: 28611769 PMCID: PMC5446983 DOI: 10.3389/fimmu.2017.00589] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 05/03/2017] [Indexed: 11/29/2022] Open
Abstract
Preeclampsia (PE) is a common vascular disease of pregnancy with genetic predisposition. Dysregulation of the complement system has been implicated, but molecular mechanisms are incompletely understood. In this study, we determined the potential linkage of severe PE to the most central complement gene, C3. Three cohorts of Finnish patients and controls were recruited for a genetic case-control study. Participants were genotyped using Sequenom genotyping and Sanger sequencing. Initially, we studied 259 Finnish patients with severe PE and 426 controls from the Southern Finland PE and the Finnish population-based PE cohorts. We used a custom-made single nucleotide polymorphism (SNP) genotyping assay consisting of 98 SNPs in 18 genes that encode components of the complement system. Following the primary screening, C3 was selected as the candidate gene and consequently Sanger sequenced. Fourteen SNPs from C3 were also genotyped by a Sequenom panel in 960 patients with severe PE and 705 controls, including already sequenced individuals. Three of the 43 SNPs observed within C3 were associated with severe PE: rs2287845 (p = 0.038, OR = 1.158), rs366510 (p = 0.039, OR = 1.158), and rs2287848 (p = 0.041, OR = 1.155). We also discovered 16 SNP haplotypes with extreme linkage disequilibrium in the middle of the gene with a protective (p = 0.044, OR = 0.628) or a predisposing (p = 0.011, OR = 2.110) effect to severe PE depending on the allele combination. Genetic variants associated with PE are located in key domains of C3 and could thereby influence the function of C3. This is, as far as we are aware, the first candidate gene in the complement system with an association to a clinically relevant PE subphenotype, severe PE. The result highlights a potential role for the complement system in the pathogenesis of PE and may help in defining prognostic and therapeutic subgroups of preeclamptic women.
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Affiliation(s)
- A Inkeri Lokki
- Immunobiology, Research Programs Unit, University of Helsinki, Helsinki, Finland.,Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Bacteriology and Immunology, University of Helsinki, Helsinki, Finland
| | - Tea Kaartokallio
- Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Holmberg
- Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Clinic of Infectious Diseases, HYKS Inflammation Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Päivi Onkamo
- Department of Biosciences, University of Helsinki, Helsinki, Finland
| | - Lotta L E Koskinen
- Immunobiology, Research Programs Unit, University of Helsinki, Helsinki, Finland
| | - Päivi Saavalainen
- Immunobiology, Research Programs Unit, University of Helsinki, Helsinki, Finland
| | - Seppo Heinonen
- Department of Obstetrics and Gynecology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Eero Kajantie
- Chronic Disease Prevention Unit, Department of Health, National Institute for Health and Welfare, Helsinki, Finland.,Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,PEDEGO Research Unit, MRC Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Juha Kere
- Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, Sweden.,Folkhälsan Institute of Genetics, Helsinki, Finland.,Molecular Neurology, Research Programs Unit, University of Helsinki, Helsinki, Finland
| | - Katja Kivinen
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - Anneli Pouta
- PEDEGO Research Unit, MRC Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland.,Department of Government Services, National Institute for Health and Welfare, Helsinki, Finland
| | - Pia M Villa
- Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Obstetrics and Gynecology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - Hannele Laivuori
- Medical and Clinical Genetics, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Obstetrics and Gynecology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Institute for Molecular Medicine Finland, HiLIFE, University of Helsinki, Helsinki, Finland
| | - Seppo Meri
- Immunobiology, Research Programs Unit, University of Helsinki, Helsinki, Finland.,Bacteriology and Immunology, University of Helsinki, Helsinki, Finland
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26
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Chen J, Khalil RA. Matrix Metalloproteinases in Normal Pregnancy and Preeclampsia. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2017; 148:87-165. [PMID: 28662830 PMCID: PMC5548443 DOI: 10.1016/bs.pmbts.2017.04.001] [Citation(s) in RCA: 169] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Normal pregnancy is associated with marked hemodynamic and uterine changes that allow adequate uteroplacental blood flow and uterine expansion for the growing fetus. These pregnancy-associated changes involve significant uteroplacental and vascular remodeling. Matrix metalloproteinases (MMPs) are important regulators of vascular and uterine remodeling. Increases in MMP-2 and MMP-9 have been implicated in vasodilation, placentation, and uterine expansion during normal pregnancy. The increases in MMPs could be induced by the increased production of estrogen and progesterone during pregnancy. MMP expression/activity may be altered during complications of pregnancy. Decreased vascular MMP-2 and MMP-9 may lead to decreased vasodilation, increased vasoconstriction, hypertensive pregnancy, and preeclampsia. Abnormal expression of uteroplacental integrins, cytokines, and MMPs may lead to decreased maternal tolerance, apoptosis of invasive trophoblast cells, inadequate remodeling of spiral arteries, and reduced uterine perfusion pressure (RUPP). RUPP may cause imbalance between the antiangiogenic factors soluble fms-like tyrosine kinase-1 and soluble endoglin and the proangiogenic vascular endothelial growth factor and placental growth factor, or stimulate the release of inflammatory cytokines, hypoxia-inducible factor, reactive oxygen species, and angiotensin AT1 receptor agonistic autoantibodies. These circulating factors could target MMPs in the extracellular matrix as well as endothelial and vascular smooth muscle cells, causing generalized vascular dysfunction, increased vasoconstriction and hypertension in pregnancy. MMP activity can also be altered by endogenous tissue inhibitors of metalloproteinases (TIMPs) and changes in the MMP/TIMP ratio. In addition to their vascular effects, decreases in expression/activity of MMP-2 and MMP-9 in the uterus could impede uterine growth and expansion and lead to premature labor. Understanding the role of MMPs in uteroplacental and vascular remodeling and function could help design new approaches for prediction and management of preeclampsia and premature labor.
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Affiliation(s)
- Juanjuan Chen
- Vascular Surgery Research Laboratories, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States
| | - Raouf A Khalil
- Vascular Surgery Research Laboratories, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States.
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27
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From apelin to exercise: emerging therapies for management of hypertension in pregnancy. Hypertens Res 2017; 40:519-525. [PMID: 28381873 DOI: 10.1038/hr.2017.40] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/20/2017] [Accepted: 02/21/2017] [Indexed: 01/03/2023]
Abstract
Studies over the last couple of decades have provided exciting new insights into mechanisms underlying the pathogenesis of preeclampsia. In addition, several novel and innovative molecules and ideas for management of the syndrome have also come forth. While our basic understanding of the initiating events of preeclampsia continues to be placental ischemia/hypoxia stimulating the release of a variety of factors from the placenta that act on the cardiovascular and renal systems, the number of candidate pathways for intervention continues to increase. Recent studies have identified apelin and its receptor, APJ, as an important contributor to the regulation of cardiovascular and fluid balance that is found to be disrupted in preeclampsia. Likewise, continued studies have revealed a critical role for the complement arm of the innate immune system in placental ischemia induced hypertension and in preeclampsia. Finally, the recent increase in animal models for studying hypertensive disorders of pregnancy has provided opportunities to evaluate the potential role for physical activity and exercise in a more mechanistic fashion. While the exact quantitative importance of the various endothelial and humoral factors that mediate vasoconstriction and elevation of arterial pressure during preeclampsia remains unclear, significant progress has been made. Thus, the goal of this review is to discuss recent efforts towards identifying therapies for hypertension during pregnancy that derive from work exploring the apelinergic system, the complement system as well as the role that exercise and physical activity may play to that end.
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28
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Bao X, Meng G, Zhang Q, Liu L, Wu H, Du H, Shi H, Xia Y, Guo X, Liu X, Han P, Dong R, Wang X, Li C, Su Q, Gu Y, Fang L, Yu F, Yang H, Kang L, Ma Y, Yu B, Ma X, Sun S, Wang X, Zhou M, Jia Q, Guo Q, Song K, Wang G, Huang G, Niu K. Elevated serum complement C3 levels are associated with prehypertension in an adult population. Clin Exp Hypertens 2017; 39:42-49. [PMID: 28055286 DOI: 10.1080/10641963.2016.1210622] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Xue Bao
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Ge Meng
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Qing Zhang
- Health Management Center, Tianjin Medical University General Hospital, Tianjin, China
| | - Li Liu
- Health Management Center, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongmei Wu
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Huanmin Du
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Hongbin Shi
- Health Management Center, Tianjin Medical University General Hospital, Tianjin, China
| | - Yang Xia
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Xiaoyan Guo
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Xing Liu
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Peipei Han
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Renwei Dong
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Xiuyang Wang
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Chunlei Li
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Qian Su
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Yeqing Gu
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Liyun Fang
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Fei Yu
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Huijun Yang
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Li Kang
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Yixuan Ma
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Bin Yu
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Xinyu Ma
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Shaomei Sun
- Health Management Center, Tianjin Medical University General Hospital, Tianjin, China
| | - Xing Wang
- Health Management Center, Tianjin Medical University General Hospital, Tianjin, China
| | - Ming Zhou
- Health Management Center, Tianjin Medical University General Hospital, Tianjin, China
| | - Qiyu Jia
- Health Management Center, Tianjin Medical University General Hospital, Tianjin, China
| | - Qi Guo
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Kun Song
- Health Management Center, Tianjin Medical University General Hospital, Tianjin, China
| | - GuoLin Wang
- Health Management Center, Tianjin Medical University General Hospital, Tianjin, China
| | - Guowei Huang
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
| | - Kaijun Niu
- Nutritional Epidemiology Institute and School of Public Health, Tianjin Medical University, Tianjin, China
- Health Management Center, Tianjin Medical University General Hospital, Tianjin, China
- Collaborative Innovation Center of Non-communicable Disease, Tianjin Medical University, Tianjin, China
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29
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Ushida T, Kotani T, Tsuda H, Imai K, Nakano T, Hirako S, Ito Y, Li H, Mano Y, Wang J, Miki R, Yamamoto E, Iwase A, Bando YK, Hirayama M, Ohno K, Toyokuni S, Kikkawa F. Molecular hydrogen ameliorates several characteristics of preeclampsia in the Reduced Uterine Perfusion Pressure (RUPP) rat model. Free Radic Biol Med 2016; 101:524-533. [PMID: 27789293 DOI: 10.1016/j.freeradbiomed.2016.10.491] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 10/21/2016] [Accepted: 10/21/2016] [Indexed: 12/27/2022]
Abstract
Oxidative stress plays an important role in the pathogenesis of preeclampsia. Recently, molecular hydrogen (H2) has been shown to have therapeutic potential in various oxidative stress-related diseases. The aim of this study is to investigate the effect of H2 on preeclampsia. We used the reduced utero-placental perfusion pressure (RUPP) rat model, which has been widely used as a model of preeclampsia. H2 water (HW) was administered orally ad libitum in RUPP rats from gestational day (GD) 12-19, starting 2 days before RUPP procedure. On GD19, mean arterial pressure (MAP) was measured, and samples were collected. Maternal administration of HW significantly decreased MAP, and increased fetal and placental weight in RUPP rats. The increased levels of soluble fms-like tyrosine kinase-1 (sFlt-1) and diacron reactive oxygen metabolites as a biomarker of reactive oxygen species in maternal blood were decreased by HW administration. However, vascular endothelial growth factor level in maternal blood was increased by HW administration. Proteinuria, and histological findings in kidney were improved by HW administration. In addition, the effects of H2 on placental villi were examined by using a trophoblast cell line (BeWo) and villous explants from the placental tissue of women with or without preeclampsia. H2 significantly attenuated hydrogen peroxide-induced sFlt-1 expression, but could not reduce the expression induced by hypoxia in BeWo cells. H2 significantly attenuated sFlt-1 expression in villous explants from women with preeclampsia, but not affected them from normotensive pregnancy. The prophylactic administration of H2 attenuated placental ischemia-induced hypertension, angiogenic imbalance, and oxidative stress. These results support the theory that H2 has a potential benefit in the prevention of preeclampsia.
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Affiliation(s)
- Takafumi Ushida
- Department of Gynecology and Obstetrics, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Tomomi Kotani
- Department of Gynecology and Obstetrics, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Hiroyuki Tsuda
- Department of Gynecology and Obstetrics, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Kenji Imai
- Department of Gynecology and Obstetrics, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Tomoko Nakano
- Department of Gynecology and Obstetrics, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Shima Hirako
- Department of Gynecology and Obstetrics, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Yumiko Ito
- Department of Gynecology and Obstetrics, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Hua Li
- Department of Gynecology and Obstetrics, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Yukio Mano
- Mano Women's Clinic, 2-5 Matsushin-cho, Kasugai city, Aichi Prefecture 486-0931, Japan
| | - Jingwen Wang
- Laboratory of Bell Research Center-Department of Obstetrics and Gynaecology Collaborative Research, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Rika Miki
- Laboratory of Bell Research Center-Department of Obstetrics and Gynaecology Collaborative Research, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Eiko Yamamoto
- Department of Healthcare Administration, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Akira Iwase
- Department of Gynecology and Obstetrics, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Yasuko K Bando
- Department of Cardiology, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Masaaki Hirayama
- Division of Neurogenetics, Center for Neurological Diseases and Cancer, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Kinji Ohno
- Division of Neurogenetics, Center for Neurological Diseases and Cancer, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Shinya Toyokuni
- Department of Pathology and Biological Responses, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
| | - Fumitaka Kikkawa
- Department of Gynecology and Obstetrics, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
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30
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Regal JF, Strehlke ME, Peterson JM, Wing CR, Parker JE, Nieto NF, Bemis LT, Gilbert JS, Fleming SD. Role of IgM and angiotensin II Type I receptor autoantibodies in local complement activation in placental ischemia-induced hypertension in the rat. Mol Immunol 2016; 78:38-47. [PMID: 27588825 DOI: 10.1016/j.molimm.2016.08.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/17/2016] [Accepted: 08/23/2016] [Indexed: 01/27/2023]
Abstract
Preeclampsia is characterized by development of hypertension during pregnancy and reduced placental perfusion. Previous studies in a rat model of placental ischemia-induced hypertension demonstrated that inhibiting complement activation attenuated increased maternal blood pressure with C3a and C5a identified as the important products of complement activation. Given that in other forms of ischemia both natural IgM and antigen antibody complexes initiate complement activation, we hypothesized that placental ischemia exposes neoepitopes recognized by IgM to cause local complement activation and hypertension. Alternatively, we postulated that autoantibody to angiotensin II Type 1 receptor (AT1-AA) interacts with AT1 receptors to cause complement activation. Since complement activation occurs in kidney and placenta in preeclampsia, we used immunohistochemistry to determine IgM deposition and local complement activation in each organ (C3 deposition), and quantitative real-time polymerase chain reaction (qRT-PCR) to quantitate mRNA for endogenous regulators of complement activation CD55, CD59 and Complement receptor 1-related gene/protein y (Crry). On gestation day (GD)14.5, timed pregnant Sprague Dawley rats underwent Sham surgery or placement of clips on inferior abdominal aorta and ovarian arteries to create placental ischemia using the reduced utero-placental perfusion pressure (RUPP) model. As previously reported, RUPP surgery increased mean arterial pressure and circulating C3a on GD19.5. In placenta, IgM and C3 deposition increased, whereas mRNA for complement regulators Crry and CD59 decreased along with Crry protein in RUPP compared to Sham treated animals. In kidney, IgM deposition increased in animals subjected to RUPP vs Sham surgery without a significant change in C3 deposition and coincident with an increase in mRNA for CD55 and CD59. The AT1 receptor antagonist losartan prevents placental ischemia-induced hypertension as well as AT1-AA interaction with AT1 receptors. However, losartan did not attenuate complement activation as measured by circulating C3a or placental C3 deposition. Importantly, our studies indicate that following placental ischemia, complement activation is not due to AT1-AA but is associated with IgM deposition. These studies suggest a role for natural antibodies interacting with placental ischemia-induced neoepitopes to activate complement and contribute to hypertension.
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Affiliation(s)
- Jean F Regal
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth campus, Duluth, MN, United States.
| | - Megan E Strehlke
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth campus, Duluth, MN, United States.
| | - Jenna M Peterson
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth campus, Duluth, MN, United States.
| | - Cameron R Wing
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth campus, Duluth, MN, United States.
| | - Jordan E Parker
- Division of Biology, Kansas State University, Manhattan, KS, United States.
| | | | - Lynne T Bemis
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth campus, Duluth, MN, United States.
| | - Jeffrey S Gilbert
- Department of Biomedical Sciences, University of Minnesota Medical School, Duluth campus, Duluth, MN, United States.
| | - Sherry D Fleming
- Division of Biology, Kansas State University, Manhattan, KS, United States.
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31
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Khan R, Maduray K, Moodley J, Naicker T. Activation of CD35 and CD55 in HIV associated normal and pre-eclamptic pregnant women. Eur J Obstet Gynecol Reprod Biol 2016; 204:51-6. [PMID: 27521598 DOI: 10.1016/j.ejogrb.2016.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 06/01/2016] [Accepted: 06/11/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The delicate balance which exists between complement activation and its regulation is altered in HIV infection and pregnancy disorders such as pre-eclampsia. Therefore, the purpose of this study was to investigate the expression of complement regulatory (Creg) proteins (CD35 and CD55) in HIV associated normal and pre-eclamptic pregnancies. STUDY DESIGN The total study population (n=100) consisted of normotensive pregnant (n=50) and pre-eclamptic (n=50) women. These groups were equally sub-stratified into HIV infected and uninfected groups (n=25 per group). Standard haematological tests were conducted. Flow cytometric analysis of isolated neutrophils were performed using fluorescein isothiocyanate-conjugated anti-CD35 and phycoerythrin-cyanine 5 conjugated anti-CD55. RESULTS HELLP syndrome characteristics of increased lactate dehydrogenase enzymes levels, low platelet counts, cell morphological abnormalities (red cell fragmentation) and anaemia were observed in 40% of the HIV infected pre-eclamptic group. Red cell fragmentation inclusive of burr cells and schistocytes were also noted. Activated partial thromboplastin time and fibrinogen differed significantly between the HIV uninfected pre-eclamptic compared to the HIV infected pre-eclamptic groups (p<0.01). Irrespective of HIV status, the mean fluorescence intensity of CD35 and CD55 were significantly higher in the pre-eclamptic compared to the normotensive pregnant (p=0.0001; p=0.0001 respectively) groups. In the pre-eclamptic groups, the expression of both CD35 and CD55 did not significantly differ between HIV infected and uninfected women (p=0.486; p=0.767 respectively). CONCLUSIONS This study demonstrates an up-regulation of complement regulatory proteins, CD35 and CD55 in HIV associated pre-eclamptic compared to normotensive pregnancy. This elevation of the Creg proteins is an adaptive immune response to the high complement-mediated cell lysis that occurs in HIV infection and further aggravated by the complement activated state of pre-eclampsia.
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Affiliation(s)
- R Khan
- Optics and Imaging Centre, University of KwaZulu-Natal, South Africa.
| | - K Maduray
- Optics and Imaging Centre, University of KwaZulu-Natal, South Africa
| | - J Moodley
- Womens' Health and HIV Research Group, University of KwaZulu-Natal, South Africa
| | - T Naicker
- Optics and Imaging Centre, University of KwaZulu-Natal, South Africa.
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32
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He Y, Xu B, Song D, Yu F, Chen Q, Zhao M. Correlations between complement system’s activation factors and anti-angiogenesis factors in plasma of patients with early/late-onset severe preeclampsia. Hypertens Pregnancy 2016; 35:499-509. [DOI: 10.1080/10641955.2016.1190845] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Possomato-Vieira JS, Khalil RA. Mechanisms of Endothelial Dysfunction in Hypertensive Pregnancy and Preeclampsia. ADVANCES IN PHARMACOLOGY 2016; 77:361-431. [PMID: 27451103 DOI: 10.1016/bs.apha.2016.04.008] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Preeclampsia is a pregnancy-related disorder characterized by hypertension and could lead to maternal and fetal morbidity and mortality. Although the causative factors and pathophysiological mechanisms are unclear, endothelial dysfunction is a major hallmark of preeclampsia. Clinical tests and experimental research have suggested that generalized endotheliosis in the systemic, renal, cerebral, and hepatic circulation could decrease endothelium-derived vasodilators such as nitric oxide, prostacyclin, and hyperpolarization factor and increase vasoconstrictors such as endothelin-1 and thromboxane A2, leading to increased vasoconstriction, hypertension, and other manifestation of preeclampsia. In search for the upstream mechanisms that could cause endothelial dysfunction, certain genetic, demographic, and environmental risk factors have been suggested to cause abnormal expression of uteroplacental integrins, cytokines, and matrix metalloproteinases, leading to decreased maternal tolerance, apoptosis of invasive trophoblast cells, inadequate spiral arteries remodeling, reduced uterine perfusion pressure (RUPP), and placental ischemia/hypoxia. RUPP may cause imbalance between the antiangiogenic factors soluble fms-like tyrosine kinase-1 and soluble endoglin and the proangiogenic factors vascular endothelial growth factor and placental growth factor, or stimulate the release of other circulating bioactive factors such as inflammatory cytokines, hypoxia-inducible factor-1, reactive oxygen species, and angiotensin AT1 receptor agonistic autoantibodies. These circulating factors could then target endothelial cells and cause generalized endothelial dysfunction. Therapeutic options are currently limited, but understanding the factors involved in endothelial dysfunction could help design new approaches for prediction and management of preeclampsia.
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Affiliation(s)
- J S Possomato-Vieira
- Vascular Surgery Research Laboratories, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - R A Khalil
- Vascular Surgery Research Laboratories, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
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Lynch AM, Wagner BD, Giclas PC, West NA, Gibbs RS, Holers VM. The Relationship of Longitudinal Levels of Complement Bb During Pregnancy with Preeclampsia. Am J Reprod Immunol 2015; 75:104-11. [PMID: 26510395 DOI: 10.1111/aji.12439] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 09/25/2015] [Indexed: 12/14/2022] Open
Abstract
PROBLEM To determine the understudied relationship between complement Bb during pregnancy in subjects with preeclampsia compared with normotensive controls. METHOD OF STUDY Nested case-control study. RESULTS Average Bb levels significantly decreased over time in pregnancy [weekly slope (S.E.): -0.0094 (0.0005), P < 0.01]. Cross-sectionally, at less than 10 weeks, Bb levels decreased with increasing gestational age in women who remained normotensive [weekly slope (S.E.): -0.007 (0.02) and for women who developed preeclampsia (weekly slope (S.E.): -0.059 (0.03) P = 0.12]. Among women who developed preeclampsia, Bb levels were greatest when samples were drawn in the gestational window of 15-20 weeks [(weekly slope (S.E.): 0.06 (0.02)], while levels among normotensive women were inversely related with gestational age [weekly slope (S.E.): -0.02 (0.01)]. The differences in slopes between cases and controls between 10 and 21 weeks' gestation were statistically significant (P = 0.003). CONCLUSIONS We suggest dysregulation of Bb activation between 10 and 20 weeks' gestation in women who develop preeclampsia.
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Affiliation(s)
- Anne M Lynch
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Patricia C Giclas
- Department of Pediatrics, Division of Allergy and Immunology, National Jewish Health, Denver, CO, USA
| | - Nancy A West
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Ronald S Gibbs
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO, USA
| | - V Michael Holers
- Department of Medicine and Immunology, University of Colorado School of Medicine, Aurora, CO, USA
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Complement Split Products in Amniotic Fluid in Pregnancies Subsequently Developing Early-Onset Preeclampsia. DISEASE MARKERS 2015; 2015:263109. [PMID: 26556948 PMCID: PMC4628677 DOI: 10.1155/2015/263109] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 09/27/2015] [Indexed: 11/17/2022]
Abstract
Objective. To determine the second-trimester amniotic fluid concentrations of complement split products in pregnancies subsequently affected by early-onset preeclampsia. Study Design. Cohort of 731 women with singleton pregnancies undergoing second-trimester genetic amniocentesis followed up to delivery and analyzed as a nested case-control study. Cases of preeclampsia developing before 34 weeks' gestation (n = 15) were compared with 47 uncomplicated term controls. Amniotic fluid collected at amniocentesis was tested for complement split products Bb, C4a, C3a, and C5a. Results. Women who developed early-onset preeclampsia as compared with the term pregnant controls had significantly higher (P = 0.04) median amniotic fluid C3a levels (318.7 ng/mL versus 254.5 ng/mL). Median amniotic fluid Bb levels were also significantly higher (P = 0.03) in preeclamptic women than in normal pregnant women (1127 ng/mL versus 749 ng/mL). Median levels of C4a and C5a were not significantly different between the groups. Conclusion. Our data suggest that complement activation in early pregnancy is associated with early-onset preeclampsia. We believe this to be the first prospective study to link complement activation in amniotic fluid in early pregnancy and later development of preeclampsia. Our findings provide evidence that immune dysregulation may precede the clinical manifestations of preeclampsia and that the alternative complement pathway is principally involved.
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Regal JF, Lillegard KE, Bauer AJ, Elmquist BJ, Loeks-Johnson AC, Gilbert JS. Neutrophil Depletion Attenuates Placental Ischemia-Induced Hypertension in the Rat. PLoS One 2015; 10:e0132063. [PMID: 26135305 PMCID: PMC4509576 DOI: 10.1371/journal.pone.0132063] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 06/09/2015] [Indexed: 12/25/2022] Open
Abstract
Preeclampsia is characterized by reduced placental perfusion with placental ischemia and hypertension during pregnancy. Preeclamptic women also exhibit a heightened inflammatory state and greater number of neutrophils in the vasculature compared to normal pregnancy. Since neutrophils are associated with tissue injury and inflammation, we hypothesized that neutrophils are critical to placental ischemia-induced hypertension and fetal demise. Using the reduced uteroplacental perfusion pressure (RUPP) model of placental ischemia-induced hypertension in the rat, we determined the effect of neutrophil depletion on blood pressure and fetal resorptions. Neutrophils were depleted with repeated injections of polyclonal rabbit anti-rat polymorphonuclear leukocyte (PMN) antibody (antiPMN). Rats received either antiPMN or normal rabbit serum (Control) on 13.5, 15.5, 17.5, and 18.5 days post conception (dpc). On 14.5 dpc, rats underwent either Sham surgery or clip placement on ovarian arteries and abdominal aorta to reduce uterine perfusion pressure (RUPP). On 18.5 dpc, carotid arterial catheters were placed and mean arterial pressure (MAP) was measured on 19.5 dpc. Neutrophil-depleted rats had reduced circulating neutrophils from 14.5 to 19.5 dpc compared to Control, as well as decreased neutrophils in lung and placenta on 19.5 dpc. MAP increased in RUPP Control vs Sham Control rats, and neutrophil depletion attenuated this increase in MAP in RUPP rats without any effect on Sham rats. The RUPP-induced increase in fetal resorptions and complement activation product C3a were not affected by neutrophil depletion. Thus, these data are the first to indicate that neutrophils play an important role in RUPP hypertension and that cells of the innate immune system may significantly contribute to pregnancy-induced hypertension.
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Affiliation(s)
- Jean F. Regal
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth, Duluth, Minnesota, United States of America
- * E-mail:
| | - Kathryn E. Lillegard
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth, Duluth, Minnesota, United States of America
| | - Ashley J. Bauer
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth, Duluth, Minnesota, United States of America
| | - Barbara J. Elmquist
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth, Duluth, Minnesota, United States of America
| | - Alex C. Loeks-Johnson
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth, Duluth, Minnesota, United States of America
| | - Jeffrey S. Gilbert
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth, Duluth, Minnesota, United States of America
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Regal JF, Gilbert JS, Burwick RM. The complement system and adverse pregnancy outcomes. Mol Immunol 2015; 67:56-70. [PMID: 25802092 DOI: 10.1016/j.molimm.2015.02.030] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 02/20/2015] [Accepted: 02/24/2015] [Indexed: 02/08/2023]
Abstract
Adverse pregnancy outcomes significantly contribute to morbidity and mortality for mother and child, with lifelong health consequences for both. The innate and adaptive immune system must be regulated to insure survival of the fetal allograft, and the complement system is no exception. An intact complement system optimizes placental development and function and is essential to maintain host defense and fetal survival. Complement regulation is apparent at the placental interface from early pregnancy with some degree of complement activation occurring normally throughout gestation. However, a number of pregnancy complications including early pregnancy loss, fetal growth restriction, hypertensive disorders of pregnancy and preterm birth are associated with excessive or misdirected complement activation, and are more frequent in women with inherited or acquired complement system disorders or complement gene mutations. Clinical studies employing complement biomarkers in plasma and urine implicate dysregulated complement activation in components of each of the adverse pregnancy outcomes. In addition, mechanistic studies in rat and mouse models of adverse pregnancy outcomes address the complement pathways or activation products of importance and allow critical analysis of the pathophysiology. Targeted complement therapeutics are already in use to control adverse pregnancy outcomes in select situations. A clearer understanding of the role of the complement system in both normal pregnancy and complicated or failed pregnancy will allow a rational approach to future therapeutic strategies for manipulating complement with the goal of mitigating adverse pregnancy outcomes, preserving host defense, and improving long term outcomes for both mother and child.
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Affiliation(s)
- Jean F Regal
- Department of Biomedical Sciences, University of Minnesota Medical School, 1035 University Drive, Duluth, MN 55812, USA.
| | - Jeffrey S Gilbert
- Department of Biomedical Sciences, University of Minnesota Medical School, 1035 University Drive, Duluth, MN 55812, USA.
| | - Richard M Burwick
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Oregon Health & Science University, Mail Code: L-458, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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Velickovic I, Dalloul M, Wong KA, Bakare O, Schweis F, Garala M, Alam A, Medranda G, Lekovic J, Shuaib W, Tedjasukmana A, Little P, Hanono D, Wijetilaka R, Weedon J, Lin J, Toledano RD, Zhang M. Complement factor B activation in patients with preeclampsia. J Reprod Immunol 2015; 109:94-100. [PMID: 25604034 DOI: 10.1016/j.jri.2014.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 11/14/2014] [Accepted: 12/08/2014] [Indexed: 01/28/2023]
Abstract
Preeclampsia is a leading cause of maternal and fetal morbidity and mortality. Bb, the active fragment of complement factor B (fB), has been reported to be a predictor of preeclampsia. However, conflicting results have been found by some investigators. We hypothesized that the disagreement in findings may be due to the racial/ethnic differences among various study groups, and that fB activation is significant in women of an ethnic minority with preeclampsia. We investigated the maternal and fetal levels of Bb (the activated fB fragment) in pregnant women of an ethnic minority with or without preeclampsia. We enrolled 291 pregnant women (96% of an ethnic minority, including 78% African-American). Thirteen percent of these were diagnosed with preeclampsia. Maternal venous blood was collected from all participants together with fetal umbilical cord blood samples from 154 deliveries in the 291 women. The results were analyzed using the Mann-Whitney U test and multivariate analyses. Maternal Bb levels were significantly higher in the preeclamptic group than in the nonpreeclamptic group. Levels of Bb in fetal cord blood were similar in both groups. Subgroup analyses of African-American patients' results confirmed the study hypothesis that there would be a significant increase in Bb in the maternal blood of the preeclamptic group and no increase in Bb in the fetal cord blood of this group. These results suggest that a maternal immune response through complement fB might play a role in the development of preeclampsia, particularly in African-American patients.
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Affiliation(s)
- Ivan Velickovic
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Mudar Dalloul
- Department of Obstetrics & Gynecology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Karen A Wong
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Olufunke Bakare
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Franz Schweis
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Maya Garala
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Amit Alam
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Giorgio Medranda
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Jovana Lekovic
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Waqas Shuaib
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Andreas Tedjasukmana
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Perry Little
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Daniel Hanono
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Ruvini Wijetilaka
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA; Department of Anesthesiology, Lutheran Medical Center, Brooklyn, NY 11220, USA
| | - Jeremy Weedon
- Scientific Computing Center, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Jun Lin
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA; Department of Anesthesiology, University Hospital of Brooklyn at Long Island College Hospital, Brooklyn, NY 11201, USA
| | - Roulhac d'Arby Toledano
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA; Department of Anesthesiology, Lutheran Medical Center, Brooklyn, NY 11220, USA
| | - Ming Zhang
- Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA; Department of Cell Biology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA.
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Guseh SH, Feinberg BB, Dawood HY, Yamamoto HS, Fichorova RN, Burwick RM. Urinary Excretion of C5b-9 is Associated With the Anti-Angiogenic State in Severe Preeclampsia. Am J Reprod Immunol 2014; 73:437-44. [DOI: 10.1111/aji.12349] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 11/18/2014] [Indexed: 11/26/2022] Open
Affiliation(s)
- Stephanie H. Guseh
- Department of Obstetrics, Gynecology and Reproductive Biology; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Bruce B. Feinberg
- Division of Maternal Fetal Medicine; Department of Obstetrics and Gynecology; Columbia University Medical Center; New York NY USA
| | - Hassan Y. Dawood
- Department of Obstetrics, Gynecology and Reproductive Biology; Laboratory of Genital Tract Biology; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Hidemi S. Yamamoto
- Department of Obstetrics, Gynecology and Reproductive Biology; Laboratory of Genital Tract Biology; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Raina N. Fichorova
- Department of Obstetrics, Gynecology and Reproductive Biology; Laboratory of Genital Tract Biology; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Richard M. Burwick
- Division of Maternal Fetal Medicine; Department of Obstetrics and Gynecology; Oregon Health and Science University; Portland OR USA
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40
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Lillegard KE, Loeks-Johnson AC, Opacich JW, Peterson JM, Bauer AJ, Elmquist BJ, Regal RR, Gilbert JS, Regal JF. Differential effects of complement activation products c3a and c5a on cardiovascular function in hypertensive pregnant rats. J Pharmacol Exp Ther 2014; 351:344-51. [PMID: 25150279 DOI: 10.1124/jpet.114.218123] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Early-onset pre-eclampsia is characterized by decreased placental perfusion, new-onset hypertension, angiogenic imbalance, and endothelial dysfunction associated with excessive activation of the innate immune complement system. Although our previous studies demonstrated that inhibition of complement activation attenuates placental ischemia-induced hypertension using the rat reduced uterine perfusion pressure (RUPP) model, the important product(s) of complement activation has yet to be identified. We hypothesized that antagonism of receptors for complement activation products C3a and C5a would improve vascular function and attenuate RUPP hypertension. On gestational day (GD) 14, rats underwent sham surgery or vascular clip placement on ovarian arteries and abdominal aorta (RUPP). Rats were treated once daily with the C5a receptor antagonist (C5aRA), PMX51 (acetyl-F-[Orn-P-(D-Cha)-WR]), the C3a receptor antagonist (C3aRA), SB290157 (N(2)-[(2,2-diphenylethoxy)acetyl]-l-arginine), or vehicle from GD 14-18. Both the C3aRA and C5aRA attenuated placental ischemia-induced hypertension without affecting the decreased fetal weight or decreased concentration of free circulating vascular endothelial growth factor (VEGF) also present in this model. The C5aRA, but not the C3aRA, attenuated placental ischemia-induced increase in heart rate and impaired endothelial-dependent relaxation. The C3aRA abrogated the acute pressor response to C3a peptide injection, but it also unexpectedly attenuated the placental ischemia-induced increase in C3a, suggesting nonreceptor-mediated effects. Overall, these results indicate that both C3a and C5a are important products of complement activation that mediate the hypertension regardless of the reduction in free plasma VEGF. The mechanism by which C3a contributes to placental ischemia-induced hypertension appears to be distinct from that of C5a, and management of pregnancy-induced hypertension is likely to require a broad anti-inflammatory approach.
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Affiliation(s)
- Kathryn E Lillegard
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth (K.E.L., A.C.L.-J., J.W.O., J.M.P., A.J.B., B.J.E., J.S.G., J.F.R.) and Department of Mathematics and Statistics, University of Minnesota Duluth (R.R.R.), Duluth, Minnesota
| | - Alex C Loeks-Johnson
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth (K.E.L., A.C.L.-J., J.W.O., J.M.P., A.J.B., B.J.E., J.S.G., J.F.R.) and Department of Mathematics and Statistics, University of Minnesota Duluth (R.R.R.), Duluth, Minnesota
| | - Jonathan W Opacich
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth (K.E.L., A.C.L.-J., J.W.O., J.M.P., A.J.B., B.J.E., J.S.G., J.F.R.) and Department of Mathematics and Statistics, University of Minnesota Duluth (R.R.R.), Duluth, Minnesota
| | - Jenna M Peterson
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth (K.E.L., A.C.L.-J., J.W.O., J.M.P., A.J.B., B.J.E., J.S.G., J.F.R.) and Department of Mathematics and Statistics, University of Minnesota Duluth (R.R.R.), Duluth, Minnesota
| | - Ashley J Bauer
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth (K.E.L., A.C.L.-J., J.W.O., J.M.P., A.J.B., B.J.E., J.S.G., J.F.R.) and Department of Mathematics and Statistics, University of Minnesota Duluth (R.R.R.), Duluth, Minnesota
| | - Barbara J Elmquist
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth (K.E.L., A.C.L.-J., J.W.O., J.M.P., A.J.B., B.J.E., J.S.G., J.F.R.) and Department of Mathematics and Statistics, University of Minnesota Duluth (R.R.R.), Duluth, Minnesota
| | - Ronald R Regal
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth (K.E.L., A.C.L.-J., J.W.O., J.M.P., A.J.B., B.J.E., J.S.G., J.F.R.) and Department of Mathematics and Statistics, University of Minnesota Duluth (R.R.R.), Duluth, Minnesota
| | - Jeffrey S Gilbert
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth (K.E.L., A.C.L.-J., J.W.O., J.M.P., A.J.B., B.J.E., J.S.G., J.F.R.) and Department of Mathematics and Statistics, University of Minnesota Duluth (R.R.R.), Duluth, Minnesota
| | - Jean F Regal
- Department of Biomedical Sciences, University of Minnesota Medical School Duluth (K.E.L., A.C.L.-J., J.W.O., J.M.P., A.J.B., B.J.E., J.S.G., J.F.R.) and Department of Mathematics and Statistics, University of Minnesota Duluth (R.R.R.), Duluth, Minnesota
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Ahmed S, Kemp MW, Payne MS, Kallapur SG, Stock SJ, Marsh HC, Jobe AH, Newnham JP, Spiller OB. Comparison of complement activity in adult and preterm sheep serum. Am J Reprod Immunol 2014; 73:232-41. [PMID: 25046333 DOI: 10.1111/aji.12299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 07/02/2014] [Indexed: 01/25/2023] Open
Abstract
PROBLEM Functional complement activity is routinely measured utilizing rabbit antibody-sensitized sheep erythrocytes. Due to complement inhibitor expression on erythrocytes, the development of an alternative method to measure complement function in sheep serum was required. METHOD OF STUDY Several species of target erythrocyte and sensitizing antibody were investigated for improved measurement of complement function testing. RESULTS AND CONCLUSION Guinea pig erythrocytes were identified as the optimal target, although sensitizing them with rabbit antiguinea pig erythrocyte antibody did not enhance the lysis by maternal sheep serum. In contrast, preterm neonatal sheep serum was unable to efficiently lyse guinea pig erythrocytes unless pre-sensitized with antibody. Further investigation revealed that maternal serum contained high levels of antibodies that cross-reacted with guinea pig and rabbit erythrocytes, while no cross-reacting antierythrocyte antibodies were found in preterm neonatal serum. Therefore, unlike primates, rabbits, and guinea pigs, no transplacental transfer of maternal IgG to foetal sheep occurs. Use of exogenous complement regulators is often used to dissect the contribution of complement to disease pathogenesis; however, we found that while full-length soluble human complement receptor 1 (sCR1, CDX-1135) was able to inhibit lysis of guinea pig erythrocytes by human and rat serum, no inhibition of sheep serum could be observed. Investigation of complement contribution to disease pathogenesis in the future will require the identification of an inhibitor that is effective against sheep complement.
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Affiliation(s)
- Shatha Ahmed
- School of Medicine, Institute of Molecular and Experimental Medicine, Cardiff University, University Hospital of Wales, Cardiff, UK; Department of Pathology, Nineveh College of Medicine, University of Mosul, Mosul, Iraq
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Weissgerber TL, McConico A, Knudsen BE, Butters KA, Hayman SR, White WM, Milic N, Miller VM, Garovic VD. Methodological differences account for inconsistencies in reported free VEGF concentrations in pregnant rats. Am J Physiol Regul Integr Comp Physiol 2014; 306:R796-803. [PMID: 24622973 DOI: 10.1152/ajpregu.00544.2013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Free vascular endothelial growth factor (VEGF) is undetectable in plasma during human pregnancy. However, studies examining pregnant rats have reported both low (8-29 pg/ml) and high (527-1,030 pg/ml) free VEGF. These discrepancies cast uncertainty over the use of rat models to study angiogenic factors in pregnancy and preeclampsia. This study investigates methodological factors that may explain these discrepancies. Plasma VEGF in nonpregnant, day 7 pregnant, and day 19 pregnant rats was measured using rat and mouse ELISAs (R&D Systems). The rat ELISA detected VEGF in plasma from nonpregnant rats but not in plasma from day 19 pregnant rats. The mouse ELISA detected higher VEGF concentrations than the rat ELISA in every sample tested. This discrepancy was greater in day 19 pregnant rats (median: 2,273 vs. 0 pg/ml) than in nonpregnant (97 vs. 20 pg/ml) and day 7 pregnant (66 vs. 2 pg/ml) rats. Recovery of recombinant rat VEGF (rrVEGF) spiked into plasma from nonpregnant and day 7 pregnant rats was high for the rat ELISA (82-105%) but low for the mouse ELISA (17-22%). The rat ELISA did not recover rrVEGF in plasma from day 19 pregnant rats, suggesting that this ELISA measures free VEGF. The use of the rat versus mouse ELISA likely explains the differences in reported VEGF concentrations in pregnant rats. While the rat ELISA appears to measure free VEGF, plasma concentrations in nonpregnant and pregnant rats are below the assay sensitivity limit. As most previous studies of pregnant rats used the mouse VEGF ELISA, these data should be interpreted cautiously.
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Affiliation(s)
| | | | - Bruce E Knudsen
- Department of Experimental Pathology and Lab Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kim A Butters
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | | | - Wendy M White
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Natasa Milic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota; Department of Biostatistics, Belgrade Medical School, Belgrade, Serbia; and
| | - Virginia M Miller
- Departments of Surgery, Physiology and Biomedical Engineering Mayo Clinic, Rochester, Minnesota
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
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