Neonatal Hyperoxia Exposure Induces Kidney Fibrosis in Rats

Neonatal hyperoxia exposure leads to developmental programming of cardiovascular and renal disease in adult rats

Premature infants are often exposed to hyperoxia. However, there is limited data regarding the mechanistic underpinnings linking neonatal hyperoxia exposure and its contribution to cardio-renal dysfunction in adults born preterm. Our objective was to determine whether neonatal hyperoxia induces systemic vascular stiffness and cardio-renal dysfunction in adulthood. Newborn rats were randomly assigned to room air (RA) or hyperoxia (85% O2) from postnatal day 1 to 14, then recovered in RA until 1 year of life. Arterial stiffness, cardio-renal histomorphometry, and fibrosis in the aorta, heart, and kidney were assessed. RNA-sequencing (RNA-seq) of the aorta and kidney was also done. Adult rats exposed to neonatal hyperoxia had increased aortic and mesenteric artery stiffness as demonstrated by wire and pressure myography. They also had cardiomyocyte hypertrophy, glomerulomegaly, and tubular injury. Hyperoxia exposure altered the transcriptome profile associated with fibrosis and matrix remodeling in the aorta and kidney. There was also increased TGF-β1 levels and fibrosis in the aorta, left ventricle, and kidney. In conclusion, neonatal hyperoxia exposure was associated with systemic vascular and cardio-renal alterations in 1-year-old rats. Further studies to determine how targeted therapies could reprogram cardio-renal injury after neonatal hyperoxia exposure are indicated.

The Mechanism of Hyperoxia-Induced Neonatal Renal Injury and the Possible Protective Effect of Resveratrol

With recent advances in neonatal intensive care, preterm infants are surviving into adulthood. Nonetheless, epidemiological data on the health status of these preterm infants have begun to reveal a worrying theme; prematurity and the supplemental oxygen therapy these infants receive after birth appear to be risk factors for kidney disease in adulthood, affecting their quality of life. As the incidence of chronic kidney disease and the survival time of preterm infants both increase, the management of the hyperoxia-induced renal disease is becoming increasingly relevant to neonatologists. The mechanism of this increased risk is currently unknown, but prematurity itself and hyperoxia exposure after birth may predispose to disease by altering the normal trajectory of kidney maturation. This article reviews altered renal reactivity due to hyperoxia, the possible mechanisms of renal injury due to hyperoxia, and the role of resveratrol in renal injury. KEY POINTS: · Premature infants commonly receive supplementary oxygen.. · Hyperoxia can cause kidney damage via signal pathways.. · We should reduce the occurrence of late sequelae..

The danger of hyperoxia on the rat kidneys: is tadalafil a real shield?

PURPOSE

Continuous oxygen therapy to compensate for decreased oxygen saturation in the blood is a life-saving treatment used in case lung involvement. Excess oxygen delivery was reported to be a common situation, in which about 50% of the patients showed hyperoxemia and 4% in severe hyperoxemia. In this work, we investigated the effects of hyperoxia on the rat kidneys and whether tadalafil has an effect to reduce this damage.

MATERIALS AND METHODS

Three groups of 8 male rats each weighing 300-350 g were formed. The groups were divided into the control group, hyperoxia group, and hyperoxia and tadalafil administered group for 10 days. At the end of the 10th day, blood and kidney samples were taken for biochemical analysis (SOD and NO levels) and histopathological examination.

RESULTS

While our findings showed that SOD levels were significantly different among the control and experimental groups and within the experimental groups, no statistical difference was found in terms of NO levels among the groups (Table 1). While the glomerular and tubular injury was higher in the Hyperoxia group and the Hyperoxia + Tadalafil group than in the control group (p < 0.001), as a result of the rate of severe glomerular and tubular injury in the hyperoxia group, was 62.5% and 43.8% and in the group given tadalafil was 43.8% and 31.3%, respectively (Table 2).

CONCLUSIONS

Exposure to hyperoxia condition causes renal glomerular and tubular damage, and tadalafil does not show a protective effect on this damage according to this study's dose and exposure time.

Kidney Injuries and Evolution of Chronic Kidney Diseases Due to Neonatal Hyperoxia Exposure Based on Animal Studies

Preterm birth interrupts the development and maturation of the kidneys during the critical growth period. The kidneys can also exhibit structural defects and functional impairment due to hyperoxia, as demonstrated by various animal studies. Furthermore, hyperoxia during nephrogenesis impairs renal tubular development and induces glomerular and tubular injuries, which manifest as renal corpuscle enlargement, renal tubular necrosis, interstitial inflammation, and kidney fibrosis. Preterm birth along with hyperoxia exposure induces a pathological predisposition to chronic kidney disease. Hyperoxia-induced kidney injuries are influenced by several molecular factors, including hypoxia-inducible factor-1α and interleukin-6/Smad2/transforming growth factor-β, and Wnt/β-catenin signaling pathways; these are key to cell proliferation, tissue inflammation, and cell membrane repair. Hyperoxia-induced oxidative stress is characterized by the attenuation or the induction of multiple molecular factors associated with kidney damage. This review focuses on the molecular pathways involved in the pathogenesis of hyperoxia-induced kidney injuries to establish a framework for potential interventions.

Translational insights into mechanisms and preventive strategies after renal injury in neonates

Adverse perinatal circumstances can cause acute kidney injury (AKI) and contribute to chronic kidney disease (CKD). Accumulating evidence indicate that a wide spectrum of perinatal conditions interferes with normal kidney development and ultimately leads to aberrant kidney structure and function later in life. The present review addresses the lack of mechanistic knowledge with regard to perinatal origins of CKD and provides a comprehensive overview of pre- and peri-natal insults, including genetic predisposition, suboptimal nutritional supply, obesity and maternal metabolic disorders as well as placental insufficiency leading to intrauterine growth restriction (IUGR), prematurity, infections, inflammatory processes, and the need for life-saving treatments (e.g. oxygen supplementation, mechanical ventilation, medications) in neonates. Finally, we discuss future preventive, therapeutic, and regenerative directions. In summary, this review highlights the perinatal vulnerability of the kidney and the early origins of increased susceptibility toward AKI and CKD during postnatal life. Promotion of kidney health and prevention of disease require the understanding of perinatal injury in order to optimize perinatal micro- and macro-environments and enable normal kidney development.

Educational Review: The Impact of Perinatal Oxidative Stress on the Developing Kidney

Oxidative stress occurs when there is an imbalance between reactive oxygen species/reactive nitrogen species and antioxidant systems. The interplay between these complex processes is crucial for normal pregnancy and fetal development; however, when oxidative stress predominates, pregnancy related complications and adverse fetal programming such as preterm birth ensues. Understanding how oxidative stress negatively impacts outcomes for the maternal-fetal dyad has allowed for the exploration of antioxidant therapies to prevent and/or mitigate disease progression. In the developing kidney, the negative impact of oxidative stress has also been noted as it relates to the development of hypertension and kidney injury mostly in animal models. Clinical research addressing the implications of oxidative stress in the developing kidney is less developed than that of the neurodevelopmental and respiratory conditions of preterm infants and other vulnerable neonatal groups. Efforts to study the oxidative stress pathway along the continuum of the perinatal period using a team science approach can help to understand the multi-organ dysfunction that the maternal-fetal dyad sustains and guide the investigation of antioxidant therapies to ameliorate the global toxicity. This educational review will provide a comprehensive and multidisciplinary perspective on the impact of oxidative stress during the perinatal period in the development of maternal and fetal/neonatal complications, and implications on developmental programming of accelerated aging and cardiovascular and renal disease for a lifetime.

Anti-Tn Monoclonal Antibody Ameliorates Hyperoxia-Induced Kidney Injury by Suppressing Oxidative Stress and Inflammation in Neonatal Mice

The Tn antigen, an N-acetylgalactosamine structure linked to serine or threonine, has been shown to induce high-specificity, high-affinity anti-Tn antibodies in mice. Maternal immunization with the Tn vaccine increases serum anti-Tn antibody titers and attenuates hyperoxia-induced kidney injury in neonatal rats. However, immunizing mothers to treat neonatal kidney disease is clinically impractical. This study is aimed at determining whether anti-Tn monoclonal antibody treatment ameliorates hyperoxia-induced kidney injury in neonatal mice. Newborn BALB/c mice were exposed to room air (RA) or normobaric hyperoxia (85% O₂) for 1 week. On postnatal days 2, 4, and 6, the mice were injected intraperitoneally with PBS alone or with anti-Tn monoclonal antibodies at 25 μg/g body weight in 50 μL phosphate-buffered saline (PBS). The mice were divided into four study groups: RA + PBS, RA + anti-Tn monoclonal antibody, O₂ + PBS, and O₂ + anti-Tn monoclonal antibody. The kidneys were excised for histology, oxidative stress, cytokine, and Western blot analyses on postnatal day 7. The O₂ + PBS mice exhibited significantly higher kidney injury scores, 8-hydroxy-2'-deoxyguanosine (8-OHdG) and nuclear factor-κB (NF-κB) expression, and cytokine levels than did the RA + PBS mice or RA + anti-Tn mice. Anti-Tn monoclonal antibody treatment reduced kidney injury and cytokine levels to normoxic levels. The attenuation of kidney injury was accompanied by a reduction of oxidative stress and NF-κB expression. Therefore, we propose that anti-Tn monoclonal antibody treatment ameliorates hyperoxia-induced kidney injury by suppressing oxidative stress and inflammation in neonatal mice.

Neonatal Hyperoxia Downregulates Claudin-4, Occludin, and ZO-1 Expression in Rat Kidney Accompanied by Impaired Proximal Tubular Development

Hyperoxia is essential to manage in preterm infants but causes injury to immature kidney. Previous study indicates that hyperoxia causes oxidative damage to neonatal kidney and impairs renal development. However, the underlying mechanisms by which neonatal hyperoxia effects on immature kidney still need to be elucidated. Tight junction, among which the representative proteins are claudin-4, occludin, and ZO-1, plays a crucial role in nephrogenesis and maintaining renal function. Inflammatory cytokines are involved in the pleiotropic regulation of tight junction proteins. Here, we investigated how neonatal hyperoxia affected the expression of key tight junction proteins and inflammatory factors (IL-6 and TNF-α) in the developing rat kidneys and elucidated their correlation with renal injury. We found claudin-4, occludin, and zonula occludens-1 (ZO-1) expression in proximal tubules was significantly downregulated after neonatal hyperoxia. The expression of these tight junction proteins was positively correlated with that of IL-6 and TNF-α, while claudin-4 expression was positively correlated with injury score of proximal tubules in mature kidneys. These findings indicated that impaired expression of tight junction proteins in kidney might be a potential mechanism of hyperoxia-induced nephrogenic disorders. It provides new insights to further study oxidative renal injury and development disorders and will be helpful for seeking potential therapeutics for hyperoxia-induced renal injury in the future.

Effects of Klotho supplementation on hyperoxia-induced renal injury in a rodent model of postnatal nephrogenesis

BACKGROUND

Hyperoxia (HO) causes kidney injury in preterm infants; however, whether these effects are modifiable is unknown. We hypothesized that administration of exogenous soluble Klotho, a kidney-derived antioxidant, would attenuate HO-induced kidney injury during postnatal nephrogenesis in rats.

METHODS

Sprague Dawley neonatal rats assigned to normoxia (21% O₂) or HO (85% O₂) groups from postnatal day (P) 1 to 21 were randomly assigned to receive alternate day intraperitoneal injections of recombinant Klotho or placebo for 3 weeks. They were recovered in normoxia for an additional 3 weeks and sacrificed at 6 weeks. Renal artery resistance and pulsatility indices, tubular injury scores, glomerular area, and renal antioxidant capacity were assessed.

RESULTS

Rodents exposed to HO during postnatal nephrogenesis had reduced kidney Klotho expression, glomerulomegaly, and higher tubular injury scores. Exogenous Klotho administration improved renal perfusion as indicated by decreases in both resistance and pulsatility indices and increased antioxidant enzyme expression.

CONCLUSIONS

HO exposure during postnatal nephrogenesis in rodents results in a decline in kidney Klotho expression, decreased renal perfusion, enlarged glomerular size, and tubular injury. The exogenous administration of Klotho attenuated HO-induced kidney injury and augmented antioxidant capacity.

Neonatal hyperoxia: effects on nephrogenesis and the key role of klotho as an antioxidant factor

A congenital or programmed reduction in glomerular number increases the susceptibility to hypertension and kidney injury in adulthood thus, premature birth or low birth weight, leading to a low glomerular endowment, can be associated with these two diseases. Renal morphogenesis is sensitive to hypoxia which is a physiological trigger for the expression of vascular endothelial growth factor. On the other hand, hyperoxia increases oxidative stress and adversely affects glomerular and tubular development, and is associated with a substantial reduction of renal klotho expression in adulthood. Preterm newborns are often submitted to oxygen therapy, exposing them to an acute high-oxygen level situation, in contrast to the intrauterine low-oxygen environment. Investigating the role of klotho on kidney development leads to the understanding of the possible mechanisms related to disorders in the preterm neonatal kidney exposed to hyperoxia and its long term effects in adulthood.

Cathelicidin attenuates hyperoxia-induced kidney injury in newborn rats

Aim: Supplemental oxygen is often used to treat neonates with respiratory disorders. Human and animal studies have demonstrated that neonatal hyperoxia increases oxidative stress and induces damage and collagen deposition in kidney during the perinatal period. Cathelicidin LL-37 is one important group of human antimicrobial peptides which exhibits antioxidant activity and its overexpression resists hyperoxia-induced oxidative stress. This study was designed to evaluate the protective effects of cathelicidin in hyperoxia-induced kidney injury in newborn rats.

Methods: Sprague-Dawley rat pups were reared in either room air (RA) or hyperoxia (85% O₂) and were randomly treated with low-dose (4 mg/kg) and high-dose (8 mg/kg) cathelicidin in normal saline (NS) administered intraperitoneally on postnatal days 1–6. The following six groups were obtained: RA + NS, RA + low-dose cathelicidin, RA + high-dose cathelicidin, O₂ + NS, O₂ + low-dose cathelicidin, and O₂ + high-dose cathelicidin. Kidneys were taken for Western blot and histological analyses on postnatal day 7.

Results: The hyperoxia-reared rats exhibited significantly lower body weights and anti-inflammatory M2 macrophages, but the kidney injury scores, oxidative stress marker 8-hydroxy-2'-deoxyguanosine (8-OHdG)-positive cells, pro-inflammatory M1 macrophages, collagen deposition, and NF-κB expression were higher than did the RA-reared rats.

Conclusions: Cathelicidin treatment attenuated kidney injury as evidenced by lower kidney injury scores, 8-OHdG-positive cells, collagen deposition, and reversion of hyperoxia-induced M1/M2 macrophage polarization. The role of Cathelicidin in ameliorates kidney injury of the hyperoxia newborn rats was accompanied by decreased NF-κB expression, which probably through the modulating NF-κB activity in the kidney.

Proximal Tubular Development Is Impaired with Downregulation of MAPK/ERK Signaling, HIF-1α, and Catalase by Hyperoxia Exposure in Neonatal Rats

Supplemental oxygen therapy (hyperoxia) is a widely used treatment for alveolar hypoxia in preterm infants. Despite being closely monitored, hyperoxia exposure is believed to undermine neonatal nephrogenesis and renal function caused by elevated oxidative stress. Previous studies have mostly focused on the hyperoxia-induced impairment of glomerular development, while the long-term impact of neonatal hyperoxia on tubular development and the regulatory component involved in this process remain to be clarified. Here, we examined tubular histology and apoptosis, along with the expression profile of mitogen-activated protein kinase (MAPK)/extracellular signal-regulated kinase (ERK) signaling, hypoxia-inducible factor 1α (HIF-1α), and catalase, following hyperoxia exposure in neonatal rats. Hematoxylin and eosin (H&E) staining revealed the early disappearance of the nephrogenic zone, as well as dilated lumens and reduced epithelial cells, of mature proximal tubules following neonatal hyperoxia. A robust increase in tubular cell apoptosis caused by neonatal hyperoxia was found using a TUNEL assay. Moreover, neonatal hyperoxia altered renal MAPK/ERK signaling activity and downregulated the expression of HIF-1α and catalase in the proximal tubules throughout nephrogenesis from S-shaped bodies to mature proximal tubules. Cell apoptosis in the proximal tubules was positively correlated with HIF-1α expression on the 14th postnatal day. Our data indicates that proximal tubular development is impaired by neonatal hyperoxia, which is accompanied by altered MAPK/ERK signaling as well as downregulated HIF-1α and catalase. Therapeutic management that targets MAPK/ERK signaling, HIF-1α, or catalase may serve as a protective agent against hyperoxia-induced oxidative damage to neonatal proximal tubules.

Maternal inflammation exacerbates neonatal hyperoxia-induced kidney injury in rat offspring

BACKGROUND

Preclinical studies have demonstrated that maternal inflammation or neonatal hyperoxia adversely affects kidney maturation. This study explored whether prenatal lipopolysaccharide (LPS) exposure can augment neonatal hyperoxia-induced kidney injury.

METHODS

Pregnant Sprague-Dawley rats received intraperitoneal injections of LPS (0.5 mg/kg) in normal saline (NS) or NS on 20 and 21 days of gestation. The pups were reared in room air (RA) or 2 weeks of 85% O₂, creating the four study groups, NS + RA, NS + O₂, LPS + RA, and LPS + O₂. Kidneys were taken for oxidase stress and histological analyses.

RESULTS

The rats exposed to maternal LPS or neonatal hyperoxia exhibited significantly higher kidney injury score, lower glomerular number, higher toll-like receptor 4 (TLR4), myeloperoxidase (MPO), and 8-hydroxy-2'-deoxyguanosine (8-OHdG) expressions, and higher MPO activity compared with the rats exposed to maternal NS and neonatal RA. The rats exposed to both maternal LPS and neonatal hyperoxia exhibited significantly lower glomerular number, higher kidney injury score, TLR4, MPO, and 8-OHdG expressions compared with the rats exposed to maternal LPS or neonatal hyperoxia.

CONCLUSION

Maternal inflammation exacerbates neonatal hyperoxia-induced kidney injury and the underlying mechanism may be related to activation of TLR4 and increased oxidative stress.

IL-6/Smad2 signaling mediates acute kidney injury and regeneration in a murine model of neonatal hyperoxia

Prematurity is linked to incomplete nephrogenesis and risk of chronic kidney diseases (CKDs). Oxygen is life-saving in that context but induces injury in numerous organs. Here, we studied the structural and functional impact of hyperoxia on renal injury and its IL-6 dependency. Newborn wild-type (WT) and IL-6 knockout (IL-6^-/-) mice were exposed to 85% O₂ for 28 d, followed by room air until postnatal d (P) 70. Controls were in room air throughout life. At P28, hyperoxia reduced estimated kidney cortex area (KCA) in WT; at P70, KCA was greater, number of glomeruli was fewer, fractional potassium excretion was higher, and glomerular filtration rate was slightly lower than in controls. IL-6^-/- mice were protected from these changes after hyperoxia. Mechanistically, the acute renal injury phase (P28) showed in WT but not in IL-6^-/- mice an activation of IL-6 (signal transducer and activator of transcription 3) and TGF-β [mothers against decapentaplegic homolog (Smad)2] signaling, increased inflammatory markers, disrupted mitochondrial biogenesis, and reduced tubular proliferation. Regenerative phase at P70 was characterized by tubular proliferation in WT but not in IL-6^-/- mice. These data demonstrate that hyperoxia increases the risk of CKD through a novel IL-6-Smad2 axis. The amenability of these pathways to pharmacological approaches may offer new avenues to protect premature infants from CKD.-Mohr, J., Voggel, J., Vohlen, C., Dinger, K., Dafinger, C., Fink, G., Göbel, H., Liebau, M. C., Dötsch, J., Alejandre Alcazar, M. A. IL-6/Smad2 signaling mediates acute kidney injury and regeneration in a murine model of neonatal hyperoxia.

Comparative Study of the Severity of Renal Damage in Newborn and Adult Rats under Conditions of Ischemia/Reperfusion and Endotoxin Administration

Oxidative kidney injury was compared in newborn and adult rats under conditions of ischemia/reperfusion and in experimental model of systemic inflammation induced by endotoxin (LPS of bacterial cell wall) administration. Oxidative stress in the kidney accompanied both experimental models, but despite similar oxidative tissue damage, kidney dysfunction in neonates was less pronounced than in adult animals. It was found that neonatal kidney has a more potent regenerative potential with higher level of cell proliferation than adult kidney, where the level proliferating cell antigen (PCNA) increased only on day 2 after ischemia/reperfusion. The pathological process in the neonatal kidney developed against the background of active cell proliferation, and, as a result, proliferating cells could almost immediately replace the damaged structures. In the adult kidney, regeneration of the renal tissue was activated only after significant loss of functional nephrons and impairment of renal function.

Hepatoprotective effects of capping protein gelsolin against hyperoxia-induced hepatotoxicity, oxidative stress and DNA damage in neonatal rats

Tissues and organs get exposed to high oxygen (O₂) supply in hyperoxia conditions. The goal of this research was to investigate the protective effect of actin binding protein gelsolin on hyperoxia-induced hepatotoxicity through histopathology and measurement of oxidative stress parameters and DNA damage in a neonatal Wistar albino rats. The pups were randomly separated to four equal groups such as: normoxia control group (NC), normoxia plus gelsolin group (NG, 10 ng/kg bw/day gelsolin), hyperoxia (≥85% O₂) group (HC), hyperoxia plus gelsolin group (HG, ≥85% O₂; 10 ng/kg bw/day gelsolin). Histopathological changes of pups in hyperoxia condition were revealed in the form of severe leukocyte infiltration, vascular congestion, necrosis, vacuolar degeneration, binucleated hepatocytes and hemorrhage in the liver tissue. SOD, CAT, GPx and GST activities decreased and MDA level increased in the hyperoxia-induced group in liver tissue (P < 0.05). Tail DNA%, tail length and moment indicating DNA damage statistically increased in hyperoxia treatment groups when compared to controls. Treatment of rats with hyperoxia plus gelsolin prevented hyperoxia-induced changes in tissue structure, antioxidant enzyme activities and MDA level, mean tail DNA% and length. Based on these findings, gelsolin restored these changing to near normal levels but it does not protect completely in the hyperoxia conditions.

Age- and sex-related changes in rat renal function and pathology following neonatal hyperoxia exposure

Preterm neonates are prematurely exposed to high oxygen levels at birth which may adversely impact ongoing renal development. The aim of this study was to determine the effects of neonatal hyperoxia exposure on renal function and morphology with aging. Sprague Dawley rat pups were raised in a hyperoxic environment (80% oxygen) from P3 to P10 during ongoing postnatal nephrogenesis. Control litters were kept in room air (n = 6–8 litters/group; one male, one female/litter/age). Kidney function (urine and plasma creatinine, sodium, and protein) and morphology (renal corpuscle size, glomerulosclerosis, fibrosis, and glomerular crescents) were assessed at 1, 5, and 11 months of age. Neonatal hyperoxia exposure had no impact on body or kidney weights. Creatinine clearance was significantly reduced following hyperoxia exposure at 5 months; there was no significant effect on renal function at 1 or 11 months. The percentage of crescentic glomeruli (indicative of glomerular injury) was markedly increased in 11 month hyperoxia‐exposed males. Renal corpuscle size, glomerulosclerosis index, and renal fibrosis were not affected. Findings suggest that exposure to high oxygen levels during development may impact renal functional capacity and increase susceptibility to renal disease in adulthood depending on age and sex.

Bronchopulmonary dysplasia: new becomes old again!

Despite the many advances in neonatology, bronchopulmonary dysplasia (BPD) continues to be a frustrating disease of prematurity. BPD is a disease which is defined oddly by its treatment rather than its pathophysiology, leading to frequently changing nomenclature which has widespread implications on our ability to both understand and follow the progression of BPD. As various treatment modalities for BPD were developed and a larger number of extremely preterm infants survived, the "old" BPD based on lung injury from oxygen therapy and mechanical ventilation transitioned into a "new" BPD focused more on the interruption of normal development. However, the interruption of normal development does not solely apply to lung development. The effects of prematurity on vascular development cannot be overstated and pulmonary vascular disease has become the new frontier of BPD. As we begin to better understand the complex, multifactorial pathophysiology of BPD, it is necessary to again focus on appropriate, pathology-driven nomenclature that can effectively describe the multiple clinical phenotypes of BPD.

The Overexpression of TGF-β and CCN2 in Intrauterine Adhesions Involves the NF-κB Signaling Pathway

Intrauterine adhesions (IUA) are a significant cause of menstrual disturbance and infertility, but their pathogenesis still remains unclear. Here, we investigated the expression of TGF-β and CCN2 in IUA endometrial tissue by immunohistochemistry, western blotting and qRT-PCR assays, and found the expression of TGF-β and CCN2 in the endometrial tissue of IUA was significantly increased compared to normal endometrium and uterine septum (P<0.01), suggesting that TGF-β and CCN2 may play an important role in the formation of IUA. Moreover, the activity of the NF-κB signaling pathway in endometrial tissue of IUA was also significantly enhanced compared to normal endometrial and uterine septum (P<0.01) and positively correlated with the expression of TGF-β and CCN2, which suggested that TGF-β and CCN2 expression may be involved in the NF-κB signaling pathway. Blocking the NF-κB signaling pathway using SN50 resulted in the reduced expression of TGF-β in RL95-2 cells, which confirmed the association of the NF-κB signaling pathway and TGF-β in endometrial cells. Additionally, the expression of TGF-β and CCN2 was associated with IUA recurrence, which provides a potential prognostic indictor for IUA. Together, these results demonstrated that TGF-β and CCN2 play an important role in IUA formation, whose mechanism was associated with the activation of the NF-κB signaling pathway.