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Figueira RL, Khoshgoo N, Doktor F, Khalaj K, Islam T, Moheimani N, Blundell M, Antounians L, Post M, Zani A. Antenatal Administration of Extracellular Vesicles Derived From Amniotic Fluid Stem Cells Improves Lung Function in Neonatal Rats With Congenital Diaphragmatic Hernia. J Pediatr Surg 2024; 59:1771-1777. [PMID: 38519389 DOI: 10.1016/j.jpedsurg.2024.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/26/2024] [Accepted: 02/21/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND The severity of pulmonary hypoplasia is a main determinant of outcome for babies with congenital diaphragmatic hernia (CDH). Antenatal administration of extracellular vesicles derived from amniotic fluid stem cells (AFSC-EVs) has been shown to rescue morphological features of lung development in the rat nitrofen model of CDH. Herein, we evaluated whether AFSC-EV administration to fetal rats with CDH is associated with neonatal improvement in lung function. METHODS AFSC-EVs were isolated by ultracentrifugation and characterized by size, morphology, and canonical marker expression. At embryonic (E) day 9.5, dams were gavaged with olive oil (control) or nitrofen to induce CDH. At E18.5, fetuses received an intra-amniotic injection of either saline or AFSC-EVs. At E21.5, rats were delivered and subjected to a tracheostomy for mechanical ventilation (flexiVent system). Groups were compared for lung compliance, resistance, Newtonian resistance, tissue damping and elastance. Lungs were evaluated for branching morphogenesis and collagen quantification. RESULTS Compared to healthy control, saline-treated pups with CDH had fewer airspaces, more collagen deposition, and functionally exhibited reduced compliance and increased airway resistance, elastance, and tissue damping. Conversely, AFSC-EV administration resulted in improvement of lung mechanics (compliance, resistance, tissue damping, elastance) as well as lung branching morphogenesis and collagen deposition. CONCLUSIONS Our studies show that the rat nitrofen model reproduces lung function impairment similar to that of human babies with CDH. Antenatal administration of AFSC-EVs improves lung morphology and function in neonatal rats with CDH. LEVEL OF EVIDENCE N/A (animal and laboratory study).
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Affiliation(s)
- Rebeca L Figueira
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Naghmeh Khoshgoo
- Translational Medicine Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Fabian Doktor
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kasra Khalaj
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Tasneem Islam
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nazgol Moheimani
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Matisse Blundell
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Lina Antounians
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Martin Post
- Translational Medicine Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Augusto Zani
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada.
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2
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Antounians L, Figueira RL, Kukreja B, Litvack ML, Zani-Ruttenstock E, Khalaj K, Montalva L, Doktor F, Obed M, Blundell M, Wu T, Chan C, Wagner R, Lacher M, Wilson MD, Post M, Kalish BT, Zani A. Fetal hypoplastic lungs have multilineage inflammation that is reversed by amniotic fluid stem cell extracellular vesicle treatment. SCIENCE ADVANCES 2024; 10:eadn5405. [PMID: 39058789 PMCID: PMC11277482 DOI: 10.1126/sciadv.adn5405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 06/21/2024] [Indexed: 07/28/2024]
Abstract
Antenatal administration of extracellular vesicles from amniotic fluid stem cells (AFSC-EVs) reverses features of pulmonary hypoplasia in models of congenital diaphragmatic hernia (CDH). However, it remains unknown which lung cellular compartments and biological pathways are affected by AFSC-EV therapy. Herein, we conducted single-nucleus RNA sequencing (snRNA-seq) on rat fetal CDH lungs treated with vehicle or AFSC-EVs. We identified that intra-amniotically injected AFSC-EVs reach the fetal lung in rats with CDH, where they promote lung branching morphogenesis and epithelial cell differentiation. Moreover, snRNA-seq revealed that rat fetal CDH lungs have a multilineage inflammatory signature with macrophage enrichment, which is reversed by AFSC-EV treatment. Macrophage enrichment in CDH fetal rat lungs was confirmed by immunofluorescence, flow cytometry, and inhibition studies with GW2580. Moreover, we validated macrophage enrichment in human fetal CDH lung autopsy samples. Together, this study advances knowledge on the pathogenesis of pulmonary hypoplasia and further evidence on the value of an EV-based therapy for CDH fetuses.
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Affiliation(s)
- Lina Antounians
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto M5G 1X8, Canada
| | - Rebeca Lopes Figueira
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto M5G 1X8, Canada
| | - Bharti Kukreja
- Neurosciences and Mental Health Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
| | - Michael L. Litvack
- Translational Medicine Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
| | - Elke Zani-Ruttenstock
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto M5G 1X8, Canada
| | - Kasra Khalaj
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto M5G 1X8, Canada
| | - Louise Montalva
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto M5G 1X8, Canada
| | - Fabian Doktor
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto M5G 1X8, Canada
| | - Mikal Obed
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto M5G 1X8, Canada
| | - Matisse Blundell
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto M5G 1X8, Canada
| | - Taiyi Wu
- Neurosciences and Mental Health Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
| | - Cadia Chan
- Genetics and Genome Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
- Department of Molecular Genetics, University of Toronto, Toronto M5S 1A8, Canada
| | - Richard Wagner
- Department of Pediatric Surgery, Leipzig University, Leipzig 04109, Germany
| | - Martin Lacher
- Department of Pediatric Surgery, Leipzig University, Leipzig 04109, Germany
| | - Michael D. Wilson
- Genetics and Genome Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
- Department of Molecular Genetics, University of Toronto, Toronto M5S 1A8, Canada
| | - Martin Post
- Translational Medicine Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
- Laboratory Medicine and Pathobiology, University of Toronto, Toronto M5T 1P5, Canada
| | - Brian T. Kalish
- Neurosciences and Mental Health Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
- Department of Molecular Genetics, University of Toronto, Toronto M5S 1A8, Canada
- Division of Neonatology, The Hospital for Sick Children, Toronto M5G 1X8, Canada
| | - Augusto Zani
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto M5G 0A4, Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto M5G 1X8, Canada
- Department of Surgery, University of Toronto, Toronto M5T 1P5, Canada
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3
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Stokes G, Li Z, Talaba N, Genthe W, Brix MB, Pham B, Wienhold MD, Sandok G, Hernan R, Wynn J, Tang H, Tabima DM, Rodgers A, Hacker TA, Chesler NC, Zhang P, Murad R, Yuan JXJ, Shen Y, Chung WK, McCulley DJ. Rescuing lung development through embryonic inhibition of histone acetylation. Sci Transl Med 2024; 16:eadc8930. [PMID: 38295182 DOI: 10.1126/scitranslmed.adc8930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 01/10/2024] [Indexed: 02/02/2024]
Abstract
A major barrier to the impact of genomic diagnosis in patients with congenital malformations is the lack of understanding regarding how sequence variants contribute to disease pathogenesis and whether this information could be used to generate patient-specific therapies. Congenital diaphragmatic hernia (CDH) is among the most common and severe of all structural malformations; however, its underlying mechanisms are unclear. We identified loss-of-function sequence variants in the epigenomic regulator gene SIN3A in two patients with complex CDH. Tissue-specific deletion of Sin3a in mice resulted in defects in diaphragm development, lung hypoplasia, and pulmonary hypertension, the cardinal features of CDH and major causes of CDH-associated mortality. Loss of SIN3A in the lung mesenchyme resulted in reduced cellular differentiation, impaired cell proliferation, and increased DNA damage. Treatment of embryonic Sin3a mutant mice with anacardic acid, an inhibitor of histone acetyltransferase, reduced DNA damage, increased cell proliferation and differentiation, improved lung and pulmonary vascular development, and reduced pulmonary hypertension. These findings demonstrate that restoring the balance of histone acetylation can improve lung development in the Sin3a mouse model of CDH.
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Affiliation(s)
- Giangela Stokes
- Department of Pediatrics, University of California, San Diego, San Diego, CA 92093, USA
| | - Zhuowei Li
- Department of Pediatrics, University of California, San Diego, San Diego, CA 92093, USA
| | - Nicole Talaba
- Department of Pediatrics, University of California, San Diego, San Diego, CA 92093, USA
| | - William Genthe
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Maria B Brix
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Betty Pham
- Department of Pediatrics, University of California, San Diego, San Diego, CA 92093, USA
| | | | - Gracia Sandok
- Department of Pediatrics, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Rebecca Hernan
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Julia Wynn
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Haiyang Tang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, Guangdong, China
| | - Diana M Tabima
- Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Allison Rodgers
- Department of Medicine, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Timothy A Hacker
- Department of Medicine, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Naomi C Chesler
- Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center and Department of Biomedical Engineering, University of California, Irvine, Irvine, CA 92697, USA
| | - Pan Zhang
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Rabi Murad
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Jason X-J Yuan
- Section of Physiology, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | - Yufeng Shen
- Department of Systems Biology, Department of Biomedical Informatics, and JP Sulzberger Columbia Genome Center, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Wendy K Chung
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - David J McCulley
- Department of Pediatrics, University of California, San Diego, San Diego, CA 92093, USA
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4
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Khalaj K, Figueira RL, Antounians L, Gandhi S, Wales M, Montalva L, Biouss G, Zani A. Treatment with Amniotic Fluid Stem Cell Extracellular Vesicles Promotes Fetal Lung Branching and Cell Differentiation at Canalicular and Saccular Stages in Experimental Pulmonary Hypoplasia Secondary to Congenital Diaphragmatic Hernia. Stem Cells Transl Med 2022; 11:1089-1102. [PMID: 36103370 PMCID: PMC9585953 DOI: 10.1093/stcltm/szac063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 07/31/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Pulmonary hypoplasia secondary to congenital diaphragmatic hernia (CDH) is characterized by impaired branching morphogenesis and differentiation. We have previously demonstrated that administration of extracellular vesicles derived from rat amniotic fluid stem cells (AFSC-EVs) rescues development of hypoplastic lungs at the pseudoglandular and alveolar stages in rodent models of CDH. Herein, we tested whether AFSC-EVs exert their regenerative effects at the canalicular and saccular stages, as these are translationally relevant for clinical intervention. To induce fetal pulmonary hypoplasia, we gavaged rat dams with nitrofen at embryonic day 9.5 and demonstrated that nitrofen-exposed lungs had impaired branching morphogenesis, dysregulated signaling pathways relevant to lung development (FGF10/FGFR2, ROBO/SLIT, Ephrin, Neuropilin 1, β-catenin) and impaired epithelial and mesenchymal cell marker expression at both stages. AFSC-EVs administered to nitrofen-exposed lung explants rescued airspace density and increased the expression levels of key factors responsible for branching morphogenesis. Moreover, AFSC-EVs rescued the expression of alveolar type 1 and 2 cell markers at both canalicular and saccular stages and restored markers of club, ciliated epithelial, and pulmonary neuroendocrine cells at the saccular stage. AFSC-EV-treated lungs also had restored markers of lipofibroblasts and PDGFRA+ cells to control levels at both stages. EV tracking showed uptake of AFSC-EV RNA cargo throughout the fetal lung and an mRNA-miRNA network analysis identified that several miRNAs responsible for regulating lung development processes were contained in the AFSC-EV cargo. These findings suggest that AFSC-EV-based therapies hold potential for restoring fetal lung growth and maturation in babies with pulmonary hypoplasia secondary to CDH.
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Affiliation(s)
- Kasra Khalaj
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children , Toronto, ON , Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children , Toronto, ON , Canada
| | - Rebeca Lopes Figueira
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children , Toronto, ON , Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children , Toronto, ON , Canada
| | - Lina Antounians
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children , Toronto, ON , Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children , Toronto, ON , Canada
| | - Sree Gandhi
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children , Toronto, ON , Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children , Toronto, ON , Canada
| | - Matthew Wales
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children , Toronto, ON , Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children , Toronto, ON , Canada
| | - Louise Montalva
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children , Toronto, ON , Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children , Toronto, ON , Canada
| | - George Biouss
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children , Toronto, ON , Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children , Toronto, ON , Canada
| | - Augusto Zani
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children , Toronto, ON , Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children , Toronto, ON , Canada
- Department of Surgery, University of Toronto , Toronto, ON , Canada
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5
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De Bie FR, Avitabile CM, Joyeux L, Hedrick HL, Russo FM, Basurto D, Deprest J, Rintoul NE. Neonatal and fetal therapy of congenital diaphragmatic hernia-related pulmonary hypertension. Arch Dis Child Fetal Neonatal Ed 2022; 107:458-466. [PMID: 34952853 DOI: 10.1136/archdischild-2021-322617] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/06/2021] [Indexed: 01/01/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a complex malformation characterised by a triad of pulmonary hypoplasia, pulmonary hypertension (PH) and cardiac ventricular dysfunction. Much of the mortality and morbidity in CDH is largely accounted for by PH, especially when persistent beyond the neonatal period and refractory to available treatment. Gentle ventilation, haemodynamic optimisation and pulmonary vasodilation constitute the foundations of neonatal treatment of CDH-related PH (CDH-PH). Moreover, early prenatal diagnosis, the ability to assess severity and the developmental nature of the condition generate the perfect rationale for fetal therapy. Shortcomings of currently available clinical therapies in combination with increased understanding of CDH pathophysiology have spurred experimental drug trials, exploring new therapeutic mechanisms to tackle CDH-PH. We herein discuss clinically available neonatal and fetal therapies specifically targeting CDH-PH and review the most promising experimental treatments and future research avenues.
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Affiliation(s)
- Felix R De Bie
- Department of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA .,My FetUZ, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Catherine M Avitabile
- Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Luc Joyeux
- My FetUZ, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Holly L Hedrick
- Department of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francesca M Russo
- My FetUZ, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium.,Department of Obstetrics and Gynaecology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - David Basurto
- My FetUZ, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Jan Deprest
- My FetUZ, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium.,Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Natalie E Rintoul
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Division of Neonatal Intensive Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Khalaj K, Antounians L, Lopes Figueira R, Post M, Zani A. Autophagy is Impaired in Fetal Hypoplastic Lungs and Rescued by Administration of Amniotic Fluid Stem Cell Extracellular Vesicles. Am J Respir Crit Care Med 2022; 206:476-487. [PMID: 35671495 DOI: 10.1164/rccm.202109-2168oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Pulmonary hypoplasia secondary to congenital diaphragmatic hernia (CDH) is characterized by reduced branching morphogenesis, which is responsible for poor clinical outcomes. Administration of amniotic fluid stem cell extracellular vesicles (AFSC-EVs) rescues branching morphogenesis in rodent fetal models of pulmonary hypoplasia. Herein, we hypothesized that AFSC-EVs exert their regenerative potential by affecting autophagy, a process required for normal lung development. OBJECTIVES To evaluate autophagy in hypoplastic lungs throughout gestation and establish whether AFSC-EV administration improves branching morphogenesis through autophagy-mediated mechanisms. METHODS EVs were isolated from c-kit+ AFSC conditioned medium by ultracentrifugation and characterized by size, morphology, and EV marker expression. Branching morphogenesis was inhibited in rat fetuses by nitrofen administration to dams and in human fetal lung explants by blocking RAC1 activity with NSC23766. Expression of autophagy activators (BECN1 and ATG5) and adaptor (SQSTM1) was analyzed in vitro (rat and human fetal lung explants) and in vivo (rat fetal lungs). Mechanistic studies on rat fetal primary lung epithelial cells were conducted using inhibitors for microRNA-17 and -20a contained in the AFSC-EV cargo and known to regulate autophagy. MEASUREMENTS AND MAIN RESULTS Rat and human models of fetal pulmonary hypoplasia showed reduced autophagy at different developmental stages. AFSC-EV administration restored autophagy levels in both pulmonary hypoplasia models by transferring miR-17~92 cluster members contained in the EV cargo. CONCLUSIONS AFSC-EV treatment rescues branching morphogenesis partly by restoring autophagy through miRNA cargo transfer. This study enhances our understanding of pulmonary hypoplasia pathogenesis and creates new opportunities for fetal therapeutic intervention in CDH babies. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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Affiliation(s)
- Kasra Khalaj
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lina Antounians
- The Hospital for Sick Children, 7979, Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada.,The Hospital for Sick Children, 7979, Division of General and Thoracic Surgery, Toronto, Ontario, Canada
| | - Rebeca Lopes Figueira
- The Hospital for Sick Children, Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada.,The Hospital for Sick Children, Division of General and Thoracic Surgery, Toronto, Ontario, Canada
| | - Martin Post
- Hospital for Sick Children, Lung Biology, Toronto, Ontario, Canada
| | - Augusto Zani
- The Hospital for Sick Children, 7979, Developmental and Stem Cell Biology Program, Toronto, Ontario, Canada.,The Hospital for Sick Children, 7979, Division of General and Thoracic Surgery, Toronto, Ontario, Canada.,The Hospital for Sick Children, 7979, Department of Surgery, Toronto, Ontario, Canada;
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7
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Figueira RL, Antounians L, Zani-Ruttenstock E, Khalaj K, Zani A. Fetal lung regeneration using stem cell-derived extracellular vesicles: A new frontier for pulmonary hypoplasia secondary to congenital diaphragmatic hernia. Prenat Diagn 2022; 42:364-372. [PMID: 35191057 DOI: 10.1002/pd.6117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 11/12/2022]
Abstract
The poor outcomes of babies with congenital diaphragmatic hernia (CDH) are directly related to pulmonary hypoplasia, a cosndition characterized by impaired lung development. Although the pathogenesis of pulmonary hypoplasia is not fully elucidated, there is now evidence that CDH patients have missing or dysregulated microRNAs (miRNAs) that regulate lung development. A prenatal therapy that supplements these missing/dysregulated miRNAs could be a strategy to rescue normal lung development. Extracellular vesicles (EVs), also known as exosomes when of small dimensions, are lipid-bound nanoparticles that can transfer their heterogeneous cargo (proteins, lipids, small RNAs) to target cells to induce biological responses. Herein, we review all studies that show evidence for stem cell-derived EVs as a regenerative therapy to rescue normal development in CDH fetal lungs. Particularly, we report studies showing that administration of EVs derived from amniotic fluid stem cells (AFSC-EVs) to models of pulmonary hypoplasia promotes fetal lung growth and maturation via transfer of miRNAs that are known to regulate lung developmental processes. We also describe that stem cell-derived EVs exert effects on vascular remodeling, thus possibly preventing postnatal pulmonary hypertension. Finally, we discuss future perspectives and challenges to translate this promising stem cell EV-based therapy to clinical practice. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Rebeca Lopes Figueira
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, M5G 0A4, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada
| | - Lina Antounians
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, M5G 0A4, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada
| | - Elke Zani-Ruttenstock
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, M5G 0A4, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada
| | - Kasra Khalaj
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, M5G 0A4, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada
| | - Augusto Zani
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, M5G 0A4, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada.,Department of Surgery, University of Toronto, Toronto, M5T 1P5, Canada
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8
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Antounians L, Catania VD, Montalva L, Liu BD, Hou H, Chan C, Matei AC, Tzanetakis A, Li B, Figueira RL, da Costa KM, Wong AP, Mitchell R, David AL, Patel K, De Coppi P, Sbragia L, Wilson MD, Rossant J, Zani A. Fetal lung underdevelopment is rescued by administration of amniotic fluid stem cell extracellular vesicles in rodents. Sci Transl Med 2021; 13:13/590/eaax5941. [PMID: 33883273 DOI: 10.1126/scitranslmed.aax5941] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 03/04/2020] [Accepted: 12/28/2020] [Indexed: 12/11/2022]
Abstract
Fetal lung underdevelopment, also known as pulmonary hypoplasia, is characterized by decreased lung growth and maturation. The most common birth defect found in babies with pulmonary hypoplasia is congenital diaphragmatic hernia (CDH). Despite research and clinical advances, babies with CDH still have high morbidity and mortality rates, which are directly related to the severity of lung underdevelopment. To date, there is no effective treatment that promotes fetal lung growth and maturation. Here, we describe a stem cell-based approach in rodents that enhances fetal lung development via the administration of extracellular vesicles (EVs) derived from amniotic fluid stem cells (AFSCs). Using fetal rodent models of pulmonary hypoplasia (primary epithelial cells, organoids, explants, and in vivo), we demonstrated that AFSC-EV administration promoted branching morphogenesis and alveolarization, rescued tissue homeostasis, and stimulated epithelial cell and fibroblast differentiation. We confirmed this regenerative ability in in vitro models of lung injury using human material, where human AFSC-EVs obtained following good manufacturing practices restored pulmonary epithelial homeostasis. Investigating EV mechanism of action, we found that AFSC-EV beneficial effects were exerted via the release of RNA cargo. MicroRNAs regulating the expression of genes involved in lung development, such as the miR17-92 cluster and its paralogs, were highly enriched in AFSC-EVs and were increased in AFSC-EV-treated primary lung epithelial cells compared to untreated cells. Our findings suggest that AFSC-EVs hold regenerative ability for underdeveloped fetal lungs, demonstrating potential for therapeutic application in patients with pulmonary hypoplasia.
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Affiliation(s)
- Lina Antounians
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Vincenzo D Catania
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Louise Montalva
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Benjamin D Liu
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Huayun Hou
- Genetics and Genome Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada.,Department of Molecular Genetics, University of Toronto, Toronto, M5S 1A8, Canada
| | - Cadia Chan
- Genetics and Genome Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada.,Department of Molecular Genetics, University of Toronto, Toronto, M5S 1A8, Canada
| | - Andreea C Matei
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Areti Tzanetakis
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada.,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada
| | - Bo Li
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada.,Translational Medicine Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada
| | - Rebeca L Figueira
- Laboratory of Experimental Fetal and Neonatal Surgery, Division of Pediatric Surgery, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paolo, 14049-900, Brazil
| | - Karina M da Costa
- Laboratory of Experimental Fetal and Neonatal Surgery, Division of Pediatric Surgery, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paolo, 14049-900, Brazil
| | - Amy P Wong
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada
| | - Robert Mitchell
- School of Biological Sciences, University of Reading, Reading RG6 6AS, UK
| | - Anna L David
- Institute for Women's Health, University College London, London WC1E 6HU, UK.,NIHR University College London Hospitals Biomedical Research Centre, London W1T 7HA, UK
| | - Ketan Patel
- School of Biological Sciences, University of Reading, Reading RG6 6AS, UK.,FRIAS Freiburg Institute for Advanced Studies, University of Freiburg, Freiburg 79104, Germany
| | - Paolo De Coppi
- Stem Cell and Regenerative Medicine Section, Great Ormond Street Institute of Child Health, University College of London, London WC1N 1EH, UK.,NIHR Biomedical Research Centre and Specialist Neonatal and Paediatric Unit, Great Ormond Street Hospital, London WC1N 1EH, UK
| | - Lourenço Sbragia
- Laboratory of Experimental Fetal and Neonatal Surgery, Division of Pediatric Surgery, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paolo, 14049-900, Brazil
| | - Michael D Wilson
- Genetics and Genome Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada.,Department of Molecular Genetics, University of Toronto, Toronto, M5S 1A8, Canada
| | - Janet Rossant
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada.,Department of Molecular Genetics, University of Toronto, Toronto, M5S 1A8, Canada
| | - Augusto Zani
- Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, M5G 0A4, Canada. .,Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, M5G 1X8, Canada.,Department of Surgery, University of Toronto, Toronto, M5T 1P5, Canada
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9
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Sharma D, Tsibizova VI. Current perspective and scope of fetal therapy: part 1. J Matern Fetal Neonatal Med 2020; 35:3783-3811. [PMID: 33135508 DOI: 10.1080/14767058.2020.1839880] [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] [Indexed: 10/23/2022]
Abstract
Fetal therapy term has been described for any therapeutic intervention either invasive or noninvasive for the purpose of correcting or treating any fetal malformation or condition. Fetal therapy is a rapidly evolving specialty and has gained pace in last two decades and now fetal intervention is being tried in many malformations with rate of success varying with the type of different fetal conditions. The advances in imaging techniques have allowed fetal medicine persons to make earlier and accurate diagnosis of numerous fetal anomalies. Still many fetal anomalies are managed postnatally because the fetal outcomes have not changed significantly with the use of fetal therapy and this approach avoids unnecessary maternal risk secondary to inutero intervention. The short-term maternal risk associated with fetal surgery includes preterm labor, premature rupture of membranes, uterine wall bleeding, chorioamniotic separation, placental abruption, chorioamnionitis, and anesthesia risk. Whereas, maternal long-term complications include risk of infertility, uterine rupture, and need for cesarean section in future pregnancies. The decision for invasive fetal therapy should be taken after discussion with parents about the various aspects like postnatal fetal outcome without fetal intervention, possible outcome if the fetal intervention is done, available postnatal intervention for the fetal condition, and possible short-term and long-term maternal complications. The center where fetal intervention is done should have facility of multi-disciplinary team to manage both maternal and fetal complications. The major issues in the development of fetal surgery include selection of patient for intervention, crafting effective fetal surgical skills, requirement of regular fetal and uterine monitoring, effective tocolysis, and minimizing fetal and maternal fetal risks. This review will cover the surgical or invasive aspect of fetal therapy with available evidence and will highlight the progress made in the management of fetal malformations in last two decades.
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Affiliation(s)
- Deepak Sharma
- Department of Neonatology, National Institute of Medical Science, Jaipur, India
| | - Valentina I Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation, Saint Petersburg, Russia
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10
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Nakamura H, Doi T, Puri P, Friedmacher F. Transgenic animal models of congenital diaphragmatic hernia: a comprehensive overview of candidate genes and signaling pathways. Pediatr Surg Int 2020; 36:991-997. [PMID: 32591848 PMCID: PMC7385019 DOI: 10.1007/s00383-020-04705-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2020] [Indexed: 01/10/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a relatively common and life-threatening birth defect, characterized by incomplete formation of the diaphragm. Because CDH herniation occurs at the same time as preacinar airway branching, normal lung development becomes severely disrupted, resulting almost invariably in pulmonary hypoplasia. Despite various research efforts over the past decades, the pathogenesis of CDH and associated lung hypoplasia remains poorly understood. With the advent of molecular techniques, transgenic animal models of CDH have generated a large number of candidate genes, thus providing a novel basis for future research and treatment. This review article offers a comprehensive overview of genes and signaling pathways implicated in CDH etiology, whilst also discussing strengths and limitations of transgenic animal models in relation to the human condition.
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Affiliation(s)
- Hiroki Nakamura
- National Children’s Research Centre, Our Lady’s Children’s Hospital, Dublin, Ireland ,Department of Pediatric Surgery, Kansai Medical University, Osaka, Japan
| | - Takashi Doi
- National Children’s Research Centre, Our Lady’s Children’s Hospital, Dublin, Ireland ,Department of Pediatric Surgery, Kansai Medical University, Osaka, Japan
| | - Prem Puri
- National Children’s Research Centre, Our Lady’s Children’s Hospital, Dublin, Ireland ,Beacon Hospital, University College Dublin, Dublin, Ireland
| | - Florian Friedmacher
- National Children’s Research Centre, Our Lady’s Children’s Hospital, Dublin, Ireland ,Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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11
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Abstract
Fetal surgery and fetal therapy involve surgical interventions on the fetus in utero to correct or ameliorate congenital abnormalities and give a developing fetus the best chance at a healthy life. Historical use of biomaterials in fetal surgery has been limited, and most biomaterials used in fetal surgeries today were originally developed for adult or pediatric patients. However, as the field of fetal surgery moves from open surgeries to minimally invasive procedures, many opportunities exist for innovative biomaterials engineers to create materials designed specifically for the unique challenges and opportunities of maternal-fetal surgery. Here, we review biomaterials currently used in clinical fetal surgery as well as promising biomaterials in development for eventual clinical translation. We also highlight unmet challenges in fetal surgery that could particularly benefit from novel biomaterials, including fetal membrane sealing and minimally invasive myelomeningocele defect repair. Finally, we conclude with a discussion of the underdeveloped fetal immune system and opportunities for exploitation with novel immunomodulating biomaterials.
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Affiliation(s)
- Sally M Winkler
- Department of Bioengineering, University of California, Berkeley, CA, USA. and University of California, Berkeley-University of California, San Francisco Graduate Program in Bioengineering, Berkeley, CA, USA
| | - Michael R Harrison
- Division of Pediatric Surgery, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Phillip B Messersmith
- Department of Bioengineering, University of California, Berkeley, CA, USA. and Department of Materials Science and Engineering, University of California, Berkeley, CA, USA and Materials Sciences Division, Lawrence Berkeley National Laboratory, Berkeley, CA, USA
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12
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Takahashi T, Friedmacher F, Zimmer J, Puri P. Down-regulation of N-deacetylase-N-sulfotransferase-1 signaling in the developing diaphragmatic vasculature of nitrofen-induced congenital diaphragmatic hernia. J Pediatr Surg 2017; 52:1035-1039. [PMID: 28363469 DOI: 10.1016/j.jpedsurg.2017.03.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/09/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) has been attributed to various developmental abnormalities of the underlying tissue components. N-deacetylase-N-sulfotransferase-1 (Ndst1) is a strongly expressed biosynthetic enzyme in endothelial cells, which has recently been identified as an important factor during diaphragmatic vascularization. Loss of endothelial Ndst1 has been demonstrated to cause angiogenic defects in the developing diaphragm and disrupt normal diaphragmatic development. Furthermore, deficiency of Ndst1 diminishes the expression of slit homolog 3 (Slit3), a known CDH-related gene that has been associated with reduced vascular density and muscle defects in the diaphragm of Slit3-/- mice. We hypothesized that expression of Ndst1 and Slit3 is decreased in the diaphragmatic vasculature of fetal rats with nitrofen-induced CDH. METHODS Time-mated rats received either nitrofen or vehicle on gestational day 9 (D9). Fetal diaphragms were microdissected on D13, D15 and D18, and divided into control and nitrofen-exposed specimens. Gene expression levels of Ndst1 and Slit3 were assessed using qRT-PCR. Immunofluorescence-double-staining for Ndst1 and Slit3 was performed to evaluate protein expression and localization. RESULTS Relative mRNA expression of Ndst1 and Slit3 was significantly decreased in pleuroperitoneal folds (D13), developing diaphragms (D15) and fully muscularized diaphragms (D18) of nitrofen-exposed fetuses compared to controls. Confocal-laser-scanning-microscopy revealed markedly diminished Ndst1 and Slit3 expression in endothelial cells within the diaphragmatic vasculature on D13, D15 and D18 compared to controls. CONCLUSIONS Down-regulation of Ndst1 signaling in the developing diaphragm may impair endothelial cell migration and angiogenesis, thus leading to defective diaphragmatic vascular development and CDH. LEVEL OF EVIDENCE Ib.
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Affiliation(s)
- Toshiaki Takahashi
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Florian Friedmacher
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland; Department of Paediatric Surgery, King's College Hospital, Denmark Hill, London, UK
| | - Julia Zimmer
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Prem Puri
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland; Conway Institute of Biomolecular and Biomedical Research, School of Medicine & Medical Science, University College Dublin, Dublin, Ireland.
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13
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Abstract
Congenital diaphragmatic hernia (CDH) is a complex entity wherein a diaphragmatic defect allows intrathoracic herniation of intra-abdominal contents and both pulmonary parenchymal and vascular development are stifled. Pulmonary pathology and pathophysiology, including pulmonary hypoplasia and pulmonary hypertension, are hallmarks of CDH and are associated with disease severity. Pulmonary hypertension (PH) is sustained, supranormal pulmonary arterial pressure, and among patients with CDH (CDH-PH), is driven by hypoplastic pulmonary vasculature, including alterations at the molecular, cellular, and tissue levels, along with pathophysiologic pulmonary vasoreactivity. This review addresses the basic mechanisms, altered anatomy, definition, diagnosis, and management of CDH-PH. Further, emerging therapies targeting CDH-PH and PH are explored.
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Affiliation(s)
- Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston and Children's Memorial Hermann Hospital, 6431 Fannin St, MSB 5.233, Houston, Texas 77030.
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14
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Abstract
Congenital diaphragmatic hernia (CDH) remains a major challenge and associated mortality is still significant. Patients have benefited from current therapeutic options, but most severe cases are still associated to poor outcome. Regenerative medicine is emerging as a valid option in many diseases and clinical trials are currently happening for various conditions in children and adults. We report here the advancement in the field which will help both in the understanding of further CDH development and in offering new treatment options for the difficult situations such as repair of large diaphragmatic defects and lung hypoplasia. The authors believe that advancements in regenerative medicine may lead to increase of CDH patients׳ survival.
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Affiliation(s)
- Paolo De Coppi
- Institute of Women׳s Health, Great Ormond Street, Institute of Child Health, University College London, London, UK; Academic Department of Development and Regeneration, Clinical Specialties Research Groups, Biomedical Sciences, KU Leuven, Leuven, Belgium.
| | - Jan Deprest
- Institute of Women׳s Health, Great Ormond Street, Institute of Child Health, University College London, London, UK; Academic Department of Development and Regeneration, Clinical Specialties Research Groups, Biomedical Sciences, KU Leuven, Leuven, Belgium
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15
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Takahashi T, Zimmer J, Friedmacher F, Puri P. Follistatin-like 1 expression is decreased in the alveolar epithelium of hypoplastic rat lungs with nitrofen-induced congenital diaphragmatic hernia. J Pediatr Surg 2017; 52:706-709. [PMID: 28188034 DOI: 10.1016/j.jpedsurg.2017.01.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 01/23/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND/PURPOSE Pulmonary hypoplasia (PH), characterized by incomplete alveolar development, remains a major therapeutic challenge associated with congenital diaphragmatic hernia (CDH). Follistatin-like 1 (Fstl1) is a crucial regulator of alveolar formation and maturation, which is strongly expressed in distal airway epithelium. Fstl1-deficient mice exhibit reduced airspaces, impaired alveolar epithelial cell differentiation, and insufficient production of surfactant proteins similar to PH in human CDH. We hypothesized that pulmonary Fstl1 expression is decreased during alveolarization in the nitrofen-induced CDH model. METHODS Timed-pregnant rats received nitrofen or vehicle on gestational day 9 (D9). Fetal lungs were harvested on D18 and D21 and divided into control-/nitrofen-exposed specimens. Alveolarization was assessed using morphometric analysis techniques. Pulmonary gene expression of Fstl1 was determined by qRT-PCR. Immunofluorescence-double-staining for Fstl1 and alveolar epithelial marker surfactant protein C (SP-C) was performed to evaluate protein expression/localization. RESULTS Radial alveolar count was significantly reduced in hypoplastic lungs of nitrofen-exposed fetuses with significant down regulation of Fstl1 mRNA expression on D18 and D21 compared to controls. Confocal-laser-scanning-microscopy revealed strikingly diminished Fstl1 immunofluorescence and SP-C expression in distal alveolar epithelium of nitrofen-exposed fetuses with CDH-associated PH on D18 and D21 compared to controls. CONCLUSIONS Decreased expression of Fstl1 in alveolar epithelium may disrupt alveolarization and pulmonary surfactant production, thus contributing to the development of PH in the nitrofen-induced CDH model. LEVEL OF EVIDENCE 2b (Centre for Evidence-Based Medicine, Oxford).
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Affiliation(s)
- Toshiaki Takahashi
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Gate 5, Dublin 12, Dublin, Ireland
| | - Julia Zimmer
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Gate 5, Dublin 12, Dublin, Ireland
| | - Florian Friedmacher
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Gate 5, Dublin 12, Dublin, Ireland
| | - Prem Puri
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Gate 5, Dublin 12, Dublin, Ireland; Conway Institute of Biomolecular and Biomedical Research, School of Medicine & Medical Science, University College Dublin, Belfield, Dublin, 4, Dublin, Ireland.
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16
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Takahashi T, Friedmacher F, Zimmer J, Puri P. Expression of T-box transcription factors 2, 4 and 5 is decreased in the branching airway mesenchyme of nitrofen-induced hypoplastic lungs. Pediatr Surg Int 2017; 33:139-143. [PMID: 27833996 DOI: 10.1007/s00383-016-4005-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE Pulmonary hypoplasia (PH), characterized by smaller lung size and reduced airway branching, remains a major therapeutic challenge in newborns with congenital diaphragmatic hernia (CDH). T-box transcription factors (Tbx) have been identified as key components of the gene network that regulates fetal lung development. Tbx2, Tbx4 and Tbx5 are expressed throughout the mesenchyme of the developing lung, regulating the process of lung branching morphogenesis. Furthermore, lungs of Tbx2-, Tbx4- and Tbx5-deficient mice are hypoplastic and exhibit decreased lung branching, similar to PH in human CDH. We hypothesized that the expression of Tbx2, Tbx4 and Tbx5 is decreased in the branching airway mesenchyme of hypoplastic rat lungs with nitrofen-induced CDH. METHODS Time-mated rats received either nitrofen or vehicle on gestational day 9 (D9). Fetuses were killed on D15, D18 and D21, and dissected lungs were divided into control and nitrofen-exposed specimens. Pulmonary gene expression of Tbx2, Tbx4 and Tbx5 was investigated by quantitative real-time polymerase chain reaction. Immunofluorescence double staining for Tbx2, Tbx4 and Tbx5 was combined with the mesenchymal marker Fgf10 to assess protein expression and localization in branching airway tissue. RESULTS Relative mRNA levels of Tbx2, Tbx4 and Tbx5 were significantly reduced in lungs of nitrofen-exposed fetuses on D15, D18 and D21 compared to controls. Confocal laser scanning microscopy showed markedly diminished immunofluorescence of Tbx2, Tbx4 and Tbx5 in mesenchymal cells surrounding branching airways of nitrofen-exposed fetuses on D15, D18 and D21 compared to controls. CONCLUSION Decreased expression of Tbx2, Tbx4 and Tbx5 in the pulmonary mesenchyme during fetal lung development may lead to a decrease or arrest of airway branching, thus contributing to PH in the nitrofen-induced CDH model.
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Affiliation(s)
- Toshiaki Takahashi
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, 12, Ireland
| | - Florian Friedmacher
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, 12, Ireland
| | - Julia Zimmer
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, 12, Ireland
| | - Prem Puri
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, 12, Ireland. .,Conway Institute of Biomolecular and Biomedical Research, School of Medicine and Medical Science, University College Dublin, Dublin, Ireland.
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Takahashi T, Zimmer J, Friedmacher F, Puri P. Expression of Prx1 and Tcf4 is decreased in the diaphragmatic muscle connective tissue of nitrofen-induced congenital diaphragmatic hernia. J Pediatr Surg 2016; 51:1931-1935. [PMID: 27665494 DOI: 10.1016/j.jpedsurg.2016.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 09/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND/PURPOSE Pleuroperitoneal folds (PPFs) are the source of the primordial diaphragm's muscle connective tissue (MCT), and developmental mutations have been shown to result in congenital diaphragmatic hernia (CDH). The protein paired-related homeobox 1 (Prx1) labels migrating PPF cells and stimulates expression of transcription factor 4 (Tcf4), a novel MCT marker that controls morphogenesis of the fetal diaphragm. We hypothesized that diaphragmatic Prx1 and Tcf4 expression is decreased in the nitrofen-induced CDH model. METHODS Time-mated rats were exposed to either nitrofen or vehicle on gestational day 9 (D9). Fetal diaphragms were microdissected on D13, D15, and D18, and divided into control and nitrofen-exposed specimens. Gene expression levels of Prx1 and Tcf4 were analyzed by qRT-PCR. Immunofluorescence double staining for Prx1 and Tcf4 was performed to evaluate protein expression and localization. RESULTS Relative mRNA expression of Prx1 and Tcf4 was significantly downregulated in PPFs (D13), developing diaphragms (D15) and fully muscularized diaphragms (D18) of nitrofen-exposed fetuses compared to controls. Confocal laser scanning microscopy revealed markedly diminished Prx1 and Tcf4 expression in diaphragmatic MCT of nitrofen-exposed fetuses on D13, D15, and D18 compared to controls. CONCLUSIONS Decreased expression of Prx1 and Tcf4 in the fetal diaphragm may cause defects in the PPF-derived MCT, leading to development of CDH in the nitrofen model. LEVEL OF EVIDENCE Level 2c (Centre for Evidence-Based Medicine, Oxford).
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Affiliation(s)
- Toshiaki Takahashi
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Julia Zimmer
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Florian Friedmacher
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Prem Puri
- National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland; Conway Institute of Biomolecular and Biomedical Research, School of Medicine & Medical Science, University College Dublin, Dublin, Ireland.
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18
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Decreased expression of hepatocyte growth factor in the nitrofen model of congenital diaphragmatic hernia. Pediatr Surg Int 2016; 32:967-73. [PMID: 27480986 DOI: 10.1007/s00383-016-3944-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Pleuroperitoneal folds (PPFs) are essential for normal diaphragmatic development, representing the only source of the diaphragm's muscle connective tissue. Hepatocyte growth factor (Hgf), which is secreted in PPFs, plays a crucial role in the formation of the muscular diaphragmatic components by regulating the migration of myogenic progenitor cells into the primordial diaphragm. Hgf is also a known downstream target of Gata4 and it has been demonstrated that the expression of Hgf was significantly downregulated in PPF cells of Gata4 knockouts with congenital diaphragmatic hernia (CDH). Furthermore, mutations in PPF-derived cells have been shown to result in CDH. We hypothesized that Hgf expression is decreased in developing diaphragms of fetal rats with nitrofen-induced CDH. METHODS Timed-pregnant rats were exposed to either nitrofen or vehicle on gestational day 9 (D9). Fetuses were harvested on selected time-points D13, D15 and D18. Dissected diaphragms (n = 72) were divided into control and nitrofen-exposed specimens (n = 12 per time-point and experimental group, respectively). Diaphragmatic gene expression of Hgf was analyzed by qRT-PCR. Immunofluorescence double staining for Hgf and the mesenchymal marker Gata4 or muscular progenitor marker Myogenin was performed to evaluate protein expression and localization in fetal diaphragms. RESULTS Relative mRNA expression of Hgf was significantly downregulated in PPFs of nitrofen-exposed fetuses on D13 (3.08 ± 1.46 vs. 5.24 ± 1.93; p < 0.05), developing diaphragms of nitrofen-exposed fetuses on D15 (2.01 ± 0.79 vs. 4.10 ± 1.50; p < 0.05) and fully muscularized diaphragms of nitrofen-exposed fetuses on D18 (1.60 ± 0.78 vs. 3.21 ± 1.89; p < 0.05) compared to controls. Confocal laser scanning microscopy revealed markedly diminished diaphragmatic immunofluorescence of Hgf in nitrofen-exposed fetuses on D13, D15 and D18 compared to controls, which was associated with disruptions in muscle connective tissue formation and reduced myogenic progenitor cell invasion. CONCLUSION Decreased diaphragmatic expression of Hgf may disturb the formation of muscle connective tissue in PPFs and thus prevent essential migration of muscle progenitor cells into the developing diaphragm, leading to diaphragmatic defects in the nitrofen CDH model.
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