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Martinez M, Yu W, Menden HL, Lei T, Monaghan-Nichols P, Sampath V. Butyrate suppresses experimental necrotizing enterocolitis-induced brain injury in mice. Front Pediatr 2023; 11:1284085. [PMID: 38130941 PMCID: PMC10733464 DOI: 10.3389/fped.2023.1284085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 11/15/2023] [Indexed: 12/23/2023] Open
Abstract
Background Necrotizing enterocolitis (NEC) is a devastating disease in premature infants, and 50% of infants with surgical NEC develop neurodevelopmental defects. The mechanisms by which NEC-induced cytokine release and activation of inflammatory cells in the brain mediate neuronal injury, and whether enteral immunotherapy attenuates NEC-associated brain injury remain understudied. Based on our prior work, which demonstrated that experimental NEC-like intestinal injury is attenuated by the short-chain fatty acid, butyrate, in this study, we hypothesize that NEC-induced brain injury would be suppressed by enteral butyrate supplementation. Methods A standardized NEC mouse model [enteral formula feeding, lipopolysaccharide (LPS), and hypoxia] was used. Mice were randomized into the following groups: control, NEC, butyrate pretreated NEC, and butyrate control. NEC scoring (1-4 with 4 representing severe injury) was performed on ileal sections using a validated scoring system. Intestinal and brain lysates were used to assess inflammation, proinflammatory signaling, and apoptosis. Results NEC-induced intestinal injury was attenuated by butyrate supplementation. NEC-induced microglial activation in the cerebral cortex and hippocampus was suppressed with butyrate. NEC increased the number of activated microglial cells but decreased the number of oligodendrocytes. Butyrate pretreatment attenuated these changes. Increased activation of proinflammatory Toll-like receptor signaling, cytokine expression, and induction of GFAP and IBA1 in the cerebral cortex observed with NEC was suppressed with butyrate. Conclusion Experimental NEC induced inflammation and activation of microglia in several regions of the brain, most prominently in the cortex. NEC-induced neuroinflammation was suppressed with butyrate pretreatment. The addition of short-chain fatty acids to diet may be used to attenuate NEC-induced intestinal injury and neuroinflammation in preterm infants.
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Affiliation(s)
- Maribel Martinez
- Division of Neonatology, Department of Pediatrics, Children’s Mercy Kansas City, Kansas, MO, United States
- Neonatal Diseases Research Program, Children’s Mercy Research Institute, Children’s Mercy Kansas City, Kansas, MO, United States
| | - Wei Yu
- Division of Neonatology, Department of Pediatrics, Children’s Mercy Kansas City, Kansas, MO, United States
- Neonatal Diseases Research Program, Children’s Mercy Research Institute, Children’s Mercy Kansas City, Kansas, MO, United States
| | - Heather L. Menden
- Division of Neonatology, Department of Pediatrics, Children’s Mercy Kansas City, Kansas, MO, United States
- Neonatal Diseases Research Program, Children’s Mercy Research Institute, Children’s Mercy Kansas City, Kansas, MO, United States
| | - Tianhua Lei
- Department of Biomedical Sciences, University of Missouri Kansas City School of Medicine, Kansas, MO, United States
| | - Paula Monaghan-Nichols
- Department of Biomedical Sciences, University of Missouri Kansas City School of Medicine, Kansas, MO, United States
| | - Venkatesh Sampath
- Division of Neonatology, Department of Pediatrics, Children’s Mercy Kansas City, Kansas, MO, United States
- Neonatal Diseases Research Program, Children’s Mercy Research Institute, Children’s Mercy Kansas City, Kansas, MO, United States
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2
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Zaikova EK, Kaplina AV, Petrova NA, Pervunina TM, Kostareva AA, Kalinina OV. SIGIRR gene variants in term newborns with congenital heart defects and necrotizing enterocolitis. Ann Pediatr Cardiol 2023; 16:337-344. [PMID: 38766461 PMCID: PMC11098289 DOI: 10.4103/apc.apc_30_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/28/2023] [Accepted: 08/03/2023] [Indexed: 05/22/2024] Open
Abstract
Background Necrotizing enterocolitis (NEC) is a common gastrointestinal emergency among neonates which is characterized by acute intestinal inflammation and necrosis. The main risk factors for NEC are prematurity, low birth weight, and some preexisting health conditions such as congenital heart defects (CHDs). Investigation of the potential genetic predisposition to NEC is a promising approach that might provide new insights into its pathogenesis. One of the most important proteins that play a significant role in the pathogenesis of NEC is Toll-like receptor 4 (TLR4) which recognizes lipopolysaccharide found in Gram-negative bacteria. In intestinal epithelial cells, a protein encoded by the SIGIRR gene is a major inhibitor of TLR4 signaling. A few SIGIRR variants, including rare p.Y168X and p.S80Y, have already been identified in preterm infants with NEC, but their pathogenic significance remains unclear. This study aimed to investigate the spectrum of SIGIRR genetic variants in term newborns with CHD and to assess their potential association with NEC. Methods and Results A total of 93 term newborns with critical CHD were enrolled in this study, 33 of them developed NEC. SIGIRR genetic variants were determined by Sanger sequencing of all exons. In total, eight SIGIRR genetic variants were identified, two of which were found only in newborns with NEC (P = 0.12). The rare missense p.S80Y (rs117739035) variant in exon 4 was found in two infants with NEC stage IIA. Two infants with NEC stage III and stage IB carried a novel duplication c. 102_121dup (rs552367848) variant in exon 10 that has not been previously associated with any clinical phenotype. Conclusions The presence of both variants only in neonates who developed NEC, together with earlier published data, may suggest their potential contribution to the risk of developing NEC in term infants with CHD and allow planning larger cohort studies to clarify their relevance.
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Affiliation(s)
- Ekaterina Konstantinovna Zaikova
- World-Class Research Centre for Personalized Medicine, Almazov National Medical Research Centre, Research Laboratory of Autoimmune and Autoinflammatory Diseases, St. Petersburg, Russia
| | - Aleksandra Vladimirovna Kaplina
- Almazov National Medical Research Centre, Research Laboratory of Physiology and Diseases of Newborns, St. Petersburg, Russia
| | - Natalia Aleksandrovna Petrova
- Almazov National Medical Research Centre, Research Laboratory of Physiology and Diseases of Newborns, St. Petersburg, Russia
| | | | | | - Olga Viktorovna Kalinina
- Almazov National Medical Research Centre, Research Laboratory of Physiology and Diseases of Newborns, St. Petersburg, Russia
- Department of Laboratory Medicine and Genetics, Institution of Medical Education, Almazov National Medical Research Centre, St. Petersburg, Russia
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3
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Scheese DJ, Sodhi CP, Hackam DJ. New insights into the pathogenesis of necrotizing enterocolitis and the dawn of potential therapeutics. Semin Pediatr Surg 2023; 32:151309. [PMID: 37290338 PMCID: PMC10330774 DOI: 10.1016/j.sempedsurg.2023.151309] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disorder in premature infants that causes significant morbidity and mortality. Research efforts into the pathogenesis of NEC have discovered a pivotal role for the gram-negative bacterial receptor, Toll-like receptor 4 (TLR4), in its development. TLR4 is activated by dysbiotic microbes within the intestinal lumen, which leads to an exaggerated inflammatory response within the developing intestine, resulting in mucosal injury. More recently, studies have identified that the impaired intestinal motility that occurs early in NEC has a causative role in disease development, as strategies to enhance intestinal motility can reverse NEC in preclinical models. There has also been broad appreciation that NEC also contributes to significant neuroinflammation, which we have linked to the effects of gut-derived pro-inflammatory molecules and immune cells which activate microglia in the developing brain, resulting in white matter injury. These findings suggest that the management of the intestinal inflammation may secondarily be neuroprotective. Importantly, despite the significant burden of NEC on premature infants, these and other studies have provided a strong rationale for the development of small molecules with the capability of reducing NEC severity in pre-clinical models, thus guiding the development of specific anti-NEC therapies. This review summarizes the roles of TLR4 signaling in the premature gut in the pathogenesis of NEC, and provides insights into optimal clinical management strategies based upon findings from laboratory studies.
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Affiliation(s)
- Daniel J Scheese
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Chhinder P Sodhi
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287, USA
| | - David J Hackam
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287, USA.
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4
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Cuna A, Nsumu M, Menden HL, Chavez-Bueno S, Sampath V. The Detrimental Effects of Peripartum Antibiotics on Gut Proliferation and Formula Feeding Injury in Neonatal Mice Are Alleviated with Lactobacillus rhamnosus GG. Microorganisms 2023; 11:1482. [PMID: 37374984 DOI: 10.3390/microorganisms11061482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 05/29/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
Peripartum antibiotics can negatively impact the developing gut microbiome and are associated with necrotizing enterocolitis (NEC). The mechanisms by which peripartum antibiotics increase the risk of NEC and strategies that can help mitigate this risk remain poorly understood. In this study, we determined mechanisms by which peripartum antibiotics increase neonatal gut injury and evaluated whether probiotics protect against gut injury potentiated by peripartum antibiotics. To accomplish this objective, we administered broad-spectrum antibiotics or sterile water to pregnant C57BL6 mice and induced neonatal gut injury to their pups with formula feeding. We found that pups exposed to antibiotics had reduced villus height, crypt depth, and intestinal olfactomedin 4 and proliferating cell nuclear antigen compared to the controls, indicating that peripartum antibiotics impaired intestinal proliferation. When formula feeding was used to induce NEC-like injury, more severe intestinal injury and apoptosis were observed in the pups exposed to antibiotics compared to the controls. Supplementation with the probiotic Lactobacillus rhamnosus GG (LGG) reduced the severity of formula-induced gut injury potentiated by antibiotics. Increased intestinal proliferating cell nuclear antigen and activation of the Gpr81-Wnt pathway were noted in the pups supplemented with LGG, suggesting partial restoration of intestinal proliferation by probiotics. We conclude that peripartum antibiotics potentiate neonatal gut injury by inhibiting intestinal proliferation. LGG supplementation decreases gut injury by activating the Gpr81-Wnt pathway and restoring intestinal proliferation impaired by peripartum antibiotics. Our results suggest that postnatal probiotics may be effective in mitigating the increased risk of NEC associated with peripartum antibiotic exposure in preterm infants.
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Affiliation(s)
- Alain Cuna
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO 64108, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Marianne Nsumu
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO 64108, USA
| | - Heather L Menden
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO 64108, USA
| | - Susana Chavez-Bueno
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
- Division of Infectious Diseases, Children's Mercy Kansas City, Kansas City, MO 64108, USA
| | - Venkatesh Sampath
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO 64108, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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5
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Bautista GM, Cera AJ, Chaaban H, McElroy SJ. State-of-the-art review and update of in vivo models of necrotizing enterocolitis. Front Pediatr 2023; 11:1161342. [PMID: 37082706 PMCID: PMC10112335 DOI: 10.3389/fped.2023.1161342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/13/2023] [Indexed: 04/22/2023] Open
Abstract
NEC remains one of the most common causes of mortality and morbidity in preterm infants. Animal models of necrotizing enterocolitis (NEC) have been crucial in improving our understanding of this devastating disease and identifying biochemical pathways with therapeutic potential. The pathogenesis of NEC remains incompletely understood, with no specific entity that unifies all infants that develop NEC. Therefore, investigators rely on animal models to manipulate variables and provide a means to test interventions, making them valuable tools to enhance our understanding and prevent and treat NEC. The advancements in molecular analytic tools, genetic manipulation, and imaging modalities and the emergence of scientific collaborations have given rise to unique perspectives and disease correlates, creating novel pathways of investigation. A critical review and understanding of the current phenotypic considerations of the highly relevant animal models of NEC are crucial to developing novel therapeutic and preventative strategies for NEC.
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Affiliation(s)
- Geoanna M. Bautista
- Department of Pediatrics, Division of Neonatology, University of California, Davis, Sacramento, CA, United States
| | - Anjali J. Cera
- Department of Pediatrics, Division of Neonatology, University of California, Davis, Sacramento, CA, United States
| | - Hala Chaaban
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma, OK, United States
| | - Steven J. McElroy
- Department of Pediatrics, Division of Neonatology, University of California, Davis, Sacramento, CA, United States
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6
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Sampath V, Martinez M, Caplan M, Underwood MA, Cuna A. Necrotizing enterocolitis in premature infants-A defect in the brakes? Evidence from clinical and animal studies. Mucosal Immunol 2023; 16:208-220. [PMID: 36804483 DOI: 10.1016/j.mucimm.2023.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023]
Abstract
A key aspect of postnatal intestinal adaptation is the establishment of symbiotic relationships with co-evolved gut microbiota. Necrotizing enterocolitis (NEC) is the most severe disease arising from failure in postnatal gut adaptation in premature infants. Although pathological activation of intestinal Toll-like receptors (TLRs) is believed to underpin NEC pathogenesis, the mechanisms are incompletely understood. We postulate that unregulated aberrant TLR activation in NEC arises from a failure in intestinal-specific mechanisms that tamponade TLR signaling (the brakes). In this review, we discussed the human and animal studies that elucidate the developmental mechanisms inhibiting TLR signaling in the postnatal intestine (establishing the brakes). We then evaluate evidence from preclinical models and human studies that point to a defect in the inhibition of TLR signaling underlying NEC. Finally, we provided a framework for the assessment of NEC risk by screening for signatures of TLR signaling and for NEC prevention by TLR-targeted therapy in premature infants.
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Affiliation(s)
- Venkatesh Sampath
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA; School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA.
| | - Maribel Martinez
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA; School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Michael Caplan
- Department of Pediatrics, North Shore University Health System, Evanston, Illinois, USA
| | - Mark A Underwood
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | - Alain Cuna
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA; School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
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7
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Green EA, Garrick SP, Peterson B, Berger PJ, Galinsky R, Hunt RW, Cho SX, Bourke JE, Nold MF, Nold-Petry CA. The Role of the Interleukin-1 Family in Complications of Prematurity. Int J Mol Sci 2023; 24:ijms24032795. [PMID: 36769133 PMCID: PMC9918069 DOI: 10.3390/ijms24032795] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 02/05/2023] Open
Abstract
Preterm birth is a major contributor to neonatal morbidity and mortality. Complications of prematurity such as bronchopulmonary dysplasia (BPD, affecting the lung), pulmonary hypertension associated with BPD (BPD-PH, heart), white matter injury (WMI, brain), retinopathy of prematurity (ROP, eyes), necrotizing enterocolitis (NEC, gut) and sepsis are among the major causes of long-term morbidity in infants born prematurely. Though the origins are multifactorial, inflammation and in particular the imbalance of pro- and anti-inflammatory mediators is now recognized as a key driver of the pathophysiology underlying these illnesses. Here, we review the involvement of the interleukin (IL)-1 family in perinatal inflammation and its clinical implications, with a focus on the potential of these cytokines as therapeutic targets for the development of safe and effective treatments for early life inflammatory diseases.
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Affiliation(s)
- Elys A. Green
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC 3168, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, VIC 3168, Australia
| | - Steven P. Garrick
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC 3168, Australia
| | - Briana Peterson
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC 3168, Australia
| | - Philip J. Berger
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC 3168, Australia
| | - Robert Galinsky
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC 3168, Australia
| | - Rod W. Hunt
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC 3168, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, VIC 3168, Australia
| | - Steven X. Cho
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC 3168, Australia
| | - Jane E. Bourke
- Department of Pharmacology, Biomedicine Discovery Institute, Monash University, Melbourne, VIC 3168, Australia
| | - Marcel F. Nold
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC 3168, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, VIC 3168, Australia
| | - Claudia A. Nold-Petry
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC 3168, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC 3168, Australia
- Correspondence:
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8
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Yu W, Venkatraman A, Menden HL, Martinez M, Umar S, Sampath V. Short-chain fatty acids ameliorate necrotizing enterocolitis-like intestinal injury through enhancing Notch1-mediated single immunoglobulin interleukin-1-related receptor, toll-interacting protein, and A20 induction. Am J Physiol Gastrointest Liver Physiol 2023; 324:G24-G37. [PMID: 36410023 PMCID: PMC9799135 DOI: 10.1152/ajpgi.00057.2022] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 11/23/2022]
Abstract
Single immunoglobulin interleukin-1-related receptor (SIGIRR), toll-interacting protein (TOLLIP), and A20 are major inhibitors of toll-like receptor (TLR) signaling induced postnatally in the neonatal intestine. Short-chain fatty acids (SCFAs), fermentation products of indigestible carbohydrates produced by symbiotic bacteria, inhibit intestinal inflammation. Herein, we investigated the mechanisms by which SCFAs regulate SIGIRR, A20, and TOLLIP expression and mitigate experimental necrotizing enterocolitis (NEC). Butyrate induced NOTCH activation by repressing sirtuin 1 (SIRT1)-mediated deacetylation of the Notch intracellular domain (NICD) in human intestinal epithelial cells (HIECs). Overexpression of NICD induced SIGIRR, A20, and TOLLIP expression. Chromatin immunoprecipitation revealed that butyrate-induced NICD binds to the SIGIRR, A20, and TOLLIP gene promoters. Notch1-shRNA suppressed butyrate-induced SIGIRR/A20 upregulation in mouse enteroids and HIEC. Flagellin (TLR5 agonist)-induced inflammation in HIEC was inhibited by butyrate in a SIGIRR-dependent manner. Neonatal mice fed butyrate had increased NICD, A20, SIGIRR, and TOLLIP expression in the ileal epithelium. Butyrate inhibited experimental NEC-induced intestinal apoptosis, cytokine expression, and histological injury. Our data suggest that SCFAs can regulate the expression of the major negative regulators of TLR signaling in the neonatal intestine through Notch1 and ameliorate experimental NEC. Enteral SCFAs supplementation in preterm infants provides a promising bacteria-free, therapeutic option for NEC.NEW & NOTEWORTHY Short-chain fatty acids (SCFAs), such as propionate and butyrate, metabolites produced by symbiotic gut bacteria are known to be anti-inflammatory, but the mechanisms by which they protect against NEC are not fully understood. In this study, we reveal that SCFAs regulate intestinal inflammation by inducing the key TLR and IL1R inhibitors, SIGIRR and A20, through activation of the pluripotent transcriptional factor NOTCH1. Butyrate-mediated SIGIRR and A20 induction represses experimental NEC in the neonatal intestine.
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MESH Headings
- Infant, Newborn
- Animals
- Mice
- Humans
- Enterocolitis, Necrotizing/drug therapy
- Enterocolitis, Necrotizing/prevention & control
- Enterocolitis, Necrotizing/genetics
- Receptors, Interleukin-1/genetics
- Receptors, Interleukin-1/metabolism
- Infant, Premature
- Inflammation/metabolism
- Intestinal Mucosa/metabolism
- Fatty Acids, Volatile/pharmacology
- Fatty Acids, Volatile/metabolism
- Butyrates/metabolism
- Immunoglobulins/metabolism
- Interleukin-1/metabolism
- Receptor, Notch1/metabolism
- Intracellular Signaling Peptides and Proteins/metabolism
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Affiliation(s)
- Wei Yu
- Division of Neonatology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
- Neonatal Diseases Research Program, Children's Mercy Research Institute, Children's Mercy Kansas City, Kansas City, Missouri
| | - Aparna Venkatraman
- Division of Neonatology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
- Neonatal Diseases Research Program, Children's Mercy Research Institute, Children's Mercy Kansas City, Kansas City, Missouri
| | - Heather L Menden
- Division of Neonatology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
- Neonatal Diseases Research Program, Children's Mercy Research Institute, Children's Mercy Kansas City, Kansas City, Missouri
| | - Maribel Martinez
- Division of Neonatology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
- Neonatal Diseases Research Program, Children's Mercy Research Institute, Children's Mercy Kansas City, Kansas City, Missouri
| | - Shahid Umar
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Venkatesh Sampath
- Division of Neonatology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
- Neonatal Diseases Research Program, Children's Mercy Research Institute, Children's Mercy Kansas City, Kansas City, Missouri
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9
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Rao K, Cuna A, Chavez-Bueno S, Menden H, Yu W, Ahmed I, Srinivasan P, Umar S, Sampath V. Effect of Various Preterm Infant Milk Formulas on NEC-Like Gut Injury in Mice. Front Pediatr 2022; 10:902798. [PMID: 35874567 PMCID: PMC9299064 DOI: 10.3389/fped.2022.902798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/10/2022] [Indexed: 11/13/2022] Open
Abstract
Formula feeding is an important risk factor for the development of necrotizing enterocolitis in preterm infants. The potential harmful effects of different preterm formulas on the developing intestinal tract remain incompletely understood. Here we demonstrate that feeding newborn mouse pups with various preterm formulas resulted in differing effects on intestinal inflammation, apoptosis, and activation of the pro-inflammatory transcription factor NFκB. 16S rRNA sequencing revealed that each preterm formula resulted in significant gut microbial alterations that were different from dam-fed controls. Formula feeding with EleCare and Similac Special Care caused greater intestinal injury compared to NeoSure. Pre-treatment with Lactobacillus rhamnosus GG ameliorated severity of intestinal injury from EleCare and Similac Special Care. Our findings indicate that not all preterm formulas are the same, and different formulations can have varying effects on intestinal inflammation, apoptosis, and microbiome composition.
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Affiliation(s)
- Karishma Rao
- Division of Neonatology, Children’s Mercy Hospital, Kansas City, MO, United States
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Alain Cuna
- Division of Neonatology, Children’s Mercy Hospital, Kansas City, MO, United States
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Susana Chavez-Bueno
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States
- Division of Infectious Disease, Children’s Mercy Hospital, Kansas City, MO, United States
| | - Heather Menden
- Division of Neonatology, Children’s Mercy Hospital, Kansas City, MO, United States
| | - Wei Yu
- Division of Neonatology, Children’s Mercy Hospital, Kansas City, MO, United States
| | - Ishfaq Ahmed
- Department of Biology, Kansas City Kansas Community College, Kansas City, KS, United States
| | - Pugazhendhi Srinivasan
- Department of Urology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Shahid Umar
- Department of Surgery, University of Kansas Medical Center, Kansas City, KS, United States
| | - Venkatesh Sampath
- Division of Neonatology, Children’s Mercy Hospital, Kansas City, MO, United States
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, United States
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10
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Howarth C, Banerjee J, Eaton S, Aladangady N. Biomarkers of gut injury in neonates - where are we in predicting necrotising enterocolitis? Front Pediatr 2022; 10:1048322. [PMID: 36518779 PMCID: PMC9742605 DOI: 10.3389/fped.2022.1048322] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/07/2022] [Indexed: 11/29/2022] Open
Abstract
Despite advances in neonatal care Necrotising Enterocolitis (NEC) continues to have a significant mortality and morbidity rate, and with increasing survival of those more immature infants the population at risk of NEC is increasing. Ischaemia, reperfusion, and inflammation underpin diseases affecting intestinal blood flow causing gut injury including Necrotising Enterocolitis. There is increasing interest in tissue biomarkers of gut injury in neonates, particularly those representing changes in intestinal wall barrier and permeability, to determine whether these could be useful biomarkers of gut injury. This article reviews current and newly proposed markers of gut injury, the available literature evidence, recent advances and considers how effective they are in clinical practice. We discuss each biomarker in terms of its effectiveness in predicting NEC onset and diagnosis or predicting NEC severity and then those that will aid in surveillance and identifying those infants are greatest risk of developing NEC.
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Affiliation(s)
- Claire Howarth
- Neonatal Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom
| | - Jayanta Banerjee
- Neonatal Unit, Imperial College Healthcare NHS Trust and Imperial College London, London, United Kingdom
| | - Simon Eaton
- University College London Great Ormond Street Institute of Child Health, London, England
| | - Narendra Aladangady
- Neonatal Unit, Homerton Healthcare NHS Foundation Trust, London, United Kingdom.,Barts and The London School of Medicine and Dentistry, Queen Mary University of London (QMUL), London, United Kingdom
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11
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SIGIRR Mutation in Human Necrotizing Enterocolitis (NEC) Disrupts STAT3-Dependent microRNA Expression in Neonatal Gut. Cell Mol Gastroenterol Hepatol 2021; 13:425-440. [PMID: 34563711 PMCID: PMC8688179 DOI: 10.1016/j.jcmgh.2021.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND & AIMS Single immunoglobulin interleukin-1-related receptor (SIGIRR) is a major inhibitor of Toll-like receptor signaling. Our laboratory identified a novel SIGIRR stop mutation (p.Y168X) in an infant who died of severe necrotizing enterocolitis (NEC). Herein, we investigated the mechanisms by which SIGIRR mutations induce Toll-like receptor hyper-responsiveness in the neonatal gut, disrupting postnatal intestinal adaptation. METHODS Clustered regularly interspaced short palindromic repeats (CRISPR)/Cas9 was used to generate transgenic mice encoding the SIGIRR p.Y168X mutation. Ileal lysates, mouse intestinal epithelial cell (IEC) lysates, and intestinal sections were used to assess inflammation, signal transducer and activator of transcription 3 (STAT3) phosphorylation, microRNA (miRNA), and interleukin-1-related-associated kinase 1 (IRAK1) expression. Western blot, quantitative reverse-transcription polymerase chain reaction(qRT-PCR), and luciferase assays were performed to investigate SIGIRR-STAT3 signaling in human intestinal epithelial cells (HIEC) expressing wild-type or SIGIRR (p.Y168X) plasmids. RESULTS SigirrTg mice showed increased intestinal inflammation and nuclear factor-κB activation concomitant with decreased IEC expression of miR-146a and miR-155. Mechanistic studies in HIECs showed that although SIGIRR induced STAT3-mediated expression of miR-146a and miR-155, the p.Y168X mutation disrupted SIGIRR-mediated STAT3-dependent miRNA expression. Chromatin immunoprecipitation and luciferase assays showed that SIGIRR activation of STAT3-induced miRNA expression is dependent on IRAK1. Both in HIECs and in the mouse intestine, decreased expression of miR-146a observed with the p.Y168X mutation increased expression of IRAK1, a protein whose down-regulation is important for postnatal gut adaptation. CONCLUSIONS Our results uncover a novel pathway (SIGIRR-STAT3-miRNA-IRAK1 repression) by which SIGIRR regulates postnatal intestine adaptation, which is disrupted by a SIGIRR mutation identified in human NEC. These data provide new insights into how human genetic mutations in SIGIRR identified in NEC result in loss of postnatal intestinal immune tolerance.
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12
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Lu P, Yamaguchi Y, Fulton WB, Wang S, Zhou Q, Jia H, Kovler ML, Salazar AG, Sampah M, Prindle T, Wipf P, Sodhi CP, Hackam DJ. Maternal aryl hydrocarbon receptor activation protects newborns against necrotizing enterocolitis. Nat Commun 2021; 12:1042. [PMID: 33589625 PMCID: PMC7884836 DOI: 10.1038/s41467-021-21356-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 01/25/2021] [Indexed: 02/07/2023] Open
Abstract
Necrotizing enterocolitis (NEC) is a disease of premature infants characterized by acute intestinal necrosis. Current dogma suggests that NEC develops in response to post-natal dietary and bacterial factors, and so a potential role for in utero factors in NEC remains unexplored. We now show that during pregnancy, administration of a diet rich in the aryl hydrocarbon receptor (AHR) ligand indole-3-carbinole (I3C), or of breast milk, activates AHR and prevents NEC in newborn mice by reducing Toll-like receptor 4 (TLR4) signaling in the newborn gut. Protection from NEC requires activation of AHR in the intestinal epithelium which is reduced in mouse and human NEC, and is independent of leukocyte activation. Finally, we identify an AHR ligand ("A18") that limits TLR4 signaling in mouse and human intestine, and prevents NEC in mice when administered during pregnancy. In summary, AHR signaling is critical in NEC development, and maternally-delivered, AHR-based therapies may alleviate NEC.
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MESH Headings
- Animals
- Animals, Newborn
- Basic Helix-Loop-Helix Transcription Factors/agonists
- Basic Helix-Loop-Helix Transcription Factors/genetics
- Basic Helix-Loop-Helix Transcription Factors/immunology
- Cytochrome P-450 CYP1A1/genetics
- Cytochrome P-450 CYP1A1/immunology
- Diet/methods
- Disease Models, Animal
- Enterocolitis, Necrotizing/genetics
- Enterocolitis, Necrotizing/immunology
- Enterocolitis, Necrotizing/pathology
- Enterocolitis, Necrotizing/prevention & control
- Female
- Gene Expression Regulation
- Humans
- Indoles/administration & dosage
- Infant, Newborn
- Infant, Premature
- Intestinal Mucosa/drug effects
- Intestinal Mucosa/immunology
- Intestinal Mucosa/pathology
- Ligands
- Maternal Exposure
- Mice
- Milk, Human/physiology
- Pregnancy
- Receptors, Aryl Hydrocarbon/agonists
- Receptors, Aryl Hydrocarbon/genetics
- Receptors, Aryl Hydrocarbon/immunology
- Signal Transduction
- Swine
- Toll-Like Receptor 4/genetics
- Toll-Like Receptor 4/immunology
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Affiliation(s)
- Peng Lu
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine and the Johns Hopkins Children's Center, Baltimore, MD, USA.
| | - Yukihiro Yamaguchi
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine and the Johns Hopkins Children's Center, Baltimore, MD, USA
| | - William B Fulton
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine and the Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Sanxia Wang
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine and the Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Qinjie Zhou
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine and the Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Hongpeng Jia
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine and the Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Mark L Kovler
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine and the Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Andres Gonzalez Salazar
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine and the Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Maame Sampah
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine and the Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Thomas Prindle
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine and the Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Peter Wipf
- Department of Chemistry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chhinder P Sodhi
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine and the Johns Hopkins Children's Center, Baltimore, MD, USA
| | - David J Hackam
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine and the Johns Hopkins Children's Center, Baltimore, MD, USA.
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13
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Venkatraman A, Yu W, Nitkin C, Sampath V. Intestinal Stem Cell Development in the Neonatal Gut: Pathways Regulating Development and Relevance to Necrotizing Enterocolitis. Cells 2021; 10:cells10020312. [PMID: 33546361 PMCID: PMC7913590 DOI: 10.3390/cells10020312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/21/2021] [Accepted: 01/29/2021] [Indexed: 12/15/2022] Open
Abstract
The intestine is extremely dynamic and the epithelial cells that line the intestine get replaced every 3–5 days by highly proliferative intestinal stem cells (ISCs). The instructions for ISCs to self-renew or to differentiate come as cues from their surrounding microenvironment or their niche. A small number of evolutionarily conserved signaling pathways act as a critical regulator of the stem cells in the adult intestine, and these pathways are well characterized. However, the mechanisms, nutritional, and environmental signals that help establish the stem cell niche in the neonatal intestine are less studied. Deciphering the key signaling pathways that regulate the development and maintenance of the stem cells is particularly important to understanding how the intestine regenerates from necrotizing enterocolitis, a devastating disease in newborn infants characterized by inflammation, tissues necrosis, and stem cell injury. In this review, we piece together current knowledge on morphogenetic and immune pathways that regulate intestinal stem cell in neonates and highlight how the cross talk among these pathways affect tissue regeneration. We further discuss how these key pathways are perturbed in NEC and review the scientific knowledge relating to options for stem cell therapy in NEC gleaned from pre-clinical experimental models of NEC.
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14
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Gomart A, Vallée A, Lecarpentier Y. Necrotizing Enterocolitis: LPS/TLR4-Induced Crosstalk Between Canonical TGF-β/Wnt/β-Catenin Pathways and PPARγ. Front Pediatr 2021; 9:713344. [PMID: 34712628 PMCID: PMC8547806 DOI: 10.3389/fped.2021.713344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 09/13/2021] [Indexed: 12/13/2022] Open
Abstract
Necrotizing enterocolitis (NEC) represents one of the major causes of morbidity and mortality in premature infants. Several recent studies, however, have contributed to a better understanding of the pathophysiology of this dreadful disease. Numerous intracellular pathways play a key role in NEC, namely: bacterial lipopolysaccharide (LPS), LPS toll-like receptor 4 (TLR4), canonical Wnt/β-catenin signaling and PPARγ. In a large number of pathologies, canonical Wnt/β-catenin signaling and PPARγ operate in opposition to one another, so that when one of the two pathways is overexpressed the other is downregulated and vice-versa. In NEC, activation of TLR4 by LPS leads to downregulation of the canonical Wnt/β-catenin signaling and upregulation of PPARγ. This review aims to shed light on the complex intracellular mechanisms involved in this pathophysiological profile by examining additional pathways such as the GSK-3β, NF-κB, TGF-β/Smads, and PI3K-Akt pathways.
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Affiliation(s)
- Alexia Gomart
- Département de Pédiatrie et Médecine de l'adolescent, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Alexandre Vallée
- Department of Clinical Research and Innovation, Foch Hospital, Suresnes, France
| | - Yves Lecarpentier
- Centre de Recherche Clinique, Grand Hôpital de l'Est Francilien, Meaux, France
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15
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Cho SX, Rudloff I, Lao JC, Pang MA, Goldberg R, Bui CB, McLean CA, Stock M, Klassert TE, Slevogt H, Mangan NE, Cheng W, Fischer D, Gfroerer S, Sandhu MK, Ngo D, Bujotzek A, Lariviere L, Schumacher F, Tiefenthaler G, Beker F, Collins C, Kamlin COF, König K, Malhotra A, Tan K, Theda C, Veldman A, Ellisdon AM, Whisstock JC, Berger PJ, Nold-Petry CA, Nold MF. Characterization of the pathoimmunology of necrotizing enterocolitis reveals novel therapeutic opportunities. Nat Commun 2020; 11:5794. [PMID: 33188181 PMCID: PMC7666196 DOI: 10.1038/s41467-020-19400-w] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 10/14/2020] [Indexed: 12/17/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is a severe, currently untreatable intestinal disease that predominantly affects preterm infants and is driven by poorly characterized inflammatory pathways. Here, human and murine NEC intestines exhibit an unexpected predominance of type 3/TH17 polarization. In murine NEC, pro-inflammatory type 3 NKp46−RORγt+Tbet+ innate lymphoid cells (ILC3) are 5-fold increased, whereas ILC1 and protective NKp46+RORγt+ ILC3 are obliterated. Both species exhibit dysregulation of intestinal TLR repertoires, with TLR4 and TLR8 increased, but TLR5-7 and TLR9-12 reduced. Transgenic IL-37 effectively protects mice from intestinal injury and mortality, whilst exogenous IL-37 is only modestly efficacious. Mechanistically, IL-37 favorably modulates immune homeostasis, TLR repertoires and microbial diversity. Moreover, IL-37 and its receptor IL-1R8 are reduced in human NEC epithelia, and IL-37 is lower in blood monocytes from infants with NEC and/or lower birthweight. Our results on NEC pathomechanisms thus implicate type 3 cytokines, TLRs and IL-37 as potential targets for novel NEC therapies. Necrotizing Enterocolitis (NEC) is an untreatable intestinal disease in infants. Here the authors show that human and experimental mouse NEC is associated with altered toll-like receptor expression in the intestine, enhanced Th17/type 3 polarization in adaptive immune and innate lymphoid cells, dysregulated microbiota, and reduced interleukin-37 signaling.
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Affiliation(s)
- Steven X Cho
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Immunology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Ina Rudloff
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Jason C Lao
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Merrin A Pang
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Rimma Goldberg
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Medicine, Monash University, Melbourne, VIC, Australia.,Department of Gastroenterology, Monash Health, Melbourne, VIC, Australia
| | - Christine B Bui
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Catriona A McLean
- Department of Anatomical Pathology, Alfred Hospital, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | | | | | | | - Niamh E Mangan
- Department of Molecular and Translational Science, Monash University, Melbourne, VIC, Australia.,Centre for Innate Immunity and Infectious Diseases, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Wei Cheng
- Department of Surgery, Beijing United Family Hospital, Beijing, China.,Capital Institute of Pediatrics, Beijing, China
| | - Doris Fischer
- Department of Pediatrics, Goethe University Hospital, Frankfurt, Germany.,Department of Pediatrics, St. Vincenz Hospital, Limburg, Germany
| | - Stefan Gfroerer
- Department of Pediatric Surgery, Goethe University Hospital, Frankfurt, Germany.,Helios Clinic Berlin-Buch, Berlin, Germany
| | - Manjeet K Sandhu
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Gastroenterology, Monash Health, Melbourne, VIC, Australia
| | - Devi Ngo
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Alexander Bujotzek
- Roche Pharma Research and Early Development, Roche Innovation Center Munich, Penzberg, Germany
| | - Laurent Lariviere
- Roche Pharma Research and Early Development, Roche Innovation Center Munich, Penzberg, Germany
| | - Felix Schumacher
- Roche Pharma Research and Early Development, Roche Innovation Center Munich, Penzberg, Germany
| | - Georg Tiefenthaler
- Roche Pharma Research and Early Development, Roche Innovation Center Munich, Penzberg, Germany
| | - Friederike Beker
- Mater Research Institute, University of Queensland, Brisbane, QLD, Australia.,Neonatal Services, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Clare Collins
- Neonatal Services, Mercy Hospital for Women, Melbourne, VIC, Australia.,Joan Kirner Women's & Children's, Sunshine Hospital, Melbourne, VIC, Australia
| | - C Omar F Kamlin
- Department of Newborn Research, Royal Women's Hospital, Melbourne, VIC, Australia.,University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Kai König
- Medicum Wesemlin, Department of Paediatrics, Lucerne, Switzerland
| | - Atul Malhotra
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Kenneth Tan
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Christiane Theda
- Department of Newborn Research, Royal Women's Hospital, Melbourne, VIC, Australia.,University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Alex Veldman
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Pediatrics, St. Vincenz Hospital, Limburg, Germany.,Department of Pediatrics, Liebig University Hospital, Giessen, Germany
| | - Andrew M Ellisdon
- Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology, Monash University, Melbourne, VIC, Australia
| | - James C Whisstock
- Biomedicine Discovery Institute and Department of Biochemistry and Molecular Biology, Monash University, Melbourne, VIC, Australia.,Australian Research Council Centre of Excellence in Advanced Molecular Imaging, Monash University, Melbourne, VIC, Australia
| | - Philip J Berger
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Claudia A Nold-Petry
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Marcel F Nold
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia. .,Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia. .,Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.
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16
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Cuna A, Yu W, Menden H, Feng L, Srinivasan P, Chavez-Bueno S, Ahmed I, Umar S, Sampath V. NEC-like intestinal injury is ameliorated by Lactobacillus rhamnosus GG in parallel with SIGIRR and A20 induction in neonatal mice. Pediatr Res 2020; 88:546-555. [PMID: 32053825 PMCID: PMC8213439 DOI: 10.1038/s41390-020-0797-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/13/2020] [Accepted: 01/24/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Exaggerated Toll-like receptor (TLR) signaling and intestinal dysbiosis are key contributors to necrotizing enterocolitis (NEC). Lactobacillus rhamnosus GG (LGG) decreases NEC in preterm infants, but underlying mechanisms of protection remain poorly understood. We hypothesized that LGG alleviates dysbiosis and upregulates TLR inhibitors to protect against TLR-mediated gut injury. METHODS Effects of LGG (low- and high-dose) on intestinal pro-inflammatory TLR signaling and injury in neonatal mice subjected to formula feeding (FF) and NEC were determined. 16S sequencing of stool and expression of anti-TLR mediators SIGIRR (single immunoglobulin interleukin-1-related receptor) and A20 were analyzed. RESULTS FF induced mild intestinal injury with increased expression of interleukin-1β (IL-1β) and Kupffer cell (KC) (mouse homolog of IL-8) compared to controls. LGG decreased IL-1β and KC in association with attenuated TLR signaling and increased SIGIRR and A20 expression in a dose-dependent manner. Low- and high-dose LGG had varying effects on gut microbiome despite both doses providing gut protection. Subsequent experiments of LGG on NEC revealed that pro-inflammatory TLR signaling and intestinal injury were also decreased, and SIGIRR and A20 expression increased, in a dose-dependent manner with LGG pre-treatment. CONCLUSIONS LGG protects against intestinal TLR-mediated injury by upregulating TLR inhibitors without major changes in gut microbiome composition.
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Affiliation(s)
- Alain Cuna
- University of Missouri-Kansas City, Kansas City MO,Children’s Mercy Kansas City, Kansas City MO
| | - Wei Yu
- Children’s Mercy Kansas City, Kansas City MO
| | | | - Linda Feng
- Children’s Mercy Kansas City, Kansas City MO
| | | | - Susana Chavez-Bueno
- University of Missouri-Kansas City, Kansas City MO,Children’s Mercy Kansas City, Kansas City MO
| | - Ishfaq Ahmed
- University of Kansas Medical Center, Kansas City KS
| | - Shahid Umar
- University of Kansas Medical Center, Kansas City KS
| | - Venkatesh Sampath
- University of Missouri-Kansas City, Kansas City, MO, USA. .,Children's Mercy Kansas City, Kansas City, MO, USA.
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17
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Zhao R, Song C, Liu L, Liu Q, Zhou N, Zhou X, Xie Y. Single immunoglobulin and Toll‑interleukin‑1 receptor domain containing molecule protects against severe acute pancreatitis in vitro by negatively regulating the Toll‑like receptor‑4 signaling pathway: A clinical and experimental study. Mol Med Rep 2020; 22:2851-2859. [PMID: 32945488 PMCID: PMC7453662 DOI: 10.3892/mmr.2020.11379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 07/10/2020] [Indexed: 02/05/2023] Open
Abstract
Single immunoglobulin and Toll-interleukin-1 receptor domain-containing molecule (SIGIRR) is a specific inhibitor of IL-1R and Toll-like receptor (TLR) signaling and considered a potential target for the treatment of inflammatory diseases. Pathogenic mechanisms associated with the TLR4 signaling pathway have a critical role in the development of severe acute pancreatitis (SAP). The aim of the present study was to determine the role of SIGIRR in the regulation of TLR4 signaling during the progression of SAP. Pancreatitis-associated ascitic fluid (PAAF) was collected from patients with SAP. Murine RAW264.7 macrophages were transfected with a SIGIRR overexpression plasmid and co-cultured with the PAAF from the donors in order to evaluate the effect of SIGIRR in vitro. The mRNA expression of TLR4, SIGIRR and other key downstream signaling molecules was quantified using semi-quantitative PCR with agarose gel electrophoresis. Furthermore, the levels of pro-inflammatory cytokines in the culture supernatant were detected using ELISA. In contrast to SIGIRR, the mRNA expression levels of TLR4, myeloid differentiation factor 88 (MyD88), IL-1R-associated kinase-1 (IRAK-1) and TNF receptor-associated factor-6 (TRAF-6) were significantly increased in RAW264.7 cells following treatment with PAAF. Furthermore, TLR4, MyD88, IRAK-1 and TRAF-6 mRNA levels were significantly downregulated following SIGIRR overexpression and PAAF treatment in RAW264.7 cells. The levels of IL-2, IL-12, IL-17 and IFN-γ in the culture supernatant were also significantly decreased, while IL-10 levels were increased. Overall, SIGIRR negatively regulated the TLR4 signaling pathway to protect against the development of SAP in an in vitro model. Therefore, SIGIRR may represent a promising therapeutic target for SAP.
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Affiliation(s)
- Rulin Zhao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Conghua Song
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Li Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Qiong Liu
- Jiangxi Institute of Medical Sciences, Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Nanjin Zhou
- Jiangxi Institute of Medical Sciences, Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Xiaojiang Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Yong Xie
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
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18
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Shelby RD, Raab R, Besner GE, McElroy SJ. Hope on the horizon: promising novel therapies for necrotizing enterocolitis. Pediatr Res 2020; 88:30-34. [PMID: 32855510 DOI: 10.1038/s41390-020-1077-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Necrotizing enterocolitis (NEC) remains among the most common and devastating diseases in neonates. Despite advances in neonatal clinical care, specific treatment strategies and diagnostic modalities remain lacking. As a result, morbidity and mortality remain high. Improved understanding of the pathogenesis of NEC has the potential for improved therapeutics. Some of the areas of research leading to promising discoveries include inhibition of Toll-like receptor signaling, modulation of vascular endothelial growth factor signal pathways, defining metabolomic alterations in NEC to discover potential biomarkers, probing for genetic predispositions to NEC susceptibility, determining mechanistic relations between anemia and NEC, and microflora modulation through the use of probiotics. All of these areas may represent novel promising approaches to the prevention and treatment of NEC. This review will focus on these current and possible therapeutic perspectives.
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Affiliation(s)
- Rita D Shelby
- Department of Pediatric Surgery, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Gail E Besner
- Department of Pediatric Surgery, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Steven J McElroy
- Stead Family Department of Pediatrics and Department of Microbiology and Immunology, University of Iowa, Iowa City, IA, USA.
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19
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Agakidou E, Agakidis C, Gika H, Sarafidis K. Emerging Biomarkers for Prediction and Early Diagnosis of Necrotizing Enterocolitis in the Era of Metabolomics and Proteomics. Front Pediatr 2020; 8:602255. [PMID: 33425815 PMCID: PMC7793899 DOI: 10.3389/fped.2020.602255] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022] Open
Abstract
Necrotizing Enterocolitis (NEC) is a catastrophic disease affecting predominantly premature infants and is characterized by high mortality and serious long-term consequences. Traditionally, diagnosis of NEC is based on clinical and radiological findings, which, however, are non-specific for NEC, thus confusing differential diagnosis of other conditions such as neonatal sepsis and spontaneous intestinal perforation. In addition, by the time clinical and radiological findings become apparent, NEC has already progressed to an advanced stage. During the last three decades, a lot of research has focused on the discovery of biomarkers, which could accurately predict and make an early diagnosis of NEC. Biomarkers used thus far in clinical practice include acute phase proteins, inflammation mediators, and molecules involved in the immune response. However, none has been proven accurate enough to predict and make an early diagnosis of NEC or discriminate clinical from surgical NEC or other non-NEC gastrointestinal diseases. Complexity of mechanisms involved in NEC pathogenesis, which remains largely poorly elucidated, could partly explain the unsatisfactory diagnostic performance of the existing NEC biomarkers. More recently applied technics can provide important insight into the pathophysiological mechanisms underlying NEC but can also aid the detection of potentially predictive, early diagnostic, and prognostic biomarkers. Progress in omics technology has allowed for the simultaneous measurement of a large number of proteins, metabolic products, lipids, and genes, using serum/plasma, urine, feces, tissues, and other biological specimens. This review is an update of current data on emerging NEC biomarkers detected using proteomics and metabolomics, further discussing limitations and future perspectives in prediction and early diagnosis of NEC.
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Affiliation(s)
- Eleni Agakidou
- 1st Department of Neonatology, Faculty of Medicine, Ippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Charalampos Agakidis
- 1st Department of Pediatrics, Faculty of Medicine, Ippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Helen Gika
- Laboratory of Forensic Medicine and Toxicology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.,BIOMIC_AUTH, Bioanalysis and Omics Laboratory, Centre for Interdisciplinary Research and Innovation, CIRI-AUTH B1.4, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kosmas Sarafidis
- 1st Department of Neonatology, Faculty of Medicine, Ippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Liang S, Lai P, Li X, Xu J, Bao Y, Fang Y, Ding M. Ulinastatin Reduces the Severity of Intestinal Damage in the Neonatal Rat Model of Necrotizing Enterocolitis. Med Sci Monit 2019; 25:9123-9130. [PMID: 31786582 PMCID: PMC6904988 DOI: 10.12659/msm.919413] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Ulinastatin is a protease inhibitor derived from urine that has shown anti-inflammatory effects in human disease, including in sepsis. Necrotizing enterocolitis (NEC) is a common gastrointestinal disease in premature infants. Our aim was to explore the effects of ulinastatin on a neonatal NEC rat model. Material/Methods Forty-five neonatal rats were divided into 3 groups: normal control; NEC+sepsis-induced kidney injury (SIRS); NEC/SIRS+ulinastatin. The NEC/SIRS model was induced by injection of intraperitoneal saline, enteral formula feeding, hypoxia-hyperoxide, and cold stress exposure. The NEC/SIRS neonatal rats were perfused with ulinastatin at a dose of 10 000 u/kg/day. Giemsa staining and hematoxylin and eosin (H&E) were performed to evaluate the severity of intestinal damage. To assess intestinal cell apoptosis, we examined the expression of caspase-3 by TUNEL staining and western blot analysis. Intestinal levels of inflammatory cytokines (IL-1β, IL-6, and TNF-α) were examined using ELISA assay. Results Rats in the NEC treated with ulinastatin group had better physiological status and histological score compared to the NEC/SIRS group. Ulinastatin reduced NEC-induced weight loss. Macroscopic and microscopic morphology analyses showed that rats in the NEC treated with ulinastatin group had lower severity of intestinal damage compared to the NEC/SIRS group. TUNEL staining and caspase-3 expression detection results revealed that ulinastatin significantly inhibited intestinal cell apoptosis of NEC. Furthermore, ulinastatin decreased the intestinal levels of IL-1β, IL-6, and TNF-α in NEC. Conclusions Ulinastatin could ameliorate the severity of intestinal damage in NEC and possess anti-apoptosis and anti-inflammation effects.
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Affiliation(s)
- Shuxia Liang
- Department of Ophthalmology, Jinhua Hospital of Zhejiang University, Jinhua, Zhejiang, China (mainland)
| | - Panjian Lai
- Department of Pediatrics, Jinhua Hospital of Zhejiang University, Jinhua, Zhejiang, China (mainland)
| | - Xiaobing Li
- Department of Pediatrics, Jinhua Hospital of Zhejiang University, Jinhua, Zhejiang, China (mainland)
| | - Jie Xu
- Operating Room, Jinhua Hospital of Zhejiang University, Jinhua, Zhejiang, China (mainland)
| | - Yunguang Bao
- Department of Pediatrics, Jinhua Hospital of Zhejiang University, Jinhua, Zhejiang, China (mainland)
| | - Yuanshu Fang
- Department of Laboratory Animals Center, Jinhua Institute for Food and Drug Control, Jinhua, Zhejiang, China (mainland)
| | - Mingxing Ding
- Medical Molecular Biology Laboratory, School of Medicine, Jinhua Polytechnic, Jinhua, Zhejiang, China (mainland)
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Porcine Circovirus Type 2 Induces Single Immunoglobulin Interleukin-1 Related Receptor (SIGIRR) Downregulation to Promote Interleukin-1β Upregulation in Porcine Alveolar Macrophage. Viruses 2019; 11:v11111021. [PMID: 31684202 PMCID: PMC6893714 DOI: 10.3390/v11111021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 12/18/2022] Open
Abstract
Multisystemic inflammation in pigs affected by porcine circovirus type 2 (PCV2) indicates the disordered expression of inflammatory cytokines. However, the PCV2-induced expression profile of inflammation cytokines and its regulating mechanism remain poorly understood. In this study, inflammatory cytokines and receptors in porcine alveolar macrophages (PAMs) after PCV2 infection were profiled in vitro by an RT2 ProfilerTM PCR array assay. The regulatory mechanism of interleukin-1β (IL-1β) expression was investigated. Results showed that 49 of 84 inflammation cytokines and receptors were differentially expressed (p < 0.05, absolute fold change ≥2) in PAMs at different stages post-PCV2 infection. Moreover, the overexpression of single-immunoglobulin interleukin-1 related receptor (SIGIRR) or the blocking of NF-κB activation by its inhibitor markedly decreased IL-1β secretion. This finding suggested that PCV2-induced overexpression of IL-1β was associated with the downregulation of SIGIRR and the activation of NF-κB. Furthermore, the excessive activity of NF-κB in SIGIRR-knockout PAMs cell line, indicating that SIGIRR negatively regulated IL-1β production by inhibiting the activation of NF-κB. Overall, PCV2-induced downregulation of SIGIRR induction of NF-κB activation is a critical process in enhancing IL-1β production in PAMs. This study may provide insights into the underlying inflammatory response that occurs in pigs following PCV2 infection.
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Abstract
Necrotizing enterocolitis is a devastating intestinal disease affecting preterm infants. In spite of ongoing research and advancement in neonatal care, mortality remains high, especially in infants with advanced disease. The mechanism of disease development, the progression of intestinal injury, and management remain areas of ongoing research and controversy. In this review, we examine our current understanding of the disease, its epidemiology, the risk factors associated with the development of the disease, and its pathophysiology. We also describe current management and new emerging research highlighting potential future directions.
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Affiliation(s)
- Mashriq Alganabi
- Division of General and Thoracic Surgery, Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carol Lee
- Division of General and Thoracic Surgery, Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Edoardo Bindi
- Division of General and Thoracic Surgery, Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bo Li
- Division of General and Thoracic Surgery, Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
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Cuna A, George L, Sampath V. Genetic predisposition to necrotizing enterocolitis in premature infants: Current knowledge, challenges, and future directions. Semin Fetal Neonatal Med 2018; 23:387-393. [PMID: 30292709 PMCID: PMC6626706 DOI: 10.1016/j.siny.2018.08.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The role of genetics in the pathogenesis of necrotizing enterocolitis (NEC) was initially informed by epidemiological data indicating differences in prevalence among different ethnic groups as well as concordance in twins. These early observations, together with major advances in genomic research, paved the way for studies that begin to reveal the contribution of genetics to NEC. Using the candidate gene or pathway approach, several potential pathogenic variants for NEC in premature infants have already been identified. More recently, genome-wide association studies and exome-sequencing based studies for NEC have been reported. These advances, however, are tempered by the lack of adequately powered replication cohorts to validate the accuracy of these discoveries. Despite many challenges, genetic research in NEC is expected to increase, providing new insights into its pathogenesis and bringing the promise of personalized care closer to reality. In this review we provide a summary of genetic studies in NEC along with defining the challenges and possible future approaches.
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Affiliation(s)
| | | | - Venkatesh Sampath
- Division of Neonatology, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA.
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Hackam DJ, Sodhi CP. Toll-Like Receptor-Mediated Intestinal Inflammatory Imbalance in the Pathogenesis of Necrotizing Enterocolitis. Cell Mol Gastroenterol Hepatol 2018; 6:229-238.e1. [PMID: 30105286 PMCID: PMC6085538 DOI: 10.1016/j.jcmgh.2018.04.001] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/02/2018] [Indexed: 02/08/2023]
Abstract
Necrotizing enterocolitis (NEC) remains the leading cause of death from gastrointestinal disease in premature infants and attacks the most fragile patients at a time when they appear to be the most stable. Despite significant advances in our overall care of the premature infant, NEC mortality remains stubbornly high. There is no specific treatment for NEC beyond broad-spectrum antibiotics and intestinal resection, and current efforts have focused on preventive strategies. Over the past decade, we have proposed a unifying hypothesis to explain the pathogenesis of NEC in premature infants that suggests that NEC develops in response to an imbalance between exaggerated proinflammatory signaling in the mucosa of the premature gut leading to mucosal injury, which is not countered effectively by endogenous repair processes, and in the setting of impaired mesenteric perfusion leads to intestinal ischemia and disease development. One of the most important pathways that mediates the balance between injury and repair in the premature intestine, and that plays a key role in NEC pathogenesis, is Toll-like receptor 4 (TLR4), which recognizes lipopolysaccharide on gram-negative bacteria. This review focuses on the role that the TLR4-mediated imbalance between proinflammatory and anti-inflammatory signaling in the premature intestinal epithelium leads to the development of NEC, and will explore how an understanding of the role of TLR4 in NEC pathogenesis has led to the identification of novel preventive or treatment approaches for this devastating disease.
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MESH Headings
- Enterocolitis, Necrotizing/metabolism
- Enterocolitis, Necrotizing/microbiology
- Enterocolitis, Necrotizing/pathology
- Humans
- Infant
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/metabolism
- Infant, Premature, Diseases/microbiology
- Infant, Premature, Diseases/pathology
- Inflammation/metabolism
- Inflammation/microbiology
- Inflammation/pathology
- Intestinal Mucosa/metabolism
- Intestinal Mucosa/microbiology
- Intestinal Mucosa/pathology
- Milk, Human/metabolism
- Mortality, Premature
- Risk Factors
- Toll-Like Receptor 4/metabolism
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Affiliation(s)
- David J. Hackam
- Division of General Pediatric Surgery, Johns Hopkins University, Johns Hopkins Hospital, Baltimore, Maryland
- Johns Hopkins Children’s Center, Johns Hopkins Hospital, Baltimore, Maryland
| | - Chhinder P. Sodhi
- Division of General Pediatric Surgery, Johns Hopkins University, Johns Hopkins Hospital, Baltimore, Maryland
- Johns Hopkins Children’s Center, Johns Hopkins Hospital, Baltimore, Maryland
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