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Jank M, Doktor F, Zani A, Keijzer R. Cellular origins and translational approaches to congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151444. [PMID: 38996507 DOI: 10.1016/j.sempedsurg.2024.151444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2024]
Abstract
Congenital Diaphragmatic Hernia (CDH) is a complex developmental abnormality characterized by abnormal lung development, a diaphragmatic defect and cardiac dysfunction. Despite significant advances in management of CDH, mortality and morbidity continue to be driven by pulmonary hypoplasia, pulmonary hypertension, and cardiac dysfunction. The etiology of CDH remains unknown, but CDH is presumed to be caused by a combination of genetic susceptibility and external/environmental factors. Current research employs multi-omics technologies to investigate the molecular profile and pathways inherent to CDH. The aim is to discover the underlying pathogenesis, new biomarkers and ultimately novel therapeutic targets. Stem cells and their cargo, non-coding RNAs and agents targeting inflammation and vascular remodeling have produced promising results in preclinical studies using animal models of CDH. Shortcomings in current therapies combined with an improved understanding of the pathogenesis in CDH have given rise to novel promising experimental treatments that are currently being evaluated in clinical trials. This review provides insight into current developments in translational research, ranging from the cellular origins of abnormal cardiopulmonary development in CDH and the identification of novel treatment targets in preclinical CDH models at the bench and their translation to clinical trials at the bedside.
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Affiliation(s)
- Marietta Jank
- Department of Surgery, Division of Pediatric Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, and Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada; Department of Pediatric Surgery, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Fabian Doktor
- Division of General and Thoracic Surgery, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada; Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany
| | - Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Richard Keijzer
- Department of Surgery, Division of Pediatric Surgery, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, and Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada.
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Ibarra C, Bergh E, Tsao K, Johnson A. Prenatal diagnostic and intervention considerations in congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151436. [PMID: 39018717 DOI: 10.1016/j.sempedsurg.2024.151436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
Congenital diaphragmatic hernia (CDH) is a life-threatening birth defect with significant morbidity and mortality. The prenatal management of a pregnancy with a fetus affected with CDH is complex and requires a multi-disciplinary team approach. An improved understanding of prenatal diagnosis and management is essential to developing strategies to optimize outcomes for these patients. In this review, we explore the current knowledge on diagnosis, severity stratification, prognostic prediction, and indications for fetal intervention in the fetus with CDH.
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Affiliation(s)
- Claudia Ibarra
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
| | - Eric Bergh
- Department of Obstetrics and Gynecology, Division of Fetal Intervention, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States.
| | - Kuojen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Anthony Johnson
- Department of Obstetrics and Gynecology, Division of Fetal Intervention, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
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3
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Surak A, Mahgoub L, Ting JY. Hemodynamic management of congenital diaphragmatic hernia: the role of targeted neonatal echocardiography. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000790. [PMID: 38737963 PMCID: PMC11086387 DOI: 10.1136/wjps-2024-000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/17/2024] [Indexed: 05/14/2024] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a major congenital anomaly, resulting from the herniation of abdominal contents into the thoracic cavity, thereby impeding the proper development of the lungs and pulmonary vasculature. CDH severity correlates with a spectrum of pulmonary hypoplasia, pulmonary hypertension (PHT), and cardiac dysfunction, constituting the pathophysiological triad of this complex condition. The accurate diagnosis and effective management of PHT and cardiac dysfunction is pivotal to optimizing patient outcomes. Targeted neonatal echocardiography is instrumental in delivering real-time data crucial for the bespoke, pathophysiology-targeted hemodynamic management of CDH-associated PHT.
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Affiliation(s)
- Aimann Surak
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Linda Mahgoub
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph Y Ting
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Bhutada S, Tran-Lundmark K, Kramer B, Conner P, Lowry AM, Blackstone E, Frenckner B, Mesas-Burgos C, Apte SS. Identification of protein biomarkers associated with congenital diaphragmatic hernia in human amniotic fluid. Sci Rep 2023; 13:15483. [PMID: 37726509 PMCID: PMC10509251 DOI: 10.1038/s41598-023-42576-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 09/12/2023] [Indexed: 09/21/2023] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a severe birth defect frequently associated with pulmonary hypoplasia, pulmonary hypertension, and heart failure. Since amniotic fluid comprises proteins of both fetal and maternal origin, its analysis could provide insights on mechanisms underlying CDH and provide biomarkers for early diagnosis, severity of pulmonary changes and treatment response. The study objective was to identify proteomic changes in amniotic fluid consistently associated with CDH. Amniotic fluid was obtained at term (37-39 weeks) from women with normal pregnancies (n = 5) or carrying fetuses with CDH (n = 5). After immuno-depletion of the highest abundance proteins, off-line fractionation and high-resolution tandem mass spectrometry were performed and quantitative differences between the proteomes of the groups were determined. Of 1036 proteins identified, 218 were differentially abundant. Bioinformatics analysis showed significant changes in GP6 signaling, in the MSP-RON signaling in macrophages pathway and in networks associated with cardiovascular system development and function, connective tissue disorders and dermatological conditions. Differences in selected proteins, namely pulmonary surfactant protein B, osteopontin, kallikrein 5 and galectin-3 were validated by orthogonal testing using ELISA in larger cohorts and showed statistically significant differences aiding in the diagnosis and prediction of CDH. The findings provide potential tools for clinical management of CDH.
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Affiliation(s)
- Sumit Bhutada
- Department of Biomedical Engineering-ND20, Cleveland Clinic Lerner Research Institute, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Karin Tran-Lundmark
- Department of Experimental Medical Science and Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- The Pediatric Heart Center, Skane University Hospital, Lund, Sweden
| | - Benjamin Kramer
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Peter Conner
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Ashley M Lowry
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Eugene Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Bjorn Frenckner
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Carmen Mesas-Burgos
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Suneel S Apte
- Department of Biomedical Engineering-ND20, Cleveland Clinic Lerner Research Institute, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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De Bie FR, Tate T, Antiel RM. Maternal-fetal surgery as part of pediatric palliative care. Semin Fetal Neonatal Med 2023; 28:101440. [PMID: 37173213 DOI: 10.1016/j.siny.2023.101440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Maternal-fetal surgical interventions have become a more common part of prenatal care. This third option, beside termination or post-natal interventions, complicates prenatal decision-making: while interventions may be lifesaving, survivors may face a life with disability. Pediatric palliative care (PPC) is more than end of life or hospice care, it aims at helping patients with complex medical conditions live well. In this paper, we briefly discuss maternal-fetal surgery, challenges regarding counseling and benefit-risk evaluation, argue that PPC should be a routine part of prenatal consultation, discuss the pivotal role of the maternal-fetal surgeon in the PCC-team, and finally discuss some of the ethical considerations of maternal-fetal surgery. We illustrate this with a case example of an infant diagnosed with congenital diaphragmatic hernia (CDH).
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Affiliation(s)
- Felix R De Bie
- Department of General Surgery, KU Leuven University Hospital, Leuven, Belgium
| | - Tyler Tate
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Ryan M Antiel
- Division of Pediatric Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
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Singh K. Prenatal Interventions for the Treatment of Congenital Disorders. Regen Med 2023. [DOI: 10.1007/978-981-19-6008-6_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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Schwab ME, Lee H, Tsao K. In Utero Therapy for Congenital Diaphragmatic Hernia. Clin Perinatol 2022; 49:863-872. [PMID: 36328604 DOI: 10.1016/j.clp.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Congenital diaphragmatic hernia is an anomaly that is often prenatally diagnosed and spans a wide spectrum of disease, with high morbidity and mortality associated with fetuses with severe defects. Congenital diaphragmatic hernia is thus an ideal target for fetal intervention. We review the literature on prenatal diagnosis, describe the history of fetal intervention for congenital diaphragmatic hernia, and discuss fetal endoscopic tracheal occlusion and the Tracheal Occlusion To Accelerate Lung growth trial results. Finally, we present preclinical studies for potential future directions.
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Affiliation(s)
- Marisa E Schwab
- Division of Pediatric Surgery, University of California San Francisco, 550 16th Street, San Francisco, San Francisco, CA 94158, USA; Department of Surgery, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Hanmin Lee
- Division of Pediatric Surgery, University of California San Francisco, 550 16th Street, San Francisco, San Francisco, CA 94158, USA
| | - KuoJen Tsao
- Department of Pediatric Surgery and Obstetrics, Gynecology & Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, 6410 Fannin Street, Suite 950, Houston, TX 77030, USA.
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8
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Danzer E, Rintoul NE, van Meurs KP, Deprest J. Prenatal management of congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2022; 27:101406. [PMID: 36456433 DOI: 10.1016/j.siny.2022.101406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Recently, two randomized controlled, prospective trials, the Tracheal Occlusion to Accelerate Lung Growth (TOTAL) trials, reported the outcomes on fetal endoluminal tracheal occlusion (FETO) for isolated left congenital diaphragmatic hernia (CDH). FETO significantly improved outcomes for severe hypoplasia. The effect in moderate cases, where the balloon was inserted later in pregnancy, did not reach significance. In a pooled analysis investigating the effect of the heterogeneity of the treatment effect by the time point of occlusion and severity, the difference may be explained by a difference in the duration of occlusion. Nevertheless, FETO carries a significant risk of preterm birth. The primary objective of this review is to provide an overview of the rationale for fetal intervention in CDH and the results of the randomized trials. The secondary objective is to discuss the technical aspects of FETO. Finally, recent developments of potential alternative fetal approaches will be highlighted.
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Affiliation(s)
- Enrico Danzer
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Division of Neonatal and Developmental Medicine, Palo Alto, CA, USA; Division of Pediatric Surgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA.
| | - Natalie E Rintoul
- The Richard Wood Jr. Center for Fetal Diagnosis and Treatment and Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Krisa P van Meurs
- Stanford University School of Medicine and Lucile Packard Children's Hospital, Division of Neonatal and Developmental Medicine, Palo Alto, CA, USA
| | - Jan Deprest
- Academic Department Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium; Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Obstetrics and Gynecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium; Institute of Women's Health, University College London Hospitals, London, United Kingdom
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9
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De Bie FR, Basurto D, Kumar S, Deprest J, Russo FM. Sildenafil during the 2nd and 3rd Trimester of Pregnancy: Trials and Tribulations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11207. [PMID: 36141480 PMCID: PMC9517616 DOI: 10.3390/ijerph191811207] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/02/2022] [Accepted: 09/03/2022] [Indexed: 06/16/2023]
Abstract
Sildenafil, a phosphodiesterase 5 inhibitor with a vasodilatory and anti-remodeling effect, has been investigated concerning various conditions during pregnancy. Per indication, we herein review the rationale and the most relevant experimental and clinical studies, including systematic reviews and meta-analyses, when available. Indications for using sildenafil during the second and third trimester of pregnancy include maternal pulmonary hypertension, preeclampsia, preterm labor, fetal growth restriction, oligohydramnios, fetal distress, and congenital diaphragmatic hernia. For most indications, the rationale for administering prenatal sildenafil is based on limited, equivocal data from in vitro studies and rodent disease models. Clinical studies report mild maternal side effects and suggest good fetal tolerance and safety depending on the underlying pathology.
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Affiliation(s)
| | - David Basurto
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
| | - Sailesh Kumar
- Mater Research Institute and School of Medicine, University of Queensland, Brisbane, QLD 4343, Australia
| | - Jan Deprest
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Department of Obstetrics and Gynecology, UZ Leuven, 3000 Leuven, Belgium
| | - Francesca Maria Russo
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Department of Obstetrics and Gynecology, UZ Leuven, 3000 Leuven, Belgium
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10
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de Coppi P, Loukogeorgakis S, Götherström C, David AL, Almeida-Porada G, Chan JKY, Deprest J, Wong KKY, Tam PKH. Regenerative medicine: prenatal approaches. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:643-653. [PMID: 35963269 PMCID: PMC10664288 DOI: 10.1016/s2352-4642(22)00192-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 05/24/2022] [Accepted: 05/31/2022] [Indexed: 10/15/2022]
Abstract
This two-paper Series focuses on recent advances and applications of regenerative medicine that could benefit paediatric patients. Innovations in genomic, stem-cell, and tissue-based technologies have created progress in disease modelling and new therapies for congenital and incurable paediatric diseases. Prenatal approaches present unique opportunities associated with substantial biotechnical, medical, and ethical obstacles. Maternal plasma fetal DNA analysis is increasingly adopted as a noninvasive prenatal screening or diagnostic test for chromosomal and monogenic disorders. The molecular basis for cell-free DNA detection stimulated the development of circulating tumour DNA testing for adult cancers. In-utero stem-cell, gene, gene-modified cell (and to a lesser extent, tissue-based) therapies have shown early clinical promise in a wide range of paediatric disorders. Fetal cells for postnatal treatment and artificial placenta for ex-utero fetal therapies are new frontiers in this exciting field.
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Affiliation(s)
- Paolo de Coppi
- Stem Cell and Regenerative Medicine Section, Department of Developmental Biology and Cancer Research and Teaching, Great Ormond Street Institute of Child Health, University College London, London, UK; Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Institute of Child Health, University College London, London, UK.
| | - Stavros Loukogeorgakis
- Stem Cell and Regenerative Medicine Section, Department of Developmental Biology and Cancer Research and Teaching, Great Ormond Street Institute of Child Health, University College London, London, UK; Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Cecilia Götherström
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Womens Health, University College London, London, UK
| | - Graça Almeida-Porada
- Wake Forest Institute for Regenerative Medicine, Fetal Research and Therapy Program, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem NC, USA
| | - Jerry K Y Chan
- Academic Clinical Program in Obstetrics and Gynaecology, Duke-NUS Medical School, Singapore; Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
| | - Jan Deprest
- Clinical Department of Obstetrics and Gynaecology, UZ Leuven, Leuven, Belgium
| | - Kenneth Kak Yuen Wong
- Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, Special Administrative Region, China
| | - Paul Kwong Hang Tam
- Division of Paediatric Surgery, Department of Surgery, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, Special Administrative Region, China; Faculty of Medicine, Macau University of Science and Technology, Macau Special Administrative Region, China.
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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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De Bie FR, Halline CG, Kotzur T, Hayes K, Rouse CC, Chang J, Larson AC, Khan SA, Spina A, Tilden S, Russo FM, Hedrick HL, Deprest J, Partridge EA. Prenatal treprostinil reduces the pulmonary hypertension phenotype in the rat model of congenital diaphragmatic hernia. EBioMedicine 2022; 81:104106. [PMID: 35779494 PMCID: PMC9244734 DOI: 10.1016/j.ebiom.2022.104106] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 11/30/2022] Open
Abstract
Background Persistent pulmonary hypertension (PH) causes significant mortality and morbidity in infants with congenital diaphragmatic hernia (CDH). Since pulmonary vascular abnormalities in CDH develop early during foetal development, we hypothesized that prenatal maternal administration of treprostinil, through its anti-remodelling effect, would improve the PH-phenotype in the nitrofen rat model of CDH. Methods In a dose-finding study in normal, healthy pregnant rats, we demonstrated target-range foetal plasma treprostinil concentrations without signs of toxicity. Next, an efficacy study was performed assessing the effects of treprostinil administration at 900 and 1500ng/kg/min from gestational day (GD) 16 until term (GD 21) in CDH and control pups. Pulmonary vascular and airway morphometry, lung mechanics, and expression patterns of genes implicated in the prostaglandin vasoactive pathway were studied. Findings In rats maternal administration of 1500ng/kg/min treprostinil reached target foetal concentrations, with no detrimental maternal or foetal side-effects. Prenatal exposure to 900 and 1500 ng/kg/min treprostinil reduced the medial wall thickness (%MWT) (CDH·900, 38.5± 8·4%; CDH.1500, 40·2±9·7%; CDH, 46·6±8·2%; both p < 0·0001) in rat pups with CDH, however increased the %MWT in normal foetuses (C.T.900, 36·6±11·1%; C.T.1500, 36·9±9·3%; C.P., 26·9±6·2%; both p < 0·001). Pulmonary airway development, lung hypoplasia and pulmonary function were unaffected by drug exposure. Interpretation In pregnant rats maternally administered treprostinil crosses the placenta, attains foetal target concentrations, and is well tolerated by both mother and foetuses. This report shows a significant reduction of pulmonary arteriole muscularization with prenatal treprostinil in a nitrofen rat model, supporting the promise of this treatment approach for PH of CDH. Funding United Therapeutics Corporation provided treprostinil and financial support (ISS-2020-10879).
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13
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De Bie FR, Russo FM, Van Brantegem P, Coons BE, Moon JK, Yang Z, Pang C, Senra JC, Omann C, Annaert P, Allegaert K, Davey MG, Flake AW, Deprest J. Pharmacokinetics and pharmacodynamics of sildenafil in fetal lambs on extracorporeal support. Biomed Pharmacother 2021; 143:112161. [PMID: 34537676 DOI: 10.1016/j.biopha.2021.112161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/24/2021] [Accepted: 09/03/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Maternal transplacental administration of sildenafil is being considered for a variety of fetal conditions. Clinical translation also requires evaluation of fetal safety in a higher species, such as the fetal lamb. Experiments with the pregnant ewe are curtailed by minimal transplacental transfer as well as limited access to the fetus. The EXTra-uterine Environment for Neonatal Development (EXTEND) model renders the isolated fetal lamb readily accessible and allows for direct fetal administration of sildenafil. METHODS Five fetal lambs were placed on extracorporeal support in the EXTEND device and received continuous intravenous (IV) sildenafil (0.3-0.5-0.7 mg/kg/24hr) for a duration of one to seven days. Plasma sildenafil concentrations were sampled at regular intervals to establish the pharmacokinetic profile using population pharmacokinetic modeling. Serial Doppler ultrasound examination, continuous non-invasive hemodynamic monitoring and blood gas analysis were done to evaluate the pharmacodynamic effects and fetal response. FINDINGS The target concentration range (47-500 ng/mL) was attained with all doses. Sildenafil induced an immediate and temporary reduction of pulmonary vascular resistance, mean arterial pressure and circuit flow, without change in fetal lactate levels and acid-base status. The duration of the systemic effects increased with the dose. INTERPRETATION Immediate temporary pulmonary vascular and systemic hemodynamic changes induced by sildenafil were biochemically well tolerated by fetal lambs on extracorporeal support, with the 0.5 mg/kg/24 h dose balancing rapid attainment of target concentrations with short-lived systemic effects. RESEARCH IN CONTEXT None. SEARCH STRATEGY BEFORE UNDERTAKING THE STUDY A literature review was conducted searching online databases (Medline, Embase and Cochrane), using search terms: fetal OR prenatal OR antenatal AND sildenafil, without time-limit and excluding human studies. Where relevant, investigators were contacted in order to avoid duplication of work. EVIDENCE BEFORE THIS STUDY Prenatal therapy with sildenafil, a phosphodiesterase-5 inhibitor with vasodilatory and anti-remodeling effects on vascular smooth muscle cells, has been considered for a variety of fetal conditions. One multicenter clinical trial investigating the benefit of sildenafil in severe intrauterine growth restriction (the STRIDER-trial) was halted early due to excess mortality in the sildenafil-exposed arm at one treatment site. Such findings demonstrate the importance of extensive preclinical safety assessment in relevant animal models. Transplacentally administered sildenafil leads to decreased pulmonary arterial muscularization, preventing or reducing the occurrence of pulmonary hypertension in rat and rabbit fetuses with diaphragmatic hernia (DH). Validation of these results in a higher and relevant animal model, e.g. fetal lambs, is the next step to advance clinical translation. We recently demonstrated that, in contrast to humans, transplacental transfer of sildenafil in sheep is minimal, precluding the in vivo study of fetal effects at target concentrations using the conventional pregnant ewe model. ADDED VALUE OF THIS STUDY We therefore used the extracorporeal support model for fetal lambs, referred to as the EXTra-uterine Environment for Neonatal Development (EXTEND) system, bypassing placental and maternal metabolism, to investigate at what dose the target concentrations are reached, and what the fetal hemodynamic impact and response are. Fetal hemodynamic and metabolic tolerance to sildenafil are a crucial missing element on the road to clinical translation. This is therefore the first study investigating the pharmacokinetics, hemodynamic and biochemical effects of clinical-range concentrations of sildenafil in fetal lambs, free from placental and maternal interference. IMPLICATIONS OF ALL THE AVAILABLE EVIDENCE We demonstrated self-limiting pulmonary vasodilation, a decrease of both systemic arterial pressures and circuit flows, induced by clinical range concentrations of sildenafil, without the development of fetal acidosis. This paves the way for further investigation of prenatal sildenafil in fetal lambs on extracorporeal support. A dose of 0.5 mg/kg/24 h offered the best trade-off between rapid achievement of target concentrations and shortest duration of systemic effects. This is also the first study using the EXTEND as a model for pharmacotherapy during pregnancy.
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Affiliation(s)
- Felix R De Bie
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, United States; MyFetUZ, Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
| | - Francesca M Russo
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, United States
| | | | - Barbara E Coons
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, United States
| | - James K Moon
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, United States
| | - Zexuan Yang
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, United States
| | - Chengcheng Pang
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, United States
| | - Janaina C Senra
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, United States
| | - Camilla Omann
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, United States
| | - Pieter Annaert
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Belgium
| | - Karel Allegaert
- MyFetUZ, Department of Development and Regeneration, KU Leuven, Leuven, Belgium; Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Belgium; Department of Hospital Pharmacy, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Marcus G Davey
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, United States
| | - Alan W Flake
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, United States
| | - Jan Deprest
- MyFetUZ, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Perrone EE, Deprest JA. Fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia: a narrative review of the history, current practice, and future directions. Transl Pediatr 2021; 10:1448-1460. [PMID: 34189104 PMCID: PMC8192998 DOI: 10.21037/tp-20-130] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Fetal intervention for fetuses with congenital diaphragmatic hernia (CDH) has been investigated for over 30 years and is summarized in this manuscript. The review begins with a discussion of the history of fetal intervention for this severe congenital anomaly beginning with open fetal surgery with repair of the anatomical defect, shifting towards tracheal occlusion via open surgery techniques, and finally fetoscopic endoluminal balloon tracheal occlusion using a percutaneous approach. The current technique of fetal endoscopic tracheal occlusion (FETO) is described in detail with steps of the procedure and complementary figures. The main outcomes of single-institutional studies and multiple systematic reviews are examined and discussed. Despite these studies, the fetal community agrees that FETO remains investigational at this time as there is insufficient evidence to recommend it as the standard of care for CDH. A randomized controlled trial, The Tracheal Occlusion to Accelerate Lung Growth (TOTAL) trial, has been designed to attempt to answer this question in an elaborate, international, multi-institutional study and is described in the text. Finally, future directions of fetal intervention for antenatally diagnosed CDH are discussed, including options for non-isolated CDH, the Smart-TO balloon for nonoperative reversal of occlusion, and transplacental sildenafil for treatment of pulmonary hypertension prior to birth.
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Affiliation(s)
- Erin E Perrone
- Department of Surgery, Section of Pediatric Surgery, Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Jan A Deprest
- Clinical Department of Obstetrics and Gynecology, Academic Department of Development and Regeneration, Woman and Child, Leuven, Belgium.,Institute of Women's Health, University College London, London, UK
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