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Caritis SN, Dodeja P, Sharma S, Zhao W, Venkataramanan R. The dosing regimen for 17-hydroxyprogesterone caproate was suboptimal: lessons for future pharmacotherapy for pregnant women. Am J Obstet Gynecol 2024:S0002-9378(24)00526-X. [PMID: 38670444 DOI: 10.1016/j.ajog.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 04/15/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Makena (17-hydroxyprogesterone caproate) was approved by the United States Food and Drug Administration for the prevention of recurrent spontaneous preterm birth in 2011 under the accelerated approval pathway, but fundamental pharmacokinetic or pharmacodynamic (Phase 1 and Phase 2) studies were not performed. At the time, there were no dose-response or concentration-response data. The therapeutic concentration was not known. The lack of such data brings into question the dosing regimen for 17-hydroxyprogesterone caproate and if it was optimized. OBJECTIVE The purpose of this study was to evaluate the dosing regimen for 17-hydroxyprogesterone by analyzing 3 data sets in which the 17-hydroxyprogesterone caproate pharmacology was evaluated, namely the Maternal-Fetal Medicine Omega 3 study, the Obstetric-Fetal Pharmacology Research Units study, and the Obstetrical-Fetal Pharmacology Research Centers study. If an inappropriate dosing regimen could be identified, such information could inform future studies of pharmacotherapy in pregnancy. STUDY DESIGN Data from the Omega 3 study were used to determine if plasma concentration was related to spontaneous preterm birth risk and if a threshold concentration could be identified. Data from the Obstetric-Fetal Pharmacology Research Units study were used to determine the half-life of 17-hydroxyprogesterone caproate and to develop a model to simulate drug concentrations with various dosing regimens. Data from the Obstetrical-Fetal Pharmacology Research Centers study were used to determine the relationship between dose and safety outcomes. RESULTS Analysis of the Omega 3 data set indicated that the risk for spontaneous preterm birth decreased as the log concentration of 17-hydroxyprogesterone caproate increased (odds ratio, 0.04; 95% confidence interval, 0.00-0.90). A steady state concentration of >9 ng/mL (equivalent to >8 ng/mL at 25-28 weeks) was associated with the lowest risk for spontaneous preterm birth (hazard ratio, 0.52; 95% confidence interval, 0.27-0.98; P=.04); this concentration was not achieved in 25% of subjects who received the 250 mg weekly dose. In the Obstetrical-Fetal Pharmacology Research Units study, the adjusted half-life (median and interquartile range) of 17-hydroxyprogesterone caproate was 14.0 (11.5-17.2) days. Simulations indicated that with the 250 mg weekly dose, >5 weekly injections were required to reach the 9 ng/mL target; however, those with the shortest half-life (corresponding to higher clearance), never reached the targeted 9 ng/mL concentration. In 75% of subjects, a loading dose of 500 mg weekly for 2 weeks followed by 250 mg weekly achieved and maintained the 9 ng/mL concentration within 2 weeks but in those 25% with the shortest half-life, concentrations exceeded the 9 ng/mL target for only 3 weeks. In the Obstetrical-Fetal Pharmacology Research Centers study, all 65 subjects who received a weekly dose of 500 mg exceeded the 9 ng/mL steady state. CONCLUSION The dosing regimen for 17-hydroxyprogesterone caproate was inadequate. There is a significant inverse relationship between drug concentration and spontaneous preterm birth. The risk was lowest when the concentration exceeded 9 ng/mL, but 25% of women who received the 250 mg weekly dose never reached or maintained this concentration. The drug's long half-life necessitates a loading dose to achieve therapeutic concentrations rapidly. The omission of basic pharmacologic studies to determine the proper dosing may have compromised the effectiveness of 17-hydroxyprogesterone caproate. Future pharmacotherapy trials in pregnancy must first complete fundamental pharmacology studies.
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Affiliation(s)
- Steve N Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, PA.
| | - Prerna Dodeja
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Shringi Sharma
- Department of Clinical Pharmacology, AstraZeneca, South San Francisco, CA
| | - Wenchen Zhao
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA
| | - Raman Venkataramanan
- Departments of Pharmaceutical Sciences and Pathology, University of Pittsburgh School of Pharmacy, Pittsburgh, PA; Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Brown EC, Hallinger DR, Simmons SO. High-throughput AR dimerization assay identifies androgen disrupting chemicals and metabolites. FRONTIERS IN TOXICOLOGY 2023; 5:1134783. [PMID: 37082740 PMCID: PMC10112521 DOI: 10.3389/ftox.2023.1134783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/07/2023] [Indexed: 04/07/2023] Open
Abstract
Introduction: Analysis of streamlined computational models used to predict androgen disrupting chemicals revealed that assays measuring androgen receptor (AR) cofactor recruitment/dimerization were particularly indispensable to high predictivity, especially for AR antagonists. As the original dimerization assays used to develop the minimal assay models are no longer available, new assays must be established and evaluated as suitable alternatives to assess chemicals beyond the original 1,800+ supported by the current data. Here we present the AR2 assay, which is a stable, cell-based method that uses an enzyme complementation approach.Methods: Bipartite domains of the NanoLuc luciferase enzyme were fused to the human AR to quantitatively measure ligand-dependent AR homodimerization. 128 chemicals with known endocrine activity profiles including 43 AR reference chemicals were screened in agonist and antagonist modes and compared to the legacy assays. Test chemicals were rescreened in both modes using a retrofit method to incorporate robust cytochrome P450 (CYP) metabolism to assess CYP-mediated shifts in bioactivity.Results: The AR2 assay is amenable to high-throughput screening with excellent robust Z’-factors (rZ’) for both agonist (0.94) and antagonist (0.85) modes. The AR2 assay successfully classified known agonists (balanced accuracy = 0.92) and antagonists (balanced accuracy = 0.79–0.88) as well as or better than the legacy assays with equal or higher estimated potencies. The subsequent reevaluation of the 128 chemicals tested in the presence of individual human CYP enzymes changed the activity calls for five compounds and shifted the estimated potencies for several others.Discussion: This study shows the AR2 assay is well suited to replace the previous AR dimerization assays in a revised computational model to predict AR bioactivity for parent chemicals and their metabolites.
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Affiliation(s)
- Evan C. Brown
- Oak Ridge Institute for Science Education Fellow, Research Triangle Park, NC, United States
- Rapid Assay Development Branch, Biomolecular and Computational Toxicology Division, Center for Computational Toxicology and Exposure, Office of Research and Development, U. S. Environmental Protection Agency, Research Triangle Park, NC, United States
| | - Daniel R. Hallinger
- Rapid Assay Development Branch, Biomolecular and Computational Toxicology Division, Center for Computational Toxicology and Exposure, Office of Research and Development, U. S. Environmental Protection Agency, Research Triangle Park, NC, United States
| | - Steven O. Simmons
- Rapid Assay Development Branch, Biomolecular and Computational Toxicology Division, Center for Computational Toxicology and Exposure, Office of Research and Development, U. S. Environmental Protection Agency, Research Triangle Park, NC, United States
- *Correspondence: Steven O. Simmons,
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Murphy CC, Cirillo PM, Krigbaum NY, Cohn BA. In utero exposure to 17α-hydroxyprogesterone caproate and risk of cancer in offspring. Am J Obstet Gynecol 2022; 226:132.e1-132.e14. [PMID: 34767803 PMCID: PMC8748293 DOI: 10.1016/j.ajog.2021.10.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/15/2021] [Accepted: 10/28/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND 17α-hydroxyprogesterone caproate is a synthetic progestogen initially approved in the 1950s to treat gynecologic and obstetrical conditions. Despite continued concerns about safety and short-term efficacy regarding the use of 17α-hydroxyprogesterone caproate for the prevention of preterm birth in pregnant women, little is known about the long-term effects of 17α-hydroxyprogesterone caproate on the health of the offsprings. OBJECTIVE To examine the association between in utero exposure to 17α-hydroxyprogesterone caproate and the risk of cancer in the offspring. STUDY DESIGN The Child Health and Development Studies was a population-based cohort of >18,000 mother-child dyads receiving prenatal care in the Kaiser Foundation Health Plan (Oakland, CA) between 1959 and 1966. Clinical information was abstracted from the mothers' medical records beginning 6 months before pregnancy through delivery. We identified the number and timing of 17α-hydroxyprogesterone caproate injections during pregnancy. Incident cancers diagnosed in the offspring were ascertained through 2019 by linkage to the California Cancer Registry. We used the Cox proportional hazard models to estimate the adjusted hazard ratios and their 95% confidence intervals, with the follow-up time accrued from the date of birth through the date of cancer diagnosis, death, or last contact. RESULTS A total of 1008 offspring were diagnosed with cancer over 730,817 person-years of follow-up. Approximately 1.0% of the offspring (n=234) were exposed in utero to 17α-hydroxyprogesterone caproate. Exposure in the first trimester was associated with an increased risk of any cancer (adjusted hazard ratio, 2.57; 95% confidence interval, 1.59-4.15), and the risk increased with the number of injections (1-2 injections: adjusted hazard ratio, 1.80; 95% confidence interval, 1.12-2.90; ≥3 injections: adjusted hazard ratio, 3.07; 95% confidence interval, 1.34-7.05). Exposure in the second or third trimester conferred an additional risk for the male (adjusted hazard ratio, 2.59; 95% confidence interval, 1.07-6.28) but not for the female (adjusted hazard ratio, 0.30; 95% confidence interval, 0.04-1.11) offspring. The risk of colorectal (adjusted hazard ratio, 5.51; 95% confidence interval, 1.73-17.59), prostate (adjusted hazard ratio, 5.10; 95% confidence interval, 1.24-21.00), and pediatric brain (adjusted hazard ratio, 34.72; 95% confidence interval, 7.29-164.33) cancer was higher in the offspring first exposed to 17α-hydroxyprogesterone caproate in the first trimester than the offspring not exposed. CONCLUSION Caution using 17α-hydroxyprogesterone caproate in early pregnancy is warranted, given the possible link with cancer in the offspring.
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Affiliation(s)
- Caitlin C Murphy
- School of Public Health, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX.
| | - Piera M Cirillo
- Child Health and Development Studies, Public Health Institute, Berkeley, CA
| | | | - Barbara A Cohn
- Child Health and Development Studies, Public Health Institute, Berkeley, CA
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Ren Z, Bremer AA, Pawlyk AC. Drug development research in pregnant and lactating women. Am J Obstet Gynecol 2021; 225:33-42. [PMID: 33887238 DOI: 10.1016/j.ajog.2021.04.227] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/08/2021] [Accepted: 04/11/2021] [Indexed: 12/15/2022]
Abstract
Pregnant and lactating women are considered "therapeutic orphans" because they generally have been excluded from clinical drug research and the drug development process owing to legal, ethical, and safety concerns. Most medications prescribed for pregnant and lactating women are used "off-label" because most of the clinical approved medications do not have appropriate drug labeling information for pregnant and lactating women. Medications that lack human safety data on use during pregnancy and lactation may pose potential risks for adverse effects in pregnant and lactating women as well as risks of teratogenic effects to their unborn and newborn babies. Federal policy requiring the inclusion of women in clinical research and trials led to considerable changes in research design and practice. Despite more women being included in clinical research and trials, the inclusion of pregnant and lactating women in drug research and clinical trials remains limited. A recent revision to the "Common Rule" that removed pregnant women from the classification as a "vulnerable" population may change the culture of drug research and drug development in pregnant and lactating women. This review article provides an overview of medications studied by the Obstetric-Fetal Pharmacology Research Units Network and Centers and describes the challenges in current obstetrical pharmacology research and alternative strategies for future research in precision therapeutics in pregnant and lactating women. Implementation of the recommendations of the Task Force on Research Specific to Pregnant Women and Lactating Women can provide legislative requirements and opportunities for research focused on pregnant and lactating women.
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Affiliation(s)
- Zhaoxia Ren
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD.
| | - Andrew A Bremer
- Pediatric Growth and Nutrition Branch, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD; Pregnancy and Perinatology Branch, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Aaron C Pawlyk
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
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Li H, Lampe JN. Neonatal cytochrome P450 CYP3A7: A comprehensive review of its role in development, disease, and xenobiotic metabolism. Arch Biochem Biophys 2019; 673:108078. [PMID: 31445893 DOI: 10.1016/j.abb.2019.108078] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 08/17/2019] [Accepted: 08/18/2019] [Indexed: 12/14/2022]
Abstract
The human cytochrome P450 CYP3A7, once thought to be an enzyme exclusive to fetal livers, has more recently been identified in neonates and developing infants as old as 24 months post-gestational age. CYP3A7 has been demonstrated to metabolize two endogenous compounds that are known to be important in the growth and development of the fetus and neonate, namely dehydroepiandrosterone sulfate (DHEA-S) and all-trans retinoic acid (atRA). In addition, it is also known to metabolize a variety of drugs and xenobiotics, albeit generally to a lesser extent relative to CYP3A4/5. CYP3A7 is an important component in the development and protection of the fetal liver and additionally plays a role in certain disease states, such as cancer and adrenal hyperplasia. Ultimately, a full understanding of the expression, regulation, and metabolic properties of CYP3A7 is needed to provide neonates with appropriate individualized pharmacotherapy. This article summarizes the current state of knowledge of CYP3A7, including its discovery, distribution, alleles, RNA splicing, expression and regulation, metabolic properties, substrates, and inhibitors.
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Affiliation(s)
- Haixing Li
- Sino-German Joint Research Institute Nanchang University, 235 East Nanjing Road, Nanchang, 330047, Jiangxi, PR China
| | - Jed N Lampe
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Pharmaceutical Sciences, Mail Stop C238, 12850 E. Montview Blvd., Aurora, CO, 80045, USA.
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Manuck TA. Refining Pharmacologic Research to Prevent and Treat Spontaneous Preterm Birth. Front Pharmacol 2017; 8:118. [PMID: 28360854 PMCID: PMC5350137 DOI: 10.3389/fphar.2017.00118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 02/27/2017] [Indexed: 01/12/2023] Open
Affiliation(s)
- Tracy A Manuck
- Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill Chapel Hill, NC, USA
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Sharma S, Caritis S, Hankins G, Miodovnik M, Hebert MF, Mattison D, Venkataramanan R. Population pharmacokinetics of 17α-hydroxyprogesterone caproate in singleton gestation. Br J Clin Pharmacol 2016; 82:1084-93. [PMID: 27133963 DOI: 10.1111/bcp.12990] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 03/12/2016] [Accepted: 04/07/2016] [Indexed: 11/28/2022] Open
Abstract
AIMS 17α-hydroxyprogesterone caproate (17-OHPC) reduces the rate of preterm birth in women with a prior preterm birth. Limited data exist on the pharmacokinetics (PK) of 17-OHPC or the plasma concentrations achieved during therapy. In this study, we evaluated the population PK of 17-OHPC in pregnant subjects with singleton gestation and also evaluated intrinsic and extrinsic factors that may potentially affect 17-OHPC PK in this patient population. METHODS Sixty-one women with singleton pregnancies participated in this trial. Subjects received weekly intramuscular injections of 250 mg 17-OHPC in 1 ml castor oil from the time of enrolment (16 0/7 weeks - 20 6/7 weeks) up to 35 weeks gestation or until delivery. Blood samples were obtained between 24 and 28 weeks, between 32 and 35 weeks and over a 28-day period beyond the last injection. Maternal and/or cord blood were obtained at delivery. Data analysis was performed by nonlinear mixed effects modelling (NONMEM(®) ). RESULTS The 17-OHPC PK were best described by a model with one maternal compartment and one fetal compartment, with first-order absorption and elimination from the maternal compartment. Maternal body weight was a significant covariate for both clearance (CL/F) and volume of distribution (Vmaternal /F). The final population mean estimates were: CL/F 1797 l/d, Vmaternal /F 32 610 l and mother to cord rate constant 0.005 day(-1) . This report describes for the first time the population PK of 17-OHPC in singleton pregnancy. CONCLUSIONS The population PK study reported here represents the initial steps in understanding and optimizing 17-OHPC therapy for preventing preterm birth.
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Affiliation(s)
- Shringi Sharma
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Steve Caritis
- Departments of Obstetrics, Gynecology and Reproductive Sciences, Magee-Women's Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gary Hankins
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - Menachem Miodovnik
- Medstar Health Research Institute, Hyatsville, MD, USA.,Georgetown-Howards University Center for Clinical and Translational Science, Washington, DC, USA
| | - Mary F Hebert
- Department of Pharmacy and Obstetrics & Gynecology, University of Washington, Seattle, WA, USA
| | - Don Mattison
- McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, and Risk Sciences International, Ottawa, ON, Canada
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
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Zhao C, Han LY, Ren W, Zhao HY, Han SY, Zheng WX, Pang LN, Li XH, Li PP. Metabolic profiling of tenacigenin B, tenacissoside H and tenacissoside I using UHPLC-ESI-Orbitrap MS/MS. Biomed Chromatogr 2016; 30:1757-1765. [PMID: 27106066 DOI: 10.1002/bmc.3750] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/10/2016] [Accepted: 04/19/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Can Zhao
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education); Beijing 100142 People's Republic of China
- Department of Integration of Chinese and Western Medicine; Peking University Cancer Hospital and Institute; Beijing 100142 People's Republic of China
| | - Ling-Yu Han
- Institute of Chinese Materia Medica; China Academy of Chinese Medical Sciences; Beijing 100700 People's Republic of China
| | - Wei Ren
- Institute of Chinese Materia Medica; China Academy of Chinese Medical Sciences; Beijing 100700 People's Republic of China
- Capital Medical University School of Traditional Chinese Medicine; Beijing 100069 People's Republic of China
| | - Hai-Yu Zhao
- Institute of Chinese Materia Medica; China Academy of Chinese Medical Sciences; Beijing 100700 People's Republic of China
| | - Shu-Yan Han
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education); Beijing 100142 People's Republic of China
- Department of Integration of Chinese and Western Medicine; Peking University Cancer Hospital and Institute; Beijing 100142 People's Republic of China
| | - Wen-Xian Zheng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education); Beijing 100142 People's Republic of China
- Department of Integration of Chinese and Western Medicine; Peking University Cancer Hospital and Institute; Beijing 100142 People's Republic of China
| | - Li-Na Pang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education); Beijing 100142 People's Republic of China
- Department of Integration of Chinese and Western Medicine; Peking University Cancer Hospital and Institute; Beijing 100142 People's Republic of China
| | - Xiao-Hong Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education); Beijing 100142 People's Republic of China
- Department of Integration of Chinese and Western Medicine; Peking University Cancer Hospital and Institute; Beijing 100142 People's Republic of China
| | - Ping-Ping Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education); Beijing 100142 People's Republic of China
- Department of Integration of Chinese and Western Medicine; Peking University Cancer Hospital and Institute; Beijing 100142 People's Republic of China
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Shaik IH, Bastian JR, Zhao Y, Caritis SN, Venkataramanan R. Route of administration and formulation dependent pharmacokinetics of 17-hydroxyprogesterone caproate in rats. Xenobiotica 2015; 46:169-74. [PMID: 26153441 DOI: 10.3109/00498254.2015.1057547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
1. Weekly intramuscular injections of (250 mg/week) of 17-hydroxyprogesterone caproate (17-OHPC) are the only treatment option for prevention of preterm birth in women with a prior history of preterm delivery. 2. The objective of the current study was to evaluate the use of an alternate formulation and the feasibility of an alternate route of administration of this agent. 17-OHPC was administered to adult female SD rats, as marketed oily formulation intramuscularly, or as a solution IV, IM, or PO. 3. Plasma concentrations of 17-OHPC were measured by LC-MS-MS and pharmacokinetic parameters were calculated by non-compartmental analysis, using WinNonLin (Certara, St. Louis, MO). 4. After IV or IM administration as a solution, the mean half-life of 17-OHPC was around 11 h. The bioavailability was nearly 100% after IM administration, but was very low (<3%) after PO administration of a solution dosage form. 5. Intramuscular injection of the oily formulation resulted in low levels of 17-OHPC that were sustained for a prolonged time period with a projected bioavailability close to 100%. 6. The pharmacokinetics of 17-OHPC is dependent on the formulation and the route of administration. 7. The low bioavailability after oral administration indicates that oral administration of 17-OHPC may not be feasible with simple formulations of this drug.
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Affiliation(s)
- Imam H Shaik
- a Department of Pharmaceutical Sciences , School of Pharmacy, University of Pittsburgh , Pittsburgh , PA , USA
| | - Jaime R Bastian
- a Department of Pharmaceutical Sciences , School of Pharmacy, University of Pittsburgh , Pittsburgh , PA , USA .,b Department of Obstetrics , Gynecology and Reproductive Sciences, School of Medicine, Magee-Women's Hospital , Pittsburgh , PA , USA
| | - Yang Zhao
- a Department of Pharmaceutical Sciences , School of Pharmacy, University of Pittsburgh , Pittsburgh , PA , USA
| | - Steve N Caritis
- b Department of Obstetrics , Gynecology and Reproductive Sciences, School of Medicine, Magee-Women's Hospital , Pittsburgh , PA , USA .,c Magee-Women's Research Institute , Pittsburgh , PA , USA , and
| | - Raman Venkataramanan
- a Department of Pharmaceutical Sciences , School of Pharmacy, University of Pittsburgh , Pittsburgh , PA , USA .,c Magee-Women's Research Institute , Pittsburgh , PA , USA , and.,d Department of Pathology , School of Medicine, University of Pittsburgh , Pittsburgh , PA , USA
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Chinnici CM, Timoneri F, Amico G, Pietrosi G, Vizzini G, Spada M, Pagano D, Gridelli B, Conaldi PG. Characterization of Liver-Specific Functions of Human Fetal Hepatocytes in Culture. Cell Transplant 2015; 24:1139-53. [DOI: 10.3727/096368914x680082] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
This study was designed to assess liver-specific functions of human fetal liver cells proposed as a potential source for hepatocyte transplantation. Fetal liver cells were isolated from livers of different gestational ages (16-22 weeks), and the functions of cell preparations were evaluated by establishing primary cultures. We observed that 20- to 22-week-gestation fetal liver cell cultures contained a predominance of cells with hepatocytic traits that did not divide in vitro but were functionally competent. Fetal hepatocytes performed liver-specific functions at levels comparable to those of their adult counterpart. Moreover, exposure to dexamethasone in combination with oncostatin M promptly induced further maturation of the cells through the acquisition of additional functions (i.e., ability to store glycogen and uptake of indocyanine green). In some cases, particularly in cultures obtained from fetuses of earlier gestational ages (16-18 weeks gestation), cells with mature hepatocytic traits proved to be sporadic, and the primary cultures were mainly populated by clusters of proliferating cells. Consequently, the values of liver-specific functions detected in these cultures were low. We observed that a low cell density culture system rapidly prompted loss of the mature hepatocytic phenotype with downregulations of all the liver-specific functions. We found that human fetal liver cells can be cryopreserved without significant loss of viability and function and evaluated up to 1 year in storage in liquid nitrogen. They might, therefore, be suitable for cell banking and allow for the transplantation of large numbers of cells, thus improving clinical outcomes. Overall, our results indicate that fetal hepatocytes could be used as a cell source for hepatocyte transplantation. Fetal liver cells have been used so far to treat end-stage liver disease. Additional studies are needed to include these cells in cell-based therapies aimed to treat liver failure and inborn errors of metabolism.
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Affiliation(s)
- Cinzia Maria Chinnici
- Fondazione Ri.MED, Regenerative Medicine and Biomedical Technologies Unit, Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS-ISMETT, Palermo, Italy
| | - Francesca Timoneri
- Fondazione Ri.MED, Regenerative Medicine and Biomedical Technologies Unit, Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS-ISMETT, Palermo, Italy
| | - Giandomenico Amico
- Fondazione Ri.MED, Regenerative Medicine and Biomedical Technologies Unit, Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS-ISMETT, Palermo, Italy
| | - Giada Pietrosi
- Hepatology Unit, Department of Medicine, IRCCS-ISMETT, Palermo, Italy
| | - Giovanni Vizzini
- Hepatology Unit, Department of Medicine, IRCCS-ISMETT, Palermo, Italy
| | - Marco Spada
- Department of Surgery, IRCCS-ISMETT, Palermo, Italy
| | | | - Bruno Gridelli
- Fondazione Ri.MED, Regenerative Medicine and Biomedical Technologies Unit, Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS-ISMETT, Palermo, Italy
- Department of Surgery, IRCCS-ISMETT, Palermo, Italy
| | - Pier Giulio Conaldi
- Fondazione Ri.MED, Regenerative Medicine and Biomedical Technologies Unit, Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS-ISMETT, Palermo, Italy
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11
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Feghali M, Venkataramanan R, Caritis S. Prevention of preterm delivery with 17-hydroxyprogesterone caproate: pharmacologic considerations. Semin Perinatol 2014; 38:516-22. [PMID: 25256193 PMCID: PMC4253874 DOI: 10.1053/j.semperi.2014.08.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Despite advances in neonatal care, the burden of preterm birth remains high. Preterm birth is a multifactorial problem, and strategies to identify and treat medical risk factors in early pregnancy have not been effective in reducing preterm birth rates. In a sentinel clinical trial, prophylactic therapy with 17-hydoxyprogesterone caproate (17-OHPC) reduced the risk of recurrent, spontaneous preterm birth in 34% of women. As a result, clinical practice changed and extensive research on 17-OHPC followed. The increasing body of evidence demonstrated a variable efficacy of the drug. This review will examine the plausibility, pharmacology, clinical efficacy, and safety of 17-OHPC when used in the setting of preterm birth prevention. We will also discuss pharmacokinetic and pharmacodynamics data to highlight drug metabolism and mechanism of action, which will help clarify the variability in clinical outcomes and efficacy.
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Affiliation(s)
- Maisa Feghali
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA
| | - Steve Caritis
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA
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12
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Zhao Y, Alshabi AM, Caritis S, Venkataramanan R. Impact of 17-alpha-hydroxyprogesterone caproate on cytochrome P450s in primary cultures of human hepatocytes. Am J Obstet Gynecol 2014; 211:412.e1-6. [PMID: 24681287 DOI: 10.1016/j.ajog.2014.03.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/26/2014] [Accepted: 03/21/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The aim of this study was to examine the effects of 17-alpha-hydroxyprogesterone caproate (17OHP-C) on the activity and expression of several common hepatic cytochrome P450 (CYP) enzymes. STUDY DESIGN Primary human hepatocytes were pretreated with vehicle or 17OHP-C (0.1 and 1 μmol/L) for 72 hours, then incubated for 1 hour with a cocktail of CYP substrates. The activity of various CYP enzymes was determined by measuring the formation of the metabolites of specific CYP substrates, using liquid chromatography-tandem mass spectrometry. The messenger RNA expression of various CYP enzymes was determined by real-time polymerase chain reaction. RESULTS In primary cultures of human hepatocytes, 17OHP-C minimally altered the activity or messenger RNA levels of CYP1A2, CYP2C9, CYP2D6, and CYP3A. However, 17OHP-C at 1 μmol/L increased CYP2C19 activity by 2.8-fold (P < .01) and CYP2C19 expression by 2.4-fold (P < .001), compared with vehicle-treated cells. A strong positive correlation between activity and expression of CYP2C19 was also observed (r = 0.9, P < .001). CONCLUSION The activity and expression of hepatic CYP2C19 was significantly increased by 17OHP-C in primary cultures of human hepatocytes. This suggests that exposure to medications that are metabolized by CYP2C19 may be decreased in pregnant patients receiving 17OHP-C. Metabolism of substrates of CYP1A2, CYP2C9, CYP2D6, and CYP3A are not expected to be altered in patients receiving 17OHP-C.
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Byrns MC. Regulation of progesterone signaling during pregnancy: implications for the use of progestins for the prevention of preterm birth. J Steroid Biochem Mol Biol 2014; 139:173-81. [PMID: 23410596 DOI: 10.1016/j.jsbmb.2013.01.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 01/22/2013] [Accepted: 01/31/2013] [Indexed: 12/12/2022]
Abstract
Preterm birth is a major cause of neonatal morbidity and mortality. Progesterone plays a critical role in suppressing the inflammatory signals that would induce parturition prior to term. Progesterone signaling is regulated in a variety of ways during pregnancy. Endocrine production of high levels of progesterone by the placenta ensures the availability of high levels of progesterone throughout pregnancy. Paracrine regulation of progesterone metabolism in target tissues, particularly the myometrium and cervix, also determines the amount of progesterone ligand available. Progesterone metabolism can also lead to the formation of metabolites that contribute to its effects. In particular, 5β-dihydroprogesterone formation by aldo-keto reductase 1D1 appears to play an important role in maintaining uterine quiescence. Progesterone signaling can also be regulated at the receptor level through changes in the relative expression of the nuclear progesterone receptor isoforms, reduced expression of membrane receptors, and changes in the expression levels of coactivators and/or corepressors, including nuclear factor κB. Progesterone and 17α-hydroxyprogesterone caproate (17OH-PC) have recently been shown to reduce preterm births in women with previous preterm birth or shortened cervix. It is important to realize that these two progestins are likely to act in significantly different ways, which will likely influence their efficacy. The structural differences and resistance to metabolism exhibited by 17OH-PC means that it will be unable to activate some of the pathways that progesterone activates, but that it also will not be subject to paracrine inactivation. The fact that progesterone therapy works for maintaining pregnancy in some women, indicates that for those women insufficient levels of progesterone ligand in target tissues is a determining factor in early parturition, despite high levels of circulating progesterone. This article is part of a Special Issue entitled 'Pregnancy and Steroids'.
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Affiliation(s)
- Michael C Byrns
- Department of Health Sciences, Illinois State University, Normal, IL, USA.
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Vidaeff AC, Belfort MA. Critical appraisal of the efficacy, safety, and patient acceptability of hydroxyprogesterone caproate injection to reduce the risk of preterm birth. Patient Prefer Adherence 2013; 7:683-91. [PMID: 23874089 PMCID: PMC3714001 DOI: 10.2147/ppa.s35612] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Prevention of preterm delivery is a major desiderate in contemporary obstetrics and a societal necessity. The means to achieve this goal remain elusive. Progesterone has been used in an attempt to prevent preterm delivery since the 1970s, but the evidence initially accumulated was fraught by mixed results and was based on mostly underpowered studies with variable eligibility criteria, including history of spontaneous abortion as an indication for treatment. More recent randomized controlled clinical trials restimulated the interest in progesterone supplementation, suggesting that progesterone may favorably influence the rate of preterm delivery. Preterm delivery is a complex disorder and consequently it is unlikely that one generalized prevention strategy will be effective in all patients. Further, an additional impediment in accepting progesterone as the "magic bullet" in the prevention of preterm delivery is that its mechanism of action is not fully understood and the optimal formulations, route of administration, and dose have yet to be established. We have concerned ourselves in this review with the most recent status of 17 alpha-hydroxyprogesterone caproate (17OH-PC) supplementation for prevention of preterm delivery. Our intention is to emphasize the efficacy, safety, and patient acceptability of this intervention, based on a comprehensive and unbiased review of the available literature. Currently there are insufficient data to suggest that 17OH-PC is superior or inferior to natural progesterone. Based on available evidence, we suggest a differential approach giving preferential consideration to either 17OH-PC or other progestins based on obstetric history and cervical surveillance. Progestin therapy for risk factors other than a history of preterm birth and/or a short cervix in the current pregnancy is not currently supported by the published evidence. The experience to date with 17OH-PC indicates that there are population subgroups that may be harmed by administration of 17OH-PC. Therefore, extending the use of 17OH-PC to unstudied populations or for indications that are not evidence-based is inadvisable outside of a research protocol.
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Affiliation(s)
- Alex C Vidaeff
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, USA
- Correspondence: Alex C Vidaeff Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children’s Hospital, 6651 Main Street, Suite F1020, Houston, TX 77030, USA, Tel +1 83 2826 3737, Fax +1 83 2825 9351, Email
| | - Michael A Belfort
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, USA
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15
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Caritis SN, Sharma S, Venkataramanan R, Hankins GD, Miodovnik M, Hebert MF, Umans JG, Benedetti T, Mattison D, Zajicek A, Fischer D, Jackson A. Pharmacology and placental transport of 17-hydroxyprogesterone caproate in singleton gestation. Am J Obstet Gynecol 2012; 207:398.e1-8. [PMID: 22967833 PMCID: PMC3586341 DOI: 10.1016/j.ajog.2012.08.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 07/27/2012] [Accepted: 08/08/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The purpose of this study was to estimate pharmacokinetic parameters and to evaluate placental transport of 17-hydroxyprogesterone caproate (17-OHPC) in singleton gestation. STUDY DESIGN Sixty-one women who received weekly injections of 17-OHPC underwent 2 pharmacokinetic studies at 20 + 0 to 24 + 6 weeks' gestation (study 1) and 31 + 0 to 34 + 6 weeks' gestation (study 2); daily blood samples were obtained between injections. In 18 women, blood samples were obtained over a 28-day period beyond the last injection (extended study). Maternal and/or cord blood were obtained at delivery. RESULTS The half-life (median ± SD) of 17-OHPC was 16.2 ± 6 days. Concentrations of 17-OHPC were higher during study 2 than during study 1. Body mass index affected maternal 17-OHPC concentrations. Cord:maternal 17-OHPC concentration ratios averaged 0.2; 17-OHPC was detectible in cord plasma 44 days after the last maternal injection. CONCLUSION The apparent half-life of 17-OHPC is long, and pharmacokinetic parameters vary widely between subjects and are affected by maternal body mass index. The drug crosses the placental barrier.
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Affiliation(s)
- Steve N Caritis
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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16
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Merlob P, Stahl B, Klinger G. 17α Hydroxyprogesterone caproate for prevention of recurrent spontaneous preterm birth. Reprod Toxicol 2012; 33:15-9. [PMID: 22120850 DOI: 10.1016/j.reprotox.2011.10.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 10/09/2011] [Accepted: 10/31/2011] [Indexed: 11/30/2022]
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Abstract
17 α-hydroxyprogesterone caproate is a synthetic progestin of which there is now a US FDA-approved formulation available for intramuscular administration (Makena™) to reduce the risk of preterm birth. Intramuscular 17 α-hydroxyprogesterone caproate (identical in formulation and manufacturing process to Makena™, thus hereafter referred to as Makena™) 250 mg once weekly, initiated at 16-20 weeks' gestation, was effective in reducing the risk of preterm birth in women with a singleton pregnancy at high risk of delivering preterm in a large, well designed, placebo-controlled trial (n = 463 randomized). Rates of delivery before 37 (primary endpoint), 35, or 32 weeks' gestation were significantly lower with Makena™ than with placebo, corresponding to relative risk reductions of 34%, 33%, and 42%, respectively. The benefit of the drug in reducing the risk of preterm birth was observed when deliveries were spontaneous (but not when indicated because of complications) and regardless of maternal race. In addition, there was a significantly lower rate of several adverse fetal/neonatal outcomes among infants of women who received Makena™ than among infants of placebo recipients, including necrotizing enterocolitis, need for supplemental oxygen, birth weight of <2500 g, and intraventricular hemorrhage. Makena™ was generally well tolerated in pregnant women in this trial. Moreover, fetal exposure to the drug appeared to be safe according to a 2- to 5-year follow-up of the study, with no evidence of a detrimental effect of the drug on child neurodevelopment and a low overall incidence (≈2%) of reproductive or genital abnormalities that was not significantly different from placebo.
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Affiliation(s)
- Emma D Deeks
- Adis, a Wolters Kluwer Business, Auckland, New Zealand.
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18
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Hall NR. What agent should be used to prevent recurrent preterm birth: 17-P or natural progesterone? Obstet Gynecol Clin North Am 2011; 38:235-46, ix-x. [PMID: 21575799 DOI: 10.1016/j.ogc.2011.02.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Preterm birth has increased over the last decade. In 2006, 12.5% of all births in the United States occurred at fewer than 37 weeks gestation. This is associated with significant health care costs as well as related neonatal morbidity and mortality. In 2003, costs related to care for infants with preterm-birth or low-birth weight exceeded 11 billion dollars. This article reviews the literature on 17 alpha-hydroxyprogesterone caproate (17-P) and natural progesterone and concludes that 17-P is indicated for prevention of preterm birth in women with a documented history of a preterm birth before 37 weeks.
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Affiliation(s)
- Nicole Ruddock Hall
- Division of Maternal Fetal Medicine, Department of Obstetrics/Gynecology, University of Texas Health Science Center, Houston, TX 77026, USA.
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19
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Marongiu F, Gramignoli R, Dorko K, Miki T, Ranade AR, Serra MP, Doratiotto S, Sini M, Sharma S, Mitamura K, Sellaro TL, Tahan V, Skvorak KJ, Ellis EC, Badylak SF, Davila JC, Hines R, Laconi E, Strom SC. Hepatic differentiation of amniotic epithelial cells. Hepatology 2011; 53:1719-29. [PMID: 21374689 PMCID: PMC3103747 DOI: 10.1002/hep.24255] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Hepatocyte transplantation to treat liver disease is largely limited by the availability of useful cells. Human amniotic epithelial cells (hAECs) from term placenta express surface markers and gene characteristics of embryonic stem cells and have the ability to differentiate into all three germ layers, including tissues of endodermal origin (i.e., liver). Thus, hAECs could provide a source of stem cell-derived hepatocytes for transplantation. We investigated the differentiation of hAECs in vitro and after transplantation into the livers of severe combined immunodeficient (SCID)/beige mice. Moreover, we tested the ability of rat amniotic epithelial cells (rAECs) to replicate and differentiate upon transplantation into a syngenic model of liver repopulation. In vitro results indicate that the presence of extracellular matrix proteins together with a mixture of growth factors, cytokines, and hormones are required for differentiation of hAECs into hepatocyte-like cells. Differentiated hAECs expressed hepatocyte markers at levels comparable to those of fetal hepatocytes. They were able to metabolize ammonia, testosterone, and 17α-hydroxyprogesterone caproate, and expressed inducible fetal cytochromes. After transplantation into the liver of retrorsine (RS)-treated SCID/beige mice, naïve hAECs differentiated into hepatocyte-like cells that expressed mature liver genes such as cytochromes, plasma proteins, transporters, and other hepatic enzymes at levels equal to adult liver tissue. When transplanted in a syngenic animal pretreated with RS, rAECs were able to engraft and generate a progeny of cells with morphology and protein expression typical of mature hepatocytes. CONCLUSION Amniotic epithelial cells possess the ability to differentiate into cells with characteristics of functional hepatocytes both in vitro and in vivo, thus representing a useful and noncontroversial source of cells for transplantation.
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Affiliation(s)
- Fabio Marongiu
- Department of Pathology, University of Pittsburgh, PA, USA
- Department of Biomedical Sciences and Technologies, Università degli Studi di Cagliari, Italy
| | | | - Kenneth Dorko
- Department of Pathology, University of Pittsburgh, PA, USA
| | - Toshio Miki
- Department of Pathology, University of Pittsburgh, PA, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, PA, USA
| | | | - Maria Paola Serra
- Department of Biomedical Sciences and Technologies, Università degli Studi di Cagliari, Italy
| | - Silvia Doratiotto
- Department of Biomedical Sciences and Technologies, Università degli Studi di Cagliari, Italy
| | - Marcella Sini
- Department of Biomedical Sciences and Technologies, Università degli Studi di Cagliari, Italy
| | - Shringi Sharma
- Department of Pharmaceutical Sciences, University of Pittsburgh, PA, USA
| | | | - Tiffany L. Sellaro
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, PA, USA
| | - Veysel Tahan
- Department of Pathology, University of Pittsburgh, PA, USA
| | | | - Ewa C.S. Ellis
- Department of Pathology, University of Pittsburgh, PA, USA
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Stephen F. Badylak
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, PA, USA
| | - Julio C. Davila
- Pfizer Inc., Pfizer Global Research and Development, St. Louis, MO, USA
| | - Ronald Hines
- Children’s Research Institute, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ezio Laconi
- Department of Biomedical Sciences and Technologies, Università degli Studi di Cagliari, Italy
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