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Lin ET, Bae Y, Birkett R, Sharma AM, Zhang R, Fisch KM, Funk W, Mestan KK. Cord Blood Adductomics Reveals Oxidative Stress Exposure Pathways of Bronchopulmonary Dysplasia. Antioxidants (Basel) 2024; 13:494. [PMID: 38671941 PMCID: PMC11047351 DOI: 10.3390/antiox13040494] [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: 03/06/2024] [Revised: 04/13/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Fetal and neonatal exposures to perinatal oxidative stress (OS) are key mediators of bronchopulmonary dysplasia (BPD). To characterize these exposures, adductomics is an exposure science approach that captures electrophilic addition products (adducts) in blood protein. Adducts are bound to the nucleophilic cysteine loci of human serum albumin (HSA), which has a prolonged half-life. We conducted targeted and untargeted adductomics to test the hypothesis that adducts of OS vary with BPD. We studied 205 preterm infants (≤28 weeks) and 51 full-term infants from an ongoing birth cohort. Infant plasma was collected at birth (cord blood), 1-week, 1-month, and 36-weeks postmenstrual age. HSA was isolated from plasma, trypsin digested, and analyzed using high-performance liquid chromatography-mass spectrometry to quantify previously annotated (known) and unknown adducts. We identified 105 adducts in cord and postnatal blood. A total of 51 known adducts (small thiols, direct oxidation products, and reactive aldehydes) were increased with BPD. Postnatally, serial concentrations of several known OS adducts correlated directly with supplemental oxygen exposure. The application of large-scale adductomics elucidated OS-mediated pathways of BPD. This is the first study to investigate the "neonatal-perinatal exposome" and to identify oxidative stress-related exposure biomarkers that may inform antioxidant strategies to protect the health of future generations of infants.
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Affiliation(s)
- Erika T. Lin
- Department of Pediatrics, Division of Neonatology, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Yeunook Bae
- Department of Preventive Medicine, Northwestern University, 680 North Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA; (Y.B.)
| | - Robert Birkett
- Department of Pediatrics, Division of Neonatology, Northwestern University, Chicago, IL 60611, USA
| | - Abhineet M. Sharma
- Department of Pediatrics, Division of Neonatology, Northwestern University, Chicago, IL 60611, USA
| | - Runze Zhang
- Department of Preventive Medicine, Northwestern University, 680 North Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA; (Y.B.)
| | - Kathleen M. Fisch
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, CA 92093, USA;
| | - William Funk
- Department of Preventive Medicine, Northwestern University, 680 North Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA; (Y.B.)
| | - Karen K. Mestan
- Department of Pediatrics, Division of Neonatology, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
- Department of Pediatrics, Division of Neonatology, Northwestern University, Chicago, IL 60611, USA
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Mani S, Mirza H, Ziegler J, Chandrasekharan P. Early Pulmonary Hypertension in Preterm Infants. Clin Perinatol 2024; 51:171-193. [PMID: 38325940 PMCID: PMC10850766 DOI: 10.1016/j.clp.2023.11.005] [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] [Indexed: 02/09/2024]
Abstract
Pulmonary hypertension (PH) in preterm neonates has multifactorial pathogenesis with unique characteristics. Premature surfactant-deficient lungs are injured following exposure to positive pressure ventilation and high oxygen concentrations resulting in variable phenotypes of PH. The prevalence of early PH is variable and reported to be between 8% and 55% of extremely preterm infants. Disruption of the lung development and vascular signaling pathway could lead to abnormal pulmonary vascular transition. The management of early PH and the off-label use of selective pulmonary vasodilators continue to be controversial.
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Affiliation(s)
- Srinivasan Mani
- Section of Neonatology, Department of Pediatrics, The University of Toledo/ ProMedica Russell J. Ebeid Children's Hospital, Toledo, OH 43606, USA
| | - Hussnain Mirza
- Section of Neonatology, Department of Pediatrics, Advent Health for Children/ UCF College of Medicine, Orlando, FL 32408, USA
| | - James Ziegler
- Division of Cardiovascular Diseases, Department of Pediatrics, Hasbro Children's Hospital/ Brown University, Providence, RI 02903, USA
| | - Praveen Chandrasekharan
- Division of Neonatology, Department of Pediatrics, Jacobs School of Medicine & Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY 32408, USA; Oishei Children's Hospital, 818 Ellicott Street, Buffalo, NY 14203, USA.
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Van Mechelen K, Hundscheid TM, van Westering-Kroon E, Bartoš F, Villamor E. Association between Antenatal Antibiotic Exposure and Bronchopulmonary Dysplasia: A Systematic Review and Bayesian Model-Averaged Meta-Analysis. Neonatology 2024; 121:378-387. [PMID: 38310865 DOI: 10.1159/000536220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/08/2024] [Indexed: 02/06/2024]
Abstract
INTRODUCTION Antenatal antibiotic exposure has been suggested as a risk factor for bronchopulmonary dysplasia (BPD). We aimed to summarize the evidence from randomized controlled trials (RCTs) and observational studies on this potential association. METHODS PubMed/Medline and Embase databases were searched. BPD was classified as BPD28 (supplemental oxygen during 28 days or at postnatal day 28), BPD36 (supplemental oxygen at 36 weeks postmenstrual age), BPD36 or death, and BPD-associated pulmonary hypertension (BPD-PH). Bayesian model-averaged (BMA) meta-analysis was used to calculate Bayes factors (BFs). The BF10 is the ratio of the probability of the data under the alternative hypothesis (H1) over the probability of the data under the null hypothesis (H0). RESULTS We included 6 RCTs and 27 observational studies (126,614 infants). Regarding BPD28, BMA showed that the evidence in favor of H0 (lack of association with antenatal antibiotics) was weak for the RCTS (BF10 = 0.506, 6 studies) and moderate for the observational studies (BF10 = 0.286, 10 studies). Regarding BPD36, the evidence in favor of H0 was moderate for the RCTs (BF10 = 0.127, 2 studies) and weak for the observational studies (BF10 = 0.895, 14 studies). Evidence in favor of H0 was also weak for the associations with BPD36 or death (BF10 = 0.429, 2 studies) and BPD-PH (BF10 = 0.384, 2 studies). None of the meta-analyses showed evidence in favor of H1. CONCLUSIONS The currently available evidence suggests a lack of association between antenatal antibiotics and BPD. However, our results should not be interpreted as an argument for widespread use of antibiotics in the setting of preterm delivery.
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Affiliation(s)
- Karen Van Mechelen
- Department of Neonatology, School for Oncology and Reproduction (GROW), Maastricht University, MosaKids Children's Hospital, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands,
| | - Tamara M Hundscheid
- Department of Neonatology, School for Oncology and Reproduction (GROW), Maastricht University, MosaKids Children's Hospital, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Elke van Westering-Kroon
- Department of Neonatology, School for Oncology and Reproduction (GROW), Maastricht University, MosaKids Children's Hospital, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - František Bartoš
- Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Eduardo Villamor
- Department of Neonatology, School for Oncology and Reproduction (GROW), Maastricht University, MosaKids Children's Hospital, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
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Abstract
Bronchopulmonary dysplasia (BPD) remains the most common complication of premature birth, imposing a significant and potentially life-long burden on patients and their families. Despite advances in our understanding of the mechanisms that contribute to patterns of lung injury and dysfunctional repair, current therapeutic strategies remain non-specific with limited success. Contemporary definitions of BPD continue to rely on clinician prescribed respiratory support requirements at specific time points. While these criteria may be helpful in broadly identifying infants at higher risk of adverse outcomes, they do not offer any precise information regarding the degree to which each compartment of the lung is affected. In this review we will outline the different pulmonary phenotypes of BPD and discuss important features in the pathogenesis, clinical presentation, and management of these frequently overlapping scenarios.
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Affiliation(s)
- Margaret Gilfillan
- Division of Neonatology, St. Christopher's Hospital for Children/Drexel University College of Medicine, Philadelphia, PA, USA
| | - Vineet Bhandari
- Division of Neonatology, The Children's Regional Hospital at Cooper/Cooper Medical School of Rowan University, Camden, NJ 08103, USA.
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Gonzalez-Luis GE, Borges-Lujan M, Villamor E. Association between endotypes of prematurity and pharmacological closure of patent ductus arteriosus: A systematic review and meta-analysis. Front Pediatr 2023; 11:1078506. [PMID: 36937978 PMCID: PMC10020634 DOI: 10.3389/fped.2023.1078506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/10/2023] [Indexed: 03/06/2023] Open
Abstract
Introduction Endotypes leading to very and extremely preterm birth are clustered into two groups: infection/inflammation and dysfunctional placentation. We conducted a systematic review of observational studies exploring the association between these two endotypes and the pharmacological closure of patent ductus arteriosus (PDA) induced by cyclooxygenase (COX) inhibitors. Chorioamnionitis represented the infectious-inflammatory endotype, while dysfunctional placentation proxies were hypertensive disorders of pregnancy (HDP) and small for gestational age (SGA) or intrauterine growth restriction. Methods PubMed/Medline and Embase databases were searched. The random-effects odds ratio (OR) and 95% confidence interval (CI) were calculated for each association. We included 30 studies (12,639 infants). Results Meta-analysis showed a significant association between exposure to HDP and increased rate of pharmacological closure of PDA (17 studies, OR 1.41, 95% CI 1.10-1.81, p = 0.006). In contrast, neither chorioamnionitis (13 studies, OR 0.75, 95% CI 0.47-1.18, p = 0.211) nor SGA (17 studies, OR 1.20, 95% CI 0.96-1.50, p = 0.115) were significantly associated with the response to therapy. Subgroup analyses showed that the higher response to COX inhibitors in the HDP group was significant for indomethacin (OR 1.568, 95% CI 1.147-2.141, p = 0.005) but not for ibuprofen (OR 1.107, 95% CI 0.248-4.392, p = 0.894) or for the studies using both drugs (OR 1.280, 95% CI 0.935-1.751, p = 0.124). However, meta-regression showed that this difference between the drugs was not statistically significant (p = 0.404). Discussion/Conclusion Our data suggest that the pathologic condition that triggers prematurity may alter the response to pharmacological treatment of PDA. The DA of infants exposed to HDP appears to be more responsive to COX inhibitors.
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Affiliation(s)
- Gema E Gonzalez-Luis
- Department of Neonatology, Complejo Hospitalario Universitario Insular Materno-Infantil (CHUIMI) de Canarias, Las Palmas de Gran Canaria, Spain
| | - Moreyba Borges-Lujan
- Department of Neonatology, Complejo Hospitalario Universitario Insular Materno-Infantil (CHUIMI) de Canarias, Las Palmas de Gran Canaria, Spain
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Centre (MUMC+), School for Oncology and Developmental Biology (GROW), Maastricht, Netherlands
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Villamor E, Borges-Luján M, González-Luis G. Association of patent ductus arteriosus with fetal factors and endotypes of prematurity. Semin Perinatol 2023; 47:151717. [PMID: 36914506 DOI: 10.1016/j.semperi.2023.151717] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
During fetal life, the ductus arteriosus (DA) acquires the mechanisms for its postnatal closure following a thorough developmental program. This program can be interrupted by preterm birth and is also susceptible to alteration during fetal life by numerous physiological and pathological stimuli. In this review, we aim to summarize the evidence on how physiological and pathological factors affect DA development, eventually leading to patent DA (PDA). Specifically, we reviewed the associations of sex, race, and pathophysiological pathways leading to very preterm birth (endotypes) with PDA incidence and pharmacological closure. Summary of evidence suggests that there are no male-female differences in the incidence of PDA among very preterm infants. In contrast, risk of developing PDA appears to be higher in infants exposed to chorioamnionitis or who are small for gestational age. Finally, hypertensive disorders of pregnancy may be associated with a better response to pharmacological treatment of PDA. All of this evidence comes from observational studies and therefore associations do not imply causation. The current trend for many neonatologists is to wait for the natural evolution of preterm PDA. Continued research is needed to identify which fetal and perinatal factors modulate the eventual late closure of PDA in very and extremely preterm infants.
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Affiliation(s)
- Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Centre (MUMC+), School for Oncology and Reproduction (GROW), University of Maastricht, P. Debyelaan 25. P.O. Box 5800, Maastricht, AZ 6202, the Netherlands.
| | - Moreyba Borges-Luján
- Department of Neonatology, Complejo Hospitalario Universitario Insular Materno-Infantil (CHUIMI) de Canarias, Las Palmas de Gran Canaria, Spain
| | - Gema González-Luis
- Department of Neonatology, Complejo Hospitalario Universitario Insular Materno-Infantil (CHUIMI) de Canarias, Las Palmas de Gran Canaria, Spain
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Hundscheid TM, Huizing MJ, Villamor-Martinez E, Bartoš F, Villamor E. Association of Funisitis with Short-Term Outcomes of Prematurity: A Frequentist and Bayesian Meta-Analysis. Antioxidants (Basel) 2023; 12:antiox12020534. [PMID: 36830092 PMCID: PMC9951960 DOI: 10.3390/antiox12020534] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/08/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
The fetal systemic inflammatory response associated with intra-amniotic inflammation may play a key role in the pathogenesis of complications of preterm birth. Funisitis is the histologic equivalent of the fetal inflammatory response, whereas chorioamnionitis represents a maternal inflammatory response. We conducted a frequentist and Bayesian model average (BMA) meta-analysis of studies investigating the effects of funisitis on short-term outcomes of prematurity. Thirty-three studies (12,237 infants with gestational age ≤ 34 weeks) were included. Frequentist meta-analysis showed that funisitis was associated with an increased risk of any bronchopulmonary dysplasia (BPD), moderate/severe BPD, retinopathy of prematurity (ROP), intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), any sepsis, early-onset sepsis (EOS), and mortality. However, Bayesian meta-analysis showed that the evidence in favor of the alternative hypothesis (i.e., funisitis is associated with an increased risk of developing the outcome) was strong for any IVH, moderate for severe IVH and EOS, and weak for the other outcomes. When the control group was restricted to infants having chorioamnionitis without funisitis, the only outcome associated with funisitis was any IVH. In conclusion, our data suggest that the presence of funisitis does not add an additional risk to preterm birth when compared to chorioamnionitis in the absence of fetal inflammatory response.
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Affiliation(s)
- Tamara Maria Hundscheid
- Department of Pediatrics, University Medical Center (MUMC+), School for Oncology and Reproduction (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands
| | - Maurice Jacob Huizing
- Department of Pediatrics, University Medical Center (MUMC+), School for Oncology and Reproduction (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands
| | | | - František Bartoš
- Department of Psychology, University of Amsterdam, 1001 NK Amsterdam, The Netherlands
| | - Eduardo Villamor
- Department of Pediatrics, University Medical Center (MUMC+), School for Oncology and Reproduction (GROW), Maastricht University, 6202 AZ Maastricht, The Netherlands
- Correspondence:
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Chen P, Gu M, Wan S, Jiang X, Zhang F, Li Y, Zhou Q, Lu Y, Li L, Wang X. Gestational Diabetes Mellitus Impedes Fetal Lung Development Through Exosome-Dependent Crosstalk Between Trophoblasts and Lung Epithelial Cells. Int J Nanomedicine 2023; 18:641-657. [PMID: 36789391 PMCID: PMC9922507 DOI: 10.2147/ijn.s396194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 02/02/2023] [Indexed: 02/10/2023] Open
Abstract
Background Fetal lung underdevelopment (FLUD) is associated with neonatal and childhood severe respiratory diseases, among which gestational diabetes mellitus (GDM) play crucial roles as revealed by recent prevalence studies, yet mechanism underlying GDM-induced FLUD, especially the role of trophoblasts, is not all known. Methods From the perspective of trophoblast-derived exosomes, we established in vitro, ex vivo, in vivo and GDM trophoblast models. Utilizing placenta-derived exosomes (NUB-exos and GDMUB-exos) isolated from normal and GDM umbilical cord blood plasma and trophoblast-derived exosomes (NC-exos and HG-exos) isolated from HTR8/SVneo trophoblasts medium with/without high glucose treatment, we examined their effects on fetal lung development and biological functions. Results We found that, compared with the NUB-exos group, the exosome concentration increased in GDMUB-exos group, and the content of exosomes also changed evidenced by 61 dysregulated miRNAs. After applying these exosomes to A549 alveolar type II epithelial cells, the proliferation and biological functions were suppressed while the proportion of apoptotic cells was increased as compared to the control. In ex vivo studies, we found that GDMUB-exos showed significant suppression on the growth of the fetal lung explants, where the number of terminal buds and the area of explant surface decreased and shrank. Besides, the expression of Fgf10, Vegfa, Flt-1, Kdr and surfactant proteins A, B, C, and D was downregulated in GDMUB-exos group, whilst Sox9 was upregulated. For in vivo studies, we found significant suppression of fetal lung development in GDMUB-exos group. Importantly, we found consistent alterations when we used NC-exos and HG-exos, suggesting a dominant role of trophoblasts in placenta-derived exosome-induced FLUD. Conclusion In conclusion, GDM can adversely affect trophoblasts and alter exosome contents, causing crosstalk disorder between trophoblasts and fetal lung epithelial cells and finally leading to FLUD. Findings of this study will shine insight into the theoretical explanation for the pathogenesis of FLUD.
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Affiliation(s)
- Pengzheng Chen
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, People’s Republic of China
| | - Mengqi Gu
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, People’s Republic of China
| | - Shuting Wan
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, People’s Republic of China
| | - Xiaotong Jiang
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, People’s Republic of China
| | - Fengyuan Zhang
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, People’s Republic of China
| | - Yuchen Li
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, People’s Republic of China
| | - Qian Zhou
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, People’s Republic of China
| | - Yuan Lu
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, People’s Republic of China
| | - Lei Li
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, People’s Republic of China,Department of Obstetrics and Gynaecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, People’s Republic of China,Laboratory of Medical Science and Technology Innovation Center (Institute of Translational Medicine), Shandong First Medical University (Shandong Academy of Medical Sciences), Jinan, People’s Republic of China,Correspondence: Lei Li; Xietong Wang, Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, People’s Republic of China, Tel +8615168889200; +8615168888928, Email ;
| | - Xietong Wang
- Department of Obstetrics and Gynaecology, Shandong Provincial Hospital, Shandong University, Jinan, People’s Republic of China,Department of Obstetrics and Gynaecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, People’s Republic of China,Laboratory of Medical Science and Technology Innovation Center (Institute of Translational Medicine), Shandong First Medical University (Shandong Academy of Medical Sciences), Jinan, People’s Republic of China,Key Laboratory of Birth Regulation and Control Technology of National Health Commission of China, Shandong Provincial Maternal and Child Health Care Hospital, Jinan, People’s Republic of China
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Van Mechelen K, van Westering-Kroon E, Hütten M, Mahieu L, Villamor E. Placing Ureaplasma within the Context of Bronchopulmonary Dysplasia Endotypes and Phenotypes. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020256. [PMID: 36832386 PMCID: PMC9955705 DOI: 10.3390/children10020256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/17/2023] [Accepted: 01/29/2023] [Indexed: 02/03/2023]
Abstract
Different pathophysiological pathways (endotypes), leading to very preterm birth may result in distinct clinical phenotypes of bronchopulmonary dysplasia (BPD). Ureaplasma is a unique player in the pathogenesis of BPD. The interaction between factors inherent to Ureaplasma (virulence, bacterial load, duration of exposure), and to the host (immune response, infection clearance, degree of prematurity, respiratory support, concomitant infections) may contribute to BPD development in a variable manner. The data reviewed herein support the hypothesis that Ureaplasma, as a representative of the infectious/inflammatory endotype, may produce pulmonary damage predominantly in parenchyma, interstitium, and small airways. In contrast, Ureaplasma may have a very limited role in the pathogenesis of the vascular phenotype of BPD. In addition, if Ureaplasma is a key factor in BPD pathogenesis, its eradication by macrolides should prevent BPD. However, various meta-analyses do not show consistent evidence that this is the case. The limitations of current definitions and classifications of BPD, based on respiratory support needs instead of pathophysiology and phenotypes, may explain this and other failures in strategies aimed to prevent BPD. The precise mechanisms through which Ureaplasma infection leads to altered lung development and how these pathways can result in different BPD phenotypes warrant further investigation.
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Affiliation(s)
- Karen Van Mechelen
- Department of Pediatrics, Maastricht University Medical Center, School for Oncology and Reproduction (GROW), Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Elke van Westering-Kroon
- Department of Pediatrics, Maastricht University Medical Center, School for Oncology and Reproduction (GROW), Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Matthias Hütten
- Department of Pediatrics, Maastricht University Medical Center, School for Oncology and Reproduction (GROW), Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Ludo Mahieu
- Department of Neonatology, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Center, School for Oncology and Reproduction (GROW), Maastricht University, 6229 HX Maastricht, The Netherlands
- Correspondence:
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