Neonatal encephalopathy therapy optimization for better neuroprotection with inhalation of CO2: the HENRIC feasibility and safety trial.

BACKGROUND: There is an association between hypocapnia and adverse neurodevelopmental outcome in infants with neonatal encephalopathy (NE). Our aim was to test the safety and feasibility of 5% CO2 and 95% air inhalation to correct hypocapnia in mechanically ventilated infants with NE undergoing therapeutic hypothermia. METHODS: Ten infants were assigned to this open-label, single-center trial. The gas mixture of 5% CO2 and 95% air was administered through patient circuits if the temperature-corrected PCO2 ≤40 mm Hg. The CO2 inhalation was continued for 12 h or was stopped earlier if the base deficit (BD) level decreased <5 mmol/L. Follow-up was performed using Bayley Scales of Infant Development II. RESULTS: The patients spent a median 95.1% (range 44.6-98.5%) of time in the desired PCO2 range (40-60 mm Hg) during the inhalation. All PCO2 values were >40 mm Hg, the lower value of the target range. Regression modeling revealed that BD and lactate had a tendency to decrease during the intervention (by 0.61 and 0.55 mmol/L/h, respectively), whereas pH remained stable. The rate of moderate disabilities and normal outcome was 50%. CONCLUSIONS: Our results suggest that inhaled 5% CO2 administration is a feasible and safe intervention for correcting hypocapnia.

Asphyxiated neonates who received active therapeutic hypothermia during transport had higher rates of hypocapnia than controls.

AIM: We investigated the association between active hypothermia and hypocapnia in neonates with moderate-to-severe hypoxic-ischaemic encephalopathy (HIE) transported after birth. METHODS: This was a retrospective cohort study of neonates with HIE born between 2007 and 2011 and transported to Semmelweis University, Hungary, for hypothermia treatment before and after we introduced active cooling during transport in 2009. Of these, 71 received intensive care plus controlled active hypothermia during transport, while the 46 controls just received standard intensive care. Incident hypocapnia was defined as a partial pressure of carbon-dioxide (pCO2 ) that decreased below 35 mm Hg during transport. Multivariable logistic regression investigated the relationship between hypothermia and incident hypocapnia. RESULTS: Incident hypocapnia was more frequent in the actively cooled transport group (36.6%) than control group (17.4%; p = 0.025). pCO2 decreased from a median of 45 to 35 mm Hg (p < 0.0001) in the intervention group, but remained unchanged in the controls. After adjusting for confounders, hypothermia remained an independent risk factor for hypocapnia with an odds ratio (OR) of 4.23 and 95% confidence interval (95% CI) of 1.30-13.79. Sedation was associated with a reduction in OR of hypocapnia, at 0.35 (95% CI 0.12-0.98). CONCLUSIONS: Hypothermia increased the risk of hypocapnia in neonates with HIE during transport.

[Role of iron metabolism-regulator hepcidin in perinatal iron homeostasis]. / A vasháztartást szabályzó hepcidin kimutatása és szerepe a perinatalis vasháztartásban.

Hepcidin is a recently recognized defensin-like peptide, which is considered to be the central regulator of iron metabolism. Hepcidin decreases the expression of iron transporting molecules. Hepcidin reduces gastrointestinal iron absorption, iron release from the macrophages, and hence it decreases serum iron levels. Clarification of hepcidin role in iron homeostasis could provide an explanation to anemia of inflammation and chronic diseases. At start of our work there was no commercially available method for measuring urine hepcidin levels. The aim of our study was to develop an easily achievable, reliable quantification method for the determination of urine hepcidin levels in human, in addition to examine a possible association of hepcidin with neonatal iron homeostasis. According to the sequence of native, human hepcidin we have synthesized peptide derivatives from which 1-7 peptide derivatives might be suitable representatives of the 25-amino-acid form of hepcidin in immune adsorption method. We presented a novel laser-desorption mass spectrometry based semi-quantitative, reproducible method for measuring hepcidin concentration in human urine first using the synthesized peptide derivative acetyl-1-25 peptide as hepcidin related internal standard. We described an easy and quickly achievable solid-phase extraction method which is suitable for purification of urine and concentration of hepcidin. In our study we have first measured serum prohepcidin and urine hepcidin in healthy human newborns. Serum prohepcidin levels showed no significant changes, however, urine hepcidin levels increased significantly during the first postnatal days. Serum prohepcidin and urine hepcidin levels showed no significant association in healthy human newborns. Associations have been demonstrated between cord blood prohepcidin values and mean corpuscular hemoglobin concentration as well as between urine hepcidin levels and serum iron and total iron binding capacity values. We have demonstrated that neonates with detectable non-protein-bound iron levels in cord blood were presented with lower prohepcidin concentrations. In summary, our results suggest a possible link between hepcidin and early iron adaptation of newborn's, however, further investigations should be done to elucidate this issue.

Effect of inhibition of neuronal nitric oxide synthase and L-arginine supplementation on renal ischaemia-reperfusion injury and the renal nitric oxide system.

The role of nitric oxide synthases (NOS) and the nitric oxide (NO) substrate l-arginine in renal ischaemia-reperfusion (I/R) has been studied extensively. However, the results reported are often controversial. In the present study, we examined the effects of the neuronal (n) NOS inhibitor 7-nitroindazole (7-NI) and L-arginine administration on renal I/R injury and the renal NO system in rats. Following 7 days pretreatment with 7-NI (50 mg/kg per day), L-arginine (2 g/kg per day) or vehicle (dimethylsulphoxide : sesame oil, 1 : 9), the left renal vascular pedicles were clamped for 50 min in male Sprague-Dawley rats and kidneys were removed 24 h after reperfusion (n = 7/group). Neither 7-NI nor L-arginine had any effect on parameters of renal function, the grade of tissue injury or the number of terminal deoxyribonucleotidyl transferase-mediated dUTP-digoxigenin nick end-labelling (TUNEL)-positive tubular cells compared with vehicle-treated rats. 7-Nitroindazole decreased nNOS mRNA expression and inducible (i) NOS protein levels, but had no effect on endothelial NOS expression. L-arginine supplementation increased mRNA expression of all NOS isoforms, but only increased protein expression of iNOS. The results of the present study demonstrate that selective inhibition of nNOS has no effect on renal injury, indicating that nNOS does not play a central role in the pathophysiology of renal I/R. In addition, although L-arginine has no effect on renal I/R injury in the model used in the present study, its administration increases the mRNA expression of NOS isoforms.

Dysplasia: a review.

Bronchopulmonary dysplasia (BPD) is a common perinatal complication of very low birth weight preterm infants with a significant risk of long-term disability and morbidity. While clinical conditions such as prematurity and mechanical ventilation are its major risk factors, studies suggest that there is an individual susceptibility to BPD. This comprehensive review summarizes data collected about the implication of genetic polymorphisms in BPD and in its risk factors. Some studies have directly related the risk of BPD to genotype. Indeed, carrier states of genetic variants of cytokines (IFNgamma T+874A), adhesion molecules (L-selectin-Pro213Ser), elements of renin-angiotensin system (ACE-I/D), antioxidant enzymes (GST-P1 Val105Ile), and surfactant proteins (SPA1, SPB intron 4) has been identified as risk factors to BPD. Other studies investigated the role of genotype in BPD risk factors. Premature birth has been linked to carrier states of genetic variants with an impact on immune status (such as IL-6 G(-174)C, MBL2 54G/A, VEGF G+405C, HSP72 A+1267G genes) and matrix metalloproteases. Fetal inflammatory response syndrome, a major determinant of BPD is also affected by genotype (including LTalpha A+250G). Disturbed intrauterine lung development and vascularization may also contribute to BPD; these processes may be impaired in the presence of some rare genetic mutations. Furthermore, there is also a genetic component in the susceptibility to other perinatal adaptational disturbances such as respiratory distress syndrome that are associated with an increased need for mechanical ventilation, and, hence, with lung damage. The genetic variants presented in this article may help to identify infants at risk for BPD.

Increased mucosal expression of Toll-like receptor (TLR)2 and TLR4 in coeliac disease.

OBJECTIVES: The dysregulation of adaptive immunity is extensively investigated in celiac disease (CD). Recent data also suggest, however, the implication of innate immunity in CD. Toll-like receptors (TLRs) play a central role in the initiation or maintenance of innate immune responses. The aim of this study was to characterise the expression of TLR2, TLR3, and TLR4 in duodenal biopsy samples taken from children with CD and from controls. PATIENTS AND METHODS: Duodenal biopsy specimens were collected from 16 children with untreated CD, 9 children with treated CD, and 10 controls. The mRNA expression of TLR2, TLR3, and TLR4 was determined by semiquantitative reverse transcription-polymerase chain reaction. Protein levels of TLRs were determined by Western blot. RESULTS: We found higher TLR2 and TLR4 mRNA expression and protein levels in the duodenal mucosa of children with treated CD and untreated CD compared with controls. TLR2 and TLR4 mRNA expression and protein levels were even higher in the duodenal mucosa of children with treated CD than in untreated CD. TLR3 mRNA expression was increased in the duodenal mucosa of children with treated CD compared with untreated CD and controls. We were able to detect TLR3 protein only in the biopsy specimens of treated patients with CD. CONCLUSIONS: The alteration of TLR2 and TLR4 expression in the duodenal mucosa of patients with CD supports the potential implication of innate immune system in the pathomechanism of this disease.

Ser128Arg E-selectin and Thr715Pro P-selectin polymorphisms and severe preeclampsia.

OBJECTIVE: To investigate the association of functional E and P selectin polymorphisms with severe preeclampsia. STUDY DESIGN: P-selectin Thr715Pro and E-selectin Serl28Arg polymorphism were determined with the polymerase chain reaction in 126 women with severe preeclampsia and in 106 healthy pregnant women. Genotype distribution and allele prevalence of both groups were compared. Regression analysis was used to analyze the association between disease characteristics and genotype. RESULTS: Genotype distributions and the allele prevalence were similar in the tested populations. Furthermore, the genotypes investigated had no impact on the risk of eclampsia of the hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome. Multiple linear regression analysis identified the P-selectin 715Pro allele as an independent determinant of the time of onset of hypertension (p = 0.034) along with maternal age, smoking and body mass index before pregnancy. CONCLUSION: The polymorphisms tested are not associated with the risk of severe preeclampsia.

Genetic polymorphisms for vascular endothelial growth factor in perinatal complications.

Low birth weight (LBW) infants have increased susceptibility to perinatal complications. An immature and impaired vascular system may possibly participate in these complications. There is evidence that supports the notion that vascular endothelial growth factor (VEGF), which is an essential regulator of embryonic angiogenesis, plays a central role in the pathogenesis of perinatal complications. We aimed to test whether functional genetic polymorphisms of VEGF are associated with the risk of preterm birth or perinatal morbidity. We enrolled 128 LBW infants (< or = 1500 grams). VEGF T-460C, VEGF C-2578A and VEGF G+405C polymorphisms were determined by real-time PCR or PCR-RFLP, respectively. Their genotypes were compared with VEGF genotypes of 200 healthy, term neonates. The prevalence of the VEGF+405 C allele was higher in LBW infants than in healthy, term neonates (OR [95% CI]: 1.29 [1.01-1.65]). Carrier state for the VEGF -2578A allele was an independent risk factor for enterocolitis necrotisans (NEC) (adjusted OR [95% CI]: 2.77 [1.00-7.65]). The carrier state for the VEGF -2578AA genotype was associated with a decreased risk of acute renal failure (ARF) (adjusted OR [95% CI]: 0.2 [0.05-0.78]). These results suggest that VEGF G+405C polymorphism might be associated with a higher risk of preterm birth and that VEGF C-2578A polymorphism may participate in the development of perinatal complications such as NEC and ARF.

Genetic polymorphisms of vascular endothelial growth factor and angiopoietin 2 in retinopathy of prematurity.

Angiogenic factors such as vascular endothelial growth factor (VEGF) and angiopoietin 2 (Ang2) contribute to development of retinopathy of prematurity (ROP). We aimed to test whether polymorphisms of these factors are associated with ROP. VEGF(-2578) and Ang2(-35) polymorphisms were analyzed with PCR-RFLP method in 200 preterm infants without ROP or with ROP stages 1-5. Our results suggest that there is no association between carrier state of VEGF(-2578) and Ang2(-35) and risk of ROP in preterm infants. The prevalence of VEGF(-2578) "A" allele was lower in preterm boys with severe ROP (stages 4-5) than in those without or with mild ROP (stages 1-3).

The association of the carrier state of the tumor necrosis factor-alpha (TNFalpha) -308A allele with the duration of oxygen supplementation in preterm neonates.

BACKGROUND: High levels of inflammatory cytokines lead to lung damage in premature newborns. We investigated whether single nucleotide polymorphisms (SNP) of innate immunity cytokine genes influence the length of oxygen supplementation. METHODS: We genotyped 123 very low birth weight (VLBW) infants for the tumour necrosis factor (TNF)- alpha G(-308)A, interleukin (IL)-1beta C(3954)T, IL-6 G(-174)C and IL-10 G(-1082)A SNPs. Genomic DNA was isolated from remnant dried blood samples from the neonates. We tested the association between SNPs and ventilation characteristics using a stepwise multiple regression analysis model. RESULTS: The carrier state of the TNF-alpha G(-308)A allele was associated with a 40-hour longer period of mechanical ventilation (p=0.004) and, on average, an additional 36 hours of oxygen supplementation (p=0.0008). The association was significant after its adjustment for perinatal risk factors for lung damage. CONCLUSIONS: The TNF-alpha G(308)A genotype - which is associated with increased TNF-alpha levels - might influence the supplemental oxygen requirement of VLBW infants.

Severe Hyperinsulinemic Hypoglycemia in a Neonate: Response to Sirolimus Therapy.

Hyperinsulinemic hypoglycemia (HH) is one of the most common causes of persistent hypoglycemic episodes in neonates. Current pharmacologic treatment of neonatal HH includes diazoxide and octreotide, whereas for diffuse, unresponsive cases a subtotal pancreatectomy may be the last resort, with questionable efficacy. Here we report a case of congenital diffuse neonatal HH, first suspected when severe hypoglycemia presented with extremely high serum insulin levels immediately after birth. Functional imaging and genetic tests later confirmed the diagnosis. Failure to respond to a sequence of different treatments and to avoid extensive surgery with predictable morbidity prompted us to introduce a recently suggested alternative therapy with sirolimus, a mammalian target of rapamycin inhibitor. Glucose intake could be reduced gradually while euglycemia was maintained, and we were able to achieve exclusively enteral feeding within 6 weeks. Sirolimus was found to be effective and well tolerated, with no major adverse side effects attributable to its administration.

Selectin polymorphisms and perinatal morbidity in low-birthweight infants.

BACKGROUND: Studies have shown an association between altered expression of selectins and premature birth, early sepsis and bronchopulmonary dysplasia. AIM: To investigate the possible link between functional polymorphisms of the E-, P- and L-selectin genes and perinatal morbidity. METHODS: We compared the genotype distribution of the E-selectin Ser128Arg, P-selectin Thr715Pro and L-selectin Pro213Ser polymorphisms in 125 low-birthweight singleton infants with those of 156 healthy term neonates. We also analysed the association of genotype with risk of sepsis and bronchopulmonary dysplasia. RESULTS: We found no association between E-selectin or P-selectin polymorphisms and premature birth, nor did we find any association between E-selectin or P-selectin and early postnatal sepsis or bronchopulmonary dysplasia. Carriers of the 213Ser L-selectin allele were found to be more prevalent in low-birthweight infants, particularly in those with bronchopulmonary dysplasia. We found no association between the L-selectin polymorphism and early postnatal sepsis. CONCLUSION: Our results underline the importance of L-selectin in perinatal pathology, but further studies are needed to evaluate the alteration of L-selectin levels in carriers of the 213Ser allele and their possible contribution to premature birth and bronchopulmonary dysplasia.

Genetic polymorphisms of vascular endothelial growth factor in severe pre-eclampsia.

Several lines of evidence support the hypothesis that vascular endothelial growth factor (VEGF) plays an important role in the pathogenesis of pre-eclampsia (PE). VEGF is a key component in the regulation of vascular remodelling and the survival of cytotrophoblasts in the placenta. In this case-control study, we aimed to test whether VEGF genetic polymorphisms are associated with the risk of severe PE. We enrolled 84 nulliparous pregnant women with severe PE (PE group). Their VEGF G(+405)C and VEGF C(-2578)A genotypes were determined by PCR-restriction fragment length polymorphism (PCR-RFLP) from venous blood samples and were compared with the corresponding VEGF genotypes of 96 nulliparous patients with uncomplicated pregnancies (control group). Carriers of the VEGF(+405)G allele occurred less frequently in PE than in the control group [P = 0.039; adjusted odds ratio (aOR) = 0.28, range: 0.08-0.93]. Hypertension and proteinuria were diagnosed earlier (by 1.6 weeks and 1.9 weeks, respectively) in PE patients with VEGF(-2578)A only after adjustment of this association for risk factors of PE. Our results suggest that carriers of VEGF(+405)G allele have a decreased susceptibility to PE and that the progression of PE may be modified by the presence of VEGF(-2578)A allele. Nevertheless, the clinical significance of these findings remains to be determined.