Am J Perinatol 2022; 39(07): 732-749
DOI: 10.1055/s-0040-1717072
Original Article

Blood Biomarkers and 6- to 7-Year Childhood Outcomes Following Neonatal Encephalopathy

Athina Pappas
1   Department of Pediatrics, Wayne State University, Detroit, Michigan
,
Seetha Shankaran
1   Department of Pediatrics, Wayne State University, Detroit, Michigan
,
Scott A. McDonald
2   Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
,
Waldemar A. Carlo
3   Department of Pediatrics, University of Alabama at Birmingham and Children's Hospital of Alabama, Birmingham, Alabama
,
Abbot R. Laptook
4   Department of Pediatrics, Women & Infant's Hospital, Brown University, Providence, Rhode Island
,
Jon E. Tyson
5   Department of Pediatrics, University of Texas Medical School at Houston, Houston, Texas
,
6   Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, Maryland
,
Kristin Skogstrand
7   Department for Congenital Disorders, Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
,
David M. Hougaard
7   Department for Congenital Disorders, Center for Neonatal Screening, Statens Serum Institut, Copenhagen, Denmark
,
Rosemary D. Higgins*
8   Department of Global and Community Health, George Mason University, Fairfax, Virginia
› Author Affiliations
Funding The National Institutes of Health and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) provided grant support for the NRN's Whole-Body Hypothermia Trial and its 6–7 Year School-age Follow-up through cooperative agreements. While NICHD staff did have input into the study design, conduct, analysis, and manuscript drafting, the content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This is a secondary study of ClinicalTrials.gov ID Whole-Body Cooling for Birth Asphyxia in Term Infants: NCT00005772 (U.S. Department of Health and Human Services, National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development [U10 HD21373, M01 RR2588, U10 HD21385, U10 HD27904, U10 HD34216, M01 RR32, and U10 HD36790]).

Abstract

Objective This study aimed to profile the cytokine/chemokine response from day 0 to 7 in infants (≥36 weeks of gestational age) with neonatal encephalopathy (NE) and to explore the association with long-term outcomes.

Study Design This was a secondary study of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network randomized controlled trial of whole body hypothermia for NE. Eligible infants with moderate–severe NE were randomized to cooling or normothermia. Blood spots were collected on days 0 to 1, 2 to 4, and 6 to 7. Twenty-four cytokines/chemokines were measured using a multiplex platform. Surviving infants underwent neurodevelopmental assessment at 6 to 7 years. Primary outcome was death or moderate–severe impairment defined by any of the following: intelligence quotient <70, moderate–severe cerebral palsy (CP), blindness, hearing impairment, or epilepsy.

Results Cytokine blood spots were collected from 109 participants. In total 99 of 109 (91%) were assessed at 6 to 7 years; 54 of 99 (55%) developed death/impairment. Neonates who died or were impaired had lower early regulated upon activation normal T cell expressed and secreted (RANTES) and higher day 7 monocyte chemotactic protein (MCP)-1 levels than neonates who survived without impairment. Though TNF-α levels had no association with death/impairment, higher day 0 to 1 levels were observed among neonates who died/developed CP. On multiple regression analysis adjusted for center, treatment group, sex, race, and level of hypoxic ischemic encephalopathy, higher RANTES was inversely associated with death/impairment (odds ratio (OR): 0.31, 95% confidence interval [CI]: 0.13–0.74), while day seven MCP-1 level was directly associated with death/impairment (OR: 3.70, 95% CI: 1.42–9.61). Targeted cytokine/chemokine levels demonstrated little variation with hypothermia treatment.

Conclusion RANTES and MCP-1 levels in the first week of life may provide potential targets for future therapies among neonates with encephalopathy.

Key Points

  • Elevation of specific cytokines and chemokines in neonates with encephalopathy has been noted along with increased risk of neurodevelopmental impairment in infancy.

  • Cytokine/chemokines at <7 days were assessed among neonates in a trial of hypothermia for HIE.

  • Neonates who died or were impaired at 6 to 7 years following hypoxic-ischemic encephalopathy had lower RANTES and higher MCP-1 levels than those who survived without impairment.

* A complete list of study investigators appears in the [Supplementary Material] (available in the online version).


Authors' Contributions

A.P. drafted the initial manuscript and revised multiple revisions of the manuscript. S.S. and W.A.C. conceptualized and designed the study, designed the data collection instruments, supervised data collection, and reviewed and revised the manuscript. S.A.M. performed the statistical analysis and critically reviewed the manuscript A.D. supervised the data collection instruments, supervised the analysis, and critically reviewed the manuscript. A.R.L., J.E.T., and R.D.H. critically reviewed draft of the study and critically reviewed the manuscript. K.S. and D.M.H. performed the blood protein analysis and analysis and critically reviewed the manuscript.


Note

Participating NRN sites collected data and transmitted it to RTI International, the data coordinating center (DCC) for the network, which stored, managed, and analyzed the data for this study. On behalf of the NRN, Dr. Abhik Das (DCC Principal Investigator) and Mr. Scott A. McDonald (DCC Statistician) had full access to all of the data in the study, and with the NRN Center Principal Investigators, take responsibility for the integrity of the data and accuracy of the data analysis.


Supplementary Material



Publication History

Received: 16 April 2020

Accepted: 24 August 2020

Article published online:
10 October 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Bona E, Andersson AL, Blomgren K. et al. Chemokine and inflammatory cell response to hypoxia-ischemia in immature rats. Pediatr Res 1999; 45 (4 Pt 1): 500-509
  • 2 Hagberg H, Mallard C, Ferriero DM. et al. The role of inflammation in perinatal brain injury. Nat Rev Neurol 2015; 11 (04) 192-208
  • 3 Tekgul H, Yalaz M, Kutukculer N. et al. Value of biochemical markers for outcome in term infants with asphyxia. Pediatr Neurol 2004; 31 (05) 326-332
  • 4 Bartha AI, Foster-Barber A, Miller SP. et al. Neonatal encephalopathy: association of cytokines with MR spectroscopy and outcome. Pediatr Res 2004; 56 (06) 960-966
  • 5 Chiesa C, Pellegrini G, Panero A. et al. Umbilical cord interleukin-6 levels are elevated in term neonates with perinatal asphyxia. Eur J Clin Invest 2003; 33 (04) 352-358
  • 6 Fotopoulos S, Mouchtouri A, Xanthou G, Lipsou N, Petrakou E, Xanthou M. Inflammatory chemokine expression in the peripheral blood of neonates with perinatal asphyxia and perinatal or nosocomial infections. Acta Paediatr 2005; 94 (06) 800-806
  • 7 Jenkins DD, Rollins LG, Perkel JK. et al. Serum cytokines in a clinical trial of hypothermia for neonatal hypoxic-ischemic encephalopathy. J Cereb Blood Flow Metab 2012; 32 (10) 1888-1896
  • 8 Chalak LF, Sánchez PJ, Adams-Huet B, Laptook AR, Heyne RJ, Rosenfeld CR. Biomarkers for severity of neonatal hypoxic-ischemic encephalopathy and outcomes in newborns receiving hypothermia therapy. J Pediatr 2014; 164 (03) 468-74.e1
  • 9 Massaro AN, Wu YW, Bammler TK. et al. Plasma biomarkers of brain injury in neonatal hypoxic-ischemic encephalopathy. J Pediatr 2018; 194: 67-75.e1
  • 10 Nelson KB, Dambrosia JM, Grether JK, Phillips TM. Neonatal cytokines and coagulation factors in children with cerebral palsy. Ann Neurol 1998; 44 (04) 665-675
  • 11 Shankaran S, Laptook AR, Ehrenkranz RA. et al; National Institute of Child Health and Human Development Neonatal Research Network. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med 2005; 353 (15) 1574-1584
  • 12 Skogstrand K, Thorsen P, Nørgaard-Pedersen B, Schendel DE, Sørensen LC, Hougaard DM. Simultaneous measurement of 25 inflammatory markers and neurotrophins in neonatal dried blood spots by immunoassay with xMAP technology. Clin Chem 2005; 51 (10) 1854-1866
  • 13 Shankaran S, Pappas A, McDonald SA. et al; Eunice Kennedy Shriver NICHD Neonatal Research Network. Childhood outcomes after hypothermia for neonatal encephalopathy. N Engl J Med 2012; 366 (22) 2085-2092
  • 14 Rosenbaum P, Paneth N, Leviton A. et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl 2007; 109: 8-14
  • 15 Rosenbaum P. The natural history of gross motor development in children with cerebral palsy aged 1 to 15 years. Dev Med Child Neurol 2007; 49 (10) 724
  • 16 Rothman KJ. No adjustments are needed for multiple comparisons. Epidemiology 1990; 1 (01) 43-46
  • 17 Vexler ZS, Yenari MA. Does inflammation after stroke affect the developing brain differently than adult brain?. Dev Neurosci 2009; 31 (05) 378-393
  • 18 Hudome S, Palmer C, Roberts RL, Mauger D, Housman C, Towfighi J. The role of neutrophils in the production of hypoxic-ischemic brain injury in the neonatal rat. Pediatr Res 1997; 41 (05) 607-616
  • 19 Hagberg H, Gilland E, Bona E. et al. Enhanced expression of interleukin (IL)-1 and IL-6 messenger RNA and bioactive protein after hypoxia-ischemia in neonatal rats. Pediatr Res 1996; 40 (04) 603-609
  • 20 Ivacko J, Szaflarski J, Malinak C, Flory C, Warren JS, Silverstein FS. Hypoxic-ischemic injury induces monocyte chemoattractant protein-1 expression in neonatal rat brain. J Cereb Blood Flow Metab 1997; 17 (07) 759-770
  • 21 Silverstein FS, Barks JD, Hagan P, Liu XH, Ivacko J, Szaflarski J. Cytokines and perinatal brain injury. Neurochem Int 1997; 30 (4-5): 375-383
  • 22 Hedtjärn M, Mallard C, Hagberg H. Inflammatory gene profiling in the developing mouse brain after hypoxia-ischemia. J Cereb Blood Flow Metab 2004; 24 (12) 1333-1351
  • 23 Hedtjärn M, Mallard C, Eklind S, Gustafson-Brywe K, Hagberg H. Global gene expression in the immature brain after hypoxia-ischemia. J Cereb Blood Flow Metab 2004; 24 (12) 1317-1332
  • 24 Kim SU, de Vellis J. Microglia in health and disease. J Neurosci Res 2005; 81 (03) 302-313
  • 25 Park KW, Lee DY, Joe EH, Kim SU, Jin BK. Neuroprotective role of microglia expressing interleukin-4. J Neurosci Res 2005; 81 (03) 397-402
  • 26 Yoon BH, Romero R, Park JS. et al. Fetal exposure to an intra-amniotic inflammation and the development of cerebral palsy at the age of three years. Am J Obstet Gynecol 2000; 182 (03) 675-681
  • 27 Liu XH, Kwon D, Schielke GP, Yang GY, Silverstein FS, Barks JD. Mice deficient in interleukin-1 converting enzyme are resistant to neonatal hypoxic-ischemic brain damage. J Cereb Blood Flow Metab 1999; 19 (10) 1099-1108
  • 28 Sävman K, Blennow M, Gustafson K, Tarkowski E, Hagberg H. Cytokine response in cerebrospinal fluid after birth asphyxia. Pediatr Res 1998; 43 (06) 746-751
  • 29 Youn YA, Kim SJ, Sung IK, Chung SY, Kim YH, Lee IG. Serial examination of serum IL-8, IL-10 and IL-1Ra levels is significant in neonatal seizures induced by hypoxic-ischaemic encephalopathy. Scand J Immunol 2012; 76 (03) 286-293
  • 30 Brochu ME, Girard S, Lavoie K, Sébire G. Developmental regulation of the neuroinflammatory responses to LPS and/or hypoxia-ischemia between preterm and term neonates: an experimental study. J Neuroinflammation 2011; 8: 55
  • 31 Ramaswamy V, Horton J, Vandermeer B, Buscemi N, Miller S, Yager J. Systematic review of biomarkers of brain injury in term neonatal encephalopathy. Pediatr Neurol 2009; 40 (03) 215-226
  • 32 Ennen CS, Huisman TA, Savage WJ. et al. Glial fibrillary acidic protein as a biomarker for neonatal hypoxic-ischemic encephalopathy treated with whole-body cooling. Am J Obstet Gynecol 2011; 205 (03) 251.e1-251.e7
  • 33 Berger RP, Bazaco MC, Wagner AK, Kochanek PM, Fabio A. Trajectory analysis of serum biomarker concentrations facilitates outcome prediction after pediatric traumatic and hypoxemic brain injury. Dev Neurosci 2010; 32 (5-6): 396-405
  • 34 Stolp HB. Neuropoietic cytokines in normal brain development and neurodevelopmental disorders. Mol Cell Neurosci 2013; 53: 63-68
  • 35 Bauer S, Kerr BJ, Patterson PH. The neuropoietic cytokine family in development, plasticity, disease and injury. Nat Rev Neurosci 2007; 8 (03) 221-232
  • 36 Zang YC, Samanta AK, Halder JB. et al. Aberrant T cell migration toward RANTES and MIP-1 alpha in patients with multiple sclerosis. Overexpression of chemokine receptor CCR5. Brain 2000; 123 (Pt 9): 1874-1882
  • 37 Mori F, Nisticò R, Nicoletti CG. et al. RANTES correlates with inflammatory activity and synaptic excitability in multiple sclerosis. Mult Scler 2016; 22 (11) 1405-1412
  • 38 Tripathy D, Thirumangalakudi L, Grammas P. RANTES upregulation in the Alzheimer's disease brain: a possible neuroprotective role. Neurobiol Aging 2010; 31 (01) 8-16
  • 39 Gamo K, Kiryu-Seo S, Konishi H. et al. G-protein-coupled receptor screen reveals a role for chemokine receptor CCR5 in suppressing microglial neurotoxicity. J Neurosci 2008; 28 (46) 11980-11988
  • 40 Campbell LA, Avdoshina V, Day C, Lim ST, Mocchetti I. Pharmacological induction of CCL5 in vivo prevents gp120-mediated neuronal injury. Neuropharmacology 2015; 92: 98-107
  • 41 Valerio A, Ferrario M, Martinez FO. et al. Gene expression profile activated by the chemokine CCL5/RANTES in human neuronal cells. J Neurosci Res 2004; 78 (03) 371-382
  • 42 Sakurai-Yamashita Y, Shigematsu K, Yamashita K, Niwa M. Expression of MCP-1 in the hippocampus of SHRSP with ischemia-related delayed neuronal death. Cell Mol Neurobiol 2006; 26 (4-6): 823-831
  • 43 Lee S, Chu HX, Kim HA. et al. Effect of a broad-specificity chemokine-binding protein on brain leukocyte infiltration and infarct development. Stroke 2015; 46 (02) 537-544
  • 44 Georgakis MK, Malik R, Björkbacka H. et al. Circulating monocyte chemoattractant protein-1 and risk of stroke: meta-analysis of population-based studies involving 17 180 individuals. Circ Res 2019; 125 (08) 773-782
  • 45 Varvel NH, Neher JJ, Bosch A. et al. Infiltrating monocytes promote brain inflammation and exacerbate neuronal damage after status epilepticus. Proc Natl Acad Sci U S A 2016; 113 (38) E5665-E5674
  • 46 Manley NC, Bertrand AA, Kinney KS, Hing TC, Sapolsky RM. Characterization of monocyte chemoattractant protein-1 expression following a kainate model of status epilepticus. Brain Res 2007; 1182: 138-143
  • 47 Choi J, Nordli Jr DR, Alden TD. et al. Cellular injury and neuroinflammation in children with chronic intractable epilepsy. J Neuroinflammation 2009; 6: 38
  • 48 Hung YW, Lai MT, Tseng YJ, Chou CC, Lin YY. Monocyte chemoattractant protein-1 affects migration of hippocampal neural progenitors following status epilepticus in rats. J Neuroinflammation 2013; 10: 11
  • 49 Yang G, Meng Y, Li W. et al. Neuronal MCP-1 mediates microglia recruitment and neurodegeneration induced by the mild impairment of oxidative metabolism. Brain Pathol 2011; 21 (03) 279-297
  • 50 Madrigal JL, Caso JR. The chemokine (C-C motif) ligand 2 in neuroinflammation and neurodegeneration. Adv Exp Med Biol 2014; 824: 209-219
  • 51 Zerbo O, Yoshida C, Grether JK. et al. Neonatal cytokines and chemokines and risk of autism spectrum disorder: the early Markers for Autism (EMA) study: a case-control study. J Neuroinflammation 2014; 11: 113
  • 52 Bianconi V, Sahebkar A, Atkin SL, Pirro M. The regulation and importance of monocyte chemoattractant protein-1. Curr Opin Hematol 2018; 25 (01) 44-51
  • 53 Frink M, Flohe S. van Grien Facts and Fictionsven M, Mommsen P, Hildebrand F. Facts and fiction: the impact of hypothermia on hypothermia on molecular mechanisms following major challenge. Mediators Inflamm 2012; DOI: 10.1155/2012/762840.
  • 54 Orrock JE, Panchapakesan K, Vezina G. et al. Association of brain injury and neonatal cytokine response during therapeutic hypothermia in newborns with hypoxic-ischemic encephalopathy. Pediatr Res 2016; 79 (05) 742-747
  • 55 Leviton A, Allred EN, Yamamoto H, Fichorova RN. ELGAN Study Investigators. Relationships among the concentrations of 25 inflammation-associated proteins during the first postnatal weeks in the blood of infants born before the 28th week of gestation. Cytokine 2012; 57 (01) 182-190
  • 56 Olson S, Berger AC. Institute of Medicine. (U.S.), Roundtable on Translating Genomic-Based Research for Health, Challenges and opportunities in using residual newborn screening samples for translational research. Washington, D.C.: National Academies Press; 2010: 67
  • 57 Shankaran S, Laptook AR, Pappas A. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Effect of depth and duration of cooling on death or disability at age 18 months among neonates with hypoxic-ischemic encephalopathy: a randomized clinical trial. JAMA 2017; 318 (01) 57-67