Fetal Lung and Diaphragm Development in Congenital Diaphragmatic Hernia

doi:10.1053/j.semperi.2005.04.004

Seminars in Perinatology

Volume 29, Issue 2, April 2005, Pages 86-93

https://doi.org/10.1053/j.semperi.2005.04.004 Get rights and content

Congenital Diaphragmatic Hernia (CDH) is a congenital disorder with an incidence of 1 in 2500 live births. Respiratory distress of newborns with CDH is the result of pulmonary hypoplasia and pulmonary hypertension. Hypoplastic lungs are characterized by a decreased number of airways with smaller airspaces, whereas the combination of a decreased number of vascular branches and an increased adventitia and medial thickness of the pulmonary arterial walls result in pulmonary hypertension. The appearance of the CDH lungs suggests that its complete formation is stalled during development. Understanding the basic mechanisms of lung development is mandatory to unravel the origin of CDH. Although the histological abnormalities in CDH lungs have been well described, less is known about the underlying molecular mechanisms. In this review we will discuss the current molecular and genetic background of lung formation, as well as a reflection of this knowledge towards CDH.

Section snippets

Lung Specification

Before the outgrowth of the lung bud, cells in the prospective foregut region must receive signals to become future lung cells. It is possible that before the first morphological sign of the lung bud formation, the foregut cells in the prospective bud region are already committed to become part of the developing lung, as has been shown for the liver. Cirillo and coworkers showed that two sequence-specific DNA binding proteins, HNF3 (hepatocyte nuclear factor) and Gata-4, occupied the albumin

Onset of Lung Development

Research in the past decades has unraveled genes that are involved in the early development of the lung. The identification of a number of these genes is based on the homology between mammalian lung development and tracheal formation in the fruit fly Drosophila.⁹ Analyses of mutant flies resulted in the unraveling of a cascade of linked genes whose homologous parts in mammals play a part in lung formation. The forkhead transcription factor Foxa2 (HNF-3β) is expressed in foregut endoderm and in

Growth Factors in Lung Development

The formation of the tracheal system in Drosophila is initiated by cells surrounding a placode of tracheal-committed cells. These surrounding cells secrete a soluble Fgf (branchless), which is bound by the tracheal cells through a specific receptor (breathless), and the cells respond by migrating toward the source of the ligand.⁹ The mammalian homologues for these genes are fibroblast growth factor 10 (Fgf-10) and Fgf receptor 2 (FgfR-2), respectively. However, the inactivation in mice of

Sonic Hedgehog Pathway and Lung Development

Another factor secreted by the epithelial cells of the lung and also related to a Drosophila gene is the patterning morphogen sonic hedgehog (Shh).²⁹ Disruption of Shh in mice indicates that Shh is not required for the initial induction of lung development, since the lungs form as two rudimentary sacs without subsequent branching. However, proximal-distal differentiation of the airway epithelium is not affected, indicating that Shh is not required for maturation of the lung and induces the

Retinoic Acid and Lung Development

Retinoic acid (RA), the active form of vitamin A generated by the enzyme Raldh2, affects many developmental processes and exerts its activity through a number of closely related receptors.³⁸ Vitamin A-deprived dams can give birth to embryos which have blunt-end trachea and lung agenesis. This phenotype is similar to that described in Fgf-10^−/− mice and thus corroborates the concept of vitamin A being essential for foregut morphogenesis.³⁹ RA exerts its morphogen activity by binding to a number

Vasculature in CDH

In CDH patients, an abnormal pattern of the lung vasculature has been documented. In affected lungs, the total size of the pulmonary vascular bed is reduced but, most strikingly, the adventitia and media of the pulmonary arteries are thickened.⁵⁰ These aberrations of the pulmonary vessels lead to functional abnormalities such as pulmonary hypertension.² Similar aberrations of pulmonary vascular structures have also been described in pulmonary hypoplasia secondary to conditions other than CDH.⁵¹

Biochemical Aspects of the Lungs in CDH

Studies in animal models and humans have reported conflicting data about a primary surfactant deficiency in CDH.68, 69, 70 In rats with nitrofen-induced CDH and in lambs with surgically induced CDH, total phospholipids, disaturated phosphatidylcholine (PC), and surfactant protein A (SP-A) in lung tissue are lower than in controls.71, 72, 73, 74, 75 However, in the CDH rat model no differences in mRNA expression of surfactant protein (SP)-A, -B, and -C were observed between control and CDH lungs.

Hormonal Modulation of Lung Growth

Changes in thyroid hormone (TH) metabolism are thought to be involved in the pathogenesis of nitrofen-induced CDH associated with pulmonary hypoplasia.⁸⁶ Analysis of the expression patterns of lung development related nuclear receptors, glucocorticoid receptor (GR), the thyroid hormone receptor (TR) α and β, and retinoid-X receptor (RXR) α and β, in normal and CDH lungs from humans and rats showed that TR α was specifically expressed in the developing mesenchyme and TR β in the developing

Surgical Modulation of Lung Growth

Several surgical models have been developed to perform fetal interventions to reduce the severity of CDH. The surgically created fetal lamb model showed clinical features also observed in human CDH, namely lung hypoplasia, a reduction in pulmonary arterial density, and increased muscularization of the pulmonary tree.⁹⁰ This model produces bilateral lung hypoplasia characterized by a reduction in lung volume and total alveolar surface area.⁹¹ Tracheal occlusion (TO) induces hyperplasia of the

Development of the Diaphragm

Several theories related to development of the diaphragm have been proposed as the cause of CDH.¹⁰⁹ One of these suggests that premature migration of the primitive gut from the yolk sac into the abdominal cavity interferes with normal development of the diaphragm, resulting in the “classical” compression theory interfering with lung development. Also, it has been suggested that abnormal lung development or pulmonary hypoplasia leads to abnormal development of the diaphragm permitting herniation

The Future

The application of new technologies such as the use of micro-arrays will help us to understand pulmonary development at the molecular level. The time-dependent expression of a number of genes relevant to lung development should be taken into account, both in spontaneous as well as in experimental induced CDH. In this way, we will be able to pinpoint the exact mechanisms resulting in pulmonary hypoplasia in CDH as well as the effect of modulating “agents” such as corticosteroids, retinoic acid,

Acknowledgments

The authors apologize to many contributors in the field whose work we could not cite because of space limitations.

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Cited by (81)

Quantitative Measures of Right Ventricular Size and Function by Echocardiogram Correlate with Cardiac Catheterization Hemodynamics in Congenital Diaphragmatic Hernia
2023, Journal of Pediatrics
To evaluate associations between cardiac catheterization (cath) hemodynamics, quantitative measures of right ventricular (RV) function by echocardiogram, and survival in patients with congenital diaphragmatic hernia (CDH).
This single-center retrospective cohort study enrolled patients with CDH who underwent index cath from 2003 to 2022. Tricuspid annular plane systolic excursion z score, RV fractional area change, RV free wall and global longitudinal strain, left ventricular (LV) eccentricity index, RV/LV ratio, and pulmonary artery acceleration time were measured from preprocedure echocardiograms. Associations between hemodynamic values, echocardiographic measures, and survival were evaluated by Spearman correlation and Wilcoxon rank sum test, respectively.
Fifty-three patients (68% left-sided, 74% liver herniation, 57% extracorporeal membrane oxygenation, 93% survival) underwent cath (39 during index hospitalization, 14 later) including device closure of a patent ductus arteriosus in 5. Most patients (n = 31, 58%) were on pulmonary hypertension treatment at cath, most commonly sildenafil (n = 24, 45%) and/or intravenous treprostinil (n = 16, 30%). Overall, hemodynamics were consistent with precapillary pulmonary hypertension. Pulmonary capillary wedge pressure was >15 mm Hg in 2 patients (4%). Lower fractional area change and worse ventricular strain were associated with higher pulmonary artery pressure while higher LV eccentricity index and higher RV/LV ratio were associated with both higher pulmonary artery pressure and higher pulmonary vascular resistance. Hemodynamics did not differ based on survival status.
Worse RV dilation and dysfunction by echocardiogram correlate with higher pulmonary artery pressure and pulmonary vascular resistance on cath in this CDH cohort. These measures may represent novel, noninvasive clinical trial targets in this population.
Left Ventricular Dysfunction and Persistent Perfusion Abnormalities in Infants with Congenital Diaphragmatic Hernia
2020, Journal of Pediatrics
Tandem mass tag (TMT) proteomic analysis of fetal lungs revealed differential expression of tight junction proteins in a rat model of congenital diaphragmatic hernia
2020, Biomedicine and Pharmacotherapy
Congenital diaphragmatic hernia (CDH) is a common and often lethal birth defect characterized by congenital lung malformation, which severely affects neonate prognosis and mortality. This study aimed to investigate differences in protein expression in order to elucidate the mechanism of CDH-associated pulmonary hypoplasia during the early stage of lung development using tandem mass tag (TMT) quantitative proteomics.
Nitrofen was administered orally to establish a rat CDH model, and pathological changes were evaluated through hematoxylin-eosin (H&E), PCNA, and Ki67 staining at the pseudoglandular stage. Fetal lungs were then collected, pooled before TMT labeling, and subjected to mass spectrometry. Immunohistochemistry (IHC), Western blotting, and Q-PCR were used to further validate the candidate proteins.
A total of 79 differentially expressed proteins (DEPs) were identified when CDH and control lungs were compared, and further bioinformatics analysis showed that these proteins play important roles in tight-junctions, phospholipase D signaling, and the HIF-1 signaling pathway. Three differentially expressed proteins, Cldn3, Magi1, and Myh9 are involved in the tight-junction pathway (P < 0.05), and their differential expressions were confirmed by IHC, Western blotting, and Q-PCR.
These findings indicate that alterations of tight-junction protein expression may play an important role in the pathogenesis of abnormal lung development in CDH. Further studies are warranted to verify the mechanism by which these tight-junction proteins influence the pathogenesis of CDH-associated pulmonary hypoplasia.
Congenital Diaphragmatic Hernia
2019, Shackelford's Surgery of the Alimentary Tract: 2 Volume Set
Fetal lung transcriptome patterns in an ex vivo compression model of diaphragmatic hernia
2018, Journal of Surgical Research
Citation Excerpt :
Nevertheless, this classical paradigm has been challenged as being too simplistic based on several important observations.8 First, despite the fact that the diaphragmatic defect almost always occurs in only one hemidiaphragm, the observed pulmonary hypoplasia and pulmonary hypertension at birth also affect the contralateral lung, albeit to a lesser degree.9 Second, other space-occupying lesions because of which there is extrinsic mass effect on the early fetal lung (e.g., congenital lung malformations) do not typically result in significant lung hypoplasia and pulmonary hypertension at birth.10
The purpose of this study was to employ a novel ex vivo lung model of congenital diaphragmatic hernia (CDH) to determine how a mechanical compression affects early pulmonary development.
Day-15 whole fetal rat lungs (n = 6-12/group) from nitrofen-exposed and normal (vehicle only) dams were explanted and cultured ex vivo in compression microdevices (0.2 or 0.4 kPa) for 16 h to mimic physiologic compression forces that occur in CDH in vivo. Lungs were evaluated with significance set at P < 0.05.
Nitrofen-exposed lungs were hypoplastic and expressed lower levels of surfactant protein C at baseline. Although compression alone did not alter the α-smooth muscle actin (ACTA2) expression in normal lungs, nitrofen-exposed lungs had significantly increased ACTA2 transcripts (0.2 kPa: 2.04 ± 0.15; 0.4 kPa: 2.22 ± 0.11; both P < 0.001). Nitrofen-exposed lungs also showed further reductions in surfactant protein C expression at 0.2 and 0.4 kPa (0.53 ± 0.04, P < 0.01; 0.69 ± 0.23, P < 0.001; respectively). Whereas normal lungs exposed to 0.2 and 0.4 kPa showed significant increases in periostin (POSTN), a mechanical stress–response molecule (1.79 ± 0.10 and 2.12 ± 0.39, respectively; both P < 0.001), nitrofen-exposed lungs had a significant decrease in POSTN expression (0.4 kPa: 0.67 ± 0.15, P < 0.001), which was confirmed by immunohistochemistry.
Collectively, these pilot data in a model of CDH lung hypoplasia suggest a primary aberration in response to mechanical stress within the nitrofen lung, characterized by an upregulation of ACTA2 and a downregulation in SPFTC and POSTN. This ex vivo compression system may serve as a novel research platform to better understand the mechanobiology and complex regulation of matricellular dynamics during CDH fetal lung development.
Lung function and pulmonary artery blood flow following prenatal maternal retinoic acid and imatinib in the nitrofen model of congenital diaphragmatic hernia
2018, Journal of Pediatric Surgery
Citation Excerpt :
One potential prenatal intervention is the maternal administration of pharmacologic agents targeting pathways involved in pulmonary hypertension/hypoplasia [14,22,23,41,42]. Data from experimental studies with animal models support a complex molecular and cellular etiology of abnormal lung and pulmonary vascular development [43–45]. In the current study we evaluated pharmacologic interventions targeting the retinoic acid pathway and the role of PDGF in the pathophysiology of the nitrofen-induced rat CDH model.
Lung and pulmonary vascular maldevelopment in congenital diaphragmatic hernia (CDH) results in significant morbidity and mortality. Retinoic acid (RA) and imatinib have been shown to improve pulmonary morphology following prenatal administration in the rat nitrofen-induced CDH model. It remains unclear if these changes translate into improved function. We evaluated the effect of prenatal RA and imatinib on postnatal lung function, structure, and pulmonary artery (PA) blood flow in the rat CDH model.
Olive oil or nitrofen was administered alone or in combination with RA or imatinib to pregnant rats. Pups were assessed for PA blood flow by ultrasound and pulmonary function/morphology following delivery, intubation, and short-term ventilation.
Neither RA nor imatinib had a negative effect on lung and body growth. RA accelerated lung maturation indicated by increased alveoli number and thinner interalveolar septa and was associated with decreased PA resistance and improved oxygenation. With the exception of a decreased PA pulsatility index, no significant changes in morphology and pulmonary function were noted following imatinib.
Prenatal treatment with RA but not imatinib was associated with improved pulmonary morphology and function, and decreased pulmonary vascular resistance. This study highlights the potential of prenatal pharmacologic therapies, such as RA, for management of CDH.

View all citing articles on Scopus

: This work is supported in part by the Sophia Foundation for Medical Research (SSWO).

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Fetal Lung and Diaphragm Development in Congenital Diaphragmatic Hernia

Section snippets

Lung Specification

Onset of Lung Development

Growth Factors in Lung Development

Sonic Hedgehog Pathway and Lung Development

Retinoic Acid and Lung Development

Vasculature in CDH

Biochemical Aspects of the Lungs in CDH

Hormonal Modulation of Lung Growth

Surgical Modulation of Lung Growth

Development of the Diaphragm

The Future

Acknowledgments

Mech Dev

Mol Cell

Mech Dev

Am J Pathol

Curr Opin Cell Biol

Cell

Dev Biol

J Pediatr Surg

J Pediatr Surg

J Biol Chem

Dev Biol

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Dev Biol

Cell

Am J Pathol

Curr Top Dev Biol

J Steroid Biochem Mol Biol

Am J Pathol

Biochim Biophys Acta

Dev Biol

J Surg Res

J Surg Res

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Surg Res

Biochim Biophys Acta

J Pediatr Surg

J Pediatr Surg

J Pediatr

J Pediatr

J Pediatr

Biochim Biophys Acta

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Surgery

J Pediatr Surg

J Pediatr Surg

Lung morphogenesis revisitedold facts, current ideas

Dev Dyn

Lung growth and development

Front Biosci

Genetic control of lung development

Biol Neonate

Early restriction of peripheral and proximal cell lineages during formation of the lung

Proc Natl Acad Sci U S A

The forkhead transcription factor Foxf1 is required for differentiation of extra-embryonic and lateral plate mesoderm

Development

Haploinsufficiency of the forkhead gene Foxf1, a target for sonic hedgehog signaling, causes lung and foregut malformations

Development

Fgf10 is essential for limb and lung formation

Nat Genet

An important role for the IIIb isoform of fibroblast growth factor receptor 2 (FGFR2) in mesenchymal-epithelial signalling during mouse organogenesis

Development

Tbx4-Fgf10 system controls lung bud formation during chicken embryonic development

Development