Advertisement

Sildenafil attenuates intestinal injury in necrotizing enterocolitis independently of endothelial nitric oxide synthase

  • Author Footnotes
    1 These authors contributed equally to this work.
    Chelsea E. Hunter
    Footnotes
    1 These authors contributed equally to this work.
    Affiliations
    Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, RI 2500, Indianapolis, IN 46202, USA
    Search for articles by this author
  • Author Footnotes
    1 These authors contributed equally to this work.
    Brian D. Hosfield
    Footnotes
    1 These authors contributed equally to this work.
    Affiliations
    Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, RI 2500, Indianapolis, IN 46202, USA
    Search for articles by this author
  • Fikir M. Mesfin
    Affiliations
    Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, RI 2500, Indianapolis, IN 46202, USA
    Search for articles by this author
  • Anthony R. Pecoraro
    Affiliations
    Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, RI 2500, Indianapolis, IN 46202, USA
    Search for articles by this author
  • Jianyun Liu
    Affiliations
    Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, RI 2500, Indianapolis, IN 46202, USA
    Search for articles by this author
  • W. Christopher Shelley
    Affiliations
    Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, RI 2500, Indianapolis, IN 46202, USA
    Search for articles by this author
  • Krishna Manohar
    Affiliations
    Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, RI 2500, Indianapolis, IN 46202, USA
    Search for articles by this author
  • Troy A. Markel
    Correspondence
    Corresponding author.
    Affiliations
    Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, RI 2500, Indianapolis, IN 46202, USA
    Search for articles by this author
  • Author Footnotes
    1 These authors contributed equally to this work.

      Highlights

      • Necrotizing enterocolitis is a devastating disease that afflicts premature infants and for which targeted treatment options are lacking.
      • Sildenafil improves clinical outcomes and protects the intestine when administered orally in a murine model of necrotizing enterocolitis. This protection is provided through eNOS dependent and eNOS independent mechanisms.

      Abstract

      Background

      Necrotizing enterocolitis (NEC) is a devastating disease that impacts the intestine of premature infants. Sildenafil has shown benefit in colitis and ischemia/reperfusion models but has not been adequately studied in NEC. Sildenafil's best studied mechanism involves augmenting nitric oxide induced vasodilation. We hypothesized that sildenafil would improve outcomes during experimental NEC in an eNOS dependent manner.

      Materials

      NEC was induced in five-day old mouse pups with gavage formula feeds plus intermittent hypoxia and hypothermia. Using wild type (WT) mice, the route of sildenafil administration was studied in the following groups: (1) breastfed controls, (2) NEC + oral (PO) sildenafil, (3) NEC + PO vehicle, (4) NEC + intraperitoneal (IP) sildenafil, (5) NEC + IP vehicle. The eNOS KO groups studied included: (1) breastfed controls, (2) NEC + PO sildenafil, (3) NEC + PO vehicle. Data were tested for normality and compared using t-tests or Mann-Whitney with a p-value <0.05 considered significant.

      Results

      In WT mice, oral and IP sildenafil resulted in improved clinical outcomes compared to their respective vehicle group. Only orally administered sildenafil significantly improved perfusion to the intestine and protected it from macroscopic and histologic injury. When repeated in eNOS KO mice, oral sildenafil improved clinical scores and attenuated intestinal injury scores, despite no effect on intestinal perfusion.

      Conclusions

      Sildenafil, when administered orally, improves clinical outcomes and protects the intestine in a murine model of experimental necrotizing enterocolitis. While sildenafil requires eNOS to impact mesenteric perfusion, it does not appear to be dependent on eNOS to attenuate intestinal injury.

      Keywords

      Abbreviations:

      BF (breastfed), CFTR (cystic fibrosis transmembrane conductance regulator), cGMP (cyclic guanosine monophosphate), eNOS (endothelial nitric oxide synthase), eNOS KO (endothelial nitric oxide synthase knockout), ET-1 (Endothelin-1), GC-C (guanylate cyclase c), GMP (guanosine monophosphate), GTP (guanosine triphosphate), IP (intraperitoneal), I/R (ischemia and reperfusion), NEC (necrotizing enterocolitis), NHE3 (sodium hydrogen exchanger 3), NO (nitric oxide), p5 (postnatal day 5), PBS (phosphate buffered saline), PDE5 (phosphodiesterase 5), PKG II (c-GMP-dependent protein kinase II), PO (oral), sGC (soluble guanylate cyclase), WT (wild type)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Pediatric Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Neu J.
        • Walker W.A.
        Necrotizing enterocolitis.
        N Engl J Med. 2011; 364: 255-264https://doi.org/10.1056/NEJMra1005408
        • Jones I.H.
        • Hall N.J.
        Contemporary Outcomes for Infants with Necrotizing Enterocolitis-A Systematic Review.
        J Pediatr. 2020; 220 (e3): 86-92https://doi.org/10.1016/j.jpeds.2019.11.011
        • Meister A.L.
        • Doheny K.K.
        • Travagli R.A.
        Necrotizing enterocolitis: it's not all in the gut.
        Exp Biol Med. 2020; 245 (Maywood): 85-95https://doi.org/10.1177/1535370219891971
        • Warner B.B.
        • Deych E.
        • Zhou Y.
        • et al.
        Gut bacteria dysbiosis and necrotising enterocolitis in very low birthweight infants: a prospective case-control study.
        Lancet. 2016; 387: 1928-1936https://doi.org/10.1016/S0140-6736(16)00081-7
        • Niño D.F.
        • Sodhi C.P.
        • Hackam D.J.
        Necrotizing enterocolitis: new insights into pathogenesis and mechanisms.
        Nat Rev Gastroenterol Hepatol. 2016; 13: 590-600https://doi.org/10.1038/nrgastro.2016.119
        • Nair J.
        • Lakshminrusimha S.
        Role of NO and other vascular mediators in the etiopathogenesis of necrotizing enterocolitis.
        Front Biosci. 2019; 11 (Schol Ed): 9-28https://doi.org/10.2741/S524
        • Nankervis C.A.
        • Giannone P.J.
        • Reber K.M.
        The neonatal intestinal vasculature: contributing factors to necrotizing enterocolitis.
        Semin Perinatol. 2008; 32: 83-91https://doi.org/10.1053/j.semperi.2008.01.003
        • Nossaman B.
        • Pankey E.
        • Kadowitz P.
        Stimulators and activators of soluble guanylate cyclase: review and potential therapeutic indications.
        Crit Care Res Pract. 2012; 2012290805https://doi.org/10.1155/2012/290805
        • Te Winkel J.
        • John Q.E.
        • Hosfield B.D.
        • et al.
        Mesenchymal stem cells promote mesenteric vasodilation through hydrogen sulfide and endothelial nitric oxide.
        Am J Physiol Gastrointest Liver Physiol. 2019; 317: G441-G446https://doi.org/10.1152/ajpgi.00132.2019
        • Drucker N.A.
        • Jensen A.R.
        • Te Winkel J.P.
        • et al.
        Hydrogen sulfide donor GYY4137 acts through endothelial nitric oxide to protect intestine in murine models of necrotizing enterocolitis and intestinal ischemia.
        J Surg Res. 2019; 234: 294-302https://doi.org/10.1016/j.jss.2018.08.048
        • Ala M.
        • Mohammad Jafari R.
        • Dehpour A.R.
        Sildenafil beyond erectile dysfunction and pulmonary arterial hypertension: thinking about new indications.
        Fundam Clin Pharmacol. 2021; 35: 235-259https://doi.org/10.1111/fcp.12633
        • Han X.
        • Mann E.
        • Gilbert S.
        • et al.
        Loss of guanylyl cyclase C (GCC) signaling leads to dysfunctional intestinal barrier.
        PLoS One. 2011; 6: e16139https://doi.org/10.1371/journal.pone.0016139
        • Moore H.M.
        • Drucker N.A.
        • Hosfield B.D.
        • et al.
        Sildenafil as a rescue agent following intestinal ischemia and reperfusion injury.
        J Surg Res. 2020; 246: 512-518https://doi.org/10.1016/j.jss.2019.09.037
        • Inan M.
        • Uz Y.H.
        • Kizilay G.
        • et al.
        Protective effect of sildenafil on liver injury induced by intestinal ischemia/reperfusion.
        J Pediatr Surg. 2013; 48: 1707-1715https://doi.org/10.1016/j.jpedsurg.2012.12.054
        • Islam B.N.
        • Sharman S.K.
        • Hou Y.
        • et al.
        Sildenafil suppresses inflammation-driven colorectal cancer in mice.
        Cancer Prev Res. 2017; 10 (Phila): 377-388https://doi.org/10.1158/1940-6207.CAPR-17-0015
        • Drucker N.A.
        • Jensen A.R.
        • Ferkowicz M.
        • et al.
        Hydrogen sulfide provides intestinal protection during a murine model of experimental necrotizing enterocolitis.
        J Pediatr Surg. 2018; 53: 1692-1698https://doi.org/10.1016/j.jpedsurg.2017.12.003
        • Valatsou A.
        • Briasoulis A.
        • Vogiatzi G.
        • et al.
        Beneficial effects of sildenafil on tissue perfusion and inflammation in a murine model of limb ischemia and atherosclerosis.
        Curr Vasc Pharmacol. 2017; 15: 282-287https://doi.org/10.2174/1570161115666170126123258
        • Yazji I.
        • Sodhi C.P.
        • Lee E.K.
        • et al.
        Endothelial TLR4 activation impairs intestinal microcirculatory perfusion in necrotizing enterocolitis via eNOS-NO-nitrite signaling.
        Proc Natl Acad Sci U S A. 2013; 110: 9451-9456https://doi.org/10.1073/pnas.1219997110
        • Zani A.
        • Cordischi L.
        • Cananzi M.
        • et al.
        Assessment of a neonatal rat model of necrotizing enterocolitis.
        Eur J Pediatr Surg. 2008; 18: 423-426https://doi.org/10.1055/s-2008-1038951
        • Soydan G.
        • Sökmensüer C.
        • Kilinç K.
        • et al.
        The effects of sildenafil on the functional and structural changes of ileum induced by intestinal ischemia-reperfusion in rats.
        Eur J Pharmacol. 2009; 610: 87-92https://doi.org/10.1016/j.ejphar.2009.03.038
        • Sharman S.K.
        • Islam B.N.
        • Hou Y.
        • et al.
        Sildenafil normalizes bowel transit in preclinical models of constipation.
        PLoS One. 2017; 12e0176673https://doi.org/10.1371/journal.pone.0176673
        • Steinbrecher K.A.
        The multiple roles of guanylate cyclase C, a heat stable enterotoxin receptor.
        Curr Opin Gastroenterol. 2014; 30: 1-6https://doi.org/10.1097/MOG.0000000000000020
        • Shailubhai K.
        • Palejwala V.
        • Arjunan K.P.
        • et al.
        Plecanatide and dolcanatide, novel guanylate cyclase-C agonists, ameliorate gastrointestinal inflammation in experimental models of murine colitis.
        World J Gastrointest Pharmacol Ther. 2015; 6: 213-222https://doi.org/10.4292/wjgpt.v6.i4.213
        • Layer P.
        • Stanghellini V.
        Review article: linaclotide for the management of irritable bowel syndrome with constipation.
        Aliment Pharmacol Ther. 2014; 39: 371-384https://doi.org/10.1111/apt.12604
        • Thomas R.H.
        • Luthin D.R.
        Current and emerging treatments for irritable bowel syndrome with constipation and chronic idiopathic constipation: focus on prosecretory agents.
        Pharmacotherapy. 2015; 35: 613-630https://doi.org/10.1002/phar.1594
        • Nowicki P.T.
        • Caniano D.A.
        • Hammond S.
        • et al.
        Endothelial nitric oxide synthase in human intestine resected for necrotizing enterocolitis.
        J Pediatr. 2007; 150: 40-45https://doi.org/10.1016/j.jpeds.2006.09.029