Radici profondeper l’adultodi domani

Vassilios Fanos

Terapia Intensiva Neonatale,Patologia Neonatale, e Nido

Azienda Mista eUniversità degli Studi di Cagliari

Agendafrom Eliot to Eliot

• Background• Barker: developmental programming• An endless story of trees• Who are the actors ot the scenario?• Programming in the different organs• U-shaped risk• 3 examples: brain, heart, kidney• 3 M and Maternal Milk: Metabolomics,

Microbiomics, Multipotent stem cells• Take-home messages• Conclusions: 10 P Pediatrics

In my beginning is my end…

Thomas S. Eliot. Four Quartets

In my beginning is my end…We had the experience but miss themeaning,And approach to meaning restores theexperienceIn a different form, beyond any meaning…The only wisdom we can hope to acquireIs the wisdom of humility:humility is endless.

Thomas S. Eliot. Four Quartets

What is life? (E. Schrödinger)

Le cinque grandi ideedella biologia e della medicina (P. Nurse)Cosa non buttare dalla mongolfiera

• Genoma• Cellula• Biochimica• Evoluzione• Biologia dei sistemi

(systems biology)

Geographic Information Systemof a Human Being:one health, so many omics

The new languages of Medicine (I)Metabolomics

Systems Biology

Systems Medicine

Networks Medicine

Omics Technologies

Data trained Medicine

Big data in Medicine

Resilience, antifragility, fragility

Olistic Medicine

Individualized Medicine

Key word: complexityThe whole is not equivalentto the sum of its parts (Aristotle)

The new languages of Medicine (II)Microbiomics

Microbiota

Olobionte

Networking batterico

Sociomicrobiologia batterica

Ecosistema corporeo

Co-evoluzione

Simbiotici

Sistema NEI (neuro-endocrino-

immunitario)

Batteri ed evoluzione del

cervello

Trapianto di microbiota

Perinatalprogramming

“The response by a developing

organism to a specific challenge

during a critical time window that

alters the trajectory of development

qualitatively and/or quantitatively with

resulting persistent effects on

phenotype»

Perinatalprogramming

“The response by a developing

organism to a specific challenge

during a critical time window that

alters the trajectory of development

qualitatively and/or quantitatively with

resulting persistent effects on

phenotype»

Perinatalprogramming

“The response by a developing

organism to a specific challenge

during a critical time window that

alters the trajectory of development

qualitatively and/or quantitatively with

resulting persistent effects on

phenotype»

Are the fetus and thenewborn father to theman?

CV DiseaseHypertensionDyslipidemiaObesity

PulmonaryDiseaseRenal Disease

DiabetesDepressionSchizophreniaAnti-SocialPersonalityDisorderAutism

First Trimester Second Trimester Third Trimester

Windows of vulnerability/Windows of opportunity

During the Dutch Famine of 1944–1945, energy intakedropped from 1,800 to 400–800 calories per day for about 5 months.

…an endless story of trees

Struttura dell'albero bronchiale: un albero senza foglie,rovesciato, con i rami vuoti internamente.

Santiago Ramon y Cayal (1852 – 1934) Spanish pathologist, histologist,neuroscientist and Nobel laureate, the father of modern neuroscience

“The totalarborization of aneuron representsthe graphic historyof conflicts sufferedduring thedevelopmental life”.

NOREGENERATION

….we have not yet unravelled themistery of what is our brain.

…looking to the patient, not tothe disease.

PRECISION MEDICINE

Barack Obama, interviewto Popular Science, 15February, 2016

Ecole Polytechnique Fèdèrale deLausanne, blue Brain Project 2008

Thirty millions connections betweenten thousand neurons.The different colors indicatedistinctive levels of electric activity

Jackson Pollock, Number 5, 1948

The brain is not a computer, it is a jungle of trees

Metanephric mesenchymeand Branching ureteric bud

The kidney: How does it make a tree?

The Mysterious Treeof a Newborn’s Life

Understanding the Placenta, the least understood human organAn innocent bystander?

By DENISE GRADY New York Times JULY 14, 2014

A print of a placenta was created by dipping the organ’s treelike branches in blueacrylic paint. The blood vessels that feed the branches were painted red before theblot was made.

Placenta is the first ofthe trees of theorganism: when it isstrongly involved inpathologies, especiallyat ≤ 26 weeks ofgestation, it probablydetermines a negativeinfluence on all theother trees.

Editorial (Curr Pharmac Design 2012)

Cells, The Tree, Drugs and The Tailor

Vassilios Fanos

•Hypoplasia: less cells•Dysplasia: less function

Reduction/inhibition of arborizationbrain connectionsbronchial treeureteric bud……….

Reduction of vascular arborization

What is a disease?

At high power (13,000X), interior of the liver mitochondria is presented, allowing a goodevaluation of cristae volume and architecture. Mocci C, J Pediatr Neonat Individual Med. 2014

At high power (13,000X), interior of the liver mitochondria is presented, allowing a goodevaluation of cristae volume and architecture. Mocci C, J Pediatr Neonat Individual Med. 2014

Uteroplacental insufficiency Reduction in energy supplyand oxygen activation of mitochondria in the fetus to satisfy

the cellular need of energy increased production of ROSand oxidative stress mitochondrial dysfunction long term

problems in all organs

Finestra di vulnerabilità

Identical twinsare notidentical!

SameGenome/DifferentEpigenome• Acetylome• Metylome• Microbiome• Virome• Fungome• Inflammasome• Metabolome• Phenome• Diseasome

TWINS

Food Microbiota

Metabolites Programming

Who are thenew actorsof thescenario?

Gut microbiotachanges duringpregnancy

ProteobacteriaActionobacteria

DiversityFecalibacterion

Koren O.Cell 2012

AVETE MAI VISTODEI TOPI PRIVI DIGERMI?

SONO ANIMALISERIAMENTEINCASINATI!

MARIA GLORIA DOMINGUEZ-BELLOMicrobiologa presso la New YorkUniversity

EnvironmentalHealthPerspective

7 July 2016,Vol. 124

La scatolanera dellagravidanza

Si stima che un lattante che ingerisce 800 ml di latte materno al giornopossa recepire, per questa via, fra i 100.000 e i 10.000.000 di batteri

Obesity?Autism?

From tyrosine via the gut bacteria

Abnormal metabolites arising from anaerobic bacteria of the gut(Clostridia spp.). Elevated in urine in previous studies on autism.Decrease after treatment with oral vancomycin: a valid biomarkerfor Clostridia spp.

Do each of these babies havedifferent adult health fates?

Urinary metabolomics reveals that low and high birthweights infants share elevated inositol concentrations at

birth

L. Barberini 1, A. Noto 6, C. Fattuoni 2, D. Grapov 5, A. Casanova 3, G. Fenu 4, M.Gaviano 4, R. Carboni 6, G. Ottonello 6, M. Crisafulli 6, V. Fanos 6, A. Dessì 6

Universities of Cagliari and California Davis (submittedBiomed Res Intern)

inositol

AUC=1

RISCHIO CARDIOVASCOLARE INSUFFICIENZA RENALECRONICA

DIABETE AUTISMO

October 2015

Segmento 2.

Sviluppo delcervello: come siforma una giungla

Abbot A,Nature 5February2015

Fetal Programming of the Human Brain: is there a Linkwith Insurgence of Neurodegenerative Disorders inAdulthood?

Author(s): G Faa, M A. Marcialis, A Ravarino, M Piras, M CPintus and V Fanos

Aluminum sources that infants may receive duringthe first 6 months of life

• Evitare di bere bevande acide (speciegassate) o the in contenitori di alluminio.

• Restringere l’assunzione di the e preferirel’aggiunta di latte (riduce labiodisponibilità) a quella del limone(aumenta assorbimento)

• Limitare l’uso di dentifrici e traspiranticontenenti alluminio.

• Evitare l’assunzione di caffè ottenuto conla moka in alluminio.

• Limitare il consumo di cibi cotti oconservati in contenitori di alluminio.

• Evitare formaggi o dolci contenentialluminio.

• Evitare l’assunzione di erbe ove non siaspecificato il livello di contaminazione daalluminio.

• Evitare, durante l’allattamento, l’uso diprodotti di bellezza contenenti alluminio.

• Scegliere le formule lattee con minorecontenuto di alluminio.

• Scegliere le acque minerali con minorecontenuto di alluminio per diluire leformule lattee.

• Porre grande attenzione alle formule disoia per l’elevato contenuto di alluminio.

• Porre grande attenzione alle terapieparenterali per l’elevato contenuto dialluminio.

• Evitare i farmaci contenenti alluminio, inparticolare gli antiacidi.

• Non rimandare la vaccinazione convaccini conteneti alluminio (la quantità èmodesta

I consigli perle mamme ingravidanza!

FANNI D, FANOS V, …FAA G. WORLD J PEDIATRICS 2014

Ethanol exposure during pregnancy causes apoptosis ofPurkinje cells and cerebellar granule cells.

Messaggio da portare a casa: alcol zero!!!

Luo J, Cerebellum 2012, 31, 543-549

SMOKE

Fanos V et al. BMC Embryo Today, submitted

Perinatal Heart Programming:Long-Term Consequences

Author(s): A. Faa, R. Ambu, G.Faa and V. Fanos 2014

The Cagliari Experience

Long term problems in young adults born ELBWBassareo PP, Fanos V et al. Int J Cardiov Epidemiol 2012, Int J Cardiol 2011, JMFNM

2009, 2010, Acta Pediatrica 2010, JDOHaD 2015

R = - 0,67

350

400

450

500

24 25 26 27 28 29 30 31 32

Gestational age (weeks)

QTc

(mse

c)

Significant QT interval prolongation and long QT inyoung adult ex preterm newborns with extremely lowbirth weight

Pier Paolo Bassareo1, Vassilios Fanos2, Melania Puddu2 , Christian Cadeddu1,Marta Balzarini1, Giuseppe Mercuro (JMFNM 2010)

Differences in the two groups related to the alterations in the arginine andproline metabolism, in the purine and pyrimidine metabolism in thehystidine, beta-alanine metabolism and with the urea cycle(Fanos V. et al Clinical Biochemistry 2011 , mod)

Metabolomics in adult patients (mean age 20 years)born at Term born ELBW

20years

BarkerhypothesisAltered embryonic/fetal developmentresults in lowbirthweight andpredisposes for adultdiseases (renal,metabolic,cardiovascular)

EventsPrenatalperturbation

Reducednephronnumber

Reduction intotal filtrationsurface area

Hypertensionand renaldisease

BrennerhypothesisLow nephronsnumber predisposesto adult hypertension

genes

Main ModifiersPerinatalProgramming

Extreme prematurity

Low birth weight

Nutritional setting

Catch-up growth

Obstructive andrefluxing nephropathy

Nephrotoxic drugs

Puddu M,Fanos V.Am J Nephrol 2009

What Perinatologist do not know …

•Preterm infant: window of 6 wks of postnatal renal maturation

ex. 24 wks: maturation until 30 wks stop

•Preterm infant with acute kidney failure: window of 4 wks ofpostnatal renal maturation

ex. 24 wks: maturation until 28 wks stop

• If IUGR: maturation window further reducted

Reduction final number of nephrons

Variability in total nephron number for single kidney at birth

CLINICAL SIGNIFICANCE (basal value + postnatal kidney injury)

200.000 900.000 2.500.000

IUGR

NSAIDs

THE BLUE STRIP WIDTH

Immunoistochimica tissutaleMarcatori in corso di studioCollaborazione Prof. G. Faa

• WT1• MUC1• CD10• CD44• Proteina mTOR• BCL2• BCL1• Kim1• Timosina beta 4• Timosina beta 10• hCTR1• Glypican 3• Galectina• …….

Neonatal Physiological Rigenerative Medicine ?

3 MMammasarda cheallatta incostumetipico

FORMULA

PRETERMBREAST MILK

NMR (acqueous phase): Principal Component Analysis (PCA)Tallin 2012, Proceedings 20th European Workshop on Neonatology,

J Perin Med June 2012, JMFNM 2012

-100

-80

-60

-40

-20

0

20

40

60

80

100

120

-260 -240 -220 -200 -180 -160 -140 -120 -100 -80 -60 -40 -20 0 40 60 80 100 120 140 160 180 200 220 240 260

F

B

D

E1

C

A

Human MilkFormula Milk

Maltose, Myo-inositol, Lactose, Glucose, GalactoseAlanine, Valine, Leucine, Isoleucine, Glutammate

Citric, Lactic, Fumaric acid, Creatine, Phospho/creatine, Creatinine, Taurine

Using the best formula for the patient, when mother’s milk is notavailablese non è disponibile il latte materno

Milk ofmothers whodelivered apreterm baby

LGAIUGRAGA

ATBIRTH

BreastfeedingFormula milk

7° DAY

2016

AGA IUGRLGA

FormulaBreastfeeding

CD 44 good marker of stemness

CD 133 positive only in the first 3 days

Ki67 marker of asymmetric division

Couldmetabolomicsbe useful forstudying stemcells in brestmilk?Correlationwith presenceandpercentageof stem cells

BREASTMILK STEM CELL TRANSFERFROM MOTHER TO NEONATAL ORGANS

Maternal stem cells may:Migrate across the intestinal

BarrierDifferentiateAssimilate and integrate

with newborn tissues

Hassiotou F. Faseb Journal 2014, 28

FROM BREAST MILK TO BRAIN

+

Twigger A-J J Hum Lact, 2013

Le cellulestaminali del lattematerno

Programmazione della salute e dellamalattia da parte del latte materno

Prof G. Faa Cagliari

FROM BREAST MILK TO BRAIN

Hosseini SM Neurol Res Int 2014

Differentiation of breast-milkstem cells to neural stem cellsand neurons

Neurons

Oligodendrocytes

Astrocytes

Metabolomica liquidocellule staminali

In collaborazione con l’Università di Atene:Prof.ssa Malamitsi-Puchner

(dati non pubblicati)

Cellule CD44 +

IUGR= 20 volte maggiori

Radici Profonde…Messaggi da portare a casa

• Periodi critici di vulnerabilità (“trasformare le finestre divulnerabilità in finestre di opportunità”).

• Il programming determina cambiamenti strutturali permanenti inorgani importanti (God save the brain...) e può modificare lasuscettibilità alle malattie

• La placenta svolge un ruolo chiave (“E’ la placenta un innocentbystander, un testimone innnocente? No, non lo è”).

• Il compenso che si verifica vuole farci raggiungere l’immortalità(“Per riprodurmi, son nato”) ma ha dei costi (“una tassa dapagare”).

• Gli effetti del programming sono transgenerazionali. Dalloslogan paradossale “devi sceglierti i genitori” al “devi sceglierti igenitori, i nonni e i bisnonni!”

Fanos V. Metabolomica e microbiomica. Hygeia Press 2015

Siamo tutti diversi

Straordinaria variabilità interindividuale basale che aumenta dopo unostimolo intenso (es. asfissia, sepsi, digiuno prolungato….)

Concetti di FRAGILITA’ E RESILIENZA

EARLY INTERVENTIONSCOULD PREVENT EARLY ONSET

•What to do?

PRENATAL• Prudent diet• Micronutrients• Avoid toxic substancesPOSTNATAL• Close monitoring• Appropriate lifestyle

- promote physical activity,- avoid secondary smoking,- prevent obesity)

• Dietary interventions- breastfeeding- avoid rapid growth periods- monitor newborns at risk

Godfrey KM, Gluckman PD, Hanson MA:Developmental origins of metabolic disease:

life course and intergenerational perspectives.Trends Endocrin Met 2010;21:199–205.

• Italian Edition, July 2015• English Edition, ELSEVIER 1st

September 2016

I have a dream

PEDIATRICS of 10 P

• Personalized• Prospective• Predictive• Preventive• Precise• Participated• Patient-centered• Psycocognitive• Postgenomic• Public

In my beginning is my end…

Four Quartets

Thomas S. Eliot

In my beginning is my end…

Four Quartets

…Pray for us nowand at the hour of our birth.

Animula

Thomas S. Eliot

Graziedell’attenzione

Are we born with innate knowledge,ideas and virtues?

YES

PLATO

THEPERFORMATIONTHEORY

GENETIC VIEW

NO

ARISTOTELE

THE BLANK SLATE

EPIGENETIC VIEW

Are we born with innate knowledge,ideas and virtues?

YES

PLATO

THEPERFORMATIONTHEORY

GENETIC VIEW1/3

NO

ARISTOTELE

THE BLANK SLATE

EPIGENETIC VIEW2/3

Acknowledgmentsand permanentcollaborations

Luigi Atzori, Luigi BarberiniScienze Neur. e Cardiovascolari,University of Cagliari

Melania Puddu, Giovanni Ottonello,Antonio Noto, Angelica DessìNICU Cagliari

Emanuela Locci, Flaminia Marincola,Paola Scano Dip. Scienze Chimiche,University of Cagliari Dmitry Grapov, California, USA

Michele MussapSan Martino Hospital, Univ. of Genoa

Giuseppe Buonocore, Univ. of Siena

Julian Griffin Aalim WeljieDepartment of Biochemistry Metabolomics Research Centre

University of Cambridge Univ. of Calgary

95 collaborations with 19 countriesin 5 continents

95 collaborations with 19 countriesin 5 continents

Genetica Ambiente

AlimentazioneBoth undernutritionand overnutrition

are MALNUTRITION

Lezioni di Pediatria, Università di Verona, 1981Prof. Dino Gaburro

Il primo pastoè come ilprimo respiro

4 DECEMBER 2015

ITALIAN SOCIETYDOHaD

VASSILIOS FANOS (CHIEF)

IRENE CETINSERGIO BERNASCONIGIAN CARLO DI RENZOLUCA RAMENGHIVASSILIOS FANOSBENITO CAPPUCCINILUCIA MIGLIOREERNESTO BURGIOGIAN PAOLO DONZELLIFEDERICO MECACCI

4 DICEMBRE 2015

GRUPPO COSTITUENTEDOHAD SOCIETY ITALY

VASSILIOS FANOS(RESPONSABILE) vafanos@tin.it

IRENE CETINSERGIO BERNASCONIGIAN CARLO DI RENZOLUCA RAMENGHIVASSILIOS FANOSBENITO CAPPUCCINILUCIA MIGLIOREERNESTO BURGIOGIAN PAOLO DONZELLIFEDERICO MECACCI

STRUCTURE ANDFUNCTION

In my beginning is my end…We had the experience but miss themeaning,And approach to meaning restores theexperienceIn a different form, beyond any meaning…The only wisdom we can hope to acquireIs the wisdom of humility:humility is endless.

Thomas S. Eliot. Four Quartets

Group 1 (spontaneous) related togroup 3 (cesarean) at birth.Higher0.62 (s) ppm1.24 (sb) ppm suberic acid1.27 (sb) ppm sebacic acid1.63 (s) ppm alpha-amino adipic acid (to confirm)2.72 (s) ppm dimethylamine2.06 (sb) ppm Glycoprotein signal2.08 (sb) ppm Glyco protein signal2.38 (s) oxaloacetate2.43 (s) beta-keto-adipic acid

Lower3.208 (s) Choline3.02, 1.73(m), Lysine4.08 (m) Myoinositol7.84 Hippurate8.45 Formate7.09, 7.91 (s) Histidine

Geographic Information Systemof a Human Being

The new languages of MedicineMicrobiomics

Microbiota

Olobionte

Networking batterico

Sociomicrobiologia batterica

Ecosistema corporeo

Co-evoluzione

Simbiotici

Sistema NEI (neuro-endocrino-

immunitario)

Batteri ed evoluzione del

cervello

Trapianto di microbiota

3? ?

Leonardo da Vinci studies of the fetus on the womb:circa 1510-1513

8th International Workshop on Neonatology, Cagliari 24-27 October 2012

Differences in the two groups related to the alterations inthe arginine and proline metabolism, in the purine andpyrimidine metabolism in the hystidine, beta-alaninemetabolism and with the urea cycle(Fanos V. et al Clinical Biochemistry 2011 , mod)

Metabolomics in adult patients (mean age 24 years)born at Term born ELBW

24years

Who do we think we are?

• Cellule organismo

• Microbiota

• Viroma

• Fungoma

• Chimerismo

Diverse mammals, including humans, have been found to carrydistinct genomes in their cells. What does such genetic chimerismmean for health and disease?

In my beginning is my end…

Four Quartets

Thomas S. Eliot

What is life? (E. Schrödinger)

Le cinque grandi ideedella biologia e della medicina (P. Nurse)

What is life? (E. Schrödinger)

Le cinque grandi ideedella biologia e della medicina (P. Nurse)

Cover of the April10, 2014 issue ofNature

This is what weare: lots and lots of

connections

“cells that firetogether, wire

together”

PLS-DA of IUGR vs control (at birth)

Controls

IUGR

In collaboration withUtrecht and PaduaUniversities andAlessandria Hospital

ControlNewborn

IUGRNewborn

6 VIP: creatinine, creatine, myoinositol,betaine, succinate, sarcosine.

1H-NMR urine samples