Phthalate-associated hypertension in premature infants: a prospective mechanistic cohort study

Randall Jenkins, Shane Tackitt, Ladawna Gievers, Sandra Iragorri, Kylie Sage, Tonya Cornwall, Declan O’Riordan, Jennifer Merchant, David Rozansky

Research output: Contribution to journalArticlepeer-review

29 Scopus citations


Background: Phthalates are associated with increased blood pressure in children. Large exposures to di-(2-ethylhexyl) phthalate (DEHP) among premature infants have been a cause for concern. Methods: We conducted a prospective observational cohort study to determine if DEHP exposures are related to systolic blood pressure (SBP) in premature infants, and if this exposure is associated with activation of the mineralocorticoid receptor (MR). Infants were monitored longitudinally for 8 months from birth. Those who developed idiopathic hypertension were compared with normotensive infants for DEHP exposures. Appearance of urinary metabolites after exposure was documented. Linear regression evaluated the relationship between DEHP exposures and SBP index and whether urinary cortisol/cortisone ratio (a surrogate marker for 11β-HSD2 activity) mediated those relationships. Urinary exosomes were quantified for sodium transporter/channel expression and interrogated against SBP index. Results: Eighteen patients met the study criteria, nine developed transient idiopathic hypertension at a postmenstrual age of 40.6 ± 3.4 weeks. The presence of urinary DEHP metabolites was associated with prior IV and respiratory tubing DEHP exposures (p < 0.05). Both IV and respiratory DEHP exposures were greater in hypertensive infants (p < 0.05). SBP index was related to DEHP exposure from IV fluid (p = 0.018), but not respiratory DEHP. Urinary cortisol/cortisone ratio was related to IV DEHP and SBP index (p < 0.05). Sodium transporter/channel expression was also related to SBP index (p < 0.05). Conclusions: Increased blood pressure and hypertension in premature infants are associated with postnatal DEHP exposure. The mechanism of action appears to be activation of the MR through inhibition of 11β-HSD2.

Original languageEnglish (US)
Pages (from-to)1413-1424
Number of pages12
JournalPediatric Nephrology
Issue number8
StatePublished - Aug 1 2019


  • Blood pressure
  • Hypertension
  • Neonatal
  • Phthalates

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Nephrology


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