Female metabolic resilience and male-biased protein quality defects under hypoxia in human brain organoids

Hypoxic-ischemic encephalopathy (HIE) is a major cause of neonatal mortality and long-term neurological impairment caused by reduced oxygen and blood supply to the brain. Although sex differences influence HIE outcomes, the underlying cellular and molecular mechanisms remain poorly understood. Human cerebral organoids (hCOs) provide a relevant model to investigate hypoxic responses with a focus on sexual dimorphism. We generated hCOs at different maturation stages (2, 4, and 6 months) and selected the optimal stage to study hypoxic injury during brain development. Proteomic analyses revealed maturation-dependent features, including neurogenesis, astrogliogenesis, and cell growth. Hypoxic stress was associated with mitochondrial dysfunction and altered energy metabolism in both sexes. Female-derived hCOs showed enhanced metabolic adaptation, whereas male-derived hCOs exhibited alterations in protein quality control pathways. Overall, this study highlights sex as an important biological variable in hypoxic brain injury and provides insights relevant to HIE pathophysiology, while suggesting potential biomarkers for therapeutic development.