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Zhuang H, Han S, Harris NS, Reeves WH. MEK1/2- and ERK1/2-Mediated Lung Endothelial Injury and Altered Hemostasis Promote Diffuse Alveolar Hemorrhage in Murine Lupus. Arthritis Rheumatol 2024. [PMID: 38923837 DOI: 10.1002/art.42936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 04/25/2024] [Accepted: 05/30/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE About 3% of patients with lupus develop severe diffuse alveolar hemorrhage (DAH) with pulmonary vasculitis. C57BL/6 (B6) mice with pristane-induced lupus also develop DAH, but BALB/c mice are resistant. DAH is independent of Toll-like receptor signaling and other inflammatory pathways. This study examined the role of the MEK1/2 pathway (MEK1/2-ERK1/2, JNK, p38). METHODS B6 and BALB/c mice were treated with pristane with or without inhibitors of MEK1/2 (trametinib/GSK1120212 [GSK]), ERK1/2 (SCH772984 [SCH]), JNK, or p38. Effects on lung hemorrhage and hemostasis were determined. RESULTS GSK and SCH abolished DAH, whereas JNK and p38 inhibitors were ineffective. Apoptotic cells were present in lung samples from pristane-treated mice but not in mice receiving pristane and GSK, and endothelial dysfunction was normalized. Expression of the ERK1/2-regulated transcription factor early growth response 1 increased in pristane-treated B6, but not BALB/c, mice and was normalized by GSK. Pristane also increased expression of the anticoagulant genes Tfpi and Thbd in B6 mice. The ratio of Tfpi to tissue factor (F3) to Tfpi increased in B6 (but not BALB/c) mice and was normalized by GSK. Circulating thrombomodulin protein levels increased in B6 mice and returned to normal after GSK treatment. Consistent with augmented endothelial anticoagulant activity, pristane treatment increased tail bleeding in B6 mice. CONCLUSION Pristane treatment promotes lung endothelial injury and DAH in B6 mice by activating the MEK1/2-ERK1/2 pathway and impairing hemostasis. The hereditary factors determining susceptibility to lung injury and bleeding in pristane-induced lupus are relevant to the pathophysiology of life-threatening DAH in systemic lupus erythematosus and may help to optimize therapy.
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Affiliation(s)
- Haoyang Zhuang
- University of Florida College of Medicine, Gainesville, Florida
| | - Shuhong Han
- University of Florida College of Medicine, Gainesville, Florida
| | - Neil S Harris
- University of Florida College of Medicine, Gainesville, Florida
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Zhuang H, Han S, Harris NS, Reeves WH. MEK1/2 and ERK1/2 mediated lung endothelial injury and altered hemostasis promote diffuse alveolar hemorrhage in murine lupus. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.07.593006. [PMID: 38766226 PMCID: PMC11100673 DOI: 10.1101/2024.05.07.593006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Objective About 3% of lupus patients develop severe diffuse alveolar hemorrhage (DAH) with pulmonary vasculitis. B6 mice with pristane-induced lupus also develop DAH, but BALB/c mice are resistant. DAH is independent of TLR signaling and other inflammatory pathways. This study examined the role of the mitogen-activated protein kinase pathway (MEK1/2-ERK1/2, JNK, p38). Methods B6 and BALB/c mice were treated with pristane ± inhibitors of MEK1/2 (trametinib/GSK1120212, "GSK"), ERK1/2 (SCH772984, "SCH"), JNK, or p38. Effects on lung hemorrhage and hemostasis were determined. Results GSK and SCH abolished DAH, whereas JNK and p38 inhibitors were ineffective. Apoptotic cells were present in lung from pristane-treated mice, but not mice receiving pristane+GSK and endothelial dysfunction was normalized. Expression of the ERK1/2-regulated transcription factor Egr1 increased in pristane-treated B6, but not BALB/c, mice and was normalized by GSK. Pristane also increased expression of the anticoagulant genes Tfpi (tissue factor pathway inhibitor) and Thbd (thrombomodulin) in B6 mice. The ratio of tissue factor ( F3 ) to Tfpi increased in B6 (but not BALB/c) mice and was normalized by GSK. Circulating Thbd protein increased in B6 mice and returned to normal after GSK treatment. Consistent with augmented endothelial anticoagulant activity, pristane treatment increased tail bleeding in B6 mice. Conclusion Pristane treatment promotes lung endothelial injury and DAH in B6 mice by activating the MEK1/2-ERK1/2 pathway and impairing hemostasis. The hereditary factors determining susceptibility to lung injury and bleeding in pristane-induced lupus are relevant to the pathophysiology of life-threatening DAH in SLE and may help to optimize therapy.
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Arya P, Prickett KK, Raol N, Briones M, Evans S. Sirolimus-induced pulmonary hemorrhage of an infant with massive cervicofacial lymphatic malformation: A case report. Int J Pediatr Otorhinolaryngol 2023; 164:111404. [PMID: 36469963 DOI: 10.1016/j.ijporl.2022.111404] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/11/2022] [Accepted: 11/23/2022] [Indexed: 11/27/2022]
Abstract
Lymphatic malformations (LMs) are uncommon congenital abnormalities of the lymphatic system. As more than half of these lesions develop in the head and neck, LMs can be life-threatening if associated with airway involvement. LMs necessitate a multidisciplinary treatment approach, frequently including surgery and sclerotherapy. We present a case report of a 32-week pre-term male infant with a massive cervicofacial LM necessitating delivery via ex-utero intrapartum treatment (EXIT). The patient was treated with numerous rounds of sclerotherapy, systemic sirolimus, and surgical debulking, but ultimately died at 4 months of age due to acute pulmonary hemorrhage, which may have been related to sirolimus due to the absence of any other associable organ involvement or derangement. We document the patient's clinical course and treatment regimen, highlighting the myriad modalities employed to treat these challenging lesions, and describe a potentially lethal complication of sirolimus therapy not previously described in the treatment of pediatric LM.
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Affiliation(s)
- Priya Arya
- Mercer University School of Medicine, 1250 E 66th St, Savannah, GA, 31404, USA
| | - Kara K Prickett
- Children's Healthcare of Atlanta, 1405 Clifton Rd NE, Atlanta, GA, 30322, USA; Emory University School of Medicine, Department of Otolaryngology, 100 Woodruff Circle, Atlanta, GA, 30322, USA
| | - Nikhila Raol
- Children's Healthcare of Atlanta, 1405 Clifton Rd NE, Atlanta, GA, 30322, USA; Emory University School of Medicine, Department of Otolaryngology, 100 Woodruff Circle, Atlanta, GA, 30322, USA
| | - Michael Briones
- Children's Healthcare of Atlanta, 1405 Clifton Rd NE, Atlanta, GA, 30322, USA; Emory University School of Medicine, Department of Otolaryngology, 100 Woodruff Circle, Atlanta, GA, 30322, USA
| | - Sean Evans
- Children's Healthcare of Atlanta, 1405 Clifton Rd NE, Atlanta, GA, 30322, USA; Emory University School of Medicine, Department of Otolaryngology, 100 Woodruff Circle, Atlanta, GA, 30322, USA.
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Gendarme S, Pastré J, Billaud EM, Gibault L, Guillemain R, Oudard S, Medioni J, Lillo-Lelouet A, Israël-Biet D. Pulmonary toxicity of mTOR inhibitors. Comparisons of two populations: Solid organ recipients and cancer patients. Therapie 2022; 78:267-278. [DOI: 10.1016/j.therap.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 04/14/2022] [Accepted: 05/24/2022] [Indexed: 10/18/2022]
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Almeida F, Amorim S, Sarmento A, Santos L. Life-Threatening Everolimus-Associated Pneumonitis: A Case Report and a Review of the Literature. Transplant Proc 2018; 50:933-938. [PMID: 29588066 DOI: 10.1016/j.transproceed.2017.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 12/04/2017] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Noninfective pneumonitis is a class-related effect within mammalian target of rapamycin (mTOR) inhibitors, including everolimus, and can occasionally be severe. CASE REPORT A 62-year-old man, medicated with everolimus due to a heart transplantation 17 years previously and with chronic kidney disease, was admitted to the intensive care unit (ICU) with acute respiratory failure, cardiovascular shock, and impaired renal function requiring dialysis. Computed tomography (CT) scan revealed right upper lobe consolidation. Extensive microbiological workup, autoimmune testing, and cytology were negative and echocardiography showed preserved heart function. Everolimus levels were normal (5.7-6.1 ng/mL) and the drug was suspended at day 9. The patient was difficult to ventilate and responded poorly to broad-spectrum antibiotic and antifungal therapy. On day 25, CT scan and bronchoscopy revealed left-sided alveolar hemorrhage, and corticosteroid pulses were performed. The patient gradually improved. After discharge and 6 months of follow-up, clinical recovery was complete and chest imaging substantially improved. DISCUSSION Pneumonitis occurs in up to 4.3% of transplant recipients using everolimus for immunosuppression. Despite usually presenting as a mild and self-limited disease, severe cases have been described. Alveolar hemorrhage can occur and is associated with poor outcome. Everolimus levels do not seem to accurately predict toxicity. Corticosteroid therapy has been used with success in severe disease. We review the pathophysiological, clinical, and management-related aspects of this entity with emphasis on its potential severity. CONCLUSION Our case was a rare occurrence of severe life-threatening pulmonary disease related to everolimus. Awareness of the potential severity of this entity is important for the management of patients using mTOR inhibitors.
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Affiliation(s)
- F Almeida
- Infectious Diseases Department, Centro Hospitalar de São João, Porto, Portugal.
| | - S Amorim
- Cardiology Department, Centro Hospitalar de São João, Porto, Portugal
| | - A Sarmento
- Infectious Diseases Department, Centro Hospitalar de São João, Alameda Professor Hernani Monteiro, Porto, Portugal; i3S, Instituto de Inovação e Investigação em Saúde, Grupo de I&D em Nefrologia e Doenças Infeciosas, Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - L Santos
- Infectious Diseases Department, Centro Hospitalar de São João, Porto, Portugal
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Gadre S, Kotloff RM. Noninfectious Pulmonary Complications of Liver, Heart, and Kidney Transplantation: An Update. Clin Chest Med 2017; 38:741-749. [PMID: 29128022 DOI: 10.1016/j.ccm.2017.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite significant advances in surgical techniques, perioperative care, and immunosuppressive therapy, solid organ transplantation still carries considerable risk of complications. Pulmonary complications, in particular, are a major cause of morbidity and mortality. Although infectious complications prevail, the lungs are also vulnerable to a variety of noninfectious complications related to the transplant surgery and adverse effects of the immunosuppressive regimen. This article focuses on noninfectious pulmonary complications associated with the 3 most commonly performed solid organ transplant procedures: liver, kidney, and heart.
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Affiliation(s)
- Shruti Gadre
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Robert M Kotloff
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Balcan B, Simsek E, Ugurlu AO, Demiralay E, Sahin S. Sirolimus-Induced Diffuse Alveolar Hemorrhage: A Case Report. Am J Ther 2017; 23:e1938-e1941. [PMID: 26849007 DOI: 10.1097/mjt.0000000000000427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Sirolimus is a mammalian target of the rapamycin, a protein kinase, which is responsible for inhibition of T cell and B cell proliferation. Sirolimus has side effects on lugs, and may cause cryptogenic organizing pneumonia, diffuse alveolar hemorrhage, lymphocytic pneumonitis, hypersensitivity pneumonitis, desquamative interstitial pneumonia, and pulmonary alveolar proteinosis. Diagnosis is based on the combination of clinical, radiological, histological, and pathological investigation. We report a case of diffuse alveolar hemorrhage in a 33-year-old, female renal transplant recipient. After discontinuation of sirolimus, radiological images and clinical condition of the patient got better. We also planned steroid therapy for 6 months by tapering the dosage slowly. After steroid therapy, full recovery of pulmonary functions achieved, and the patient is observed in our outpatient clinic with lack of any pulmonary symptoms.
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Affiliation(s)
- Baran Balcan
- Departments of 1Pulmonary Medicine, 2Nephrology, and 3Pathology, Faculty of Medicine, Baskent University, Istanbul, Turkey
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Ventura-Aguiar P, Campistol JM, Diekmann F. Safety of mTOR inhibitors in adult solid organ transplantation. Expert Opin Drug Saf 2016; 15:303-19. [PMID: 26667069 DOI: 10.1517/14740338.2016.1132698] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Mammalian target of rapamycin (mTOR) inhibitors (sirolimus and everolimus) are a class of immunosuppressive drugs approved for solid organ transplantation (SOT). By inhibiting the ubiquitous mTOR pathway, they present a peculiar safety profile. The increased incidence of serious adverse events in early studies halted the enthusiasm as a kidney sparing alternative to calcineurin inhibitors (CNI). AREAS COVERED Herein we review mTOR inhibitors safety profile for adult organ transplantation, ranging from acute side effects, such as lymphoceles, delayed wound healing, or cytopenias, to long-term ones which increase morbidity and mortality, such as cancer risk and metabolic profile. Infection, proteinuria, and cutaneous safety profiles are also addressed. EXPERT OPINION In the authors' opinion, mTOR inhibitors are a safe alternative to standard immunosuppression therapy with CNI and mycophenolate/azathioprine. Mild adverse events can be easily managed with an increased awareness and close monitoring of trough levels. Most serious side effects are dose- and organ-dependent. In kidney and heart transplantation mTOR inhibitors may be safely used as either low-dose de novo or through early-conversion. In the liver, conversion 4 weeks post-transplantation may reduce long-term chronic kidney disease secondary to calcineurin nephrotoxicity, without increasing hepatic artery/portal vein thrombosis.
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Affiliation(s)
- Pedro Ventura-Aguiar
- a Department of Nephrology and Renal Transplantation , Hospital Clínic , Villarroel, 170, E-08036 Barcelona , Spain
| | - Josep Maria Campistol
- a Department of Nephrology and Renal Transplantation , Hospital Clínic , Villarroel, 170, E-08036 Barcelona , Spain.,b August Pi i Sunyer Biomedical Research Institute (IDIBAPS) , University of Barcelona , Barcelona , Spain
| | - Fritz Diekmann
- a Department of Nephrology and Renal Transplantation , Hospital Clínic , Villarroel, 170, E-08036 Barcelona , Spain
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Abdalla M, Sabbineni H, Prakash R, Ergul A, Fagan SC, Somanath PR. The Akt inhibitor, triciribine, ameliorates chronic hypoxia-induced vascular pruning and TGFβ-induced pulmonary fibrosis. Br J Pharmacol 2015; 172:4173-88. [PMID: 26033700 PMCID: PMC4543621 DOI: 10.1111/bph.13203] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 04/22/2015] [Accepted: 05/21/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND AND PURPOSE Interstitial lung disease accounts for a group of chronic and progressive disorders associated with severe pulmonary vascular remodelling, peripheral vascular rarefaction and fibrosis, thus limiting lung function. We have previously shown that Akt is necessary for myofibroblast differentiation, a critical event in organ fibrosis. However, the contributory role of the Akt-mTOR pathway in interstitial lung disease and the therapeutic benefits of targeting Akt and mTOR remain unclear. EXPERIMENTAL APPROACH We investigated the role of the Akt-mTOR pathway and its downstream molecular mechanisms in chronic hypoxia- and TGFβ-induced pulmonary vascular pruning and fibrosis in mice. We also determined the therapeutic benefits of the Akt inhibitor triciribine and the mTOR inhibitor rapamycin for the treatment of pulmonary fibrosis in mice. KEY RESULTS Akt1(-) (/) (-) mice were protected from chronic hypoxia-induced peripheral vascular pruning. In contrast, hyperactivation of Akt1 induced focal fibrosis similar to TGFβ-induced fibrosis. Pharmacological inhibition of Akt, but not the Akt substrate mTOR, inhibited hypoxia- and TGFβ-induced pulmonary vascular rarefaction and fibrosis. Mechanistically, we found that Akt1 modulates pulmonary remodelling via regulation of thrombospondin1 (TSP1) expression. Hypoxic Akt1(-) (/) (-) mice lungs expressed less TSP1. Moreover, TSP1(-) (/) (-) mice were resistant to adMyrAkt1-induced pulmonary fibrosis. CONCLUSIONS AND IMPLICATIONS Our study identified Akt1 as a novel target for the treatment of interstitial lung disease and provides preclinical data on the potential benefits of the Akt inhibitor triciribine for the treatment of interstitial lung disease.
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Affiliation(s)
- Maha Abdalla
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia and Charlie Norwood VA Medical CenterAugusta, GA, USA
- Department of Pharmaceutical Sciences, South College School of PharmacyKnoxville, TN, USA
| | - Harika Sabbineni
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia and Charlie Norwood VA Medical CenterAugusta, GA, USA
| | - Roshini Prakash
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia and Charlie Norwood VA Medical CenterAugusta, GA, USA
| | - Adviye Ergul
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia and Charlie Norwood VA Medical CenterAugusta, GA, USA
- Department of Physiology, Georgia Regents UniversityAugusta, GA, USA
| | - Susan C Fagan
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia and Charlie Norwood VA Medical CenterAugusta, GA, USA
- Department of Neurology, Georgia Regents UniversityAugusta, GA, USA
| | - Payaningal R Somanath
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia and Charlie Norwood VA Medical CenterAugusta, GA, USA
- Department of Medicine, Georgia Regents UniversityAugusta, GA, USA
- Vascular Biology Center, Georgia Regents UniversityAugusta, GA, USA
- Cancer Center, Georgia Regents UniversityAugusta, GA, USA
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Shin YC, Yang WJ, Lee JH, Oh JW, Kim TW, Park JC, Hyon SH, Han DW. PLGA nanofiber membranes loaded with epigallocatechin-3-O-gallate are beneficial to prevention of postsurgical adhesions. Int J Nanomedicine 2014; 9:4067-78. [PMID: 25187710 PMCID: PMC4149440 DOI: 10.2147/ijn.s68197] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
This study concentrates on the development of biodegradable nanofiber membranes with controlled drug release to ensure reduced tissue adhesion and accelerated healing. Nanofibers of poly(lactic-co-glycolic acid) (PLGA) loaded with epigallocatechin-3-O-gallate (EGCG), the most bioactive polyphenolic compound in green tea, were electrospun. The physicochemical and biomechanical properties of EGCG-releasing PLGA (E-PLGA) nanofiber membranes were characterized by atomic force microscopy, EGCG release and degradation profiles, and tensile testing. In vitro antioxidant activity and hemocompatibility were evaluated by measuring scavenged reactive oxygen species levels and activated partial thromboplastin time, respectively. In vivo antiadhesion efficacy was examined on the rat peritonea with a surgical incision. The average fiber diameter of E-PLGA membranes was approximately 300–500 nm, which was almost similar to that of pure PLGA equivalents. E-PLGA membranes showed sustained EGCG release mediated by controlled diffusion and PLGA degradation over 28 days. EGCG did not adversely affect the tensile strength of PLGA membranes, whereas it significantly decreased the elastic modulus and increased the strain at break. E-PLGA membranes were significantly effective in both scavenging reactive oxygen species and extending activated partial thromboplastin time. Macroscopic observation after 1 week of surgical treatment revealed that the antiadhesion efficacy of E-PLGA nanofiber membranes was significantly superior to those of untreated controls and pure PLGA equivalents, which was comparable to that of a commercial tissue-adhesion barrier. In conclusion, the E-PLGA hybrid nanofiber can be exploited to craft strategies for the prevention of postsurgical adhesions.
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Affiliation(s)
- Yong Cheol Shin
- Department of Cogno-Mechatronics Engineering, Pusan National University, Busan, Republic of Korea
| | - Won Jun Yang
- Department of Cogno-Mechatronics Engineering, Pusan National University, Busan, Republic of Korea
| | - Jong Ho Lee
- Department of Cogno-Mechatronics Engineering, Pusan National University, Busan, Republic of Korea
| | - Jin-Woo Oh
- Department of Nanomaterials Engineering, College of Nanoscience and Nanotechnology, Pusan National University, Busan, Republic of Korea
| | - Tai Wan Kim
- Department of Design, College of Arts, Pusan National University, Busan, Republic of Korea
| | - Jong-Chul Park
- Department of Medical Engineering, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Suong-Hyu Hyon
- Center for Fiber and Textile Science, Kyoto Institute of Technology, Kyoto, Japan
| | - Dong-Wook Han
- Department of Cogno-Mechatronics Engineering, Pusan National University, Busan, Republic of Korea
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Baas MC, Struijk GH, Moes DJAR, van den Berk IAH, Jonkers RE, de Fijter JW, van der Heide JJH, van Dijk M, ten Berge IJM, Bemelman FJ. Interstitial pneumonitis caused by everolimus: a case-cohort study in renal transplant recipients. Transpl Int 2014; 27:428-36. [PMID: 24484452 DOI: 10.1111/tri.12275] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 08/20/2013] [Accepted: 01/23/2014] [Indexed: 12/21/2022]
Abstract
The use of inhibitors of the mammalian target of rapamycin (mTORi) in renal transplantation is associated with many side effects, the potentially most severe being interstitial pneumonitis. Several papers have reported on sirolimus-induced pneumonitis, but less is published on everolimus-induced pneumonitis (EIP). Data on risk factors for contracting EIP are even more scarce. In the present case-cohort study in renal transplant recipients (RTR), we aimed to assess the incidence and risk factors of EIP after renal transplantation. This study is a retrospective substudy of a multicenter randomized controlled trial. All patients included in the original trial and treated with prednisolone/everolimus were included in this substudy. RTR who developed EIP were identified as cases. RTR without pulmonary symptoms served as controls. Thirteen of 102 patients (12.7%) developed EIP. We did not find any predisposing factors, especially no correlation with everolimus concentration. On pulmonary CT scan, EIP presented with an organizing pneumonia-like pattern, a nonspecific interstitial pneumonitis-like pattern, or both. Median time (range) to the development of EIP after start of everolimus was 162 (38-407) days. In conclusion, EIP is common in RTR, presenting with an organizing pneumonia, a nonspecific interstitial pneumonitis-like pattern, or both. No predisposing factors could be identified (Trial registration number: NTR567 (www.trialregister.nl), ISRCTN69188731).
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Affiliation(s)
- Marije C Baas
- Renal Transplant Unit, Department of Nephrology, Division of Internal Medicine, Academic Medical Center, Amsterdam, the Netherlands
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Das S, Cherian SV, Das N, Garcha AS, Lenox R, Sexton J. Persistent dyspnea in a 59-year-old woman receiving immunosuppressants. Chest 2011; 140:818-822. [PMID: 21896528 DOI: 10.1378/chest.11-0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Subhraleena Das
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY.
| | - Sujith V Cherian
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY
| | - Nabamita Das
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY
| | | | - Robert Lenox
- Department of Pulmonary and Critical Care, SUNY Upstate Medical University, Syracuse, NY
| | - James Sexton
- Department of Pulmonary and Critical Care, SUNY Upstate Medical University, Syracuse, NY
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Caruso S, Crino’ F, Milazzo M, Vitulo P, Bertani A, Marrone G, Mamone G, Maruzzelli L, Miraglia R, Carollo V, Luca A, Gridelli B. Thoracic complications following lung transplantation: 64-MDCT findings. Clin Transplant 2011; 25:673-84. [DOI: 10.1111/j.1399-0012.2011.01439.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Ramsey J, Amari M, Kantrow SP. Pulmonary vasculitis: clinical presentation, differential diagnosis, and management. Curr Rheumatol Rep 2011; 12:420-8. [PMID: 20882372 DOI: 10.1007/s11926-010-0136-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This review focuses on vasculitides with prominent pulmonary manifestations and discusses key contributions from the recent literature. Pulmonary vasculitis should be considered when clinical findings include alveolar hemorrhage, nodular and cavitary lung disease, airway stenosis, pulmonary artery aneurysms, or pulmonary artery stenosis. The differential diagnostic considerations for common clinical presentations of vasculitis in the lung are important, and several recent additions are discussed. Treatment for established pulmonary vasculitis is effective and has decreased the morbidity and mortality associated with these diseases while introducing an increased risk of infectious complications. Advances in immunosuppressive therapy have improved treatment of refractory disease and are likely to change initial treatment strategies in the future.
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Affiliation(s)
- Jennifer Ramsey
- Cleveland Clinic Main Campus, Mail Code A90, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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White DA, Camus P, Endo M, Escudier B, Calvo E, Akaza H, Uemura H, Kpamegan E, Kay A, Robson M, Ravaud A, Motzer RJ. Noninfectious pneumonitis after everolimus therapy for advanced renal cell carcinoma. Am J Respir Crit Care Med 2010; 182:396-403. [PMID: 20194812 DOI: 10.1164/rccm.200911-1720oc] [Citation(s) in RCA: 172] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
RATIONALE Noninfectious pneumonitis is a known class effect of mammalian target of rapamycin (mTOR) inhibitors. OBJECTIVES To assess the incidence, radiographic patterns, management, and outcome of pneumonitis in patients with advanced renal cell carcinoma receiving everolimus. METHODS Clinical study data from 416 patients, randomized to receive everolimus versus placebo, were analyzed for adverse events of pneumonitis. Radiographic studies performed every 8 weeks were subject to a prospective, independent, blinded central review for the presence of findings indicative of pneumonitis. MEASUREMENTS AND MAIN RESULTS Of 274 patients receiving everolimus, clinical pneumonitis was suspected for 37 patients (13.5%) (none with placebo). Nine cases (3.3%) were grade 1 (asymptomatic), 18 (6.6%) were grade 2 (not interfering with daily living), and 10 (3.6%) were grade 3 (interfering with daily living or oxygen indicated). No grade 4 (life-threatening) pneumonitis was observed. Of the 10 patients with grade 3 pneumonitis, 5 had baseline radiological evidence of pneumonitis before everolimus therapy. Twenty of the 37 cases (54.0%) were reversible within the follow-up period; resolution followed dose reduction for 20 patients and treatment discontinuation in 10 patients. Corticosteroid therapy was initiated in 16 cases. Dedicated radiological review of available serial radiographic studies (245 patients receiving everolimus and 132 receiving placebo) found a higher percentage of new radiographic findings even in patients without a diagnosis of clinical pneumonitis who were receiving everolimus versus placebo (38.9 vs. 15.2%). CONCLUSIONS Early recognition, prompt intervention, and a conservative approach are important in managing the risk associated with noninfectious pneumonitis in association with everolimus. Clinical trial registered with www.clinicaltrials.gov (NCT 00410124).
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Affiliation(s)
- Dorothy A White
- Memorial Sloan-Kettering Cancer Center, Pulmonary Medicine, New York, NY 10021, USA.
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Patel AV, Hahn T, Bogner PN, Loud PA, Brown K, Paplham P, Syta M, Battiwalla M, McCarthy PL. Fatal diffuse alveolar hemorrhage associated with sirolimus after allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2009; 45:1363-4. [PMID: 19966843 DOI: 10.1038/bmt.2009.339] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Rabe C, Appenrodt B, Hoff C, Ewig S, Klehr HU, Sauerbruch T, Nickenig G, Tasci S. Severe respiratory failure due to diffuse alveolar hemorrhage: clinical characteristics and outcome of intensive care. J Crit Care 2009; 25:230-5. [PMID: 19592204 DOI: 10.1016/j.jcrc.2009.04.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2008] [Revised: 03/23/2009] [Accepted: 04/28/2009] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of this study was to characterize patients and report outcome of diffuse alveolar hemorrhage (DAH) requiring intensive care unit support. PATIENTS AND METHODS Thirty-seven patients were identified. Clinical characteristics and outcome were determined by chart review. RESULTS Eighty-nine percent of patients presented with shortness of breath, 23% with cough, and 3% with hemoptysis. In 9% of patients, a diagnosis of DAH was suspected on admission. Diagnosis was confirmed by finding a progressively hemorrhagic bronchoalveolar lavage fluid in 89% and by a positive iron stain in 11% of patients. Vasculitis was causative in 19%, drug toxicity in 11%, thrombocytopenia in 27%, stem-cell transplantation in 5%, sepsis-associated lung injury in 22%, and unknown mechanisms in 16%. Thirty-two patients were mechanically ventilated, 4 received noninvasive ventilation, and 1 received supplemental oxygen therapy. Overall, 18 (49%) of 37 patients survived the intensive care unit stay. Survival was markedly different between patients with an immunologic/unknown etiology (82%) and patients with thrombocytopenia and/or sepsis (22%). DISCUSSION Diffuse alveolar hemorrhage should be considered in all patients with persistent pulmonary infiltrates. Both bronchoalveolar lavage fluid and iron stain are mandatory diagnostic means. Patients with an immunologic/idiopathic pathogenetic mechanism have a relatively good prognosis, whereas the outcome in individuals with DAH secondary to cancer therapy or sepsis is poor.
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Affiliation(s)
- Christian Rabe
- Medical ICU, Department of Internal Medicine I, University of Bonn, D-53105 Bonn, Germany.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2008. [DOI: 10.1002/pds.1483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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