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Chandel A, Pastre J, Valery S, King CS, Nathan SD. Derivation and validation of a simple multidimensional index incorporating exercise capacity parameters for survival prediction in idiopathic pulmonary fibrosis. Thorax 2023; 78:368-375. [PMID: 35332096 PMCID: PMC10086452 DOI: 10.1136/thoraxjnl-2021-218440] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 02/18/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The gender-age-physiology (GAP) index is an easy-to-use baseline mortality prediction model in idiopathic pulmonary fibrosis (IPF). The GAP index does not incorporate exercise capacity parameters such as 6 min walk distance (6MWD) or exertional hypoxia. We evaluated if the addition of 6MWD and exertional hypoxia to the GAP index improves survival prediction in IPF. METHODS Patients with IPF were identified at a tertiary care referral centre. Discrimination and calibration of the original GAP index were assessed. The cohort was then randomly divided into a derivation and validation set and performance of the GAP index with the addition of 6MWD and exertional hypoxia was evaluated. A final model was selected based on improvement in discrimination. Application of this model was then evaluated in a geographically distinct external cohort. RESULTS There were 562 patients with IPF identified in the internal cohort. Discrimination of the original GAP index was measured by a C-statistic of 0.676 (95% CI 0.635 to 0.717) and overestimated observed risk. 6MWD and exertional hypoxia were strongly predictive of mortality. The addition of these variables to the GAP index significantly improved model discrimination. A revised index incorporating exercise capacity parameters was constructed and performed well in the internal validation set (C-statistic: 0.752; 95% CI 0.701 to 0.802, difference in C-statistic compared with the refit GAP index: 0.050; 95% CI 0.004 to 0.097) and external validation set (N=108 (C-statistic: 0.780; 95% CI 0.682 to 0.877)). CONCLUSION A simple point-based baseline-risk prediction model incorporating exercise capacity predictors into the original GAP index may improve prognostication in patients with IPF.
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Affiliation(s)
- Abhimanyu Chandel
- Pulmonary and Critical Care, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Jean Pastre
- Service de Pneumologie et Soins Intensifs, Hopital Europeen Georges Pompidou, Paris, France
- Advanced Lung Disease and Transplant, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Solène Valery
- Service de Pneumologie et Soins Intensifs, Hopital Europeen Georges Pompidou, Paris, France
| | - Christopher S King
- Advanced Lung Disease and Transplant, Inova Fairfax Hospital, Falls Church, Virginia, USA
| | - Steven D Nathan
- Advanced Lung Disease and Transplant, Inova Fairfax Hospital, Falls Church, Virginia, USA
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Nathan SD, Fernandes P, Psotka M, Vitulo P, Piccari L, Antoniou K, Nikkho SM, Stockbridge N. Pulmonary hypertension in interstitial lung disease: Clinical trial design and endpoints: A consensus statement from the Pulmonary Vascular Research Institute's Innovative Drug Development Initiative-Group 3 Pulmonary Hypertension. Pulm Circ 2022; 12:e12178. [PMID: 36578976 PMCID: PMC9780699 DOI: 10.1002/pul2.12178] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Pulmonary hypertension (PH) associated with interstitial lung disease (ILD) is an attractive target for clinical trials of PH medications. There are many factors that need to be considered to prime such studies for success. The patient phenotype most likely to respond to the intervention requires weighing the extent of the parenchymal lung disease against the severity of the hemodynamic impairment. The inclusion criteria should not be too restrictive, thus enabling recruitment. The trial should be of sufficient duration to meet the chosen endpoint which should reflect how the patient feels, functions, or survives. This paper summarizes prior studies in PH-ILD and provides a framework of the type of studies to be considered. Inclusion criteria, clinical trial endpoints, and pharmacovigilance in the context of PH-ILD trials are also addressed. Through lessons learnt from prior studies, suggestions and guidance for future clinical trials in PH-ILD are also provided.
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Affiliation(s)
- Steven D. Nathan
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular InstituteFalls ChurchVirginiaUSA
| | - Peter Fernandes
- Bellerophon Therapeutics Inc., Regulatory, Safety and Quality DepartmentWarrenNew JerseyUSA
| | - Mitchell Psotka
- Division of Cardiology and Nephrology, Food and Drug AdministrationSilver SpringMarylandUSA
| | - Patrizio Vitulo
- Department of Pulmonary Medicine, IRCCS Mediterranean Institute for Transplantation and Advanced Specialized, TherapiesPalermoSiciliaItaly
| | - Lucilla Piccari
- Hospital del Mar, Pulmonary Hypertension Unit, Department of Pulmonary MedicineBarcelonaCatalunya, ESSpain
| | - Katerina Antoniou
- University of Crete School of Medicine, Department of Thoracic MedicineHeraklionCreteGreece
| | | | - Norman Stockbridge
- US Food and Drug Administration, Division of Cardiology and NephrologySilver SpringMarylandUSA
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Majewski S, Szewczyk K, Jerczyńska H, Miłkowska-Dymanowska J, Białas AJ, Gwadera Ł, Piotrowski WJ. Longitudinal and Comparative Measures of Serum Chitotriosidase and YKL-40 in Patients With Idiopathic Pulmonary Fibrosis. Front Immunol 2022; 13:760776. [PMID: 35222369 PMCID: PMC8866556 DOI: 10.3389/fimmu.2022.760776] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/24/2022] [Indexed: 12/14/2022] Open
Abstract
Background Although chitin is absent in humans, chitinases are present in healthy subjects and show dysregulated expression in a variety of diseases resulting from abnormal tissue injury and repair responses. It was shown that chitotriosidase (chitinase 1/CHIT1) and structurally-related chitinase 3-like 1 protein (CHI3L1/YKL-40) play important roles in the pathobiology of idiopathic pulmonary fibrosis (IPF), however little is known about their longitudinal serum levels and relationship to clinical measures in IPF. Methods The present study is the first to evaluate serial measurements of serum CHIT1 activity and YKL-40 concentrations in patients with IPF starting antifibrotic treatment and followed up for 24 months. In addition, baseline serum CHIT1 and YKL-40 were compared between patients with IPF and control subjects, and possible CHIT1 and YKL-40 relationships to longitudinal clinical assessments in IPF were explored. Results Baseline serum CHIT1 activity and YKL-40 concentrations were significantly elevated in patients with IPF compared to control subjects and showed similar discriminatory ability in distinguishing IPF from controls. No significant differences between the median serum CHIT1 activity and YKL-40 concentration measured over a study follow-up were noted. We found significantly elevated baseline serum CHIT1 activity in the progressors compared with the stables in the first year, while significantly increased baseline serum CHIT1 activity was noted in the stables compared to the progressors in the second year. Additionally, we observed a significant negative correlation between a change in serum YKL-40 concentration and a change in forced vital capacity (FVC) % predicted (% pred.) in the stables subgroup, whereas, a change in serum CHIT1 activity correlated negatively with a change in FVC% pred. in the progressors subgroup. Conclusions This explorative study findings add further evidence that CHIT1 and YKL-40 are upregulated in patients with IPF, and suggest that longitudinally stable serum CHIT1 activity and YKL-40 concentration levels may potentially be associated with the antifibrotic treatment response. In addition, our findings are supporting the possible role of CHIT1 and YKL-40 as candidate diagnostic and prognostic biomarkers in IPF. Further research is needed to validate present study findings.
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Affiliation(s)
| | - Karolina Szewczyk
- Department of Pathobiology of Respiratory Diseases, Medical University of Lodz, Lodz, Poland
| | - Hanna Jerczyńska
- Central Scientific Laboratory (CoreLab), Medical University of Lodz, Lodz, Poland
| | | | - Adam J Białas
- Department of Pathobiology of Respiratory Diseases, Medical University of Lodz, Lodz, Poland
| | - Łukasz Gwadera
- Department of Pneumology, Medical University of Lodz, Lodz, Poland
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Efficacy and Safety of Dahuang Zhechong Pill in Silicosis: A Randomized Controlled Trial. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:4354054. [PMID: 34840587 PMCID: PMC8616670 DOI: 10.1155/2021/4354054] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/19/2021] [Accepted: 10/23/2021] [Indexed: 12/26/2022]
Abstract
Background There is no effective therapy for silicosis, and Dahuang Zhechong pill (DHZCP), an ancient Chinese medicine prescription, may have a therapeutic effect on silicosis. This study aims to verify the efficacy and safety of DHZCP in silicosis. Methods This is a randomized controlled clinical trial done at Panzhihua Second People's Hospital (Panzhihua City, Sichuan Province, China). Participants diagnosed with silicosis were recruited and randomized to the conventional treatment group (CG) or DHZCP combined with the conventional treatment group (DG). Forced vital capacity % predicted (FVC%), diffusing capacity of the lung for carbon monoxide % predicted (DLCO%), six-minute walk distance (6MWD), peripheral oxygen (SpO2), King's Brief Interstitial Lung Disease Questionnaire (K-BILD), and safety outcomes were measured at baseline and 9 weeks. Results Fifty-six participants (28 in each group) completed the study, and 53 of them (26 in DG and 27 in CG) completed pulmonary function. At 9 weeks, compared with no DHZCP, DHZCP treatment was associated with significant improvements in FVC% (mean ± SD, 95%CI) (8.2 ± 3.9, 0.3 to 16.0), DLCO% (8.6 ± 3.5, 1.5 to 15.7), SpO2 (3.8 ± 0.7, 2.3 to 5.2), and K-BILD total score (6.0 ± 2.3, 1.4 to 10.7). And, there were no statistical differences of safety outcomes between the two groups. Eight patients accepting DHZCP developed mild diarrhea during the first week, which subsequently resolved on its own. Conclusion DHZCP could improve the pulmonary function, the quality of life, and the exercise capacity of silicosis patients.
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Serial Measurements of Circulating KL-6, SP-D, MMP-7, CA19-9, CA-125, CCL18, and Periostin in Patients with Idiopathic Pulmonary Fibrosis Receiving Antifibrotic Therapy: An Exploratory Study. J Clin Med 2021; 10:jcm10173864. [PMID: 34501312 PMCID: PMC8432145 DOI: 10.3390/jcm10173864] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/10/2021] [Accepted: 08/26/2021] [Indexed: 12/17/2022] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a progressive and inevitably fatal disease with a heterogeneous clinical course. This study aimed to evaluate the usefulness of circulating biomarkers in routine IPF clinical practice. We conducted an exploratory study in a cohort of 28 IPF subjects qualified for anti-fibrotic therapy with up to 24 months serial measurements of seven IPF biomarkers, including those that are well-established, Krebs von den Lungen-6 (KL-6), surfactant protein D (SP-D), matrix metalloproteinase 7 (MMP-7), and more recently introduced ones, cancer antigen 19-9 (CA19-9), cancer antigen 125 (CA-125), chemokine (C-C motif) ligand 18 (CCL18), and periostin. Among studied biomarkers, SP-D had the highest diagnostic accuracy to differentiate IPF subjects from controls, followed by MMP-7 and KL-6. At each study timepoint, KL-6 levels correlated inversely with forced vital capacity % predicted (FVC% pred.), and transfer factor of the lung for carbon monoxide % predicted (TL,CO% pred.), while SP-D levels correlated inversely with FVC% pred. and TL,CO% pred. at 24 months of anti-fibrotic therapy. Baseline KL-6 and CA19-9 concentrations were significantly elevated in patients with progressive disease in comparison to patients with stable disease. In addition, in the progressors subgroup CA19-9 concentrations significantly increased over the second year of study follow-up. In patients with progressive disease, we observed a significant inverse correlation between a change in SP-D levels and a change in FVC% pred. in the first year of treatment, whereas in the second year a significant inverse correlation between a change in KL-6 levels and a change in FVC% pred. was noted. Our study findings support the view that both well-established IPF biomarkers, including KL-6, SP-D, and MMP-7, and more recently introduced ones, like CA19-9, have the potential to support clinical practice in IPF.
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Mura M, Bouros D. Exercise Testing in Idiopathic Pulmonary Fibrosis: Expanding Our Options. Respiration 2021; 100:568-570. [PMID: 33849041 DOI: 10.1159/000515665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Marco Mura
- Division of Respirology. Western University, London, Ontario, Canada
| | - Demosthenes Bouros
- First Academic Department of Pneumonology, Medical School, National and Kapodistrian University of Athens, and Athens Medical Center, Athens, Greece
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Gao J, Kalafatis D, Carlson L, Pesonen IHA, Li CX, Wheelock Å, Magnusson JM, Sköld CM. Baseline characteristics and survival of patients of idiopathic pulmonary fibrosis: a longitudinal analysis of the Swedish IPF Registry. Respir Res 2021; 22:40. [PMID: 33546682 PMCID: PMC7866760 DOI: 10.1186/s12931-021-01634-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 01/21/2021] [Indexed: 02/08/2023] Open
Abstract
Background Observational data under real-life conditions in idiopathic pulmonary fibrosis (IPF) is scarce. We explored anti-fibrotic treatment, disease severity and phenotypes in patients with IPF from the Swedish IPF Registry (SIPFR). Methods Patients enrolled between September 2014 and April 2020 and followed ≥ 6 months were investigated. Demographics, comorbidities, lung function, composite variables, six-minute walking test (6MWT), quality of life, and anti-fibrotic therapy were evaluated. Agreements between classification of mild physiological impairment (defined as gender-age-physiology (GAP) stage 1) with physiological and composite measures of severity was assessed using kappa values and their impact on mortality with hazard ratios. The factor analysis and the two-step cluster analysis were used to identify phenotypes. Univariate and multivariable survival analyses were performed between variables or groups. Results Among 662 patients with baseline data (median age 72.7 years, 74.0% males), 480 had a follow up ≥ 6 months with a 5 year survival rate of 48%. Lung function, 6MWT, age, and BMI were predictors of survival. Patients who received anti-fibrotic treatment ≥ 6 months had better survival compared to untreated patients [p = 0.007, HR (95% CI): 1.797 (1.173–2.753)] after adjustment of age, gender, BMI, smoking status, forced vital capacity (FVC) and diffusion capacity of carbon monoxide (DLCO). Patients with mild physiological impairment (GAP stage 1, composite physiological index (CPI) ≤ 45, DLCO ≥ 55%, FVC ≥ 75%, and total lung capacity (TLC) ≥ 65%, respectively) had better survival, after adjustment for age, gender, BMI and smoking status and treatment. Patients in cluster 1 had the worst survival and consisted mainly of male patients with moderate-severe disease and an increased prevalence of heart diseases at baseline; Cluster 2 was characterized by mild disease with more than 50% females and few comorbidities, and had the best survival; Cluster 3 were younger, with moderate-severe disease and had few comorbidities. Conclusion Disease severity, phenotypes, and anti-fibrotic treatment are closely associated with the outcome in IPF, with treated patients surviving longer. Phenotypes may contribute to predicting outcomes of patients with IPF and suggest the patients’ need for special management, whereas single or composite variables have some limitations as disease predictors.
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Affiliation(s)
- Jing Gao
- Respiratory Medicine Unit, Department of Medicine, Karolinska Institute, Solna, Solnavägen 30, 17176, Stockholm, Sweden.
| | - Dimitrios Kalafatis
- Respiratory Medicine Unit, Department of Medicine, Karolinska Institute, Solna, Solnavägen 30, 17176, Stockholm, Sweden
| | - Lisa Carlson
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Ida H A Pesonen
- Respiratory Medicine Unit, Department of Medicine, Karolinska Institute, Solna, Solnavägen 30, 17176, Stockholm, Sweden.,Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Chuan-Xing Li
- Respiratory Medicine Unit, Department of Medicine, Karolinska Institute, Solna, Solnavägen 30, 17176, Stockholm, Sweden
| | - Åsa Wheelock
- Respiratory Medicine Unit, Department of Medicine, Karolinska Institute, Solna, Solnavägen 30, 17176, Stockholm, Sweden
| | - Jesper M Magnusson
- Department of Internal Medicine/Respiratory Medicine and Allergology, Institute of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - C Magnus Sköld
- Respiratory Medicine Unit, Department of Medicine, Karolinska Institute, Solna, Solnavägen 30, 17176, Stockholm, Sweden.,Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
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