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Tagami Y, Hara Y, Murohashi K, Nagasawa R, Fujii H, Izawa A, Yabe A, Saigusa Y, Kobayashi M, Shiida M, Hirata M, Otsu Y, Watanabe K, Horita N, Kobayashi N, Kaneko T. Serum heme oxygenase-1 as a prognostic biomarker in patients with acute exacerbation of interstitial lung disease. Sci Rep 2023; 13:22639. [PMID: 38114539 PMCID: PMC10730846 DOI: 10.1038/s41598-023-49342-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/07/2023] [Indexed: 12/21/2023] Open
Abstract
Serum heme oxygenase (HO)-1 level has been reported as a clinically reliable diagnostic biomarker for acute exacerbation of interstitial lung disease (ILD); however, its utility for predicting mortality among these patients is unclear. Serum HO-1 levels of patients newly diagnosed with acute exacerbation of ILD were measured at the time of initiating steroid pulse therapy. The relationship between serum HO-1 and various other serum biomarkers, change in HRCT findings, and disease prognosis at 12 weeks after diagnosis of acute exacerbation was evaluated in 51 patients, of whom 17 (33%) had idiopathic pulmonary fibrosis (IPF). Serum HO-1 was higher in patients with acute exacerbation of IPF than in patients with acute exacerbation of other ILDs. Serum HO-1 levels were higher in patients who died within these 12 weeks than in survivors. Among age, sex, comorbidities, IPF diagnosis, HRCT findings, and blood biomarkers, serum HO-1 was a primary predictor of 12-week mortality. In 41 patients who underwent repeat HRCT, serum HO-1 was higher in patients with honeycomb progression than in those without. Serum HO-1 measurement could be useful for evaluating disease mortality and morbidity of patients with acute exacerbation of ILDs.
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Affiliation(s)
- Yoichi Tagami
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Yu Hara
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan.
| | - Kota Murohashi
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Ryo Nagasawa
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Hiroaki Fujii
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Ami Izawa
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Aya Yabe
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Yusuke Saigusa
- Department of Biostatistics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Miyu Kobayashi
- Department of Biostatistics, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masafumi Shiida
- Research and Development Division, Minaris Medical Co., Ltd, 600-1 Minami-Ishiki, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-0932, Japan
| | - Momo Hirata
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Yukiko Otsu
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Keisuke Watanabe
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Nobuyuki Horita
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Nobuaki Kobayashi
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Takeshi Kaneko
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, 236-0004, Japan
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Hara Y, Tsukiji J, Yabe A, Onishi Y, Hirose H, Yamamoto M, Kudo M, Kaneko T, Ebina T. Heme oxygenase-1 as an important predictor of the severity of COVID-19. PLoS One 2022; 17:e0273500. [PMID: 36001619 PMCID: PMC9401165 DOI: 10.1371/journal.pone.0273500] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 08/09/2022] [Indexed: 01/08/2023] Open
Abstract
Background and objective
A cytokine storm is caused by inflammatory cells, including pro-inflammatory macrophage phenotype (M1), and play a critical role in the pathogenesis of COVID-19, in which diffuse alveolar damage occurs in the lungs due to oxidative stress exposure. Heme oxygenase (HO)-1 is a stress-induced protein produced by the anti-inflammatory / anti-oxidative macrophage phenotype (M2), which also produces soluble CD163 (sCD163). In our study, we investigated and determined that serum HO-1 can be a predictive biomarker for assessing both the severity and the outcome of COVID-19 patients.
Method
The serum concentrations of HO-1 and sCD163 of COVID-19 patients were measured on admission. The relationship between these biomarkers and other clinical parameters and outcomes were evaluated.
Results
Sixty-four COVID-19 patients (11 mild, 38 moderate, and 15 severe cases) were assessed. The serum HO-1 tended to increase (11.0 ng/mL vs. 24.3 ng/mL vs. 59.6 ng/mL with severity). Serum HO-1 correlated with serum lactate dehydrogenase (R = 0.422), C-reactive protein (R = 0.463), and the ground glass opacity (GGO) and consolidation score (R = 0.625) of chest computed tomography. The serum HO-1 showed a better area under the curve (AUC) for predicting ICU admission than the serum sCD163 (HO-1; 0.816 and sCD163; 0.743). In addition, composite parameters including serum HO-1 and the GGO and consolidation score showed a higher AUC for predicting ICU admission than the AUC of a single parameter.
Conclusion
Clinically, serum HO-1, reflecting the activation of M2, could be a very useful marker for evaluating disease severity and predicting prognoses for COVID-19 patients. In addition, controlling activated M2 might be a preventative COVID-19 therapeutic target.
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Affiliation(s)
- Yu Hara
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Jun Tsukiji
- Department of Prevention and Infection Control, Kanagawa Cancer Center, Yokohama, Japan
- * E-mail:
| | - Aya Yabe
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yoshika Onishi
- Department of Laboratory Medicine and Clinical Investigation, Yokohama City University Medical Center, Yokohama, Japan
| | - Haruka Hirose
- Department of Laboratory Medicine and Clinical Investigation, Yokohama City University Medical Center, Yokohama, Japan
| | - Masaki Yamamoto
- Respiratory Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Makoto Kudo
- Respiratory Disease Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Takeshi Kaneko
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Toshiaki Ebina
- Department of Laboratory Medicine and Clinical Investigation, Yokohama City University Medical Center, Yokohama, Japan
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Assessment of diagnostic utility of serum hemeoxygenase-1 measurement for acute exacerbation of interstitial pneumonias. Sci Rep 2022; 12:12935. [PMID: 35902685 PMCID: PMC9334264 DOI: 10.1038/s41598-022-17290-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 07/22/2022] [Indexed: 11/08/2022] Open
Abstract
The present study aimed to evaluate whether serum heme oxygenase (HO)-1 could be a reliable blood biomarker for diagnosing acute exacerbations (AEs) of both idiopathic interstitial pneumonia (IIP) and secondary interstitial pneumonia (SIP). Serum HO-1 levels of newly diagnosed patients with IP were measured, and the relationships between serum HO-1 and other serum biomarkers and high-resolution CT scores, were evaluated. Blood samples were collected from 90 patients with IIP, including 32 having an AE, and 32 with SIP, including 9 having an AE. The patients having an AE had significantly higher HO-1 levels than those not having an AE (35.2 ng/mL vs. 16.4 ng/mL; p < 0.001). On receiver operating characteristics (ROC) curve analysis for serum HO-1 ability to detect an AE, the area under the ROC curve (AUC) was 0.87 in patients with IIPs and 0.86 in those with SIPs. Also, in patients with both IIPs and SIPs, the combination of the serum HO-1 level and the GGO score showed favorable AUCs (IIPs: 0.92, SIPs: 0.83), though HO-1-not-including model (combination of LDH and GGO) also showed acceptable AUCs. Serum HO-1 could be a clinically useful biomarker for the accurate diagnosis of patients with AEs.
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Zhang Y, Luo Y, Hou X, Lu K, He Y, Yang B, Qin Y. Xiaoyao powder alleviates the hippocampal neuron damage in chronic unpredictable mild stress-induced depression model rats in hippocampus via connexin 43Cx43/glucocorticoid receptor/brain-derived neurotrophic factor signaling pathway. Bioengineered 2022; 13:383-394. [PMID: 34984950 PMCID: PMC8805874 DOI: 10.1080/21655979.2021.2005744] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Xiaoyao Powder (XYP) has been widely applied in China to treat stress-related illnesses, such as migraine, depression, Parkinson’s disease, insomnia, and hypertension. Herein, this study aims to explore the effect of XYP on chronic unpredictable mild stress (CUMS)-induced depression and its underlying mechanisms. CUMS-induced depression rat models were established, they were subsequently randomly divided and treated with various conditions. Results of this study indicated that supplementation of XYP observably abolished CUMS-induced hippocampal damage and serum corticosterone (CORT) elevation. In mechanism, we discovered that CUMS induction could cause a prominent downregulation in glucocorticoid receptor (GR), phosphorylated-GR (p-GR), connexin 43 (Cx43), and brain-derived neurotrophic factor (BDNF), a remarkable upregulation in c-Src. While the introduction of XYP could reverse the changes in all of these indicators mediated by CUMS. Furthermore, we proved that Cx43 could interact with GR, and the protective effect of XYP on hippocampal neurons is realized by up-regulating GR. Summarized, this study indicated that XYP could ameliorate hippocampal neuron damage in CUMS-induced depression model rats through acting on Cx43/GR/BDNF axis.
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Affiliation(s)
- Yuanyuan Zhang
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou City, China
| | - Yong Luo
- Centre for Integrative Medicine, School of Basic Medical Science, Guangzhou University of Chinese Medicine, Guangzhou City, China
| | - Xuenan Hou
- The Forth Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou City, China
| | - Kang Lu
- Centre for Integrative Medicine, School of Basic Medical Science, Guangzhou University of Chinese Medicine, Guangzhou City, China
| | - Yanhong He
- Centre for Integrative Medicine, School of Basic Medical Science, Guangzhou University of Chinese Medicine, Guangzhou City, China
| | - Baoying Yang
- The 3rd Departments of Neurosurgery, Guangdong Sanjiu Brain Hospital, Guangzhou City, China
| | - Yi Qin
- Department of Orthopaedics, Zhuhai People's Hospital, Zhuhai City, China
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Hara Y, Nakashima K, Nagasawa R, Murohashi K, Tagami Y, Aoki A, Okudela K, Kaneko T. Heme Oxygenase-1 in Patients With Interstitial Lung Disease: A Review of the Clinical Evidence. Am J Med Sci 2021; 362:122-129. [PMID: 33587911 DOI: 10.1016/j.amjms.2021.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 02/09/2021] [Indexed: 11/17/2022]
Abstract
The clinical course and rate of progression of interstitial lung disease (ILD) are extremely variable among patients. For the purpose of monitoring disease activity, ILD diagnosis, and predicting disease prognosis, there are various biomarkers, including symptoms, physiological, radiological, and pathological findings, and peripheral blood and bronchoalveolar lavage fluid results. Of these, blood biomarkers such as sialylated carbohydrate antigen, surfactant proteins-A and -D, CC-chemokine ligand 18, matrix metalloprotease-1 and -7, CA19-9, and CA125 have been previously proposed. In the future, heme oxygenase-1 (HO-1) may also become a candidate ILD biomarker; it is a 32-kDa heat shock protein converting heme to carbon monoxide, biliverdin/bilirubin, and free iron to play a role in the pulmonary cytoprotective reaction in response to various stimuli. Recent research suggests that HO-1 can increase in lung tissues of patients with ILD, reflecting anti-inflammatory M2 macrophage activation, and the measurement of HO-1 levels in peripheral blood can be useful for evaluating the severity of lung damage in ILD and for predicting subsequent fibrosis formation.
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Affiliation(s)
- Yu Hara
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 4-57 Fukuura, Kanazawa-ku, Yokohama City, 236-0024, Japan.
| | - Kentaro Nakashima
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 4-57 Fukuura, Kanazawa-ku, Yokohama City, 236-0024, Japan
| | - Ryo Nagasawa
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 4-57 Fukuura, Kanazawa-ku, Yokohama City, 236-0024, Japan
| | - Kota Murohashi
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 4-57 Fukuura, Kanazawa-ku, Yokohama City, 236-0024, Japan
| | - Yoichi Tagami
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 4-57 Fukuura, Kanazawa-ku, Yokohama City, 236-0024, Japan
| | - Ayako Aoki
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 4-57 Fukuura, Kanazawa-ku, Yokohama City, 236-0024, Japan
| | - Koji Okudela
- Department of Pathology, Yokohama City University Graduate School of Medicine, Kanazawa-ku, Yokohama City, Japan
| | - Takeshi Kaneko
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 4-57 Fukuura, Kanazawa-ku, Yokohama City, 236-0024, Japan
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Nagasawa R, Hara Y, Murohashi K, Aoki A, Kobayashi N, Takagi S, Hashimoto S, Kawana A, Kaneko T. Serum heme oxygenase-1 measurement is useful for evaluating disease activity and outcomes in patients with acute respiratory distress syndrome and acute exacerbation of interstitial lung disease. BMC Pulm Med 2020; 20:310. [PMID: 33238962 PMCID: PMC7687749 DOI: 10.1186/s12890-020-01341-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/09/2020] [Indexed: 02/07/2023] Open
Abstract
Background Oxidative stress plays an important role in acute lung injury, which is associated with the development and progression of acute respiratory failure. Here, we investigated whether the degree of oxidative stress as indicated by serum heme oxygenase-1 (HO-1) is clinically useful for predicting prognosis among the patients with acute respiratory distress syndrome (ARDS) and acute exacerbation of interstitial lung disease (AE-ILD). Methods Serum HO-1 levels of newly diagnosed or untreated ARDS and AE-ILD patients were measured at diagnosis. Relationships between serum HO-1 and other clinical parameters and 1 and 3-month mortality were evaluated. Results Fifty-five patients including 22 of ARDS and 33 of AE-ILD were assessed. Serum HO-1 level at diagnosis was significantly higher in ARDS patients than AE-ILD patients (87.8 ± 60.0 ng/mL vs. 52.5 ± 36.3 ng/mL, P < 0.001). Serum HO-1 correlated with serum total bilirubin (R = 0.454, P < 0.001) and serum LDH (R = 0.500, P < 0.001). In both patients with ARDS and AE-ILDs, serum HO-1 level tended to decrease from diagnosis to 2 weeks after diagnosis, however, did not normalized. Composite parameters including serum HO-1, age, sex, and partial pressure of oxygen in arterial blood/fraction of inspired oxygen (P/F) ratio for prediction of 3-month mortality showed a higher AUC (ARDS: 0.925, AE-ILDs: 0.892) than did AUCs of a single predictor or combination of two or three predictors. Conclusion Oxidative stress assessed by serum HO-1 is persistently high among enrolled patients for 2 weeks after diagnosis. Also, serum HO-1 levels at the diagnosis combined with age, sex, and P/F ratio could be clinically useful for predicting 3-month mortality in both ARDS and AE-ILD patients.
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Affiliation(s)
- Ryo Nagasawa
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama City, 236-0004, Japan
| | - Yu Hara
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama City, 236-0004, Japan.
| | - Kota Murohashi
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama City, 236-0004, Japan
| | - Ayako Aoki
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama City, 236-0004, Japan
| | - Nobuaki Kobayashi
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama City, 236-0004, Japan
| | - Shigeto Takagi
- Seamen's Insurance Health Management Center, Yokohama, Japan
| | - Satoru Hashimoto
- Division of Intensive Care Unit, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akihiko Kawana
- Division of Infectious Diseases and Pulmonary Medicine, Department of Internal Medicine, National Defense Medical College, Saitama, Japan
| | - Takeshi Kaneko
- Department of Pulmonology, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama City, 236-0004, Japan
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Diffuse alveolar hemorrhage complicating acute exacerbation of IPF. Respir Med Case Rep 2020; 29:101022. [PMID: 32071858 PMCID: PMC7016274 DOI: 10.1016/j.rmcr.2020.101022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/06/2020] [Accepted: 02/06/2020] [Indexed: 11/22/2022] Open
Abstract
An 83-year-old man with a history of interstitial lung disease (ILD) presented with a 1-week history of progressive dyspnea. Computed tomography of the chest revealed right lung-predominant, diffuse, ground glass opacities superimposed upon reticular opacities. Despite methylprednisolone pulse therapy under a diagnosis of acute exacerbation (AE) of ILD, lung involvement and renal dysfunction worsened and disseminated intravascular coagulation developed. The patient died on day 5 of hospitalization. Pathological examination at autopsy revealed diffuse alveolar hemorrhage (DAH) superimposed upon organizing diffuse alveolar damage and usual interstitial pneumonia. We reached a final diagnosis of DAH-predominant AE of idiopathic pulmonary fibrosis (IPF). Abundant expression of the oxidative stress marker hemeoxygenase-1 (HO-1) was observed in alveolar macrophages. These suggest that HO-1 expression in the lungs may offer a useful biomarker for this atypical histological subtype of AE of IPF.
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Key Words
- AE, acute exacerbation
- CO, carbon monoxide
- DAD, diffuse alveolar damage
- DAH, diffuse alveolar hemorrhage
- DIC, disseminated intravascular coagulation
- Diffuse alveolar damage
- Diffuse alveolar hemorrhage
- Disseminated intravascular coagulation
- HO-1, hemeoxygenase-1
- Hemeoxygenase-1
- ILD, interstitial lung disease
- IP, interstitial pneumonia
- IPF, idiopathic pulmonary fibrosis
- Oxidative stress
- UIP, usual interstitial pneumonia
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Clinical Significance of Serum Hemeoxygenase-1 as a New Biomarker for the Patients with Interstitial Pneumonia. Can Respir J 2018; 2018:7260178. [PMID: 30595776 PMCID: PMC6282126 DOI: 10.1155/2018/7260178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/02/2018] [Accepted: 11/08/2018] [Indexed: 02/02/2023] Open
Abstract
Background Serum hemeoxygenase-1 (HO-1) has been proposed to be a biomarker of lung disease activity and prognosis. The present study aimed at evaluating whether HO-1 could be a useful marker for evaluating disease activity and predicting prognosis in patients with interstitial pneumonia (IP). Materials and Methods Serum HO-1 levels of newly diagnosed or untreated patients with IP were measured at hospitalization. We evaluated the relationships between serum HO-1 and other serum biomarkers, high resolution CT (HRCT) findings, and hospital mortality. Results Twenty-eight patients with IP, including 14 having an acute exacerbation (AE) and 14 not having an AE, were evaluated. The patients having an AE had significantly higher HO-1 levels than those not having an AE (53.5 ng/mL vs. 24.1 ng/mL; p < 0.001), and the best cut-off level to discriminate between having an AE or not having an AE was 41.6 ng/mL. Serum HO-1 levels were positively correlated with serum levels of surfactant protein-D (r=0.66, p < 0.001) and the ground glass opacity score (calculated from HRCT; r=0.40, p=0.036). Patients who subsequently died in hospital had presented with significantly higher HO-1 levels than those who did not die in hospital (64.8 ng/mL vs. 32.0 ng/mL; p=0.009). Conclusion Serum HO-1 may serve as a useful biomarker for detecting AE or predicting hospital mortality in patients with IP.
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