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Sanges S, Tian W, Dubucquoi S, Chang JL, Collet A, Launay D, Nicolls MR. B-cells in pulmonary arterial hypertension: friend, foe or bystander? Eur Respir J 2024; 63:2301949. [PMID: 38485150 PMCID: PMC11043614 DOI: 10.1183/13993003.01949-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 03/01/2024] [Indexed: 04/22/2024]
Abstract
There is an unmet need for new therapeutic strategies that target alternative pathways to improve the prognosis of patients with pulmonary arterial hypertension (PAH). As immunity has been involved in the development and progression of vascular lesions in PAH, we review the potential contribution of B-cells in its pathogenesis and evaluate the relevance of B-cell-targeted therapies. Circulating B-cell homeostasis is altered in PAH patients, with total B-cell lymphopenia, abnormal subset distribution (expansion of naïve and antibody-secreting cells, reduction of memory B-cells) and chronic activation. B-cells are recruited to the lungs through local chemokine secretion, and activated by several mechanisms: 1) interaction with lung vascular autoantigens through cognate B-cell receptors; 2) costimulatory signals provided by T follicular helper cells (interleukin (IL)-21), type 2 T helper cells and mast cells (IL-4, IL-6 and IL-13); and 3) increased survival signals provided by B-cell activating factor pathways. This activity results in the formation of germinal centres within perivascular tertiary lymphoid organs and in the local production of pathogenic autoantibodies that target the pulmonary vasculature and vascular stabilisation factors (including angiotensin-II/endothelin-1 receptors and bone morphogenetic protein receptors). B-cells also mediate their effects through enhanced production of pro-inflammatory cytokines, reduced anti-inflammatory properties by regulatory B-cells, immunoglobulin (Ig)G-induced complement activation, and IgE-induced mast cell activation. Precision-medicine approaches targeting B-cell immunity are a promising direction for select PAH conditions, as suggested by the efficacy of anti-CD20 therapy in experimental models and a trial of rituximab in systemic sclerosis-associated PAH.
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Affiliation(s)
- Sébastien Sanges
- Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
- INSERM, F-59000 Lille, France
- CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France
- Centre National de Référence Maladies Auto-immunes Systémiques Rares du Nord, Nord-Ouest, Méditerranée et Guadeloupe (CeRAINOM), F-59000 Lille, France
- Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET), F-59000 Lille, France
- Veteran Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, School of Medicine, Stanford, CA, USA
- Both authors contributed equally and share co-first authorship
| | - Wen Tian
- Veteran Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, School of Medicine, Stanford, CA, USA
- Both authors contributed equally and share co-first authorship
| | - Sylvain Dubucquoi
- Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
- INSERM, F-59000 Lille, France
- CHU Lille, Institut d'Immunologie, Pôle de Biologie Pathologie Génétique, F-59000 Lille, France
| | - Jason L Chang
- Veteran Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, School of Medicine, Stanford, CA, USA
| | - Aurore Collet
- Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
- INSERM, F-59000 Lille, France
- CHU Lille, Institut d'Immunologie, Pôle de Biologie Pathologie Génétique, F-59000 Lille, France
| | - David Launay
- Univ. Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, F-59000 Lille, France
- INSERM, F-59000 Lille, France
- CHU Lille, Département de Médecine Interne et Immunologie Clinique, F-59000 Lille, France
- Centre National de Référence Maladies Auto-immunes Systémiques Rares du Nord, Nord-Ouest, Méditerranée et Guadeloupe (CeRAINOM), F-59000 Lille, France
- Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET), F-59000 Lille, France
- Veteran Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, School of Medicine, Stanford, CA, USA
- Both authors contributed equally and share co-last authorship
| | - Mark R Nicolls
- Veteran Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, School of Medicine, Stanford, CA, USA
- Both authors contributed equally and share co-last authorship
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Zhao H, Song J, Li X, Xia Z, Wang Q, Fu J, Miao Y, Wang D, Wang X. The role of immune cells and inflammation in pulmonary hypertension: mechanisms and implications. Front Immunol 2024; 15:1374506. [PMID: 38529271 PMCID: PMC10962924 DOI: 10.3389/fimmu.2024.1374506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 02/26/2024] [Indexed: 03/27/2024] Open
Abstract
Pulmonary hypertension (PH) is a malignant disease with progressive increase of pulmonary vascular pressure, which eventually leads to right heart failure. More and more evidences show that immune cells and inflammation play an important role in the occurrence and development of PH. In the context of pulmonary vascular diseases, immune cells migrate into the walls of the pulmonary vascular system. This leads to an increase in the levels of cytokines and chemokines in both the bloodstream and the surrounding tissues of the pulmonary vessels. As a result, new approaches such as immunotherapy and anti-inflammatory treatments are being considered as potential strategies to halt or potentially reverse the progression of PH. We reviewed the potential mechanisms of immune cells, cytokines and chemokines in PH development. The potential relationship of vascular cells or bone morphogenetic protein receptor 2 (BMPR2) in immune regulation was also expounded. The clinical application and future prospect of immunotherapy were further discussed.
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Affiliation(s)
- Hui Zhao
- School of Materials and Chemistry, Institute of Bismuth and Rhenium, University of Shanghai for Science and Technology, Shanghai, China
| | - Jialin Song
- Department of Limb Trauma, Wendeng Orthopaedic Hospital of Shandong Province, Weihai, Shandong, China
| | - Xiujun Li
- Department of Medicine, Chifeng University, Chifeng, China
| | - Zhaoyi Xia
- Department of Library, Children's Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Department of Library, Jinan Children's Hospital, Shandong, Jinan, Shandong, China
| | - Qian Wang
- School of Materials and Chemistry, Institute of Bismuth and Rhenium, University of Shanghai for Science and Technology, Shanghai, China
| | - Jiaqi Fu
- School of Materials and Chemistry, Institute of Bismuth and Rhenium, University of Shanghai for Science and Technology, Shanghai, China
| | - Yuqing Miao
- School of Materials and Chemistry, Institute of Bismuth and Rhenium, University of Shanghai for Science and Technology, Shanghai, China
| | - Dapeng Wang
- Department of Intensive Medicine, Wuxi People’s Hospital Affiliated to Nanjing Medical University, Wuxi, Jiangsu, China
| | - Xuguang Wang
- Department of Limb Trauma, Wendeng Orthopaedic Hospital of Shandong Province, Weihai, Shandong, China
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Zhao J, Wang Q, Deng X, Qian J, Tian Z, Liu Y, Li M, Zeng X. The treatment strategy of connective tissue disease associated pulmonary arterial hypertension: Evolving into the future. Pharmacol Ther 2022; 239:108192. [DOI: 10.1016/j.pharmthera.2022.108192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 04/07/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
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Chen Y, Wu C, Wang X, Zhou X, Kang K, Cao Z, Yang Y, Zhong Y, Xiao G. Weighted gene co-expression network analysis identifies dysregulated B-cell receptor signaling pathway and novel genes in pulmonary arterial hypertension. Front Cardiovasc Med 2022; 9:909399. [PMID: 36277750 PMCID: PMC9583267 DOI: 10.3389/fcvm.2022.909399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 09/13/2022] [Indexed: 11/21/2022] Open
Abstract
Background Pulmonary arterial hypertension (PAH) is a devastating cardio-pulmonary vascular disease in which chronic elevated pulmonary arterial pressure and pulmonary vascular remodeling lead to right ventricular failure and premature death. However, the exact molecular mechanism causing PAH remains unclear. Methods RNA sequencing was used to analyze the transcriptional profiling of controls and rats treated with monocrotaline (MCT) for 1, 2, 3, and 4 weeks. Weighted gene co-expression network analysis (WGCNA) was employed to identify the key modules associated with the severity of PAH. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were performed to explore the potential biological processes and pathways of key modules. Real-time PCR and western blot analysis were used to validate the gene expression. The hub genes were validated by an independent dataset obtained from the Gene Expression Omnibus database. Results A total of 26 gene modules were identified by WGCNA. Of these modules, two modules showed the highest correlation with the severity of PAH and were recognized as the key modules. GO analysis of key modules showed the dysregulated inflammation and immunity, particularly B-cell-mediated humoral immunity in MCT-induced PAH. KEGG pathway analysis showed the significant enrichment of the B-cell receptor signaling pathway in the key modules. Pathview analysis revealed the dysregulation of the B-cell receptor signaling pathway in detail. Moreover, a series of humoral immune response-associated genes, such as BTK, BAFFR, and TNFSF4, were found to be differentially expressed in PAH. Additionally, five genes, including BANK1, FOXF1, TLE1, CLEC4A1, and CLEC4A3, were identified and validated as the hub genes. Conclusion This study identified the dysregulated B-cell receptor signaling pathway, as well as novel genes associated with humoral immune response in MCT-induced PAH, thereby providing a novel insight into the molecular mechanisms underlying inflammation and immunity and therapeutic targets for PAH.
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Affiliation(s)
- Yuanrong Chen
- Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases of Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Chaoling Wu
- Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases of Ministry of Education, Gannan Medical University, Ganzhou, China
| | - Xiaoping Wang
- Department of Cardiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Xufeng Zhou
- Department of Cardiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Kunpeng Kang
- Department of Cardiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Zuofeng Cao
- Department of Cardiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Yihong Yang
- Department of Cardiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Yiming Zhong
- Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases of Ministry of Education, Gannan Medical University, Ganzhou, China,Department of Cardiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China,Gannan Branch Center of National Geriatric Disease Clinical Medical Research Center, Gannan Medical University, Ganzhou, China,*Correspondence: Yiming Zhong
| | - Genfa Xiao
- Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases of Ministry of Education, Gannan Medical University, Ganzhou, China,Department of Cardiology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China,Gannan Branch Center of National Geriatric Disease Clinical Medical Research Center, Gannan Medical University, Ganzhou, China,Genfa Xiao
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Dramatic Response of Lupus Enteritis, Nephritis, and Pancytopenia to Plasmapheresis and Rituximab. Case Rep Gastrointest Med 2022; 2022:3443141. [PMID: 35706566 PMCID: PMC9192312 DOI: 10.1155/2022/3443141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/26/2022] [Indexed: 12/05/2022] Open
Abstract
Background Although lupus enteritis is a rare manifestation of systemic lupus erythematosus yet results in significant distress. This disorder contributes to diagnostic and therapeutic dilemma leading to enhanced mortality. Case Description. We report a case history of a 29-year-old female who presented with severe abdominal pain, watery stools, and vomiting, and later on, she developed pancytopenia and renal impairment. On intensive workup, diagnosis of lupus-associated enteritis, nephritis, and pancytopenia was discovered. She improved drastically on initiation of plasmapheresis followed by low-dose intravenous rituximab. One year posttreatment, she remained in complete remission. Conclusion From this case, it can be suggested that in a young female with intractable abdominal pain, the remote possibility of lupus enteritis must be kept in mind. Besides this, plasmapheresis can have a potential role in refractory lupus enteritis. Furthermore, low-dose intravenous rituximab can be a safe and cost-effective treatment option in achieving sustained remission of clinical and laboratory parameters in lupus enteritis.
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Wang RR, Yuan TY, Wang JM, Chen YC, Zhao JL, Li MT, Fang LH, Du GH. Immunity and inflammation in pulmonary arterial hypertension: From pathophysiology mechanisms to treatment perspective. Pharmacol Res 2022; 180:106238. [DOI: 10.1016/j.phrs.2022.106238] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 02/08/2023]
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Saleem M, Kola S, Shah R. Severe Pulmonary Artery Hypertension in Otherwise Silent Lupus: A Unique Hybrid Treatment Approach Using Hydroxychloroquine and Sildenafil. Cureus 2022; 14:e25411. [PMID: 35769687 PMCID: PMC9233934 DOI: 10.7759/cureus.25411] [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] [Accepted: 05/27/2022] [Indexed: 11/23/2022] Open
Abstract
Pulmonary hypertension (PH) is a rare manifestation of systemic lupus erythematosus (SLE). Even more rare is pulmonary artery hypertension (PAH) presenting as the initial manifestation of SLE and may be a cause of diagnostic delay. As symptoms of PAH are very mild in the early stages, prompt diagnosis is crucial to prevent the progression of the disease. Echocardiographic evaluation involving the measurement of different right-sided heart variables in addition to estimated pulmonary artery pressure helps in reducing the false-positive rates of detection of PAH. The role of immunosuppression in addition to PAH-specific vasodilator therapy is one of the key aspects of management to minimize flares and improve hemodynamics. Equally important is the choice of a regimen best suited to minimize complications. We present a case of PAH in newly diagnosed SLE and the diagnostic and treatment challenges as a safety net hospital.
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Chen YJ, Lin YJ, Guo MMH. Pediatric Lupus Presenting as Pulmonary Hypertension, Myocarditis, and Massive Pericardial Effusion in an 11-Year-Old Girl: A Case Report and Literature Review. Front Pediatr 2022; 10:772422. [PMID: 35155304 PMCID: PMC8826687 DOI: 10.3389/fped.2022.772422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/03/2022] [Indexed: 12/02/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease that may cause vital organ damage. Although not rare for child-onset SLE to have cardiovascular or pulmonary involvement, myocarditis, and pulmonary hypertension are infrequent features and can be life-threatening. In this case report, we describe an 11-year-old girl with SLE who initially presented with fulminant myocarditis pulmonary hypertension, and massive pericardial effusion. Initial immunosuppressive therapy with methylprednisolone pulse therapy, and IVIG were administered, followed by cyclophosphamide, which was ultimately successful, with no residual pulmonary hypertension and no recurrence of myocarditis for over 3 years after the initial episode. Our case highlights the need for clinicians to be aware of systemic lupus erythematosus as a possible diagnostic entity in pediatric patients with severe myocarditis or pulmonary hypertension. Aggressive immunosuppressive therapy should be strongly considered in such cases, as it may lead to good short-term and long-term outcomes.
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Affiliation(s)
- Yu-Jhen Chen
- Department of Pediatric Allergy Immunology and Rheumatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Jui Lin
- Department of Pediatric Cardiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mindy Ming-Huey Guo
- Department of Pediatric Allergy Immunology and Rheumatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Depascale R, Del Frate G, Gasparotto M, Manfrè V, Gatto M, Iaccarino L, Quartuccio L, De Vita S, Doria A. Diagnosis and management of lung involvement in systemic lupus erythematosus and Sjögren's syndrome: a literature review. Ther Adv Musculoskelet Dis 2021; 13:1759720X211040696. [PMID: 34616495 PMCID: PMC8488521 DOI: 10.1177/1759720x211040696] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/03/2021] [Indexed: 12/20/2022] Open
Abstract
Lung involvement in systemic lupus erythematosus (SLE) and primary Sjögren's syndrome (pSS) has extensively been outlined with a multiplicity of different manifestations. In SLE, the most frequent finding is pleural effusion, while in pSS, airway disease and parenchymal disorders prevail. In both cases, there is an increased risk of pre-capillary and post-capillary pulmonary arterial hypertension (PAH) and pulmonary venous thromboembolism (VTE). The risk of VTE is in part due to an increased thrombophilic status secondary to systemic inflammation or to the well-established association with antiphospholipid antibody syndrome (APS). The lung can also be the site of an organ-specific complication due to the aberrant pathologic immune-hyperactivation as occurs in the development of lymphoma or amyloidosis in pSS. Respiratory infections are a major issue to be addressed when approaching the differential diagnosis, and their exclusion is required to safely start an immunosuppressive therapy. Treatment strategy is mainly based on glucocorticoids (GCs) and immunosuppressants, with a variable response according to the primary pathologic process. Anticoagulation is recommended in case of VTE and multi-targeted treatment regimens including different drugs are the mainstay for PAH management. Antibiotics and respiratory physiotherapy can be considered relevant complement therapeutic measures. In this article, we reviewed lung manifestations in SLE and pSS with the aim to provide a comprehensive overview of their diagnosis and management to physicians taking care of patients with connective tissue diseases.
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Affiliation(s)
- Roberto Depascale
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Giulia Del Frate
- Rheumatology Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Michela Gasparotto
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Valeria Manfrè
- Rheumatology Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Mariele Gatto
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Luca Quartuccio
- Rheumatology Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Salvatore De Vita
- Rheumatology Unit, Department of Medicine, University of Udine, Udine, Italy
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
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Mansueto G, Di Napoli M, Campobasso CP, Slevin M. Pulmonary arterial hypertension (PAH) from autopsy study: T-cells, B-cells and mastocytes detection as morphological evidence of immunologically mediated pathogenesis. Pathol Res Pract 2021; 225:153552. [PMID: 34352438 DOI: 10.1016/j.prp.2021.153552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 07/10/2021] [Accepted: 07/14/2021] [Indexed: 02/09/2023]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is characterized by severe vascular remodelling, resulting in increased pulmonary vascular resistance with cardiac hypertrophy and heart failure. However, the diagnosis of PAH is often inaccurate. Many cases of PAH are incorrectly diagnosed or missed, and they are often associated with death. The aim of this study was to verify the morphological and histological criteria of fatal cases of PAH and evaluate the lymphocytic populations associated to lesions with reactive neo-angiogenesis. METHODS Pulmonary lung sections from 10 cases of sudden unexpected death (SUD) in the absence of previously diagnosed diseases and in an apparent state of well-being, with final histological post autopsy diagnosis of PAH were collected. The pathological findings were compared using ten controls from non-pathological lung from deaths from other causes. The autopsies included 4 males (40%) and 6 females (60%) with an average age of 52.1 ± 10.1 years. Sections stained with hematoxylin and eosin (H&E) were revised for a morphological diagnosis. Subsequently, serial sections were performed and stained with immunohistochemistry for anti-CD20 (B-lymphocytes), anti-CD3 (T-lymphocytes), anti-CD4 (T-helper lumphocytes), anti-CD8 (T-cytotoxic lymphocytes) and anti-CD117/C-Kit (mast cells/MCs) to detect inflammatory infiltrate and different ratios of cell-type. Statistical analysis was conducted using a paired t-test looking at 100 cells in 3 different tissue samples representative of vascular lesion and 3 different random normal lung parenchyma fields without lesion (from 10 normal control lungs), to identify specific lymphocyte subpopulations in inflammatory infiltrates. RESULTS There was a significant percentage increase of CD20 (p < 0.001), CD8 (p = 0.002), CD4 (p < 0.001), and CD117/C-Kit positive (C-Kit+; p < 0.001) cells mainly detected around wall vessels; while increased MCs positivity and C-Kit+ were observed especially in alveolar septa. In addition, reactive angiomatosis was observed. CONCLUSIONS The inflammatory infiltrate should be included for a correct diagnosis of PAH besides the vascular remodelling. The inflammatory infiltrate seems to be implicated as a main factor in the pathogenesis. This finding is important to rule out secondary pulmonary hypertension, to identify SUDs of unknown causes and to add new elements to the literature that can explain the immunologically related pathogenesis of PAH.
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Affiliation(s)
- Gelsomina Mansueto
- Department of Advanced Medical and SurgicalSciences, University of Campania "Luigi Vanvitelli"; Clinical Department of Laboratory Services and Public Health, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy; Clinical Department of Laboratory Services and Public Health, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy.
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Viale Mazzini 100 Sulmona, 67039 L'Aquila, Italy.
| | - Carlo Pietro Campobasso
- Clinical Department of Laboratory Services and Public Health, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy; Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", 80138 Naples, Italy.
| | - Mark Slevin
- Departmentof Life Sciences Manchester Metropolitan University, Chester Street, Manchester M1 5GD, United Kingdom; University of Medicine and Pharmacy, Scienceand Technology, W1G 7ET Târgu Mures, Romania.
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Ali MK, Ichimura K, Spiekerkoetter E. Promising therapeutic approaches in pulmonary arterial hypertension. Curr Opin Pharmacol 2021; 59:127-139. [PMID: 34217109 DOI: 10.1016/j.coph.2021.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/12/2021] [Accepted: 05/11/2021] [Indexed: 12/19/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a debilitating multifactorial disease characterized by progressive pulmonary vascular remodeling, elevated pulmonary arterial pressure, and pulmonary vascular resistance, resulting in right ventricular failure and subsequent death. Current available therapies do not reverse the disease, resulting in a persistent high morbidity and mortality. Thus, there is an urgent unmet medical need for novel effective therapies to better treat patients with PAH. Over the past few years, enthusiastic attempts have been made to identify novel effective therapies that address the essential roots of PAH with targeting key signaling pathways in both preclinical models and patients with PAH. This review aims to discuss the most emerging and promising therapeutic interventions in PAH pathogenesis.
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Affiliation(s)
- Md Khadem Ali
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford Medical School, USA; Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, USA
| | - Kenzo Ichimura
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford Medical School, USA; Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, USA
| | - Edda Spiekerkoetter
- Division of Pulmonary, Allergy and Critical Care Medicine, Stanford Medical School, USA; Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, USA.
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12
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Di Bartolomeo S, Alunno A, Carubbi F. Respiratory Manifestations in Systemic Lupus Erythematosus. Pharmaceuticals (Basel) 2021; 14:276. [PMID: 33803847 PMCID: PMC8003168 DOI: 10.3390/ph14030276] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 12/11/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease characterized by a wide spectrum of clinical manifestations. The respiratory system can be involved in up to 50-70% of patients and be the presenting manifestation of the disease in 4-5% of cases. Every part of the respiratory part can be involved, and the severity can vary from mild self-limiting to life threatening forms. Respiratory involvement can be primary (caused by SLE itself) or secondary (e.g., infections or drug toxicity), acute or chronic. The course, treatment and prognosis vary greatly depending on the specific pattern of the disease. This review article aims at providing an overview of respiratory manifestations in SLE along with an update about therapeutic approaches including novel biologic therapies.
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Affiliation(s)
| | - Alessia Alunno
- Rheumatology Unit, Department of Medicine, University of Perugia, 06123 Perugia, Italy;
| | - Francesco Carubbi
- Internal Medicine and Nephrology Unit, Department of Life, Health & Environmental Sciences, University of L’Aquila and Department of Medicine, ASL 1 Avezzano-Sulmona-L’Aquila, 67100 L’Aquila, Italy
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Zamanian RT, Badesch D, Chung L, Domsic RT, Medsger T, Pinckney A, Keyes-Elstein L, D'Aveta C, Spychala M, White RJ, Hassoun PM, Torres F, Sweatt AJ, Molitor JA, Khanna D, Maecker H, Welch B, Goldmuntz E, Nicolls MR. Safety and Efficacy of B-Cell Depletion with Rituximab for the Treatment of Systemic Sclerosis-associated Pulmonary Arterial Hypertension: A Multicenter, Double-Blind, Randomized, Placebo-controlled Trial. Am J Respir Crit Care Med 2021; 204:209-221. [PMID: 33651671 PMCID: PMC8650794 DOI: 10.1164/rccm.202009-3481oc] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Rationale: Systemic sclerosis (SSc)-pulmonary arterial hypertension (PAH) is one of the most prevalent and deadly forms of PAH. B cells may contribute to SSc pathogenesis. Objectives: We investigated the safety and efficacy of B-cell depletion for SSc-PAH. Methods: In an NIH-sponsored, multicenter, double-blinded, randomized, placebo-controlled, proof-of-concept trial, 57 patients with SSc-PAH on stable-dose standard medical therapy received two infusions of 1,000 mg rituximab or placebo administered 2 weeks apart. The primary outcome measure was the change in 6-minute-walk distance (6MWD) at 24 weeks. Secondary endpoints included safety and invasive hemodynamics. We applied a machine learning approach to predict drug responsiveness. Measurements and Main Results: We randomized 57 subjects from 2010 to 2018. In the primary analysis, using data through Week 24, the adjusted mean change in 6MWD at 24 weeks favored the treatment arm but did not reach statistical significance (23.6 ± 11.1 m vs. 0.5 ± 9.7 m; P = 0.12). Although a negative study, when data through Week 48 were also considered, the estimated change in 6MWD at Week 24 was 25.5 ± 8.8 m for rituximab and 0.4 ± 7.4 m for placebo (P = 0.03). Rituximab treatment appeared to be safe and well tolerated. Low levels of RF (rheumatoid factor), IL-12, and IL-17 were sensitive and specific as favorable predictors of a rituximab response as measured by an improved 6MWD (receiver operating characteristic area under the curve, 0.88-0.95). Conclusions: B-cell depletion therapy is a potentially effective and safe adjuvant treatment for SSc-PAH. Future studies in these patients can confirm whether the identified biomarkers predict rituximab responsiveness. Clinical trial registered with www.clinicaltrails.gov (NCT01086540).
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Affiliation(s)
- Roham T Zamanian
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, California
| | - David Badesch
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lorinda Chung
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Division of Rheumatology and Immunology, Stanford University, Stanford University School of Medicine, Stanford, California
| | - Robyn T Domsic
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Thomas Medsger
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | - Carla D'Aveta
- Rho Federal Systems Division, Durham, North Carolina
| | | | - R James White
- Division of Pulmonary and Critical Care Medicine, University of Rochester, Rochester, New York
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern, Dallas, Texas
| | - Andrew J Sweatt
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, California
| | - Jerry A Molitor
- Division of Rheumatic and Autoimmune Diseases, University of Minnesota, Minneapolis, Minnesota
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan
| | - Holden Maecker
- Division of Pulmonary, Allergy, and Critical Care Medicine and
| | - Beverly Welch
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland; and
| | - Ellen Goldmuntz
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland; and
| | - Mark R Nicolls
- Division of Pulmonary, Allergy, and Critical Care Medicine and.,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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14
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Amarnani R, Yeoh SA, Denneny EK, Wincup C. Lupus and the Lungs: The Assessment and Management of Pulmonary Manifestations of Systemic Lupus Erythematosus. Front Med (Lausanne) 2021; 7:610257. [PMID: 33537331 PMCID: PMC7847931 DOI: 10.3389/fmed.2020.610257] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 12/07/2020] [Indexed: 12/25/2022] Open
Abstract
Pulmonary manifestations of systemic lupus erythematosus (SLE) are wide-ranging and debilitating in nature. Previous studies suggest that anywhere between 20 and 90% of patients with SLE will be troubled by some form of respiratory involvement throughout the course of their disease. This can include disorders of the lung parenchyma (such as interstitial lung disease and acute pneumonitis), pleura (resulting in pleurisy and pleural effusion), and pulmonary vasculature [including pulmonary arterial hypertension (PAH), pulmonary embolic disease, and pulmonary vasculitis], whilst shrinking lung syndrome is a rare complication of the disease. Furthermore, the risks of respiratory infection (which often mimic acute pulmonary manifestations of SLE) are increased by the immunosuppressive treatment that is routinely used in the management of lupus. Although these conditions commonly present with a combination of dyspnea, cough and chest pain, it is important to consider that some patients may be asymptomatic with the only suggestion of the respiratory disorder being found incidentally on thoracic imaging or pulmonary function tests. Treatment decisions are often based upon evidence from case reports or small cases series given the paucity of clinical trial data specifically focused on pulmonary manifestations of SLE. Many therapeutic options are often initiated based on studies in severe manifestations of SLE affecting other organ systems or from experience drawn from the use of these therapeutics in the pulmonary manifestations of other systemic autoimmune rheumatic diseases. In this review, we describe the key features of the pulmonary manifestations of SLE and approaches to investigation and management in clinical practice.
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Affiliation(s)
- Raj Amarnani
- Department of Rheumatology, University College London Hospital, London, United Kingdom
| | - Su-Ann Yeoh
- Department of Rheumatology, University College London Hospital, London, United Kingdom
- Division of Medicine, Department of Rheumatology, University College London, London, United Kingdom
| | - Emma K. Denneny
- Department of Respiratory Medicine, University College London Hospital, London, United Kingdom
- Leukocyte Trafficking Laboratory, Centre for Inflammation and Tissue Repair, UCL Respiratory, University College London, London, United Kingdom
| | - Chris Wincup
- Department of Rheumatology, University College London Hospital, London, United Kingdom
- Division of Medicine, Department of Rheumatology, University College London, London, United Kingdom
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15
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Xiao Y, Chen PP, Zhou RL, Zhang Y, Tian Z, Zhang SY. Pathological Mechanisms and Potential Therapeutic Targets of Pulmonary Arterial Hypertension: A Review. Aging Dis 2020; 11:1623-1639. [PMID: 33269111 PMCID: PMC7673851 DOI: 10.14336/ad.2020.0111] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 01/11/2020] [Indexed: 12/22/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive cardiovascular disease characterized by pulmonary vasculature reconstruction and right ventricular dysfunction. The mortality rate of PAH remains high, although multiple therapeutic strategies have been implemented in clinical practice. These drugs mainly target the endothelin-1, prostacyclin and nitric oxide pathways. Management for PAH treatment includes improving symptoms, enhancing quality of life, and extending survival rate. Existing drugs developed to treat the disease have resulted in enormous economic and healthcare liabilities. The estimated cost for advanced PAH has exceeded $200,000 per year. The pathogenesis of PAH is associated with numerous molecular processes. It mainly includes germline mutation, inflammation, dysfunction of pulmonary arterial endothelial cells, epigenetic modifications, DNA damage, metabolic dysfunction, sex hormone imbalance, and oxidative stress, among others. Findings based on the pathobiology of PAH may have promising therapeutic outcomes. Hence, faced with the challenges of increasing healthcare demands, in this review, we attempted to explore the pathological mechanisms and alternative therapeutic targets, including other auxiliary devices or interventional therapies, in PAH. The article will discuss the potential therapies of PAH in detail, which may require further investigation before implementation.
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Affiliation(s)
- Ying Xiao
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Pei-Pei Chen
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui-Lin Zhou
- School of Medicine, Tsinghua University, Beijing 100084, China
| | - Yang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Yang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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16
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Hu Y, Chi L, Kuebler WM, Goldenberg NM. Perivascular Inflammation in Pulmonary Arterial Hypertension. Cells 2020; 9:cells9112338. [PMID: 33105588 PMCID: PMC7690279 DOI: 10.3390/cells9112338] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/15/2020] [Accepted: 10/20/2020] [Indexed: 12/12/2022] Open
Abstract
Perivascular inflammation is a prominent pathologic feature in most animal models of pulmonary hypertension (PH) as well as in pulmonary arterial hypertension (PAH) patients. Accumulating evidence suggests a functional role of perivascular inflammation in the initiation and/or progression of PAH and pulmonary vascular remodeling. High levels of cytokines, chemokines, and inflammatory mediators can be detected in PAH patients and correlate with clinical outcome. Similarly, multiple immune cells, including neutrophils, macrophages, dendritic cells, mast cells, T lymphocytes, and B lymphocytes characteristically accumulate around pulmonary vessels in PAH. Concomitantly, vascular and parenchymal cells including endothelial cells, smooth muscle cells, and fibroblasts change their phenotype, resulting in altered sensitivity to inflammatory triggers and their enhanced capacity to stage inflammatory responses themselves, as well as the active secretion of cytokines and chemokines. The growing recognition of the interaction between inflammatory cells, vascular cells, and inflammatory mediators may provide important clues for the development of novel, safe, and effective immunotargeted therapies in PAH.
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Affiliation(s)
- Yijie Hu
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, ON M5B1W8, Canada;
- Department of Cardiovascular Surgery, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Leon Chi
- Department of Physiology, University of Toronto, Toronto, ON M5B1W8, Canada;
| | - Wolfgang M. Kuebler
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, ON M5B1W8, Canada;
- Departments of Physiology and Surgery, University of Toronto, Toronto, ON M5B1W8, Canada
- Institute of Physiology, Charité Universitäts Medizin Berlin, 10117 Berlin, Germany
- Correspondence: ; Tel.: +49-30-450-528-501
| | - Neil M. Goldenberg
- Departments of Physiology and Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON M5B1W8, Canada;
- Department of Anesthesia and Pain Medicine, Program in Cell Biology, The Hospital for Sick Children, Toronto, ON M5B1W8, Canada
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17
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Zolty R. Pulmonary arterial hypertension specific therapy: The old and the new. Pharmacol Ther 2020; 214:107576. [PMID: 32417272 DOI: 10.1016/j.pharmthera.2020.107576] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2020] [Indexed: 02/08/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a vascular disorder associated with high morbidity and mortality rate and is characterized by pulmonary vascular remodeling and increased pulmonary vascular resistance, ultimately resulting in right ventricular failure and death. Over the past few decades, significant advances in the understanding of the epidemiology, pathogenesis, and pathophysiology of pulmonary arterial hypertension have occured. This has led to the development of disease specific treatment including prostanoids, endothelin receptor antagonists, phosphodiesterase inhibitors, and soluble guanylate cyclase stimulators. These therapies significantly improve exercise capacity, quality of life, pulmonary hemodynamics, but none of the current treatments are actually curative and long-term prognosis remains poor. Thus, there is a clear need to develop new therapies. Several potential pharmacologic agents for the treatment of pulmonary arterial hypertension are under clinical development and some promising results with these treatments have been reported. These agents include tyrosine protein kinase inhibitors, rho-kinase inhibitors, synthetically produced vasoactive intestinal peptide, antagonists of the 5-HT2 receptors, and others. This article will review several of these promising new therapies and will discuss the current evidence regarding their potential benefit in pulmonary arterial hypertension.
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Affiliation(s)
- Ronald Zolty
- Cardiovascular Divisions, 982265 Nebraska Medical Center, University of Nebraska Medical Center, Omaha, NE 68198, United States of America.
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18
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Koudstaal T, Boomars KA, Kool M. Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension: An Immunological Perspective. J Clin Med 2020; 9:E561. [PMID: 32092864 PMCID: PMC7074374 DOI: 10.3390/jcm9020561] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/10/2020] [Accepted: 02/16/2020] [Indexed: 12/24/2022] Open
Abstract
Pulmonary hypertension (PH) is a debilitating progressive disease characterized by increased pulmonary arterial pressures, leading to right ventricular (RV) failure, heart failure and, eventually, death. Based on the underlying conditions, PH patients can be subdivided into the following five groups: (1) pulmonary arterial hypertension (PAH), (2) PH due to left heart disease, (3) PH due to lung disease, (4) chronic thromboembolic PH (CTEPH), and (5) PH with unclear and/or multifactorial mechanisms. Currently, even with PAH-specific drug treatment, prognosis for PAH and CTEPH patients remains poor, with mean five-year survival rates of 57%-59% and 53%-69% for PAH and inoperable CTEPH, respectively. Therefore, more insight into the pathogenesis of PAH and CTEPH is highly needed, so that new therapeutic strategies can be developed. Recent studies have shown increased presence and activation of innate and adaptive immune cells in both PAH and CTEPH patients. Moreover, extensive biomarker research revealed that many inflammatory and immune markers correlate with the hemodynamics and/or prognosis of PAH and CTEPH patients. Increased evidence of the pathological role of immune cells in innate and adaptive immunity has led to many promising pre-clinical interventional studies which, in turn, are leading to innovative clinical trials which are currently being performed. A combination of immunomodulatory therapies might be required besides current treatment based on vasodilatation alone, to establish an effective treatment and prevention of progression for this disease. In this review, we describe the recent progress on our understanding of the involvement of the individual cell types of the immune system in PH. We summarize the accumulating body of evidence for inflammation and immunity in the pathogenesis of PH, as well as the use of inflammatory biomarkers and immunomodulatory therapy in PAH and CTEPH.
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Affiliation(s)
- Thomas Koudstaal
- Department of Pulmonary Medicine, Erasmus MC, Doctor Molenwaterplein 40, 3015 GD Rotterdam, The Netherlands; (K.A.B.); (M.K.)
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19
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Kreidy M, Al-Hilli A, Yachoui R, Resnick J. Severe but reversible pulmonary hypertension in scleromyxedema and multiple myeloma: a case report. BMC Pulm Med 2020; 20:8. [PMID: 31918690 PMCID: PMC6953266 DOI: 10.1186/s12890-019-1020-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 12/06/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Scleromyxedema is a progressive, systemic connective tissue disorder characterized by fibro-mucous skin lesions and increased serum monoclonal immunoglobulin levels. Pulmonary involvement occurs in a subset of patients, though the overall prevalence of pulmonary lesions in scleromyxedema is unknown. Since pulmonary hypertension presumably occurs in these patients due to disease progression and development of additional conditions, treatment of the underlying plasma cell dyscrasia and connective tissue disorder may improve pulmonary hypertension symptoms. CASE PRESENTATION An elderly patient with scleromyxedema developed pulmonary hypertension refractory to vasodilator and diuretic therapy and subsequently multiple myeloma that responded to a combination therapy of bortezomib, cyclophosphamide, and dexamethasone treatment. CONCLUSIONS Treatment of the underlying disease(s) that contributed to pulmonary hypertension development with anti-neoplastic agents like bortezomib may improve cardiopulmonary symptoms secondary to reducing abnormal blood cell counts and paraprotein levels.
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Affiliation(s)
- Mazen Kreidy
- Department of Pulmonary and Critical Care Medicine, Marshfield Clinic, Marshfield, WI USA
- Present affiliation: Christiana Care Health System, PO Box 1668, Wilmington, DE 19899 USA
| | - Ali Al-Hilli
- Department of Internal Medicine, Marshfield Clinic, Marshfield, WI USA
| | - Ralph Yachoui
- Department of Rheumatology, Ronald Reagan UCLA Medical Center, Santa Monica, California, USA
| | - Jeffrey Resnick
- Department of Pathology, Marshfield Clinic, Marshfield, WI USA
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20
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Zanatta E, Polito P, Famoso G, Larosa M, De Zorzi E, Scarpieri E, Cozzi F, Doria A. Pulmonary arterial hypertension in connective tissue disorders: Pathophysiology and treatment. Exp Biol Med (Maywood) 2019; 244:120-131. [PMID: 30669861 PMCID: PMC6405825 DOI: 10.1177/1535370218824101] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPACT STATEMENT Our article focuses on the pathogenesis and treatment of CTD-PAH. In the latest ESC/ESR guidelines for PAH, the authors underline that although CTD-PAH should follow the same treatment protocol as idiopathic PAH, the therapeutic approach is more complex and difficult in the former. This review throws light on several peculiar aspects of CTD-PAH and the latest findings in the pathogenesis, namely, the role of inflammation in the maladaptive right ventricle remodeling in SSc-PAH where immunosuppressants are classically believed to be ineffective. Furthermore, we discuss the major critical points in the therapy of CTD-PAH which is one of the strengths of our article. To the best of our knowledge, there are no other reviews that exclusively focus on the pathogenesis and treatment of CTD-PAH patients, with an emphasis on the more critical issues. Thus, it is our contention that our work would be of interest to the readers.
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Affiliation(s)
- Elisabetta Zanatta
- Department of Medicine-DIMED, Division of Rheumatology,
University of Padova, 35128 Padova, Italy
| | - Pamela Polito
- Department of Medicine-DIMED, Division of Rheumatology,
University of Padova, 35128 Padova, Italy
| | - Giulia Famoso
- Department of Cardiac, Thoracic and Vascular Sciences,
University of Padova, 35128 Padova, Italy
| | - Maddalena Larosa
- Department of Medicine-DIMED, Division of Rheumatology,
University of Padova, 35128 Padova, Italy
| | - Elena De Zorzi
- Department of Medicine-DIMED, Division of Rheumatology,
University of Padova, 35128 Padova, Italy
| | - Elena Scarpieri
- Department of Medicine-DIMED, Division of Rheumatology,
University of Padova, 35128 Padova, Italy
| | - Franco Cozzi
- Department of Medicine-DIMED, Division of Rheumatology,
University of Padova, 35128 Padova, Italy
| | - Andrea Doria
- Department of Medicine-DIMED, Division of Rheumatology,
University of Padova, 35128 Padova, Italy
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21
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Kato M, Atsumi T. Pulmonary arterial hypertension associated with connective tissue diseases: A review focusing on distinctive clinical aspects. Eur J Clin Invest 2018; 48. [PMID: 29285766 DOI: 10.1111/eci.12876] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 12/10/2017] [Indexed: 02/06/2023]
Abstract
Recent studies have clarified that pulmonary arterial hypertension associated with connective tissue diseases (CTD-PAH) has some distinctive clinical aspects from other PAH, such as high prevalence, venous and cardiac involvement, less favourable outcome, helpfulness of detection algorithm, response to immunosuppression, pre-PAH conditions in borderline pulmonary arterial pressure and coexistence of interstitial lung disease. In this review, by focusing on these distinctive aspects, we discuss how to provide an efficacious and safe management of CTD-PAH and garner attention to areas where further evidence is desired.
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Affiliation(s)
- Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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22
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Jafri S, Ormiston ML. Immune regulation of systemic hypertension, pulmonary arterial hypertension, and preeclampsia: shared disease mechanisms and translational opportunities. Am J Physiol Regul Integr Comp Physiol 2017; 313:R693-R705. [PMID: 28978513 DOI: 10.1152/ajpregu.00259.2017] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/11/2017] [Accepted: 10/02/2017] [Indexed: 12/22/2022]
Abstract
Systemic hypertension, preeclampsia, and pulmonary arterial hypertension (PAH) are diseases of high blood pressure in the systemic or pulmonary circulation. Beyond the well-defined contribution of more traditional pathophysiological mechanisms, such as changes in the renin-angiotensin-aldosterone system, to the development of these hypertensive disorders, there is substantial clinical evidence supporting an important role for inflammation and immunity in the pathogenesis of each of these three conditions. Over the last decade, work in small animal models, bearing targeted deficiencies in specific cytokines or immune cell subsets, has begun to clarify the immune-mediated mechanisms that drive changes in vascular structure and tone in hypertensive disease. By summarizing the clinical and experimental evidence supporting a contribution of the immune system to systemic hypertension, preeclampsia, and PAH, the current review highlights the cellular and molecular pathways that are common to all three hypertensive disorders. These mechanisms are centered on an imbalance in CD4+ helper T cell populations, defined by excessive Th17 responses and impaired Treg activity, as well as the excessive activation or impairment of additional immune cell types, including macrophages, dendritic cells, CD8+ T cells, B cells, and natural killer cells. The identification of common immune mechanisms in systemic hypertension, preeclampsia, and PAH raises the possibility of new therapeutic strategies that target the immune component of hypertension across multiple disorders.
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Affiliation(s)
- Salema Jafri
- University of Cambridge, Department of Medicine, Cambridge, United Kingdom; and
| | - Mark L Ormiston
- Queen's University, Departments of Biomedical and Molecular Sciences, Medicine and Surgery, Kingston, Canada
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23
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Nagel C, Ewert R, Egenlauf B, Lehmkuhl HB, Rosenkranz S, Benjamin N, Schwenger V, Herth FJF, Grünig E. Safety and Efficacy of Immunoadsorption as an Add-On to Medical Treatment in Patients with Severe Idiopathic Pulmonary Arterial Hypertension. Respiration 2017; 94:263-271. [PMID: 28787715 DOI: 10.1159/000478744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 06/13/2017] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Despite optimized medical therapy, severe idiopathic pulmonary arterial hypertension (IPAH) is a devastating disease with a poor outcome. Autoantibodies have been detected in IPAH that can contribute to worsening of the disease. OBJECTIVES The objective of this prospective, open-label, single-arm, multicenter trial was to evaluate the safety and efficacy of immunoadsorption (IA) as an add-on to optimized medical treatment for patients with IPAH. METHODS A total of 10 IPAH patients received IA over 5 days. Their clinical parameters, including hemodynamics measured by right heart catheter, were assessed at baseline and after 3 and 6 months. The primary endpoint was the change in pulmonary vascular resistance (PVR). Secondary endpoints included the change in 6-min walking distance, quality of life, safety, and plasma levels of IgG and autoantibodies. RESULTS The evaluation of the 10 IPAH patients (75% female; 51 ± 12 years; 166 ± 10 cm; WHO functional class III; 53% on combination therapy) revealed that IA was a safe procedure that efficiently removed IgG and autoantibodies from the circulation. After 3 months, the mean PVR improved significantly by 13.2% (p = 0.03) and the cardiac index improved by 13.1%, but no significant changes were found in 6-min walking distance. The quality of life physical functioning subscale score significantly improved after 6 months. The serious adverse events in 3 patients were possibly related to IA and included pneumonia, temporary disturbance in attention, and thrombocytopenia. CONCLUSIONS IA as an add-on to targeted medical treatment for IPAH is a safe procedure with beneficial effects on hemodynamics, especially in patients with high levels of autoantibodies. Larger-scale controlled studies are needed to assess its efficacy in IPAH and to identify responders.
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24
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Tselios K, Gladman DD, Urowitz MB. Systemic lupus erythematosus and pulmonary arterial hypertension: links, risks, and management strategies. Open Access Rheumatol 2016; 9:1-9. [PMID: 28053559 PMCID: PMC5191623 DOI: 10.2147/oarrr.s123549] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is characterized by the second highest prevalence of pulmonary arterial hypertension (PAH), after systemic sclerosis, among the connective tissue diseases. SLE-associated PAH is hemodynamically defined by increased mean pulmonary artery pressure at rest (≥25 mmHg) with normal pulmonary capillary wedge pressure (≤15 mmHg) and increased pulmonary vascular resistance. Estimated prevalence ranges from 0.5% to 17.5% depending on the diagnostic method used and the threshold of right ventricular systolic pressure in studies using transthoracic echocardiogram. Its pathogenesis is multifactorial with vasoconstriction, due to imbalance of vasoactive mediators, leading to hypoxia and impaired vascular remodeling, collagen deposition, and thrombosis of the pulmonary circulation. Multiple predictive factors have been recognized, such as Raynaud’s phenomenon, pleuritis, pericarditis, anti-ribonuclear protein, and antiphospholipid antibodies. Secure diagnosis is based on right heart catheterization, although transthoracic echocardiogram has been shown to be reliable for patient screening and follow-up. Data on treatment mostly come from uncontrolled observational studies and consist of immunosuppressive drugs, mainly corticosteroids and cyclophosphamide, as well as PAH-targeted approaches with endothelin receptor antagonists (bosentan), phosphodiesterase type 5 inhibitors (sildenafil), and vasodilators (epoprostenol). Prognosis is significantly affected, with 1- and 5-year survival estimated at 88% and 68%, respectively.
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Affiliation(s)
- Konstantinos Tselios
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, ON, Canada
| | - Dafna D Gladman
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, ON, Canada
| | - Murray B Urowitz
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, ON, Canada
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25
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Tang CP, Lee KL, Ying KY. Review of the diagnosis and pharmacological management of pulmonary arterial hypertension in connective tissue disease. HONG KONG BULLETIN ON RHEUMATIC DISEASES 2016. [DOI: 10.1515/hkbrd-2016-0004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Connective-tissue-disease-associated pulmonary arterial hypertension (CTD-PAH) is a well-recognised pulmonary complication most commonly seen in patients with systemic sclerosis, followed by systemic lupus erythematosus and mixed connective tissue disease. In systemic-sclerosis-associated-pulmonary arterial hypertension (SSc-PAH), patients usually present late and the progression can be rapid with poor prognosis and survival. Early detection and prompt intervention of SSc-PAH is an important cornerstone to halt the disease progression. Various pulmonary vasodilatory agents were developed over the past two decades. They were shown to improve patients’ symptoms, functional status, exercise capacity, haemodynamics and long-term survival. Other immunosuppressive therapies also demonstrated to improve symptoms and functional status in certain group of patients. This article is to review the diagnosis and pharmacological management of patient with CTD-PAH.
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Affiliation(s)
- Chun-Pong Tang
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong
| | - Ka-Lai Lee
- Consultant, Department of Medicine, Princess Margaret Hospital, Hong Kong
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26
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Thakkar V, Lau EMT. Connective tissue disease-related pulmonary arterial hypertension. Best Pract Res Clin Rheumatol 2016; 30:22-38. [PMID: 27421214 DOI: 10.1016/j.berh.2016.03.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/12/2016] [Accepted: 03/29/2016] [Indexed: 01/05/2023]
Abstract
Over the past two decades, there have been several advances in the assessment and management of connective tissue disease-related pulmonary arterial hypertension (CTD-PAH) that improved outcomes of the treatment of this lethal disease, and this will be the focus of this study. Systemic sclerosis is the leading cause of CTD-PAH, followed by systemic lupus erythematosus, mixed connective tissue disease, idiopathic inflammatory myositis, rheumatoid arthritis, and Sjogren's syndrome. Clinical registries have been invaluable in informing about the burden of disease, risk and prognostic factors, and temporal trends with respect to treatment and outcome in CTD-PAH. The major advances have centered on improved disease classification and diagnostic criteria, screening and early diagnosis, the emergence of evidence-based therapies including combination goal-orientated treatment strategies, and the establishment of centers with expertise in PAH.
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Affiliation(s)
- Vivek Thakkar
- Department of Rheumatology, Liverpool Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia; Ingham Institute, Liverpool, Australia.
| | - Edmund M T Lau
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Medical School, University of Sydney, Camperdown, Australia.
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27
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Sardana M, Moll M, Farber HW. Novel investigational therapies for treating pulmonary arterial hypertension. Expert Opin Investig Drugs 2015; 24:1571-96. [DOI: 10.1517/13543784.2015.1098616] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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28
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Abstract
Pulmonary arterial hypertension is a progressive and debilitating disorder with an associated high morbidity and mortality rate. Significant advances in our understanding of the epidemiology, pathogenesis, and pathophysiology of pulmonary hypertension have occurred over the past several decades. This has allowed the development of new therapeutic options in this disease. Today, our selection of therapeutic modalities is broader, including calcium channel blockers, prostanoids, endothelin receptor antagonists, phosphodiesterase inhibitors, and soluble guanylate cyclase stimulators, but the disease remains fatal. This underscores the need for a continued search for novel therapies. Several potential pharmacologic agents for the treatment of pulmonary arterial hypertension are under clinical development and some promising results with these treatments have been reported. These agents include rho-kinase inhibitors, long-acting nonprostanoid prostacyclin receptor agonists, tyrosine protein kinase inhibitors, endothelial nitric oxide synthase couplers, synthetically produced vasoactive intestinal peptide, antagonists of the 5-HT2 receptors, and others. This article will review several of these promising new therapies and will discuss the current evidence regarding their potential benefit in pulmonary arterial hypertension.
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29
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Sung YK, Chung L. Connective tissue disease-associated pulmonary arterial hypertension. Rheum Dis Clin North Am 2015; 41:295-313. [PMID: 25836644 DOI: 10.1016/j.rdc.2015.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pulmonary arterial hypertension (PAH) is characterized by vascular remodeling of pulmonary arterioles that leads to increased pulmonary vascular resistance, right heart failure, and death. It is associated with connective tissue diseases, including systemic sclerosis, systemic lupus erythematosus, and mixed connective tissue disease. PAH is characterized by dyspnea on exertion and fatigue. Syncopal events suggest severe disease. Patients may present with signs of right heart failure. One- and 3-year survival rates are approximately 81% and 52%, respectively. Given the high prevalence and mortality, algorithms for screening are currently under investigation and will hopefully lead to earlier diagnosis and improved survival.
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Affiliation(s)
- Yon K Sung
- Division of Pulmonary and Critical Care Medicine, Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Lorinda Chung
- Division of Rheumatology and Immunology, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA; Division of Rheumatology, VA Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304, USA.
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30
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The lung in rheumatic disease. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00036-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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31
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Inflammation in pulmonary hypertension: what we know and what we could logically and safely target first. Drug Discov Today 2014; 19:1251-6. [DOI: 10.1016/j.drudis.2014.04.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 04/11/2014] [Indexed: 12/29/2022]
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32
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O'Connell C, O'Callaghan DS, Humbert M. Novel medical therapies for pulmonary arterial hypertension. Clin Chest Med 2014; 34:867-80. [PMID: 24267310 DOI: 10.1016/j.ccm.2013.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Available targeted therapies for pulmonary arterial hypertension are capable only of slowing progression of the disease and a cure remains elusive. However with the improved understanding of the pulmonary vascular remodeling that characterizes the disease, there is optimism that the disconnect between preclinical and clinical studies may be bridged with some of the newer therapies that are now at different stages of clinical evaluation. This article examines the evidence behind these new candidate treatments that may become part of the arsenal available for clinicians managing this devastating disease.
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Affiliation(s)
- Caroline O'Connell
- Department of Respiratory Medicine, Mater Misericordiae University Hospital, 56 Eccles Street, Dublin 7, Ireland.
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33
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Schreiber BE, Connolly MJ, Coghlan JG. Pulmonary hypertension in systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2014; 27:425-34. [PMID: 24238697 DOI: 10.1016/j.berh.2013.07.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Systemic lupus erythematosus is associated with several forms of pulmonary hypertension. It can cause pulmonary hypertension through pulmonary thromboembolic disease, left heart disease and lung disease as well as causing an isolated pulmonary vasculopathy called pulmonary arterial hypertension. The true prevalence of pulmonary arterial hypertension in patients with lupus is not known but probably is no more than 1%. Currently, treatment for lupus-associated pulmonary arterial hypertension is with pulmonary vasodilators including phosphodiesterase-5 inhibitors, endothelin receptor antagonists and prostacyclin analogues, as it is for other causes of pulmonary arterial hypertension. Case series suggest there may be a special role for immunosuppression in this rare group of patients. We present two brief case histories and summarise our experience over 15 years. Prognosis is better in lupus-associated pulmonary arterial hypertension than in systemic sclerosis-associated pulmonary arterial hypertension, but unfortunately it remains a fatal condition in most patients.
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Affiliation(s)
- Benjamin E Schreiber
- National Pulmonary Hypertension Service, Royal Free Hospital NHS Foundation Trust, UK.
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34
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Zhao L, Ashek A, Wang L, Fang W, Dabral S, Dubois O, Cupitt J, Pullamsetti SS, Cotroneo E, Jones H, Tomasi G, Nguyen QD, Aboagye EO, El-Bahrawy MA, Barnes G, Howard LS, Gibbs JSR, Gsell W, He JG, Wilkins MR. Heterogeneity in lung (18)FDG uptake in pulmonary arterial hypertension: potential of dynamic (18)FDG positron emission tomography with kinetic analysis as a bridging biomarker for pulmonary vascular remodeling targeted treatments. Circulation 2013; 128:1214-24. [PMID: 23900048 DOI: 10.1161/circulationaha.113.004136] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a disease of progressive vascular remodeling, characterized by dysregulated growth of pulmonary vascular cells and inflammation. A prevailing view is that abnormal cellular metabolism, notably aerobic glycolysis that increases glucose demand, underlies the pathogenesis of PAH. Increased lung glucose uptake has been reported in animal models. Few data exist from patients with PAH. METHODS AND RESULTS Dynamic positron emission tomography imaging with fluorine-18-labeled 2-fluoro-2-deoxyglucose ((18)FDG) ligand with kinetic analysis demonstrated increased mean lung parenchymal uptake in 20 patients with PAH, 18 with idiopathic PAH (IPAH) (FDG score: 3.27±1.22), and 2 patients with connective tissue disease (5.07 and 7.11) compared with controls (2.02±0.71; P<0.05). Further compartment analysis confirmed increased lung glucose metabolism in IPAH. Lung (18)FDG uptake and metabolism varied within the IPAH population and within the lungs of individual patients, consistent with the recognized heterogeneity of vascular pathology in this disease. The monocrotaline rat PAH model also showed increased lung (18)FDG uptake, which was reduced along with improvements in vascular pathology after treatment with dicholoroacetate and 2 tyrosine kinase inhibitors, imatinib and sunitinib. Hyperproliferative pulmonary vascular fibroblasts isolated from IPAH patients exhibited upregulated glycolytic gene expression, along with increased cellular (18)FDG uptake; both were reduced by dicholoroacetate and imatinib. CONCLUSIONS Some patients with IPAH exhibit increased lung (18)FDG uptake. (18)FDG positron emission tomography imaging is a tool to investigate the molecular pathology of PAH and its response to treatment.
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Affiliation(s)
- Lan Zhao
- Centre for Pharmacology and Therapeutics, Experimental Medicine, Imperial College London, Hammersmith Hospital, London, UK (L.Z., A.A., L.W., O.D., J.C., E.C., H.J., G.B., M.R.W.); Department of Nuclear Medicine, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (W.F.); Max-Planck Institute for Heart and Lung Research and University of Giessen and Marburg Lung Center, German Center for Lung Research, Bad Nauheim, Germany (S.D., S.S.P.); Comprehensive Cancer Imaging Centre, Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK (G.T., Q.N., E.O.A.); Department of Histopathology, Imperial College London, UK (M.A.E.-B.); National Heart and Lung Institute, Imperial College London, and National Pulmonary Hypertension Service, Department of Cardiology, Hammersmith Hospital, London, UK (L.S.H., J.S.R.G.); Biological Imaging Centre, Medical Research Council Clinical Sciences Centre, Imperial College London, Hammersmith Hospital, London, UK (W.G.); and Center for Diagnosis and Management of Pulmonary Vascular Diseases, Department of Cardiology, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (J.H.)
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Perros F, Humbert M, Cohen-Kaminsky S. [Pulmonary arterial hypertension: a flavor of autoimmunity]. Med Sci (Paris) 2013; 29:607-16. [PMID: 23859515 DOI: 10.1051/medsci/2013296013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
It is admitted that autoimmunity results from a combination of risks such as genetic background, environmental triggers, and stochastic events. Pulmonary arterial hypertension (PAH) shares with the so-called prototypic autoimmune diseases, genetic risk factors, female predominance and sex hormone influence, association with other chronic inflammatory and autoimmune diseases, defects in regulatory T cells function, and presence of autoantibodies. Case reports have been published indicating the beneficial effect of some immunosuppressive and anti-inflammatory therapies in PAH, supporting the potential role of immune mechanisms in the pathophysiology of the disease. In this review, we discuss the current knowledge on autoimmune mechanisms operating in PAH, especially mounting a local autoimmune response inside the pulmonary tissue, namely pulmonary lymphoid neogenesis. A better understanding of the role of autoimmunity in pulmonary vascular remodelling may help develop targeted immunomodulatory strategies in PAH.
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Affiliation(s)
- Frédéric Perros
- Université Paris-Sud, faculté de médecine, hôpital de Bicêtre, Le Kremlin-Bicêtre, France
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36
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Rituximab: rescue therapy in life-threatening complications or refractory autoimmune diseases: a single center experience. Rheumatol Int 2012; 33:1495-504. [DOI: 10.1007/s00296-012-2587-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 11/30/2012] [Indexed: 10/27/2022]
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37
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Voelkel NF, Gomez-Arroyo J, Abbate A, Bogaard HJ, Nicolls MR. Pathobiology of pulmonary arterial hypertension and right ventricular failure. Eur Respir J 2012; 40:1555-65. [PMID: 22743666 DOI: 10.1183/09031936.00046612] [Citation(s) in RCA: 202] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pulmonary arterial hypertension (PAH) is no longer an orphan disease. There are three different classes of drugs for the treatment of PAH that are currently being used and an increasing number of patients are being treated with a single drug or combination therapy. During the last 25 yrs, new insights into the pathobiology of PAH have been gained. The classical mechanical concepts of pressure, flow, shear stress, right ventricle wall stress and impedance have been complemented with the new concepts of cell injury and repair and interactions of complex multicellular systems. Integrating these concepts will become critical as we design new medical therapies in order to change the prognosis of patients with these fatal diseases. This review intends to summarise recent pathobiological concepts of PAH and right ventricle failure mainly derived from human studies, which reflect the progress made in the understanding of this complex group of pulmonary vascular diseases.
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Affiliation(s)
- Norbert F Voelkel
- Dept of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA.
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38
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Pulmonary arterial hypertension in systemic lupus erythematosus: current status and future direction. Clin Dev Immunol 2012; 2012:854941. [PMID: 22489252 PMCID: PMC3318206 DOI: 10.1155/2012/854941] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Accepted: 01/02/2012] [Indexed: 12/18/2022]
Abstract
Pulmonary arterial hypertension (PAH) is commonly associated with connective tissue diseases (CTDs) including systemic sclerosis and systemic lupus erythematosus (SLE). The prevalence of PAH in SLE is estimated to be 0.5% to 17.5%. The pathophysiology of PAH involves multiple mechanisms from vasculitis and in-situ thrombosis to interstitial pulmonary fibrosis which increases pulmonary vascular resistance, potentially leading to right heart failure. Immune and inflammatory mechanisms may play a significant role in the pathogenesis or progression of PAH in patients with CTDs, establishing a role for anti-inflammatory and immunosuppressive therapies. The leading predictors of PAH in SLE are Raynaud phenomenon, anti-U1RNP antibody, and anticardiolipin antibody positivity. The first-line of diagnostic testing for patients with suspected SLE-associated PAH (SLE-aPAH) involves obtaining a Doppler echocardiogram. Once the diagnosis is confirmed by right heart catheterization, SLE-aPAH patients are generally treated with oxygen, anticoagulants, and vasodilators. Although the prognosis and therapeutic responsiveness of these patients have improved with the addition of intensive immunosuppressive therapies, these treatments are still largely unproven. Recent data put the one-year survival rate for SLE-aPAH patients at 94%. Pregnant women are most at risk of dying due to undiagnosed SLE-aPAH, and screening should be considered essential in this population.
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de Lauretis A, Veeraraghavan S, Renzoni E. Review series: Aspects of interstitial lung disease: connective tissue disease-associated interstitial lung disease: how does it differ from IPF? How should the clinical approach differ? Chron Respir Dis 2011; 8:53-82. [PMID: 21339375 DOI: 10.1177/1479972310393758] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The lung is frequently involved in connective tissue diseases (CTDs), although the frequency of lung manifestations varies according to the type of CTD. Interstitial lung diseases (ILD) are frequently seen in CTDs, particularly systemic sclerosis (SSc), polymyositis/dermatomyositis (PM/DM) and rheumatoid arthritis (RA), accounting for a significant proportion of deaths. A large percentage of patients with CTD-associated ILD has limited and stable disease, not requiring treatment. However, a significant minority has severe and/or progressive disease, necessitating prompt initiation of treatment. CTD-ILD histological patterns include non-specific interstitial pneumonia (NSIP), usual interstitial pneumonia (UIP), organizing pneumonia (OP), diffuse alveolar damage (DAD) and lymphocytic interstitial pneumonia (LIP). NSIP is the most common pattern in all CTDs, except for RA, characterized by a higher frequency of UIP. ILD can present acutely or chronically, with acute presentations being more common in systemic lupus erythematosus and PM/DM. Idiopathic pulmonary fibrosis (IPF) is a progressively worsening ILD characterized by inflammation and fibrosis. The characteristic histological pattern of IPF is UIP. Interestingly, a UIP pattern is associated with a significantly better survival in CTD-related disease compared to the idiopathic variety. Prognosis in IPF is dismal, with a median survival since diagnosis of 2-3 years. No treatment regimen has been shown to improve survival in IPF. By contrast, although there have been only two randomized placebo-controlled trials investigating the effect of immunosuppressive treatment in SSc-associated ILD, clinical experience suggests that immunosuppressive drugs in CTD-related ILDs are capable of benefiting a significant proportion of patients, particularly those with certain histological patterns of disease. This review will essentially focus on CTD-associated ILD and will compare aspects of clinical presentation and management to those of IPF.
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Affiliation(s)
- Angelo de Lauretis
- Department of Respiratory Medicine, Catholic University of the Sacred Heart, Rome, Italy
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40
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Kato M, Kataoka H, Odani T, Fujieda Y, Otomo K, Oku K, Horita T, Yasuda S, Atsumi T, Ohira H, Tsujino I, Nishimura M, Koike T. The short-term role of corticosteroid therapy for pulmonary arterial hypertension associated with connective tissue diseases: report of five cases and a literature review. Lupus 2011; 20:1047-56. [PMID: 21676917 DOI: 10.1177/0961203311403347] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening complication in connective tissue diseases (CTD). It remains controversial whether immunosuppressive therapy is useful for PAH associated with CTD (PAH-CTD). The Dana Point algorithm does not refer such treatments in patients with PAH-CTD due to the lack of evidence. However, some case reports have shown the potential efficacy of immunosuppression for PAH-CTD. Here we report five cases of PAH-CTD treated with corticosteroids and discuss the current management of PAH-CTD with immunosuppressive agents. Our cases consisted of three active systemic lupus erythematosus (SLE), a quiescent SLE and an active polymyositis. WHO functional classes at baseline were class III in three cases and class II in two. Median follow-up period was 44 (28-92) weeks. PAH was diagnosed by right heart catheterization in all cases (median pulmonary arterial pressure was 45 (29-49) mmHg). All patients received 1 mg/kg of prednisolone (PSL) for 2-4 weeks, followed by appropriate dose reduction. Methylprednisolone pulse therapy was performed in patients resistant to the high dosage of PSL. Four patients received vasodilators in combination. The therapy as above improved WHO functional class 4 weeks after the initiation of PSL in all the patients. Two patients required dose increase or additional administration of vasodilators due to the dose reduction of PSL. Corticosteroid therapy may be effective for PAH-CTD at least in the short term, even in low general activity of CTD or moderate PAH. Our experience suggests that corticosteroid therapy, by itself or in conjunction with standard vasodilators, is effective for PAH-CTD patients.
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Affiliation(s)
- M Kato
- Department of Medicine II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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41
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Dellaripa PF, O. Rosas I. The lung in rheumatic disease. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00035-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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42
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Kynyk JA, Kraut E, Sood N. Acute Right Ventricular Failure and Pulmonary Arterial Hypertension Secondary to Antiphospholipid Antibody Syndrome. Chest 2010. [DOI: 10.1378/chest.10792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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