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Chong WH, Agrawal D, Tan ZY, Venkateswaran S, Tan AYY, Tan CY, Ling NCA, Tay NSWT. A systematic review and meta-analysis of the clinical benefits and adverse reactions of anti-fibrotics in non-IPF progressive fibrosing ILD. Heart Lung 2024; 68:242-253. [PMID: 39089077 DOI: 10.1016/j.hrtlng.2024.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/17/2024] [Accepted: 07/17/2024] [Indexed: 08/03/2024]
Abstract
BACKGROUND Anti-fibrotics can reduce restrictive impairment in idiopathic pulmonary fibrosis (IPF). However, its effectiveness in non-IPF progressive fibrosing interstitial lung disease (non-IPF PF-ILD) remains uncertain. OBJECTIVE We assess the efficacy and safety of anti-fibrotics pirfenidone and nintedanib versus placebo among non-IPF PF-ILD adult patients. METHODS Meta-analysis was performed using PubMed, SCOPUS, and Cochrane databases to identify randomized controlled trials (RCTs). At respective centers, non-IPF PF-ILD was defined as clinical and radiological findings inconsistent with IPF and greater than 5 % forced vital capacity (FVC) decline, worsening radiological fibrosis or respiratory symptoms. RESULTS Among seven RCTs involving 1,816 non-IPF PF-ILD patients, anti-fibrotics significantly reduced decline in FVC from baseline in milliliters (MD -66.80milliliters; P < 0.01) and percent predicted (MD -1.80 %; P < 0.01) compared to placebo. However, severity of FVC decline was less than 10 % (P = 0.33) in both groups. No significant difference in the decline of 6MWD from baseline in meters (P = 0.19) while on anti-fibrotics, although those on pirfenidone had less decline in 6MWD (MD -25.12 m; P < 0.01) versus placebo. The rates of all-cause mortality (P = 0.34), all-cause hospitalization (P = 0.44), and hospitalization for respiratory etiology (P = 0.06) were comparable in both groups. Adverse events of nausea/vomiting (54.2 % vs. 20.3 %; P < 0.01), diarrhea (65.2 % vs. 27.6 %; P = 0.02), anorexia/weight loss (23.0 % vs. 7.7 %; P < 0.01), neurological disorders (20.8 % vs. 12.6 %; P < 0.01), and events requiring therapy discontinuation were higher (18.4 % vs. 9.9 %; P < 0.01) in the anti-fibrotic group. Other adverse events of skin (P = 0.18) and respiratory disorders (P = 0.20) were equal. CONCLUSION The advent of anti-fibrotics offers alternative treatment to reduce lung function decline.
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Affiliation(s)
- Woon Hean Chong
- Department of Respiratory Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606.
| | - Dipika Agrawal
- Department of Respiratory Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606
| | - Ze Ying Tan
- Department of Respiratory Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606
| | - Sridhar Venkateswaran
- Department of Respiratory Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606
| | - Adeline Yit Ying Tan
- Department of Respiratory Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606
| | - Ching Yee Tan
- Department of Respiratory Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606
| | - Norris Chun Ang Ling
- Department of Respiratory Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606
| | - Noel Stanley Wey Tut Tay
- Department of Respiratory Medicine, Ng Teng Fong General Hospital, National University Health System, 1 Jurong East Street 21, Singapore, 609606
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Polat G, Özdemir Ö, Ermin S, Serçe Unat D, Demirci Üçsular F. Predictive factors of mortality in patients with idiopathic pulmonary fibrosis treated with antifibrotics: a novel prognostic scoring system. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2024; 41:e2024021. [PMID: 38940720 PMCID: PMC11275550 DOI: 10.36141/svdld.v41i2.13779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/25/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND AND AIM Any test that provides sufficient prognostic information to guide treatment decisions in idiopathic pulmonary fibrosis (IPF) is not available. The aim of our study was to determine the predictive factors of mortality in patients with IPF treated with antifibrotics. METHODS Patients with diagnosis of IPF who were treated with antifibrotics between 2016 - 2021 were included in the study. Demographic, clinical and laboratory characteristics of the patients was derived from hospital records retrospectively. Kaplan Meier and multivariate cox regression analysis were achieved for detection of mortality predictors. RESULTS Study population was composed of 119 IPF patients with a male predominance of 80.7% (n=96). Mean age of the patients was 67.9 ± 7.07 years. On univariate analysis, sex was not a significant predictor of mortality (HR 1.79; 95% CI: 0.87 - 3.69, p =0.11). BMI ≤ 26,6 m2/kg, DLCO ≤ 3.11 ml/mmHg/min, age over 62 years, 6DWT ≤ 382 meters, NLR ≤ 2.67 and PDW ≤ 16.7% were found to be significant for predicting mortality. On multivariate cox regression analysis four parameters remained significant for prediction of mortality: RDW > 14%, NLR ≤ 2.67, BMI ≤ 26,6 m2/kg and DLCO ≤ 3.11 ml/mmHg/min (respectively, HR: 2.0. 95% CI: 1.02 - 3.91, p=0.44; HR: 2.68. 95% CI: 1.48 - 4.85, p=0.001, HR: 2.07. 95% CI: 1.14 - 3.76, p=0.02, HR: 3.46. 95% CI: 1.85 - 6.47, p<0.001). A scoring system with these parameters discriminated patients with worse prognosis with a sensitivity of 89.1 % and a specificity of 65.8 % when total point was over 2 (AUC0.83, p<0.001). Conclusions In this study, DLCO, BMI, RDW and NLR levels significantly predicted mortality in IPF patients. Along with GAP index, scoring system with these simple parameters may give information about the prognosis of an IPF patient treated with antifibrotics.
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Affiliation(s)
- Gülru Polat
- Department of Pulmonology, University of Health Sciences, Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey
| | - Özer Özdemir
- Department of Pulmonology, University of Health Sciences, Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey
| | - Sinem Ermin
- Department of Pulmonology, University of Health Sciences, Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey
| | - Damla Serçe Unat
- Department of Pulmonology, University of Health Sciences, Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey
| | - Fatma Demirci Üçsular
- Department of Pulmonology, University of Health Sciences, Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey
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Zamora AC, Wesselius LJ, Gotway MB, Tazelaar HD, Diaz-Arumir A, Nagaraja V. Diagnostic Approach to Interstitial Lung Diseases Associated with Connective Tissue Diseases. Semin Respir Crit Care Med 2024; 45:287-304. [PMID: 38631369 DOI: 10.1055/s-0044-1785674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Interstitial lung disorders are a group of respiratory diseases characterized by interstitial compartment infiltration, varying degrees of infiltration, and fibrosis, with or without small airway involvement. Although some are idiopathic (e.g., idiopathic pulmonary fibrosis, idiopathic interstitial pneumonias, and sarcoidosis), the great majority have an underlying etiology, such as systemic autoimmune rheumatic disease (SARD, also called Connective Tissue Diseases or CTD), inhalational exposure to organic matter, medications, and rarely, genetic disorders. This review focuses on diagnostic approaches in interstitial lung diseases associated with SARDs. To make an accurate diagnosis, a multidisciplinary, personalized approach is required, with input from various specialties, including pulmonary, rheumatology, radiology, and pathology, to reach a consensus. In a minority of patients, a definitive diagnosis cannot be established. Their clinical presentations and prognosis can be variable even within subsets of SARDs.
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Affiliation(s)
- Ana C Zamora
- Division of Pulmonary and Sleep Medicine, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Lewis J Wesselius
- Division of Pulmonary and Sleep Medicine, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Michael B Gotway
- Division of Cardiothoracic Radiology, Department of Radiology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Henry D Tazelaar
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Alejandro Diaz-Arumir
- Division of Pulmonary and Sleep Medicine, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Vivek Nagaraja
- Division of Rheumatology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
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Lee J, Kim K, Jo YS. Comparison of the diagnostic criteria for progressive pulmonary fibrosis in connective tissue disease related interstitial lung disease. Respir Med 2023; 212:107242. [PMID: 37031806 DOI: 10.1016/j.rmed.2023.107242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Progressive pulmonary fibrosis (PPF) is possible among patients with connective tissue disease (CTD) related interstitial lung disease (ILD). Our aim herein was to compare the prevalence and clinical characteristics of patients with CTD-ILD, with and without PPF, according to the different diagnostic criteria currently used in practice. METHODS This retrospective study included patients diagnosed with CTD-ILD, with a ≥1-year follow-up of their lung function, at a single tertiary hospital in South Korea. Diagnostic criteria from two clinical trials (RELIEF and TRAIL1) and from a recently updated guideline (ATS/ERS/JRS/ALAT) were applied. RESULTS Of the 107 patients included, 80% tested positive for Sjogren's disease, rheumatoid arthritis, and systemic sclerosis. The prevalence of CTD-ILD with PPF for the different diagnostic criteria was as follows: RELIEF, 25.2%; TRAIL1, 20.6%; and ATS/ERS/JRS/ALAT, 38.3%. A previous history of pulmonary tuberculosis and less positivity for antinuclear antibodies were identified in the PPF group. The radiologic pattern of ILD did not differ between patients with and without PPF, with a usual interstitial pneumonia pattern identified in 34.6% of the patients, independent of the diagnostic criteria used. Systemic steroids and immunomodulatory agents were used in about 80% of patients with PPF and 50% without PPF, irrespective of the diagnostic criteria used. Antifibrotic therapy was used in a limited number of patients in both groups. CONCLUSIONS The proportion of patients with CTD-ILD and PPF was higher for the ATS/ERS/JRS/ALAT guideline criteria, without a between-group difference in clinical characteristics.
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Affiliation(s)
- Jongmin Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyuhwan Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong Suk Jo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Survival of adults with rheumatoid arthritis associated interstitial lung disease - A systematic review and meta-analysis. Semin Arthritis Rheum 2023; 60:152187. [PMID: 36933302 DOI: 10.1016/j.semarthrit.2023.152187] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 01/16/2023] [Accepted: 03/02/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Rheumatoid arthritis associated interstitial lung disease (RA-ILD) is associated with high levels of morbidity and mortality. The primary aim of this systematic review was to determine the duration of survival, from time of diagnosis of RA-ILD. METHODS Medline (Ovid), Embase (OVID), CINAHL (EBSCO), PubMed, and the Cochrane Library were searched for studies that reported duration of survival from time of diagnosis of RA-ILD. Risk of bias of included studies was assessed based upon 4 domains of the Quality In Prognosis Studies tool. Results for median survival were presented by tabulation and discussed qualitatively. Meta-analysis of cumulative mortality at 1 year, >1y to ≤3 years, >3 years to ≤5 years, and >5 years to≤ 10 years was undertaken, for total RA-ILD population, and according to ILD pattern. RESULTS 78 studies were included. Median survival for the total RA-ILD population ranged from 2 to 14 years. Pooled estimates for cumulative percentage mortality up to 1 year were 9.0% (95% CI 6.1, 12.5, I2 88.9%), >1 to ≤3 years 21.4% (17.3, 25.9, I2 85.7%), >3 to ≤ 5 years 30.2% (24.8, 35.9, I2 87.7%), and > 5 to ≤ 10 years 49.1% (40.6, 57.7 I2 85.0%). Heterogeneity was high. Only 15 studies were rated as low risk of bias in all 4 domains assessed. CONCLUSION This review summarises the high mortality of RA-ILD, however the strength of conclusions that can be made is limited by the heterogeneity of the available studies, due to methodological and clinical factors. Further studies are needed to better understand the natural history of this condition.
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Ben Tekaya A, Mokaddem S, Athimini S, Kamoun H, Mahmoud I, Abdelmoula L. Risk factors for rheumatoid arthritis-associated interstitial lung disease: a retrospective study. Multidiscip Respir Med 2022; 17:877. [PMID: 36507116 PMCID: PMC9728125 DOI: 10.4081/mrm.2022.877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/04/2022] [Indexed: 11/19/2022] Open
Abstract
Background The objective of this study was to assess clinical and imaging features of rheumatoid arthritis (RA) associated with interstitial lung disease (ILD), (RA-ILD) group, in comparison to RA without ILD (RA-C) and to identify the associated factors to ILD. Methods This was a retrospective comparative study (from June 2015 to March 2022) including RA patients aged ≥18 years. The RA-C control group was matched according to age (±2 years), gender, and RA duration (±2 years). General data, RA characteristics, ILD features, and treatment modalities were recorded. Statistical analysis was performed to determine the predictive factors of ILD. Results A total of 104 patients were included (52 RA-ILD and 52 RA-C); sex ratio was 0.36. Mean age was 66.3±11 years (RA-ILD) versus 65.6±10.8 years (RA-C) (p=0.72). In comparison to RA-C, RA-ILD patients were significantly higher smokers (p=0.01) and physically inactive (p=0.01). Regarding RA features, RA-ILD patients have significantly increased positive anti-citrullinated peptide antibody (ACPA) (p=0.01), ACPA rate (p<0.001), erosive disease (p<0.001), and disease activity score (p<0.001). Mean time to ILD diagnosis was 5.85±7.16 years. Chest high-resolution computed tomography (HRCT) patterns of disease were identified: nonspecific interstitial pneumonia (NSIP) (28.8%), usual interstitial pneumonia (UIP) (17.3%), organizing pneumonia (OP) (25%), acute interstitial pneumonia (13.5%), and respiratory bronchiolitis (3.8%). Multivariate analysis identified smoking, high baseline DAS28 (disease activity score 28) and ACPA positivity as predictive factors of ILD. Conclusion Our results confirmed the reported associated factors of ILD in RA (smoking, higher disease activity, ACPA positivity). Thus, we need to target the modifiable factors by supporting and educating RA patients to quit smoking and intensify disease modifying anti-rheumatoid drugs (DMARD) to reach remission.
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Affiliation(s)
- Aicha Ben Tekaya
- Rheumatology Department, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis el Manar, Tunis,Rheumatology Department, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis el Manar, Bd du 9 Avril 1938, Tunis, Tunisia. Tel. +216.97850485.
| | - Salma Mokaddem
- Department of Physiology, Faculty of Medicine of Tunis, University of Tunis el Manar, Tunis
| | - Selma Athimini
- Rheumatology Department, Mahmoud El Matri Hospital, Ariana
| | - Hela Kamoun
- Pulmonary Department, Abderrahmanen Mami Hospital, Faculty of Medicine de Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Ines Mahmoud
- Rheumatology Department, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis el Manar, Tunis
| | - Leila Abdelmoula
- Rheumatology Department, Charles Nicolle Hospital, Faculty of Medicine of Tunis, University of Tunis el Manar, Tunis
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Interstitial Pneumonia with Autoimmune Features: Implications for Clinical Practice. CURRENT PULMONOLOGY REPORTS 2022. [DOI: 10.1007/s13665-022-00296-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Liu M, Xue M, Zhang T, Lin R, Guo B, Chen Y, Cheng ZJ, Sun B. Detection of interstitial pneumonia with autoimmune features and idiopathic pulmonary fibrosis are enhanced by involvement of matrix metalloproteinases levels and clinical diagnosis. J Clin Lab Anal 2022; 36:e24734. [PMID: 36250225 DOI: 10.1002/jcla.24734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/06/2022] [Accepted: 10/05/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Higher detection of interstitial pneumonia with autoimmune features (IPAF), and idiopathic pulmonary fibrosis (IPF), has significant diagnostic and therapeutic implications. Some matrix metalloproteinases (MMPs) have become reliable diagnostic biomarkers in IPAF and IPF in previous studies, yet relevant reliability remains to be recognized. MATERIALS AND METHODS In this study, 36 ILDs patients, including 31 IPAF patients (Mean ± SD, 50.20 ± 5.10 years; 16 [51.6%] females) and five IPF patients (Mean ± SD, 61.20 ± 6.73 years; one [20.0%] females) were retrospectively enrolled. Serial serum samples were collected from patients with IPAF and IPF between January 2019 and December 2020. Notably, Serum MMPs levels were measured by U-PLEX Biomarker Group 1(Human) Multiplex Assays (MSD, USA). RESULTS A combination of MMPs and combinatorial biomarkers was strongly associated with clinical subjects in this study (AUC, 0.597 for Stability vs. Improvement and 0.756 for Stability vs. Exacerbation). Importantly, the AUC of MMP-12 reaches 0.730 (p < 0.05, Stability AUC vs. Improvement AUC) while MMP-13 reaches 0.741 (p < 0.05, Stability AUC vs. Exacerbation AUC) showed better performance than other MMPs in two comparisons. CONCLUSIONS Clinical risk factors and MMPs are strongly associated with either stratification of the disease of progression of IPAF or in two IPAF and IPF independent cohorts. To our knowledge, this is the first to illustrate that MMP-12 and MMP-13 may be expected to become typical promising biomarkers in Improvement - IPAF and Exacerbation - IPAF, respectively.
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Affiliation(s)
- Mingtao Liu
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Mingshan Xue
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Teng Zhang
- Faculty of Health Sciences, University of Macau, Taipa, China
| | - Runpei Lin
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Baojun Guo
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | | | - Zhangkai J Cheng
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Baoqing Sun
- Department of Allergy and Clinical Immunology, Guangzhou Institute of Respiratory Health, State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Yamakawa H, Nishizawa T, Ohta H, Tsukahara Y, Nakamura T, Sato S, Kawabe R, Oba T, Akasaka K, Amano M, Kuwano K, Sasaki H, Matsushima H. Patient background and prognosis of chronic pulmonary aspergillosis in fibrosing interstitial lung disease. Medicine (Baltimore) 2022; 101:e29936. [PMID: 35960067 PMCID: PMC9371541 DOI: 10.1097/md.0000000000029936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Several previous reports have shown interstitial lung disease (ILD) to be a predictor of poor prognosis in patients with chronic pulmonary aspergillosis (CPA). However, there is a lack of clarity regarding patient background and the prognostic factors in CPA associated with ILD (CPA-ILD). Therefore, we assessed these points to obtain valuable information for clinical practice. We retrospectively surveyed and collected data from 459 patients who had serum examination for anti-Aspergillus antibody. Of these patients, we extracted and investigated CPA-ILD patients. We ultimately analyzed 32 CPA-ILD patients. Patient background factors more frequently showed the patients to be older (mean: 74.9 years), male (75.0%), and to have a smoking history (71.9%). Median survival time from the diagnosis of ILD was 76.0 months, whereas that from the diagnosis of CPA-ILD was 25.5 months. No significant differences in survival were found in regard to each ILD pattern and the presence of idiopathic pulmonary fibrosis. A higher level of C-reactive protein was a significant predictor of mortality by Cox regression analysis. CPA complicating ILD is associated with poor prognosis. ILD patients with older age, male sex, and smoking history should be aware of the potential for the development of CPA in ILD. If such patients have elevated markers of inflammation, prompt induction of antifungal treatment may improve their prognosis. Clinicians should be aware of which complications of CPA may lead to a poor prognosis for any ILD not just those limited to idiopathic pulmonary fibrosis or usual interstitial pneumonia pattern.
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Affiliation(s)
- Hideaki Yamakawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
- Department of Respiratory Medicine, Tokyo Jikei University Hospital, Tokyo, Japan
- *Correspondence: Hideaki Yamakawa, MD, PhD, Department of Respiratory Medicine, Saitama Red Cross Hospital, 1-5 Shintoshin, Chuo-ku, Saitama 330-0081, Japan (e-mail: )
| | - Tomotaka Nishizawa
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Hiroki Ohta
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Yuta Tsukahara
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Tomohiko Nakamura
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Shintaro Sato
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Rie Kawabe
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Tomohiro Oba
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Keiichi Akasaka
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Masako Amano
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Kazuyoshi Kuwano
- Department of Respiratory Medicine, Tokyo Jikei University Hospital, Tokyo, Japan
| | - Hiroki Sasaki
- Department of Radiology, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
| | - Hidekazu Matsushima
- Department of Respiratory Medicine, Saitama Red Cross Hospital, Chuo-ku, Saitama, Japan
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Human epididymis protein 4 is associated with severity and poor prognosis of connective tissue disease-associated interstitial lung disease with usual interstitial pneumonia pattern. Int Immunopharmacol 2022; 108:108704. [DOI: 10.1016/j.intimp.2022.108704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/09/2022] [Accepted: 03/12/2022] [Indexed: 12/30/2022]
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11
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Liu L, Fang C, Sun B, Bao R, Zhang H. Predictors of progression in rheumatoid arthritis-associated interstitial lung disease: A single-center retrospective study from China. Int J Rheum Dis 2022; 25:795-802. [PMID: 35633522 DOI: 10.1111/1756-185x.14351] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/01/2022] [Accepted: 05/08/2022] [Indexed: 12/17/2022]
Abstract
AIM Interstitial lung disease (ILD) is a common extra-articular manifestation of rheumatoid arthritis (RA) and is associated with high mortality, especially in progressive ILD. We aimed to identify predictors of disease progression in the early stages of ILD in a large sample of patients with RA. METHOD The medical records of 201 RA-ILD patients were retrospectively analyzed. According to changes in their pulmonary function tests, patients were divided into progressive disease and stable disease groups. Data were collected on clinical characteristics, laboratory findings, chest high-resolution computed tomography, and therapeutic agents. Univariate and multivariate analyses were performed to identify predictors of ILD progression. RESULTS During a median follow up of 38 months, 105 (52.5%) patients were diagnosed with progressive ILD. These patients were mostly male, past or present smokers (P = 0.028, P = 0.021, respectively). Higher Health Assessment Questionnaire-Disability Index score and higher Disease Activity Score in 28 joints with erythrocyte sedimentation rate (DAS28-ESR) were observed in the ILD progression group (P = 0.003, P < 0.001, respectively). There were no significant differences in baseline respiratory symptoms, pulmonary function, or laboratory features. Multivariate analysis indicated that high DAS28-ESR, definite usual interstitial pneumonia pattern, fibrosis score, and less use of cyclophosphamide were independent risk factors for RA-ILD progression. Fifteen (7.46%) patients died during the follow up, and the most frequent cause of death was lung infection. CONCLUSION Our results suggested that high disease activity, definite usual interstitial pneumonia pattern, fibrosis score, and less use of cyclophosphamide at the onset of ILD may indicate the progression of ILD in RA patients.
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Affiliation(s)
- Lei Liu
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Chunxiao Fang
- Department of Respiratory Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Bo Sun
- Department of Radiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Ruyi Bao
- Department of Radiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - Hongfeng Zhang
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
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Ge Y, Shu X, He L, Li C, Lu X, Wang G. Interstitial Lung Disease Is a Major Characteristic of Patients Who Test Positive for Anti-PM/Scl Antibody. Front Med (Lausanne) 2022; 8:778211. [PMID: 35118087 PMCID: PMC8804089 DOI: 10.3389/fmed.2021.778211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022] Open
Abstract
Objective This study aimed to analyze the clinical features of anti-PM/Scl antibodies in Chinese patients. Method We reviewed the clinical data of anti-PM/Scl antibody-positive patients, including their long-term follow-up. Results A total of 30 patients carried anti-PM/Scl antibodies, 21 (70%) were females, and the mean age was 55.4 years, 15 (50%) and 10 (33.3%) patients were positive for anti-PM/Scl-75 and anti-PM/Scl-100, respectively. Fifteen cases (50%) were diagnosed as inflammatory myopathy, namely, 11 dermatomyositis (DM) and 4 polymyositis (PM). Five (16.7%) patients were diagnosed with overlap syndrome, and only one (3.3%) was diagnosed as systemic sclerosis. The other 9 (30%) patients were classified as undifferentiated connective tissue disease. Twenty-six (86.7%) had interstitial lung disease (ILD) and was the sole manifestation in 8 (26.7%) patients, 15 (58.0%) showed non-specific interstitial pneumonia based on high-resolution CT or lung biopsy. The majority of patients (95%) with mild and moderate groups on basis of pulmonary function tests. Compared to the anti-PM/Scl-100 group, the occurrence of clinical characteristics was not significantly different from the anti-PM/Scl-75 group, except the levels of C-reactive protein and erythrocyte sedimentation rate in the anti-PM/Scl-75 antibody-positive group were higher (p < 0.05). All patients with positive Ro-52 antibodies had ILD and were more likely to develop skin rash in the group with Ro-52 (p = 0.024). With a follow-up of the present cohort, 70.8% improved with treatment, but 16.7% of patients are easy to relapse. Conclusion The anti-PM/Scl antibody occurred frequently in DM/PM patients, ILD was the major clinical feature, especially in patients combined with Ro-52. Some patients may complicate with ILD alone without extrapulmonary manifestations. Anti-PM/Scl antibodies positive patients were responsive to treatment.
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13
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Bourne MH, Kottom TJ, Hebrink DM, Choudhury M, Leof EB, Limper AH. Vardenafil Activity in Lung Fibrosis and In Vitro Synergy with Nintedanib. Cells 2021; 10:3502. [PMID: 34944010 PMCID: PMC8699915 DOI: 10.3390/cells10123502] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/22/2021] [Accepted: 12/03/2021] [Indexed: 12/22/2022] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) remains an intractably fatal disorder, despite the recent advent of anti-fibrotic medication. Successful treatment of IPF, like many chronic diseases, may benefit from the concurrent use of multiple agents that exhibit synergistic benefit. In this light, phosphodiesterase type 5 inhibitors (PDE5-Is), have been studied in IPF primarily for their established pulmonary vascular effects. However, recent data suggest certain PDE5-Is, particularly vardenafil, may also reduce transforming growth factor beta 1 (TGF-β1) activation and extracellular matrix (ECM) accumulation, making them a potential target for therapy for IPF. We evaluated fibroblast TGF-β1-driven extracellular matrix (ECM) generation and signaling as well as epithelial mesenchymal transformation (EMT) with pretreatment using the PDE5-I vardenafil. In addition, combinations of vardenafil and nintedanib were evaluated for synergistic suppression of EMC using a fibronectin enzyme-linked immunosorbent assay (ELISA). Finally, the effects of vardenafil on fibrosis were investigated in a bleomycin mouse model. Our findings demonstrate that vardenafil suppresses ECM generation alone and also exhibits significant synergistic suppression of ECM in combination with nintedanib in vitro. Interestingly, vardenafil was shown to improve fibrosis markers and increase survival in bleomycin-treated mice. Vardenafil may represent a potential treatment for IPF alone or in combination with nintedanib. However, additional studies will be required.
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Affiliation(s)
| | | | | | | | | | - Andrew H. Limper
- Thoracic Diseases Research Unit, Departments of Medicine and Biochemistry, 8-24 Stabile, Mayo Clinic, Rochester, MN 55905, USA; (M.H.B.J.); (T.J.K.); (D.M.H.); (M.C.); (E.B.L.)
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14
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Chen X, Guo J, Yu D, Jie B, Zhou Y. Predictors of Mortality in Progressive Fibrosing Interstitial Lung Diseases. Front Pharmacol 2021; 12:754851. [PMID: 34712141 PMCID: PMC8546258 DOI: 10.3389/fphar.2021.754851] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/29/2021] [Indexed: 02/04/2023] Open
Abstract
Background: Progressive fibrosing interstitial lung disease (PF-ILD) and idiopathic pulmonary fibrosis (IPF) share similar progression phenotype but with different pathophysiological mechanism. The purpose of this study was to assess clinical characteristics and outcomes of patients with PF-ILD in a single-center cohort. Methods: Patients with PF-ILD treated in Shanghai Pulmonary Hospital from Jan. 2013 to Dec. 2014 were retrospectively analyzed. Baseline characteristics and clinical outcomes were collected for survival analysis to identifying clinical predictors of mortality. Results: Among 608 patients with ILD, 132 patients met the diagnostic criteria for PF-ILD. In this single-center cohort, there were 51 (38.6%) cases with connective tissue disease-associated interstitial lung disease (CTD-ILD) and 45 (34.1%) with unclassifiable ILDs. During follow-up, 83 patients (62.9%) either died (N = 79, 59.8%) or underwent lung transplantations (N = 4, 3.0%) with a median duration follow-up time of 53.7 months. Kaplan-Meier survival curves revealed that the 1, 3 and 5-years survival of PF-ILD were 90.9, 58.8 and 48.1%, respectively. In addition, the prognosis of patients with PF-ILD was similar to those with IPF, while it was worse than non-PF-ILD ones. Multivariate Cox regression analysis demonstrated that high-resolution computed tomography (HRCT) scores (HR 1.684, 95% CI 1.017-2.788, p = 0.043) and systolic pulmonary artery pressure (SPAP) > 36.5 mmHg (HR 3.619, 95%CI 1.170-11.194, p = 0.026) were independent risk factors for the mortality of PF-ILD. Conclusion: Extent of fibrotic changes on HRCT and pulmonary hypertension were predictors of mortality in patients with PF-ILD.
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Affiliation(s)
- Xianqiu Chen
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jian Guo
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Dong Yu
- Department of Radiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Bing Jie
- Department of Radiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ying Zhou
- Department of Respiratory Medicine and Clinical Research Center, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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15
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Popper H, Stacher-Priehse E, Brcic L, Nerlich A. Lung fibrosis in autoimmune diseases and hypersensitivity: how to separate these from idiopathic pulmonary fibrosis. Rheumatol Int 2021; 42:1321-1330. [PMID: 34605934 PMCID: PMC9287245 DOI: 10.1007/s00296-021-05002-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/15/2021] [Indexed: 11/29/2022]
Abstract
Lung involvement in autoimmune diseases (AID) is uncommon, but may precede other organ manifestations. A diagnostic problem is chronicity presenting with lung fibrosis. A new category of interstitial pneumonia with autoimmune features for patients with clinical symptoms of AID and presenting with usual interstitial pneumonia (UIP) enables antifibrotic treatment for these patients. Hypersensitivity pneumonia (HP) and other forms of lung fibrosis were not included into this category. As these diseases based on adverse immune reactions often present with unspecific clinical symptoms, a specified pathological diagnosis will assist the clinical evaluation. We aimed to establish etiology-relevant differences of patterns associated with AID or HP combined with lung fibrosis. We retrospectively evaluated 51 cases of AID, and 29 cases of HP with lung fibrosis, and compared these to 24 cases of idiopathic pulmonary fibrosis (UIP/IPF). Subacute AID and HP most often presented with organizing pneumonia (OP), whereas chronicity was associated with UIP. Unspecified fibrosis was seen in a few cases, whereas NSIP pattern was rare. In 9 cases, the underlying etiology could not be defined. Statistically significant features differentiating chronic AID or HP from UIP/IPF are lymphocytic infiltrations into myofibroblastic/fibroblastic foci. Other features significantly associated with AID and HP were granulomas, isolated Langhans giant cells, and protein deposits, but seen in only a minority of cases. A combination of UIP with one of these features enabled a specific etiology-based diagnosis. Besides the antifibrotic drug regimen, additional therapies might be considered.
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Affiliation(s)
- Helmut Popper
- Medical University Graz, Diagnostic and Research Institute of Pathology, Neue Stiftingtalstr. 6, 8036, Graz, Austria.
| | | | - Luka Brcic
- Medical University Graz, Diagnostic and Research Institute of Pathology, Neue Stiftingtalstr. 6, 8036, Graz, Austria
| | - Andreas Nerlich
- Department of Pathology, Teaching Hospital Munich-Bogenhausen, Munich, Germany
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16
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Buschulte K, Hoffmann-Vold AM, Dobrota RD, Höger P, Krause A, Kreuter M. [Treatment of lung fibrosis in systemic rheumatic diseases (new treatment)]. Z Rheumatol 2021; 80:743-754. [PMID: 34505934 PMCID: PMC8429885 DOI: 10.1007/s00393-021-01067-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 11/25/2022]
Abstract
An interstitial lung disease represents a relevant organ manifestation in many systemic rheumatic diseases (connective tissue disease-interstitial lung disease, CTD-ILD). In 10% of the cases pulmonary fibrosis even results in an underlying systemic disease. The CTD-ILDs are frequently associated with a poor prognosis. Therefore, it is important to test patients with systemic rheumatic diseases timely and regularly for the presence of an ILD. Treatment decisions should be made together with pneumologists and rheumatologists, particularly with respect to the initiation of a specific treatment. Treatment is based on randomized studies only in a few cases and can mostly be derived from case control studies. For systemic sclerosis-associated ILD (SSc-ILD) antifibrotic treatment with nintedanib has also now been approved in addition to an immunosuppressive treatment. For other CTD-ILDs an antifibrotic treatment should be discussed in an interdisciplinary approach depending on the underlying disease corresponding to a progressively fibrosing ILD.
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Affiliation(s)
- Katharina Buschulte
- Zentrum für seltene und interstitielle Lungenerkrankungen, Pneumologie, Thoraxklinik, Universitätsklinikum Heidelberg und Deutsches Zentrum für Lungenforschung (DZL), Röntgenstr. 1, 69126, Heidelberg, Deutschland
| | | | | | - Philipp Höger
- Zentrum für seltene und interstitielle Lungenerkrankungen, Pneumologie, Thoraxklinik, Universitätsklinikum Heidelberg und Deutsches Zentrum für Lungenforschung (DZL), Röntgenstr. 1, 69126, Heidelberg, Deutschland
| | - Andreas Krause
- Abteilung für Rheumatologie, Klinische Immunologie und Osteologie, Immanuel Krankenhaus Berlin, Berlin, Deutschland
| | - Michael Kreuter
- Zentrum für seltene und interstitielle Lungenerkrankungen, Pneumologie, Thoraxklinik, Universitätsklinikum Heidelberg und Deutsches Zentrum für Lungenforschung (DZL), Röntgenstr. 1, 69126, Heidelberg, Deutschland.
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17
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Mena-Vázquez N, Rojas-Gimenez M, Romero-Barco CM, Manrique-Arija S, Hidalgo Conde A, Arnedo Díez de los Ríos R, Cabrera César E, Ortega-Castro R, Espildora F, Aguilar-Hurtado MC, Añón-Oñate I, Pérez-Albaladejo L, Abarca-Costalago M, Ureña-Garnica I, Velloso-Feijoo ML, Redondo-Rodriguez R, Fernández-Nebro A. Characteristics and Predictors of Progression Interstitial Lung Disease in Rheumatoid Arthritis Compared with Other Autoimmune Disease: A Retrospective Cohort Study. Diagnostics (Basel) 2021; 11:diagnostics11101794. [PMID: 34679492 PMCID: PMC8534825 DOI: 10.3390/diagnostics11101794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/14/2021] [Accepted: 09/27/2021] [Indexed: 12/22/2022] Open
Abstract
Objectives: To describe the characteristics and progression of interstitial lung disease in patients with associated systemic autoimmune disease (ILD-SAI) and to identify factors associated with progression and mortality. Patients and methods: We performed a multicenter, retrospective, observational study of patients with ILD-SAI followed between 2015 and 2020. We collected clinical data and performed pulmonary function testing and high-resolution computed tomography at diagnosis and at the final visit. The main outcome measure at the end of follow-up was forced vital capacity (FVC) >10% or diffusing capacity of the lungs for carbon monoxide >15% and radiological progression or death. Cox regression analysis was performed to identify factors associated with worsening of ILD. Results: We included 204 patients with ILD-SAI: 123 (60.3%) had rheumatoid arthritis (RA), 58 had (28.4%) systemic sclerosis, and 23 (11.3%) had inflammatory myopathy. After a median (IQR) period of 56 (29.8–93.3) months, lung disease had stabilized in 98 patients (48%), improved in 33 (16.1%), and worsened in 44 (21.5%). A total of 29 patients (14.2%) died. Progression and hospitalization were more frequent in patients with RA (p = 0.010). The multivariate analysis showed the independent predictors for worsening of ILD-SAI to be RA (HR, 1.9 [95% CI, 1.3–2.7]), usual interstitial pneumonia pattern (HR, 1.7 [95% CI, 1.0–2.9]), FVC (%) (HR, 2.3 [95% CI, 1.4–3.9]), and smoking (HR, 2.7 [95%CI, 1.6–4.7]). Conclusion: Disease stabilizes or improves after a median of 5 years in more than half of patients with ILD-SAI, although more than one-third die. Data on subgroups and risk factors could help us to predict poorer outcomes.
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Affiliation(s)
- Natalia Mena-Vázquez
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (C.M.R.-B.); (S.M.-A.); (I.U.-G.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
- Correspondence: ; Tel.: +34-952290360
| | - Marta Rojas-Gimenez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Córdoba, Spain; (M.R.-G.); (R.O.-C.)
- UGC de Reumatología, Hospital Universitario Reina Sofía de Córdoba, 14004 Córdoba, Spain
| | - Carmen María Romero-Barco
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (C.M.R.-B.); (S.M.-A.); (I.U.-G.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Clínico Universitario Virgen de la Victoria, 29010 Málaga, Spain
| | - Sara Manrique-Arija
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (C.M.R.-B.); (S.M.-A.); (I.U.-G.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
| | - Ana Hidalgo Conde
- Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain; (A.H.C.); (R.A.D.d.l.R.); (M.A.-C.)
| | - Rocío Arnedo Díez de los Ríos
- Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain; (A.H.C.); (R.A.D.d.l.R.); (M.A.-C.)
| | - Eva Cabrera César
- UGC Neumología, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain;
| | - Rafaela Ortega-Castro
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Córdoba, Spain; (M.R.-G.); (R.O.-C.)
- UGC de Reumatología, Hospital Universitario Reina Sofía de Córdoba, 14004 Córdoba, Spain
| | - Francisco Espildora
- UGC de Neumología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain;
| | | | | | | | - Manuel Abarca-Costalago
- Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain; (A.H.C.); (R.A.D.d.l.R.); (M.A.-C.)
| | - Inmaculada Ureña-Garnica
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (C.M.R.-B.); (S.M.-A.); (I.U.-G.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
| | | | - Rocio Redondo-Rodriguez
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (C.M.R.-B.); (S.M.-A.); (I.U.-G.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
| | - Antonio Fernández-Nebro
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain; (C.M.R.-B.); (S.M.-A.); (I.U.-G.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
- Departamento de Medicina, Universidad de Málaga, 29010 Málaga, Spain
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Chung JH, Montner SM, Thirkateh P, Cannon B, Barnett SD, Nathan SD. Computed Tomography Findings Suggestive of Connective Tissue Disease in the Setting of Usual Interstitial Pneumonia. J Comput Assist Tomogr 2021; 45:776-781. [PMID: 34546682 DOI: 10.1097/rct.0000000000001230] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE A usual interstitial pneumonia (UIP) pattern is common in idiopathic pulmonary fibrosis (IPF) and connective tissue disease-related interstitial lung disease (CTD-ILD). The purpose of the study was to validate imaging findings differentiating CTD-ILD from IPF in UIP. METHODS Patients with a multidisciplinary diagnosis of CTD-ILD or IPF and a UIP pattern on computed tomography and/or pathology were included in this study. Prevalence of 3 computed tomography findings shown to be associated with CTD-ILD (the straight edge sign [SES], the exuberant honeycombing sign, and the anterior upper lobe sign [AULS]) were tabulated in CTD-ILD and IPF subjects. The ability of each of these signs to discriminate between CTD-ILD and IPF was evaluated. Survival analysis was also performed using log-rank analysis. RESULTS The study cohort included 50 CTD-ILD and 100 IPF subjects with UIP. The SES and the AULS were more common in CTD-ILD than IPF (prevalence, 36.0% and 34.9% in CTD-ILD vs 8.3% and 17.2% in IPF, respectively [P = 0.0105 - <0.001]). The highest specificity (95.7%) of CTD-ILD diagnosis was seen with bilateral SES. Moreover, the SES was associated with improved survival (P = 0.0383), which appeared to be largely because of improvement in survival in IPF subjects. The presence of AULS was associated with pulmonary functional abnormalities. CONCLUSIONS A radiographic UIP pattern with evidence of SES or the AULS should raise suspicion for CTD-ILD rather than IPF. Patients with IPF and SES have an attenuated disease course and might represent a different phenotype than those without the SES.
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Affiliation(s)
- Jonathan H Chung
- From the Department of Radiology, The University of Chicago Medical Center, Chicago, IL
| | - Steven M Montner
- From the Department of Radiology, The University of Chicago Medical Center, Chicago, IL
| | - Prahasit Thirkateh
- From the Department of Radiology, The University of Chicago Medical Center, Chicago, IL
| | | | | | - Steven D Nathan
- Lung Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Falls Church, VA
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Decision-Making Strategy for the Treatment of Rheumatoid Arthritis-Associated Interstitial Lung Disease (RA-ILD). J Clin Med 2021; 10:jcm10173806. [PMID: 34501253 PMCID: PMC8432201 DOI: 10.3390/jcm10173806] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023] Open
Abstract
Rheumatoid arthritis (RA) is a common type of autoimmune arthritis. Patient clinical outcomes might be influenced by numerous respiratory diseases, but interstitial lung disease (ILD) is the most important comorbidity. RA-associated ILD (RA-ILD) is divided into acute/subacute and chronic forms. In the acute/subacute course, if the disease is severe as indicated by a diffuse alveolar damage pattern, high-dose corticosteroids combined with antimicrobial agents should be promptly initiated while considering the differential diagnoses, primarily acute exacerbation (AE) of RA-ILD, drug-induced pneumonitis, and Pneumocystis pneumonia. As initial therapeutic management in the chronic course, the RA itself should be stabilized without delay; thereafter, the activity of ILD itself can be stabilized, considering the safety of each anti-rheumatic drug. The formation of the usual interstitial pneumonia (UIP) pattern is the most important determinant because lung function can worsen more quickly with this pattern. However, because clinicians can fail to identify specific radiological patterns, it is important to determine whether each patient with RA-ILD has UIP-like lesions such as subpleural reticulation, traction bronchiectasis, and honeycombing especially progressively enlarged cysts. In patients with progressive RA-ILD and high risk for infection or AE of ILD in whom fibrosis is dominant, clinicians should consider starting an anti-fibrotic agent.
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20
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Mummy DG, Bier EA, Wang Z, Korzekwinski J, Morrison L, Barkauskas C, McAdams HP, Tighe RM, Driehuys B, Mammarappallil JG. Hyperpolarized 129Xe MRI and Spectroscopy of Gas-Exchange Abnormalities in Nonspecific Interstitial Pneumonia. Radiology 2021; 301:211-220. [PMID: 34313473 DOI: 10.1148/radiol.2021204149] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Recent studies demonstrate that antifibrotic drugs previously reserved for idiopathic pulmonary fibrosis (IPF) may slow progression in other interstitial lung diseases (ILDs), creating an urgent need for tools that can sensitively assess disease activity, progression, and therapy response across ILDs. Hyperpolarized xenon 129 (129Xe) MRI and spectroscopy have provided noninvasive measurements of regional gas-exchange abnormalities in IPF. Purpose To assess gas exchange function using 129Xe MRI in a group of study participants with nonspecific interstitial pneumonia (NSIP) compared with healthy control participants. Materials and Methods In this prospective study, participants with NSIP and healthy control participants were enrolled between November 2017 and February 2020 and underwent 129Xe MRI and spectroscopy. Quantitative imaging provided three-dimensional maps of ventilation, interstitial barrier uptake, and transfer into the red blood cell (RBC) compartment. Spectroscopy provided parameters of the static RBC and barrier uptake compartments, as well as cardiogenic oscillations in RBC signal amplitude and chemical shift. Differences between NSIP and healthy control participants were assessed using the Wilcoxon rank-sum test. Results Thirty-six participants with NSIP (mean age, 57 years ± 11 [standard deviation]; 27 women) and 15 healthy control participants (mean age, 39 years ± 18; two women) were evaluated. Participants with NSIP had no difference in ventilation compared with healthy control participants (median, 4.4% [first quartile, 1.5%; third quartile, 8.7%] vs 6.0% [first quartile, 2.8%; third quartile, 6.9%]; P = .91), but they had a higher barrier uptake (median, 6.2% [first quartile, 1.8%; third quartile, 23.9%] vs 0.53% [first quartile, 0.33%; third quartile, 2.9%]; P = .003) and an increased RBC transfer defect (median, 20.6% [first quartile, 11.6%; third quartile, 27.8%] vs 2.8% [first quartile, 2.3%; third quartile, 4.9%]; P < .001). NSIP participants also had a reduced ratio of RBC-to-barrier peaks (median, 0.24 [first quartile, 0.19; third quartile, 0.31] vs 0.57 [first quartile, 0.52; third quartile, 0.67]; P < .001) and a reduced RBC chemical shift (median, 217.5 ppm [first quartile, 217.0 ppm; third quartile, 218.0 ppm] vs 218.2 ppm [first quartile, 217.9 ppm; third quartile, 218.6 ppm]; P = .001). Conclusion Participants with nonspecific interstitial pneumonia had increased barrier uptake and decreased red blood cell (RBC) transfer compared with healthy controls measured using xenon 129 gas-exchange MRI and reduced RBC-to-barrier ratio and RBC chemical shift measured using spectroscopy. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Wild in this issue.
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Affiliation(s)
- David G Mummy
- From the Department of Radiology (D.G.M., J.K., B.D., J.G.M.), Center for In Vivo Microscopy (D.G.M., B.D.), Department of Biomedical Engineering (E.A.B., Z.W., B.D.), Department of Medicine (L.M., C.B., H.P.M., R.T.), and Department of Medical Physics (B.D.), Duke University, DUMC Box 3302, Durham, NC 27710
| | - Elianna A Bier
- From the Department of Radiology (D.G.M., J.K., B.D., J.G.M.), Center for In Vivo Microscopy (D.G.M., B.D.), Department of Biomedical Engineering (E.A.B., Z.W., B.D.), Department of Medicine (L.M., C.B., H.P.M., R.T.), and Department of Medical Physics (B.D.), Duke University, DUMC Box 3302, Durham, NC 27710
| | - Ziyi Wang
- From the Department of Radiology (D.G.M., J.K., B.D., J.G.M.), Center for In Vivo Microscopy (D.G.M., B.D.), Department of Biomedical Engineering (E.A.B., Z.W., B.D.), Department of Medicine (L.M., C.B., H.P.M., R.T.), and Department of Medical Physics (B.D.), Duke University, DUMC Box 3302, Durham, NC 27710
| | - Jennifer Korzekwinski
- From the Department of Radiology (D.G.M., J.K., B.D., J.G.M.), Center for In Vivo Microscopy (D.G.M., B.D.), Department of Biomedical Engineering (E.A.B., Z.W., B.D.), Department of Medicine (L.M., C.B., H.P.M., R.T.), and Department of Medical Physics (B.D.), Duke University, DUMC Box 3302, Durham, NC 27710
| | - Lake Morrison
- From the Department of Radiology (D.G.M., J.K., B.D., J.G.M.), Center for In Vivo Microscopy (D.G.M., B.D.), Department of Biomedical Engineering (E.A.B., Z.W., B.D.), Department of Medicine (L.M., C.B., H.P.M., R.T.), and Department of Medical Physics (B.D.), Duke University, DUMC Box 3302, Durham, NC 27710
| | - Christina Barkauskas
- From the Department of Radiology (D.G.M., J.K., B.D., J.G.M.), Center for In Vivo Microscopy (D.G.M., B.D.), Department of Biomedical Engineering (E.A.B., Z.W., B.D.), Department of Medicine (L.M., C.B., H.P.M., R.T.), and Department of Medical Physics (B.D.), Duke University, DUMC Box 3302, Durham, NC 27710
| | - H Page McAdams
- From the Department of Radiology (D.G.M., J.K., B.D., J.G.M.), Center for In Vivo Microscopy (D.G.M., B.D.), Department of Biomedical Engineering (E.A.B., Z.W., B.D.), Department of Medicine (L.M., C.B., H.P.M., R.T.), and Department of Medical Physics (B.D.), Duke University, DUMC Box 3302, Durham, NC 27710
| | - Robert M Tighe
- From the Department of Radiology (D.G.M., J.K., B.D., J.G.M.), Center for In Vivo Microscopy (D.G.M., B.D.), Department of Biomedical Engineering (E.A.B., Z.W., B.D.), Department of Medicine (L.M., C.B., H.P.M., R.T.), and Department of Medical Physics (B.D.), Duke University, DUMC Box 3302, Durham, NC 27710
| | - Bastiaan Driehuys
- From the Department of Radiology (D.G.M., J.K., B.D., J.G.M.), Center for In Vivo Microscopy (D.G.M., B.D.), Department of Biomedical Engineering (E.A.B., Z.W., B.D.), Department of Medicine (L.M., C.B., H.P.M., R.T.), and Department of Medical Physics (B.D.), Duke University, DUMC Box 3302, Durham, NC 27710
| | - Joseph G Mammarappallil
- From the Department of Radiology (D.G.M., J.K., B.D., J.G.M.), Center for In Vivo Microscopy (D.G.M., B.D.), Department of Biomedical Engineering (E.A.B., Z.W., B.D.), Department of Medicine (L.M., C.B., H.P.M., R.T.), and Department of Medical Physics (B.D.), Duke University, DUMC Box 3302, Durham, NC 27710
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21
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Konopka KE, Myers JL. Interstitial lung disease pathology in systemic sclerosis. Ther Adv Musculoskelet Dis 2021; 13:1759720X211032437. [PMID: 34349846 PMCID: PMC8287363 DOI: 10.1177/1759720x211032437] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/25/2021] [Indexed: 12/11/2022] Open
Abstract
Interstitial lung disease is a relatively frequent manifestation of systemic
sclerosis with approximately one-third of patients developing clinical
restrictive lung disease. Fibrotic nonspecific interstitial pneumonia is the
most common cause of diffuse parenchymal lung disease in patients with systemic
sclerosis-associated interstitial lung disease (SSc-ILD), followed by usual
interstitial pneumonia (UIP). Radiographic pleuroparenchymal fibroelastosis-like
changes may accompany other forms of interstitial lung disease, most commonly
UIP. In an appropriate clinical setting with supportive high-resolution computed
tomography findings, lung biopsy is not needed to confirm the presence of
interstitial lung disease and surgical lung biopsies are often reserved for
atypical presentations. In this review, we discuss the histological findings
that define the most common patterns of SSc-ILD and outline other findings
sometimes encountered in lung biopsies obtained from systemic sclerosis
patients, including pulmonary vascular changes, aspiration, chronic pleuritis,
and diffuse alveolar damage.
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Affiliation(s)
- Kristine E Konopka
- Department of Pathology, University of Michigan, Michigan Medicine, 2800 Plymouth Road, Building 35, Ann Arbor, MI 48109, USA
| | - Jeffrey L Myers
- Department of Pathology, University of Michigan, Ann Arbor, MI, USA
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Abstract
PURPOSE OF REVIEW The progressive fibrotic phenotype (PFP), a term that covers large sub-groups of patients with fibrotic lung diseases that clinically progress despite appropriate usual management, is now an everyday problem for patients and clinicians alike. This review covers recent data that are relevant to major clinical uncertainties. RECENT FINDINGS The clinical relevance of the PFP is covered by a brief review of data from which this entity was constructed. Estimates of the prevalence of the PFP are cited. The importance of an accurate initial diagnosis is emphasized - with refutation of the belief that diagnosis now matters less because of recent antifibrotic trial data. Pivotal trials are reviewed briefly with emphasis on the range of diseases studied and the efficacy signals. Included in this section are analyses of treatment effects in individual diseases and data that validate the progression criteria that define the PFP. SUMMARY Clinicians can now implement the findings from recent antifibrotic trials in non-idiopathic pulmonary fibrosis lung diseases. However, the appropriate application of recent data requires an understanding of the critical importance of initial diagnosis, key measures of disease progression and knowledge of the strengths and weaknesses of trial data. Important clinical uncertainties not informed by current data include the evaluation of the adequacy of traditional management (before antifibrotic therapy is introduced) and agreement on the exact definition of disease progression that should trigger consideration of antifibrotic therapy.
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Differentiation of Idiopathic Pulmonary Fibrosis from Connective Tissue Disease-Related Interstitial Lung Disease Using Quantitative Imaging. J Clin Med 2021; 10:jcm10122663. [PMID: 34204184 PMCID: PMC8233999 DOI: 10.3390/jcm10122663] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/04/2021] [Accepted: 06/04/2021] [Indexed: 11/29/2022] Open
Abstract
A usual interstitial pneumonia (UIP) imaging pattern can be seen in both idiopathic pulmonary fibrosis (IPF) and connective tissue disease-related interstitial lung disease (CTD-ILD). The purpose of this multicenter study was to assess whether quantitative imaging data differ between IPF and CTD-ILD in the setting of UIP. Patients evaluated at two medical centers with CTD-ILD or IPF and a UIP pattern on CT or pathology served as derivation and validation cohorts. Chest CT data were quantitatively analyzed including total volumes of honeycombing, reticulation, ground-glass opacity, normal lung, and vessel related structures (VRS). VRS was compared with forced vital capacity percent predicted (FVC%) and percent predicted diffusing capacity of the lungs for carbon monoxide (DLCO%). There were 296 subjects in total, with 40 CTD-ILD and 85 IPF subjects in the derivation cohort, and 62 CTD-ILD and 109 IPF subjects in the validation cohort. VRS was greater in IPF across the cohorts on univariate (p < 0.001) and multivariable (p < 0.001–0.047) analyses. VRS was inversely correlated with DLCO% in both cohorts on univariate (p < 0.001) and in the derivation cohort on multivariable analysis (p = 0.003) but not FVC%. Total volume of normal lung was associated with DLCO% (p < 0.001) and FVC% (p < 0.001–0.009) on multivariable analysis in both cohorts. VRS appears to have promise in differentiating CTD-ILD from IPF. The underlying pathophysiological relationship between VRS and ILD is complex and is likely not explained solely by lung fibrosis.
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24
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Zheng Y, Lou Y, Zhu F, Wang X, Wu W, Wu X. Utility of fractional exhaled nitric oxide in interstitial lung disease. J Breath Res 2021; 15. [PMID: 34128832 DOI: 10.1088/1752-7163/ac01c1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 05/14/2021] [Indexed: 11/11/2022]
Abstract
The majority of interstitial lung diseases (ILDs) develop rapidly and are associated with a poor prognosis. Therefore, new noninvasive markers are needed to guide the classification and prognostication of ILD. We enrolled 95 patients with ILD, including dermatomyositis-associated ILD (n =69), Sjögren's syndrome-associated ILD (n= 7), mixed connective tissue disease-associated ILD (n= 9), idiopathic pulmonary fibrosis (n= 5) and hypersensitivity pneumonitis (n= 5), 82 patients with connective tissue disease but without ILD as well as 24 healthy controls, then evaluated fractional exhaled nitric oxide (FeNO50; 50 ml s-1) (Bisenkovet al2006Vestn. Khir. Im. I. I. Grek.1659-14), pulmonary function and high-resolution computed tomography (HRCT) scores. Blood samples were analyzed and bronchoalveolar lavage fluid parameters were measured. There was no significant difference in FeNO50 values between different subgroups of ILD patients or between different subgroups of ILD patients and healthy controls. However, we found that FeNO50 was negatively correlated with the HRCT score and positively correlated with forced vital capacity. FeNO50 values did not play a clinical role in the diagnosis, differential diagnosis or prognostication of ILD.
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Affiliation(s)
- Yu Zheng
- Department of Pulmonology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Yueyan Lou
- Department of Pulmonology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Feng Zhu
- Department of Pulmonology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Xiaodong Wang
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Wanlong Wu
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Xueling Wu
- Department of Pulmonology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
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25
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Castelino FV, Moua T. Detection and Management of Interstitial Lung Diseases Associated With Connective Tissue Diseases. ACR Open Rheumatol 2021; 3:295-304. [PMID: 33779080 PMCID: PMC8126753 DOI: 10.1002/acr2.11253] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/26/2021] [Indexed: 01/08/2023] Open
Abstract
Interstitial lung disease (ILD) is a common manifestation of connective tissue diseases (CTDs). A proportion of patients with CTD-ILDs develop progressive fibrosing ILD, which is characterized by worsening fibrotic abnormalities on high-resolution computed tomography scan, decline in lung function, worsening symptoms, and early mortality. Here, we review the impact of ILD in patients with CTDs, the importance of prompt diagnosis and close monitoring, and the evidence available to guide the management of CTD-ILDs. Management of patients with CTD-ILDs should be individualized and involve close collaboration between rheumatologists and pulmonologists. Immunosuppression is the mainstay of therapy for CTDs, but evidence for its effectiveness in slowing the progression of ILD is limited. Recently, nintedanib has been approved to slow decline in lung function in patients with systemic sclerosis-associated ILD and chronic fibrosing ILDs with a progressive phenotype. The results of ongoing clinical trials will help clinicians take a more evidence-based approach to the treatment of CTD-ILDs.
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26
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Risk of progression of idiopathic pulmonary fibrosis to connective tissue disease: a long-term observational study in 527 patients. Clin Rheumatol 2021; 40:2447-2456. [PMID: 33754221 DOI: 10.1007/s10067-021-05659-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Connective tissue disease (CTD) might occur during the course of idiopathic pulmonary fibrosis (IPF). Clinical factors associated with CTD development in IPF patients have still not been identified. We investigated which antibodies have a significant association with the development of CTD during the clinical course of IPF. METHODS We retrospectively reviewed the records of 527 patients with a first diagnosis of IPF between January 2007 and March 2014 and investigated the time to CTD development after IPF diagnosis in these patients. RESULTS CTD developed in 15 patients at a median of 2.1 years (range 1.2-4.8) after IPF diagnosis. All patients had anti-neutrophil cytoplasmic antibodies (ANCA) or autoantibodies that met the serology criteria for interstitial pneumonia with autoimmune features (IPAF). Survival duration for IPF patients with progression to CTD was 5.3 (3.8, 6.7) years, which was significantly longer than for IPF patients without progression to CTD [2.9 (1.7, 4.8), p = 0.001]. Independent risk factors for CTD development in IPF patients included female gender [adjusted hazard ratio (HR) 5.319, p = 0.0082], titer of rheumatoid factor (RF; adjusted HR, 1.006; p = 0.022), titer of anti-citrullinated protein antibody (ACPA; adjusted HR, 1.009; p = 0.0011), and titer of myeloperoxidase (MPO)-ANCA (adjusted HR, 1.02; p < 0.0001). CONCLUSION Progression to CTD is uncommon in IPF patients. However, a significant number of IPF patients with high titers of RF, ACPA, or MPO-ANCA progressed to CTD. RF, ACPA, and MPO-ANCA might be significantly associated with CTD development in IPF patients. Key Points • A significant number of IPF patients with high titers of RF, ACPA, or MPO-ANCA progressed to CTD. • IPF/UIP with high titers of RF, ACPA, or MPO-ANCA might be the initial clinical manifestation of CTD. • RF, ACPA, and MPO-ANCA may be significantly associated with the development of pulmonary fibrosis in patients with CTD.
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27
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Kreuter M, Müller-Ladner U, Costabel U, Jonigk D, Peter Heussel C. The Diagnosis and Treatment of Pulmonary Fibrosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0018. [PMID: 33531115 PMCID: PMC8212400 DOI: 10.3238/arztebl.m2021.0018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 10/14/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The different types of pulmonary fibrosis are a subgroup of the interstitial lung diseases (ILDs). They are associated with a chronic and often progressive course. METHODS This review is based on pertinent publications retrieved by a selective search in the EMBASE and PubMed databases, with an emphasis on articles published from 2000 to 2020. RESULTS The most common type of pulmonary fibrosis is idiopathic pulmonary fibrosis (IPF). Among other relevant types, the most important ones are fibrosing hypersensitivity pneumonitis (fHP) and ILDs associated with systemic diseases, all of which are rare and generally carry a poor prognosis. The essential prerequisite to accurate diagnosis is aninterdisciplinary approach, taking account of the clinical, histological, and radiological aspects. The main complications of pulmonary fibrosis are acute exacerbations and pulmonary hypertension; comorbidities are also of prognostic relevance. Treatment of pulmonary fibrosis depends on the subtype and clinical behavior. For IPF, antifibrotic therapy is indicated; fHP, on the other hand, is mainly treated by antigen avoidance and immune modulation. The predominant mode of treatment for systemic disease-associated pulmonary fibrosis is immune suppression. Antifibrotic agents can also be useful in the treatment of other types of progressivepulmonary fibrosis besides IPF. CONCLUSION The differential diagnosis of pulmonary fibrosis, though complex, is clinically essential, as different types of pulmonary fibrosis are treated differently.
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Affiliation(s)
- Michael Kreuter
- Center for Interstitial and Rare Lung Diseases, Pneumology and Respiratory Critical Care Medicine, Thoraxklinik at Heidelberg University Hospital
- German Center for Lung Research (DZL)
| | - Ulf Müller-Ladner
- Department of Internal Medicine and Rheumatology, Campus Kerckhoff, Justus-Liebig-University Giessen, Bad Nauheim
| | - Ulrich Costabel
- Department of Pneumology, Ruhrlandklinik, University Medical Center Essen
| | - Danny Jonigk
- German Center for Lung Research (DZL)
- Institute of Pathology, Hannover Medical School
| | - Claus Peter Heussel
- German Center for Lung Research (DZL)
- Department of Diagnostic and Interventional Radiology, Thoraxklinik at Heidelberg University Hospital
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28
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Bi Y, Rekić D, Paterniti MO, Chen J, Marathe A, Chowdhury BA, Karimi-Shah BA, Wang Y. A disease progression model of longitudinal lung function decline in idiopathic pulmonary fibrosis patients. J Pharmacokinet Pharmacodyn 2020; 48:55-67. [PMID: 32949322 DOI: 10.1007/s10928-020-09718-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/01/2020] [Indexed: 11/24/2022]
Abstract
Pirfenidone and nintedanib are the first two FDA-approved therapies for treatment of idiopathic pulmonary fibrosis (IPF). The clinical programs for pirfenidone and nintedanib included 1132 patients in the placebo arms and 1691 patients in the treatment arms across 6 trials. We developed a disease progression model to characterize the observed variability in lung function decline, measured as percent predicted forced vital capacity (%p-FVC), and its decrease in decline after treatment. The non-linear longitudinal change in %p-FVC was best described by a Weibull function. The median decreased decline in %p-FVC after treatment was estimated to be 1.50% (95% CI [1.12, 1.79]) and 1.96% (95% CI [1.47, 2.36]) at week 26 and week 52, respectively. Smoking status, weight, %p-FVC, %p-DLco and oxygen use at baseline were identified as significant covariates affecting decline in %p-FVC. The decreased decline in %p-FVC were observed among all subgroups of interest, of which the effects were larger at 1 year compared to 6 months. Based on the disease progression model smoking status and oxygen use at baseline may affect the treatment effect size. At week 52, the decreased decline in %p-FVC for current smokers and patients with oxygen use at baseline were 1.56 (90% CI [1.02, 1.99]) and 2.32 (90% CI [1.74, 2.86]), respectively. These prognostic factors may be used to enrich studies with patients who are more likely to respond to treatment, by demonstrating a lesser decline in lung function, and therefore provide the potential to allow for IPF studies with smaller study populations or shorter durations.
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Affiliation(s)
- Youwei Bi
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Dinko Rekić
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA.,AstraZeneca, Cambridge, UK
| | - Miya O Paterniti
- Division of Pulmonary, Allergy, and Rheumatology Products, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Jianmeng Chen
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Anshu Marathe
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA.,Novartis, East Hanover, NJ, USA
| | - Badrul A Chowdhury
- Division of Pulmonary, Allergy, and Rheumatology Products, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA.,Savara Inc., Austin, TX, USA
| | - Banu A Karimi-Shah
- Division of Pulmonary, Allergy, and Rheumatology Products, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Yaning Wang
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA.
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29
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Aschner Y, Nelson M, Brenner M, Roybal H, Beke K, Meador C, Foster D, Correll KA, Reynolds PR, Anderson K, Redente EF, Matsuda J, Riches DWH, Groshong SD, Pozzi A, Sap J, Wang Q, Rajshankar D, McCulloch CAG, Zemans RL, Downey GP. Protein tyrosine phosphatase-α amplifies transforming growth factor-β-dependent profibrotic signaling in lung fibroblasts. Am J Physiol Lung Cell Mol Physiol 2020; 319:L294-L311. [PMID: 32491951 PMCID: PMC7473933 DOI: 10.1152/ajplung.00235.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 04/06/2020] [Accepted: 04/25/2020] [Indexed: 01/06/2023] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a progressive, often fatal, fibrosing lung disease for which treatment remains suboptimal. Fibrogenic cytokines, including transforming growth factor-β (TGF-β), are central to its pathogenesis. Protein tyrosine phosphatase-α (PTPα) has emerged as a key regulator of fibrogenic signaling in fibroblasts. We have reported that mice globally deficient in PTPα (Ptpra-/-) were protected from experimental pulmonary fibrosis, in part via alterations in TGF-β signaling. The goal of this study was to determine the lung cell types and mechanisms by which PTPα controls fibrogenic pathways and whether these pathways are relevant to human disease. Immunohistochemical analysis of lungs from patients with IPF revealed that PTPα was highly expressed by mesenchymal cells in fibroblastic foci and by airway and alveolar epithelial cells. To determine whether PTPα promotes profibrotic signaling pathways in lung fibroblasts and/or epithelial cells, we generated mice with conditional (floxed) Ptpra alleles (Ptpraf/f). These mice were crossed with Dermo1-Cre or with Sftpc-CreERT2 mice to delete Ptpra in mesenchymal cells and alveolar type II cells, respectively. Dermo1-Cre/Ptpraf/f mice were protected from bleomycin-induced pulmonary fibrosis, whereas Sftpc-CreERT2/Ptpraf/f mice developed pulmonary fibrosis equivalent to controls. Both canonical and noncanonical TGF-β signaling and downstream TGF-β-induced fibrogenic responses were attenuated in isolated Ptpra-/- compared with wild-type fibroblasts. Furthermore, TGF-β-induced tyrosine phosphorylation of TGF-β type II receptor and of PTPα were attenuated in Ptpra-/- compared with wild-type fibroblasts. The phenotype of cells genetically deficient in PTPα was recapitulated with the use of a Src inhibitor. These findings suggest that PTPα amplifies profibrotic TGF-β-dependent pathway signaling in lung fibroblasts.
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Affiliation(s)
- Yael Aschner
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, Aurora, Colorado
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Meghan Nelson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Matthew Brenner
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Helen Roybal
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Keriann Beke
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Carly Meador
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Daniel Foster
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Kelly A Correll
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Paul R Reynolds
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Kelsey Anderson
- Center for Genes, Environment, and Health, National Jewish Health, Denver, Colorado
| | - Elizabeth F Redente
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, Aurora, Colorado
- Division of Cell Biology, Department of Pediatrics, National Jewish Health, Denver, Colorado
- Veterans Affairs Eastern Colorado Heath Care System, Denver, Colorado
| | - Jennifer Matsuda
- Department of Biomedical Research, National Jewish Health, Denver, Colorado
| | - David W H Riches
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, Aurora, Colorado
- Division of Cell Biology, Department of Pediatrics, National Jewish Health, Denver, Colorado
- Veterans Affairs Eastern Colorado Heath Care System, Denver, Colorado
- Department of Immunology and Microbiology, University of Colorado, Aurora, Colorado
| | - Steve D Groshong
- Division of Pathology, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Ambra Pozzi
- Division of Nephrology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Veterans Affairs Medical Center, Nashville, Tennessee
| | - Jan Sap
- Epigenetics and Cell Fate, Université Paris, Paris, France
| | - Qin Wang
- Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | - Dhaarmini Rajshankar
- Matrix Dynamics Group, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada
| | | | - Rachel L Zemans
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Gregory P Downey
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado, Aurora, Colorado
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
- Department of Pediatrics, National Jewish Health, Denver, Colorado
- Department of Biomedical Research, National Jewish Health, Denver, Colorado
- Department of Immunology and Microbiology, University of Colorado, Aurora, Colorado
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30
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Sogkas G, Hirsch S, Olsson KM, Hinrichs JB, Thiele T, Seeliger T, Skripuletz T, Schmidt RE, Witte T, Jablonka A, Ernst D. Lung Involvement in Primary Sjögren's Syndrome-An Under-Diagnosed Entity. Front Med (Lausanne) 2020; 7:332. [PMID: 32766261 PMCID: PMC7378373 DOI: 10.3389/fmed.2020.00332] [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: 12/15/2019] [Accepted: 06/04/2020] [Indexed: 01/20/2023] Open
Abstract
Interstitial lung disease (ILD) represents a frequent extra-glandular manifestation of primary Sjögren's Syndrome (pSS). Limited published data regarding phenotyping and treatment exists. Advances in managing specific ILD phenotypes have not been comprehensively explored in patients with coexisting pSS. This retrospective study aimed to phenotype lung diseases occurring in a well-described pSS-ILD cohort and describe treatment course and outcomes. Between April 2018 and February 2020, all pSS patients attending our Outpatient clinic were screened for possible lung involvement. Clinical, laboratory and high-resolution computed tomography (HRCT) findings were analyzed. Patients were classified according to HRCT findings into five groups: usual interstitial pneumonia (UIP), non-specific interstitial pneumonia (NSIP), desquamative interstitial pneumonia (DIP), combined pulmonary fibrosis and emphysema (CPFE), and non-specific-ILD. Lung involvement was confirmed in 31/268 pSS patients (13%). One-third (10/31) of pSS-ILD patients were Ro/SSA antibody negative. ILD at pSS diagnosis was present in 19/31 (61%) patients. The commonest phenotype was UIP n = 13 (43%), followed by NSIP n = 9 (29%), DIP n = 2 (6 %), CPFE n = 2 (6 %), and non-specific-ILD n = 5 (16%). Forced vital capacity (FVC) and carbon monoxide diffusion capacity (DLCO) appeared lower in UIP and DIP, without reaching a significant difference. Treatment focused universally on intensified immunosuppression, with 13/31 patients (42%) receiving cyclophosphamide. No anti-fibrotic treatments were used. Median follow-up was 38.2 [12.4–119.6] months. Lung involvement in pSS is heterogeneous. Better phenotyping and tailored treatment may improve outcomes and requires further evaluation in larger prospective studies.
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Affiliation(s)
- Georgios Sogkas
- Department of Immunology and Rheumatology, Medical School Hannover, Hanover, Germany
| | - Stefanie Hirsch
- Department of Immunology and Rheumatology, Medical School Hannover, Hanover, Germany
| | - Karen Maria Olsson
- Department of Respiratory Medicine, Hannover Medical School, Hanover, Germany.,BREATH German Centre for Lung Research (DZL), Hanover, Germany
| | - Jan B Hinrichs
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hanover, Germany
| | - Thea Thiele
- Department of Immunology and Rheumatology, Medical School Hannover, Hanover, Germany
| | - Tabea Seeliger
- Department of Neurology, Hannover Medical School, Hanover, Germany
| | | | | | - Torsten Witte
- Department of Immunology and Rheumatology, Medical School Hannover, Hanover, Germany
| | - Alexandra Jablonka
- Department of Immunology and Rheumatology, Medical School Hannover, Hanover, Germany
| | - Diana Ernst
- Department of Immunology and Rheumatology, Medical School Hannover, Hanover, Germany
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31
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Abstract
Interstitial pneumonia with autoimmune features (IPAF) is a research classification proposed by the European Respiratory Society/American Thoracic Society Task Force on Undifferentiated Forms of Connective Tissue Disease-associated Interstitial Lung Disease as an initial step to uniformly define, identify, and study patients with interstitial lung disease (ILD) who have features of autoimmunity, yet fall short of a characterizable connective tissue disease. Since its publication in July 2015, there has been substantial interest in IPAF. Centers from around the world have published their findings of retrospectively identified cohorts of patients who fulfill IPAF criteria, suggestions for modification of the criteria have been offered, and patients who fulfill IPAF criteria are being included as a subset in the ongoing phase II multicenter unclassifiable ILD treatment trial with pirfenidone. The IPAF designation represents an important first step toward studying and furthering our understanding of the natural history of this cohort of patients with ILD using uniform nomenclature and a standardized set of criteria. Prospective evaluations and, ideally, interdisciplinary and multicenter collaborations will inform best practices for treatment and management and will guide future refinement to the IPAF criteria. This review focuses on the relevant background that led to the development of IPAF, summarizes the proposed criteria, discusses cohort studies of patients with IPAF published to date and what they have taught us about the IPAF phenotype, and offers insights into future directions in this arena. Clinical trial registered with www.clinicaltrials.gov (NCT03099187).
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32
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Abstract
The European Respiratory Society/American Thoracic Society Task Force on Undifferentiated Forms of Connective Tissue Disease-associated Interstitial Lung Disease put forth the research classification interstitial pneumonia with autoimmune features as a step toward uniformly describing these patients. Diverse nomenclature and classification schemes had been proposed to characterize them. This classification has provided uniform nomenclature and criteria, fostering interdisciplinary engagement and research. Longitudinal surveillance is needed; some patients evolve to a defined connective tissue disease. This review discusses cohort studies of interstitial pneumonia with autoimmune features and what they have taught us about the phenotype, and offers insights into future directions.
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Affiliation(s)
- Aryeh Fischer
- Divisions of Rheumatology, Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus, University of Colorado School of Medicine, 12631 East 17th Avenue, Academic Office Building One, Aurora, CO 80045, USA.
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Nathan SD, Flaherty KR, Glassberg MK, Raghu G, Swigris J, Alvarez R, Ettinger N, Loyd J, Fernandes P, Gillies H, Kim B, Shah P, Lancaster L. A Randomized, Double-Blind, Placebo-Controlled Study of Pulsed, Inhaled Nitric Oxide in Subjects at Risk of Pulmonary Hypertension Associated With Pulmonary Fibrosis. Chest 2020; 158:637-645. [PMID: 32092321 DOI: 10.1016/j.chest.2020.02.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/28/2020] [Accepted: 02/06/2020] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The interstitial lung diseases include a variety of disorders, many of which are characterized by fibrotic changes (fILD). Of the fILDs, Idiopathic pulmonary fibrosis is the most common. Pulmonary hypertension (PH) frequently complicates fILD and is associated with impaired functional capability, lower physical activity, and significantly reduced life expectancy. There is no proven treatment for patients with fILD-PH. We report results from the first cohort of a phase 2b/3 trial with pulsed inhaled nitric oxide (iNO) in patients with fILD-PH. METHODS Subjects in cohort 1 were randomized to iNO 30 μg/kg ideal body weight/h (iNO30) or placebo for 8 weeks of blinded treatment; subjects then transitioned to open-label extension (OLE) on iNO30 followed by dose escalation to iNO45 then iNO75. Activity monitoring was used to assess changes in daily activity. Safety and efficacy were evaluated. RESULTS Twenty-three patients were randomized to iNO30 and 18 to placebo. During blinded treatment, iNO30 subjects showed an average improvement in moderate/vigorous physical activity (MVPA) and remained stable in overall activity. Placebo subjects showed an average drop of 26% in MVPA and a 12% drop in overall activity. The iNO group had an improvement in oxygen saturation. During OLE, subjects maintained their activity levels including placebo subjects who transitioned from a decline to a maintenance in all activity parameters. Inhaled nitric oxide at all doses (30, 45, and 75) was safe and well tolerated. CONCLUSIONS Treatment with iNO30 demonstrated clinically and statistically significant benefit in MVPA and clinically significant benefit in overall activity. In the OLE, higher doses of iNO were also safe and well tolerated while showing maintenance in activity parameters.
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Affiliation(s)
- Steven D Nathan
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, Richmond, VA; Virginia Commonwealth University, Richmond, VA.
| | | | | | - Ganesh Raghu
- the University of Arizona College of Medicine - Phoenix and Banner; University of Washington Medical Center, Seattle, WA
| | | | - Roger Alvarez
- University of Miami Miller School of Medicine, Miami, FL
| | | | - Jim Loyd
- Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Bo Kim
- Bellerophon Therapeutics, Warren, NJ
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Zaman T, Moua T, Vittinghoff E, Ryu JH, Collard HR, Lee JS. Differences in Clinical Characteristics and Outcomes Between Men and Women With Idiopathic Pulmonary Fibrosis: A Multicenter Retrospective Cohort Study. Chest 2020; 158:245-251. [PMID: 32084394 DOI: 10.1016/j.chest.2020.02.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/20/2020] [Accepted: 02/04/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is a disease with a male predominance. Prior data suggest that male sex is associated with disease progression and survival. The basis for this sex difference is unknown. RESEARCH QUESTION Are there differences in clinical disease characteristics and outcomes between men and women with IPF? STUDY DESIGN AND METHODS Two tertiary care center IPF cohorts were pooled to analyze sex differences in outcomes of time to lung transplantation or death. Predictors of outcome that were analyzed included age, FVC % predicted, diffusion capacity for carbon monoxide (Dlco) % predicted, BMI, smoking history, and respiratory variables of cough, phlegm, and need for supplemental oxygen. The associations of these factors with mortality were estimated by sex and then compared using tests for interaction. RESULTS There were a total of 1,263 patients in the pooled cohort with follow-up data; approximately 71% of the patients were men. Male sex was independently associated with higher risk for death or lung transplantation after adjusting for age, FVC % predicted, and Dlco % predicted (hazard ratio for men, 1.4; 95% CI, 1.2-1.7; P < .001). Older age, lower Dlco % predicted, and presence of cough or phlegm were negatively associated with transplant-free survival in men but not in women, but only the association for cough differed statistically by sex (interaction P = .007). INTERPRETATION Male sex is associated with worse transplant-free survival in IPF. Cough may be a sex-specific predictor of survival in this population.
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Affiliation(s)
- Tanzira Zaman
- University of Colorado, Aurora, CO; Cedars-Sinai Medical Center, Los Angeles, CA.
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Lai RS, Chen CF, Chu KA, Lin MH. The effect of emphysema on survival in patients with idiopathic pulmonary fibrosis: A retrospective study in Taiwan. J Chin Med Assoc 2019; 82:922-928. [PMID: 31800533 DOI: 10.1097/jcma.0000000000000201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is a rare and chronic fibrosing interstitial lung disease. However, the clinical features and outcomes of IPF in Taiwan have not been well studied. In addition, the survival difference between patients with IPF alone and combined pulmonary fibrosis and emphysema (CPFE) remains controversial. METHODS Patients diagnosed with IPF between 2006 and 2016 were retrospectively enrolled in this study. IPF was defined according to the 2011 American Thoracic Society/European Respiratory Society guideline. The clinical features, comorbidities, and outcomes of CPFE group and IPF-alone group were compared. The extents of emphysema and fibrosis were evaluated. RESULTS In total, 114 patients with IPF were enrolled, and 86.8% of them were men with a mean age of 77.8 years. The median survival was 3.33 years in all patients with IPF. Moreover, 30 patients (26.3%) met the CPFE criteria. The CPFE group had a higher percentage of smokers (90% vs 50%, p < 0.001), higher forced vital capacity (82% vs 59%, p < 0.001), and lower fibrosis scores (8.5 ± 2.9 vs 10 ± 3.2, p = 0.022) than did the IPF-alone group. The baseline room air saturation and percentage of pulmonary hypertension were similar between the two groups. The survival time was not significantly different between the CPFE and IPF-alone groups (median survival, 3.58 vs 2.39 years, p = 0.163). In the multivariate analysis, higher fibrosis score, room air saturation < 90%, and lung cancer were significant factors associated with mortality. CONCLUSION Our study showed that emphysema had no significant effect on the survival of patients with IPF. The outcome of IPF was mainly determined by the baseline disease severity and other comorbidities.
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Affiliation(s)
- Ruay-Sheng Lai
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chiu-Fan Chen
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Department of Internal Medicine, Taipei Veterans General Hospital, Taitung Branch, Taitung, Taiwan, ROC
| | - Kuo-An Chu
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Nursing, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan, ROC
| | - Min-Hsi Lin
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
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Chan C, Ryerson CJ, Dunne JV, Wilcox PG. Demographic and clinical predictors of progression and mortality in connective tissue disease-associated interstitial lung disease: a retrospective cohort study. BMC Pulm Med 2019; 19:192. [PMID: 31672127 PMCID: PMC6824100 DOI: 10.1186/s12890-019-0943-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/20/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Connective tissue disease-associated interstitial lung disease (CTD-ILD) is associated with reduced quality of life and poor prognosis. Prior studies have not identified a consistent combination of variables that accurately predict prognosis in CTD-ILD. The objective of this study was to identify baseline demographic and clinical characteristics that are associated with progression and mortality in CTD-ILD. METHODS Patients were retrospectively identified from an adult CTD-ILD clinic. The predictive significance of baseline variables on serial forced vital capacity (FVC), diffusion capacity (DLCO), and six-minute walk distance (6MWD) was assessed using linear mixed effects models, and Cox regression analysis was performed to assess impact on mortality. RESULTS 359 patients were included in the study. Median follow-up time was 4.0 (IQR 1.5-7.6) years. On both unadjusted and multivariable analysis, male sex and South Asian ethnicity were associated with decline in FVC. Male sex, positive smoking history, and diagnosis of systemic sclerosis (SSc) vs. other CTD were associated with decline in DLCO. Male sex and usual interstitial pneumonia (UIP) pattern predicted decline in 6MWD. There were 85 (23.7%) deaths. Male sex, older age, First Nations ethnicity, and a diagnosis of systemic sclerosis vs. rheumatoid arthritis were predictors of mortality on unadjusted and multivariable analysis. CONCLUSION Male sex, older age, smoking, South Asian or First Nations ethnicity, and UIP pattern predicted decline in lung function and/or mortality in CTD-ILD. Further longitudinal studies may add to current clinical prediction models for prognostication in CTD-ILD.
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Affiliation(s)
- Chrystal Chan
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Christopher J Ryerson
- Department of Medicine, University of British Columbia, Vancouver, Canada.,Centre for Heart Lung Innovation, University of British Columbia, Vancouver, Canada
| | - James V Dunne
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Pearce G Wilcox
- Department of Medicine, University of British Columbia, Vancouver, Canada.
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Kam MLW, Li HH, Tan YH, Low SY. Validation of the ILD-GAP Model and a Local Nomogram in a Singaporean Cohort. Respiration 2019; 98:383-390. [PMID: 31578022 DOI: 10.1159/000502985] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 08/27/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The ILD-GAP model was developed and validated in a Western cohort to predict 1-, 2- and 3-year mortality in chronic interstitial lung disease (ILD). OBJECTIVES We aimed to validate the ILD-GAP model and identify predictors of mortality to derive a nomogram to predict mortality in our local Asian population. METHODS Characteristics of patients on follow-up in a tertiary ILD referral center were retrospectively reviewed. RESULTS There were 181 patients and 48 mortalities. 29.8% had idiopathic pulmonary fibrosis, 2.8% unclassifiable ILD, 33.1% connective tissue disease-associated interstitial lung disease (CTD-ILD), 28.7% idiopathic nonspecific interstitial pneumonia and 5.5% chronic hypersensitivity pneumonitis. Univariable analysis showed that a higher ILD-GAP index, unclassified ILD, males, older age, higher pulmonary artery systolic pressure, lower forced vital capacity percent predicted and carbon monoxide diffusion capacity (DLCO) correlated with increased mortality, and CTD had lower mortality. Multivariable analysis utilizing Akaike's information criterion stopping rule showed males and a lower DLCO predicted increased mortality, while CTD predicted lower mortality. These were used to generate a nomogram which predicted overall mortality better (C index 0.817, adequacy index 99.5%) than ILD-GAP (C index 0.777, adequacy index 60.7%) and provided superior estimates based on likelihood ratio testing. Calibration plots showed the nomogram predicted 1-year mortality better, whilst the ILD-GAP model predicted 2- and 3-year mortality closer to actual mortality rates but underpredicted 1-year mortality. CONCLUSION The nomogram performed better than ILD-GAP in predicting overall mortality and 1-year mortality. Both demonstrated good performance in predicting mortality risk.
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Affiliation(s)
- Michelle L W Kam
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore,
| | - Hui Hua Li
- Health Service Research Unit, Singapore General Hospital, Singapore, Singapore
| | - Yi Hern Tan
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Su Ying Low
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
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Moua T, Lee AS, Ryu JH. Comparing effectiveness of prognostic tests in idiopathic pulmonary fibrosis. Expert Rev Respir Med 2019; 13:993-1004. [PMID: 31405303 DOI: 10.1080/17476348.2019.1656069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Idiopathic pulmonary fibrosis (IPF) is a debilitating and progressive fibrotic interstitial lung disease often resulting in death over several years. Prediction of disease course or survival remains of keen interest for clinicians and patients though a commonly used test or tool remain elusive. Areas covered: We undertook a comprehensive review of the published literature highlighting prognostic indicators and predictors of survival in IPF. Baseline and longitudinal clinical, functional, histopathologic, and radiologic findings have been extensively studied as prognostic predictors, both individually and in composite models. Recent approaches include automated quantifiable radiologic scoring, circulating biomarkers, and genetic polymorphisms or abnormalities. This review highlights individual and composite predictors and their relative utility in clinical practice and research studies. Expert opinion: There is a growing body of knowledge highlighting readily available individual and composite predictors of outcome, though none have come to the forefront for common clinical use. Recent advances include quantitative imaging analysis, circulating serologic markers, and genetic testing, which may be more standardized and less prone to lead-time bias or related complications and comorbidities.
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Affiliation(s)
- Teng Moua
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester , MN , USA
| | - Augustine S Lee
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Jacksonville , FL , USA
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester , MN , USA
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Elicker BM, Kallianos KG, Henry TS. Imaging of the Thoracic Manifestations of Connective Tissue Disease. Clin Chest Med 2019; 40:655-666. [PMID: 31376898 DOI: 10.1016/j.ccm.2019.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Imaging, specifically computed tomography (CT), is a key component in the characterization, management, and follow-up of patients with connective tissue disease (CTD)-related diffuse lung disease. The main role of CT is to help direct treatment by determining the primary pattern of lung injury present. Other roles include follow-up of lung disease over time, evaluation of acute symptoms, and monitoring for treatment complications. Although diagnosis is typically made using clinical and serologic criteria, CT plays an important role when lung disease is the dominant presenting feature. This article delineates the roles of CT in patients with CTD-related lung disease.
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Affiliation(s)
- Brett M Elicker
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, Box 0628, San Francisco, CA 94143, USA.
| | - Kimberly G Kallianos
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, Box 0628, San Francisco, CA 94143, USA
| | - Travis S Henry
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, Box 0628, San Francisco, CA 94143, USA
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Clinical significance of autoantibody positivity in idiopathic pulmonary fibrosis. Respir Med 2019; 155:43-48. [PMID: 31299466 DOI: 10.1016/j.rmed.2019.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 05/24/2019] [Accepted: 07/01/2019] [Indexed: 01/12/2023]
Abstract
RATIONALE The concept of interstitial pneumonia with autoimmune features (IPAF) was recently proposed by the American Thoracic Society. However, the clinical significance of the serologic domain of IPAF has not yet been established in idiopathic pulmonary fibrosis (IPF). OBJECTIVES We aimed to investigate the clinical significance of autoantibody positivity in IPF. METHODS We retrospectively reviewed the records of 512 patients diagnosed as IPF from January 2007 through March 2014. The patients were divided into two subgroups: (i) an autoantibody-positive IPF subgroup (n = 138), consisting of patients with anti-neutrophil cytoplasmic antibody (ANCA) or autoantibodies that met the criteria for the IPAF serologic domain; (ii) a lone IPF subgroup (n = 374), consisting of the rest of the IPF patients. MEASUREMENTS AND MAIN RESULTS Autoantibody-positivity (HR 0.736, p = 0.043) was an independent risk factors for 5-year mortality on multivariable analysis in the overall IPF patients. In the autoantibody-positive IPF patients, use of glucocorticoid (not for management of acute exacerbation, HR 2.121, p = 0.019), use of immunomodulators (HR 0.310, p = 0.002), malignancy (HR 3.359, p = 0.002), baseline forced vital capacity (HR 0.974, p = 0.017), baseline diffusing capacity of the lung for carbon monoxide (HR 0.981, p = 0.041), and baseline 6-min walk test distance (HR 0.996, p = 0.002) were independent risk factors for 5-year mortality. CONCLUSIONS Presence of ANCA or autoantibodies of the IPAF serologic domain in IPF patients is associated with better survival outcomes, and the use of immunomodulators is associated with superior survival outcomes.
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Choi WI, Lee DY, Choi HG, Lee CW. Lung Cancer development and mortality in interstitial lung disease with and without connective tissue diseases: a five-year Nationwide population-based study. Respir Res 2019; 20:117. [PMID: 31182103 PMCID: PMC6558868 DOI: 10.1186/s12931-019-1094-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 06/05/2019] [Indexed: 12/20/2022] Open
Abstract
Background Connective tissue disease associated with interstitial lung disease (CTD-ILD) and interstitial lung disease (ILD) alone have same pathological and imaging backgrounds. However, the differences between lung cancer development and the mortality risk between these two conditions are unclear. Incidence of primary lung cancer and all-cause mortality were studied between interstitial lung disease patients with and without connective tissue disease. Methods Data were extracted from the Korean National Health Insurance Research Database in 2009. A total of 12,787 cases of ILD without idiopathic pulmonary fibrosis and 2491 cases of CTD-ILD were diagnosed in 2009. The cohort was followed up until June 30, 2014. Incident lung cancers and all-cause mortality were ascertained. Results The overall incidence of lung cancer was 165.7 and 161.8 per 10,000 person-years in the CTD-ILD and ILD-only, respectively (rate ratio, 1.08; 95% confidence interval, 0.89–1.30). CTD-ILD patients in the 40–49 and 50–59 years old age groups had lung cancer incidence rates of 92.5 and 139.2, which were 2.0 and 1.7 times higher than those in the ILD-only, respectively. All-cause mortality was significantly higher in the CTD-ILD group compared to ILD-only group in patients aged 50–79 years. All-cause mortality of women in the 50–59, 60–69 and 70–79 age groups was 2.0, 1.8, and 1.4 times higher in the CTD-ILD group than in the ILD-only group, respectively. Conclusions CTD-ILD patients aged < 60 years had a higher lung cancer incidence than ILD-only patients in the same age group. Furthermore, CTD-ILD patients aged 50–79 years had higher all-cause mortality than ILD-only patients in the same age group.
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Affiliation(s)
- Won-Il Choi
- Department of Internal Medicine, Keimyung University Dongsan Hospital, 56 Dalseong-ro, Jung-gu, Daegu, 41931, Republic of Korea. .,Department of Internal Medicine, Keimyung University Dongsan Hospital, 56 Dalseong-ro, Jung-gu, Daegu, 700-712, Republic of Korea.
| | - Dong Yoon Lee
- Department of Internal Medicine, Keimyung University Dongsan Hospital, 56 Dalseong-ro, Jung-gu, Daegu, 41931, Republic of Korea
| | - Hyun-Gi Choi
- Department of Chemistry, Konkuk University, Seoul, 05029, Republic of Korea
| | - Choong Won Lee
- Department of Occupational and Environmental Medicine, Sungso Hospital, Andong, 99 Seodongmun-ro, Andong, Gyeongsangbuk-do, 36690, Republic of Korea
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Ratwani AP, Ahmad KI, Barnett SD, Nathan SD, Brown AW. Connective tissue disease-associated interstitial lung disease and outcomes after hospitalization: A cohort study. Respir Med 2019; 154:1-5. [PMID: 31176795 DOI: 10.1016/j.rmed.2019.05.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/16/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The impact of hospitalization on patient outcomes is increasingly recognized and considered in the prognostication of many pulmonary disorders. We sought to evaluate the impact of hospitalization on survival in connective tissue disease-interstitial lung disease (CTD-ILD) patients. METHODS A chart review of patients with CTD-ILD followed at a tertiary care center was performed. Patients were stratified into two groups based on hospitalization status. Outcomes of the groups were compared using Kaplan-Meier survival analyses as well as multivariate competing risk analysis. RESULTS There were 137 patients identified with confirmed CTD-ILD. Patients who underwent hospitalization for any reason had a significant decrease in transplant-free survival compared to the never hospitalized cohort (3-year survival 60% vs. 94%; p = 0.0001). Hospitalization for ≥7 days was associated with worse outcomes than those hospitalized for <7 days (median survival 1.59 years vs. 7.17 years, p = 0.0012). Based on multivariate competing risk analysis, factors associated with death, with lung transplantation as a competing risk, were age (HR = 1.05 [95% 1.01-1.09]; P = 0.0443), male gender (HR = 4.94 [95% CI: 1.58-15.41]; P = 0.006), and all cause hospitalization (HR = 11.97 [95% CI: 1.36-105.49]; P = 0.0253). CONCLUSION This study highlights the impact of hospitalization on subsequent outcomes in the CTD-ILD population with a significantly reduced transplant-free survival demonstrated, especially after cardiopulmonary hospitalization events.
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Affiliation(s)
- Ankush P Ratwani
- Department of Internal Medicine, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Kareem I Ahmad
- Advanced Lung Disease and Transplant Program. Inova Fairfax Hospital, Falls Church, VA, USA
| | - Scott D Barnett
- Advanced Lung Disease and Transplant Program. Inova Fairfax Hospital, Falls Church, VA, USA
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Program. Inova Fairfax Hospital, Falls Church, VA, USA
| | - A Whitney Brown
- Advanced Lung Disease and Transplant Program. Inova Fairfax Hospital, Falls Church, VA, USA.
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Koo SM, Kim SY, Choi SM, Lee HK. Korean Guidelines for Diagnosis and Management of Interstitial Lung Diseases: Part 5. Connective Tissue Disease Associated Interstitial Lung Disease. Tuberc Respir Dis (Seoul) 2019; 82:285-297. [PMID: 31172701 PMCID: PMC6778739 DOI: 10.4046/trd.2019.0009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/08/2019] [Accepted: 04/10/2019] [Indexed: 01/13/2023] Open
Abstract
Connective tissue disease (CTD) is a collection of disorders characterized by various signs and symptoms such as circulation of autoantibodies in the entire system causing damage to internal organs. Interstitial lung disease (ILD) which is associated with CTD is referred to as CTD-ILD. Patients diagnosed with ILD should be thoroughly examined for the co-occurrence of CTD, since the treatment procedures and prognosis of CTD-ILD are vary from those of idiopathic interstitial pneumonia. The representative types of CTD which may accompany ILD include rheumatoid arthritis, systemic sclerosis (SSc), Sjögren's syndrome, mixed CTD, idiopathic inflammatory myopathies, and systemic lupus erythematous. Of these, ILD most frequently co-exists with SSc. If an ILD is observed in the chest, high resolution computed tomography and specific diagnostic criteria for any type of CTD are met, then a diagnosis of CTD-ILD is made. It is challenging to conduct a properly designed randomized study on CTD-ILD, due to low incidence. Therefore, CTD-ILD treatment approach is yet to been established in absence of randomized controlled clinical trials, with the exception of SSc-ILD. When a patient is presented with acute CTD-ILD or if symptoms occur due to progression of the disease, steroid and immunosuppressive therapy are generally considered.
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Affiliation(s)
- So My Koo
- Division of Allergy and Respiratory Medicine, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Sun Mi Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Meidicine, Seoul National University Hospital, Seoul, Korea.
| | - Hyun Kyung Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, Korea
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Cameli P, Bargagli E, Bergantini L, Refini RM, Pieroni M, Sestini P, Rottoli P. Evaluation of multiple-flows exhaled nitric oxide in idiopathic and non-idiopathic interstitial lung disease. J Breath Res 2019; 13:026008. [DOI: 10.1088/1752-7163/ab0233] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Mira-Avendano I, Abril A, Burger CD, Dellaripa PF, Fischer A, Gotway MB, Lee AS, Lee JS, Matteson EL, Yi ES, Ryu JH. Interstitial Lung Disease and Other Pulmonary Manifestations in Connective Tissue Diseases. Mayo Clin Proc 2019; 94:309-325. [PMID: 30558827 DOI: 10.1016/j.mayocp.2018.09.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/24/2018] [Accepted: 09/17/2018] [Indexed: 12/22/2022]
Abstract
Lung involvement in connective tissue diseases is associated with substantial morbidity and mortality, most commonly in the form of interstitial lung disease, and can occur in any of these disorders. Patterns of interstitial lung disease in patients with connective tissue disease are similar to those seen in idiopathic interstitial pneumonias, such as idiopathic pulmonary fibrosis. It may be difficult to distinguish between the 2 ailments, particularly when interstitial lung disease presents before extrapulmonary manifestations of the underlying connective tissue disease. There are important clinical implications in achieving this distinction. Given the complexities inherent in the management of these patients, a multidisciplinary evaluation is needed to optimize the diagnostic process and management strategies. The aim of this article was to summarize an approach to diagnosis and management based on the opinion of experts on this topic.
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Affiliation(s)
- Isabel Mira-Avendano
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL.
| | - Andy Abril
- Division of Rheumatology, Mayo Clinic, Jacksonville, FL
| | - Charles D Burger
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Paul F Dellaripa
- Division of Rheumatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Aryeh Fischer
- Department of Medicine, University of Colorado, Denver, Aurora, CO
| | - Michael B Gotway
- Division of Cardiothoracic Radiology, Mayo Clinic, Scottsdale, AZ
| | - Augustine S Lee
- Division of Pulmonary, Allergy, and Sleep Medicine, Mayo Clinic, Jacksonville, FL
| | - Joyce S Lee
- Department of Medicine, University of Colorado, Denver, Aurora, CO
| | - Eric L Matteson
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN
| | - Eunhee S Yi
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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46
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Cottin V, Hirani NA, Hotchkin DL, Nambiar AM, Ogura T, Otaola M, Skowasch D, Park JS, Poonyagariyagorn HK, Wuyts W, Wells AU. Presentation, diagnosis and clinical course of the spectrum of progressive-fibrosing interstitial lung diseases. Eur Respir Rev 2018; 27:180076. [PMID: 30578335 PMCID: PMC9489068 DOI: 10.1183/16000617.0076-2018] [Citation(s) in RCA: 337] [Impact Index Per Article: 56.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 11/08/2018] [Indexed: 01/22/2023] Open
Abstract
Although these conditions are rare, a proportion of patients with interstitial lung diseases (ILDs) may develop a progressive-fibrosing phenotype. Progressive fibrosis is associated with worsening respiratory symptoms, lung function decline, limited response to immunomodulatory therapies, decreased quality of life and, potentially, early death. Idiopathic pulmonary fibrosis may be regarded as a model for other progressive-fibrosing ILDs. Here we focus on other ILDs that may present a progressive-fibrosing phenotype, namely idiopathic nonspecific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, connective tissue disease-associated ILDs (e.g. rheumatoid arthritis-related ILD), fibrotic chronic hypersensitivity pneumonitis, fibrotic chronic sarcoidosis and ILDs related to other occupational exposures. Differential diagnosis of these ILDs can be challenging, and requires detailed consideration of clinical, radiological and histopathological features. Accurate and early diagnosis is crucial to ensure that patients are treated optimally.
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Affiliation(s)
- Vincent Cottin
- Louis Pradel Hospital, Reference Center for Rare Pulmonary Diseases, Hospices Civils de Lyon, UMR 754, Université Claude Bernard Lyon 1, Lyon, France
- Co-lead authors of this paper
| | - Nikhil A. Hirani
- Edinburgh Lung Fibrosis Clinic and MRC Centre for Inflammation Research, The Queen's Medical Research Centre, The University of Edinburgh, Edinburgh, UK
| | - David L. Hotchkin
- Division of Pulmonary and Critical Care Medicine, Oregon Clinic, Portland, OR, USA
| | - Anoop M. Nambiar
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, University of Texas Health Science Center San Antonio and the South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Takashi Ogura
- Kanagawa Cardiovascular and Respiratory Center, Kanagawa, Japan
| | - María Otaola
- Fundación FUNEF, Instituto de Rehabilitacion Psicofísica (IREP Hospital), Buenos Aires, Argentina
| | - Dirk Skowasch
- Dept of Internal Medicine II, Cardiology, Pneumology and Angiology, University Hospital Bonn, Bonn, Germany
| | - Jong Sun Park
- Division of Pulmonary and Critical Care Medicine, Dept of Internal Medicine and Lung Institute of Medical Research Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | | | - Wim Wuyts
- Unit for Interstitial Lung Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Athol U. Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, UK
- Co-lead authors of this paper
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47
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Walsh SLF, Devaraj A, Enghelmayer JI, Kishi K, Silva RS, Patel N, Rossman MD, Valenzuela C, Vancheri C. Role of imaging in progressive-fibrosing interstitial lung diseases. Eur Respir Rev 2018; 27:27/150/180073. [PMID: 30578332 PMCID: PMC9488692 DOI: 10.1183/16000617.0073-2018] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/01/2018] [Indexed: 01/03/2023] Open
Abstract
Imaging techniques are an essential component of the diagnostic process for interstitial lung diseases (ILDs). Chest radiography is frequently the initial indicator of an ILD, and comparison of radiographs taken at different time points can show the rate of disease progression. However, radiography provides only limited specificity and sensitivity and is primarily used to rule out other diseases, such as left heart failure. High-resolution computed tomography (HRCT) is a more sensitive method and is considered central in the diagnosis of ILDs. Abnormalities observed on HRCT can help identify specific ILDs. HRCT also can be used to evaluate the patient's prognosis, while disease progression can be assessed through serial imaging. Other imaging techniques such as positron emission tomography-computed tomography and magnetic resonance imaging have been investigated, but they are not commonly used to assess patients with ILDs. Disease severity may potentially be estimated using quantitative methods, as well as visual analysis of images. For example, comprehensive assessment of disease staging and progression in patients with ILDs requires visual analysis of pulmonary features that can be performed in parallel with quantitative analysis of the extent of fibrosis. New approaches to image analysis, including the application of machine learning, are being developed. Imaging techniques, particularly HRCT, are the cornerstone for ILD diagnosis and new approaches to analysing HRCT images, including machine-learning technology, are being developedhttp://ow.ly/1R1e30mOqhn
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Affiliation(s)
- Simon L F Walsh
- Dept of Radiology, King's College NHS Foundation Trust, London, UK.,Both authors contributed equally
| | - Anand Devaraj
- Dept of Radiology, Royal Brompton & Harefield Hospital, London, UK.,Both authors contributed equally
| | - Juan Ignacio Enghelmayer
- División Neumonología, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Fundación Funef, Buenos Aires, Argentina
| | - Kazuma Kishi
- Dept of Respiratory Medicine, Respiratory Center, Toranomon Hospital, Tokyo, Japan
| | - Rafael S Silva
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca, Chile
| | - Nina Patel
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Milton D Rossman
- Pulmonary, Allergy & Critical Care Division, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Carlo Vancheri
- Regional Referral Centre for Rare Lung Diseases, University Hospital "Policlinico", Dept of Clinical and Respiratory Medicine, University of Catania, Catania, Italy
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48
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Interstitial Lung Disease and Pulmonary Fibrosis: A Practical Approach for General Medicine Physicians with Focus on the Medical History. J Clin Med 2018; 7:jcm7120476. [PMID: 30477216 PMCID: PMC6306719 DOI: 10.3390/jcm7120476] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 11/21/2018] [Accepted: 11/22/2018] [Indexed: 12/26/2022] Open
Abstract
Interstitial lung disease (ILD) and pulmonary fibrosis comprise a wide array of inflammatory and fibrotic lung diseases which are often confusing to general medicine and pulmonary physicians alike. In addition to the myriad of clinical and radiologic nomenclature used in ILD, histopathologic descriptors may be particularly confusing, and are often extrapolated to radiologic imaging patterns which may further add to the confusion. We propose that rather than focusing on precise histologic findings, focus should be on identifying an accurate etiology of ILD through a comprehensive and detailed medical history. Histopathologic patterns from lung biopsy should not be dismissed, but are often nonspecific, and overall treatment strategy and prognosis are likely to be determined more by the specific etiology of ILD rather than any particular histologic pattern. In this review, we outline a practical approach to common ILDs, highlight important aspects in obtaining an exposure history, clarify terminology and nomenclature, and discuss six common subgroups of ILD likely to be encountered by general medicine physicians in the inpatient or outpatient setting: Smoking-related, hypersensitivity pneumonitis, connective tissue disease-related, occupation-related, medication-induced, and idiopathic pulmonary fibrosis. Accurate diagnosis of these forms of ILD does require supplementing the medical history with results of the physical examination, autoimmune serologic testing, and chest radiographic imaging, but the importance of a comprehensive environmental, avocational, occupational, and medication-use history cannot be overstated and is likely the single most important factor responsible for achieving the best possible outcomes for patients.
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Wilfong EM, Lentz RJ, Guttentag A, Tolle JJ, Johnson JE, Kropski JA, Kendall PL, Blackwell TS, Crofford LJ. Interstitial Pneumonia With Autoimmune Features: An Emerging Challenge at the Intersection of Rheumatology and Pulmonology. Arthritis Rheumatol 2018; 70:1901-1913. [PMID: 30058242 DOI: 10.1002/art.40679] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 07/24/2018] [Indexed: 01/03/2023]
Abstract
Interstitial lung disease (ILD) remains a cause of significant morbidity and mortality in patients with connective tissue disease (CTD)-associated ILD. While some patients meet clear classification criteria for a systemic rheumatic disease, a subset of patients do not meet classification criteria but still benefit from immunosuppressive therapy. In 2015, the American Thoracic Society and European Respiratory Society described classification criteria for interstitial pneumonia with autoimmune features (IPAF) to identify patients with lung-predominant CTD who lack sufficient features of a systemic rheumatic disease to meet classification criteria. Although these criteria are imperfect, they are an important attempt to classify the patient with undifferentiated disease for future study. Rheumatologists play a key role in the evaluation of potential IPAF in patients, especially as many patients with a myositis-spectrum disease (e.g., non-Jo-1 antisynthetase syndrome, anti-melanoma differentiation-associated protein 5 antibody inflammatory myositis, or anti-PM/Scl antibody-associated inflammatory myositis) would be classified under IPAF using the currently available criteria for inflammatory myositis, and would therefore benefit from rheumatologic comanagement. The aim of this review was to describe the historical context that led to the development of these criteria and to discuss the limitations of the current criteria, diagnostic challenges, treatment options, and strategies for disease monitoring.
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Affiliation(s)
- Erin M Wilfong
- Vanderbilt University, Nashville, Tennessee, and University of California San Francisco
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Wells AU, Brown KK, Flaherty KR, Kolb M, Thannickal V. What's in a name? That which we call IPF, by any other name would act the same. Eur Respir J 2018; 51:13993003.00692-2018. [DOI: 10.1183/13993003.00692-2018] [Citation(s) in RCA: 168] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/01/2018] [Indexed: 12/11/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) remains a truly idiopathic fibrotic disease, with a modest genetic predilection and candidate triggers but no overall explanation for the development of disease in non-familial cases. Agreement on terminology has contributed to major clinical and translational advances since the millennium. It is likely that the entity currently captured by the term “IPF” will be radically reclassified over the next decade, either through “splitting” (into IPF subgroups responding selectively to individual disease-modifying agents) or through “lumping” of IPF with other forms of progressive fibrotic lung disease (with shared pathogenetic mechanisms and IPF-like disease behaviour). In this perspective, we summarise the clinical and pathogenetic justification for a focus on “the progressive fibrotic phenotype” in future clinical and translational research. By this means, we can hope to address the needs of non-IPF patients with inexorably progressive fibrotic disease, currently disenfranchised by lack of access to agents that are efficacious in IPF. In this regard, ongoing trials of anti-fibrotic therapies in non-IPF patients with progressive fibrosis may be highly influential. Future revision of IPF nomenclature may be warranted if there are major conceptual changes but without compelling justification, the benefits of renaming IPF are likely to be outweighed by the resulting confusion.
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