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Matteson EL, Bendstrup E, Strek ME, Dieudé P. Clinical Course of Interstitial Lung Disease in Patients With Rheumatoid Arthritis. ACR Open Rheumatol 2024. [PMID: 39243209 DOI: 10.1002/acr2.11736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/13/2024] [Accepted: 03/22/2024] [Indexed: 09/09/2024] Open
Abstract
Interstitial lung disease (ILD) is a frequent manifestation of rheumatoid arthritis (RA) that is associated with high mortality. RA-ILD may initially be asymptomatic, and lung function may be markedly impaired by the time it is diagnosed. The course of RA-ILD is highly variable, with some patients experiencing no discernable progression or a slow decline, whereas others experience more rapid deterioration. Some patients develop progressive pulmonary fibrosis, which is associated with high mortality. Although risk factors for the progression of RA-ILD have been identified, including older age, worse lung function, and a usual interstitial pneumonia pattern on high-resolution computed tomography, it is not possible to predict the course of RA-ILD in an individual patient. The association between RA disease activity and progression of RA-ILD remains unclear. Regular monitoring is important to enable the prompt identification of progression and early intervention to preserve lung function. The management of RA-ILD requires a multidisciplinary and individualized approach, taking account of the severity and progression of articular and lung disease, risk factors for the progression of RA-ILD, and the patient's preferences, and may include immunosuppression, antifibrotic therapy, and supportive care.
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Affiliation(s)
- Eric L Matteson
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | | | | | - Philippe Dieudé
- Assistance Publique-Hôpitaux de Paris Cité, Bichat-Claude Bernard University Hospital, INSERM UMR1152, University of Paris, Paris, France
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Xing Y, Liu Y, Sha S, Zhang Y, Dou Y, Liu C, Xu M, Zhao L, Wang J, Wang Y, Ma X, Yan Q, Kong X. Multikingdom characterization of gut microbiota in patients with rheumatoid arthritis and rheumatoid arthritis-associated interstitial lung disease. J Med Virol 2024; 96:e29781. [PMID: 38961767 DOI: 10.1002/jmv.29781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 04/24/2024] [Accepted: 06/25/2024] [Indexed: 07/05/2024]
Abstract
Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) is a serious and common extra-articular disease manifestation. Patients with RA-ILD experience reduced bacterial diversity and gut bacteriome alterations. However, the gut mycobiome and virome in these patients have been largely neglected. In this study, we performed whole-metagenome shotgun sequencing on fecal samples from 30 patients with RA-ILD, and 30 with RA-non-ILD, and 40 matched healthy controls. The gut bacteriome and mycobiome were explored using a reference-based approach, while the gut virome was profiled based on a nonredundant viral operational taxonomic unit (vOTU) catalog. The results revealed significant alterations in the gut microbiomes of both RA-ILD and RA-non-ILD groups compared with healthy controls. These alterations encompassed changes in the relative abundances of 351 bacterial species, 65 fungal species, and 4,367 vOTUs. Bacteria such as Bifidobacterium longum, Dorea formicigenerans, and Collinsella aerofaciens were enriched in both patient groups. Ruminococcus gnavus (RA-ILD), Gemmiger formicilis, and Ruminococcus bromii (RA-non-ILD) were uniquely enriched. Conversely, Faecalibacterium prausnitzii, Bacteroides spp., and Roseburia inulinivorans showed depletion in both patient groups. Mycobiome analysis revealed depletion of certain fungi, including Saccharomyces cerevisiae and Candida albicans, in patients with RA compared with healthy subjects. Notably, gut virome alterations were characterized by an increase in Siphoviridae and a decrease in Myoviridae, Microviridae, and Autographiviridae in both patient groups. Hence, multikingdom gut microbial signatures showed promise as diagnostic indicators for both RA-ILD and RA-non-ILD. Overall, this study provides comprehensive insights into the fecal virome, bacteriome, and mycobiome landscapes of RA-ILD and RA-non-ILD gut microbiota, thereby offering potential biomarkers for further mechanistic and clinical research.
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Affiliation(s)
- Yida Xing
- Department of Rheumatology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yiping Liu
- Department of Rheumatology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Shanshan Sha
- Department of Microbiology, Department of Biochemistry and Molecular Biology, College of Basic Medical Sciences, Dalian Medical University, Dalian, China
| | - Yue Zhang
- Puensum Genetech Institute, Wuhan, China
| | - Yuemeng Dou
- Department of Rheumatology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Changyan Liu
- Department of Rheumatology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Mingxi Xu
- Department of Rheumatology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Lin Zhao
- Department of Rheumatology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jingdan Wang
- Department of Rheumatology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yan Wang
- College of Integrative Medicine, Dalian Medical University, Dalian, China
| | - Xiaochi Ma
- College of Integrative Medicine, Dalian Medical University, Dalian, China
| | - Qiulong Yan
- Department of Microbiology, Department of Biochemistry and Molecular Biology, College of Basic Medical Sciences, Dalian Medical University, Dalian, China
| | - Xiaodan Kong
- Department of Rheumatology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
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Mena-Vázquez N, Redondo-Rodriguez R, Rojas-Gimenez M, Romero-Barco CM, Fuego-Varela C, Perez-Gómez N, Añón-Oñate I, Castro Pérez P, García-Studer A, Hidalgo-Conde A, Arnedo Díez de los Ríos R, Cabrera-César E, Velloso-Feijoo ML, Manrique-Arija S, Calvo-Gutiérrez J, Gandía-Martínez M, Morales-Garrido P, Godoy-Navarrete FJ, Mouriño-Rodriguez C, Espildora F, Aguilar-Hurtado MC, Fernández-Nebro A. Rate of severe and fatal infections in a cohort of patients with interstitial lung disease associated with rheumatoid arthritis: a multicenter prospective study. Front Immunol 2024; 15:1341321. [PMID: 38605950 PMCID: PMC11007097 DOI: 10.3389/fimmu.2024.1341321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 03/21/2024] [Indexed: 04/13/2024] Open
Abstract
Objective To describe severe infection, foci of infection, microorganisms, associated factors, and impact on mortality in patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD). Patients and methods The study was based on a multicenter prospective cohort of patients with RA-ILD followed up from 2015 to 2023. The main outcome measures were incident severe infection and fatal infection. We evaluated infectious foci, etiologic agents, vaccination status, variables associated with lung function, and clinical-therapeutic variables in RA. The incidence rate (IR) for infection and mortality was calculated per 100 person-years, and 3 multivariate models were constructed to explore factors associated with infection. Results We followed up 148 patients with RA-ILD for a median 56.7 months (699.3 person-years). During this period, 142 patients (96%) had at least 1 infection. A total of 368 infectious episodes were recorded, with an IR of 52.6 per 100 person-years. Of the 48 patients who died, 65% did so from infection. Respiratory infections were the most common first infection (74%), infection overall (74%), and fatal infection (80%) and were caused mostly by SARS CoV-2, Streptococcus pneumoniae, Pseudomonas aeruginosa, and influenza A virus. The factors associated with an increased risk of infection and death in patients with RA-ILD were age, inflammatory activity, and therapy with corticosteroids and immunosuppressants. Conclusion Patients with RA-ILD have a high risk of serious infection, especially respiratory infection. Infection develops early, is recurrent, and is frequently fatal. The presence of associated factors such as advanced age, joint inflammation, and treatment highlight the importance of integrated and preventive medical care.
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Affiliation(s)
- Natalia Mena-Vázquez
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- UGC de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Rocío Redondo-Rodriguez
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- UGC de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
- Departamento de Medicina, Universidad de Málaga, Málaga, Spain
| | - Marta Rojas-Gimenez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
- UGC de Reumatología, Hospital Universitario Reina Sofía de Córdoba, Córdoba, Spain
| | - Carmen María Romero-Barco
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- UGC de Reumatología, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain
| | | | - Nair Perez-Gómez
- UGC de Reumatología, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
| | | | | | - Aimara García-Studer
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- UGC de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
- Departamento de Medicina, Universidad de Málaga, Málaga, Spain
| | - Ana Hidalgo-Conde
- Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | | | - Eva Cabrera-César
- UGC Neumología, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | | | - Sara Manrique-Arija
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- UGC de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
- Departamento de Medicina, Universidad de Málaga, Málaga, Spain
| | - Jerusalem Calvo-Gutiérrez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
- UGC de Reumatología, Hospital Universitario Reina Sofía de Córdoba, Córdoba, Spain
| | | | | | | | | | | | | | - Antonio Fernández-Nebro
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
- UGC de Reumatología, Hospital Regional Universitario de Málaga, Málaga, Spain
- Departamento de Medicina, Universidad de Málaga, Málaga, Spain
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Petelytska L, Bonomi F, Cannistrà C, Fiorentini E, Peretti S, Torracchi S, Bernardini P, Coccia C, De Luca R, Economou A, Levani J, Matucci-Cerinic M, Distler O, Bruni C. Heterogeneity of determining disease severity, clinical course and outcomes in systemic sclerosis-associated interstitial lung disease: a systematic literature review. RMD Open 2023; 9:e003426. [PMID: 37940340 PMCID: PMC10632935 DOI: 10.1136/rmdopen-2023-003426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/02/2023] [Indexed: 11/10/2023] Open
Abstract
Objective The course of systemic sclerosis-associated interstitial lung disease (SSc-ILD) is highly variable and different from continuously progressive idiopathic pulmonary fibrosis (IPF). Most proposed definitions of progressive pulmonary fibrosis or SSc-ILD severity are based on the research data from patients with IPF and are not validated for patients with SSc-ILD. Our study aimed to gather the current evidence for severity, progression and outcomes of SSc-ILD.Methods A systematic literature review to search for definitions of severity, progression and outcomes recorded for SSc-ILD was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in Medline, Embase, Web of Science and Cochrane Library up to 1 August 2023.Results A total of 9054 papers were reviewed and 342 were finally included. The most frequent tools used for the definition of SSc-ILD progression and severity were combined changes of carbon monoxide diffusing capacity (DLCO) and forced vital capacity (FVC), isolated FVC or DLCO changes, high-resolution CT (HRCT) extension and composite algorithms including pulmonary function test, clinical signs and HRCT data. Mortality was the most frequently reported long-term event, both from all causes or ILD related.Conclusions The studies presenting definitions of SSc-ILD 'progression', 'severity' and 'outcome' show a large heterogeneity. These results emphasise the need for developing a standardised, consensus definition of severe SSc-ILD, to link a disease specific definition of progression as a surrogate outcome for clinical trials and clinical practice.PROSPERO registration number CRD42022379254.Cite Now.
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Affiliation(s)
- Liubov Petelytska
- Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department Internal Medicine #3, Bogomolets National Medical University, Kiiv, Ukraine
| | - Francesco Bonomi
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Carlo Cannistrà
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Elisa Fiorentini
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Silvia Peretti
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Sara Torracchi
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Pamela Bernardini
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Carmela Coccia
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Riccardo De Luca
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Alessio Economou
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Juela Levani
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, San Raffaele Hospital, Milan, Italy
| | - Oliver Distler
- Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Cosimo Bruni
- Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence - Careggi University Hospital, Florence, Italy
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El-Kalashy MM, Elbeltagy SA, Zahran ES, Salman MM, Elrahman SRA, Abdalraouf MM, El-Koa AA. Assessment of cardiopulmonary manifestations and its correlation with semi-quantitative scoring of high-resolution computed tomography in patients with autoimmune rheumatic diseases. BMC Pulm Med 2023; 23:131. [PMID: 37076832 PMCID: PMC10114390 DOI: 10.1186/s12890-023-02404-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 03/30/2023] [Indexed: 04/21/2023] Open
Abstract
PURPOSE Autoimmune rheumatic diseases (ARD) are groups of diseases that are commonly associated with cardiac and pulmonary manifestations and may affect the morbidity and mortality of the patients. The study aimed to the assessment of cardiopulmonary manifestations and their correlation with the semi-quantitative scoring of high-resolution computed tomography (HRCT) in ARD patients. METHODS AND PATIENTS 30 patients with ARD were included in the study (mean age 42.2 ± 9.76 years) [10 patients were scleroderma (SSc), 10 patients were rheumatoid arthritis (RA), and 10 patients were systemic lupus erythematosus (SLE)]. They all met the diagnostic criteria of the American College of Rheumatology and underwent spirometry, echocardiography, and chest HRCT. The HRCT was assessed by a semi-quantitative score for parenchymal abnormalities. Correlation between HRCT lung scores and: inflammatory markers, lung volumes in spirometry, and echocardiographic indices has been performed. RESULTS The total lung score (TLS) by HRCT was 14.8 ± 8.78 (mean ± SD), ground glass opacity score (GGO) was 7.20 ± 5.79 (mean ± SD) and fibrosis lung score (F) was 7.63 ± 6.05 (mean ± SD). TLS correlated significantly with ESR (r 0.528, p 0.003), CRP (r 0.439, p 0.015), PaO2 (r -0.395, P 0.031) FVC% (r -0.687, p 0.001), and echocardiographic Tricuspid E (r -0.370, p 0.044), Tricuspid E/è (r -0.397,p 0.03), ESPAP (r 0.459,p 0.011), TAPSE (r -0.405, p 0.027), MPI-TDI (r -0.428, p 0.018) and RV Global strain(r -0.567, p 0.001). GGO score correlated significantly with ESR (r 0.597, p 0.001), CRP (r 0.473, p 0.008), FVC% (r -0.558, p 0.001), and RV Global strain(r -0.496, p 0.005). F score correlated significantly with FVC% (r -0.397, p 0.030), Tricuspid E/è (r -0.445, p 0.014), ESPAP (r 0.402, p 0.028), and MPI-TDI (r -0.448, p 0.013). CONCLUSION The total lung score and GGO score in ARD were found to be consistently significantly correlated with FVC% predicted, PaO2, inflammatory markers, and RV functions. Fibrotic score correlated with ESPAP. Therefore, in a clinical setting, most clinicians who monitor patients suffering from ARD should concern with the applicability of semiquantitative HRCT scoring in clinical practice.
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Affiliation(s)
- Mai M El-Kalashy
- Chest Disease and Tuberculosis, Faculty of Medicine, Menoufia University, Shibin Al Kawm, Egypt
| | - Samah A Elbeltagy
- Chest Disease and Tuberculosis, Faculty of Medicine, Menoufia University, Shibin Al Kawm, Egypt
| | - Enas S Zahran
- Internal Medicine, Rheumatology and Clinical Immunology Unit, Faculty of Medicine, Menoufia University, Shibin Al Kawm, Egypt
| | - Maha M Salman
- Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Menoufia University, Shibin Al Kawm, Egypt
| | | | - Mai M Abdalraouf
- Cardiology, Faculty of Medicine, Menoufia University, Shibin Al Kawm, Egypt
| | - Amal A El-Koa
- Chest Disease and Tuberculosis, Faculty of Medicine, Menoufia University, Shibin Al Kawm, Egypt.
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Mena-Vázquez N, Godoy-Navarrete FJ, Lisbona-Montañez JM, Redondo-Rodriguez R, Manrique-Arija S, Rioja J, Mucientes A, Ruiz-Limón P, Garcia-Studer A, Ortiz-Márquez F, Oliver-Martos B, Cano-García L, Fernández-Nebro A. Inflammatory Biomarkers in the Diagnosis and Prognosis of Rheumatoid Arthritis-Associated Interstitial Lung Disease. Int J Mol Sci 2023; 24:ijms24076800. [PMID: 37047772 PMCID: PMC10095191 DOI: 10.3390/ijms24076800] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/22/2023] [Accepted: 04/03/2023] [Indexed: 04/14/2023] Open
Abstract
This study aimed to identify inflammatory factors and soluble cytokines that act as biomarkers in the diagnosis and prognosis of rheumatoid arthritis-associated interstitial lung disease (RA-ILD). We performed a nested prospective observational case-control study of patients with RA-ILD matched by sex, age, and time since the diagnosis of RA. All participants underwent pulmonary function testing and high-resolution computed tomography. ILD was defined according to the criteria of the American Thoracic Society/European Respiratory Society; the progression of lung disease was defined as the worsening of FVC > 10% or DLCO > 15%. Inflammation-related variables included the inflammatory activity measured using the DAS28-ESR and a multiplex cytokine assay. Two Cox regression models were run to identify factors associated with ILD and the progression of ILD. The study population comprised 70 patients: 35 patients with RA-ILD (cases) and 35 RA patients without ILD (controls). A greater percentage of cases had higher DAS28-ESR (p = 0.032) and HAQ values (p = 0.003). The variables associated with RA-ILD in the Cox regression analysis were disease activity (DAS28) (HR [95% CI], 2.47 [1.17-5.22]; p = 0.017) and high levels of ACPA (HR [95% CI], 2.90 [1.24-6.78]; p = 0.014), IL-18 in pg/mL (HR [95% CI], 1.06 [1.00-1.12]; p = 0.044), MCP-1/CCL2 in pg/mL (HR [95% CI], 1.03 [1.00-1.06]; p = 0.049), and SDF-1 in pg/mL (HR [95% CI], 1.00 [1.00-1.00]; p = 0.010). The only variable associated with the progression of ILD was IL-18 in pg/mL (HR [95% CI], 1.25 [1.07-1.46]; p = 0.004). Our data support that the inflammatory activity was higher in patients with RA-ILD than RA patients without ILD. Some cytokines were associated with both diagnosis and poorer prognosis in patients with RA-ILD.
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Affiliation(s)
- Natalia Mena-Vázquez
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, 29010 Málaga, Spain
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
| | | | - Jose Manuel Lisbona-Montañez
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, 29010 Málaga, Spain
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, 29010 Málaga, Spain
| | - Rocío Redondo-Rodriguez
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, 29010 Málaga, Spain
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, 29010 Málaga, Spain
| | - Sara Manrique-Arija
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, 29010 Málaga, Spain
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, 29010 Málaga, Spain
| | - José Rioja
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, 29010 Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, 29010 Málaga, Spain
| | - Arkaitz Mucientes
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, 29010 Málaga, Spain
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
| | - Patricia Ruiz-Limón
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, 29010 Málaga, Spain
- UGC de Endocrinología y Nutrición, Hospital Clínico Virgen de la Victoria, 29010 Málaga, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Aimara Garcia-Studer
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, 29010 Málaga, Spain
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
| | - Fernando Ortiz-Márquez
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, 29010 Málaga, Spain
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, 29010 Málaga, Spain
| | - Begoña Oliver-Martos
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, 29010 Málaga, Spain
- UGC de Neurociencias, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain
| | - Laura Cano-García
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, 29010 Málaga, Spain
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
| | - Antonio Fernández-Nebro
- Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, 29010 Málaga, Spain
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, 29010 Málaga, Spain
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Stainer A, Tonutti A, De Santis M, Amati F, Ceribelli A, Bongiovanni G, Torrisi C, Iacopino A, Mangiameli G, Aliberti S, Selmi C. Unmet needs and perspectives in rheumatoid arthritis-associated interstitial lung disease: A critical review. Front Med (Lausanne) 2023; 10:1129939. [PMID: 37007765 PMCID: PMC10062456 DOI: 10.3389/fmed.2023.1129939] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/20/2023] [Indexed: 03/18/2023] Open
Abstract
Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease characterized by synovitis as the most common clinical manifestation, and interstitial lung disease (RA-ILD) represents one of the most common and potentially severe extra-articular features. Our current understanding of the mechanisms and predictors of RA-ILD is limited despite the demonstration that an early identification of progressive fibrosing forms is crucial to provide timely treatment with antifibrotic therapies. While high resolution computed tomography is the gold standard technique for the diagnosis and follow-up of RA-ILD, it has been hypothesized that serum biomarkers (including novel and rare autoantibodies), new imaging techniques such as ultrasound of the lung, or the application of innovative radiologic algorithms may help towards predicting and detecting early forms of diseases. Further, while new treatments are becoming available for idiopathic and connective tissue disease-associated forms of lung fibrosis, the treatment of RA-ILD remains anecdotal and largely unexplored. We are convinced that a better understanding of the mechanisms connecting RA with ILD in a subgroup of patients as well as the creation of adequate diagnostic pathways will be mandatory steps for a more effective management of this clinically challenging entity.
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Affiliation(s)
- Anna Stainer
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Respiratory Medicine, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Maria De Santis
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Milan, Italy
- *Correspondence: Maria De Santis,
| | - Francesco Amati
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Respiratory Medicine, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Angela Ceribelli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Gabriele Bongiovanni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Chiara Torrisi
- Department of Radiology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Antonio Iacopino
- Department of Radiology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Giuseppe Mangiameli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Thoracic Surgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Respiratory Medicine, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Carlo Selmi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Division of Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, Milan, Italy
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Lee SK, Shin K, Jung JY, Suh CH, Kim JW, Kim HA. Retention Rate and Safety of Biologic and Targeted Synthetic DMARDs in Patients with RA-Associated Interstitial Lung Disease: A KOBIO Registry Study. BioDrugs 2023; 37:247-257. [PMID: 36757601 DOI: 10.1007/s40259-023-00578-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2022] [Indexed: 02/10/2023]
Abstract
OBJECTIVES This study aimed to evaluate the long-term retention and safety of biologic disease-modifying antirheumatic drugs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs) and identify the factors associated with drug withdrawal in patients with rheumatoid arthritis (RA) with interstitial lung disease (ILD) enrolled in the Korean College of Rheumatology Biologics and Targeted Therapy registry. METHODS We investigated adults with RA (n = 2266) administered with bDMARDs or tsDMARDs between 2012 and 2021. Propensity score matching (1:3) was performed between patients with RA with ILD (RA-ILD) and without ILD (RA-no ILD). The Kaplan-Meier method was used to analyse drug survival and a logistic regression model to identify withdrawal-related factors in RA-ILD. RESULTS One hundred and fifty-nine patients with RA-ILD were matched with 477 patients with RA-no ILD. The 5-year drug retention rate was lower in RA-ILD than in RA-no ILD (log-rank p = 0.020), and both the ILD and no-ILD groups had statistical differences of drug retention rate among agents (log-rank p = 0.019 and 0.020, respectively). In the RA-ILD group, Janus kinase inhibitors had the highest drug retention rate (64.3%), and tumour necrosis factor-α inhibitors showed the lowest retention rate (30.6%). Approximately 58.5% and 48.4% of the patients with RA-ILD and RA-no ILD, respectively, withdrew from their regimen, and the main cause of withdrawal in RA-ILD was adverse events, followed by inefficacy. In the logistic regression analysis, current smoking had a negative effect on drug retention (odds ratio [OR]: 9.938, 95% confidence interval [CI]: 2.550-38.733; p < 0.001), while concomitant corticosteroid use had a protective effect against withdrawal (OR: 0.284, 95% CI: 0.008-0.917; p = 0.035) in RA-ILD. CONCLUSION The patients with RA-ILD had lower bDMARD and tsDMARD retention rates than those with RA-no ILD. In the RA-ILD group, current smoking and concomitant corticosteroid use were associated factors affecting drug withdrawal.
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Affiliation(s)
- Sun-Kyung Lee
- Department of Mathematics, College of Natural Sciences, Hanyang University, Seoul, Korea
| | - Kichul Shin
- Division of Rheumatology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ju-Yang Jung
- Department of Rheumatology, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon, 16499, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon, 16499, Korea
| | - Ji-Won Kim
- Department of Rheumatology, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon, 16499, Korea.
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon, 16499, Korea.
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9
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Nasonov EL, Ananyeva LP, Avdeev SN. Interstitial lung disease in rheumatoid arthritis: A multidisciplinary problem in rheumatology and pulmonology. RHEUMATOLOGY SCIENCE AND PRACTICE 2022. [DOI: 10.47360/1995-4484-2022-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Rheumatoid arthritis (RA) is an immune-mediated rheumatic disease (IMRDs) characterized by chronic erosive arthritis and systemic damage to internal organs, leading to early disability and reduced life expectancy in patients. A particularly important place among the systemic manifestations of RA is occupied by interstitial lung diseases (ILD) – the most severe form of pulmonary pathology in RA, defined as RA-ILD, which is pathogenetically associated with risk factors (smoking, etc.) and autoimmune mechanisms underlying RA. RA-ILD is a subtype of RA characterized by a severe course and a poor prognosis и неблагоприятным прогнозом. The review presents new data regarding risk factors and biomarkers for RA-ILD; modern diagnostic capabilities based on the use of functional lung tests, high-resolution computed tomography, ultrasound examination of the lungs. Particular attention is paid to the efficacy and safety of pharmacotherapy, including methotrexate, biologics, JAK inhibitors, and antifibrotic therapy. An algorithm for the pharmacotherapy of RA-ILD has been proposed.
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Affiliation(s)
- E. L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; I.M. Sechenov First Moscow State Medical University of the Ministry of Health Care of Russian Federation (Sechenov University)
| | | | - S. N. Avdeev
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health Care of Russian Federation (Sechenov University)
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10
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Mononen M, Saari E, Hasala H, Kettunen HP, Suoranta S, Nurmi H, Kärkkäinen M, Selander T, Randell J, Laurikka J, Uibu T, Koskela H, Kaarteenaho R, Purokivi M. Reticulation pattern without honeycombing on high-resolution CT is associated with the risk of disease progression in interstitial lung diseases. BMC Pulm Med 2022; 22:313. [PMID: 35965320 PMCID: PMC9375921 DOI: 10.1186/s12890-022-02105-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background The disease course of idiopathic pulmonary fibrosis (IPF) is progressive and occasionally, other types of interstitial lung disease (ILD) may progress similarly to IPF. This study aimed to evaluate risk factors for disease progression within 24 months in patients with various ILDs. Methods This prospective study obtained 97 patients with a suspected ILD who underwent a transbronchial lung cryobiopsy. The extent of several high-resolution computed tomography (HRCT) patterns was assessed. Due to the inclusion criteria the study population presented a low extent of honeycombing and definite usual interstitial pneumonia (UIP) pattern on HRCT suggesting an early stage of ILD. Disease progression within 24 months despite treatment was defined as a relative decline of ≥ 10% in forced vital capacity (FVC), or a relative decline in FVC of ≥ 5% and one of the three additional criteria: (1) a decline in diffusion capacity to carbon monoxide (DLCO) ≥ 15%; (2) increased fibrosis on HRCT; (3) progressive symptoms, or progressive symptoms and increased fibrosis on HRCT. The same definition was utilized in patients with IPF and other ILDs. Risk factors for disease progression were evaluated in a multivariable logistic regression model. Results Disease progression was revealed in 52% of the patients with ILD, 51% of the patients with IPF, and 53% of the patients with other types of ILD. A high extent of reticulation on HRCT (Odds ratio [OR] 3.11, 95% Confidence interval [CI] 1.21–7.98, P = 0.019) and never smoking (OR 3.11, CI 1.12–8.63, P = 0.029) were associated with disease progression whereas platelet count (OR 2.06 per 100 units increase, CI 0.96–4.45, P = 0.065) did not quite reach statistical significance. Conclusion Higher extent of reticulation on HRCT and never smoking appeared to associate with the risk of disease progression within 24 months in ILD patients without honeycombing. Approximately half of the patients with ILD revealed disease progression, and similar proportions were observed in patients with IPF and in other types of ILD. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02105-9.
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11
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Mena-Vázquez N, Rojas-Gimenez M, Fuego-Varela C, García-Studer A, Perez-Gómez N, Romero-Barco CM, Godoy-Navarrete FJ, Manrique-Arija S, Gandía-Martínez M, Calvo-Gutiérrez J, Morales-Garrido P, Mouriño-Rodriguez C, Castro-Pérez P, Añón-Oñate I, Espildora F, Aguilar-Hurtado MC, Hidalgo Conde A, Arnedo Díez de los Ríos R, Cabrera César E, Redondo-Rodriguez R, Velloso-Feijoo ML, Fernández-Nebro A. Safety and Effectiveness of Abatacept in a Prospective Cohort of Patients with Rheumatoid Arthritis–Associated Interstitial Lung Disease. Biomedicines 2022; 10:biomedicines10071480. [PMID: 35884786 PMCID: PMC9313094 DOI: 10.3390/biomedicines10071480] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/16/2022] [Accepted: 06/21/2022] [Indexed: 11/16/2022] Open
Abstract
Objective: To prospectively evaluate the safety and efficacy profile of abatacept in patients with rheumatoid arthritis–associated interstitial lung disease (RA-ILD). Methods: We performed a prospective observational multicenter study of a cohort of patients with RA-ILD treated with abatacept between 2015 and 2021. Patients were evaluated using high-resolution computed tomography and pulmonary function tests at initiation, 12 months, and the end of follow-up. The effectiveness of abatacept was evaluated based on whether ILD improved, stabilized, progressed, or was fatal. We also evaluated factors such as infection, hospitalization, and inflammatory activity using the 28-joint Disease Activity Score with the erythrocyte sedimentation rate (DAS28-ESR). Cox regression analysis was performed to identify factors associated with progression of lung disease. Results: The study population comprised 57 patients with RA-ILD treated with abatacept for a median (IQR) of 27.3 (12.2–42.8) months. Lung disease had progressed before starting abatacept in 45.6% of patients. At the end of follow-up, lung disease had improved or stabilized in 41 patients (71.9%) and worsened in 13 (22.8%); 3 patients (5.3%) died. No significant decreases were observed in forced vital capacity (FVC) or in the diffusing capacity of the lung for carbon monoxide (DLCO).The factors associated with progression of RA-ILD were baseline DAS28-ESR (OR [95% CI], 2.52 [1.03–3.12]; p = 0.041), FVC (OR [95% CI], 0.82 [0.70–0.96]; p = 0.019), and DLCO (OR [95% CI], 0.83 [0.72–0.96]; p = 0.018). Only 10.5% of patients experienced severe adverse effects. Conclusion: Pulmonary function and joint inflammation stabilized in 71% of patients with RA-ILD treated with abatacept. Abatacept had a favorable safety profile.
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Affiliation(s)
- Natalia Mena-Vázquez
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
- Correspondence:
| | - Marta Rojas-Gimenez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Cordova, Spain; (M.R.-G.); (J.C.-G.)
- UGC de Reumatología, Hospital Universitario Reina Sofía de Córdoba, 14004 Cordova, Spain
| | - Clara Fuego-Varela
- UGC de Reumatología, Hospital Universitario de Jerez, 11407 Cadiz, Spain; (C.F.-V.); (M.G.-M.)
| | - Aimara García-Studer
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
| | - Nair Perez-Gómez
- UGC de Reumatología, Complejo Hospitalario Universitario de Vigo, 36214 Vigo, Spain; (N.P.-G.); (C.M.-R.)
| | - Carmen María Romero-Barco
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Clínico Universitario Virgen de la Victoria, 29010 Malaga, Spain
| | | | - Sara Manrique-Arija
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
- Departamento de Medicina, Universidad de Málaga, 29010 Malaga, Spain
| | - Myriam Gandía-Martínez
- UGC de Reumatología, Hospital Universitario de Jerez, 11407 Cadiz, Spain; (C.F.-V.); (M.G.-M.)
| | - Jerusalem Calvo-Gutiérrez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Cordova, Spain; (M.R.-G.); (J.C.-G.)
- UGC de Reumatología, Hospital Universitario Reina Sofía de Córdoba, 14004 Cordova, Spain
| | - Pilar Morales-Garrido
- UGC de Reumatología, Hospital Universitario Clínico San Cecilio, 18016 Granada, Spain;
| | - Coral Mouriño-Rodriguez
- UGC de Reumatología, Complejo Hospitalario Universitario de Vigo, 36214 Vigo, Spain; (N.P.-G.); (C.M.-R.)
| | | | - Isabel Añón-Oñate
- UGC de Reumatología, Hospital Universitario de Jaén, 23007 Jaen, Spain; (F.J.G.-N.); (I.A.-O.)
| | - Francisco Espildora
- UGC de Neumología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain;
| | | | - Ana Hidalgo Conde
- Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, 29010 Malaga, Spain; (A.H.C.); (R.A.D.d.l.R.)
| | - Rocío Arnedo Díez de los Ríos
- Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, 29010 Malaga, Spain; (A.H.C.); (R.A.D.d.l.R.)
| | - Eva Cabrera César
- UGC Neumología, Hospital Universitario Virgen de la Victoria, 29010 Malaga, Spain;
| | - Rocío Redondo-Rodriguez
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
| | | | - Antonio Fernández-Nebro
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (R.R.-R.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain
- Departamento de Medicina, Universidad de Málaga, 29010 Malaga, Spain
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12
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Mena-Vázquez N, García-Studer A, Rojas-Gimenez M, Romero-Barco CM, Manrique-Arija S, Mucientes A, Velloso-Feijoo ML, Godoy-Navarrete FJ, Morales-Garrido P, Redondo-Rodríguez R, Ordoñez-Cañizares MC, Ortega-Castro R, Lisbona-Montañez JM, Hidalgo Conde A, Arnedo Díez de los Ríos R, Cabrera César E, Espildora F, Aguilar-Hurtado MC, Añón-Oñate I, Ureña-Garnica I, Fernández-Nebro A. Importance of Vaccination against SARS-CoV-2 in Patients with Interstitial Lung Disease Associated with Systemic Autoimmune Disease. J Clin Med 2022; 11:jcm11092437. [PMID: 35566564 PMCID: PMC9106041 DOI: 10.3390/jcm11092437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/23/2022] [Accepted: 04/24/2022] [Indexed: 01/09/2023] Open
Abstract
Objectives: To describe the frequency of COVID-19 and the effect of vaccination in patients with interstitial lung disease and systemic autoimmune disease (ILD-SAD) and to identify factors associated with infection and severity of COVID-19. Methods: We performed a cross-sectional multicenter study of patients with ILD-SAD followed between June and October 2021. The main variable was COVID-19 infection confirmed by a positive polymerase chain reaction (PCR) result for SARS-CoV-2. The secondary variables included severity of COVID-19, if the patient had to be admitted to hospital or died of the disease, and vaccination status. Other variables included clinical and treatment characteristics, pulmonary function and high-resolution computed tomography. Two logistic regression was performed to explore factors associated with “COVID-19” and “severe COVID-19”. Results: We included 176 patients with ILD-SAD: 105 (59.7%) had rheumatoid arthritis, 49 (27.8%) systemic sclerosis, and 22 (12.54%) inflammatory myopathies. We recorded 22/179 (12.5%) SARS-CoV-2 infections, 7/22 (31.8%) of them were severe and 3/22 (13.22%) died. As to the vaccination, 163/176 (92.6%) patients received the complete doses. The factors associated with SARS-CoV-2 infection were FVC (OR (95% CI), 0.971 (0.946−0.989); p = 0.040), vaccination (OR (95% CI), 0.169 (0.030−0.570); p = 0.004), and rituximab (OR (95% CI), 3.490 (1.129−6.100); p = 0.029). The factors associated with severe COVID-19 were the protective effect of the vaccine (OR (95% CI), 0.024 (0.004−0.170); p < 0.001) and diabetes mellitus (OR (95% CI), 4.923 (1.508−19.097); p = 0.018). Conclusions: Around 13% of patients with ILD-SAD had SARS-CoV-2 infection, which was severe in approximately one-third. Most patients with severe infection were not fully vaccinated.
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Affiliation(s)
- Natalia Mena-Vázquez
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (A.M.); (R.R.-R.); (M.O.-C.); (I.U.-G.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain;
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Cordoba, Spain; (M.R.-G.); (R.O.-C.)
- Correspondence:
| | - Aimara García-Studer
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (A.M.); (R.R.-R.); (M.O.-C.); (I.U.-G.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain;
| | - Marta Rojas-Gimenez
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Cordoba, Spain; (M.R.-G.); (R.O.-C.)
- UGC de Reumatología, Hospital Universitario Reina Sofía de Córdoba, 14004 Cordoba, Spain
| | - Carmen María Romero-Barco
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (A.M.); (R.R.-R.); (M.O.-C.); (I.U.-G.); (A.F.-N.)
- UGC de Reumatología, Hospital Clínico Universitario Virgen de la Victoria, 29010 Malaga, Spain
| | - Sara Manrique-Arija
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (A.M.); (R.R.-R.); (M.O.-C.); (I.U.-G.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain;
- Departamento de Medicina, Universidad de Málaga, 29016 Malaga, Spain
| | - Arkaitz Mucientes
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (A.M.); (R.R.-R.); (M.O.-C.); (I.U.-G.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain;
| | | | | | | | - Rocío Redondo-Rodríguez
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (A.M.); (R.R.-R.); (M.O.-C.); (I.U.-G.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain;
| | - MC Ordoñez-Cañizares
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (A.M.); (R.R.-R.); (M.O.-C.); (I.U.-G.); (A.F.-N.)
- UGC de Reumatología, Hospital Clínico Universitario Virgen de la Victoria, 29010 Malaga, Spain
| | - Rafaela Ortega-Castro
- Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Cordoba, Spain; (M.R.-G.); (R.O.-C.)
- UGC de Reumatología, Hospital Universitario Reina Sofía de Córdoba, 14004 Cordoba, Spain
| | - Jose Manuel Lisbona-Montañez
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain;
- Departamento de Medicina, Universidad de Málaga, 29016 Malaga, Spain
| | - Ana Hidalgo Conde
- Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, 29010 Malaga, Spain; (A.H.C.); (R.A.D.d.l.R.)
| | - Rocío Arnedo Díez de los Ríos
- Servicio de Medicina Interna, Hospital Universitario Virgen de la Victoria, 29010 Malaga, Spain; (A.H.C.); (R.A.D.d.l.R.)
| | - Eva Cabrera César
- UGC Neumología, Hospital Universitario Virgen de la Victoria, 29010 Malaga, Spain;
| | - Francisco Espildora
- UGC de Neumología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain;
| | | | - Isabel Añón-Oñate
- Hospital Universitario de Jaén, 23007 Jaén, Spain; (F.J.G.-N.); (I.A.-O.)
| | - Inmaculada Ureña-Garnica
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (A.M.); (R.R.-R.); (M.O.-C.); (I.U.-G.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain;
| | - Antonio Fernández-Nebro
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Malaga, Spain; (A.G.-S.); (C.M.R.-B.); (S.M.-A.); (A.M.); (R.R.-R.); (M.O.-C.); (I.U.-G.); (A.F.-N.)
- UGC de Reumatología, Hospital Regional Universitario de Málaga, 29009 Malaga, Spain;
- Departamento de Medicina, Universidad de Málaga, 29016 Malaga, Spain
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