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Fibrosis
OBJECTIVES
Know the definitions of ILD, IIP, and IPF
Understand the pathogenesis of IPF
Appreciate the clinical features
Realize how the diagnosis of IPF is made
Know current therapies
Become aware of areas of current research
and novel therapeutic approaches
Be able to summarize current thinking about
IPF
Death occurred about three months and a half after the onset of the acute
disease and the lung was two thirds of the normal size, grayish in color, and hard
as cartilage. Microscopically these areas showed advanced fibrotic changes and
great thickening of the alveolar walls.
- Sir William Osler, 1892
Treatment-Related / Drug-Induced
Antibiotics nitrofurantoin, sulfasalazine
Antiarrhythmics amiodarone, propanolol
Anti-inflammatories gold, penacillamine
Anti-convulsants dilantin
Chemotherapeutic agents bleomycin, cyclophosphamide,
methotrexate, azathioprine
Therapeutic radiation
Oxygen toxicity
Narcotics
Occupational and Environmental Diseases
Inorganic
Organic
Silicosis
Asbestosis
Hard-metal pneumoconiosis
Coal workers pneumoconiosis
Berylliosis
Aluminum oxide fibrosis
Talc pneumoconiosis
Siderosis (arc welder)
Stannosis (tin)
Histologic Pattern
Organizing pneumonia
Respiratory bronchiolitis
UIP IPF
HONEYCOMB PATTERN
EPIDEMIOLOGY
Estimated to affect approx 5 million people worldwide
The most common (and deadly) interstitial lung disease
Most cases are sporadic, but rare cases of familial IPF have
been described
EPIDEMIOLOGY
Pathogenesis IPF
4. Matrix metalloproteinases
- MMP7, MMP1 and MMP2 genes are highly expressed in
IPF
- most of these MMP are localized in the AEC
- MMP2 is increased in alveolar and bronchiolar epithelial
cells and in fibroblastic foci
- increased expression of MMP1 is associated with two
gene polymorphisms
5. Angiogenesis
- an aberrant vascular remodelling occurs in lungs
affected by IPF: fibrotic areas have fewer blood vessels,
whereas adjacent non-fibrotic tissue is highly
vascularized
GENETIC SUSCEPTIBILITY?
Up to 3% of cases of IPF appear to cluster in families (Familial IPF)
Armanios et al, NEJM 2007.
Chronic aspiration?
PATHOGENESIS
Originally thought inflammation fibrosis
Animal models
Early IPF is dominated by inflammatory cells
Asymptomatic relatives of patients with familial IPF
have evidence of alveolitis in the absence of disease
PROBLEMS:
PATHOGENESIS
Starting around 1998, studies began to demonstrate that inflammation is
NOT a prominent finding in most cases of IPF/UIP.
PATHOGENESIS
CLINICAL PRESENTATION
Middle age 50-70s
New onset of progressive exertional dyspnea and nonproductive cough
Most have symptoms for 12-18 months prior to definitive
evaluation
Constitutional symptoms are uncommon
Weight loss, fever, fatigue, myalgias, or arthralgias
occasionally present
Detailed occupational and exposure history
PHYSICAL EXAM
Bibasilar late inspiratory fine crackles (Velcro rales)
Tachypnea
Clubbing 40-75% - late in disease course
Cardiac exam usually normal until middle-late stages
- augmented P2, right-sided heave, S3 gallop
Cyanosis
Rash, arthritis, myositis should suggest an alternate
diagnosis
CXR
16% of patients with
ILD have normal
chest x-rays
CXR
CXR
PFTs
PFTs
= Restrictive pattern
Source: images.md
ABG
ABG
HIGH RES CT
Can be used to detect disease, especially in pts with no
or minimal changes on CXR
Can determine extent and severity of disease activity
Can now be used to differentiate IPF from other ILD
HIGH RES CT
BAL in IPF
Role and value of serial BAL in IPF previously unknown
Increased inflammatory cells in IPF, but no predominant type
Kinder et al, Chest, Jan 2008
156 subjects with biopsy proven UIP/IPF enrolled between 1982-1996
BAL within 3 weeks of lung biopsy
Linear relationship between increasing neutrophil percentage and the risk of
mortality
Each doubling in the neutrophil percentage was associated with a nearly 30%
increased risk of death or transplantation in adjusted analysis ([HR] 1.28;
95% CI, 1.01 to 1.62; p = 0.04). There was no association with lymphocyte or
eosinophil percentage.
Suggests that BAL fluid neutrophil percentage at the time of diagnosis of IPF is an
independent predictor of time to death.
LUNG BIOPSY
Gold Standard for diagnosis of IPF (and IIPs)
Large piece of lung parenchyma is required, optimally from several sites
Transbronchial biopsy is only useful for ruling out other disorders
Can be performed by thoracotomy, thorascopy, or VATS
VQ scan
Histopathological Criteria
Minor Criteria:
Age > 50
Insidious onset of otherwise unexplained dyspnea on exertion
Duration of illness greater than 3 months
Bibasilar inspiratory crackles (dry or Velcro-type in quality)
ALL of the major criteria plus at least THREE minor criteria.
Accelerated variant
- a subgroup of patients, mainly male cigarette smokers,
has a rapidly progressive course with shortened survival
- the upregulated genes in the group whose disease
progressed rapidly included members of the MAPK-EGR1HSP70 (mitogen-activated protein kinase-early growth
response gene protein-heat shock protein 70) pathway,
which regulate cigarette smoke-induced inflamation
Acute exacerbation
- acute exacerbation of IPF is defined by rapid
deterioration of the disease in the absence of infection,
heart failure, pulmonary embolism, or other identifiable
causes
- diagnosis is made by a combination of clinical,
physiological and radiographical findings
Diagnosis of IPF
Unexplained development of worsening of dyspnea within 30 days
HRCT with new ground-glass abnormalities
No evidence of pulmonary infection by ET aspirate or BAL
Exclusion of alternative causes, e.g. HF, PE
PATHOGENESIS
TREATMENT
STEROIDS
Fifteen studies were selected as potentially eligible for meta-analysis. After further
analysis of full text papers, no RCTs or CCTs were identified as suitable and therefore no
data was available for inclusion in any meta-analysis. All studies were excluded due to
inadequate methodologies.
AZATHIOPRINE
Raghu et al, Am Rev Respir Dis 1991.
27 newly diagnosed patients with IPF
Prednisone + Azathioprine vs. Prednisone + Placebo, follow-up 9 years
After 1 year, P+A had better lung function, but was not significant
43% (6/14) died vs. 77% (10/13)
Side effects:
leukopenia,
GI-related
Probability of
Survival
1.0
P = 0.16
P = 0.02 (age adjusted)
0.8
Azathioprine +
Prednisone (n = 14)
0.6
0.4
Prednisone (n = 13)
0.2
0
0 1 2 3 4 5 6 7 8 9
Years
CYCLOPHOSPHAMIDE
N-acetylcysteine (NAC)
Demedts et al, NEJM, 2005.
182 patients with UIP
Prednisone + Azathioprine + High-dose NAC (600mg TID) vs. P/A
Significant difference in the deterioration of VC and DLCO at 12 months
Relative difference of 9% and 24% respectively
Oxidant-antioxidant imbalance?
Mortality, P =
NS
NAC+Pred+Aza
Pred+Aza+
Placebo
7/80 (9%)
8/75 (11%)
LUNG TRANSPLANT
IPF is the most common ILD among referrals for transplant and the 2 nd
most frequent disease for which lung transplantation is performed
Criteria:
PERFENIDONE
Mechanism of Action:
Drug
Mechanism
Status
Bosentan
(BUILD-1)
Endothelin
receptor
agonist
Phase III
Etanercept
TNF- blocker
Phase II
Imatinib
FG-3019
Anti-CTGF
monoclonal Ab
Limited data:
Methotrexate
Cyclosporine
Colchicine
Penicillamine
Phase II
planned
SUMMARY
IPF is the most common ILD with the worst prognosis
The most important distinction is differentiate IPF from the other IIPs
Biopsy is the gold standard for diagnosis, histology = UIP pattern with
fibroblast foci (hallmark of IPF)
Most common presentation is 50-60 y.o. male with progressive dyspnea
and non-productive cough
Most common physical exam findings are Velcro rales +/- clubbing
Most important diagnostic studies are CXR, PFTs, ABG, and HRCT
Higher BAL neutrophil percentage at time of diagnosis = worse prognosis?
If certain clinical criteria are met, can diagnose IPF without biopsy
Acute exacerbations are now recognized to be an important target for
therapy
SUMMARY
Possible genetic component involving mutant telomeres, resulting in
apoptosis of alveolar cells
Newly accepted hypothesis that fibrosis is a result of aberrant wound
healing resulting from repeated injury of unknown cause
There is a high correlation with GERD in IPF
There is still no effective therapy for IPF
Current recommendation is steroids + azathioprine + NAC
SLT improves 5-year survival, LDLLT shows promise in advanced disease
Perfenidone will likely be the next option in therapy for IPF
There are a number of novel therapies on the horizon
References
Mason: Murray & Nadels Textbook of Respiratory Medicine, 4 th ed. Chapter 53 Approach to Diagnosis and Management of the Idiopathic
Interstitial Pneumonias. King and Schwarz, 2005.
American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic
Interstitial Pneumonias. Am J Respir Crit Care Med. Vol 165, pp 277-304, 2002.
Verma and Slutsky , Idiopathic Pulmonary Fibrosis New Insights. NEJM. Vol 356, No 13: pp 1370-1372, 2007.
Gross and Hunninghake, Idiopathic Pulmonary Fibrosis. NEJM. Vol 345, No 7: pp 517-525, 2001.
Kinder BW et al. , Baseline BAL neutrophilia predicts early mortality in idiopathic pulmonary fibrosis. Chest. Vol 133(1): pp 226-32, Jan 2008.
Martinez FJ et al. (IPF Study Group). The Clinical Course of Patients with Idiopathic Pulmonary Fibrosis. Ann Intern Med. Vol 142: pp 963-967,
2005.
Kim DS et al. Acute exacerbation of idiopathic pulmonary fibrosis: frequency and clinical features. Eur Resp J. Vol 27: pp143-150, 2006.
Selman et al. Idiopathic Pulmonary Fibrosis: Prevailing and Evolving Hypotheses about Its Pathogenesis and Implications for Therapy.
Annals of Internal Medicine. Vol 134: 2, pp. 136-151, 2001.
Raghu, G et al . Azathioprine combined with prednisone in the treatment of idiopathic pulmonary fibrosis: a prospective, double-blind
randomized, placebo-controlled clinical trial. Am. Rev. Respir. Dis. 144: 291-296, 1991.
Collard et al, Combined corticosteroid and cyclophosphamide therapy does not alter survival in idiopathic pulmonary fibrosis. Chest.
125(6):2169-74, 2004.
Maurits Demedts et al, High-dose acetylcysteine in Idiopathic Pulmonary Fibrosis. NEJM, Vol 353: 2229-2242, 2005.
Armanios MY et al. Telomerase mutations in families with idiopathic pulmonary fibrosis. NEJM 356: 1317-26, 2007.
Noth and Martinez. Recent Advances in Idiopathic Pulmonary Fibrosis. Chest 132: 637-50, 2007.
Noble PW. Idiopathic Pulmonary Fibrosis: Natural History and Prognosis. Clin Chest Med 27, S11-16, 2006.
American Thoracic Society, Idiopathic Pulmonary Fibrosis: Diagnosis and Treatment. Am. J. Respir. Crit. Care Med., Volume 161, Number 2, 646664, 2000.
Richeldi L, Davies HR, Ferrara G, Franco F. Corticosteroids for idiopathic pulmonary fibrosis. Cochrane Database of Systematic Reviews 2003, Iss 3.
Raghu G et al. High prevalence of abnormal acid gastro-oesophageal reflux in idiopathic pulmonary fibrosis. Eur Respir J. Vol 28(4): 884-5,
2006.
Orens et al. International Guidelines for the Selection of Lung Transplant Candidates: 2006 UpdateA Consensus Report From the
Pulmonary Scientific Council of the International Society for Heart and Lung Transplantation. The Journal of Heart and Lung
Transplantation. Volume 25, Issue 7, Pages A1-A20, 745-868 (July 2006)
Date et al. A New Treatment Strategy for Advanced Idiopathic Interstitial Pneumonia*: Living-Donor Lobar Lung Transplantation
Chest, Sep 2005; 128: 1364 1370.
NINTEDANIB
inhibitor intracelular pentru multiple tyrosin kinaze (VEGF,
FGF, PDGF);
STUDIU FAZA 3 (INPULSIS 1 si 2)
1066 pts randomizati 3:2 nintedanib (150mg x 2/zi) sau
placebo 52 sapt;
End-point primar: rata anuala de declin FVC
End-point secundar: timpul pana la prima exacerbare acuta
si scorul total al St. George`s Respiratory Questionnaire
(simptome, activitate si impact).
Rezultate:
Nintedanib reduce declinul FVC (hazard value: 0.38; 95%
0.19-0.77, p<0.005)
Ef. Secundare: diaree.