Predicting survival in newly diagnosed idiopathic pulmonary fibrosis: a 3-year prospective study

Prognosis and longitudinal changes of physical activity in idiopathic pulmonary fibrosis

Background

Physical activity (PA) is associated with disease severity in idiopathic pulmonary fibrosis (IPF), but longitudinal studies evaluating its prognostic value and changes over time are lacking.

Methods

We measured PA (steps per day, SPD) in a cohort of 46 IPF-patients (mean age, 67 years; mean FVC, 76.1%pred.) by accelerometry at baseline, recorded survival status during 3 years follow-up and repeated measurements in survivors. We compared the prognostic value of PA to established mortality predictors including lung function (FVC, DLCO) and 6-min walking-distance (6MWD).

Results

During follow-up (median 34 months) 20 patients (43%) died. SPD and FVC best identified non-survivors (AUROC-curve 0.79, p < 0.01). After adjustment for confounders (sex, age, therapy), a standardized increase (i.e. one SD) in SPD, FVC%pred. or DLCO%pred. was associated with a more than halved risk of death (HR < 0.50; p < 0.01). Compared to baseline, SPD, FVC, and 6MWD annually declined in survivors by 973 SPD, 130 ml and 9 m, resulting in relative declines of 48.3% (p < 0.001), 13.3% (p < 0.001) and 7.8% (p = 0.055), respectively.

Conclusion

While PA predicts mortality of IPF patients similar to established functional measures, longitudinal decline of PA seems to be disproportionally large. Our data suggest that the clinical impact of disease progression could be underestimated by established functional measures.

Dyspnoea-12: a translation and linguistic validation study in a Swedish setting

BACKGROUND

Dyspnoea consists of multiple dimensions including the intensity, unpleasantness, sensory qualities and emotional responses which may differ between patient groups, settings and in relation to treatment. The Dyspnoea-12 is a validated and convenient instrument for multidimensional measurement in English. We aimed to take forward a Swedish version of the Dyspnoea-12.

METHODS

The linguistic validation of the Dyspnoea-12 was performed (Mapi Language Services, Lyon, France). The standardised procedure involved forward and backward translations by three independent certified translators and revisions after feedback from an in-country linguistic consultant, the developerand three native physicians. The understanding and convenience of the translated version was evaluated using qualitative in-depth interviews with five patients with dyspnoea.

RESULTS

A Swedish version of the Dyspnoea-12 was elaborated and evaluated carefully according to international guidelines. The Swedish version, 'Dyspné-12', has the same layout as the original version, including 12 items distributed on seven physical and five affective items. The Dyspnoea-12 is copyrighted by the developer but can be used free of charge after permission for not industry-funded research.

CONCLUSION

A Swedish version of the Dyspnoea-12 is now available for clinical validation and multidimensional measurement across diseases and settings with the aim of improved evaluation and management of dyspnoea.

A comparison of published multidimensional indices to predict outcome in idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) has an unpredictable course and prognostic factors are incompletely understood. We aimed to identify prognostic factors, including multidimensional indices from a significant IPF cohort at the Bristol Interstitial Lung Disease Centre in the UK.

Patients diagnosed with IPF between 2007 and 2014 were identified. Longitudinal pulmonary physiology and exercise testing results were collated, with all-cause mortality used as the primary outcome. Factors influencing overall, 12- and 24-month survival were identified using Cox proportional hazards modelling and receiver operating characteristic curve analysis.

We found in this real-world cohort of 167 patients, diffusing capacity for carbon monoxide (D_LCO) and initiation of long-term oxygen were independent markers of poor prognosis. Exercise testing results predicted 12-month mortality as well as D_LCO, but did not perform as well for overall survival. The Composite Physiological Index was the best performing multidimensional index, but did not outperform D_LCO. Our data confirmed that patients who experienced a fall in forced vital capacity (FVC) >10% had significantly worse survival after that point (p=0.024).

Our data from longitudinal follow-up in IPF show that D_LCO is the best individual prognostic marker, outperforming FVC. Exercise testing is important in predicting early poor outcome. Regular and complete review should be conducted to ensure appropriate care is delivered in a timely fashion.

D_LCOis a powerful prognostic marker in IPFhttp://ow.ly/EaEr307VTRN

Predicting Life Expectancy for Pirfenidone in Idiopathic Pulmonary Fibrosis

BACKGROUND

Conducting an adequately powered survival study in idiopathic pulmonary fibrosis (IPF) is challenging due to the rare nature of the disease and the need for extended follow-up. Consequently, registration trials of IPF treatments have not been designed to estimate long-term survival.

OBJECTIVE

To predict life expectancy for patients with IPF receiving pirfenidone versus best supportive care (BSC) in a population that met the inclusion criteria of patients enrolled in the ASCEND and CAPACITY trials.

METHODS

Kaplan-Meier survival data for pirfenidone and BSC were obtained from randomized controlled clinical studies (CAPACITY, ASCEND), an open-label extension study (RECAP), and the Inova Fairfax Hospital database. Data from the Inova registry were matched to the inclusion criteria of the CAPACITY and ASCEND trials. Life expectancy was estimated by the area under the curve of parametric survival distributions fit to the Kaplan-Meier data.

RESULTS

Mean (95% confidence interval) life expectancy was calculated as 8.72 (7.65-10.15) years with pirfenidone and 6.24 (5.38-7.18) years with BSC. Therefore, pirfenidone improved life expectancy by 2.47 (1.26-4.17) years compared with BSC. In addition, treatment with pirfenidone recuperated 25% of the expected years of life lost due to IPF. Sensitivity analyses found that results were sensitive to the choice of parametric survival distribution, and alternative piecewise and parametric approaches.

CONCLUSIONS

This analysis suggests that this population of patients with IPF has an improved life expectancy if treated with pirfenidone compared with BSC.

DISCLOSURES

This study was funded by InterMune International AG, a wholly owned Roche subsidiary since 2014. Fisher was previously employed by InterMune UK, a wholly owned Roche subsidiary, until July 2015. He is currently employed by FIECON, which has received funding from F. Hoffmann-La Roche for consulting services. Nathan has received consulting fees from Roche-Genentech and Boehringer Ingelheim. He is also on the speakers' bureau for Roche-Genentech and Boehringer Ingelheim and has received research funding from both companies. Hill was previously employed by InterMune UK until October 2014. Hill and Marshall are employees of MAP BioPharma, which has received funding from F. Hoffmann-La Roche for consulting services. Dejonckheere and Thuresson are employees of F. Hoffmann-La Roche. Maher has received grants, consulting fees, and speaker fees from GlaxoSmithKline and UCB, and grants from Novartis. He has also received consulting fees and speaker fees from AstraZeneca, Bayer, Biogen Idec, Boehringer Ingelheim, Cipla, Lanthio, InterMune International AG, F. Hoffmann-La Roche, Sanofi-Aventis, and Takeda. Maher is supported by a National Institute for Health Research Clinician Scientist Fellowship (NIHR Ref: CS: -2013-13-017). Study concept and design were contributed by Fisher, Hill, Marshall, and Dejonckheere. Fisher, Nathan, and Thuresson collected the data, along with Hill and Marshall. Data interpretation was performed by Fisher, Maher, Nathan, and Dejonckheere. The manuscript was written primarily by Fisher, along with Maher and Dejonckheere, and revised by Fisher and Maher, along with the other authors.

Idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis is a fibrosing interstitial pneumonia associated with the radiological and/or histological pattern of usual interstitial pneumonia. Its aetiology is unknown, but probably comprises the action of endogenous and exogenous micro-environmental factors in subjects with genetic predisposition. Its diagnosis is based on the presence of characteristic findings of high-resolution computed tomography scans and pulmonary biopsies in absence of interstitial lung diseases of other aetiologies. Its clinical evolution is variable, although the mean survival rate is 2-5 years as of its clinical presentation. Patients with idiopathic pulmonary fibrosis may present complications and comorbidities which modify the disease's clinical course and prognosis. In the mild-moderate disease, the treatment consists of the administration of anti-fibrotic drugs. In severe disease, the best therapeutic option is pulmonary transplantation. In this paper we review the diagnostic and therapeutic aspects of the disease.

COPD Assessment Test for measurement of health status in patients with idiopathic pulmonary fibrosis: A cross-sectional study

BACKGROUND AND OBJECTIVE

The COPD Assessment Test (CAT) has been reported to have potential utility for measuring health status of idiopathic pulmonary fibrosis (IPF). Although the CAT has been developed for the assessment of COPD patients, it has not been fully evaluated exclusively in IPF. This study was designed to evaluate the validity of the CAT in IPF.

METHODS

The clinical data for 106 consecutive subjects with newly diagnosed IPF who completed pulmonary function tests, partial pressure of oxygen in arterial blood (PaO₂ ) at rest, 6-min walk test (6MWT), CAT, St George's Respiratory Questionnaire (SGRQ), modified Medical Research Council (mMRC) dyspnoea grade and Hospital Anxiety and Depression Scale (HADS), were analysed. We assessed the validity of the CAT in comparison with the SGRQ.

RESULTS

The present subjects showed mild to moderate restrictive impairment on spirometry. Mean CAT score and total SGRQ were 12.8 ± 8.0 and 30.8 ± 17.7, respectively. The concurrent validity of the CAT score in comparison with the SGRQ total score was significant (r = 0.72, P < 0.001). Internal consistency (Cronbach's α = 0.869) and repeatability over 3 months (intraclass correlation coefficient = 0.742) of the CAT were also significant. Single regression analysis showed that the CAT had significant construct validity. In multiple regression analysis, mMRC, PaO₂ at rest, minimum SpO₂ during 6MWT and anxiety of HADS were independent predictors for the CAT.

CONCLUSIONS

The CAT is a valid health status measurement in IPF patients. Multiple regression analysis showed that the CAT was significantly correlated with dyspnoea severity, oxygenation impairment and anxiety.

A simple dyspnoea scale as part of the assessment to predict outcome across chronic interstitial lung disease

BACKGROUND AND OBJECTIVE

The Medical Research Council dyspnoea score (MRCDS) is a simple, objective scale to assess dyspnoea, the main complaint in patients with chronic interstitial lung disease (ILD). We sought to investigate whether MRCDS is a predictor of outcome in patients with chronic ILD.

METHODS

One hundred and fifteen patients (50 idiopathic pulmonary fibrosis (IPF) and 65 non-IPF ILD) were retrospectively studied. Baseline (time of diagnosis) MRCDS and 3-6-month changes were considered. Endpoints were (i) 18-month clinical progression, defined as either: ≥10% absolute reduction in forced vital capacity (FVC) percent predicted; ≥50-m decline in 6-min walk distance; hospitalization for respiratory causes; lung transplantation (LTx) assessment or death and (ii) 18-month survival.

RESULTS

At the end of the observation period, 54 subjects (47%) experienced clinical progression (including 22 deaths and 3 LTx). In patients with IPF, a longitudinal increase in MRCDS predicted clinical progression significantly (area under the curve (AUC) = 0.76, sensitivity = 62%, specificity = 91%); baseline MRCDS was a strong predictor of mortality (AUC = 0.80, sensitivity = 87%, specificity = 57%). In patients with non-IPF ILD, longitudinal increases in MRCDS, but not baseline values, were predictive of both clinical progression (AUC = 0.81, sensitivity = 85%, specificity = 77%) and mortality (AUC = 0.76, sensitivity = 91%, specificity = 61%). Considering the whole population, MRCDS increase and FVC decline were independent predictors of mortality.

CONCLUSION

Longitudinal increases of MRCDS predict poor outcome in chronic ILD, with good accuracy. Baseline MRCDS remains a strong predictor of mortality in IPF. MRCDS should be included in the global assessment of the clinical course of chronic ILD.

Plasma Vascular Endothelial Growth Factor Concentration and Alveolar Nitric Oxide as Potential Predictors of Disease Progression and Mortality in Idiopathic Pulmonary Fibrosis

Background: Declining lung function signifies disease progression in idiopathic pulmonary fibrosis (IPF). Vascular endothelial growth factor (VEGF) concentration is associated with declining lung function in 6 and 12-month studies. Alveolar nitric oxide concentration (CANO) is increased in patients with IPF, however its significance is unclear. This study investigated whether baseline plasma VEGF concentration and CANO are associated with disease progression or mortality in IPF. Methods: 27 IPF patients were studied (maximum follow-up 65 months). Baseline plasma VEGF concentration, CANO and pulmonary function tests (PFTs) were measured. PFTs were performed the preceding year and subsequent PFTs and data regarding mortality were collected. Disease progression was defined as one of: death, relative decrease of ≥10% in baseline forced vital capacity (FVC) % predicted, or relative decrease of ≥15% in baseline single breath diffusion capacity of carbon monoxide (TLCO-SB) % predicted. Results: Plasma VEGF concentration was not associated with progression-free survival or mortality. There was a trend towards shorter time to disease progression and death with higher CANO. CANO was significantly higher in patients with previous declining versus stable lung function. Conclusion: The role of VEGF in IPF remains uncertain. It may be of value to further investigate CANO in IPF.

Physical Activity and Exertional Desaturation Are Associated with Mortality in Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic lung disease that manifests in hypoxemia, inactivity, and poor prognosis. This study aimed to assess the prognostic role of physical activity (PA) and exertional desaturation (ED) with mortality in IPF. At baseline, 34 IPF patients (68 (50–81) years) were interviewed using the International Physical Activity Questionnaire (IPAQ), and SpO₂ was assessed pre to post 6-min walking test (∆SpO₂). Patients were prospectively followed up for 40 months. Receiver operating characteristics curve analysis determined cut-off points associated with mortality, and Cox proportional hazard ratio (HR) were conducted. Thresholds for increased mortality risk in IPF patients were determined as IPAQ ≤ 417 metabolic equivalent task (METS)-min/week, p = 0.004 (HR; 9.7, CI 95% (1.3–71.9), p = 0.027), and ∆SpO₂ ≥ 10%, p = 0.002, (HR; 23.3, CI 95% (1.5–365), p = 0.025). This study demonstrated a significant association of PA and ED with mortality in IPF patients. The findings emphasize the clinical importance of PA and ED assessments to aid in IPF risk stratification, prognosis prediction, and in providing early appropriate treatments, such as pulmonary rehabilitation, PA consultation, oxygen supplementation, and lung transplantation referral. These results underscore that even low levels of PA corresponding to 100–105 min/week were associated with a reduced mortality risk and better survival in IPF.

Exercise training in idiopathic pulmonary fibrosis: is it of benefit?

Key points

Educational aims

Exercise is a well-documented safe and effective intervention for prevention and rehabilitation of chronic diseases. Idiopathic pulmonary fibrosis (IPF) is a chronic deadly lung disease associated with severe signs and symptoms, exercise intolerance, diminished quality of life and poor prognosis. In the short term, supervised exercise training programmes have demonstrated clinical benefits in improving exercise capacity, dyspnoea and quality of life in patients with IPF. The underlying mechanisms of chronic adaption to a regular exercise regimen in IPF have yet to be well described and require further investigation. The available data underscore the importance of implementing training principles to target the pathophysiological impairments of IPF in order to optimise training adaption and enhance the outcomes. The current exercise training data in IPF provide sufficient evidence of clinical benefit for consideration to be given to recommending exercise-based pulmonary rehabilitation as standard of care for IPF.

An overview of data on exercise for IPF patients, highlighting the importance of exercise training in IPF managementhttp://ow.ly/4mWCCd

Prognostic scoring systems for clinical course and survival in idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is the most common and rapidly fatal among idiopathic interstitial pneumonias. Its clinical course is variable. A significant fraction of the population of patients display a slow disease course and can remain stable for years, while other patients show a rapid progressive course and may die within few months from diagnosis. For these reasons estimating prognosis of IPF patients is extremely difficult and has important clinical repercussions on optimal patients management including patients referral for lung transplantation. Several studies have tried to address this key point in the course of the two last decades analyzing different clinical, functional, radiological and biological variables. The purpose of this review is to assess relevant studies published on this subject and to examine the variety of prognostic predictors proposed along with staging systems.

Rationale for and design of the Idiopathic Pulmonary Fibrosis-PRospective Outcomes (IPF-PRO) registry

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a chronic interstitial lung disease characterised by progressive loss of lung function. Its clinical course is variable but ultimately fatal. There is a need for a multicentre patient registry incorporating longitudinal clinical data and biological samples to improve understanding of the natural history of IPF and contemporary practice patterns.

METHODS/DESIGN

The Idiopathic Pulmonary Fibrosis-PRospective Outcomes (IPF-PRO) registry is a national IPF registry in the USA. This registry will enrol approximately 300 patients with newly diagnosed IPF over 2 years at approximately 14 tertiary pulmonary care sites. Participants will be followed for 3-5 years and will receive usual care, as defined by their physician. Clinical data from the year prior to diagnosis will be collected from medical record review on enrolment. Subsequently, data on diagnostic evaluations, pulmonary function tests, physical examinations, laboratory data and clinical events will be collected at routine clinical visits and via a call centre. Participants will complete patient-reported outcome questionnaires at enrolment and then at approximately 6-month intervals. Blood samples for cellular, genetic and transcriptomic analyses will be collected at the same intervals.

RESULTS

The first results from the IPF-PRO registry will be presented in 2015.

CONCLUSIONS

The IPF-PRO registry will improve understanding of the natural history of IPF, its impact on patients and current practice in the diagnosis and care of patients with IPF. The registry will establish a repository of biological samples from a well-characterised patient population for future research.

CLINICAL TRIAL NUMBER

NCT01915511.

Staging systems and disease severity assessment in interstitial lung diseases

PURPOSE OF REVIEW

In the evaluation of patients with interstitial lung diseases (ILD), treatment decisions made by clinicians, including referral for lung transplant, are based on disease severity assessment. It is crucial to quantify disease severity and numerous attempts were made to find a reliable prognostic assessment method.

RECENT FINDINGS

Research focused on which severity thresholds should be used to identify patients at higher risk of death and, more recently, on prognostic composite physiologic indices and staging systems, which compared with single variables offer a number of advantages. Composite indices, such as the composite physiologic index, provide a more accurate overall estimate of disease severity and account for confounding coexisting disease process, such as pulmonary hypertension and emphysema. In idiopathic pulmonary fibrosis clinical measures have been integrated in the GAP model that strongly correlates with disease severity and mortality. Recently, the GAP model derived for idiopathic pulmonary fibrosis (IPF) has been successfully applied to non-IPF fibrotic ILD.

SUMMARY

The heterogeneity in ILDs related to both disease and patient-specific factors, for many years, has impeded progress in the development of a reliable method to quantify disease severity. In the last decade, novel composite physiologic indices and staging systems have been shown to accurately reflect disease severity and reliably predict survival. Moreover, the recent finding of one informative staging system applicable to different subgroups of ILD patients has the potential to radically transform both clinical practice and research strategy in the near future of ILD.

Exercise training in idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic devastating interstitial lung disease associated with exercise intolerance, dyspnea, hypoxemia, diminished quality of life and poor prognosis. A growing body of evidence with respect to short-term effects of exercise training has demonstrated clinical benefits in IPF patients. A recent systematic review showed significant improvements in 6-min walking distance, peak aerobic capacity, reduced dyspnea and improved quality of life. However, aspects of training programs, maintenance and predictors of improvement and the impact on prognosis need to be further explored. The aim of this paper was to comprehensively review the existing scientific literature regarding exercise training in patients with IPF and identify important gaps that should be studied in the future.

Adherence to guidelines in idiopathic pulmonary fibrosis: a follow-up national survey

A new survey coordinated by the French expert centres for rare pulmonary diseases investigated French pulmonologists' diagnostic and therapeutic practice for idiopathic pulmonary fibrosis (IPF) and explored changes since a previous survey in 2011-2012. From May 16 to August 30, 2014, 524 pulmonologists were contacted. Those following at least one patient with IPF were invited to complete a questionnaire administered by telephone or e-mail. 166 (31.7%) pulmonologists, 161 (97%) of whom had participated to the first survey, completed the questionnaire. Of those, 46% and 52%, respectively, discussed the cases with radiologists and pathologists. Out of 144 pulmonologists practicing outside of expert centres, 80% indicated referring patients to those centres. The 2013 French practical guidelines for IPF were known by 92% of pulmonologists involved in IPF, 96% of whom considered them appropriate for practice. The multidisciplinary discussion form for IPF diagnosis was known by 74% and considered appropriate by 94%. Diagnosis and management resulted from multidisciplinary discussion in 50% of the cases. About 58% of patients were diagnosed with "mild to moderate IPF" as defined by forced vital capacity ≥50% of the predicted value and diffusing capacity for carbon monoxide ≥35% of predicted. At the time of the survey, 31% of physicians were using pirfenidone to treat patients with "mild-to-moderately severe IPF" and 30% generally prescribed no treatment. Substantial improvement has occurred since the 2011-2012 survey with regard to knowledge of guidelines and proper management of IPF. Early diagnosis still needs to be improved through the network of expert centres.

Comorbidities in idiopathic pulmonary fibrosis patients: a systematic literature review

Idiopathic pulmonary fibrosis (IPF) is associated with a fatal prognosis and manifests in patients over 60 years old who may have comorbidities. The prevalence and impact of comorbidities on the clinical course of IPF is unclear.

This systematic literature review examined the prevalence of comorbidities and mortality associated with comorbidities in IPF patients. Relevant observational studies published in English from January 1990 to January 2015 identifiedviaMEDLINE and EMBASE were included; bibliographies of articles were also searched.

Among the 126 studies included, prevalence of pulmonary hypertension (PH) was 3–86%, 6–91% for obstructive sleep apnoea, 3–48% for lung cancer and 6–67% for chronic obstructive pulmonary disease (COPD). Nonrespiratory comorbidities included ischaemic heart disease (IHD) (3–68%) and gastro-oesophageal reflux (GER) (0–94%). Mortality was highest among patients with IPF and lung cancer. Most studies assessed relatively small samples of patients with IPF.

PH, COPD, lung cancer, GER and IHD are significant comorbidities; differences in IPF severity, case definitions and patient characteristics limited the comparability of findings. The identification and prompt treatment of comorbidities may have a clinically significant impact on overall outcome that is meaningful for patients with IPF.

The need for patient-centred clinical research in idiopathic pulmonary fibrosis

Patient-centredness is an accepted term and is perceived by healthcare professionals to be morally and ethically desirable. We are motivated by the belief that this approach will improve the patient-professional experience of the decision-making process and improve health outcomes. We acknowledge that patients, either as participants or as co-investigators, have positive contributions to make to research. As the idiopathic pulmonary fibrosis (IPF) community enters a new era of clinical research activity we consider that there is greater capacity for patient involvement and partnership.Patient involvement in research can be optimised through collaborations in the research design, study conduct, and dissemination. There is increasing interest in using patient- reported outcomes (PROs), such as health-related quality of life, and symptoms measures to inform decision-making and ensure patient perspectives are taken into account. PROs are an essential component of specialist IPF services, to monitor and improve care delivery and to measure and benchmark performance. In clinical trials, PROs can additionally be used to define entry criteria, evaluate efficacy of an intervention, and evaluate adverse events. We suggest that there is a much wider scope for including patient-centred PROs in clinical research and for creative thought in developing patient co-investigator roles.Participation in research activity requires highly refined decision-making processes, particularly in a condition such as IPF, which has an often unpredictable trajectory. The IPF research landscape has changed and the design and conduct of clinical trials in IPF requires some radical rethinking. It is accepted that involving patients in the role of co-investigators will impact the research questions we ask and result in study designs that are patient-centred. IPF clinical trials have been hindered by the lack of availability of validated, disease-specific questionnaires. A conservative approach appears to have been taken to the inclusion of generic symptom or quality of life measures as PRO endpoints. Thus, the impact of new drugs on the quality of life of research participants demonstrates only minimal benefit. It is time to refocus on a patient-centred approach with regards to the co-investigator role, PRO development, and research participants.

Early decline in six-minute walk distance from the time of diagnosis predicts clinical worsening in pulmonary arterial hypertension

BACKGROUND

The six-minute walk distance (6MWD) is commonly used to assess pulmonary arterial hypertension (PAH). However, the role of 6MWD in predicting outcomes in PAH is controversial. Clinical worsening is being increasingly considered as a clinically meaningful end point in PAH.

OBJECTIVES

We aimed to investigate whether early longitudinal changes in 6MWD (Δ6MWD) in meters and percent predicted (%pred) from the time of diagnosis predict clinical worsening of PAH.

METHODS

One hundred patients with group I PAH were retrospectively assessed. 6MWD was calculated using American (%pred US) or Canadian (%pred CAN) reference equations. Δ6MWD at 6 months were recorded. Clinical worsening was defined as either: development of right heart failure, hospital admission for PAH, referral for lung transplantation or initiation of prostanoids after oral therapy failed. Optimal 6-month differences in 6MWD to detect worsening were defined with receiver operating characteristics (ROC) analysis.

RESULTS

Progressors, i.e. patients with clinical worsening, and nonprogressors showed significant differences in Δ6MWD. The most clinically significant declines in 6MWD at 6 months were ≥35 m, ≥8%pred US and ≥6%pred CAN. ROC and Cox proportional hazard analyses showed equivalent results for 6MWD %pred and meters. Six-month declines in 6MWD predicted worsening with a high specificity (94%) but a low sensitivity (33%).

CONCLUSIONS

Early declines in 6MWD (within the first 6 months) predict future clinical worsening of PAH with high specificity. Δ6MWD may still be part of a comprehensive assessment of a patient's clinical status. However, given the poor sensitivity, a decline in 6MWD should be used with other clinical tools to make an appropriate assessment of the progression of PAH.

Update on therapeutic management of idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive diffuse parenchymal lung disease of unknown origin, with a mortality rate exceeding that of many cancers. The diagnostic process is complex and relies on the clinician integrating clinical, laboratory, radiological, and histological data. In the last decade, major advances in our understanding of the pathogenesis of IPF have shifted the paradigm from a primarily inflammatory process evolving to fibrosis to a condition driven by aberrant wound healing following alveolar epithelial cell injury that results in scarring of the lung, architectural distortion, and irreversible loss of function. Improved understanding of disease pathogenesis has led to the identification of several therapeutic targets and the design of high-quality clinical trials evaluating novel compounds. However, the results of these studies have been mostly disappointing, probably due to the plethora of mediators, growth factors, and signaling pathways involved in the fibrotic process. Most recently, pirfenidone and nintedanib, two compounds with pleiotropic anti-fibrotic properties, have been proven effective in reducing functional decline and disease progression in IPF. This is a major breakthrough. Nevertheless, we still have a long way to go. In fact, neither pirfenidone nor nintedanib is a cure for IPF, and most patients continue to progress despite treatment. As such, comprehensive care of patients with IPF, including management of concomitant conditions and physical debility, as well as timely referral for lung transplantation, remains essential. Several agents with a high potential are currently being tested, and many more are ready for clinical trials. Their completion is critical for achieving the ultimate goal of curing patients with IPF.

A prospective survey of idiopathic interstitial pneumonias in a web registry in Japan

BACKGROUND

There have been no prospective large-scale multicenter epidemiological studies on the clinical course and treatment from the time of diagnosis of idiopathic interstitial pneumonias (IIPs) in Japan. The purpose of this study was to clarify the current clinical situation of IIP in Japan.

METHODS

This study was supported by a grant from the Ministry of Health, Labour and Welfare to the Diffuse Lung Diseases Research Group. Data including clinical findings, course, and treatment of IIP from a web database created by a collaborative effort of medical institutions across Japan that specialize in the care of interstitial pneumonias were collected and analyzed.

RESULTS

A total of 436 IIP patients from 19 institutions were newly registered during a 5-year period. Idiopathic pulmonary fibrosis (IPF) was the most frequently encountered IIP, and 28% of the IPF cases were initially diagnosed by abnormal chest X-ray or CT in asymptomatic patients. Until the 2008 fiscal year, no treatment was given for most cases of IPF. After the end of 2008, when pirfenidone was approved for manufacture, the number of patients for whom no treatment was recommended declined, and pirfenidone therapy was initiated in 32.9% of cases in 2009. The median survival times for IPF from the onset symptoms and from the initial visit were 105 months and 69 months, respectively.

CONCLUSIONS

This study should provide valuable information for understanding the current state of IIP in Japan.

Natural history of idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a parenchymal lung disease characterized by progressive interstitial fibrosis. IPF has a poor prognosis, with a median survival time of 2-3 years from diagnosis, but varying from a few months to a decade. The natural history of IPF is highly variable and the course of disease in an individual patient is difficult to predict. Some patients with IPF experience rapid decline, others progress much more slowly, and some patients show periods of relative stability interspersed with acute deteriorations in respiratory function. Many clinical, radiographic, serologic, and histopathologic variables have been shown to predict mortality in IPF. However, the accuracy of these predictors varies due to the retrospective nature of some of the studies and variations in study design. The ability to identify clinical characteristics that predict disease progression and survival would be useful for counseling patients, treatment decision-making, and prompt consideration for lung transplantation. A number of indices for predicting mortality in patients with IPF are available, but they require further validation. As high-resolution computed tomography scans become more widely available and patients with IPF are diagnosed earlier, survival times following diagnosis will improve. Early referral to interstitial lung disease specialty centers is important for accurate diagnosis and may be associated with improved outcomes. The goal of this review is to examine the natural history of IPF, discuss predictors of mortality, and highlight the importance of prompt diagnosis and referral for patients with IPF.

Outcome Measures for Clinical Trials in Interstitial Lung Diseases

The chronic fibrosing idiopathic interstitial pneumonias (IIPs) are a group of heterogeneous pulmonary parenchymal disorders described by radiologic and histological patterns termed usual interstitial pneumonia (UIP) and non-specific interstitial pneumonia (NSIP). These include idiopathic pulmonary fibrosis (IPF) and those related to connective tissue disease (CTD) and are associated with substantial morbidity and mortality. Beyond the importance of establishing an appropriate diagnosis, designing optimal clinical trials for IIPs has been fraught with difficulties in consistency of clinical endpoints making power analyses, and the establishment of efficacy and interpretation of results across trials challenging. Preliminary recommendations, developed by rigorous consensus methods, proposed a minimum set of outcome measures, a 'core set', to be incorporated into future clinical trials (Saketkoo et al, THORAX. 2014.). This paper sets out to examine the candidate instruments for each domain (Dyspnea, Cough, Health Related Quality of Life, Imaging, Lung Physiology and Function, Mortality). Candidate measures that were not selected as well as measures that were not available for examination at the time of the consensus process will also be discussed.

[Acute on chronic respiratory failure in interstitial pneumonias]

BACKGROUND

Acute exacerbations of idiopathic interstitial pneumonias and exacerbations of pleuropulmonary disease in connective tissue diseases are associated with a high mortality.

DIAGNOSTIC PROCEDURES

They have to be differentiated from respiratory failure in patients with interstitial lung disease as a result of infections, pulmonary embolism, cardiac failure and drug toxicity, because the latter can be treated causally. The extent and the invasivity of diagnostic procedures have to be adopted to the patient's situation. A rapid diagnosis is important in order to initiate therapies (antibiotics, anticoagulation, immunosuppression) in treatable causes of exacerbations.

IMPORTANCE OF VENTILATION

The prognosis for patients who are under invasive mechanical ventilation in acute exacerbations of interstitial lung disease is poor. Especially in acute exacerbations of idiopathic pulmonary fibrosis (IPF), there is no general recommendation for either invasive or for noninvasive ventilation. In acute exacerbations of other subtypes of interstitial pneumonia, either idiopathic or as a pulmonary manifestation of connective tissue disease, and in all secondary exacerbations of idiopathic interstitial pneumonias which offer further treatment options, the decision about mechanical ventilation requires a differentiated assessment.

LUNG TRANSPLANTATION

In younger patients with interstitial lung disease and a progressive disease, indication for lung transplantation should be made early and before an exacerbation. If patients listed for lung transplantation experience an acute exacerbation, bridging-to-transplant has to be discussed with the transplant unit. In cases without further causal treatment options palliative care must be initiated.

A retrospective study of prognostic factors in patients with interstitial pneumonia receiving long-term oxygen therapy

PURPOSE

We retrospectively analyzed patients with clinically diagnosed interstitial pneumonia to investigate the factors which contribute to the difference in prognosis from the initiation of long-term oxygen therapy (LTOT) among subtypes.

METHODS

Seventy-six patients with clinically diagnosed idiopathic interstitial pneumonia (IIP; n = 49) or interstitial pneumonia associated with collagen vascular disease (CVD-IP; n = 27) in whom LTOT was initiated in our facility from January 1999 to December 2012 were analyzed.

RESULTS

Patients with CVD-IP had significantly longer survival time from the initiation of LTOT than those with IIP with the median survival of 51.7 months versus 18.8 months, respectively. The 1-year survival rate was 92.4% for patients with CVD-IP versus 76.5% for those with IIP, and 2-year survival was 88.6 versus 36.0%, respectively. The patterns classified with high-resolution computed tomography (HRCT) were not associated with prognosis. The association between pulmonary hypertension and prognosis was unclear. In results of the multivariate Cox analysis which included factors demonstrating p < 0.1 in the univariate Cox analysis, male gender, low body mass index, and the absence of collagen vascular disease (CVD) were significantly associated with poor prognosis.

CONCLUSIONS

After the initiation of LTOT, patients with IIP had poor prognosis regardless of the patterns classified with HRCT, while those with CVD-IP survived longer. Male gender, low body mass index, and the absence of CVD were the independent negative prognostic factors in patients with interstitial pneumonia receiving LTOT.

Acute Exacerbation of Idiopathic Pulmonary Fibrosis: A Proposal

Acute exacerbation of idiopathic pulmonary fibrosis (IPF) occurs in roughly 10% of patients annually, and is a leading cause of morbidity and mortality in this disease. While currently defined as idiopathic acute worsenings, acute exacerbations of IPF may in fact have a variety of causes, in particular infection and aspiration. Central to the pathobiology of clinically meaningful events is a diffuse injury to the IPF lung manifest histopathologically as diffuse alveolar damage, and biologically as accelerated alveolar epithelial cell injury or repair. Based on these recent observations, we propose a new paradigm for acute exacerbation of IPF that removes the idiopathic requirement and focuses on the pathophysiological mechanism involved.

WNT/β-catenin signaling induces IL-1β expression by alveolar epithelial cells in pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a lethal lung disease of unknown etiology. It is characterized by alterations of the alveolar epithelium, myofibroblast activation, and increased extracellular matrix deposition. Recently, reactivation of the developmental WNT/β-catenin pathway has been linked with pulmonary fibrosis. The cell-specific mechanisms and mediators of WNT/β-catenin signaling in the lung, however, remain elusive. Here, we applied an unbiased gene expression screen to identify epithelial cell-specific mediators of WNT/β-catenin signaling. We found the proinflammatory cytokine IL-1β to be one of the most up-regulated genes in primary murine alveolar epithelial Type II (ATII) cells after WNT3a treatment. Increased transcript and protein expression of IL-1β upon WNT3a treatment was further detected in primary ATII cells by quantitative RT-PCR (log fold change, 2.0 ± 0.5) and ELISA (1.8-fold increase). We observed significant up-regulation of IL-1β and IL-6 in bronchoalveolar lavage fluid (BALF) in bleomycin-induced lung fibrosis in vivo. Importantly, primary fibrotic ATII cells isolated from lungs subjected to bleomycin secreted enhanced IL-1β and IL-6 in vitro. Furthermore, the orotracheal application of recombinant WNT protein in the Tcf optimal promoter (TOP)-β-galactosidase reporter animals led to WNT/β-catenin activation in epithelial cells, along with significant increases in IL-1β and IL-6 in vivo (2.7-fold and 6.0-fold increases, respectively). Finally, we found increased WNT3a protein in fibrotic alveolar epithelia, accompanied by enhanced IL-1β and IL-6 concentrations in BALF from patients with IPF. Taken together, our findings reveal that the alveolar epithelium is a relevant source of proinflammatory cytokines induced by active WNT/β-catenin in pulmonary fibrosis. Thus, WNT/interleukin signaling represents a novel link between developmental pathway reactivation and inflammation in the development of pulmonary fibrosis.

Acute exacerbations in patients with idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic, fibrosing interstitial lung disease that primarily affects older adults. Median survival after diagnosis is 2–3 years. The clinical course of IPF may include periods of acute deterioration in respiratory function, which are termed acute exacerbations of IPF (AEx-IPF) when a cause cannot be identified. AEx-IPF may represent a sudden acceleration of the underlying disease process of IPF, or a biologically distinct pathological process that is clinically undiagnosed. An AEx-IPF can occur at any time during the course of IPF and may be the presenting manifestation. The incidence of AEx-IPF is hard to establish due to variation in the methodology used to assess AEx-IPF in different studies, but AEx-IPF are believed to occur in between 5 and 10% of patients with IPF every year. Risk factors for AEx-IPF are unclear, but there is evidence that poorer lung function increases the risk of an AEx-IPF and reduces the chances of a patient surviving an AEx-IPF. The presence of comorbidities such as gastroesophageal reflux disease (GERD) and pulmonary hypertension may also increase the risk of an AEx-IPF. AEx-IPF are associated with high morbidity and mortality. Patients who experience an AEx-IPF show a worsened prognosis and AEx-IPF are believed to reflect disease progression in IPF. Current treatments for AEx-IPF have only limited data to support their effectiveness. The latest international treatment guidelines state that supportive care remains the mainstay of treatment for AEx-IPF, but also give a weak recommendation for the treatment of the majority of patients with AEx-IPF with corticosteroids. There is emerging evidence from clinical trials of investigational therapies that chronic treatment of IPF may reduce the incidence of AEx-IPF. Additional clinical trials investigating this are underway.

Idiopathic pulmonary fibrosis: diagnosis and prognostic evaluation

Idiopathic pulmonary fibrosis (IPF) is the most common type of idiopathic interstitial pneumonia and has a dismal prognosis. Median age at IPF onset is 60-70 years and it is mainly related to cigarette smoke exposure. Its clinical profile is heterogeneous and different clinical phenotypes are now better defined: familial IPF, slow and rapid progressors, combined pulmonary fibrosis and emphysema, anti-neutrophil cytoplasmic antibodies/microscopic polyangiitis and IPF, and IPF associated with lung cancer. Acute exacerbation associated with rapid functional decline is an event that does not happen infrequently and affects survival. Diagnosis requires a typical usual interstitial pneumonia (UIP) pattern on computed tomography in the appropriate clinical setting or morphological confirmation of the UIP pattern when imaging findings are not characteristic enough. Surgical lung biopsy is the gold standard to obtain valuable information for histological analysis. However, less invasive procedures (transbronchial lung biopsy or even improved transbronchial lung biopsy by cryoprobes) are now under consideration. Prognostic indicators are mainly derived by pulmonary function tests. Recently, staging systems have been proposed.

[Idiopathic pulmonary fibrosis and sleep disorders]

Idiopathic pulmonary fibrosis (IPF) is the most common interstitial lung disease. Despite progress made in understanding the pathophysiological mechanisms behind the development of the disease, its prognosis is poor. For this reason, any measure to improve the quality of life for these patients should be preferred. Some authors are interested in sleep disorders, and possible impact on quality of life. Patients with IPF have lowered scores of quality of life compared to those found in general population, with some correlation with the scores of sleep quality. There is a hyperfragmentation with many arousals and desaturation events. Some authors also report an apnea-hypopnea index higher in these patients, but these data are not found in all the studies. Correcting these obstructive phenomena may have a beneficial effect on survival, which would make systematic the sleep assessment in these patients. Finally, the relationship between IPF, gastroesophageal reflux and sleep apnea syndrome remains unclear.