Treatment of pulmonary arterial hypertension in patients with connective tissue diseases: a systematic review and meta-analysis

Long-Term Prospective Observation Study of Patients with Pulmonary Arterial Hypertension Associated with Connective Tissue Diseases

Aim    Analysis of survival and the impact of etiology, adverse prognosis factors, and therapy on the survival of patients with pulmonary arterial hypertension associated with immune-mediated inflammatory rheumatic diseases (PAH-IIRD).Material and methods    The study included 95 patients: 76 with systemic scleroderma (SSc), 9 with mixed connective tissue disease (MCTD), 8 with systemic lupus erythematosus (SLE), one with rheumatoid arthritis, and one with Sjogren's disease with diagnosed PAH. All patients were prescribed PAH-specific therapy and followed up for at least 5 years during this treatment. The endpoint of the study was all-cause death.Results    During the 5-year follow-up period, 37 patients with PAH-SSc and 4 with PAH-MCTD (43%) died. There were no fatal outcomes in PAH-SLE. One-, two-, three-, and five-year survival rates in the overall group of patients were 91%, 80%, 73%, and 57%, respectively. In patients with PAH-SSc, one-, two-, three-, and five-year survival rates were worse than in PAH-MCTD (88%, 76%, 68%, 51% and 100%, 89%, 89%, 56%, respectively). The factors associated with a fatal outcome included age, gender, functional class, 6-minute walk test distance, right atrial pressure, cardiac output, pulmonary vascular resistance, and biomarker (uric acid and N-terminal pro-brain natriuretic peptide) concentrations. The use of macitentan and/or riociguat, as monotherapy or in combination with another PAH-specific drug, significantly reduced the 5-year risk of fatal outcome (OR 0.38 [0.16; 0.89], p=0.027).Conclusion    The survival of patients with PAH-IIRD remains low. Further studies aimed at finding new pathogenetic targets are needed; the use of modern PAH-specific drugs (macitentan and/or riociguat) modifies the course of the disease, increasing the survival.

Innovations in the care of childhood interstitial lung disease associated with connective tissue disease and immune-mediated disorders

Childhood interstitial lung disease (chILD) associated with connective tissue and immune mediated disorders is the second most common chILD diagnostic category. As knowledge of the molecular and genetic underpinnings of these rare disorders advances, the recognized clinical spectrum of associated pulmonary manifestations continues to expand. Pulmonary complications of these diseases, including ILD, confer increased risk for morbidity and mortality and contribute to increased complexity for providers tasked with managing the multiple organ systems that can be impacted in these systemic disorders. While pulmonologists play an important role in diagnosis and management of these conditions, thankfully they do not have to work alone. In collaboration with a multidisciplinary team of subspecialists, the pulmonary and other systemic manifestations of these conditions can be managed effectively together. The goal of this review is to familiarize the reader with the classic patterns of chILD and other pulmonary complications associated with primary immune-mediated disorders (monogenic inborn errors of immunity) and acquired systemic autoimmune and autoinflammatory diseases. In addition, this review will highlight current, emerging, and innovative therapeutic strategies and will underscore the important role of multidisciplinary management to improving outcomes for these patients.