1
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Mismetti V, Si-Mohamed S, Cottin V. Interstitial Lung Disease Associated with Systemic Sclerosis. Semin Respir Crit Care Med 2024; 45:342-364. [PMID: 38714203 DOI: 10.1055/s-0044-1786698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2024]
Abstract
Systemic sclerosis (SSc) is a rare autoimmune disease characterized by a tripod combining vasculopathy, fibrosis, and immune-mediated inflammatory processes. The prevalence of interstitial lung disease (ILD) in SSc varies according to the methods used to detect it, ranging from 25 to 95%. The fibrotic and vascular pulmonary manifestations of SSc, particularly ILD, are the main causes of morbidity and mortality, contributing to 35% of deaths. Although early trials were conducted with cyclophosphamide, more recent randomized controlled trials have been performed to assess the efficacy and tolerability of several medications, mostly mycophenolate, rituximab, tocilizumab, and nintedanib. Although many uncertainties remain, expert consensus is emerging to optimize the therapeutic management and to provide clinicians with evidence-based clinical practice guidelines for patients with SSc-ILD. This article provides an overview, in the light of the latest advances, of the available evidence for the diagnosis and management of SSc-ILD.
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Affiliation(s)
- Valentine Mismetti
- Department of Respiratory Medicine, National Coordinating Reference Centre for Rare Pulmonary Diseases, ERN-LUNG, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Salim Si-Mohamed
- INSA-Lyon, University of Lyon, University Claude-Bernard Lyon 1, Lyon, France
- Radiology Department, Hospices Civils de Lyon, Lyon, France
| | - Vincent Cottin
- Department of Respiratory Medicine, National Coordinating Reference Centre for Rare Pulmonary Diseases, ERN-LUNG, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
- UMR 754, INRAE, Claude Bernard University Lyon 1, Lyon, France
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2
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Stącel T, Sybila P, Mędrala A, Ochman M, Nęcki M, Pasek P, Kegler K, Przybyłowski P, Hrapkowicz T, Borowik D, Urlik M. Lung Transplantation in Patients With Systemic Scleroderma-Description of the First Consecutive Cases in Poland: Case Series Report and a Short Literature Review. Transplant Proc 2024:S0041-1345(24)00243-4. [PMID: 38702265 DOI: 10.1016/j.transproceed.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 04/08/2024] [Accepted: 04/08/2024] [Indexed: 05/06/2024]
Abstract
Pulmonary complications of systemic scleroderma (SSc), such as interstitial lung disease and pulmonary hypertension (PH), are responsible for up to 60% of deaths among patients. For many years, most centers considered SSc a contraindication to lung transplantation (LTx); however, recent publications show that appropriately selected SSc candidates for LTx give results comparable to patients with idiopathic PH or idiopathic pulmonary fibrosis. This paper presents the cases of a 60-year-old male patient (patient 1) and a 42-year-old female patient (patient 2) diagnosed with SSc in 2019 and 2013, respectively. In both patients, interstitial-fibrotic changes in the lungs leading to respiratory failure were confirmed by high-resolution computed tomography as well as pulmonary hypertension (WHO group 3), which was also diagnosed during right heart catheterization. In both cases, despite pharmacotherapy, pulmonary fibrosis progressed, leading to severe respiratory failure. The patients were referred for LTx qualification. LTx was possible to consider in patients due to the lack of significant changes in other internal organs. Double LTx was successfully performed in both patients (patient 1-July 19, 2022; patient 2-September 14, 2022). They were discharged from the hospital in good condition on the 22nd and 20th postoperative day, respectively. LTx is a last-chance therapy that saves lives among patients with extreme respiratory failure in the course of SSc. It prolongs and improves the quality of life. The selection of appropriate patients is key to the success of the procedure.
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Affiliation(s)
- Tomasz Stącel
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Paweł Sybila
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland.
| | - Agata Mędrala
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Marek Ochman
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Mirosław Nęcki
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Piotr Pasek
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Kamil Kegler
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Piotr Przybyłowski
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Tomasz Hrapkowicz
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Dawid Borowik
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac Anaesthesia and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Maciej Urlik
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
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3
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Sanges S, Sobanski V, Lamblin N, Hachulla E, Savale L, Montani D, Launay D. Pulmonary hypertension in connective tissue diseases: What every CTD specialist should know - but is afraid to ask! Rev Med Interne 2024; 45:26-40. [PMID: 37925256 DOI: 10.1016/j.revmed.2023.10.450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 11/06/2023]
Abstract
Pulmonary hypertension (PH) is a possible complication of connective tissue diseases (CTDs), especially systemic sclerosis (SSc), systemic lupus erythematosus (SLE) and mixed connective tissue disease (MCTD). It is defined by an elevation of the mean pulmonary arterial pressure above 20mmHg documented during a right heart catheterization (RHC). Due to their multiorgan involvement, CTDs can induce PH by several mechanisms, that are sometimes intricated: pulmonary vasculopathy (group 1) affecting arterioles (pulmonary arterial hypertension, PAH) and possibly venules (pulmonary veno-occlusive-like disease), left-heart disease (group 2), chronic lung disease (group 3) and/or chronic thromboembolic PH (group 4). PH suspicion is often raised by clinical manifestations (dyspnea, fatigue), echocardiographic data (increased peak tricuspid regurgitation velocity), isolated decrease in DLCO in pulmonary function tests, and/or unexplained elevation of BNP/NT-proBNP. Its formal diagnosis always requires a hemodynamic confirmation by RHC. Strategies for PH screening and RHC referral have been extensively investigated for SSc-PAH but data are lacking in other CTDs. Therapeutic management of PH depends of the underlying mechanism(s): PAH-approved therapies in group 1 PH (with possible use of immunosuppressants, especially in case of SLE or MCTD); management of an underlying left-heart disease in group 2 PH; management of an underlying chronic lung disease in group 3 PH; anticoagulation, pulmonary endartectomy, PAH-approved therapies and/or balloon pulmonary angioplasty in group 4 PH. Regular follow-up is mandatory in all CTD-PH patients.
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Affiliation(s)
- S Sanges
- Université de Lille, U1286, INFINITE, Institute for Translational Research in Inflammation, 59000 Lille, France; Inserm, 59000 Lille, France; CHU de Lille, Département de Médecine Interne et Immunologie Clinique, 59000 Lille, France; Centre National de Référence Maladies Auto-immunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), 59000 Lille, France; Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET), 59000 Lille, France.
| | - V Sobanski
- Université de Lille, U1286, INFINITE, Institute for Translational Research in Inflammation, 59000 Lille, France; Inserm, 59000 Lille, France; CHU de Lille, Département de Médecine Interne et Immunologie Clinique, 59000 Lille, France; Centre National de Référence Maladies Auto-immunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), 59000 Lille, France; Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET), 59000 Lille, France
| | - N Lamblin
- CHU de Lille, Service de Cardiologie, 59000 Lille, France; Institut Pasteur de Lille, Inserm U1167, 59000 Lille, France
| | - E Hachulla
- Université de Lille, U1286, INFINITE, Institute for Translational Research in Inflammation, 59000 Lille, France; Inserm, 59000 Lille, France; CHU de Lille, Département de Médecine Interne et Immunologie Clinique, 59000 Lille, France; Centre National de Référence Maladies Auto-immunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), 59000 Lille, France; Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET), 59000 Lille, France
| | - L Savale
- Université Paris Saclay, School of Medicine, Le Kremlin-Bicêtre, France; AP-HP, Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - D Montani
- Université Paris Saclay, School of Medicine, Le Kremlin-Bicêtre, France; AP-HP, Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - D Launay
- Université de Lille, U1286, INFINITE, Institute for Translational Research in Inflammation, 59000 Lille, France; Inserm, 59000 Lille, France; CHU de Lille, Département de Médecine Interne et Immunologie Clinique, 59000 Lille, France; Centre National de Référence Maladies Auto-immunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), 59000 Lille, France; Health Care Provider of the European Reference Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNET), 59000 Lille, France
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4
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Le Pavec J, Launay D, Cottin V, Reynaud-Gaubert M. [Lung transplantation for systemic sclerosis-associated interstitial lung disease]. Rev Mal Respir 2023; 40 Suppl 1:e73-e79. [PMID: 36725441 DOI: 10.1016/j.rmr.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- J Le Pavec
- Service de Pneumologie et de Transplantation Pulmonaire, Groupe Hospitalier Marie-Lannelongue-Paris Saint Joseph, Le Plessis-Robinson, France; Université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Université Paris-Sud, Inserm, Groupe hospitalier Marie-Lannelongue-Saint Joseph, Le Plessis-Robinson, France.
| | - D Launay
- University Lille, Inserm, CHU Lille, Service de Médecine Interne et Immunologie Clinique, Centre de référence des maladies autoimmunes systémiques rares du Nord et Nord-Ouest de France (CeRAINO), U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000 Lille, France; University Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000 Lille, France; Inserm, 59000 Lille, France; CHU Lille, Service de Médecine Interne et Immunologie Clinique, Centre de référence des maladies autoimmunes systémiques rares du Nord et Nord-Ouest de France (CeRAINO), 59000 Lille, France
| | - V Cottin
- Université de Lyon, INRA, IVPC, Lyon, Centre national de référence des maladies pulmonaires rares, hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - M Reynaud-Gaubert
- Service de Pneumologie et Equipe de Transplantation Pulmonaire, Centre Hospitalo-Universitaire Nord, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
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5
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Zanatta E, Marra MP, Famoso G, Balestro E, Giraudo C, Calabrese F, Rea F, Doria A. The Challenge of Diagnosing and Managing Pulmonary Arterial Hypertension in Systemic Sclerosis with Interstitial Lung Disease. Pharmaceuticals (Basel) 2022; 15:ph15091042. [PMID: 36145263 PMCID: PMC9504220 DOI: 10.3390/ph15091042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/12/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Pulmonary hypertension (PH) in patients with Systemic Sclerosis (SSc) may stem from a variety of underlying causes, thus making a correct diagnosis and management difficult. The main challenges lie in the distinction between pulmonary arterial hypertension (PAH, group 1) and PH due to interstitial lung disease (PH-ILD, group 3) in patients with concomitant lung fibrosis — a very common occurrence in SSc. A consensus among experts remains elusive. Some studies have suggested that among SSc patients with PH, those with an ILD extension > 20% at high-resolution computed tomography (HRCT) should be considered as affected by PH-ILD, whereas other Authors have found that a wide proportion of these patients exhibit features of both PAH and group 3 PH-ILD. We report the case of a 46-year-old male SSc patient with a stable and extensive ILD (>20%) who developed a histologically documented pulmonary vasculopathy typical of PAH and received PAH-specific treatment as bridge to transplant. Moreover, we documented PH disease course by right heart catheterization (RHC), with and without specific vasodilator therapies, which are essential in PAH but not indicated and/or harmful in PH-ILD.
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Affiliation(s)
- Elisabetta Zanatta
- Department of Medicine-DIMED, Padova University Hospital, Via Giustiniani 2, 35126 Padova, Italy
- Correspondence: ; Tel.: +39-049-821-2193
| | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, Via Giustiniani 2, 35126 Padova, Italy
| | - Giulia Famoso
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, Via Giustiniani 2, 35126 Padova, Italy
| | - Elisabetta Balestro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, Via Giustiniani 2, 35126 Padova, Italy
| | - Chiara Giraudo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, Via Giustiniani 2, 35126 Padova, Italy
| | - Fiorella Calabrese
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, Via Giustiniani 2, 35126 Padova, Italy
| | - Federico Rea
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padova University Hospital, Via Giustiniani 2, 35126 Padova, Italy
| | - Andrea Doria
- Department of Medicine-DIMED, Padova University Hospital, Via Giustiniani 2, 35126 Padova, Italy
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6
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Lung Transplantation in Systemic Sclerosis: a Practice Survey of United States Lung Transplant Centers. Transplant Direct 2021; 7:e757. [PMID: 34514112 PMCID: PMC8425834 DOI: 10.1097/txd.0000000000001209] [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: 06/01/2021] [Revised: 06/17/2021] [Accepted: 07/03/2021] [Indexed: 11/27/2022] Open
Abstract
Supplemental Digital Content is available in the text. Lung transplantation in patients with systemic sclerosis (SSc) can be complicated by extrapulmonary manifestations of the disease, leading to concerns regarding posttransplant complications and outcomes.
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7
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Bermudez CA, Crespo MM, Shlobin OA, Cantu E, Mazurek JA, Levine D, Gutsche J, Kanwar M, Dellgren G, Bush EL, Heresi GA, Cypel M, Hadler R, Kolatis N, Franco V, Benvenuto L, Mooney J, Pipeling M, King C, Mannem H, Raman S, Knoop C, Douglas A, Mercier O. ISHLT consensus document on lung transplantation in patients with connective tissue disease: Part II: Cardiac, surgical, perioperative, operative, and post-operative challenges and management statements. J Heart Lung Transplant 2021; 40:1267-1278. [PMID: 34404570 DOI: 10.1016/j.healun.2021.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 01/09/2023] Open
Abstract
Patients with connective tissue disease (CTD) present unique surgical, perioperative, operative, and postoperative challenges related to the often underlying severe pulmonary hypertension and right ventricular dysfunction. The International Society for Heart and Lung Transplantation-supported consensus document on lung transplantation in patients with CTD standardization addresses the surgical challenges and relevant cardiac involvement in the perioperative, operative, and postoperative management in patients with CTD.
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Affiliation(s)
- Christian A Bermudez
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Oksana A Shlobin
- Department of Pulmonary and Critical Care Medicine, Inova Fairfax Hospital, Falls Church, Virginia
| | - Edward Cantu
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy A Mazurek
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Deborah Levine
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center San Antonio, Texas
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Göran Dellgren
- Department of Cardiothoracic Surgery and Transplant Institute, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Errol L Bush
- Division of Thoracic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Marcello Cypel
- Division of Thoracic Surgery, Toronto General Hospital UHN, Toronto, Ontario, Canada
| | - Rachel Hadler
- Division of Critical Care, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Nicholas Kolatis
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco Medical Center, San Francisco, California
| | - Veronica Franco
- Department of Cardiology, The Ohio State university Wexner Medical Center, Columbus, Ohio
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical center, New York, New York
| | - Joshua Mooney
- Division of Pulmonary and Critical Care Medicine, Stanford Health Care, Palo Alto, California
| | - Matthew Pipeling
- Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
| | - Christopher King
- Department of Pulmonary and Critical Care Medicine, Inova Fairfax Hospital, Falls Church, Virginia
| | - Hannah Mannem
- Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, Virginia
| | - Sanjeev Raman
- Division of Pulmonary Medicine, University of Utah, Salt Lake City, Utah
| | | | - Aaron Douglas
- Division of Anesthesiology and Critical Care, Cleveland Clinic, Cleveland, Ohio
| | - Olaf Mercier
- Department of Thoracic Surgery, Université Paris-Saclay, Marie Lannelongue Hospital, Le Plessis Robinson, France
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Hachulla E, Agard C, Allanore Y, Avouac J, Bader-Meunier B, Belot A, Berezne A, Bouthors AS, Condette-Wojtasik G, Constans J, De Groote P, Diot E, Dumas F, Jego P, Joly F, Launay D, Le Guern V, Le Quintrec JS, Lescaille G, Meune C, Moulin B, Nguyen C, Omeish N, Pene F, Richard MA, Rochefort J, Roren A, Sitbon O, Sobanski V, Truchetet ME, Mouthon L. French recommendations for the management of systemic sclerosis. Orphanet J Rare Dis 2021; 16:322. [PMID: 34304732 PMCID: PMC8310704 DOI: 10.1186/s13023-021-01844-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 12/13/2022] Open
Abstract
Systemic sclerosis (SSc) is a generalized disease of the connective tissue, arterioles, and microvessels, characterized by the appearance of fibrosis and vascular obliteration. There are two main phenotypical forms of SSc: a diffuse cutaneous form that extends towards the proximal region of the limbs and/or torso, and a limited cutaneous form where the cutaneous sclerosis only affects the extremities of the limbs (without passing beyond the elbows and knees). There also exists in less than 10% of cases forms that never involve the skin. This is called SSc sine scleroderma. The prognosis depends essentially on the occurrence of visceral damage and more particularly interstitial lung disease (which is sometimes severe), pulmonary arterial hypertension, or primary cardiac damage, which represent the three commonest causes of mortality in SSc. Another type of involvement with poor prognosis, scleroderma renal crisis, is rare (less than 5% of cases). Cutaneous extension is also an important parameter, with the diffuse cutaneous forms having less favorable prognosis.
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Affiliation(s)
- Eric Hachulla
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France.
| | - Christian Agard
- Internal Medicine, Nantes University Hospital, University of Nantes, Nantes, France
| | - Yannick Allanore
- Rheumatology Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Jerome Avouac
- Rheumatology Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Brigitte Bader-Meunier
- Department of Pediatric Immunology and Rheumatology; Hospital Necker, APHP, Paris, France
| | - Alexandre Belot
- Pediatric Nephrology, Rheumatology, Dermatology, HFME, Hospices Civils de Lyon, Bron, France
| | - Alice Berezne
- Department of Internal Medicine, CHR Annecy-Genevois, Annecy, France
| | - Anne-Sophie Bouthors
- Anaesthesia Intensive Care Unit, Jeanne de Flandre Women Hospital, Academic Hospital, ULR 7365 - GRITA - Groupe de Recherche Sur Les Formes Injectables Et Les Technologies Associées, University Lille, Lille, France
| | - Geraldine Condette-Wojtasik
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France
| | - Joël Constans
- Vascular Medicine Department, Bordeaux University Hospital Centre, Saint André Hospital, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists) PeripherAL Artery DIsease Network (PALADIN), Bordeaux, France
| | - Pascal De Groote
- Cardiology Department, Lung-Heart Institute, CHU de Lille, 59000, Lille, France
| | | | - Florence Dumas
- Emergency Department, Cochin Hospital, Paris University, Paris, France
| | - Patrick Jego
- Internal Medicine and Clinical Immunology Unit, CHU Rennes, Rennes, France
| | - Francisca Joly
- Department of Gastroenterology, IBD and Nutrition Support, Beaujon Hospital, INSERM UMRS-1149, Assistance Publique-Hôpitaux de Paris, University of Paris, Clichy, France
| | - David Launay
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France
| | - Veronique Le Guern
- Service de Médecine Interne, Centre de Référence Maladies Autoimmunes Systémiques Rares D'Ile de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), APHP-CUP, Hôpital Cochin, Université de Paris, 75014, Paris, France
| | | | - Geraldine Lescaille
- Centre d'Immunologie et Maladies Infectieuses (CIMI-Paris), Department of Odontology, Paris Diderot/Paris 07, Sorbonne Paris Cité, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Christophe Meune
- Cardiology Department, Hôpital Avicenne, AP-HP, Université de Paris, Paris, France
| | - Bruno Moulin
- Department of Nephrology and Kidney Transplantation, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France
| | - Christelle Nguyen
- Physical Medicine and Rehabilitation Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Nadine Omeish
- Oral and Dental Medicine, Hôpital Pitié-Salpêtrière, APHP, Université de Paris, Paris, France
| | - Frederic Pene
- Medical Intensive Care Unit, Hôpital Cochin, AP-HP. Centre & Université de Paris, Paris, France
| | - Marie-Aleth Richard
- Department of Dermatology, Timone Hospital, University Hospital of Marseille, Marseille, France
| | - Juliette Rochefort
- Oral and Dental Medicine, Hôpital Pitié-Salpêtrière, APHP, Université de Paris, Paris, France
| | - Alexandra Roren
- AP-HP Cochin Hospital, Université Paris Descartes Sorbonne Paris Cité, INSERM U1153, Paris, France
| | - Olivier Sitbon
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Laboratoire d'Excellence en Recherche Sur le Médicament et Innovation Thérapeutique, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - Vincent Sobanski
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France
| | | | - Luc Mouthon
- Service de Médecine Interne, Centre de Référence Maladies Autoimmunes Systémiques Rares D'Ile de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), APHP-CUP, Hôpital Cochin, Université de Paris, 75014, Paris, France.
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9
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Bruni C, Guignabert C, Manetti M, Cerinic MM, Humbert M. The multifaceted problem of pulmonary arterial hypertension in systemic sclerosis. THE LANCET. RHEUMATOLOGY 2021; 3:e149-e159. [PMID: 38279370 DOI: 10.1016/s2665-9913(20)30356-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 01/16/2023]
Abstract
Cardiopulmonary complications are a leading cause of death in systemic sclerosis. Pulmonary hypertension in particular carries a high mortality and morbidity burden. Patients with systemic sclerosis can suffer from all of the clinical groups of pulmonary hypertension, particularly pulmonary arterial hypertension and pulmonary hypertension related to interstitial lung disease. Despite a similar pathogenetic background with idiopathic pulmonary arterial hypertension, different mechanisms determine a worse prognostic outcome for patients with systemic sclerosis. In this Viewpoint, we will consider the link between pathogenetic and potential therapeutic targets for the treatment of pulmonary hypertension in the context of systemic sclerosis, with a focus on the current unmet needs, such as the importance of early screening and detection, the absence of agreed criteria to distinguish pulmonary arterial hypertension with interstitial lung disease from pulmonary hypertension due to lung fibrosis, and the need for a holistic treatment approach to target all the vascular, immunological, and inflammatory components of the disease.
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Affiliation(s)
- Cosimo Bruni
- Division of Rheumatology, and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Christophe Guignabert
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; Department of Pulmonary Hypertension, Pathophysiology, and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Mirko Manetti
- Section of Anatomy and Histology, and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marco Matucci Cerinic
- Division of Rheumatology, and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Marc Humbert
- School of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; Department of Pulmonary Hypertension, Pathophysiology, and Novel Therapies, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; Department of Respiratory and Intensive Care Medicine, Pulmonary Hypertension National Referral Center, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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10
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Minalyan A, Gabrielyan L, Khanal S, Basyal B, Derk C. Systemic Sclerosis: Current State and Survival After Lung Transplantation. Cureus 2021; 13:e12797. [PMID: 33628666 PMCID: PMC7893677 DOI: 10.7759/cureus.12797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Systemic sclerosis (SSc) is an autoimmune disorder characterized by the involvement of skin and internal organs. With the introduction of angiotensin-converting enzyme inhibitors (ACEIs), scleroderma renal crisis (SRC) is no longer considered a leading cause of death in affected patients. In fact, pulmonary manifestations [interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH)] are currently the major cause of death in patients with SSc. Historically, many centers have been reluctant to offer lung transplantation to patients with SSc due to multiple extrapulmonary manifestations and the assumption of poor post-transplant survival. The purpose of this review is to highlight the recent advances in the evaluation and management of patients with pulmonary manifestations of SSc. We also engage in a systematic literature review to assess all the available data on the survival of patients with SSc after lung transplantation.
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Affiliation(s)
- Artem Minalyan
- Internal Medicine, Abington Hospital-Jefferson Health, Abington, USA
| | - Lilit Gabrielyan
- Pharmacy, School of Pharmacy, University of Southern California, Los Angeles, USA
| | - Shristi Khanal
- Internal Medicine, Abington Hospital-Jefferson Health, Abington, USA
| | - Bikash Basyal
- Internal Medicine, Abington Hospital-Jefferson Health, Abington, USA
| | - Chris Derk
- Internal Medicine: Rheumatology, Hospital of the University of Pennsylvania, Philadelphia, USA
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11
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Morrisroe K, Nikpour M. Controversies and advances in connective tissue disease‐related pulmonary arterial hypertension. Int J Rheum Dis 2020. [DOI: 10.1111/1756-185x.13926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Kathleen Morrisroe
- Department of Medicine The University of Melbourne at St Vincent's Hospital Melbourne Vic Australia
- Department of Rheumatology St Vincent's Hospital Melbourne Vic Australia
| | - Mandana Nikpour
- Department of Medicine The University of Melbourne at St Vincent's Hospital Melbourne Vic Australia
- Department of Rheumatology St Vincent's Hospital Melbourne Vic Australia
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12
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Hinze AM, Lin CT, Hussien AF, Perin J, Venado A, Golden JA, Boin F, Brown RH, Wise RA, Wigley FM. Longitudinal assessment of interstitial lung disease in single lung transplant recipients with scleroderma. Rheumatology (Oxford) 2020; 59:790-798. [PMID: 31504916 DOI: 10.1093/rheumatology/kez341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/02/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate the natural history of fibrotic lung disease in recipients of a single lung transplant for scleroderma-associated interstitial lung disease (ILD). METHODS Global ILD (including ground glass, nodular opacities and fibrosis) was categorized into severity quintiles on first and last post-transplant CT scans, and percent fibrosis by manual contouring was also determined, in nine single lung transplant recipients. Quantitative mean lung densities and volumes for the native and allograft lungs were also acquired. RESULTS In the native lung, global ILD severity quintile worsened in two cases and percent fibrosis worsened in four cases (range 5-28%). In the lung allograft, one case each developed mild, moderate and severe ILD; of these, new fibrotic ILD (involving <10% of lung) occurred in two cases and acute cellular rejection occurred in one. The average change in native lung density over time was +2.2 Hounsfield Units per year and lung volume +1.4 ml per year, whereas the allograft lung density changed by -5.5 Hounsfield Units per year and total volume +27 ml per year (P = 0.011 and P = 0.039 for native vs allograft density and volume comparisons, respectively). CONCLUSIONS While the course of ILD in the native and transplanted lungs varied in this series, these cases illustrate that disease progression is common in the native lung, suggesting that either the immune process continues to target autoantigens or ongoing fibrotic pathways are active in the native lung. Mild lung disease may occur in the allograft after several years due to either allograft rejection or recurrent mild ILD.
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Affiliation(s)
- Alicia M Hinze
- Department of Medicine, Division of Rheumatology, Mayo Clinic, Rochester, MN, USA
| | - Cheng T Lin
- Department of Radiology, Johns Hopkins University, Baltimore, MD, USA
| | - Amira F Hussien
- Department of Radiology, Johns Hopkins University, Baltimore, MD, USA
| | - Jamie Perin
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Aida Venado
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy, & Sleep Medicine, USA
| | - Jeffrey A Golden
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy, & Sleep Medicine, USA
| | - Francesco Boin
- Department of Medicine, Division of Rheumatology, University of California San Francisco, San Francisco, CA, USA
| | - Robert H Brown
- Department of Radiology, Johns Hopkins University, Baltimore, MD, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA.,Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Medicine, Division of Pulmonary, MD, USA
| | - Robert A Wise
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Medicine, Division of Pulmonary, MD, USA
| | - Fredrick M Wigley
- Department of Medicine, Division of Clinical and Molecular Rheumatology, Johns Hopkins University, Baltimore, MD, USA
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13
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Perelas A, Silver RM, Arrossi AV, Highland KB. Systemic sclerosis-associated interstitial lung disease. THE LANCET RESPIRATORY MEDICINE 2020; 8:304-320. [PMID: 32113575 DOI: 10.1016/s2213-2600(19)30480-1] [Citation(s) in RCA: 160] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/19/2019] [Accepted: 12/19/2019] [Indexed: 12/15/2022]
Abstract
Systemic sclerosis is an autoimmune connective tissue disease, which is characterised by immune dysregulation and progressive fibrosis that typically affects the skin, with variable internal organ involvement. It is a rare condition that affects mostly young and middle-aged women, resulting in disproportionate morbidity and mortality. Currently, interstitial lung disease is the most common cause of death among patients with systemic sclerosis, with a prevalence of up to 30% and a 10-year mortality of up to 40%. Interstitial lung disease is more common among African Americans and in people with the diffuse cutaneous form of systemic sclerosis or anti-topoisomerase 1 antibodies. Systemic sclerosis-associated interstitial lung disease most commonly presents with dyspnoea, cough, and a non-specific interstitial pneumonia pattern on CT scan, with a minority of cases fulfilling the criteria for usual interstitial pneumonia. The standard therapy has traditionally been combinations of immunosuppressants, particularly mycophenolate mofetil or cyclophosphamide. These immunosuppressants can be supplemented by targeted biological and antifibrotic therapies, whereas autologous haematopoietic stem-cell transplantation and lung transplantation are reserved for refractory cases.
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Affiliation(s)
- Apostolos Perelas
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Richard M Silver
- Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA
| | - Andrea V Arrossi
- Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
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14
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Stern LK, Selby VN, Kolaitis NA, Boin F, Aras M, Klein L, De Marco T. Heart-lung transplantation: A viable option for connective tissue diseases. Clin Transplant 2020; 34:e13776. [PMID: 31867763 DOI: 10.1111/ctr.13776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 11/06/2019] [Accepted: 12/03/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND While lung transplantation (LTx) has been effective for connective tissue disease (CTD) patients with pulmonary involvement, outcomes for heart-lung transplantation (HLTx) are less defined. The aim of this study is to evaluate HLTx in CTD patients utilizing the UNOS database. METHODS HLTx patients with CTD (HLTx-CTD) were compared to both LTx patients with CTD (LTx-CTD) and HLTx patients with all other indications (HLTx-OI) from 1999 to 2018. Primary outcome was 1- and 5-year graft survival. Secondary outcomes included freedom from first-year rejection and outcomes prior to transplant discharge. RESULTS 1143/29 323 adults received first-time HLTx or LTx for CTD. Seventeen were HLTx-CTD (3.3% of total HLTx) and 1126 were LTx-CTD (3.9% of total LTx). There were 492 HLTx-OI. Transplant hemodynamic values including cardiac output, pulmonary capillary wedge pressure, and calculated pulmonary vascular resistance were significantly worse for HLTx-CTD vs LTx-CTD (4.2 vs 5.4 L/min, P = .005; 14 vs 10 mm Hg, P = .009; 439 vs 267 dynes, P = .007, respectively). Cardiac status 1 was more common for HLTx-CTD vs HLTx-OI (94% vs 56%, P < .001). HLTx-CTD 1 and 5-year graft survival was similar compared to LTx-CTD and HLTx-OI. CONCLUSION HLTx-CTD is a valid option for carefully selected patients with CTD cardiac and pulmonary involvement with similar morbidity and mortality compared to LTx-CTD and HLTx-OI.
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Affiliation(s)
- Lily K Stern
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Van N Selby
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Nicholas A Kolaitis
- Division of Pulmonary and Critical Care, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Francesco Boin
- Division of Rheumatology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Mandar Aras
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Liviu Klein
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Teresa De Marco
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
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15
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Turcotte‐Gosselin F, Turgeon PY, Ikic A, Beaudoin J, Joubert P, Dubois M, Voisine P, Sénéchal M. Is heart transplantation a valuable option in patients with diffuse systemic sclerosis and primary cardiac involvement? Clin Case Rep 2020; 8:137-141. [PMID: 31998504 PMCID: PMC6982482 DOI: 10.1002/ccr3.2600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 10/15/2019] [Accepted: 10/31/2019] [Indexed: 11/25/2022] Open
Abstract
Systemic sclerosis patients with primary cardiac involvement can be reliably diagnosed by cardiac magnetic resonance imaging and are associated with a poor prognosis. This case report highlights the importance of considering heart transplantation in those patients as a lifesaving procedure.
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Affiliation(s)
- Frédéric Turcotte‐Gosselin
- Department of CardiologyInstitut Universitaire de Cardiologie et de Pneumologie de QuébecLaval UniversityQuebecQCCanada
| | - Pierre Yves Turgeon
- Department of CardiologyInstitut Universitaire de Cardiologie et de Pneumologie de QuébecLaval UniversityQuebecQCCanada
| | - Alena Ikic
- Department of RheumatologyCHUL‐CHU of QuebecLaval UniversityQuebecQCCanada
| | - Jonathan Beaudoin
- Department of CardiologyInstitut Universitaire de Cardiologie et de Pneumologie de QuébecLaval UniversityQuebecQCCanada
| | - Philippe Joubert
- Department of AnatomopathologyInstitut Universitaire de Cardiologie et de Pneumologie de QuébecLaval UniversityQuebecQCCanada
| | - Michelle Dubois
- Research CenterInstitut Universitaire de Cardiologie et de Pneumologie de QuébecLaval UniversityQuebecQCCanada
| | - Pierre Voisine
- Department of Cardiac SurgeryInstitut Universitaire de Cardiologie et de Pneumologie de QuébecLaval UniversityQuebecQCCanada
| | - Mario Sénéchal
- Department of CardiologyInstitut Universitaire de Cardiologie et de Pneumologie de QuébecLaval UniversityQuebecQCCanada
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16
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Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight recent data regarding feasibility and outcomes following lung transplantation for patients with systemic sclerosis related pulmonary disease as well as to emphasize areas of uncertainly in need of further study. We include a description of our centre's approach to lung transplant evaluation and posttransplant management in this complex patient population. RECENT FINDINGS Historical data have demonstrated that patients with scleroderma have an increased risk of complications following lung transplantation owing to the multisystem nature of disease, particularly concurrent gastrointestinal, cardiac and renal involvement. Emerging data support the safety of lung transplant in appropriately selected patients with scleroderma-related interstitial lung disease and pulmonary arterial hypertension. SUMMARY Accumulating evidence validates that a diagnosis of scleroderma is not a priori a contraindication to lung transplant. In the carefully selected patient, both short-term and long-term outcomes following lung transplantation are comparable to counterparts with fibrotic lung disease or pulmonary arterial hypertension. However, further prospective study to detail how these patients should be evaluated and managed posttransplant is definitely needed. Cardiac disease is an emerging cause of morbidity and mortality in the scleroderma population and deserves particular attention during the pre and posttransplant period.
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17
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Zanatta E, Codullo V, Avouac J, Allanore Y. Systemic sclerosis: Recent insight in clinical management. Joint Bone Spine 2019; 87:293-299. [PMID: 31568838 DOI: 10.1016/j.jbspin.2019.09.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 09/18/2019] [Indexed: 12/12/2022]
Abstract
Systemic sclerosis (SSc) is a connective tissue disease characterized by diffuse microangiopathy and immune dysregulation which ultimately result in widespread fibrosis of skin and internal organs. Although the 2013 EULAR/ACR criteria have allowed to improve the sensitivity for SSc diagnosis, it has recently come to light that the traditional subclassification into limited and diffuse cutaneous forms does not appear to fully capture the different phenotypes of the scleroderma spectrum. In this regard, a recent large cluster analysis-based study and other ongoing projects are trying to achieve a better stratification of SSc patients, as the disease course remains largely unpredictable to date. Recent preclinical studies and randomized controlled trials have yielded encouraging results with new drugs targeting inflammatory/immunological and fibrotic pathways. One of the main unmet needs in SSc remains the early identification of patients at high mortality risk, for whom aggressiveness of therapies ought to be determined and weighed against disease prognosis. Furthermore, lung and cardiac transplantation may also be taken into account in some carefully selected patients. Though the prognosis of SSc remains poor, an optimized stratification of patients along with the recent and ongoing advances in therapies could greatly impact the natural course of the disease in the near future. Moreover, it is envisioned that there will be an increasing need in the future to further develop combination therapies to better fight against this complex disease. In this review we discussed new insights into organ involvements and therapeutic options.
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Affiliation(s)
- Elisabetta Zanatta
- Rhumatologie, université Paris Descartes, hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Veronica Codullo
- Rhumatologie, université Paris Descartes, hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Jérôme Avouac
- Rhumatologie, université Paris Descartes, hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Yannick Allanore
- Rhumatologie, université Paris Descartes, hôpital Cochin, 27, rue du Faubourg Saint-Jacques, 75014 Paris, France.
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18
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Bode H, Verleden SE, Wuyts WA, Yserbyt J, Verleden GM, Vos R. Outcome of lung transplantation in non-idiopathic pulmonary fibrosis interstitial lung disease. Clin Transplant 2019; 33:e13661. [PMID: 31286560 DOI: 10.1111/ctr.13661] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 06/29/2019] [Accepted: 07/02/2019] [Indexed: 01/20/2023]
Abstract
Lung transplantation remains the only curative treatment option for selected patients with end-stage interstitial lung disease (ILD). Candidate selection is impeded by patient heterogeneity, particularly in the subgroup of non-idiopathic pulmonary fibrosis (non-IPF) interstitial lung diseases. We performed a descriptive analysis of all non-IPF ILD patients who underwent lung transplantation in our center between July 1991 and November 2016 (n = 129) and searched for pre-transplant variables correlating with graft loss and chronic lung allograft dysfunction (CLAD). Our study cohort was characterized by a significantly affected medical condition, an extensive pre-transplant corticosteroid use (73.8%), and a high prevalence of pulmonary hypertension (55.7%). Earlier year of transplantation (P = .004), higher bilirubin level (P < .0001), older recipient age (P = .04), and smaller recipient height (P = .02) were found to be associated with earlier graft loss in multivariate analysis. Moreover, pre-transplant corticosteroid treatment tended to be related to earlier graft loss (P = .06), while pulmonary hypertension did not significantly correlate. None of the pre-transplant variables were shown to be associated with CLAD development. Ongoing research is required to further explore this diverse patient population and the pre-transplant variables determining their post-transplant outcome.
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Affiliation(s)
- Hannelore Bode
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Stijn E Verleden
- Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Leuven, Belgium
| | - Wim A Wuyts
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Leuven, Belgium
| | - Jonas Yserbyt
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Leuven, Belgium
| | - Geert M Verleden
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Leuven, Belgium
| | - Robin Vos
- Department of Respiratory Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Leuven, Belgium
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19
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Koo SM, Kim SY, Choi SM, Lee HK. Korean Guidelines for Diagnosis and Management of Interstitial Lung Diseases: Part 5. Connective Tissue Disease Associated Interstitial Lung Disease. Tuberc Respir Dis (Seoul) 2019; 82:285-297. [PMID: 31172701 PMCID: PMC6778739 DOI: 10.4046/trd.2019.0009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/08/2019] [Accepted: 04/10/2019] [Indexed: 01/13/2023] Open
Abstract
Connective tissue disease (CTD) is a collection of disorders characterized by various signs and symptoms such as circulation of autoantibodies in the entire system causing damage to internal organs. Interstitial lung disease (ILD) which is associated with CTD is referred to as CTD-ILD. Patients diagnosed with ILD should be thoroughly examined for the co-occurrence of CTD, since the treatment procedures and prognosis of CTD-ILD are vary from those of idiopathic interstitial pneumonia. The representative types of CTD which may accompany ILD include rheumatoid arthritis, systemic sclerosis (SSc), Sjögren's syndrome, mixed CTD, idiopathic inflammatory myopathies, and systemic lupus erythematous. Of these, ILD most frequently co-exists with SSc. If an ILD is observed in the chest, high resolution computed tomography and specific diagnostic criteria for any type of CTD are met, then a diagnosis of CTD-ILD is made. It is challenging to conduct a properly designed randomized study on CTD-ILD, due to low incidence. Therefore, CTD-ILD treatment approach is yet to been established in absence of randomized controlled clinical trials, with the exception of SSc-ILD. When a patient is presented with acute CTD-ILD or if symptoms occur due to progression of the disease, steroid and immunosuppressive therapy are generally considered.
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Affiliation(s)
- So My Koo
- Division of Allergy and Respiratory Medicine, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Sun Mi Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Meidicine, Seoul National University Hospital, Seoul, Korea.
| | - Hyun Kyung Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, Korea
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20
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Faust I, Weile J, Fujita B, Kandolf R, Hendig D, Vollmer T, Stan AC, Kellner U, Kuhn J, Gummert JF, Knabbe C. Heart Transplantation in Systemic Sclerosis: New Impulses for Conventional Scleroderma Transplantation Regimen and Scleroderma Diagnostic Monitoring: 2 Case Reports. Transplant Proc 2019; 51:865-870. [PMID: 30979477 DOI: 10.1016/j.transproceed.2019.01.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 01/04/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although low (but increasing) rates of lung/lung-heart transplantations of scleroderma (systemic sclerosis [SSc]) patients have been reported, exclusive heart transplantation is a rare approach for treatment of heart failure due to SSc. CASES We report on 2 cases of SSc patients receiving a heart transplantation (HTx) due to severe and progressive right heart failure without pulmonary artery hypertension. One patient received a hepatitis C virus (HCV)-positive donor heart and recovered excellently from viral transmission after administration of a direct-acting antiviral (DAA) regimen. This is the first published case of an SSc patient who underwent HTx using an HCV-positive donor heart. The clinical course of both patients was monitored by different serum SSc biomarkers. Only xylosyltransferase activity proved to be a promising biomarker for disease stage determination and therapeutic monitoring, precisely reflecting fibrotic remodeling and successful organ recovery. CONCLUSIONS Successful implementation of the 2 cases described here demonstrates that HTx is a safe and effective therapeutic option for defined SSc sub-patient groups despite the progressive character of the underlying disease. In the future, xylosyltransferase activity might be conducive to simplify the identification of patients with low systemic involvement but a strong indication for single heart transplantation. Finally, we demonstrate that treatment of HCV viral transmission from HCV-positive donor to organ recipient using DAA gives us new opportunities to consider HCV-positive donor organs for HTx and might reveal new possibilities to ease the lack of donor organs.
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Affiliation(s)
- I Faust
- Institute for Laboratory and Transfusion Medicine, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr University Bochum, Bad Oeynhausen, Germany.
| | - J Weile
- Institute for Laboratory and Transfusion Medicine, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - B Fujita
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - R Kandolf
- Abteilung für Molekulare Pathologie, Institut für Pathologie und Neuropathologie, Universitätsklinikum Tübingen, Tübingen, Germany
| | - D Hendig
- Institute for Laboratory and Transfusion Medicine, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - T Vollmer
- Institute for Laboratory and Transfusion Medicine, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - A-C Stan
- Institut für Pathologie, Johannes Wesling Klinikum Minden, Minden, Germany
| | - U Kellner
- Institut für Pathologie, Johannes Wesling Klinikum Minden, Minden, Germany
| | - J Kuhn
- Institute for Laboratory and Transfusion Medicine, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - J F Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - C Knabbe
- Institute for Laboratory and Transfusion Medicine, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr University Bochum, Bad Oeynhausen, Germany
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21
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Ahmed S, Pattanaik SS, Rai MK, Nath A, Agarwal V. Interstitial lung disease in Systemic sclerosis: insights into pathogenesis and evolving therapies. Mediterr J Rheumatol 2018; 29:140-147. [PMID: 32185315 PMCID: PMC7046043 DOI: 10.31138/mjr.29.3.140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 09/02/2018] [Accepted: 09/13/2018] [Indexed: 01/05/2023] Open
Abstract
Interstitial lung disease (ILD) is a leading cause of mortality in systemic sclerosis (SSc). However, mortality is improving as pathogenesis is being better understood and new therapies emerge. The roles of the inflammasome and NETosis in fibrosis are being elucidated. Epigenetic targets like DNA methylation and microRNA show promise as new targets for anti-fibrotic agents. The IL17-23 pathway has been shown to be active in SSc-ILD. Newer biomarkers are being described like CCL18 and the anti-eIF2B antibody. Hypothesis-free approaches are identifying newer genes like the ALOX5AP and XRCC4 genes. Computer-aided interpretations of CT scans, screening with ultrasonography and magnetic resonance imaging (MRI) are gradually emerging into practice. Imaging can also predict prognosis. A plethora of studies has shown the benefit of immunosuppression in halting ILD progression. Extent of lung involvement and PFT parameters are used to initiate therapy. The best evidence is for cyclophosphamide and mycophenolate. Besides these, corticosteroids and rituximab are being used in cases refractory to the first line drugs. Stem cell transplant is also backed by evidence in SSc. Longer studies on maintenance therapy are awaited. The inflammation in SSc is mostly subclinical and there is great interest in developing anti-fibrotic drugs for SSc-ILD. Perfinidone and nintedanib are under trial. The last resort is lung transplantation.
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Affiliation(s)
- Sakir Ahmed
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Sarit Sekhar Pattanaik
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Mohit Kumar Rai
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Alok Nath
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Vikas Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Denton CP, Wells AU, Coghlan JG. Major lung complications of systemic sclerosis. Nat Rev Rheumatol 2018; 14:511-527. [DOI: 10.1038/s41584-018-0062-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Delplanque M, Gatfosse M, Ait-Oufella H, Mercier O, Savale L, Fain O, Mekinian A. Transplantation bipulmonaire pour une atteinte pulmonaire interstitielle grave au cours d’un syndrome des antisynthétases. Rev Med Interne 2018. [DOI: 10.1016/j.revmed.2018.03.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Lung transplantation for scleroderma lung disease: An international, multicenter, observational cohort study. J Heart Lung Transplant 2018; 37:903-911. [PMID: 29628135 DOI: 10.1016/j.healun.2018.03.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/16/2018] [Accepted: 03/12/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Due to its multisystemic nature, scleroderma is considered a relative contraindication to lung transplantation at many centers. However, recent studies suggest similar post-transplant outcomes in patients with scleroderma compared to those with other causes of interstitial lung disease (ILD). Furthermore, it remains unknown whether scleroderma-associated pulmonary arterial hypertension (PAH) influences post-transplant outcomes. Our objective in this study was to assess the indications, survival, and prognostic factors of lung or heart-lung transplantation for scleroderma lung disease. METHODS We retrospectively reviewed the data of 90 patients with scleroderma who underwent lung or heart-lung transplantation between 1993 and 2016 at 14 European centers. International criteria were used to diagnose scleroderma. Pulmonary hypertension (PH) was diagnosed during right heart catheterization based on international guidelines. RESULTS Survival rates after 1, 3, and 5 years were 81%, 68%, and 61%, respectively. By univariate analysis, borderline-significant associations with poorer survival were found for female gender (hazard ratio 2.11; 95% confidence interval [CI] 0.99 to 4.50; p = 0.05) and PAH as the reason for transplantation (hazard ratio 1.90; 95% CI 0.96 to 3.92; p = 0.06). When both these factors were present in combination, the risk of death was 3-fold that in males without PAH. The clinical and histologic presentation resembled veno-occlusive disease in 75% of patients with PAH. CONCLUSIONS Post-transplant survival rates and freedom from chronic lung allograft dysfunction in patients with scleroderma were similar to those in patients with other reasons for lung transplantation. Female sex and PAH in combination was associated with lower survival.
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Fernández-Codina A, Berastegui C, Pinal-Fernández I, Silveira MG, López-Meseguer M, Monforte V, Guillén-del Castillo A, Simeón-Aznar CP, Fonollosa-Plà V, Solé J, Bravo-Masgoret C, Román-Broto A. Lung transplantation in systemic sclerosis: A single center cohort study. Joint Bone Spine 2018; 85:79-84. [DOI: 10.1016/j.jbspin.2017.03.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/15/2017] [Indexed: 10/19/2022]
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Rituximab Experience in Patients With Long-standing Systemic Sclerosis–Associated Interstitial Lung Disease. J Clin Rheumatol 2017; 23:411-415. [PMID: 28926468 DOI: 10.1097/rhu.0000000000000584] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abstract
PURPOSE OF REVIEW The purpose of this study was to highlight recent findings on evaluation for lung transplantation and outcomes after transplantation in patients with systemic sclerosis (scleroderma). RECENT FINDINGS The recognition that extra-pulmonary disease manifestations can seriously compromise post-transplant outcomes has changed the way patients are screened for lung transplant candidacy. Reluctance to transplant subjects affected by scleroderma has been driven by the complexity and multisystem nature of this disease. Multiple recent reports provide convincing findings that scleroderma patients undergoing lung transplantation have similar outcomes as those with other non-rheumatologic pulmonary conditions, even when significant esophageal dysmotility is present. New evidence supports the notion that scleroderma should not be a contraindication for referral to lung transplant. Future studies are needed to improve risk stratification, to define protocols for screening and management of extra-pulmonary complications, and to optimize immunosuppression before and after transplant.
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Current Approaches to the Treatment of Systemic-Sclerosis-Associated Pulmonary Arterial Hypertension (SSc-PAH). Curr Rheumatol Rep 2016; 18:10. [PMID: 26841964 DOI: 10.1007/s11926-015-0560-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a severe condition causing significant morbidity and mortality in patients with systemic sclerosis (SSc). Despite the use of specific treatments, SSc-PAH survival remains poorer than in idiopathic PAH (IPAH). Recent therapeutic advances in PAH show a lower magnitude of response in SSc-PAH and a higher risk of adverse events, as compared to IPAH. The multifaceted underlying mechanisms and the multisystem nature of SSc probably explain part of the worse outcomes in SSc-PAH compared to IPAH. This review describes the current management of SSc-PAH with an emphasis on the impact of the different organ involvements in the prognosis and treatment response. An earlier detection of PAH and a better characterization of the clinical phenotypes of SSc-PAH are warranted in clinical practice and future trials. Determinants of prognosis, surrogate markers of clinical improvement or worsening, and relevance of the common endpoints used in clinical trials should be evaluated in this specific population. A multidisciplinary approach in expert referral centers is mandatory for SSc-PAH management.
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Abstract
Systemic sclerosis (SSc) is a multi-systemic autoimmune disease that mainly affects the skin, lungs, gastrointestinal tract, heart and kidneys. Pulmonary disease in patients with SSc is strongly associated with mortality. The mechanisms involved into its pathophysiology include the activation of autoimmune cells and hyperplasia of fibroblasts with an increased capacity to produce collagen and diminished collagen breakdown. Although pulmonary biopsy is the gold standard for the diagnosis of interstitial lung disease in SSc, the most commonly used method is high-resolution computed tomography due to its high sensitivity and specificity. Herein, a comprehensive review on the pulmonary involvement in SSc is presented highlighting the radiologic-pathologic correlations.
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Cappelli S, Bellando Randone S, Camiciottoli G, De Paulis A, Guiducci S, Matucci-Cerinic M. Interstitial lung disease in systemic sclerosis: where do we stand? Eur Respir Rev 2016; 24:411-9. [PMID: 26324802 DOI: 10.1183/16000617.00002915] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Interstitial lung disease (ILD) is common in systemic sclerosis (SSc) patients and despite recent advances in the treatment is, at present, the major cause of death. Today, an early diagnosis of ILD is possible, and is mandatory to improve the prognosis of the disease. Pulmonary function tests and high-resolution computed tomography remain the mainstay for the diagnosis of SSc-ILD, but there is a growing interest in lung ultrasound. Recently, the correlation between severity of fibrosis and some peripheral blood biomarkers has been described. Nonselective immunosuppressors are still the main treatment for ILD, with cyclophosphamide (CYC) most widely used to obtain remission. Novel therapies towards specific molecular and cellular targets have been suggested; in particular, rituximab (RTX) has shown promising results, but further research is needed. It is of paramount importance to define the severity of the disease and the risk of progression in order to define the need for treatment and the treatment intensity. We propose the division of the treatment strategies at our disposal to induce remission into three categories: high intensity (haematopoietic stem cell transplantation), medium intensity (CYC and RTX) and low intensity (azathioprine (AZA) and mycophenolate mofetil (MMF)). After obtaining remission, maintenance treatment with AZA or MMF should be started. In this review we explore new advances in the pathogenesis, diagnosis and treatment of SSc-ILD.
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Affiliation(s)
- Susanna Cappelli
- Dept of Experimental and Clinical Medicine, Division of Rheumatology AOUC, School of Medicine, University of Florence, Florence, Italy
| | - Silvia Bellando Randone
- Dept of Experimental and Clinical Medicine, Division of Rheumatology AOUC, School of Medicine, University of Florence, Florence, Italy
| | - Gianna Camiciottoli
- Dept of Experimental and Clinical Medicine, Division of Pneumology and Lung Physiopathology AOUC, School of Medicine, University of Florence, Florence, Italy
| | - Amato De Paulis
- Dept of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Serena Guiducci
- Dept of Experimental and Clinical Medicine, Division of Rheumatology AOUC, School of Medicine, University of Florence, Florence, Italy
| | - Marco Matucci-Cerinic
- Dept of Experimental and Clinical Medicine, Division of Rheumatology AOUC, School of Medicine, University of Florence, Florence, Italy
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Maria ATJ, Maumus M, Le Quellec A, Jorgensen C, Noël D, Guilpain P. Adipose-Derived Mesenchymal Stem Cells in Autoimmune Disorders: State of the Art and Perspectives for Systemic Sclerosis. Clin Rev Allergy Immunol 2016; 52:234-259. [DOI: 10.1007/s12016-016-8552-9] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, Ghofrani A, Gomez Sanchez MA, Hansmann G, Klepetko W, Lancellotti P, Matucci M, McDonagh T, Pierard LA, Trindade PT, Zompatori M, Hoeper M. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2015; 46:903-75. [DOI: 10.1183/13993003.01032-2015] [Citation(s) in RCA: 1929] [Impact Index Per Article: 214.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Guidelines summarize and evaluate all available evidence on a particular issue at the time of the writing process, with the aim of assisting health professionals in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.
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Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, Ghofrani A, Gomez Sanchez MA, Hansmann G, Klepetko W, Lancellotti P, Matucci M, McDonagh T, Pierard LA, Trindade PT, Zompatori M, Hoeper M. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2015; 37:67-119. [DOI: 10.1093/eurheartj/ehv317] [Citation(s) in RCA: 3916] [Impact Index Per Article: 435.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Dobrota R, Distler O, Wells A, Humbert M. Management of Scleroderma-Associated Pulmonary Involvement. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2015. [DOI: 10.1007/s40674-014-0011-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Mouthon L. Systemic sclerosis: Views and thoughts for the future. Presse Med 2014; 43:e265-6. [DOI: 10.1016/j.lpm.2014.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 08/21/2014] [Indexed: 12/01/2022] Open
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