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Israël-Biet D, Pastré J, Nunes H. Sarcoidosis-Associated Pulmonary Hypertension. J Clin Med 2024; 13:2054. [PMID: 38610818 PMCID: PMC11012707 DOI: 10.3390/jcm13072054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/25/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Sarcoidosis-associated pulmonary hypertension (SAPH) is a very severe complication of the disease, largely impacting its morbidity and being one of its strongest predictors of mortality. With the recent modifications of the hemodynamic definition of pulmonary hypertension (mean arterial pulmonary pressure >20 instead of <25 mmHg,) its prevalence is presently not precisely known, but it affects from 3 to 20% of sarcoid patients; mostly, although not exclusively, those with an advanced, fibrotic pulmonary disease. Its gold-standard diagnostic tool remains right heart catheterization (RHC). The decision to perform it relies on an expert decision after a non-invasive work-up, in which echocardiography remains the screening tool of choice. The mechanisms underlying SAPH, very often entangled, are crucial to define, as appropriate and personalized therapeutic strategies will aim at targeting the most significant ones. There are no recommendations so far as to the indications and modalities of the medical treatment of SAPH, which is based upon the opinion of a multidisciplinary team of sarcoidosis, pulmonary hypertension and sometimes lung transplant experts.
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Affiliation(s)
| | - Jean Pastré
- Service de Pneumologie, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France;
| | - Hilario Nunes
- Service de Pneumologie, Hôpital Avivenne, AP-HP, 93000 Bobigny, France;
- Inserm UMR 1272 “Hypoxie et Poumon”, UFR de Santé, Médecine et Biologie Humaine (SMBH), Université Sorbonne Paris-Nord, 93000 Bobigny, France
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2
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Parikh R, Farber HW. Response to "Derivation and validation of a noninvasive prediction tool to identify pulmonary hypertension in patients with IPF: Evolution of the model FORD" by Nathan et al. J Heart Lung Transplant 2024; 43:691-692. [PMID: 38158103 DOI: 10.1016/j.healun.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024] Open
Affiliation(s)
- R Parikh
- Division of Pulmonary, Critical Care and Sleep Medicine, Hartford Hospital, Hartford, Connecticut.
| | - H W Farber
- Division of Pulmonary, Sleep and Critical Care Medicine, Tufts Medical Center, Boston, Massachusetts
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3
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Savale L, Dorfmüller P, Boucly A, Jaïs X, Lacoste-Palasset T, Jevnikar M, Seferian A, Humbert M, Sitbon O, Montani D. Sarcoidosis-Associated Pulmonary Hypertension. Clin Chest Med 2024; 45:185-197. [PMID: 38245366 DOI: 10.1016/j.ccm.2023.08.007] [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] [Indexed: 01/22/2024]
Abstract
Pulmonary hypertension is a life-threatening complication of advanced sarcoidosis. Many mechanisms can cause an elevation of pulmonary pressure in sarcoidosis, leading to precapillary or postcapillary pulmonary hypertension. Sarcoidosis-associated pulmonary hypertension contributes to severe exertional dyspnea, reduced exercise capacity, and notably compromised the survival. Despite the critical functional and prognostic implications of pulmonary hypertension in sarcoidosis, there is a scarcity of specific guidelines on the management of these patients due to a lack of evidence. Hence, further research is required to identify subgroups of patients who may benefit from pulmonary arterial hypertension-targeted therapies and/or immunosuppressive therapies.
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Affiliation(s)
- Laurent Savale
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; AP-HP, Department of Respiratory and Intensive CareMedicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.
| | - Peter Dorfmüller
- Pathology Department, University Hospital of Giessen and Marburg, Rudolf-Buchheim-Straße 8, Gießen 35392, Deutschland; German Center for Lung Research (DZL), Giessen, Germany
| | - Athénaïs Boucly
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; AP-HP, Department of Respiratory and Intensive CareMedicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Xavier Jaïs
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; AP-HP, Department of Respiratory and Intensive CareMedicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Thomas Lacoste-Palasset
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; AP-HP, Department of Respiratory and Intensive CareMedicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Mitja Jevnikar
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; AP-HP, Department of Respiratory and Intensive CareMedicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Andrei Seferian
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; AP-HP, Department of Respiratory and Intensive CareMedicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; AP-HP, Department of Respiratory and Intensive CareMedicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olivier Sitbon
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; AP-HP, Department of Respiratory and Intensive CareMedicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - David Montani
- Université Paris-Saclay, School of Medicine, Le Kremlin-Bicêtre, France; INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France; AP-HP, Department of Respiratory and Intensive CareMedicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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4
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Zhao M, Zhou Y. Diagnosis of Pulmonary Sarcoidosis. Clin Chest Med 2024; 45:15-24. [PMID: 38245363 DOI: 10.1016/j.ccm.2023.06.005] [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] [Indexed: 01/22/2024]
Abstract
Diagnosis of sarcoidosis depends on a compatible clinical and imaging presentation, histologic finding of non-necrotizing granulomatous inflammation, and exclusion of alternative causes of granulomatous diseases. This study has reviewed the diagnostic algorithms and approaches of sarcoidosis.
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Affiliation(s)
- Mengmeng Zhao
- Department of Pulmonary and Critical Care Medicine, Shanghai Pulmonary Hospital of Tongji University, 507 Zheng Min Road, Shanghai 200433, China
| | - Ying Zhou
- Department of Pulmonary and Critical Care Medicine, Shanghai Pulmonary Hospital of Tongji University, 507 Zheng Min Road, Shanghai 200433, China.
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5
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Israël-Biet D, Bernardinello N, Pastré J, Tana C, Spagnolo P. High-Risk Sarcoidosis: A Focus on Pulmonary, Cardiac, Hepatic and Renal Advanced Diseases, as Well as on Calcium Metabolism Abnormalities. Diagnostics (Basel) 2024; 14:395. [PMID: 38396434 PMCID: PMC10887913 DOI: 10.3390/diagnostics14040395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Although sarcoidosis is generally regarded as a benign condition, approximately 20-30% of patients will develop a chronic and progressive disease. Advanced pulmonary fibrotic sarcoidosis and cardiac involvement are the main contributors to sarcoidosis morbidity and mortality, with failure of the liver and/or kidneys representing additional life-threatening situations. In this review, we discuss diagnosis and treatment of each of these complications and highlight how the integration of clinical, pathological and radiological features may help predict the development of such high-risk situations in sarcoid patients.
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Affiliation(s)
- Dominique Israël-Biet
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Nicol Bernardinello
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy;
| | - Jean Pastré
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Claudio Tana
- Geriatrics Clinic, SS Annunziata University-Hospital of Chieti, 66100 Chieti, Italy
| | - Paolo Spagnolo
- Section of Respiratory Diseases, University of Padova, 35121 Padova, Italy
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6
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Liu A, Price LC, Sharma R, Wells AU, Kouranos V. Sarcoidosis Associated Pulmonary Hypertension. Biomedicines 2024; 12:177. [PMID: 38255282 PMCID: PMC10813665 DOI: 10.3390/biomedicines12010177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
In patients with sarcoidosis, the development of pulmonary hypertension is associated with significant morbidity and mortality. The global prevalence of sarcoidosis-associated pulmonary hypertension (SAPH) reportedly ranges between 2.9% and 20% of sarcoidosis patients. Multiple factors may contribute to the development of SAPH, including advanced parenchymal lung disease, severe systolic and/or diastolic left ventricular dysfunction, veno-occlusive or thromboembolic disease, as well as extrinsic factors such as pulmonary vascular compression from enlarged lymph nodes, anemia, and liver disease. Early diagnosis of SAPH is important but rarely achieved primarily due to insufficiently accurate screening strategies, which rely entirely on non-invasive tests and clinical assessment. The definitive diagnosis of SAPH requires right heart catheterization (RHC), with transthoracic echocardiography as the recommended gatekeeper to RHC according to current guidelines. A 6-min walk test (6MWT) had the greatest prognostic value in SAPH patients based on recent registry outcomes, while advanced lung disease determined using a reduced DLCO (<35% predicted) was associated with reduced transplant-free survival in pre-capillary SAPH. Clinical management involves the identification and treatment of the underlying mechanism. Pulmonary vasodilators are useful in several scenarios, especially when a pulmonary vascular phenotype predominates. End-stage SAPH may warrant consideration for lung transplantation, which remains a high-risk option. Multi-centered randomized controlled trials are required to develop existing therapies further and improve the prognosis of SAPH patients.
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Affiliation(s)
| | | | | | | | - Vasileios Kouranos
- Royal Brompton Hospital, Part of Guy’s and St. Thomas’ NHS Foundation Trust, London SW3 6NP, UK; (A.L.); (L.C.P.); (R.S.); (A.U.W.)
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Contreras J, Nussbaum J, Cangialosi P, Thapi S, Radakrishnan A, Hall J, Ramesh P, Trivieri MG, Sandoval AF. Pulmonary Hypertension in Underrepresented Minorities: A Narrative Review. J Clin Med 2024; 13:285. [PMID: 38202292 PMCID: PMC10779488 DOI: 10.3390/jcm13010285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/28/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
Minoritized racial and ethnic groups suffer disproportionately from the incidence and morbidity of pulmonary hypertension (PH), as well as its associated cardiovascular, pulmonary, and systemic conditions. These disparities are largely explained by social determinants of health, including access to care, systemic biases, socioeconomic status, and environment. Despite this undue burden, minority patients remain underrepresented in PH research. Steps should be taken to mitigate these disparities, including initiatives to increase research participation, combat inequities in access to care, and improve the treatment of the conditions associated with PH.
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Affiliation(s)
- Johanna Contreras
- Division of Heart Failure and Cardiac Transplantation, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (J.N.); (P.C.); (S.T.); (A.R.); (M.G.T.)
| | - Jeremy Nussbaum
- Division of Heart Failure and Cardiac Transplantation, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (J.N.); (P.C.); (S.T.); (A.R.); (M.G.T.)
| | - Peter Cangialosi
- Division of Heart Failure and Cardiac Transplantation, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (J.N.); (P.C.); (S.T.); (A.R.); (M.G.T.)
| | - Sahityasri Thapi
- Division of Heart Failure and Cardiac Transplantation, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (J.N.); (P.C.); (S.T.); (A.R.); (M.G.T.)
| | - Ankitha Radakrishnan
- Division of Heart Failure and Cardiac Transplantation, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (J.N.); (P.C.); (S.T.); (A.R.); (M.G.T.)
| | - Jillian Hall
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA; (J.H.); (P.R.)
| | - Prashasthi Ramesh
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA; (J.H.); (P.R.)
| | - Maria Giovanna Trivieri
- Division of Heart Failure and Cardiac Transplantation, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (J.N.); (P.C.); (S.T.); (A.R.); (M.G.T.)
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8
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Parikh R, Thomas A, Sharofi A, Moallem N, Fiscus G, Farber HW. Severe pulmonary hypertension-interstitial lung disease presenting as right ventricular failure: stabilisation with intravenous prostacyclin and maintenance with inhaled prostacyclin. ERJ Open Res 2024; 10:00659-2023. [PMID: 38288084 PMCID: PMC10823367 DOI: 10.1183/23120541.00659-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/05/2023] [Indexed: 01/31/2024] Open
Abstract
Background Pulmonary hypertension (PH) leads to increased morbidity and mortality in interstitial lung disease (ILD). While the INCREASE trial highlighted the use of inhaled prostacyclin in PH-ILD patients, such therapy may be inadequate when right ventricular failure (RVF) is also present. In this study, we report the use of intravenous prostacyclin in three PH-ILD patients to stabilise right ventricular (RV) function, with a subsequent transition to maintenance therapy with inhaled prostacyclin. Methods We evaluated three consecutive PH-ILD patients with RVF. RV afterload and pulmonary vascular resistance (PVR) were treated with intravenous prostacyclin during the induction phase of the therapy. Patients transitioned from intravenous prostacyclin to the maintenance phase of the treatment with inhaled prostacyclin once three transition criteria were met: cardiac index (CI) >2 L·min-1·m-2, PVR <7 Wood units (WU) and tricuspid annular plane systolic excursion (TAPSE) change >1 mm or TAPSE >1.6 cm. Results Pre-treatment parameters for the three patients were a mean PVR of 14.3 WU, a mean Fick CI of 1.8 L·min-1·m-2 and a mean TAPSE of 1.4 cm. The average intravenous prostacyclin dose at the time of transition to maintenance therapy was 20.7 ng·kg-1·m-2 of treprostinil. At 3-months follow-up, the mean PVR was 6.3 WU, Fick CI 2.2 L·min-1·m-2 and TAPSE 1.7 cm. Conclusion This case series of three PH-ILD patients with RVF introduces the concept of an initial intravenous prostacyclin induction phase, followed by a transition to maintenance therapy with inhaled prostacyclin. Further development of this treatment algorithm with a refinement of the transition criteria, potential testing in a clinical trial and a longer-term follow-up period is warranted to improve the outcomes of advanced PH-ILD patients with concomitant RVF.
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Affiliation(s)
- Raj Parikh
- Division of Pulmonary, Critical Care and Sleep, Hartford Hospital, Hartford, CT, USA
| | - Alysse Thomas
- A.T. Still University Osteopathic Medical School, Mesa, AZ, USA
| | | | - Niala Moallem
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Garrett Fiscus
- Division of Pulmonary, Critical Care and Sleep, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Harrison W. Farber
- Division of Pulmonary, Sleep and Critical Care Medicine, Tufts Medical Center, Boston, MA, USA
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9
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Lichtblau M, Mayer L, Gopalan D, Dorfmüller P, Ulrich S. Clinical-radiological-pathological correlation in pulmonary hypertension with unclear and/or multifactorial mechanisms. Eur Respir Rev 2023; 32:230119. [PMID: 38123234 PMCID: PMC10731469 DOI: 10.1183/16000617.0119-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/16/2023] [Indexed: 12/23/2023] Open
Abstract
Ever since the second world symposium on pulmonary hypertension (PH) held in Evian, France, in 1998, PH has been classified into five major clinical groups. Group 5 PH includes a variety of distinct conditions with unclear and/or multifactorial underlying pathologies. Management of these patients is challenging as the number of patients within these groups is often small, not all individuals with certain underlying conditions are affected by PH and patients exhibit distinct symptoms due to different underlying diseases. Studies and clinical trials in these groups are largely lacking and mostly restricted to case series and registry reports. Nonetheless, the worldwide burden of group 5 PH is estimated to be significant in terms of the prevalence of some associated diseases. Group 5 PH encompasses six subgroups, including haematological disorders (inherited and acquired chronic haemolytic anaemia and chronic myeloproliferative disorders), systemic disorders (sarcoidosis, pulmonary Langerhans's cell histiocytosis and neurofibromatosis type 1), metabolic disorders (glycogen storage diseases and Gaucher disease), chronic renal failure with or without haemodialysis, pulmonary tumour thrombotic microangiopathy and fibrosing mediastinitis.
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Affiliation(s)
- Mona Lichtblau
- University and University Hospital of Zurich, Zurich, Switzerland
| | - Laura Mayer
- University and University Hospital of Zurich, Zurich, Switzerland
| | - Deepa Gopalan
- Imperial College London, London, UK
- Cambridge University Hospital, Cambridge, UK
| | - Peter Dorfmüller
- Universitätsklinikum Gießen und Marburg GmbH, Pathology Department, Giessen, Germany
| | - Silvia Ulrich
- University and University Hospital of Zurich, Zurich, Switzerland
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10
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Kacprzak A, Tomkowski W, Szturmowicz M. Phenotypes of Sarcoidosis-Associated Pulmonary Hypertension-A Challenging Mystery. Diagnostics (Basel) 2023; 13:3132. [PMID: 37835874 PMCID: PMC10572558 DOI: 10.3390/diagnostics13193132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/27/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023] Open
Abstract
Sarcoidosis has been a well-recognised risk factor for pulmonary hypertension (PH) for a long time, but still, the knowledge about this concatenation is incomplete. Sarcoidosis-associated PH (SAPH) is an uncommon but serious complication associated with increased morbidity and mortality among sarcoidosis patients. The real epidemiology of SAPH remains unknown, and its pathomechanisms are not fully explained. Sarcoidosis is a heterogeneous and dynamic condition, and SAPH pathogenesis is believed to be multifactorial. The main roles in SAPH development play: parenchymal lung disease with the destruction of pulmonary vessels, the extrinsic compression of pulmonary vessels by conglomerate masses, lymphadenopathy or fibrosing mediastinitis, pulmonary vasculopathy, LV dysfunction, and portal hypertension. Recently, it has been recommended to individually tailor SAPH management according to the predominant pathomechanism, i.e., SAPH phenotype. Unfortunately, SAPH phenotyping is not a straightforward process. First, there are gaps in our understanding of undergoing processes. Second, the assessment of such a pivotal element as pulmonary vasculature on a microscopic level is non-feasible in SAPH patients antemortem. Finally, SAPH is a dynamic condition, multiple phenotypes usually coexist, and patients can switch between phenotypes during the course of sarcoidosis. In this article, we summarise the basic knowledge of SAPH, describe SAPH phenotypes, and highlight some practical problems related to SAPH phenotyping.
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Affiliation(s)
- Aneta Kacprzak
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Institute, Plocka 26, 01-138 Warsaw, Poland
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11
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Gayen SK, Baughman RP, Nathan SD, Wells AU, Kouranos V, Alhamad EH, Culver DA, Barney J, Carmoma EM, Cordova FC, Huitema M, Scholand MB, Wijsenbeek M, Ganesh S, Birring SS, Price LC, Wort SJ, Shlobin OA, Gupta R. Pulmonary hemodynamics and transplant-free survival in sarcoidosis-associated pulmonary hypertension: Results from an international registry. Pulm Circ 2023; 13:e12297. [PMID: 37840561 PMCID: PMC10568201 DOI: 10.1002/pul2.12297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/17/2023] [Accepted: 10/06/2023] [Indexed: 10/17/2023] Open
Abstract
Pulmonary hypertension (PH) is a risk factor for mortality in patients with sarcoidosis. Severe PH in chronic lung disease has previously been defined as mean pulmonary arterial pressure (mPAP) ≥ 35 mmHg or mPAP 25 ≥ mmHg with cardiac index (CI) ≤ 2 L/min/m2. However, there is no clear definition denoting severity of sarcoidosis-associated PH (SAPH). We aimed to determine pulmonary hemodynamic cut-off values where transplant-free survival was worse among patients with SAPH. This was a retrospective cohort analysis of the Registry of SAPH database focusing on pulmonary hemodynamic predictors of transplant-free survival among patients with precapillary SAPH. Cox regression was performed to determine which pulmonary hemodynamic values predicted death or lung transplantation. Kaplan-Meier survival analysis was performed on statistically significant predictors to determine pulmonary hemodynamic cut-off values where transplant-free survival was decreased. Decreased transplant-free survival occurred among SAPH patients with mPAP ≥ 40 mmHg and SAPH patients with pulmonary vascular resistance (PVR) ≥ 5 Woods units (WU). Transplant-free survival was not decreased in patients who fulfilled prior criteria of severe PH in chronic lung disease. We identified new cut-offs with decreased transplant-free survival in the SAPH population. Neither cut-off of mPAP ≥ 40 mmHg nor PVR ≥ 5 WU has previously been shown to be associated with decreased transplant-free survival in SAPH. These values could suggest a new definition of severe SAPH. Our PVR findings are in line with the most recent European Society of Cardiology/European Respiratory Society guideline definition of severe PH in chronic lung disease.
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Affiliation(s)
- Shameek K. Gayen
- Department of Thoracic Medicine and SurgeryLewis Katz School of Medicine at Temple University HospitalPhiladelphiaPennsylvaniaUSA
| | - Robert P. Baughman
- Department of MedicineUniversity of Cincinnati Medical CenterCincinnatiOhioUSA
| | - Steven D. Nathan
- The Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Athol U. Wells
- Interstitial Lung Disease/Sarcoidosis unitRoyal Brompton Hospital, National Heart and Lung Institute, Imperial College LondonLondonUK
| | - Vasilis Kouranos
- Interstitial Lung Disease/Sarcoidosis unitRoyal Brompton Hospital, National Heart and Lung Institute, Imperial College LondonLondonUK
| | - Esam H. Alhamad
- Division of Pulmonary Medicine, College of MedicineKing Saud UniversityRiyadhSaudi Arabia
| | - Daniel A. Culver
- Department of Pulmonary Medicine, and Department of Inflammation and ImmunityCleveland ClinicClevelandOhioUSA
| | - Joseph Barney
- The University of Alabama at Birmingham School of MedicineBirminghamAlabamaUSA
| | - Eva M. Carmoma
- Pulmonary and Critical Care, Mayo ClinicRochesterMinnesotaUSA
| | - Francis C. Cordova
- Department of Thoracic Medicine and SurgeryLewis Katz School of Medicine at Temple University HospitalPhiladelphiaPennsylvaniaUSA
| | - Marloes Huitema
- Department of CardiologySint Antonius HospitalNieuwegeinNetherlands
| | | | - Marlies Wijsenbeek
- Department of Respiratory MedicineCentre of Excellence for Interstitial Lung Diseases and Sarcoidosis, Erasmus Medical CentreRotterdamThe Netherlands
| | - Sivagini Ganesh
- Pulmonary, Critical Care and Sleep MedicineKeck School of Medicine of the University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Surinder S. Birring
- Centre for Human & Applied Physiological SciencesSchool of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King's College LondonLondonUK
| | - Laura C. Price
- National pulmonary hypertension serviceRoyal Brompton HospitalLondonUK
| | | | - Oksana A. Shlobin
- The Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Rohit Gupta
- Department of Thoracic Medicine and SurgeryLewis Katz School of Medicine at Temple University HospitalPhiladelphiaPennsylvaniaUSA
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12
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Judson MA. The Symptoms of Pulmonary Sarcoidosis. J Clin Med 2023; 12:6088. [PMID: 37763028 PMCID: PMC10532418 DOI: 10.3390/jcm12186088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
The aim of this manuscript is to provide a comprehensive review of the etiology, measurement, and treatment of common pulmonary symptoms associated with sarcoidosis. The assessment of symptoms associated with pulmonary sarcoidosis is an important component of disease management. Some symptoms of pulmonary sarcoidosis are sensitive but nonspecific markers of disease activity, and the absence of such symptoms provides evidence that the disease is quiescent. Although quantifiable objective measurements of pulmonary physiology and chest imaging are important in the assessment of pulmonary sarcoidosis, they correlate poorly with the patient's quality of life. Because the symptoms of pulmonary sarcoidosis directly relate to how the patient feels, they are reasonable endpoints in terms of clinical research and individual patient care. Recently, the symptoms of pulmonary sarcoidosis are capable of being quantified via patient-reported outcome measures and electronic devices. We conclude that a thorough assessment of the symptoms associated with pulmonary sarcoidosis improves patient care because it is a useful screen for manifestations of the disease, provides insight into the pathophysiology of manifestations of sarcoidosis, and may assist in optimizing treatment.
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Affiliation(s)
- Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY 12208, USA
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13
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Abstract
The current approach for the management of pulmonary arterial hypertension (PAH) relies on data gathered from clinical trials and large registries. However, there is concern that minorities including Black, Indigenous, and People of Color are underrepresented in these trials and registries, making current data not generalizable to these groups of patients. Hence, it is important to discuss the significance of race/ethnicity and socioeconomic factors in patients with PAH. Here, we review the current knowledge on health care disparities in PAH. We also propose future steps in the global task of assuring justice and equality in access to pulmonary hypertension health care.
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Affiliation(s)
- Roberto J Bernardo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Boulevard, Suite 8400, Oklahoma City, OK 73104, USA
| | - Vinicio A de Jesus Perez
- Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Grant S140B, Stanford, CA 94305, USA; Vera Moulton Wall Center for Pulmonary Disease at Stanford University, Stanford, CA, USA.
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14
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Bernaudin JF, Le Pavec J, Fadel E, Jeny F, Valeyre D, Thomas de Montpreville V. Intimal granulomatous angiitis in sarcoid pulmonary vasculitis: worth remembering. ERJ Open Res 2023; 9:00549-2022. [PMID: 37143848 PMCID: PMC10152265 DOI: 10.1183/23120541.00549-2022] [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: 10/17/2022] [Accepted: 11/09/2022] [Indexed: 05/06/2023] Open
Abstract
Intimal granulomatous angiitis is a facet of pulmonary sarcoidosis vasculitis that has almost been forgotten. Its observation may offer new understanding of the various patterns of pulmonary hypertension associated with sarcoidosis. https://bit.ly/3g6Ms76.
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Affiliation(s)
- Jean-François Bernaudin
- INSERM UMR 1272 Université Sorbonne Paris-Nord AP-HP, Hôpital Avicenne Service de Pneumologie, Bobigny, France
- Faculté de Médecine, Sorbonne Université, Paris, France
- Jean-François Bernaudin ()
| | - Jérôme Le Pavec
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Université Paris–Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France
- UMR_S 999, Université Paris–Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Elie Fadel
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Université Paris–Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France
- UMR_S 999, Université Paris–Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Florence Jeny
- INSERM UMR 1272 Université Sorbonne Paris-Nord AP-HP, Hôpital Avicenne Service de Pneumologie, Bobigny, France
| | - Dominique Valeyre
- INSERM UMR 1272 Université Sorbonne Paris-Nord AP-HP, Hôpital Avicenne Service de Pneumologie, Bobigny, France
- Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Vincent Thomas de Montpreville
- Université Paris–Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France
- UMR_S 999, Université Paris–Sud, INSERM, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Service d'Anatomie Pathologique, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
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15
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Parikh R, O'Sullivan DM, Farber HW. The PH-ILD Detection tool: External validation and use in patients with ILD. Pulm Circ 2023; 13:e12273. [PMID: 37564922 PMCID: PMC10410234 DOI: 10.1002/pul2.12273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/14/2023] [Accepted: 07/30/2023] [Indexed: 08/12/2023] Open
Abstract
Pulmonary hypertension (PH) results in increased morbidity and mortality in patients with interstitial lung disease (ILD). Early recognition of PH in this population is essential for planning diagnostic testing, initiating therapy, and evaluating for lung transplantation. The previously developed PH-ILD Detection tool has significant potential in the evaluation and treatment of ILD patients; the aim of this study was to validate the tool in an independent, multicenter cohort of patients. We conducted a retrospective review of prospectively collected data from 161 ILD patients. Patients were stratified into low- (n = 78, 48.4%), intermediate- (n = 54, 33.5%), and high-risk (n = 29, 18.0%) groups based on the score obtained with the tool. Intermediate- and high-risk patients underwent follow-up echocardiogram (TTE); 49.4% (n = 41) had an abnormal TTE suggestive of underlying PH. These patients underwent right heart catheterization; PH-ILD was diagnosed in 73.2% (n = 30) of these cases. The PH-ILD Detection tool has a sensitivity of 93.3%, specificity of 90.9%, and area-under-the-curve of 0.921 for diagnosing PH in ILD patients, validating the findings from the original study and establishing the tool as a fundamental resource for early recognition of PH in ILD patients.
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Affiliation(s)
- Raj Parikh
- Division of Pulmonary, Critical Care and Sleep, Hartford HospitalHartfordConnecticutUSA
| | - David M. O'Sullivan
- Department of Research AdministrationHartford HealthCareHartfordConnecticutUSA
| | - Harrison W. Farber
- Division of Pulmonary, Sleep and Critical Care Medicine, Tufts Medical CenterBostonMassachusettsUSA
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16
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Parente YDDM, Fernandes da Silva N, Souza R. Unusual Forms of Pulmonary Hypertension. Heart Fail Clin 2023; 19:25-33. [DOI: 10.1016/j.hfc.2022.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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17
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Lawrie A, Hamilton N, Wood S, Exposto F, Muzwidzwa R, Raiteri L, Beaudet A, Muller A, Sauter R, Pillai N, Kiely DG. Healthcare resource utilization and quality of life in patients with sarcoidosis-associated pulmonary hypertension. Pulm Circ 2022; 12:e12136. [PMID: 36204241 PMCID: PMC9525996 DOI: 10.1002/pul2.12136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 11/08/2022] Open
Abstract
A retrospective, observational cohort study was conducted to generate real-world evidence in adult patients diagnosed with sarcoidosis-associated pulmonary hypertension (SAPH) at a referral center in England between 2012 and 2019. Data from the referral center electronic medical record database were linked to the National Health Service Hospital Episode Statistics database to collect and analyze patient demographics, clinical characteristics, comorbidities, treatment patterns, health-related quality of life (HRQoL; assessed using the EmPHasis-10 questionnaire), healthcare resource utilization (HCRU), costs, and survival. Sixty-two patients with SAPH were identified. At diagnosis, 84% were in WHO functional class III and presented with significant pulmonary hemodynamic impairment. Cardiovascular and respiratory comorbidities were commonly reported prediagnosis. Median EmPHasis-10 score at diagnosis was 34, indicative of poor HRQoL. In the 1st year after diagnosis, median (Q1, Q3) per-patient HCRU was 1 (0, 2) all-cause inpatient hospitalizations; 3 (2, 4) same-day hospitalizations; and 9 (6, 11) outpatient consultations. In 24 patients who were hospitalized longer than 1 day in the 1st year after diagnosis, the median duration of hospitalization was 4 days. With a median follow-up of 1.8 years, the median overall survival was 2.9 years. In this cohort of patients with SAPH, poor HRQoL and high HCRU were observed following diagnosis. To our knowledge, this is the first study to report on HRQoL and HCRU in patients with SAPH. More research is needed on treatment options for this population with high unmet needs.
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Affiliation(s)
- Allan Lawrie
- National Heart and Lung Institute, Imperial College LondonLondonUK
- Insigneo Institute for In‐Silico MedicineUniversity of SheffieldSheffieldUK
| | - Neil Hamilton
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire HospitalSheffieldUK
| | - Steven Wood
- Insigneo Institute for In‐Silico MedicineUniversity of SheffieldSheffieldUK
- Scientific Computing, Sheffield Teaching Hospitals NHS Foundation TrustRoyal Hallamshire HospitalSheffieldUK
| | | | | | | | | | | | | | - Nadia Pillai
- Actelion Pharmaceuticals Ltd.AllschwilSwitzerland
| | - David G. Kiely
- Insigneo Institute for In‐Silico MedicineUniversity of SheffieldSheffieldUK
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire HospitalSheffieldUK
- Department of Infection, Immunity and Cardiovascular DiseaseUniversity of SheffieldSheffieldUK
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18
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Schimmelpennink MC, Meek DB, Vorselaars ADM, Langezaal LCM, van Moorsel CHM, van der Vis JJ, Veltkamp M, Grutters JC. Characterization of the PF-ILD phenotype in patients with advanced pulmonary sarcoidosis. Respir Res 2022; 23:169. [PMID: 35752806 PMCID: PMC9233403 DOI: 10.1186/s12931-022-02094-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 05/21/2022] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Advanced pulmonary sarcoidosis causes significant morbidity and can lead to death. Large trials demonstrated efficacy of antifibrotics in patients with progressive fibrosing interstitial lung diseases (PF-ILD), including a few with sarcoidosis. To date, little is known about this progressive fibrosing phenotype in sarcoidosis. Diffusion capacity of carbon monoxide (DLCO) may be a useful functional marker to screen for advanced pulmonary sarcoidosis. In this study, we describe a cohort with advanced pulmonary sarcoidosis and we gain insights in the progressive fibrosing phenotype in sarcoidosis. METHODS Patients with sarcoidosis and a DLCO < 50% predicted were included in this retrospective cohort study. First measurement of DLCO < 50% predicted was the baseline. Lung function data, HRCT, pulmonary hypertension (PH) and mortality were collected. Patients with > 10% fibrosis on HRCT meeting the criteria for ILD-progression within 24 months were labelled as PF-ILD. With Cox-regression analysis predictors of mortality were established. RESULTS 106 patients with a DLCO < 50% predicted were included. Evolution of forced vital capacity (FVC) varied widely between patients from - 34% to + 45% after 2 years follow-up, whereas change in DLCO varied between - 11% and + 26%. Fourteen patients (15%) met the PF-ILD criteria, of whom 6 (43%) died within 10 years versus 10 (13%) in the non PF-ILD group (p = 0.006). PH was present 12 (11%), 56 (53%) demonstrated > 10% fibrosis on HRCT. Independent predictors of mortality and lung transplantation in the whole cohort are PH, PF-ILD and UIP-like pattern. CONCLUSION In conclusion, within this group with advanced pulmonary sarcoidosis disease course varied widely from great functional improvement to death. PF-ILD patients had higher mortality rate than the mortality in the overall pulmonary sarcoidosis group. Future research should focus on the addition of antifibrotics in these patients. Trial registration retrospectively registered.
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Affiliation(s)
- M C Schimmelpennink
- Interstitial Lung Diseases Center of Excellence, Department of Pulmonology, St Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.
| | - D B Meek
- Interstitial Lung Diseases Center of Excellence, Department of Radiology, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Radiology, Treant Health Care Group, Emmen, Hoogeveen, Stadskanaal, The Netherlands
| | - A D M Vorselaars
- Interstitial Lung Diseases Center of Excellence, Department of Pulmonology, St Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.,Division of Heart and Lungs, University Medical Center, Utrecht, The Netherlands
| | - L C M Langezaal
- Interstitial Lung Diseases Center of Excellence, Department of Radiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - C H M van Moorsel
- Interstitial Lung Diseases Center of Excellence, Department of Pulmonology, St Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - J J van der Vis
- Interstitial Lung Diseases Center of Excellence, Department of Pulmonology, St Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.,Interstitial Lung Diseases Center of Excellence, Department of Clinical Chemistry, St Antonius Hospital, Nieuwegein, The Netherlands
| | - M Veltkamp
- Interstitial Lung Diseases Center of Excellence, Department of Pulmonology, St Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.,Division of Heart and Lungs, University Medical Center, Utrecht, The Netherlands
| | - J C Grutters
- Interstitial Lung Diseases Center of Excellence, Department of Pulmonology, St Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.,Division of Heart and Lungs, University Medical Center, Utrecht, The Netherlands
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19
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Gupta R, Baughman RP, Nathan SD, Wells AU, Kouranos V, Alhamad EH, Culver DA, Barney J, Carmona EM, Cordova FC, Huitema M, Scholand MB, Wijsenbeek M, Ganesh S, Birring SS, Price LC, Wort SJ, Shlobin OA. The six-minute walk test in sarcoidosis associated pulmonary hypertension: Results from an international registry. Respir Med 2022; 196:106801. [DOI: 10.1016/j.rmed.2022.106801] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 06/27/2021] [Accepted: 03/01/2022] [Indexed: 12/17/2022]
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20
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Savale L, Huitema M, Shlobin O, Kouranos V, Nathan SD, Nunes H, Gupta R, Grutters JC, Culver DA, Post MC, Ouellette D, Lower EE, Al-Hakim T, Wells AU, Humbert M, Baughman RP. WASOG statement on the diagnosis and management of sarcoidosis-associated pulmonary hypertension. Eur Respir Rev 2022; 31:31/163/210165. [PMID: 35140103 DOI: 10.1183/16000617.0165-2021] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/13/2021] [Indexed: 12/14/2022] Open
Abstract
Sarcoidosis-associated pulmonary hypertension (SAPH) is an important complication of advanced sarcoidosis. Over the past few years, there have been several studies dealing with screening, diagnosis and treatment of SAPH. This includes the results of two large SAPH-specific registries. A task force was established by the World Association of Sarcoidosis and Other Granulomatous disease (WASOG) to summarise the current level of knowledge in the area and provide guidance for the management of patients. A group of sarcoidosis and pulmonary hypertension experts participated in this task force. The committee developed a consensus regarding initial screening including who should undergo more specific testing with echocardiogram. Based on the results, the committee agreed upon who should undergo right-heart catheterisation and how to interpret the results. The committee felt there was no specific phenotype of a SAPH patient in whom pulmonary hypertension-specific therapy could be definitively recommended. They recommended that treatment decisions be made jointly with a sarcoidosis and pulmonary hypertension expert. The committee recognised that there were significant defects in the current knowledge regarding SAPH, but felt the statement would be useful in directing future studies.
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Affiliation(s)
- Laurent Savale
- Université Paris-Saclay; INSERM UMR_S 999; Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Marloes Huitema
- Dept of Cardiology, St. Antonius Hospital, Nieuwegein and University Medical Center Utrecht, Utrecht, The Netherlands
| | - Oksana Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Vasilis Kouranos
- Interstitial Lung Disease/Sarcoidosis Unit, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Hiliaro Nunes
- INSERM UMR 1272, Université Sorbonne Paris Nord; Service de Pneumologie, Centre de Référence des Maladies Pulmonaires Rares, APHP, Hôpital Avicenne, Bobigny, France
| | - Rohit Gupta
- Dept of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA USA
| | - Jan C Grutters
- Dept of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein and University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Marco C Post
- Dept of Cardiology, St. Antonius Hospital, Nieuwegein and University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Elyse E Lower
- Dept of Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | | | - Athol U Wells
- Interstitial Lung Disease/Sarcoidosis Unit, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Marc Humbert
- Université Paris-Saclay; INSERM UMR_S 999; Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Robert P Baughman
- Dept of Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
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21
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Baughman RP, Shlobin OA, Gupta R, Engel PJ, Stewart JI, Lower EE, Rahaghi FF, Zeigler J, Nathan SD. Riociguat for Sarcoidosis-Associated Pulmonary Hypertension: Results of a 1-Year Double-Blind, Placebo-Controlled Trial. Chest 2022; 161:448-457. [PMID: 34363816 PMCID: PMC9005858 DOI: 10.1016/j.chest.2021.07.2162] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/30/2021] [Accepted: 07/24/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Riociguat is effective in delaying the time to clinical worsening (TCW) in patients with groups 1 and 4 pulmonary hypertension. RESEARCH QUESTION Is riociguat more effective than placebo in prolonging TCW in sarcoidosis-associated pulmonary hypertension (SAPH)? STUDY DESIGN AND METHODS This was a double-blind placebo-controlled trial. Patients with SAPH confirmed by right heart catheterization were randomized 1:1 to riociguat or placebo. Patients underwent 6-min walk distance (6MWD) and spirometry testing every 8 weeks. The primary end point was TCW, which was defined by the time to the first of the following: (1) all-cause mortality, (2) need for hospitalization because of worsening cardiopulmonary status attributable to progression of disease, (3) > 50 m decrease in the 6MWD test, or (4) worsening of World Health Organization functional class. RESULTS A total of 16 patients were randomized to riociguat (n = 8) or placebo (n = 8). No difference was found in pulmonary artery mean, pulmonary vascular resistance, initial 6MWD, or FVC between the two groups. Five of eight patients who received placebo met TCW criteria, whereas none of the patients who received riociguat experienced a qualifying event. By log-rank analysis, patients who received riociguat were in the study for a significantly longer period (χ 2 = 6.259; P = .0124). The 6MWD decreased in the placebo group (median, -55.9 m; range, -176.8 to 60 m), but rose in the riociguat group (median, +42.7 m; range, -7.5 to +91.4 m; P = .0149), with a placebo-corrected difference of 94 m (P < .01). Four of eight patients who received riociguat, but only 1 of 8 patients who received placebo, showed a > 30-m improvement in 6MWD (P > .05). No significant adverse events associated with riociguat occurred. INTERPRETATION Over the 1 year of the study, riociguat was effective in preventing clinical worsening and improving exercise capacity in patients with SAPH. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02625558; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Robert P. Baughman
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OH,CORRESPONDENCE TO: Robert P. Baughman, MD
| | - Oksana A. Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA
| | - Rohit Gupta
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA
| | | | - Jeffrey I. Stewart
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA
| | - Elyse E. Lower
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OH
| | | | - Joyce Zeigler
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OH
| | - Steven D. Nathan
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA
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22
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Abstract
PURPOSE OF REVIEW Pulmonary hypertension in sarcoidosis is a well known entity. Sarcoidosis-associated pulmonary hypertension (SAPH) incurs substantial morbidity and mortality. This review examines recent literatures published on epidemiology, prognosis and therapeutic management in SAPH. RECENT FINDINGS Several registries have been published between 2017 and 2020. The consensus conclusion - SAPH is a harbinger for poor prognosis. Several factors were noted for predicting adverse outcome in SAPH like reduced 6-min walk distance and diffusing capacity for carbon monoxide. Given its adverse outcome, experts have now focused on methods for early screening of SAPH in sarcoid patients. The exploration of pulmonary vasodilator drugs in SAPH is ongoing. In recent times, trials have been published utilizing Macitentan and parenteral prostacyclin in severe SAPH. Although these trials show encouraging results, the evidence from these studies are limited to approve these agents as preferred drugs for treating SAPH. A large multicentric trial of drugs used for pulmonary arterial hypertension with meaningful, yet feasible, event driven endpoint is still lacking. Lately, interventional treatment by pulmonary artery balloon pulmonary angioplasty and stenting has gained traction for treating pulmonary artery stenosis and chronic thromboembolic pulmonary hypertension. However, the conclusion is still based on small cohorts or case series. SUMMARY Several registries have highlighted SAPH portends an unfavorable consequence. On the contrary, no published guideline exists to treat SAPH. The precise role of immunosuppressive agents is unclear. The limited evidence favoring use of pulmonary vasodilators arise from small retrospective case series and/or single-center nonrandomized observational studies. Further multicenter randomized research is warranted to better define patient population to treat and how best to treat them.
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23
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Samaranayake CB, McCabe C, Wort SJ, Price LC. Sarcoidosis associated pulmonary hypertension: an update. Curr Opin Pulm Med 2021; 27:285-295. [PMID: 34127623 DOI: 10.1097/mcp.0000000000000793] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Sarcoidosis associated pulmonary hypertension (SAPH) is a well-recognised complication, associated with a seven-fold increase in mortality. This comprehensive review will summarise these recent developments and proposes the use of a phenotype-based management approach in SAPH. RECENT FINDINGS Recent registry-based studies have highlighted the adverse outcomes associated with SAPH and shown that reduced 6-min walk distance and diffusion capacity for carbon monoxide are predictive of poor prognosis. There is increasing interest in methods for early detection of SAPH, although whether early diagnosis impacts on survival remains uncertain. The pathophysiology underpinning SAPH is complex and often incorporates multiple mechanisms. Once the diagnosis is confirmed, understanding the underlying phenotypes of SAPH is key to providing the most effective management plan. There is some evidence that treating patients with precapillary PH with pulmonary vasodilators may improve some haemodynamic and quality life measures. However, more work is needed to determine whether mortality is affected. SUMMARY SAPH is associated with worsened survival. A range of phenotypes are recognised in SAPH. Multimodality risk assessment in patients with SAPH is likely to be important and is an area that requires further work. Published evidence for pulmonary vasodilator therapies in SAPH with a Pulmonary arterial hypertension-like phenotype is encouraging so far, but multiple confounding factors affects the quality of the evidence. The role of immunosuppressive agents for improving pulmonary pressures is unclear. Urgent controlled trials are needed.
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Affiliation(s)
| | - Colm McCabe
- National Pulmonary Hypertension Service, Royal Brompton Hospital.,National Lung and Heart Institute, Imperial College London, London, UK
| | - Stephen John Wort
- National Pulmonary Hypertension Service, Royal Brompton Hospital.,National Lung and Heart Institute, Imperial College London, London, UK
| | - Laura C Price
- National Pulmonary Hypertension Service, Royal Brompton Hospital.,National Lung and Heart Institute, Imperial College London, London, UK
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24
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Kirkil G, Lower E, Baughman R. Advances in predicting patient survival in pulmonary sarcoidosis. Expert Opin Orphan Drugs 2021. [DOI: 10.1080/21678707.2021.1925107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Gamze Kirkil
- Medicine Faculty, Department of Chest Disease, Firat University, Elazig, Turkey
| | - Elyse Lower
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Robert Baughman
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Cincinnati, USA
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25
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Mathijssen H, Huitema MP, Bakker ALM, Smits F, Mager JJ, Snijder RJ, Grutters JC, Post MC. Clinical Phenotypes of Sarcoidosis-Associated Pulmonary Hypertension. Heart Lung Circ 2021; 30:1502-1508. [PMID: 33933365 DOI: 10.1016/j.hlc.2021.03.279] [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: 07/21/2020] [Revised: 02/03/2021] [Accepted: 03/30/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Pulmonary hypertension (PH) is a known complication of pulmonary sarcoidosis and its aetiology is unclear. Different pathophysiological mechanisms in sarcoidosis-associated pulmonary hypertension (SAPH) are known. Clinical phenotyping can aid clinicians in choosing the optimal treatment strategy. This study aimed to describe clinical phenotypes of SAPH and their characteristics. METHODS A retrospective cohort study was performed on all SAPH patients at a tertiary referral centre. All patients were extensively analysed and discussed case by case in a multidisciplinary expert team to determine the most likely pathophysiological mechanism of PH. Patients were then classified into conceptual clinical phenotypes. RESULTS Forty (40) patients with SAPH were identified between 2010 and 2019. Three (3) patients were classified as the postcapillary phenotype. Of the remaining 37 patients with precapillary PH, six were classified as 'compression of pulmonary vasculature', 29 as 'parenchymal', one as 'suspected vasculopathy', and one as 'chronic pulmonary emboli' phenotypes. Of the patients with compression of pulmonary vasculature, four showed compression by fibrotic disease and two by active sarcoidosis-based disease. Within the parenchymal phenotype, 20 patients (69%) showed pulmonary vascular resistance >3.0 Wood Units (WU) and had significantly lower diffusing capacity of the lung for carbon monoxide compared with the nine patients (31%) with pulmonary vascular resistance ≤3.0 WU. CONCLUSION SAPH had multiple pathophysiological mechanisms and clinical phenotypes in this retrospective study. Further studies are necessary to examine how these phenotypes can affect appropriate treatment and prognosis.
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Affiliation(s)
- Harold Mathijssen
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - Marloes P Huitema
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Annelies L M Bakker
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Fokko Smits
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Johannes J Mager
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Repke J Snijder
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jan C Grutters
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Pulmonology, Utrecht University Medical Center, Utrecht University, The Netherlands
| | - Marco C Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiology, Utrecht University Medical Center, Utrecht University, The Netherlands
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26
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Judson MA. Antifibrotic drugs for pulmonary sarcoidosis: A treatment in search of an indication. Respir Med 2021; 180:106371. [PMID: 33798872 DOI: 10.1016/j.rmed.2021.106371] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA.
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Challenges in Cardiac and Pulmonary Sarcoidosis: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 76:1878-1901. [PMID: 33059834 DOI: 10.1016/j.jacc.2020.08.042] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/12/2020] [Accepted: 08/13/2020] [Indexed: 12/17/2022]
Abstract
Sarcoidosis is a complex disease with heterogeneous clinical presentations that can affect virtually any organ. Although the lung is typically the most common organ involved, combined pulmonary and cardiac sarcoidosis (CS) account for most of the morbidity and mortality associated with this disease. Pulmonary sarcoidosis can be asymptomatic or result in impairment in quality of life and end-stage, severe, and/or life-threatening disease. The latter outcome is seen almost exclusively in those with fibrotic pulmonary sarcoidosis, which accounts for 10% to 20% of pulmonary sarcoidosis patients. CS is problematic to diagnose and may cause significant morbidity and death from heart failure or ventricular arrhythmias. The diagnosis of CS usually requires surrogate cardiac imaging biomarkers, as endomyocardial biopsy has relatively low yield, even with directed electrophysiological mapping. Treatment of CS is often multifactorial, involving a combination of antigranulomatous therapy and pharmacotherapy for cardiac arrhythmias and/or heart failure in addition to device placement and cardiac transplantation.
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Narula N, Iannuzzi M. Sarcoidosis: Pitfalls and Challenging Mimickers. Front Med (Lausanne) 2021; 7:594275. [PMID: 33505980 PMCID: PMC7829200 DOI: 10.3389/fmed.2020.594275] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/30/2020] [Indexed: 12/17/2022] Open
Abstract
Sarcoidosis, a systemic granulomatous disease of unknown etiology, may mimic other conditions at presentation often resulting in delayed diagnosis. These conditions include infections, neoplasms, autoimmune, cardiovascular, and drug-induced diseases. This review highlights the most common sarcoidosis mimics that often lead to pitfalls in diagnosis and delay in appropriate treatment. Prior to invasive testing and initiating immunosuppressants (commonly corticosteroids), it is important to exclude sarcoid mimickers.
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Affiliation(s)
- Naureen Narula
- Staten Island University Hospital, New York, NY, United States
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Thillai M, Atkins CP, Crawshaw A, Hart SP, Ho LP, Kouranos V, Patterson K, Screaton NJ, Whight J, Wells AU. BTS Clinical Statement on pulmonary sarcoidosis. Thorax 2020; 76:4-20. [PMID: 33268456 DOI: 10.1136/thoraxjnl-2019-214348] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Muhunthan Thillai
- Cambridge Interstitial Lung Disease Unit, Royal Papworth Hospital, Cambridge, Cambridgeshire, UK
| | - Christopher P Atkins
- Department of Respiratory Medicine, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
| | - Anjali Crawshaw
- Interstitial Lung Disease Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Simon P Hart
- Respiratory Research Group, Hull York Medical School/University of Hull, Cottingham, UK
| | - Ling-Pei Ho
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, Oxford, UK.,Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
| | - Vasileios Kouranos
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, London, UK
| | - Karen Patterson
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
| | | | | | - Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton Hospital, London, London, UK
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Abstract
At least 5% of sarcoidosis patients die from their disease, usually from advanced pulmonary sarcoidosis. The three major problems encountered in advanced pulmonary sarcoidosis are pulmonary fibrosis, pulmonary hypertension, and respiratory infections. Pulmonary fibrosis is the result of chronic inflammation, but other factors including abnormal wound healing may be important. Sarcoidosis-associated pulmonary hypertension (SAPH) is multifactorial including parenchymal fibrosis, vascular granulomas, and hypoxia. Respiratory infections can be cause by structural changes in the lung and impaired immunity due to sarcoidosis or therapy. Anti-inflammatory therapy alone is not effective in most forms of advanced pulmonary sarcoidosis. New techniques, including high-resolution computer tomography and 18F-fluorodeoxyglucose positron emission tomography (PET) have proved helpful in identifying the cause of advanced disease and directing specific therapy.
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Affiliation(s)
- Rohit Gupta
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Robert P Baughman
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio
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Huitema MP, Mathijssen H, Mager JJ, Snijder RJ, Grutters JC, Post MC. Sarcoidosis-Associated Pulmonary Hypertension. Semin Respir Crit Care Med 2020; 41:659-672. [DOI: 10.1055/s-0040-1713615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AbstractPulmonary hypertension (PH) is a well-known complication of sarcoidosis, defined by a mean pulmonary artery pressure of ≥25 mm Hg. Since both PH and sarcoidosis are rare diseases, data on sarcoidosis-associated PH (SAPH) is retrieved mostly from small retrospective studies. Estimated prevalence of SAPH ranges from 3% in patients referred to a tertiary center up to 79% in patients awaiting lung transplant. Most patients with SAPH show advanced parenchymal disease as the underlying mechanism. However, some patients have disproportional elevated pulmonary artery pressure, and PH can occur in sarcoidosis patients without parenchymal disease. Other mechanisms such as vascular disease, pulmonary embolisms, postcapillary PH, extrinsic compression, and other sarcoidosis-related comorbidities might contribute to SAPH. The diagnosis of PH in sarcoidosis is challenging since symptoms and signs overlap. Suspicion can be raised based on symptoms or tests, such as pulmonary function tests, laboratory findings, electrocardiography, or chest CT. PH screening mainly relies on transthoracic echocardiography. Right heart catheterization should be considered on a case-by-case basis in patients with clinical suspicion of PH, taking into account clinical consequences. Treatment options are considered on patient level in a PH expert center, and might include oxygen therapy, immunosuppressive, or PH-specific therapy. However, qualitative evidence is scarce. Furthermore, in a subset of patients, interventional therapy or eventually lung transplant can be considered. SAPH is associated with high morbidity. Mortality is higher in sarcoidosis patients with PH compared with those without PH, and increases in patients with more advanced stages of sarcoidosis and/or PH.
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Affiliation(s)
- Marloes P. Huitema
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Harold Mathijssen
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Johannes J. Mager
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Repke J. Snijder
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jan C. Grutters
- Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Pulmonology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Marco C. Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Chest CT scan: The best predictor of mortality in advanced pulmonary sarcoidosis? Respir Med 2020; 170:106059. [DOI: 10.1016/j.rmed.2020.106059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Models Contribution to the Understanding of Sarcoidosis Pathogenesis: "Are There Good Models of Sarcoidosis?". J Clin Med 2020; 9:jcm9082445. [PMID: 32751786 PMCID: PMC7464295 DOI: 10.3390/jcm9082445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/27/2020] [Accepted: 07/27/2020] [Indexed: 12/29/2022] Open
Abstract
Sarcoidosis is a systemic, granulomatous, and noninfectious disease of unknown etiology. The clinical heterogeneity of the disease (targeted tissue(s), course of the disease, and therapy response) supports the idea that a multiplicity of trigger antigens may be involved. The pathogenesis of sarcoidosis is not yet completely understood, although in recent years, considerable efforts were put to develop novel experimental research models of sarcoidosis. In particular, sarcoidosis patient cells were used within in vitro 3D models to study their characteristics compared to control patients. Likewise, a series of transgenic mouse models were developed to highlight the role of particular signaling pathways in granuloma formation and persistence. The purpose of this review is to put in perspective the contributions of the most recent models in the understanding of sarcoidosis.
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Abstract
A sarcoidosis patient may be refractory to corticosteroid therapy. This may be because corticosteroids are ineffective in relieving the sarcoidosis patient's symptoms/dysfunction or because the clinician has determined that the risks of corticosteroids outweigh their benefits. Interestingly, when corticosteroids truly fail to improve a sarcoidosis patient's condition, it is very rarely because of failure of the drug as an anti-granulomatous agent; rather, it is usually because the patient's symptoms were unrelated to active sarcoid granulomas. In this manuscript, we review the causes of corticosteroid refractory sarcoidosis. The clinician should consider these causes when confronted with a sarcoidosis patient who is either not responding to corticosteroids, developing corticosteroid side-effects, or is at significant risk of developing such side-effects. We believe that determining the cause of corticosteroid refractory sarcoidosis may aid the clinicians in optimizing the care of sarcoidosis patients and clinical researchers in appropriately stratifying patients for clinical trials.
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Crouser ED, Maier LA, Wilson KC, Bonham CA, Morgenthau AS, Patterson KC, Abston E, Bernstein RC, Blankstein R, Chen ES, Culver DA, Drake W, Drent M, Gerke AK, Ghobrial M, Govender P, Hamzeh N, James WE, Judson MA, Kellermeyer L, Knight S, Koth LL, Poletti V, Raman SV, Tukey MH, Westney GE. Diagnosis and Detection of Sarcoidosis. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 201:e26-e51. [PMID: 32293205 PMCID: PMC7159433 DOI: 10.1164/rccm.202002-0251st] [Citation(s) in RCA: 437] [Impact Index Per Article: 109.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: The diagnosis of sarcoidosis is not standardized but is based on three major criteria: a compatible clinical presentation, finding nonnecrotizing granulomatous inflammation in one or more tissue samples, and the exclusion of alternative causes of granulomatous disease. There are no universally accepted measures to determine if each diagnostic criterion has been satisfied; therefore, the diagnosis of sarcoidosis is never fully secure. Methods: Systematic reviews and, when appropriate, meta-analyses were performed to summarize the best available evidence. The evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation approach and then discussed by a multidisciplinary panel. Recommendations for or against various diagnostic tests were formulated and graded after the expert panel weighed desirable and undesirable consequences, certainty of estimates, feasibility, and acceptability. Results: The clinical presentation, histopathology, and exclusion of alternative diagnoses were summarized. On the basis of the available evidence, the expert committee made 1 strong recommendation for baseline serum calcium testing, 13 conditional recommendations, and 1 best practice statement. All evidence was very low quality. Conclusions: The panel used systematic reviews of the evidence to inform clinical recommendations in favor of or against various diagnostic tests in patients with suspected or known sarcoidosis. The evidence and recommendations should be revisited as new evidence becomes available.
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Sobiecka M, Lewandowska K, Kober J, Franczuk M, Skoczylas A, Tomkowski W, Kuś J, Szturmowicz M. Can a New Scoring System Improve Prediction of Pulmonary Hypertension in Newly Recognised Interstitial Lung Diseases? Lung 2020; 198:547-554. [PMID: 32206858 PMCID: PMC7242254 DOI: 10.1007/s00408-020-00346-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 03/12/2020] [Indexed: 12/11/2022]
Abstract
Introduction Pulmonary hypertension (PH) is a well-recognised complication of interstitial lung diseases (ILD), which worsens prognosis and impairs exercise capacity. Echocardiography is the most widely used, non-invasive method for PH assessment. The aim of our study was to identify the factors predictive for echocardiographic signs of PH in newly recognised ILD patients. Methods Ninety-three consecutive patients (28F/65M) with different ILD were prospectively evaluated from January 2009 to March 2014. Pulmonary function testing, 6-min walk distance (6MWD), initial and sixth minute room air oxygen saturation, NT-proBNP and echocardiography were assessed in each patient. Echocardiographic PH probability was determined according to the 2009 ESC/ERS guidelines. Results In 41 patients (Group B) increased PH possibility has been diagnosed on echocardiography, in 52 patients (Group A)—low PH probability. Most pronounced differences (p ≤ 0.0005) between groups B and A concerned: age, 6MWD, room air oxygen saturation at 6 min, DLCO and TLC/DLCO index (57.6 vs 43.8 years; 478 vs 583 m; 89.1% vs 93.4%; 54.8% predicted vs 70.5% predicted and 1.86 vs 1.44; respectively). Univariate analysis showed four-fold increased probability of PH when TLC/DLCO exceeded 1.67. A scoring system incorporating age, TLC/DLCO index, 6MWD and room air oxygen saturation at 6 min provided high diagnostic utility, AUC 0.867 (95% CI 0.792–0.867). Conclusion ILD patients with TLC/DLCO index > 1.67 have a high likelihood of PH and should undergo further evaluation. The composite model of PH prediction, including age, 6-min walk test and TLC/DLCO was highly specific for recognition of PH on echocardiography.
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Affiliation(s)
- Małgorzata Sobiecka
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland.
| | - Katarzyna Lewandowska
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland
| | - Jarosław Kober
- Department of Radiology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Monika Franczuk
- Department of Respiratory Physiopathology, National Tuberculosis and Lung Diseases Research Institute, Warsaw, Poland
| | - Agnieszka Skoczylas
- Department of Geriatrics, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Witold Tomkowski
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland
| | - Jan Kuś
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland
| | - Monika Szturmowicz
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Research Institute, Plocka 26, 01-138, Warsaw, Poland
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Shlobin OA, Kouranos V, Barnett SD, Alhamad EH, Culver DA, Barney J, Cordova FC, Carmona EM, Scholand MB, Wijsenbeek M, Ganesh S, Lower EE, Engel PJ, Wort J, Price L, Wells AU, Nathan SD, Baughman RP. Physiological predictors of survival in patients with sarcoidosis-associated pulmonary hypertension: results from an international registry. Eur Respir J 2020; 55:13993003.01747-2019. [DOI: 10.1183/13993003.01747-2019] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 02/11/2020] [Indexed: 11/05/2022]
Abstract
IntroductionSarcoidosis-associated pulmonary hypertension (SAPH) is associated with reduced survival in single-centre studies. The international Registry for SAPH (ReSAPH) with long-term follow-up was established to enrich our knowledge of this complication of sarcoidosis. This analysis aims to elucidate factors associated with reduced transplant-free survival in SAPH patients.MethodsReSAPH contains prospectively collected outcomes of SAPH patients since the time of registry enrolment. Information analysed includes right heart catheterisation data, pulmonary function testing, chest radiography, Scadding stage and 6-min walk distance (6MWD), among others. Cox regression models were used to identify independent predictors of transplant-free survival.ResultsData from 215 patients followed for a mean±sd 2.5±1.9 years were available for analysis. In the 159 precapillary patients, the Kaplan–Meier-adjusted 1-, 3- and 5-year transplant-free survival was 89.2%, 71.7% and 62.0%, respectively. Kaplan–Meier-adjusted 1-, 3- and 5-year transplant-free survival in the incident group was 83.5%, 70.3% and 58.3%, respectively, and in the prevalent group was 94.7%, 72.2% and 66.3%, respectively. Patients with reduced diffusing capacity of the lung for carbon monoxide (DLCO) (<35% predicted) and 6MWD <300 m in the precapillary cohort had significantly worse transplant-free survival. Reduced 6MWD and preserved forced expiratory volume (FEV1)/forced vital capacity (FVC) ratio were identified as independent risk factors for reduced transplant-free survival in the precapillary cohort.ConclusionReduced DLCO (<35% pred) and 6MWD (<300 m) at the time of registry enrolment were associated with reduced transplant-free survival in the overall precapillary cohort. Preserved FEV1/FVC ratio was identified as an independent risk factor for worsened outcomes.
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Neder JA, Berton DC, Muller PT, O'Donnell DE. Incorporating Lung Diffusing Capacity for Carbon Monoxide in Clinical Decision Making in Chest Medicine. Clin Chest Med 2020; 40:285-305. [PMID: 31078210 DOI: 10.1016/j.ccm.2019.02.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Lung diffusing capacity for carbon monoxide (Dlco) remains the only noninvasive pulmonary function test to provide an integrated picture of gas exchange efficiency in human lungs. Due to its critical dependence on the accessible "alveolar" volume (Va), there remains substantial misunderstanding on the interpretation of Dlco and the diffusion coefficient (Dlco/Va ratio, Kco). This article presents the physiologic and methodologic foundations of Dlco measurement. A clinically friendly approach for Dlco interpretation that takes those caveats into consideration is outlined. The clinical scenarios in which Dlco can effectively assist the chest physician are discussed and illustrative clinical cases are presented.
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Affiliation(s)
- J Alberto Neder
- Laboratory of Clinical Exercise Physiology, Division of Respirology and Sleep Medicine, Department of Medicine, Kingston Health Science Center, Queen's University, Richardson House, 102 Stuart Street, Kingston, Ontario K7L 2V6, Canada.
| | - Danilo C Berton
- Division of Respirology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Paulo T Muller
- Division of Respirology, Federal University of Mato Grosso do Sul, Campo Grande, Brazil
| | - Denis E O'Donnell
- Respiratory Investigation Unit, Division of Respirology and Sleep Medicine, Kingston Health Science Center & Queen's University, Kingston, Ontario, Canada
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Judson MA. Developing better drugs for pulmonary sarcoidosis: determining indications for treatment and endpoints to assess therapy based on patient and clinician concerns. F1000Res 2019; 8:F1000 Faculty Rev-2149. [PMID: 31942239 PMCID: PMC6944258 DOI: 10.12688/f1000research.20696.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2019] [Indexed: 12/19/2022] Open
Abstract
Pulmonary sarcoidosis involves the deposition of granulomas within the lung. These granulomas may affect lung function and lead to pulmonary symptoms, pulmonary dysfunction, functional impairment, and worsening of quality of life. Corticosteroids are generally highly effective in resolving the granulomatous inflammation of sarcoidosis. However, despite the effectiveness of corticosteroids, many corticosteroid-responsive patients continue to experience significant problems because of the development of fibrosis from previously active or active smoldering granulomatous inflammation, inflammatory effects from sarcoidosis unrelated to granuloma deposition in lung tissue (parasarcoidosis syndromes), and the development of significant corticosteroid-related side effects. For these reasons, the decision to treat pulmonary sarcoidosis and endpoints to measure meaningful outcomes may extend beyond considerations of pulmonary granulomatous inflammation alone. In this article, we propose a conceptual framework to describe the mechanisms by which pulmonary sarcoidosis significantly impacts patients. This conceptual framework suggests that indications for the treatment of pulmonary sarcoidosis and endpoints to assess treatment depend on the specific mechanisms that are causing functional or quality-of-life impairment (or both) in patients with pulmonary sarcoidosis. We believe that these concepts are important to clinicians treating pulmonary sarcoidosis and to clinical researchers designing pulmonary sarcoidosis trials.
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Affiliation(s)
- Marc A Judson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Albany Medical College, Albany, NY, USA
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41
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Abstract
PURPOSE OF REVIEW Advanced sarcoidosis is an important cause of morbidity and mortality in sarcoidosis. Over the past few years, several studies have been published clarifying the prevalence and severity of this condition. RECENT FINDINGS Pulmonary involvement is the most common form of sarcoidosis. Increased morbidity and significant mortality is encountered in advanced lung disease. Although many sarcoidosis patients with pulmonary fibrosis have a normal life expectancy, at least 20% develop progression and may die from this complication. Sarcoidosis-associated pulmonary hypertension (SAPH) is an independent cause of death in advanced pulmonary sarcoidosis. Two large multicenter registries and a large single-center report provide more details regarding presentation and outcome of SAPH. Advanced neurologic disease is associated with significant morbidity, but not much mortality. Two large retrospective reviews demonstrated the effectiveness of infliximab in treating advanced neurosarcoidosis. Advanced cardiac sarcoidosis can lead to mortality. SUMMARY Advanced sarcoidosis is associated with significant morbidity and some mortality. Up to a quarter of all sarcoidosis patients have one or more forms of advanced disease. These patients require closer monitoring and often multiples treatments.
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Affiliation(s)
- Robert P Baughman
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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Clinical Features and Outcomes of Patients with Sarcoidosis-associated Pulmonary Hypertension. Sci Rep 2019; 9:4061. [PMID: 30858405 PMCID: PMC6411962 DOI: 10.1038/s41598-019-40030-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 12/31/2018] [Indexed: 11/09/2022] Open
Abstract
The presence of pulmonary hypertension (PH) significantly worsens outcomes in patients with advanced sarcoidosis, but its optimal management is unknown. We aimed to characterize a large sarcoidosis-associated pulmonary hypertension (SAPH) cohort to better understand patient characteristics, clinical outcomes, and management strategies including treatment with PH therapies. Patients at Duke University Medical Center with biopsy-proven sarcoidosis and SAPH confirmed by right heart catheterization (RHC) were identified from 1990–2010. Subjects were followed for up to 11 years and assessed for differences by treatment strategy for their SAPH, including those who were not treated with PH-specific therapies. Our primary outcomes of interest were change in 6-minute walk distance (6MWD) and change in N-terminal pro-brain natriuretic peptide (NT-proBNP) by after therapy. We included 95 patients (76% women, 86% African American) with SAPH. Overall, 70% of patients had stage IV pulmonary sarcoidosis, and 77% had functional class III/IV symptoms. Median NT-proBNP value was elevated (910 pg/mL), and right ventricular dysfunction was moderate/severe in 55% of patients. Median values for mean pulmonary artery pressure (49 mmHg) and pulmonary vascular resistance (8.5 Woods units) were consistent with severe pulmonary hypertension. The mortality rate over median 3-year follow-up was 32%. Those who experienced a clinical event and those who did not had similar overall echocardiographic findings, hemodynamics, 6MWD and NT-proBNP at baseline, and unadjusted analysis showed that only follow-up NT-proBNP was associated with all-cause hospitalization or mortality. A sign test to evaluate the difference between NT-Pro-BNP before and after PH therapy produced evidence that a significant difference existed between the median pre- and post-NT-Pro-BNP (−387.0 (IQR: −1373.0-109), p = 0.0495). Use of PH-specific therapy may be helpful in selected patients with SAPH and pre-capillary pulmonary vascular disease. Prospective trials are needed to characterize responses to PH-specific therapy in this subset of patients with SAPH.
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Nathan SD, Barbera JA, Gaine SP, Harari S, Martinez FJ, Olschewski H, Olsson KM, Peacock AJ, Pepke-Zaba J, Provencher S, Weissmann N, Seeger W. Pulmonary hypertension in chronic lung disease and hypoxia. Eur Respir J 2019; 53:13993003.01914-2018. [PMID: 30545980 PMCID: PMC6351338 DOI: 10.1183/13993003.01914-2018] [Citation(s) in RCA: 342] [Impact Index Per Article: 68.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 02/07/2023]
Abstract
Pulmonary hypertension (PH) frequently complicates the course of patients with various forms of chronic lung disease (CLD). CLD-associated PH (CLD-PH) is invariably associated with reduced functional ability, impaired quality of life, greater oxygen requirements and an increased risk of mortality. The aetiology of CLD-PH is complex and multifactorial, with differences in the pathogenic sequelae between the diverse forms of CLD. Haemodynamic evaluation of PH severity should be contextualised within the extent of the underlying lung disease, which is best gauged through a combination of physiological and imaging assessment. Who, when, if and how to screen for PH will be addressed in this article, as will the current state of knowledge with regard to the role of treatment with pulmonary vasoactive agents. Although such therapy cannot be endorsed given the current state of findings, future studies in this area are strongly encouraged. State of the art and research perspectives in pulmonary hypertension in chronic lung disease and hypoxiahttp://ow.ly/XcW730meWxy
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Affiliation(s)
| | - Joan A Barbera
- Dept of Pulmonary Medicine, Hospital Clínic-IDIBAPS, University of Barcelona, Barcelona, Spain.,Biomedical Research Networking Center on Respiratory Diseases, Madrid, Spain
| | - Sean P Gaine
- Respiratory Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sergio Harari
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria, Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe, MultiMedica IRCCS, Milan, Italy
| | | | - Horst Olschewski
- Division of Pulmonology, Medizinische Universitat Graz, Graz, Austria
| | - Karen M Olsson
- Dept of Respiratory Medicine, Hannover Medical School and Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Andrew J Peacock
- Scottish Pulmonary Vascular Unit, Regional Lung and Heart Centre, Glasgow, UK
| | | | - Steeve Provencher
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Laval University, Quebec City, QC, Canada
| | - Norbert Weissmann
- University of Giessen and Marburg Lung Center (UGMLC), Justus-Liebig University Giessen and Member of the German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- University of Giessen and Marburg Lung Center (UGMLC), Justus-Liebig University Giessen and Member of the German Center for Lung Research (DZL), Giessen, Germany
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