1
|
Munsif M, Sweeney D, Leong TL, Stirling RG. Nebulised granulocyte-macrophage colony-stimulating factor (GM-CSF) in autoimmune pulmonary alveolar proteinosis: a systematic review and meta-analysis. Eur Respir Rev 2023; 32:230080. [PMID: 37993127 PMCID: PMC10663936 DOI: 10.1183/16000617.0080-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/29/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Autoimmune pulmonary alveolar proteinosis (aPAP) results from impaired macrophage-mediated clearance of alveolar surfactant lipoproteins. Whole lung lavage has been the first-line treatment but recent reports suggest the efficacy of granulocyte-macrophage colony-stimulating factor (GM-CSF). We aimed to review the efficacy and safety of nebulised GM-CSF in aPAP. METHODS We conducted a systematic review and meta-analysis searching Embase, CINAHL, MEDLINE and Cochrane Collaborative databases (1946-1 April 2022). Studies included patients aged >18 years with aPAP receiving nebulised GM-CSF treatment and a comparator cohort. Exclusion criteria included secondary or congenital pulmonary alveolar proteinosis, GM-CSF allergy, active infection or other serious medical conditions. The protocol was prospectively registered with PROSPERO (CRD42021231328). Outcomes assessed were St George's Respiratory Questionnaire (SGRQ), 6-min walk test (6MWT), gas exchange (diffusing capacity of the lung for carbon monoxide (D LCO) % predicted) and arterial-alveolar oxygen gradient. RESULTS Six studies were identified for review and three for meta-analysis, revealing that SGRQ score (mean difference -8.09, 95% CI -11.88- -4.3, p<0.0001), functional capacity (6MWT) (mean difference 21.72 m, 95% CI -2.76-46.19 m, p=0.08), gas diffusion (D LCO % predicted) (mean difference 5.09%, 95% CI 2.05-8.13%, p=0.001) and arterial-alveolar oxygen gradient (mean difference -4.36 mmHg, 95% CI -7.19- -1.52 mmHg, p=0.003) all significantly improved in GM-CSF-treated patients with minor statistical heterogeneity (I2=0%). No serious trial-related adverse events were reported. CONCLUSIONS Patients with aPAP treated with inhaled GM-CSF demonstrated significant improvements in symptoms, dyspnoea scores, lung function, gas exchange and radiology indices after treatment with nebulised GM-CSF of varying duration. There is an important need to review comparative effectiveness and patient choice in key clinical outcomes between the current standard of care, whole lung lavage, with the noninvasive treatment of nebulised GM-CSF in aPAP.
Collapse
Affiliation(s)
- Maitri Munsif
- Department of Respiratory Medicine, Alfred Health, Melbourne, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
| | - Duncan Sweeney
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
| | - Tracy L Leong
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Rob G Stirling
- Department of Respiratory Medicine, Alfred Health, Melbourne, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| |
Collapse
|
2
|
Mabo A, Borie R, Wemeau-Stervinou L, Uzunhan Y, Gomez E, Prevot G, Reynaud-Gaubert M, Traclet J, Bergot E, Cadranel J, Marchand-Adam S, Bergeron A, Blanchard E, Bondue B, Bonniaud P, Bourdin A, Burgel PR, Hirschi S, Marquette CH, Quétant S, Nunes H, Chenivesse C, Crestani B, Guirriec Y, Monnier D, Ménard C, Tattevin P, Cottin V, Luque Paz D, Jouneau S. Infections in autoimmune pulmonary alveolar proteinosis: a large retrospective cohort. Thorax 2023; 79:68-74. [PMID: 37758458 DOI: 10.1136/thorax-2023-220040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 08/21/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Autoimmune pulmonary alveolar proteinosis (aPAP) is a rare disease, predisposing to an increased risk of infection. A complete picture of these infections is lacking. RESEARCH QUESTION Describe the characteristics and clinical outcomes of patients diagnosed with aPAP, and to identify risk factors associated with opportunistic infections. METHODS We conducted a retrospective cohort including all patients diagnosed with aPAP between 2008 and 2018 in France and Belgium. Data were collected using a standardised questionnaire including demographics, comorbidities, imaging features, outcomes and microbiological data. RESULTS We included 104 patients, 2/3 were men and median age at diagnosis was 45 years. With a median follow-up of 3.4 years (IQR 1.7-6.6 years), 60 patients (58%), developed at least one infection, including 23 (22%) with opportunistic infections. Nocardia spp was the main pathogen identified (n=10). Thirty-five (34%) patients were hospitalised due to infection. In univariate analysis, male gender was associated with opportunistic infections (p=0.04, OR=3.88; 95% CI (1.02 to 22.06)). Anti-granulocyte macrophage colony-stimulating factor antibody titre at diagnosis was significantly higher among patients who developed nocardiosis (1058 (316-1591) vs 580 (200-1190), p=0.01). Nine patients had died (9%), but only one death was related to infection. INTERPRETATION Patients with aPAP often presented with opportunistic infections, especially nocardiosis, which highlights the importance of systematic search for slow-growing bacteria in bronchoalveolar lavage or whole lung lavage.
Collapse
Affiliation(s)
- Axelle Mabo
- Service de Pneumologie, Centre de Compétence pour les Maladies Pulmonaires Rares, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - Raphael Borie
- Centre de Référence Constitutif des Maladies Pulmonaires Rares, Service de Pneumologie A, Hopital Bichat, APHP, Paris, France
| | - Lidwine Wemeau-Stervinou
- Centre de Référence Constitutif des Maladies Pulmonaires Rares, Institut Cœur-Poumon, Service de Pneumologie et Immuno-Allergologie, CHRU Lille, Lille, France
| | - Yurdagül Uzunhan
- Centre de Référence Constitutif des Maladies Pulmonaires Rares, Service de Pneumologie, Hôpital Avicenne, APHP, Bobigny, France
| | - Emmanuel Gomez
- Centre de Compétence pour les Maladies Pulmonaires Rares, Département de Pneumologie, Hôpitaux de Brabois, CHRU de Nancy, Vandoeuvre-les Nancy, France
| | - Gregoire Prevot
- Service de Pneumologie, Centre de Compétence pour les Maladies Pulmonaires Rares, Hôpital Larry, CHU Toulouse, Toulouse, France
| | - Martine Reynaud-Gaubert
- Service de Pneumologie et Transplantation Pulmonaire, Centre de Compétences des Maladies Rares Pulmonaires et de l'Hypertension Pulmonaire, CHU Nord de Marseille, AP-HM, Aix Marseille Université, Marseille, France
| | - Julie Traclet
- Service de Pneumologie, Centre National Coordonnateur de Référence des Maladies Pulmonaires Rares, Hôpital Louis-Pradel, Hospices Civils de Lyon (HCL), UMR754, INRAE, Université Lyon 1, ERN-LUNG, Lyon, France
| | - Emmanuel Bergot
- Centre de Compétence pour les Maladies Pulmonaires Rares de l'Adulte, Service de Pneumologie et Oncologie Thoracique, Hôpital Côte de Nacre, CHU de Caen, Caen, France
| | - Jacques Cadranel
- Service de Pneumologie et Oncologie Thoracique, Centre Constitutif Maladies Pulmonaires Rares, Hôpital Tenon, APHP, Sorbonne Université, Paris, France
| | - Sylvain Marchand-Adam
- Service de Pneumologie, CHRU de Tours, Université François Rabelais de Tours, INSERM U1100, Tours, France
| | - Anne Bergeron
- Service de Pneumologie, Hôpitaux Universitaires de Genève, Genève, Switzerland
| | - Elodie Blanchard
- Service de Pneumologie, centre de compétence pour les maladies pulmonaires rares, CHU de Bordeaux, Pessac, France
| | - Benjamin Bondue
- Service de Pneumologie, CUB Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Philippe Bonniaud
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence Constitutif des Maladies Pulmonaires Rares de l'Adulte, CHU Dijon-Bourgogne, Inserm U123, Université de Bourgogne, Dijon, France
| | - Arnaud Bourdin
- Service de Pneumologie, CHU Montpellier, Université de Montpellier, Inserm U1046, Montpellier, France
| | - Pierre Regis Burgel
- Service de Pneumologie, Hopital Cochin Pneumologie, AP-HP, Université Paris Cité Paris, Paris, France
| | - Sandrine Hirschi
- Service de Pneumologie et Transplantation Pulmonaire, Hopitaux universitaires de Strasbourg, Strasbourg, France
| | - Charles Hugo Marquette
- Service de Pneumologie, CHU Nice, Fédération Hospitalo-Universitaire OncoAge, Nice, France
| | - Sébastien Quétant
- Service Hospitalo-Universitaire de Pneumologie et Physiologie, Pôle Thorax et Vaisseaux, CHU de Grenoble-Alpes, La Tronche, Grenoble, France
| | - Hilario Nunes
- Centre de Référence Constitutif des Maladies Pulmonaires Rares, Service de Pneumologie, Hôpital Avicenne, APHP, Bobigny, France
| | - Cécile Chenivesse
- Centre de Référence Constitutif des Maladies Pulmonaires Rares, Institut Cœur-Poumon, Service de Pneumologie et Immuno-Allergologie, CHRU Lille, Lille, France
| | - Bruno Crestani
- Centre de Référence Constitutif des Maladies Pulmonaires Rares, Service de Pneumologie A, Hopital Bichat, APHP, Paris, France
| | - Yoann Guirriec
- Service de Pneumologie, Centre de Compétence pour les Maladies Pulmonaires Rares, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - Delphine Monnier
- Service d'Immunologie, Laboratoire de Biologie Médicale de Référence Lipoprotéinose Alvéolaire, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - Cédric Ménard
- Service d'Immunologie, Laboratoire de Biologie Médicale de Référence Lipoprotéinose Alvéolaire, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - Pierre Tattevin
- Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Inserm U1230, Université de Rennes, Rennes, France
| | - Vincent Cottin
- Service de Pneumologie, Centre National Coordonnateur de Référence des Maladies Pulmonaires Rares, Hôpital Louis-Pradel, Hospices Civils de Lyon (HCL), UMR754, INRAE, Université Lyon 1, ERN-LUNG, Lyon, France
| | - David Luque Paz
- Service de Pneumologie, Centre de Compétence pour les Maladies Pulmonaires Rares, Hôpital Pontchaillou, CHU Rennes, Rennes, France
- Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Inserm U1230, Université de Rennes, Rennes, France
| | - Stéphane Jouneau
- Service de Pneumologie, Centre de Compétence pour les Maladies Pulmonaires Rares, Hôpital Pontchaillou, CHU Rennes, Rennes, France
- Inserm UMR1085 IRSET, Université de Rennes, EHESP, Rennes, France
| |
Collapse
|
3
|
Arao Y, Stumpo DJ, Hoenerhoff MJ, Tighe RM, Yu YR, Sutton D, Kashyap A, Beerman I, Blackshear PJ. Lethal eosinophilic crystalline pneumonia in mice expressing a stabilized Csf2 mRNA. FASEB J 2023; 37:e23100. [PMID: 37462673 DOI: 10.1096/fj.202300757r] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/29/2023] [Accepted: 07/05/2023] [Indexed: 07/21/2023]
Abstract
Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a cytokine that stimulates the proliferation and differentiation of granulocyte and macrophage precursors. The mouse gene-encoding GM-CSF, Csf2, is regulated at both transcriptional and post-transcriptional levels. An adenine-uridine-rich element (ARE) within the 3'-untranslated region of Csf2 mRNA was shown in cell transfection studies to confer instability on this transcript. To explore the physiological importance of this element in an intact animal, we generated mice with a knock-in deletion of the 75-nucleotide ARE. Mice heterozygous for this ARE deletion developed severe respiratory distress and death within about 12 weeks of age. There was dense infiltration of lung alveolar spaces by crystal-containing macrophages. Increased stability of Csf2 mRNA was confirmed in bone marrow-derived macrophages, and elevated GM-CSF levels were observed in serum and lung. These mice did not exhibit notable abnormalities in blood or bone marrow, and transplantation of bone marrow from mutant mice into lethally irradiated WT mice did not confer the pulmonary phenotype. Mice with a conditional deletion of the ARE restricted to lung type II alveolar cells exhibited an essentially identical lethal lung phenotype at the same ages as the mice with the whole-body deletion. In contrast, mice with the same conditional ARE deletion in myeloid cells, including macrophages, exhibited lesser degrees of macrophage infiltration into alveolar spaces much later in life, at approximately 9 months of age. Post-transcriptional Csf2 mRNA stability regulation in pulmonary alveolar epithelial cells appears to be essential for normal physiological GM-CSF secretion and pulmonary macrophage homeostasis.
Collapse
Affiliation(s)
- Yukitomo Arao
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences/NIH, Durham, North Carolina, USA
| | - Deborah J Stumpo
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences/NIH, Durham, North Carolina, USA
| | - Mark J Hoenerhoff
- In Vivo Animal Core, Unit for Laboratory Animal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert M Tighe
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Yen-Rei Yu
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Deloris Sutton
- Cellular & Molecular Pathology Branch, National Institute of Environmental Health Sciences/NIH, Durham, North Carolina, USA
| | - Amogh Kashyap
- Epigenetics and Stem Cell Aging Unit, National Institute on Aging/NIH, Baltimore, Maryland, USA
| | - Isabel Beerman
- Epigenetics and Stem Cell Aging Unit, National Institute on Aging/NIH, Baltimore, Maryland, USA
| | - Perry J Blackshear
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences/NIH, Durham, North Carolina, USA
- Departments of Medicine and Biochemistry, Duke University Medical Center, Durham, North Carolina, USA
| |
Collapse
|
4
|
Huang X, Cao M, Xiao Y. Alveolar macrophages in pulmonary alveolar proteinosis: origin, function, and therapeutic strategies. Front Immunol 2023; 14:1195988. [PMID: 37388737 PMCID: PMC10303123 DOI: 10.3389/fimmu.2023.1195988] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/31/2023] [Indexed: 07/01/2023] Open
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disorder that is characterized by the abnormal accumulation of surfactant within the alveoli. Alveolar macrophages (AMs) have been identified as playing a pivotal role in the pathogenesis of PAP. In most of PAP cases, the disease is triggered by impaired cholesterol clearance in AMs that depend on granulocyte-macrophage colony-stimulating factor (GM-CSF), resulting in defective alveolar surfactant clearance and disruption of pulmonary homeostasis. Currently, novel pathogenesis-based therapies are being developed that target the GM-CSF signaling, cholesterol homeostasis, and immune modulation of AMs. In this review, we summarize the origin and functional role of AMs in PAP, as well as the latest therapeutic strategies aimed at addressing this disease. Our goal is to provide new perspectives and insights into the pathogenesis of PAP, and thereby identify promising new treatments for this disease.
Collapse
Affiliation(s)
- Xinmei Huang
- Department of Respiratory and Critical Care Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Nanjing Institute of Respiratory Diseases, Nanjing, China
| | - Mengshu Cao
- Department of Respiratory and Critical Care Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Nanjing Institute of Respiratory Diseases, Nanjing, China
- Department of Respiratory and Critical Care Medicine, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- Department of Respiratory and Critical Care Medicine, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Yonglong Xiao
- Department of Respiratory and Critical Care Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Nanjing Institute of Respiratory Diseases, Nanjing, China
| |
Collapse
|
5
|
Kim C, Garcia-Tome R, Hurtado C, Ding L, Wang T, Chang CF. Characteristics of hospital admissions for pulmonary alveolar proteinosis: analysis of the nationwide inpatient sample (2012-2014). BMC Pulm Med 2022; 22:365. [PMID: 36153570 PMCID: PMC9509629 DOI: 10.1186/s12890-022-02082-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 07/20/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Pulmonary alveolar proteinosis (PAP) is a rare clinical syndrome involving the accumulation of lipid-rich proteinaceous material in the alveoli. There is a paucity of published studies on this condition. To better characterize the demographics, complication rates, mortality, and healthcare costs of patients hospitalized for PAP in the United States, a secondary analysis on the Hospital Cost and Utilization Project's Nationwide Inpatient Sample (NIS) was performed on patients admitted from 2012 to 2014 with a diagnosis of pulmonary alveolar proteinosis. METHODS Using the NIS database, a secondary analysis was performed on 500 admissions with the diagnosis "pulmonary alveolar proteinosis." The clinical variables and outcome measures extracted were: patient demographics, hospital costs, length of stay, frequency of admissions, and inpatient mortality rate. RESULTS Among a weighted estimate of 500 hospital admissions from 2012 to 2014, the number of PAP admissions averaged 4.7 per million. The population was predominantly male (55%) with a mean age of 41.45 (CI 38.3-44.5) from all socioeconomic levels. Inpatient mortality was calculated to be 5%, which may result from the fact that the majority of admitted patients had few or no comorbid conditions (CCI 0.72). The most common procedure performed during admission was a bronchoalveolar lavage. Mean length of stay was 6.2 days (CI 3.9-8.5) and average cost of admission was $29,932.20 (CI 13,739-46,124). Of note, 50% of these admissions were considered "elective." CONCLUSIONS Demographics of patients with PAP who have been hospitalized in the United States are similar to previously reported demographics from prior patient cohorts, specifically a male predominance and a mean age in the 40 s. The inpatient mortality rate of 5% we found is consistent with prior studies demonstrating good disease-specific survival rates. Notably, the cost per admission and overall annual cost associated with PAP hospitalization was calculated to be $29932.20 and $5 million respectively. This reflects the high economic cost associated with hospitalization of PAP patients, and provokes thought about ways to make treatment more cost-effective.
Collapse
Affiliation(s)
- Chongiin Kim
- grid.42505.360000 0001 2156 6853Department of Internal Medicine, University of Southern California, Los Angeles, CA USA
| | - Rodrigo Garcia-Tome
- grid.42505.360000 0001 2156 6853Department of Pulmonary, Critical Care and Sleep Medicine, University of Southern California, Los Angeles, CA USA
| | - Carolina Hurtado
- grid.19006.3e0000 0000 9632 6718Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, University of California Los Angeles, Los Angeles, CA USA
| | - Li Ding
- grid.42505.360000 0001 2156 6853Department of Population and Public Health Sciences, Keck School of Medicine, Los Angeles, CA USA
| | - Tisha Wang
- grid.19006.3e0000 0000 9632 6718Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA USA
| | - Ching-Fei Chang
- grid.42505.360000 0001 2156 6853Department of Pulmonary, Critical Care and Sleep Medicine, University of Southern California, Los Angeles, CA USA
| |
Collapse
|
6
|
Lund-Palau H, Juarez-Molina CI, Meng C, Bhargava A, Pilou A, Aziz K, Clarke N, Atsumi N, Ashek A, Wilson MR, Takata M, Padley S, Gill DR, Hyde SC, Morgan C, Alton EWFW, Griesenbach U. Correction of a chronic pulmonary disease through lentiviral vector-mediated protein expression. Mol Ther Methods Clin Dev 2022; 25:382-391. [PMID: 35573048 PMCID: PMC9065048 DOI: 10.1016/j.omtm.2022.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/10/2022] [Indexed: 11/16/2022]
Abstract
We developed a novel lentiviral vector, pseudotyped with the F and HN proteins from Sendai virus (rSIV.F/HN), that produces long-lasting, high-efficiency transduction of the respiratory epithelium. Here we addressed whether this platform technology can secrete sufficient levels of a therapeutic protein into the lungs to ameliorate a fatal pulmonary disease as an example of its translational capability. Pulmonary alveolar proteinosis (PAP) results from alveolar granulocyte-macrophage colony-stimulating factor (GM-CSF) insufficiency, resulting in abnormal surfactant homeostasis and consequent ventilatory problems. Lungs of GM-CSF knockout mice were transduced with a single dose of rSIV.F/HN-expressing murine GM-CSF (mGM-CSF; 1e5-92e7 transduction units [TU]/mouse); mGM-CSF expression was dose related and persisted for at least 11 months. PAP disease biomarkers were rapidly and persistently corrected, but we noted a narrow toxicity/efficacy window. rSIV.F/HN may be a useful platform technology to deliver therapeutic proteins for lung diseases requiring long-lasting and stable expression of secreted proteins.
Collapse
Affiliation(s)
- Helena Lund-Palau
- National Heart and Lung Institute, Gene Therapy Group, Imperial College London, Faculty of Medicine, Manresa Road, London SW3 6LR, UK.,UK Respiratory Gene Therapy Consortium, London SW3 6LR, UK
| | - Claudia Ivette Juarez-Molina
- National Heart and Lung Institute, Gene Therapy Group, Imperial College London, Faculty of Medicine, Manresa Road, London SW3 6LR, UK.,UK Respiratory Gene Therapy Consortium, London SW3 6LR, UK
| | - Cuixiang Meng
- National Heart and Lung Institute, Gene Therapy Group, Imperial College London, Faculty of Medicine, Manresa Road, London SW3 6LR, UK
| | - Anushka Bhargava
- National Heart and Lung Institute, Gene Therapy Group, Imperial College London, Faculty of Medicine, Manresa Road, London SW3 6LR, UK.,UK Respiratory Gene Therapy Consortium, London SW3 6LR, UK
| | - Aikaterini Pilou
- National Heart and Lung Institute, Gene Therapy Group, Imperial College London, Faculty of Medicine, Manresa Road, London SW3 6LR, UK.,UK Respiratory Gene Therapy Consortium, London SW3 6LR, UK
| | - Kiran Aziz
- National Heart and Lung Institute, Gene Therapy Group, Imperial College London, Faculty of Medicine, Manresa Road, London SW3 6LR, UK.,UK Respiratory Gene Therapy Consortium, London SW3 6LR, UK
| | - Nora Clarke
- National Heart and Lung Institute, Gene Therapy Group, Imperial College London, Faculty of Medicine, Manresa Road, London SW3 6LR, UK.,UK Respiratory Gene Therapy Consortium, London SW3 6LR, UK
| | - Naoko Atsumi
- National Heart and Lung Institute, Gene Therapy Group, Imperial College London, Faculty of Medicine, Manresa Road, London SW3 6LR, UK.,UK Respiratory Gene Therapy Consortium, London SW3 6LR, UK
| | - Ali Ashek
- National Heart and Lung Institute, Gene Therapy Group, Imperial College London, Faculty of Medicine, Manresa Road, London SW3 6LR, UK
| | - Michael R Wilson
- Division of Anesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Masao Takata
- Division of Anesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Simon Padley
- Royal Brompton Hospital & Harefield Hospitals, London, UK
| | - Deborah R Gill
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,UK Respiratory Gene Therapy Consortium, London SW3 6LR, UK
| | - Stephen C Hyde
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,UK Respiratory Gene Therapy Consortium, London SW3 6LR, UK
| | - Cliff Morgan
- Royal Brompton Hospital & Harefield Hospitals, London, UK
| | - Eric W F W Alton
- National Heart and Lung Institute, Gene Therapy Group, Imperial College London, Faculty of Medicine, Manresa Road, London SW3 6LR, UK.,UK Respiratory Gene Therapy Consortium, London SW3 6LR, UK
| | - Uta Griesenbach
- National Heart and Lung Institute, Gene Therapy Group, Imperial College London, Faculty of Medicine, Manresa Road, London SW3 6LR, UK.,UK Respiratory Gene Therapy Consortium, London SW3 6LR, UK
| |
Collapse
|
7
|
McCarthy C, Carey BC, Trapnell BC. Autoimmune Pulmonary Alveolar Proteinosis. Am J Respir Crit Care Med 2022; 205:1016-1035. [PMID: 35227171 PMCID: PMC9851473 DOI: 10.1164/rccm.202112-2742so] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 02/24/2022] [Indexed: 01/23/2023] Open
Abstract
Autoimmune pulmonary alveolar proteinosis (PAP) is a rare disease characterized by myeloid cell dysfunction, abnormal pulmonary surfactant accumulation, and innate immune deficiency. It has a prevalence of 7-10 per million; occurs in individuals of all races, geographic regions, sex, and socioeconomic status; and accounts for 90% of all patients with PAP syndrome. The most common presentation is dyspnea of insidious onset with or without cough, production of scant white and frothy sputum, and diffuse radiographic infiltrates in a previously healthy adult, but it can also occur in children as young as 3 years. Digital clubbing, fever, and hemoptysis are not typical, and the latter two indicate that intercurrent infection may be present. Low prevalence and nonspecific clinical, radiological, and laboratory findings commonly lead to misdiagnosis as pneumonia and substantially delay an accurate diagnosis. The clinical course, although variable, usually includes progressive hypoxemic respiratory insufficiency and, in some patients, secondary infections, pulmonary fibrosis, respiratory failure, and death. Two decades of research have raised autoimmune PAP from obscurity to a paradigm of molecular pathogenesis-based diagnostic and therapeutic development. Pathogenesis is driven by GM-CSF (granulocyte/macrophage colony-stimulating factor) autoantibodies, which are present at high concentrations in blood and tissues and form the basis of an accurate, commercially available diagnostic blood test with sensitivity and specificity of 100%. Although whole-lung lavage remains the first-line therapy, inhaled GM-CSF is a promising pharmacotherapeutic approach demonstrated in well-controlled trials to be safe, well tolerated, and efficacious. Research has established GM-CSF as a pulmonary regulatory molecule critical to surfactant homeostasis, alveolar stability, lung function, and host defense.
Collapse
Affiliation(s)
- Cormac McCarthy
- Department of Respiratory Medicine, St. Vincent’s University Hospital, Dublin, Ireland
- University College Dublin, Dublin, Ireland
| | - Brenna C. Carey
- Translational Pulmonary Science Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Bruce C. Trapnell
- Translational Pulmonary Science Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
8
|
Liu S, Cui X, Xia K, Wang D, Han J, Yao X, Liu X, Bian L, Zhang J, Li G. A Bibliometric Analysis of Pulmonary Alveolar Proteinosis From 2001 to 2021. Front Med (Lausanne) 2022; 9:846480. [PMID: 35391885 PMCID: PMC8980592 DOI: 10.3389/fmed.2022.846480] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/28/2022] [Indexed: 12/05/2022] Open
Abstract
Background Pulmonary alveolar proteinosis (PAP) is a rare syndrome first described by Rosen et al. in 1958. Despite our considerably evolved understanding of PAP over the past decades, no bibliometric studies have been reported on this field. We aimed to analyze and visualize the research hotspots and current trends of the PAP research field using a bibliometric analysis to help understand the future development of basic and clinical research. Methods The literature regarding PAP was culled from the Web of Science Core Collection (WoSCC) database. Data were extracted from the relevant articles and visually analyzed using CiteSpace and VOSviewer software. Results Nine hundred and nine qualifying articles were included in the analysis. Publications regarding PAP increased over time. These articles mainly come from 407 institutions of 57 countries. The leading countries were the USA and Japan. University of Cincinnati (USA) and Niigata University (Japan) featured the highest number of publications among all institutions. Bruce C Trapnell exerts a significant publication impact and has made the most outstanding contributions in the field of PAP. American Journal of Physiology-Lung Cellular and Molecular Physiology was the journal with the most publications, and American Journal of Respiratory and Critical Care Medicine was the most commonly cited journal. All the top 5 co-cited journals belong to Q1. Keyword citation bursts revealed that inflammation, deficiency, tissue resident macrophage, classification, autoimmune pulmonary alveolar proteinosis, sarcoidosis, gm csf, high resolution ct, and fetal monocyte were the emerging research hotspots. Conclusion Research on PAP is prosperous. International cooperation is also expected to deepen and strengthen in the future. Our results indicated that the etiology and pathogenesis of PAP, current and emerging therapies, especially the novel pathogenesis-based options will remain research hotspots in the future.
Collapse
Affiliation(s)
- Shixu Liu
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School of China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiangning Cui
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Kun Xia
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Dandan Wang
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School of China Academy of Chinese Medical Sciences, Beijing, China
| | - Jing Han
- Affilated Hospital of Weifang Medical University, Weifang, China
| | - Xiaoyan Yao
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiaohong Liu
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School of China Academy of Chinese Medical Sciences, Beijing, China
| | - Lingjie Bian
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jinzhi Zhang
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School of China Academy of Chinese Medical Sciences, Beijing, China
| | - Guangxi Li
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- *Correspondence: Guangxi Li
| |
Collapse
|
9
|
Livingstone C, Corallo C, Siemienowicz M, Pilcher D, Stirling RG. NEBULISED SARGRAMOSTIM IN PULMONARY ALVEOLAR PROTEINOSIS. Br J Clin Pharmacol 2022; 88:3523-3528. [DOI: 10.1111/bcp.15266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 01/01/2022] [Accepted: 01/26/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
| | | | | | - David Pilcher
- Intensive Care Unit, Alfred Hospital Melbourne Australia
- Department of Medicine Monash University Melbourne Australia
| | - Robert G. Stirling
- Department of Medicine Monash University Melbourne Australia
- Respiratory Medicine, Alfred Hospital Melbourne Australia
| |
Collapse
|
10
|
Kahn P, Siegelin M, Carroll M, D'ovidio F, Arcasoy S. Bronchoscopic Lobar Lavage in the Treatment of a Single Lung Transplant Recipient With Pulmonary Alveolar Proteinosis: A Case Report. Transplant Proc 2022; 54:169-172. [PMID: 34973839 DOI: 10.1016/j.transproceed.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/20/2021] [Accepted: 11/30/2021] [Indexed: 11/28/2022]
Abstract
Pulmonary alveolar proteinosis is a rare disorder that results from impaired clearance of surfactant. There are few case reports in lung transplant recipients. We report the case of a 57-year-old man with chronic hypersensitivity pneumonitis who underwent left single lung transplantation. Approximately 1 year after transplant, he was diagnosed as having pulmonary alveolar proteinosis by surgical lung biopsy. He was successfully treated with bronchoscopic lobar lavage of his allograft but later was diagnosed as having peritoneal mesothelioma. We highlight the challenges in the diagnosis, discuss potential etiologies, and describe a unique therapy of this rare disorder in lung transplant recipients.
Collapse
Affiliation(s)
- Phoebe Kahn
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York.
| | - Markus Siegelin
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Maggie Carroll
- Lung Transplant Program, Columbia University Irving Medical Center, New York, New York
| | - Frank D'ovidio
- Lung Transplant Program, Columbia University Irving Medical Center, New York, New York; Section of Thoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Selim Arcasoy
- Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Irving Medical Center, New York, New York; Lung Transplant Program, Columbia University Irving Medical Center, New York, New York
| |
Collapse
|
11
|
Feld L, Jennings J, Fiorino EK, Harris M. Pulmonary Alveolar Proteinosis: A Case of Profound Hypoxemia in a Previously Healthy Teenager. Pediatr Emerg Care 2021; 37:e571-e573. [PMID: 30973497 DOI: 10.1097/pec.0000000000001820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT The profoundly hypoxemic child presents an interesting set of diagnostic and management challenges in the pediatric emergency department. While common pathologies including pneumonia, asthma, bronchiolitis, and pneumothoraces are managed using evidence-based algorithms, more enigmatic pathologies may present the treating physician with less diagnostic and therapeutic clarity. We present the case of a profoundly hypoxemic 16-year-old girl who presented in minimal distress, with oxyhemoglobin saturation of 63% on room air.
Collapse
Affiliation(s)
- Lance Feld
- From the Steven and Alexandra Cohen Children's Medical Center New Hyde Park
| | - John Jennings
- From the Steven and Alexandra Cohen Children's Medical Center New Hyde Park
| | | | | |
Collapse
|
12
|
Wu XK, Lin Q. Pulmonary alveolar proteinosis complicated with nocardiosis: A case report and review of the literature. World J Clin Cases 2021; 9:2874-2883. [PMID: 33969072 PMCID: PMC8058687 DOI: 10.12998/wjcc.v9.i12.2874] [Citation(s) in RCA: 3] [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: 12/01/2020] [Revised: 01/26/2021] [Accepted: 02/22/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pulmonary alveolar proteinosis (PAP) is a pulmonary syndrome wherein large volumes of phospholipid and protein-rich surfactants accumulate within the alveoli. PAP forms include primary (auto-immune PAP), secondary, and congenital. Nocardiosis is a form of suppurative disease induced upon infection with bacteria of the Nocardia genus. Clinically, cases of PAP complicated with Nocardia infections are rare, regardless of form. Unfortunately, as such, they are easily overlooked or misdiagnosed. We describe, here, the case of a patient suffering from simultaneous primary PAP and nocardiosis.
CASE SUMMARY A 45-year-old Chinese man, without history of relevant disease, was admitted to our hospital on August 8, 2018 to address complaints of activity-related respiratory exertion and cough lasting over 6 mo. Lung computed tomography (CT) revealed diffuse bilateral lung infiltration with local consolidation in the middle right lung lobe. Subsequent transbronchial lung biopsy and CT-guided lung biopsy led to a diagnosis of primary PAP (granulocyte-macrophage colony-stimulating factor antibody-positive) complicated with nocardiosis (periodic acid-Schiff-positive). After a 6 mo course of anti-infective treatment (sul-famethoxazole), the lesion was completely absorbed, such that only fibrous foci remained, and the patient exhibited significant symptom improvement. Follow-up also showed improvement in pulmonary function and the CT imaging findings of PAP. No whole-lung lavage has been conducted to date. This case highlights that active anti-nocardia treatment may effectively improve the symptoms and alleviate PAP in patients with PAP and nocardia, possibly reducing the need for whole-lung lavage.
CONCLUSION When evaluating patients presenting with PAP and pulmonary infections, the potential for nocardiosis should be considered.
Collapse
Affiliation(s)
- Xiao-Kang Wu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325015, Zhejiang Province, China
| | - Quan Lin
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325015, Zhejiang Province, China
| |
Collapse
|
13
|
Kaushal B, Chauhan S, Hasija S. Bilateral whole lung lavage by lung isolation in a child with pulmonary alveolar proteinosis: A new technique. Ann Card Anaesth 2021; 24:266-268. [PMID: 33884993 PMCID: PMC8253022 DOI: 10.4103/aca.aca_90_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
We present two rare cases of children who presented with progressive exertional breathlessness and dry cough. They also had history of bluish discoloration of mucous membranes, hands and feet on exertion. Both were diagnosed to have pulmonary alveolar proteinosis after a high-resolution computed tomography and bronchoalveolar lavage. They were subjected to bilateral whole lung lavage (WLL) as a salvage therapy. Bilateral WLL was performed in a single sitting with the help of a modified endotracheal tube. The anesthetic technique included a modified cuffed endotracheal tube for accomplishing WLL. After the procedure, both children improved clinically and functionally.
Collapse
Affiliation(s)
- Brajesh Kaushal
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, AIIMS, New Delhi, India
| | - Sandeeps Chauhan
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, AIIMS, New Delhi, India
| | - Suruchi Hasija
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, AIIMS, New Delhi, India
| |
Collapse
|
14
|
Hirose M, Arai T, Sugimoto C, Takimoto T, Sugawara R, Minomo S, Shintani S, Takeuchi N, Katayama K, Inoue Y, Kagawa T, Kasai T, Akira M, Inoue Y. B cell-activating factors in autoimmune pulmonary alveolar proteinosis. Orphanet J Rare Dis 2021; 16:115. [PMID: 33653382 PMCID: PMC7923513 DOI: 10.1186/s13023-021-01755-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/18/2021] [Indexed: 11/21/2022] Open
Abstract
Background Autoimmune pulmonary alveolar proteinosis (APAP) results from the suppression of granulocyte-macrophage colony-stimulating factor (GM-CSF) signaling by a neutralizing autoantibody against GM-CSF. B cell-activating factor (BAFF) and a proliferation-inducing ligand (APRIL) are involved in immunoglobulin G production and are overproduced in various autoimmune disorders. We hypothesized that BAFF and/or APRIL levels would be elevated in serum and bronchoalveolar lavage fluid (BALF) and serum and BALF levels of BAFF and APRIL respond to the treatments (whole lung lavage (WLL) or inhalation of recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF)) in patients with APAP. Subjects and methods
BAFF and APRIL levels in serum and BALF from 110 patients with APAP were measured at baseline and during and after treatment, using an enzyme-linked immunosorbent assay kit. We enrolled 34 healthy volunteers as serum cytokine controls, and 13 disease controls for BALF. Associations of BAFF and APRIL levels with clinical measures were assessed to clarify their clinical roles. Results In patients with APAP, serum BAFF and APRIL levels were significantly increased relative to healthy volunteers (p < 0.0001 and p < 0.05, respectively), and BALF BAFF and APRIL levels were significantly increased versus disease controls (p < 0.0001 and p < 0.01, respectively). Serum BAFF levels (but not APRIL levels) were significantly correlated with Krebs von den Lungen-6 (KL-6), surfactant protein (SP)-D, SP-A, and lactate dehydrogenase (p < 0.0001). There was no significant correlation between serum BAFF or APRIL levels and anti-GM-CSF autoantibody. BAFF and APRIL were negatively correlated with single-breath diffusion capacity for carbon monoxide (DLco) (p = 0.004) and forced vital capacity (p = 0.04), respectively. BAFF (but not APRIL) in BALF was negatively correlated with vital capacity (p = 0.04) and DLco (p = 0.006). There were significant correlations between disease severity and BAFF levels in serum (p = 0.04) and BALF (p = 0.007). Serum levels of anti-GM-CSF autoantibody, BAFF, and APRIL were not significantly affected by WLL or inhalation of recombinant human GM-CSF. Conclusions BAFF and APRIL levels of sera and BALF in APAP were significantly increased compared with healthy volunteer and disease control, and the BAFF and APRIL pathway might have important specific roles in pathogenesis of APAP. Our data suggest a new perspective of future treatment for APAP.
Collapse
Affiliation(s)
- Masaki Hirose
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-Cho, Kita-Ku, Sakai City, Osaka, 591-8555, Japan
| | - Toru Arai
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-Cho, Kita-Ku, Sakai City, Osaka, 591-8555, Japan
| | - Chikatoshi Sugimoto
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-Cho, Kita-Ku, Sakai City, Osaka, 591-8555, Japan
| | - Takayuki Takimoto
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-Cho, Kita-Ku, Sakai City, Osaka, 591-8555, Japan
| | - Reiko Sugawara
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-Cho, Kita-Ku, Sakai City, Osaka, 591-8555, Japan
| | - Shojiro Minomo
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-Cho, Kita-Ku, Sakai City, Osaka, 591-8555, Japan
| | - Sayoko Shintani
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-Cho, Kita-Ku, Sakai City, Osaka, 591-8555, Japan
| | - Naoko Takeuchi
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-Cho, Kita-Ku, Sakai City, Osaka, 591-8555, Japan
| | - Kanako Katayama
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-Cho, Kita-Ku, Sakai City, Osaka, 591-8555, Japan
| | - Yasushi Inoue
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-Cho, Kita-Ku, Sakai City, Osaka, 591-8555, Japan
| | - Tomoko Kagawa
- Department of Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-Cho, Kita-Ku, Sakai City, Osaka, 591-8555, Japan
| | - Takahiko Kasai
- Department of Pathology, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-Cho, Kita-Ku, Sakai City, Osaka, 591-8555, Japan
| | - Masanori Akira
- Department of Radiology, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-Cho, Kita-Ku, Sakai City, Osaka, 591-8555, Japan
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, 1180 Nagasone-Cho, Kita-Ku, Sakai City, Osaka, 591-8555, Japan.
| |
Collapse
|
15
|
Trapnell BC, Inoue Y, Bonella F, Morgan C, Jouneau S, Bendstrup E, Campo I, Papiris SA, Yamaguchi E, Cetinkaya E, Ilkovich MM, Kramer MR, Veltkamp M, Kreuter M, Baba T, Ganslandt C, Tarnow I, Waterer G, Jouhikainen T. Inhaled Molgramostim Therapy in Autoimmune Pulmonary Alveolar Proteinosis. N Engl J Med 2020; 383:1635-1644. [PMID: 32897035 PMCID: PMC8083051 DOI: 10.1056/nejmoa1913590] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Autoimmune pulmonary alveolar proteinosis (aPAP) is a rare disease characterized by progressive surfactant accumulation and hypoxemia. It is caused by disruption of granulocyte-macrophage colony-stimulating factor (GM-CSF) signaling, which pulmonary alveolar macrophages require to clear surfactant. Recently, inhaled GM-CSF was shown to improve the partial pressure of arterial oxygen in patients with aPAP. METHODS In a double-blind, placebo-controlled, three-group trial, we randomly assigned patients with aPAP to receive the recombinant GM-CSF molgramostim (300 μg once daily by inhalation), either continuously or intermittently (every other week), or matching placebo. The 24-week intervention period was followed by an open-label treatment-extension period. The primary end point was the change from baseline in the alveolar-arterial difference in oxygen concentration (A-aDo2) at week 24. RESULTS In total, 138 patients underwent randomization; 46 were assigned to receive continuous molgramostim, 45 to receive intermittent molgramostim, and 47 to receive placebo. Invalid A-aDo2 data for 4 patients (1 in each molgramostim group and 2 in the placebo group) who received nasal oxygen therapy during arterial blood gas measurement were replaced by means of imputation. For the primary end point - the change from baseline in the A-aDo2 at week 24 - improvement was greater among patients receiving continuous molgramostim than among those receiving placebo (-12.8 mm Hg vs. -6.6 mm Hg; estimated treatment difference, -6.2 mm Hg; P = 0.03 by comparison of least-squares means). Patients receiving continuous molgramostim also had greater improvement than those receiving placebo for secondary end points, including the change from baseline in the St. George's Respiratory Questionnaire total score at week 24 (-12.4 points vs. -5.1 points; estimated treatment difference, -7.4 points; P = 0.01 by comparison of least-squares means). For multiple end points, improvement was greater with continuous molgramostim than with intermittent molgramostim. The percentages of patients with adverse events and serious adverse events were similar in the three groups, except for the percentage of patients with chest pain, which was higher in the continuous-molgramostim group. CONCLUSIONS In patients with aPAP, daily administration of inhaled molgramostim resulted in greater improvements in pulmonary gas transfer and functional health status than placebo, with similar rates of adverse events. (Funded by Savara Pharmaceuticals; IMPALA ClinicalTrials.gov number, NCT02702180.).
Collapse
Affiliation(s)
- Bruce C Trapnell
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Yoshikazu Inoue
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Francesco Bonella
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Cliff Morgan
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Stéphane Jouneau
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Elisabeth Bendstrup
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Ilaria Campo
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Spyros A Papiris
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Etsuro Yamaguchi
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Erdogan Cetinkaya
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Mikhail M Ilkovich
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Mordechai R Kramer
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Marcel Veltkamp
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Michael Kreuter
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Tomohisa Baba
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Cecilia Ganslandt
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Inge Tarnow
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Grant Waterer
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | - Taneli Jouhikainen
- From the Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati (B.C.T.); National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I.), Aichi Medical University Hospital, Nagakute, Aichi (E.Y.), and Kanagawa Cardiovascular and Respiratory Center, Yokohama (T.B.) - all in Japan; Outpatients Clinic for Interstitial and Rare Lung Disease, Ruhrlandklinik University Hospital, Essen (F.B.), and Center for Interstitial and Rare Lung Diseases, Pulmonology, Thoraxklinik, Heidelberg University Hospital, and German Center for Lung Research, Heidelberg (M.K.) - all in Germany; the Departments of Critical Care and Respiratory Medicine, Royal Brompton Hospital, London (C.M.); Respiratory Diseases Department, Pontchaillou Hospital, IRSET UMR 1085, Rennes 1 University, Rennes, France (S.J.); the Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus (E.B.), and Savara, Horsholm (C.G., I.T.) - both in Denmark; the Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (I.C.); the 2nd Pulmonary Medicine Department, General University Hospital "Attikon," Medical School, National and Kapodistrian University of Athens, Athens (S.A.P.); University of Health Sciences Turkey, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Istanbul (E.C.); Pulmonary Clinic of St. Petersburg Pavlov State Medical University, St. Petersburg, Russia (M.M.I.); Institute of Pulmonary and Allergy Medicine, Rabin Medical Center, Petah Tikva, Israel (M.R.K.); ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands (M.V.); the University of Western Australia, Royal Perth Hospital, Perth, Australia (G.W.); and Savara, Austin, TX (T.J.)
| | | |
Collapse
|
16
|
Tian X, Yang Y, Chen L, Sui X, Xu W, Li X, Guo X, Liu L, Situ Y, Wang J, Zhao Y, Meng S, Song W, Xiao Y, Xu KF. Inhaled granulocyte-macrophage colony stimulating factor for mild-to-moderate autoimmune pulmonary alveolar proteinosis - a six month phase II randomized study with 24 months of follow-up. Orphanet J Rare Dis 2020; 15:174. [PMID: 32615994 PMCID: PMC7330972 DOI: 10.1186/s13023-020-01450-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 06/23/2020] [Indexed: 11/29/2022] Open
Abstract
Background Treatment of autoimmune pulmonary alveolar proteinosis (aPAP) by inhaled granulocyte-macrophage colony stimulating factor (GM-CSF) is considered safe and effective. Evidence of benefit from GM-CSG inhalation for mild to moderate aPAP patients is limited. Methods In this multicenter, randomized, open-labeled clinical trial, 36 aPAP patients with mild to moderate disease severity were randomized into either the GM-CSF treatment group or control group. Inhaled GM-CSF was prescribed for 6 months, and patients received follow-up for another 18 months without treatment. Physiological features of the patients were analyzed. Results There were 36 patients (19 in the treatment group, 17 in the control group) included. There were no significant differences in the primary endpoints as measured by the change of alveolar arterial oxygen gradient (A-aDO2) from the baseline values to the values obtained during treatment or during the following 18-month non-treatment observation period [control group vs. treatment group: 0.51 ± 12.09 mmHg vs. -0.35 ± 13.76 mmHg, p = 0.848 (3 month); 1.85 ± 11.21 mmHg vs. 7.31 ± 8.81 mmHg, p = 0.146 (6 months); 6.05 ± 11.14 mmHg vs. 6.61 ± 10.64 mmHg, p = 0.899 (24 months)]). Percentage of diffusion capacity predicted (DLCO%) and percentage of total lung capacity predicted (TLC%), however, were significantly improved in the treatment group by the end of the study (P = 0.010 and 0.027). St. George Respiratory questionnaire (SGRQ) scores were better after 6 months treatment with GM-CSF compared to the control group, and the benefits of treatment were maintained throughout the observation period. No severe side effects were observed during the study. Conclusion Six months of inhaled GM-CSF treatment had no effect on the alveolar–arterial oxygen gradient in patients with mild to moderate pulmonary alveolar proteinosis. There were changes in some clinical or laboratory measures, but no clinically important changes were noted at the end of study. (Clinical Trial Registry: NCT02243228, Registered on September 17, 2014, https://www.clinicaltrials.gov/ct2/show/NCT02243228?term=NCT02243228&draw=2&rank=1)
Collapse
Affiliation(s)
- Xinlun Tian
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yanli Yang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lulu Chen
- Department of Pulmonary and Critical Care Medicine, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Jiangsu, China
| | - Xin Sui
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wenshuai Xu
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xue Li
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaobei Guo
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Emergency Center, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Lingshan Liu
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yusen Situ
- Department of Biochemistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Jun Wang
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yang Zhao
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shuzhen Meng
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wei Song
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yonglong Xiao
- Department of Pulmonary and Critical Care Medicine, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Jiangsu, China.
| | - Kai-Feng Xu
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| |
Collapse
|
17
|
Antoniu SA, Rajnoveanu R, Grigore M, Antohe I. Pharmacotherapy options in pulmonary alveolar proteinosis. Expert Opin Pharmacother 2020; 21:1359-1366. [PMID: 32511020 DOI: 10.1080/14656566.2020.1757650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Pulmonary alveolar proteinosis (PAP) is a heterogeneous group of rare diseases characterized by the abnormal production and impaired degradation of pulmonary surfactant as a result of malfunctioning of alveolar macrophages. This is due to the downstream dysregulation of the GM-CSF pathway, which can be caused by specific autoantibodies (autoimmune, aPAP formerly known as idiopathic iPAP), direct injury to alveolar macrophages (e.g. by toxic inhaled agents.), or by genetic defects (hereditary or congenital PAP). Few pharmacotherapy options are currently available to treat this disease. AREA COVERED The authors discuss the exogenous administration of GM-CSF, rituximab, and the potential role of cholesterol lowering medications in this review. The authors, furthermore, provide their opinion on the available pharmacotherapeutic options and give their future perspectives. EXPERT OPINION Inhaled GM-CSF remains the most commonly used therapy in patients with iPAP but other inhaled therapies such as PPARγ activators should be considered, especially in patients who are partially responsive or unresponsive to traditional treatments.
Collapse
Affiliation(s)
| | - Ruxandra Rajnoveanu
- Faculty of Medicine, University of Medicine and Pharmacy Iuliu Hatieganu , Cluj Napoca, Romania
| | - Mihaela Grigore
- Mother and Child Department, University of Medicine and Pharmacy Grigore T Popa , Iasi, Romania
| | - Ileana Antohe
- Faculty of Medicine, University of Medicine and Pharmacy Grigore T Popa , Iasi, Romania
| |
Collapse
|
18
|
Wadden D, Buckley A, Ghosh C, Vidyasankar G. Respiratory failure in a 28-year-old male. Breathe (Sheff) 2020; 16:190337. [PMID: 33304397 PMCID: PMC7714546 DOI: 10.1183/20734735.0337-2019] [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] [Indexed: 11/25/2022] Open
Abstract
A 28-year-old male was admitted to the intensive care unit (ICU) for hypoxic respiratory failure requiring intubation and ventilation. He had been dyspnoeic for months leading up to admission with acute worsening 2 weeks prior and reported a 6-kg weight loss over the same time. Occasional dark sputum was reported without haemoptysis, wheeze, chest pain, fever or infectious symptoms. In regard to social history, he smoked 10 cigarettes per day at the time of presentation (<10-pack-year history) and occasionally used marijuana. He worked as a soapstone carver daily and did not use any respiratory protection. In addition, the patient had exposure to a tuberculosis contact ∼1 year prior to presentation. An interesting case of respiratory failure secondary to occupational exposure in a 28-year-old malehttp://bit.ly/2SzR6dK
Collapse
|
19
|
Granulocyte-Macrophage Colony-Stimulating Factor Inhalation Therapy for Severe Pulmonary Alveolar Proteinosis. Am J Ther 2020; 28:e171-e178. [PMID: 31513019 DOI: 10.1097/mjt.0000000000001053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Some patients with pulmonary alveolar proteinosis (PAP) still present with high recurrence rate after large-volume whole lung lavage (WLL). Granulocyte-macrophage colony-stimulating factor (GM-CSF) has been proved to be effective for PAP, but clinical research on GM-CSF inhalation therapy combined with WLL for severe PAP is rare in Asia. STUDY QUESTION This study aimed to investigate the clinical efficacy of GM-CSF inhalation combined with WLL in Chinese patients with PAP. STUDY DESIGN We performed regression analysis on 33 patients with severe PAP who underwent WLL alone or WLL combined with GM-CSF inhalation. The patients were put into 2 groups, WLL group and GM-CSF/WLL group. MEASURES AND OUTCOMES Physiologic, serologic, and radiologic features of the 2 groups at different time points after treatment and the recurrence rates at 1-year follow-up were compared. RESULTS There were no significant differences in lung function, blood gas analysis indices, and lung CT between the 2 groups after 1-week treatment (P > 0.05). After 3-month treatment, the GM-CSF/WLL group showed significantly faster improvement in FEV1%Pred (P = 0.028), FVC%Pred (P = 0.014), PaO2 (P = 0.022), PA-aO2 (P = 0.009), PaO2/FiO2 (P = 0.025), 6-minute walking test (P = 0.002), and lung CT parameters (P < 0.05) compared with the WLL group. The recurrence rate at the 1-year follow-up in the GM-CSF/WLL group (5.5%) was significantly higher than that in the WLL group (46.67%; P < 0.05). CONCLUSIONS GM-CSF inhalation therapy combined with WLL is an effective treatment for patients with severe PAP, with further improvement in lung function at the base of WILL as well as reduction on re-WLL incidence.
Collapse
|
20
|
Zhang F, Weng D, Su Y, Yin C, Shen L, Zhang Y, Zhou Y, Li Q, Hu Y, Li H. Therapeutic effect of subcutaneous injection of low dose recombinant human granulocyte-macrophage colony-stimulating factor on pulmonary alveolar proteinosis. Respir Res 2020; 21:1. [PMID: 31898493 PMCID: PMC6941258 DOI: 10.1186/s12931-019-1261-1] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/12/2019] [Indexed: 01/15/2023] Open
Abstract
Objective To observe the efficacy of recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) for pulmonary alveolar proteinosis (PAP). Materials and methods A total of 55 patients with PAP were screened at Shanghai Pulmonary Hospital between May 2014 and May 2018. Among these, 42 were diagnosed with idiopathic PAP, 24 were included in this study, 20 were treated for 6 months, and 17 were followed up for additional 6 months. All patients received a subcutaneous injection of 75μg/d GM-CSF qd for 1 month. The therapeutic dose was adjusted according to the changes in the lesions of chest CT. If the lesions were absorbed, subcutaneous injections of 75μg/d GM- CSF qd and 75μg/d GM-CSF qod were given for 2 and 3 months, otherwise, the dose was increased to 150μg/d GM-CSF qd and 150μg/d qod for 2 and 3 months, respectively. All cases were treated once a day in the first 3 months and once every other day in the last 3 months. The total course of treatment was 6 months. After withdrawal, the patients were followed up for another 6 months. The deadline of follow up was September 30, 2019. Results Twenty patients completed the treatment and efficacy evaluation. One patient was completely cured, 16 cases improved, three cases were noneffective. After 1-month evaluation, 12 patients received an increased dose (150μg) from the second month of treatment. Seventeen patients completed the 12-month follow-up, among which fourteen improved. CT showed the lesions were slightly increased in three cases. Economic burden was the following: RMB 7324–15,190 Yuan were required for the 6-month treatment course, which is significantly lower compared to other treatment methods. Conclusion Subcutaneous injection of rhGM-CSF at low dose (75μg-150μg /d) is effective treatment for patients with idiopathic PAP. Trial registration NCT01983657. Registered 16 April 2013.
Collapse
Affiliation(s)
- Fen Zhang
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, 507 Zheng Min Road, Shanghai, 200433, China
| | - Dong Weng
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, 507 Zheng Min Road, Shanghai, 200433, China
| | - Yiliang Su
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, 507 Zheng Min Road, Shanghai, 200433, China
| | - Chengsheng Yin
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, 507 Zheng Min Road, Shanghai, 200433, China
| | - Li Shen
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, 507 Zheng Min Road, Shanghai, 200433, China
| | - Yuan Zhang
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, 507 Zheng Min Road, Shanghai, 200433, China
| | - Ying Zhou
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, 507 Zheng Min Road, Shanghai, 200433, China
| | - Qiuhong Li
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, 507 Zheng Min Road, Shanghai, 200433, China
| | - Yang Hu
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, 507 Zheng Min Road, Shanghai, 200433, China
| | - Huiping Li
- Department of Respiratory Medicine, Shanghai Pulmonary Hospital, Tongji University, School of Medicine, 507 Zheng Min Road, Shanghai, 200433, China.
| |
Collapse
|
21
|
Tazawa R, Ueda T, Abe M, Tatsumi K, Eda R, Kondoh S, Morimoto K, Tanaka T, Yamaguchi E, Takahashi A, Oda M, Ishii H, Izumi S, Sugiyama H, Nakagawa A, Tomii K, Suzuki M, Konno S, Ohkouchi S, Tode N, Handa T, Hirai T, Inoue Y, Arai T, Asakawa K, Sakagami T, Hashimoto A, Tanaka T, Takada T, Mikami A, Kitamura N, Nakata K. Inhaled GM-CSF for Pulmonary Alveolar Proteinosis. N Engl J Med 2019; 381:923-932. [PMID: 31483963 DOI: 10.1056/nejmoa1816216] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pulmonary alveolar proteinosis is a disease characterized by abnormal accumulation of surfactant in the alveoli. Most cases are autoimmune and are associated with an autoantibody against granulocyte-macrophage colony-stimulating factor (GM-CSF) that prevents clearing of pulmonary surfactant by alveolar macrophages. An open-label, phase 2 study showed some therapeutic efficacy of inhaled recombinant human GM-CSF in patients with severe pulmonary alveolar proteinosis; however, the efficacy in patients with mild-to-moderate disease remains unclear. METHODS We conducted a double-blind, placebo-controlled trial of daily inhaled recombinant human GM-CSF (sargramostim), at a dose of 125 μg twice daily for 7 days, every other week for 24 weeks, or placebo in 64 patients with autoimmune pulmonary alveolar proteinosis who had a partial pressure of arterial oxygen (Pao2) while breathing ambient air of less than 70 mm Hg (or <75 mm Hg in symptomatic patients). Patients with severe pulmonary alveolar proteinosis (Pao2 <50 mm Hg) were excluded to avoid possible exacerbation of the disease in patients who were assigned to receive placebo. The primary end point was the change in the alveolar-arterial oxygen gradient between baseline and week 25. RESULTS The change in the mean (±SD) alveolar-arterial oxygen gradient was significantly better in the GM-CSF group (33 patients) than in the placebo group (30 patients) (mean change from baseline, -4.50±9.03 mm Hg vs. 0.17±10.50 mm Hg; P = 0.02). The change between baseline and week 25 in the density of the lung field on computed tomography was also better in the GM-CSF group (between-group difference, -36.08 Hounsfield units; 95% confidence interval, -61.58 to -6.99, calculated with the use of the Mann-Whitney U test and the Hodges-Lehmann estimate of confidence intervals for pseudo-medians). Serious adverse events developed in 6 patients in the GM-CSF group and in 3 patients in the placebo group. CONCLUSIONS In this randomized, controlled trial, inhaled recombinant human GM-CSF was associated with a modest salutary effect on the laboratory outcome of arterial oxygen tension, and no clinical benefits were noted. (Funded by the Japan Agency for Medical Research and Development and the Ministry of Health, Labor, and Welfare of Japan; PAGE ClinicalTrials.gov number, NCT02835742; Japan Medical Association Center for Clinical Trials number, JMA-IIA00205.).
Collapse
Affiliation(s)
- Ryushi Tazawa
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Takahiro Ueda
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Mitsuhiro Abe
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Koichiro Tatsumi
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Ryosuke Eda
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Shotaro Kondoh
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Konosuke Morimoto
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Takeshi Tanaka
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Etsuro Yamaguchi
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Ayumu Takahashi
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Miku Oda
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Haruyuki Ishii
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Shinyu Izumi
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Haruhito Sugiyama
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Atsushi Nakagawa
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Keisuke Tomii
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Masaru Suzuki
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Satoshi Konno
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Shinya Ohkouchi
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Naoki Tode
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Tomohiro Handa
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Toyohiro Hirai
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Yoshikazu Inoue
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Toru Arai
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Katsuaki Asakawa
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Takuro Sakagami
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Atsushi Hashimoto
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Takahiro Tanaka
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Toshinori Takada
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Ayako Mikami
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Nobutaka Kitamura
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| | - Koh Nakata
- From Niigata University Medical and Dental Hospital, Niigata (R.T., T.U., K.A., T.S., A.H., Takahiro Tanaka, T. Takada, N.K., K.N.), the Department of Respirology, Graduate School of Medicine, Chiba University, Chiba (M.A., K. Tatsumi), Kurashiki Municipal Hospital, Kurashiki (R.E., S. Kondoh), the Department of Clinical Medicine, Institute of Tropical Medicine, Nagasaki University, Nagasaki (K.M., Takeshi Tanaka), the Division of Respiratory Medicine and Allergology, Department of Medicine, Aichi Medical University School of Medicine, Aichi (E.Y., A.T.), the Department of Respiratory Medicine, Kyorin University School of Medicine (M.O., H.I.), and the Center Hospital of the National Center for Global Health and Medicine (S.I., H.S., A.M.), Tokyo, Kobe City Medical Center General Hospital, Kobe (A.N., K. Tomii), the Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo (M.S., S. Konno), the Department of Respiratory Medicine and Department of Occupational Health, Tohoku University Graduate School of Medicine, Sendai (S.O., N.T.), the Departments of Advanced Medicine for Respiratory Failure (T. Handa) and Respiratory Medicine (T. Handa, T. Hirai), Graduate School of Medicine, Kyoto University, Kyoto, and the National Hospital Organization Kinki-Chuo Chest Medical Center, Osaka (Y.I., T.A.) - all in Japan
| |
Collapse
|
22
|
McCarthy C, Kokosi M, Bonella F. Shaping the future of an ultra-rare disease: unmet needs in the diagnosis and treatment of pulmonary alveolar proteinosis. Curr Opin Pulm Med 2019; 25:450-458. [PMID: 31365379 DOI: 10.1097/mcp.0000000000000601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Pulmonary alveolar proteinosis (PAP) can be considered the archetype of ultra-rare diseases with a prevalence of under 10 cases per million. We discuss the classification of PAP, the current diagnostic practice and the supplementary role of genetic testing and granulocyte-macrophage colony-stimulating factor (GM-CSF) signalling in the diagnosis of congenital and hereditary PAP. We report on novel therapeutic approaches such as GM-CSF substitution, stem cell transplantation, pioglitazone, statins and immunomodulation. RECENT FINDINGS The discovery of new genetic mutations underlying this syndrome raises the question whether the classification should be radically revised in the future. Serum GM-CSF autoantibody is the best diagnostic marker for autoimmune PAP, the most common form, but does not correlate with disease severity. Several circulating biomarkers have been investigated to assess disease activity and predict outcome. Imaging techniques have also enormously evolved and offer new tools to quantify disease burden and possibly drive therapeutic decisions. Promising clinical trials are ongoing and will generate new treatment strategies besides or in addition to whole lung lavage in the next future. SUMMARY Despite impressive advances in understanding pathogenesis, PAP remains a rare syndrome with several unanswered questions impacting diagnosis, management and treatment, and, as a result, patients' quality of life.
Collapse
Affiliation(s)
- Cormac McCarthy
- Department of Respiratory Medicine, Rare Lung Disease Centre, St. Vincent's University Hospital, University College Dublin, Dublin, Ireland
| | - Maria Kokosi
- Interstitial Lung Disease Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
| | - Francesco Bonella
- Department of Pneumology, Centre for Interstitial and Rare Lung Disease, Ruhrlandklinik, University Hospital Essen, Essen, Germany
| |
Collapse
|
23
|
Misra S, Das PK, Bal SK, Elayat A, Sahoo S, Dahl AB, Kurian D, Raphael IJ, Youness HA. Therapeutic Whole Lung Lavage for Alveolar Proteinosis. J Cardiothorac Vasc Anesth 2019; 34:250-257. [PMID: 31399308 DOI: 10.1053/j.jvca.2019.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Satyajeet Misra
- Department of Anesthesiology, All India Institute of Medical Sciences, Bhubaneswar, India.
| | - Prasanta Kumar Das
- Department of Anesthesiology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Shakti Kumar Bal
- Pulmonary Medicine, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Anirudh Elayat
- Department of Anesthesiology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Satyajeet Sahoo
- Pulmonary Medicine, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Aaron B Dahl
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Dinesh Kurian
- Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, IL
| | - Ibrahim J Raphael
- Interventional Pulmonary Program, Section of Pulmonary, Critical Care, and Sleep, Oklahoma City VA Health Care System, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Houssein A Youness
- Interventional Pulmonary Program, Section of Pulmonary, Critical Care, and Sleep, Oklahoma City VA Health Care System, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| |
Collapse
|
24
|
Piloni D, Campo I. Current management strategies and the potential of inhaled GM-CSF for the treatment of autoimmune pulmonary alveolar proteinosis. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1589450] [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: 10/27/2022]
Affiliation(s)
- Davide Piloni
- Pneumology Unit, IRCCS Policlinico San Matteo Hospital Foundation, Pavia, Italy
| | - Ilaria Campo
- Pneumology Unit, IRCCS Policlinico San Matteo Hospital Foundation, Pavia, Italy
| |
Collapse
|
25
|
Boyce DSK, Lee JW, Shah P, Freeman JH, Aboudara MC, Hostler DC. Combined-modality therapy for pulmonary alveolar proteinosis in a remote setting: a case report. BMC Pulm Med 2019; 19:61. [PMID: 30866900 PMCID: PMC6417025 DOI: 10.1186/s12890-019-0822-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 02/25/2019] [Indexed: 01/15/2023] Open
Abstract
Background Pulmonary alveolar proteinosis (PAP) is a rare lung disease characterized by accumulation of phospholipoproteinaceous material in the alveoli. The presentation is nonspecific but typically includes dyspnea; the spectrum of disease includes rapidly progressive hypoxic respiratory failure. Whole lung lavage (WLL) is the treatment of choice in symptomatic PAP, but transient worsening of oxygenation sometimes requires salvage modalities of support such as extracorporeal membrane oxygenation (ECMO). Granulocyte macrophage colony-stimulating factor (GM-CSF) plays a role in the pathophysiology of PAP. We highlight a case of severe PAP treated with exogenous GM-CSF and sequential lobar lavage due to the unavailability of salvage methods of oxygenation. Case presentation A 36 year old female was admitted with fevers, chills, and progressive dyspnea. On presentation she was tachypneic, tachycardic, and hypoxemic; labs revealed leukocytosis and lactic acidosis. Chest CT identified diffuse ground glass opacities in a ‘crazy-paving’ pattern. Following intubation due to impending respiratory failure, bronchoscopy with bronchoalveolar lavage was performed. The lavage return stained positive with Periodic Acid Schiff, confirming the diagnosis of PAP. Continued deterioration necessitated treatment; however, at this geographically remote center without ECMO services WLL was judged to carry significant risk. Nebulized GM-CSF was administered without significant improvement. Subcutaneous GM-CSF was administered and isolated subsegmental lavages of the bilateral upper lobes were performed, with rapid improvement in oxygenation. Additional sequential lobar lavage and continued GM-CSF therapy as an outpatient resulted in complete resolution of oxygen requirement and return to normal pulmonary physiology. Conclusions The autoimmune form of PAP is the most common, indicating that therapy with GM-CSF may play an important role for many patients. Treatment with WLL may be impractical in some clinical settings due to the expertise and salvage modalities required. Sequential lobar lavage requires less specialized expertise and may incur less risk of refractory hypoxemia. We posit that this combined-modality therapy is ideally suited to geographically-remote centers such as our own.
Collapse
Affiliation(s)
- Dacia S K Boyce
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Rd, Tripler AMC, Hawaii, 96859, USA.
| | - John W Lee
- Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Phalgoon Shah
- Division of Pulmonary, Critical Care & Sleep Medicine, Case Western Reserve MetroHealth Medical Center, Cleveland, USA
| | - Judy H Freeman
- Department of Pathology & Laboratory Services, Tripler Army Medical Center, Tripler AMC, USA
| | - Matthew C Aboudara
- Division of Allergy, Pulmonary & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David C Hostler
- Department of Medicine, Tripler Army Medical Center, 1 Jarrett White Rd, Tripler AMC, Hawaii, 96859, USA
| |
Collapse
|
26
|
Trapnell BC, Nakata K, Bonella F, Campo I, Griese M, Hamilton J, Wang T, Morgan C, Cottin V, McCarthy C. Pulmonary alveolar proteinosis. Nat Rev Dis Primers 2019; 5:16. [PMID: 30846703 DOI: 10.1038/s41572-019-0066-3] [Citation(s) in RCA: 185] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Pulmonary alveolar proteinosis (PAP) is a syndrome characterized by the accumulation of alveolar surfactant and dysfunction of alveolar macrophages. PAP results in progressive dyspnoea of insidious onset, hypoxaemic respiratory failure, secondary infections and pulmonary fibrosis. PAP can be classified into different types on the basis of the pathogenetic mechanism: primary PAP is characterized by the disruption of granulocyte-macrophage colony-stimulating factor (GM-CSF) signalling and can be autoimmune (caused by elevated levels of GM-CSF autoantibodies) or hereditary (due to mutations in CSF2RA or CSF2RB, encoding GM-CSF receptor subunits); secondary PAP results from various underlying conditions; and congenital PAP is caused by mutations in genes involved in surfactant production. In most patients, pathogenesis is driven by reduced GM-CSF-dependent cholesterol clearance in alveolar macrophages, which impairs alveolar surfactant clearance. PAP has a prevalence of at least 7 cases per million individuals in large population studies and affects men, women and children of all ages, ethnicities and geographical locations irrespective of socioeconomic status, although it is more-prevalent in smokers. Autoimmune PAP accounts for >90% of all cases. Management aims at improving symptoms and quality of life; whole-lung lavage effectively removes excessive surfactant. Novel pathogenesis-based therapies are in development, targeting GM-CSF signalling, immune modulation and cholesterol homeostasis.
Collapse
Affiliation(s)
- Bruce C Trapnell
- Translational Pulmonary Science Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Koh Nakata
- Bioscience Medical Research Center, Niigata University, Niigata, Japan
| | - Francesco Bonella
- Interstitial and Rare Lung Disease Unit, Pneumology Department, Ruhrlandklinik University Hospital, University of Essen, Essen, Germany
| | - Ilaria Campo
- Pneumology Unit, IRCCS San Matteo Hospital Foundation, Pavia, Italy
| | - Matthias Griese
- Pediatric Pneumology, University of Munich, German Center for Lung Research (DZL), Munich, Germany
| | - John Hamilton
- University of Melbourne, Parkville, Victoria, Australia
| | - Tisha Wang
- Department of Medicine, University of California, Los Angeles, CA, USA
| | - Cliff Morgan
- Department of Critical Care and Anaesthesia, Royal Brompton Hospital, London, UK
| | - Vincent Cottin
- National Reference Center for Rare Pulmonary Diseases, University of Lyon, Lyon, France
| | - Cormac McCarthy
- Department of Medicine, St. Vincent's University Hospital and University College Dublin, Dublin, Ireland
| |
Collapse
|
27
|
D'Silva K, Brown S, Hunninghake GM, Vivero M, Loscalzo J. Gasping for a Diagnosis. N Engl J Med 2019; 380:961-967. [PMID: 30855747 PMCID: PMC7189901 DOI: 10.1056/nejmcps1809942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Kristin D'Silva
- From the Departments of Medicine (K.D., S.B., G.M.H., J.L.) and Pathology (M.V.), Brigham and Women's Hospital, Boston
| | - Sarah Brown
- From the Departments of Medicine (K.D., S.B., G.M.H., J.L.) and Pathology (M.V.), Brigham and Women's Hospital, Boston
| | - Gary M Hunninghake
- From the Departments of Medicine (K.D., S.B., G.M.H., J.L.) and Pathology (M.V.), Brigham and Women's Hospital, Boston
| | - Marina Vivero
- From the Departments of Medicine (K.D., S.B., G.M.H., J.L.) and Pathology (M.V.), Brigham and Women's Hospital, Boston
| | - Joseph Loscalzo
- From the Departments of Medicine (K.D., S.B., G.M.H., J.L.) and Pathology (M.V.), Brigham and Women's Hospital, Boston
| |
Collapse
|
28
|
Sheng G, Chen P, Wei Y, Chu J, Cao X, Zhang HL. Better approach for autoimmune pulmonary alveolar proteinosis treatment: inhaled or subcutaneous granulocyte-macrophage colony-stimulating factor: a meta-analyses. Respir Res 2018; 19:163. [PMID: 30165864 PMCID: PMC6117963 DOI: 10.1186/s12931-018-0862-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 08/14/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Autoimmune pulmonary alveolar proteinosis (aPAP) is a rare pulmonary disease caused by functional deficiency of granulocyte-macrophage colony-stimulating factor (GM-CSF). GM-CSF therapy in aPAP has been reported effective in some studies. This meta-analyses aimed to evaluate whether GM-CSF therapy, including inhaled and subcutaneous GM-CSF have therapeutic effect in aPAP patients. METHODS We analyzed 10 studies searched from PubMed, EmBase, Web of Science, Wiley Online Library and Cochrane Collaboration databases to evaluate the pooled effects of GM-CSF treatment in aPAP patients. RESULTS Ten observational studies involving 115 aPAP patients were included. The pooled analyses of response rate (81%, p < 0.001), relapse rate (22%, p = 0.009), PaO2 (13.76 mmHg, p < 0.001) and P(A-a)O2 (19.44 mmHg, p < 0.001) showed that GM-CSF treatment was effective on aPAP patients. Further analyses showed that inhaled GM-CSF treatment was more effective than subcutaneous GM-CSF therapy, including a higher response rate (89% vs. 71%, p = 0.023), more improvements in PaO2 (21.02 mmHg vs. 8.28 mmHg, p < 0.001) and P(A-a)O2 (19.63 mmHg vs. 9.15 mmHg, p < 0.001). CONCLUSIONS As two routes of exogenous GM-CSF treatment, inhaled and subcutaneous were both proven to have effect on aPAP patients. Furthermore, inhaled GM-CSF therapy showed a higher response rate, more improvements on PaO2 and P(A-a)O2 than subcutaneous GM-CSF treatment in aPAP patients, suggesting inhaled GM-CSF therapy could have more benefits on aPAP patients. Therefore, GM-CSF therapy, especially inhaled GM-CSF, might be a promising therapeutic option in treating aPAP.
Collapse
Affiliation(s)
- Gaohong Sheng
- Department of Respiratory and Critical Care Medicine, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, No.1095, Jie Fang Road, Han Kou District, Wu Han, 430030, Hu Bei Province, China
| | - Peng Chen
- Division of Cardiology, Departments of Internal Medicine and Genetic Diagnosis Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wu Han, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiological Disorders, Wuhan, 430030, China
| | - Yanqiu Wei
- Department of Respiratory and Critical Care Medicine, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, No.1095, Jie Fang Road, Han Kou District, Wu Han, 430030, Hu Bei Province, China
| | - Jiaojiao Chu
- Department of Respiratory and Critical Care Medicine, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, No.1095, Jie Fang Road, Han Kou District, Wu Han, 430030, Hu Bei Province, China
| | - Xiaolei Cao
- Division of Respiratory and Critical Care Medicine, the Second Hospital of Huangshi, Huangshi, 435000, China
| | - Hui-Lan Zhang
- Department of Respiratory and Critical Care Medicine, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, No.1095, Jie Fang Road, Han Kou District, Wu Han, 430030, Hu Bei Province, China.
| |
Collapse
|
29
|
Dhagat U, Hercus TR, Broughton SE, Nero TL, Cheung Tung Shing KS, Barry EF, Thomson CA, Bryson S, Pai EF, McClure BJ, Schrader JW, Lopez AF, Parker MW. The mechanism of GM-CSF inhibition by human GM-CSF auto-antibodies suggests novel therapeutic opportunities. MAbs 2018; 10:1018-1029. [PMID: 29969365 DOI: 10.1080/19420862.2018.1494107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a hematopoietic growth factor that can stimulate a variety of cells, but its overexpression leads to excessive production and activation of granulocytes and macrophages with many pathogenic effects. This cytokine is a therapeutic target in inflammatory diseases, and several anti-GM-CSF antibodies have advanced to Phase 2 clinical trials in patients with such diseases, e.g., rheumatoid arthritis. GM-CSF is also an essential factor in preventing pulmonary alveolar proteinosis (PAP), a disease associated with GM-CSF malfunction arising most typically through the presence of GM-CSF neutralizing auto-antibodies. Understanding the mechanism of action for neutralizing antibodies that target GM-CSF is important for improving their specificity and affinity as therapeutics and, conversely, in devising strategies to reduce the effects of GM-CSF auto-antibodies in PAP. We have solved the crystal structures of human GM-CSF bound to antigen-binding fragments of two neutralizing antibodies, the human auto-antibody F1 and the mouse monoclonal antibody 4D4. Coordinates and structure factors of the crystal structures of the GM-CSF:F1 Fab and the GM-CSF:4D4 Fab complexes have been deposited in the RCSB Protein Data Bank under the accession numbers 6BFQ and 6BFS, respectively. The structures show that these antibodies bind to mutually exclusive epitopes on GM-CSF; however, both prevent the cytokine from interacting with its alpha receptor subunit and hence prevent receptor activation. Importantly, identification of the F1 epitope together with functional analyses highlighted modifications to GM-CSF that would abolish auto-antibody recognition whilst retaining GM-CSF function. These results provide a framework for developing novel GM-CSF molecules for PAP treatment and for optimizing current anti-GM-CSF antibodies for use in treating inflammatory disorders.
Collapse
Affiliation(s)
- Urmi Dhagat
- a St. Vincent's Institute of Medical Research , Australian Cancer Research Foundation Rational Drug Discovery Centre , Fitzroy , Victoria , Australia.,c Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute , University of Melbourne , Parkville , Victoria , Australia
| | - Timothy R Hercus
- b The Centre for Cancer Biology , SA Pathology and the University of South Australia , Adelaide , South Australia , Australia
| | - Sophie E Broughton
- a St. Vincent's Institute of Medical Research , Australian Cancer Research Foundation Rational Drug Discovery Centre , Fitzroy , Victoria , Australia.,c Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute , University of Melbourne , Parkville , Victoria , Australia
| | - Tracy L Nero
- a St. Vincent's Institute of Medical Research , Australian Cancer Research Foundation Rational Drug Discovery Centre , Fitzroy , Victoria , Australia.,c Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute , University of Melbourne , Parkville , Victoria , Australia
| | - Karen S Cheung Tung Shing
- a St. Vincent's Institute of Medical Research , Australian Cancer Research Foundation Rational Drug Discovery Centre , Fitzroy , Victoria , Australia.,c Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute , University of Melbourne , Parkville , Victoria , Australia
| | - Emma F Barry
- b The Centre for Cancer Biology , SA Pathology and the University of South Australia , Adelaide , South Australia , Australia
| | - Christy A Thomson
- d The Biomedical Research Centre , University of British Columbia , Vancouver , British Columbia , Canada
| | - Steve Bryson
- e Princess Margaret Cancer Centre, University Health Network, University of Toronto , Toronto , Ontario , Canada.,f Department of Biochemistry , University of Toronto , Toronto , Ontario , Canada
| | - Emil F Pai
- e Princess Margaret Cancer Centre, University Health Network, University of Toronto , Toronto , Ontario , Canada.,f Department of Biochemistry , University of Toronto , Toronto , Ontario , Canada.,g Department of Medical Biophysics , University of Toronto , Toronto , Ontario , Canada.,h Department of Molecular Genetics , University of Toronto , Toronto , Ontario , Canada
| | - Barbara J McClure
- b The Centre for Cancer Biology , SA Pathology and the University of South Australia , Adelaide , South Australia , Australia
| | - John W Schrader
- d The Biomedical Research Centre , University of British Columbia , Vancouver , British Columbia , Canada.,g Department of Medical Biophysics , University of Toronto , Toronto , Ontario , Canada
| | - Angel F Lopez
- b The Centre for Cancer Biology , SA Pathology and the University of South Australia , Adelaide , South Australia , Australia.,i Department of Medicine , University of Adelaide , Adelaide , South Australia , Australia
| | - Michael W Parker
- a St. Vincent's Institute of Medical Research , Australian Cancer Research Foundation Rational Drug Discovery Centre , Fitzroy , Victoria , Australia.,c Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute , University of Melbourne , Parkville , Victoria , Australia
| |
Collapse
|
30
|
Gajewska ME, Sritharan SS, Santoni-Rugiu E, Bendstrup EM. Autoimmune pulmonary alveolar proteinosis in an adolescent successfully treated with inhaled rhGM-CSF (molgramostim). Respir Med Case Rep 2018; 23:167-169. [PMID: 29719809 PMCID: PMC5925949 DOI: 10.1016/j.rmcr.2018.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/21/2018] [Accepted: 02/22/2018] [Indexed: 11/12/2022] Open
Abstract
Autoimmune pulmonary alveolar proteinosis (aPAP) is a rare parenchymal lung disease characterized by accumulation of surfactant in the airways with high levels of granulocyte-macrophage colony stimulating factor (GM-CSF) antibodies in blood. Disease leads to hypoxemic respiratory failure. Whole lung lavage (WLL) is considered the first line therapy, but procedure can be quite demanding, specifically for children. Recently alternative treatment options with inhaled GM-CSF have been described but no consensus about the standard treatment exists. We here describe a unique case of a 14-year-old patient who was successfully treated with WLL and subsequent inhalations with molgramostim – new recombinant human GM-CSF (rhGM-CSF).
Collapse
Affiliation(s)
- Marta E Gajewska
- Department of Respiratory Diseases and Allergology, Aarhus University Hospital, Denmark
| | - Sajitha S Sritharan
- Department of Respiratory Diseases and Allergology, Aarhus University Hospital, Denmark
| | | | - Elisabeth M Bendstrup
- Department of Respiratory Diseases and Allergology, Aarhus University Hospital, Denmark
| |
Collapse
|
31
|
Kumar A, Abdelmalak B, Inoue Y, Culver DA. Pulmonary alveolar proteinosis in adults: pathophysiology and clinical approach. THE LANCET RESPIRATORY MEDICINE 2018; 6:554-565. [PMID: 29397349 DOI: 10.1016/s2213-2600(18)30043-2] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/16/2017] [Accepted: 11/23/2017] [Indexed: 12/24/2022]
Abstract
Pulmonary alveolar proteinosis (PAP) is a diffuse lung disease that results from the accumulation of lipoproteinaceous material in the alveoli and alveolar macrophages due to abnormal surfactant homoeostasis. Identification of the granulocyte-macrophage colony-stimulating factor (GM-CSF) as an indispensable mediator of macrophage maturation and surfactant catabolism was the key discovery leading to the current understanding of the pathogenesis of most forms of PAP. Impaired GM-CSF bioavailability due to anti-GM-CSF autoimmunity is the cause of approximately 90% of adult PAP cases. Abnormal macrophage function due to endogenous or exogenous triggers, GM-CSF receptor defects, and other genetic abnormalities of surfactant production account for the remainder of causes. The usual physiological consequence of PAP is impairment of gas exchange, which can lead to dyspnoea, hypoxaemia, or even respiratory failure and death. Pulmonary fibrosis occurs occasionally in patients with PAP. For patients with moderate to severe disease, whole lung lavage is still the first-line treatment of choice. Supplemental GM-CSF is also useful, but details about indications, choice of agent, and dosing remain unclear. Other therapies, including rituximab, plasmapheresis, and lung transplantation have been described but should be reserved for refractory cases.
Collapse
Affiliation(s)
- Anupam Kumar
- Division of Pulmonary & Critical Care Medicine, Spectrum Health-Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
| | - Basem Abdelmalak
- Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland, OH, USA
| | - Yoshikazu Inoue
- Clinical Research Center, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Osaka, Japan
| | - Daniel A Culver
- Department of Pulmonary Medicine, Respiratory Institute, and Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
32
|
Kaner RJ, Brown KK, Martinez FJ. AJRCCM: 100-Year Anniversary. Progress in Interstitial Lung Disease. Am J Respir Crit Care Med 2017; 195:1104-1107. [PMID: 28459330 DOI: 10.1164/rccm.201703-0584ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Robert J Kaner
- 1 Joan and Sanford I. Weill Department of Medicine Weill Cornell Medicine New York, New York.,2 Department of Genetic Medicine Weill Cornell Medicine New York, New York and
| | - Kevin K Brown
- 3 Department of Medicine National Jewish Health Denver, Colordao
| | - Fernando J Martinez
- 1 Joan and Sanford I. Weill Department of Medicine Weill Cornell Medicine New York, New York
| |
Collapse
|
33
|
A Semiquantitative Computed Tomographic Grading System for Evaluating Therapeutic Response in Pulmonary Alveolar Proteinosis. Ann Am Thorac Soc 2017; 14:1403-1411. [DOI: 10.1513/annalsats.201607-574oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
|
34
|
Campo I, Mariani F, Paracchini E, Piloni D, Kadija Z, Salvaterra E. Inhaled GM-CSF in a Pulmonary Alveolar Proteinosis Patient Refractory to Plasmapheresis Combined with Multiple Whole Lung Lavages. ACTA ACUST UNITED AC 2017. [DOI: 10.17352/aprc.000018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
35
|
Gay P, Wallaert B, Nowak S, Yserbyt J, Anevlavis S, Hermant C, Lovis A, Menard O, Maitre B, Vandemoortele T, Dutau H, Briault A, Bourdin A, Vergnon JM, Froudarakis ME. Efficacy of Whole-Lung Lavage in Pulmonary Alveolar Proteinosis: A Multicenter International Study of GELF. Respiration 2017; 93:198-206. [DOI: 10.1159/000455179] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 12/16/2016] [Indexed: 11/19/2022] Open
|
36
|
Kobayashi T, Arai T, Hirose M, Homma T, Matsumuro A, Sugimoto C, Kitaichi M, Akira M, Inoue Y. Temporary remission of autoimmune pulmonary alveolar proteinosis after infectious episodes. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2017; 34:85-90. [PMID: 32476827 DOI: 10.36141/svdld.v34i1.5086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 01/25/2017] [Indexed: 11/02/2022]
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare disease of unknown aetiology. Although resolution occurs in about 30% of autoimmune PAP (APAP) cases, its pathogenesis is not yet sufficiently understood. Two APAP cases at our institute showed remission following infectious episodes. Case 1: a 40-year-old female APAP patient suffered from herpes encephalitis and was treated with an antiviral drug. Her symptoms and radiological results resolved within two months of her recovery from the encephalitis. Case 2: A 53-year-old male current-smoker APAP patient was admitted for pneumonia. After treatment with antibiotics, his radiological results and symptoms improved. He experienced a similar resolution of APAP after another infectious episode two years later. Remission of APAP may occur following viral or bacterial infection. We hypothesise that remission of APAP is triggered by the induction of granulocyte-macrophage colony-stimulating factor (GM-CSF) following viral or bacterial infection. Further studies of APAP remission, and especially of the effects of GM-CSF induction, are needed. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 85-90).
Collapse
Affiliation(s)
| | | | | | | | | | | | - Masanori Kitaichi
- Department of Pathology.,Department of Pathology, National Hospital Organization Minami Wakayama Medical Center, Tanabe City, Wakayama, Japan
| | - Masanori Akira
- Department of Radiology, National Hospital Organization, Kinki-Chuo Chest Medical Center, Sakai City, Osaka, Japan
| | | |
Collapse
|
37
|
Zhao YY, Huang H, Liu YZ, Song XY, Li S, Xu ZJ. Whole Lung Lavage Treatment of Chinese Patients with Autoimmune Pulmonary Alveolar Proteinosis: A Retrospective Long-term Follow-up Study. Chin Med J (Engl) 2016; 128:2714-9. [PMID: 26481735 PMCID: PMC4736873 DOI: 10.4103/0366-6999.167295] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Pulmonary alveolar proteinosis (PAP) is a rare lung disease, the most common type of which is autoimmune PAP. The gold standard therapy for PAP is whole lung lavage (WLL). Few studies have reported the optimal technique with which to evaluate the response to WLL. In this study, we aimed to identify parameters with which to assess the need for repeat WLL during a long-term 8-year follow-up. METHODS We conducted a retrospective analysis of 120 patients with autoimmune PAP with 80 of whom underwent WLL. Physiologic, serologic, and radiologic features of the patients were analyzed during an 8-year follow-up after the first WLL treatment. RESULTS Of the 40 patients without any intervention, 39 patients either achieved remission or remained stable and only one died of pulmonary infection. Of the 56 patients who underwent WLL for 1 time, 55 remained free from a second WLL and 1 patient died of cancer. Twenty-four required additional treatments after their first WLL. The baseline PaO 2 (P = 0.000), PA-aO 2 (P = 0.000), shunt fraction rate (P = 0.001), percent of predicted normal diffusing capacity of the lung for carbon monoxide (DLCO%Pred) (P = 0.016), 6-min walk test (P = 0.013), carcinoembryonic antigen (CEA) (P = 0.007), and neuron-specific enolase (NSE) (P = 0.003) showed significant differences among the three groups. The need for a second WLL was significantly associated with PaO 2 (P = 0.000), CEA (P = 0.050) , the 6-minute walk test (P = 0.026), and DLCO%Pred (P = 0.041). The DLCO%Pred on admission with a cut-off value of 42.1% (P = 0.001) may help to distinguish whether patients with PAP require a second WLL. CONCLUSIONS WLL is the optimal treatment method for PAP and provides remarkable improvements for affected patients. The DLCO%Pred on admission with a cut-off value of 42.1% may distinguish whether patients with PAP require a second WLL.
Collapse
Affiliation(s)
| | | | | | | | | | - Zuo-Jun Xu
- Department of Respiratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| |
Collapse
|
38
|
Alvarado A, Arce I. Metabolic Functions of the Lung, Disorders and Associated Pathologies. J Clin Med Res 2016; 8:689-700. [PMID: 27635172 PMCID: PMC5012236 DOI: 10.14740/jocmr2668w] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 01/04/2023] Open
Abstract
The primary function of the lungs is gas exchange. Approximately 400 million years ago, the Earth's atmosphere gained enough oxygen in the gas phase for the animals that emerged from the sea to breathe air. The first lungs were merely primitive air sacs with a few vessels in the walls that served as accessory organs of gas exchange to supplement the gills. Eons later, as animals grew accustomed to a solely terrestrial life, the lungs became highly compartmentalized to provide the vast air-blood surface necessary for O2 uptake and CO2 elimination, and a respiratory control system was developed to regulate breathing in accordance with metabolic demands and other needs. With the evolution and phylogenetic development, lungs were taking a variety of other specialized functions to maintain homeostasis, which we will call the non-respiratory functions of the lung and that often, and by mistake, are believed to have little or no connection with the replacement gas. In this review, we focus on the metabolic functions of the lung, perhaps the least known, and mainly, in the lipid metabolism and blood-adult lung vascular endothelium interaction. When these functions are altered, respiratory disorders or diseases appear, which are discussed concisely, emphasizing how they impact the most important function of the lungs: external respiration.
Collapse
Affiliation(s)
- Alcibey Alvarado
- Internal Medicine and Neumology, Clinica de Diagnostico Medico, San Jose, Costa Rica
| | - Isabel Arce
- Medicine and General Surgery, Medicine School, University of Costa Rica, San Jose, Costa Rica
| |
Collapse
|
39
|
The Clinical Clues of Pulmonary Alveolar Proteinosis: A Report of 11 Cases and Literature Review. Can Respir J 2016; 2016:4021928. [PMID: 27445535 PMCID: PMC4904541 DOI: 10.1155/2016/4021928] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/16/2016] [Accepted: 04/06/2016] [Indexed: 01/15/2023] Open
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare interstitial lung disease characterized by the abnormal alveolar accumulation of surfactant components. The diagnosis of PAP can be easily missed since it is rare and lacks specific clinical symptoms. It is of great importance to have a better understanding of the crucial clue to clinically diagnose PAP and take PAP into consideration in the differential diagnosis of interstitial pulmonary diseases or other diseases with similar manifestations. Here, we analyze the clinical characteristics of 11 cases of PAP patients in local hospital and review the relevant literature in order to provide more information in diagnosis and management of PAP. In our observation, cyfra21-1 and neuron-specific enolase (NSE) known as tumor markers probably can be useful serum markers for diagnosis of PAP. As for the method of pathologic diagnosis, open-lung biopsy was the gold standard but now it is less required because findings on examination of bronchoalveolar lavage fluid (BALF) can help to make the diagnosis. We also have deep experience about when and how to carry out lung lavage.
Collapse
|
40
|
Anticytokine Autoantibodies: Association with Infection and Immune Dysregulation. Antibodies (Basel) 2016; 5:antib5010003. [PMID: 31557985 PMCID: PMC6698860 DOI: 10.3390/antib5010003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 12/15/2015] [Accepted: 01/05/2016] [Indexed: 12/14/2022] Open
Abstract
The association of autoantibodies to cytokines with immune deficiency, autoimmunity and/or immune dysregulation is increasingly being recognized. For example, autoantibodies to interferon gamma have been found to be associated with chronic, treatment refractory infections with intracellular organisms such as mycobacteria, autoantibodies to interleukin 17 with chronic mucocutaneous candidiasis, and anti-interferon alpha autoantibodies with systemic lupus erythematosus. While low titer autoantibodies to these and other cytokines may be detected in normal individuals, patients with infectious or autoimmune manifestations tend to have high titer autoantibodies that may block or potentiate the function of the respective cytokine. Recognition of these autoantibodies is important because it may direct treatment toward a combination of adjunctive immunotherapy to modulate the autoantibody level while continuing with appropriate anti-microbial therapy. This review focuses on the anti-cytokine autoantibodies documented to date, their autoimmune, immune dysregulation and infectious disease associations, methods for detection of these antibodies and potential treatment options.
Collapse
|
41
|
Tazawa R, Nakata K. Pulmonary alveolar proteinosis and granulocyte/macrophage-colony stimulating factor (GM-CSF) inhalation. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2016.1123150] [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: 11/05/2022]
|
42
|
Kwon-Chung KJ, Saijo T. Is Cryptococcus gattii a Primary Pathogen? J Fungi (Basel) 2015; 1:154-167. [PMID: 27795955 PMCID: PMC5084617 DOI: 10.3390/jof1020154] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 07/09/2015] [Indexed: 01/01/2023] Open
Abstract
The two etiologic agents of cryptococcal meningoencephalitis, Cryptococcus neoformans and C. gattii, have been commonly designated as either an opportunistic pathogen for the first species or as a primary pathogen for the second species. Such a distinction has been based on epidemiological findings that the majority of patients presenting meningoencephalitis caused by C. neoformans are immunocompromised while C. gattii infection has been reported more often in immunocompetent patients. A recent report, however, showed that GM-CSF (granulocyte-macrophage colony-stimulating factor) neutralizing antibodies were prevalent in the plasma of "apparently immunocompetent" C. gattii patients with meningoencephalitis. Because GM-CSF is essential for differentiation of monocytes to macrophages and modulating the immune response, it is not surprising that the lack of GM-CSF function predisposes otherwise healthy individuals to infection via inhalation of environmental pathogens such as C. gattii. Since the test for anti-GM-CSF autoantibodies is not included in routine immunological profiling at most hospitals, healthy patients with GM-CSF neutralizing antibodies are usually categorized as immunocompetent. It is likely that a comprehensive immunological evaluation of patients with C. gattii meningoencephalitis, who had been diagnosed as immunocompetent, would reveal a majority of them had hidden immune dysfunction. This paper reviews the relationship between GM-CSF neutralizing antibodies and the risk for C. gattii infection with CNS involvement.
Collapse
Affiliation(s)
- Kyung J. Kwon-Chung
- Molecular Microbiology Section, Laboratory of Clinical Infectious Diseases, National Institutes of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892, USA
| | - Tomomi Saijo
- Second Department of Internal Medicine, Nagasaki University Hospital, Sakamoto 1-7-1, Nagasaki-city, 851-8501, Japan; E-Mail:
| |
Collapse
|
43
|
Zhou WW, Guan YY, Liu XM. Pulmonary alveolar proteinosis and clear cell renal cell carcinoma. CLINICAL RESPIRATORY JOURNAL 2015; 11:400-402. [PMID: 26148820 DOI: 10.1111/crj.12347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Wei-Wei Zhou
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| | - You-Yan Guan
- Department of Urology, Cancer Institute & Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - Xin-Min Liu
- Department of Geriatrics, Peking University First Hospital, Beijing, China
| |
Collapse
|
44
|
Bhattacharya P, Thiruppathi M, Elshabrawy HA, Alharshawi K, Kumar P, Prabhakar BS. GM-CSF: An immune modulatory cytokine that can suppress autoimmunity. Cytokine 2015; 75:261-71. [PMID: 26113402 DOI: 10.1016/j.cyto.2015.05.030] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/22/2015] [Accepted: 05/25/2015] [Indexed: 12/12/2022]
Abstract
GM-CSF was originally identified as a colony stimulating factor (CSF) because of its ability to induce granulocyte and macrophage populations from precursor cells. Multiple studies have demonstrated that GM-CSF is also an immune-modulatory cytokine, capable of affecting not only the phenotype of myeloid lineage cells, but also T-cell activation through various myeloid intermediaries. This property has been implicated in the sustenance of several autoimmune diseases like arthritis and multiple sclerosis. In contrast, several studies using animal models have shown that GM-CSF is also capable of suppressing many autoimmune diseases such as Crohn's disease, Type-1 diabetes, Myasthenia gravis and experimental autoimmune thyroiditis. Knockout mouse studies have suggested that the role of GM-CSF in maintaining granulocyte and macrophage populations in the physiological steady state is largely redundant. Instead, its immune-modulatory role plays a significant role in the development or resolution of autoimmune diseases. This is mediated either through the differentiation of precursor cells into specialized non-steady state granulocytes, macrophages and dendritic cells, or through the modulation of the phenotype of mature myeloid cells. Thus, outside of myelopoiesis, GM-CSF has a profound role in regulating the immune response and maintaining immunological tolerance.
Collapse
Affiliation(s)
- Palash Bhattacharya
- Department of Microbiology and Immunology, University of Illinois College of Medicine, Chicago, IL 60612, USA
| | - Muthusamy Thiruppathi
- Department of Microbiology and Immunology, University of Illinois College of Medicine, Chicago, IL 60612, USA
| | - Hatem A Elshabrawy
- Department of Microbiology and Immunology, University of Illinois College of Medicine, Chicago, IL 60612, USA
| | - Khaled Alharshawi
- Department of Microbiology and Immunology, University of Illinois College of Medicine, Chicago, IL 60612, USA
| | - Prabhakaran Kumar
- Department of Microbiology and Immunology, University of Illinois College of Medicine, Chicago, IL 60612, USA
| | - Bellur S Prabhakar
- Department of Microbiology and Immunology, University of Illinois College of Medicine, Chicago, IL 60612, USA.
| |
Collapse
|
45
|
Rodríguez Portal JA. Treatment of Adult Primary Alveolar Proteinosis. Arch Bronconeumol 2015; 51:344-9. [PMID: 25896950 DOI: 10.1016/j.arbres.2015.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Revised: 01/25/2015] [Accepted: 02/09/2015] [Indexed: 12/15/2022]
Abstract
Pulmonary alveolar proteinosis (PAP) is a rare disease characterized by the accumulation of surfactant-like lipoproteinaceous material in the distal air spaces and terminal bronchi, which may lead to impaired gas exchange. This accumulation of surfactant is due to decreased clearance by the alveolar macrophages. Its primary, most common form, is currently considered an autoimmune disease. Better knowledge of the causes of PAP have led to the emergence of alternatives to whole lung lavage, although this is still considered the treatment of choice. Most studies are case series, often with limited patient numbers, so the level of evidence is low. Since the severity of presentation and clinical course are variable, not all patients will require treatment. Due to the low level of evidence, some objective criteria based on expert opinion have been arbitrarily proposed in an attempt to define in which patients it is best to initiate treatment.
Collapse
Affiliation(s)
- José Antonio Rodríguez Portal
- UMQER Centro de investigación en red de enfermedades respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Hospital Universitario Virgen del Rocío/Virgen Macarena, Instituto de Biomedicina de Sevilla (IBIS)/CSIC/Universidad de Sevilla, Sevilla, España.
| |
Collapse
|
46
|
Papiris SA, Tsirigotis P, Kolilekas L, Papadaki G, Papaioannou AI, Triantafillidou C, Papaporfyriou A, Karakatsani A, Kagouridis K, Griese M, Manali ED. Pulmonary alveolar proteinosis: time to shift? Expert Rev Respir Med 2015; 9:337-49. [DOI: 10.1586/17476348.2015.1035259] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
|
47
|
Kyung Y, Kim J, Kim HK, Han J, Ahn K. Pulmonary alveolar proteinosis in a 15-year-old girl. ALLERGY ASTHMA & RESPIRATORY DISEASE 2015. [DOI: 10.4168/aard.2015.3.1.86] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Yechan Kyung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jihyun Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Kwan Kim
- Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joungho Han
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kangmo Ahn
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
48
|
Potential association between membranous nephropathy and sargramostim therapy for pulmonary alveolar proteinosis. Clin Nephrol Case Stud 2014; 3:31-36. [PMID: 29043131 PMCID: PMC5437997 DOI: 10.5414/cncs108420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 10/21/2014] [Indexed: 11/18/2022] Open
Abstract
We present the case of a 43-year-old woman with a diagnosis of pulmonary alveolar proteinosis, on chronic treatment with sargramostim, a recombinant granulocyte-macrophage colony-stimulating factor, who presented with the nephrotic syndrome secondary to biopsy-proven membranous nephropathy. We discuss potential underlying mechanisms, including speculated effects of sargramostim on mesangial cells and the kidney resident macrophages, and review the existing literature on the potential association between these two disorders.
Collapse
|
49
|
Jouneau S, Kerjouan M, Briens E, Lenormand JP, Meunier C, Letheulle J, Chiforeanu D, Lainé-Caroff C, Desrues B, Delaval P. La protéinose alvéolaire pulmonaire. Rev Mal Respir 2014; 31:975-91. [DOI: 10.1016/j.rmr.2014.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 08/20/2014] [Indexed: 01/30/2023]
|
50
|
Secondary pulmonary alveolar proteinosis in hematologic malignancies. Hematol Oncol Stem Cell Ther 2014; 7:127-35. [PMID: 25300566 DOI: 10.1016/j.hemonc.2014.09.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 07/30/2014] [Accepted: 09/01/2014] [Indexed: 12/14/2022] Open
Abstract
Pulmonary alveolar proteinosis (PAP), characterized by deposition of intra-alveolar PAS positive protein and lipid rich material, is a rare cause of progressive respiratory failure first described by Rosen et al. in 1958. The intra-alveolar lipoproteinaceous material was subsequently proven to have been derived from pulmonary surfactant in 1980 by Singh et al. Levinson et al. also reported in 1958 the case of 19-year-old female with panmyelosis afflicted with a diffuse pulmonary disease characterized by filling of the alveoli with amorphous material described as "intra-alveolar coagulum". This is probably the first reported case of PAP in relation to hematologic malignancy. Much progress has been made on PAP first described by Rosen which is currently classified as idiopathic or primary or autoimmune PAP. Idiopathic PAP occurs as a result of auto-antibodies directed against granulocyte-macrophage colony stimulating factor (GM-CSF) impeding the surfactant clearing function of alveolar macrophages leading to progressive respiratory failure. Whole lung lavage and GM-CSF therapy has improved outcomes in patients with idiopathic PAP. Despite major advancement in the management of hematologic malignancy and its complications, little is known about the type of PAP first described by Levinson and now known as secondary PAP; a term also used when PAP occurs due to other causes such as occupational dusts. In this article we review and analyze the limited literature available in secondary PAP due to hematologic malignancies and present a case of PAP associated with chronic lymphocytic leukemia successfully treated with bendamustine and rituximab.
Collapse
|