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Amoakon JP, Mylavarapu G, Amin RS, Naren AP. Pulmonary Vascular Dysfunctions in Cystic Fibrosis. Physiology (Bethesda) 2024; 39:0. [PMID: 38501963 DOI: 10.1152/physiol.00024.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/26/2024] [Accepted: 03/14/2024] [Indexed: 03/20/2024] Open
Abstract
Cystic fibrosis (CF) is an inherited disorder caused by a deleterious mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Given that the CFTR protein is a chloride channel expressed on a variety of cells throughout the human body, mutations in this gene impact several organs, particularly the lungs. For this very reason, research regarding CF disease and CFTR function has historically focused on the lung airway epithelium. Nevertheless, it was discovered more than two decades ago that CFTR is also expressed and functional on endothelial cells. Despite the great strides that have been made in understanding the role of CFTR in the airway epithelium, the role of CFTR in the endothelium remains unclear. Considering that the airway epithelium and endothelium work in tandem to allow gas exchange, it becomes very crucial to understand how a defective CFTR protein can impact the pulmonary vasculature and overall lung function. Fortunately, more recent research has been dedicated to elucidating the role of CFTR in the endothelium. As a result, several vascular dysfunctions associated with CF disease have come to light. Here, we summarize the current knowledge on pulmonary vascular dysfunctions in CF and discuss applicable therapies.
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Affiliation(s)
- Jean-Pierre Amoakon
- Department of Systems Biology and Physiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Division of Pulmonary Medicine and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Goutham Mylavarapu
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Raouf S Amin
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Anjaparavanda P Naren
- Department of Systems Biology and Physiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Division of Pulmonary Medicine and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, United States
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
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Ticona JH, Lapinel N, Wang J. Future Comorbidities in an Aging Cystic Fibrosis Population. Life (Basel) 2023; 13:1305. [PMID: 37374088 DOI: 10.3390/life13061305] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/27/2023] [Accepted: 05/28/2023] [Indexed: 06/29/2023] Open
Abstract
Cystic fibrosis (CF) is an autosomal recessive disease due to mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. With the advent of highly effective modulator therapy targeting the abnormal CFTR protein, people with CF (PwCF) are living more than 40 years longer than the pre-modulator therapy era. As a result, PwCF are facing new challenges of managing similar comorbidities affecting the average aging population. While CF is notoriously identified as a chronic respiratory disease, the multisystem presence of the CFTR gene can contribute to other organ-related complications acutely, but also heighten the likelihood of chronic conditions not routinely encountered in this cohort. In this overview, we will focus on risk factors and epidemiology for PwCF as they relate to cardiovascular disease, dyslipidemia, CF-related diabetes, pulmonary hypertension, obstructive sleep apnea, CF-liver disease, bone health and malignancy. With increased awareness of diseases affecting a newly aging CF population, a focus on primary and secondary prevention will be imperative to implementing a comprehensive care plan to improve long-term morbidity and mortality.
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Affiliation(s)
- Javier Humberto Ticona
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Nicole Lapinel
- Division of Pulmonary, Critical Care and Sleep Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY 11042, USA
| | - Janice Wang
- Division of Pulmonary, Critical Care and Sleep Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY 11042, USA
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Mannem H, Aversa M, Keller T, Kapnadak SG. The Lung Transplant Candidate, Indications, Timing, and Selection Criteria. Clin Chest Med 2023; 44:15-33. [PMID: 36774161 DOI: 10.1016/j.ccm.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Lung transplantation can be lifesaving for patients with advanced lung disease. Demographics are evolving with recipients now sicker but determining candidacy remains predicated on one's underlying lung disease prognosis, along with the likelihood of posttransplant success. Determining optimal timing can be challenging, and most programs favor initiating the process early and proactively to allow time for patient education, informed decision-making, and preparation. A comprehensive, multidisciplinary evaluation is used to elucidate disease progrnosis and identify risk factors for poor posttransplant outcomes. Candidacy criteria vary significantly by center, and close communication between referring and transplant providers is necessary to improve access to transplant and outcomes.
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Affiliation(s)
- Hannah Mannem
- Division of Pulmonary and Critical Care Medicine, University of Virginia School of Medicine, PO Box 800546, Clinical Department Wing, 1 Hospital Drive, Charlottesville, VA 22908, USA
| | - Meghan Aversa
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, C. David Naylor Building, 6 Queen's Park Crescent West, Third Floor, Toronto, ON M5S 3H2, Canada
| | - Thomas Keller
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Campus Box 356522, Seattle, WA 98195, USA
| | - Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Campus Box 356522, Seattle, WA 98195, USA.
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Ramos KJ, Hee Wai T, Stephenson AL, Sykes J, Stanojevic S, Rodriguez PJ, Bansal A, Mayer-Hamblett N, Goss CH, Kapnadak SG. Development and Internal Validation of a Prognostic Model of the Probability of Death or Lung Transplantation Within 2 Years for Patients With Cystic Fibrosis and FEV 1 ≤ 50% Predicted. Chest 2022; 162:757-767. [PMID: 35643116 PMCID: PMC9633811 DOI: 10.1016/j.chest.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 04/19/2022] [Accepted: 05/13/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Improved methods are needed to risk-stratify patients with cystic fibrosis (CF) and reduced FEV1. RESEARCH QUESTIONS What are the predictors of death or lung transplantation (LTx) within 2 years among patients with CF whose FEV1 ≤ 50% predicted? Do these markers similarly predict outcomes among G551D patients taking ivacaftor since 2012? STUDY DESIGN AND METHODS Patients with CF, age ≥ 6 years with FEV1 ≤ 50% predicted as of December 31, 2014, were identified in a data set that merged Cystic Fibrosis Foundation and United Network for Organ Sharing (UNOS) registries. The least absolute shrinkage and selection operator (LASSO) method was applied to a randomly selected training set to select important prognostic variables. Accuracy and association of the model with death or LTx with 2 years (2-year death or LTx) were validated via logistic regression on an independent test set. Sensitivity analyses explored predictors for patients with UNOS data. RESULTS FEV1 percent predicted (OR, 1.51 for 5% decrease; 95% CI, 1.27-1.81), number of pulmonary exacerbations treated with IV antibiotics (OR, 1.35; 95% CI, 1.11-1.65), and continuous or nocturnal oxygen (OR, 3.71; 95% CI, 1.81-7.59) were significantly associated with 2-year death or LTx. Our model predicted outcomes with greater sensitivity (ratio of sensitivity, 1.26; 95% CI, 1.02-1.54), ratio of positive predictive value (1.25; 95% CI, 1.05-1.51), and ratio of negative predictive value (1.04; 95% CI, 1.01-1.07) than FEV1 < 30% predicted. Among those taking ivacaftor in 2014, only FEV1 remained associated with 2-year death or LTx. For patients with UNOS data, LASSO identified additional covariates of interest, including noninvasive ventilation use, low hemoglobin, pulmonary arterial systolic pressure, supplemental oxygen, mechanical ventilation, FEV1 percent predicted, and cardiac index. INTERPRETATION Among individuals with CF and FEV1 ≤ 50% predicted, FEV1 percent predicted, oxygen therapy, and number of pulmonary exacerbations predicted 2-year death or LTx. Although limited by small sample size, only FEV1 remained predictive in patients receiving highly effective modulator therapy. Additional physiologic variables could improve prognostication in CF.
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Affiliation(s)
- Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA.
| | - Travis Hee Wai
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Anne L Stephenson
- Department of Respirology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Jenna Sykes
- Department of Respirology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Sanja Stanojevic
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Patricia J Rodriguez
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA
| | - Aasthaa Bansal
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA
| | - Nicole Mayer-Hamblett
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Seattle Children's Research Institute, Seattle, WA
| | - Christopher H Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA; Seattle Children's Research Institute, Seattle, WA
| | - Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
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Lee AJ, Huffmyer JL, Thiele EL, Zeitlin PL, Chatterjee D. The Changing Face of Cystic Fibrosis: An Update for Anesthesiologists. Anesth Analg 2022; 134:1245-1259. [PMID: 35020677 DOI: 10.1213/ane.0000000000005856] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Cystic fibrosis (CF) is the most common fatal genetic disease in North America. While CF is more common among Whites, it is increasingly being recognized in other races and ethnicities. Although there is no cure, life expectancy has steadily improved, with the median survival exceeding 46 years in the United States. There are now more adults than children with CF in the United States. CF is caused by mutations in a gene that encodes the cystic fibrosis transmembrane conductance regulator (CFTR) protein, expressed in many epithelial cells. More than 2100 CFTR mutations have been linked to CF, and newer CFTR modulator drugs are being used to improve the production, intracellular processing, and function of the defective CFTR protein. CF is a multisystem disease that affects primarily the lungs, pancreas, hepatobiliary system, and reproductive organs. Anesthesiologists routinely encounter CF patients for various surgical and medical procedures, depending on the age group. This review article focuses on the changing epidemiology of CF, advances in the classification of CFTR mutations, the latest innovations in CFTR modulator therapies, the impact of the coronavirus disease pandemic, and perioperative considerations that anesthesiologists must know while caring for patients with CF.
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Affiliation(s)
- Amy J Lee
- From the Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Julie L Huffmyer
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - Eryn L Thiele
- Department of Anesthesiology, University of Virginia Health, Charlottesville, Virginia
| | - Pamela L Zeitlin
- Department of Pediatrics, National Jewish Health, Denver, Colorado
| | - Debnath Chatterjee
- From the Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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6
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Zorzo C, Girón RM, Caballero P. Temporal Changes on Pulmonary Artery Size on Computed Tomography in Adults With Cystic Fibrosis. OPEN RESPIRATORY ARCHIVES 2022. [PMID: 37497314 PMCID: PMC10369578 DOI: 10.1016/j.opresp.2022.100155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Muralidharan P, Hayes D, Fineman JR, Black SM, Mansour HM. Advanced Microparticulate/Nanoparticulate Respirable Dry Powders of a Selective RhoA/Rho Kinase (Rock) Inhibitor for Targeted Pulmonary Inhalation Aerosol Delivery. Pharmaceutics 2021; 13:2188. [PMID: 34959469 PMCID: PMC8707591 DOI: 10.3390/pharmaceutics13122188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/26/2022] Open
Abstract
Pulmonary hypertension (PH) is a progressive disease that eventually leads to heart failure and potentially death for some patients. There are many unique advantages to treating pulmonary diseases directly and non-invasively by inhalation aerosols and dry powder inhalers (DPIs) possess additional unique advantages. There continues to be significant unmet medical needs in the effective treatment of PH that target the underlying mechanisms. To date, there is no FDA-approved DPI indicated for the treatment of PH. Fasudil is a novel RhoA/Rho kinase (ROCK) inhibitor that has shown great potential in effectively treating pulmonary hypertension. This systematic study is the first to report on the design and development of DPI formulations comprised of respirable nanoparticles/microparticles using particle engineering design by advanced spray drying. In addition, comprehensive physicochemical characterization, in vitro aerosol aerosol dispersion performance with different types of human DPI devices, in vitro cell-drug dose response cell viability of different human respiratory cells from distinct lung regions, and in vitro transepithelial electrical resistance (TEER) as air-interface culture (AIC) demonstrated that these innovative DPI fasudil formulations are safe on human lung cells and have high aerosol dispersion performance properties.
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Affiliation(s)
- Priya Muralidharan
- Department of Pharmaceutical Sciences, College of Pharmacy, The University of Arizona, Tucson, AZ 85721, USA;
| | - Don Hayes
- Departments of Pediatrics and Internal Medicine, Lung and Heart-Lung Transplant Programs, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH 43205, USA;
| | - Jeffrey R. Fineman
- UCSF School of Medicine & Benioff Children’s Hospital, San Francisco, CA 94158, USA;
| | - Stephen M. Black
- Center for Translational Science, Florida International University, Port Saint Lucie, FL 34987, USA;
| | - Heidi M. Mansour
- Department of Pharmaceutical Sciences, College of Pharmacy, The University of Arizona, Tucson, AZ 85721, USA;
- Center for Translational Science, Florida International University, Port Saint Lucie, FL 34987, USA;
- The BIO5 Research Institute, The University of Arizona, Tucson, AZ 85721, USA
- Institute of the Environment, The University of Arizona, Tucson, AZ 85721, USA
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8
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Tabeling C, Witzenrath M, Kuebler WM. CFTR in the regulation of pulmonary vascular tone and remodeling. Eur Respir J 2021; 58:13993003.01861-2021. [PMID: 34795040 DOI: 10.1183/13993003.01861-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/22/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Christoph Tabeling
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Dept of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Witzenrath
- Division of Pulmonary Inflammation, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,Dept of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,German Center for Lung Research (DZL), Partner Site Charité, Berlin, Germany
| | - Wolfgang M Kuebler
- German Center for Lung Research (DZL), Partner Site Charité, Berlin, Germany .,Institute of Physiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada.,Depts of Physiology and Surgery, University of Toronto, Toronto, ON, Canada
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9
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Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2021; 40:1349-1379. [PMID: 34419372 DOI: 10.1016/j.healun.2021.07.005] [Citation(s) in RCA: 282] [Impact Index Per Article: 94.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023] Open
Abstract
Tens of thousands of patients with advanced lung diseases may be eligible to be considered as potential candidates for lung transplant around the world each year. The timing of referral, evaluation, determination of candidacy, and listing of candidates continues to pose challenges and even ethical dilemmas. To address these challenges, the International Society for Heart and Lung Transplantation appointed an international group of members to review the literature, to consider recent advances in the management of advanced lung diseases, and to update prior consensus documents on the selection of lung transplant candidates. The purpose of this updated consensus document is to assist providers throughout the world who are caring for patients with pulmonary disease to identify potential candidates for lung transplant, to optimize the timing of the referral of these patients to lung transplant centers, and to provide transplant centers with a framework for evaluating and selecting candidates. In addition to addressing general considerations and providing disease specific recommendations for referral and listing, this updated consensus document includes an ethical framework, a recognition of the variability in acceptance of risk between transplant centers, and establishes a system to account for how a combination of risk factors may be taken into consideration in candidate selection for lung transplantation.
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10
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Recipient Age Impacts Long-Term Survival in Adult Subjects with Cystic Fibrosis after Lung Transplantation. Ann Am Thorac Soc 2021; 18:44-50. [PMID: 32795188 DOI: 10.1513/annalsats.201908-637oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Rationale: Lung transplant is an effective treatment option providing survival benefit in patients with cystic fibrosis (CF). Several studies have suggested survival benefit in adults compared with pediatric patients with CF undergoing lung transplant. However, it remains unclear whether this age-related disparity persists in adult subjects with CF.Objectives: We investigated the impact of age at transplant on post-transplant outcomes in adult patients with CF.Methods: The United Network of Organ Sharing Registry was queried for all adult patients with CF who underwent lung transplantation between 1992 and 2016. Pertinent baseline characteristics, demographics, clinical parameters, and outcomes were recorded. The patients were divided into two groups based on age at transplant (18-29 yr old and 30 yr or older). The primary endpoint was survival time. Assessment of post-transplant survival was performed using Kaplan-Meier tests and log-rank tests with multivariable Cox proportional hazards analysis to adjust for confounding variables.Results: A total of 3,881 patients with CF underwent lung transplantation between 1992 and 2016; mean age was 31.0 (± 9.3) years. The 18-29-year-old at transplant cohort consisted of 2,002 subjects and the 30 years or older cohort had 1,879 subjects. Survival analysis demonstrated significantly higher survival in subjects in the 30 years or older cohort (9.47 yr; 95% confidence interval [CI], 8.7-10.2) compared with the 18-29-year-old cohort (5.21 yr; 95% CI, 4.6-5.8). After adjusting for confounders, survival remained higher in recipients aged 30 years or older (hazard ratio, 0.44; 95% CI, 0.2-0.9). Mortality due to allograft failure was significantly lower in patients with CF aged 30 years or older (28% vs. 36.5%; odds ratio [OR], 0.7; 95% CI, 0.6-0.8), whereas the incidence of malignancy was higher in the 30 years or older cohort (8% vs. 2.9%; OR, 3.0; 95% CI, 1.9-4.6).Conclusions: Age at transplant influences lung transplant outcomes in recipients with CF. Subjects with CF aged 30 years or older at transplant have superior survival compared with adult subjects with CF transplanted between the ages 18 and 29 years.
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11
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Yang Q, Zhang Z, Liao J, Zhang J, He W, Zhang C, Yang K, Lu W, Hong C, Liu X, Ning Y, Wang R, Wang J, Chen Y. The causality between CFTR and pulmonary hypertension: insights from Mendelian randomization studies. Hypertens Res 2021; 44:1230-1232. [PMID: 34155362 DOI: 10.1038/s41440-021-00680-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/14/2021] [Accepted: 03/24/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Qifeng Yang
- State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine,Guangdong Key Laboratory of Vascular Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zizhou Zhang
- State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine,Guangdong Key Laboratory of Vascular Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jing Liao
- State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine,Guangdong Key Laboratory of Vascular Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jiarui Zhang
- State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine,Guangdong Key Laboratory of Vascular Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wenjun He
- State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine,Guangdong Key Laboratory of Vascular Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Chenting Zhang
- State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine,Guangdong Key Laboratory of Vascular Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Kai Yang
- State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine,Guangdong Key Laboratory of Vascular Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wenju Lu
- State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine,Guangdong Key Laboratory of Vascular Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Cheng Hong
- State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine,Guangdong Key Laboratory of Vascular Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xinyi Liu
- State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine,Guangdong Key Laboratory of Vascular Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yao Ning
- State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine,Guangdong Key Laboratory of Vascular Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Rui Wang
- State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine,Guangdong Key Laboratory of Vascular Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jian Wang
- State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine,Guangdong Key Laboratory of Vascular Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China. .,Section of Physiology, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, La Jolla, CA, USA.
| | - Yuqin Chen
- State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine,Guangdong Key Laboratory of Vascular Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.
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12
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Mingora CM, Flume PA. Pulmonary Complications in Cystic Fibrosis: Past, Present, and Future. Chest 2021; 160:1232-1240. [PMID: 34147501 DOI: 10.1016/j.chest.2021.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/14/2021] [Accepted: 06/14/2021] [Indexed: 12/22/2022] Open
Abstract
Cystic fibrosis (CF) is an autosomal recessive genetic condition with multisystemic disease manifestations, the most prominent of which occur in the respiratory system. Despite significant developments in disease understanding and therapeutics, each contributing to improved lung function and survival in patients with CF, several pulmonary complications, including pneumothorax, massive hemoptysis, and respiratory failure, continue to occur. In this review, we briefly describe each of these complications and their management and discuss how they impact the care and disease trajectory of individuals in whom they occur. Finally, we discuss the evolving role that palliative care and CF transmembrane conductance regular modulator therapies play in the natural disease course and care of patients with CF.
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Affiliation(s)
- Christina M Mingora
- Department of Medicine, Medical University of South Carolina, Charleston, SC.
| | - Patrick A Flume
- Department of Medicine, Medical University of South Carolina, Charleston, SC
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13
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Le Ribeuz H, To L, Ghigna MR, Martin C, Nagaraj C, Dreano E, Rucker-Martin C, Girerd B, Bouliguan J, Pechoux C, Lambert M, Boet A, Issard J, Mercier O, Hoetzenecker K, Manoury B, Becq F, Burgel PR, Cottart CH, Olschewski A, Sermet-Gaudelus I, Perros F, Humbert M, Montani D, Antigny F. Involvement of CFTR in the pathogenesis of pulmonary arterial hypertension. Eur Respir J 2021; 58:13993003.00653-2020. [PMID: 33926975 DOI: 10.1183/13993003.00653-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/16/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION A reduction in pulmonary artery (PA) relaxation is a key event in pulmonary arterial hypertension (PAH) pathogenesis. CFTR dysfunction in airway epithelial cells plays a central role in cystic fibrosis (CF); CFTR is also expressed in PAs and has been shown to control endothelium-independent relaxation. AIM AND OBJECTIVES We aimed to delineate the role of CFTR in PAH pathogenesis through observational and interventional experiments in human tissues and animal models. METHODS AND RESULTS RT-Q-PCR, confocal imaging and electron microscopy showed that CFTR expression was reduced in PAs from patients with idiopathic PAH (iPAH) and in rats with monocrotaline-induced pulmonary hypertension (PH). Moreover, using myograph on human, pig and rat PAs, we demonstrated that CFTR activation induces PAs relaxation. CFTR-mediated PA relaxation was reduced in PAs from iPAH patients and rats with monocrotaline- or chronic hypoxia-induced PH. Long-term in vivo CFTR inhibition in rats significantly increased right ventricular systolic pressure, which was related to exaggerated pulmonary vascular cell proliferation in situ and vessel neomuscularization. Pathologic assessment of lungs from patients with severe CF (F508del-CFTR) revealed severe PA remodeling with intimal fibrosis and medial hypertrophy. Lungs from homozygous F508delCftr rats exhibited pulmonary vessel neomuscularization. The elevations in right ventricular systolic pressure and end diastolic pressure in monocrotaline-exposed rats with chronic CFTR inhibition were more prominent than those in vehicle-exposed rats. CONCLUSIONS CFTR expression is strongly decreased in PA smooth muscle and endothelial cells in human and animal models of PH. CFTR inhibition increases vascular cell proliferation and strongly reduces PA relaxation.
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Affiliation(s)
- Hélène Le Ribeuz
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 " Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique ", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Lucie To
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 " Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique ", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Maria-Rosa Ghigna
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 " Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique ", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Clémence Martin
- Hôpitaux de Paris (AP-HP), Dept of Respiratory Medicine, Centre de Référence Maladie Rare Mucoviscidose, ERN-Lung, Cochin Hospital, , Paris, France.,Inserm U1016, Institut Cochin, Université de Paris, Paris, France
| | - Chandran Nagaraj
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Elise Dreano
- Inserm U1151 - CNRS UMR 8253 - Institut Necker Enfants Malades, Centre Maladie Rare Mucoviscidose, ERN Lung, Université de Paris, Paris, France
| | - Catherine Rucker-Martin
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 " Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique ", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Barbara Girerd
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 " Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique ", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Jérôme Bouliguan
- Laboratoire de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bicêtre, Le Kremlin-Bicêtre, France; INSERM UMR-1185, Université Paris Saclay, Faculté de Médecine, Le Kremlin Bicêtre, France
| | - Christine Pechoux
- GABI, INRA, AgroParisTech, Université Paris-Saclay, Jouy-en-Josas, France
| | - Mélanie Lambert
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 " Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique ", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Angèle Boet
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 " Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique ", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Justin Issard
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 " Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique ", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olaf Mercier
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 " Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique ", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Konrad Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Boris Manoury
- Signalisation et Physiopathologie Cardiovasculaire - UMR_S 1180, Univ. Paris-Sud, INSERM, Université Paris-Saclay, Châtenay-Malabry, France
| | - Frédéric Becq
- Laboratoire Signalisation et Transports Ioniques Membranaires, Université de Poitiers, Poitiers Cedex 9, France
| | - Pierre-Régis Burgel
- Hôpitaux de Paris (AP-HP), Dept of Respiratory Medicine, Centre de Référence Maladie Rare Mucoviscidose, ERN-Lung, Cochin Hospital, , Paris, France.,Inserm U1016, Institut Cochin, Université de Paris, Paris, France
| | - Charles-Henry Cottart
- Inserm U1151 - CNRS UMR 8253 - Institut Necker Enfants Malades, Centre Maladie Rare Mucoviscidose, ERN Lung, Université de Paris, Paris, France
| | - Andrea Olschewski
- Inserm U1016, Institut Cochin, Université de Paris, Paris, France.,Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Isabelle Sermet-Gaudelus
- Inserm U1151 - CNRS UMR 8253 - Institut Necker Enfants Malades, Centre Maladie Rare Mucoviscidose, ERN Lung, Université de Paris, Paris, France
| | - Frédéric Perros
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 " Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique ", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Marc Humbert
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 " Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique ", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - David Montani
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999 " Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique ", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Fabrice Antigny
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France .,INSERM UMR_S 999 " Hypertension pulmonaire: Physiopathologie et Innovation Thérapeutique ", Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
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14
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Leuchte HH, Halank M, Held M, Borst M, Ewert R, Klose H, Lange TJ, Meyer FJ, Skowasch D, Wilkens H, Seyfarth HJ. [Differential Diagnosis of Pulmonary Hypertension Using the Example of Collagenosis-associated PAH in the Context of Chronic Lung and Left Heart Disease]. Pneumologie 2021; 75:122-137. [PMID: 33578434 DOI: 10.1055/a-1204-3248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Pulmonary hypertension (PH) can be diagnosed in the context of connective tissue diseases (CTD) as well as in elderly patients with multiple comorbidities. A correct clinical differential diagnosis and classification is essential before adequate therapeutic decisions can be made. Differential diagnosis of PH in CTD comprises associated pulmonary arterial hypertension (APAH), group 2 or 3 PH (PH arising from left heart or chronic lung disease), chronic thromboembolic PH (PH) and group 5 (e. g. in the context of terminal renal insufficiency). This is also true of elderly patients in whom the decision has to be made if the increasing number of coincident diseases lead to PH or have to be interpreted as comorbidities. In this manuscript, the differential diagnosis of PH is elucidated, focusing on CTD, in the context of left heart disease and chronic lung disease. Furthermore, criteria are presented facilitating an objective approach in this context.
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Affiliation(s)
- H H Leuchte
- Klinik der Barmherzigen Schwestern, Krankenhaus Neuwittelsbach, Lehrkrankenhaus der LMU München, Mitglied des DZL
| | - M Halank
- Universitätsklinikum Carl Gustav Carus, Medizinische Klinik 1, Bereich Pneumologie, Dresden
| | - M Held
- Klinikum Würzburg Mitte, Standort Missioklinik, Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Würzburg
| | - M Borst
- Medizinische Klinik 1 Caritas-Krankenhaus Bad Mergentheim gemeinnützige GmbH, Bad Mergentheim
| | - R Ewert
- Universitätsmedizin Greifswald. Klinik für Innere Medizin B, Bereich Pneumologie, Greifswald
| | - H Klose
- Universitätsklinikum Hamburg-Eppendorf, Abteilung für Pneumologie, Hamburg
| | - T J Lange
- Uniklinik Regensburg, Klinik für Innere Medizin II, Bereich Pneumologie, Regensburg
| | - F J Meyer
- Lungenzentrum München (Bogenhausen-Harlaching), München Klinik gGmbH, München
| | - D Skowasch
- Universitätsklinikum Bonn, Medizinische Klinik II, Sektion Pneumologie, Bonn
| | - H Wilkens
- Pneumologie, Uniklinik Homburg, Homburg
| | - H-J Seyfarth
- Bereich Pneumologie, Universitätsklinikum Leipzig, Leipzig
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15
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Acosta MF, Muralidharan P, Grijalva CL, Abrahamson MD, Hayes D, Fineman JR, Black SM, Mansour HM. Advanced therapeutic inhalation aerosols of a Nrf2 activator and RhoA/Rho kinase (ROCK) inhibitor for targeted pulmonary drug delivery in pulmonary hypertension: design, characterization, aerosolization, in vitro 2D/3D human lung cell cultures, and in vivo efficacy. Ther Adv Respir Dis 2021; 15:1753466621998245. [PMID: 33719747 PMCID: PMC7968029 DOI: 10.1177/1753466621998245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 01/27/2021] [Indexed: 12/16/2022] Open
Abstract
Inhalable nanostructured microparticles of simvastatin, a Nrf2 activator and RhoA/Rho kinase (ROCK) inhibitor, were rationally designed for targeted pulmonary delivery as dry powder inhalers (DPIs) for the treatment of pulmonary hypertension (PH). Advanced particle engineering design technology was employed to develop inhalable dry powders using different dilute feed concentrations and spray drying pump rates. Several analytical techniques were used comprehensively to characterize the physicochemical properties of the resulting powders. Scanning electron microscopy (SEM) was used to visualize particle morphology (shape), surface structure, size, and size distribution. Karl Fischer titration (KFT) was employed to quantify the residual water content in the powders. X-ray powder diffraction (XRPD) was used to determine crystallinity. Hot-stage microscopy (HSM) under cross-polarizing lens was used to observe the presence or absence of birefringence characteristic of crystallinity. Differential scanning calorimetry (DSC) was employed to quantify thermotropic phase behavior. Attenuated total reflectance (ATR)-Fourier-transform infrared (FTIR) spectroscopy and Raman spectroscopy were used to determine the molecular fingerprint of simvastatin powders before and after particle engineering design. In vitro aerosol dispersion performance was performed with three different Food and Drug Administration (FDA)-approved human DPI devices. Cell viability and transepithelial electrical resistance (TEER) were demonstrated using different in vitro human pulmonary cell two and three-dimensional models at the air-liquid interface, and in vivo safety in healthy rats by inhalation. Efficacy was demonstrated in the in vivo lamb model of PH. Four different inhalable powders of simvastatin were successfully produced. They possessed nanostructured surfaces and were in the inhalable size range. Simvastatin retained its crystallinity following particle engineering design. The more dilute feed concentration spray dried at the lower pump rate produced the smallest particles. All powders successfully aerosolized with all three DPI human devices. Inhaled simvastatin as an aerosol restored the endothelial function in the shunt lamb model of PH, as demonstrated by the reduction of pulmonary vascular resistance (PVR) in response to the endothelium-dependent vasodilator acetylcholine.The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Maria F. Acosta
- Skaggs Pharmaceutical Sciences Center, The University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Priya Muralidharan
- Skaggs Pharmaceutical Sciences Center, The University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Carissa L. Grijalva
- Skaggs Pharmaceutical Sciences Center, The University of Arizona College of Pharmacy, Tucson, AZ, USA
- Department of Biomedical Engineering, The University of Arizona College of Engineering, Tucson, AZ, USA
| | - Michael D. Abrahamson
- Skaggs Pharmaceutical Sciences Center, The University of Arizona College of Pharmacy, Tucson, AZ, USA
| | - Don Hayes
- Departments of Pediatrics and Internal Medicine, Lung and Heart-Lung Transplant Programs, The Ohio State University College of Medicine, Columbus, OH, USA
- The Davis Heart and Lung Research Institute, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jeffrey R. Fineman
- Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Stephen M. Black
- Department of Medicine, Division of Translational and Regenerative Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
- Department of Medicine, Center for Lung Vascular Pathobiology, The University of Arizona College of Medicine, Tucson, AZ, USA
- Department of Physiology, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Heidi M. Mansour
- Skaggs Pharmaceutical Sciences Center, The University of Arizona College of Pharmacy, Tucson, AZ, USA
- Department of Medicine, Division of Translational and Regenerative Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
- The University of Arizona, BIO5 Institute, Tucson, AZ, USA
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16
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Scaravilli V, Scansani S, Grasso A, Guzzardella A, Vicenzi M, Rota I, Nosotti M, Zanella A, Blasi F, Pesenti A, Grasselli G. Right Ventricle Dysfunction in Patients With Adult Cystic Fibrosis Enlisted for Lung Transplant. Transplant Proc 2020; 53:260-264. [PMID: 33257002 DOI: 10.1016/j.transproceed.2020.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/17/2020] [Accepted: 09/14/2020] [Indexed: 10/22/2022]
Abstract
Knowledge of preoperative right heart function of adult patients with cystic fibrosis (CF) awaiting lung transplant (LUTX) is limited. The echocardiography of adult patients with CF enlisted for LUTX was retrospectively analyzed and compared with standards and invasive analyses (right heart catheterization, multigated radionuclide ventriculography). We included 49 patients (reported as mean ± standard deviation; 29 ± 9 years of age; forced expiratory volume in first second of expiration, 31% ± 11% predicted; lung allocation score, 36 ± 5; invasive mean pulmonary artery pressure, 17 ± 5 mm Hg; multigated radionuclide ventriculography right ventricle [RV] ejection fraction, 50% ± 9%). Patients had increased RV end-diastolic area, RV wall thickness, and increased pulmonary artery acceleration time with subnormal tricuspid annular plane systolic excursion, tissue Doppler positive peak systolic velocity, and fraction area change. Subnormal tricuspid annular plane systolic excursion (< 23 mm), tissue Doppler positive peak systolic velocity (< 14 cm/s), and fraction area change (< 49%) had high sensitivity and negative predictive value in predicting impaired RV. EJECTION FRACTION: A good correlation between echocardiographic estimated and invasively measured systolic pulmonary artery pressure was observed (R2 = 0.554, P < .001). Adults with CF awaiting LUTX have morphologic alterations of the right heart, with subclinical impairment of RV systolic function. Echocardiography may be used as a bedside, repeatable, and reliable noninvasive test to screen further deterioration in RV function while on the waiting list for LUTX. More prospective follow-up echocardiographic studies are necessary to confirm such a hypothesis.
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Affiliation(s)
- Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.
| | - Silvia Scansani
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alice Grasso
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Amedeo Guzzardella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Marco Vicenzi
- Internal Medicine Department, Cardiovascular Disease Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Irene Rota
- Internal Medicine Department, Cardiovascular Disease Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Nosotti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Department of Internal Medicine, Respiratory Unit and Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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17
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Acosta MF, Abrahamson MD, Encinas-Basurto D, Fineman JR, Black SM, Mansour HM. Inhalable Nanoparticles/Microparticles of an AMPK and Nrf2 Activator for Targeted Pulmonary Drug Delivery as Dry Powder Inhalers. AAPS J 2020; 23:2. [PMID: 33200330 PMCID: PMC7669792 DOI: 10.1208/s12248-020-00531-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/31/2020] [Indexed: 12/19/2022] Open
Abstract
Metformin is an activator of the AMPK and Nrf2 pathways which are important in the pathology of several complex pulmonary diseases with unmet medical needs. Organic solution advanced spray drying in the absence of water in closed-mode was used to design and develop respirable dry powders. Following comprehensive characterization, the influence of physicochemical properties was correlated with performance as aerosols using inertial impaction and three different human dry powder inhaler (DPI) devices varying in device properties. In vitro cell assays were conducted to test safety in 2D human pulmonary cell lines and in 3D small airway epithelia comprising primary cells at the air-liquid interface (ALI). In addition, in vitro transepithelial electrical resistance (TEER) was carried out. Metformin remained crystalline following advanced spray drying under these conditions. All SD powders consisted of nanoparticles/microparticles in the solid state. In vitro aerosol dispersion performance showed high aerosolization for all SD metformin powders with all DPI devices tested. High emitted dose for all powders with all three DPI devices was measured. Differences in other aerosol performance parameters and the interplay between the properties of different formulations produced at specific pump rates and the three different DPI devices were correlated with spray drying pump rate and device properties. Safety over a wide metformin dose range was also demonstrated in vitro. Aerosol delivery of metformin nanoparticles/microparticles has the potential to be a new "first-in-class" therapeutic for the treatment of a number of pulmonary diseases including pulmonary vascular diseases such as pulmonary hypertension.
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Affiliation(s)
- Maria F Acosta
- Skaggs Pharmaceutical Sciences Center, The University of Arizona College of Pharmacy, 1703 E. Mabel St, Skaggs Pharmaceutical Sciences Center, Tucson, Arizona, 85721-0207, USA
| | - Michael D Abrahamson
- Skaggs Pharmaceutical Sciences Center, The University of Arizona College of Pharmacy, 1703 E. Mabel St, Skaggs Pharmaceutical Sciences Center, Tucson, Arizona, 85721-0207, USA
| | - David Encinas-Basurto
- Skaggs Pharmaceutical Sciences Center, The University of Arizona College of Pharmacy, 1703 E. Mabel St, Skaggs Pharmaceutical Sciences Center, Tucson, Arizona, 85721-0207, USA
| | - Jeffrey R Fineman
- Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, California, USA
- University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA
- University of California San Francisco Cardiovascular Research Institute, San Francisco, California, USA
| | - Stephen M Black
- Department of Medicine, Division of Translational and Regenerative Medicine, The University of Arizona College of Medicine, Tucson, Arizona, USA
- Department of Medicine, Center for Lung Vascular Pathobiology, The University of Arizona College of Medicine, Tucson, Arizona, USA
- Department of Physiology, The University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Heidi M Mansour
- Skaggs Pharmaceutical Sciences Center, The University of Arizona College of Pharmacy, 1703 E. Mabel St, Skaggs Pharmaceutical Sciences Center, Tucson, Arizona, 85721-0207, USA.
- Department of Medicine, Division of Translational and Regenerative Medicine, The University of Arizona College of Medicine, Tucson, Arizona, USA.
- BIO5 Institute, The University of Arizona, Tucson, Arizona, USA.
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18
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Kapnadak SG, Dimango E, Hadjiliadis D, Hempstead SE, Tallarico E, Pilewski JM, Faro A, Albright J, Benden C, Blair S, Dellon EP, Gochenour D, Michelson P, Moshiree B, Neuringer I, Riedy C, Schindler T, Singer LG, Young D, Vignola L, Zukosky J, Simon RH. Cystic Fibrosis Foundation consensus guidelines for the care of individuals with advanced cystic fibrosis lung disease. J Cyst Fibros 2020; 19:344-354. [DOI: 10.1016/j.jcf.2020.02.015] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 02/14/2020] [Accepted: 02/19/2020] [Indexed: 12/25/2022]
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19
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Zouk AN, Gulati S, Xing D, Wille KM, Rowe SM, Wells JM. Pulmonary artery enlargement is associated with pulmonary hypertension and decreased survival in severe cystic fibrosis: A cohort study. PLoS One 2020; 15:e0229173. [PMID: 32078644 PMCID: PMC7032721 DOI: 10.1371/journal.pone.0229173] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 02/02/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pulmonary artery (PA) enlargement, defined as pulmonary artery to ascending aorta diameter ratio (PA:A)>1 on computed tomography (CT), is a marker of pulmonary vascular disease in chronic lung diseases. PA enlargement is prevalent in cystic fibrosis (CF), but its relationship to hemodynamics and prognostic utility in severe CF are unknown. We hypothesized that the PA:A would have utility in identifying pulmonary hypertension (PH) in severe CF and that PA enlargement would be associated with reduced transplant-free survival. METHODS We conducted a retrospective study of adults with CF undergoing lung transplant evaluation at a single center between 2000 and 2015. CT, right heart catheterization (RHC), and clinical data were collected. The PA:A was measured from a single CT slice. We measured associations between PA:A and invasive hemodynamic parameters including PH defined as a mPAP ≥25mmHg using adjusted linear and logistic regression models. Kaplan-Meier and adjusted Cox regression models were used to measure associations between PA:A>1, RHC-defined PH, and transplant-free survival in severe CF. RESULTS We analyzed 78 adults with CF that had CT scans available for review, including 44 that also had RHC. RHC-defined PH defined as a mPAP ≥25mmHg was present in 36% of patients with CF undergoing transplant evaluation. The PA:A correlated with mPAP (r = 0.73; 95% CI 3.87-7.80; p<0.001) and PVR (r = 0.42, p = 0.005) and the PA:A>1 was an independent predictor of PH (aOR 4.50; 95% CI 1.05-19.2; p = 0.042). PA:A>1 was independently associated with increased hazards for death or transplant (aHR 2.69; 95% CI 1.41-5.14; P = 0.003). The presence of mPAP ≥25mmHg was independently associated with decreased survival in this cohort. CONCLUSIONS PA enlargement is associated with pulmonary hemodynamics and PH in severe CF. PA enlargement is an independent prognostic indicator of PH and decreased survival in this population.
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Affiliation(s)
- Aline N. Zouk
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, United States of America
| | - Swati Gulati
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, United States of America
| | - Dongqi Xing
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, United States of America
- Gregory Fleming James Cystic Fibrosis Research Center, Birmingham, AL, United States of America
- UAB Lung Health Center, Birmingham, AL, United States of America
| | - Keith M. Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, United States of America
| | - Steven M. Rowe
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, United States of America
- Gregory Fleming James Cystic Fibrosis Research Center, Birmingham, AL, United States of America
- UAB Lung Health Center, Birmingham, AL, United States of America
| | - J. Michael Wells
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, United States of America
- Gregory Fleming James Cystic Fibrosis Research Center, Birmingham, AL, United States of America
- UAB Lung Health Center, Birmingham, AL, United States of America
- Birmingham VA Medical Center, Birmingham, AL, United States of America
- * E-mail:
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20
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Advanced Stage Lung Disease. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_11] [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: 10/24/2022]
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21
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The role of endothelial cells in cystic fibrosis. J Cyst Fibros 2019; 18:752-761. [DOI: 10.1016/j.jcf.2019.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 06/18/2019] [Accepted: 07/23/2019] [Indexed: 12/22/2022]
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Scaravilli V, Morlacchi LC, Merrino A, Piacentino E, Marasco D, Zanella A, Nosotti M, Rosso L, Polli F, Blasi F, Pesenti A, Grasselli G. Intraoperative extracorporeal membrane oxygenation for lung transplantation in cystic fibrosis patients: Predictors and impact on outcome. J Cyst Fibros 2019; 19:659-665. [PMID: 31676344 DOI: 10.1016/j.jcf.2019.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/19/2019] [Accepted: 10/15/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Predictors and outcomes of intraoperative extracorporeal membrane oxygenation (ECMO) during lung transplantation (LUTX) for cystic fibrosis (CF) are unknown. METHODS We retrospectively collected the clinical data at enlistment of the CF patients who underwent double LUTX from January 2013 to December 2018 at an Italian tertiary referral center. We compared blood transfusions, incidence of primary graft dysfunction (PGD), duration of mechanical ventilation, intensive care unit (ICU) length of stay (LOS), hospital LOS and survival of ECMO and non-ECMO patients. Chi-square, Kruskal-Wallis, and log-rank tests were used. RESULTS Twenty-eight (40%) of the 70 included patients needed intraoperative central veno-arterial ECMO with postoperative veno-venous prolongation in 6 subjects. Lower right ventricle ejection fraction (p = 0.013, OR 0.92(0.86-0.98)), higher oxygen requirement (p = 0.026, OR 1.39(1.01-1.90)), lower body surface area (p = 0.044, OR 0.05(0.00-1.03)), and CF-related diabetes (p = 0.044, OR 2.81(1.03-7.66)) were associated with intraoperative ECMO. Compared to non-ECMO patients, ECMO patients needed almost fivefold intraoperative transfusion (2227 mL vs. 570 mL, p<0.001) and had PGD grade > 0 at 72 h more frequently (16/57% vs. 12/28%, p = 0.017, OR 3.33(1.22-9.09)). Mechanical ventilation, ICU LOS and hospital LOS were significantly longer in ECMO patients. Survival at follow-up (651(326-1277) days) of ECMO and non-ECMO patients was 78% vs. 83%, respectively (OR 0.73 (0.21-2.46), p = 0.616, log-rank test p = 0.498). CONCLUSION Pre-operative risk assessment and clinical planning should be done according to the predictors above. While undeniably useful as a life-saving procedure, ECMO during LUTX for CF is associated with worsened short-term outcomes. ECMO should be implemented weighing its risk and benefits.
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Affiliation(s)
- Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milano, (MI) Italy.
| | - Letizia Corinna Morlacchi
- Department of Internal Medicine, Respiratory Unit and Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan (MI), Italy
| | - Alessandra Merrino
- Department of Pathophysiology and Transplantation, University of Milan, Milan (MI), Italy
| | - Edoardo Piacentino
- Department of Pathophysiology and Transplantation, University of Milan, Milan (MI), Italy
| | - Davide Marasco
- Department of Pathophysiology and Transplantation, University of Milan, Milan (MI), Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milano, (MI) Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan (MI), Italy
| | - Mario Nosotti
- Department of Pathophysiology and Transplantation, University of Milan, Milan (MI), Italy; Thoracic Syrgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan (MI), Italy
| | - Lorenzo Rosso
- Department of Pathophysiology and Transplantation, University of Milan, Milan (MI), Italy; Thoracic Syrgery and Lung Transplant Unit, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan (MI), Italy
| | - Federico Polli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milano, (MI) Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milan, Milan (MI), Italy; Department of Internal Medicine, Respiratory Unit and Cystic Fibrosis Center, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan (MI), Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milano, (MI) Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan (MI), Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milano, (MI) Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan (MI), Italy
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Abstract
Lung transplantation is a valuable therapeutic option for many patients with severe lung disease who have exhausted other medical or surgical therapies. However, since lungs are not a manufacturable organ like artificial heart valves or left ventricular assist devices, and since they are a limited resource compared to number of patients requiring the organs, the Department of Health and Human Services set the Final Rule of organ allocation in 1998. This led to development and implementation of Lung Allocation Score (LAS) in 2005. The score broadly divides lung diseases into 4 diagnostic criteria with a coefficient factor given to each category. The score is based on the prognostic factors of each patient to determine the risk of mortality without a transplant combined with the probability of patient survival post-transplant. Most of the guidelines for "Indications for referral and listing in lung transplant" is based on consensus opinion as there is limited amount of robust data and trials about this topic. The International Society for Heart and Lung Transplant (ISHLT) has published three editions for candidate selection and listing. In this article, we have attempted to highlight the guidelines and incorporated other disease specific prognostic factors that are not captured in the LAS. Ultimately, there are other factors like geographic location, height, blood group, preformed antibodies, transplant center experience, past wait times and transplant rate, availability of organs, etc., which also play a role especially when considering listing a patient for lung transplant. We also highlighted a representative disease in each category and most criteria for that disease will apply to other diseases in that category. Finally, this article does not delve into the history and reasoning behind each guideline but is meant to provide a general overview of indications and contraindications applicable in the field of adult lung transplantation.
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Affiliation(s)
- Omar Shweish
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Goutham Dronavalli
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
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24
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Ramos KJ, Smith PJ, McKone EF, Pilewski JM, Lucy A, Hempstead SE, Tallarico E, Faro A, Rosenbluth DB, Gray AL, Dunitz JM. Lung transplant referral for individuals with cystic fibrosis: Cystic Fibrosis Foundation consensus guidelines. J Cyst Fibros 2019; 18:321-333. [PMID: 30926322 DOI: 10.1016/j.jcf.2019.03.002] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/08/2019] [Accepted: 03/09/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Provide recommendations to the cystic fibrosis (CF) community to facilitate timely referral for lung transplantation for individuals with CF. METHODS The CF Foundation organized a multidisciplinary committee to develop CF Lung Transplant Referral Consensus Guidelines. Three workgroups were formed: timing for transplant referral; modifiable barriers to transplant; and transition to transplant care. A focus group of lung transplant recipients with CF and spouses of CF recipients informed guideline development. RESULTS The committee formulated 21 recommendation statements based on literature review, committee member practices, focus group insights, and in response to public comment. Critical approaches to optimizing access to lung transplant include early discussion of this treatment option, assessment for modifiable barriers to transplant, and open communication between the CF and lung transplant centers. CONCLUSIONS These guidelines will help CF providers counsel their patients and may reduce the number of individuals with CF who die without consideration for lung transplant.
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Affiliation(s)
- Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Dept of Medicine, University of Washington, Seattle, WA, USA.
| | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Behavioral Medicine Division, Department of Medicine, Pulmonary Division, Duke University Medical Center, Durham, NC, USA.
| | - Edward F McKone
- National Referral Centre for Adult Cystic Fibrosis, St. Vincent's University Hospital, Dublin, Ireland.
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy & Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Amy Lucy
- Cystic Fibrosis Foundation, Bethesda, MD, USA
| | | | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, MD, USA.
| | - Daniel B Rosenbluth
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
| | - Alice L Gray
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA.
| | - Jordan M Dunitz
- Division of Pulmonary, Allergy, Critical Care Medicine and Sleep, Dept of Medicine, University of Minnesota, Minneapolis, MN, USA.
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Williams CA, Wedgwood KCA, Mohammadi H, Prouse K, Tomlinson OW, Tsaneva-Atanasova K. Cardiopulmonary responses to maximal aerobic exercise in patients with cystic fibrosis. PLoS One 2019; 14:e0211219. [PMID: 30759119 PMCID: PMC6373911 DOI: 10.1371/journal.pone.0211219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 12/17/2018] [Indexed: 12/31/2022] Open
Abstract
Cystic fibrosis (CF) is a debilitating chronic condition, which requires complex and expensive disease management. Exercise has now been recognised as a critical factor in improving health and quality of life in patients with CF. Hence, cardiopulmonary exercise testing (CPET) is used to determine aerobic fitness of young patients as part of the clinical management of CF. However, at present there is a lack of conclusive evidence for one limiting system of aerobic fitness for CF patients at individual patient level. Here, we perform detailed data analysis that allows us to identify important systems-level factors that affect aerobic fitness. We use patients’ data and principal component analysis to confirm the dependence of CPET performance on variables associated with ventilation and metabolic rates of oxygen consumption. We find that the time at which participants cross the gas exchange threshold (GET) is well correlated with their overall performance. Furthermore, we propose a predictive modelling framework that captures the relationship between ventilatory dynamics, lung capacity and function and performance in CPET within a group of children and adolescents with CF. Specifically, we show that using Gaussian processes (GP) we can predict GET at the individual patient level with reasonable accuracy given the small sample size of the available group of patients. We conclude by presenting an example and future perspectives for improving and extending the proposed framework. The modelling and analysis have the potential to pave the way to designing personalised exercise programmes that are tailored to specific individual needs relative to patient’s treatment therapies.
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Affiliation(s)
- Craig A. Williams
- Children’s Health and Exercise Research Centre, Sport and Health Sciences, University of Exeter, Exeter, United Kingdom
- * E-mail:
| | - Kyle C. A. Wedgwood
- Department of Mathematics and Living Systems Institute, University of Exeter, Exeter, United Kingdom
- Centre for Biomedical Modelling and Analysis, University of Exeter, Exeter, United Kingdom
| | - Hossein Mohammadi
- Department of Mathematics and Living Systems Institute, University of Exeter, Exeter, United Kingdom
- EPSRC Centre for Predictive Modelling in Healthcare, University of Exeter, Exeter, United Kingdom
| | - Katie Prouse
- Department of Mathematics and Living Systems Institute, University of Exeter, Exeter, United Kingdom
| | - Owen W. Tomlinson
- Children’s Health and Exercise Research Centre, Sport and Health Sciences, University of Exeter, Exeter, United Kingdom
| | - Krasimira Tsaneva-Atanasova
- Department of Mathematics and Living Systems Institute, University of Exeter, Exeter, United Kingdom
- Centre for Biomedical Modelling and Analysis, University of Exeter, Exeter, United Kingdom
- EPSRC Centre for Predictive Modelling in Healthcare, University of Exeter, Exeter, United Kingdom
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Abstract
PURPOSE OF REVIEW Pulmonary hypertension is common (25-90%) in chronic obstructive pulmonary diseases (COPDs). Severe pulmonary hypertension, however, is quite rare (1-3%). The term 'out of proportion' pulmonary hypertension is still widely used. New guidelines instead propose to use the term 'Severe pulmonary hypertension' if mean pulmonary arterial pressure at least 35 mmHg or cardiac index (CI) is less than 2.0 l/min/m on right heart catheterization (RHC). Why only a minority of COPD patients develop severe pulmonary hypertension is unclear. RECENT FINDINGS When present, severe pulmonary hypertension in COPD is associated with increased dyspnea and decreased survival and often does not closely correlate with degree of obstructive abnormality on pulmonary function testing. COPD patients with severe pulmonary hypertension experience circulatory limitation at maximum exercise, and not ventilatory limitation, which is typical for moderate-to-severe COPD patients with no or moderate pulmonary hypertension. SUMMARY There is no conclusive evidence to support or completely reject the possibility of the use of specific pulmonary arterial hypertension (PAH) therapies in pulmonary hypertension associated with COPD. In mild-to-moderate COPD patients who have severe and progressive symptoms, and have evidence of severe pulmonary hypertension on RHC, specific PAH therapies may be used similar to WHO group-I PAH guidelines.
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27
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CT-measured pulmonary artery diameter as an independent predictor of pulmonary hypertension in cystic fibrosis. Pol J Radiol 2019; 83:e401-e406. [PMID: 30655917 PMCID: PMC6334125 DOI: 10.5114/pjr.2018.79204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 08/13/2018] [Indexed: 12/02/2022] Open
Abstract
Purpose The role of computed tomography (CT) scan, as a promising prognostic imaging modality in cystic fibrosis (CF), has been widely investigated, focusing on parenchymal abnormalities. The aim of the present study was to evaluate the diagnostic performance of thoracic vascular parameters on CT to detect pulmonary hypertension (PH). Material and methods CF patients who contemporaneously underwent CT and echocardiography were retrospectively enrolled. Baseline characteristics in addition to pulmonary artery diameter (PAD) and pulmonary to aortic (PA/A) ratio were compared between cohorts with and without PH, based on the results of echocardiography separately in paediatric patients (< 18) and adults (≥ 18). Results Of a total 119 CF patients, 39 (32.8%) had PH (paediatric: 23/78, 29.5%, adult: 16/41, 39%). In paediatric CF patients, mean age, HCo3, PCo2, and pulmonary artery diameter (PAD) were significantly higher in the PH group compared to the non-PH group. Mean pulmo however, only PAD remained as the independent predictor of PH based on multivariate analysis (overall: 22.86 mm [±3.86] vs. 18.43 mm [±4.72], p = 0.005, paediatric patients: 22.63 mm [±4.4] vs. 17.10 mm [±4.64], p = 0.03). Using a cut off of 19.25 mm, the diagnostic performance of PAD to detect PH was found to be as follows: sensitivity = 82%, specificity = 70%, and accuracy = 73.1%. No significant difference was demonstrated in PAD between PH and non-PH groups in adults with CF (23.19 [±3.60] vs. 21.34 [±3.49], p = 0.7). Conclusions In CF patients, PAD revealed an age-dependent performance to detect PH. PAD can be applied to predict pulmonary hypertension in paediatric CF patients and may be recommended to be routinely measured on follow-up chest CT scan in childhood CF.
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Cogolludo A, Villamor E, Perez-Vizcaino F, Moreno L. Ceramide and Regulation of Vascular Tone. Int J Mol Sci 2019; 20:ijms20020411. [PMID: 30669371 PMCID: PMC6359388 DOI: 10.3390/ijms20020411] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/02/2019] [Accepted: 01/16/2019] [Indexed: 02/07/2023] Open
Abstract
In addition to playing a role as a structural component of cellular membranes, ceramide is now clearly recognized as a bioactive lipid implicated in a variety of physiological functions. This review aims to provide updated information on the role of ceramide in the regulation of vascular tone. Ceramide may induce vasodilator or vasoconstrictor effects by interacting with several signaling pathways in endothelial and smooth muscle cells. There is a clear, albeit complex, interaction between ceramide and redox signaling. In fact, reactive oxygen species (ROS) activate different ceramide generating pathways and, conversely, ceramide is known to increase ROS production. In recent years, ceramide has emerged as a novel key player in oxygen sensing in vascular cells and mediating vascular responses of crucial physiological relevance such as hypoxic pulmonary vasoconstriction (HPV) or normoxic ductus arteriosus constriction. Likewise, a growing body of evidence over the last years suggests that exaggerated production of vascular ceramide may have detrimental effects in a number of pathological processes including cardiovascular and lung diseases.
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Affiliation(s)
- Angel Cogolludo
- Department of Pharmacology and Toxicology, School of Medicine, University Complutense of Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Ciudad Universitaria S/N, 28040 Madrid, Spain.
- Ciber Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain.
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), School for Oncology and Developmental Biology (GROW), 6202 AZ Maastricht, The Netherlands.
| | - Francisco Perez-Vizcaino
- Department of Pharmacology and Toxicology, School of Medicine, University Complutense of Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Ciudad Universitaria S/N, 28040 Madrid, Spain.
- Ciber Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain.
| | - Laura Moreno
- Department of Pharmacology and Toxicology, School of Medicine, University Complutense of Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Ciudad Universitaria S/N, 28040 Madrid, Spain.
- Ciber Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain.
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Lenihan M, Mullane D, Buggy D, Flood G, Griffin M. Anesthesia for Lung Transplantation in Cystic Fibrosis: Retrospective Review from the Irish National Transplantation Centre. J Cardiothorac Vasc Anesth 2018; 32:2372-2380. [DOI: 10.1053/j.jvca.2017.11.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Indexed: 12/25/2022]
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Goss K. Long-term pulmonary vascular consequences of perinatal insults. J Physiol 2018; 597:1175-1184. [PMID: 30067297 DOI: 10.1113/jp275859] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/10/2018] [Indexed: 01/01/2023] Open
Abstract
Development of the pulmonary circulation is a critical component of fetal lung development, and continues throughout infancy and childhood, marking an extended window of susceptibility to vascular maldevelopment and maladaptation. Perinatal vascular insults may result in abnormal vascular structure or function, including decreased angiogenic signaling and vascular endowment, impaired vasoreactivity through increased pulmonary artery endothelial dysfunction and remodeling, or enhanced genetic susceptibility to pulmonary vascular disease through epigenetic modifications or germline mutations. Although some infants develop early onset pulmonary hypertension, due to the unique adaptive capabilities of the immature host many do not have clinically evident early pulmonary vascular dysfunction. These individuals remain at increased risk for development of late-onset pulmonary hypertension, and may be particularly susceptible to secondary insults. This review will address the role of perinatal vascular insults in the development of late pulmonary vascular dysfunction with an effort to highlight areas of critical research need.
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Affiliation(s)
- Kara Goss
- Department of Medicine, University of Wisconsin, Madison, WI, USA
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31
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Cottini SR, Brandi G, Pagnamenta A, Weder W, Schuepbach RA, Béchir M, Huber LC, Benden C. Pulmonary hypertension is not a risk factor for grade 3 primary graft dysfunction after lung transplantation. Clin Transplant 2018; 32:e13251. [DOI: 10.1111/ctr.13251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2018] [Indexed: 01/21/2023]
Affiliation(s)
- Silvia R. Cottini
- Surgical Intensive Care Medicine; University Hospital Zurich; Zurich Switzerland
| | - Giovanna Brandi
- Surgical Intensive Care Medicine; University Hospital Zurich; Zurich Switzerland
| | - Alberto Pagnamenta
- Department of Intensive Care Medicine of the Ente Ospedaliero Cantonale (EOC): Intensive Care Unit of Regional Hospital of Mendrisio; Mendrisio Switzerland
- Unit of Clinical Epidemiology; Ente Ospedaliero Cantonale; Bellinzona Switzerland
| | - Walter Weder
- Division of Thoracic Surgery; University Hospital Zurich; Zurich Switzerland
| | - Reto A. Schuepbach
- Surgical Intensive Care Medicine; University Hospital Zurich; Zurich Switzerland
| | - Markus Béchir
- Surgical Intensive Care Medicine; University Hospital Zurich; Zurich Switzerland
- Swiss Paraplegic Center; Nottwil Switzerland
| | - Lars C. Huber
- Division of Pulmonology; University Hospital Zurich; Zurich Switzerland
- Clinic for Internal Medicine; City Hospital Triemli; Zurich Switzerland
| | - Christian Benden
- Division of Pulmonology; University Hospital Zurich; Zurich Switzerland
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Abstract
Comparative effectiveness research (CER) has become increasing central to clinical research in medicine. CER seeks to conduct clinical trials that compare different commonly used interventions in real-world settings (pragmatic clinical trials) and use a multitude of sources of evidence (including registries and cohort studies) to inform clinical decision making. CER also ensures that stakeholders (patients, families, care providers, insurers) have a voice in the research process by integrating formal stakeholder engagement as part of the research. This innovative approach to clinical research has distinct benefits and pitfalls. This review first defines what CER is and then describes some of its benefits and then pitfalls. The focus is on the role of CER in pediatrics.
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Li D, Wang B, Wang H, Liu Q. Prognostic significance of pulmonary hypertension in patients with cystic fibrosis: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e9708. [PMID: 29443734 PMCID: PMC5839836 DOI: 10.1097/md.0000000000009708] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Pulmonary hypertension (PH) is frequently found in advanced parenchymal lung diseases like cystic fibrosis (CF), but the role played by PH in the clinical outcome of CF patients remains unclear. The aim of this study is to determine the influence of PH on survival in the CF population by meta-analysis. METHODS Publications addressing the associations between PH and overall survival (OS) or other clinical characteristics in CF patients were selected from electronic databases. Odds ratios (ORs) or mean differences (MDs) were used to estimate the association between PH and the clinical characteristics. The hazard ratios (HRs) with 95% confidence interval (CI) were abstracted or calculated to evaluate the association between PH and CF survival outcome. Subgroup analyses were also conducted. RESULTS Seven studies including 2141 CF patients who met the inclusion criteria were included in our meta-analysis. With respect to clinical features, PH was significantly associated with lower PaO2 (P < .001), higher PaCO2 (P = .02), lower forced expiratory volume in 1 second percent (P < .001) and lower forced vital capacity percent (P < .001). However, PH had no significant impact on CF patients' OS (HR = 1.29, 95% CI 0.81 to 2.06, P = .283). Furthermore, subgroup analyses also showed no evidence of prognostic role of PH in CF patients (all P values >.05). CONCLUSIONS Our findings suggest that the presence of PH was strongly correlated with worse blood-gas parameters and worse lung function, but surprisingly had no significant prognostic value on survival among CF patients. Further large-scale and prospective studies are needed to confirm these findings.
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Affiliation(s)
- Diandian Li
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Bo Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Hao Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- Division of Allergy & Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Qun Liu
- Division of Allergy & Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, MD
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Constrictive Bronchiolitis in Cystic Fibrosis Adolescents with Refractory Pulmonary Decline. Ann Am Thorac Soc 2018; 13:2174-2183. [PMID: 27684511 DOI: 10.1513/annalsats.201412-594oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
RATIONALE Refractory lung function decline in association with recurrent pulmonary exacerbations is a common, yet poorly explained finding in cystic fibrosis (CF). To investigate the histopathologic mechanisms of pulmonary deterioration during adolescence and early adulthood, we reviewed clinically-indicated lung biopsy specimens obtained during a period of persistent decline. OBJECTIVES To determine if peribronchiolar remodeling is prominent in lung biopsy specimens obtained in adolescents with CF refractory to conventional therapy. METHODS Six adolescents with CF (mean age, 16.2 y; mean FEV1, 52% predicted at biopsy) with significant pulmonary deterioration over 12-24 months (mean FEV1 decline of 14% predicted/year) despite aggressive intervention underwent computed tomography imaging and ultimately lung biopsy to aid clinical management. In addition to routine clinical evaluation, histopathologic investigation included staining for transforming growth factor-β (TGF-β, a genetic modifier of CF lung disease), collagen deposition (a marker of fibrosis), elastin (to evaluate for bronchiectasis), and α-smooth muscle actin (to identify myofibroblasts). MEASUREMENTS AND MAIN RESULTS All computed tomography scans demonstrated a mix of bronchiectasis and hyperinflation that was variable across lung regions and within patients. Lung biopsy revealed significant peribronchiolar remodeling, particularly in patients with more advanced disease, with near complete obliteration of the peribronchiolar lumen (constrictive bronchiolitis). Myofibroblast differentiation (a TGF-β-dependent process) was prominent in specimens with significant airway remodeling. CONCLUSIONS Constrictive bronchiolitis is widely present in the lung tissue of adolescents with CF with advanced disease and may contribute to impaired lung function that is refractory to conventional therapy (antibiotics, antiinflammatories, and mucolytics). TGF-β-dependent myofibroblast differentiation is prominent in areas of active fibrogenesis and may foster small airway remodeling in CF lung disease.
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Zhang Y, Wu S. Effects of fasudil on pulmonary hypertension in clinical practice. Pulm Pharmacol Ther 2017; 46:54-63. [PMID: 28782712 DOI: 10.1016/j.pupt.2017.08.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 06/02/2017] [Accepted: 08/03/2017] [Indexed: 01/09/2023]
Abstract
Pulmonary hypertension (PH) is a pathophysiologic disorder that may involve multiple clinical conditions and can complicate the majority of cardiovascular and respiratory diseases. The presence of PH is associated with worse outcomes, but the efficacy of current therapy is still unsatisfactory. Because Rho-kinase (ROCK) plays an important role in the pathogenesis of PH, the ROCK inhibitor fasudil is expected to contribute to PH treatment. In animal models of PH, fasudil reduced pulmonary artery pressure (PAP) and improved survival. Furthermore, the short-term efficacy and safety of fasudil in the treatment of PH are demonstrated in clinical trials. Both PAP and pulmonary vascular resistance in patients with PH are significantly decreased by intravenous or inhaled fasudil without apparent side effect. However, no clinical trial has assessed the long-term efficacy of fasudil in the treatment of PH. Limited data suggest that the mid-term use of fasudil could improve exercise capacity and reduce in-hospital mortality. We also discuss the combined use of fasudil and other drugs for PH treatment. However, these combinations have not yet been evaluated in a clinical trial. According to animal studies, the combination of fasudil with beraprost or sildenafil shows synergistic effects, whereas the combination of fasudil with bosentan has no additional ameliorating effects on PH development.
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Affiliation(s)
- Yiqing Zhang
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Research Unit of Respiratory Disease, Central South University, Changsha, Hunan 410011, China; Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan 410011, China.
| | - Shangjie Wu
- Department of Respiratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Research Unit of Respiratory Disease, Central South University, Changsha, Hunan 410011, China; Diagnosis and Treatment Center of Respiratory Disease, Central South University, Changsha, Hunan 410011, China.
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Aziz DA, Billoo AG, Qureshi A, Khalid M, Kirmani S. Clinical and laboratory profile of children with Cystic Fibrosis: Experience of a tertiary care center in Pakistan. Pak J Med Sci 2017; 33:554-559. [PMID: 28811770 PMCID: PMC5510102 DOI: 10.12669/pjms.333.12188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: To determine the clinical presentation, diagnostic investigations and laboratory workup done in admitted children with cystic fibrosis at Aga Khan University Hospital Karachi, Pakistan. Methods: This is athree years retrospective study from January 2013 to December 2015 conducted at The Aga Khan University Hospital Karachi Pakistan, enrolling admitted patient from birth to 15 years of either gender, diagnosed with CF on the basis of clinical features and positive sweat chloride test. Different clinical presentations were noted including initial presentations. Sweat chloride values more than 60mmol/L were labeled as positive and consistent with diagnosis of CF. Available Delta F-508 mutation analyses were noted. Relevant laboratory and radiological investigations including sputum culture and HR-CT chest findings were documented. Results were analyzed using SPSS version 20. Results: Total 43 children were selected according to the inclusion criteria. Chronic cough (69.76%) was the most common initial clinical presentation. Mean age at onset of symptoms was 14.41± 26.18 months and mean age at diagnosis was 47.20 ± 45.80 months Respiratory features were most common in our cohort including chronic productive cough (90.71%), recurrent bronchopneumonia (72.09%) and asthma like presentation (44.19%) with wheezing and cough. 86% patients presented with failure to thrive. Gastroenterological features including steatorrhea were seen in 55.81% patients and 44.19% patients had abdominal distension. Mean sweat chloride value in our population was 82.70± 22.74. Gene analysis for Delta F-508 was identified in 12 (27.90%) patients. Bronchiectatic pulmonary changes on HRCT were seen in 18 patients (41.86%). Pseudomonas grew in 12 patients (27.90%) in sputum cultures at the time of diagnosis. Conclusion: Respiratory presentations predominate in CF children followed by gastrointestinal features. Nearly half of our patient had bronchiectatic changes on CT scan chest and more than quarter had pseudomonas colonization in the airways at the time of diagnosis. Delta F-508 mutation was found to be uncommon in our study population. There is significant delay in diagnosing patients with CF.
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Affiliation(s)
- Danish Abdul Aziz
- Dr. Danish Abdul Aziz. MBBS, MRCPCH, FCPS. Senior Instructor, Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
| | - Abdul Gaffar Billoo
- Prof. Dr. Abdul Gaffar Billoo, MBBS, MRCP, FRCP. Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
| | - Ahad Qureshi
- Dr. Ahad Qureshi, MBBS. Graduate from Aga Khan University Hospital, Karachi, Pakistan. Aga Khan University Hospital, Karachi, Pakistan
| | - Misha Khalid
- Misha Khalid, Fourth Year Medical Student, Aga Khan University Hospital, Karachi, Pakistan
| | - Salman Kirmani
- Dr. Salman Kirmani, MBBS, FAAP. Associate Professor, Department of Paediatrics, Aga Khan University Hospital, Karachi, Pakistan
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Somayaji R, Ramos KJ, Kapnadak SG, Aitken ML, Goss CH. Common clinical features of CF (respiratory disease and exocrine pancreatic insufficiency). Presse Med 2017; 46:e109-e124. [PMID: 28554722 DOI: 10.1016/j.lpm.2017.03.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/06/2017] [Accepted: 03/29/2017] [Indexed: 12/17/2022] Open
Abstract
First described as a disease of the pancreas, cystic fibrosis is a genetically inherited progressive disease affecting multiple organ systems. Pulmonary and pancreatic involvement is common in individuals with cystic fibrosis, and the former is attributable to most of the mortality that occurs with the condition. This chapter provides an overview of a clinical approach to the pulmonary and pancreatic manifestations of cystic fibrosis.
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Affiliation(s)
- Ranjani Somayaji
- University of Calgary, Department of Medicine, Calgary, AB, Canada
| | - Kathleen J Ramos
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Siddhartha G Kapnadak
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Moira L Aitken
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA
| | - Christopher H Goss
- University of Washington, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Seattle, WA, USA; University of Washington, Department of Pediatrics, Division of Pediatric Pulmonology, Seattle, WA, USA; Seattle Children's Research Institute, Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle, WA, USA.
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38
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39
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Chaparro C, Keshavjee S. Lung transplantation for cystic fibrosis: an update. Expert Rev Respir Med 2016; 10:1269-1280. [DOI: 10.1080/17476348.2016.1261016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Ratjen F. Pulmonary artery hypertension: an underrated disease manifestation in cystic fibrosis? THE LANCET RESPIRATORY MEDICINE 2016; 4:596-598. [PMID: 27298018 DOI: 10.1016/s2213-2600(16)30107-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 05/02/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics, Physiology and Experimental Medicine, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada.
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41
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Pulmonary artery enlargement and cystic fibrosis pulmonary exacerbations: a cohort study. THE LANCET RESPIRATORY MEDICINE 2016; 4:636-645. [PMID: 27298019 PMCID: PMC5672808 DOI: 10.1016/s2213-2600(16)30105-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/28/2016] [Accepted: 04/28/2016] [Indexed: 01/04/2023]
Abstract
Background Acute pulmonary exacerbations are associated with progressive lung function decline and increased mortality in cystic fibrosis (CF). The role of pulmonary vascular disease in pulmonary exacerbations is unknown. We investigated the association between pulmonary artery enlargement (PA:A>1), a marker of pulmonary vascular disease, and exacerbations. Methods We analyzed clinical, computed tomography (CT), and prospective exacerbation data in a derivation cohort of 74 adult CF patients, measuring the PA:A at the level of the PA bifurcation. We then replicated our findings in a validation cohort of 190 adult CF patients. Patients were separated into groups based on the presence or absence of a PA:A>1 and were followed for 1-year in the derivation cohort and 2-years in the validation cohort. The primary endpoint was developing ≥1 acute pulmonary exacerbation during follow-up. Linear and logistic regression models were used to determine associations between clinical factors, the PA:A ratio, and pulmonary exacerbations. We used Cox regression to determine time to first exacerbation in the validation cohort. Findings We found that PA:A>1 was present in n=37/74 (50%) of the derivation and n=89/190 (47%) of the validation cohort. In the derivation cohort, n=50/74 (68%) had ≥1 exacerbation at 1 year and n=133/190 (70%) in the validation cohort had ≥1 exacerbation after 2 years. PA:A>1 was associated with younger age in both cohorts and with elevated sweat chloride (100.5±10.9 versus 90.4±19.9mmol/L, difference between groups 10.1mmol/L [95%CI 2.5–17.7], P=0.017) in the derivation group. PA:A>1 was associated with exacerbations in the derivation (OR 3.49, 95%CI 1.18–10.3, P=0.023) and validation (OR 2.41, 95%CI 1.06–5.52, P=0.037) cohorts when adjusted for confounders. Time to first exacerbation was shorter in PA:A>1 versus PA:A<1 [HR 1.66 (95%CI 1.18–2.34), P=0.004] in unadjusted analysis, but not when adjusted for sex, BMI, prior exacerbation, positive Pseudomonas status, and FEV1/FVC [HR 1.14 (95%CI 0.80–1.62), P=0.82]). Interpretation PA enlargement is prevalent in adult CF patients and is associated with acute pulmonary exacerbation risk in two well-characterized cohorts. PA:A may be a predictive marker in CF.
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Hayes D, Tumin D, Daniels CJ, McCoy KS, Mansour HM, Tobias JD, Kirkby SE. Pulmonary Artery Pressure and Benefit of Lung Transplantation in Adult Cystic Fibrosis Patients. Ann Thorac Surg 2016; 101:1104-9. [DOI: 10.1016/j.athoracsur.2015.09.086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 09/02/2015] [Accepted: 09/28/2015] [Indexed: 10/22/2022]
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Rowan SC, Keane MP, Gaine S, McLoughlin P. Hypoxic pulmonary hypertension in chronic lung diseases: novel vasoconstrictor pathways. THE LANCET RESPIRATORY MEDICINE 2016; 4:225-36. [PMID: 26895650 DOI: 10.1016/s2213-2600(15)00517-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/03/2015] [Accepted: 12/07/2015] [Indexed: 11/29/2022]
Abstract
Pulmonary hypertension is a well recognised complication of chronic hypoxic lung diseases, which are among the most common causes of death and disability worldwide. Development of pulmonary hypertension independently predicts reduced life expectancy. In chronic obstructive pulmonary disease, long-term oxygen therapy ameliorates pulmonary hypertension and greatly improves survival, although the correction of alveolar hypoxia and pulmonary hypertension is only partial. Advances in understanding of the regulation of vascular smooth muscle tone show that chronic vasoconstriction plays a more important part in the pathogenesis of hypoxic pulmonary hypertension than previously thought, and that structural vascular changes contribute less. Trials of existing vasodilators show that pulmonary hypertension can be ameliorated and systemic oxygen delivery improved in carefully selected patients, although systemic hypotensive effects limit the doses used. Vasoconstrictor pathways that are selective for the pulmonary circulation can be blocked to reduce hypoxic pulmonary hypertension without causing systemic hypotension, and thus provide potential targets for novel therapeutic strategies.
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Affiliation(s)
- Simon C Rowan
- UCD School of Medicine, Conway Institute, Dublin, Ireland
| | - Michael P Keane
- UCD School of Medicine, Respiratory Medicine, St Vincent's University Hospital, Dublin, Ireland
| | - Seán Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
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Affiliation(s)
- Thida Ong
- 1 Department of Pediatrics, University of Washington, Seattle, Washington.,2 Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, Washington; and
| | - Bonnie W Ramsey
- 1 Department of Pediatrics, University of Washington, Seattle, Washington.,3 Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
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Goncharova EA, Gladwin MT, Kawut SM. Update in Pulmonary Vascular Diseases 2014. Am J Respir Crit Care Med 2015; 192:544-50. [PMID: 26561677 DOI: 10.1164/rccm.201504-0829up] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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46
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Affiliation(s)
- Ben Wormser
- Pediatric Residency Program, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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47
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Survival in Patients with Advanced Non-cystic Fibrosis Bronchiectasis Versus Cystic Fibrosis on the Waitlist for Lung Transplantation. Lung 2015; 193:933-8. [DOI: 10.1007/s00408-015-9811-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 09/21/2015] [Indexed: 10/23/2022]
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Sawicki GS, Goss CH. Tackling the increasing complexity of CF care. Pediatr Pulmonol 2015; 50 Suppl 40:S74-9. [PMID: 26335957 PMCID: PMC4562023 DOI: 10.1002/ppul.23244] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/05/2015] [Accepted: 06/16/2015] [Indexed: 12/28/2022]
Abstract
Health outcomes for individuals with cystic fibrosis (CF) have dramatically improved in parallel with better organization of clinical care systems, evolution of novel therapeutics, and improvements in diagnosis and screening for CF and CF-related complications. In parallel with these advances has come an increasing complexity and burden of care, leading to challenges with adherence to treatment regimens. As novel therapeutics continue to be developed and introduced to the CF care regimen, there are clear opportunities to refine and personalize care. This can be done by adding comparative effectiveness research to the CF clinical research paradigm and integrating novel technologies in drug delivery and remote monitoring that can facilitate adherence but also reduce the burden of treatment while maintaining efficacy. This review highlights both the challenges of the increasingly complex treatment regimens in CF and the opportunities to advance care by addressing adherence, implementation science, comparative effectiveness, and integration of novel technologies in CF care.
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Affiliation(s)
- Gregory S Sawicki
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, Massachusetts
| | - Christopher H Goss
- Division of Pulmonary Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington
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49
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Lynch JP, Sayah DM, Belperio JA, Weigt SS. Lung transplantation for cystic fibrosis: results, indications, complications, and controversies. Semin Respir Crit Care Med 2015; 36:299-320. [PMID: 25826595 DOI: 10.1055/s-0035-1547347] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Survival in patients with cystic fibrosis (CF) has improved dramatically over the past 30 to 40 years, with mean survival now approximately 40 years. Nonetheless, progressive respiratory insufficiency remains the major cause of mortality in CF patients, and lung transplantation (LT) is eventually required. Timing of listing for LT is critical, because up to 25 to 41% of CF patients have died while awaiting LT. Globally, approximately 16.4% of lung transplants are performed in adults with CF. Survival rates for LT recipients with CF are superior to other indications, yet LT is associated with substantial morbidity and mortality (∼50% at 5-year survival rates). Myriad complications of LT include allograft failure (acute or chronic), opportunistic infections, and complications of chronic immunosuppressive medications (including malignancy). Determining which patients are candidates for LT is difficult, and survival benefit remains uncertain. In this review, we discuss when LT should be considered, criteria for identifying candidates, contraindications to LT, results post-LT, and specific complications that may be associated with LT. Infectious complications that may complicate CF (particularly Burkholderia cepacia spp., opportunistic fungi, and nontuberculous mycobacteria) are discussed.
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David M Sayah
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S Sam Weigt
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
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Abstract
Hypoxic pulmonary vasoconstriction (HPV) optimizes pulmonary ventilation-perfusion matching in regional hypoxia, but promotes pulmonary hypertension in global hypoxia. Ventilation-perfusion mismatch is a major cause of hypoxemia in cystic fibrosis. We hypothesized that cystic fibrosis transmembrane conductance regulator (CFTR) may be critical in HPV, potentially by modulating the response to sphingolipids as mediators of HPV. HPV and ventilation-perfusion mismatch were analyzed in isolated mouse lungs or in vivo. Ca(2+) mobilization and transient receptor potential canonical 6 (TRPC6) translocation were studied in human pulmonary (PASMCs) or coronary (CASMCs) artery smooth muscle cells. CFTR inhibition or deficiency diminished HPV and aggravated ventilation-perfusion mismatch. In PASMCs, hypoxia caused CFTR to interact with TRPC6, whereas CFTR inhibition attenuated hypoxia-induced TRPC6 translocation to caveolae and Ca(2+) mobilization. Ca(2+) mobilization by sphingosine-1-phosphate (S1P) was also attenuated by CFTR inhibition in PASMCs, but amplified in CASMCs. Inhibition of neutral sphingomyelinase (nSMase) blocked HPV, whereas exogenous nSMase caused TRPC6 translocation and vasoconstriction that were blocked by CFTR inhibition. nSMase- and hypoxia-induced vasoconstriction, yet not TRPC6 translocation, were blocked by inhibition or deficiency of sphingosine kinase 1 (SphK1) or antagonism of S1P receptors 2 and 4 (S1P2/4). S1P and nSMase had synergistic effects on pulmonary vasoconstriction that involved TRPC6, phospholipase C, and rho kinase. Our findings demonstrate a central role of CFTR and sphingolipids in HPV. Upon hypoxia, nSMase triggers TRPC6 translocation, which requires its interaction with CFTR. Concomitant SphK1-dependent formation of S1P and activation of S1P2/4 result in phospholipase C-mediated TRPC6 and rho kinase activation, which conjointly trigger vasoconstriction.
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