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John TM, Shrestha N, Hasan L, Pappan K, Birch O, Grove DE, Boyle B, Allsworth M, Shrestha P, Procop G, Dweik RA. Detection of Clostridioides difficileinfection by assessment of exhaled breath volatile organic compounds. J Breath Res 2024. [PMID: 38502958 DOI: 10.1088/1752-7163/ad3572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Clostridioides difficileinfection (CDI) is the leading cause of hospital-acquired infective diarrhea. Current methods for diagnosing CDI have limitations; enzyme immunoassays for toxin have low sensitivity andClostridioides difficilePCR cannot differentiate infection from colonization. An ideal diagnostic test that incorporates microbial factors, host factors, and host-microbe interaction might characterize true infection. Assessing volatile organic compounds (VOCs) in exhaled breath may be a useful test for identifying CDI. To identify a wide selection of VOCs in exhaled breath, we used thermal desorption-gas chromatography-mass spectrometry to study breath samples from 17 patients with CDI. Age- and sex-matched patients with diarrhea and negative C.difficile testing (no CDI) were used as controls. Of the 65 VOCs tested, 9 were used to build a quadratic discriminant model that showed a final cross-validated accuracy of 74%, a sensitivity of 71%, a specificity of 76%, and a receiver operating characteristic area under the curve of 0.72. If these findings are proven by larger studies, breath VOC analysis may be a helpful adjunctive diagnostic test for CDI.
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Affiliation(s)
- Teny M John
- Infectious Diseases, UH MD Anderson Library, 1515 Holcombe Blvd, Houston, Texas, 77204-2000, UNITED STATES
| | - Nabin Shrestha
- Infectious Disease/Medicine Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA, Cleveland, 44195, UNITED STATES
| | - Leen Hasan
- Medicine, Columbia University Irving Medical Center, New York, New York, New York, 10032-3784, UNITED STATES
| | - Kirk Pappan
- Acclivity technology, 6135 Park South Drive Ste 510, Charlotte, NC, Charlotte, 28210, UNITED STATES
| | - Owen Birch
- Owlstone Medical Ltd, 183 Cambridge Science Park, Cambridge, CB4 0GJ, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - David E Grove
- Inflammation and Immunity, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA, Cleveland , Ohio, 44195, UNITED STATES
| | - Billy Boyle
- Owlstone Ltd, Owlstone Inc., Cambridge, Cambridgeshire, CB4 0GJ, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Max Allsworth
- Owlstone Ltd, 183 Cambridge Science Park Milton Road Cambridge, Cambridge, Cambridgeshire, CB4 0GJ, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
| | - Priyanka Shrestha
- Computer Science, Stanford University, Stanford, California, Stanford, California, 94305-6104, UNITED STATES
| | - Gary Procop
- The American Board of Pathology, Tampa Florida, Tampa, Florida, 33609-2571, UNITED STATES
| | - Raed A Dweik
- Departments of Pulmonary and Critical Care Medicine / Respiratory Institute, and Pathobiology / Lerner Research Institute, Cleveland Clinic Foundation, Director, Cleveland Clinic, Cleveland, Ohio, 44195, cleveland, Ohio, 44195, UNITED STATES
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Tang WHW, Tranchito L, Albert C, Gul ZG, Cikach FS, Grove D, Wu Y, Dweik RA. Exhaled Breath Analysis Using Selected Ion Flow Tube Mass Spectrometry and Disease Severity in Heart Failure. Metabolites 2023; 13:1049. [PMID: 37887374 PMCID: PMC10608518 DOI: 10.3390/metabo13101049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/28/2023] Open
Abstract
Exhaled breath volatile organic compounds (VOCs) are elevated in heart failure (HF). The ability of VOCs to predict long term cardiovascular mortality and morbidity has not been independently verified. In 55 patients admitted with acute decompensated heart failure (ADHF), we measured exhaled breath acetone and pentane levels upon admission and after 48 h of diuresis. In a separate cohort of 51 cardiac patients undergoing cardiopulmonary exercise testing (CPET), we measured exhaled breath acetone and pentane levels before and at peak exercise. In the ADHF cohort, admission acetone levels correlated with lower left ventricular ejection fraction (LVEF, r = -0.297, p = 0.035). Greater weight loss with diuretic therapy correlated with a greater reduction in both acetone levels (r = -0.398, p = 0.003) and pentane levels (r = -0.309, p = 0.021). In patients with above-median weight loss (≥4.5 kg), patients demonstrated significantly greater percentage reduction in acetone (59% reduction vs. 7% increase, p < 0.001) and pentane (23% reduction vs. 2% reduction, p = 0.008). In the CPET cohort, admission acetone and pentane levels correlated with higher VE/VCO2 (r = 0.39, p = 0.005), (r = 0.035, p = 0.014). However, there were no significant correlations between baseline or peak exercise acetone and pentane levels and peak VO2. In longitudinal follow-up with a median duration of 33 months, patients with elevated exhaled acetone and pentane levels experienced higher composite adverse events of death, ventricular assist device implantation, or orthotopic heart transplantation. In patients admitted with ADHF, higher exhaled breath acetone levels are associated with lower LVEF and poorer outcomes, and greater reductions in exhaled breath acetone and pentane tracked with greater weight loss. Exhaled acetone and pentane may be novel biomarkers in heart failure worthy of future investigation.
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Affiliation(s)
- Wai Hong Wilson Tang
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Lily Tranchito
- Endocrinology & Metabolism Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Chonyang Albert
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Zeynep G. Gul
- Department of Surgery, Washington University School of Medicine at St Louis, St Louis, MO 63110, USA
| | - Frank S. Cikach
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - David Grove
- Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (D.G.); (R.A.D.)
- Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Yuping Wu
- Department of Mathematics, Cleveland State University, Cleveland, OH 44195, USA
| | - Raed A. Dweik
- Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (D.G.); (R.A.D.)
- Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Sullivan AB, Davin SA, Lapin B, Schuster AT, Dweik RA, Murray KF, Rehm SJ, Machado AG. Effects of flexible scheduling and virtual visits on burnout for clinicians: 1- year follow-up. Mult Scler Relat Disord 2023; 75:104721. [PMID: 37178579 DOI: 10.1016/j.msard.2023.104721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/28/2023] [Accepted: 04/15/2023] [Indexed: 05/15/2023]
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Khirfan G, Melillo CA, Al Abdi S, Lane JE, Dweik RA, Chatburn RL, Hatipoğlu U, Tonelli AR. Impact of Esophageal Pressure Measurement on Pulmonary Hypertension Diagnosis in Patients With Obesity. Chest 2022; 162:684-692. [PMID: 35405108 PMCID: PMC9808718 DOI: 10.1016/j.chest.2022.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/28/2022] [Accepted: 04/03/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Elevated intrathoracic pressure could affect pulmonary vascular pressure measurements and influence pulmonary hypertension (PH) diagnosis and classification. Esophageal pressure (Pes) measurement adjusts for the increase in intrathoracic pressure, better reflecting the pulmonary hemodynamics in patients with obesity. RESEARCH QUESTION In individuals with obesity, what is the impact of adjusting pulmonary hemodynamic determinations for Pes on PH diagnosis and classification? Can Pes be estimated by positional or respiratory hemodynamic changes? STUDY DESIGN AND METHODS In this prospective cohort study, we included patients with obesity who underwent right heart catheterization and demonstrated elevated pulmonary artery wedge pressure (PAWP; ≥ 12 mm Hg). After placement of an esophageal balloon, we performed pressure determination using an air-filled transducer connected to a regular hemodynamic monitor. We measured pulmonary pressures changes when sitting and the variations during the respiratory cycle. RESULTS We included 53 patients (mean ± SD age, 59 ± 12 years; mean ± SD BMI, 44.4 ± 10.2 kg/m2). Supine end-expiratory pressures revealed a mean pulmonary artery pressure of > 20 mm Hg in all patients and a PAWP of >15 mm Hg in most patients (n = 50). The Pes adjustment led to a significant decrease in percentage of patients with postcapillary PH (from 60% to 8%) and combined precapillary and postcapillary PH (from 34% to 11%), at the expense of an increase in percentage of patients with no PH (0% to 23%), isolated precapillary PH (2% to 25%), and undifferentiated PH (4% to 34%). INTERPRETATION Adjusting pulmonary hemodynamics for Pes in patients with obesity leads to a pronounced reduction in the number of patients who receive a diagnosis of postcapillary PH. Measuring Pes should be considered in patients with obesity, particularly those with elevated PAWP.
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Affiliation(s)
- Ghaleb Khirfan
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland
| | - Celia A Melillo
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland
| | - Sami Al Abdi
- Department of Internal Medicine, Cleveland Clinic Fairview Hospital, Fairview, OH
| | | | - Raed A Dweik
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland
| | | | - Umur Hatipoğlu
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland
| | - Adriano R Tonelli
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland.
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Aggarwal M, Li M, Bhardwaj A, Wallace WD, Wang X, Carey WD, Dweik RA, Heresi GA, Tonelli AR. Predictors of survival in portopulmonary hypertension: a 20-year experience. Eur J Gastroenterol Hepatol 2022; 34:449-456. [PMID: 34907982 PMCID: PMC8891035 DOI: 10.1097/meg.0000000000002322] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND OBJECTIVES Portopulmonary hypertension (PoPH) is a rare complication of portal hypertension associated with poor survival. Scarce data is available on predictors of survival in PoPH with conflicting results. We sought to characterize the outcomes and variables associated with survival in a large cohort of patients with PoPH in an American population of patients. STUDY DESIGN AND METHODS We identified PoPH patients from the Cleveland Clinic Pulmonary Hypertension Registry between 1998 and 2019. We collected prespecified data, particularly focusing on hepatic and cardiopulmonary assessments and tested their effect on long-term survival. RESULTS Eighty patients with PoPH with a mean ± SD age of 54 ± 10 years, (54% females) were included in the analysis. The median Model for End-Stage Liver Disease with sodium (MELD-Na) score was 13.0 (10.0-18.0) at PoPH diagnosis. World Health Association functional class III-IV was noted in 57%. Mean pulmonary arterial pressure was 47 ± 10 mmHg and pulmonary vascular resistance 6.0 ± 2.8 Woods units. A total of 63 (78.5%) patients were started on pulmonary arterial hypertension (PAH)-specific treatment during the first 6 months of diagnosis. Survival rates at 1-, 3- and 5-year were 77, 52 and 34%, respectively. Cardiopulmonary hemodynamics as well as PAH-specific treatment did not affect survival. In the multivariable model, MELD-Na, resting heart rate and the presence of hepatic encephalopathy were independent predictors of survival. CONCLUSION PoPH patients have poor 5-year survival which is strongly associated to the severity of underlying liver disease and not to the hemodynamic severity of PoPH; therefore efforts should be focused in facilitating liver transplantation for these patients.
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Affiliation(s)
- Manik Aggarwal
- Department of Internal Medicine, Cleveland Clinic, OH, USA
| | - Manshi Li
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Abhishek Bhardwaj
- Department of Pulmonary and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - William D. Carey
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Raed A. Dweik
- Department of Pulmonary and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gustavo A. Heresi
- Department of Pulmonary and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Adriano R. Tonelli
- Department of Pulmonary and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Anand CL, Dweik RA. Physician Interactions With Industry: Striking the Right Balance. J Natl Compr Canc Netw 2021; 20:jnccn21487. [PMID: 34965509 DOI: 10.6004/jnccn.2021.7100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Al Abdi S, Almoushref A, Naal T, Melillo CA, Aulak KS, Ahmed MK, Chatterjee S, Highland KB, Dweik RA, Tonelli AR. Cutaneous iontophoresis of vasoactive medications in patients with scleroderma-associated pulmonary arterial hypertension. Microcirculation 2021; 29:e12734. [PMID: 34741773 DOI: 10.1111/micc.12734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 10/26/2021] [Accepted: 10/30/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND It remains unknown whether the cutaneous microvascular responses are different between patients with scleroderma-associated pulmonary arterial hypertension (SSc-PAH) and SSc without pulmonary hypertension (PH). METHODS We included 59 patients with SSc between March 2013 and September 2019. We divided patients into 4 groups: (a) no PH by right heart catheterization (RHC) (n = 8), (b) no PH by noninvasive screening tests (n = 16), (c) treatment naïve PAH (n = 16), and (d) PAH under treatment (n = 19). Microvascular studies using laser Doppler flowmetry (LDF) were done immediately after RHC or at the time of an outpatient clinic visit (group b). RESULTS The median (IQR) age was 59 (54-68) years, and 90% were females. The responses to local thermal stimulation and postocclusive reactive hyperemia, acetylcholine, and sodium nitroprusside iontophoresis were similar among groups. The microvascular response to treprostinil was more pronounced in SSc patients without PH by screening tests (% change: 340 (214-781)) compared with SSc-PAH (naïve + treatment) (Perfusion Units (PU) % change: 153 (94-255) % [p = .01]). The response to A-350619 (a soluble guanylate cyclase (sGC) activator) was significantly higher in patients with SSc without PH by screening tests (PU % change: 168 (46-1,296)) than those with SSc-PAH (PU % change: 22 (15-57) % [p = .006]). The % change in PU with A350619 was directly associated with cardiac index and stroke volume index (R: 0.36, p = .03 and 0.39, p = .02, respectively). CONCLUSIONS Patients with SSc-PAH have a lower cutaneous microvascular response to a prostacyclin analog treprostinil and the sGC activator A-350619 when compared with patients with SSc and no evidence of PH on screening tests, presumably due to a peripheral reduction in prostacyclin receptor expression and nitric oxide bioavailability.
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Affiliation(s)
- Sami Al Abdi
- Cleveland Clinic Fairview Hospital, Cleveland Clinic, Cleveland, Ohio, USA
| | - Allaa Almoushref
- Internal medicine Department, University of Connecticut, Hartford, Connecticut, USA
| | - Tawfeq Naal
- Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Celia A Melillo
- Inflammation and Immunity Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kulwant S Aulak
- Inflammation and Immunity Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mostafa K Ahmed
- Department of Chest Diseases, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Soumya Chatterjee
- Department of Rheumatic and Immunologic Diseases, Orthopaedic and Rheumatologic Institute Cleveland Clinic, Cleveland, OH, USA
| | - Kristin B Highland
- Department of Pulmonary, Allergy and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Raed A Dweik
- Department of Pulmonary, Allergy and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Adriano R Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Mey JT, Rath MC, McLaughlin K, Galang M, Lynch K, DiMattio J, Nason H, Yang S, Melillo CA, Grove DE, Tonelli AR, Heresi GA, Kirwan JP, Dweik RA. The breath print represents a novel biomarker of malnutrition in pulmonary arterial hypertension: A proof of concept study. JPEN J Parenter Enteral Nutr 2021; 45:1645-1652. [PMID: 34633675 PMCID: PMC9244406 DOI: 10.1002/jpen.2277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND The breath print is a quantitative measurement of molecules in exhaled breath and represents a new frontier for biomarker identification. It is unknown whether this state-of-the-art, noninvasive method can detect malnutrition. We hypothesize that individuals with malnutrition will present with a distinguishable breath print. METHODS We conducted a retrospective chart review on patients with previously analyzed breath samples to identify malnutrition. Breath was analyzed by selected-ion flow-tube mass spectrometry. Registered dietitians conducted a retrospective chart review to collect malnutrition diagnoses and nutrition status indicators. Patients were categorized into one of four groups: pulmonary arterial hypertension (PAH), PAH with malnutrition (PAH-Mal), control, and control with malnutrition (Control-Mal), based on the malnutrition diagnosis present in the patient's chart. Principle component analysis was conducted to characterize the breath print. A logistic regression model with forward selection was used to detect the best breath predictor combination of malnutrition. RESULTS A total of 74 patients met inclusion criteria (PAH: 52; PAH-Mal: 10; control: 10; Control-Mal: 2). Levels of 1-octene (PAH-Mal, 5.1 ± 1.2; PAH, 12.5 ± 11.2; P = 0.005) and ammonia (PAH-Mal, 14.6 ± 15.8; PAH, 56.2 ± 64.2; P = 0.013) were reduced in PAH-Mal compared with PAH. The combination of 1-octene (P = 0.010) and 3-methylhexane (P = 0.045) distinguished malnutrition in PAH (receiver operating characteristic area under the curve: 0.8549). CONCLUSIONS This proof of concept study provides the first evidence that the breath print is altered in malnutrition. Larger prospective studies are needed to validate these results and establish whether breath analysis may be a useful tool to screen for malnutrition in the clinical setting.
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Affiliation(s)
- Jacob T. Mey
- Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Mary C. Rath
- Center for Human Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Marianne Galang
- Center for Human Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kathryn Lynch
- Center for Human Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jaime DiMattio
- Center for Human Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hillary Nason
- Center for Human Nutrition, Cleveland Clinic, Cleveland, Ohio, USA,Nutrition Department, Case Western Reserve University, Cleveland, Ohio, USA
| | - Shengping Yang
- Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Celia A. Melillo
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - David E. Grove
- Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - John P. Kirwan
- Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Raed A. Dweik
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Navaneethan U, Spencer C, Zhu X, Vargo JJ, Grove D, Dweik RA. Volatile organic compounds in bile can distinguish pancreatic cancer from chronic pancreatitis: a prospective observational study. Endoscopy 2021; 53:732-736. [PMID: 32894868 DOI: 10.1055/a-1255-9169] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Early and accurate diagnosis of pancreatic cancer is important. Our aim was to identify potential volatile organic compounds (VOCs) in the bile that can help distinguish pancreatic cancer from chronic pancreatitis. METHODS In this prospective observational study, bile was aspirated from patients undergoing endoscopic retrograde cholangiopancreatography for chronic pancreatitis and pancreatic cancer, and the gaseous headspace was analyzed using mass spectrometry. RESULTS The study included a discovery cohort of 57 patients (46 pancreatic cancer, 11 chronic pancreatitis) and a validation cohort of 31 patients (19 and 12, respectively). Using logistic regression analysis, the model [0.158 × age + 9.747 × log (ammonia) - 3.994 × log (acetonitrile) + 5.044 × log (trimethylamine) - 30.23] successfully identified patients with pancreatic cancer with a sensitivity of 93.5 % and specificity of 100 % (likelihood ratio 40.9, area under the curve 0.98, 95 % confidence interval 0.95 - 1.00). The diagnostic accuracy of this model was confirmed in the second independent validation cohort. CONCLUSION The measurement of VOCs in bile helped to accurately distinguish pancreatic cancer from chronic pancreatitis.
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Affiliation(s)
| | - Chad Spencer
- Department of Gastroenterology and Hepatology, University of South Alabama College of Medicine, Mobile, Alabama, United States
| | - Xiang Zhu
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, Florida, United States
| | - John J Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland, Ohio, United States
| | - David Grove
- Pathobiology, Lerners Research Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Raed A Dweik
- Pathobiology, Lerners Research Institute, Cleveland Clinic, Cleveland, Ohio, United States
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Khirfan G, Li M, Wang X, Dweik RA, Heresi GA, Tonelli AR. Is pulmonary vascular resistance index better than pulmonary vascular resistance in predicting outcomes in pulmonary arterial hypertension? J Heart Lung Transplant 2021; 40:614-622. [PMID: 33962868 DOI: 10.1016/j.healun.2021.03.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/09/2021] [Accepted: 03/29/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In contrast to pulmonary vascular resistance (PVR), PVR index (PVRI) accounts for variations in body habitus. We tested the association of PVRI compared to PVR with clinical outcomes in lean and obese (BMI ≥30 kg/m2) patients with pulmonary arterial hypertension (PAH). METHODS This retrospective study included adult patients with PAH who underwent right heart catheterization at Cleveland Clinic between February 1992 and November 2019. RESULTS We included 644 patients (mean age, 53 ± 16 years, and 74 % females). PAH was idiopathic or heritable in 44% of patients. Cardiac output increased (p <0.0001), while PVR decreased (p <0.0001) with increasing body weight. Both PVR and PVRI were associated with markers of disease severity, with more pronounced association for PVRI. Both PVR and PVRI were risk factors for first PAH hospitalization, mortality and mortality or lung transplant in the whole cohort and the group of patients with BMI < 30 kg/m2. However, PVRI (HR (95% CI): 1.06 (1.02 -1.11)), but not PVR (HR (95% CI): 1.03 (0.99-1.07)), was a risk factor for first PAH hospitalization in obese patients. In the obese group, neither PVR nor PVRI were risk factors for mortality. CONCLUSIONS PVRI appears to have a stronger association than PVR with disease severity markers in PAH; however, both PVR and PVRI were similarly associated with hospitalizations and survival in the overall cohort. We found no strong evidence to recommend a change from PVR to PVRI in the definition of PAH.
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Affiliation(s)
- Ghaleb Khirfan
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manshi Li
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Raed A Dweik
- Department of Pulmonary, Allergy and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Adriano R Tonelli
- Staff, Department of Pulmonary and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, Ohio.
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Khirfan G, Li M, Wang X, DiDonato JA, Dweik RA, Heresi GA. Abnormal levels of apolipoprotein A-I in chronic thromboembolic pulmonary hypertension. Pulm Circ 2021; 11:20458940211010371. [PMID: 33996028 PMCID: PMC8071975 DOI: 10.1177/20458940211010371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/25/2021] [Indexed: 12/02/2022] Open
Abstract
Recent studies have shown low high-density lipoprotein cholesterol (HDL-C) and dysregulated lipid metabolism in chronic thromboembolic pulmonary hypertension (CTEPH). Apolipoprotein A-I (ApoA-I) is the major protein component of HDL-C and mediates most of its functions. We hypothesize that ApoA-1 and its oxidative state might be more sensitive biomarkers in CTEPH. Plasma levels of HDL-C, ApoA-I, paraoxonase-1 enzyme activity (PON1), and the oxidized dysfunctional ApoA-I (oxTrp72-ApoA-I) were measured in patients with CTEPH and compared to those in healthy controls. Association with markers of disease severity in CTEPH was assessed. We included a total of 61 patients with CTEPH (age: 61.2 ± 15 years; male 52.5%) and 28 control subjects (age: 60.1 ± 8 years; male 59.3%). When adjusting for age, sex, body mass index, and statin use, ApoA-I was lower in CTEPH compared to controls (CTEPH:125.2 ± 27 mg/dl; control:158.3 ± 29.4 mg/dl; p < 0.001), but HDL-C levels were not statistically different. There were no significant differences in PON and oxTrp72-ApoA-I/ApoA-I ratio. In exploratory analyses, ApoA-I was associated with mean right atrial pressure (rs = -0.32, p = 0.013) and N-terminal pro B-type natriuretic peptide (rs = -0.31, p = 0.038). There were no significant associations between HDL-C, PON1, or oxTrp72-ApoA-I/ApoA-I ratio and markers of disease severity. We conclude that ApoA-I is a more sensitive biomarker than HDL-C in CTEPH, and may be associated with right heart dysfunction.
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Affiliation(s)
- Ghaleb Khirfan
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Manshi Li
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Joseph A. DiDonato
- Department of Cellular and Molecular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Raed A. Dweik
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gustavo A. Heresi
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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MacMurdo MG, Dweik RA. Cluster of Beryllium-Sensitized Individuals May Be Related to Environmental Exposure to Beryllium-Containing Concrete Dust. Chest 2021; 159:900-901. [PMID: 33678270 DOI: 10.1016/j.chest.2020.09.242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 11/26/2022] Open
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13
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Aulak KS, Al Abdi S, Li L, Crabb JS, Ghosh A, Willard B, Stuehr DJ, Crabb JW, Dweik RA, Tonelli AR. Disease-specific platelet signaling defects in idiopathic pulmonary arterial hypertension. Am J Physiol Lung Cell Mol Physiol 2021; 320:L739-L749. [PMID: 33596129 DOI: 10.1152/ajplung.00500.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Idiopathic pulmonary arterial hypertension (IPAH) is a rapidly progressive disease with several treatment options. Long-term mortality remains high with great heterogeneity in treatment response. Even though most of the pathology of IPAH is observed in the lung, there is systemic involvement. Platelets from patients with IPAH have characteristic metabolic shifts and defects in activation; therefore, we investigated whether they could be used to identify other disease-specific abnormalities. We used proteomics to investigate protein expression changes in platelets from patients with IPAH compared with healthy controls. Key abnormalities of nitric oxide pathway were tested in platelets from a larger cohort of unique patients with IPAH. Platelets showed abnormalities in the prostacyclin and nitric oxide pathways, which are dysregulated in IPAH and hence targets of therapy. We detected reduced expression of G protein αs and increased expression of the regulatory subunits of the cAMP-dependent protein kinase (PKA) type II isoforms, supporting an overall decrease in the activation of the prostacyclin pathway. We noted reduced levels of the soluble guanylate cyclase (sGC) subunits and increased expression of the phosphodiesterase type 5 A (PDE5A), conditions that affect the response to nitric oxide. Ensuing analysis of 38 unique patients with IPAH demonstrated considerable variation in the levels and specific activity of sGC, a finding with novel implications for personalized therapy. Platelets have some of the characteristic vasoactive signal abnormalities seen in IPAH and may provide comprehensive ex vivo mechanistic information to direct therapeutic decisions.
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Affiliation(s)
- Kulwant S Aulak
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sami Al Abdi
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ling Li
- Proteomics Shared Laboratory Resource, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jack S Crabb
- Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Arnab Ghosh
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Belinda Willard
- Proteomics Shared Laboratory Resource, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dennis J Stuehr
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - John W Crabb
- Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Raed A Dweik
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Adriano R Tonelli
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
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14
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Al-Naamani N, Krowka MJ, Forde KA, Krok KL, Feng R, Heresi GA, Dweik RA, Bartolome S, Bull TM, Roberts KE, Austin ED, Hemnes AR, Patel MJ, Oh JK, Lin G, Doyle MF, Denver N, Andrew R, MacLean MR, Fallon MB, Kawut SM. Estrogen Signaling and Portopulmonary Hypertension: The Pulmonary Vascular Complications of Liver Disease Study (PVCLD2). Hepatology 2021; 73:726-737. [PMID: 32407592 PMCID: PMC8115214 DOI: 10.1002/hep.31314] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/18/2020] [Accepted: 03/27/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Portopulmonary hypertension (POPH) was previously associated with a single-nucleotide polymorphism (SNP) rs7175922 in aromatase (cytochrome P450 family 19 subfamily A member 1 [CYP19A1]). We sought to determine whether genetic variants and metabolites in the estrogen signaling pathway are associated with POPH. APPROACH AND RESULTS We performed a multicenter case-control study. POPH patients had mean pulmonary artery pressure >25 mm Hg, pulmonary vascular resistance >240 dyn-sec/cm-5 , and pulmonary artery wedge pressure ≤15 mm Hg without another cause of pulmonary hypertension. Controls had advanced liver disease, right ventricular (RV) systolic pressure <40 mm Hg, and normal RV function by echocardiography. We genotyped three SNPs in CYP19A1 and CYP1B1 using TaqMan and imputed SNPs in estrogen receptor 1 using genome-wide markers. Estrogen metabolites were measured in blood and urine samples. There were 37 patients with POPH and 290 controls. Mean age was 57 years, and 36% were female. The risk allele A in rs7175922 (CYP19A1) was significantly associated with higher levels of estradiol (P = 0.02) and an increased risk of POPH (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.12-4.91; P = 0.02) whereas other SNPs were not. Lower urinary 2-hydroxyestrogen/16-α-hydroxyestrone (OR per 1-ln decrease = 2.04; 95% CI, 1.16-3.57; P = 0.01), lower plasma levels of dehydroepiandrosterone-sulfate (OR per 1-ln decrease = 2.38; 95% CI, 1.56-3.85; P < 0.001), and higher plasma levels of 16-α-hydroxyestradiol (OR per 1-ln increase = 2.16; 95% CI, 1.61-2.98; P < 0.001) were associated with POPH. CONCLUSIONS Genetic variation in aromatase and changes in estrogen metabolites were associated with POPH.
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Affiliation(s)
- Nadine Al-Naamani
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Kimberly A. Forde
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Karen L. Krok
- Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Rui Feng
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Raed A. Dweik
- Department of Medicine, Cleveland Clinic, Cleveland, OH
| | | | - Todd M. Bull
- Department of Medicine, University of Colorado, Denver, CO
| | | | - Eric D. Austin
- Department of Pediatrics, Vanderbilt University, Nashville, TN
| | - Anna R. Hemnes
- Department of Medicine, Vanderbilt University, Nashville, TN
| | - Mamta J. Patel
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jae K. Oh
- Department of Medicine, Mayo Clinic, Rochester, MN
| | - Grace Lin
- Department of Medicine, Mayo Clinic, Rochester, MN
| | - Margaret F. Doyle
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, VT
| | - Nina Denver
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Ruth Andrew
- University/British Heart Foundation Centre for Cardiovascular Science and Edinburgh Mass Spectrometry Core, University of Edinburgh, Edinburgh, UK
| | - Margaret R. MacLean
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, Scotland
| | | | - Steven M. Kawut
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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15
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Gershon AS, Lindenauer PK, Wilson KC, Rose L, Walkey AJ, Sadatsafavi M, Anstrom KJ, Au DH, Bender BG, Brookhart MA, Dweik RA, Han MK, Joo MJ, Lavergne V, Mehta AB, Miravitlles M, Mularski RA, Roche N, Oren E, Riekert KA, Schoenberg NC, Stukel TA, Weiss CH, Wunsch H, Africk JJ, Krishnan JA. Informing Healthcare Decisions with Observational Research Assessing Causal Effect. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 203:14-23. [PMID: 33385220 PMCID: PMC7781125 DOI: 10.1164/rccm.202010-3943st] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Decisions in medicine are made on the basis of knowledge and reasoning, often in shared conversations with patients and families in consideration of clinical practice guideline recommendations, individual preferences, and individual goals. Observational studies can provide valuable knowledge to inform guidelines, decisions, and policy. Objectives: The American Thoracic Society (ATS) created a multidisciplinary ad hoc committee to develop a research statement to clarify the role of observational studies—alongside randomized controlled trials (RCTs)—in informing clinical decisions in pulmonary, critical care, and sleep medicine. Methods: The committee examined the strengths of observational studies assessing causal effects, how they complement RCTs, factors that impact observational study quality, perceptions of observational research, and, finally, the practicalities of incorporating observational research into ATS clinical practice guidelines. Measurements and Main Results: There are strengths and weakness of observational studies as well as RCTs. Observational studies can provide evidence in representative and diverse patient populations. Quality observational studies should be sought in the development of ATS clinical practice guidelines, and medical decision-making in general, when 1) no RCTs are identified or RCTs are appraised as being of low- or very low-quality (replacement); 2) RCTs are of moderate quality because of indirectness, imprecision, or inconsistency, and observational studies mitigate the reason that RCT evidence was downgraded (complementary); or 3) RCTs do not provide evidence for outcomes that a guideline committee considers essential for decision-making (e.g., rare or long-term outcomes; “sequential”). Conclusions: Observational studies should be considered in developing clinical practice guidelines and in making clinical decisions.
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16
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Pleil JD, Beauchamp JD, Dweik RA, Risby TH. A special issue: Flow, pressure, volume and time as dependent variables in breath analysis. J Breath Res 2020; 15:010201. [PMID: 33084604 DOI: 10.1088/1752-7163/abbe39] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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17
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18
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Dweik RA, Nigam A. Ten minutes with Dr Raed A Dweik, Chairman of the Respiratory Institute at the Cleveland Clinic. leader 2020. [DOI: 10.1136/leader-2020-000278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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19
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MacMurdo MG, Mroz MM, Culver DA, Dweik RA, Maier LA. Chronic Beryllium Disease: Update on a Moving Target. Chest 2020; 158:2458-2466. [PMID: 32768458 DOI: 10.1016/j.chest.2020.07.074] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/05/2020] [Accepted: 07/19/2020] [Indexed: 10/23/2022] Open
Abstract
Beryllium exposure remains an ongoing occupational health concern for workers worldwide. Since the initial Occupational Safety and Health Administration (OSHA) ruling on a permissible exposure limit (PEL) for beryllium in 1971, our understanding of the risks of beryllium sensitization and chronic beryllium disease (CBD) has evolved substantially. A new OSHA ruling released in early 2017 and implemented in late 2018 reduced the PEL for beryllium, increased requirements for medical screening and monitoring, and may ultimately enhance worker protection. This review highlights advances in our understanding of the pathway from beryllium exposure to sensitization and progression to CBD that guided the development of this OSHA ruling. Screening workers exposed to beryllium and management of CBD will also be discussed. Finally, we will discuss the role of beryllium as a cause of morbidity and mortality among exposed workers in this potentially preventable occupational lung disease.
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Affiliation(s)
| | - Margaret M Mroz
- Division of Environmental and Occupational Health Sciences, National Jewish Health, Denver, CO
| | | | - Raed A Dweik
- Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Lisa A Maier
- Division of Environmental and Occupational Health Sciences, National Jewish Health, Denver, CO
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20
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Khirfan G, Almoushref A, Naal T, Abuhalimeh B, Dweik RA, Heresi GA, Tonelli AR. Mixed Venous Oxygen Saturation Is a Better Prognosticator Than Cardiac Index in Pulmonary Arterial Hypertension. Chest 2020; 158:2546-2555. [PMID: 32629034 DOI: 10.1016/j.chest.2020.06.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/10/2020] [Accepted: 06/27/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND European Society of Cardiology (ESC) and European Respiratory Society (ERS) guidelines include thermodilution cardiac index (TDCI) and mixed venous oxygen saturation (SvO2) as two of the three hemodynamic determinations used in risk assessment of patients with pulmonary arterial hypertension (PAH). SvO2 may be a better measurement than TDCI to assess prognosis in patients with either idiopathic or heritable PAH. RESEARCH QUESTION What is the concordance between TDCI and SvO2 ESC/ERS risk group allocation and their prognostic value in patients with PAH? STUDY DESIGN AND METHODS In this retrospective study, we assessed the correlation between SvO2 and TDCI in patients with idiopathic and heritable PAH. We determined concordance in the ESC/ERS risk group allocation and association with survival, both at baseline and follow-up. RESULTS A total of 158 patients (mean age, 58 ± 17 years; 72% women) with idiopathic (91%) and heritable (9%) PAH were included. There was moderate association between TDCI and SvO2 (r = 0.50; 95% CI, 0.37-0.62). Weighted kappa revealed a fair agreement between TDCI and SvO2 (κ = 0.30; 95% CI, 0.18-0.42), with concordance in risk group allocation in 49% of patients. During a median follow-up of 45 months (interquartile range, 23-105), 62 patients (39%) died. Using Kaplan-Meier analysis, survival was impacted by the SvO2 (log rank = 0.002) but not by the TDCI risk group allocation (log-rank = 0.51). Using the Cox proportional hazard model, adjusted for age and sex, SvO2 (but not TDCI) was associated with mortality (hazard ratio per 1% change, 0.94; 95% CI, 0.91-0.97; P < .001). INTERPRETATION When using the cutoffs proposed by the ESC/ERS guidelines, we noted poor concordance in risk score allocation between TDCI and SvO2. In patients with idiopathic or heritable PAH, SvO2 measurements are superior to TDCI in predicting long-term mortality.
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Affiliation(s)
- Ghaleb Khirfan
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | | | - Tawfeq Naal
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Raed A Dweik
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Adriano R Tonelli
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.
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21
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Aulak KS, Barnes JW, Tian L, Mellor NE, Haque MM, Willard B, Li L, Comhair SC, Stuehr DJ, Dweik RA. Specific O-GlcNAc modification at Ser-615 modulates eNOS function. Redox Biol 2020; 36:101625. [PMID: 32863226 PMCID: PMC7334407 DOI: 10.1016/j.redox.2020.101625] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/11/2020] [Accepted: 06/24/2020] [Indexed: 01/17/2023] Open
Abstract
Idiopathic pulmonary arterial hypertension (IPAH) is a progressive and devastating disease characterized by vascular smooth muscle and endothelial cell proliferation leading to a narrowing of the vessels in the lung. The increased resistance in the lung and the higher pressures generated result in right heart failure. Nitric Oxide (NO) deficiency is considered a hallmark of IPAH and altered function of endothelial nitric oxide synthase (eNOS), decreases NO production. We recently demonstrated that glucose dysregulation results in augmented protein serine/threonine hydroxyl-linked N-Acetyl-glucosamine (O-GlcNAc) modification in IPAH. In diabetes, dysregulated glucose metabolism has been shown to regulate eNOS function through inhibition of Ser-1177 phosphorylation. However, the link between O-GlcNAc and eNOS function remains unknown. Here we show that increased protein O-GlcNAc occurs on eNOS in PAH and Ser-615 appears to be a novel site of O-GlcNAc modification resulting in reduced eNOS dimerization. Functional characterization of Ser-615 demonstrated the importance of this residue on the regulation of eNOS activity through control of Ser-1177 phosphorylation. Here we demonstrate a previously unidentified regulatory mechanism of eNOS whereby the O-GlcNAc modification of Ser-615 results in reduced eNOS activity and endothelial dysfunction under conditions of glucose dysregulation.
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Affiliation(s)
- Kulwant S Aulak
- Inflammation and Immunity, Lerner Research Institute. Cleveland Clinic, OH, USA
| | - Jarrod W Barnes
- Inflammation and Immunity, Lerner Research Institute. Cleveland Clinic, OH, USA
| | - Liping Tian
- Inflammation and Immunity, Lerner Research Institute. Cleveland Clinic, OH, USA
| | - Noel E Mellor
- Inflammation and Immunity, Lerner Research Institute. Cleveland Clinic, OH, USA
| | - Mohammad M Haque
- Inflammation and Immunity, Lerner Research Institute. Cleveland Clinic, OH, USA
| | - Belinda Willard
- Mass Spectrometry Laboratory for Protein Sequencing, Cleveland Clinic, OH, USA
| | - Ling Li
- Mass Spectrometry Laboratory for Protein Sequencing, Cleveland Clinic, OH, USA
| | - Suzy C Comhair
- Inflammation and Immunity, Lerner Research Institute. Cleveland Clinic, OH, USA
| | - Dennis J Stuehr
- Inflammation and Immunity, Lerner Research Institute. Cleveland Clinic, OH, USA
| | - Raed A Dweik
- Inflammation and Immunity, Lerner Research Institute. Cleveland Clinic, OH, USA; Department of Pulmonary, Allergy and Critical Care Medicine. Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
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22
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Grove D, Miller-Atkins G, Melillo C, Rieder F, Kurada S, Rotroff DM, Tonelli AR, Dweik RA. Comparison of volatile organic compound profiles in exhaled breath versus plasma headspace in different diseases. J Breath Res 2020; 14:036003. [PMID: 32272466 DOI: 10.1088/1752-7163/ab8866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Breath analysis is the study of volatile organic compounds (VOC's) in exhaled breath. This analysis provides information on the body's condition. In this study we investigated the relationship between 22 VOC's detected in exhaled breath and plasma headspace using a selected ion flow tube mass spectrometer (SYFT-MS). We compared pairs of exhaled breath and plasma samples from patients with pulmonary hypertension inflammatory bowel disease (IBD), and IBD patients after J-pouch surgery (pouch group). Half of the measured VOC's from exhaled breath were significantly associated with the VOC's from plasma headspace. Interestingly, six breath VOC's (trimethyl amine (FDR p = 0.02), hydrogen sulfide (FDR p = 7.64 × 10-30), ethanol (FDR p = 1.56 × 10-4), dimethyl sulfide (FDR p = 5.70 × 10-19), benzene (FDR p = 8.40 × 10-27), and acetaldehyde (FDR p = 4.27 × 10-17)) and two plasma headspace VOC's (1-Octene (FDR p = 0.02) and 2-propanol (FDR p = 2.47 × 10-9)) were able to differentiate between the three groups. Breath and plasma headspace share a similar signature with significant association in half of the measured VOCs. The disease discriminatory capacity of breath and plasma headspace appear to be different. Therefore, using the VOC's print from both breath and plasma headspace may better help diagnose patients.
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Affiliation(s)
- David Grove
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States of America
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23
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Pleil JD, Beauchamp JD, Risby TH, Dweik RA. The scientific rationale for the use of simple masks or improvised facial coverings to trap exhaled aerosols and possibly reduce the breathborne spread of COVID-19. J Breath Res 2020; 14:030201. [PMID: 32303016 PMCID: PMC7350772 DOI: 10.1088/1752-7163/ab8a55] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/17/2020] [Indexed: 01/23/2023]
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24
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Miller-Atkins G, Acevedo-Moreno LA, Grove D, Dweik RA, Tonelli AR, Brown JM, Allende DS, Aucejo F, Rotroff DM. Breath Metabolomics Provides an Accurate and Noninvasive Approach for Screening Cirrhosis, Primary, and Secondary Liver Tumors. Hepatol Commun 2020; 4:1041-1055. [PMID: 32626836 PMCID: PMC7327218 DOI: 10.1002/hep4.1499] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/30/2019] [Accepted: 02/07/2020] [Indexed: 12/20/2022] Open
Abstract
Hepatocellular carcinoma (HCC) and secondary liver tumors, such as colorectal cancer liver metastases are significant contributors to the overall burden of cancer‐related morality. Current biomarkers, such as alpha‐fetoprotein (AFP) for HCC, result in too many false negatives, necessitating noninvasive approaches with improved sensitivity. Volatile organic compounds (VOCs) detected in the breath of patients can provide valuable insight into disease processes and can differentiate patients by disease status. Here, we investigate whether 22 VOCs from the breath of 296 patients can distinguish those with no liver disease (n = 54), cirrhosis (n = 30), HCC (n = 112), pulmonary hypertension (n = 49), or colorectal cancer liver metastases (n = 51). This work extends previous studies by evaluating the ability for VOC signatures to differentiate multiple diseases in a large cohort of patients. Pairwise disease comparisons demonstrated that most of the VOCs tested are present in significantly different relative abundances (false discovery rate P < 0.1), indicating broad impacts on the breath metabolome across diseases. A predictive model developed using random forest machine learning and cross validation classified patients with 85% classification accuracy and 75% balanced accuracy. Importantly, the model detected HCC with 73% sensitivity compared with 53% for AFP in the same cohort. An added value of this approach is that influential VOCs in the predictive model may provide insight into disease etiology. Acetaldehyde and acetone, both of which have roles in tumor promotion, were considered important VOCs for differentiating disease groups in the predictive model and were increased in patients with cirrhosis and HCC compared to patients with no liver disease (false discovery rate P < 0.1). Conclusion: The use of machine learning and breath VOCs shows promise as an approach to develop improved, noninvasive screening tools for chronic liver disease and primary and secondary liver tumors.
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Affiliation(s)
- Galen Miller-Atkins
- Department of Quantitative Health Sciences Lerner Research Institute Cleveland Clinic Cleveland OH
| | | | - David Grove
- Department of Inflammation and Immunity Lerner Research Institute Cleveland Clinic Cleveland OH
| | - Raed A Dweik
- Respiratory Institute Cleveland Clinic Cleveland OH
| | | | - J Mark Brown
- Department of Cardiovascular and Metabolic Sciences Cleveland Clinic Cleveland OH.,Center for Microbiome in Human Health Cleveland Clinic Cleveland OH
| | | | | | - Daniel M Rotroff
- Department of Quantitative Health Sciences Lerner Research Institute Cleveland Clinic Cleveland OH
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25
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Mey JT, Hari A, Axelrod CL, Fealy CE, Erickson ML, Kirwan JP, Dweik RA, Heresi GA. Lipids and ketones dominate metabolism at the expense of glucose control in pulmonary arterial hypertension: a hyperglycaemic clamp and metabolomics study. Eur Respir J 2020; 55:13993003.01700-2019. [PMID: 32108049 PMCID: PMC7263739 DOI: 10.1183/13993003.01700-2019] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/18/2020] [Indexed: 12/31/2022]
Abstract
Individuals with idiopathic pulmonary arterial hypertension (PAH) display reduced oral glucose tolerance. This may involve defects in pancreatic function or insulin sensitivity but this hypothesis has not been tested; moreover, fasting nutrient metabolism remains poorly described in PAH. Thus, we aimed to characterise fasting nutrient metabolism and investigated the metabolic response to hyperglycaemia in PAH.12 participants (six PAH, six controls) were administered a hyperglycaemic clamp, while 52 (21 PAH, 31 controls) underwent plasma metabolomic analysis. Glucose, insulin, C-peptide, free fatty acids and acylcarnitines were assessed from the clamp. Plasma metabolomics was conducted on fasting plasma samples.The clamp verified a reduced insulin response to hyperglycaemia in PAH (-53% versus control), but with similar pancreatic insulin secretion. Skeletal muscle insulin sensitivity was unexpectedly greater in PAH. Hepatic insulin extraction was elevated in PAH (+11% versus control). Plasma metabolomics identified 862 metabolites: 213 elevated, 145 reduced in PAH (p<0.05). In both clamp and metabolomic cohorts, lipid oxidation and ketones were elevated in PAH. Insulin sensitivity, fatty acids, acylcarnitines and ketones correlated with PAH severity, while hepatic extraction and fatty acid:ketone ratio correlated with longer six-min walk distance.Poor glucose control in PAH could not be explained by pancreatic β-cell function or skeletal muscle insulin sensitivity. Instead, elevated hepatic insulin extraction emerged as an underlying factor. In agreement, nutrient metabolism in PAH favours lipid and ketone metabolism at the expense of glucose control. Future research should investigate the therapeutic potential of reinforcing lipid and ketone metabolism on clinical outcomes in PAH.
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Affiliation(s)
- Jacob T. Mey
- Integrative Physiology and Molecular Medicine Laboratory, Pennington Biomedical Research Center, Baton Rouge, LA,Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland OH
| | - Adithya Hari
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland OH
| | - Christopher L. Axelrod
- Integrative Physiology and Molecular Medicine Laboratory, Pennington Biomedical Research Center, Baton Rouge, LA,Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland OH,Department of Translational Services, Pennington Biomedical Research Center, Baton Rouge, LA
| | - Ciarán E. Fealy
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland OH,Diabetes and Metabolism Research Group, Maastricht University, Maastricht, Netherlands,Metabolic Translational Research Center, Endocrinology & Metabolism Institute, Cleveland Clinic, Cleveland, OH
| | - Melissa L. Erickson
- Integrative Physiology and Molecular Medicine Laboratory, Pennington Biomedical Research Center, Baton Rouge, LA,Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland OH
| | - John P. Kirwan
- Integrative Physiology and Molecular Medicine Laboratory, Pennington Biomedical Research Center, Baton Rouge, LA,Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland OH,Metabolic Translational Research Center, Endocrinology & Metabolism Institute, Cleveland Clinic, Cleveland, OH
| | - Raed A. Dweik
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland OH,Department of Pulmonary Care and Critical Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Gustavo A. Heresi
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland OH,Department of Pulmonary Care and Critical Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
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Mokhlesi B, Masa JF, Brozek JL, Gurubhagavatula I, Murphy PB, Piper AJ, Tulaimat A, Afshar M, Balachandran JS, Dweik RA, Grunstein RR, Hart N, Kaw R, Lorenzi-Filho G, Pamidi S, Patel BK, Patil SP, Pépin JL, Soghier I, Tamae Kakazu M, Teodorescu M. Evaluation and Management of Obesity Hypoventilation Syndrome. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 200:e6-e24. [PMID: 31368798 PMCID: PMC6680300 DOI: 10.1164/rccm.201905-1071st] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: The purpose of this guideline is to optimize evaluation and management of patients with obesity hypoventilation syndrome (OHS). Methods: A multidisciplinary panel identified and prioritized five clinical questions. The panel performed systematic reviews of available studies (up to July 2018) and followed the Grading of Recommendations, Assessment, Development, and Evaluation evidence-to-decision framework to develop recommendations. All panel members discussed and approved the recommendations. Recommendations: After considering the overall very low quality of the evidence, the panel made five conditional recommendations. We suggest that: 1) clinicians use a serum bicarbonate level <27 mmol/L to exclude the diagnosis of OHS in obese patients with sleep-disordered breathing when suspicion for OHS is not very high (<20%) but to measure arterial blood gases in patients strongly suspected of having OHS, 2) stable ambulatory patients with OHS receive positive airway pressure (PAP), 3) continuous positive airway pressure (CPAP) rather than noninvasive ventilation be offered as the first-line treatment to stable ambulatory patients with OHS and coexistent severe obstructive sleep apnea, 4) patients hospitalized with respiratory failure and suspected of having OHS be discharged with noninvasive ventilation until they undergo outpatient diagnostic procedures and PAP titration in the sleep laboratory (ideally within 2–3 mo), and 5) patients with OHS use weight-loss interventions that produce sustained weight loss of 25% to 30% of body weight to achieve resolution of OHS (which is more likely to be obtained with bariatric surgery). Conclusions: Clinicians may use these recommendations, on the basis of the best available evidence, to guide management and improve outcomes among patients with OHS.
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McDowell RE, Aulak KS, Almoushref A, Melillo CA, Brauer BE, Newman JE, Tonelli AR, Dweik RA. Platelet glycolytic metabolism correlates with hemodynamic severity in pulmonary arterial hypertension. Am J Physiol Lung Cell Mol Physiol 2020; 318:L562-L569. [PMID: 32022593 DOI: 10.1152/ajplung.00389.2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Group 1 pulmonary hypertension (PH), i.e., pulmonary arterial hypertension (PAH), is associated with a metabolic shift favoring glycolysis in cells comprising the lung vasculature as well as skeletal muscle and right heart. We sought to determine whether this metabolic switch is also detectable in circulating platelets from PAH patients. We used Seahorse Extracellular Flux to measure bioenergetics in platelets isolated from group 1 PH (PAH), group 2 PH, patients with dyspnea and normal pulmonary artery pressures, and healthy controls. We show that platelets from group 1 PH patients exhibit enhanced basal glycolysis and lower glycolytic reserve compared with platelets from healthy controls but do not differ from platelets of group 2 PH or dyspnea patients without PH. Although we were unable to identify a glycolytic phenotype unique to platelets from PAH patients, we found that platelet glycolytic metabolism correlated with hemodynamic severity only in group 1 PH patients, supporting the known link between PAH pathology and altered glycolytic metabolism and extending this association to ex vivo platelets. Pulmonary artery pressure and pulmonary vascular resistance in patients with group 1 PH were directly associated with basal platelet glycolysis and inversely associated with maximal and reserve glycolysis, suggesting that PAH progression reduces the capacity for glycolysis even while demanding an increase in glycolytic metabolism. Therefore, platelets may provide an easy-to-harvest, real-time window into the metabolic shift occurring in the lung vasculature and represent a useful surrogate for interrogating the glycolytic shift central to PAH pathology.
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Affiliation(s)
- Ruth E McDowell
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kulwant S Aulak
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Allaa Almoushref
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Celia A Melillo
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brittany E Brauer
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jennie E Newman
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Adriano R Tonelli
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Raed A Dweik
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
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Abstract
We aimed to characterize the plasma metabolome of chronic thromboembolic pulmonary hypertension patients using a high-throughput unbiased omics approach. We collected fasting plasma from a peripheral vein in 33 operable chronic thromboembolic pulmonary hypertension patients, 31 healthy controls, and 21 idiopathic pulmonary arterial hypertension patients matched for age, gender, and body mass index. Metabolomic analysis was performed using an untargeted approach (Metabolon Inc. Durham, NC). Of the total of 862 metabolites identified, 362 were different in chronic thromboembolic pulmonary hypertension compared to controls: 178 were higher and 184 were lower. Compared to idiopathic pulmonary arterial hypertension, 147 metabolites were different in chronic thromboembolic pulmonary hypertension: 45 were higher and 102 were lower. The plasma metabolome allowed us to distinguish subjects with chronic thromboembolic pulmonary hypertension and healthy controls with a predictive accuracy of 89%, and chronic thromboembolic pulmonary hypertension versus idiopathic pulmonary arterial hypertension with 80% accuracy. Compared to idiopathic pulmonary arterial hypertension and healthy controls, chronic thromboembolic pulmonary hypertension patients had higher fatty acids and glycerol; while acyl cholines and lysophospholipids were lower. Compared to healthy controls, both idiopathic pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension patients had increased acyl carnitines, beta-hydroxybutyrate, amino sugars and modified amino acids and nucleosides. The plasma global metabolomic profile of chronic thromboembolic pulmonary hypertension suggests aberrant lipid metabolism characterized by increased lipolysis, fatty acid oxidation, and ketogenesis, concomitant with reduced acyl choline and phospholipid moieties. Future research should investigate the pathogenetic and therapeutic potential of modulating lipid metabolism in chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Gustavo A. Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland, OH, USA
| | - Jacob T. Mey
- Integrative Physiology and Molecular Medicine Laboratory, Pennington Biomedical Research Center, Baton Rouge, LA, USA
| | - John R. Bartholomew
- Section of Vascular Medicine, Heart and Vascular Institute, Cleveland, OH, USA
| | - Ihab S. Haddadin
- Department of Diagnostic Radiology, Imaging Institute, Cleveland, OH, USA
| | - Adriano R. Tonelli
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland, OH, USA
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH, USA
| | - Raed A. Dweik
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland, OH, USA
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH, USA
| | - John P. Kirwan
- Integrative Physiology and Molecular Medicine Laboratory, Pennington Biomedical Research Center, Baton Rouge, LA, USA
| | - Satish C. Kalhan
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH, USA
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Barnes JW, Tian L, Krick S, Helton ES, Denson RS, Comhair SAA, Dweik RA. O-GlcNAc Transferase Regulates Angiogenesis in Idiopathic Pulmonary Arterial Hypertension. Int J Mol Sci 2019; 20:E6299. [PMID: 31847126 PMCID: PMC6941156 DOI: 10.3390/ijms20246299] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 12/17/2022] Open
Abstract
Idiopathic pulmonary arterial hypertension (IPAH) is considered a vasculopathy characterized by elevated pulmonary vascular resistance due to vasoconstriction and/or lung remodeling such as plexiform lesions, the hallmark of the PAH, as well as cell proliferation and vascular and angiogenic dysfunction. The serine/threonine hydroxyl-linked N-Acetylglucosamine (O-GlcNAc) transferase (OGT) has been shown to drive pulmonary arterial smooth muscle cell (PASMC) proliferation in IPAH. OGT is a cellular nutrient sensor that is essential in maintaining proper cell function through the regulation of cell signaling, proliferation, and metabolism. The aim of this study was to determine the role of OGT and O-GlcNAc in vascular and angiogenic dysfunction in IPAH. Primary isolated human control and IPAH patient PASMCs and pulmonary arterial endothelial cells (PAECs) were grown in the presence or absence of OGT inhibitors and subjected to biochemical assessments in monolayer cultures and tube formation assays, in vitro vascular sprouting 3D spheroid co-culture models, and de novo vascularization models in NODSCID mice. We showed that knockdown of OGT resulted in reduced vascular endothelial growth factor (VEGF) expression in IPAH primary isolated vascular cells. In addition, specificity protein 1 (SP1), a known stimulator of VEGF expression, was shown to have higher O-GlcNAc levels in IPAH compared to control at physiological (5 mM) and high (25 mM) glucose concentrations, and knockdown resulted in decreased VEGF protein levels. Furthermore, human IPAH PAECs demonstrated a significantly higher degree of capillary tube-like structures and increased length compared to control PAECs. Addition of an OGT inhibitor, OSMI-1, significantly reduced the number of tube-like structures and tube length similar to control levels. Assessment of vascular sprouting from an in vitro 3D spheroid co-culture model using IPAH and control PAEC/PASMCs and an in vivo vascularization model using control and PAEC-embedded collagen implants demonstrated higher vascularization in IPAH compared to control. Blocking OGT activity in these experiments, however, altered the vascular sprouting and de novo vascularization in IPAH similar to control levels when compared to controls. Our findings in this report are the first to describe a role for the OGT/O-GlcNAc axis in modulating VEGF expression and vascularization in IPAH. These findings provide greater insight into the potential role that altered glucose uptake and metabolism may have on the angiogenic process and the development of plexiform lesions. Therefore, we believe that the OGT/O-GlcNAc axis may be a potential therapeutic target for treating the angiogenic dysregulation that is present in IPAH.
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Affiliation(s)
- Jarrod W. Barnes
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, THT 422, 1720 2nd Ave S, Birmingham, AL 35294-0006, USA; (S.K.); (E.S.H.)
| | - Liping Tian
- Department of Inflammation & Immunity, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; (L.T.); (S.A.A.C.); (R.A.D.)
| | - Stefanie Krick
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, THT 422, 1720 2nd Ave S, Birmingham, AL 35294-0006, USA; (S.K.); (E.S.H.)
| | - E. Scott Helton
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, THT 422, 1720 2nd Ave S, Birmingham, AL 35294-0006, USA; (S.K.); (E.S.H.)
| | - Rebecca S. Denson
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, THT 422, 1720 2nd Ave S, Birmingham, AL 35294-0006, USA; (S.K.); (E.S.H.)
| | - Suzy A. A. Comhair
- Department of Inflammation & Immunity, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; (L.T.); (S.A.A.C.); (R.A.D.)
| | - Raed A. Dweik
- Department of Inflammation & Immunity, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; (L.T.); (S.A.A.C.); (R.A.D.)
- Respiratory Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
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Hamilton BK, Rybicki LA, Grove D, Ferraro C, Starn J, Hodgeman B, Elberson J, Winslow V, Corrigan D, Gerds AT, Hanna R, Kalaycio ME, Sobecks RM, Majhail NS, Dweik RA. Breath analysis in gastrointestinal graft-versus-host disease after allogeneic hematopoietic cell transplantation. Blood Adv 2019; 3:2732-2737. [PMID: 31530545 PMCID: PMC6759739 DOI: 10.1182/bloodadvances.2019000345] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 06/19/2019] [Indexed: 12/18/2022] Open
Abstract
Volatile organic compounds (VOCs) are generated during pathologic processes, and their assessment can be used to diagnose and monitor a variety of diseases. Given the role of the microbiome in graft-versus-host disease (GVHD), we hypothesized that microorganisms producing volatile metabolites may alter VOCs expelled in breath in patients with gastrointestinal (GI) GVHD. In this pilot study, exhaled breath samples were obtained from 19 patients with grade 2 to 4 acute GI GVHD, 10 patients with no GVHD at day 100, and 10 healthy control subjects; the samples were analyzed by using mass spectrometry. Overall, nine (47%) patients had grade 2 GVHD, eight (42%) patients had grade 3 GVHD, and two (11%) patients had grade 4 GVHD; 26% had upper GI, 21% had lower GI, and 53% had both upper and lower GI manifestations. Stepwise canonical discriminant analysis identified 5 VOCs distinguishing patients with and without GI GVHD: 2-propanol, acetaldehyde, dimethyl sulfide, isoprene, and 1-decene (Wilks' Λ, 0.43; F statistic, 6.08; P = .001). The model correctly classified 89% (17 of 19) and 90% (9 of 10) of patients with and without GI GVHD, respectively. Breath analysis is a feasible and promising noninvasive method to detect acute GI GVHD. Further study of serial breath analysis and the gut microbiome in a larger cohort are ongoing to validate these findings.
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Affiliation(s)
- Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH
| | - Lisa A Rybicki
- Quantitative Health Sciences, Cleveland Clinic Lerner Research Institute, Cleveland, OH
| | - David Grove
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, and
| | - Christina Ferraro
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH
| | - Jamie Starn
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH
| | - Brittany Hodgeman
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH
| | - Jamie Elberson
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH
| | - Victoria Winslow
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH
| | - Donna Corrigan
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH
| | - Aaron T Gerds
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH
| | - Rabi Hanna
- Pediatric Hematology Oncology, Cleveland Clinic, Cleveland, OH
| | - Matt E Kalaycio
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH
| | - Ronald M Sobecks
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH
| | - Navneet S Majhail
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH
| | - Raed A Dweik
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, and
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Heresi GA, Love TE, Tonelli AR, Highland KB, Dweik RA. Choice of Initial Oral Therapy for Pulmonary Arterial Hypertension: Age and Long-Term Survival. Am J Respir Crit Care Med 2019; 198:1090-1093. [PMID: 29949380 DOI: 10.1164/rccm.201801-0059le] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Thomas E Love
- 2 Case Western Reserve University School of Medicine Cleveland, Ohio
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Tonelli AR, Aulak KS, Ahmed MK, Hausladen A, Abuhalimeh B, Casa CJ, Rogers SC, Timm D, Doctor A, Gaston B, Dweik RA. A pilot study on the kinetics of metabolites and microvascular cutaneous effects of nitric oxide inhalation in healthy volunteers. PLoS One 2019; 14:e0221777. [PMID: 31469867 PMCID: PMC6716644 DOI: 10.1371/journal.pone.0221777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 08/14/2019] [Indexed: 11/19/2022] Open
Abstract
RATIONALE Inhaled nitric oxide (NO) exerts a variety of effects through metabolites and these play an important role in regulation of hemodynamics in the body. A detailed investigation into the generation of these metabolites has been overlooked. OBJECTIVES We investigated the kinetics of nitrite and S-nitrosothiol-hemoglobin (SNO-Hb) in plasma derived from inhaled NO subjects and how this modifies the cutaneous microvascular response. FINDINGS We enrolled 15 healthy volunteers. Plasma nitrite levels at baseline and during NO inhalation (15 minutes at 40 ppm) were 102 (86-118) and 114 (87-129) nM, respectively. The nitrite peak occurred at 5 minutes of discontinuing NO (131 (104-170) nM). Plasma nitrate levels were not significantly different during the study. SNO-Hb molar ratio levels at baseline and during NO inhalation were 4.7E-3 (2.5E-3-5.8E-3) and 7.8E-3 (4.1E-3-13.0E-3), respectively. Levels of SNO-Hb continued to climb up to the last study time point (30 min: 10.6E-3 (5.3E-3-15.5E-3)). The response to acetylcholine iontophoresis both before and during NO inhalation was inversely associated with the SNO-Hb level (r: -0.57, p = 0.03, and r: -0.54, p = 0.04, respectively). CONCLUSIONS Both nitrite and SNO-Hb increase during NO inhalation. Nitrite increases first, followed by a more sustained increase in Hb-SNO. Nitrite and Hb-SNO could be a mobile reservoir of NO with potential implications on the systemic microvasculature.
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Affiliation(s)
- Adriano R. Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, United States of America
- Pathobiology Division, Lerner Research Institute, Cleveland Clinic, OH, United States of America
| | - Kulwant S. Aulak
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, OH, United States of America
| | - Mostafa K. Ahmed
- Department of Chest Diseases, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Alfred Hausladen
- Institute for Transformative Molecular Medicine and Department of Medicine, Case Western Reserve University School of Medicine and University Hospitals Cleveland Medical Center, Cleveland, OH, United States of America
| | - Batool Abuhalimeh
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, OH, United States of America
| | - Charlie J. Casa
- Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, OH, United States of America
| | - Stephen C. Rogers
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - David Timm
- Department of Psychiatry, School of Medicine, Washington University, St. Louis, MO, United States of America
| | - Allan Doctor
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Benjamin Gaston
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Raed A. Dweik
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, United States of America
- Pathobiology Division, Lerner Research Institute, Cleveland Clinic, OH, United States of America
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Khirfan G, Ahmed MK, Almaaitah S, Almoushref A, Agmy GM, Dweik RA, Tonelli AR. Comparison of Different Methods to Estimate Cardiac Index in Pulmonary Arterial Hypertension. Circulation 2019; 140:705-707. [PMID: 31424987 DOI: 10.1161/circulationaha.119.041614] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ghaleb Khirfan
- Department of Pulmonary, Allergy, and Critical Care Medicine (G.K., R.A.D., A.R.T.), Respiratory Institute
| | - Mostafa K Ahmed
- Department of Pulmonary and Critical Care Medicine (M.K.A.), Respiratory Institute.,Department of Chest Diseases, Faculty of Medicine, Assiut University, Egypt (M.K.A., G.M.A.)
| | - Saja Almaaitah
- Department of Internal Medicine (S.A.), Medicine Institute
| | | | - Gamal M Agmy
- Department of Chest Diseases, Faculty of Medicine, Assiut University, Egypt (M.K.A., G.M.A.)
| | - Raed A Dweik
- Department of Pulmonary, Allergy, and Critical Care Medicine (G.K., R.A.D., A.R.T.), Respiratory Institute
| | - Adriano R Tonelli
- Department of Pulmonary, Allergy, and Critical Care Medicine (G.K., R.A.D., A.R.T.), Respiratory Institute
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Affiliation(s)
- Raed A Dweik
- Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Charlie Strange
- Department of Medicine, Medical University of South Carolina, Charleston
| | - Kevin C Wilson
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
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Khan NA, Khan RA, Tonelli AR, Highland KB, Chaisson NF, Jacob M, Renapurkar R, Dweik RA, Heresi GA. Pulmonary Edema Following Initiation of Parenteral Prostacyclin Therapy for Pulmonary Arterial Hypertension: A Retrospective Study. Chest 2019; 156:45-52. [PMID: 30776364 DOI: 10.1016/j.chest.2019.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/27/2019] [Accepted: 02/01/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Pulmonary edema may complicate the use of pulmonary arterial hypertension (PAH)-targeted therapies. We aimed to determine the proportion of patients who develop pulmonary edema after initiation of parenteral prostacyclin therapy, to identify its risk factors, and to assess its implications for hospital length of stay and mortality. METHODS A retrospective cohort study of patients with PAH at the initiation of parenteral prostacyclin between 1997 and 2015 enrolled in the Cleveland Clinic PAH registry. Pulmonary edema was defined as at least one symptom or clinical sign and radiographic evidence of pulmonary edema. We determined patient characteristics predictive of pulmonary edema as well as the association between pulmonary edema and hospital length of stay (LOS) and 6-month mortality. RESULTS One hundred and fifty-five patients were included (median age, 51 years; female, 72%; white, 85%; idiopathic, 64%; and connective tissue disease [CTD], 23%). Pulmonary edema developed in 33 of 155 patients (21%). Independent predictors of pulmonary edema were high right atrial pressure (RAP), CTD etiology, and the presence of three or more risk factors for left heart disease (LHD). Pulmonary edema was associated with a 4.5-day increase in hospital LOS (95% CI, 1.4-7.5 days; P < .001) and a 4-fold increase in 6-month mortality (OR, 4.3; 95% CI, 1.28-14.36; P = .031). CONCLUSIONS Pulmonary edema occurred in 21% of patients with PAH initiated on parenteral prostacyclin. Three or more risk factors for LHD, CTD-PAH, and a high baseline RAP were independent predictors of pulmonary edema. Pulmonary edema was associated with a prolonged hospital LOS and increased 6-month mortality.
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Affiliation(s)
- Nauman A Khan
- Department of Hospital Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Rizwan A Khan
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH
| | - Adriano R Tonelli
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Kristin B Highland
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Neal F Chaisson
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Miriam Jacob
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Rahul Renapurkar
- Department of Thoracic Imaging, Imaging Institute, Cleveland Clinic, Cleveland, OH
| | - Raed A Dweik
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Gustavo A Heresi
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.
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36
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Raeisi-Giglou P, Wang XF, Dakkak W, Bair N, Dweik RA, Tonelli AR. Effect of Weight on Parenteral Prostacyclin Analogues Dosing in Pulmonary Hypertension. Chest 2019; 151:1189-1192. [PMID: 28483121 DOI: 10.1016/j.chest.2017.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 01/24/2017] [Indexed: 11/18/2022] Open
Affiliation(s)
| | - Xiao-Feng Wang
- Respiratory Institute Biostatistics Core, Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Wael Dakkak
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL
| | - Nancy Bair
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Raed A Dweik
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Adriano R Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH.
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37
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Khirfan G, Ahmed MK, Faulx MD, Dakkak W, Dweik RA, Tonelli AR. Gasometric gradients between blood obtained from the pulmonary artery wedge and pulmonary artery positions in pulmonary arterial hypertension. Respir Res 2019; 20:6. [PMID: 30621691 PMCID: PMC6325872 DOI: 10.1186/s12931-018-0969-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 12/20/2018] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Little is known on the pulmonary gradients of oxyhemoglobin, carboxyhemoglobin and methemoglobin in pulmonary arterial hypertension (PAH). We sought to determine these gradients in group 1 PAH and assess their association with disease severity and survival. METHODS During right heart catheterization (RHC) we obtained blood from pulmonary artery (PA) and pulmonary artery wedge (PAW) positions and used co-oximetry to test their gasometric differences. RESULTS We included a total of 130 patients, 65 had group 1 PAH, 40 had pulmonary hypertension (PH) from groups 2-5 and 25 had no PH during RHC. In all groups, PAW blood had higher pH, carboxyhemoglobin and lactate as well as lower pCO2 than PA blood. In group 1 PAH (age 58 ± 15 years, 72% females), methemoglobin in the PAW was lower than in the PA blood (0.83% ± 0.43 vs 0.95% ± 0.50, p = 0.03) and was directly associated with the degree of change in pulmonary vascular resistance (R = 0.35, p = 0.02) during inhaled nitric oxide test. Oxyhemoglobin in PA (HR (95%CI): 0.90 (0.82-0.99), p = 0.04) and PAW (HR (95%CI): 0.91 (0.84-0.98), p = 0.003) blood was associated with adjusted survival in PAH. CONCLUSIONS Marked differences were observed in the gasometric determinations between PAW and PA blood. The pulmonary gradient of methemoglobin was lower in PAH patients compared to controls and a higher PAW blood methemoglobin was associated with a more pronounced pulmonary vascular response to inhaled nitric oxide. Pulmonary artery and PAW oxyhemoglobin tracked with disease severity and survival in PAH.
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Affiliation(s)
- Ghaleb Khirfan
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
| | - Mostafa K. Ahmed
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
- Department of Chest Diseases, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Michael D. Faulx
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH USA
| | - Wael Dakkak
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL USA
| | - Raed A. Dweik
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
| | - Adriano R. Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue A-90, Cleveland, OH 44195 USA
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Tejwani V, Patel DC, Zein J, Guzman JA, Diaz-Guzman E, Mireles-Cabodevila E, Dweik RA, Heresi GA. Survival After an ICU Hospitalization for Pulmonary Hypertension. Chest 2018; 154:229-231. [PMID: 30044743 PMCID: PMC10548453 DOI: 10.1016/j.chest.2018.03.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 03/13/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Vickram Tejwani
- Pulmonary and Critical Care, Johns Hopkins Hospital, Baltimore, MD
| | - Divya C Patel
- Pulmonary and Critical Care Faculty, University of Florida, Gainesville, FL
| | - Joe Zein
- Pulmonary and Critical Care Faculty, Cleveland Clinic, Cleveland, OH
| | - Jorge A Guzman
- Pulmonary and Critical Care Faculty, Cleveland Clinic, Cleveland, OH
| | - Enrique Diaz-Guzman
- Pulmonary and Critical Care Faculty, University of Alabama-Birmingham, Birmingham, AL
| | | | - Raed A Dweik
- Pulmonary and Critical Care Faculty, Cleveland Clinic, Cleveland, OH
| | - Gustavo A Heresi
- Pulmonary and Critical Care Faculty, Cleveland Clinic, Cleveland, OH.
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Klinke A, Berghausen E, Friedrichs K, Molz S, Lau D, Remane L, Berlin M, Kaltwasser C, Adam M, Mehrkens D, Mollenhauer M, Manchanda K, Ravekes T, Heresi GA, Aytekin M, Dweik RA, Hennigs JK, Kubala L, Michaëlsson E, Rosenkranz S, Rudolph TK, Hazen SL, Klose H, Schermuly RT, Rudolph V, Baldus S. Myeloperoxidase aggravates pulmonary arterial hypertension by activation of vascular Rho-kinase. JCI Insight 2018; 3:97530. [PMID: 29875311 PMCID: PMC6124430 DOI: 10.1172/jci.insight.97530] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 04/19/2018] [Indexed: 01/28/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) remains a disease with limited therapeutic options and dismal prognosis. Despite its etiologic heterogeneity, the underlying unifying pathophysiology is characterized by increased vascular tone and adverse remodeling of the pulmonary circulation. Myeloperoxidase (MPO), an enzyme abundantly expressed in neutrophils, has potent vasoconstrictive and profibrotic properties, thus qualifying as a potential contributor to this disease. Here, we sought to investigate whether MPO is causally linked to the pathophysiology of PAH. Investigation of 2 independent clinical cohorts revealed that MPO plasma levels were elevated in subjects with PAH and predicted adverse outcome. Experimental analyses showed that, upon hypoxia, right ventricular pressure was less increased in Mpo-/- than in WT mice. The hypoxia-induced activation of the Rho-kinase pathway, a critical subcellular signaling pathway yielding vasoconstriction and structural vascular remodeling, was blunted in Mpo-/- mice. Mice subjected to i.v. infusion of MPO revealed activation of Rho-kinase and increased right ventricular pressure, which was prevented by coinfusion of the Rho-kinase inhibitor Y-27632. In the Sugen5416/hypoxia rat model, PAH was attenuated by the MPO inhibitor AZM198. The current data demonstrate a tight mechanistic link between MPO, the activation of Rho-kinase, and adverse pulmonary vascular function, thus pointing toward a potentially novel avenue of treatment.
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Affiliation(s)
- Anna Klinke
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
- International Clinical Research Center, Centre of Biomolecular and Cellular Engineering (CBCE), St. Anne’s University Hospital Brno, Brno, Czech Republic
| | - Eva Berghausen
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
| | - Kai Friedrichs
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
| | - Simon Molz
- University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Denise Lau
- University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lisa Remane
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
| | - Matthias Berlin
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
| | - Charlotte Kaltwasser
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
| | - Matti Adam
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
| | - Dennis Mehrkens
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
| | - Martin Mollenhauer
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
| | - Kashish Manchanda
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
| | - Thorben Ravekes
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
| | | | - Metin Aytekin
- Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Raed A. Dweik
- Pulmonary and Critical Care Medicine, Respiratory Institute, and
| | - Jan K. Hennigs
- Cardiovascular Institute, Stanford University, School of Medicine, Stanford, California, USA
- Department of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Kubala
- International Clinical Research Center, Centre of Biomolecular and Cellular Engineering (CBCE), St. Anne’s University Hospital Brno, Brno, Czech Republic
- Institute of Biophysics, Czech Academy of Sciences, Brno, Czech Republic
| | - Erik Michaëlsson
- Bioscience Heart Failure, Cardiovascular, Renal and Metabolism, Innovative Medicines and Early Development (IMED) Biotech Unit, AstraZeneca, Gothenburg, Sweden
| | - Stephan Rosenkranz
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
| | - Tanja K. Rudolph
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
| | - Stanley L. Hazen
- Department of Cellular and Molecular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hans Klose
- Department of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ralph T. Schermuly
- Universities of Giessen and Marburg Lung Center (UGMLC), Member of the German Center for Lung Research, Giessen, Germany
| | - Volker Rudolph
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
| | - Stephan Baldus
- Heart Center, Department of Cardiology
- Center for Molecular Medicine Cologne CMMC, University of Cologne, Cologne, Germany
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Khirfan G, Tejwani V, Wang X, Li M, DiDonato J, Dweik RA, Smedira N, Heresi GA. Plasma levels of high density lipoprotein cholesterol and outcomes in chronic thromboembolic pulmonary hypertension. PLoS One 2018; 13:e0197700. [PMID: 29813091 PMCID: PMC5973565 DOI: 10.1371/journal.pone.0197700] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/07/2018] [Indexed: 02/03/2023] Open
Abstract
Background High Density Lipoprotein Cholesterol (HDL-C) has various anti-inflammatory, anti-atherogenic, anti-oxidant and anti-coagulant properties that improve vascular function. The utility of HDL-C as a biomarker of severity and predictor of survival was described in patients with pulmonary arterial hypertension (PAH). No prior study has assessed the utility of HDL-C in patients with Chronic Thromboembolic Pulmonary Hypertension (CTEPH). Objectives We aim to measure HDL-C levels in CTEPH patients and compare it to those in PAH patients and controls and determine HDL-C associations with markers of disease severity, hemodynamics and mortality in CTEPH. Methods We retrospectively included patients with CTEPH, identified from the Cleveland Clinic Pulmonary Hypertension Registry. All patients had right heart catheterization (RHC) and imaging studies consistent with CTEPH. We collected demographics, co-morbidities, baseline laboratory data including plasma HDL-C, six-minute walk test (6MWT), echocardiography and RHC. HDL-C levels were compared to a cohort of patients with cardiovascular risk factors and a previously published PAH cohort. Results HDL-C levels were available for 90 patients with CTEPH (age: 57.4±13.9 years; female 40%), 69 patients with PAH (age: 46.7±12.8 years; female 90%) and 254 control subjects (age: 56.7±13 years; female 48%). HDL-C levels in CTEPH patients were lower compared to controls and higher compared to PAH patients (median, IQR: CTEPH: 44, 34–57 mg/dl; PAH: 35.3, 29–39 mg/dl; Control: 49, 40–60 mg/dl; p < 0.01 for both pairwise comparisons). In CTEPH, higher HDL-C was associated with decreased prevalence of right ventricular dilation on echocardiography (p = 0.02). 57 patients with CTEPH underwent pulmonary thromboendarterectomy, higher HDL-C was associated with a larger decrement in postoperative pulmonary vascular resistance (PVR) (r = 0.37, p = 0.049). HDL-C was not associated with mortality or other markers of disease severity. Conclusions HDL-C levels in CTEPH patients were lower compared to control subjects, but higher compared to PAH patients. Higher HDL-C in CTEPH was associated with less right ventricular dilation and greater decrement in postoperative PVR. These data suggest that HDL-C may be a useful marker of small vessel disease in CTEPH.
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Affiliation(s)
- Ghaleb Khirfan
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Vickram Tejwani
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Manshi Li
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Joseph DiDonato
- Department of Cellular and Molecular Medicine, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Raed A. Dweik
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Nicholas Smedira
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Gustavo A. Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, United States of America
- * E-mail:
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Abstract
Hyponatremia is associated with poor prognosis in left heart failure and liver disease. Its prognostic role in pulmonary arterial hypertension (PAH) is not well defined. We investigated the association between hyponatremia and one-year mortality in two large cohorts of PAH. This study is a secondary analysis evaluating the association between hyponatremia and one-year mortality in patients treated with subcutaneous treprostinil (cohort 1). The results are validated using a PAH registry at a tertiary referral center (cohort 2). Eight-hundred and twenty patients were enrolled in cohort 1 (mean age = 47 ± 14 years) and 791 in cohort 2 (mean age = 55 ± 15 years). Sodium level is negatively correlated with mean right atrial pressure (r = -0.09, P = 0.018; r = -0.089, P = 0.015 in cohorts 1 and 2, respectively). In unadjusted analyses of cohort 1, the sodium level (as a continuous variable) is associated with one-year mortality (hazard ratio = 0.94; P = 0.035). Hyponatremia loses its significance (as a continuous variable and when dichotomized at ≤ 137 mmol/L; P = 0.12) when adjusted for functional class (FC), which is identified as the variable whose presence turns the effect of sodium level into non-significant. Secondary analyses using a cut-off value of < 135 mmol/L showed similar results. These results are validated in cohort 2. Although the sample size for patients with sodium < 130 mmol/L is small (n = 31), severe hyponatremia is associated with higher overall mortality (47% versus 23%; P = 0.01), even when adjusting for age, FC, and baseline 6-min walk distance ( P < 0.001). Although baseline hyponatremia is associated with one-year mortality, it loses its significance when adjusted for FC.
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Affiliation(s)
| | | | - Youlan Rao
- 3 United Therapeutics Inc., Research Triangle Park, NC, USA
| | | | - Gregory K Buller
- 4 Yale New Haven Health, Bridgeport Hospital, Nephrology Section, Department of Medicine, Bridgeport, CT, USA
| | - Raed A Dweik
- 2 Cleveland Clinic, Respiratory Institute, Cleveland, OH, USA
| | - Wassim H Fares
- 5 Yale University, Pulmonary Critical Care & Sleep Medicine, New Haven, CT, USA
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Affiliation(s)
- Jarrod W Barnes
- 1 Lerner Research Institute Cleveland Clinic Cleveland, Ohio.,2 Department of Pulmonary, Allergy and Critical Care Medicine University of Alabama at Birmingham Birmingham, Alabama and
| | - Raed A Dweik
- 1 Lerner Research Institute Cleveland Clinic Cleveland, Ohio.,3 Respiratory Institute Cleveland Clinic Cleveland, Ohio
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Tonelli AR, Naal T, Dakkak W, Park MM, Dweik RA, Stoller JK. Assessing the kinetics of microbubble appearance in cirrhotic patients using transthoracic saline contrast-enhanced echocardiography. Echocardiography 2017; 34:1439-1446. [PMID: 28840954 DOI: 10.1111/echo.13662] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The number of cardiac cycles that need to be reviewed by echocardiography before a significant intrapulmonary shunt can be excluded remains unclear. METHODS We retrospectively identified patients with cirrhosis who underwent technetium-99 m-labeled macroaggregated albumin scanning. The kinetics of bubble appearance after the injection of agitated saline during transthoracic echocardiograms were assessed in these patients. RESULTS For the 64 eligible patients, the mean ± SD age was 56 ± 9 years. The median (IQR) shunt fraction by radionuclide scanning was 7.7% (2.8%-19.9%). Microbubbles were seen in the left atrium (LA) and left ventricle (LV) at a median (IQR) of 4 (2-5) and 4 (2-5) beats, respectively. The number of heart cycles before microbubbles appeared in the LA or LV was inversely associated with the nuclear scanning shunt fraction (R = -0.42, P = .001, R = -0.46, P < .001, respectively). If no microbubbles were detected by heart cycle 7, the shunt fraction was uniformly less than 3%. Patients with arterial oxygen <60 mm Hg, compared to ≥60 mm Hg, had earlier appearance of microbubbles in the left heart chambers (2.6 ± 1.9 vs 4.0 ± 2.3 beats, P = .046). CONCLUSIONS In patients with advanced cirrhosis suspected of having hepatopulmonary syndrome, a greater shunt fraction during nuclear scanning was associated with more pronounced hypoxemia and a prompt and more intense appearance of microbubbles in the left-sided heart chambers. Patients with a shunt fraction above 3% have microbubbles in the LA or LV at some point during the first seven heart cycles.
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Affiliation(s)
- Adriano R Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tawfeq Naal
- Pathobiology Department, Cleveland Clinic, Cleveland, OH, USA
| | - Wael Dakkak
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA
| | - Margaret M Park
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Raed A Dweik
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - James K Stoller
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Education Institute, Cleveland Clinic, Cleveland, OH, USA
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Tonelli AR, Fares WH, Dakkak W, Rao Y, Zhou X, Dweik RA. Do single or sequential measurements of leptin and adiponectin in plasma have prognostic value in pulmonary arterial hypertension? Pulm Circ 2017; 7:727-729. [PMID: 28604281 PMCID: PMC5841903 DOI: 10.1177/2045893217717219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Leptin (a neuroendocrine peptide that enhances metabolism and acts on the hypothalamus to suppress appetite) and adiponectin (a protein that has insulin-sensitizing, anti-inflammatory, and antiproliferative properties) are involved in the pathobiology of pulmonary arterial hypertension (PAH). We hypothesized that plasma leptin and adiponectin as well as the leptin/adiponectin ratio are abnormal in PAH patients and their levels track with disease severity and functional changes during follow-up. We tested this hypothesis in a cohort of patients included in the 16-week, international, multicenter, double-blind, placebo-controlled FREEDOM-C2 study. Blood was collected at baseline and week 16 in 178 out of 310 randomized patients with PAH. Baseline plasma leptin and adiponectin concentrations were 25 ± 31 ng/mL and 7.8 ± 6.1 ug/mL, respectively. Leptin, adiponectin, and leptin/adiponectin (mean ± SD) changes at 16 week were of small magnitude. Leptin at baseline was significantly associated with older age, higher BMI, higher Borg dyspnea index, and lower NT-pro BNP. Women had higher levels of leptin than men (30.5 ± 33.2 versus 7.2 ± 6.4 ng/mL), even when adjusting for background therapy and etiology (linear regression: β = 21.8, P < 0.001). Adiponectin was negatively associated with BMI and positively associated with NT-pro BNP. Changes in leptin, adiponectin, and leptin/adiponectin ratio adjusted for weight at 16 weeks did not predict functional class, distance walk in 6 min or survival at one, two, three, or four years. Plasma leptin and adiponectin at baseline and their change at 16-week do not appear to significantly impact prognosis in PAH.
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Affiliation(s)
- Adriano R Tonelli
- 1 Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Wassim H Fares
- 2 Section of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Wael Dakkak
- 1 Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Youlan Rao
- 3 United Therapeutics, Research Triangle Park, NC, USA
| | - Xuan Zhou
- 3 United Therapeutics, Research Triangle Park, NC, USA
| | - Raed A Dweik
- 1 Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Demirjian S, Paschke KM, Wang X, Grove D, Heyka RJ, Dweik RA. Molecular breath analysis identifies the breathprint of renal failure. J Breath Res 2017; 11:026009. [DOI: 10.1088/1752-7163/aa7143] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Tonelli AR, Johnson S, Alkukhun L, Yadav R, Dweik RA. Changes in main pulmonary artery diameter during follow-up have prognostic implications in pulmonary arterial hypertension. Respirology 2017; 22:1649-1655. [PMID: 28514116 DOI: 10.1111/resp.13073] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 03/10/2017] [Accepted: 04/10/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVE A dilated pulmonary artery (PA) is a common finding in patients with pulmonary arterial hypertension (PAH). Little is known on the variations in PA size over time and whether these changes track with disease severity and/or predict long-term survival. METHODS We included patients with PAH who had at least two computed tomography (CT) scans of the chest done on different visits. Both scans matched the use of i.v. contrast. RESULTS Pairs of CT scans were compared in 113 PAH patients. During a median (interquartile range (IQR)) time difference between scans of 8 (IQR: 3.5-20.0) months, we noted an increase in main PA diameter of 0.5 ± 1.8 mm (mean ± SD) (P = 0.008). When CT scans were performed >12 months apart (n = 47), the main PA diameter increased or decreased by >1 mm in 40% and 13% of the patients, respectively. An increase in main PA diameter was associated with lower PA compliance, higher right ventricular (RV) systolic pressure, worse RV function and a decline in 6-min walk distance. During a median (IQR) follow-up of 33 (IQR: 4.5-47) months, 53 (46.9%) patients died. The change in PA diameter was a significant predictor of mortality (hazard ratio (HR) per mm increase: 1.33 (95% CI: 1.11-1.61), P = 0.002) when adjusted for difference in time and slice thickness between CT scans, age, gender, PAH aetiology and pulmonary vascular resistance. CONCLUSION In PAH patients, an increase in CT-derived main PA diameter over time is associated with progression in pulmonary pressures, RV dysfunction, a decline in functional capacity and higher mortality.
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Affiliation(s)
- Adriano R Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott Johnson
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Laith Alkukhun
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ruchi Yadav
- Department of Diagnostic Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Raed A Dweik
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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47
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Hunter GW, Dweik RA, Makel DB, Grigsby CC, Mayes RS, Davis CE. Portable Breath Monitoring: A New Frontier in Personalized Health Care. Electrochem Soc Interface 2017. [DOI: 10.1149/2.f04164if] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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48
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Affiliation(s)
- Mostafa Ahmed
- Research Fellow, Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Assistant Lecturer, Department of Chest Diseases, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Raed A Dweik
- Director of Pulmonary Vascular Diseases Program, Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA. E-mail: .,Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Adriano R Tonelli
- Staff, Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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49
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Raeisi-Giglou P, Lam L, Tamarappoo BK, Newman J, Dweik RA, Tonelli AR. Evaluation of left ventricular diastolic function profile in patients with pulmonary hypertension due to heart failure with preserved ejection fraction. Clin Cardiol 2016; 40:356-363. [PMID: 28026030 DOI: 10.1002/clc.22664] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/22/2016] [Accepted: 11/24/2016] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Echocardiography plays an important role in the diagnostic work up of heart failure with preserved ejection fraction (HFpEF). We sought to determine the left ventricular (LV) diastolic profile by echocardiography in patients diagnosed with pulmonary hypertension (PH) due to PH-HFpEF. HYPOTHESIS The study of LV diastolic function by echocardiography has limitations in patients with HFpEF and PH, and certain LV diastolic determinations convey a worse prognosis. METHODS We included patients with postcapillary PH and diagnosis of PH-HFpEF. Investigators reviewed Doppler echocardiograms completed within 3 months of the diagnostic right heart catheterization. RESULTS We included 149 patients with a mean ± standard deviation age of 63 ± 14 years; 58% were women. LV diastolic function profile was determined as normal (41%), grade I (34%), and grade II and grade III (25%). Pulmonary artery pressure and pulmonary vascular resistance were higher and cardiac output lower in patients with LV diastolic dysfunction profile; however, pulmonary artery wedge pressure was not significantly different among grades of LV diastolic function. Although there was an association between the presence of LV diastolic dysfunction profile and long-term survival (P = 0.03), it disappeared when adjusting for age and gender. Right ventricular (RV) dysfunction, paradoxical septal motion, and higher RV systolic pressure remained the only variables significantly associated with poor survival. CONCLUSIONS The profile of LV diastolic dysfunction by conventional echocardiography is highly variable in patients with PH-HFpEF and has no significant impact on long-term survival. A more severe RV function and higher right ventricle systolic pressure were associated with worse survival.
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Affiliation(s)
| | - Louis Lam
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Balaji K Tamarappoo
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jennie Newman
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Raed A Dweik
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Adriano R Tonelli
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
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Sandur S, Dweik RA, Arroliga AC. Alveolar Hemorrhage. J Intensive Care Med 2016. [DOI: 10.1177/088506669801300603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Alveolar hemorrhage (AH) is a clinical syndrome with diverse etiologies both immune and nonimmune. The defining pathological feature of AH is the presence or absence of pulmonary capillaritis. The antineutrophil cytoplasmic antibody (ANCA) related vasculitis and systemic lupus erythematosus are the commonest causes of immune AH with pulmonary capillaritis, whereas Goodpasture's syndrome and idiopathic pulmonary hemosiderosis are common causes of immune AH without pulmonary capillaritis. The major nonimmune causes of AH are primarily drug induced, or due to hematological malignancy and disorders of coagulation. Clinical features of AH include: dyspnea, fever, hemotypsis, bilateral crackles and pallor. Hypoxemia and bilateral diffuse airspace disease on the chest radiograph with relative sparing of the bases and apices which most often clears within 48 hours after its onset further characterize this syndrome. The major clinical implications of this syndrome are its potential to cause respiratory failure in severe cases and its sequelae of pulmonary fibrosis with associated morbidity and disability. In addition, AH may be the initial manifestation of a systemic immune disorder which can be managed optimally if recognized early. The diagnosis of AH is confirmed by bronchoalveolar lavage by demonstrating a progressively bloody return on successive aliquots of instilled saline or hemosiderin laden macrophages in the bronchoalveolar lavage fluid. The open lung biopsy remains the gold standard for the diagnosis of AH but is reserved for inapparent cases in whom corticosteroids and immunosuppressive therapy may be life saving. Serologic testing and examination of the urine sediment are useful adjuncts to the diagnosis. The treatment of AH is primarily supportive while an attempt is made to determine its etiology and initiate specific therapy. Glucocorticoids and cyclophosphamide are the cornerstones of therapy in immune AH with adjunctive plasmapheresis in life-threatening cases.
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Affiliation(s)
- Sunder Sandur
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Raed A. Dweik
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Alejandro C. Arroliga
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH
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