Predictors of diagnosis and survival in idiopathic pulmonary fibrosis and connective tissue disease-related usual interstitial pneumonia

Background

Although usual interstitial pneumonia (UIP) appears to portend better survival when associated with connective tissue disease (CTD-UIP), little is known about the presenting clinical, radiologic, and pathologic features that differentiate pathologically confirmed UIP with CTD from idiopathic pulmonary fibrosis (IPF). In patients with atypical radiologic and clinical features, what specific findings predict underlying IPF vs. CTD-UIP diagnosis and their respective long term survival?

Methods

A large retrospective cohort analysis was done of consecutive patients seen from 1995 through 2010 with biopsy confirmed UIP completed or reviewed at our institution. CTD-UIP was defined by independent rheumatology consultation with exclusion of all other secondary causes of lung fibrosis. Primary clinical data was collected and compared for IPF and CTD-UIP along with logistic regression performed for predictors of disease likelihood and Cox proportional hazards analysis for predictors of survival.

Results

Six hundred and twenty five patients were included in the study of which 89 had diagnosed CTD-UIP representing 7 disease entities. Survival was better among those with CTD-UIP except in UIP associated with rheumatoid arthritis, which had similar presenting features and survival to IPF. Predictors of underlying CTD included female gender, younger age, positive autoimmune serology, and inconsistent presenting radiologic findings. Only age and forced vital capacity corrected for a priori covariates were predictive of survival in CTD-UIP.

Conclusions

UIP pathology occurs frequently among patients with atypically presenting clinical and radiologic features, and may represent IPF or CTD-UIP with improved prognosis if underlying CTD is diagnosed. Presenting radiologic and pathologic features alone are not predictive of underlying secondary cause or survival between the two groups.     

Second harmonic generation microscopy reveals altered collagen microstructure in usual interstitial pneumonia versus healthy lung

Background

It is not understood why some pulmonary fibroses such as cryptogenic organizing pneumonia (COP) respond well to treatment, while others like usual interstitial pneumonia (UIP) do not. Increased understanding of the structure and function of the matrix in this area is critical to improving our understanding of the biology of these diseases and developing novel therapies. The objectives herein are to provide new insights into the underlying collagen- and matrix-related biological mechanisms driving COP versus UIP.

Methods

Two-photon second harmonic generation (SHG) and excitation fluorescence microscopies were used to interrogate and quantify differences between intrinsic fibrillar collagen and elastin matrix signals in healthy, COP, and UIP lung.

Results

Collagen microstructure was different in UIP versus healthy lung, but not in COP versus healthy, as indicated by the ratio of forward-to-backward propagating SHG signal (F_SHG/B_SHG). This collagen microstructure as assessed by F_SHG/B_SHG was also different in areas with preserved alveolar architecture adjacent to UIP fibroblastic foci or honeycomb areas versus healthy lung. Fibrosis was evidenced by increased col1 and col3 content in COP and UIP versus healthy, with highest col1:col3 ratio in UIP. Evidence of elastin breakdown (i.e. reduced mature elastin fiber content), and increased collagen:mature elastin ratios, were seen in COP and UIP versus healthy.

Conclusions

Fibrillar collagen’s subresolution structure (i.e. “microstructure”) is altered in UIP versus COP and healthy lung, which may provide novel insights into the biological reasons why unlike COP, UIP is resistant to therapies, and demonstrates the ability of SHG microscopy to potentially distinguish treatable versus intractable pulmonary fibroses.     

Circulating microRNAs as potential biomarkers for smoking-related interstitial fibrosis

Numerous efforts have been made to indentify reliable and predictive biomarkers to detect the early signs of smoking-induced lung disease. Using 6-month cigarette smoking in mice, we have established smoking-related interstitial fibrosis (SRIF). Microarray analyses and cytokine/chemokine biomarker measurements were made to select circulating microRNAs (miRNAs) biomarkers. We have demonstrated that specific miRNAs species (miR-125b-5p, miR-128, miR-30e, and miR-20b) were significantly changed, both in the lung tissue and in plasma, and exhibited mainstream (MS) exposure duration-dependent pathological changes in the lung. These findings suggested a potential use of specific circulating miRNAs as sensitive and informative biomarkers for smoking-induced lung disease.     

Circulating peripheral blood fibrocytes in human fibrotic interstitial lung disease

Fibrotic interstitial lung diseases are illnesses of unknown cause characterized by progressive decline in lung function. Fibrocytes are bone marrow-derived, circulating progenitor cells capable of differentiating into diverse mesenchymal cell types. Prior work has shown fibrocytes to traffic to the lung via the CXCL12-CXCR4 chemokine axis in an animal model of pulmonary fibrosis. We therefore assessed the relevance of fibrocytes in patients with fibrotic interstitial lung disease. We found enhanced expression of CXCL12 in both the lungs and plasma of patients with lung fibrosis. CXCL12 levels were associated with an order of magnitude higher number of circulating fibrocytes in the peripheral blood of these patients. Most of the circulating fibrocytes in patients with interstitial lung diseases were negative for the myofibroblast marker alpha-smooth muscle actin, suggesting a relatively undifferentiated phenotype. Taken together, these data suggest that fibrocytes are involved in the pathogenesis of human lung fibrosis.     

Interstitial and vascular type V collagen morphologic disorganization in usual interstitial pneumonia.

Recent evidence suggests that type V collagen plays a role in organizing collagen fibrils, thus maintaining fibril size and spatial organization uniform. In this study we sought to characterize the importance of type V collagen morphological disorganization and to study the relationship between type V collagen, active remodeling of the pulmonary vascular/parenchyma (fibroblastic foci), and other collagen types in usual interstitial pneumonia (UIP). We examined type V collagen and several other collagens in 24 open lung biopsies with histological pattern of UIP from patients with idiopathic pulmonary fibrosis (IPF). We used immunofluorescence, morphometry, and three-dimensional reconstruction to evaluate the amount of collagen V and its interaction with the active remodeling progression in UIP, as well as types I and III collagen fibers. Active remodeling progression was significantly related to type V collagen density (p<0.05), showing a gradual and direct increase to minimal, moderate, and severe fibrosis degree in UIP and in the three different areas: normal, intervening, and mural-organizing fibrosis in UIP. Parenchymal changes were characterized by morphological disorganization of fibrillar collagen with diverse disarray and thickness when observed by three-dimensional reconstruction. We concluded that in the different temporal stages of UIP, vascular/parenchyma collagen type V is increased, in disarray, and is the most important predictor of survival.     

Localization of precursor proteins and mRNA of type I and III collagens in usual interstitial pneumonia and sarcoidosis

Summary The aim of this study was to assess and compare the accumulation and distribution of newly synthesized type I and III collagens in usual interstitial pneumonia (UIP) and pulmonary sarcoidosis. Lung biopsies from 10 patients with UIP and 13 patients with sarcoidosis were investigated by immunohistochemical technique and mRNA in situ hybridization. The antibodies for the aminoterminal propeptide of type I procollagen and the aminoterminal propeptide of type III procollagen (PINP and PIIINP, respectively) were used. When compared to healthy lung, levels of type I pN- and type III pN-collagens were increased in both of these disorders. Type I procollagen was mostly present as intracellular spots in newly formed fibrosis in UIP while type III pN-collagen was expressed extracellularly underneath metaplastic alveolar epithelium. Type I procollagen was present intracellularly within and around the granulomas of sarcoidosis, whereas type III pN-collagen was expressed extracellularly, mainly around the granulomas. mRNAs of both collagens colocalized with the precursor proteins. We conclude that the expression of precursor proteins and mRNA of type I and type III collagens is increased in UIP and sarcoidosis, reflecting mainly active synthesis of these collagens in different areas of the lung.     

Estimation of lymphocyte subsets and cytokine levels in workers occupationally exposed to cadmium

IntroductionOccupational exposure to Cadmium (Cd) may have serious health effect on workers. However, little is known about its effect on immune system. Moreover, previous studies have been inconclusive in stating the effect of Cd on immune system. The aim of our study was to estimate immune parameters in workers occupationally exposed to Cd.Material and methods110 individuals occupationally exposed to Cd and 97 apparently healthy non-exposed individuals were recruited for this study. Blood Cadmium levels were determined by AAS. Lymphocyte subset were analyzed using flow cytometry and the cytokine levels were determined by ELISA.ResultsExposed group have significantly higher levels of B-Cd. % of CD8 cells were higher in exposed while % of CD4 cells showed a decreasing trend in the exposed group. Among the CD3CD4 T cell subsets Th1 (%) and Tregs (%) cells were lower while Th17 (%) were higher in exposed group. Increased levels of IL-4 (Th2), IL-6 (Th2) and TNF- α (Th1) and decreased levels of IL-2 (Th1) and IL-10 (Tregs) were observed in Cd exposed workers which is indicative of a predominant pro-inflammatory response in Cd exposed workers. IL-17 (Th17) levels did not show any significant difference between the two groups. Increased Th17/Tregs ratio in the exposed group is also suggestive of an increased pro-inflammatory immune response in exposed group.ConclusionTo conclude, even low level of exposure to Cd in occupational settings is associated with alterations in Th17 cells, which may further predispose an individual to other systemic abnormalities.     

肾间质纤维化相关信号通路的研究进展

肾间质纤维化是以正常的肾间质和肾小管结构被大量聚集的细胞外基质所替代为特征的病理过程,是多数慢性肾脏疾病进展为终末期肾衰竭共同的病变过程,其病理变化主要由多种细胞因子和多条信号通路控制,是众多关键信号通路的交互影响与共同作用的结果。深入了解信号通路的相互作用对进一步揭示肾间质纤维化的分子机制有重要意义。现综述肾间质纤维化病理变化中关键的信号通路,以期为肾间质纤维化分子机制的研究提供参考。     

Up-regulation of THY1 attenuates interstitial pulmonary fibrosis and promotes lung fibroblast apoptosis during acute interstitial pneumonia by blockade of the WNT signaling pathway

Acute interstitial pneumonia (AIP) is an idiopathic pulmonary disease featuring rapid progressive dyspnea and respiratory failure. These symptoms typically develop within several days or weeks in patients without any pre-existing lung disease or external chest disease. Thymocyte differentiation antigen-1 (THY1) has been reported to have an effect on lung fibroblast proliferation and fibrogenic signaling. In this study, the mechanism of THY1 in AIP in influencing pulmonary fibrosis in terms of lung fibroblast proliferation and apoptosis was examined. An AIP mouse model with the pathological changes of lung tissues observed was established to identify the role of THY1 in the pathogenesis of AIP. The expression of THY1, a key regulator of the WNT pathway β-catenin and fibroblasts markers MMP-2, Occludin, α-SMA and Vimentin were determined. Lung fibroblasts of mice were isolated, in which THY1 expression was altered to identify roles THY1 plays in cell viability and apoptosis. A TOP/TOPflash assay was utilized to determine the activation of WNT pathway. Decrement of pulmonary fibrosis was achieved through THY1 up-regulation. The expression of MMP-2, Occludin, α-SMA, Vimentin and β-catenin, and the extent of β-catenin phosphorylation, significantly decreased, thereby indicating that THY1 overexpression inactivated WNT. Cell proliferation was inhibited and apoptosis was accelerated in lung fibroblasts transfected with vector carrying overexpressed THY1. Altogether, this study defines the potential role of THY1 in remission of AIP, via the upregulation of THY1, which renders the WNT pathway inactive. This inactivation of the WNT signaling pathway could alleviate pulmonary fibrosis by reducing lung fibroblast proliferation in AIP.

Abbreviations: AIP: Acute interstitial pneumonia; ILDs: interstitial lung diseases; DAD: diffuse alveolar damage; SPF: specific-pathogen-free; NC: negative control; HCMV: human cytomegalovirus; HE: Hematoxylin-eosin; RIPA: radio-immunoprecipitation assay; SDS-PAGE: sodium dodecyl sulfate-polyacrylamide gel electrophoresis; BSA: bovine serum albumin; HRP: horseradish peroxidase; ECL: electrochemiluminescence; FBS: fetal bovine serum; DMSO: dimethyl sulfoxide; OD: optical density     

High molecular weight vimentin complex is formed after proteolytic digestion of vimentin by caspase-3: detection by sera of patients with interstitial pneumonia

In a previous study, we demonstrated anti-vimentin antibodies in sera of patients with interstitial pneumonia. We hypothesized that antibodies in sera might detect vimentin fragments formed during the process of apoptosis. To prove this, recombinant human vimentin was digested by recombinant human caspase-3 or caspase-8. Then, Western blotting using several commercially available antibodies against human vimentin or patients' sera which had anti-vimentin autoantibodies, was performed. As a result, after recombinant human vimentin was digested by caspase-3 or caspase-8, several vimentin fragments were formed and detected by 2 kinds of monoclonal anti-vimentin antibodies (clone 3B4 and clone V9) as well as by polyclonal sheep anti-human vimentin antibody. It was demonstrated that high molecular weight vimentin was formed after the digestion of vimentin by caspase-3, which was only detected by patients' sera. The high molecular weight vimentin was not formed after digestion of vimentin by caspase-8. Our present results show that high molecular weight vimentin was formed after the digestion of vimentin by caspase-3. In addition, it is suggested that this high molecular weight vimentin acted as an autoantigen to form anti-vimentin autoantibody in vivo.     

Transbronchial biopsy is useful in predicting UIP pattern

Background

The development of COPD in subjects with alpha-1 antitrypsin (AAT) deficiency is likely to be influenced by modifier genes. Genome-wide association studies and integrative genomics approaches in COPD have demonstrated significant associations with SNPs in the chromosome 15q region that includes CHRNA3 (cholinergic nicotine receptor alpha3) and IREB2 (iron regulatory binding protein 2). We investigated whether SNPs in the chromosome 15q region would be modifiers for lung function and COPD in AAT deficiency.

Methods

The current analysis included 378 PIZZ subjects in the AAT Genetic Modifiers Study and a replication cohort of 458 subjects from the UK AAT Deficiency National Registry. Nine SNPs in LOC123688, CHRNA3 and IREB2 were selected for genotyping. FEV₁ percent of predicted and FEV₁/FVC ratio were analyzed as quantitative phenotypes. Family-based association analysis was performed in the AAT Genetic Modifiers Study. In the replication set, general linear models were used for quantitative phenotypes and logistic regression models were used for the presence/absence of emphysema or COPD.

Results

Three SNPs (rs2568494 in IREB2, rs8034191 in LOC123688, and rs1051730 in CHRNA3) were associated with pre-bronchodilator FEV₁ percent of predicted in the AAT Genetic Modifiers Study. Two SNPs (rs2568494 and rs1051730) were associated with the post-bronchodilator FEV₁ percent of predicted and pre-bronchodilator FEV₁/FVC ratio; SNP-by-gender interactions were observed. In the UK National Registry dataset, rs2568494 was significantly associated with emphysema in the male subgroup; significant SNP-by-smoking interactions were observed.

Conclusions

IREB2 and CHRNA3 are potential genetic modifiers of COPD phenotypes in individuals with severe AAT deficiency and may be sex-specific in their impact.     

血清标记物在类风湿关节炎相关间质性肺疾病中的作用

类风湿关节炎相关间质性肺疾病(rheumatoid arthritis-associated interstitial lung disease, RA-ILD)是类风湿关节炎(rheumatoid arthritis, RA)最具破坏性的并发症,一旦发展成普通型间质性肺炎模式,患者的死亡率急剧上升,且缺乏有效的治疗手段和特异性的诊断方法。血清标记物,特别是MMPs、KL-6、SP-D、CCL18、OPN、WNT5A、Anti-CarP抗体、抗MAA抗体、抗PAD抗体等,可以早期识别RA-ILD的高危患者,预测亚型、评价疗效、监测预后,日益受到人们关注。本文就血清标记物与RAILD异常表达和肺纤维化发生、进展及预后的相关性作一综述,旨在为RA-ILD寻找可靠的血清标记物,为临床诊治工作提供参考。     

循环纤维细胞及其在肺纤维化中的作用

循环纤维细胞（circulating fibrocytes CF）是一类骨髓来源的间质性细胞,可以同时表达造血细胞、单核细胞和成纤维细胞系的细胞标记。现有越来越多动物实验证据表明,CF的分化、转移功能在慢性炎症反应和胶原过度沉积中起着重要作用。近年来的实验表明,对CF的计数可以作为纤维化类疾病发展过程中的生物标记物,尤其在肺纤维化中更加明显。特发性肺纤维化是一种慢性肺部功能失调疾病,确诊后病人5年生存率低于30％。特发性肺纤维化是一种慢性肺部功能失调疾病,确诊后病人5年生存率低于30％。传统的免疫学疗法疗效很差。最近人们开始把注意力集中到对始祖干细胞的免疫调节机制上来。随着对循环纤维细胞研究的不断深入,对特发性纤维化的发病原因以及治疗研究方面有了较大发展。     

Progression of heart failure: A role for interstitial fibrosis

Progressive deterioration of left ventricular (LV) function is a characteristic feature of the heart failure (HF) state. The mechanism or mechanisms responsible for this hemodynamic deterioration are not known but may be related to progressive intrinsic dysfunction, degeneration and loss of viable cardiocytes. In the present study, we tested the hypothesis that accumulation of collagen in the cardiac interstitium (reactive interstitial fibrosis, RIF), known to occur in HF, results in reduced capillary density (CD=capillary/fiber ratio) and increased oxygen diffusion distance (ODD) which can lead to hypoxia and dysfunction of the collagen encircled myocyte. Studies were performed in LV tissue obtained from 10 dogs with chronic HF (LV ejection fraction 26±1%) produced by multiple sequential intracoronary, microembolizations. In each dog, CD and ODD were evaluated in LV regions that manifested severe RIF (volume fraction 16±2%) and in LV regions of little or no RIF (volume fraction 4±1%). In regions of severe RIF, CD was significantly decreased compared to regions of no RIF (0.92±0.02 vs. 1.05±0.03) (P<0.03). Similarly, ODD was significantly increased in regions of severe RIF compared to regions of no RIF (15.3±0.4 vs. 12.2±0.3 m) (P<0.001). These data suggest that in dogs with chronic HF, constituent myocytes of LV regions which manifest severe RIF may be subjected to chronic hypoxia; a condition that can adversely impact the function and viability of the collagen encircled cardiocyte.     

循环纤维细胞及其在肺纤维化中的作用

循环纤维细胞(crculating fibrocytes CF)是一类骨髓来源的间质性细胞,可以同时表达造血细胞、单核细胞和成纤维细胞系的细胞标记。现有越来越多动物实验证据表明,CF的分化、转移功能在慢性炎症反应和胶原过度沉积中起着重要作用。近年来的实验表明,对CF的计数可以作为纤维化类疾病发展过程中的生物标记物,尤其在肺纤维化中更加明显。特发性肺纤维化是一种慢性肺部功能失调疾病,确诊后病人5年生存率低于30%。特发性肺纤维化是一种慢性肺部功能失调疾病,确诊后病人5年生存率低于30%。传统的免疫学疗法疗效很差。最近人们开始把注意力集中到对始祖干细胞的免疫调节机制上来。随着对循环纤维细胞研究的不断深入,对特发性纤维化的发病原因以及治疗研究方面有了较大发展。     

Treatment of nonspecific diarrhea with metronidazole in rhesus macaques

Nonspecific diarrhea was successfully treated with metronidazole in 76% (13/17) of cases in adult rhesus macaques (Macaca mulatta). Effective treatment was achieved by oral administration of metronidazole daily at a low dose of 250 mg for at least eight days or at high daily doses of 500-1,500 mg for one to four days. Minimal effective total dose was 1500 mg. Apart from occasional vomiting, no side effects were observed.     

The ratio of various lymphocyte populations in bacillary dysentery and nonspecific ulcerative colitis

The comparative study of the content of different lymphocyte populations of the peripheral blood in pathological states accompanied by lesions of the mucous membrane of the large intestine has been made. In shigellosis patients the accumulation of lymphocytes having the signs of young post-thymic forms (theophylline-dependent populations) and functionally active forms (Ea-rosette-forming cells) occurs in the circulating blood. In unspecific ulcerous colitis only an increase in the number of immature lymphocytes (theophylline-dependent lymphocytes and autorosette-forming cells) is observed. In both pathological states an increase in the number of O-lymphocytes with Fc gamma-receptors occurs in the circulation blood.     

Characterization of molecules mediating cell-cell communication in human cardiac valve interstitial cells

Cell-cell interactions and adhesion determine cellular architectural organization, proliferation, signaling, differentiation, and death. We have identified the molecular components of different cell-cell junctions in human valve interstitial cells (ICs) both in situ and in culture. ICs were isolated, cultured, and phenotyped for cell surface and cytoplasmic markers by flow cytometry and immunocytochemistry. Western blotting was used to identify and quantify the molecular components of these cell-cell junctions in human valve ICs and compared with expression in smooth muscle and fibroblast cell types. N-cadherin and desmoglein were weakly detected on a low percentage of ICs, and the other classical cadherins were not detected. α- and β-catenin, but not γ-catenin, were expressed at equivalent levels by all valve ICs. Valve ICs did not express connexin-32 and-40; however, connexin-26 and-43 were equally expressed by a low percentage of ICs, demonstrating cell surface and cytoplasmic expression, and connexin-45 was weakly expressed. The other cell types also expressed N-cadherin, α- and β-catenin, desmoglein and connexin-43. The expression of these junctional molecules was predominantly by valve ICs on the inflow side of the valves. Human valve ICs have the ability to communicate with other valve ICs and mediate cell-cell adhesion via N-cadherin, connexin-26 and-43, and desmoglein. The junctions between valve ICs could support an interconnecting and coordinated cellular unit capable of controlling the functionality of the valve.     

Possible involvement of mitogen-activated protein kinase in the angiotensin II-induced fibronectin synthesis in renal interstitial fibroblasts

Angiotensin II (AT II) is thought to be associated with the development of renal interstitial fibrosis. However, the molecular mechanisms of the interstitial fibrosis have not been extensively studied. We have examined the role of mitogen-activated protein kinases (MAPKs) on fibronectin (FN) accumulation in cultured normal rat kidney interstitial fibroblasts (NRK 49F cell line). AT II caused dose-dependent increases in FN accumulation and FN mRNA in these cells. AT II also activated the extracellular signal-regulated kinase (ERK) and p38 MAPK in the presence of AT II. These increases in FN accumulation and activation of MAPKs were inhibited with AT I receptor antagonist (ARB; CV-11974) in renal interstitial fibroblasts. The inhibitors against ERK (PD98059) and p38 MAPK (SB203580) significantly inhibited AT II-induced increases in FN mRNA. These findings suggest that the MAPKs play an important role in AT II-mediated renal interstitial fibrosis and that ARB may be useful for preventing renal interstitial fibrosis.