Elisabetta Cocconcelli

Prevalence of liver fibrosis among patients with definite diagnosis of

Idiopathic Pulmonary Fibrosis

Azienda Ospedaliero - Universitaria Policlinico di Modena

Clinica di Malattie dell’Apparato RespiratorioDirettore L.M. Fabbri

Ospedale Privato Accreditato Villa PinetaU.O. di Pneumologia e Riabilitazione Respiratoria

Direttore E. M. Clini

Pavullo n/F (MO), 4 Luglio 2014

Fibrosis Across Organ System Symposium, March 8th, 2012 - March 11th, 2012 Denver, CO

Key Priorities of Meeting:

1.Set Priorities for Research: Identify the scientific priorities for future investigations in single organ and cross-organ fibrotic disease 2.Assess Existing Models: Assess the currently available experimental models and their relevance to human health and disease (identify new models, if needed) 3.Identify Fibrosis Therapies: Identify potential promising therapies for pathologic tissue fibrosis

Idiopathic Pulmonary Fibrosis (IPF)IPF is defined as a specific form of chronic, progressive fibrosing interstitial pneumonia of unknown cause, occurring primarily in

elderly male adults, limited to the lungs, and associated with the histopathologic and/or radiologic pattern of UIP

Image courtesy of Giovanni Della Casa

T. E. King Jr. A. Pardo, M. Selman. Idiopathic Pulmonary Fibrosis. Lancet 2011

PATHOGENESIS OF IPFAbnormal wound healing model

Selman M., Ann Intern Med 2001; 134:136.

The CLINICAL DIAGNOSIS OF IPFrequires

Exclusion of other known causes of ILDand

The presence of a UIP pattern on HRCTor

Specific combinations of HRCT and surgical lung biopsy pattern

ATS/ERS/JRS/ALAT Guidelines; AJRCCM 2011.

Suspected IPFSuspected IPF

MDDMDD

Surgical Lung BiopsySurgical Lung Biopsy

HRCTHRCT

Identificable causes of ILDs?Identificable causes of ILDs?

Not IPFNot IPFIPF/ Not IPFIPF/ Not IPFIPFIPF

No

Possible UIPInconsistent w/ UIP

UIPNot UIP

Yes

UIPProbable UIP/ possible UIPNon-classificable fibrosis

EPIDEMIOLOGY OF IPF and RISK FACTORS

Prevalence: 13 - 20 /100,000 individuals

M:F = 1.5 to 1.7:1

Older age: VI-VII decades Median survival time 3 yrs

Despite the uncertain cause, some potential risk factors might be:History of cigarette smokingEnvironmental exposureMicrobial agentsGastroesophageal reflux AgeingGenetic factors

Sporadic forms

Familial forms

Raghu G, Collard HR, Egan J. et al. Am J Respir Crit Care Med. 2011. T. E. King Jr. A. Pardo, M. Selman. Idiopathic Pulmonary Fibrosis. Lancet 2011

AJRCCM 2011; 183: 788-824 (modified)

Clinical features and NATURAL HISTORY of IPF

RAPID PROGRESSION

STABLE

DIS

EASE

PRO

GRE

SSIO

N

TIME

SLOW PROGRESSION

Bibasilar dry ‘velcro’-crackles Finger clubbing (50%)

Dyspnea Dry cough

TREATMENT OF IPF

MECHANISMS OF FIBROSIS

Wynn TA & Ramalingam TR, Nature Medicine 2012; 18(7): 1028-40.

Chronic liver disease and Cirrhosis

Chronic hepatitis is characterized by a combination of hepatocyte necrosis and inflammation, persisting from more than 6 months and associated with a

variable degree of fibrosis.

Cirrhosis is the final common histologic pathway for a wide variety of chronic liver diseases. Mean features are: hepatic

fibrosis and regenerative nodules.

HEPATIC FIBROSISClinical evaluations

Alterations in the normally balanced process of extracellular matrix (ECM) production and

degradation develop hepatic fibrosis

NON-INVASIVE TESTS:

APRI 1.5 : significant fibrosisAPRI < 0.5 :significant fibrosis excluded

Biopsy METAVIR

F0: no fibrosisF1: portal fibrosis aloneF2: portal fibrosis with rare septaeF3: portal fibrosis with many septaeF4: cirrhosis

TRANSIENT ELASTOGRAPHY

TRANSIENT ELASTOGRAPHY (FibroScan)Transient elastography (TE, FibroScan) is a non-invasive method for the assessment of

hepatic fibrosis and steatosis, by measuring liver stiffness. Results are immediately available (5-7min) and operator-independent

Principles

An ultrasound transducer probe is mounted on the axis of a vibrator. Vibrations of mild amplitude and low frequency (50 Hz) are transmitted by the transducer, inducing an elastic shear wave that propagates through the underlying tissues. Pulse-echo ultrasound acquisition is used to follow the propagation of the shear wave and to measure its velocity, which is directly related to tissue stiffness: the stiffer the tissue, the faster the shear wave propagates.

Castera L., Forns X., Alberti A. Journal of Hepatology 48. 2008; 835-847.

TRANSIENT ELASTOGRAPHY (FibroScan) TE measures liver stiffness in a volume that approximates a cylinder 1

cm wide and 4 cm long, between 25 mm and 65 mm below the skin surface

volume 100 times bigger than a biopsy sample The tip of the probe transducer is placed on the skin between the rib

bones at the level of the right lobe of the liver where liver biopsy would be performed.

The software determines whether each measurement is successful or not. When a shot is unsuccessful, the machine does not give any reading.

Castera L., Forns X., Alberti A. Journal of Hepatology 48. 2008; 835-847.

TRANSIENT ELASTOGRAPHY (FibroScan) Results are expressed in kPa and correspond to the median of 10 validated

measurements. Liver stiffness values range from 2.5 to 75 kPa. Use of ranges of values rather than a single cut-off value

Combining TE results with serum markers increases diagnostic accuracy and liver biopsy can be avoided.

Limitations:-Failure in ≈5% of cases, mainly in obese patients (BMI > 29) or in those with narrow intercostal space -Not feasible in patients with ascites

Existing models for multi-organ fibroticinvolvement

Telomeres shortening and telomere syndrome

IgG4-related sclerosis disease

TELOMERE SHORTENINGShort telomeres limit tissue renewal capacity and

ultimately lead to organ failure.

Involved in degenerative age-related disease. In a subset of patients with familiar (8-15%) or sporadic (1-3%)

IPF, germ-line mutations in telomerase components (hTERT and hTR) have been described.

Telomere shortening has been described in sporadic cirrhosis. Mutations in telomerase have heterogeneous manifestations

(telomere syndromes), e.g. dyskeratosis congenita, where both pulmonary and liver fibrosis display anticipation.

Diaz de Leon A, et al. PLoS ONE 2010; 5(5):e10680.Armanios MY, et al. NEJM 2007; 356:1317-26.Calado RT, et al. Hepatology 2011; 53:1600-1607.

TELOMERE SHORTENINGShort telomeres limit tissue renewal capacity and

ultimately lead to organ failure.

It has been identified a cluster of individuals (3%) with concomitant IPF and cryptogenic liver cirrhosis. They had telomeres in the lowest percentiles.

None of these patients had detectable telomerase mutations, although they had telomeres in the lowest percentiles.

Therefore, telomere length, rather than telomerase mutations, might predict disease onset in syndromes of telomere shortening.

Diaz de Leon A, et al. PLoS ONE 2010; 5(5):e10680.Armanios MY, et al. NEJM 2007; 356:1317-26.Calado RT, et al. Hepatology 2011; 53:1600-1607.

IgG4-RELATED SCLEROSIS DISEASE (ISD)ISD is a fibroinflammatory disease associated with elevated circulating

levels of IgG4 (> 140 mg/dL), occurring primarly in males with median age of 60-65 years.

• The characteristic lesions of dense lymphoplasmocytic infiltrates containing IgG4-positive plasma cells have been documented in many organs, including bile duct, liver (IgG4-hepatopathy), kidney, retroperitoneum, as well as the lung.

• The disease can either be localized or systemic. Lesions in different organs can present simultaneously or metachronously.

• Intrathoracic manifestations are heterogeneous, involving lung parenchyma, intrathoracic lymph nodes, pleura, as well as the mediastinum.

Ryu JH, Sekiguchi H, Yi ES, Eur Respir J. 2012 Jan;39(1):180-6. Epub 2011 Jun 30.

AIM of the studyRESEARCH QUESTION

What is the prevalence of subclinical liver fibrosis among patients with a definite

diagnosis of IPF?

Answer is unknown

METHODSInclusion criteria•Patients with a diagnosis of IPF according to 2011 ATS/ERS/JRS/ALAT Guidelines

Exclusion criteria•BMI > 29•Previous history of chronic liver disease

Approved by the local Ethics Committee.

METHODS

Enrolled patients undergo FibroScan to detect any degree of liver fibrosis.

Patients with FibroScan results suggesting liver fibrosis underwent:

• additional testing for markers of liver injury • extensive screening for possible secondary causes of liver fibrosis

DEMOGRAPHICS

Characteristics Results (N=55)

Patients, M:F 41 : 14

Mean age years ± SD 69 ± 10

Diagnosis HRCT vs. SLB 41 vs. 14

Mean FVC, % pred. 73,4 % (range 22-120%)

Mean DLCO-SB, % pred. 40 % (range 11-102%)

GAP score

• Stage I 36%

• Stage II 43%

• Stage III 21%

Definition of abbreviations: HRCT= high resolution computed tomography, SLB= surgical lung biopsy, FVC=forced vital capacity, DLCO-SB= diffusing capacity for carbon monoxide, single breath, G=gender, A=age, P= lung pulmonary variables.

FIBROSCAN RESULTSFibroScan – METAVIR scale Results (N=43) Mean Stiffness ±SD

F0-F1, n (%) 18 (42%) 3.72 ±0.7 kPa

F1, n (%) 1 6.60 kPa

F1-F2, n (%) 4 (9%) 6.78 ±0,74 kPa

F2, n (%) 6 (14%) 7.87 ±0.43 kPa

F2-F3, n 1 9.5 kPa

F4, n 1 14.3 kPa

Probable fibrosis 1 40.3 kPa

Not reliable/Low quality 11 (25%)

• 12 pts (22%) were excluded because of BMI > 29.

• A certain degree of liver fibrosis was documented in 14 pts (33%).

RESULTS F0-F1 F1-F2 ≥ F2 n 25° median 75°n 25° median 75°n 25° median 75°

kPa 18 3,05 3,65 4,28 5 6,20 6,60 7,20 9 7,60 8,40 9,50

APRI 17 0,19 0,23 0,31 3 0,20 0,22 0,40 9 0,17 0,24 0,29

AST 18 19 20 24,75 4 15,50 17,50 23,25 9 14 25 27

ALT 18 10,25 14 17,50 4 10,25 12 26 9 17 29 32

γ GT 17 15 21 30 4 15,75 18,50 21,50 9 15 58 120

Bilirubin 15 0,37 0,41 0,45 3 0,38 0,51 0,65 7 0,44 0,59 0,73

IgG4 12 43 52 146,50 2 42,00 60 78 5 32 126 419

MCV 16 87,68 91,85 95,83 3 94,85 97 101,15 8 90,43 91,75 94,83

RESULTSData show that about one third (33%) of patients with IPF has a concomitant

fibrosing process in the liver.

Minor impairment of markers of liver injury was found in a minority of patients with liver fibrosis.

Secondary causes of liver fibrosis were excluded in all patients.

IgG4 levels were measured in 19 patients and isolated increased levels were found in 5 patients.

One patient with F4 fibrosis on FibroScan and elevated IgG4, underwent liver biopsy showing a chronic non-alcoholic liver disease. No evidence of IgG4 on liver histology.

Limitations and problems

Sample size In patients with BMI > 29, results are not reliable

Is the incidence of liver fibrosis in IPF patients really higher than in age-matched controls?

Future directions Investigate the possibility of final common pathways

leading to fibrosis both in the lung and in the liver Increase the sample size Possibly enroll an age-matched control population More analysis of telomerase mutations and telomere

length should be performed Assess the presence of pulmonary fibrosis among patients

with cryptogenic liver fibrosis

Unanswered question What is the effect of any degree of liver fibrosis on the

biological response to IPF treatments?

American Thoracic Society’s International Conference 2014 San Diego, May 16 - May 21

Thank you

Elisabetta Cocconcelli

Prevalence of liver fibrosis among patients with definite diagnosis of

Idiopathic Pulmonary Fibrosis

Azienda Ospedaliero - Universitaria Policlinico di Modena

Clinica di Malattie dell’Apparato RespiratorioDirettore L.M. Fabbri

Ospedale Privato Accreditato Villa PinetaU.O. di Pneumologia e Riabilitazione Respiratoria

Direttore E. M. Clini

Pavullo n/F (MO), 4 Luglio 2014