Transplant
Investigating clinical practice of lung transplantation in systemic sclerosis
Interstitial lung disease (ILD) as a sequela of systemic sclerosis (SSc) poses a significant health concern. Patients with SSc-ILD experience symptoms of shortness of breath, reduced exercise capacity, and limited activities of daily living. Inducing fibrotic parenchymal change and pulmonary hypertension, SSc-ILD presents as both the most common extra-cutaneous manifestation and cause for mortality in this cohort (Mathai et al. Springer. 2014;139). Although rare, the prognosis of SSc-ILD is both difficult to understand and complex to manage.
Dr. Clauden Louis
With lung transplant being a treatment for end stage pulmonary disease, the role for lung transplantation in SSc-ILD is considered; however, remains controversial. Published literature exist without consensus. According to the recommendations of ISHLT, SSc is to be “carefully selected,” however, for some institutions, SSc remains a relative contraindication for lung transplant as definitive therapy (Weill et al. J Heart Lung Transplant. 2014;34[1]:1). Disease-specific concerns for SSc patients following lung transplant are esophageal dysmotility, dysphagia, gastroparesis, aspiration, and reflux disease. These comorbidities are associated with worsening prognosis in transplant survival (De Cruz, et al. Curr Opin Rheumatol. 2013;25[6]:714).
As clinical practices vary significantly in the management of SSc-ILD, we will survey transplant pulmonologist and surgeons from programs listed in Scientific Registry of Transplant Recipients (SRTR). We will evaluate transplant candidacy, preoperative transplant testing, postoperative transplant care, and outcomes. With this survey, we plan to determine the key practices of lung transplant programs regarding candidacy of patients with SSc-ILD perioperative management.
Clauden Louis, MD
Fellow-in-Training Member
Women’s lung health
Asthma and sex hormones
Overall asthma prevalence, severity, exacerbation rate, hospitalizations, and mortality are higher among women than men. Population studies show that asthma becomes more prevalent and severe in women following puberty, particularly in women with early menarche or multiple gestations. These findings suggest that sex hormones are important to the development and severity of asthma. Additional confounding variables include obesity, exposures, atopy, and age (Zien, et al. Curr Allergy Asthma Rep. 2015;15[6]:28).
Dr. Candace Huebert
Recent studies further define the gender disparity by detailing sex hormone differences in men and women with asthma. Han and colleagues recently reported on a cross-sectional study of serum-free testosterone and estradiol levels in over 7,000 adults in the National Health and Nutrition Examination Survey (NHANES, 2013-2016) (Han, et al. Am J Respir Crit Care Med. 2020;201[2]:158).
Dr. Margaret Pisani
Elevated free testosterone levels were associated with lower odds of current asthma in women. After stratification for obesity, elevated free testosterone and estradiol levels were associated with reduced odds of current asthma in obese women, and elevated estradiol was associated with lower odds of asthma in non-obese men. It should be noted that increased luteal phase progesterone levels have also been implicated in increasing airway hyperresponsiveness (AHR) in asthmatics (Lipworth, et al. Am J Respir Crit Care Med. 2019; Oct 22, 2019).
Dr. Jill Poole
In summary, testosterone is suggested to provide a protective, anti-inflammatory effect in women with asthma (Sathish, et al. Pharmacol Ther. 2015;150:94). Obesity interaction with sex hormones highlights its role as an important risk factor and disease modifier (Peters, et al. J Allergy Clin Immunol. 2018;141:1169). Future studies should continue to expand upon the role of sex hormones in relationship to multiple confounders. These insights will continue to define mechanisms that can be manipulated leading to novel pathway targeted therapies.
Candace Huebert, MD, FCCP
Margaret Pisani, MD, MPH, FCCP
Jill Poole, MD
Steering Committee Members