EARLY LUNG DISEASE IN CF

Peter D. Sly MBBS, MD, FRACP, DSc

THE AREST CF PROGRAM

Comprehensive early surveillance program• CF diagnosed following detection by NBS

• Initial assessment soon after diagnosis ( 3 months)

• Annual assessment close to birthday until 6 years

• Clinical and research components

• Separate consent for each component• Assessments undertaken when clinically stable

• Very well accepted, >95% complete participation

AREST CF ASSESSMENTS

CT/BAL• GA; EI (25 cmH2O), EE (0 cmH2O)• 3-slice scans; low-dose volumetric scans• BAL after CT

Infant lung function• SF6MBW, LF-FOT, RVRTC

Preschool lung function• FOT, spirometry from 5 years

Biomarker discovery and validation• Matched BAL, serum, urine• Infection, inflammation, metabolomics

AREST CF ASSESSMENTS

Bronchoalveolar lavage

• Following CT, via LMA• 3 x 1ml/kg RML, 1 x1ml/kg LLL or most affected

• Microbiology (aliquots 1 & 4)

− Standard culture-based assessment

− Metagenomics• Inflammation (aliquots 2 & 3)

BAL: WHAT ARE WE TRYING TO MEASURE?

What constitutes normality?

Kanakoudi1 (n=20)

Midulla2 (n=16)

Armstrong3 (n=19)

Gangell4 (n=65, CF never infected)

Age range (y) 0.25-14 0.17-2.67 0.17-4 1.06-1.83

TCC (x103/ml) 199.2±8.12 599 (200-1300)

151(102,223) 242 (194,301)

Neuts (%) 2.94±2.82 5.5 (0-17) 8.2 (4.6,15) 13.6 (11.3,15.6)

IL-8 (pg/ml) 234.9±528.44

24 (12,47) 322 (234,444)

1Hippokratia 2010;14:109-14. 2Pediatr Pulmonol 1995;20:112-118. 3Pediatr Pulmonol 2005;40:500-10. 4Clin Infect Dis 2011;53:425-32.

AREST CF RESULTS

Overall results•1285 BAL (305 children), 869 CT (258 children)•Lung disease begins early in CF

−Bx, air trapping from 3 months−Infection, including with P. aeruginosa from 3 months−May occur in asymptomatic children

•Neutrophilic inflammation prominent− Free NE activity from 3 months− Associated with presence, extent and progression of Bx

•Infection common− At least one infection in 78% by 6 years− Successful eradication of P. aeruginosa if treated early

•Early infection on BAL associated with− Structural lung disease− Abnormal lung function in infancy− Low BMI

Assessment over the first 3y (longitudinal) 127 consecutive infants with CF (NBS) AREST CF ESP

CT, BAL 3m (n=127), 1 (n=109), 2 (n=92), 3y (n=81)

longitudinal analyses 3m-3y

Sly et al NEJM 2013

Early Lung Disease in CF

EARLY LUNG DISEASE IN CF

Bx defined as B:A>1

• A 15 month old child with no abnormalities in inspiration or B expiration • C 2 year old child with bronchiectasis in inspiration • D 2 year old child with gas-trapping in expiration

DEMOGRAPHIC AND CLINICAL DATA

3m (n=127)

1y (n=109) 2y (n=92) 3y (n=81)

BMI Z-score -1.34±1.19 -0.42±1.29 -0.16±1.46 0.22±0.96

NE +ve 28 (23.3%) 19 (18.1%) 20 (21.7%) 19 (25.0%)

Neuts x103/ml 416±810 482±761 1441±2822

2334±5618

Any infection 22.4% 21.1% 40.2% 46.9%

Bx prevalence 29.3% 31.5% 44.0% 61.5%

GT prevalence 68.0% 68.5% 71.6% 69.5%

Sly et al NEJM 2013

EARLY LUNG DISEASE IN CF

Inflammation is increased in those with respiratory symptoms and infection.

Respiratory symptoms Pulmonary infection

Absent (n=93)

Present (n=19)

p Absent (n=94)

Present (n=27)

p

Neutrophils (x103/ml)

326.4 947.5 0.031 303.3 822.4 0.02

Neutrophils (%) 17.9 30.5 0.017 17.5 28.8 0.013

IL-8 (pg/ml) 815.4 1607.9 0.03 988.0 1123.3 0.22

NE activity (%) 19.4 52.6 0.007 19.1 40.7 0.021

Bx (%) 23.7 55.0 0.005 24.2 46.2 0.029

GT (%) 72.0 68.4 0.40 68.1 74.1 0.46

3M DATA STRATIFIED BY NE STATUS

NE positive (n=28)

NE negative (n=92)

p

Sex (M/F) 15/13 47/45 0.82

Severe genotype 100% 88.5% 0.11

BMI Z-score -1.45±0.84 -1.33±1.23 0.66

Respiratory symptoms

35.7% 10.7% 0.007

Meconium Ileus 25.9% 17.7% 0.40

Pancreatic insufficient

100% 78.2% 0.006

Any infection 39.3% 17.4% 0.021

S. aureus 10.7% 4.3% 0.35

P. aeruginosa 10.7% 3.3% 0.14

Sly et al NEJM 2013

3M DATA STRATIFIED BY BX STATUS

Bx positive (n=36)

Bx negative (n=91)

p

Sex (M/F) 15/21 48/40 0.12

Severe genotype 100% 88.5% 0.11

BMI Z-score -1.34±1.05 -1.33±1.25 0.98

Respiratory symptoms

33.3% 12.0% 0.014

Meconium Ileus 40.0% 12.3% 0.002

Pancreatic insufficient 93.1% 78.8% 0.094

Any infection 34.3% 17.8% 0.028

S. aureus 8.6% 5.6% 0.69

P. aeruginosa 14.3% 2.2% 0.018

Sly et al NEJM 2013

Inflammatory markers

No current infection (n=213) [0-6y old]

Past infection* (n=112)

Never infected* (n=101)

Single organism (n=292)

Multiple organisms (n=148)

Total cell count (x103 cells/ml)

254 (218-295) 260 (212-320) 242 (194-301) 296 (258-338)p=0.13

408 (342-487)p=0.001

Neutrophils (x103 cells/ml)

33 (26-43) 28 (20-40) 33 (22-47) 207 (165-260)p<0.001

181 (132-248)p<0.001

Neutrophil elastase (ng/ml)

155 (126-190) 159 (120-210) 144 (106-195) 239 (198-287)p<0.001

346 (272-441)p<0.001

Interleukin-8 (pg/ml)

404 (324-503) 470 (348-636) 322 (234-444) 672 (552-819)p<0.001

856 (660-1112)p<0.001

Inflammatory response score

4.36 (4.22-4.49) 4.36 (4.17-4.56) 4.28 (4.08-4.48) 4.97 (4.84-5.10)p< 0.001

5.12 (4.96-5.29)p<0.001

Inflammatory response is associated with current infection

* Subgroups of no current infection

Gangell. Clin Infect Dis 2011;53:525-32.

Organism Any Bacterial Density Bacterial Density ≥105 cfu/mln Coefficient Std error p n Coefficient Std error p

Aspergillus spp. 19 0.89 0.24 <0.001 7 1.19 0.33 <0.001Candida spp. 7 0.46 0.32 0.15 0 - - -

H. influenzae 12 0.68 0.27 0.01 8 0.59 0.31 0.05P. aeruginosa 29 1.07 0.24 <0.001 25 1.32 0.22 <0.001Staph aureus 31 1.05 0.20 <0.001 17 1.12 0.23 <0.001

Strep pneumoniae 6 1.38 0.37 <0.001 5 1.31 0.38 <0.001

Mixed oral flora 165 0.42 0.11 <0.001 97 0.51 0.12 <0.001Multiple organisms 148 0.58 0.14 <0.001 - - - -

* Regression analyses, adjusted for pancreatic insufficiency, detection by newborn screening, age and the presence of respiratory symptoms, comparing the inflammatory response score associated with the presence of individual organisms in BAL compared with the inflammatory response score associated with BAL from children in the never infected group.

Increased inflammation with some organisms

Gangell. Clin Infect Dis 2011;53:525-32.

AREST CF ESP653 BAL samples from 215 children 3m to 6y old

Longitudinal risk factors for Bx: 3m to 3y

Odds Ratio (95% CI)

GEE with binomial family, logit link and AR(1) correlation matrix

Sly et al NEJM 2013

Univariate analysis

Sly et al NEJM 2013

Odds Ratio (95% CI)

GEE with binomial family, logit link and AR(1) correlation matrix

Longitudinal risk factors for Bx from 3m to 3y

Multivariate analysis

GAS TRAPPING ON CT

What does Gas trapping mean? Uneven emptying of lung units

Is it associated with disease? Increases risk of bronchiectasis Weak association with M2/MO but not LCI

[Hall PLoS ONE 2011;6:e23932]

Can it be treated? No data in infants

Those with NE in BAL develop Bx earlier

Sly et al NEJM 2013

Initial scan Subsequent scan Bx label

DetectedDetected Persistent

Not detected Resolved

Not detectedDetected Acquired

Not detected Negative

Persistent Bx

Odds Ratio (95% CI)

Risk factors at 3m for persistent Bx: 12m

Logistic regression; Blue=univariate; Red=multivariate

Sly et al NEJM 2013

Odds Ratio (95% CI)

Risk factors at 3m for persistent Bx: 3y

Logistic regression; Blue=univariate; Red=multivariate

Sly et al NEJM 2013

CONCLUSION

Lung disease begins early in CF Respiratory symptoms and infection are associated

with more disease Inflammation, Bx and gas trapping can occur in

asymptomatic infants Free NE activity in BAL at 3M increases risk for

persistent Bx 7 fold at 12 months 4 fold at 3y

Prevention of lung disease requires early intervention