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Lee, Choi, Kim, Kim, Park, Kim, Hyun, Jung, Bae, and Choe: Prognostic Factors of the RA Patients with ILD
Original Article

J Rheum Dis 2013;20(1):9-16.

Published online: 31 February 2013

DOI: https://doi.org/10.4078/jrd.2013.20.1.9

Prognostic Factors of the RA Patients with ILD

Hwajeong Lee1, 2, Han Na Choi1, Si Hye Kim1, Ji Hun Kim1, 2, Sung-Hoon Park1, 2, Seong-Kyu Kim1, 2, Dae Sung Hyun1, Kyung-Jae Jung3, Jisuk Bae4, Jung-Yoon Choe1, 2

1Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea

2Arthritis and Autoimmunity Research Center, Catholic University of Daegu School of Medicine, Daegu, Korea

3Department of Radiology, Catholic University of Daegu School of Medicine, Daegu, Korea

4Department of Preventive Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea

Corresponding to : Jung-Yoon Choe, Division of Rheumatology, Department of Internal Medicine, Arthritis and Autoimmunity Research Center, Catholic University of Daegu School of Medicine, 3056-6, Daemyung 4-dong, Nam-gu, Daegu 705-718, Korea. E-mail : jychoe@cu.ac.kr

Received 21 September 201231 October 2012       Accepted 31 October 2012

Copyright © 2013 The Korean College of Rheumatology

This is a Free Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

Interstitial lung disease (ILD) is a common pulmonary manifestation of rheumatoid arthritis (RA), and an important cause of morbidity and mortality in RA. We compared demographic and clinical characteristics of usual interstitial pneumonia (UIP) and nonspecific interstitial pneumonia (NSIP) patterns in RA patients and determined the prognostic factors that influence the survival of RA-ILD patients.

Methods

51 enrolled RA patients (male n=21, female n=30) with ILD underwent HRCT. We categorized ILD into two groups, as the UIP pattern and the NSIP pattern, using HRCT. HRCT scans were scored to investigate the extent of the ILD. We divided the extent of the interstitial lung disease into 4 groups 1∼14%, 15∼19%, 20∼24%, >25%.

Results

There were no significant differences between the UIP and NSIP pattern in the clinical characteristics, except for age at the time of the study (RA-NSIP pattern vs RA-UIP pattern 62.3±11.7 vs 68.2±8.4, p=0.042). There were no significant differences in survival time between the RA-UIP and RA-NSIP pattern (Log rank p=0.985). The extent of ILD on chest HRCT was significantly associated with mortality (HR=1.044, 95% CI 1.019∼1.069) and patients that were diagnosed with ILD at an older age (HR=1.109, 95% CI 1.024∼1.200) were associated with a worse prognosis. Comparing four groups divided by the extent of the lung disease, there were significant differences in survival estimates (Log-rank p-value<0.001) based on an ILD extent of 15%.

Conclusion

Our study reveals that the extent of ILD on chest HRCT was found to be significantly associated with poor prognosis of RA-ILD patients.

Keywords: Rheumatoid arthritis, Interstitial lung disease, High resolution computed tomography, Lung disease extent, Prognosis

References

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Figure 1.
Kaplan-meier survival curve for patients with a RA associated UIP pattern and RA associated NSIP pattern. There were no significant differences in survival time between the RA-UIP and RA-NSIP pattern (Log rank p=0.985).
jrd-20-9f1.tif
Figure 2.
Survival compared between the extent of limited lung disease and extensive lung disease. There were significant differences in survival estimates based on an ILD extent of 15% (Log-rank p-value<0.001). Median survival time of an ILD extent less than 15% was 89.4 months and median survival time of an ILD extent in excess of 15% was 49 months.
jrd-20-9f2.tif
Table 1.
Demographic and clinical characteristics of RA with ILD according to HRCT pattern
  UIP (n=35) NSIP (n=16) p-value
Age 68.3±8.5 62.3±11.7 0.042
RA diagnosed age 57.5±14.4 54.4±13.3 0.464
RA duration (years) 7.5±5.7 7.9±8.2 0.856
ILD diagnosed age 64.9±8.9 59.8±10.8 0.079
ILD duration (month) 51.8±23.8 40.9±24.1 0.139
Female n (%) 20 (57.1%) 10 (62.5%) 0.718
Ever-smoker n (%) 11 (31.4%) 7 (43.8%) 0.393
Baseline FVC (L) 2.4±1.1 2.9±1.8 0.390
Baseline FEV1 (% predicted) 72.9±24.9 67.8±31.7 0.608
Baseline DLco (% predicted) 86.9±21.1 65.4±42.3 0.108
Lung extent (%) 19.1±14.6 17.9±17.8 0.823
RF (IU/mL) 224±241.9 199.9±214 0.734
Anti-CCP Ab positive 22 (62.9%) 12 (75%) 0.393
ANA positive 10 (28.6%) 3 (18.8%) 0.455
WBC count (103/μ L) 9.5±4.4 10.3±3.5 0.539
LDH (IU/L) 481.7±155.5 482.6±254.2 0.988
ESR (mm) 48.6±32.7 44.5±20.8 0.597
CRP (mg/L) 25.6±41.7 29.2±46.3 0.783
Prednisone (mg) 3.69±2.0 4.8±2.6 0.107
Methotrexate n (%) 20 (57.1%) 10 (62.5%) 0.718
Leflunomide n (%) 2 (5.7%) 2 (12.5%) 0.403
Hydroxychloroquine n (%) 28 (80%) 11 (68.8%) 0.379
Sulfasalazine n (%) 24 (68.6%) 12 (75%) 0.640
Bucillamine n (%) 9 (25.7%) 4 (25%) 0.957
TNF-a inhibitor n (%) 1 (2.9%) 0 (0%) 0.495
Cyclosporine n (%) 5 (14.3%) 3 (18.8%) 0.684

RA: rheumatoid arthritis, ILD: interstitial lung disease, HRCT: high resolution computed tomography, FVC: forced vital capacity, FEV1: forced expiratory volume in 1 second, DLco: pulmonary diffusion capacity of carbon monoxide, ANA: anti-nuclear antibody, WBC: white blood cell, LDH: lactate dehydrogenase, ESR: erythrocyte sedimentation rate, CRP: C-reactive protein, TNF-a: tumor necrosis factor alpha

Table 2.
Predictors of survival in RA patients with ILD (univariate analysis)
Variables HR 95% CI p-value
Age 1.087 1.004∼1.176 0.039
Male 1.381 0.490∼3.889 0.542
Smoking 1.242 0.395∼3.907 0.711
Age at RA diagnosis 1.055 0.994∼1.119 0.077
RA duration (year) 0.922 0.816∼1.040 0.186
Age at ILD diagnosis 1.109 1.024∼1.200 0.011
ILD duration (month) 0.710 0.587∼0.857 <0.001
UIP pattern on HRCT 1.314 0.366∼4.715 0.675
Extent of ILD 1.044 1.019∼1.069 <0.001
Baseline FVC 0.823 0.582∼1.163 0.27
Baseline FEV1 0.999 0.984∼1.014 0.898
Baseline DLco 0.996 0.978∼1.014 0.667
Anti-CCP antibody 1.008 0.344∼2.956 0.988
ANA 3.226 0.716∼14.525 0.127
WBC count 1.239 1.038∼1.478 0.017
LDH 1.003 1.000∼1.005 0.040
ESR 1.017 1.000∼1.035 0.046
CRP 1.012 1.002∼1.022 0.017
RF 1.002 1.000∼1.004 0.025
Prednisolone 1.095 0.913∼1.314 0.328
MTX 2.924 0.991∼8.628 0.052
MTX accumulated dose 1 0.999∼1.000 0.337
MTX mean dose 0.912 0.797∼1.045 0.185

RA: rheumatoid arthritis, ILD: interstitial lung disease, UIP: usual interstitial pneumonia, HRCT: high resolution computed tomography, FVC: forced vital capacity, FEV1: forced expiratory volume in 1 second, DLco: pulmonary diffusion capacity of carbon monoxide, ANA: anti-nuclear antibody, WBC: white blood cell, LDH: lactate dehydrogenase, ESR: erythrocyte sedimentation rate, CRP: C-reactive protein, RF: rheumatoid factor, MTX: methotrexate

Table 3.
Predictors of survival in RA patients with ILD (multivariate analysis)
Variables HR 95% CI p-value
UIP pattern on HRCT 3.45 0.683∼17.437 0.134
Age at ILD diagnosis 1.035 0.942∼1.137 0.477
Male 0.712 0.109∼4.650 0.722
Smoking 0.577 0.115∼2.905 0.505
ILD duration 0.426 0.274∼0.663 <0.001
Extent of ILD 1.078 1.029∼1.130 0.002

RA: rheumatoid arthritis, ILD: interstitial lung disease, UIP: usual interstitial pneumonia, HRCT: high resolution computed tomography

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