Treatment of Adult Primary Alveolar Proteinosis | Archivos de Bronconeumología

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Jiménez Ruiz, Daniel Buljubasich, Raúl Sansores, Juan Antonio Riesco Miranda, Alfredo Guerreros Benavides, Susana Luhning, José Miguel Chatkin, Gustavo Zabert, José Ignacio de Granda Orive, Segismundo Solano Reina, Alejandro Casas Herrera, Pilar de Lucas Ramos" "autores" => array:12 [ 0 => array:2 [ "nombre" => "Carlos A." 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"autores" => array:1 [ 0 => array:4 [ "nombre" => "José Antonio" "apellidos" => "Rodríguez Portal" "email" => array:2 [ 0 => "jarportal@ecua.es" 1 => "josea.rodriguez.sspa@juntadeandalucia.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "UMQER Centro de investigación en red de enfermedades respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Universitario Virgen del Rocío/Virgen Macarena, Instituto de Biomedicina de Sevilla (IBIS)/CSIC/Universidad de Sevilla, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento de la proteinosis alveolar primaria del adulto" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1676 "Ancho" => 3105 "Tamanyo" => 205416 ] ] "descripcion" => array:1 [ "en" => "Suggested PAP-treatment algorithm, according to severity, based on the opinions of different authors.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>" ] ] ] "textoCompleto" => "DefinitionPulmonary alveolar proteinosis (PAP) is a rare disease that was first described in 1958.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> It is characterized by the accumulation of surfactant-like lipoproteinaceous material in the distal air spaces and terminal bronchi, which may lead to impaired gas exchange<a class="elsevierStyleCrossRef" href="#bib0010">2</a> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). This accumulation of surfactant is due to reduced clearance by the alveolar macrophages, and another feature of the disease is the presence of phospholipoproteic material within the alveolar macrophages. Estimated yearly incidence is 0.2–0.4cases/million, and prevalence is 3.7–6.2persons/year.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> As of 2002, around 410 cases had been described in the literature.<a class="elsevierStyleCrossRef" href="#bib0020">4</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Classification and PathogenesisThe main elements in the development of PAP are the appearance of defective granulocyte-macrophage colony stimulating factor (GM-CSF) activity or changes in the cell surface GM-CSF receptor and in its signaling mechanisms. GM-CSF is necessary for final alveolar macrophage differentiation and maturing.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> One of the major advances in the understanding of the pathogenic mechanisms of PAP occurred unexpectedly following work carried out in an animal model with GM-CSF knockout mice. Investigators were surprised to find that although these mice showed no hematological manifestations, they developed a pulmonary condition very similar to human PAP. Moreover, lungs recovered once the GM-CSF function was reestablished, irrespective of whether GM-CSF was administered exogenously by inhalation, the non-functioning gene was repaired, or the mice underwent bone marrow transplant.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Subsequent studies in mice models showed that local GM-CSF deficit produced by inhibiting the GM-CSF gene or by deletion of the GM-CSF/IL-3/IL-5 receptor β-subunit on the cell surface leads to the development of PAP.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>From a clinical point of view, there are 3 main forms of PAP: hereditary or congenital; autoimmune or primary; and secondary. Mechanisms leading to alveolar macrophage dysfunction differ in each of these 3 forms.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>In primary PAP, anti-GM-CSF IgG-type neutralizing antibodies are detected. This form accounts for 90% of all cases of the disease. These antibodies are found in both serum and bronchoalveolar lavage (BAL) fluid, and confirm the autoimmune mechanism involved in primary PAP.<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a> These neutralizing antibodies cause alveolar macrophage dysfunction, affecting catabolism and clearance of surfactant from the distal air spaces.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> In cases of congenital or hereditary PAP, the defective elimination of surfactant is caused by mutations in genes coding for surfactant protein-B (SP-B),<a class="elsevierStyleCrossRef" href="#bib0060">12</a> surfactant protein-C (SP-C),<a class="elsevierStyleCrossRef" href="#bib0065">13</a> or in genes coding for GM-CSF receptor chains (CSF2RA-α<a class="elsevierStyleCrossRef" href="#bib0070">14</a> and CSF2RB-β<a class="elsevierStyleCrossRef" href="#bib0075">15</a>), preventing GM-CSF from binding to its membrane receptor.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Other germline mutations can also cause different diseases, including PAP.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> Secondary PAP, for its part, occurs in several diseases that involve a reduction in the number or function of the alveolar macrophages, such as myelodysplastic syndrome, leukemias or lymphomas.<a class="elsevierStyleCrossRef" href="#bib0090">18</a> PAP may also occur in association with some infections (Nocardia, Pneumocystis jirovecii) or after environmental or occupational exposure to substances such as silica, aluminum, titanium or some fertilizers.<a class="elsevierStyleCrossRef" href="#bib0095">19</a>TreatmentIn this review, we will discuss the treatment of primary or autoimmune PAP, as the treatment of secondary PAP depends mainly on the specific disease with which it is associated. There are currently no firm, universally accepted criteria for starting treatment for PAP, particularly for milder cases, and the decision to initiate specific treatment will depend on the severity of the clinical presentation. This consideration is based on the natural disease course, in which a high percentage of cases show spontaneous remission. In the largest series published to date, patients who were asymptomatic had a high probability of remaining stable or even improving without treatment, and only 8% deteriorated during follow-up. Of those with symptoms, the proportion of patients who remained stable, improved or worsened was 45%, 30%, and 25%, respectively.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Those with longer disease courses were more likely to deteriorate.Treatment of choice is still whole lung lavage, although there have been advances in alternative or complementary treatments, such as the administration of GM-CSF, rituximab, plasmapheresis or stem cell transplants. Due to the rarity of this disease—and thus the scant number of patients—most of these treatments are based on the results obtained from case series, rather than randomized clinical trials. Some of them are still in an experimental phase, so the level of evidence in most cases is weak and based solely on expert opinion.In order to achieve the best risk-benefit ratio when the decision has been taken to start treatment, most authors agree to arbitrarily classify the patients into 3 categories or groups,<a class="elsevierStyleCrossRef" href="#bib0100">20</a> as follows:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Group 1. Asymptomatic patients and/or those with mild gas exchange impairment. These patients do not need immediate treatment and must be monitored periodically for symptoms, lung function and imaging studies.</li><li class="elsevierStyleListItem" id="lsti0010">•Group 2. Patients with mild/moderate symptoms (dyspnea on exertion) and oxygenation changes during exercise (not at rest). This group should be managed with oxygen therapy during exercise and more closely monitored for any clinical or functional deterioration that may require more aggressive treatment. The recommendation of oxygen therapy in this group is not supported by clinical trial results; rather it is based on expert opinion with little scientific evidence.</li><li class="elsevierStyleListItem" id="lsti0015">•Group 3. This group includes patients with moderate or severe symptoms, who have gas exchange impairment at rest. This group needs specific, more aggressive treatment. The treatment of choice is whole lung lavage, and other therapeutic interventions can be adopted, depending on the results obtained and the progress of the disease.</li></ul>Due to the scant evidence on which treatment is based and to more accurately define cases of PAP that require more specific treatment, some authors have proposed more objective criteria, based primarily on oxygenation factors. Patients with the following parameters would be candidates for treatment: (a) resting PaO2<65mmHg; (b) alveolar-arterial oxygen tension gradient≥40mmHg, and (c)shunt fraction >10%–12%.<a class="elsevierStyleCrossRef" href="#bib0105">21</a>Whole Lung LavageWhole lung lavage remains the treatment of choice for PAP. It was first described over 40 years ago, and since then the technique has undergone very few changes.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> It needs to be performed under general anesthesia with double-lumen endotracheal intubation. One lung is ventilated and oxygenated via one lumen, while the contralateral lung is washed with saline solution at a temperature of approximately 37°C. Aliquots of 1–1.5L of warmed saline solution are usually needed for each lavage, and between 10 and 15 lavages are needed to treat one whole lung. The procedure generally lasts around 3–4h. Chest percussion during the procedure has been reported to significantly increase the extraction of lipoproteinaceous material.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Lavage of the other lung can be done on a separate occasion or sequentially in the same session.Oxygenation and pulmonary mechanics must be monitored during the procedure. The double-lumen tube must be carefully positioned and care must be taken to recover the saline solution that has been instilled, to avoid possible complications caused by poor placement of the endotracheal tube, passage of serum to the ventilated lung, or the development of hydropneumothorax. Other complications include pneumonia, laryngospasm or arrhythmias.<a class="elsevierStyleCrossRef" href="#bib0120">24</a>In 75%–95% of cases, symptoms, oxygenation capacity, and radiological changes improve rapidly after whole lung lavage, generally in the first few days after the procedure.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> This benefit tends to be sustained for a mean period of 15 months, although relapses are common, and occur in up to 45%–70% of cases over the subsequent 3 years. However, whole lung lavage does not need to be repeated in all cases of relapse. The results of the different series vary widely, and repeating whole lung lavage has been reported in a range of between 15% and 70% of cases. It should be emphasized that around 30%–40% of cases will require only one lavage. It is important to note that 5-year survival is greater in patients who have undergone whole lung lavage that in those who have not (94% vs 85%, P<.04).<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Subcutaneous GM-CSFAfter anti-GM-CSF antibodies in the serum and BAL of patients with primary PAP and their role in PAP pathogenesis were discovered, the possibility of exogenous administration of this cytokine was proposed as a potential treatment. No randomized clinical trials have been performed and most published papers are observational studies including small numbers of patients<a class="elsevierStyleCrossRefs" href="#bib0125">25,26</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Seymour et al.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> published the first case of clinical improvement in an adult receiving GM-CSF subcutaneously. This author subsequently treated another 14 patients<a class="elsevierStyleCrossRef" href="#bib0140">28</a> at a dose of 3μg/kg/day for 5 days, increasing to 5μg/kg/day for a period of 12 weeks. One patient discontinued treatment after 13 days due to neutropenia, and 5 discontinued after 6 weeks due to lack of response. Seven patients continued treatment for 12 weeks and one patient was treated for 26 weeks. Treatment was considered effective in 6/14 (43%, 95% CI 18%–71%), with a mean treatment period of 39 weeks. Of these 6 cases, 5 worsened after discontinuation of the therapy, and 4 improved after it was resumed.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Kavuru et al.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> treated a group of 4 patients for 12 weeks. The dose for the first 4 weeks was 250μg/day, with daily 5μg/kg increments during the next 4 weeks, and finally, 9μg/kg/day for the last 4 weeks. Three of the 4 patients experienced improved lung function, oxygenation and exercise capacity.In a prospective trial, Bonfield et al.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> included 14 cases of PAP, of whom 11 completed the study. All patients had previously undergone whole lung lavage. The initial dose was 250μg/day, with dose increases every 2 weeks to a maximum of 18μg/kg/day. Total time on treatment was 12–48 weeks. Six patients experienced improved oxygenation, from 69.1±3.4mmHg to 84.0±2.0mmHg. The group that responded to treatment showed reduced levels of anti-GM-CSF antibodies in both serum and BAL.In a prospective open-label clinical trial in 25 patients,<a class="elsevierStyleCrossRef" href="#bib0155">31</a> 12 (57%) of the 21 patients that completed the trial showed significant improvement, and 6 (67%) did not need either whole lung lavage or home oxygen therapy.Despite the methodological limitations, the range of doses used and the variable duration of treatment, subcutaneous administration of GM-CSF appears to be effective in up to 2/3 of cases. It has a few side effects, including edema and erythema in the injection site and low-grade fever; no changes are generally seen in blood tests. Subcutaneous GM-CSF can be considered an alternative treatment for PAP.Inhaled GM-CSFTazawa et al.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> reported a series of 50 patients with primary PAP who were given inhaled GM-CSF at a dose of 125μg every 12h for 1 week, followed by 1 rest week, for a total of six 2-week cycles (12 weeks of treatment in all). They were followed up for 52 weeks after completion of the treatment. Of the 35 patients who completed the trial, 24 showed clear improvement in alveolar-arterial oxygen gradient (12.3mmHg, 95% CI 8.4–16.2mmHg, P<.001), with an overall improvement in 62% (in 24/39 patients in the final intent-to-treat analysis). During follow-up, 29 of the 35 patients were clinically stable, and did not require any additional treatment.Wylam et al.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> carried out a retrospective study in 12 patients with primary PAP who received increasing doses of GM-CSF in aerosol up to a maximum of 500μg/day for a period of 12 weeks. Results were positive, with 11 patients achieving improved symptoms, and 10 achieving significantly improved gas exchange parameters. These results were maintained in the long-term: 8 patients achieved partial remission and 3 achieved complete radiological remission.Inhaled GM-CSF treatment can be considered effective in 4/5 cases, with few side effects. Doses and treatment duration are variable.RituximabRituximab is a monoclonal antibody that targets the CD20 antigen receptor on the surface of the B-cells. This target is a 35kD membrane protein that plays an essential role in the cell cycle and B-cell differentiation.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> Administration of rituximab causes a rapid reduction of B-cells in peripheral blood. Several mechanisms of action have been suggested: complement-mediated cytotoxicity, antibody-dependent cell-mediated cytotoxicity, or increased antibody-mediated apoptosis. Rituximab is used in the treatment of lymphoproliferative diseases of the B-cells and in various autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis or vasculitis.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> As primary PAP is considered an autoimmune disease involving anti-GM-CSF antibodies, the reduction of B-cells and anti-GM-CSF levels induced by rituximab may be an effective treatment option.<a class="elsevierStyleCrossRef" href="#bib0180">36</a>Borie et al.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> described the effect of rituximab in a PAP patient who refused lung lavage. Two 1g doses were administered 15 days apart, producing a fall in serum B-cells and anti-GM-CSF levels. After 6 months of treatment, the alveolar-arterial gradient had improved but DLCO and HRCT results were unchanged. Amital et al.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> described the effect of rituximab in a PAP patient who showed no improvement after whole lung lavage and subsequent administration of subcutaneous GM-CSF. She received a weekly dose of 375mg/m2 for 4 weeks, showing improved gas exchange, DLCO and radiological findings.The largest study to date is an open-label clinical trial with rituximab in 10 PAP patients.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> Two 1g doses were administered on day 0 and day 15. Alveolar-arterial oxygen gradient and PaO2 improved in 7 of 9 patients who completed the trial. Improvement was sustained at 3 and 6 months after treatment completion. Improved findings on HRCT and lung function tests were also observed.Rituximab treatment is not free of side effects; some of which are serious. Although the results of trials have been promising, its use in PAP is still is an experimental phase.Several clinical trials evaluating both rituximab and GM-CSF in PAP are currently ongoing: for more information, see <a href="http://apps.who.int/trialsearch/">http://apps.who.int/trialsearch/</a>.PlasmapheresisPlasmapheresis for reducing anti-GM-CSF levels in serum has been attempted in several isolated cases in which other treatments, such as lung lavage, anti-GM-CSF or rituximab, were ineffective. Results have been varied, and its efficacy as a treatment for PAP has not yet been established.<a class="elsevierStyleCrossRefs" href="#bib0200">40,41</a>Lung TransplantationLung transplantation has been performed in cases in which other treatments were ineffective and the disease progressed. Isolated cases of lung transplantation in adults have been reported, while in a series of 270 transplantations performed in 190 children between 1990 and 2002, the indication in 12 (6.3%) was PAP.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> This is an option for severe, treatment-refractory cases. Recurrent PAP in the transplanted lung at 3 years has been reported,<a class="elsevierStyleCrossRef" href="#bib0215">43</a> but the incidence of recurrence is unknown. If new treatments can be developed for PAP, transplantation may be confined to very exceptional cases.CorticosteroidsCorticosteroids are not indicated in the treatment of PAP, and indeed, they may worsen prognosis, since they can interfere with surfactant metabolism<a class="elsevierStyleCrossRef" href="#bib0220">44</a> and alter the immune response.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> In early papers published on PAP, fatalities associated with the development of norcardiosis, cryptococcosis or mucormycosis were reported in patients treated with corticosteroids.<a class="elsevierStyleCrossRef" href="#bib0225">45</a>Allogenic Hematopoietic Stem Cell TransplantationPAP was reversed in a mouse model after hematopoietic stem cell transplantation, and reports of good response to this treatment in secondary or hereditary PAP have been published.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> However, it is a treatment that is still under investigation and for which very little evidence is available. A new line of research that would avoid prior ablative treatment may be alveolar macrophage transplantation.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> This approach has shown promising results in mouse models and may become a treatment option in the future.<a class="elsevierStyleCrossRef" href="#bib0235">47</a>Finally, these patients may have bacterial infection who need appropriate antibiotic treatment. Defective macrophage activity in the lungs heightens susceptibility to infection from Nocardia or Pneumocystis jirovecii, for example. For this reason, some authors recommend prophylaxis with trimethoprim/sulfamethoxazole until complete disease remission.<a class="elsevierStyleCrossRef" href="#bib0240">48</a>ConclusionThe treatment of choice for PAP is still whole lung lavage, but it is not required in all patients. Better understanding of the pathogenic mechanisms of this disease has led to more therapeutic options (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). GM-CSF, both inhaled and subcutaneous, has been used successfully in primary or autoimmune PAP, but the optimal dose, treatment duration and route of administration have not yet been definitively established. Other promising treatments are emerging, but they are still in the research phase. As this is a very rare disease, and some patients remit spontaneously, it is difficult to establish a high level of evidence for these treatments. Perhaps combined therapies will be used for more severe cases in the future.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Conflict of InterestThe authors declare that they have no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres526634" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec546871" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres526635" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec546872" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Definition" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Classification and Pathogenesis" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Treatment" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Whole Lung Lavage" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Subcutaneous GM-CSF" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Inhaled GM-CSF" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Rituximab" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Plasmapheresis" ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Lung Transplantation" ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Corticosteroids" ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Allogenic Hematopoietic Stem Cell Transplantation" ] ] ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflict of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-10-22" "fechaAceptado" => "2015-02-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec546871" "palabras" => array:4 [ 0 => "Pulmonary alveolar proteinosis" 1 => "Rare diseases" 2 => "Treatment" 3 => "Granulocyte colony-stimulating factor-macrophage" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec546872" "palabras" => array:4 [ 0 => "Proteinosis alveolar pulmonar" 1 => "Enfermedades raras" 2 => "Tratamiento" 3 => "Factor estimulante de colonias de granulocitos-macrófagos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Pulmonary alveolar proteinosis (PAP) is a rare disease characterized by the accumulation of surfactant-like lipoproteinaceous material in the distal air spaces and terminal bronchi, which may lead to impaired gas exchange. This accumulation of surfactant is due to decreased clearance by the alveolar macrophages. Its primary but most common form is currently considered an autoimmune disease. Better knowledge of the causes of PAP has led to the emergence of alternatives to whole lung lavage, although this is still considered the treatment of choice. Most studies are case series, often with limited patient numbers, so the level of evidence is low. Since the severity of presentation and clinical course are variable, not all patients will require treatment. Due to the low level of evidence, some objective criteria based on expert opinion have been arbitrarily proposed in an attempt to define in which patients it is best to initiate treatment." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La proteinosis alveolar pulmonar es una enfermedad rara que se caracteriza por la acumulación del material lipoproteináceo del surfactante en los espacios alveolares y los bronquiolos terminales, lo que puede llegar a producir alteraciones en el intercambio gaseoso. Esta acumulación del surfactante es debida a una disminución en su aclaramiento por parte de los macrófagos alveolares. Su forma primaria, la más frecuente, es considerada actualmente una enfermedad autoinmune. El mayor conocimiento de las causas que la provocan ha conducido a la aparición de tratamientos alternativos al lavado pulmonar total, que sigue siendo considerado de elección. La mayoría de los trabajos están constituidos por series de casos, la mayoría de las veces con pocos pacientes, por lo que el nivel de evidencia es bajo. Dado que la gravedad de su presentación y su curso son variables, no todos los pacientes van a requerir tratamiento. Debido al bajo nivel de evidencia de que se dispone, ya que la mayoría de estudios son series de casos, se han propuesto de manera arbitraria algunos criterios objetivos, basados en la opinión de expertos, que intentan definir en qué pacientes es más adecuado iniciar el tratamiento." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rodríguez Portal JA. Tratamiento de la proteinosis alveolar primaria del adulto. Arch Bronconeumol. 2015;51:344–349." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 707 "Ancho" => 900 "Tamanyo" => 137651 ] ] "descripcion" => array:1 [ "en" => "High-resolution computed tomography of a patient with pulmonary alveolar proteinosis (PAP) showing typical characteristics of interlobular septal thickening against a background of ground-glass opacities, producing the distinctive crazy paving appearance." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1676 "Ancho" => 3105 "Tamanyo" => 205416 ] ] "descripcion" => array:1 [ "en" => "Suggested PAP-treatment algorithm, according to severity, based on the opinions of different authors.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "inh: inhaled; iv: intravenously; sc: subcutaneously." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dose \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Response \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Seymour et al.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GM-CSF sc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5mg/kg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10–26 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36% (n=14) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Kavuru et al.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GM-CSF sc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">250μg/day to 5–9μg/kg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75% (n=4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Bonfield et al.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GM-CSF sc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">250μg/day to 18μg/kg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12–48 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55% (n=11) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Venkateshiah et al.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GM-CSF sc \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">250μg/day to 5–18μg/kg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12–52 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48% (n=21) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Tazawa et al.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GM-CSF inh \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">250μg/day alternate weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100% (n=3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Wylam et al.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GM-CSF inh \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">250–500μg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83% (n=12) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Borie et al.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rituximab iv \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1g day 0 and day 15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100% (n=1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Amital et al.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rituximab iv \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">375mg/m2 weekly \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100% (n=1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Kavuru et al.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Rituximab iv \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1g day 0 and day 15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78% (n=9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab848517.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Summary of Studies Published Investigating Treatments Other Than Whole Lung Lavage.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:48 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary alveolar proteinosis" 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Review

Treatment of Adult Primary Alveolar Proteinosis

Tratamiento de la proteinosis alveolar primaria del adulto

José Antonio Rodríguez Portala,b

a UMQER Centro de investigación en red de enfermedades respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain

b Hospital Universitario Virgen del Rocío/Virgen Macarena, Instituto de Biomedicina de Sevilla (IBIS)/CSIC/Universidad de Sevilla, Sevilla, Spain

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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Suggested PAP-treatment algorithm&#44; according to severity&#44; based on the opinions of different authors&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Definition</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary alveolar proteinosis &#40;PAP&#41; is a rare disease that was first described in 1958&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is characterized by the accumulation of surfactant-like lipoproteinaceous material in the distal air spaces and terminal bronchi&#44; which may lead to impaired gas exchange<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; This accumulation of surfactant is due to reduced clearance by the alveolar macrophages&#44; and another feature of the disease is the presence of phospholipoproteic material within the alveolar macrophages&#46; Estimated yearly incidence is 0&#46;2&#8211;0&#46;4<span class="elsevierStyleHsp" style=""></span>cases&#47;million&#44; and prevalence is 3&#46;7&#8211;6&#46;2<span class="elsevierStyleHsp" style=""></span>persons&#47;year&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> As of 2002&#44; around 410 cases had been described in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Classification and Pathogenesis</span><p id="par0010" class="elsevierStylePara elsevierViewall">The main elements in the development of PAP are the appearance of defective granulocyte-macrophage colony stimulating factor &#40;GM-CSF&#41; activity or changes in the cell surface GM-CSF receptor and in its signaling mechanisms&#46; GM-CSF is necessary for final alveolar macrophage differentiation and maturing&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> One of the major advances in the understanding of the pathogenic mechanisms of PAP occurred unexpectedly following work carried out in an animal model with GM-CSF knockout mice&#46; Investigators were surprised to find that although these mice showed no hematological manifestations&#44; they developed a pulmonary condition very similar to human PAP&#46; Moreover&#44; lungs recovered once the GM-CSF function was reestablished&#44; irrespective of whether GM-CSF was administered exogenously by inhalation&#44; the non-functioning gene was repaired&#44; or the mice underwent bone marrow transplant&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Subsequent studies in mice models showed that local GM-CSF deficit produced by inhibiting the GM-CSF gene or by deletion of the GM-CSF&#47;IL-3&#47;IL-5 receptor &#946;-subunit on the cell surface leads to the development of PAP&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">From a clinical point of view&#44; there are 3 main forms of PAP&#58; hereditary or congenital&#59; autoimmune or primary&#59; and secondary&#46; Mechanisms leading to alveolar macrophage dysfunction differ in each of these 3 forms&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In primary PAP&#44; anti-GM-CSF IgG-type neutralizing antibodies are detected&#46; This form accounts for 90&#37; of all cases of the disease&#46; These antibodies are found in both serum and bronchoalveolar lavage &#40;BAL&#41; fluid&#44; and confirm the autoimmune mechanism involved in primary PAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> These neutralizing antibodies cause alveolar macrophage dysfunction&#44; affecting catabolism and clearance of surfactant from the distal air spaces&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In cases of congenital or hereditary PAP&#44; the defective elimination of surfactant is caused by mutations in genes coding for surfactant protein-B &#40;SP-B&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> surfactant protein-C &#40;SP-C&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> or in genes coding for GM-CSF receptor chains &#40;CSF2RA-&#945;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and CSF2RB-&#946;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#41;&#44; preventing GM-CSF from binding to its membrane receptor&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Other germline mutations can also cause different diseases&#44; including PAP&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Secondary PAP&#44; for its part&#44; occurs in several diseases that involve a reduction in the number or function of the alveolar macrophages&#44; such as myelodysplastic syndrome&#44; leukemias or lymphomas&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> PAP may also occur in association with some infections &#40;<span class="elsevierStyleItalic">Nocardia&#44; Pneumocystis jirovecii</span>&#41; or after environmental or occupational exposure to substances such as silica&#44; aluminum&#44; titanium or some fertilizers&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Treatment</span><p id="par0025" class="elsevierStylePara elsevierViewall">In this review&#44; we will discuss the treatment of primary or autoimmune PAP&#44; as the treatment of secondary PAP depends mainly on the specific disease with which it is associated&#46; There are currently no firm&#44; universally accepted criteria for starting treatment for PAP&#44; particularly for milder cases&#44; and the decision to initiate specific treatment will depend on the severity of the clinical presentation&#46; This consideration is based on the natural disease course&#44; in which a high percentage of cases show spontaneous remission&#46; In the largest series published to date&#44; patients who were asymptomatic had a high probability of remaining stable or even improving without treatment&#44; and only 8&#37; deteriorated during follow-up&#46; Of those with symptoms&#44; the proportion of patients who remained stable&#44; improved or worsened was 45&#37;&#44; 30&#37;&#44; and 25&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Those with longer disease courses were more likely to deteriorate&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment of choice is still whole lung lavage&#44; although there have been advances in alternative or complementary treatments&#44; such as the administration of GM-CSF&#44; rituximab&#44; plasmapheresis or stem cell transplants&#46; Due to the rarity of this disease&#8212;and thus the scant number of patients&#8212;most of these treatments are based on the results obtained from case series&#44; rather than randomized clinical trials&#46; Some of them are still in an experimental phase&#44; so the level of evidence in most cases is weak and based solely on expert opinion&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In order to achieve the best risk-benefit ratio when the decision has been taken to start treatment&#44; most authors agree to arbitrarily classify the patients into 3 categories or groups&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> as follows&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Group 1&#46;</span> Asymptomatic patients and&#47;or those with mild gas exchange impairment&#46; These patients do not need immediate treatment and must be monitored periodically for symptoms&#44; lung function and imaging studies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Group 2&#46;</span> Patients with mild&#47;moderate symptoms &#40;dyspnea on exertion&#41; and oxygenation changes during exercise &#40;not at rest&#41;&#46; This group should be managed with oxygen therapy during exercise and more closely monitored for any clinical or functional deterioration that may require more aggressive treatment&#46; The recommendation of oxygen therapy in this group is not supported by clinical trial results&#59; rather it is based on expert opinion with little scientific evidence&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Group 3&#46;</span> This group includes patients with moderate or severe symptoms&#44; who have gas exchange impairment at rest&#46; This group needs specific&#44; more aggressive treatment&#46; The treatment of choice is whole lung lavage&#44; and other therapeutic interventions can be adopted&#44; depending on the results obtained and the progress of the disease&#46;</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">Due to the scant evidence on which treatment is based and to more accurately define cases of PAP that require more specific treatment&#44; some authors have proposed more objective criteria&#44; based primarily on oxygenation factors&#46; Patients with the following parameters would be candidates for treatment&#58; &#40;a&#41; resting PaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>65<span class="elsevierStyleHsp" style=""></span>mmHg&#59; &#40;b&#41; alveolar-arterial oxygen tension gradient<span class="elsevierStyleHsp" style=""></span>&#8805;40<span class="elsevierStyleHsp" style=""></span>mmHg&#44; and &#40;c&#41;<span class="elsevierStyleHsp" style=""></span>shunt fraction &#62;10&#37;&#8211;12&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Whole Lung Lavage</span><p id="par0060" class="elsevierStylePara elsevierViewall">Whole lung lavage remains the treatment of choice for PAP&#46; It was first described over 40 years ago&#44; and since then the technique has undergone very few changes&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> It needs to be performed under general anesthesia with double-lumen endotracheal intubation&#46; One lung is ventilated and oxygenated via one lumen&#44; while the contralateral lung is washed with saline solution at a temperature of approximately 37<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; Aliquots of 1&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>L of warmed saline solution are usually needed for each lavage&#44; and between 10 and 15 lavages are needed to treat one whole lung&#46; The procedure generally lasts around 3&#8211;4<span class="elsevierStyleHsp" style=""></span>h&#46; Chest percussion during the procedure has been reported to significantly increase the extraction of lipoproteinaceous material&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Lavage of the other lung can be done on a separate occasion or sequentially in the same session&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Oxygenation and pulmonary mechanics must be monitored during the procedure&#46; The double-lumen tube must be carefully positioned and care must be taken to recover the saline solution that has been instilled&#44; to avoid possible complications caused by poor placement of the endotracheal tube&#44; passage of serum to the ventilated lung&#44; or the development of hydropneumothorax&#46; Other complications include pneumonia&#44; laryngospasm or arrhythmias&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In 75&#37;&#8211;95&#37; of cases&#44; symptoms&#44; oxygenation capacity&#44; and radiological changes improve rapidly after whole lung lavage&#44; generally in the first few days after the procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> This benefit tends to be sustained for a mean period of 15 months&#44; although relapses are common&#44; and occur in up to 45&#37;&#8211;70&#37; of cases over the subsequent 3 years&#46; However&#44; whole lung lavage does not need to be repeated in all cases of relapse&#46; The results of the different series vary widely&#44; and repeating whole lung lavage has been reported in a range of between 15&#37; and 70&#37; of cases&#46; It should be emphasized that around 30&#37;&#8211;40&#37; of cases will require only one lavage&#46; It is important to note that 5-year survival is greater in patients who have undergone whole lung lavage that in those who have not &#40;94&#37; vs 85&#37;&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;04&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Subcutaneous GM-CSF</span><p id="par0075" class="elsevierStylePara elsevierViewall">After anti-GM-CSF antibodies in the serum and BAL of patients with primary PAP and their role in PAP pathogenesis were discovered&#44; the possibility of exogenous administration of this cytokine was proposed as a potential treatment&#46; No randomized clinical trials have been performed and most published papers are observational studies including small numbers of patients<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Seymour et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> published the first case of clinical improvement in an adult receiving GM-CSF subcutaneously&#46; This author subsequently treated another 14 patients<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> at a dose of 3<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;day for 5 days&#44; increasing to 5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;day for a period of 12 weeks&#46; One patient discontinued treatment after 13 days due to neutropenia&#44; and 5 discontinued after 6 weeks due to lack of response&#46; Seven patients continued treatment for 12 weeks and one patient was treated for 26 weeks&#46; Treatment was considered effective in 6&#47;14 &#40;43&#37;&#44; 95&#37; CI 18&#37;&#8211;71&#37;&#41;&#44; with a mean treatment period of 39 weeks&#46; Of these 6 cases&#44; 5 worsened after discontinuation of the therapy&#44; and 4 improved after it was resumed&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Kavuru et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> treated a group of 4 patients for 12 weeks&#46; The dose for the first 4 weeks was 250<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;day&#44; with daily 5<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg increments during the next 4 weeks&#44; and finally&#44; 9<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;day for the last 4 weeks&#46; Three of the 4 patients experienced improved lung function&#44; oxygenation and exercise capacity&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In a prospective trial&#44; Bonfield et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> included 14 cases of PAP&#44; of whom 11 completed the study&#46; All patients had previously undergone whole lung lavage&#46; The initial dose was 250<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;day&#44; with dose increases every 2 weeks to a maximum of 18<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;day&#46; Total time on treatment was 12&#8211;48 weeks&#46; Six patients experienced improved oxygenation&#44; from 69&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;4<span class="elsevierStyleHsp" style=""></span>mmHg to 84&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;0<span class="elsevierStyleHsp" style=""></span>mmHg&#46; The group that responded to treatment showed reduced levels of anti-GM-CSF antibodies in both serum and BAL&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In a prospective open-label clinical trial in 25 patients&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> 12 &#40;57&#37;&#41; of the 21 patients that completed the trial showed significant improvement&#44; and 6 &#40;67&#37;&#41; did not need either whole lung lavage or home oxygen therapy&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Despite the methodological limitations&#44; the range of doses used and the variable duration of treatment&#44; subcutaneous administration of GM-CSF appears to be effective in up to 2&#47;3 of cases&#46; It has a few side effects&#44; including edema and erythema in the injection site and low-grade fever&#59; no changes are generally seen in blood tests&#46; Subcutaneous GM-CSF can be considered an alternative treatment for PAP&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Inhaled GM-CSF</span><p id="par0100" class="elsevierStylePara elsevierViewall">Tazawa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> reported a series of 50 patients with primary PAP who were given inhaled GM-CSF at a dose of 125<span class="elsevierStyleHsp" style=""></span>&#956;g every 12<span class="elsevierStyleHsp" style=""></span>h for 1 week&#44; followed by 1 rest week&#44; for a total of six 2-week cycles &#40;12 weeks of treatment in all&#41;&#46; They were followed up for 52 weeks after completion of the treatment&#46; Of the 35 patients who completed the trial&#44; 24 showed clear improvement in alveolar-arterial oxygen gradient &#40;12&#46;3<span class="elsevierStyleHsp" style=""></span>mmHg&#44; 95&#37; CI 8&#46;4&#8211;16&#46;2<span class="elsevierStyleHsp" style=""></span>mmHg&#44; <span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#44; with an overall improvement in 62&#37; &#40;in 24&#47;39 patients in the final intent-to-treat analysis&#41;&#46; During follow-up&#44; 29 of the 35 patients were clinically stable&#44; and did not require any additional treatment&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Wylam et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> carried out a retrospective study in 12 patients with primary PAP who received increasing doses of GM-CSF in aerosol up to a maximum of 500<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;day for a period of 12 weeks&#46; Results were positive&#44; with 11 patients achieving improved symptoms&#44; and 10 achieving significantly improved gas exchange parameters&#46; These results were maintained in the long-term&#58; 8 patients achieved partial remission and 3 achieved complete radiological remission&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Inhaled GM-CSF treatment can be considered effective in 4&#47;5 cases&#44; with few side effects&#46; Doses and treatment duration are variable&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Rituximab</span><p id="par0115" class="elsevierStylePara elsevierViewall">Rituximab is a monoclonal antibody that targets the CD20 antigen receptor on the surface of the B-cells&#46; This target is a 35<span class="elsevierStyleHsp" style=""></span>kD membrane protein that plays an essential role in the cell cycle and B-cell differentiation&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Administration of rituximab causes a rapid reduction of B-cells in peripheral blood&#46; Several mechanisms of action have been suggested&#58; complement-mediated cytotoxicity&#44; antibody-dependent cell-mediated cytotoxicity&#44; or increased antibody-mediated apoptosis&#46; Rituximab is used in the treatment of lymphoproliferative diseases of the B-cells and in various autoimmune diseases such as systemic lupus erythematosus&#44; rheumatoid arthritis or vasculitis&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> As primary PAP is considered an autoimmune disease involving anti-GM-CSF antibodies&#44; the reduction of B-cells and anti-GM-CSF levels induced by rituximab may be an effective treatment option&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Borie et al&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> described the effect of rituximab in a PAP patient who refused lung lavage&#46; Two 1<span class="elsevierStyleHsp" style=""></span>g doses were administered 15 days apart&#44; producing a fall in serum B-cells and anti-GM-CSF levels&#46; After 6 months of treatment&#44; the alveolar-arterial gradient had improved but DLCO and HRCT results were unchanged&#46; Amital et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> described the effect of rituximab in a PAP patient who showed no improvement after whole lung lavage and subsequent administration of subcutaneous GM-CSF&#46; She received a weekly dose of 375<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> for 4 weeks&#44; showing improved gas exchange&#44; DLCO and radiological findings&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The largest study to date is an open-label clinical trial with rituximab in 10 PAP patients&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> Two 1<span class="elsevierStyleHsp" style=""></span>g doses were administered on day 0 and day 15&#46; Alveolar-arterial oxygen gradient and PaO<span class="elsevierStyleInf">2</span> improved in 7 of 9 patients who completed the trial&#46; Improvement was sustained at 3 and 6 months after treatment completion&#46; Improved findings on HRCT and lung function tests were also observed&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Rituximab treatment is not free of side effects&#59; some of which are serious&#46; Although the results of trials have been promising&#44; its use in PAP is still is an experimental phase&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Several clinical trials evaluating both rituximab and GM-CSF in PAP are currently ongoing&#58; for more information&#44; see <a href="http://apps.who.int/trialsearch/">http&#58;&#47;&#47;apps&#46;who&#46;int&#47;trialsearch&#47;</a>&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Plasmapheresis</span><p id="par0140" class="elsevierStylePara elsevierViewall">Plasmapheresis for reducing anti-GM-CSF levels in serum has been attempted in several isolated cases in which other treatments&#44; such as lung lavage&#44; anti-GM-CSF or rituximab&#44; were ineffective&#46; Results have been varied&#44; and its efficacy as a treatment for PAP has not yet been established&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;41</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Lung Transplantation</span><p id="par0145" class="elsevierStylePara elsevierViewall">Lung transplantation has been performed in cases in which other treatments were ineffective and the disease progressed&#46; Isolated cases of lung transplantation in adults have been reported&#44; while in a series of 270 transplantations performed in 190 children between 1990 and 2002&#44; the indication in 12 &#40;6&#46;3&#37;&#41; was PAP&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> This is an option for severe&#44; treatment-refractory cases&#46; Recurrent PAP in the transplanted lung at 3 years has been reported&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> but the incidence of recurrence is unknown&#46; If new treatments can be developed for PAP&#44; transplantation may be confined to very exceptional cases&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Corticosteroids</span><p id="par0150" class="elsevierStylePara elsevierViewall">Corticosteroids are not indicated in the treatment of PAP&#44; and indeed&#44; they may worsen prognosis&#44; since they can interfere with surfactant metabolism<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> and alter the immune response&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In early papers published on PAP&#44; fatalities associated with the development of norcardiosis&#44; cryptococcosis or mucormycosis were reported in patients treated with corticosteroids&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Allogenic Hematopoietic Stem Cell Transplantation</span><p id="par0155" class="elsevierStylePara elsevierViewall">PAP was reversed in a mouse model after hematopoietic stem cell transplantation&#44; and reports of good response to this treatment in secondary or hereditary PAP have been published&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; it is a treatment that is still under investigation and for which very little evidence is available&#46; A new line of research that would avoid prior ablative treatment may be alveolar macrophage transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> This approach has shown promising results in mouse models and may become a treatment option in the future&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Finally&#44; these patients may have bacterial infection who need appropriate antibiotic treatment&#46; Defective macrophage activity in the lungs heightens susceptibility to infection from <span class="elsevierStyleItalic">Nocardia</span> or <span class="elsevierStyleItalic">Pneumocystis jirovecii</span>&#44; for example&#46; For this reason&#44; some authors recommend prophylaxis with trimethoprim&#47;sulfamethoxazole until complete disease remission&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusion</span><p id="par0165" class="elsevierStylePara elsevierViewall">The treatment of choice for PAP is still whole lung lavage&#44; but it is not required in all patients&#46; Better understanding of the pathogenic mechanisms of this disease has led to more therapeutic options &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; GM-CSF&#44; both inhaled and subcutaneous&#44; has been used successfully in primary or autoimmune PAP&#44; but the optimal dose&#44; treatment duration and route of administration have not yet been definitively established&#46; Other promising treatments are emerging&#44; but they are still in the research phase&#46; As this is a very rare disease&#44; and some patients remit spontaneously&#44; it is difficult to establish a high level of evidence for these treatments&#46; Perhaps combined therapies will be used for more severe cases in the future&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of Interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests&#46;</p></span></span>"
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            0 => "Proteinosis alveolar pulmonar"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pulmonary alveolar proteinosis &#40;PAP&#41; is a rare disease characterized by the accumulation of surfactant-like lipoproteinaceous material in the distal air spaces and terminal bronchi&#44; which may lead to impaired gas exchange&#46; This accumulation of surfactant is due to decreased clearance by the alveolar macrophages&#46; Its primary but most common form is currently considered an autoimmune disease&#46; Better knowledge of the causes of PAP has led to the emergence of alternatives to whole lung lavage&#44; although this is still considered the treatment of choice&#46; Most studies are case series&#44; often with limited patient numbers&#44; so the level of evidence is low&#46; Since the severity of presentation and clinical course are variable&#44; not all patients will require treatment&#46; Due to the low level of evidence&#44; some objective criteria based on expert opinion have been arbitrarily proposed in an attempt to define in which patients it is best to initiate treatment&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La proteinosis alveolar pulmonar es una enfermedad rara que se caracteriza por la acumulaci&#243;n del material lipoprotein&#225;ceo del surfactante en los espacios alveolares y los bronquiolos terminales&#44; lo que puede llegar a producir alteraciones en el intercambio gaseoso&#46; Esta acumulaci&#243;n del surfactante es debida a una disminuci&#243;n en su aclaramiento por parte de los macr&#243;fagos alveolares&#46; Su forma primaria&#44; la m&#225;s frecuente&#44; es considerada actualmente una enfermedad autoinmune&#46; El mayor conocimiento de las causas que la provocan ha conducido a la aparici&#243;n de tratamientos alternativos al lavado pulmonar total&#44; que sigue siendo considerado de elecci&#243;n&#46; La mayor&#237;a de los trabajos est&#225;n constituidos por series de casos&#44; la mayor&#237;a de las veces con pocos pacientes&#44; por lo que el nivel de evidencia es bajo&#46; Dado que la gravedad de su presentaci&#243;n y su curso son variables&#44; no todos los pacientes van a requerir tratamiento&#46; Debido al bajo nivel de evidencia de que se dispone&#44; ya que la mayor&#237;a de estudios son series de casos&#44; se han propuesto de manera arbitraria algunos criterios objetivos&#44; basados en la opini&#243;n de expertos&#44; que intentan definir en qu&#233; pacientes es m&#225;s adecuado iniciar el tratamiento&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rodr&#237;guez Portal JA&#46; Tratamiento de la proteinosis alveolar primaria del adulto&#46; Arch Bronconeumol&#46; 2015&#59;51&#58;344&#8211;349&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">High-resolution computed tomography of a patient with pulmonary alveolar proteinosis &#40;PAP&#41; showing typical characteristics of interlobular septal thickening against a background of ground-glass opacities&#44; producing the distinctive crazy paving appearance&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Suggested PAP-treatment algorithm&#44; according to severity&#44; based on the opinions of different authors&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">inh&#58; inhaled&#59; iv&#58; intravenously&#59; sc&#58; subcutaneously&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Response&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Seymour et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GM-CSF sc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;26 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&#37; &#40;n&#61;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Kavuru et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GM-CSF sc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;day to 5&#8211;9<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&#37; &#40;n&#61;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Bonfield et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GM-CSF sc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;day to 18<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#8211;48 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#37; &#40;n&#61;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Venkateshiah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GM-CSF sc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;day to 5&#8211;18<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;kg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#8211;52 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#37; &#40;n&#61;21&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Tazawa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GM-CSF inh&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;day alternate weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37; &#40;n&#61;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Wylam et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GM-CSF inh&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250&#8211;500<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&#37; &#40;n&#61;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Borie et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rituximab iv&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>g day 0 and day 15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37; &#40;n&#61;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Amital et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rituximab iv&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">375<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> weekly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#37; &#40;n&#61;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Kavuru et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rituximab iv&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>g day 0 and day 15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78&#37; &#40;n&#61;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Summary of Studies Published Investigating Treatments Other Than Whole Lung Lavage&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p>"
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Article information

ISSN: 15792129
Original language: English

DOI:10.1016/j.arbr.2015.04.026

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	1	0	1
2024 October	46	18	64
2024 September	48	14	62
2024 August	65	36	101
2024 July	43	17	60
2024 June	70	33	103
2024 May	122	25	147
2024 April	56	23	79
2024 March	54	18	72
2024 February	38	32	70
2023 November	1	1	2
2023 October	1	0	1
2023 September	1	0	1
2023 July	12	0	12
2023 March	16	10	26
2023 February	62	40	102
2023 January	77	58	135
2022 December	69	61	130
2022 November	96	52	148
2022 October	79	48	127
2022 September	99	45	144
2022 August	89	50	139
2022 July	75	50	125
2022 June	51	38	89
2022 May	64	49	113
2022 April	88	32	120
2022 March	115	70	185
2022 February	154	50	204
2022 January	96	42	138
2021 December	66	52	118
2021 November	77	72	149
2021 October	67	65	132
2021 September	61	69	130
2021 August	90	56	146
2021 July	106	58	164
2021 June	92	56	148
2021 May	90	47	137
2021 April	237	134	371
2021 March	185	55	240
2021 February	112	36	148
2021 January	140	47	187
2020 December	100	45	145
2020 November	104	38	142
2020 October	96	36	132
2020 September	91	35	126
2020 August	78	40	118
2020 July	101	40	141
2020 June	119	24	143
2020 May	116	21	137
2020 April	96	28	124
2020 March	61	22	83
2020 February	71	21	92
2020 January	104	30	134
2019 December	90	26	116
2019 November	65	38	103
2019 October	46	18	64
2019 September	87	22	109
2019 August	55	25	80
2019 July	62	22	84
2019 June	51	26	77
2019 May	79	26	105
2019 April	115	29	144
2019 March	107	34	141
2019 February	57	27	84
2019 January	73	26	99
2018 December	82	28	110
2018 November	89	47	136
2018 October	214	28	242
2018 September	35	23	58
2018 May	47	2	49
2018 April	54	9	63
2018 March	51	9	60
2018 February	41	10	51
2018 January	44	12	56
2017 December	45	3	48
2017 November	39	11	50
2017 October	42	17	59
2017 September	36	16	52
2017 August	24	14	38
2017 July	26	17	43
2017 June	44	37	81
2017 May	45	24	69
2017 April	29	21	50
2017 March	25	19	44
2017 February	39	17	56
2017 January	26	19	45
2016 December	39	17	56
2016 November	47	23	70
2016 October	44	31	75
2016 September	45	26	71
2016 August	55	29	84
2016 July	42	30	72
2016 March	2	0	2
2015 December	3	0	3
2015 October	22	1	23
2015 September	1	2	3
2015 August	0	1	1
2015 July	1	4	5
2015 June	0	1	1

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