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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary alveolar proteinosis &#40;PAP&#41; is a rare entity&#44; characterized by the excessive accumulation of surfactant proteins and phospholipids in the alveolar spaces and terminal bronchioles&#44; that can typically cause a serious deterioration in gas exchange&#44; with the onset of progressive respiratory failure&#44; or else present without clinical symptoms&#46; First described in 1958&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> PAP is considered a rare disease&#44; with an estimated incidence of 0&#46;2&#8211;0&#46;4 cases per million individuals&#47;year<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> and a prevalence of 3&#46;7&#8211;6&#46;2 cases per million individuals&#47;year&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> It is a heterogeneous entity&#44; divided into 2 categories&#58; congenital PAP and acquired PAP&#44; which in turn is divided into 2 distinct clinical forms&#44; idiopathic PAP &#40;iPAP&#41; and secondary PAP&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> In all of its forms&#44; the underlying physiopathological feature is the accumulation of surfactant in the alveolar spaces&#44; caused by macrophages failing to process these compounds&#44; or by acquired neutralization&#44; due to congenital dysfunction of the granulocyte-macrophage colony-stimulating factor &#40;GM-CSF&#41;&#44; by gene mutations in cell-surface receptors&#44; and in some cases&#44; by changes in proteins in the surfactant itself&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The mechanisms that lead to macrophage dysfunction differ in each clinical form&#46; Congenital PAP&#44; for example&#44; has been associated with recessive anomalies of the gene that encodes GM-CSF-binding &#945; and &#946; chains&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> and with mutations in the genes encoding B and C surfactant proteins&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> Secondary forms are associated with blood disorders&#44; infections&#44; or exposure to diverse environmental substances&#46; The idiopathic variant &#40;iPAP&#41; is the most common form of presentation&#44; accounting for up to 90&#37; of cases of PAP&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> This clinical form&#44; also known as autoimmune PAP&#44; is characterized by the presence of anti-GM-CSF antibodies that block GM-CSF bioactivity in vivo&#44; affecting the terminal differentiation of macrophages&#44; and consequently their capacity to process lung surfactant&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The detection of high levels of anti-GM-CSF antibodies in peripheral blood and bronchoalveolar lavage &#40;BAL&#41; using ELISA techniques is now accepted as a useful tool in the diagnosis of iPAP&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> with a sensitivity of 100&#37; and a specificity of 98&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> even in asymptomatic phases&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> This has also guided the development of new treatment strategies for iPAP&#44; such as the exogenous administration of GM-CSF as an alternative or therapeutic complement to whole lung lavage &#40;WLL&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The applicability of anti-GM-CSF antibodies in follow-up and as a marker of therapeutic response is still under discussion&#46; Another line of research involves the possible correlation between anti-GM-CSF antibody titers and the degree of disease extension&#44; but results from studies performed to date have been contradictory&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;10&#44;11</span></a> Unlike other serological markers&#44; no association has been observed between anti-GM-CSF antibody levels and iPAP severity&#44; quantified by symptoms and decline in partial pressure of oxygen&#46; Nor has any concordance been demonstrated with lung function decline&#44; or with variations in other serum biomarkers &#40;carcinoembryonic antigen&#44; Krebs von den Lungen-6&#44; surfactant protein A&#44; surfactant protein D&#44; and lactate dehydrogenase&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> However&#44; antibody levels in BAL samples&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> and the ratio of anti-GM-CSF kappa and lambda &#40;&#954;&#47;&#955;&#41; light chains in serum have shown some association with the degree of hypoxemia and with Krebs von den Lungen-6 and surfactant protein D levels&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> previously reported as markers of severity&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The response of anti-GM-CSF antibodies in serum after WWL&#44; the therapeutic technique of choice for PAP&#44; is controversial&#46; Although there are few references in the literature&#44; Sugimoto et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> in a study of 8 patients with iPAP who underwent WWL&#44; showed a decrease in serum levels of Krebs von den Lungen-6&#44; surfactant protein A&#44; surfactant protein D and carcinoembryonic antigen after the WWL&#46; However&#44; anti-GM-CSF antibody levels fell only temporarily in 7 cases&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> On the other hand&#44; an association between anti-GM-CSF antibodies in BAL and the need to perform WWL as a therapeutic strategy has been observed in some patients&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The response of anti-GM-CSF antibodies in serum after the administration of inhaled and&#47;or subcutaneous GM-CSF has also shown mixed results&#46; Ohashi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> determined anti-GM-CSF antibody levels in the serum and BAL of patients with iPAP before and after the administration of inhaled therapy with GM-CSF&#44; and found a decrease in antibody levels in BAL&#44; but not in serum&#44; after administration of the drug&#46; They also observed a greater decline of these levels in patients who responded to treatment&#59; these same patients also had higher antibody titers at the outset&#46; To date&#44; no studies have been performed to monitor anti-GM-CSF antibody levels after treatment with rituximab&#44; or after lung transplantation&#44; which could be interesting in order to assess early disease recurrence in the graft&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Given the available scientific evidence&#44; we believe that while the determination of anti-GM-CSF antibodies has proven to be a useful tool in the diagnosis of iPAP&#44; the implications of these proteins in the follow-up or response to treatment have yet to be defined&#46; The long-term monitoring of anti-GM-CSF serum levels could clarify their usefulness as an early detector of recurrence and would let us determine&#44; individually for each patient&#44; the baseline values and cut-off points that precede the onset of clinical symptoms&#46; Other studies&#44; such as those addressing the standardization of methodology with the international distribution of reference standards&#44; or the possible natural immunomodulator role of cytokine autoantibodies&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> open up new lines of research which will help us better understand and manage this disease&#46;</p></span>"
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Editorial
Alveolar Proteinosis: The Role of Anti-GM-CSF Antibodies
Proteinosis alveolar: rol de los anticuerpos anti-GM-CSF
Ana Villara,b,
Corresponding author
avillar@vhebron.net

Corresponding author.
, Ricardo Rojoc
a Servei de Pneumologia, Hospital Universitari Vall d’Hebron, Barcelona, Spain
b CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Barcelona, Spain
c Servicio de Inmunología, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
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    "titulo" => "Alveolar Proteinosis&#58; The Role of Anti-GM-CSF Antibodies"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary alveolar proteinosis &#40;PAP&#41; is a rare entity&#44; characterized by the excessive accumulation of surfactant proteins and phospholipids in the alveolar spaces and terminal bronchioles&#44; that can typically cause a serious deterioration in gas exchange&#44; with the onset of progressive respiratory failure&#44; or else present without clinical symptoms&#46; First described in 1958&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> PAP is considered a rare disease&#44; with an estimated incidence of 0&#46;2&#8211;0&#46;4 cases per million individuals&#47;year<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> and a prevalence of 3&#46;7&#8211;6&#46;2 cases per million individuals&#47;year&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> It is a heterogeneous entity&#44; divided into 2 categories&#58; congenital PAP and acquired PAP&#44; which in turn is divided into 2 distinct clinical forms&#44; idiopathic PAP &#40;iPAP&#41; and secondary PAP&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> In all of its forms&#44; the underlying physiopathological feature is the accumulation of surfactant in the alveolar spaces&#44; caused by macrophages failing to process these compounds&#44; or by acquired neutralization&#44; due to congenital dysfunction of the granulocyte-macrophage colony-stimulating factor &#40;GM-CSF&#41;&#44; by gene mutations in cell-surface receptors&#44; and in some cases&#44; by changes in proteins in the surfactant itself&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The mechanisms that lead to macrophage dysfunction differ in each clinical form&#46; Congenital PAP&#44; for example&#44; has been associated with recessive anomalies of the gene that encodes GM-CSF-binding &#945; and &#946; chains&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> and with mutations in the genes encoding B and C surfactant proteins&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> Secondary forms are associated with blood disorders&#44; infections&#44; or exposure to diverse environmental substances&#46; The idiopathic variant &#40;iPAP&#41; is the most common form of presentation&#44; accounting for up to 90&#37; of cases of PAP&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> This clinical form&#44; also known as autoimmune PAP&#44; is characterized by the presence of anti-GM-CSF antibodies that block GM-CSF bioactivity in vivo&#44; affecting the terminal differentiation of macrophages&#44; and consequently their capacity to process lung surfactant&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The detection of high levels of anti-GM-CSF antibodies in peripheral blood and bronchoalveolar lavage &#40;BAL&#41; using ELISA techniques is now accepted as a useful tool in the diagnosis of iPAP&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> with a sensitivity of 100&#37; and a specificity of 98&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> even in asymptomatic phases&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> This has also guided the development of new treatment strategies for iPAP&#44; such as the exogenous administration of GM-CSF as an alternative or therapeutic complement to whole lung lavage &#40;WLL&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The applicability of anti-GM-CSF antibodies in follow-up and as a marker of therapeutic response is still under discussion&#46; Another line of research involves the possible correlation between anti-GM-CSF antibody titers and the degree of disease extension&#44; but results from studies performed to date have been contradictory&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;10&#44;11</span></a> Unlike other serological markers&#44; no association has been observed between anti-GM-CSF antibody levels and iPAP severity&#44; quantified by symptoms and decline in partial pressure of oxygen&#46; Nor has any concordance been demonstrated with lung function decline&#44; or with variations in other serum biomarkers &#40;carcinoembryonic antigen&#44; Krebs von den Lungen-6&#44; surfactant protein A&#44; surfactant protein D&#44; and lactate dehydrogenase&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> However&#44; antibody levels in BAL samples&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> and the ratio of anti-GM-CSF kappa and lambda &#40;&#954;&#47;&#955;&#41; light chains in serum have shown some association with the degree of hypoxemia and with Krebs von den Lungen-6 and surfactant protein D levels&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> previously reported as markers of severity&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The response of anti-GM-CSF antibodies in serum after WWL&#44; the therapeutic technique of choice for PAP&#44; is controversial&#46; Although there are few references in the literature&#44; Sugimoto et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> in a study of 8 patients with iPAP who underwent WWL&#44; showed a decrease in serum levels of Krebs von den Lungen-6&#44; surfactant protein A&#44; surfactant protein D and carcinoembryonic antigen after the WWL&#46; However&#44; anti-GM-CSF antibody levels fell only temporarily in 7 cases&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> On the other hand&#44; an association between anti-GM-CSF antibodies in BAL and the need to perform WWL as a therapeutic strategy has been observed in some patients&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The response of anti-GM-CSF antibodies in serum after the administration of inhaled and&#47;or subcutaneous GM-CSF has also shown mixed results&#46; Ohashi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> determined anti-GM-CSF antibody levels in the serum and BAL of patients with iPAP before and after the administration of inhaled therapy with GM-CSF&#44; and found a decrease in antibody levels in BAL&#44; but not in serum&#44; after administration of the drug&#46; They also observed a greater decline of these levels in patients who responded to treatment&#59; these same patients also had higher antibody titers at the outset&#46; To date&#44; no studies have been performed to monitor anti-GM-CSF antibody levels after treatment with rituximab&#44; or after lung transplantation&#44; which could be interesting in order to assess early disease recurrence in the graft&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Given the available scientific evidence&#44; we believe that while the determination of anti-GM-CSF antibodies has proven to be a useful tool in the diagnosis of iPAP&#44; the implications of these proteins in the follow-up or response to treatment have yet to be defined&#46; The long-term monitoring of anti-GM-CSF serum levels could clarify their usefulness as an early detector of recurrence and would let us determine&#44; individually for each patient&#44; the baseline values and cut-off points that precede the onset of clinical symptoms&#46; Other studies&#44; such as those addressing the standardization of methodology with the international distribution of reference standards&#44; or the possible natural immunomodulator role of cytokine autoantibodies&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> open up new lines of research which will help us better understand and manage this disease&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Villar A&#44; Rojo R&#46; Proteinosis alveolar&#58; rol de los anticuerpos anti-GM-CSF&#46; Arch Bronconeumol&#46; 2018&#59;54&#58;601&#8211;602&#46;</p>"
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Article information
ISSN: 15792129
Original language: English
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