Molecular Endotypes of Idiopathic Pulmonary Fibrosis: A Latent Class Analysis of Two Multicenter Observational Cohorts.

Abstract

<b>Rationale:</b> Idiopathic pulmonary fibrosis (IPF) causes irreversible fibrosis of the lung parenchyma. Although antifibrotic therapy can slow IPF progression, treatment response is variable. There exists a critical need to develop a precision medicine approach to IPF. <b>Objectives:</b> To identify and validate biologically driven molecular endotypes of IPF. <b>Methods:</b> Latent class analysis (LCA) was independently performed in prospectively recruited discovery (<i>n</i> = 875) and validation (<i>n</i> = 347) cohorts. Twenty-five plasma biomarkers associated with fibrogenesis served as class-defining variables. The association between molecular endotype and 4-year transplant-free survival was tested using multivariable Cox regression adjusted for baseline confounders. Endotype-dependent differential treatment response to future antifibrotic exposure was then assessed in a pooled cohort of patients naive to antifibrotic therapy at the time of biomarker measurement (<i>n</i> = 555). <b>Measurements and Main Results:</b> LCA independently identified two latent classes in both cohorts (<i>P</i> < 0.0001). WFDC2 (WAP four-disulfide core domain protein 2) was the most important determinant of class membership across cohorts. Membership in class 2 was characterized by higher biomarker concentrations and a higher risk of death or transplant (discovery, hazard ratio [HR], 2.02; 95% confidence interval [CI], 1.64-2.48; <i>P</i> < 0.001; validation, HR, 1.95; 95% CI, 1.34-2.82; <i>P</i> < 0.001). In pooled analysis, significant heterogeneity in treatment effect was observed between endotypes (<i>P</i> = 0.030 for interaction), with a favorable antifibrotic response in class 2 (HR, 0.64; 95% CI, 0.45-0.93; <i>P</i> = 0.018) but not in class 1 (HR, 1.19; 95% CI, 0.77-1.84; <i>P</i> = 0.422). <b>Conclusions:</b> In this multicohort study, we identified two novel molecular endotypes of IPF with divergent clinical outcomes and responses to antifibrotic therapy. Pending further validation, these endotypes could enable a precision medicine approach for future IPF clinical trials.