Abstract:
A method is provided along with related reagent kits for aiding the diagnosis of IPF or other interstitial lung diseases, as well as for potential monitoring of disease progression or therapeutic response to treatment.

Description:
CROSS REFERENCE TO RELATED APPLICATIONS 
     This application is a National Stage of International Application No. PCT/US2009/059388, filed Oct. 2, 2009, which in turn claims the benefit of U.S. Provisional Patent Application No. 61/107,188, filed Oct. 21, 2008, which is incorporated herein by reference in its entirety. 
    
    
     STATEMENT REGARDING FEDERAL FUNDING 
     This invention was made with government support under the National Institutes of Health Grant Nos. R01 HL63700 and R21ES01386. The government has certain rights in this invention. 
    
    
     Idiopathic pulmonary fibrosis (IPF) is a chronic interstitial lung disease of unknown etiology. IPF is a progressive life threatening disease that is characterized as excessive deposition of fibrotic tissue in the interstitium with minimal associated inflammation. The incidence of IPF is 29/100,000 in the general population and the median survival rate for individuals diagnosed with IPF is between 3 to 5 years. There is currently no cure or significant treatment for this disease and no effective method to monitor progression in IPF patients. Historically IPF has been seen as a gradually progressive disease. However, some patients with IPF experience a rapid deterioration of lung function and accelerated death. These episodes have been termed acute exacerbations of IPF. 
     Matrix metalloproteases (MMPs) are a family of at least 25 proteases that regulate extracellular matrix turnover. Several studies have shown that MMP activation contributes to the pathogenesis of pulmonary fibrosis in animal models (Corbel M, et al.,  J Pathol  193: 538-545, 2001; Tan R J, et al.  Am J Respir Cell Mol Biol  35: 289-297, 2006; and Zuo F, et al.  Proc Natl Acad Sci USA  99: 6292-6297, 2002). Also, there are many studies that have found increased MMP expression and activation in human IPF lungs (Zuo F, et al.  Proc Natl Acad Sci USA  99: 6292-6297, 2002; Henry M T, et al.  Eur Respir J  20: 1220-1227, 2002; Suga M, et al.  Am J Respir Crit. Care Med  162: 1949-1956, 2000; Rosas I O, et al.  PLoS Med  5: e93, 2008; and Garcia-Alvarez J, et al.  Sarcoidosis Vasc Diffuse Lung Dis  23: 13-21, 2006)(6-10). Most MMPs including MMP2, MMP7, MMP8, and MMP9 are secreted as pro-enzymes with a signal sequence and pro peptide of about 80 amino acids that gets cleaved extracellularly upon activation. All members of the MMP family share a common catalytic core with a Zn 2+  in its active site. The pro peptide domain contains a sequence (PRCGxPD) termed the cysteine switch which contains a conserved cysteine that is involved in chelating the active Zn 2+  site. Full MMP activation is brought about by disruption of the cysteine-zinc interaction and removal of the pro peptide (Visse R, et al.  Circ Res  92: 827-839, 2003). 
     Activated MMPs react rapidly with protease inhibitors including tissue inhibitor of metalloproteinases (TIMPS) and α 2 -macroglobulin in the blood. These protein complexes are removed from the circulatory system by hepatocyte-mediated endocytosis. This rapid clearance likely interferes with detection of the active MMP proteins in the urine or bloodstream resulting in the inability to accurately detect the total amount of MMP activation occurring simply by measuring the steady state amount in biological fluids. 
     SUMMARY 
     Activation peptide concentration in urine is shown herein to be representative of total protease activation. Therefore detection of the activation peptides for MMPs will give a more accurate representation of MMP activation due to their simple renal clearance as opposed to the complex clearance mechanisms of the full length active MMPs. Because MMP activation contributes to disease initiation and progression, we feel that the accurate detection of activation of these proteases will be relevant clinically and may allow for earlier detection and/or following progression of lung injury associated, for example, with IPF and other diseases, such as HP (Hypersensitivity Pneumonitis), NSIP (Nonspecific Interstitial Pneumonia), COPD (Chronic Obstructive Pulmonary Disease), and sarcoidosis, in which lung injury occurs and MMP activation is observed. 
     Our experiments show that the activation peptides of MMPs are detectable in the urine via immunoassay (ELISA) in mice with lung injury (lung fibrosis) and human patients with IPF, and are at elevated levels compared to what is found in the urine of controls without pulmonary fibrosis. These data indicate that urine detection of MMP activation peptides is feasible and correlates with disease. Because MMP activation contributes to disease initiation and progression, accurate detection of activation of these proteases will be relevant clinically and should allow for earlier detection of disease as well as allow for prediction of acute exacerbations. 
     Thus provided is a method of identifying interstitial lung disease, monitoring interstitial lung disease progression, or determining effectiveness of treatment of an interstitial lung disease in a patient. The method comprises determining a level of one or more of MMP2 activation peptide, MMP7 activation peptide, MMP8 activation peptide and MMP9 activation peptide in urine of the patient, and identifying whether the patient has interstitial lung disease by determining if levels of one or more of MMP2 activation peptide, MMP7 activation peptide, MMP8 activation peptide and MMP9 activation peptide in urine of the patient exceed a threshold level indicative of interstitial lung disease. A kit also is provided, which comprises reagents useful in the methods described herein. 
     The methods described herein have significant advantages over methods that analyze MMP concentration in blood or BAL (bronchoalveolar lavage). Biological detection of the full-length protein can be altered based on confounding factors such as receptor mediated proteinase clearance. MMP activation peptide detection as described herein is not altered by these factors as the activation peptides are cleared through simple renal filtration as opposed to receptor mediated endocytosis. Also, detection of MMP activation peptides in the urine is less invasive, and often a cheaper sampling method. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  provides a sequence of human MMP2 (UniProtKB/Swiss-Prot: P08253 (SEQ ID NO: 1, with bases 30-109 (bold) representing the MMP2 activation peptide for this sequence). 
         FIG. 2  provides a sequence of human MMP7 (UniProtKB/Swiss-Prot: P09237 (SEQ ID NO: 2, with bases 18-94 (bold) representing the MMP7 activation peptide for this sequence). 
         FIG. 3  provides a sequence of human MMP8 (UniProtKB/Swiss-Prot: P22894 (SEQ ID NO: 3, with bases 21-100 (bold) representing the MMP8 activation peptide for this sequence). 
         FIG. 4  provides a sequence of human MMP9 (UniProtKB/Swiss-Prot: P14780 (SEQ ID NO: 4, with bases 20-93 (bold) representing the MMP9 activation peptide for this sequence). 
         FIG. 5 . Each of the MMP Activation Peptide ELISAs Were Independently Validated. Validation profiles of MMP activation peptide ELISAs. When determining precision, each of the assays had a coefficient of variance less than 10% in both the (A) inter-assay test and the (B) intra-assay test. (C) All four MMP activation peptide assays shared dilution linearity. 
         FIG. 6 . MMP Activation Peptides are Detectable and Elevated in the Urine of Mice with Pulmonary Fibrosis. Activation peptides of MMP2, MMP7, MMP8 and MMP9 are detectable in the urine of mice via ELISA. All four are significantly increased in the urine of mice treated with bleomycin (black bars) or asbestos (gray bars) compared to the urine of control mice treated only with saline (white bars) (*p&lt;0.05). 
         FIGS. 7A-7C . Urine MMP Activation Peptides Distinguish IPF Patients From Controls. ( FIG. 7A ) The relative concentration of MMP2, MMP7, and MMP9 activation peptides are significantly higher in the urine of IPF patients (n=42) compared to the urine of healthy age matched controls (n=30) as detected by ELISA. ( FIG. 7B ) A classification tree obtained by CART when applied to relative urine MMP activation peptide concentration from IPF patients and controls shows that these markers can be used as classifiers to correctly identify IPF patients from controls. All data are presented as control/IPF and are based on urine MMP activation peptide levels divided by urine creatinine levels (μg/ml). ( FIG. 7C ) ROC curves for using each of the four markers, or their combination, to classify samples as IPF or control. Sensitivity, or true positive rate, is potted on the y-axis, and false positive rate, or 1—specificity, is plotted on the x-axis. The area under each ROC curve is equal to the numerator of the Mann-Whitney U-statistic comparing the marker distributions between IPF and control samples. 
         FIG. 8  is a graph of the data provided in Table 3, illustrating MMP activation peptide levels in IPF patients versus healthy age-matched controls. 
     
    
    
     DETAILED DESCRIPTION 
     The use of numerical values in the various ranges specified in this application, unless expressly indicated otherwise, are stated as approximations as though the minimum and maximum values within the stated ranges are both preceded by the word “about”. In this manner, slight variations above and below the stated ranges can be used to achieve substantially the same results as values within the ranges. Also, unless indicated otherwise, the disclosure of these ranges is intended as a continuous range including every value between the minimum and maximum values. 
     As used herein, the term “patient” refers to members of the animal kingdom including but not limited to mammals and human beings and is not limited to humans or animals in a doctor-patient or veterinarian-patient relationship. 
     “Interstitial Lung Disease” (also known as diffuse parenchymal lung disease) is a group of lung disorders which result in scarring and dysfunction of the alveolus (air sac) in the lung. Symptoms of interstitial lung disease typically arise secondary to fibrosis of the lung(s). This results in poor oxygen diffusion from the air into the bloodstream. Widespread inflammation in the lung can contribute to the fibrosis. Interstitial lung disease includes as a class: silicosis; asbestosis; berylliosis; hypersensitivity pneumonitis; drug induced interstitial lung disease from, for example, antibiotics, chemotherapeutic drugs, and antiarrhythmic agents; systemic sclerosis; polymyositis; dermatomyositis; systemic lupus erythematosus; rheumatoid arthritis; atypical pneumonia; pneumocystis pneumonia (PCP); tuberculosis; sarcoidosis; idiopathic pulmonary fibrosis (IPF); hamman-rich syndrome IPF is a form of interstitial lung disease. There are several idiopathic forms of interstitial lung diseases, including and without limitation: usual interstitial pneumonia (UIP, which is now synonymous with idiopathic pulmonary fibrosis (IPF)); interstitial pneumonitis; nonspecific interstitial pneumonitis; bronchiolitis obliterans with organizing pneumonia (BOOP); respiratory bronchiolitis-associated interstitial lung disease; desquamative interstitial pneumonitis; lymphocytic interstitial pneumonitis; and acute interstitial pneumonitis. 
     MMP2 refers to human matrix metallopeptidase 2 (gelatinase A, 72 kDa gelatinase, 72 kDa type IV collagenase), GeneID: 4313, UniProtKB/Swiss-Prot: P08253 ( FIG. 1 , SEQ ID NO: 1), OMIM 120360 and GenBank Accession Nos. NM — 001127891 (isoform b), NP — 001121363 (isoform b), NM — 004530 (isoform a), and NP — 004521 (isoform a). These are exemplary sequences. 
     MMP7 refers to human matrix metallopeptidase 7 (matrilysin, uterine), GeneID: 4316, UniProtKB/Swiss-Prot: P09237 ( FIG. 2 , SEQ ID NO: 2), OMIM 178990 and GenBank Accession Nos. NM — 002423 and NP — 002414. These are exemplary sequences. 
     MMP8 refers to human matrix metallopeptidase 8 (neutrophil collagenase), GeneID: 4317, UniProtKB/Swiss-Prot: P22894 ( FIG. 3 , SEQ ID NO: 3, OMIM 120355 and GenBank Accession Nos. NM — 002424 and NP — 002415. These are exemplary sequences. 
     MMP9 refers to human matrix metallopeptidase 9 (gelatinase B, 92 kDa gelatinase, 92 kDa type IV collagenase), GeneID: 4318, UniProtKB/Swiss-Prot: P14780 ( FIG. 4 , SEQ ID NO: 4), OMIM 120361 and GenBank Accession Nos. NM — 004994 and NP — 004985. These are exemplary sequences. 
     An MMP activation peptide is a polypeptide or propeptide cleaved from a MMP upon activation. As indicated below, examples of MMP activation peptides include: 
     
       
         
               
             
           
               
                 MMP2 activation peptide: 
               
               
                 (SEQ ID NO: 1, bases 30-109) 
               
               
                 APSPIIKFPGDVAPKTDKELAVQYLNTFYGCPKESCNLFVLKDTLKKMQ 
               
               
                   
               
               
                 KFFGLPQTGDLDQNTIETMRKPRCGNPDVAN; 
               
               
                   
               
               
                 MMP7 activation peptide: 
               
               
                 (SEQ ID NO: 2, bases 18-94) 
               
               
                 LPLPQEAGGMSELQWEQAQDYLKRFYLYDSETKNANSLEAKLKEMQKFF 
               
               
                   
               
               
                 GLPITGMLNSRVIEIMQKPRCGVPDVAE; 
               
               
                   
               
               
                 MMP8 activation peptide: 
               
               
                 (SEQ ID NO: 3, bases 21-100) 
               
               
                 FPVSSKEKNTKTVQDYLEKFYQLPSNQYQSTRKNGTNVIVEKLKEMQRF 
               
               
                   
               
               
                 FGLNVTGKPNEETLDMMKKPRCGVPDSGGFM; 
               
               
                 and 
               
               
                   
               
               
                 MMP9 activation peptide: 
               
               
                 (SEQ ID NO: 4, bases 20-93) 
               
               
                 APRQRQSTLVLFPGDLRTNLTDRQLAEEYLYRYGYTRVAEMRGESKSLG 
               
               
                   
               
               
                 PALLLLQKQLSLPETGELDSATLKA. 
               
             
          
         
       
     
     Binding reagents specific to MMP2, 7, 8 and/or 9 activation peptides bind to and are specific to these polypeptides. Polyclonal or monoclonal antibodies specific to these MMP activation peptides are commercially available or may be readily raised to these polypeptides using standard methods for preparing polyclonal serum, monoclonal antibodies other binding reagents according to common methods known in the relevant arts. 
     An “immunoassay” is a qualitative and quantitative assay that detects and can quantify an amount of a particular compound, protein, polypeptide, molecule, etc. (collectively “ligand”) in a biological sample, such as a urine, serum, blood, BAL, CSF (cerebrospinal fluid), saliva, or other samples taken from a patient, including refined preparations prepared from those biological samples, such as protein preparations, protein concentrates, fractions (e.g., prepared by size exclusion or affinity chromatography, precipitation, electrophoresis or any other method of separating a total protein preparation into two or more parts), filtration filtrates and residues, etc. In an immunoassay, binding or competition with binding of a ligand, such as one of MMP2, MMP7, MMP8, or MMP9 activation peptides (collectively “MMP activation peptides”), to a binding partner thereof, is detected and quantified. A large number of immunoassays useful in the methods described herein are known to those of ordinary skill in the fields of immunology, medical diagnostic, medicine, etc. An ELISA (Enzyme-Linked ImmunoSorbent Assay) is used in the examples, below to quantify MMP activation peptides. Other non-limiting examples of immunoassays include competitive and “sandwich” assays and include: enzyme-linked immunosorbent assay (ELISA), radioimmunoassay (RIA), agglutination test, competitive binding assay, bead-based assay, radioimmunoprecipitation assay, colloidal gold assays, lateral flow assay, fluorescence polarization assay, immunofluorescence assay, Western Blot, mass spectrometry, nuclear magnetic resonance, and chemiluminescence assay. Further the assays may be conducted in a variety of manners, including as a stand-alone assay or in an array. 
     The term “binding reagent” and like terms, refers to any compound, composition or molecule capable of specifically (“specifically” includes substantially specifically, that is, with limited cross-reactivity that does not interfere with the ability of the binding reagent to function in a given assay within acceptable tolerances) binding another compound or molecule (its “binding partner”), which, in the case of immune-recognition contains an epitope. In many instances, the binding reagents are antibodies, such as polyclonal or monoclonal antibodies. “Binding reagents” also include derivatives or analogs of antibodies, including without limitation: Fv fragments; single chain Fv (scFv) fragments; Fab′ fragments; F(ab′)2 fragments; humanized antibodies and antibody fragments; camelized antibodies and antibody fragments; and multivalent versions of the foregoing. Multivalent binding reagents also may be used, as appropriate, including without limitation: monospecific or bispecific antibodies, such as disulfide stabilized Fv fragments, scFv tandems ((scFv) fragments), diabodies, tribodies or tetrabodies, which typically are covalently linked or otherwise stabilized (i.e., leucine zipper or helix stabilized) scFv fragments, etc. “Binding reagents” also include aptamers, as are described in the art. Binding partners, such as, without limitation, biotin/avidin, receptor/substrate combinations and ligand/binding partner combinations also are considered to be within the class of “binding reagents.” Antibodies and their respective antigens also are considered to be binding partners. 
     Binding reagents, such as antibodies, can be labeled by any useful method for detecting binding. For example and without limitation, reagent/antibody-labeling techniques are known for use in ELISA assays, including direct and indirect assays, sandwich-based assays, and competitive assays. Labels of antibodies include, without limitation, fluorophores, radioactive compounds, chemiluminescent compounds, chromatographic compounds, nanoparticles, colloids, beads, enzymes to cleave detectable substrates, and additional antibodies. In one embodiment, an antibody is labeled with an enzyme. Enzymes labeled to the antibody can be one or more of any known in the art. For example and without limitation, enzymes include horseradish peroxidase, glucose oxidase, beta galactosidase, beta lactamase, collagenase, and alkaline phosphatase. The antibody can be detected by using an enzyme-cleavable substrate and measuring the signal that arises from the substrate. The substrate can be a chromogenic or fluorogenic substrate. For example and without limitation, substrates include 3,3′,5,5′-tetramethylbenzidene, diaminobenzidene, 2,2′-azino-bis-(3-ethylbenzothiazoline-6-sulfonic), fluorescein diphosphate, o-phenylenediamine, hydrogen peroxide, glucose, resorufin beta-D-galactopyranoside, fluorescein digalactoside, and p-nitrophenylphosphate. 
     In use, a binding reagent can be attached to a surface. In one embodiment, the binding reagent can be attached to a particle. For example and without limitation, particles include those comprising glass, polystyrene, polypropylene, polyethylene, dextran, nylon, amylases, natural and modified celluloses, polyacrylamides, agaroses, and magnetite. In another embodiment, the binding reagent can be attached to nanoparticles. In yet another embodiment, the binding reagent can be attached to a surface of a container. For example and without limitation, containers include microtiter plates, (multi) well plates, tubes, and petri dishes. In another embodiment, the binding reagent can be attached to a planar surface. For example and without limitation, surfaces include silicon chips, matrices of fibers, hydrogels, and membranes. Examples of fibers include, without limitation, nitrocellulose, cellulose, microcellulose, methylcellulose, carboxylmethyl-cellulose, starch, vinylalcohol, vinylpyrrolidone, polyvinylalcohol, poly(ethylene glycol), collagen, and gelatin. 
     An “array” refers either to a set of binding reagents immobilized onto one or more substrates so that each binding reagent is at a known location or a multi-chambered apparatus containing two or more discrete, identifiable reaction chambers, such as, without limitation a 96-well dish, in which reactions comprising identified constituents are performed. In an exemplary embodiment, a set of binding reagents is immobilized onto a surface in a spatially addressable manner so that each individual binding reagent is located at a different and identifiable location on the substrate. Substrates include, without limitation, multi-well plates and beads. In one embodiment, the beads contain a marker, such as a quantum dot or fluorescent tag, so that they are individually identifiable. 
     A method of quantifying activated MMP levels in urine may be performed in any feasible manner, as a single assay, in series or in parallel. Parallel screening may be performed in a multi-well dish, such as, without limitation a 96-well dish. Samples can be individually screened by binding reagent-MMP-binding in combination with any suitable binding detection method. Reactions can be performed in a suitable multi-well plate, for example and without limitation a 96-well plate or a 384-well plate. The choice of a suitable multi-well plate or reaction chamber is a matter of experimental design choice and depends on the nature of the assay, the number of assays to be run and the equipment available to perform the assay and detect binding of the reaction constituents. Fluorescence, color changes and/or luminescence can be detected using any one of a number of plate readers commercially available, such as, without limitation, TopCount NXT™ Microplate Scintillation and Luminescence Counters (PerkinElmer, Waltham, Massachusettes). Reactions can be wholly or partially automated using any one of a number of automated or semi-automated robotic fluid-handling devices available commercially. 
     In one embodiment, the methods described herein comprise determining levels of one or more of MMP2, MMP7, MMP8 or MMP9 activation peptides (propeptides), or combinations thereof in urine in a patient and identifying if one or more of MMP2, MMP7, MMP8 or MMP9 activation peptides (propeptides), or combinations thereof, in urine of the patient are elevated as compared to levels in a normal control (for example, values exceed a threshold level) as indicating the presence of interstitial lung disease, such as IPF, in the patient. In one embodiment, the levels are normalized to renal function in the patient, meaning they are adjusted based on a level of one or more constituents of urine that indicates kidney function. In the examples below, the concentration of the MMP activation peptides is normalized to creatinine levels in the urine samples from the patients, and values are expressed as a ratio of [MMP activation peptide]/[creatinine] (a ratio of the concentration of a MMP activation peptide to the concentration of creatinine, e.g., in ng/mL). Although preferable in many instances, the assays described herein are normalized to an indicator of kidney function. The methods are useful in identifying interstitial lung disease, monitoring interstitial lung disease progression, or determining effectiveness of treatment of an interstitial lung disease in a patient. In one embodiment, the patient is a human patient. 
     In one embodiment, values of MMP activation peptides are normalized, with threshold or cutoff values (values above which there is a statistically significant increased risk of pulmonary injury) for the MMP activation peptides being:
         [MMP2 activation peptide]/[creatinine]≧0.6;   [MMP7 activation peptide]/[creatinine]≧1.255;   [MMP8 activation peptide]/[creatinine]≧0.195; and   [MMP9 activation peptide]/[creatinine]≧1.135.
 
Combinations of two or more of the above would increase the statistical significance of the results.
       

     In one example, normalized levels of MMP activation peptides are used to define statistically significant thresholds or cutoffs indicative of lowered risk (or lack of risk) of interstitial lung disease in a patient. Thresholds for lowered risk of interstitial lung disease (e.g., IPF) include one or more of:
         [MMP7 activation peptide]/[creatinine]&lt;1.255;   [MMP7 activation peptide]/[creatinine]≧1.255, [MMP9 activation peptide]/[creatinine]&lt;1.135 and [MMP8 activation peptide]/[creatinine]&lt;0.195; or   [MMP7 activation peptide]/[creatinine]≧1.255, [MMP9 activation peptide]/[creatinine]≧1.135 and [MMP2 activation peptide]/[creatinine]&lt;0.6.   Exemplary thresholds for interstitial lung disease (e.g., IPF) in the patient include one or more of:   [MMP7 activation peptide]/[creatinine]≧1.255, [MMP9 activation peptide]/[creatinine]&lt;1.135 and [MMP8 activation peptide]/[creatinine]≧0.195; or   [MMP7 activation peptide]/[creatinine]≧1.255, [MMP9 activation peptide]/[creatinine]≧1.135 and [MMP2 activation peptide]/[creatinine]≧0.6.       

     In another embodiment, values of MMP activation peptides are not normalized, with threshold or cutoff values (values above which there is a statistically significant increased likelihood of interstitial lung disease (e.g., IPF)) for the MMP activation peptides in ng/mL being:
         MMP2&gt;0.780 ng/mL;   MMP7&gt;1.225 ng/mL;   MMP8&gt;0.440 ng/mL; and   MMP9&gt;1.240 ng/mL.
 
Combinations of two or more of the above would increase the statistical significance of the results.
       

     It should be noted that the values and ratios provided are merely exemplary and mathematically can be expressed in a large variety or ways. For example 10 ng/mL can be expressed as 10000 pg/mL or 0.01 μg/mL. Likewise the ratio of [MMP activation peptide]/[creatinine] can be expresses as its inverse; that is, [creatinine]/[MMP activation peptide]. Thus the cutoff of [MMP9 activation peptide]/[creatinine]&lt;1.135 would be [creatinine]/[MMP9 activation peptide]&gt;1/1.135 (or 0.881). 
     The degree to which the levels of the one or more MMP activation peptides are elevated in order to identify interstitial lung disease (e.g., IPF) in a patient are determined experimentally, as is demonstrated herein, and are statistically significant. By “statistically significant” it is meant that, irrespective of the mathematical/statistical methodology used, the levels or cutoffs used to distinguish increased risk versus less risk of interstitial lung disease in a patient yield clinically acceptable results are capable of distinguishing risk versus lack of risk in more than 50%, 60%, 70%, 75%, 80%, 90%, 95%, 97% or 90% of patients. While clinical assays rarely are 100% accurate, 90% or greater accuracy in diagnosis of risk is preferred. Thus, the exemplary cutoffs presented in  FIG. 3B , expressed in terms of cutoffs presented as the normalized ratio of [MMP activation protein in ng/mL]/[creatinine in mg/mL] is statistically significant as the accuracy (e.g., the specificity and selectivity) of the described cutoffs in distinguishing individuals having interstitial lung disease, from individuals at lower risk is above clinically-acceptable levels. A patient fitting into the high risk profile as indicated by levels of the respective MMP activation peptides as shown in  FIG. 3B , is preferably treated medically for IPF or pulmonary injury. 
     In one embodiment, the step of detection of levels of one or more of MMP2, MMP7, MMP8 or MMP9 is performed and the values are either automatically or manually entered into a computer process (a software and/or hardware-implemented computer task implemented in/on/by a computing device, e.g. a personal computer, laptop, PDA, smart phone). The process comprises computer code, functions, algorithms, etc., that compares data to threshold data values input and/or stored within or configured into the process and outputs the data and optionally a outputs values/data/indicia indicating risk of interstitial lung disease in a useful form, such as a printout or visual display and/or stores the data and/or results of analysis of the data in a computer-readable form, such as on a optical disc (e.g., CD or DVD), hard drive, ROM, RAM, memory card, networked drive, tape drive, etc. Design and implementation of useful processes is well within the abilities of those of ordinary skill in the art of computer software/process design. 
     EXAMPLE 
     Methods 
     Reagents 
     All antibodies were commercially available. A rabbit polyclonal to the MMP8 propeptide domain was obtained from Abcam (Cambridge, Mass.). A mouse monoclonal antibody to the N-terminus of MMP2 (APSPIIKFPGDVAPKTDK, SEQ ID NO: 1, bases 30-47) was obtained from Thermo Scientific (Fremont, Calif.). A rabbit monoclonal antibody to the propeptide domain of MMP9 was obtained from Novus Biologicals (Littleton, Colo.). MMP7 propeptide antibody was obtained from R&amp;D Systems (Minneapolis, Minn.). Polypeptides corresponding to the N-terminus of each MMP propeptide (activation peptide) were synthetically made by Genscript (MMP2, 7, 9) (Piscataway, N.J.) or Abcam (MMP8) (Cambridge, Mass.). All antibodies cross react with human and mouse. 
     Patient Urine Collection and Processing 
     Sixty eight samples were analyzed in this study, including samples from patients diagnosed with IPF (n=42) and controls (n=30). IPF groups and controls were comparable with respect to age both in terms of the mean (64, 59) and the range (40-81, 50-82). Control urine was purchased from Bioreclamation Inc. (Hicksville, N.Y.). Samples were collected in sterile containers and immediately frozen at −20° C. The samples were thawed, and creatinine concentrations were determined according to manufacturer&#39;s instructions (R&amp;D Systems Minneapolis, Minn.). Urine containing blood or leukocytes as determined by Multistix 9 Urinalysis Strips (Bayer) was excluded. Protein concentration of urine was determined by the Bradford method using bovine serum albumin as the standard. Urine samples were centrifuged using Microcon Centrifugal Filter Devices Ultracel YM-10 (Millipore Corporation, Billerica, Mass.). Retentate was discarded and flow through (&lt;10 kd) was used for analysis. 
     Enzyme-Linked Immunosorbent Assays (ELISAs) 
     Costar 96-well RIA/EIA plates (Costar, Cambridge, Mass.) were incubated overnight at 4° C. with sample to be tested, in a total volume of 50 μl. Wells containing known concentrations of activation peptide were simultaneously analyzed. Coated plates were washed and blocked with PBS 1% BSA, 5% sucrose, 0.05% NaN 3  (blocking buffer) for 2 hours at 37° C. Plates were washed with blocking buffer then incubated with 100 μl of MMP antisera specific to the activation peptide of interest diluted in blocking buffer for 1 h at 37° C. The plates were washed and incubated for 1 hr using 100 μl ( 1/2000 dilution) of Horseradish peroxidase coupled antibody (either anti-mouse IgG or anti-rabbit IgG). After washing with blocking buffer and PBS, the substrate o-Phenylenediamine Dihydrochloride (Sigma) was added. Horseradish peroxidase activity was read at 450 nm using a THERMOmax microplate reader (Molecular Devices, Menlo Park, Calif.). 
     Mouse Treatment and Urine Collection 
     8-10 wk. old male C57BL/6 mice (Taconic, Germantown, N.Y.) were treated with a single 0.1-mg dose of crocidolite asbestos, 0.05 units of Bleomycin, or 0.9% Saline by intratracheal instillation as previously described (12). Each mouse was individually placed in a plastic beaker and allowed to urinate. Immediately after urination, the mouse was removed and the voided urine was aspirated and transferred into a sterile micro-centrifuge tube. Samples were taken at day 0 prior to treatment and everyday following treatment. Urine volumes raged from 10 μl-300 μl per mouse. Samples were processed and stored as described for human samples. 
     Statistical Methods 
     Data are presented as mean±standard deviation. The Wilcoxon rank-sum test was used to identify which of the four markers univariately distinguish IPF samples from controls. Data were analyzed using the R language for statistical computing (http://www.r-project.org/) (13). Classification and regression trees (CART) methodology was used to identify potential combinations of markers that could be used to distinguish IPF from controls. CART was performed using the rpart package for recursive partitioning. Classification performance was assessed using the ROCR package (http://rocr.bioinf.mpi-sb.mpg.de/). 
     Results 
     ELISA Validation 
     MMP2, 7, 8, and 9 map to different chromosome regions of the human genome but are individually conserved across species with 79% (MMP2), 75% (MMP7), 80% (MMP8) and 96% (MMP9) homology to the respective mouse MMP. The protein structure of human MMPs includes a pro domain that consists of 80 to 90 amino acids (TABLE 1). The pro domain or activation peptide is cleaved from the latent protein upon activation and is detectable in the urine of mice and humans. To quantitate the release of MMP activation peptides into the urine, antibodies against the pro domain of each MMP were used. 
     
       
         
               
             
               
               
               
               
             
           
               
                 TABLE 1 
               
             
             
               
                   
               
               
                 Human MMP Characteristics 
               
             
          
           
               
                   
                 Enzyme 
                 Family name 
                 Mol. Wt. (Pro peptide) 
               
               
                   
                   
               
               
                   
                 MMP2 
                 Gelatinase 
                 8934.42 
               
               
                   
                 MMP7 
                 Matrilysin 
                 8822.25 
               
               
                   
                 MMP8 
                 Collagenase 
                 9210.61 
               
               
                   
                 MMP9 
                 Gelatinase 
                 8339.62 
               
               
                   
                   
               
             
          
         
       
     
     The determined sensitivity of the assay is &lt;1 ng/ml. Standard curves were generated using serial dilutions of synthetic peptide corresponding to the pro peptide domain of MMP2, MMP7, MMP8, and MMP9 in phosphate buffered saline (PBS) starting with 10 ng/ml for MMP2, 7, and 8 activation peptides, and 1 ng/ml for MMP9 activation peptide (data not shown). Sensitivity of these assays was defined as the lowest MMP activation peptide concentration that could be differentiated from zero (assay blank/PBS) by Student&#39;s t-test. 
     The reproducibility of the assay is determined by assessing the precision profile by using urine samples that were known to be positive for each MMP activation peptide assayed at a concentration above the midpoint of the detection rage. Inter- and intra-assay CVs ranged from 5.7% to 7.9% (n=10) and from 6.3% to 9.9% (n=2 in 10 different plates), respectively ( FIG. 5A , B). 
     To determine the dilution linearity we used a known positive urine sample containing between 2 and 3.5 ng/ml corresponding to medium concentrations of MMP activation peptide and diluted it 1:5, 1:10, and 1:20, the sample gave results close to linearity (r=0.95-0.99) ( FIG. 5C ). 
     Activation Peptides from MMP2, MMP7, MMP8, and MMP9 are Increased in the Urine of Mice Following Pulmonary Injury 
     To determine if the activation peptides of MMP2, MMP7, MMP8 and MMP9 are detectable in the urine of mice following pulmonary injury we used the same ELISA used for the human samples. For this study we collected urines from C57BL/6 mice prior to and following asbestos and bleomycin induced pulmonary injury. The mice were treated intratracheally with either 0.1-mg of asbestos, 0.05 units of bleomycin, or saline only. Urines were collected at day 0 prior to treatment and then everyday post treatment. Our results show that all of the markers assessed are significantly increased in the urine of mice with pulmonary injury compared to the urine of mice treated only with saline Δt day 14, when it has been shown that these mouse models are exhibiting detectable fibrosis, it is clear that the activation peptide levels are significantly increased in the urines of the injured mice compared to controls ( FIG. 6 ). 
     Patient Characteristics 
     Demographic data, urine MMP activation peptide concentrations, urine creatinine levels and pulmonary function test results are summarized in Table 2. IPF patients were diagnosed via lung biopsy or radiographic evidence and normal controls (NC) were healthy age range matched with a similar gender distribution. Pulmonary function tests reveal that there is no significant correlation between urine MMP activation peptide concentrations and forced vital capacity (FVC %) or carbon monoxide diffusing capacity (DL CO  %). 
     
       
         
               
             
               
               
               
               
             
           
               
                 TABLE 2 
               
             
             
               
                   
               
               
                 Patient Characteristics and MMP Activation Peptide Levels 
               
             
          
           
               
                   
                 Variable 
                 IPF 
                 NC 
               
               
                   
                   
               
               
                   
                 Age 
                 65.7 ± 11.4 
                 59.5 ± 8.8  
               
               
                   
                 Sex, male/female 
                 38/5 ?? 
                 24/6 
               
               
                   
                 Creatinine 
                 183.3 ± 74.2  
                  132 ± 75.5 
               
               
                   
                 PFT Fvc % 
                 66.74 ± 13.94 
                 — 
               
               
                   
                 PFT DlCo % 
                 50.49 ± 17.23 
                 — 
               
               
                   
                 [MMP2 activation peptide]* 
                 2.6 ± 2.0 
                 .76 ± .61 
               
               
                   
                 [MMP7 activation peptide]* 
                 3.6 ± 2.6 
                 .97 ± 1.0 
               
               
                   
                 [MMP8 activation peptide]* 
                 .88 ± 1.0 
                 0.6 ± .74 
               
               
                   
                 [MMP9 activation peptide]* 
                 3.3 ± 2.4 
                 .87 ± 1.1 
               
               
                   
                   
               
             
          
         
       
     
     MMP Activation Peptide Concentrations are Different Between IPF Patients and Controls 
     To determine whether urine MMP2, MMP7, MMP8, and MMP9 activation peptide concentrations were higher in IPF patients compared to controls, we measured their levels in 42 patients with IPF and 30 healthy age range matched controls via ELISA. The resulting concentrations are relative to each patient&#39;s urine creatinine level. Univariately, the relative urine concentrations of the activation peptides of MMP2 (p&lt;0.001), MMP7 (p&lt;0.001), and MMP9 (p&lt;0.001) are significantly higher in IPF patients compared to controls ( FIG. 7A ). MMP8 activation peptide levels were slightly increased in IPF urines but not significantly. 
     We used recursive partitioning (CART) to determine whether these 4 markers in the urine comprise a combinatorial classifier to correctly classify IPF patients from controls. The results suggest that these markers in the urine can be used to distinguish IPF from control with high sensitivity (97.6% CI (0.874, 0.999)) and specificity (96.7% CI (0.828, 0.999)). Low relative concentrations of MMP7 activation peptide alone (≦1.255) correctly exclude 41 of 42 IPF patients but incorrectly classify 1 normal sample as IPF and 1 IPF sample as control whereas the combination of high relative urine concentrations of MMP7 (≧1.255), MMP2 (≧0.985), and MMP9 (≧1.135) exclude all controls but 1. Therefore, if MMP7 is low, then a randomly selected case is almost guaranteed not to be an IPF patient ( FIG. 7B ). Further, if MMPs 7, 9, and 2 are all simultaneously high, a randomly selected case is almost guaranteed to be an IPF patient. Relative urine concentrations of MMP8 activation peptide are not independently important. Receiver operating characteristic curves (ROCS) agree that a combination of the four markers, most significantly the combination of the activation peptides of MMP2, MMP7, and MMP9 correctly classify IPF patients from controls ( FIG. 7C ). 
     Table 3 (see also  FIG. 8 ) provides raw data for the MMP activation peptide levels described above. Of note, even without normalization, quantification of levels of MMP activation peptide levels can be used clinically to classify patients having interstitial lung disease (e.g., IPF) and lower risk of interstitial lung disease (e.g., IPF). The following cutoffs are capable of classifying patients having higher and lower risk of pulmonary injury. 
     
       
         
               
               
               
               
               
               
               
               
               
             
               
               
               
               
               
               
               
               
               
             
           
               
                   
                 TABLE 3 
               
               
                   
                   
               
               
                   
                 MMP2 
                 MMP2 
                 MMP7 
                 MMP7 
                 MMP8 
                 MMP8 
                 MMP9 
                 MMP9 
               
               
                   
                 NC 
                 IPF 
                 NC 
                 IPF 
                 NC 
                 IPF 
                 NC 
                 IPF 
               
               
                   
                   
               
             
             
               
                   
               
             
          
           
               
                 Number of 
                 30 
                 42 
                 30 
                 42 
                 30 
                 42 
                 30 
                 42 
               
               
                 values 
               
               
                 Minimum 
                 0.04 
                 0.25 
                 0.06 
                 0.69 
                 0 
                 0 
                 0 
                 0.55 
               
               
                 25% 
                 0.415 
                 0.955 
                 0.325 
                 1.668 
                 0.215 
                 0.07 
                 0.1925 
                 1.903 
               
               
                 Percentile 
               
               
                 Median 
                 0.715 
                 1.78 
                 0.89 
                 3.155 
                 0.31 
                 0.58 
                 0.79 
                 2.62 
               
               
                 75% 
                 1.36 
                 4.598 
                 1.633 
                 6.108 
                 1.053 
                 1.685 
                 1.153 
                 4.57 
               
               
                 Percentile 
               
               
                 Maximum 
                 2.89 
                 9.85 
                 3.68 
                 21 
                 2.35 
                 4.53 
                 4.4 
                 15.13 
               
               
                 Mean 
                 0.9053 
                 3.067 
                 1.015 
                 4.329 
                 0.6783 
                 0.9917 
                 0.899 
                 3.82 
               
               
                 Std. 
                 0.7278 
                 2.758 
                 0.8476 
                 3.8 
                 0.7279 
                 1.159 
                 0.9453 
                 3.353 
               
               
                 Deviation 
               
               
                 Std. Error 
                 0.1329 
                 0.4256 
                 0.1548 
                 0.5863 
                 0.1329 
                 0.1788 
                 0.1726 
                 0.5173 
               
               
                 Lower 
                 0.6336 
                 2.207 
                 0.6981 
                 3.145 
                 0.4065 
                 0.6305 
                 0.546 
                 2.775 
               
               
                 95% CI of 
               
               
                 mean 
               
               
                 Upper 95% 
                 1.177 
                 3.926 
                 1.331 
                 5.513 
                 0.9501 
                 1.353 
                 1.252 
                 4.865 
               
               
                 CI of mean 
               
               
                 Sum 
                 27.16 
                 128.8 
                 30.44 
                 181.8 
                 20.35 
                 41.65 
                 26.97 
                 160.4 
               
               
                   
               
             
          
         
       
     
     Table 4 provides examples of clinically relevant cutoff (threshold values, above which a patient exhibits increased risk of having or developing IPF) values along with their respective sensitivity/specificity values. These data were obtained via ROC curve analysis (similar to  FIG. 7C ). Statistical analysis using CART analysis (as in  FIG. 7B ) is expected to yield cutoffs with higher sensitivity and specificity. 
     
       
         
               
               
               
               
               
               
               
             
               
               
               
               
               
               
               
             
           
               
                   
                 TABLE 4 
               
               
                   
                   
               
               
                   
                 Cutoff 
                 Sensitivity 
                   
                 Specificity 
                   
                 Likelihood 
               
               
                   
                 (ng/ml) 
                 % 
                 95% CI 
                 % 
                 95% CI 
                 ratio 
               
               
                   
                   
               
             
             
               
                   
               
             
          
           
               
                 MMP2 
                 &gt;0.780 
                 85.71 
                 71.46% 
                 63.33 
                 43.86% 
                 2.34 
               
               
                   
                   
                   
                 to 
                   
                 to 
               
               
                   
                   
                   
                 94.57% 
                   
                 80.07% 
               
               
                 MMP7 
                 &gt;1.225 
                 88.1 
                 74.37% 
                 70 
                 50.60% 
                 2.94 
               
               
                   
                   
                   
                 to 
                   
                 to 
               
               
                   
                   
                   
                 96.02% 
                   
                 85.27% 
               
               
                 MMP8 
                 &gt;0.440 
                 59.52 
                 43.28% 
                 60 
                 40.60% 
                 1.49 
               
               
                   
                   
                   
                 to 
                   
                 to 
               
               
                   
                   
                   
                 74.37% 
                   
                 77.34% 
               
               
                 MMP9 
                 &gt;1.240 
                 85.71 
                 71.46% 
                 83.33 
                 65.28% 
                 5.14 
               
               
                   
                   
                   
                 to 
                   
                 to 
               
               
                   
                   
                   
                 94.57% 
                   
                 94.36% 
               
               
                   
               
             
          
         
       
     
     Having described this invention above, it will be understood to those of ordinary skill in the art that the same can be performed within a wide and equivalent range of conditions, formulations and other parameters without affecting the scope of the invention or any embodiment thereof.