It is assumed that fibrosis advances over long periods of time in patients with IPF. Thus, at the time of diagnosis, modifications of lung structure have already been established by the disease and pathological features, such as various stages of epithelial damage, alveolar epithelial cell (AEC) 2s hyperplasia, dense fibrosis, and abnormally proliferating mesenchymal cells, are found. At this time, it is not possible to determine the course of events that have led to lung damage; however, it is accepted that dysfunctional epithelia are key to the pathogenesis of IPF ^[1][15].

Under normal conditions of lung injury, AEC1s are replaced with proliferating and differentiating AEC2 cells and stem cells, which restore alveolar integrity by stimulating coagulation, the formation of new vessels, activation and migration of fibroblasts, and synthesis and proper alignment of collagen. Chemokines, such as transforming growth factor (TGF)-β1, platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), and fibroblast growth factor (FGF), are central to these processes. Conversely, continued lung injury or loss of normal restorative capacity invokes an inflammatory phase of the wound healing process. The associated increases in the expression levels of interleukin-1 (IL-1) and tumor necrosis factor-alpha (TNF-α) create a biochemical environment that favors chronic flaws of regeneration and tissue remodeling ^[2][16].

Repetitive exposures of alveolar epithelium to microinjuries, such as infection, smoking, toxic environmental inhalants, and gastroesophageal reflux, contribute to AEC1 damage. AEC2s normally regenerate damaged cells, but when dysfunctional, their ability to reestablish homeostasis is impaired. This condition is considered indicative of the pathogenesis of IPF ^[30][31][44,45].

Damage to alveolar structures and the loss of AECs with basement membranes involves alveolar vessels and leads to increased vascular permeability. Wound clots form during this early phase of wound healing responses, and sequentially, new vessels are formed through the proliferation of endothelial cells and endothelial progenitor cells (EPCs). Patients with IPF with failure of re-endothelization have significantly decreased numbers of EPCs, likely resulting in dysfunctional alveolar–capillary barriers, profibrotic responses, and compensatively augmented VEGF expression. This series of endothelial changes could stimulate fibrotic processes and abnormalities of vessel functions, contributing to cardio–respiratory declines and advanced disease. Furthermore, endothelial cells may undergo a mesenchymal transition with similar consequences as those of EMT ^[34][48].

Endothelial and epithelial damage also activates coagulation cascades during the early phases of wound healing. Coagulation proteinases have several cellular effects on wound healing. In particular, the tissue factor-dependent pathway is central to the pathogenesis of IPF and promotes a pro-coagulation state with increased levels of inhibitors of plasminogen activation, active fibrinolysis, and protein C. Under these pro-coagulation conditions, degradation of ECM is decreased, resulting in profibrotic effects and the induction of fibroblast differentiation into myofibroblasts via proteinase-activated receptors ^[2][16].

The pathobiology of IPF is led by aberrant epithelial–mesenchymal signaling, but inflammation may also play an important role because inflammatory cells are involved in normal wound healing from early phases. Initially, macrophages produce cytokines that induce inflammatory responses and participate in the transition to healing environments by recruiting fibroblasts, epithelial cells, and endothelial cells. If injury persists, neutrophils and monocytes are recruited, and the production of reactive oxygen species exacerbates epithelial damage. The resulting imbalances between antioxidants and pro-oxidants may also promote apoptosis of epithelial cells and activation of pathways that impair function. Finally, monocytes and macrophages produce PDGF, CCL2, macrophage colony stimulating factor, and colony stimulating factor 1. These proteins may also have direct profibrotic effects ^[30][35][44,49].

The roles of lymphocytes in IPF are still unclear. However, some lymphocytic cytokines are considered profibrotic due to their direct effects on the activities of fibroblast and myofibroblast. Th-1, Th-2, and Th-17 T-cells have been clearly associated with the pathogenesis of IPF. The Th1 T-cell subset produces IL-1α, TNF-α, PDGF, and TGF-β1 and has net profibrotic effects. Th2 and Th17 responses appear more important in the pathogenesis of IPF. In particular, the typical Th2 interleukin IL-4 induces IL-5, IL-13, and TGF-β1 expression, leading to the recruitment of macrophages, mast cells, eosinophils, and mesenchymal cells and the direct activation of fibroblasts. Additionally, fibroblasts from patients with IPF are hyperresponsive to IL-13, which has a positive effect on fibroblast activity and enhances the production of ECM. The Th17 T-cell subset indirectly promotes fibrosis by increasing TGF-β1 levels. Th17 cells are also positively regulated by TGF-β1, suggesting the presence of a positive feedback loop ^[2][16]. Numbers of regulatory T-cells are reportedly lower in bronchoalveolar lavage fluid and peripheral blood samples from patients with IPF than in those of healthy subjects. Regulatory T-cells (Tregs) play a crucial role in immune tolerance and the prevention of autoimmunity; deficiencies in numbers and functions of these T-cells play an important role in the initial phases of pathogenesis of IPF. The function of Treg in IPF is severely impaired due to reduced number of infiltrating Tregs in addition to dysfunction of Tregs. Interestingly, the compromised Treg function in bronchoalveolar lavage is associated with parameters of the disease severity of IPF, indicating a causal relationship between the development of IPF and impaired immune regulation mediated by Tregs ^[36][50]. Previous studies have demonstrated low IFN-γ levels in the lungs of patients with IPF. IFN-γ inhibits fibroblastic activity and abolishes Th2 responses. However, further studies are required to characterize the roles of inflammation in the pathobiology of IPF. Currently, the early stages of IPF are poorly understood, as are the mechanisms of disease progression ^[35][37][49,51]. Nonetheless, pirfenidone (5-methyl-1-phenyl-2-[1H]-pyridone) was designed to have anti-inflammatory and antifibrotic effects and was efficacious in the clinical setting ^[38][6].

Contributions of mesenchymal cells, and particularly fibroblasts and myofibroblasts, are crucial for the pathogenesis of IPF. These cells are recruited, activated, and induced to differentiate and proliferate in the abnormal biochemical environments that are created by activated epithelial and endothelial cells. Although the initial trigger and source of mesenchymal cell recruitment remain unclear, the current published consensus defines fibroblasts and myofibroblasts as the key cell types for IPF. Circulating fibrocytes, pulmonary fibroblasts, and myofibroblasts have also been identified among mesenchymal cells that are involved in IPF ^[39][52]. The most recent studies of these processes are summarized in a well-integrated review ^[40][53].