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Lareau S, ZuWallack R, Nici L. Increasing Quality and Quantity of Life in Individuals with Chronic Obstructive Pulmonary Disease: A Narrative Review with an Emphasis on Pulmonary Rehabilitation. Life (Basel) 2025; 15:750. [PMID: 40430178 PMCID: PMC12112767 DOI: 10.3390/life15050750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2025] [Revised: 04/20/2025] [Accepted: 05/01/2025] [Indexed: 05/29/2025] Open
Abstract
Goals of medical management of individuals with chronic obstructive pulmonary disease (COPD) should be to live better and live longer-in other words, improve health-related quality of life (HRQL) and survival. This narrative review summarizes the literature in these areas, with an emphasis on pulmonary rehabilitation (PR). Treatments that increase HRQL include pharmacologic agents, exercise training, physical activity promotion, lung volume reduction, PR, self-management training, and supplemental oxygen. Additionally, anything that reduces the frequency or impact of exacerbations substantially increases HRQL. With respect to survival in COPD, the list of beneficial interventions for this outcome is considerably more limited. Supplemental oxygen therapy for hypoxemic patients, smoking cessation interventions, influenza vaccination, and lung volume reduction procedures have the strongest evidence in survival benefit. PR, especially when provided following discharge for exacerbations, may improve survival. A nihilistic view of COPD treatment is unwarranted, as multiple interventions are available that improve HRQL, and likely increase survival for selected patients.
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Affiliation(s)
- Suzanne Lareau
- College of Nursing, University of Colorado, Denver Anschutz Medical Campus, ED 2 North, 13120 East 19th Ave., Aurora, CO 80045, USA
| | - Richard ZuWallack
- Pulmonary and Critical Care, Trinity Health of New England, St. Francis Hospital, 114 Woodland Street, Hartford, CT 06105, USA
| | - Linda Nici
- The Warren Alpert Medical School, Brown University, 222 Richmond St., Providence, RI 02903, USA
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2
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Fromme M, Klebingat F, Ellis P, Strnad P. Alpha-1 antitrypsin deficiency-associated liver disease: From understudied disorder to the poster child of genetic medicine. Hepatol Commun 2025; 9:e0699. [PMID: 40227077 PMCID: PMC11999460 DOI: 10.1097/hc9.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2025] [Accepted: 02/07/2025] [Indexed: 04/15/2025] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD) constitutes an inborn disorder arising due to mutations in alpha-1 antitrypsin (AAT), a secreted protease inhibitor produced primarily in hepatocytes. It leads to diminished serum AAT levels, and this loss-of-function predisposes to chronic obstructive pulmonary disease and lung emphysema. The characteristic Pi*Z mutation results in hepatic Z-AAT accumulation. In its homozygous form (Pi*ZZ genotype), it is responsible for the majority of severe AATD cases and can cause both pediatric and adult liver disease, while the heterozygous form (Pi*MZ) is considered a disease modifier that becomes apparent primarily in the presence of other comorbidities or risk factors. In the current review, we collate conditions associated with AATD, introduce typical AAT variants, and discuss our understanding of disease pathogenesis. We present both cross-sectional and longitudinal data informing about the natural disease history and noninvasive tools that can be used for disease stratification as well as a basis for disease monitoring. Given that AATD-associated liver disease is highly heterogeneous, we discuss the risk factors affecting disease progression. While the loss-of-function lung disease is treated by weekly intravenous administration of purified AAT, recombinant modified AAT and oral protease inhibitors are currently in clinical trials. Among the liver candidates, small interfering RNA fazirsiran efficiently suppresses AAT production and is currently in phase 3 clinical trial, while several other genetic approaches, such as RNA editing, are at earlier stages. In summary, AATD represents a systemic disorder increasingly seen in the hepatologic routine and requiring thorough interdisciplinary care, since the currently ongoing clinical trials often address only one of the organs it affects.
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Affiliation(s)
- Malin Fromme
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
| | - Fabienne Klebingat
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
| | - Paul Ellis
- School of Health Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Pavel Strnad
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
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3
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Perales-Afán JJ, Menao S, García-Gutiérrez A, García-Zafra L, Del Castillo-Díez E, Torralba-Cabeza MÁ. Alpha-1 Antitrypsin Deficiency Screening Using Serum Protein Electrophoresis. Respir Care 2025; 70:551-558. [PMID: 39969926 DOI: 10.1089/respcare.12524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2025]
Abstract
Background: Alpha-1 antitrypsin is encoded by the polymorphic SERPINA1 gene, with pathogenic variants causing alpha-1 antitrypsin deficiency. While being underrecognized, alpha-1 antitrypsin deficiency can be screened through serum protein electrophoresis (SPE) to detect mutations. This study aimed to evaluate the effectiveness of an SPE-based screening protocol for identifying SERPINA1 mutations and diagnosing alpha-1 antitrypsin deficiency. Methods: This study involved analyzing all SPE tests over one year at the Hospital Clínico Universitario "Lozano Blesa" (Zaragoza, Spain). Alpha-1 antitrypsin concentration was measured in samples with <3% alpha-1 globulin band, selecting those with <100 mg/dL as potential study participants. Participants provided blood samples for the genetic analysis of the SERPINA1 gene. Results: Out of 12,460 SPE tests analyzed, 175 had alpha-1 globulin bands <3%, and 70 cases had alpha-1 antitrypsin concentrations <100 mg/dL. Of these cases, 39 subjects participated in the study. The mean alpha-1 antitrypsin concentration was 78.8 mg/dL. Genetic analysis showed 87.2% had SERPINA1 mutations, with common genotypes being PI*MS, PI*MZ, and PI*SZ. Conclusions: This study confirms the efficacy of SPE as a potential screening strategy for detecting mutations in the SERPINA1 gene. It can facilitate opportunistic diagnosis of alpha-1 antitrypsin deficiency, promoting early detection and treatment.
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Affiliation(s)
- Juan José Perales-Afán
- Drs. Perales-Afán, Menao, García-Gutiérrez, and del Castillo-Díez are affiliated with Clinical Biochemistry Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
- Drs. Perales-Afán, Menao, and Torralba-Cabeza are affiliated with Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | - Sebastián Menao
- Drs. Perales-Afán, Menao, García-Gutiérrez, and del Castillo-Díez are affiliated with Clinical Biochemistry Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
- Drs. Perales-Afán, Menao, and Torralba-Cabeza are affiliated with Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | - Almudena García-Gutiérrez
- Drs. Perales-Afán, Menao, García-Gutiérrez, and del Castillo-Díez are affiliated with Clinical Biochemistry Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Laura García-Zafra
- Mrs. García-Zafra is affiliated with Clinical Biochemistry Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Enrique Del Castillo-Díez
- Drs. Perales-Afán, Menao, García-Gutiérrez, and del Castillo-Díez are affiliated with Clinical Biochemistry Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Miguel Ángel Torralba-Cabeza
- Drs. Perales-Afán, Menao, and Torralba-Cabeza are affiliated with Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
- Dr. Torralba-Cabeza is affiliated with Minority Diseases Unit, Internal Medicine Service, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
- Dr. Torralba-Cabeza is affiliated with Facultad de Medicina, Universidad de Zaragoza, Zaragoza, Spain
- Dr. Torralba-Cabeza is affiliated with Grupo de Trabajo de Enfermedades Minoritarias de la Sociedad Española de Medicina Interna (GTEM-SEMI), Madrid, Spain
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Figueira Gonçalves JM, de Miguel Díez J, Alcázar Navarrete B, Almagro Mena P, Alonso-Ortiz MB, Balañá Corberó A, Barrecheguren M, Cabestre García R, Cases Viedma E, Cejudo Ramos P, Fernández-Villar A, Golpe R, Iriberri Pascual M, López-Campos JL, Molina París J, de la Rosa-Carrillo D, Sayas Catalán J, Miravitlles M. Delphi Consensus on the Management of Patients With Advanced COPD: COPD-Avanz Working Group. OPEN RESPIRATORY ARCHIVES 2025; 7:100411. [PMID: 40104202 PMCID: PMC11919417 DOI: 10.1016/j.opresp.2025.100411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2024] [Accepted: 01/27/2025] [Indexed: 03/20/2025] Open
Abstract
Introduction To reach a multidisciplinary consensus on the management of patients with advanced COPD using Delphi methodology. Material and methods A multidisciplinary committee of experts (Pneumology, Physiotherapy, Internal Medicine, Physical Medicine and Rehabilitation, Primary Care, and Nursing) developed a 105-item questionnaire to be agreed by a panel of experts grouped into the following topics: (1) Definition of advanced COPD patients; (2) Management of dyspnoea in patients with advanced COPD; (3) Prevention and recovery of exacerbation in patients with advanced COPD; and (4) Dealing with disease progression. Results After two rounds, consensus was reached on 77.1% of the items. The definition proposed for advanced COPD and agreed by 91.5% of the panellists stated: "COPD patient with FEV1 < 50% and at least two of the following criteria: dyspnoea mMRC 3-4, chronic respiratory insufficiency, and limitation in basic activities of daily living". Other relevant agreements were: the use of opioids, pulmonary rehabilitation and respiratory physiotherapy, or home high-flow therapy and long-term oxygen therapy for the improvement of dyspnoea; the role of comorbidities assessment; the inclusion of these patients in respiratory rehabilitation programmes; the use of inhaled antibiotic treatment in chronic bronchial infection by Pseudomonas aeruginosa in the prevention and recovery of exacerbations; and the criteria for lung transplantation or augmentation therapy in patients with advanced COPD and severe α1-antitrypsin deficiency. Conclusions In this document, a broad panel of experts reached a high degree of consensus on the definition of advanced COPD as well as on its approach. The information provided by this consensus is intended to assist the clinician in the identification of these patients as well as to provide guidance on their management.
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Affiliation(s)
| | - Javier de Miguel Díez
- Servicio de Neumología, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Bernardino Alcázar Navarrete
- Servicio de Neumología, Hospital Universitario Virgen de las Nieves, Departamento de Medicina, Universidad de Granada, Instituto Biosanitario de Granada Ibs-Granada, Granada, Spain
| | - Pere Almagro Mena
- Servicio de Medicina Interna, Hospital Universitario Mútua de Terrassa, Barcelona, Spain
| | - María Belén Alonso-Ortiz
- Servicio de Medicina Interna, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Spain
| | - Ana Balañá Corberó
- Servicio de Neumología, Hospital del Mar, Barcelona, Spain
- Área de Fisioterapia Respiratoria de SEPAR, Spain
| | | | - Roberto Cabestre García
- Centro de Salud Delicias Sur, Zaragoza, Spain
- Área de Enfermería Respiratoria de la SEPAR, Spain
| | - Enrique Cases Viedma
- Servicio de Neumología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Pilar Cejudo Ramos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla, IBiS/Hospital Universitario Virgen del Rocío, Sevilla, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Alberto Fernández-Villar
- Servicio de Neumología, Hospital Universitario Álvaro Cunqueiro, Instituto de Investigación Biomédica Galicia Sur, Universidad de Vigo, Vigo, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Rafael Golpe
- Servicio de Neumología, Hospital Universitario Lucus Augusti, Lugo, Spain
| | | | - José Luis López-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla, IBiS/Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Sevilla, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Molina París
- Medicina Familiar y Comunitaria, Centro de Salud Francia, Fuenlabrada, Spain
- Comité Ejecutivo de GEMA y GesEPOC, Spain
| | | | | | - Marc Miravitlles
- Servicio de Neumología, Hospital Universitario Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona Hospital Campus, Barcelona, Spain
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Raghavan S, Hatipoğlu U, Aboussouan LS. Goals of chronic obstructive pulmonary disease management: a focused review for clinicians. Curr Opin Pulm Med 2025; 31:156-164. [PMID: 39620703 DOI: 10.1097/mcp.0000000000001144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2025]
Abstract
PURPOSE OF REVIEW The diagnosis of chronic obstructive pulmonary disease (COPD) encompasses heterogeneous pathophysiological mechanisms which can shape an individual patient's experience. This paper reviews available therapeutic options for the clinician intending to individualize care toward patient goals. RECENT FINDINGS The contemporary targeted interventions for COPD include the novel phosphodiesterase inhibitor ensifentrine, the interleukin-4 receptor (IL4R alpha subunit) antibody dupilumab, augmentation therapy for alpha-1 antitrypsin deficiency. Other interventions promoting physical and mental well being include re-envisioned pulmonary rehabilitation, self-management, targeting of comorbidities such as sarcopenia, and virtual health coaching interventions to expand patient access. Opioids did not relieve dyspnea and did not change total step count. SUMMARY Advances in precision therapy are complemented by the discovery of novel pathophysiology pathways and behavioral and rehabilitation interventions as a holistic view of COPD management emerges. The management of COPD continues to evolve with new tools including precision medicine and individualized care. Comorbidities remain important determinants of health, yet their prevalence and impact are underestimated.
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Affiliation(s)
- Sairam Raghavan
- Integrated Hospital-Care Institute, Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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Afrin S, Binte Hasan T, Sagar MTA, Naima T, Maisha S, Yeasmin S, Al Masud A, Akter F. The Role of Gene Therapy as an Emerging Treatment Strategy for Alpha-1 Antitrypsin Deficiency-Associated Lung Disease: A Systematic Review. Cureus 2025; 17:e79286. [PMID: 40125236 PMCID: PMC11927519 DOI: 10.7759/cureus.79286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2025] [Indexed: 03/25/2025] Open
Abstract
Monogenetic disease alpha-1 antitrypsin deficiency (AATD) is the leading cause of emphysema, which is a major life-limiting chronic obstructive pulmonary disease (COPD). The current standard of care for severely affected individuals with lung disease is the periodic intravenous infusion of human AAT protein to restore circulating AAT levels to a protective level, known as augmentation therapy. We did a systematic review to see the effect of gene therapy as a potential therapeutic option for AATD-related lung diseases. MEDLINE (via PubMed), SCOPUS, Web of Science, Cochrane Library, and EMBASE have been searched following PICO (Population, Intervention, Comparison, Outcome) criteria. After duplication removal, abstract and title screening, full-text screening was done by two individual reviewers. Then, the data were extracted, tabulated, and analyzed. A total of 1094 articles were found in the primary search. After a comprehensive review following strict inclusion and exclusion criteria, 14 articles have been included in the review. Evidence shows the response of gene therapy depends on multiple factors, e.g., what vector is used, route of therapy administration, duration of therapy, etc. The AAV8-CASI-luc vector, delivered intratracheally (IT), achieved sustained lung transgene expression for at least 52 weeks, but 29% of mice had persistent expression up to 72 weeks, providing therapeutic AAT protein levels, reducing experimental emphysema severity in mice. Intratracheal AAV8 in mice showed the highest AAT expression in the lung, outperforming AAV9, AAV5, AAV2, and AAV2 capsid mutants, providing long-term expression up to 4 months. Intrapleural administration of AAV5-hA1AT achieved higher lung and serum A1AT levels than intramuscular delivery, with AAV5 yielding 10 times higher levels than AAV2. Gene therapy using viral vectors has a potential role in producing AAT protein, which can be beneficial for AATD-related lung diseases. Human trials are necessary to establish the effectiveness and safety of gene therapy. In conclusion, while initial studies are encouraging, more research is needed to confirm the role of gene therapy.
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Affiliation(s)
- Shanta Afrin
- Internal Medicine, Dhaka Medical College Hospital, Dhaka, BGD
| | | | | | - Tasnim Naima
- Internal Medicine, BGC Trust Medical College, Chittagong, BGD
| | - Sadia Maisha
- Internal Medicine, Sher-E-Bangla Medical College, Barisal, BGD
| | - Shamima Yeasmin
- Obstetrics and Gynecology, Impulse Hospital Limited, Dhaka, BGD
| | - Abdullah Al Masud
- Internal Medicine, Saint Louis University School of Medicine, Saint Louis, USA
- Administration, Dream USMLE, St louis, USA
| | - Fahima Akter
- Internal Medicine, Indiana University Health Ball Memorial Hospital, Indiana, USA
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7
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Pfeffer DN, Dhakne R, El Massad O, Sehgal P, Ardiles T, Calloway MO, Runken MC, Strange C. Improving the Likelihood of Identifying Alpha-1 Antitrypsin Deficiency Among Patients With COPD: A Novel Predictive Model Using Real-World Data. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2025; 12:1-11. [PMID: 39636053 PMCID: PMC11925067 DOI: 10.15326/jcopdf.2023.0491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2024]
Abstract
Background Despite guideline recommendations, most patients with chronic obstructive pulmonary disease (COPD) do not undergo alpha-1 antitrypsin deficiency (AATD) testing and approximately 90% of people with AATD in the United States remain undiagnosed. This study sought to develop a predictive model using real-world data to improve detection of AATD-positive patients in the general COPD population. Methods A predictive model using extreme gradient boosting was developed using the EVERSANA database, including longitudinal, patient-level medical claims, prescription claims, AATD-specific testing data, and electronic health records (EHR). The model was trained and then validated to predict AATD-positive status. Patients were coded as AATD positive based on the presence of any of the following criteria: (1) ≥2 AATD diagnosis codes in claims; (2) an AATD diagnosis code in the EHR; (3) a positive laboratory test for AATD; or (4) use of AATD-related medication. Over 500 variables were used to train the predictive model and >20 models were run to optimize the predictive power. Results A total of 13,585 AATD-positive patients and 7796 AATD-negative patients were included in the model. The inclusion of non-AATD laboratory test results was critical for defining cohorts and optimizing model prediction (e.g., respiratory comorbidities, and calcium, glucose, hemoglobin, and bilirubin levels). The final model yielded high predictive power, with an area under the receiver operating characteristic curve of 0.9. Conclusion Predictive modeling using real-world data is a sound approach for assessing AATD risk and useful for identifying COPD patients who should be confirmed by genetic testing. External validation is warranted to further assess the generalizability of these results.
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Affiliation(s)
- Daniel N Pfeffer
- Data and Analytics, EVERSANA, Milwaukee, Wisconsin, United States
| | | | - Omnya El Massad
- Data and Analytics, EVERSANA, Milwaukee, Wisconsin, United States
| | | | - Thomas Ardiles
- Medical Affairs, Grifols Shared Services North America, Durham, North Carolina, United States
| | - Michael O Calloway
- Global Health Economics and Outcomes Research/Real-World Evidence, Grifols Shared Services North America, Durham, North Carolina, United States
| | - M Chris Runken
- Global Health Economics and Outcomes Research/Real-World Evidence, Grifols Shared Services North America, Durham, North Carolina, United States
| | - Charlie Strange
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina, United States
- AlphaNet, Coral Gables, Florida, United States
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8
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Martín T, Miravitlles M. Response to: risk of lung disease with the Pi*SS genotype of alpha-1 antitrypsin: the evidence in context. Respir Res 2025; 26:36. [PMID: 39856768 PMCID: PMC11762059 DOI: 10.1186/s12931-024-03065-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2024] [Accepted: 12/06/2024] [Indexed: 01/27/2025] Open
Affiliation(s)
- Teresa Martín
- Pneumology Department, Hospital Beatriz Ângelo, Av. Carlos Teixeira 3, Loures, 2674-514, Portugal.
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
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9
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Keane R, Brennan V. Assessment of breathlessness: a pulmonologist's perspective - short of breath, but not short of answers. Breathe (Sheff) 2025; 21:240096. [PMID: 40104257 PMCID: PMC11915126 DOI: 10.1183/20734735.0096-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2024] [Accepted: 01/27/2025] [Indexed: 03/20/2025] Open
Abstract
Breathlessness, or dyspnoea, is a complex symptom influenced by respiratory, cardiovascular and neural mechanisms, necessitating a systematic and tiered approach for accurate diagnosis and effective management. This review presents a structured, three-tier diagnostic framework, comprising history-taking, static testing (such as pulmonary function tests and thoracic imaging), and dynamic testing (e.g., 6-minute walk test and cardiopulmonary exercise testing) for comprehensive assessment. Each tier is designed to progressively investigate and characterise underlying conditions. This framework is specifically tailored for use in an outpatient general respiratory clinic setting, where clinicians evaluate chronic or unexplained dyspnoea in non-acute patients. Literature and guidelines support this approach, highlighting the importance of combining clinical examination, imaging, laboratory testing and dynamic assessments to capture both static and exertional components of dyspnoea. Emphasising a patient-centred approach, this framework aims to improve diagnostic accuracy and guide targeted therapeutic interventions.
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Affiliation(s)
- Ruaidhrí Keane
- Respiratory Department, Beaumont Hospital, Dublin, Ireland
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10
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Brantly M, Stocks J, Lascano J, Flagg T, Jeffers AM, Owens SZ, Tucker TA, Devine M, Alagem N, Tov N. Inhaled alpha-1 antitrypsin (AAT) restores lower respiratory tract protease-antiprotease homoeostasis and reduces inflammation in AAT-deficient individuals: a randomised phase 2 study. ERJ Open Res 2025; 11:00537-2024. [PMID: 39811545 PMCID: PMC11726588 DOI: 10.1183/23120541.00537-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 07/20/2024] [Indexed: 01/16/2025] Open
Abstract
Background Alpha-1 antitrypsin (AAT)-deficient individuals have a greater risk for developing COPD than individuals with normal AAT levels. Methods This was a double-blind, randomised, parallel group, placebo-controlled trial to examine the safety and tolerability of "Kamada-AAT for Inhalation" (inhaled AAT) in subjects with AAT deficiency, and to explore its effect on AAT and biomarkers in the lung epithelial lining fluid (ELF). 36 patients with severe AAT deficiency were randomised 2:1 to receive 80 mg or 160 mg inhaled AAT or placebo once daily for 12 weeks. The primary outcomes were AAT and antineutrophil elastase capacity (ANEC) in bronchoalveolar lavage and plasma after treatment. Secondary outcomes included safety, levels of normal M-type AAT in the plasma and concentrations of AAT, neutrophil elastase (NE), AAT-NE complexes and neutrophil count in the ELF. Results 12 weeks of active treatment significantly increased AAT, ANEC and AAT-NE complexes in the ELF. Mean antigenic AAT levels in the ELF were restored to 5.2±2.3 μM in the 80 mg arm and to 17.7±2 μM in the 160 mg arm. Both doses significantly restored AAT antiprotease activity within the lung and reduced NE levels. M-specific AAT levels in plasma increased in a dose-dependent manner. A clinically meaningful reduction in ELF neutrophil % was observed in the 80 mg arm. AAT for inhalation was well tolerated. Conclusions Inhaled AAT restores protease-antiprotease homoeostasis and may represent a safe and effective therapy.
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Affiliation(s)
- Mark Brantly
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine in the College of Medicine, University of Florida, Gainesville, FL, USA
| | - James Stocks
- University of Texas Health Science Center at Tyler Center for Clinical Research, Tyler, TX, USA
| | - Jorge Lascano
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine in the College of Medicine, University of Florida, Gainesville, FL, USA
| | - Tammy Flagg
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine in the College of Medicine, University of Florida, Gainesville, FL, USA
| | - Ann M. Jeffers
- University of Texas Health Science Center at Tyler Center for Clinical Research, Tyler, TX, USA
| | - Shuzi Z. Owens
- University of Texas Health Science Center at Tyler Center for Clinical Research, Tyler, TX, USA
| | - Torry A. Tucker
- University of Texas Health Science Center at Tyler Center for Clinical Research, Tyler, TX, USA
| | - Megan Devine
- University of Texas Health Science Center at Tyler Center for Clinical Research, Tyler, TX, USA
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Turner AM, Ficker JH, Vianello A, Clarenbach CF, Janciauskiene S, Chorostowska-Wynimko J, Stolk J, McElvaney NG. Advancing the understanding and treatment of lung pathologies associated with alpha 1 antitrypsin deficiency. Ther Adv Respir Dis 2025; 19:17534666251318841. [PMID: 39980299 PMCID: PMC11843710 DOI: 10.1177/17534666251318841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Accepted: 01/22/2025] [Indexed: 02/22/2025] Open
Abstract
Alpha 1 antitrypsin deficiency (AATD) is a genetic disorder that alters the functionality and/or serum levels of alpha 1 antitrypsin (AAT). Dysfunctional forms of AAT, or low levels of serum AAT, predispose affected individuals to pulmonary complications. When AATD-associated lung disease develops, the most common pulmonary pathology is emphysema. The development of emphysema and decline in lung function varies by AATD genotype and is accelerated by risk factors, such as smoking. To improve the understanding and treatment of AATD, emerging knowledge and unresolved questions need to be discussed. Here we focus on developments in the areas of disease pathogenesis, biomarkers, and clinical endpoints for trials in AATD, as well as barriers to treatment. The clinical impact of AATD on lung function is highly variable and highlights the complexity of AATD pathogenesis, in which multiple underlying processes are involved. Reduced levels of functional AAT disrupt the protease-antiprotease homeostasis, leading to a loss of neutrophil elastase inhibition and the breakdown of elastin within the lung interstitium. Inflammatory processes also play a critical role in the development of AATD-associated lung disease, which is not yet fully understood. Biomarkers associated with the disease and its complications may have an important role in helping to address AATD underdiagnosis and evaluating response to treatment. To improve access to treatment, the problem of underdiagnosis needs to be addressed and the provision of therapeutic options needs to become uniform. Patients should also be empowered to play a key role in the self-management of the disease. Advancing our understanding of the disease will ultimately improve the life expectancy and quality of life for patients affected by AATD.
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Affiliation(s)
- Alice M. Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Joachim H. Ficker
- Department of Respiratory Medicine, Allergology and Sleep Medicine, General Hospital Nuernberg and Paracelsus Medical University, Nuernberg, Germany
| | - Andrea Vianello
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Christian F. Clarenbach
- Department of Pulmonology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Sabina Janciauskiene
- Department of Pulmonary and Infectious Diseases, Hannover Medical School, BREATH German Center for Lung Research (DZL), Hannover, Germany
| | - Joanna Chorostowska-Wynimko
- Department of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - Jan Stolk
- Department of Pulmonology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Noel Gerard McElvaney
- Department of Medicine, Royal College of Surgeons in Ireland, Irish Centre for Genetic Lung Disease, Dublin, Ireland
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12
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Li X, Zhang H, Chi X, Ruan W, Meng X, Deng J, Pan M, Ma T, Zhang J. Advances on the Role of Lung Macrophages in the Pathogenesis of Chronic Obstructive Pulmonary Disease in the Era of Single-Cell Genomics. Int J Med Sci 2025; 22:298-308. [PMID: 39781522 PMCID: PMC11704685 DOI: 10.7150/ijms.100160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 11/07/2024] [Indexed: 01/12/2025] Open
Abstract
Chronic Obstructive Pulmonary Disease (COPD) is a heterogeneous respiratory disorder characterized by persistent airflow limitation. The diverse pathogenic mechanisms underlying COPD progression remain incompletely understood. Macrophages, serving as the most representative immune cells in the respiratory tract, constitute the first line of innate immune defense and maintain pulmonary immunological homeostasis. Recent advances have provided deeper insights into the phenotypic and functional alterations of pulmonary macrophages and their role in COPD pathogenesis. Notably, the advent of single-cell RNA sequencing has revolutionized our understanding of macrophage molecular heterogeneity in COPD. Herein, we review principal investigations concerning the sophisticated mechanisms through which pulmonary macrophages influence COPD, encompassing inflammatory mediator production, protease/antiprotease release, and phagocytic activity. Additionally, we synthesize findings from available literature regarding all identified pulmonary macrophage sub-populations in COPD, thereby advancing our comprehension of macrophage heterogeneity's significance in the complex pathophysiological mechanisms of COPD.
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Affiliation(s)
- Xiaohua Li
- Department of Respiratory and Critical Medicine, the Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen 518000, Guangdong Province, China
| | - Hui Zhang
- Department of Respiratory and Critical Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Xianhong Chi
- Department of Respiratory and Critical Medicine, the Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen 518000, Guangdong Province, China
| | - Weibin Ruan
- Department of Respiratory and Critical Medicine, the Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen 518000, Guangdong Province, China
| | - Xia Meng
- Department of Respiratory and Critical Medicine, the Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen 518000, Guangdong Province, China
| | - Jiehua Deng
- Department of Respiratory and Critical Medicine, the Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen 518000, Guangdong Province, China
| | - Mianluan Pan
- Department of Respiratory and Critical Medicine, the Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen 518000, Guangdong Province, China
| | - Tingting Ma
- Department of Respiratory and Critical Medicine, Zhuhai People's Hospital (Zhuhai Hospital affiliated with Jinan University), Zhuhai, Guangdong 519000, China
| | - Jianquan Zhang
- Department of Respiratory and Critical Medicine, the Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen 518000, Guangdong Province, China
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13
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Herron M, Roche S, Fraughen DD, Heeney RC, Kanchi L, Leacy EJ, Casey M, Gunaratnam C, Carroll TP, Murphy MP, McElvaney NG. Optimising bronchoalveolar lavage: lessons from alpha-1 antitrypsin deficiency. Thorax 2024; 80:24-31. [PMID: 39586664 DOI: 10.1136/thorax-2024-221797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 10/28/2024] [Indexed: 11/27/2024]
Abstract
BACKGROUND Bronchoalveolar lavage (BAL) is essential in determining the efficacy of novel therapies in alpha-1 antitrypsin deficiency (AATD). These require initial proof-of-concept demonstration that treatment administration increases alpha-1 antitrypsin (AAT) levels and/or anti-neutrophil elastase inhibitory capacity (ANEC) in the lung. Early-phase studies often encounter high interindividual variability of BAL results, primarily stemming from the inherent dilution characteristics of returned BAL fluid. A BAL protocol that minimises this variability is needed for reliable comparison of biochemical endpoints in the lung. METHODS The study population included 21 severe AATD (ZZ), 22 moderate AATD (MZ) and 23 non-AATD (MM) individuals, further categorised as healthy, unobstructed current smokers or patients with chronic obstructive pulmonary disease (COPD). An additional six ZZ individuals were receiving intravenous alpha-1 augmentation therapy. We compared common BAL correction methods-albumin, total protein and epithelial lining fluid (ELF) volume measured by urea-when reporting early-phase biochemical endpoints, AAT and ANEC. RESULTS BAL performed with a paediatric bronchoscope (PB) improved alveolar sampling compared with a traditional adult bronchoscope. Both uncorrected and ELF-corrected BAL demonstrated high interindividual variability regardless of lung health status. BAL total protein correction minimised interindividual variability, producing significant differences in AAT and ANEC between all genotypes, the strongest relationship with plasma AAT levels (r2=0.83), greatest inter-lobar concordance in AAT levels (r2=0.76) and strong correlation between BAL AAT and ANEC (r2=0.88). CONCLUSIONS By capitalising on the marked consistency in AAT levels between AAT genotypes, and the close relationship between plasma and lung AAT levels, we demonstrate reliable alveolar sampling that aligns closely with plasma.
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Affiliation(s)
- Malcolm Herron
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
- Beaumont Hospital, Dublin, Ireland
| | - Suzanne Roche
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
- Beaumont Hospital, Dublin, Ireland
| | - Daniel D Fraughen
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
| | - Ronan C Heeney
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
| | - Lasya Kanchi
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
| | - Emma J Leacy
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
| | - Michelle Casey
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
- Beaumont Hospital, Dublin, Ireland
| | - Cedric Gunaratnam
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
- Beaumont Hospital, Dublin, Ireland
| | - Tomás P Carroll
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
| | - Mark P Murphy
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
| | - Noel G McElvaney
- Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
- Beaumont Hospital, Dublin, Ireland
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14
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Annunziata A, Fiorentino G, Coppola A, Cauteruccio R, Ferrentino L, Fiorentino L, Calabrese C. Alpha-1 antitripsyn deficiency and augmentation therapy in pregnancy: two case reports. Front Med (Lausanne) 2024; 11:1479877. [PMID: 39736979 PMCID: PMC11682898 DOI: 10.3389/fmed.2024.1479877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Accepted: 11/11/2024] [Indexed: 01/01/2025] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD) is an inherited condition characterized by reduced plasma levels of alpha-1 antitrypsin (AAT), often leading to pulmonary diseases primarily emphysema and/or chronic obstructive pulmonary disease (COPD), but also bronchiectasis, bronchial asthma, or other less common disorders. Early diagnosis enables AAT augmentation therapy, which has proven to be effective in slowing down functional decline and improving survival rates. This article presents two cases of pregnant women with rare allelic variants of AATD who received AAT augmentation therapy, exploring the limited evidence on its safety during pregnancy and the potential role of decreased serum AAT levels in pregnancy-related complications.
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Affiliation(s)
- Anna Annunziata
- Department of Intensive Care, Unit of Pathophysiology and Respiratory Rehabilitation, AORN Ospedali dei Colli, Naples, Italy
| | - Giuseppe Fiorentino
- Department of Intensive Care, Unit of Pathophysiology and Respiratory Rehabilitation, AORN Ospedali dei Colli, Naples, Italy
| | - Antonietta Coppola
- Department of Intensive Care, Unit of Pathophysiology and Respiratory Rehabilitation, AORN Ospedali dei Colli, Naples, Italy
| | - Rosa Cauteruccio
- Department of Intensive Care, Unit of Pathophysiology and Respiratory Rehabilitation, AORN Ospedali dei Colli, Naples, Italy
| | - Laura Ferrentino
- Department of Translational Medical Sciences, University Federico II, Naples, Italy
| | - Luigi Fiorentino
- Department of Intensive Care, Unit of Pathophysiology and Respiratory Rehabilitation, AORN Ospedali dei Colli, Naples, Italy
| | - Cecilia Calabrese
- Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’, AORN Ospedali dei Colli, Naples, Italy
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15
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Held J, Sivaraman K, Wrenger S, Si W, Welte T, Immenschuh S, Janciauskiene S. Ex vivo study on the human blood neutrophil circadian features and effects of alpha1-antitrypsin and lipopolysaccharide. Vascul Pharmacol 2024; 156:107396. [PMID: 38897556 DOI: 10.1016/j.vph.2024.107396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 06/10/2024] [Accepted: 06/16/2024] [Indexed: 06/21/2024]
Abstract
AIMS Neutrophils perform various functions in a circadian-dependent manner; therefore, we investigated here whether the effect of alpha1-antitrypsin (AAT), used as augmentation therapy, is dependent on the neutrophil circadian clock. AAT is a vital regulator of neutrophil functions, and its qualitative and/or quantitative defects have significant implications for the development of respiratory diseases. METHODS Whole blood from 12 healthy women age years, mean (SD) 29.92 (5.48) was collected twice daily, 8 h apart, and incubated for 30 min at 37 °C alone or with additions of 2 mg/ml AAT (Respreeza) and/or 5 μg/ml lipopolysaccharide (LPS) from Escherichia coli. Neutrophils were then isolated to examine gene expression, migration and phagocytosis. RESULTS The expression of CD14, CD16, CXCR2 and SELL (encoding CD62L) genes was significantly higher while CDKN1A lower in the afternoon than in the morning neutrophils from untreated blood. Neutrophils isolated in the afternoon had higher migratory and phagocytic activity. Morning neutrophils isolated from AAT-pretreated blood showed higher expression of CXCR2 and SELL than those from untreated morning blood. Pretreatment of blood with AAT enhanced migratory properties of morning but not afternoon neutrophils. Of all genes analysed, only CXCL8 expression was strongly upregulated in morning and afternoon neutrophils isolated from LPS-pretreated blood, whereas CXCR2 expression was downregulated in afternoon neutrophils. The addition of AAT did not reverse the effects of LPS. SIGNIFICANCE The circadian clock of myeloid cells may affect the effectiveness of various therapies, including AAT therapy used to treat patients with AAT deficiency, and needs further investigation.
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Affiliation(s)
- Julia Held
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Hannover Medical School, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Kokilavani Sivaraman
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Hannover Medical School, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Sabine Wrenger
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Hannover Medical School, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Wenzhang Si
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Hannover Medical School, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Hannover Medical School, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Stephan Immenschuh
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Sabina Janciauskiene
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Hannover Medical School, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), Hannover, Germany.
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16
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Lepiorz M, Baier J, Veith M, Greulich T, Pfeifer M. Alpha-1 antitrypsin deficiency associated with rare SERPINA1 alleles p.(Phe76del) and p.(Asp280Val): A family study. Respir Med Case Rep 2024; 51:102097. [PMID: 39286412 PMCID: PMC11403522 DOI: 10.1016/j.rmcr.2024.102097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 03/21/2024] [Accepted: 08/25/2024] [Indexed: 09/19/2024] Open
Abstract
This report describes family members with alpha-1 antitrypsin (AAT) deficiency arising from two rare alleles of SERPINA1 - p.(Phe76del) and p.(Asp280Val) along with the more common deficiency allele, Pi*Z. The index case, a 51-year-old female presented with cough, bloody sputum, fever, weight loss and night sweats. In addition to a respiratory infection, scans revealed bronchiectasis and bronchiolitis without emphysema. Her AAT level was 30 mg/dL and genetic testing revealed a Pi*Z/p.(Phe76del) genotype. Follow up testing of her relatives revealed the rare p.(Asp280Val) variant as well. AAT deficiency remains underdiagnosed. Early detection and intervention could improve quality of life and outcomes.
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Affiliation(s)
- Marc Lepiorz
- Department of Pneumology, Krankenhaus Barmherzige Brüder, Regensburg, Germany
| | - Julius Baier
- Department of Pneumology, Krankenhaus Barmherzige Brüder, Regensburg, Germany
| | - Martina Veith
- University Medical Center Giessen and Marburg, Philipps University, Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research, (DZL), Marburg, Germany
| | - Timm Greulich
- University Medical Center Giessen and Marburg, Philipps University, Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research, (DZL), Marburg, Germany
| | - Michael Pfeifer
- Department of Pneumology, Krankenhaus Barmherzige Brüder, Regensburg, Germany
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17
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Miravitlles M, Turner AM, Sucena M, Mornex JF, Greulich T, Wencker M, McElvaney NG. Assessment and monitoring of lung disease in patients with severe alpha 1 antitrypsin deficiency: a european delphi consensus of the EARCO group. Respir Res 2024; 25:318. [PMID: 39160517 PMCID: PMC11334445 DOI: 10.1186/s12931-024-02929-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 07/31/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND Currently, there is conflicting information and guidance on the effective management of Alpha 1 Antitrypsin Deficiency (AATD). Establishing a consensus of assessment and disease management specific to AATD is important for achieving a standardized treatment pathway and for improving patient outcomes. Here, we aim to utilize the Delphi method to establish a European consensus for the assessment and management of patients with severe AATD. METHODS Two rounds of a Delphi survey were completed online by members of the European Alpha-1 Research Collaboration (EARCO). Respondents were asked to indicate their agreement with proposed statements for patients with no respiratory symptoms, stable respiratory disease, and worsening respiratory disease using a Likert scale of 1-7. Levels of agreement between respondents were calculated using a weighted average. RESULTS Round 1 of the Delphi survey was sent to 103 members of EARCO and 38/103 (36.9%) pulmonologists from across 15 countries completed all 109 questions. Round 2 was sent to all who completed Round 1 and 36/38 (94.7%) completed all 79 questions. Responses regarding spirometry, body plethysmography, high-resolution computed tomography, and the initiation of augmentation therapy showed little variability among physicians, but there was discordance among other aspects, such as the use of low-dose computed tomography in both a research setting and routine clinical care. CONCLUSIONS These results provide expert opinions for the assessment and monitoring of patients with severe AATD, which could be used to provide updated recommendations and standardized treatment pathways for patients across Europe.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Health Care Provider of the European Reference Network On Rare Respiratory Diseases (ERN LUNG), Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.
| | - Alice M Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- University Hospitals Birmingham, Birmingham, UK
| | - Maria Sucena
- Pulmonology Department, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Jean-François Mornex
- Université Claude Bernard Lyon 1, INRAE, UMR754, IVPC, Hospices Civils de Lyon, Inserm, CIC1407, F-69100, Lyon, France
| | - Timm Greulich
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research (DZL), University Medical Center Giessen and Marburg, Philipps-University, Marburg, Germany
| | | | - N Gerard McElvaney
- Irish Centre for Genetic Lung Disease, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
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18
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Stockley RA, Parr DG. Antitrypsin deficiency: still more to learn about the lung after 60 years. ERJ Open Res 2024; 10:00139-2024. [PMID: 39040588 PMCID: PMC11261379 DOI: 10.1183/23120541.00139-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/22/2024] [Indexed: 07/24/2024] Open
Abstract
The past 60 years have seen multiple publications related to lung disease in α1-antitrypsin deficiency largely reflecting the pathophysiology, biochemical effect and outcomes of augmentation therapy. However, the complexity of disease phenotype and the impact of the natural history presents problems of patient management, study design and hence interpretation of outcome. Although many national and some international registries exist, the lack of consistent in-depth assessment and importantly, the impact of augmentation therapy likely influences our perception of the true natural history. Development of new therapeutic strategies, and even assessment of the role and efficacy of augmentation, remain a challenge as powering such studies for conventional COPD outcomes is impractical due to relative rarity of the genetic condition and the presence of clinical phenotypic variation. The current review approaches these issues, discusses the nature and complexity of assessing patient variability, and provides guidance on further studies required to address them.
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Affiliation(s)
- Robert A. Stockley
- Lung Investigation Unit, Medicine – University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, UK
| | - David G. Parr
- Respiratory Medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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19
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Turino GM, Cantor JO. Elastolysis in COPD: a Target for Therapy. Lung 2024; 202:233-234. [PMID: 38676772 PMCID: PMC11142970 DOI: 10.1007/s00408-024-00693-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 04/29/2024]
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20
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Lacey N, Teo JYQ, Baird R, Forde L, Hawkins P, McEnery T, Lee MQ, Hoo MCS, Gogoi D, Reeves EP. Augmentation Therapy Decreases Platelet-Neutrophil Aggregates in Alpha-1 Antitrypsin Deficiency. Am J Respir Cell Mol Biol 2024; 70:524-527. [PMID: 38819125 DOI: 10.1165/rcmb.2023-0417le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Affiliation(s)
- Noreen Lacey
- Royal College of Surgeons in Ireland Dublin, Ireland
| | | | - Rory Baird
- Royal College of Surgeons in Ireland Dublin, Ireland
| | - Luke Forde
- Royal College of Surgeons in Ireland Dublin, Ireland
| | | | - Tom McEnery
- Royal College of Surgeons in Ireland Dublin, Ireland
| | - Melvin Q Lee
- Royal College of Surgeons in Ireland Dublin, Ireland
| | | | | | - Emer P Reeves
- Royal College of Surgeons in Ireland Dublin, Ireland
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21
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Fähndrich S, Bals R. [Alpha 1-antitrypsin deficiency]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:533-537. [PMID: 38789803 DOI: 10.1007/s00108-024-01722-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 05/26/2024]
Abstract
Alpha 1‑antitrypsin (AAT) deficiency represents a complex genetic disorder and necessitates an interdisciplinary approach in the clinical practice. This article provides an overview of the epidemiology, genetics, symptoms, diagnostics and treatment of AAT deficiency. Knowledge and an in-depth understanding of AAT deficiency are indispensable to improve the early recognition of AAT, to optimize the quality of life of those affected and to enable targeted treatment interventions.
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Affiliation(s)
- Sebastian Fähndrich
- Klinik für Pneumologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität, Killianstraße 5, 79106, Freiburg, Deutschland.
| | - Robert Bals
- Klinik für Innere Medizin V, Universitätsklinikum des Saarlandes, Universität des Saarlandes, Kirrbergerstr. 100, 66421, Homburg, Deutschland.
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22
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Fraughen DD, Ghosh AJ, Carroll TP, McElvaney NG. Reply to Chan: Identification of Alpha-1 Antitrypsin-Deficient Subjects with Normal Spirometry Who May Benefit from Alpha-1 Antitrypsin Replacement. Am J Respir Crit Care Med 2024; 209:1034-1035. [PMID: 38237155 PMCID: PMC11531219 DOI: 10.1164/rccm.202312-2235le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Affiliation(s)
- Daniel D. Fraughen
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland; and
| | - Auyon J. Ghosh
- Division of Pulmonary, Critical Care, and Sleep Medicine, SUNY Upstate University Hospital, Syracuse, New York
| | - Tomás P. Carroll
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland; and
| | - Noel G. McElvaney
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland; and
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23
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Chan ED. Identification of Alpha-1 Antitrypsin-Deficient Subjects with Normal Spirometry Who May Benefit from Alpha-1 Antitrypsin Replacement. Am J Respir Crit Care Med 2024; 209:1033-1034. [PMID: 38237158 PMCID: PMC11531203 DOI: 10.1164/rccm.202311-2189le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Affiliation(s)
- Edward D Chan
- Department of Academic Affairs, National Jewish Health, Denver, Colorado
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24
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Aljama C, Martin T, Granados G, Miravitlles M, Barrecheguren M. Personalised indication of augmentation therapy for emphysema associated with severe alpha-1 antitrypsin deficiency: a case series. Ther Adv Respir Dis 2024; 18:17534666241271917. [PMID: 39132722 PMCID: PMC11320671 DOI: 10.1177/17534666241271917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 07/03/2024] [Indexed: 08/13/2024] Open
Abstract
Severe alpha-1 antitrypsin deficiency (AATD) is associated with an increased risk of emphysema. However, the clinical manifestations are very heterogeneous, and an individual prognosis is very difficult to establish. Intravenous augmentation therapy with alpha-1 antitrypsin (AAT) from pooled blood donors is the only specific treatment available, but it requires weekly or biweekly administration for life. Several guidelines provide the indication criteria for the initiation of AAT augmentation therapy. However, in clinical practice, there are situations in which the decision as to when to start treatment becomes uncertain and some studies have shown great variability in the indication of this treatment even among specialists. The usual dilemma is between initiating augmentation therapy in individuals who may not develop significant lung disease or in whom disease will not progress or delaying it in patients who may otherwise rapidly and irreversibly progress. We illustrate this dilemma with five clinical cases: from the case of a patient with normal lung function who requests initiation of therapy to a moderately stable patient without augmentation or a mild patient who, after several years of remaining stable without treatment, deterioration in lung function initiated and, consequently, augmentation therapy was begun. All the nuances associated with the indication of augmentation justify a personalised approach and the decision about initiating augmentation therapy must be made after careful consideration of the pros and cons with the patient in reference centres with experience in treatment. These reference centres can work in collaboration with local hospitals where patients can be closely followed and augmentation therapy can be administered to avoid unnecessary travelling, making periodical administrations more comfortable for the patient.
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Affiliation(s)
- Cristina Aljama
- Pneumology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Teresa Martin
- Pneumology Department, Hospital Beatriz Ângelo, Loures, Portugal
| | - Galo Granados
- Pneumology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), P. Vall d’Hebron 119-129, Barcelona 08035, Spain
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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Roche S, Carroll TP, Mcelvaney NG. Provider Education in Alpha 1 Antitrypsin Deficiency: Try Again, Fail Again, Fail Better. ATS Sch 2023; 4:396-399. [PMID: 38196687 PMCID: PMC10773271 DOI: 10.34197/ats-scholar.2023-0128ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Affiliation(s)
- Suzanne Roche
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tomás P Carroll
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Noel G Mcelvaney
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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Brantly M. Treatment for Alpha-1 Antitrypsin Deficiency: Does Augmentation Therapy Work? Am J Respir Crit Care Med 2023; 208:948-949. [PMID: 37724887 PMCID: PMC10870859 DOI: 10.1164/rccm.202309-1585ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 09/21/2023] Open
Affiliation(s)
- Mark Brantly
- Division of Pulmonary, Critical Care and Sleep Medicine University of Florida College of Medicine Gainesville, Florida
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