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Dasí F. Alpha-1 antitrypsin deficiency. Med Clin (Barc) 2024; 162:336-342. [PMID: 37993348 DOI: 10.1016/j.medcli.2023.10.014] [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: 07/27/2023] [Revised: 10/21/2023] [Accepted: 10/24/2023] [Indexed: 11/24/2023]
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a rare hereditary condition caused by decreased plasma and tissue levels of alpha-1 antitrypsin (AAT) that can lead to serious lung and liver disease in children and adults. AATD patients face challenges such as under diagnosis, clinical variability, and limited treatment options for liver disease. Early detection and biomarkers for predicting outcomes are needed to improve patient outcome. Currently, the only approved pharmacological therapy is augmentation therapy, which can delay the progression of emphysema. However, alternative strategies such as gene therapy, induced pluripotent stem cells, and prevention of AAT polymerization inside hepatocytes are being investigated. This review aims to summarize and update current knowledge on AATD, identify areas of controversy, and formulate questions for further research.
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Affiliation(s)
- Francisco Dasí
- Universitat de València, Facultad de Medicina, Departamento de Fisiología, IIS INCLIVA, Valencia, Spain.
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2
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Piloni D, Ottaviani S, Saderi L, Corda L, Baderna P, Barzon V, Balderacchi AM, Seebacher C, Balbi B, Albicini F, Corino A, Mennitti MC, Tirelli C, Spreafico F, Bosio M, Mariani F, Sotgiu G, Corsico AG, Ferrarotti I. Comparison among populations with severe and intermediate alpha1-antitrypsin deficiency and chronic obstructive pulmonary disease. Minerva Med 2024; 115:23-31. [PMID: 37021471 DOI: 10.23736/s0026-4806.22.08266-0] [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: 04/07/2023]
Abstract
BACKGROUND Severe alpha1-antitrypsin (AAT) deficiency (AATD) is associated with a high risk of airflow obstruction and emphysema. The risk of lung disease in those with intermediate AAT deficiency is unclear. Our aims were to compare pulmonary function, time of onset of symptoms, and indicators of quality of life among patients with severe AATD (PI*ZZ), patients with intermediate AATD (PI*MZ) from the Italian Registry of AATD with a chronic obstructive pulmonary disease (COPD) cohort of patients without AATD (PI*MM). METHODS We considered a total of 613 patients: 330 with the PI*ZZ genotype, 183 with the PI*MZ genotype and 100 with the PI*MM genotype. Radiological exams, pulmonary function test, and measurement of quality of life have been performed on all cohorts of patients. RESULTS The three populations differ significantly in terms of age at COPD/AATD diagnosis (P=0.00001), respiratory function (FEV1, FVC, DLCO P<0.001), quality of life (P=0.0001) and smoking history (P<0.0001). PI*ZZ genotype had 24.9 times a higher likelihood of developing airflow obstruction. The MZ genotype is not associated with a significant early risk of airflow obstruction. CONCLUSIONS The comparison of populations with PI*ZZ, MZ and MM genotypes allows to delineate the role of alpha1-antitrypsin deficiency on respiratory function and on the impact on quality of life, in relation to other risk factors. These results highlight the crucial role of primary and secondary prevention on smoking habits in PI*MZ subjects and the importance of an early diagnosis.
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Affiliation(s)
- Davide Piloni
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
- Department of Internal Medicine, and Therapeutics, Center for Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | - Stefania Ottaviani
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
- Department of Internal Medicine, and Therapeutics, Center for Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | - Laura Saderi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Luciano Corda
- First Division of Medicine, ASST Spedali Civili, Brescia, Italy
| | | | - Valentina Barzon
- Department of Internal Medicine, and Therapeutics, Center for Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | - Alice M Balderacchi
- Department of Internal Medicine, and Therapeutics, Center for Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | | | - Bruno Balbi
- Division of Pneumology, IRCCS Maugeri Scientific Clinical Institutes, Veruno, Novara, Italy
| | - Federica Albicini
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Alessandra Corino
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Maria C Mennitti
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Claudio Tirelli
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Fabio Spreafico
- First Division of Medicine, ASST Spedali Civili, Brescia, Italy
| | - Matteo Bosio
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Francesca Mariani
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
- Department of Internal Medicine, and Therapeutics, Center for Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | - Giovanni Sotgiu
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Angelo G Corsico
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
- Department of Internal Medicine, and Therapeutics, Center for Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
- AATD Core Network of European Reference Network LUNG, Frankfurt am Main, Germany
| | - Ilaria Ferrarotti
- Department of Internal Medicine, and Therapeutics, Center for Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy -
- AATD Core Network of European Reference Network LUNG, Frankfurt am Main, Germany
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Fraughen DD, Ghosh AJ, Hobbs BD, Funk GC, Meischl T, Clarenbach CF, Sievi NA, Schmid-Scherzer K, McElvaney OJ, Murphy MP, Roche AD, Clarke L, Strand M, Vafai-Tabrizi F, Kelly G, Gunaratnam C, Carroll TP, McElvaney NG. Augmentation Therapy for Severe Alpha-1 Antitrypsin Deficiency Improves Survival and Is Decoupled from Spirometric Decline-A Multinational Registry Analysis. Am J Respir Crit Care Med 2023; 208:964-974. [PMID: 37624745 PMCID: PMC10870866 DOI: 10.1164/rccm.202305-0863oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/24/2023] [Indexed: 08/27/2023] Open
Abstract
Rationale: Intravenous plasma-purified alpha-1 antitrypsin (IV-AAT) has been used as therapy for alpha-1 antitrypsin deficiency (AATD) since 1987. Previous trials (RAPID and RAPID-OLE) demonstrated efficacy in preserving computed tomography of lung density but no effect on FEV1. This observational study evaluated 615 people with severe AATD from three countries with socialized health care (Ireland, Switzerland, and Austria), where access to standard medical care was equal but access to IV-AAT was not. Objectives: To assess the real-world longitudinal effects of IV-AAT. Methods: Pulmonary function and mortality data were utilized to perform longitudinal analyses on registry participants with severe AATD. Measurements and Main Results: IV-AAT confers a survival benefit in severe AATD (P < 0.001). We uncovered two distinct AATD phenotypes based on an initial respiratory diagnosis: lung index and non-lung index. Lung indexes demonstrated a more rapid FEV1 decline between the ages of 20 and 50 and subsequently entered a plateau phase of minimal decline from 50 onward. Consequentially, IV-AAT had no effect on FEV1 decline, except in patients with a Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 2 lung index. Conclusions: This real-world study demonstrates a survival advantage from IV-AAT. This improved survival is largely decoupled from FEV1 decline. The observation that patients with severe AATD fall into two major phenotypes has implications for clinical trial design where FEV1 is a primary endpoint. Recruits into trials are typically older lung indexes entering the plateau phase and, therefore, unlikely to show spirometric benefits. IV-AAT attenuates spirometric decline in lung indexes in GOLD stage 2, a spirometric group commonly outside current IV-AAT commencement recommendations.
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Affiliation(s)
- Daniel D. Fraughen
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Auyon J. Ghosh
- Division of Pulmonary, Critical Care, and Sleep Medicine, SUNY Upstate University Hospital, Syracuse, New York
| | - Brian D. Hobbs
- Channing Division of Network Medicine and Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Georg-Christian Funk
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology and Department of Medicine II with Pneumology, Klinik Ottakring, Vienna, Austria
| | - Tobias Meischl
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology and Department of Medicine II with Pneumology, Klinik Ottakring, Vienna, Austria
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Noriane A. Sievi
- Department of Pneumology, University Hospital Zurich, Zurich, Switzerland
| | - Karin Schmid-Scherzer
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology and Department of Medicine II with Pneumology, Klinik Ottakring, Vienna, Austria
| | - Oliver J. McElvaney
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - Mark P. Murphy
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Adam D. Roche
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Louise Clarke
- Department of Respiratory Physiology, Beaumont Hospital, Dublin, Ireland; and
| | - Matthew Strand
- Division of Biostatistics and Bioinformatics, National Jewish Health, Denver, Colorado
| | - Florian Vafai-Tabrizi
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology and Department of Medicine II with Pneumology, Klinik Ottakring, Vienna, Austria
| | - Geraldine Kelly
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Cedric Gunaratnam
- Department of Respiratory Physiology, Beaumont Hospital, Dublin, Ireland; and
| | - Tomás P. Carroll
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Noel G. McElvaney
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
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Shiraishi Y, Tanabe N, Shimizu K, Oguma A, Shima H, Sakamoto R, Yamazaki H, Oguma T, Sato A, Suzuki M, Makita H, Muro S, Nishimura M, Sato S, Konno S, Hirai T. Stronger Associations of Centrilobular Than Paraseptal Emphysema With Longitudinal Changes in Diffusing Capacity and Mortality in COPD. Chest 2023; 164:327-338. [PMID: 36736486 DOI: 10.1016/j.chest.2023.01.034] [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: 09/07/2022] [Revised: 12/27/2022] [Accepted: 01/24/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The factors associated with longitudinal changes in diffusing capacity remain unclear among patients with COPD. Centrilobular emphysema (CLE) and paraseptal emphysema (PSE) are major emphysema subtypes that may have distinct clinical-physiological impacts in these patients. RESEARCH QUESTION Are CLE and PSE differently associated with longitudinal changes in diffusing capacity and mortality in patients with COPD? STUDY DESIGN AND METHODS This pooled analysis included 399 patients with COPD from two prospective observational COPD cohorts. CLE and PSE were visually assessed on CT scan according to the Fleischner Society statement. The diffusing capacity and transfer coefficient of the lung for carbon monoxide (Dlco and KCO) and FEV1 were evaluated at least annually over a 5-year period. Mortality was recorded over 10 years. Longitudinal changes in FEV1, Dlco, and KCO and mortality were compared between mild or less severe and moderate or more severe CLE and between present and absent PSE in each Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage. RESULTS The Dlco and KCO decline was weakly associated with FEV1 and greater in GOLD stage 3 or higher than in GOLD stages 1 and 2. Furthermore, moderate or more severe CLE, but not present PSE, was associated with steeper declines in Dlco for GOLD stages 1 and 3 or higher and KCO for all GOLD stages independent of age, sex, height, and smoking history. The moderate or more severe CLE, but not present PSE, was associated with additional FEV1 decline and higher 10-year mortality among patients with GOLD stage 3 or higher. INTERPRETATION A CT scan finding of moderate or more severe CLE, but not PSE, was associated with a subsequent accelerated impairment in diffusing capacity and higher long-term mortality in severe GOLD stage among patients with COPD.
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Affiliation(s)
- Yusuke Shiraishi
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Naoya Tanabe
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Kaoruko Shimizu
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Akira Oguma
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Shima
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryo Sakamoto
- Department of Diagnostic Imaging and Nuclear Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hajime Yamazaki
- Section of Clinical Epidemiology, Department of Community Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tsuyoshi Oguma
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsuyasu Sato
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hironi Makita
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan; Hokkaido Medical Research Institute for Respiratory Diseases, Sapporo, Japan
| | - Shigeo Muro
- Department of Respiratory Medicine, Nara Medical University, Kashihara, Japan
| | - Masaharu Nishimura
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan; Hokkaido Medical Research Institute for Respiratory Diseases, Sapporo, Japan
| | - Susumu Sato
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Respiratory Care and Sleep Control Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Toyohiro Hirai
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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5
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Mornex JF, Balduyck M, Bouchecareilh M, Cuvelier A, Epaud R, Kerjouan M, Le Rouzic O, Pison C, Plantier L, Pujazon MC, Reynaud-Gaubert M, Toutain A, Trumbic B, Willemin MC, Zysman M, Brun O, Campana M, Chabot F, Chamouard V, Dechomet M, Fauve J, Girerd B, Gnakamene C, Lefrançois S, Lombard JN, Maitre B, Maynié-François C, Moerman A, Payancé A, Reix P, Revel D, Revel MP, Schuers M, Terrioux P, Theron D, Willersinn F, Cottin V, Mal H. [French clinical practice guidelines for the diagnosis and management of lung disease with alpha 1-antitrypsin deficiency]. Rev Mal Respir 2022; 39:633-656. [PMID: 35906149 DOI: 10.1016/j.rmr.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/31/2022] [Indexed: 11/18/2022]
Affiliation(s)
- J-F Mornex
- Université de Lyon, université Lyon 1, INRAE, EPHE, UMR754, IVPC, 69007 Lyon, France; Centre de référence coordonnateur des maladies pulmonaires rares, hospices civils de Lyon, hôpital Louis-Pradel, service de pneumologie, 69500 Bron, France.
| | - M Balduyck
- CHU de Lille, centre de biologie pathologie, laboratoire de biochimie et biologie moléculaire HMNO, faculté de pharmacie, EA 7364 RADEME, université de Lille, service de biochimie et biologie moléculaire, Lille, France
| | - M Bouchecareilh
- Université de Bordeaux, CNRS, Inserm U1053 BaRITon, Bordeaux, France
| | - A Cuvelier
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, Rouen, France; Groupe de recherche sur le handicap ventilatoire et neurologique (GRHVN), université Normandie Rouen, Rouen, France
| | - R Epaud
- Centre de références des maladies respiratoires rares, site de Créteil, Créteil, France
| | - M Kerjouan
- Service de pneumologie, CHU Pontchaillou, Rennes, France
| | - O Le Rouzic
- CHU Lille, service de pneumologie et immuno-allergologie, Lille, France; Université de Lille, CNRS, Inserm, institut Pasteur de Lille, U1019, UMR 9017, CIIL, OpInfIELD team, Lille, France
| | - C Pison
- Service de pneumologie physiologie, pôle thorax et vaisseaux, CHU de Grenoble, Grenoble, France; Université Grenoble Alpes, Saint-Martin-d'Hères, France
| | - L Plantier
- Service de pneumologie et explorations fonctionnelles respiratoires, CHRU de Tours, Tours, France; Université de Tours, CEPR, Inserm UMR1100, Tours, France
| | - M-C Pujazon
- Service de pneumologie et allergologie, pôle clinique des voies respiratoires, hôpital Larrey, Toulouse, France
| | - M Reynaud-Gaubert
- Service de pneumologie, centre de compétence pour les maladies pulmonaires rares, AP-HM, CHU Nord, Marseille, France; Aix-Marseille université, IHU-Méditerranée infection, Marseille, France
| | - A Toutain
- Service de génétique, CHU de Tours, Tours, France; UMR 1253, iBrain, université de Tours, Inserm, Tours, France
| | | | - M-C Willemin
- Service de pneumologie et oncologie thoracique, CHU d'Angers, hôpital Larrey, Angers, France
| | - M Zysman
- Service de pneumologie, CHU Haut-Lévèque, Bordeaux, France; Université de Bordeaux, centre de recherche cardiothoracique, Inserm U1045, CIC 1401, Pessac, France
| | - O Brun
- Centre de pneumologie et d'allergologie respiratoire, Perpignan, France
| | - M Campana
- Service de pneumologie, CHR d'Orléans, Orléans, France
| | - F Chabot
- Département de pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France; Inserm U1116, université de Lorraine, Vandœuvre-lès-Nancy, France
| | - V Chamouard
- Service pharmaceutique, hôpital cardiologique, GHE, HCL, Bron, France
| | - M Dechomet
- Service d'immunologie biologique, centre de biologie sud, centre hospitalier Lyon Sud, HCL, Pierre-Bénite, France
| | - J Fauve
- Cabinet médical, Bollène, France
| | - B Girerd
- Université Paris-Saclay, faculté de médecine, Le Kremlin-Bicêtre, France; AP-HP, centre de référence de l'hypertension pulmonaire, service de pneumologie et soins intensifs respiratoires, hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - C Gnakamene
- Service de pneumologie, CH de Montélimar, GH Portes de Provence, Montélimar, France
| | | | | | - B Maitre
- Service de pneumologie, centre hospitalier intercommunal, Créteil, France; Inserm U952, UFR de santé, université Paris-Est Créteil, Créteil, France
| | - C Maynié-François
- Université de Lyon, collège universitaire de médecine générale, Lyon, France; Université Claude-Bernard Lyon 1, laboratoire de biométrie et biologie évolutive, UMR5558, Villeurbanne, France
| | - A Moerman
- CHRU de Lille, hôpital Jeanne-de-Flandre, Lille, France; Cabinet de médecine générale, Lille, France
| | - A Payancé
- Service d'hépatologie, CHU Beaujon, AP-HP, Clichy, France; Filière de santé maladies rares du foie de l'adulte et de l'enfant (FilFoie), CHU Saint-Antoine, Paris, France
| | - P Reix
- Service de pneumologie pédiatrique, allergologie, mucoviscidose, hôpital Femme-Mère-Enfant, HCL, Bron, France; UMR 5558 CNRS équipe EMET, université Claude-Bernard Lyon 1, Villeurbanne, France
| | - D Revel
- Université Claude-Bernard Lyon 1, Lyon, France; Hospices civils de Lyon, Lyon, France
| | - M-P Revel
- Université Paris Descartes, Paris, France; Service de radiologie, hôpital Cochin, AP-HP, Paris, France
| | - M Schuers
- Université de Rouen Normandie, département de médecine générale, Rouen, France; Sorbonne université, LIMICS U1142, Paris, France
| | | | - D Theron
- Asten santé, Isneauville, France
| | | | - V Cottin
- Université de Lyon, université Lyon 1, INRAE, EPHE, UMR754, IVPC, 69007 Lyon, France; Centre de référence coordonnateur des maladies pulmonaires rares, hospices civils de Lyon, hôpital Louis-Pradel, service de pneumologie, 69500 Bron, France
| | - H Mal
- Service de pneumologie B, hôpital Bichat-Claude-Bernard, AP-HP, Paris, France; Inserm U1152, université Paris Diderot, site Xavier Bichat, Paris, France
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Miravitlles M, Herepath M, Priyendu A, Sharma S, Vilchez T, Vit O, Haensel M, Lepage V, Gens H, Greulich T. Disease burden associated with alpha-1 antitrypsin deficiency: systematic and structured literature reviews. Eur Respir Rev 2022; 31:210262. [PMID: 35321931 PMCID: PMC9488933 DOI: 10.1183/16000617.0262-2021] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/24/2022] [Indexed: 12/14/2022] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a rare genetic disorder characterised by reduced levels of circulating alpha-1 antitrypsin and an increased risk of lung and liver disease. Recent reviews of AATD have focused on diagnosis, epidemiology and clinical management; comprehensive reviews examining disease burden are lacking. Therefore, we conducted literature reviews to investigate the AATD disease burden for patients, caregivers and healthcare systems. Embase, PubMed and Cochrane libraries were searched for AATD publications from database inception to June 2021, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Most published AATD studies were small and short in duration, with variations in populations, designs, measures and outcomes, complicating cross-study comparisons. AATD was associated with significant pulmonary and hepatic morbidity. COPD, emphysema and bronchiectasis were common lung morbidities, where smoking was a key risk factor. Fibrosis and steatosis were the most common liver complications reported in patients with a PiZ allele. Health status analyses suggested a poorer quality of life for AATD patients diagnosed with COPD versus those with non-AATD-associated COPD. The burden for caregivers included loss of personal time due to caring responsibilities, stress and anxiety. AATD was also associated with high direct medical costs and healthcare resource utilisation.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | | | - Asim Priyendu
- Access Consulting, HEOR, Parexel International, Mohali, India
| | - Sheetal Sharma
- Access Consulting, HEOR, Parexel International, Mohali, India
| | | | | | | | | | | | - Timm Greulich
- Dept of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps-University, Centre for Lung Research (DZL), Marburg, Germany
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7
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Clinical and functional characteristics of individuals with alpha-1 antitrypsin deficiency: EARCO international registry. Respir Res 2022; 23:352. [PMID: 36527073 PMCID: PMC9756677 DOI: 10.1186/s12931-022-02275-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/03/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Alpha-1 antitrypsin deficiency (AATD) is a rare disease that is associated with an increased risk of pulmonary emphysema. The European AATD Research Collaboration (EARCO) international registry was founded with the objective of characterising the individuals with AATD and investigating their natural history. METHODS The EARCO registry is an international, observational and prospective study of individuals with AATD, defined as AAT serum levels < 11 μM and/or proteinase inhibitor genotypes PI*ZZ, PI*SZ and compound heterozygotes or homozygotes of other rare deficient variants. We describe the characteristics of the individuals included from February 2020 to May 2022. RESULTS A total of 1044 individuals from 15 countries were analysed. The most frequent genotype was PI*ZZ (60.2%), followed by PI*SZ (29.2%). Among PI*ZZ patients, emphysema was the most frequent lung disease (57.2%) followed by COPD (57.2%) and bronchiectasis (22%). Up to 76.4% had concordant values of FEV1(%) and KCO(%). Those with impairment in FEV1(%) alone had more frequently bronchiectasis and asthma and those with impairment in KCO(%) alone had more frequent emphysema and liver disease. Multivariate analysis showed that advanced age, male sex, exacerbations, increased blood platelets and neutrophils, augmentation and lower AAT serum levels were associated with worse FEV1(%). CONCLUSIONS EARCO has recruited > 1000 individuals with AATD from 15 countries in its first 2 years. Baseline cross sectional data provide relevant information about the clinical phenotypes of the disease, the patterns of functional impairment and factors associated with poor lung function. Trial registration www. CLINICALTRIALS gov (ID: NCT04180319).
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8
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Schouten IGM, Kasteleyn MJ, Tsonaka R, Bals R, Turner AC, Ferrarotti I, Corsico AG, Lara B, Miravitlles M, Stockley RA, Stolk J. Long-term effect of α 1-antitrypsin augmentation therapy on the decline of FEV 1 in deficient patients: an analysis of the AIR database. ERJ Open Res 2021; 7:00194-2021. [PMID: 34435030 PMCID: PMC8381156 DOI: 10.1183/23120541.00194-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/21/2021] [Indexed: 11/05/2022] Open
Abstract
Background Patients with ZZ (Glu342Lys) α-1-antitrypsin deficiency (ZZ-AATD) who received augmentation therapy with α-1-antitrypsin (AAT) in randomised controlled trials over 2-3 years failed to show a significant reduction of the annual decline of forced expiratory volume in 1 s (FEV1). Methods To compare the trajectory of FEV1 change during 4 or more years in ZZ-AATD patients with emphysema receiving or not receiving intravenous augmentation therapy, a retrospective analysis of FEV1 values entered in the Alpha-1 International Registry (AIR) of ZZ-AATD patients from five different European countries (Germany, UK, Spain, Italy and the Netherlands) was performed. The post-bronchodilator FEV1 % predicted values for baseline and follow-up over time from patients were analysed using linear mixed effects models. Results Data of 374 patients were analysed: 246 untreated and 128 treated with intravenous AAT augmentation therapy. The mean±sd follow-up duration of the untreated group was 8.60±3.34 years and 8.59±2.62 years for the treated group. The mixed effects model analysis showed a mean FEV1 decline of -0.931% predicted per year (95% CI -1.144 to -0.718) in the untreated group and a decline of -1.016% predicted per year (95% CI -1.319 to -0.7145) in the treated group. The likelihood ratio test showed no difference between the two groups (p=0.71). Conclusion In our study population, we could not detect a significant difference in the annual decline of FEV1 by AAT augmentation treatment over a mean period of 8.6 years. Other approaches are needed to validate any benefit of augmentation therapy.
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Affiliation(s)
- Iris G M Schouten
- Dept of Pulmonology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marise J Kasteleyn
- Dept of Pulmonology, Leiden University Medical Center, Leiden, the Netherlands
| | - Roula Tsonaka
- Dept of Advanced Data Management and Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - Robert Bals
- Dept of Pulmonology, Hospital of the University of the Saarland, Homburg, Germany.,These authors are member of the AATD Core Network of European Reference Network LUNG
| | - Alice C Turner
- University of Birmingham, Institute of Applied Health Research, Edgbaston, UK
| | - Ilaria Ferrarotti
- Fondazione IRCCS Policlinico San Matteo, Centro Diagnosi AATD - Clinica Malattie Apparato Respiratorio, Pavia, Italy.,These authors are member of the AATD Core Network of European Reference Network LUNG
| | - Angelo G Corsico
- Fondazione IRCCS Policlinico San Matteo, Centro Diagnosi AATD - Clinica Malattie Apparato Respiratorio, Pavia, Italy.,These authors are member of the AATD Core Network of European Reference Network LUNG
| | - Beatriz Lara
- Dept of Respiratory Medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Barcelona, Spain.,These authors are member of the AATD Core Network of European Reference Network LUNG.,These authors contributed equally
| | - Robert A Stockley
- Lung Investigation Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,These authors contributed equally
| | - Jan Stolk
- Dept of Pulmonology, Leiden University Medical Center, Leiden, the Netherlands.,These authors are member of the AATD Core Network of European Reference Network LUNG.,These authors contributed equally
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9
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Fawcett KA, Song K, Qian G, Farmaki AE, Packer R, John C, Shrine N, Granell R, Ring S, Timpson NJ, Yerges-Armstrong LM, Eastell R, Wain LV, Scott RA, Tobin MD, Hall IP. Pleiotropic associations of heterozygosity for the SERPINA1 Z allele in the UK Biobank. ERJ Open Res 2021; 7:00049-2021. [PMID: 33981765 PMCID: PMC8107350 DOI: 10.1183/23120541.00049-2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 02/20/2021] [Indexed: 11/20/2022] Open
Abstract
Homozygosity for the SERPINA1 Z allele causes α1-antitrypsin deficiency, a rare condition that can cause lung and liver disease. However, the effects of Z allele heterozygosity on nonrespiratory phenotypes, and on lung function in the general population, remain unclear. We conducted a large, population-based study to determine Z allele effects on >2400 phenotypes in the UK Biobank (N=303 353). Z allele heterozygosity was strongly associated with increased height (β=1.02 cm, p=3.91×10-68), and with other nonrespiratory phenotypes including increased risk of gall bladder disease, reduced risk of heart disease and lower blood pressure, reduced risk of osteoarthritis and reduced bone mineral density, increased risk of headache and enlarged prostate, as well as with blood biomarkers of liver function. Heterozygosity was associated with higher height-adjusted forced expiratory volume in 1 s (FEV1) (β=19.36 mL, p=9.21×10-4) and FEV1/forced vital capacity (β=0.0031, p=1.22×10-5) in nonsmokers, whereas in smokers, this protective effect was abolished. Furthermore, we show for the first time that sex modifies the association of the Z allele on lung function. We conclude that Z allele heterozygosity and homozygosity exhibit opposing effects on lung function in the UK population, and that these associations are modified by smoking and sex. In exploratory analyses, heterozygosity for the Z allele also showed pleiotropic associations with nonrespiratory health-related traits and disease risk.
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Affiliation(s)
| | - Kijoung Song
- Human Genetics, GlaxoSmithKline, Collegeville, PA, USA
| | - Guoqing Qian
- Dept of General Internal Medicine, Ningbo First Hospital, Ningbo City, Zhejiang Province, China
- Division of Respiratory Medicine, University of Nottingham, and NIHR Nottingham BRC, NUH NHS Trust, Nottingham, UK
| | - Aliki-Eleni Farmaki
- MRC Unit for Lifelong Health and Ageing, Institute of Cardiovascular Science, University College London, London, UK
| | - Richard Packer
- Dept of Health Sciences, University of Leicester, Leicester, UK
| | - Catherine John
- Dept of Health Sciences, University of Leicester, Leicester, UK
| | - Nick Shrine
- Dept of Health Sciences, University of Leicester, Leicester, UK
| | - Raquel Granell
- Medical Research Council Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sue Ring
- Medical Research Council Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicholas J. Timpson
- Medical Research Council Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Richard Eastell
- Dept of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Louise V. Wain
- Dept of Health Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research, Leicester Respiratory Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Robert A. Scott
- Human Genetics – R&D, GSK Medicines Research Centre, Stevenage, UK
| | - Martin D. Tobin
- Dept of Health Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research, Leicester Respiratory Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- These authors contributed equally
| | - Ian P. Hall
- Division of Respiratory Medicine, University of Nottingham, and NIHR Nottingham BRC, NUH NHS Trust, Nottingham, UK
- These authors contributed equally
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10
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Santos G, Turner AM. Alpha-1 antitrypsin deficiency: an update on clinical aspects of diagnosis and management. Fac Rev 2021; 9:1. [PMID: 33659933 PMCID: PMC7886062 DOI: 10.12703/b/9-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Clinical heterogeneity has been demonstrated in alpha-1 antitrypsin deficiency (AATD), such that clinical suspicion plays an important role in its diagnosis. The PiZZ genotype is the most common severe deficiency genotype and so tends to result in the worst clinical presentation, hence it has been the major focus of research. However, milder genotypes, especially PiSZ and PiMZ, are also linked to the development of lung and liver disease, mainly when unhealthy behaviors are present, such as smoking and alcohol use. Monitoring and managing AATD patients remains an area of active research. Lung function tests or computed tomography (CT) densitometry may allow physicians to identify progressive disease during follow up of patients, with a view to decision making about AATD-specific therapy, like augmentation therapy, or eventually surgical procedures such as lung volume reduction or transplant. Different types of biological markers have been suggested for disease monitoring and therapy selection, although most need further investigation. Intravenous augmentation therapy reduces the progression of emphysema in PiZZ patients and is available in many European countries, but its effect in milder deficiency is less certain. AATD has also been suggested to represent a risk factor and trigger for pulmonary infections, like those induced by mycobacteria. We summarize the last 5-10 years' key findings in AATD diagnosis, assessment, and management, with a focus on milder deficiency variants.
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Affiliation(s)
- Gabriela Santos
- Pneumology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Alice M Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
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11
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Aiello M, Ghirardini M, Marchi L, Frizzelli A, Pisi R, Ferrarotti I, Bertorelli G, Chetta A. Air Trapping Is Associated with Heterozygosity for Alpha-1 Antitrypsin Mutations in Patients with Asthma. Respiration 2021; 100:318-327. [PMID: 33550308 DOI: 10.1159/000513072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/15/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Alpha-1 antitrypsin deficiency (AATD) is a hereditary disorder involving lungs, characterized by low serum concentration of the protein alpha-1 antitrypsin (AAT) also called proteinase inhibitor (PI). Asthma is common in AATD patients, but there are only few data on respiratory function in asthmatic patients with AATD. OBJECTIVES The aim of the study was to evaluate lung function in asthmatic outpatients with mutation in the SERPINA1 gene coding for AAT versus asthmatic subjects without mutation. METHODS We performed the quantitative analysis of the serum concentration of AAT in 600 outpatients affected by mild to moderate asthma from the University Hospital of Parma, Italy. Fifty-seven of them underwent the genetic analysis subsequently; they were subdivided into mutated and non-mutated subjects. All the mutated patients had a heterozygous genotype, except 1 (PI*SS). We assessed the lung function through a flow-sensing spirometer and the small airway parameters through an impulse oscillometry system. RESULTS The values of forced vital capacity (% predicted) and those of the residual volume to total lung capacity ratio (%) were, respectively, lower and higher in patients mutated versus patients without mutation, showing a significantly greater air trapping (p = 0.014 and p = 0.017, respectively). Moreover, patients with mutation in comparison to patients without mutation showed lower forced expiratory volume in 3 s (% predicted) and forced expiratory volume in 6 s (L) spirometric values, reflecting a smaller airways contribution. CONCLUSIONS In asthmatic patients, heterozygosity for AAT with PI*MZ and PI*MS genotypes was associated with small airway dysfunction and with lung air trapping.
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Affiliation(s)
- Marina Aiello
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy,
| | - Marianna Ghirardini
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Laura Marchi
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Annalisa Frizzelli
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Roberta Pisi
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Ilaria Ferrarotti
- Center for the Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, Department of Internal Medicine and Therapeutics, Pneumology Unit, University of Pavia, Pavia, Italy
| | - Giuseppina Bertorelli
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Alfredo Chetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
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12
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Smith DJ, Ellis PR, Turner AM. Exacerbations of Lung Disease in Alpha-1 Antitrypsin Deficiency. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2021; 8:162-176. [PMID: 33238089 PMCID: PMC8047608 DOI: 10.15326/jcopdf.2020.0173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/18/2020] [Indexed: 01/13/2023]
Abstract
Alpha-1 antitrypsin deficiency (AATD) is an important risk factor for development of chronic obstructive pulmonary disease (COPD). Patients with AATD classically develop a different pattern of lung disease from those with usual COPD, decline faster and exhibit a range of differences in pathogenesis, all of which may be relevant to phenotype and/or impact of exacerbations. There are a number of definitions of exacerbation, with the main features being worsening of symptoms over at least 2 days, which may be associated with a change in treatment. In this article we review the literature surrounding exacerbations in AATD, focusing, in particular, on ways in which they may differ from such events in usual COPD, and the potential impact on clinical management.
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Affiliation(s)
- Daniel J. Smith
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Paul R. Ellis
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Alice M. Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
- University Hospitals Birmingham, United Kingdom
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13
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Implications of a Change of Paradigm in Alpha1 Antitrypsin Deficiency Augmentation Therapy: From Biochemical to Clinical Efficacy. J Clin Med 2020; 9:jcm9082526. [PMID: 32764414 PMCID: PMC7465600 DOI: 10.3390/jcm9082526] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 12/18/2022] Open
Abstract
Ever since the first studies, restoring proteinase imbalance in the lung has traditionally been considered as the main goal of alpha1 antitrypsin (AAT) replacement therapy. This strategy was therefore based on ensuring biochemical efficacy, identifying a protection threshold, and evaluating different dosage regimens. Subsequently, the publication of the results of the main clinical trials showing a decrease in the progression of pulmonary emphysema has led to a debate over a possible change in the main objective of treatment, from biochemical efficacy to clinical efficacy in terms of lung densitometry deterioration prevention. This new paradigm has produced a series controversies and unanswered questions which face clinicians managing AAT deficiency. In this review, the concepts that led to the approval of AAT replacement therapy are reviewed and discussed under a new prism of achieving clinical efficacy, with the reduction of lung deterioration as the main objective. Here, we propose the use of current knowledge and clinical experience to face existing challenges in different clinical scenarios, in order to help clinicians in decision-making, increase interest in the disease, and stimulate research in this field.
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14
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Usmani OS. Feasibility of Aerosolized Alpha-1 Antitrypsin as a Therapeutic Option. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2020; 7:272-279. [PMID: 32726075 DOI: 10.15326/jcopdf.7.3.2019.0179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Inhalation therapy is integral in the management of patients with chronic obstructive pulmonary disease (COPD). Specifically, intravenous augmentation therapy is available to patients with alpha-1 antitrypsin deficiency (AATD), although there is insufficient alpha-1 antitrypsin (AAT) delivery to the lungs to modify airways inflammation. In contrast, the inhaled route allows replacement therapy to reach the target site of action and with higher AAT levels. Patients certainly support the inhalation route as an alternative to intravenous injections, obviating repetitive needle insertion and allowing treatment empowerment rather than dependency on traveling to specialized units. The difficulty with inhalation has been the ability to target the formulation to the pathophysiological site of disease: the emphysematous lung parenchyma of the small alveolated airways. Recent advances have suggested nebulizers as being able to deliver an adequate dose, consistently and reproducibly, and, coupled with developments in formulation science, allowed replacement therapy to reach the epithelial lining fluid of the small airways. The bench science has been translated to the first randomized, placebo-controlled clinical trial to study the effects of nebulized AAT, which, although not meeting the primary endpoint of prolonging time to first exacerbation, showed this treatment modality was safe and achievable in a large patient cohort. Indeed, learning from this trial suggests the importance of choosing the right clinical endpoints, and recent key advances in lung physiology indices allow better assessment of the "silent zone" of small airways disease. Knowledge from other respiratory diseases will complement treating patients with AATD, where there is considerable innovation in aerosol science and inhalation medicine directed at utilizing the inhaled route. Indeed, it could be postulated that the inhaled route may not only achieve local pulmonary therapeutic benefit, but through systemic absorption and controlled pharmacokinetic profiling, the formulation may reach and treat liver disease.
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Affiliation(s)
- Omar S Usmani
- National Heart and Lung Institute, Imperial College London, United Kingdom
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15
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Dummer J, Dobler CC, Holmes M, Chambers D, Yang IA, Parkin L, Smith S, Wark P, Dev A, Hodge S, Dabscheck E, Gooi J, Samuel S, Knowles S, Holland AE. Diagnosis and treatment of lung disease associated with alpha one-antitrypsin deficiency: A position statement from the Thoracic Society of Australia and New Zealand. Respirology 2020; 25:321-335. [PMID: 32030868 PMCID: PMC7078913 DOI: 10.1111/resp.13774] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/27/2019] [Accepted: 01/10/2020] [Indexed: 12/18/2022]
Abstract
AATD is a common inherited disorder associated with an increased risk of developing pulmonary emphysema and liver disease. Many people with AATD-associated pulmonary emphysema remain undiagnosed and therefore without access to care and counselling specific to the disease. AAT augmentation therapy is available and consists of i.v. infusions of exogenous AAT protein harvested from pooled blood products. Its clinical efficacy has been the subject of some debate and the use of AAT augmentation therapy was recently permitted by regulators in Australia and New Zealand, although treatment is not presently subsidized by the government in either country. The purpose of this position statement is to review the evidence for diagnosis and treatment of AATD-related lung disease with reference to the Australian and New Zealand population. The clinical efficacy and adverse events of AAT augmentation therapy were evaluated by a systematic review, and the GRADE process was employed to move from evidence to recommendation. Other sections address the wide range of issues to be considered in the care of the individual with AATD-related lung disease: when and how to test for AATD, changing diagnostic techniques, monitoring of progression, disease in heterozygous AATD and pharmacological and non-pharmacological therapy including surgical options for severe disease. Consideration is also given to broader issues in AATD that respiratory healthcare staff may encounter: genetic counselling, patient support groups, monitoring for liver disease and the need to establish national registries for people with AATD in Australia and New Zealand.
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Affiliation(s)
- Jack Dummer
- Department of Medicine, Dunedin School of MedicineUniversity of OtagoDunedinNew Zealand
| | - Claudia C. Dobler
- Institute for Evidence‐Based HealthcareBond University and Gold Coast University HospitalGold CoastQLDAustralia
- Department of Respiratory MedicineLiverpool HospitalSydneyNSWAustralia
| | - Mark Holmes
- Department of Thoracic MedicineRoyal Adelaide HospitalAdelaideSAAustralia
- Faculty of MedicineThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Daniel Chambers
- Faculty of MedicineThe University of QueenslandBrisbaneQLDAustralia
- Queensland Lung Transplant ProgramThe Prince Charles HospitalBrisbaneQLDAustralia
| | - Ian A. Yang
- Faculty of MedicineThe University of QueenslandBrisbaneQLDAustralia
- Department of Thoracic MedicineThe Prince Charles HospitalBrisbaneQLDAustralia
| | - Lianne Parkin
- Department of Preventive and Social Medicine, Dunedin School of MedicineUniversity of OtagoDunedinNew Zealand
| | - Sheree Smith
- School of Nursing and MidwiferyWestern Sydney UniversitySydneyNSWAustralia
| | - Peter Wark
- Centre for Healthy LungsUniversity of NewcastleNewcastleNSWAustralia
- Department of Respiratory and Sleep MedicineJohn Hunter HospitalNew LambtonNSWAustralia
| | - Anouk Dev
- Department of GastroenterologyMonash HealthMelbourneVICAustralia
| | - Sandra Hodge
- Department of Thoracic MedicineRoyal Adelaide HospitalAdelaideSAAustralia
- Faculty of MedicineThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Eli Dabscheck
- Department of Respiratory MedicineAlfred HospitalMelbourneVICAustralia
- Department of Allergy, Immunology and Respiratory Medicine, Central Clinical SchoolMonash UniversityMelbourneVICAustralia
| | - Julian Gooi
- Department of Cardiothoracic SurgeryAlfred HospitalMelbourneVICAustralia
| | - Sameh Samuel
- Department of Respiratory MedicineWollongong HospitalWollongongNSWAustralia
- School of Medicine, University of WollongongWollongongNSWAustralia
| | | | - Anne E. Holland
- Department of Allergy, Immunology and Respiratory Medicine, Central Clinical SchoolMonash UniversityMelbourneVICAustralia
- Department of PhysiotherapyAlfred HealthMelbourneVICAustralia
- Institute for Breathing and SleepMelbourneVICAustralia
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16
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Abstract
Alpha-1 antitrypsin (AAT) protects the lung by inhibiting neutrophil proteinases, but AAT has many other non-proteolytic functions that are anti-inflammatory, antiviral and homeostatic. Approximately 1 in 1600 to 1 in 5000 people have the homozygous Z mutation, which causes AAT misfolding, accumulation in (predominantly) liver cells and low circulating levels of AAT, leading to AAT deficiency (AATD). AATD is classically a disease of neutrophilic inflammation, with an aggressive and damaging innate immune response contributing to emphysema and other pathologies. AATD is one of the most common genetic disorders but considerably under-recognised. Most patients are diagnosed later in life, by which time they may have accumulated significant lung, liver and multisystem damage. Disease presentation is heterogeneous and not fully explained by deficiency levels alone or exposure to cigarette smoking. This suggests other factors influence AATD-associated pathological processes. Aging itself is associated with organ dysfunction, including emphysema and airflow obstruction, inflammation, altered immune cell responses (termed immunosenescence) and a loss of proteostasis. Many of these processes are present in AATD but at an earlier age and more advanced stage compared with chronological aging alone. Augmentation therapy does not completely abrogate the manifold disease processes present in AATD. New approaches are needed. There is emerging evidence that both age- and AATD-related disease processes are amenable to correction by targeting proteostasis, autophagy, immunosenescence and epigenetic factors. This review explores the impact of the aging process on AATD presentation and discusses novel therapeutic strategies to mitigate low levels of AAT or misfolded AAT in an aging host.
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17
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Madan A, Turner AM. Identifying the at risk smokers: who goes on to get COPD? Eur Respir J 2019; 54:54/4/1901613. [PMID: 31672906 DOI: 10.1183/13993003.01613-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 08/16/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Arina Madan
- University Hospitals Birmingham, Heartlands Hospital, Birmingham, UK
| | - Alice M Turner
- University Hospitals Birmingham, Heartlands Hospital, Birmingham, UK .,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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18
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Hiller AM, Piitulainen E, Jehpsson L, Tanash H. Decline in FEV 1 and hospitalized exacerbations in individuals with severe alpha-1 antitrypsin deficiency. Int J Chron Obstruct Pulmon Dis 2019; 14:1075-1083. [PMID: 31213789 PMCID: PMC6536893 DOI: 10.2147/copd.s195847] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 04/01/2019] [Indexed: 11/23/2022] Open
Abstract
Background and aim: The value of the forced expiratory volume in one second (FEV1) is useful in the diagnosis and prognosis of chronic obstructive pulmonary disease (COPD). Previous studies on lung function in individuals with severe alpha-1 antitrypsin deficiency (AATD) have shown a variable annual decline in FEV1 (∆FEV1). The aim of this study was to analyze ∆FEV1 and to identify risk factors for ∆FEV1 in individuals with severe AATD. Material and methods: Data on smoking habits, symptoms, results of lung function tests and exacerbations were obtained from the Swedish AATD Register and the Swedish National Patient Register (SNPR). The ∆FEV1 was analyzed by random-effects modeling and adjusted for age and FEV1 at baseline. Results: One hundred and four (9%) current smokers, 539 (48%) ex-smokers and 489 (43%) never-smokers were included in the study and followed-up from 1991 to 2016. A total of 584 (52%) individuals with severe AATD had COPD at inclusion. The median (IQR) annual severe exacerbation rate was 0.66 (1.4). The adjusted mean ∆FEV1 was significantly higher in the current smokers compared with the ex-smokers and never-smokers (70 [95% CI 56–83] vs 42 [95% CI 36–48] and 32 [95% CI 25–38) mL·yr−1], in the middle–aged individuals compared with the young individuals (48 [95% CI 41–55] vs 32 [95% CI 18–45] mL·yr−1), in the individuals with respiratory symptoms at inclusion compared with the asymptomatic individuals (46 [95% CI 40–52] vs 30 [95% CI 22–38]mL·yr−1), and in the individuals with frequent exacerbations compared with those with infrequent exacerbations (57 [95% CI 47–68] vs 27 [95% CI 17–37] mL·yr−1). Conclusion: Active smoking, age, respiratory symptoms at baseline and repeated severe exacerbations of COPD are factors associated with an accelerated decline of lung function in individuals with severe AATD.
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Affiliation(s)
- Adriana-Maria Hiller
- Department of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Eeva Piitulainen
- Department of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Lars Jehpsson
- Department of Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
| | - Hanan Tanash
- Department of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Lund, Sweden
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19
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Lopes AP, Mineiro MA, Costa F, Gomes J, Santos C, Antunes C, Maia D, Melo R, Canotilho M, Magalhães E, Vicente I, Valente C, Gonçalves BG, Conde B, Guimarães C, Sousa C, Amado J, Brandão ME, Sucena M, Oliveira MJ, Seixas S, Teixeira V, Telo L. Portuguese consensus document for the management of alpha-1-antitrypsin deficiency. Pulmonology 2019; 24 Suppl 1:1-21. [PMID: 30473034 DOI: 10.1016/j.pulmoe.2018.09.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/12/2018] [Accepted: 09/14/2018] [Indexed: 01/08/2023] Open
Abstract
Alpha-1-antitrypsin deficiency (AATD) is a genetic autosomal codominant disorder caused by mutations in SERPINA1 gene. It is one of the most prevalent genetic disorders, although it remains underdiagnosed. Whereas at international level there are several areas of consensus on this disorder, in Portugal, inter-hospital heterogeneity in clinical practice and resources available have been adding difficulties in reaching a diagnosis and in making therapeutic decisions in this group of patients. This raised a need to draft a document expressing a national consensus for AATD. To this end, a group of experts in this field was created within the Portuguese Pulmonology Society - Study group on AATD, in order to elaborate the current manuscript. The authors reviewed the existing literature and provide here general guidance and extensive recommendations for the diagnosis and management of AATD that can be adopted by Portuguese clinicians from different areas of Medicine. This article is part of a supplement entitled "Portuguese consensus document for the management of alpha-1-antitrypsin deficiency" which is sponsored by Sociedade Portuguesa de Pneumologia.
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Affiliation(s)
- A P Lopes
- Centro Hospitalar e Universitário de Coimbra (HUC); Alpha-1-antitrypsin deficiency study group coordinator.
| | | | - F Costa
- Centro Hospitalar e Universitário de Coimbra (HG)
| | | | | | | | - D Maia
- Centro Hospital Lisboa Central
| | - R Melo
- Hospital Prof. Doutor Fernando da Fonseca
| | | | | | | | | | | | - B Conde
- Centro Hospitalar de Trás os Montes e Alto Douro
| | | | - C Sousa
- Centro Hospitalar de São João
| | - J Amado
- Unidade Local de Saúde de Matosinhos
| | - M E Brandão
- Centro Hospitalar de Trás os Montes e Alto Douro
| | | | | | - S Seixas
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto (I3S); Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP)
| | - V Teixeira
- Serviço de Saúde da Região Autónoma da Madeira (SESARAM)
| | - L Telo
- Centro Hospitalar Lisboa Norte
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Craig TJ, Henao MP. Advances in managing COPD related to α 1 -antitrypsin deficiency: An under-recognized genetic disorder. Allergy 2018; 73:2110-2121. [PMID: 29984428 PMCID: PMC6282978 DOI: 10.1111/all.13558] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 06/08/2018] [Accepted: 06/15/2018] [Indexed: 12/19/2022]
Abstract
α1 -Antitrypsin deficiency (AATD) predisposes individuals to chronic obstructive pulmonary disease (COPD) and liver disease. Despite being commonly described as rare, AATD is under-recognized, with less than 10% of cases identified. The following is a comprehensive review of AATD, primarily for physicians who treat COPD or asthma, covering the genetics, epidemiology, clinical presentation, screening and diagnosis, and treatments of AATD. For patients presenting with liver and/or lung disease, screening and diagnostic tests are the only methods to determine whether the disease is related to AATD. Screening guidelines have been established by organizations such as the World Health Organization, European Respiratory Society, and American Thoracic Society. High-risk groups, including individuals with COPD, nonresponsive asthma, bronchiectasis of unknown etiology, or unexplained liver disease, should be tested for AATD. Current treatment options include augmentation therapy with purified AAT for patients with deficient AAT levels and significant lung disease. Recent trial data suggest that lung tissue is preserved by augmentation therapy, and different dosing schedules are currently being investigated. Effective management of AATD and related diseases also includes aggressive avoidance of smoking and biomass burning, vaccinations, antibiotics, exercise, good diet, COPD medications, and serial assessment.
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Affiliation(s)
- Timothy J. Craig
- Department of Medicine and PediatricsCollege of MedicinePennsylvania State UniversityHersheyPennsylvania
| | - Maria Paula Henao
- Department of MedicineCollege of MedicinePennsylvania State UniversityHersheyPennsylvania
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21
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Abstract
α1-Antitrypsin deficiency (AATD) is an inherited metabolic disorder in which mutations in the coding sequence of the SERPINA1 gene prevent secretion of α1-antitrypsin (α1-AT) and cause predisposition to pulmonary and liver diseases. The heterogeneity of clinical manifestations in AATD is related to the complexity of biological function of α1-AT. The role of smoking is crucial in the natural history of lung damage progression in severe AATD individuals, even if it also partly explains the heterogeneity in lung disease. Lung damage progression in AATD can also be related to body mass index, exacerbation rate, sex, environmental exposure and specific mutations of SERPINA1. Recent randomised controlled trials, together with previous observational work, have provided compelling evidence for the importance of early detection and intervention in order to enable patients to receive appropriate treatment and preserve functional lung tissue. Early detection and intervention in cases of α1-antitrypsin deficiency are essential to enable appropriate treatment and preserve functional lung tissuehttp://ow.ly/Mr3P30jUEyn
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Affiliation(s)
- Ilaria Ferrarotti
- Center for Diagnosis of Inherited Alpha1-antitrypsin Deficiency, Dept of Internal Medicine and Therapeutics, Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Università di Pavia, Pavia, Italy
| | - Stefania Ottaviani
- Center for Diagnosis of Inherited Alpha1-antitrypsin Deficiency, Dept of Internal Medicine and Therapeutics, Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Università di Pavia, Pavia, Italy
| | | | - Angelo G Corsico
- Center for Diagnosis of Inherited Alpha1-antitrypsin Deficiency, Dept of Internal Medicine and Therapeutics, Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Università di Pavia, Pavia, Italy
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22
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Torres-Durán M, Lopez-Campos JL, Barrecheguren M, Miravitlles M, Martinez-Delgado B, Castillo S, Escribano A, Baloira A, Navarro-Garcia MM, Pellicer D, Bañuls L, Magallón M, Casas F, Dasí F. Alpha-1 antitrypsin deficiency: outstanding questions and future directions. Orphanet J Rare Dis 2018; 13:114. [PMID: 29996870 PMCID: PMC6042212 DOI: 10.1186/s13023-018-0856-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 06/26/2018] [Indexed: 12/14/2022] Open
Abstract
Background Alpha-1 antitrypsin deficiency (AATD) is a rare hereditary condition that leads to decreased circulating alpha-1 antitrypsin (AAT) levels, significantly increasing the risk of serious lung and/or liver disease in children and adults, in which some aspects remain unresolved. Methods In this review, we summarise and update current knowledge on alpha-1 antitrypsin deficiency in order to identify and discuss areas of controversy and formulate questions that need further research. Results 1) AATD is a highly underdiagnosed condition. Over 120,000 European individuals are estimated to have severe AATD and more than 90% of them are underdiagnosed. Conclusions 2) Several clinical and etiological aspects of the disease are yet to be resolved. New strategies for early detection and biomarkers for patient outcome prediction are needed to reduce morbidity and mortality in these patients; 3) Augmentation therapy is the only specific approved therapy that has shown clinical efficacy in delaying the progression of emphysema. Regrettably, some countries reject registration and reimbursement for this treatment because of the lack of larger randomised, placebo-controlled trials. 4) Alternative strategies are currently being investigated, including the use of gene therapy or induced pluripotent stem cells, and non-augmentation strategies to prevent AAT polymerisation inside hepatocytes.
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Affiliation(s)
- María Torres-Durán
- Pulmonary Department, Hospital Álvaro Cunqueiro EOXI, Vigo, Spain.,NeumoVigo I+i Research Group, IIS Galicia Sur, Vigo, Spain
| | - José Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio, Universidad de Sevilla, Sevilla, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Miriam Barrecheguren
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Pneumology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marc Miravitlles
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Pneumology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Beatriz Martinez-Delgado
- Molecular Genetics Unit, Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Silvia Castillo
- Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, c/Menéndez y Pelayo, 4, 46010, Valencia, Spain.,School of Medicine, Department of Physiology, Research group on Rare Respiratory Diseases (ERR), University of Valencia, Valencia, Spain
| | - Amparo Escribano
- Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, c/Menéndez y Pelayo, 4, 46010, Valencia, Spain.,School of Medicine, Department of Paediatrics, Obstetrics and Gynaecology, University of Valencia, Valencia, Spain.,School of Medicine, Department of Physiology, Research group on Rare Respiratory Diseases (ERR), University of Valencia, Valencia, Spain
| | - Adolfo Baloira
- Pneumology Department, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - María Mercedes Navarro-Garcia
- Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, c/Menéndez y Pelayo, 4, 46010, Valencia, Spain.,School of Medicine, Department of Physiology, Research group on Rare Respiratory Diseases (ERR), University of Valencia, Valencia, Spain
| | - Daniel Pellicer
- Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, c/Menéndez y Pelayo, 4, 46010, Valencia, Spain.,School of Medicine, Department of Physiology, Research group on Rare Respiratory Diseases (ERR), University of Valencia, Valencia, Spain
| | - Lucía Bañuls
- Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, c/Menéndez y Pelayo, 4, 46010, Valencia, Spain.,School of Medicine, Department of Physiology, Research group on Rare Respiratory Diseases (ERR), University of Valencia, Valencia, Spain
| | - María Magallón
- Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, c/Menéndez y Pelayo, 4, 46010, Valencia, Spain.,School of Medicine, Department of Physiology, Research group on Rare Respiratory Diseases (ERR), University of Valencia, Valencia, Spain
| | - Francisco Casas
- Pneumology Department, Hospital Universitario San Cecilio, Granada, Spain
| | - Francisco Dasí
- Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, c/Menéndez y Pelayo, 4, 46010, Valencia, Spain. .,School of Medicine, Department of Physiology, Research group on Rare Respiratory Diseases (ERR), University of Valencia, Valencia, Spain.
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23
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Esquinas C, Serreri S, Barrecheguren M, Rodriguez E, Nuñez A, Casas-Maldonado F, Blanco I, Pirina P, Lara B, Miravitlles M. Long-term evolution of lung function in individuals with alpha-1 antitrypsin deficiency from the Spanish registry (REDAAT). Int J Chron Obstruct Pulmon Dis 2018; 13:1001-1007. [PMID: 29615836 PMCID: PMC5870637 DOI: 10.2147/copd.s155226] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Background The clinical course of alpha-1 antitrypsin deficiency (AATD) is very heterogeneous. It is estimated that 60% of individuals with severe AATD (Pi*ZZ) develop emphysema. The main objective of this study was to describe the outcomes of long-term lung function in individuals with AATD-associated emphysema after at least 8 years of follow-up. Materials and methods We performed a retrospective analysis of longitudinal follow-up data of AATD PiZZ patients from the Spanish registry (AATD Spanish Registry [REDAAT]). The main follow-up outcome was the annual rate of decline in forced expiratory volume in 1 second (FEV1) calculated using the FEV1 values at baseline and in the last post-bronchodilator spirometry available. Results One hundred and twenty-two AATD PiZZ patients were analyzed. The median follow-up was 11 years (interquartile range =9–14). The mean FEV1 decline was 28 mL/year (SD=54), with a median of 33 mL/year. Tobacco consumption (β=19.8, p<0.001), previous pneumonia (β=27.8, p=0.026) and higher baseline FEV1% (β=0.798, p=0.016) were independently related to a faster FEV1 decline. Conclusion In this large cohort with a long follow-up, we observed a very variable decline of FEV1. However, the mean FEV1 decline was similar to that observed in large cohorts of smoking-related COPD. Tobacco consumption, previous pneumonia and better lung function at baseline were related to a faster decline in FEV1. These results highlight the importance of early diagnosis and effective treatment.
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Affiliation(s)
- Cristina Esquinas
- Pneumology Department, University Hospital Vall d'Hebron, Barcelona, Spain.,Public Health, Mental, Maternal and Child Health Nursing Department, Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
| | | | | | - Esther Rodriguez
- Pneumology Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Alexa Nuñez
- Pneumology Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Ignacio Blanco
- Alpha-1 Antitrypsin Deficiency Spanish Registry (REDAAT), Spanish Society of Pneumology (SEPAR), Barcelona, Spain
| | | | - Beatriz Lara
- Coventry and Warwickshire University Hospital, Coventry, UK
| | - Marc Miravitlles
- Pneumology Department, University Hospital Vall d'Hebron, Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Spain
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24
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Abstract
Alpha-1 antitrypsin deficiency (AATD) is a recognized genetic cause of rapidly progressive loss of lung function conventionally assessed by the decline in FEV1. However, there is less information concerning other physiological measures and the impact on quality of life. Data derived predominantly from the UK national registry show that AATD presents with various physiological phenotypes with differing clinical impact and progression. In general, the decline in quality of life is surprisingly slow despite rapid loss of lung function, which may reflect the benefits of centralized services for patients with AATD. Use of the new GOLD classification identifies patient characteristics that relate to mortality and disparate symptomatology despite similar spirometric impairment.
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25
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Low EV, Hughes SM, Zaffarullah S, Kantas D, Stockley RA, Turner AM. ICS Use May Modify FEV1 Decline in α1-Antitrypsin Deficiency Patients with Relatively High Blood Eosinophils. Respiration 2017; 95:114-121. [PMID: 29253843 DOI: 10.1159/000481867] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/24/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND α1-Antitrypsin deficiency (AATD) predisposes to chronic obstructive pulmonary disease (COPD). In COPD unrelated to AATD, the role of a higher blood eosinophil count in disease and subsequent personalization of therapy has recently received much attention. We sought to investigate this concept in patients with AATD-associated COPD. OBJECTIVES The study aims to evaluate eosinophilia status against outcomes including mortality and FEV1 decline in patients with AATD. METHODS All patients with PiSZ and PiZZ genotypes were identified from the UK AATD registry. The participants were substratified according to inhaled corticosteroid (ICS) use. Blood eosinophil counts were assessed from baseline and annually during follow-up (range 1-18 years). Eosinophilia was defined as a level >0.2 × 109/L, and classified by the frequency of such counts into "always," "intermittent," or "never present." Univariate and multivariate analyses were conducted. RESULTS In total, 646 participants were included, 53.9% of whom demonstrated intermittent and 7.4% persistent eosinophilia. Survival did not differ according to eosinophilic group (p > 0.05). Those with persistent eosinophilia showed a slower FEV1 decline (p < 0.001). There was no clear association with exacerbation frequency. Patients on ICS at baseline were more likely to be eosinophilic (p = 0.002) and having a lower FEV1 (p < 0.001) and greater pack-year exposure (16.5 vs. 7.8 pack-years, p < 0.001). When the multivariate analyses of FEV1 decline were stratified for baseline ICS use, the association of persistent eosinophilia with slower decline persisted in those on ICS. CONCLUSIONS Blood eosinophil levels persistently >0.2 × 109/L may be an indication for ICS use in PiZZ AATD in order to reduce FEV1 decline.
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Affiliation(s)
- Emma V Low
- Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Siân M Hughes
- Queen Elizabeth Hospital, Birmingham, United Kingdom
| | | | | | | | - Alice M Turner
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
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26
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Miravitlles M, Dirksen A, Ferrarotti I, Koblizek V, Lange P, Mahadeva R, McElvaney NG, Parr D, Piitulainen E, Roche N, Stolk J, Thabut G, Turner A, Vogelmeier C, Stockley RA. European Respiratory Society statement: diagnosis and treatment of pulmonary disease in α1-antitrypsin deficiency. Eur Respir J 2017; 50:50/5/1700610. [DOI: 10.1183/13993003.00610-2017] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 08/16/2017] [Indexed: 11/05/2022]
Abstract
α1-antitrypsin deficiency (AATD) is the most common hereditary disorder in adults. It is associated with an increased risk of developing pulmonary emphysema and liver disease. The pulmonary emphysema in AATD is strongly linked to smoking, but even a proportion of never-smokers develop progressive lung disease. A large proportion of individuals affected remain undiagnosed and therefore without access to appropriate care and treatment.The most recent international statement on AATD was published by the American Thoracic Society and the European Respiratory Society in 2003. Since then there has been a continuous development of novel, more accurate and less expensive genetic diagnostic methods. Furthermore, new outcome parameters have been developed and validated for use in clinical trials and a new series of observational and randomised clinical trials have provided more evidence concerning the efficacy and safety of augmentation therapy, the only specific treatment available for the pulmonary disease associated with AATD.As AATD is a rare disease, it is crucial to organise national and international registries and collect information prospectively about the natural history of the disease. Management of AATD patients must be supervised by national or regional expert centres and inequalities in access to therapies across Europe should be addressed.
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27
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Exacerbations and duration of smoking abstinence are associated with the annual loss of FEV 1 in individuals with PiZZ alpha-1-antitrypsin deficiency. Respir Med 2017; 129:8-15. [PMID: 28732839 DOI: 10.1016/j.rmed.2017.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 05/15/2017] [Accepted: 05/21/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Alpha-1-antitrypsin deficiency (AATD) is a genetic disorder that is associated with a higher risk of chronic obstructive pulmonary disease (COPD) and emphysema. The annual declines in lung function (FEV1) and transfer factor of the lung for carbon monoxide (TLCO) predict all-cause mortality. MATERIAL AND METHODS We investigated the longitudinal follow-up data over 11 years (mean follow-up period of 4.89 years) from the German AATD registry and analyzed the relationship between annual loss of FEV1 and TLCO and sex, age, body mass index (BMI), nicotine consumption, occupational dust exposure, St. George's Respiratory Questionnaire (SGRQ) score, baseline FEV1 or TLCO, alpha-1-antitrypsin (AAT) serum level, exacerbation frequency and the duration of smoking abstinence by multiple linear generalized estimating equations models (GEE-models). RESULTS We evaluated the data of 100 individuals with post-bronchodilator FEV1 measurements and from 116 individuals with TLCO measurements. The mean overall decline was -54.06 ± 164.62 ml/year in FEV1 and -0.17 ± 0.70 mmol/min/kPa/year in TLCO. Accelerated deterioration of FEV1 was associated with occupational dust exposure (p = 0.026), shorter duration of smoking abstinence (p = 0.008), higher baseline FEV1 (p = 0.003), higher annual exacerbation frequency (p = 0.003) and higher frequency of glucocorticoids intake (p = 0.004). Furthermore, patients with an elevated decline in TLCO showed significant impaired health-related quality of life at baseline (p = 0.039) and lower AAT serum levels (p < 0.001) in multivariate analysis. CONCLUSIONS Annual decline in FEV1 is related to the exacerbation rate, occupational dust exposure and the duration of smoking abstinence.
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Poh TY, Mac Aogáin M, Chan AKW, Yii ACA, Yong VFL, Tiew PY, Koh MS, Chotirmall SH. Understanding COPD-overlap syndromes. Expert Rev Respir Med 2017; 11:285-298. [PMID: 28282995 DOI: 10.1080/17476348.2017.1305895] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Chronic obstructive pulmonary disease accounts for a large burden of lung disease. It can 'overlap' with other respiratory diseases including bronchiectasis, fibrosis and obstructive sleep apnea (OSA). While COPD alone confers morbidity and mortality, common features with contrasting clinical outcomes can occur in COPD 'overlap syndromes'. Areas covered: Given the large degree of heterogeneity in COPD, individual variation to treatment is adopted based on its observed phenotype, which in turn overlaps with features of other respiratory disease states such as asthma. This is coined asthma-COPD overlap syndrome ('ACOS'). Other examples of such overlapping clinical states include bronchiectasis-COPD ('BCOS'), fibrosis-COPD ('FCOS') and OSA-COPD ('OCOS'). The objective of this review is to highlight similarities and differences between the COPD-overlap syndromes in terms of risk factors, pathophysiology, diagnosis and potential treatment differences. Expert commentary: As a consequence of COPD overlap syndromes, a transition from the traditional 'one size fits all' treatment approach is necessary. Greater treatment stratification according to clinical phenotype using a precision medicine approach is now required. In this light, it is important to recognize and differentiate COPD overlap syndromes as distinct disease states compared to individual diseases such as asthma, COPD, fibrosis or bronchiectasis.
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Affiliation(s)
- Tuang Yeow Poh
- a Lee Kong Chian School of Medicine, Translational Respiratory Research Laboratory , Nanyang Technological University , Singapore , Singapore
| | - Micheál Mac Aogáin
- a Lee Kong Chian School of Medicine, Translational Respiratory Research Laboratory , Nanyang Technological University , Singapore , Singapore
| | - Adrian Kwok Wai Chan
- b Department of Respiratory & Critical Care Medicine , Singapore General Hospital , Singapore , Singapore
| | - Anthony Chau Ang Yii
- b Department of Respiratory & Critical Care Medicine , Singapore General Hospital , Singapore , Singapore
| | - Valerie Fei Lee Yong
- a Lee Kong Chian School of Medicine, Translational Respiratory Research Laboratory , Nanyang Technological University , Singapore , Singapore
| | - Pei Yee Tiew
- b Department of Respiratory & Critical Care Medicine , Singapore General Hospital , Singapore , Singapore
| | - Mariko Siyue Koh
- b Department of Respiratory & Critical Care Medicine , Singapore General Hospital , Singapore , Singapore
| | - Sanjay Haresh Chotirmall
- a Lee Kong Chian School of Medicine, Translational Respiratory Research Laboratory , Nanyang Technological University , Singapore , Singapore
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Henao MP, Craig TJ. Recent advances in understanding and treating COPD related to α 1-antitrypsin deficiency. Expert Rev Respir Med 2016; 10:1281-1294. [PMID: 27771979 DOI: 10.1080/17476348.2016.1249851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Alpha-1-antitrypsin deficiency (AATD) is an orphan disease that predisposes individuals to COPD and liver disease. The following is a comprehensive review of AATD from epidemiology to treatment for physicians who treat COPD or asthma. Areas covered: In this comprehensive review of alpha-1-antitrypsin deficiency, we describe the historical perspective, genetics, epidemiology, clinical presentation and symptoms, screening and diagnosis, and treatments of the condition. Expert commentary: The two most important directions for advancing the understanding of AATD involve improving detection of the condition, especially in asymptomatic patients, and advancing knowledge of treatments directed specifically at AATD-related conditions. With regard to treatment for AATD-related conditions, research must continue to explore the implications and importance of augmentation therapy as well as consider new implementations that may prove more successful taking into consideration not only factors of pulmonary function and liver health, but also product availability and financial viability.
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Affiliation(s)
- Maria Paula Henao
- a Department of Medicine , Pennsylvania State University College of Medicine at Hershey Medical Center , Hershey , PA , USA
| | - Timothy J Craig
- b Department of Medicine , Pediatrics Pennsylvania State University College of Medicine at Hershey Medical Center , Hershey , PA , USA
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30
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Stockley RA, Edgar RG, Pillai A, Turner AM. Individualized lung function trends in alpha-1-antitrypsin deficiency: a need for patience in order to provide patient centered management? Int J Chron Obstruct Pulmon Dis 2016; 11:1745-56. [PMID: 27536086 PMCID: PMC4976906 DOI: 10.2147/copd.s111508] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is characterized by fixed airflow obstruction and accelerated decline of forced expired volume in 1 second (FEV1). Alpha-1-antitrypsin deficiency is a genetic cause of COPD and associated with more rapid decline in lung function, even in some never smokers (NS) but the potential for individualized assessment to reveal differences when compared to group analyses has rarely been considered. METHODS We analyzed decline in post-bronchodilator FEV1 and gas transfer (% predicted) over at least 3 years (mean= 6.11, 95% CI 5.80-6.41) in our unique data set of 482 patients with alpha-1-antitrypsin deficiency (PiZ) to determine individual rates of decline, implications for prognosis, and potential clinical management. FINDINGS There was a marked variation in individual rates of FEV1 decline from levels consistent with normal aging (observed in 23.5% of patients with established COPD, 57.5% of those without) to those of rapidly declining COPD. Gas transfer did not decline in 12.8% of NS and 20.7% of ex-smokers with established COPD (33.3% and 25.0%, respectively, for those without COPD). There was no correlation between decline in gas transfer and FEV1 for those with COPD, although a weak relationship existed for those without (r=0.218; P<0.025). CONCLUSION These data confirm differing individual rates of lung function decline in alpha-1-antitrypsin deficiency, indicating the importance of comprehensive physiological assessment and a personalized approach to patient management.
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Affiliation(s)
- Robert A Stockley
- Department of Lung Function and Sleep, University Hospitals Birmingham NHS Foundation Trust
| | - Ross G Edgar
- Department of Lung Function and Sleep, University Hospitals Birmingham NHS Foundation Trust
| | - Anilkumar Pillai
- Department of Lung Function and Sleep, University Hospitals Birmingham NHS Foundation Trust
| | - Alice M Turner
- Department of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK
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31
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Abstract
α1-Antitrypsin deficiency is an autosomal codominant condition that predisposes to emphysema and cirrhosis. The condition is common but grossly under-recognized. Identifying patients' α1-antitrypsin deficiency has important management implications (ie, smoking cessation, genetic and occupational counseling, and specific treatment with the infusion of pooled human plasma α1-antitrypsin). The weight of evidence suggests that augmentation therapy slows the progression of emphysema in individuals with severe α1-antitrypsin deficiency.
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Affiliation(s)
- Umur Hatipoğlu
- Respiratory Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk A-90, Cleveland, OH 44195, USA.
| | - James K Stoller
- Education Institute, Cleveland Clinic Lerner School of Medicine, Cleveland Clinic, NA 22, Cleveland, OH 44195, USA
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32
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Green C, Parr D, Edgar R, Stockley R, Turner A. Lung density associates with survival in alpha 1 antitrypsin deficient patients. Respir Med 2016; 112:81-7. [DOI: 10.1016/j.rmed.2016.01.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 01/14/2016] [Accepted: 01/16/2016] [Indexed: 12/31/2022]
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Stockley RA. Antitrypsin Deficiency Assessment and Programme for Treatment (ADAPT): The United Kingdom Registry. COPD 2016; 12 Suppl 1:63-8. [PMID: 25938295 DOI: 10.3109/15412555.2015.1021911] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The study of rare diseases is compromised by its rarity. The establishment of national and international registries can overcome many of the problems and be used for many monogenetic conditions with relatively consistent outcomes and thus lead to a consistency of clinical management by centres of excellence. However, in Alpha-1 antitrypsin deficiency (AATD), the outcome is highly variable in terms of the organ(s) most affected and the diversity of disease penetration and progression. This creates the added difficulty of understanding the disease sufficiently to monitor and advise the patients to the standard required and importantly design and deliver clinical trials that address the many facets of the disease. The development of research registries and centres of excellence provides the necessary expertise and data to further the understanding and management of diseases like AATD though with significant cost implications. The ADAPT programme was established in 1996 with extensive core funding to enable patients to be seen from all regions of the United Kingdom as an addition to the National Health Service without appointment time constraints and with the purpose of collecting extensive state of the art demographics. The model has proven to be highly productive providing new insights especially into the lung disease, generating and delivering on clinical trials and importantly establishing active patient groups and participation.
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Affiliation(s)
- Robert A Stockley
- ADAPT Project, Queen Elizabeth Hospital Birmingham , Birmingham , United Kingdom
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Balbi B, Ferrarotti I, Miravitlles M. Efficacy of augmentation therapy for emphysema associated with α1-antitrypsin deficiency: enough is enough. Eur Respir J 2015; 47:35-8. [DOI: 10.1183/13993003.01145-2015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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35
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Carter RI, Ungurs MJ, Pillai A, Mumford RA, Stockley RA. The Relationship of the Fibrinogen Cleavage Biomarker Aα-Val360 With Disease Severity and Activity in α1-Antitrypsin Deficiency. Chest 2015; 148:382-388. [PMID: 25569856 DOI: 10.1378/chest.14-0520] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND New markers of COPD and emphysema disease activity are urgently required since current measures of disease severity do not reflect the total disease burden nor predict disease progression. A recently described in vivo marker of neutrophil elastase activity (Aα-Val360) may be an effective marker of COPD and emphysema disease activity, and the current study explores its use in patients with α1-antitrypsin deficiency (AATD) across the disease severity spectrum with particular interest in whether it can be used as an early predictor of the need for intervention. METHODS Cross-sectional and longitudinal relationships between Aα-Val360 and full lung-function tests, CT scan densitometry, and other biomarkers were explored in this study of a registry of untreated patients with PiZZ AATD. RESULTS The Aα-Val360 related cross-sectionally to physiologic, radiologic, and symptomatic markers of disease severity though not disease progression. Similar cross-sectional relationships were observed in subjects with mild physiologic abnormalities; however, in this subgroup, baseline Aα-Val360 concentration did relate to subsequent disease progression. CONCLUSIONS In cross-sectional studies, Aα-Val360 reflects disease severity in AATD and may be a useful marker of disease activity in patients with early disease in whom therapeutic intervention may be indicated.
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Affiliation(s)
- Richard I Carter
- The Royal Wolverhampton Hospitals NHS Trust, West Midlands, England
| | - Michael J Ungurs
- Centre for Translational Inflammation Research, University of Birmingham Research Laboratories, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
| | - Anilkumar Pillai
- Centre for Translational Inflammation Research, University of Birmingham Research Laboratories, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
| | | | - Robert A Stockley
- Centre for Translational Inflammation Research, University of Birmingham Research Laboratories, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England; ADAPT Project, Lung Function and Sleep, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England.
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Tejwani V, Wang XF, Stoller JK. The Natural History of Lung Function in Severe Deficiency of Alpha-1 Antitrypsin Following Orthotopic Liver Transplantation: A Case Report. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2015; 2:290-295. [PMID: 28848851 DOI: 10.15326/jcopdf.2.4.2015.0141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PI*ZZ alpha-1 antitrypsin (AAT) deficiency poses risk for lung disease through 2 different mechanisms: a toxic loss of function in which deficient AAT levels cause a depleted proteolytic screen and, separately, a proinflammatory effect of Z polymers produced both by alveolar macrophages and by the liver. Ample data support the first mechanism, while the possible contribution of the second 2 proinflammatory mechanisms is currently unknown. Experience with a 74 year-old PI*ZZ female who underwent single lung transplantation and subsequent orthotopic liver transplantation (OLT) may shed light on the relative contributions of each of the potential mechanisms. Availability of multiple pulmonary function tests (PFT) measurements uniquely permitted calculation of rates of lung function change before and after OLT. The rate of forced expiratory volume in 1 second (FEV1) decline normalized post-OLT (from -60 to -21 ml/yr). Her course suggests that restoring the normal serum AAT levels or, alternately, eliminating liver-derived polymers, exerted a greater effect on preventing emphysema progression than local Z polymer production contributed to furthering emphysema.
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Affiliation(s)
| | | | - James K Stoller
- Education Institute, Respiratory Institute, Cleveland Clinic, Ohio
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Green CE, Vayalapra S, Hampson JA, Mukherjee D, Stockley RA, Turner AM. PiSZ alpha-1 antitrypsin deficiency (AATD): pulmonary phenotype and prognosis relative to PiZZ AATD and PiMM COPD. Thorax 2015; 70:939-45. [DOI: 10.1136/thoraxjnl-2015-206906] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 06/15/2015] [Indexed: 12/21/2022]
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Casas F, Blanco I, Martínez MT, Bustamante A, Miravitlles M, Cadenas S, Hernández JM, Lázaro L, Rodríguez E, Rodríguez-Frías F, Torres M, Lara B. Indications for active case searches and intravenous alpha-1 antitrypsin treatment for patients with alpha-1 antitrypsin deficiency chronic pulmonary obstructive disease: an update. Arch Bronconeumol 2015; 51:185-92. [PMID: 25027067 DOI: 10.1016/j.arbres.2014.05.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 05/10/2014] [Accepted: 05/26/2014] [Indexed: 02/07/2023]
Abstract
The effect of hereditary alpha-1 antitrypsin (AAT) deficiency can manifest clinically in the form of chronic obstructive pulmonary disease (COPD). AAT deficiency (AATD) is defined as a serum concentration lower than 35% of the expected mean value or 50 mg/dl (determined by nephelometry). It is associated in over 95% of cases with Pi*ZZ genotypes, and much less frequently with other genotypes resulting from combinations of Z, S, rare and null alleles. A systematic qualitative review was made of 107 articles, focusing mainly on an active search for AATD in COPD patients and intravenous (iv) treatment with AAT. On the basis of this review, the consultant committee of the Spanish Registry of Patients with AATD recommends that all COPD patients be screened for AATD with the determination of AAT serum concentrations, and when these are low, the evaluation must be completed with phenotyping and, on occasions, genotyping. Patients with severe AATD COPD should receive the pharmacological and non-pharmacological treatment recommended in the COPD guidelines. There is enough evidence from large observational studies and randomized placebo-controlled clinical trials to show that the administration of iv AAT reduces mortality and slows the progression of emphysema, hence its indication in selected cases that meet the inclusion criteria stipulated in international guidelines. The administration of periodic infusions of AAT is the only specific treatment for delaying the progression of emphysema associated with AATD.
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Affiliation(s)
- Francisco Casas
- Unidad de Gestión Clínica de Neumología, Hospital Universitario San Cecilio, Granada, España
| | - Ignacio Blanco
- Registro Español de pacientes con déficit de alfa-1 antitripsina, Fundación Española de Pulmón, Respira, SEPAR
| | | | - Ana Bustamante
- Servicio de Neumología, Hospital de Sierrallana, Torrelavega, Cantabria, España
| | - Marc Miravitlles
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, España
| | - Sergio Cadenas
- Servicio de Neumología, Hospital Clínico Universitario de Salamanca, Salamanca, España
| | - José M Hernández
- Servicio de Neumología, Hospital General de la Palma, La Palma, Santa Cruz de Tenerife, España
| | - Lourdes Lázaro
- Servicio de Neumología, Hospital Universitario de Burgos, Burgos, España
| | - Esther Rodríguez
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, España
| | | | - María Torres
- Servicio de Neumología, Complexo Universitario de Vigo, Pontevedra, España
| | - Beatriz Lara
- Servicio de Neumología, Hospital Universitario Arnau de Vilanova, Lleida, España.
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Casas F, Blanco I, Martínez MT, Bustamante A, Miravitlles M, Cadenas S, Hernández JM, Lázaro L, Rodríguez E, Rodríguez-Frías F, Torres M, Lara B. Indications for Active Case Searches and Intravenous Alpha-1 Antitrypsin Treatment for Patients With Alpha-1 Antitrypsin Deficiency Chronic Pulmonary Obstructive Disease: An Update. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.arbr.2014.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Sorrells S, Camprubi S, Griffin R, Chen J, Ayguasanosa J. SPARTA clinical trial design: exploring the efficacy and safety of two dose regimens of alpha1-proteinase inhibitor augmentation therapy in alpha1-antitrypsin deficiency. Respir Med 2015; 109:490-9. [PMID: 25727857 DOI: 10.1016/j.rmed.2015.01.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 12/13/2014] [Accepted: 01/19/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND Alpha1-antitrypsin deficiency (AATD) is an underdiagnosed genetic disorder that results in early-onset emphysema due to low serum levels of alpha1-proteinase inhibitor (alpha1-PI), leading to increased activity of tissue-damaging neutrophil elastase. Clinical outcomes of AATD may be improved by administering alpha1-PI augmentation therapy. Here, we describe the design of the ongoing Study of ProlAstin-c Randomized Therapy with Alpha-1 augmentation (SPARTA), a phase 3 trial designed to evaluate progression of lung tissue loss in patients with severe AATD receiving human alpha1-PI (Prolastin(®)-C) versus placebo, using whole-lung computed tomography (CT) densitometry. STUDY DESIGN SPARTA is a randomized, placebo-controlled trial assessing the efficacy and safety of two separate doses of Prolastin-C (60 and 120 mg/kg) administered weekly over 3 years in patients aged 18-70 years with a diagnosis of AATD and clinical evidence of pulmonary emphysema. The primary measure of efficacy (change from baseline whole-lung 15th percentile lung density [PD15]) will be determined by CT lung densitometry measured at total lung capacity. Secondary efficacy variables will be the evaluation of severe chronic obstructive pulmonary disease exacerbations, as defined by American Thoracic Society/European Respiratory Society criteria, and PD15 of the basal lung region using CT densitometry. Adverse events will be collected and documented. CONCLUSIONS The SPARTA trial is designed to evaluate the long-term (3-year) efficacy of 2 separate doses of Prolastin-C for the treatment of emphysema in patients with AATD. Protocol number: GTi1201. CLINICAL TRIALS IDENTIFIER NCT01983241.
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Affiliation(s)
- Susan Sorrells
- Grifols Inc., 79 TW Alexander Drive, Bldg 4201, P.O. Box 110526, Research Triangle Park, NC, USA.
| | - Sandra Camprubi
- Instituto Grifols S.A., Parc Empresarial Can Joan, Av. De la Generalitat, 152-158, 08174 Sant Cugat del Vallés, Barcelona, Spain
| | - Rhonda Griffin
- Grifols Inc., 79 TW Alexander Drive, Bldg 4201, P.O. Box 110526, Research Triangle Park, NC, USA
| | - Junliang Chen
- Grifols Inc., 79 TW Alexander Drive, Bldg 4201, P.O. Box 110526, Research Triangle Park, NC, USA
| | - Jaume Ayguasanosa
- Instituto Grifols S.A., Parc Empresarial Can Joan, Av. De la Generalitat, 152-158, 08174 Sant Cugat del Vallés, Barcelona, Spain
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Brusasco V, Barisione G, Crimi E. Pulmonary physiology: Future directions for lung function testing in COPD. Respirology 2014; 20:209-18. [DOI: 10.1111/resp.12388] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Accepted: 07/31/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Vito Brusasco
- Department of Internal Medicine and Medical Specialities (DiMI); Genova University and San Martino University Hospital; Genova Italy
| | - Giovanni Barisione
- Department of Internal Medicine and Medical Specialities (DiMI); Genova University and San Martino University Hospital; Genova Italy
| | - Emanuele Crimi
- Department of Internal Medicine and Medical Specialities (DiMI); Genova University and San Martino University Hospital; Genova Italy
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42
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Turner AM. Alpha-1 antitrypsin deficiency: new developments in augmentation and other therapies. BioDrugs 2014; 27:547-58. [PMID: 23771682 DOI: 10.1007/s40259-013-0042-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Alpha 1 antitrypsin deficiency (AATD) is a rare cause of chronic obstructive pulmonary disease. The lung disease is thought to be caused primarily by a lack of effective protection against the harmful effects of neutrophil elastase due to the low AAT levels in the lung. Patients may also develop liver disease due to polymerisation of AAT within hepatocytes. Consequently there has been much research over the years into AAT augmentation therapy in patients with lung disease, initially intravenously, and more recently in inhaled forms. This review article will discuss the role of augmentation therapy in AATD and the current status of recombinant AAT. The potential for other therapeutic strategies, such as blocking polymer formation, enhancing autophagy, gene therapy and stem cell-based treatment, will also be discussed more briefly.
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Affiliation(s)
- Alice M Turner
- QEHB Research Labs, University of Birmingham, Mindelsohn Way, Birmingham, B15 2WB, UK,
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43
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Relationship of the 2011 Global Initiative for Chronic Obstructive Lung Disease Strategy to Clinically Relevant Outcomes in Individuals with α1-Antitrypsin Deficiency. Ann Am Thorac Soc 2014; 11:859-64. [DOI: 10.1513/annalsats.201311-380oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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44
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Ward H, Turner AM, Stockley RA. Spirometric and Gas Transfer Discordance in α 1 -Antitrypsin Deficiency. Chest 2014; 145:1316-1324. [DOI: 10.1378/chest.13-1886] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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45
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Cuvelier A, Mornex JF. [The alpha-1 antitrypsin deficiency: advances in knowledge and unsolved questions]. Rev Mal Respir 2014; 31:295-9. [PMID: 24750949 DOI: 10.1016/j.rmr.2014.04.087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- A Cuvelier
- Service de pneumologie, unité de soins intensifs respiratoires, université de Rouen, CHU de Rouen, UPRES EA 3830, 76031 Rouen cedex, France.
| | - J-F Mornex
- Centre de référence des maladies rares pulmonaires, hospices civils de Lyon, université Lyon 1, Inra, UMR754, France
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Stockley RA. Biomarkers in chronic obstructive pulmonary disease: confusing or useful? Int J Chron Obstruct Pulmon Dis 2014; 9:163-77. [PMID: 24532968 PMCID: PMC3923613 DOI: 10.2147/copd.s42362] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The field of biomarker research has almost reached unmanageable proportions in chronic obstructive pulmonary disease (COPD). The developments of new technology platforms have generated a huge information data base, both cross sectionally and increasingly, longitudinally. The knowledge emerging provides an enormous potential for understanding the disease pathophysiology, for developing markers specific for long-term outcomes, and for developing new therapeutic strategies. However, the excitement must be tempered with an understanding of the limitations of the data collection techniques, and of the variations in disease state, activity, impact, and progression. Nevertheless, the most crucial aspect in interpreting the current literature is the recognition of the relatively superficial characterization of what is a complex group of pathological processes with a common end point of airflow limitation. The current review explores some of these issues together with those areas where real progress appears to have been made, and provides caution on interpretation.
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Affiliation(s)
- Robert A Stockley
- Queen Elizabeth Hospital Birmingham, Lung Function and Sleep Department, Birmingham, UK
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48
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Brebner JA, Stockley RA. Recent advances in α-1-antitrypsin deficiency-related lung disease. Expert Rev Respir Med 2014; 7:213-29; quiz 230. [DOI: 10.1586/ers.13.20] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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49
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α-1-Antitrypsin deficiency: clinical variability, assessment, and treatment. Trends Mol Med 2013; 20:105-15. [PMID: 24380646 DOI: 10.1016/j.molmed.2013.11.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 11/25/2013] [Accepted: 11/26/2013] [Indexed: 12/21/2022]
Abstract
The recognition of α-1-antitrypsin deficiency, its function, and its role in predisposition to the development of severe emphysema was a watershed in our understanding of the pathophysiology of the condition. This led to the concept and development of intravenous replacement therapy used worldwide to protect against lung damage induced by neutrophil elastase. Nevertheless, much remained unknown about the deficiency and its impact, although in recent years the genetic and clinical variations in manifestation have provided new insights into assessing impact, efficacy of therapy, and development of new therapeutic strategies, including gene therapy, and outcome measures, such as biomarkers and computed tomography. The current article reviews this progress over the preceding 50 years.
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