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Mulkareddy V, Roman J. Pulmonary manifestations of alpha 1 antitrypsin deficiency. Am J Med Sci 2024:S0002-9629(24)01157-1. [PMID: 38599244 DOI: 10.1016/j.amjms.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 04/02/2024] [Indexed: 04/12/2024]
Abstract
Alpha 1 antitrypsin deficiency is a widely under recognized autosomal codominant condition caused by genetic mutations in the SERPINA 1 gene, which encodes for alpha 1 antitrypsin (AAT), a serine protease inhibitor. The SERPINA 1 gene contains 120 variants and mutations in the gene may decrease AAT protein levels or result in dysfunctional proteins. This deficiency leads to unopposed protease activity in tissues, thereby promoting pulmonary and hepatic disease. The most common genotype associated with pulmonary disease is the ZZ genotype, and the most frequent pulmonary manifestation is emphysema. Although its pathophysiology may differ from cigarette smoking related chronic obstructive pulmonary disease, smoking itself can hasten lung decline in alpha 1 antitrypsin deficiency (AATD). The diagnosis of AATD is made through AAT protein testing along with genotyping. AATD patients with obstructive airflow limitation may qualify for intravenous augmentation with AAT. However, there is ongoing research to allow for earlier detection and treatment. This review describes in general terms the genetic mechanisms of AATD; its pathogenesis and the impact of cigarette smoke; and its clinical manifestations, diagnosis, treatment, and prognosis. We hope to stimulate research in the field, but mostly we wish to enhance awareness to promote early diagnosis and treatment in those eligible for intervention.
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Affiliation(s)
- Vani Mulkareddy
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine and The Jane & Leonard Korman Respiratory Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jesse Roman
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine and The Jane & Leonard Korman Respiratory Institute, Thomas Jefferson University, Philadelphia, PA, USA.
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2
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Zemtsovski JD, Tumpara S, Schmidt S, Vijayan V, Klos A, Laudeley R, Held J, Immenschuh S, Wurm FM, Welte T, Haller H, Janciauskiene S, Shushakova N. Alpha1-antitrypsin improves survival in murine abdominal sepsis model by decreasing inflammation and sequestration of free heme. Front Immunol 2024; 15:1368040. [PMID: 38562925 PMCID: PMC10982482 DOI: 10.3389/fimmu.2024.1368040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/27/2024] [Indexed: 04/04/2024] Open
Abstract
Background Excessive inflammation, hemolysis, and accumulation of labile heme play an essential role in the pathophysiology of multi-organ dysfunction syndrome (MODS) in sepsis. Alpha1-antitrypsin (AAT), an acute phase protein with heme binding capacity, is one of the essential modulators of host responses to inflammation. In this study, we evaluate the putative protective effect of AAT against MODS and mortality in a mouse model of polymicrobial abdominal sepsis. Methods Polymicrobial abdominal sepsis was induced in C57BL/6N mice by cecal ligation and puncture (CLP). Immediately after CLP surgery, mice were treated intraperitoneally with three different forms of human AAT-plasma-derived native (nAAT), oxidized nAAT (oxAAT), or recombinant AAT (recAAT)-or were injected with vehicle. Sham-operated mice served as controls. Mouse survival, bacterial load, kidney and liver function, immune cell profiles, cytokines/chemokines, and free (labile) heme levels were assessed. In parallel, in vitro experiments were carried out with resident peritoneal macrophages (MPMΦ) and mouse peritoneal mesothelial cells (MPMC). Results All AAT preparations used reduced mortality in septic mice. Treatment with AAT significantly reduced plasma lactate dehydrogenase and s-creatinine levels, vascular leakage, and systemic inflammation. Specifically, AAT reduced intraperitoneal accumulation of free heme, production of cytokines/chemokines, and neutrophil infiltration into the peritoneal cavity compared to septic mice not treated with AAT. In vitro experiments performed using MPMC and primary MPMΦ confirmed that AAT not only significantly decreases lipopolysaccharide (LPS)-induced pro-inflammatory cell activation but also prevents the enhancement of cellular responses to LPS by free heme. In addition, AAT inhibits cell death caused by free heme in vitro. Conclusion Data from the septic CLP mouse model suggest that intraperitoneal AAT treatment alone is sufficient to improve sepsis-associated organ dysfunctions, preserve endothelial barrier function, and reduce mortality, likely by preventing hyper-inflammatory responses and by neutralizing free heme.
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Affiliation(s)
- Jan D. Zemtsovski
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Srinu Tumpara
- Department of Respiratory Medicine, Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover Medical School, Hannover, Germany
| | | | - Vijith Vijayan
- Institute for Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Andreas Klos
- Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Robert Laudeley
- Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Julia Held
- Department of Respiratory Medicine, Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover Medical School, Hannover, Germany
| | - Stephan Immenschuh
- Institute for Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Florian M. Wurm
- Faculty of Life Sciences, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Tobias Welte
- Department of Respiratory Medicine, Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover Medical School, Hannover, Germany
| | - Hermann Haller
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Sabina Janciauskiene
- Department of Respiratory Medicine, Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover Medical School, Hannover, Germany
| | - Nelli Shushakova
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
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Feitosa PH. Diagnosis and augmentation therapy for alpha-1 antitrypsin deficiency: current knowledge and future potential. Drugs Context 2023; 12:2023-3-1. [PMID: 37521109 PMCID: PMC10379007 DOI: 10.7573/dic.2023-3-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/19/2023] [Indexed: 08/01/2023] Open
Abstract
The underdiagnosis of alpha-1 antitrypsin (AAT) deficiency (AATD) has been recognized for many years, yet little progress has been made in treatment of the disease. In this review, we summarize the AATD disease process as well as its diagnosis and treatment by AAT augmentation therapy. AATD is a rare autosomal disease that primarily affects the lungs and liver. AATD is associated with an increased susceptibility to developing pulmonary emphysema. The specific pharmacological treatment for AATD is intravenous administration of exogenous AAT. Augmentation therapy with AAT increases serum and pulmonary epithelial AAT levels, restores anti-elastase capacity, and decreases inflammatory mediators in the lung. Augmentation therapy reduces the loss of lung density over time, thus slowing progression of the disease. The effects of augmentation therapy on outcomes, such as frequency/duration of flare-ups, quality of life, lung function decline and mortality, are assessed. Wider testing for AATD, potentially through primary care physicians, could result in earlier treatment and better outcomes for individuals with AATD-induced lung respiratory disease.
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Bai X, Schountz T, Buckle AM, Talbert JL, Sandhaus RA, Chan ED. Alpha-1-antitrypsin antagonizes COVID-19: a review of the epidemiology, molecular mechanisms, and clinical evidence. Biochem Soc Trans 2023; 51:1361-1375. [PMID: 37294003 PMCID: PMC10317171 DOI: 10.1042/bst20230078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 06/10/2023]
Abstract
Alpha-1-antitrypsin (AAT), a serine protease inhibitor (serpin), is increasingly recognized to inhibit SARS-CoV-2 infection and counter many of the pathogenic mechanisms of COVID-19. Herein, we reviewed the epidemiologic evidence, the molecular mechanisms, and the clinical evidence that support this paradigm. As background to our discussion, we first examined the basic mechanism of SARS-CoV-2 infection and contend that despite the availability of vaccines and anti-viral agents, COVID-19 remains problematic due to viral evolution. We next underscored that measures to prevent severe COVID-19 currently exists but teeters on a balance and that current treatment for severe COVID-19 remains grossly suboptimal. We then reviewed the epidemiologic and clinical evidence that AAT deficiency increases risk of COVID-19 infection and of more severe disease, and the experimental evidence that AAT inhibits cell surface transmembrane protease 2 (TMPRSS2) - a host serine protease required for SARS-CoV-2 entry into cells - and that this inhibition may be augmented by heparin. We also elaborated on the panoply of other activities of AAT (and heparin) that could mitigate severity of COVID-19. Finally, we evaluated the available clinical evidence for AAT treatment of COVID-19.
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Affiliation(s)
- Xiyuan Bai
- Department of Medicine, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, U.S.A
- Department of Academic Affairs, National Jewish Health, Denver, CO, U.S.A
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO, U.S.A
| | - Tony Schountz
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, CO, U.S.A
| | - Ashley M. Buckle
- Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
- PTNG Bio, Melbourne, Australia
| | - Janet L. Talbert
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, U.S.A
| | | | - Edward D. Chan
- Department of Medicine, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, U.S.A
- Department of Academic Affairs, National Jewish Health, Denver, CO, U.S.A
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO, U.S.A
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Herth FJF, Sandhaus RA, Turner AM, Sucena M, Welte T, Greulich T. Alpha 1 Antitrypsin Therapy in Patients with Alpha 1 Antitrypsin Deficiency: Perspectives from a Registry Study and Practical Considerations for Self-Administration During the COVID-19 Pandemic. Int J Chron Obstruct Pulmon Dis 2021; 16:2983-2996. [PMID: 34754184 PMCID: PMC8570922 DOI: 10.2147/copd.s325211] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/27/2021] [Indexed: 01/06/2023] Open
Abstract
Alpha 1 Antitrypsin deficiency (AATD) is a hereditary condition characterized by low serum Alpha 1 Antitrypsin (AAT) levels and a predisposition towards early-onset emphysema. Infusion of AAT is the only disease-modifying therapy that can sufficiently raise plasma AAT levels above the putative protective threshold and reduce the decline in lung density loss. Several randomized controlled trials (RCTs) and registry studies support the clinical efficacy of AAT therapy in slowing the progression of AATD-related emphysema and improving survival outcomes. The COVID-19 pandemic has prompted physicians to develop additional strategies for delivering AAT therapy, which are not only more convenient for the patient, but are “COVID-19 friendly”, thereby reducing the risk of exposing these vulnerable patients. Intravenous (IV) self-administration of AAT therapy is likely to be beneficial in certain subgroups of patients with AATD and can remove the need for weekly hospital visits, thereby improving independence and well-being. Increasing the awareness of self-administration in AATD through the development of formal guidelines and training programs is required among both physicians and patients and will play an essential role, especially post-COVID-19, in encouraging physicians to consider self-administration for AATD in suitable patients. This review summarizes the benefits of AAT therapy on the clinical endpoints of mortality and quality of life (QoL) and discusses the benefits of self-administration therapy compared with conventional therapy administered by a healthcare professional. In addition, this review highlights the challenges of providing AAT therapy during the COVID-19 pandemic and the potential considerations for its implementation thereafter.
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Affiliation(s)
- Felix J F Herth
- Department of Pneumology and Critical Care Medicine, University of Heidelberg, Heidelberg, Germany
| | - Robert A Sandhaus
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
| | - Alice M Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, England
| | - Maria Sucena
- Pulmonology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Tobias Welte
- Department of Pulmonary and Infectious Diseases, Hannover Medical School, Hannover, Germany
| | - Timm Greulich
- Department of Internal Medicine and Pneumology, University Hospital Marburg, Marburg, Germany
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Barjaktarevic I, Campos M. Management of lung disease in alpha-1 antitrypsin deficiency: what we do and what we do not know. Ther Adv Chronic Dis 2021; 12_suppl:20406223211010172. [PMID: 34408831 PMCID: PMC8367208 DOI: 10.1177/20406223211010172] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 03/25/2021] [Indexed: 12/14/2022] Open
Abstract
Management of lung disease in patients with alpha-1 antitrypsin deficiency (AATD)
includes both non-pharmacological and pharmacological approaches. Lifestyle
changes with avoidance of environmental pollutants, including tobacco smoke,
improving exercise levels and nutritional status, all encompassed under a
disease management program, are crucial pillars of AATD management.
Non-pharmacological therapies follow conventional treatment guidelines for
chronic obstructive pulmonary disease. Specific pharmacological treatment
consists of administering exogenous alpha-1 antitrypsin (AAT) protein
intravenously (augmentation therapy). This intervention raises AAT levels in
serum and lung epithelial lining fluid, increases anti-elastase capacity, and
decreases several inflammatory mediators in the lung. Radiologically,
augmentation therapy reduces lung density loss over time, thus delaying disease
progression. The effect of augmentation therapy on other lung-related outcomes,
such as exacerbation frequency/length, quality of life, lung function decline,
and mortality, are less clear and questions regarding dose optimization or route
of administration are still debatable. This review discusses the rationale and
available evidence for these interventions in AATD.
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Affiliation(s)
- Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at University of California Los Angeles, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Michael Campos
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami School of Medicine, Miami, FL, USA
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Hawkins P, Sya J, Hup NK, Murphy MP, McElvaney NG, Reeves EP. Alpha-1 Antitrypsin Augmentation Inhibits Proteolysis of Neutrophil Membrane Voltage-Gated Proton Channel-1 in Alpha-1 Deficient Individuals. ACTA ACUST UNITED AC 2021; 57:medicina57080814. [PMID: 34441020 PMCID: PMC8398194 DOI: 10.3390/medicina57080814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Alpha-1 antitrypsin is a serine protease inhibitor that demonstrates an array of immunomodulatory functions. Individuals with the genetic condition of alpha-1 antitrypsin deficiency (AATD) are at increased risk of early onset emphysematous lung disease. This lung disease is partly driven by neutrophil mediated lung destruction in an environment of low AAT. As peripheral neutrophil hyper-responsiveness in AATD leads to excessive degranulation and increased migration to the airways, we examined the expression of the membrane voltage-gated proton channel-1 (HVCN1), which is integrally linked to neutrophil function. The objectives of this study were to evaluate altered HVCN1 in AATD neutrophils, serine protease-dependent degradation of HVCN1, and to investigate the ability of serum AAT to control HVCN1 expression. Materials and Methods: Circulating neutrophils were purified from AATD patients (n = 20), AATD patients receiving AAT augmentation therapy (n = 3) and healthy controls (n = 20). HVCN1 neutrophil expression was assessed by flow cytometry and Western blot analysis. Neutrophil membrane bound elastase was measured by fluorescence resonance energy transfer. Results: In this study we demonstrated that HVCN1 protein is under-expressed in AATD neutrophils (p = 0.02), suggesting a link between reduced HVCN1 expression and AAT deficiency. We have demonstrated that HVCN1 undergoes significant proteolytic degradation in activated neutrophils (p < 0.0001), primarily due to neutrophil elastase activity (p = 0.0004). In addition, the treatment of AATD individuals with AAT augmentation therapy increased neutrophil plasma membrane HVCN1 expression (p = 0.01). Conclusions: Our results demonstrate reduced levels of HVCN1 in peripheral blood neutrophils that may influence the neutrophil-dominated immune response in the AATD airways and highlights the role of antiprotease treatment and specifically AAT augmentation therapy in protecting neutrophil membrane expression of HVCN1.
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Ostermann L, Maus R, Stolper J, Schütte L, Katsarou K, Tumpara S, Pich A, Mueller C, Janciauskiene S, Welte T, Maus UA. Alpha-1 antitrypsin deficiency impairs lung antibacterial immunity in mice. JCI Insight 2021; 6:140816. [PMID: 33554955 PMCID: PMC7934856 DOI: 10.1172/jci.insight.140816] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 12/17/2020] [Indexed: 01/05/2023] Open
Abstract
Alpha-1 antitrypsin (AAT) is a major inhibitor of serine proteases in mammals. Therefore, its deficiency leads to protease–antiprotease imbalance and a risk for developing lung emphysema. Although therapy with human plasma-purified AAT attenuates AAT deficiency–related emphysema, its impact on lung antibacterial immunity is poorly defined. Here, we examined the effect of AAT therapy on lung protective immunity in AAT-deficient (KO) mice challenged with Streptococcus pneumoniae. AAT-KO mice were highly susceptible to S. pneumoniae, as determined by severe lobar pneumonia and early mortality. Mechanistically, we found that neutrophil-derived elastase (NE) degraded the opsonophagocytically important collectins, surfactant protein A (SP-A) and D (SP-D), which was accompanied by significantly impaired lung bacterial clearance in S. pneumoniae–infected AAT-KO mice. Treatment of S. pneumoniae–infected AAT-KO mice with human AAT protected SP-A and SP-D from NE-mediated degradation and corrected the pulmonary pathology observed in these mice. Likewise, treatment with Sivelestat, a specific inhibitor of NE, also protected collectins from degradation and significantly decreased bacterial loads in S. pneumoniae–infected AAT-KO mice. Our findings show that NE is responsible for the degradation of lung SP-A and SP-D in AAT-KO mice affecting lung protective immunity in AAT deficiency.
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Affiliation(s)
| | | | | | | | | | | | - Andreas Pich
- Institute of Toxicology and Core Facility Proteomics, Hannover Medical School, Hannover, Germany
| | - Christian Mueller
- Horae Gene Therapy Center, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Sabina Janciauskiene
- Clinic for Pneumology, and.,German Center for Lung Research, partner site BREATH, Hannover, Germany
| | - Tobias Welte
- Clinic for Pneumology, and.,German Center for Lung Research, partner site BREATH, Hannover, Germany
| | - Ulrich A Maus
- Division of Experimental Pneumology.,German Center for Lung Research, partner site BREATH, Hannover, Germany
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Sieluk J, Slejko JF, Silverman H, Perfetto E, Mullins CD. Medical costs of Alpha-1 antitrypsin deficiency-associated COPD in the United States. Orphanet J Rare Dis 2020; 15:260. [PMID: 32967697 PMCID: PMC7510284 DOI: 10.1186/s13023-020-01523-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 08/24/2020] [Indexed: 11/25/2022] Open
Abstract
Background There are limited data on economic aspects of the genetic variant of chronic obstructive pulmonary disease (COPD) in the context of the more prevalent form of COPD. The objective of this study was to isolate the healthcare resource utilization and economic burden attributable to the presence of a genetic factor among COPD patients with and without Alpha-1 Antitrypsin Deficiency (AATD), twelve months before and after their initial COPD diagnosis. Methods Retrospective analysis of OptumLabs® Data Warehouse claims (OLDW; 2000–2017). The OLDW is a comprehensive, longitudinal real-world data asset with de-identified lives across claims and clinical information. AATD-associated COPD cases were matched with up to 10 unique non-AATD-associated COPD controls. Healthcare resource use and costs were assigned into the following categories: office (OV), outpatient (OP), and emergency room visits (ER), inpatients stays (IP), prescription drugs (RX), and other services (OTH). A generalized linear model was used to estimate total pre- and post-index (initial COPD diagnosis) costs from a third-party payer’s perspective (2018 USD) controlling for confounders. Healthcare resource utilization was estimated using a negative binomial regression. Results The study population consisted of 8881 patients (953 cases matched with 7928 controls). The AATD-associated COPD cohort had higher expenditures and use of office visits (OV) and other (OTH) services, as well as OV, outpatient (OP), emergency room (ER), and prescription drugs (RX) before and after the index date, respectively. Adjusted total all-healthcare cost ratios for AATD-associated COPD patients as compared to controls were 2.04 [95% CI: 1.60–2.59] and 1.98 [95% CI: 1.55–2.52] while the incremental cost difference totaled $6861 [95% CI: $3025 - $10,698] and $5772 [95% CI: $1940 - $9604] per patient before and after the index date, respectively. Conclusions Twelve months before and after their initial COPD diagnosis, patients with AATD incur higher healthcare utilization costs that are double the cost of similar COPD patients without AATD. This study also suggests that increased costs of AATD-associated COPD are not solely attributable to augmentation therapy use. Future studies should further explore the relationship between augmentation therapy, healthcare resource use, and other AATD-associated COPD expenditures.
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Affiliation(s)
- Jan Sieluk
- Pharmaceutical Health Services Research Department, University of Maryland, School of Pharmacy, 220 Arch Street, Baltimore, MD, 21201, USA.,OptumLabs Visiting Fellow, OptumLabs, Cambridge, MA, USA
| | - Julia F Slejko
- Pharmaceutical Health Services Research Department, University of Maryland, School of Pharmacy, 220 Arch Street, Baltimore, MD, 21201, USA
| | - Henry Silverman
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eleanor Perfetto
- Pharmaceutical Health Services Research Department, University of Maryland, School of Pharmacy, 220 Arch Street, Baltimore, MD, 21201, USA.,National Health Council, Washington, DC, USA
| | - C Daniel Mullins
- Pharmaceutical Health Services Research Department, University of Maryland, School of Pharmacy, 220 Arch Street, Baltimore, MD, 21201, USA.
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Cortes-Lopez R, Barjaktarevic I. Alpha-1 Antitrypsin Deficiency: a Rare Disease? Curr Allergy Asthma Rep 2020; 20:51. [PMID: 32572624 DOI: 10.1007/s11882-020-00942-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Commonly categorized as a rare disease, alpha-1 antitrypsin deficiency (AATD) is neither rare, when compared to many other genetic disorders, nor an actual disease, but rather a predisposition toward a wide variety of diseases. It is one of the most common genetic disorders which can lead to a spectrum of clinical manifestations, ranging from no symptoms to progressively debilitating systemic disease, most commonly affecting the lung and liver. It is therefore imperative for clinicians to recognize and be familiar with the spectrum of presentations, methods of diagnosis, and clinical management of AATD. It is also imperative for scientists to recognize the potential for progress in the management of this disorder. RECENT FINDINGS This review focuses on the current state of knowledge of AATD, including the wide range of presentations, diagnosis, and clinical management. In addition to the clinical implications of severe AATD, we discuss the relevance of heterozygous state with mild or moderate AATD in the development of both lung and liver disease. While our understanding of the multiple roles of alpha-1 antitrypsin (AAT) is on the rise, with appreciation of its immunomodulatory, anti-infective, and anti-inflammatory properties, this knowledge has yet to impact our ability to predict outcomes. We discuss nuances of augmentation therapy and review novel therapeutic approaches currently under investigation. With the expanding knowledge about the complexities of AAT function and its clinical relevance, and with the increasing ability to diagnose early and intervene on AATD, it should be our goal to change the perception of AATD as a correctable inherited disorder rather than a fatal disease.
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Affiliation(s)
- Roxana Cortes-Lopez
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, CHS, Los Angeles, CA, 90095, USA
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, CHS, Los Angeles, CA, 90095, USA.
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Barrecheguren M, Miravitlles M. Treatment with inhaled α1-antitrypsin: a square peg in a round hole? Eur Respir J 2019; 54:54/5/1901894. [DOI: 10.1183/13993003.01894-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 09/27/2019] [Indexed: 11/05/2022]
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Rahaghi F, Omert L, Clark V, Sandhaus RA. Managing the Alpha-1 patient in the ICU: Adapting broad critical care strategies in AATD. J Crit Care 2019; 54:212-219. [PMID: 31614323 DOI: 10.1016/j.jcrc.2019.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 07/17/2019] [Accepted: 08/27/2019] [Indexed: 10/26/2022]
Abstract
Alpha-1 Antitrypsin Deficiency (AATD) is a progressive pulmonary disease under-recognized or misdiagnosed by clinicians. Patients with AATD can develop a variety of organ-specific complications and as a result, often require hospitalization and treatment within critical care and ICU settings. Due to the complexity of AATD there are minimal guidelines in place to address the specific and highly variable needs of these patients in the critical care setting. This review presents clinical considerations with respect to the management of patients with AATD and provides treatment recommendations for these patients in the critical care setting. In addition, we have outlined certain aspects of the care of this patient population that may be of interest to critical care practitioners. With greater disease awareness and earlier diagnosis the onset of symptoms can be delayed, which will ultimately reduce the frequency of deleterious health consequences.
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Affiliation(s)
- Franck Rahaghi
- Pulmonary and Critical Care Division, Cleveland Clinic Florida, Weston, Florida, United States.
| | - Laurel Omert
- CSL Behring, King of Prussia, PA, United States.
| | - Virginia Clark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, United States.
| | - Robert A Sandhaus
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, United States.
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Balbi B, Sangiorgi C, Gnemmi I, Ferrarotti I, Vallese D, Paracchini E, Delle Donne L, Corda L, Baderna P, Corsico A, Carone M, Brun P, Cappello F, Ricciardolo FL, Ruggeri P, Mumby S, Adcock IM, Caramori G, Di Stefano A. Bacterial load and inflammatory response in sputum of alpha-1 antitrypsin deficiency patients with COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:1879-1893. [PMID: 31686800 PMCID: PMC6709647 DOI: 10.2147/copd.s207203] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/10/2019] [Indexed: 01/18/2023] Open
Abstract
Background Airway inflammation may drive the progression of chronic obstructive pulmonary disease (COPD) associated with alpha-1 antitrypsin deficiency (AATD), but the relationship between airway microbiota and inflammation has not been investigated. Methods We studied 21 non-treated AATD (AATD-noT) patients, 20 AATD-COPD patients under augmentation therapy (AATD-AT), 20 cigarette smoke-associated COPD patients, 20 control healthy smokers (CS) and 21 non-smokers (CON) with normal lung function. We quantified sputum inflammatory cells and inflammatory markers (IL-27, CCL3, CCL5, CXCL8, LTB4, MPO) by ELISA, total bacterial load (16S) and pathogenic bacteria by qRT-PCR. Results AATD-AT patients were younger but had similar spirometric and DLCO values compared to cigarette smoke-associated COPD, despite a lower burden of smoking history. Compared to cigarette smoke-associated COPD, AATD-noT and AATD-AT patients had lower sputum neutrophil levels (p=0.0446, p=0.0135), total bacterial load (16S) (p=0.0081, p=0.0223), M. catarrhalis (p=0.0115, p=0.0127) and S. pneumoniae (p=0.0013, p=0.0001). Sputum IL-27 was significantly elevated in CS and cigarette smoke-associated COPD. AATD-AT, but not AATD-noT patients, had IL-27 sputum levels (pg/ml) significantly lower than COPD (p=0.0297) and these positively correlated with FEV1% predicted values (r=0.578, p=0.0307). Conclusions Compared to cigarette smoke-associated COPD, AATD-AT (COPD) patients have a distinct airway inflammatory and microbiological profile. The decreased sputum bacterial load and IL-27 levels in AATD-AT patients suggests that augmentation therapy play a role in these changes.
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Affiliation(s)
- Bruno Balbi
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
| | - Claudia Sangiorgi
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
| | - Isabella Gnemmi
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
| | - Ilaria Ferrarotti
- Department of Internal Medicine and Medical Therapy, University of Pavia , Pavia, Italy
| | - Davide Vallese
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
| | - Elena Paracchini
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
| | - Lorena Delle Donne
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
| | - Luciano Corda
- Medicina Respiratoria, Seconda Medicina Interna, Spedali Civili , Brescia, Italy
| | - Paolo Baderna
- Division of Pneumology, Aosta Hospital , Aosta, Italy
| | - Angelo Corsico
- Department of Internal Medicine and Medical Therapy, University of Pavia , Pavia, Italy
| | - Mauro Carone
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
| | - Paola Brun
- Department of Molecular Medicine, University of Padova , Padova, Italy
| | - Francesco Cappello
- Dipartimento di Biomedicina Sperimentale e Neuroscienze Cliniche, Sezione di Anatomia Umana, Università di Palermo, Palermo, Italy.,Euro-mediterranean Institute of Science and Technology (IEMEST) , Palermo, Italy
| | - Fabio Lm Ricciardolo
- Department of Clinical and Biological Sciences, A.O.U., San Luigi Gonzaga, Orbassano, University of Turin , Turin, Italy
| | - Paolo Ruggeri
- UOC Di Pneumologia, Dipartimento di Scienze Biomediche, Odontoiatriche e Delle Immagini Morfologiche e Funzionali (BIOMORF), Università di Messina, Messina, Italy
| | - Sharon Mumby
- Airways Disease Section, National Heart and Lung Institute, Imperial College London , UK
| | - Ian M Adcock
- Airways Disease Section, National Heart and Lung Institute, Imperial College London , UK
| | - Gaetano Caramori
- UOC Di Pneumologia, Dipartimento di Scienze Biomediche, Odontoiatriche e Delle Immagini Morfologiche e Funzionali (BIOMORF), Università di Messina, Messina, Italy
| | - Antonino Di Stefano
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
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14
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Chukowry PS, Edgar RG, Turner AM. Alpha 1 antitrypsin deficiency: a rare multisystem disease, predominantly affecting the lung. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1651640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Priya S Chukowry
- University Hospitals Birmingham NHS Foundation Trust, Heartlands Hospital, Birmingham, UK
| | - Ross Gareth Edgar
- University Hospitals Birmingham NHS Foundation Trust, Heartlands Hospital, Birmingham, UK
- Therapy Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alice M Turner
- University Hospitals Birmingham NHS Foundation Trust, Heartlands Hospital, Birmingham, UK
- Therapy Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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15
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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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16
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Kaner Z, Engelman R, Schuster R, Rider P, Greenberg D, Av-Gay Y, Benhar M, Lewis EC. S-Nitrosylation of α1-Antitrypsin Triggers Macrophages Toward Inflammatory Phenotype and Enhances Intra-Cellular Bacteria Elimination. Front Immunol 2019; 10:590. [PMID: 31001247 PMCID: PMC6454134 DOI: 10.3389/fimmu.2019.00590] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 03/05/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Human α1-antitrypsin (hAAT) is a circulating anti-inflammatory serine-protease inhibitor that rises during acute phase responses. in vivo, hAAT reduces bacterial load, without directly inhibiting bacterial growth. In conditions of excess nitric-oxide (NO), hAAT undergoes S-nitrosylation (S-NO-hAAT) and gains antibacterial capacity. The impact of S-NO-hAAT on immune cells has yet to be explored. Aim: Study the effects of S-NO-hAAT on immune cells during bacterial infection. Methods: Clinical-grade hAAT was S-nitrosylated and then compared to unmodified hAAT, functionally, and structurally. Intracellular bacterial clearance by THP-1 macrophages was assessed using live Salmonella typhi. Murine peritoneal macrophages were examined, and signaling pathways were evaluated. S-NO-hAAT was also investigated after blocking free mambranal cysteine residues on cells. Results: S-NO-hAAT (27.5 uM) enhances intracellular bacteria elimination by immunocytes (up to 1-log reduction). S-NO-hAAT causes resting macrophages to exhibit a pro-inflammatory and antibacterial phenotype, including release of inflammatory cytokines and induction of inducible nitric oxide synthase (iNOS) and TLR2. These pro-inflammatory effects are dependent upon cell surface thiols and activation of MAPK pathways. Conclusions: hAAT duality appears to be context-specific, involving S-nitrosylation in a nitric oxide rich environment. Our results suggest that S-nitrosylation facilitates the antibacterial activity of hAAT by promoting its ability to activate innate immune cells. This pro-inflammatory effect may involve transferring of nitric oxide from S-NO-hAAT to a free cysteine residue on cellular targets.
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Affiliation(s)
- Ziv Kaner
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Rotem Engelman
- Department of Biochemistry, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ronen Schuster
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Peleg Rider
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - David Greenberg
- The Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer-Sheva, Israel
| | - Yossef Av-Gay
- Division of Infectious Diseases, Departments of Medicine and Microbiology and Immunology, Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada
| | - Moran Benhar
- Department of Biochemistry, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Eli C Lewis
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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17
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Brantly ML, Lascano JE, Shahmohammadi A. Intravenous Alpha-1 Antitrypsin Therapy for Alpha-1 Antitrypsin Deficiency: The Current State of the Evidence. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2018; 6:100-114. [PMID: 30775428 DOI: 10.15326/jcopdf.6.1.2017.0185] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a largely monogenetic disorder associated with a high risk for the development of chronic obstructive pulmonary disease (COPD) and cirrhosis. Intravenous alpha-1 antitrypsin (AAT) therapy has been available for the treatment of individuals with AATD and COPD since the late 1980s. Initial Food and Drug Administration (FDA) approval was granted based on biochemical efficacy. Following its approval, the FDA, scientific community and third-party payers encouraged manufacturers of AAT therapy to determine its clinical efficacy. This task has proved challenging because AATD is a rare, orphan disorder comprised of individuals who are geographically dispersed and infrequently identified. In addition, robust clinical trial outcomes have been lacking until recently. This review provides an update on the evidence for the clinical efficacy of intravenous AAT therapy for patients with AATD-related emphysema.
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Affiliation(s)
- Mark L Brantly
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville
| | - Jorge E Lascano
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville
| | - Abbas Shahmohammadi
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville
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18
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Sieluk J, Levy J, Sandhaus RA, Silverman H, Holm KE, Mullins CD. Costs of Medical Care Among Augmentation Therapy Users and Non-Users with Alpha-1 Antitrypsin Deficiency in the United States. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2018; 6:6-16. [PMID: 30775420 DOI: 10.15326/jcopdf.6.1.2017.0187] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: This study is the first to utilize a large claims database to estimate medical costs of patients with alpha-1 antitrypsin deficiency (AATD) in the United States. Methods: Adult AATD patients were identified from the OptumLabs™ Data Warehouse. Insurer and patient out-of-pocket costs were categorized into the following cost buckets, stratified by augmentation therapy use: physician visits (PV), emergency department visits (ED), inpatient stays (IP), augmentation therapy (AUG), other prescription drug costs (RX), and other costs (OTH). Costs were weighted and adjusted to 2017 U.S. dollars using the medical care component of the consumer price index. Results: The study cohort consisted of9117 AATD patients followed for 53,872 person years observed between 1993 and 2015. The annual costs among AATD patients totaled $127,537 among augmentation therapy users and $15,874 among non-users. The major drivers of annual costs to the insurer among the 7975 patients not on augmentation therapy were: PV: $5352 (37.7%) and IP: $4506 (31.8%). Among the 1142 augmentation users, major annual cost drivers to the insurer were PV: $15,064 (12.3%) and AUG: $82,002 (66.7%). Annual patient out-of-pocket costs were $4601 (AUG: $2084 [45.3%]; RX: $940 [20.4%]) and $1689 (PV: $727 [43.0%]; RX: $589 [34.9%]) among augmentation therapy users and non-users, respectively. Averaged across the entire cohort, the average annual costs per AATD patient were $22,975, paid by insurers ($21,100) and patients ($1875). Conclusions: Annual medical costs among patients with AATD are $127,537 and $15,874 among augmentation therapy users and non-users, respectively, with 75.3% of the cost difference attributable to AUG.
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Affiliation(s)
- Jan Sieluk
- Pharmaceutical Health Services Research Department, School of Pharmacy, University of Maryland, Baltimore.,OptumLabs, Cambridge, Massachusetts
| | - Joseph Levy
- Pharmaceutical Health Services Research Department, School of Pharmacy, University of Maryland, Baltimore
| | - Robert A Sandhaus
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, Colorado
| | | | - Kristen E Holm
- Division of Medical, Behavioral, and Community Health, National Jewish Health, Denver, Colorado
| | - C Daniel Mullins
- Pharmaceutical Health Services Research Department, School of Pharmacy, University of Maryland, Baltimore
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19
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Baranovski BM, Schuster R, Nisim O, Brami I, Lior Y, Lewis EC. Alpha-1 Antitrypsin Substitution for Extrapulmonary Conditions in Alpha-1 Antitrypsin Deficient Patients. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2018; 5:267-276. [PMID: 30723784 DOI: 10.15326/jcopdf.5.4.2017.0161] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a genetic disorder which most commonly manifests as pulmonary emphysema. Accordingly, alpha-1 antitrypsin (AAT) augmentation therapy aims to reduce the progression of emphysema, as achieved by life-long weekly slow-drip infusions of plasma-derived affinity-purified human AAT. However, not all AATD patients will receive this therapy, due to either lack of medical coverage or low patient compliance. To circumvent these limitations, attempts are being made to develop lung-directed therapies, including inhaled AAT and locally-delivered AAT gene therapy. Lung transplantation is also an ultimate therapy option. Although less common, AATD patients also present with disease manifestations that extend beyond the lung, including vasculitis, diabetes and panniculitis, and appear to experience longer and more frequent hospitalization times and more frequent pneumonia bouts. In the past decade, new mechanism-based clinical indications for AAT therapy have surfaced, depicting a safe, anti-inflammatory, immunomodulatory and tissue-protective agent. Introduced to non-AATD individuals, AAT appears to provide relief from steroid-refractory graft-versus-host disease, from bacterial infections in cystic fibrosis and from autoimmune diabetes; preclinical studies show benefit also in multiple sclerosis, ulcerative colitis, rheumatoid arthritis, acute myocardial infarction and stroke, as well as ischemia-reperfusion injury and aberrant wound healing processes. While the current augmentation therapy is targeted towards treatment of emphysema, it is suggested that AATD patients may benefit from AAT augmentation therapy geared towards extrapulmonary pathologies as well. Thus, development of mechanism-based, context-specific AAT augmentation therapy protocols is encouraged. In the current review, we will discuss extrapulmonary manifestations of AATD and the potential of AAT augmentation therapy for these conditions.
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Affiliation(s)
- Boris M Baranovski
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ronen Schuster
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Omer Nisim
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ido Brami
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yotam Lior
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eli C Lewis
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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20
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Lomas DA. New Therapeutic Targets for Alpha-1 Antitrypsin Deficiency. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2018; 5:233-243. [PMID: 30723781 DOI: 10.15326/jcopdf.5.4.2017.0165] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Alpha-1antitrypsin deficiency (AATD) results from the intracellular polymerization and retention of mutant alpha-1antitrypsin (AAT) within the endoplasmic reticulum of hepatocytes. This causes cirrhosis whilst the deficiency of circulating AAT predisposes to early onset emphysema. This is an exciting time for researchers in the field with the development of novel therapies based on understanding the pathobiology of disease. I review here augmentation therapy to prevent the progression of lung disease and a range of approaches to treat the liver disease associated with the accumulation of mutant AAT: modifying proteostasis networks that are activated by Z AAT polymers, stimulating autophagy, small interfering RNA and small molecules to block intracellular polymerization, and stem cell technology to correct the genetic defect that underlies AATD.
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Affiliation(s)
- David A Lomas
- UCL Respiratory, Division of Medicine, University College London, United Kingdom
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21
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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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22
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Abstract
Pheno-/endotyping chronic obstructive pulmonary disease (COPD) is really important because it provides patients with precise and personalized medicine. The central concept of precision medicine is to take individual variability into account when making management decisions. Precision medicine should ensure that patients get the right treatment at the right dose at the right time, with minimum harmful consequences and maximum efficacy. Ideally, we should search for genetic and molecular biomarker-based profiles. Given the clinical complexity of COPD, it seems likely that a panel of several biomarkers will be required to characterize pathogenetic factors and their course over time. The need for biomarkers to guide the clinical care of individuals with COPD and to enhance the possibilities of success in drug development is clear and urgent, but biomarker development is tremendously challenging and expensive, and translation of research efforts to date has been largely ineffective. Furthermore, the development of personalized treatments will require a much more detailed understanding of the clinical and biological heterogeneity of COPD. Therefore, we are still far from being able to apply precision medicine in COPD and the treatable traits and FEV1-free approaches are attempts to precision medicine in COPD that must be considered still quite unsophisticated.
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23
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Dunlea DM, Fee LT, McEnery T, McElvaney NG, Reeves EP. The impact of alpha-1 antitrypsin augmentation therapy on neutrophil-driven respiratory disease in deficient individuals. J Inflamm Res 2018; 11:123-134. [PMID: 29618937 PMCID: PMC5875399 DOI: 10.2147/jir.s156405] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Alpha-1 antitrypsin (AAT) is the most abundant serine protease inhibitor circulating in the blood. AAT deficiency (AATD) is an autosomal codominant condition affecting an estimated 3.4 million individuals worldwide. The clinical disease associated with AATD can present in a number of ways including COPD, liver disease, panniculitis and antineutrophil cytoplasmic antibody vasculitis. AATD is the only proven genetic risk factor for the development of COPD, and deficient individuals who smoke are disposed to more aggressive disease. Principally, AAT is a serine protease inhibitor; however, over the past number of years, the assessment of AAT as simply an antiprotease has evolved, and it is now recognized that AAT has significant anti-inflammatory properties affecting a wide range of cells, including the circulating neutrophil.
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Affiliation(s)
- Danielle M Dunlea
- Irish Centre for Genetic Lung Disease, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Laura T Fee
- Irish Centre for Genetic Lung Disease, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Thomas McEnery
- Irish Centre for Genetic Lung Disease, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Noel G McElvaney
- Irish Centre for Genetic Lung Disease, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Emer P Reeves
- Irish Centre for Genetic Lung Disease, Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
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Gáldiz Iturri JB. Augmentation Therapy Nowadays: Con. Arch Bronconeumol 2018; 54:S0300-2896(18)30015-2. [PMID: 29422342 DOI: 10.1016/j.arbres.2017.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 12/14/2017] [Accepted: 12/20/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Juan Bautista Gáldiz Iturri
- Laboratorio Exploración Funcional, Servicio de Neumología, Hospital Universitario Cruces, CibeRes, Biocruces, Barakaldo, España.
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25
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α 1-Antitrypsin infusion for treatment of steroid-resistant acute graft-versus-host disease. Blood 2018; 131:1372-1379. [PMID: 29437593 DOI: 10.1182/blood-2017-11-815746] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 01/24/2018] [Indexed: 12/17/2022] Open
Abstract
Corticosteroid resistance after acute graft-versus-host disease (SR-aGVHD) results in high morbidity and mortality after allogeneic hematopoietic cell transplantation. Current immunosuppressive therapies for SR-aGVHD provide marginal effectiveness because of poor response or excessive toxicity, primarily from infection. α1-Antitrypsin (AAT), a naturally abundant serine protease inhibitor, is capable of suppressing experimental GVHD by downmodulating inflammation and increasing ratios of regulatory (Treg) to effector T cells (Teffs). In this prospective multicenter clinical study, we sought to determine the safety and response rate of AAT administration in SR-aGVHD. Forty patients with a median age of 59 years received intravenous AAT twice weekly for 4 weeks as first-line treatment of SR-aGVHD. The primary end point was overall response rate (ORR), the proportion of patients with SR-aGVHD in complete (CR) or partial response by day 28 without addition of further immunosuppression. Treatment was well tolerated without drug-related adverse events. A significant increase in serum levels of AAT was observed after treatment. The ORR and CR rates by day 28 were 65% and 35%, respectively, and included responses in all aGVHD target organs. At day 60, responses were sustained in 73% of patients without intervening immunosuppression. Infectious mortality was 10% at 6 months and 2.5% within 30 days of last AAT infusion. Consistent with preclinical data, correlative samples showed an increase in ratio of activated Tregs to Teffs after AAT treatment. These data suggest that AAT is safe and may be potentially efficacious in treating SR-aGVHD. This trial was registered at www.clinicaltrials.gov as #NCT01700036.
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Hassan T, de Santi C, Mooney C, McElvaney NG, Greene CM. Alpha-1 antitrypsin augmentation therapy decreases miR-199a-5p, miR-598 and miR-320a expression in monocytes via inhibition of NFκB. Sci Rep 2017; 7:13803. [PMID: 29062067 PMCID: PMC5653852 DOI: 10.1038/s41598-017-14310-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 10/09/2017] [Indexed: 02/07/2023] Open
Abstract
Alpha-1 antitrypsin (AAT) augmentation therapy involves infusion of plasma-purified AAT to AAT deficient individuals. Whether treatment affects microRNA expression has not been investigated. This study's objectives were to evaluate the effect of AAT augmentation therapy on altered miRNA expression in monocytes and investigate the mechanism. Monocytes were isolated from non-AAT deficient (MM) and AAT deficient (ZZ) individuals, and ZZs receiving AAT. mRNA (qRT-PCR, microarray), miRNA (miRNA profiling, qRT-PCR), and protein (western blotting) analyses were performed. Twenty one miRNAs were differentially expressed 3-fold between ZZs and MMs. miRNA validation studies demonstrated that in ZZ monocytes receiving AAT levels of miR-199a-5p, miR-598 and miR-320a, which are predicted to be regulated by NFκB, were restored to levels similar to MMs. Validated targets co-regulated by these miRNAs were reciprocally increased in ZZs receiving AAT in vivo and in vitro. Expression of these miRNAs could be increased in ZZ monocytes treated ex vivo with an NFκB agonist and decreased by NFκB inhibition. p50 and p65 mRNA and protein were significantly lower in ZZs receiving AAT than untreated ZZs. AAT augmentation therapy inhibits NFκB and decreases miR-199a-5p, miR-598 and miR-320a in ZZ monocytes. These NFκB-inhibitory properties may contribute to the anti-inflammatory effects of AAT augmentation therapy.
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Affiliation(s)
- Tidi Hassan
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Medicine, Faculty of Medicine, UKM Medical Centre, Jalan Yaakob Latiff, Bandar Tun Abdul Razak, 56000, Kuala Lumpur, Malaysia
| | - Chiara de Santi
- Lung Biology Group, Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Catherine Mooney
- School of Computer Science, University College Dublin, Dublin, Ireland
| | - Noel G McElvaney
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Catherine M Greene
- Lung Biology Group, Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland.
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Parr DG, Lara B. Clinical utility of alpha-1 proteinase inhibitor in the management of adult patients with severe alpha-1 antitrypsin deficiency: a review of the current literature. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:2149-2162. [PMID: 28769553 PMCID: PMC5529111 DOI: 10.2147/dddt.s105207] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Alpha-1 antitrypsin (AAT) functions primarily to inhibit neutrophil elastase, and its deficiency predisposes individuals to the development of chronic obstructive pulmonary disease (COPD). The putative protective serum concentration is generally considered to be above a threshold of 11 μM/L, and therapeutic augmentation of AAT above this value is believed to retard the progression of emphysema. Several AAT preparations, all derived from human donor plasma, have been commercialized since approval by the US Food and Drug Administration (FDA) in 1987. Biochemical efficacy has been demonstrated by augmentation of pulmonary antiprotease activity, but demonstration of clinical efficacy in randomized, placebo-controlled trials has been hampered by the practical difficulties of performing conventional studies in a rare disease with a relatively long natural history. Computed tomography has been applied to measure lung density as a more specific and sensitive surrogate outcome measure of emphysema than physiologic indices, such as forced expiratory volume in 1 second, and studies consistently show a therapeutic reduction in the rate of lung density decline. However, convincing evidence of benefit using traditional clinical measures remains elusive. Intravenous administration of AAT at a dose of 60 mg/kg/week is the commonest regime in use and has well-documented safety and tolerability. International and national guidelines on the management of AAT deficiency recommend intravenous augmentation therapy to supplement optimized usual COPD treatment in patients with severe deficiency and evidence of lung function impairment.
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Affiliation(s)
- David G Parr
- Department of Respiratory Medicine, Cardio-Respiratory Division, University Hospital Coventry, Coventry, UK
| | - Beatriz Lara
- Department of Respiratory Medicine, Cardio-Respiratory Division, University Hospital Coventry, Coventry, UK
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Carpagnano GE, Santacroce R, Palmiotti GA, Leccese A, Giuffreda E, Margaglione M, Foschino Barbaro MP, Aliberti S, Lacedonia D. A New SERPINA-1 Missense Mutation Associated with Alpha-1 Antitrypsin Deficiency and Bronchiectasis. Lung 2017; 195:679-682. [PMID: 28668972 DOI: 10.1007/s00408-017-0033-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/19/2017] [Indexed: 10/19/2022]
Abstract
Alpha-1-antitrypsin deficiency (AATD) is a genetic condition caused by SERPINA1 mutations, which culminates into lower protease inhibitor activity in the serum and predisposes to emphysema. Clinical manifestations of AATD are often associated to ZZ (p.Glu342Lys) and SZ (p.Glu264Val) genotypes and less frequently to rare deficiency or null alleles in heterozygous and homozygous states. We report a case of a 52-year-old woman with bronchiectasis without other potential causes other than an electrophoresis that showed a decrease of alpha-1 globin band and AAT levels below the normal value (78 mg/dl; v.n. 90-200 mg/dl). No S or Z mutation was identified, but sequencing analysis found a novel missense variant Ile74Asn (c.221T > A) in heterozygous state on an M3 allele (Glu400Asp) in the exon 2 of the SERPINA-1gene, probably leading to a dysfunctional protein. This mutation has never been previously identified, and it is interesting to note the association with bronchiectasis in the absence of emphysema.
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Affiliation(s)
- G E Carpagnano
- Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, University of Foggia, Foggia, Italy
| | - R Santacroce
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - G A Palmiotti
- Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, University of Foggia, Foggia, Italy.
| | - A Leccese
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - E Giuffreda
- Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, University of Foggia, Foggia, Italy
| | - M Margaglione
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - M P Foschino Barbaro
- Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, University of Foggia, Foggia, Italy
| | - S Aliberti
- Department of Pathophysiology and Transplantation, Cardio-Thoracic Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - D Lacedonia
- Department of Medical and Surgical Sciences, Institute of Respiratory Diseases, University of Foggia, Foggia, Italy
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29
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Rahaghi FF, Miravitlles M. Long-term clinical outcomes following treatment with alpha 1-proteinase inhibitor for COPD associated with alpha-1 antitrypsin deficiency: a look at the evidence. Respir Res 2017; 18:105. [PMID: 28558837 PMCID: PMC5450185 DOI: 10.1186/s12931-017-0574-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 05/05/2017] [Indexed: 02/07/2023] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a common hereditary disorder caused by mutations in the SERPINA1 gene, which encodes alpha-1 antitrypsin (AAT; also known as alpha 1-proteinase inhibitor, A1-PI). An important function of A1-PI in the lung is to inhibit neutrophil elastase, one of various proteolytic enzymes released by activated neutrophils during inflammation. Absence or deficiency of A1-PI leads to an imbalance between elastase and anti-elastase activity, which results in progressive, irreversible destruction of lung tissue, and ultimately the development of chronic obstructive pulmonary disease with early-onset emphysema. AATD is under-diagnosed, patients can experience long delays before obtaining an accurate diagnosis, and the consequences of delayed diagnosis or misdiagnosis can be severe. Currently, A1-PI therapy is the only available treatment that addresses disease etiology in patients with AATD; however, demonstrating clinical efficacy of A1-PI therapy is challenging. In order to show therapeutic efficacy with traditional endpoints such as forced expiratory volume in one second and mortality, large sample sizes and longer duration trials are required. However, AATD is a rare, slow progressive disease, which can take decades to manifest clinically and recruiting sufficient numbers of patients into prolonged placebo-controlled trials remains a significant obstacle. Despite this, the Randomized, placebo-controlled trial of augmentation therapy in Alpha 1-Proteinase Inhibitor Deficiency (RAPID) and RAPID Extension trial, the largest clinical program completed to date, utilized quantitative chest computed tomography as a sensitive and specific measure of the extent of emphysema. Findings from the RAPID/RAPID Extension program definitively confirmed the benefits of A1-PI therapy in slowing disease progression and provided evidence of a disease-modifying effect of A1-PI therapy in patients with AATD. These findings suggest that the early introduction of treatment in patients with severe emphysema-related AATD may delay the time to death, lung transplantation or crippling respiratory complaints. In addition, there is now limited evidence that A1-PI therapy provides a gain of more than five life-years, supporting previous observations based on registry data. With the clinical efficacy of A1-PI therapy now demonstrated, further studies are required to assess long-term outcomes.
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Affiliation(s)
- Franck F Rahaghi
- Pulmonary and Critical Care Division, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Ciber de Enfermedades Respiratorias (CIBERES), Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain
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30
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Chuchalin AG. [Bronchiectasis]. TERAPEVT ARKH 2017; 89:4-17. [PMID: 28378723 DOI: 10.17116/terarkh20178934-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The paper presents information on possible approaches to the classification, pathogenesis, and determination of the etiological causes of bronchiectasis. It discusses a group of bronchiectasis-associated diseases. It gives a detailed diagnostic algorithm aimed to establish the etiology of bronchiectasis and the markers of the efficiency of different treatment options. Much attention is paid to genetically predetermined bronchiectasis. Universal approaches to treating patients with bronchiectasis as a whole, as well as treatments for certain entities of bronchiectasis are discussed.
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Affiliation(s)
- A G Chuchalin
- Pulmonology Research Institute, Federal Biomedical Agency of Health of Russia, Moscow, Russia
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Abstract
Subjects with alpha-1 antitrypsin deficiency who develop pulmonary disease are managed following general treatment guidelines, including disease management interventions. In addition, administration of intravenous infusions of alpha-1 proteinase inhibitor (augmentation therapy) at regular schedules is a specific therapy for individuals with AATD with pulmonary involvement.This chapter summarizes the manufacturing differences of commercially available formulations and the available evidence of the effects of augmentation therapy. Biologically, there is clear evidence of in vivo local antiprotease effects in the lung and systemic immunomodulatory effects. Clinically, there is cumulative evidence of slowing lung function decline and emphysema progression. The optimal dose of augmentation therapy is being revised as well as more individualized assessment of who needs this therapy.
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Affiliation(s)
- Michael Campos
- Division of Pulmonary, Sleep and Critical Care Medicine, Miller School of Medicine, University of Miami, RMSB Room 7043 A (R-47), 1600 NW 10th Ave., Miami, FL, 33136, USA.
| | - Jorge Lascano
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Miami, FL, USA
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Abstract
α1-Antitrypsin deficiency (A1ATD) is an inherited disorder caused by mutations in SERPINA1, leading to liver and lung disease. It is not a rare disorder but frequently goes underdiagnosed or misdiagnosed as asthma, chronic obstructive pulmonary disease (COPD) or cryptogenic liver disease. The most frequent disease-associated mutations include the S allele and the Z allele of SERPINA1, which lead to the accumulation of misfolded α1-antitrypsin in hepatocytes, endoplasmic reticulum stress, low circulating levels of α1-antitrypsin and liver disease. Currently, there is no cure for severe liver disease and the only management option is liver transplantation when liver failure is life-threatening. A1ATD-associated lung disease predominately occurs in adults and is caused principally by inadequate protease inhibition. Treatment of A1ATD-associated lung disease includes standard therapies that are also used for the treatment of COPD, in addition to the use of augmentation therapy (that is, infusions of human plasma-derived, purified α1-antitrypsin). New therapies that target the misfolded α1-antitrypsin or attempt to correct the underlying genetic mutation are currently under development.
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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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Berman R, Jiang D, Wu Q, Chu HW. α1-Antitrypsin reduces rhinovirus infection in primary human airway epithelial cells exposed to cigarette smoke. Int J Chron Obstruct Pulmon Dis 2016; 11:1279-86. [PMID: 27354786 PMCID: PMC4910614 DOI: 10.2147/copd.s105717] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Human rhinovirus (HRV) infections target airway epithelium and are the leading cause of acute exacerbations of COPD. Cigarette smoke (CS) increases the severity of viral infections, but there is no effective therapy for HRV infection. We determined whether α1-antitrypsin (A1AT) reduces HRV-16 infection in CS-exposed primary human airway epithelial cells. Brushed bronchial epithelial cells from normal subjects and patients diagnosed with COPD were cultured at air–liquid interface to induce mucociliary differentiation. These cells were treated with A1AT or bovine serum albumin for 2 hours and then exposed to air or whole cigarette smoke (WCS) with or without HRV-16 (5×104 50% Tissue Culture Infective Dose [TCID50]/transwell) infection for 24 hours. WCS exposure significantly increased viral load by an average of fivefold and decreased the expression of antiviral genes interferon-λ1, OAS1, and MX1. When A1AT was added to WCS-exposed cells, viral load significantly decreased by an average of 29-fold. HRV-16 infection significantly increased HRV-16 receptor intercellular adhesion molecule-1 messenger RNA expression in air-exposed cells, which was decreased by A1AT. A1AT-mediated reduction of viral load was not accompanied by increased epithelial antiviral gene expression or by inhibiting the activity of 3C protease involved in viral replication or maturation. Our findings demonstrate that A1AT treatment prevents a WCS-induced increase in viral load and for the first time suggest a therapeutic effect of A1AT on HRV infection.
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Affiliation(s)
- Reena Berman
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Di Jiang
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Qun Wu
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Hong Wei Chu
- Department of Medicine, National Jewish Health, Denver, CO, USA
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35
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Abstract
Alpha-1 antitrypsin deficiency (AATD) is associated with premature onset of emphysema resulting from low serum A1-PI levels. The only available pharmacological treatment affecting the underlying cause of AATD is A1-PI therapy. AATD-related emphysema is considered a good model to study disease-modifying effects of treatment as the causative process has been identified. Disease modification is a sustained improvement in disease state following therapeutic intervention that persists when therapy is discontinued. Appropriate trial design and the use of valid study endpoints are key to illustrating disease modification, particularly in clinical trials of rare diseases where it can be difficult to recruit sufficient numbers of patients. Delayed-start trials are advantageous ethically as all patients ultimately receive active treatment and imaging techniques have proven promising as valid study endpoints. Specifically, computed tomography (CT) measured lung density has been used to monitor emphysema and is considered a more sensitive outcome than pulmonary function tests to monitor disease progression. This review will discuss the importance of clinical endpoints and trial design to determine disease modification and will review the evidence for disease modification in AATD-related emphysema. Until recently, clinical studies have not shown a significant effect of A1-PI therapy, possibly due to insufficient numbers of patients, short duration of clinical trials and lack of appropriate trial design. A recently completed randomised trial and open-label extension study followed a larger study population for a longer duration and incorporated a delayed-start design. The results demonstrated clinical efficacy of A1-PI therapy and indicate that treatment is disease-modifying.
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Affiliation(s)
- Joanna Chorostowska-Wynimko
- a Department of Genetics and Clinical Immunology , National Institute of Tuberculosis and Lung Diseases , Warsaw , Poland
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36
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Lior Y, Geyra A, Lewis EC. Therapeutic compositions and uses of alpha1-antitrypsin: a patent review (2012 – 2015). Expert Opin Ther Pat 2016; 26:581-9. [DOI: 10.1517/13543776.2016.1165210] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Hurley K, Reeves EP, Carroll TP, McElvaney NG. Tumor necrosis factor-α driven inflammation in alpha-1 antitrypsin deficiency: a new model of pathogenesis and treatment. Expert Rev Respir Med 2015; 10:207-22. [PMID: 26634397 DOI: 10.1586/17476348.2016.1127759] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Alpha-1 antitrypsin (AAT) deficiency (AATD) has traditionally been thought of as a genetic disorder characterized by lung destruction and early emphysema in a low AAT, and high neutrophil elastase (NE) environment in the lungs of affected individuals. Recently, a growing body of evidence has emerged to support the hypothesis that tumor necrosis factor alpha (TNF-α) is essential in the pathogenesis of both genetic AATD and non-genetic chronic obstructive pulmonary disease (COPD). Reports have highlighted the importance of TNF-α driven immune cell dysfunction in the development of lung disease in AATD. The authors discuss the role of AAT as a key modulator of TNF-α signaling firstly in the setting of AATD and secondly in other conditions where AAT augmentation therapy has potential utility as a novel therapy.
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Affiliation(s)
- Killian Hurley
- a Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland Education and Research Centre , Beaumont Hospital , Dublin , Ireland
| | - Emer P Reeves
- a Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland Education and Research Centre , Beaumont Hospital , Dublin , Ireland
| | - Tomás P Carroll
- a Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland Education and Research Centre , Beaumont Hospital , Dublin , Ireland
| | - Noel G McElvaney
- a Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland Education and Research Centre , Beaumont Hospital , Dublin , Ireland
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Teschler H. Long-term experience in the treatment of α1-antitrypsin deficiency: 25 years of augmentation therapy. Eur Respir Rev 2015; 24:46-51. [PMID: 25726554 PMCID: PMC9487776 DOI: 10.1183/09059180.10010714] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although it is often under-recognised, α1-antitrypsin deficiency (AATD) represents one of the most common genetic respiratory disorders worldwide. Since the publication of studies in the late 1980s, which demonstrated that plasma-derived augmentation therapy with intravenous α1-antitrypsin (AAT) can reverse the biochemical deficiencies in serum and lung fluid that characterise emphysema, augmentation therapy has become the cornerstone of patient management. This article, with a focus on experience gained in clinical practice in Germany, provides an overview of some of the research highlights and clinical experience gained in the use of augmentation therapy for AATD during the past 25 years, and briefly discusses the potential role of AAT augmentation therapy in lung transplant recipients. Additionally, the goals of AAT augmentation therapy will be discussed, namely to delay the progression of emphysema, reduce the frequency of exacerbations and improve health-related quality of life. Beyond pulmonary disease, there is recent growing evidence to indicate that AATD could also play a role in rare disorders such as panniculitis, granulomatosis with polyangiitis and ulcerative colitis. Overview of long-term experience gained with AAT augmentation therapy for the treatment of AATDhttp://ow.ly/HmJLR
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Affiliation(s)
- Helmut Teschler
- Dept of Respiratory Medicine, West German Lung Clinic, Essen University Hospital, Essen, Germany
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Giacoboni D, Barrecheguren M, Esquinas C, Rodríguez E, Berastegui C, López-Meseguer M, Monforte V, Bravo C, Pirina P, Miravitlles M, Román A. Características de la población candidata a trasplante pulmonar por enfermedad pulmonar obstructiva crónica y por enfisema secundario a déficit de alfa 1 antitripsina. Arch Bronconeumol 2015; 51:379-83. [DOI: 10.1016/j.arbres.2014.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 07/16/2014] [Accepted: 08/05/2014] [Indexed: 11/24/2022]
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40
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Milger K, Holdt LM, Teupser D, Huber RM, Behr J, Kneidinger N. Identification of a novel SERPINA-1 mutation causing alpha-1 antitrypsin deficiency in a patient with severe bronchiectasis and pulmonary embolism. Int J Chron Obstruct Pulmon Dis 2015; 10:891-7. [PMID: 26005342 PMCID: PMC4428364 DOI: 10.2147/copd.s80173] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Deficiency in the serine protease inhibitor, alpha-1 antitrypsin (AAT), is known to cause emphysema and liver disease. Other manifestations, including airway disease or skin disorders, have also been described. A 44-year-old woman presented to our emergency department with dyspnea and respiratory insufficiency. She had never smoked, and had been diagnosed with COPD 9 years earlier. Three months previously, she had suffered a pulmonary embolism. Chest computed tomography scan revealed severe cystic bronchiectasis with destruction of the lung parenchyma. The sweat test was normal and there was no evidence of the cystic fibrosis transmembrane conductance regulator (CFTR) mutation. Capillary zone electrophoresis showed a decrease of alpha-1 globin band and AAT levels were below the quantification limit (<25 mg/dL). No S or Z mutation was identified, but sequencing analysis found a homozygous cytosine and adenine (CA) insertion in exon 2 of the SERPINA-1 gene, probably leading to a dysfunctional protein (PI Null/Null). This mutation has not been previously identified. The atypical presentation of the patient, with severe cystic bronchiectasis, highlights AAT deficiency as a differential diagnosis in bronchiectasis. Further, awareness should be raised regarding a possible increased risk of thromboembolism associated with AAT deficiency.
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Affiliation(s)
- Katrin Milger
- Department of Internal Medicine V, University of Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research, Munich, Germany
| | | | - Daniel Teupser
- Institute of Laboratory Medicine, University of Munich, Munich, Germany
| | - Rudolf Maria Huber
- Department of Internal Medicine V, University of Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research, Munich, Germany
| | - Jürgen Behr
- Department of Internal Medicine V, University of Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research, Munich, Germany
| | - Nikolaus Kneidinger
- Department of Internal Medicine V, University of Munich, Comprehensive Pneumology Center, Member of the German Center for Lung Research, Munich, Germany
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41
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Traclet J, Delaval P, Terrioux P, Mornex JF. Augmentation therapy of alpha-1 antitrypsin deficiency associated emphysema. Rev Mal Respir 2015; 32:435-46. [PMID: 25908241 DOI: 10.1016/j.rmr.2014.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 03/12/2014] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Alpha-1 antitrypsin, secreted by the liver, inhibits neutrophil elastase. Its deficiency favours the development of emphysema. Restoring a "protective" serum level in deficient patients should make it possible to inhibit the development of emphysema. STATE OF THE ART Human plasma-derived alpha-1 antitrypsin is a blood-derived drug sold in France under the name Alfalastin(®). The recommended posology is an I.V. administration of 60 mg/kg once a week. Human plasma-derived alpha-1 antitrypsin restores anti-elastase protection in the lower lung and prevents experimental emphysema induced by the elastasis of human neutrophils in hamster. The low number of patients with alpha-1 antitrypsin deficiency is one of the difficulties to perform sufficiently powerful randomised studies. However, randomised studies have reported the efficacy of human plasma-derived alpha-1 antitrypsin perfusions on mortality, FEV1 decline and the frequency of exacerbations. Randomised control trials have demonstrated the efficacy of human plasma-derived alpha-1 antitrypsin perfusions on the loss of lung density assessed by CT scan. CONCLUSION Augmentation therapy is simple in its conception and implementation, but it is expensive. However, there are currently no other solutions.
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Affiliation(s)
- J Traclet
- Hospices civils de Lyon, 69000 Lyon, France; Centre de référence des maladies rares pulmonaires, 69000 Lyon, France
| | - P Delaval
- IRSET UMR Inserm U1085, université de Rennes 1, 35000 Rennes, France; Centre hospitalier universitaire de Rennes, 35000 Rennes, France
| | - P Terrioux
- Cabinet de pneumologie, 77100 Meaux, France
| | - J-F Mornex
- Hospices civils de Lyon, 69000 Lyon, France; Centre de référence des maladies rares pulmonaires, 69000 Lyon, France; Université Lyon 1, 69000 Lyon, France; INRA, UMR754, 69000 Lyon, France.
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42
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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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43
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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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44
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Guttman O, Baranovski BM, Schuster R, Kaner Z, Freixo-Lima GS, Bahar N, Kalay N, Mizrahi MI, Brami I, Ochayon DE, Lewis EC. Acute-phase protein α1-anti-trypsin: diverting injurious innate and adaptive immune responses from non-authentic threats. Clin Exp Immunol 2015; 179:161-72. [PMID: 25351931 DOI: 10.1111/cei.12476] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2014] [Indexed: 12/29/2022] Open
Abstract
One would assume that the anti-inflammatory activity of α1-anti-trypsin (AAT) is the result of inhibiting neutrophil enzymes. However, AAT exhibits tolerogenic activities that are difficult to explain by serine-protease inhibition or by reduced inflammatory parameters. Targets outside the serine-protease family have been identified, supporting the notion that elastase inhibition, the only functional factory release criteria for clinical-grade AAT, is over-emphasized. Non-obvious developments in the understanding of AAT biology disqualify it from being a straightforward anti-inflammatory agent: AAT does not block dendritic cell activities, nor does it promote viral and tumour susceptibilities, stunt B lymphocyte responses or render treated patients susceptible to infections; accordingly, outcomes of elevated AAT do not overlap those attained by immunosuppression. Aside from the acute-phase response, AAT rises during the third trimester of pregnancy and also in advanced age. At the molecular level, AAT docks onto cholesterol-rich lipid-rafts and circulating lipid particles, directly binds interleukin (IL)-8, ADAM metallopeptidase domain 17 (ADAM17) and danger-associated molecular pattern (DAMP) molecules, and its activity is lost to smoke, high glucose levels and bacterial proteases, introducing a novel entity - 'relative AAT deficiency'. Unlike immunosuppression, AAT appears to help the immune system to distinguish between desired responses against authentic threats, and unwanted responses fuelled by a positive feedback loop perpetuated by, and at the expense of, inflamed injured innocent bystander cells. With a remarkable clinical safety record, AAT treatment is currently tested in clinical trials for its potential benefit in a variety of categorically distinct pathologies that share at least one common driving force: cell injury.
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Affiliation(s)
- O Guttman
- Ben-Gurion University of the Negev, Faculty of Health Sciences, Department of Clinical Biochemistry and Pharmacology, Beer-Sheva, Israel
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45
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Therapy with plasma purified alpha1-antitrypsin (Prolastin®) induces time-dependent changes in plasma levels of MMP-9 and MPO. PLoS One 2015; 10:e0117497. [PMID: 25635861 PMCID: PMC4311911 DOI: 10.1371/journal.pone.0117497] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 12/25/2014] [Indexed: 01/04/2023] Open
Abstract
The common Z mutation (Glu342Lys) of α1-antitrypsin (A1AT) results in the polymerization and intracellular retention of A1AT protein. The concomitant deficiency of functional A1AT predisposes PiZZ subjects to early onset emphysema. Clinical studies have implied that, among the biomarkers associated with emphysema, matrix metalloproteinase 9 (MMP-9) is of particular importance. Increased plasma MMP-9 levels are proposed to predict the decline of lung function as well as greater COPD exacerbations in A1AT deficiency-associated emphysema. The aim of the present study was to investigate the effect of A1AT therapy (Prolastin) on plasma MMP-9 and myeloperoxidase (MPO) levels. In total 34 PiZZ emphysema patients were recruited: 12 patients without and 22 with weekly intravenous (60 mg/kg body weight) A1AT therapy. The quantitative analysis of A1AT, MMP-9 and MPO was performed in serum and in supernatants of blood neutrophils isolated from patients before and after therapy. Patients with Prolastin therapy showed significantly lower serum MMP-9 and MPO levels than those without therapy. However, parallel analysis revealed that a rapid infusion of Prolastin is accompanied by a transient elevation of plasma MMP-9 and MPO levels. Experiments with freshly isolated blood neutrophils confirmed that therapy with Prolastin causes transient MMP-9 and MPO release. Prolastin induced the rapid release of MMP-9 and MPO when added directly to neutrophil cultures and this reaction was associated with the presence of IgA in A1AT preparation. Our data support the conclusion that changes in plasma levels of MMP-9 and MPO mirror the effect of Prolastin on blood neutrophils.
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46
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Chotirmall SH, Al-Alawi M, McEnery T, McElvaney NG. Alpha-1 proteinase inhibitors for the treatment of alpha-1 antitrypsin deficiency: safety, tolerability, and patient outcomes. Ther Clin Risk Manag 2015; 11:143-51. [PMID: 25673994 PMCID: PMC4321641 DOI: 10.2147/tcrm.s51474] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Alpha-1 antitrypsin (AAT) deficiency remains an underrecognized genetic disease with predominantly pulmonary and hepatic manifestations. AAT is derived primarily from hepatocytes; however, macrophages and neutrophils are secondary sources. As the natural physiological inhibitor of several proteases, most importantly neutrophil elastase (NE), it plays a key role in maintaining pulmonary protease–antiprotease balance. In deficient states, unrestrained NE activity promotes damage to the lung matrix, causing structural defects and impairing host defenses. The commonest form of AAT deficiency results in a mutated Z AAT that is abnormally folded, polymerized, and aggregated in the liver. Consequently, systemic levels are lower, resulting in diminished pulmonary concentrations. Hepatic disease occurs due to liver aggregation of the protein, while lung destruction ensues from unopposed protease-mediated damage. In this review, we will discuss AAT deficiency, its clinical manifestations, and augmentation therapy. We will address the safety and tolerability profiles of AAT replacement in the context of patient outcomes and cost-effectiveness and outline future directions for work in this field.
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Affiliation(s)
- Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Mazen Al-Alawi
- Department of Respiratory Medicine, Beaumont Hospital, Dublin, Republic of Ireland
| | - Thomas McEnery
- Department of Respiratory Medicine, Beaumont Hospital, Dublin, Republic of Ireland
| | - Noel G McElvaney
- Department of Respiratory Medicine, Beaumont Hospital, Dublin, Republic of Ireland
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Kaner Z, Ochayon DE, Shahaf G, Baranovski BM, Bahar N, Mizrahi M, Lewis EC. Acute Phase Protein α1-Antitrypsin Reduces the Bacterial Burden in Mice by Selective Modulation of Innate Cell Responses. J Infect Dis 2014; 211:1489-98. [DOI: 10.1093/infdis/jiu620] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 10/17/2014] [Indexed: 02/06/2023] Open
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Abstract
Alpha-1 antitrypsin (AAT) deficiency is an under-recognized hereditary disorder associated with the premature onset of chronic obstructive pulmonary disease, liver cirrhosis in children and adults, and less frequently, relapsing panniculitis, systemic vasculitis and other inflammatory, autoimmune and neoplastic diseases. Severe AAT deficiency mainly affects Caucasian individuals and has its highest prevalence (1 : 2000-1 : 5000 individuals) in Northern, Western and Central Europe. In the USA and Canada, the prevalence is 1: 5000-10 000. Prevalence is five times lower in Latin American countries and is rare or nonexistent in African and Asian individuals. The key to successful diagnosis is by measuring serum AAT, followed by the determination of the phenotype or genotype if low concentrations are found. Case detection allows implementation of genetic counselling and, in selected cases, the application of augmentation therapy. Over the past decade, it has been demonstrated that AAT is a broad-spectrum anti-inflammatory, immunomodulatory, anti-infective and tissue-repair molecule. These new capacities are promoting an increasing number of clinical studies, new pharmacological formulations, new patent applications and the search for alternative sources of AAT (including transgenic and recombinant AAT) to meet the expected demand for treating a large number of diseases, inside and outside the context of AAT deficiency.
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Affiliation(s)
- F de Serres
- Center for the Evaluation of Risks to Human Reproduction, National Toxicology Program, National Institute of Environmental Health Sciences, Research Triangle Park, NC, USA
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Hurley K, Lacey N, O’Dwyer CA, Bergin DA, McElvaney OJ, O’Brien ME, McElvaney OF, Reeves EP, McElvaney NG. Alpha-1 Antitrypsin Augmentation Therapy Corrects Accelerated Neutrophil Apoptosis in Deficient Individuals. THE JOURNAL OF IMMUNOLOGY 2014; 193:3978-91. [DOI: 10.4049/jimmunol.1400132] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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50
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Bergin DA, Reeves EP, Hurley K, Wolfe R, Jameel R, Fitzgerald S, McElvaney NG. The circulating proteinase inhibitor α-1 antitrypsin regulates neutrophil degranulation and autoimmunity. Sci Transl Med 2014; 6:217ra1. [PMID: 24382893 DOI: 10.1126/scitranslmed.3007116] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pathological inflammation and autoimmune disease frequently involve elevated neutrophil activity in the absence of infectious agents. Tumor necrosis factor-α (TNF-α) contributes to many of the problems associated with autoimmune diseases. We investigated the ability of serum α-1 antitrypsin (AAT) to control TNF-α biosynthesis and signaling in neutrophils and assessed whether AAT deficiency (AATD) is a TNF-α-related disease. In vitro studies demonstrate that serum AAT coordinates TNF-α intracellular signaling and neutrophil degranulation of tertiary and secondary granules via modulation of ligand-receptor interactions. AATD patients homozygous for the Z allele were characterized by increased activation of the TNF-α system, as demonstrated by increased membrane TNF-α levels and increased plasma concentrations of TNF receptor 1 and neutrophil-released secondary and tertiary granule proteins. The incidence of autoantibodies directed against degranulated lactoferrin and surface protein accessible to these antibodies was increased in ZZ-AATD, leading to an enhanced rate of neutrophil reactive oxygen species production. Treatment of ZZ-AATD individuals with AAT augmentation therapy resulted in decreased membrane TNF-α expression and plasma levels of granule antigenic proteins and immunoglobulin G class autoantibodies. These results provide a mechanism by which AAT augmentation therapy affects TNF-α signaling in the circulating neutrophil, indicating promising potential of this therapy for other TNF-α-related diseases.
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Affiliation(s)
- David A Bergin
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland
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