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Choate R, Holm KE, Sandhaus RA, Mannino DM, Strange C. Long-Term SGRQ Stability in a Cohort of Individuals with Alpha-1 Antitrypsin Deficiency-Associated Lung Disease. Int J Chron Obstruct Pulmon Dis 2024; 19:889-900. [PMID: 38617018 PMCID: PMC11016265 DOI: 10.2147/copd.s443183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/25/2024] [Indexed: 04/16/2024] Open
Abstract
Background Health-related quality of life (HRQoL) assessments such as St. George's Respiratory Questionnaire (SGRQ) are often used as outcome measures to evaluate patient-perceived changes in health status among individuals with lung disease. Several factors have been linked to deterioration in SGRQ, including symptoms (dyspnea, wheezing) and exercise intolerance. Whether these findings apply to individuals with alpha-1 antitrypsin deficiency (AATD) remains incompletely studied. This longitudinal study examines the trajectory of SGRQ scores in a cohort of United States individuals with AATD-associated lung disease and defines factors associated with longitudinal change. Methods Individuals with AATD-associated lung disease enrolled in AlphaNet, a disease management program, who had ≥3 SGRQ measurements collected between 2009 and 2019, and baseline data for clinically important variables were included in these analyses. Data collected after lung transplants were excluded. Mixed-effects model analyses were used to evaluate the changes in SGRQ total and subscale scores over time and by modified Medical Research Council (mMRC) Scale, use of oxygen, age, sex, productive cough, and exacerbation frequency at baseline. Sensitivity analyses were conducted to examine the potential effect of survivor bias. Results Participants (n=2456, mean age 57.1±9.9 years, 47% female) had a mean SGRQ total score of 44.7±18.9 at baseline, 48% used oxygen regularly, and 55% had ≥2 exacerbations per year. The median length of follow-up was 6 (IQR 3-9) years. The SGRQ total score and subscales remained stable throughout the observation period. Age, mMRC categories, presence or absence of productive cough, frequency of exacerbations, and use of oxygen at baseline were significantly associated with the rate of change of SGRQ total (p<0.0001). Conclusion We observed long-term stability in HRQoL and an association between the rate of change in SGRQ and baseline mMRC, exacerbation frequency, productive cough, and use of oxygen in this cohort of individuals with AATD-associated lung disease.
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Affiliation(s)
- Radmila Choate
- University of Kentucky College of Public Health, Lexington, Kentucky, USA
| | - Kristen E Holm
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
- Alphanet, Inc., Coral Gables, Florida, USA
| | - Robert A Sandhaus
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
- Alphanet, Inc., Coral Gables, Florida, USA
| | - David M Mannino
- University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Charlie Strange
- Alphanet, Inc., Coral Gables, Florida, USA
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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2
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Vakili O, Mafi A, Pourfarzam M. Liver Disorders Caused by Inborn Errors of Metabolism. Endocr Metab Immune Disord Drug Targets 2024; 24:194-207. [PMID: 37357514 DOI: 10.2174/1871530323666230623120935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/09/2023] [Accepted: 05/18/2023] [Indexed: 06/27/2023]
Abstract
Inborn errors of metabolism (IEMs) are a vast array of inherited/congenital disorders, affecting a wide variety of metabolic pathways and/or biochemical processes inside the cells. Although IEMs are usually rare, they can be represented as serious health problems. During the neonatal period, these inherited defects can give rise to almost all key signs of liver malfunction, including jaundice, coagulopathy, hepato- and splenomegaly, ascites, etc. Since the liver is a vital organ with multiple synthetic, metabolic, and excretory functions, IEM-related hepatic dysfunction could seriously be considered life-threatening. In this context, the identification of those hepatic manifestations and their associated characteristics may promote the differential diagnosis of IEMs immediately after birth, making therapeutic strategies more successful in preventing the occurrence of subsequent events. Among all possible liver defects caused by IEMs, cholestatic jaundice, hepatosplenomegaly, and liver failure have been shown to be manifested more frequently. Therefore, the current study aims to review substantial IEMs that mostly result in the aforementioned hepatic disorders, relying on clinical principles, especially through the first years of life. In this article, a group of uncommon hepatic manifestations linked to IEMs is also discussed in brief.
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Affiliation(s)
- Omid Vakili
- Department of Clinical Biochemistry, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Mafi
- Department of Clinical Biochemistry, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Morteza Pourfarzam
- Department of Clinical Biochemistry, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
- Bioinformatics Research Center, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
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3
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Miravitlles M, Anzueto A, Barrecheguren M. Nine controversial questions about augmentation therapy for alpha-1 antitrypsin deficiency: a viewpoint. Eur Respir Rev 2023; 32:230170. [PMID: 38056890 DOI: 10.1183/16000617.0170-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/16/2023] [Indexed: 12/08/2023] Open
Abstract
Augmentation therapy with intravenous alpha-1 antitrypsin is the only specific treatment for alpha-1 antitrypsin deficiency (AATD)-associated emphysema. This treatment has been available and remained basically unchanged for more than 35 years, but many questions persist regarding its indications, regimen of administration and efficacy. Because AATD is a rare disease, it has not been possible to conduct randomised, placebo-controlled trials that are adequately powered for the usual outcomes analysed in non-AATD-related COPD, such as lung function decline, exacerbations, symptoms or quality of life. New outcomes such as lung densitometry measured by computed tomography are more sensitive for identifying emphysema progression but are not widely accepted by regulatory agencies. In addition, clinical manifestations, severity and the natural history of lung disease associated with AATD are very heterogeneous, which means that individual prediction of prognosis is challenging. Therefore, the indication for augmentation is sometimes a dilemma between initiating treatment in individuals who may not develop significant lung disease or in whom disease will not progress and delaying it in patients who will otherwise rapidly and irreversibly progress.Other areas of debate are the possible indication for augmentation in patients with severe AATD and respiratory diseases other than emphysema, such as bronchiectasis or asthma, and the use of therapy after lung transplant in AATD patients. All these uncertainties imply that the indication for treatment must be personalised in expert reference centres after in-depth discussion of the pros and cons of augmentation with the patient.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Antonio Anzueto
- Pulmonary Disease/Critical Care, University of Texas Health, and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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4
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De Soyza J, Pye A, Turner AM. Are clinical trials into emerging drugs for the treatment of alpha-1 antitrypsin deficiency providing promising results? Expert Opin Emerg Drugs 2023; 28:227-231. [PMID: 38112023 DOI: 10.1080/14728214.2023.2296088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/13/2023] [Indexed: 12/20/2023]
Affiliation(s)
- Joshua De Soyza
- Institute of Applied Health, University of Birmingham, Birmingham, UK
| | - Anita Pye
- Institute of Applied Health, University of Birmingham, Birmingham, UK
| | - Alice M Turner
- Institute of Applied Health, University of Birmingham, Birmingham, UK
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5
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Roche S, Carroll TP, Mcelvaney NG. Provider Education in Alpha 1 Antitrypsin Deficiency: Try Again, Fail Again, Fail Better. ATS Sch 2023; 4:396-399. [PMID: 38196687 PMCID: PMC10773271 DOI: 10.34197/ats-scholar.2023-0128ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Affiliation(s)
- Suzanne Roche
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tomás P Carroll
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Noel G Mcelvaney
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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6
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Schumacher RC, Chiu CY, Lubarda J, Aboulsaoud P, Bomberger J, Wells JM. A Novel Provider Education Module to Enhance Detection of Alpha-1 Antitrypsin Deficiency. ATS Sch 2023; 4:490-501. [PMID: 38196685 PMCID: PMC10773490 DOI: 10.34197/ats-scholar.2023-0028oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/22/2023] [Indexed: 01/11/2024] Open
Abstract
Background Alpha-1 antitrypsin deficiency (AATD) is the most common genetic risk factor for early-onset emphysema. However, AATD continues to be underrecognized and underdiagnosed. Provider awareness about AATD, concerns with testing costs, and limited understanding about therapeutic options contribute to its underdiagnosis. We hypothesized that provider education would improve awareness of AATD and improve screening. Objective To evaluate the impact of a targeted provider education module on AATD screening. Methods We developed a web-based education module to address barriers to screening for AATD, deployed the education module using the Medscape Education platform, assessed perceived healthcare provider confidence in AATD screening, and conducted a prospective pre and postintervention study of AATD testing practices at a high-volume academic outpatient subspecialty pulmonary clinic. Results A total of 11,385 healthcare providers, including eight pulmonologists at our institution, completed the web-based education module. Confidence in identifying patients at high risk for AATD improved after completing the module ("not confident" in AATD screening was 7.7% postintervention compared with 19.4% preintervention). The rate of screening patients at high risk for AATD improved more than twofold (AATD screening rate 9.7% preintervention vs. 20.4% postintervention; P = 0.004). Among patients screened for AATD in our cohort, 27.2% had a genotype/phenotype or low alpha-1 antitrypsin concentration consistent with AATD. Conclusion Targeted healthcare provider education can improve the confidence in testing for AATD. Improvements in provider confidence corresponded to improvements in AATD screening in a subspecialty pulmonary clinic. More than one-fourth of screening tests suggested AATD, underpinning the value of testing in high-risk individuals.
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Affiliation(s)
- Ross C. Schumacher
- Division of Pulmonary, Allergy, and
Critical Care Medicine, Department of Medicine, and
- Lung Health Center, University of Alabama
at Birmingham, Birmingham, Alabama
| | - Chia-Ying Chiu
- Division of Pulmonary, Allergy, and
Critical Care Medicine, Department of Medicine, and
- Lung Health Center, University of Alabama
at Birmingham, Birmingham, Alabama
| | | | | | | | - J. Michael Wells
- Division of Pulmonary, Allergy, and
Critical Care Medicine, Department of Medicine, and
- Lung Health Center, University of Alabama
at Birmingham, Birmingham, Alabama
- Birmingham Veterans Affairs Healthcare
System, Birmingham, Alabama
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7
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Tural Onur S, Natoli A, Dreger B, Arınç S, Sarıoğlu N, Çörtük M, Karadoğan D, Şenyiğit A, Yıldız BP, Köktürk N, Argun Barıs S, Kodalak Cengiz S, Polatli M. An Alpha-1 Antitrypsin Deficiency Screening Study in Patients with Chronic Obstructive Pulmonary Disease, Bronchiectasis, or Asthma in Turkey. Int J Chron Obstruct Pulmon Dis 2023; 18:2785-2794. [PMID: 38046982 PMCID: PMC10693271 DOI: 10.2147/copd.s425835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/27/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose Alpha-1 antitrypsin deficiency (AATD) is a rare hereditary condition characterized by decreased serum alpha-1 antitrypsin (AAT) levels. We aim to identify AATD in patients with chronic obstructive pulmonary disease (COPD), bronchiectasis, or asthma and to report the frequency of AAT variants in Turkey. Patients and Methods This non-interventional, multicenter, prospective study was conducted between October 2021 and June 2022. Adult patients with COPD, bronchiectasis, asthma, liver symptoms, or family members with AATD were included. Demographic and clinical characteristics, pulmonary diagnosis, respiratory symptoms, and AAT serum levels were assessed. Whole blood samples were collected as dried blood spots, and the most common AATD mutations were simultaneously tested by allele-specific genotyping. Results A total of 1088 patients, mainly diagnosed with COPD (92.7%) and shortness of breath (78.7%), were assessed. Fifty-one (5%) were found to have AATD mutations. Fifteen (29.4%) patients had Pi*S or Pi*Z mutations, whereas 36 (70.6%) patients carried rare alleles Pi*M malton (n=18, 35.3% of mutations), Pi*I (n=8, 16%), Pi*P lowell (n=7, 14%), Pi*M heerlen (n=2, 4%), and Pi*S iiyama (n=1, 2%). The most common heterozygous combinations were Pi*M/Z (n=12, 24%), and Pi*M/M malton (n=11, 22%). Ten patients with severe AATD due to two deficiency alleles were identified, two with the Pi*Z/Z genotype, four with the genotype Pi*M malton/M malton, three with Pi*Z/M malton, and one with Pi*Z/M heerlen. Conclusion Our results identified AATD mutations as a genetic-based contributor to lung disease in patients with COPD or bronchiectasis and assessed their frequency in a population of Turkish patients.
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Affiliation(s)
- Seda Tural Onur
- Department of Pulmonology, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, University of Health Sciences, Istanbul, Türkiye
| | - Antonino Natoli
- Scientific and Medical Affairs, Scientific Innovation Office, Grifols, Frankfurt, Deutschland
| | - Bettina Dreger
- Scientific and Medical Affairs, Scientific Innovation Office, Grifols, Frankfurt, Deutschland
| | - Sibel Arınç
- Clinic of Chest Diseases, University of Health Sciences Turkey, S.B.Ü. Süreyyapaşa Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Türkiye
| | - Nurhan Sarıoğlu
- Department of Pulmonology, Balıkesir University Faculty of Medicine, Pulmonology Clinic, Balıkesir, Türkiye
| | - Mustafa Çörtük
- Department of Pulmonology, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, University of Health Sciences, Istanbul, Türkiye
| | - Dilek Karadoğan
- Department of Chest Diseases, Recep Tayyip Erdoğan University, School of Medicine, Rize, Türkiye
| | - Abdurrahman Şenyiğit
- Department of Chest Diseases, Dicle University Faculty of Medicine Hospital, Diyarbakır, Türkiye
| | - Birsen Pınar Yıldız
- Department of Pulmonology, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, University of Health Sciences, Istanbul, Türkiye
| | - Nurdan Köktürk
- Department of Pulmonary Medicine, Gazi University, School of Medicine, Ankara, Türkiye
| | - Serap Argun Barıs
- Department of Pulmonary Diseases, Faculty of Medicine, Kocaeli University, Kocaeli, Türkiye
| | | | - Mehmet Polatli
- Faculty of Medicine, Aydin Adnan Menderes University, Aydin, Türkiye
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8
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Choate R, Holm KE, Sandhaus RA, Mannino DM, Strange C. Health-related Quality of Life in Alpha-1 Antitrypsin Deficiency-associated Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2023; 208:1132-1134. [PMID: 37581489 DOI: 10.1164/rccm.202304-0697le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/14/2023] [Indexed: 08/16/2023] Open
Affiliation(s)
| | - Kristen E Holm
- Department of Medicine, National Jewish Health, Denver, Colorado
- AlphaNet, Inc., Coral Gables, Florida; and
| | - Robert A Sandhaus
- Department of Medicine, National Jewish Health, Denver, Colorado
- AlphaNet, Inc., Coral Gables, Florida; and
| | - David M Mannino
- College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Charlie Strange
- AlphaNet, Inc., Coral Gables, Florida; and
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina
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9
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Fraughen DD, Ghosh AJ, Hobbs BD, Funk GC, Meischl T, Clarenbach CF, Sievi NA, Schmid-Scherzer K, McElvaney OJ, Murphy MP, Roche AD, Clarke L, Strand M, Vafai-Tabrizi F, Kelly G, Gunaratnam C, Carroll TP, McElvaney NG. Augmentation Therapy for Severe Alpha-1 Antitrypsin Deficiency Improves Survival and Is Decoupled from Spirometric Decline-A Multinational Registry Analysis. Am J Respir Crit Care Med 2023; 208:964-974. [PMID: 37624745 PMCID: PMC10870866 DOI: 10.1164/rccm.202305-0863oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/24/2023] [Indexed: 08/27/2023] Open
Abstract
Rationale: Intravenous plasma-purified alpha-1 antitrypsin (IV-AAT) has been used as therapy for alpha-1 antitrypsin deficiency (AATD) since 1987. Previous trials (RAPID and RAPID-OLE) demonstrated efficacy in preserving computed tomography of lung density but no effect on FEV1. This observational study evaluated 615 people with severe AATD from three countries with socialized health care (Ireland, Switzerland, and Austria), where access to standard medical care was equal but access to IV-AAT was not. Objectives: To assess the real-world longitudinal effects of IV-AAT. Methods: Pulmonary function and mortality data were utilized to perform longitudinal analyses on registry participants with severe AATD. Measurements and Main Results: IV-AAT confers a survival benefit in severe AATD (P < 0.001). We uncovered two distinct AATD phenotypes based on an initial respiratory diagnosis: lung index and non-lung index. Lung indexes demonstrated a more rapid FEV1 decline between the ages of 20 and 50 and subsequently entered a plateau phase of minimal decline from 50 onward. Consequentially, IV-AAT had no effect on FEV1 decline, except in patients with a Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 2 lung index. Conclusions: This real-world study demonstrates a survival advantage from IV-AAT. This improved survival is largely decoupled from FEV1 decline. The observation that patients with severe AATD fall into two major phenotypes has implications for clinical trial design where FEV1 is a primary endpoint. Recruits into trials are typically older lung indexes entering the plateau phase and, therefore, unlikely to show spirometric benefits. IV-AAT attenuates spirometric decline in lung indexes in GOLD stage 2, a spirometric group commonly outside current IV-AAT commencement recommendations.
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Affiliation(s)
- Daniel D. Fraughen
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Auyon J. Ghosh
- Division of Pulmonary, Critical Care, and Sleep Medicine, SUNY Upstate University Hospital, Syracuse, New York
| | - Brian D. Hobbs
- Channing Division of Network Medicine and Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Georg-Christian Funk
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology and Department of Medicine II with Pneumology, Klinik Ottakring, Vienna, Austria
| | - Tobias Meischl
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology and Department of Medicine II with Pneumology, Klinik Ottakring, Vienna, Austria
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Noriane A. Sievi
- Department of Pneumology, University Hospital Zurich, Zurich, Switzerland
| | - Karin Schmid-Scherzer
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology and Department of Medicine II with Pneumology, Klinik Ottakring, Vienna, Austria
| | - Oliver J. McElvaney
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - Mark P. Murphy
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Adam D. Roche
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Louise Clarke
- Department of Respiratory Physiology, Beaumont Hospital, Dublin, Ireland; and
| | - Matthew Strand
- Division of Biostatistics and Bioinformatics, National Jewish Health, Denver, Colorado
| | - Florian Vafai-Tabrizi
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology and Department of Medicine II with Pneumology, Klinik Ottakring, Vienna, Austria
| | - Geraldine Kelly
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Cedric Gunaratnam
- Department of Respiratory Physiology, Beaumont Hospital, Dublin, Ireland; and
| | - Tomás P. Carroll
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Noel G. McElvaney
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
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10
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Devine AJ, Smith NJ, Joshi R, Fan Q, Borchers MT, Clair GC, Adkins JN, Varisco BM. Chymotrypsin-like Elastase-1 Mediates Progressive Emphysema in Alpha-1 Antitrypsin Deficiency. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2023; 10:380-391. [PMID: 37534975 DOI: 10.15326/jcopdf.2023.0416] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
Chymotrypsin-like elastase 1 (CELA1) is a serine protease that is neutralized by alpha-1antitrypsin (AAT) and prevents emphysema in a murine antisense oligonucleotide model of AAT-deficient emphysema. Mice with genetic ablation of AAT do not have emphysema at baseline but develop emphysema with injury and aging. We tested the role of the CELA1 gene in emphysema development in this genetic model of AAT-deficiency following tracheal lipopolysaccharide (LPS), 10 months of cigarette smoke exposure, aging, and a low-dose tracheal porcine pancreatic elastase (LD-PPE) model we developed. In this last model, we performed proteomic analysis to understand differences in lung protein composition. We were unable to show that AAT-deficient mice developed more emphysema than wild type with escalating doses of LPS. In the LD-PPE model, AAT-deficient mice developed significant and progressive emphysema from which Cela1-/- & AAT-deficient mice were protected. Cela1-/-& AAT-deficient lungs had more matrix-associated proteins than AAT-deficientlungs but also had more leukocyte-associated proteases. With cigarette smoke exposure, Cela1-/- &AAT-deficient mice had more emphysema than AAT-deficient mice but had less myeloperoxidase activity. Cela1-/-&AAT-deficient mice had less age-related airspace simplification than AAT-deficient and were comparable to wild type. While CELA1 promotes inflammation-independent emphysema progression and its absence preserves the lung matrix in multiple models of AAT-deficient emphysema, for unclear reasons Cela1 deficiency is associated with increased emphysema with cigarette smoke. While anti-CELA1 therapies could potentially be used to prevent emphysema progression in AAT deficiency after smoking cessation, an understanding of why and how cigarette smoke exacerbates emphysema in Cela1 deficiency and whether AAT replacement therapy mitigates this effect is needed first.
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Affiliation(s)
- Andrew J Devine
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Noah J Smith
- University of Cincinnati School of Medicine, Cincinnati, Ohio, United States
| | - Rashika Joshi
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Qiang Fan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Michael T Borchers
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
- Division of Pulmonary and Critical Care Medicine, University of Cincinnati, Cincinnati, Ohio, United States
| | - Geremy C Clair
- Pacific Northwest National Laboratory, Richland, Washington, United States
| | - Joshua N Adkins
- Pacific Northwest National Laboratory, Richland, Washington, United States
| | - Brian M Varisco
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
- University of Cincinnati School of Medicine, Cincinnati, Ohio, United States
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
- Arkansas Children's Research Institute, Little Rock, Arkansas, United States
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11
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He G, Yu W, Li H, Liu J, Tu Y, Kong D, Long Z, Liu R, Peng J, Wang Z, Liu P, Hai C, Yan W, Li W. Alpha-1 antitrypsin protects against phosgene-induced acute lung injury by activating the ID1-dependent anti-inflammatory response. Eur J Pharmacol 2023; 957:176017. [PMID: 37673367 DOI: 10.1016/j.ejphar.2023.176017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/24/2023] [Accepted: 08/24/2023] [Indexed: 09/08/2023]
Abstract
Phosgene is widely used as an industrial chemical, and phosgene inhalation causes acute lung injury (ALI), which may further progress into pulmonary edema. Currently, an antidote for phosgene poisoning is not known. Alpha-1 antitrypsin (α1-AT) is a protease inhibitor used to treat patients with emphysema who are deficient in α1-AT. Recent studies have revealed that α1-AT has both anti-inflammatory and anti-SARS-CoV-2 effects. Herein, we aimed to investigate the role of α1-AT in phosgene-induced ALI. We observed a time-dependent increase in α1-AT expression and secretion in the lungs of rats exposed to phosgene. Notably, α1-AT was derived from neutrophils but not from macrophages or alveolar type II cells. Moreover, α1-AT knockdown aggravated phosgene- and lipopolysaccharide (LPS)-induced inflammation and cell death in human bronchial epithelial cells (BEAS-2B). Conversely, α1-AT administration suppressed the inflammatory response and prevented death in LPS- and phosgene-exposed BEAS-2B cells. Furthermore, α1-AT treatment increased the inhibitor of DNA binding 1 (ID1) gene expression, which suppressed NF-κB pathway activation, reduced inflammation, and inhibited cell death. These data demonstrate that neutrophil-derived α1-AT acts as a self-protective mechanism, which protects against phosgene-induced ALI by activating the ID1-dependent anti-inflammatory response. This study may provide novel strategies for the treatment of patients with phosgene-induced ALI.
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Affiliation(s)
- Gaihua He
- Department of Toxicology, Shaanxi Provincial Key Lab of Free Radical Biology and Medicine, Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Weihua Yu
- Department of Toxicology, Shaanxi Provincial Key Lab of Free Radical Biology and Medicine, Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Hongwei Li
- Department of Toxicology, Shaanxi Provincial Key Lab of Free Radical Biology and Medicine, Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Jiangzheng Liu
- Department of Toxicology, Shaanxi Provincial Key Lab of Free Radical Biology and Medicine, Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Yongmei Tu
- Department of Toxicology, Shaanxi Provincial Key Lab of Free Radical Biology and Medicine, Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Deqin Kong
- Department of Toxicology, Shaanxi Provincial Key Lab of Free Radical Biology and Medicine, Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Zi Long
- Department of Toxicology, Shaanxi Provincial Key Lab of Free Radical Biology and Medicine, Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Rui Liu
- Department of Toxicology, Shaanxi Provincial Key Lab of Free Radical Biology and Medicine, Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Jie Peng
- Department of Toxicology, Shaanxi Provincial Key Lab of Free Radical Biology and Medicine, Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Zhao Wang
- Department of Toxicology, Shaanxi Provincial Key Lab of Free Radical Biology and Medicine, Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Penghui Liu
- Department of Toxicology, Shaanxi Provincial Key Lab of Free Radical Biology and Medicine, Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China
| | - Chunxu Hai
- Department of Toxicology, Shaanxi Provincial Key Lab of Free Radical Biology and Medicine, Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China.
| | - Wenjun Yan
- Department of Cardiology, Xijing Hospital, Fourth Military Medical University, 127 West Changle Rd, Xi'an, 710032, China.
| | - Wenli Li
- Department of Toxicology, Shaanxi Provincial Key Lab of Free Radical Biology and Medicine, Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, School of Public Health, Fourth Military Medical University, Xi'an, 710032, China.
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12
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Riley EL, Brunson JC, Eydgahi S, Brantly ML, Lascano JE. Development of a risk score to increase detection of severe alpha-1 antitrypsin deficiency. ERJ Open Res 2023; 9:00302-2023. [PMID: 37727673 PMCID: PMC10505949 DOI: 10.1183/23120541.00302-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/20/2023] [Indexed: 09/21/2023] Open
Abstract
Background Alpha-1 antitrypsin deficiency (AATD) is an under-recognised genetic cause of chronic obstructive lung disease, and many fewer cases than estimated have been identified. Can a reported respiratory and hepatic disease history from a large AATD testing database be used to stratify a person's risk of severe AATD? Methods We analysed data extracted from the AATD National Detection Program. Demographics and medical history were evaluated to predict AATD PI*ZZ genotype. Logistic regression and integer programming models identified predictors and obtained risk scores. These were internally validated on a subset of the data. Results Out of 301 343 subjects, 1529 (0.5%) had PI*ZZ genotype. Predictors of severe AATD were asthma, bronchitis, emphysema, allergies, bronchiectasis, family history of AATD, cirrhosis, hepatitis and history of abnormal liver function tests. The derived model establishes a subject's risk of severe AATD, and scores ≥0 had an estimated risk of 0.41%, sensitivity 84.62% and specificity 24.32%. A model simulating guideline recommendations had an estimated risk of 0.51% with a sensitivity of 37.98% and specificity 46.60%. By recommending screening for scores ≥0, we estimate that more subjects would be screened (75.7% versus 53.4%) and detected (84.6% versus 58.2%) compared to a guideline-simulated model. Conclusion This medical history risk model is a useful predictive tool to detect subjects at greater risk of having severe AATD and improves sensitivity of detection. Scores <0 are at lower risk and may need not be screened; testing is recommended for scores ≥0 and consistent with current guidelines.
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Affiliation(s)
- E. Leonard Riley
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Kansas City Veterans Affairs Medical Center, Kansas City, MO, USA
| | - J. Cory Brunson
- Laboratory for Systems Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Soroush Eydgahi
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Mark L. Brantly
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jorge E. Lascano
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL, USA
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13
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Campos M, Hagenlocker B, Lascano J, Riley L. Impact of a Computerized Clinical Decision Support System to Improve Chronic Obstructive Pulmonary Disease Diagnosis and Testing for Alpha-1 Antitrypsin Deficiency. Ann Am Thorac Soc 2023; 20:1116-1123. [PMID: 36989247 DOI: 10.1513/annalsats.202211-954oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/29/2023] [Indexed: 03/30/2023] Open
Abstract
Rationale: Chronic obstructive pulmonary disease (COPD) and alpha-1 antitrypsin deficiency (AATD) are underrecognized diseases. This is in part due to the underdiagnosis and lack of confirmation of COPD but also from poor adherence to AATD screening recommendations. Objectives: A clinical decision support system (CDSS) to guide primary care providers improves spirometry testing and confirmation of COPD diagnosis in subjects at risk and improves AATD screening in patients with confirmed COPD. Methods: A CDSS was created to be applied to all Veterans attending single-center Veterans Affairs primary care clinics. The CDSS had an algorithmic dialogue with components executed in phases during different clinic visits: screening for COPD risk using the COPD population screening (COPD-PS) questionnaire, spirometry recommendation, and ordering tool for subjects with a prior diagnosis of COPD or subjects considered high risk by the COPD-PS, dialogue to confirm or discard the diagnosis of COPD, and recommendations for AATD screening in subjects with confirmed COPD. The latter was performed by ordering alpha-1 antitrypsin (AAT) serum levels. Each step of the CDSS algorithm approach was recorded and available to be retrieved at a later date for analysis. Results: Over 6 years, a total of 6,235 Veterans >40 years of age completed the CDSS. According to the COPD-PS questionnaire, 962 (18.5%) subjects were identified as high risk for COPD. An additional 579 subjects with a prior diagnosis of COPD also entered the subsequent steps of the CDSS algorithm. Of the high-risk cohort, the CDSS led to an increase in spirometry testing from 24% to 83% and led to a new diagnosis of COPD in 342 (43%). In the prior COPD diagnosis group, spirometry testing increased from 58% to 84%, leading to COPD reconfirmation in only 326 (67%). A total of 489 (68%) subjects with confirmed COPD completed AAT testing prompted by the CDSS, with 23 subjects identified with AATD and one with severe AATD. Conclusions: In the Veterans Affairs system, the use of a clinical decision support system algorithm that incorporates screening for COPD and AATD improves COPD over- and underdiagnosis and screening rates of AATD in a primary care setting.
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Affiliation(s)
- Michael Campos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Miami, Miami, Florida
- Pulmonary Section, Department of Medicine, and
| | - Brian Hagenlocker
- Department of Primary Care Medicine, Miami Veterans Affairs Medical Center, Miami, Florida
| | - Jorge Lascano
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Florida, Gainesville, Florida; and
| | - Leonard Riley
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Kansas City Veterans Affairs Medical Center, Kansas City, Missouri
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14
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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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15
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Diaz V, Benge E, Brockway M, Truman W, Ahmed B. SARS-CoV-2 Infection Precipitates the Discovery of Underlying Liver Disease: A Case Report. Cureus 2023; 15:e37811. [PMID: 37213973 PMCID: PMC10196694 DOI: 10.7759/cureus.37811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 05/23/2023] Open
Abstract
Since the onset of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, numerous sequelae of this devastating virus have come to light. One organ known to be impacted by SARS-CoV-2 is the liver, as many SARS-CoV-2 patients demonstrate elevated liver enzymes on routine laboratory tests. In this case report, we present a patient with SARS-CoV-2 whose liver enzymes remained persistently elevated throughout his hospitalization. Due to the duration of his elevated liver enzymes, etiologies outside of SARS-CoV-2 were explored. This workup revealed that the patient had alpha-1 antitrypsin (A1AT) deficiency. Thus, this case serves to remind clinicians to continue investigating lab abnormalities despite a presumed etiology, such as SARS-CoV-2, so as not to miss the presentation of new diagnoses.
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Affiliation(s)
- Victoria Diaz
- Internal Medicine, Mountainview Hospital, Las Vegas, USA
| | | | | | - Weston Truman
- Internal Medicine, MountainView Hospital, Las Vegas, USA
| | - Birjees Ahmed
- Internal Medicine, Mountainview Hospital, Las Vegas, USA
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16
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Devine AJ, Smith NJ, Joshi R, Fan Q, Borchers MT, Clair GC, Adkins JN, Varisco BM. CELA1 Mediates Progressive Emphysema in Alpha-1 Antitrypsin Deficiency. RESEARCH SQUARE 2023:rs.3.rs-2617812. [PMID: 36865303 PMCID: PMC9980203 DOI: 10.21203/rs.3.rs-2617812/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Chymotrypsin-like elastase 1 ( CELA1 ) is a serine protease that is neutralized by α1-antitrypsin (AAT) and prevents emphysema in a murine antisense oligonucleotide model of AAT-deficient emphysema. Mice with genetic ablation of AAT do not have emphysema at baseline but develop emphysema with injury and aging. We tested the role of CELA1 in emphysema development in this genetic model of AAT -deficiency following tracheal lipopolysacharide (LPS), 8 months of cigarette smoke (CS) exposure, aging, and a low-dose tracheal porcine pancreatic elastase (LD-PPE) model. In this last model, we performed proteomic analysis to understand differences in lung protein composition. We were unable to show that AAT -/ - mice developed more emphysema than wild type with LPS. In the LD-PPE model, AAT -/- mice developed progressive emphysema from which Cela1 -/- &AAT -/- mice were protected. In the CS model, Cela1 -/- &AAT -/- mice had worse emphysema than AAT -/- , and in the aging model, 72-75 week-old Cela1 -/- &AAT -/- mice had less emphysema than AAT -/- mice. Proteomic analysis of AAT -/- vs. wildtype lungs in the LD-PPE model showed reduced amounts of AAT proteins and increased amounts of proteins related to Rho and Rac1 GTPases and protein oxidation. Similar analysis of Cela1 -/- &AAT -/- vs. AAT -/- lungs showed differences in neutrophil degranulation, elastin fiber synthesis, and glutathione metabolism. Thus, Cela1 prevents post-injury emphysema progression in AAT -deficiency, but it has no effect and potentially worsens emphysema in response to chronic inflammation and injury. Prior to developing anti-CELA1 therapies for AAT-deficient emphysema, an understanding of why and how CS exacerbates emphysema in Cela1 deficiency is needed.
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Affiliation(s)
| | | | | | - Qiang Fan
- Cincinnati Children's Hospital Medical Center
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17
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Conde B, Costa F, Gomes J, Lopes AP, Mineiro MA, Rodrigues O, Santos C, Semedo L, Sucena M, Guimarães C. Expert Perspectives on the Management of Alpha 1-Antitrypsin Deficiency. ACTA MEDICA PORT 2023; 36:49-54. [PMID: 35848753 DOI: 10.20344/amp.18497] [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: 04/27/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 01/05/2023]
Abstract
Alpha 1-antitrypsin deficiency is an inherited autosomal codominant disorder, which predisposes patients to lung and/or liver disease. Even though it is considered rare, it is one of the most frequent genetic disorders worldwide, albeit remaining underdiagnosed. Several organizations and societies, including the Portuguese Society of Pulmonology have been elaborating guidelines and recommendations for the diagnosis and management of alpha 1-antitrypsin deficiency. Nevertheless, some important matters are yet to be included in those, mainly due to lack of robust scientific evidence, and continue to represent a point of discussion. This article reviews some important scientific publications and expresses the perspectives of a group of Portuguese experts regarding the management of alpha 1-antitrypsin deficiency, namely in terms of the pre and neonatal diagnosis, the impact of the COVID-19 pandemic, the validity of replacement therapy in lung transplant-receiving, and finally, alternative strategies of alpha 1-antitrypsin deficiency treatment to improve the patients' quality of life.
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Affiliation(s)
- Bebiana Conde
- Centro Hospitalar Trás-os-Montes e Alto Douro. Vila Real; Universidade de Trás-os-Montes e Alto Douro. Vila Real. Portugal
| | - Filipa Costa
- Serviço de Pneumologia. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
| | - Joana Gomes
- Serviço de Pneumologia. Centro Hospitalar e Universitário do Porto. Porto. Portugal
| | - António Paulo Lopes
- Serviço de Pneumologia. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
| | | | - Orlando Rodrigues
- Serviço de Genética Médica. Hospital Pediátrico do Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
| | - Cristina Santos
- Serviço de Pneumologia. Centro Hospitalar e Universitário Lisboa Norte. Lisboa. Portugal
| | - Luísa Semedo
- Serviço de Pneumologia. Centro Hospitalar Universitário Lisboa Central. Lisboa. Portugal
| | - Maria Sucena
- Serviço de Pneumologia. Centro Hospitalar e Universitário do Porto. Porto. Portugal
| | - Catarina Guimarães
- Serviço de Pneumologia. Hospital Senhora da Oliveira. Guimarães. Portugal
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Meischl T, Schmid-Scherzer K, Vafai-Tabrizi F, Wurzinger G, Traunmüller-Wurm E, Kutics K, Rauter M, Grabcanovic-Musija F, Müller S, Kaufmann N, Löffler-Ragg J, Valipour A, Funk GC. The impact of diagnostic delay on survival in alpha-1-antitrypsin deficiency: results from the Austrian Alpha-1 Lung Registry. Respir Res 2023; 24:34. [PMID: 36707810 PMCID: PMC9881325 DOI: 10.1186/s12931-023-02338-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 01/18/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Alpha-1-antitrypsin (AAT) deficiency (AATD) is a genetic disorder that can manifest as lung disease. A delay between onset of symptoms and diagnosis of AATD is common and associated with worse clinical status and more advanced disease stage but the influence on survival is unclear. OBJECTIVE We aimed to investigate the impact of diagnostic delay on overall survival (OS) and transplant-free survival (TS) in AATD patients. METHODS We analysed 268 AATD patients from the prospective multi-centre Austrian Alpha-1 Lung (AAL) Registry, employing descriptive statistics, Chi-square-test as well as univariable (Kaplan-Meier plots, log-rank test) and multivariable survival analysis (Cox regression). RESULTS The predominant phenotype was Pi*ZZ (82.1%). At diagnosis, 90.2% had an AAT level below 0.6 g/L. At inclusion, 28.2% had never smoked, 68.0% had quit smoking and 3.8% continued to smoke. Lung disease was diagnosed in 98.5%, thereof most patients were diagnosed with emphysema (63.8%) and/or chronic obstructive pulmonary disease (44.0%). Median diagnostic delay was 5.3 years (inter-quartile range [IQR] 2.2-11.5 years). In multivariable analysis (n = 229), a longer diagnostic delay was significantly associated with worse OS (hazard ratio [HR] 1.61; 95% CI 1.09-2.38; p = 0.016) and TS (HR 1.43; 95% CI 1.08-1.89; p = 0.011), independent from age, smoking status, body mass index (BMI), forced expiratory volume in one second (FEV1) and long-term oxygen treatment. Furthermore, BMI, age and active smoking were significantly associated with worse OS as well as BMI, active smoking and FEV1 were with worse TS. CONCLUSIONS A delayed diagnosis was associated with significantly worse OS and TS. Screening should be improved and efforts to ensure early AATD diagnosis should be intensified.
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Affiliation(s)
- Tobias Meischl
- grid.487248.50000 0004 9340 1179Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Montleartstraße 37, 1160 Vienna, Austria ,grid.22937.3d0000 0000 9259 8492Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Karin Schmid-Scherzer
- grid.487248.50000 0004 9340 1179Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Montleartstraße 37, 1160 Vienna, Austria ,Department of Medicine II With Pneumology, Klinik Ottakring, Vienna, Austria
| | - Florian Vafai-Tabrizi
- grid.487248.50000 0004 9340 1179Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Montleartstraße 37, 1160 Vienna, Austria ,Department of Medicine II With Pneumology, Klinik Ottakring, Vienna, Austria
| | - Gert Wurzinger
- Center of Pulmology, LKH Graz II, Standort Enzenbach, Gratwein-Strassengel, Austria
| | - Eva Traunmüller-Wurm
- grid.459707.80000 0004 0522 7001Department of Pulmology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Kristina Kutics
- grid.459707.80000 0004 0522 7001Department of Pulmology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Markus Rauter
- grid.415431.60000 0000 9124 9231Department of Pulmonology, Klinikum Klagenfurt Am Woerthersee, Klagenfurt, Austria
| | | | - Simona Müller
- Department of Pulmonology, Landeskrankenhaus Hohenems, Hohenems, Austria
| | - Norbert Kaufmann
- Division of Gastroenterology, Infectiology and Pneumology, Department of Medicine, LKH Graz II, Graz, Austria
| | - Judith Löffler-Ragg
- grid.5361.10000 0000 8853 2677Department of Medicine II, Medical University of Innsbruck, Innsbruck, Austria
| | - Arschang Valipour
- grid.487248.50000 0004 9340 1179Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Montleartstraße 37, 1160 Vienna, Austria ,Department of Respiratory and Critical Care Medicine, Klinik Floridsdorf, Vienna, Austria
| | - Georg-Christian Funk
- grid.487248.50000 0004 9340 1179Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Montleartstraße 37, 1160 Vienna, Austria ,Department of Medicine II With Pneumology, Klinik Ottakring, Vienna, Austria
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A Review of Alpha-1 Antitrypsin Binding Partners for Immune Regulation and Potential Therapeutic Application. Int J Mol Sci 2022; 23:ijms23052441. [PMID: 35269582 PMCID: PMC8910375 DOI: 10.3390/ijms23052441] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 02/06/2023] Open
Abstract
Alpha-1 antitrypsin (AAT) is the canonical serine protease inhibitor of neutrophil-derived proteases and can modulate innate immune mechanisms through its anti-inflammatory activities mediated by a broad spectrum of protein, cytokine, and cell surface interactions. AAT contains a reactive methionine residue that is critical for its protease-specific binding capacity, whereby AAT entraps the protease on cleavage of its reactive centre loop, neutralises its activity by key changes in its tertiary structure, and permits removal of the AAT-protease complex from the circulation. Recently, however, the immunomodulatory role of AAT has come increasingly to the fore with several prominent studies focused on lipid or protein-protein interactions that are predominantly mediated through electrostatic, glycan, or hydrophobic potential binding sites. The aim of this review was to investigate the spectrum of AAT molecular interactions, with newer studies supporting a potential therapeutic paradigm for AAT augmentation therapy in disorders in which a chronic immune response is strongly linked.
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Balbi B, Benini F, Corda L, Corsico A, Ferrarotti I, Gatta N. An Italian expert consensus on the management of alpha1-antitrypsin deficiency: a comprehensive set of algorithms. Panminerva Med 2022; 64:215-227. [PMID: 35146988 DOI: 10.23736/s0031-0808.22.04592-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Alpha1-antitrypin deficiency (AATD) is a genetic-based risk condition, mainly affecting the lungs and liver. Despite its wide distribution, it is largely underdiagnosed, thus being considered a rare disease, and is consequently managed in ad hoc reference centers. Unfortunately, an easy-to-use algorithm for managing such a complex disease is still lacking. METHODS An expert consensus meeting was conducted among experts in the management of AATD to build a comprehensive algorithm, including diagnosis, monitoring, AAT therapy, rehabilitation and lung transplantation, and liver disease, that could serve as a guide for physicians and treating centers. A panel of AATD specialists evaluated the results of their work. RESULTS Diagnosis is the most delicate phase, and awareness about this condition should be raised among GPs. A set of recommendations has been written about the most suitable follow-up visits. Augmentation therapy with AAT may be useful to reduce the progression of emphysema and lung function decline in selected patients. Exercise capacity may be improved by pulmonary rehabilitation and, in selected cases, by lung volume reduction or lung transplantation. Support therapies are needed for those who develop liver disease, and, in selected cases, liver transplantation may be considered. Patients should be carefully educated about their lifestyle, including smoking cessation, body weight control, and reduced alcohol intake. CONCLUSIONS The proposed algorithm obtained the endorsement of the Italian Society of Pneumology (SIP). However, further studies and additional clinical data are required to confirm the validity of these recommendations.
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Affiliation(s)
- Bruno Balbi
- Pulmonary Rehabilitation of the Institute of Veruno, Istituti Clinici Scientifici Maugeri IRCCS, Novara, Italy -
| | - Federica Benini
- Center for diagnosis, monitoring and therapy of alpha1-antitrypsin deficiency, Gastroenterology Unit, Department of Medicine, Spedali Civili, Brescia, Italy
| | - Luciano Corda
- Center for diagnosis, monitoring and therapy of alpha1-antitrypsin deficiency. Respiratory, Medicine Unit, Department of Internal Medicine, Spedali Civili, Brescia, Italy
| | - Angelo Corsico
- Center for diagnosis of alpha1-antitrypsin hereditary deficiency, Chest Medicine Unit. I.R.C.C.S. Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Ilaria Ferrarotti
- Center for diagnosis of alpha1-antitrypsin hereditary deficiency, Chest Medicine Unit. I.R.C.C.S. Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Nuccia Gatta
- Patients' association Associazione Nazionale Alfa1-At per la tutela dei pazienti con Deficit di Alfa1-antitripsina, Sarezzo, Brescia, Italy
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Ghosh AJ, Hobbs BD. Recent advancements in understanding the genetic involvement of alpha-1 antitrypsin deficiency associated lung disease: a look at future precision medicine approaches. Expert Rev Respir Med 2022; 16:173-182. [PMID: 35025710 PMCID: PMC8983484 DOI: 10.1080/17476348.2022.2027755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Alpha-1 antitrypsin deficiency occurs in individuals with deleterious genetic mutations on both chromosomes (maternal and paternal) in SERPINA1, the gene encoding the alpha-1 antitrypsin protein. There has been substantial progress in understanding the genetic variation that underlies the heterogeneous penetrance of lung disease in alpha-1 antitrypsin deficiency. AREAS COVERED This review will cover SERPINA1 gene structure and genetic variation, population genetics, genome-wide genetic modifiers of lung disease, alternative mechanisms of disease, and emerging therapeutics - including gene and cell therapy - related to alpha-1 antitrypsin deficiency-associated lung disease. EXPERT OPINION There remains ample opportunity to employ precision medicine in the diagnosis, prognosis, and therapy of alpha-1 antitrypsin deficiency-associated lung disease. In particular, a genome-wide association study and subsequent polygenic risk score is an important first step in identifying genome-wide genetic modifiers contributing to the variability of lung disease in severe alpha-1 antitrypsin deficiency.
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Affiliation(s)
- Auyon J. Ghosh
- Assistant Professor of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, SUNY Upstate Medical University, 750 E. Adams St, Syracuse, NY, 13210
| | - Brian D. Hobbs
- Assistant Professor of Medicine, Channing Division of Network Medicine, Brigham and Women’s Hospital, 181 Longwood Ave, Boston, MA, 02115,Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital,Harvard Medical School
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22
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Greulich T, Albert A, Cassel W, Boeselt T, Peychev E, Klemmer A, Ferreira F, Clarenbach C, Torres-Duran ML, Turner AM, Miravitlles M. Opinions and Attitudes of Pulmonologists About Augmentation Therapy in Patients with Alpha-1 Antitrypsin Deficiency. A Survey of the EARCO Group. Int J Chron Obstruct Pulmon Dis 2022; 17:53-64. [PMID: 35023913 PMCID: PMC8743984 DOI: 10.2147/copd.s346051] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/20/2021] [Indexed: 11/23/2022] Open
Abstract
Background Augmentation therapy (AT) is the only specific treatment licensed for patients with alpha-1 antitrypsin deficiency (AATD) associated lung disease. Since patients with severe AATD may have a very different prognosis and AT requires intravenous infusions for life, the decision to initiate AT may be challenging. Methods This survey was conducted on 63 experts in AATD from 13 European countries about their opinions and attitudes regarding AT. Participants were asked to rank the importance of 11 identified factors related with the prescription of AT. In addition, each participant was asked to respond to the indication of AT for 30 out of 500 hypothetical cases developed with the combinations of the 11 factors. Each case was evaluated by 3 experts to check the concordance. Results The variables that scored higher on preferences for initiating AT were AAT genotype (score 8.6 from a Likert scale 0–10 (SD: 1.7)), AATD serum level (8.2 (SD:2.4)) and FEV1 (%) decline (7.9 (SD:2.4)). Among the 500 different cases, there was an agreement in indication of AT among the 3 experts in 291 (58.2%). Regarding the variables associated with AT, it was indicated to 81.9% of Pi*ZZ, 52.4% of Pi*SZ and 9.8% of Pi*MZ (p < 0.0001). For Pi*ZZ patients, multivariate analysis identified younger age, reduced FEV1 (%), higher FEV1 decline and worse emphysema as significantly associated with prescription (AUC = 0.8114); for Pi*SZ variables were younger age, worse FEV1 (%) and worse emphysema (AUC = 0.7414); and for Pi*MZ younger age, worse DLCO (%), higher DLCO decline and dyspnea (AUC = 0.8387). Conclusion There is a high variability in the criteria for prescription of AT among European experts. Most cases were recommended AT according to guidelines, but a significant number of patients with genotype Pi*SZ and almost 10% Pi*MZ were recommended to initiate AT despite the lack of evidence of efficacy in these genotypes.
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Affiliation(s)
- Timm Greulich
- University Medical Centre Giessen and Marburg, Philipps-University, Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Anna Albert
- University Medical Centre Giessen and Marburg, Philipps-University, Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Werner Cassel
- University Medical Centre Giessen and Marburg, Philipps-University, Department of Medicine, Pulmonary and Critical Care Medicine, Sleep Disorders Centre, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Tobias Boeselt
- University Medical Centre Giessen and Marburg, Philipps-University, Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Erika Peychev
- University Medical Centre Giessen and Marburg, Philipps-University, Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Andreas Klemmer
- University Medical Centre Giessen and Marburg, Philipps-University, Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | | | | | - Maria L Torres-Duran
- Pneumology Department, Hospital Álvaro Cunqueiro, AS Vigo, Spain.,Instituto de Investigación Sanitaria Galicia Sur (IISGS), Vigo, Spain
| | - Alice M Turner
- Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d´Hebron/Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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Padilla-Godínez FJ, Ramos-Acevedo R, Martínez-Becerril HA, Bernal-Conde LD, Garrido-Figueroa JF, Hiriart M, Hernández-López A, Argüero-Sánchez R, Callea F, Guerra-Crespo M. Protein Misfolding and Aggregation: The Relatedness between Parkinson's Disease and Hepatic Endoplasmic Reticulum Storage Disorders. Int J Mol Sci 2021; 22:ijms222212467. [PMID: 34830348 PMCID: PMC8619695 DOI: 10.3390/ijms222212467] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 12/21/2022] Open
Abstract
Dysfunction of cellular homeostasis can lead to misfolding of proteins thus acquiring conformations prone to polymerization into pathological aggregates. This process is associated with several disorders, including neurodegenerative diseases, such as Parkinson’s disease (PD), and endoplasmic reticulum storage disorders (ERSDs), like alpha-1-antitrypsin deficiency (AATD) and hereditary hypofibrinogenemia with hepatic storage (HHHS). Given the shared pathophysiological mechanisms involved in such conditions, it is necessary to deepen our understanding of the basic principles of misfolding and aggregation akin to these diseases which, although heterogeneous in symptomatology, present similarities that could lead to potential mutual treatments. Here, we review: (i) the pathological bases leading to misfolding and aggregation of proteins involved in PD, AATD, and HHHS: alpha-synuclein, alpha-1-antitrypsin, and fibrinogen, respectively, (ii) the evidence linking each protein aggregation to the stress mechanisms occurring in the endoplasmic reticulum (ER) of each pathology, (iii) a comparison of the mechanisms related to dysfunction of proteostasis and regulation of homeostasis between the diseases (such as the unfolded protein response and/or autophagy), (iv) and clinical perspectives regarding possible common treatments focused on improving the defensive responses to protein aggregation for diseases as different as PD, and ERSDs.
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Affiliation(s)
- Francisco J. Padilla-Godínez
- Neurosciences Division, Cell Physiology Institute, National Autonomous University of Mexico, Mexico City 04510, Mexico; (F.J.P.-G.); (R.R.-A.); (H.A.M.-B.); (L.D.B.-C.); (J.F.G.-F.); (M.H.)
- Regenerative Medicine Laboratory, Department of Surgery, Faculty of Medicine, National Autonomous University of Mexico, Mexico City 04510, Mexico; (A.H.-L.); (R.A.-S.)
| | - Rodrigo Ramos-Acevedo
- Neurosciences Division, Cell Physiology Institute, National Autonomous University of Mexico, Mexico City 04510, Mexico; (F.J.P.-G.); (R.R.-A.); (H.A.M.-B.); (L.D.B.-C.); (J.F.G.-F.); (M.H.)
- Regenerative Medicine Laboratory, Department of Surgery, Faculty of Medicine, National Autonomous University of Mexico, Mexico City 04510, Mexico; (A.H.-L.); (R.A.-S.)
| | - Hilda Angélica Martínez-Becerril
- Neurosciences Division, Cell Physiology Institute, National Autonomous University of Mexico, Mexico City 04510, Mexico; (F.J.P.-G.); (R.R.-A.); (H.A.M.-B.); (L.D.B.-C.); (J.F.G.-F.); (M.H.)
- Regenerative Medicine Laboratory, Department of Surgery, Faculty of Medicine, National Autonomous University of Mexico, Mexico City 04510, Mexico; (A.H.-L.); (R.A.-S.)
| | - Luis D. Bernal-Conde
- Neurosciences Division, Cell Physiology Institute, National Autonomous University of Mexico, Mexico City 04510, Mexico; (F.J.P.-G.); (R.R.-A.); (H.A.M.-B.); (L.D.B.-C.); (J.F.G.-F.); (M.H.)
- Regenerative Medicine Laboratory, Department of Surgery, Faculty of Medicine, National Autonomous University of Mexico, Mexico City 04510, Mexico; (A.H.-L.); (R.A.-S.)
| | - Jerónimo F. Garrido-Figueroa
- Neurosciences Division, Cell Physiology Institute, National Autonomous University of Mexico, Mexico City 04510, Mexico; (F.J.P.-G.); (R.R.-A.); (H.A.M.-B.); (L.D.B.-C.); (J.F.G.-F.); (M.H.)
- Regenerative Medicine Laboratory, Department of Surgery, Faculty of Medicine, National Autonomous University of Mexico, Mexico City 04510, Mexico; (A.H.-L.); (R.A.-S.)
| | - Marcia Hiriart
- Neurosciences Division, Cell Physiology Institute, National Autonomous University of Mexico, Mexico City 04510, Mexico; (F.J.P.-G.); (R.R.-A.); (H.A.M.-B.); (L.D.B.-C.); (J.F.G.-F.); (M.H.)
| | - Adriana Hernández-López
- Regenerative Medicine Laboratory, Department of Surgery, Faculty of Medicine, National Autonomous University of Mexico, Mexico City 04510, Mexico; (A.H.-L.); (R.A.-S.)
| | - Rubén Argüero-Sánchez
- Regenerative Medicine Laboratory, Department of Surgery, Faculty of Medicine, National Autonomous University of Mexico, Mexico City 04510, Mexico; (A.H.-L.); (R.A.-S.)
| | - Francesco Callea
- Department of Histopathology, Bugando Medical Centre, Catholic University of Healthy and Allied Sciences, Mwanza 1464, Tanzania;
| | - Magdalena Guerra-Crespo
- Neurosciences Division, Cell Physiology Institute, National Autonomous University of Mexico, Mexico City 04510, Mexico; (F.J.P.-G.); (R.R.-A.); (H.A.M.-B.); (L.D.B.-C.); (J.F.G.-F.); (M.H.)
- Regenerative Medicine Laboratory, Department of Surgery, Faculty of Medicine, National Autonomous University of Mexico, Mexico City 04510, Mexico; (A.H.-L.); (R.A.-S.)
- Correspondence:
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24
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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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25
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Zamora MR, Ataya A. Lung and liver transplantation in patients with alpha-1 antitrypsin deficiency. Ther Adv Chronic Dis 2021; 12_suppl:20406223211002988. [PMID: 34408830 PMCID: PMC8367211 DOI: 10.1177/20406223211002988] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/24/2021] [Indexed: 11/23/2022] Open
Abstract
Alpha-1 antitrypsin (AAT) augmentation is effective in slowing the progression of
emphysema due to AAT deficiency (AATD) but cannot prevent eventual progression
to end-stage lung disease and complete respiratory failure, which is the leading
cause of death for individuals with severe AATD. When patients develop end-stage
lung disease, lung transplantation is the only treatment option available, and
this can improve lung physiology and patient health status. The available data
suggest that survival rates for lung transplantation are significantly higher
for patients with AATD-related chronic obstructive pulmonary disease (COPD)
compared with non-AATD-related COPD, but, conversely, there is a higher risk of
common post-lung transplant complications in patients with AATD
versus non-AATD COPD. Nevertheless, lung transplantation
(single and bilateral) is favorable for patients with AATD. After respiratory
failure, the second leading cause of death in patients with AATD is liver
disease, for example, cirrhosis and hepatocellular carcinoma, caused by the
accumulation of mutant forms of AAT retained within the liver. As with lung
disease, the only treatment option for end-stage liver disease is liver
transplantation. Survival rates for patients with AATD undergoing liver
transplantation are also favorable, and patients, particularly pediatric
patients, have benefitted from advancements in peri-/post-surgical care. As the
majority of AAT is produced by the liver, the AAT phenotype of the recipient
becomes that of the donor, meaning that AAT serum levels should be normalized
(if the donor is AAT-replete), halting further lung and liver disease
progression. However, post-liver transplant respiratory function may continue to
decline in line with normal age-related lung function decline. In the most
severe cases, where patients have simultaneous end-stage lung and liver disease,
combined lung and liver transplantation is a treatment option with favorable
outcomes. However, there is very little information available on this procedure
in patients with AATD.
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Affiliation(s)
- Martin R Zamora
- Lung Transplant Program, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Aurora, CO, USA
| | - Ali Ataya
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA
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26
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Patel D, Teckman J. Liver disease with unknown etiology - have you ruled out alpha-1 antitrypsin deficiency? Ther Adv Chronic Dis 2021; 12_suppl:2040622321995684. [PMID: 34408828 PMCID: PMC8367207 DOI: 10.1177/2040622321995684] [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: 01/12/2021] [Indexed: 01/13/2023] Open
Abstract
Although a less well-known consequence of alpha-1 antitrypsin deficiency (AATD) liver disease is the second leading cause of death among patients with the condition. The alpha-1 antitrypsin (AAT) protein is produced by hepatocytes within the liver, which retain pathological variants of AAT instead of secreting the proteinase inhibitor into the systemic circulation. This intracellular retention is caused by inefficient folding and polymerization of mutant AAT and the accumulation of these AAT aggregates leads to diverse manifestations of liver disease, which can present differently in both children and adults. The progression from hepatocyte apoptosis to liver inflammation, fibrosis and cirrhosis, and liver failure is still not fully understood, but in older patients, liver disease can surpass lung disease as the principal cause of death. Liver function tests (LFTs) can measure plasma levels of liver enzymes to assess liver function but require careful interpretation. Non-invasive tests are being developed that can detect early liver disease, but liver biopsy is still the gold standard for assessing liver fibrosis once abnormal LFTs have been detected in a patient. Currently, there is no licensed treatment for AATD-related liver disease (intravenous AAT therapy is not indicated for this purpose), but liver transplantation is associated with positive outcomes and may even slow emphysema progression. Therefore, new strategies are being developed to address treatment of AATD-related liver disease, such as accelerating degradation of mutant AAT and assisting hepatocytes in the folding and secretion of mutant AAT, but these approaches remain at early stages of development.
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Affiliation(s)
- Dhiren Patel
- Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, St Louis University School of Medicine, St Louis, MO, USA
| | - Jeffrey Teckman
- Department of Pediatrics and Department of Biochemistry and Molecular Biology, St Louis University School of Medicine, St Louis, MO, USA
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27
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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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Foil KE. Variants of SERPINA1 and the increasing complexity of testing for alpha-1 antitrypsin deficiency. Ther Adv Chronic Dis 2021; 12_suppl:20406223211015954. [PMID: 34408833 PMCID: PMC8367212 DOI: 10.1177/20406223211015954] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 04/20/2021] [Indexed: 02/06/2023] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD) is caused by mutations in the SERPINA1 gene, which encodes the alpha-1 antitrypsin (AAT) protein. Currently, over 200 SERPINA1 variants have been identified, many of which cause the quantitative and/or qualitative changes in AAT responsible for AATD-associated lung and liver disease. The types of these pathogenic mutations are varied, often resulting in misfolding, or truncating of the AAT amino acid sequence, and improvements in sequencing technology are helping to identify known and novel genetic variants. However, due to the diversity and novelty of rare variants, the clinical significance of many is largely unknown. There is, therefore, a lack of guidance on how patients should be monitored and treated when the clinical significance of their variant combination is unclear or variable. Nevertheless, it is important that physicians understand the advantages and disadvantages of the different testing methodologies available to diagnose AATD. Owing to the autosomal inheritance of the genetic mutations responsible for AATD, genetic testing should be offered not only to patients at increased AATD risk (e.g. patients with chronic obstructive pulmonary disease), but also to relatives of those with an abnormal result. Genetic counseling may help patients and family members understand the possible outcomes of testing and the implications for the family. While stress/anxiety can arise from genetic diagnosis or confirmation of carrier status, there can be positive consequences to genetic testing, including improved lifestyle choices, directed medical care, and empowered family planning. As genetic testing technology grows and becomes more popular, testing without physician referral is becoming more prevalent, irrespective of the availability of genetic counseling. Therefore, the Alpha-1 Foundation offers genetic counseling, as well as other support and educational material, for patients with AATD, as well as their families and physicians, to help improve the understanding of potential benefits and consequences of genetic testing.
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Affiliation(s)
- Kimberly E Foil
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
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29
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Guan S, Darmstädter M, Xu C, Rosenecker J. In Vitro Investigations on Optimizing and Nebulization of IVT-mRNA Formulations for Potential Pulmonary-Based Alpha-1-Antitrypsin Deficiency Treatment. Pharmaceutics 2021; 13:pharmaceutics13081281. [PMID: 34452241 PMCID: PMC8399093 DOI: 10.3390/pharmaceutics13081281] [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: 07/20/2021] [Revised: 07/29/2021] [Accepted: 08/12/2021] [Indexed: 11/29/2022] Open
Abstract
In vitro-transcribed (IVT) mRNA has come into focus in recent years as a potential therapeutic approach for the treatment of genetic diseases. The nebulized formulations of IVT-mRNA-encoding alpha-1-antitrypsin (A1AT-mRNA) would be a highly acceptable and tolerable remedy for the protein replacement therapy for alpha-1-antitrypsin deficiency in the future. Here we show that lipoplexes containing A1AT-mRNA prepared in optimum conditions could successfully transfect human bronchial epithelial cells without significant toxicity. A reduction in transfection efficiency was observed for aerosolized lipoplexes that can be partially overcome by increasing the initial number of components. A1AT produced from cells transfected by nebulized A1AT-mRNA lipoplexes is functional and could successfully inhibit the enzyme activity of trypsin as well as elastase. Our data indicate that aerosolization of A1AT-mRNA therapy constitutes a potentially powerful means to transfect airway epithelial cells with the purpose of producing functional A1AT, while bringing along the unique advantages of IVT-mRNA.
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Affiliation(s)
- Shan Guan
- National Engineering Research Center of Immunological Products, Department of Microbiology and Biochemical Pharmacy, Third Military Medical University, Chongqing 400038, China;
- Correspondence: (S.G.); (J.R.); Tel.: +86-23-68771645 (S.G.); +49-89-440057713 (J.R.); Fax: +86-23-68771645 (S.G.); +49-89-440054421 (J.R.)
| | - Max Darmstädter
- Department of Pediatrics, Ludwig-Maximilians University of Munich, 80337 Munich, Germany;
| | - Chuanfei Xu
- National Engineering Research Center of Immunological Products, Department of Microbiology and Biochemical Pharmacy, Third Military Medical University, Chongqing 400038, China;
| | - Joseph Rosenecker
- Department of Pediatrics, Ludwig-Maximilians University of Munich, 80337 Munich, Germany;
- Correspondence: (S.G.); (J.R.); Tel.: +86-23-68771645 (S.G.); +49-89-440057713 (J.R.); Fax: +86-23-68771645 (S.G.); +49-89-440054421 (J.R.)
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30
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Huang YCT, Wencker M, Driehuys B. Imaging in alpha-1 antitrypsin deficiency: a window into the disease. Ther Adv Chronic Dis 2021; 12_suppl:20406223211024523. [PMID: 34408834 PMCID: PMC8367205 DOI: 10.1177/20406223211024523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 05/25/2021] [Indexed: 12/21/2022] Open
Abstract
Imaging modalities such as plain chest radiograph and computed tomography (CT) are important tools in the assessment of patients with chronic obstructive pulmonary disease (COPD) of any etiology. These methods facilitate differential diagnoses and the assessment of individual lung pathologies, such as the presence of emphysema, bullae, or fibrosis. However, as emphysema is the core pathological consequence in the lungs of patients with alpha-1 antitrypsin deficiency (AATD), and because AATD is associated with the development of other lung pathologies such as bronchiectasis, there is a greater need for patients with AATD than those with non-AATD-related COPD to undergo more detailed assessment using CT. In the field of AATD, CT provides essential information regarding the presence, distribution, and morphology of emphysema. In addition, it offers the option to quantify the extent of emphysema. These data have implications for treatment decisions such as initiation of alpha-1 antitrypsin (AAT) therapy, or suitability for surgical or endoscopic interventions for reducing lung volume. Furthermore, CT has provided vital insight regarding the natural history of emphysema progression in AATD, and CT densitometry has underpinned research into the efficacy of AAT therapy. Moving forward, hyperpolarized xenon gas (129Xe) lung magnetic resonance imaging (MRI) is emerging as a promising complement to CT by adding comprehensive measures of regional lung function. It also avoids the main disadvantage of CT: the associated radiation. This chapter provides an overview of technological aspects of imaging in AATD, as well as its role in the management of patients and clinical research. In addition, perspectives on the future potential role of lung MRI in AATD are outlined.
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Affiliation(s)
- Yuh-Chin Tony Huang
- Department of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Bastiaan Driehuys
- Department of Radiology, Duke University School of Medicine, Durham, NC, USA
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31
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Jardim JR, Casas-Maldonado F, Fernandes FLA, Castellano MVCDO, Torres-Durán M, Miravitlles M. Update on and future perspectives for the diagnosis of alpha-1 antitrypsin deficiency in Brazil. J Bras Pneumol 2021; 47:e20200380. [PMID: 34076174 PMCID: PMC8332724 DOI: 10.36416/1806-3756/e20200380] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 01/25/2021] [Indexed: 12/05/2022] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a rare genetic disorder caused by a mutation in the SERPINA1 gene, which encodes the protease inhibitor alpha-1 antitrypsin (AAT). Severe AATD predisposes individuals to COPD and liver disease. Early diagnosis is essential for implementing preventive measures and limiting the disease burden. Although national and international guidelines for the diagnosis and management of AATD have been available for 20 years, more than 85% of cases go undiagnosed and therefore untreated. In Brazil, reasons for the underdiagnosis of AATD include a lack of awareness of the condition among physicians, a racially diverse population, serum AAT levels being assessed in a limited number of individuals, and lack of convenient diagnostic tools. The diagnosis of AATD is based on laboratory test results. The standard diagnostic approach involves the assessment of serum AAT levels, followed by phenotyping, genotyping, gene sequencing, or combinations of those, to detect the specific mutation. Over the past 10 years, new techniques have been developed, offering a rapid, minimally invasive, reliable alternative to traditional testing methods. One such test available in Brazil is the A1AT Genotyping Test, which simultaneously analyzes the 14 most prevalent AATD mutations, using DNA extracted from a buccal swab or dried blood spot. Such advances may contribute to overcoming the problem of underdiagnosis in Brazil and elsewhere, as well as being likely to increase the rate detection of AATD and therefore mitigate the harmful effects of delayed diagnosis.
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Affiliation(s)
- José R Jardim
- . Centro de Reabilitação Pulmonar, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo (SP) Brasil
| | | | - Frederico Leon Arrabal Fernandes
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | - María Torres-Durán
- . Departamento de Neumología, Hospital Álvaro Cunqueiro, Vigo, España
- . Instituto de Investigación Sanitaria Galicia Sur - IISGS - Vigo, España
| | - Marc Miravitlles
- . Departamento de Neumología, Hospital Universitario Vall d'Hebron, Barcelona, España
- . Vall d'Hebron Institut de Recerca - VHIR - Hospital Universitario Vall d'Hebron Barcelona, Barcelona, España
- . CIBER de Enfermedades Respiratorias - CIBERES - Barcelona, España
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Herrera EM, Joseph C, Brouwer ES, Gandhi V, Czorniak M. Alpha-1 Antitrypsin Deficiency-Associated Clinical Manifestations and Healthcare Resource Use in the United States. COPD 2021; 18:315-324. [PMID: 34036848 DOI: 10.1080/15412555.2021.1917532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Pulmonary events (PEs) associated with alpha-1 antitrypsin deficiency (AATD) can have a severe clinical course and increase healthcare resource use (HRU). However, AATD-associated HRU and healthcare costs have not been extensively described. This study describes and compares real-world HRU and healthcare costs among US patients with severe (requiring hospitalization after AATD-related PE) versus nonsevere AATD clinical course. Administrative healthcare claims for patients with a second primary AATD diagnosis between 6/1/2008 and 12/31/2017 were analyzed from 2 databases (requiring continuous enrollment 6 months preceding diagnosis). Patient baseline characteristics and AATD-associated PE incidence rates, HRU, and healthcare costs during follow-up were compared in patients with severe versus nonsevere AATD. Of 5109 patients with a second AATD diagnosis, 2674 (severe, n = 711 [26.6%]; nonsevere, n = 1963 [73.4%]) had ≥1 AATD-associated PE. PE incidence per 100 person-years was higher in patients with severe versus nonsevere AATD. Annual incidences (mean ± SD) of emergency department (1.2 ± 5.7 vs. 0.4 ± 1.2), inpatient (1.3 ± 2.5 vs. 0.1 ± 0.5), and outpatient (10.3 ± 15.9 vs. 5.7 ± 13.2) visits were higher in patients with severe versus nonsevere AATD. Median (interquartile range) annual costs were also higher for patients with severe versus nonsevere AATD for emergency department ($185 [$0-$1665] vs. $0 [$0-$264]), inpatient ($16,038 [$2968-$70,941] vs. $0 [$0-$0]), and outpatient ($2663 [$412-$10,277] vs. $1114 [$134-$4195]) visits. Higher percentages of patients with severe AATD were prescribed augmentation therapy, antibiotics, or corticosteroids. These findings suggest that patients with severe AATD have higher incidence of AATD-associated PEs, as well as higher HRU and healthcare costs.
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Annunziata A, Lanza M, Coppola A, Fiorentino G. Alpha-1 antitrypsin deficiency in the elderly: a case report. J Med Case Rep 2021; 15:231. [PMID: 33966640 PMCID: PMC8108364 DOI: 10.1186/s13256-021-02847-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 04/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Generally, alpha-1 antitrypsin deficiency (AATD) is suspected in young patients with pulmonary emphysema or chronic obstructive pulmonary disease (COPD). Patients often suffer from diagnostic gaps and are misdiagnosed with chronic obstructive pulmonary disease (COPD), asthma, and airway hyperresponsiveness (AHR), as AATD may present with nonspecific respiratory symptoms. It is never too late to suspect AATD, especially in a patient with an unusual medical history. In recent years, evidence is beginning to emerge that there may be value in identifying and treating patients who do not already have deterioration of functional parameters. CASE PRESENTATION We describe a case of a 69-year-old Caucasian female patient, late diagnosis of AATD, with both severe bronchial hyperreactivity and numerous exacerbations due to the peculiar clinical history and the presence of a rare mutation; although not presenting forced expiratory volume in 1 second (FEV1) between 30 and 65%, the patient was treated with alpha-1 antitrypsin (AAT) augmentation therapy and achieved clinical and functional improvement. CONCLUSION AATD should always be suspected. The Alpha-1 Foundation recommendations for the diagnosis and management of AATD in adult patients indicate that treatment should be provided for patients with FEV1 between 30 and 65%. It may be useful to evaluate and treat patients based on clinical symptoms, even outside the established parameters, in particular cases.
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Affiliation(s)
- Anna Annunziata
- UOC Pathophysiology and Respiratory Rehabilitation, Intensive Care Department, Monaldi Hospital, Naples, Italy.
| | - Maurizia Lanza
- UOC Pathophysiology and Respiratory Rehabilitation, Intensive Care Department, Monaldi Hospital, Naples, Italy
| | - Antonietta Coppola
- UOC Pathophysiology and Respiratory Rehabilitation, Intensive Care Department, Monaldi Hospital, Naples, Italy
| | - Giuseppe Fiorentino
- UOC Pathophysiology and Respiratory Rehabilitation, Intensive Care Department, Monaldi Hospital, Naples, Italy
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Relationship between alpha-1 antitrypsin deficiency and obstructive sleep apnea. Sleep Breath 2021; 25:2091-2097. [PMID: 33931809 DOI: 10.1007/s11325-021-02386-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 04/18/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE This study aimed to identify if individuals with mild to severe alpha-1 antitrypsin deficiency (AATD) are at higher risk for developing obstructive sleep apnea (OSA) than the general population. METHODS A seven-question sleep apnea risk assessment questionnaire, STOP-BAG, was applied to 2338 participant responses from the Alpha-1 Coded Testing Study (ACT) and 4638 participant responses from the Kentucky Behavioral Risk Factor Survey (KyBRFS). Propensity scores were generated from a logistic regression model using continuous variables of age and body mass index (BMI). STOP-BAG scores were analyzed using chi-square analysis on this matched cohort to assess OSA risk in AATD. RESULTS Self-reported OSA was higher in the KyBRFS cohort (14.5%) than in individuals with mild or severe AATD (11.2%) (p = 0.012). However, a higher percentage of the AATD cohort met clinically meaningful thresholds for STOP-BAG scores ≥ 5 (22.7%) than the KyBRFS cohort (13.0%) (p = 0.001). These differences persisted despite 1:1 propensity score matching on age and BMI to account for differences in baseline characteristics. No statistically significant difference in OSA risk between AATD genotypes was found. CONCLUSION AATD appears to have higher risk for OSA than the general population. The 11.2% prevalence of diagnosed OSA in the AATD population is much lower than symptom scores would predict. Further studies are needed to validate the possibility that elastin loss is involved in OSA pathogenesis.
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Gurevich S, Daya A, Da Silva C, Girard C, Rahaghi F. Improving Screening for Alpha-1 Antitrypsin Deficiency with Direct Testing in the Pulmonary Function Testing Laboratory. CHRONIC OBSTRUCTIVE PULMONARY DISEASES (MIAMI, FLA.) 2021; 8:190-197. [PMID: 33290644 DOI: 10.15326/jcopdf.2020.0179] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a common but highly underdiagnosed genetic disorder that may lead to chronic obstructive pulmonary disease (COPD), bronchiectasis, and liver disease. Early diagnosis is key to altering the course of disease as well as informing family members of potential risk. This randomized, prospective observational study compares the different testing modalities for AATD testing of at-risk patients initiated in the pulmonary function testing (PFT) laboratory. Providing a recommendation with a prescription for serologic testing, providing a finger-stick testing method (AlphaKit), and providing a buccal swab testing method (AlphaID) were compared to the community standard of referring the patient back to the PFT-ordering provider only. Results show that testing directly in the PFT laboratory has an odds ratio (OR) for completing testing of 35.14 (5.33 - 999.99), p-value of <0.0001, for buccal swab testing and an OR of 17.09 (2.58 - 729.99), p-value of 0.0002, for finger-stick testing compared to the community standard. Providing a prescription was no better than referral back to the PFT-ordering provider with an OR of 2.61(0.33 - 119.36), p-value of 0.6412. Resources needed to have testing performed by the Respiratory Therapy department were minimal with an average time of 1 to 5 minutes per patient tested. Causes of testing refusal were also identified. In conclusion, direct testing for AATD by respiratory therapists at the conclusion of PFT testing shows a significant improvement in rates of testing, especially with testing that utilizes buccal swab sample collection.
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Affiliation(s)
- Samuel Gurevich
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, United States.,Department of Pulmonary Medicine, Cleveland Clinic Florida, Weston, Florida, United States
| | - Andrew Daya
- Department of Pulmonary Medicine, Cleveland Clinic Florida, Weston, Florida, United States
| | - Cristiana Da Silva
- Department of Pulmonary Medicine, Cleveland Clinic Florida, Weston, Florida, United States
| | - Christine Girard
- Department of Pulmonary Medicine, Cleveland Clinic Florida, Weston, Florida, United States
| | - Franck Rahaghi
- Department of Pulmonary Medicine, Cleveland Clinic Florida, Weston, Florida, United States
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Barjaktarevic I, Miravitlles M. Alpha-1 antitrypsin (AAT) augmentation therapy in individuals with the PI*MZ genotype: a pro/con debate on a working hypothesis. BMC Pulm Med 2021; 21:99. [PMID: 33757485 PMCID: PMC7989144 DOI: 10.1186/s12890-021-01466-x] [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: 07/04/2020] [Accepted: 03/15/2021] [Indexed: 11/20/2022] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a significantly under-diagnosed genetic condition caused by reduced levels and/or functionality of alpha-1 antitrypsin (AAT), predisposing individuals to lung, liver or other systemic diseases. The management of individuals with the PI*MZ genotype, characterized by mild or moderate AAT deficiency, is less clear than of those with the most common severe deficiency genotype (PI*ZZ). Recent genetic data suggest that the PI*MZ genotype may be significantly more prevalent than currently thought. The only specific treatment for lung disease associated with severe AATD is the intravenous infusion of AAT augmentation therapy, which has been shown to slow disease progression in PI*ZZ individuals. There is no specific evidence for the clinical benefit of AAT therapy in PI*MZ individuals, and the risk of emphysema development in this group remains controversial. As such, current guidelines do not support the use of AAT augmentation in PI*MZ individuals. Here, we discuss the limited data on the PI*MZ genotype and offer pro and con perspectives on pursuing an AAT-specific therapeutic strategy in PI*MZ individuals with lung disease. Ultimately, further research to demonstrate the safety, risk/benefit balance and efficacy of AAT therapy in PI*MZ individuals is needed.
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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, Los Angeles, CA, USA
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall D'Hebron, Vall D'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
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Mandru R, Zhou CY, Pauley R, Burkes RM. Considerations for and Mechanisms of Adjunct Therapy in COPD. J Clin Med 2021; 10:jcm10061225. [PMID: 33809583 PMCID: PMC7999347 DOI: 10.3390/jcm10061225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/26/2022] Open
Abstract
Inhaled bronchodilators and corticosteroids, when indicated, form the backbone of COPD therapy. However, over the last decade there has been an emergence of adjunct therapies in oral or inhaled form that are now part of the therapeutic approach to COPD. While these therapies have shown to be beneficial when used in the appropriate instances, there are particular considerations that need to be minded when using these therapies. This review article discussed the mechanism of roflumilast, macrolide antibiotics, other chronic antibiotic regimens, vitamin D supplementation, oral corticosteroids, n-acetylcysteine, and nebulized hypertonic saline, the clinical data behind each of these therapies, adverse events associated with therapy, and the expert recommendations for their utilization. Our goal is to provide a brief but informative and clinically useful review of commonly encountered therapies used in advanced COPD.
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Affiliation(s)
- Rachana Mandru
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH 45221, USA;
| | - Christine Y. Zhou
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45221, USA; (C.Y.Z.); (R.P.)
| | - Rachel Pauley
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45221, USA; (C.Y.Z.); (R.P.)
| | - Robert M. Burkes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH 45221, USA;
- Correspondence:
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Santos G, Turner AM. Alpha-1 antitrypsin deficiency: an update on clinical aspects of diagnosis and management. Fac Rev 2021; 9:1. [PMID: 33659933 PMCID: PMC7886062 DOI: 10.12703/b/9-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Clinical heterogeneity has been demonstrated in alpha-1 antitrypsin deficiency (AATD), such that clinical suspicion plays an important role in its diagnosis. The PiZZ genotype is the most common severe deficiency genotype and so tends to result in the worst clinical presentation, hence it has been the major focus of research. However, milder genotypes, especially PiSZ and PiMZ, are also linked to the development of lung and liver disease, mainly when unhealthy behaviors are present, such as smoking and alcohol use. Monitoring and managing AATD patients remains an area of active research. Lung function tests or computed tomography (CT) densitometry may allow physicians to identify progressive disease during follow up of patients, with a view to decision making about AATD-specific therapy, like augmentation therapy, or eventually surgical procedures such as lung volume reduction or transplant. Different types of biological markers have been suggested for disease monitoring and therapy selection, although most need further investigation. Intravenous augmentation therapy reduces the progression of emphysema in PiZZ patients and is available in many European countries, but its effect in milder deficiency is less certain. AATD has also been suggested to represent a risk factor and trigger for pulmonary infections, like those induced by mycobacteria. We summarize the last 5-10 years' key findings in AATD diagnosis, assessment, and management, with a focus on milder deficiency variants.
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Affiliation(s)
- Gabriela Santos
- Pneumology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Alice M Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
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Vuurberg NE, Van den Boom AL, Van den Heuvel MC, Klaase JM. Intrahepatic cholangiocarcinoma in a non-cirrhotic liver in a patient with homozygous ZZ alpha-1 antitrypsin deficiency. BMJ Case Rep 2021; 14:14/3/e240077. [PMID: 33658218 PMCID: PMC7931763 DOI: 10.1136/bcr-2020-240077] [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] [Indexed: 12/03/2022] Open
Abstract
Alpha-1 antitrypsin (AAT) deficiency, which is an under-recognised metabolic genetic disorder, is known to cause severe lung disease and liver cirrhosis in about 10%–15% of cases. Patients with AAT deficiency are at a higher risk for developing hepatocellular carcinoma, both in cirrhotic and in non-cirrhotic livers. In this case report, a 48-year-old woman with homozygous ZZ AAT deficiency presented with abdominal pain, and by imaging, an abnormal area in the liver was found. The initial differential diagnosis consisted of benign abnormalities but a malignancy could not be ruled out. Finally, this abnormality turned out to be an intrahepatic cholangiocarcinoma (iCCA) in a non-cirrhotic liver. Since this type of tumour has been very infrequently described to be associated with AAT deficiency, the question remains whether alpha-1 trypsin accumulation in the hepatocytes was responsible for the development of iCCA. However, other associated factors for developing an iCCA were ruled out.
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Affiliation(s)
- Nienke E Vuurberg
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, The Netherlands
| | - Anne Loes Van den Boom
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Joost M Klaase
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, The Netherlands
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Bellemare J, Gaudreault N, Valette K, Belmonte I, Nuñez A, Miravitlles M, Maltais F, Bossé Y. The Clinical Utility of Determining the Allelic Background of Mutations Causing Alpha-1 Antitrypsin Deficiency: The Case with the Null Variant Q0(Mattawa)/Q0(Ourém). CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2021; 8. [PMID: 33150777 DOI: 10.15326/jcopdf.8.1.2020.0168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Alpha-1 antitrypsin deficiency (AATD) is caused by genetic variants in the SERPINA1 gene conferring risk of developing emphysema. The clinical expression of AATD-related emphysema mostly occurs in carriers of 2 deficient alleles. By DNA sequencing of SERPINA1, numerous rare variants have been identified. Clarifying whether 2 mutations observed in 1 patient are on the same or distinct alleles has obvious clinical implications. Methods We studied 7 carriers of a rare variant, Leu353Phe_fsTer24, known to lead to undetectable serum levels of AAT. Two of them were also carriers of the S or Z allele. We developed an allele-specific DNA sequencing method to characterize the allelic background of the Leu353Phe_fsTer24 variant. Results The Leu353Phe_fsTer24 variant was transmitted on the same allele as the M3 variant (E376D) in all patients. This mutation is thus named Q0Ourém on the conventional PI system. We demonstrated that individuals harboring the E264V (S) and E342K (Z) mutations had them on distinct alleles from Q0Ourém and are, thus, compound heterozygotes. The 7 Q0Ourém carriers had AAT levels ranging from 0.18g/l to 0.82g/l. The lowest AAT serum levels were observed in compound heterozygotes (S/Q0Ourém and Z/Q0Ourém) suggesting higher risk of developing emphysema. Conclusion For the 7 patients, Leu353Phe_fsTer24 is transmitted on the M3 background and they are, thus, carriers of the Q0Ourém allele. Allele-specific DNA sequencing was useful to distinguish 1 or 2 deficient alleles in carriers of 2 mutations. In rare cases, this method is important to understand the clinical significance of genetic variants found in SERPINA1.
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Affiliation(s)
- Judith Bellemare
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec, QC, Canada
| | - Nathalie Gaudreault
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec, QC, Canada
| | - Kim Valette
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec, QC, Canada
| | - Irene Belmonte
- Pneumology Department, Hospital Universitari Vall d´Hebron, Vall d´Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Alexa Nuñez
- Pneumology Department, Hospital Universitari Vall d´Hebron, Vall d´Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d´Hebron, Vall d´Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - François Maltais
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec, QC, Canada
| | - Yohan Bossé
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec, QC, Canada.,Department of Molecular Medicine, Laval University, Quebec City, Canada
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Arnhold J. The Dual Role of Myeloperoxidase in Immune Response. Int J Mol Sci 2020; 21:E8057. [PMID: 33137905 PMCID: PMC7663354 DOI: 10.3390/ijms21218057] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/25/2020] [Accepted: 10/28/2020] [Indexed: 12/14/2022] Open
Abstract
The heme protein myeloperoxidase (MPO) is a major constituent of neutrophils. As a key mediator of the innate immune system, neutrophils are rapidly recruited to inflammatory sites, where they recognize, phagocytose, and inactivate foreign microorganisms. In the newly formed phagosomes, MPO is involved in the creation and maintenance of an alkaline milieu, which is optimal in combatting microbes. Myeloperoxidase is also a key component in neutrophil extracellular traps. These helpful properties are contrasted by the release of MPO and other neutrophil constituents from necrotic cells or as a result of frustrated phagocytosis. Although MPO is inactivated by the plasma protein ceruloplasmin, it can interact with negatively charged components of serum and the extracellular matrix. In cardiovascular diseases and many other disease scenarios, active MPO and MPO-modified targets are present in atherosclerotic lesions and other disease-specific locations. This implies an involvement of neutrophils, MPO, and other neutrophil products in pathogenesis mechanisms. This review critically reflects on the beneficial and harmful functions of MPO against the background of immune response.
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Affiliation(s)
- Jürgen Arnhold
- Institute of Medical Physics and Biophysics, Medical Faculty, Leipzig University, 04 107 Leipzig, Germany
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42
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Sandhaus R, Strange C, Stone G, Runken MC, Blanchette CM, Howden R. Comorbidity Associations with AATD Among Commercially Insured and Medicare Beneficiaries with COPD in the US. Int J Chron Obstruct Pulmon Dis 2020; 15:2389-2397. [PMID: 33116454 PMCID: PMC7547287 DOI: 10.2147/copd.s263297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/07/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction Alpha-1 antitrypsin deficiency (AATD) is often not identified in patients with chronic obstructive pulmonary disease (COPD) until advanced stages of disease, despite the availability of genetic testing. While clinical practice guidelines provide recommendations on patients who should be tested, more refined algorithms are needed to identify COPD patients who are likely candidates for AATD testing and to prevent delays in diagnosis and treatment. The objective of this study was to identify comorbid associations with AATD among patients diagnosed with COPD in the United States. Methods Using data from the 2012–2017 PharMetrics Plus Administrative Claims Database and 2011–2014 Medicare Fee for Service 5% Sample, patients with COPD (ICD-9-CM: 491.xx, 492.xx, or 496, ICD-10-CM J41, J42, J43, J44) and AATD (ICD-9-CM: 273.4, ICD-10-CM: E88.01) were identified. Patient demographic and diagnostic characteristics were assessed. Logistic regression models were developed to identify significant predictors of AATD. Results A cohort of 344,528 Medicare beneficiaries with COPD (of which 302 (0.09%) also had two diagnoses of AATD) and a cohort of 340,259 commercially insured patients with COPD (of which 1076 (0.3%) also had a diagnosis of AATD) were constructed. Associations with AATD identified in both models included ICD-9-CM and ICD-10-CM codes for chronic pulmonary heart disease, chronic liver disease and cirrhosis, and liver transplant. Discussion Significant associations with a diagnosis of AATD among patients with COPD were consistently represented in each of the datasets evaluated, which suggests meaningful comorbidity implications in AATD patients. These findings reinforce the need to test individuals with COPD for AATD as early as possible to help reduce the development of associated comorbid conditions.
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Affiliation(s)
- Robert Sandhaus
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
| | - Charlie Strange
- Department of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Glenda Stone
- Global Health Economics & Outcomes Research, Grifols Shared Services of North America, Inc, Research Triangle Park, NC, USA
| | - M Chris Runken
- Global Health Economics & Outcomes Research, Grifols Shared Services of North America, Inc, Research Triangle Park, NC, USA
| | - Christopher M Blanchette
- Department of Public Health Sciences, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, NC, USA
| | - Reuben Howden
- Department of Kinesiology, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, NC, USA
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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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Chan LW, Anahtar MN, Ong TH, Hern KE, Kunz RR, Bhatia SN. Engineering synthetic breath biomarkers for respiratory disease. NATURE NANOTECHNOLOGY 2020; 15:792-800. [PMID: 32690884 PMCID: PMC8173716 DOI: 10.1038/s41565-020-0723-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 06/02/2020] [Indexed: 05/10/2023]
Abstract
Human breath contains many volatile metabolites. However, few breath tests are currently used in the clinic to monitor disease due to bottlenecks in biomarker identification. Here we engineered breath biomarkers for respiratory disease by local delivery of protease-sensing nanoparticles to the lungs. The nanosensors shed volatile reporters upon cleavage by neutrophil elastase, an inflammation-associated protease with elevated activity in lung diseases such as bacterial infection and alpha-1 antitrypsin deficiency. After intrapulmonary delivery into mouse models with acute lung inflammation, the volatile reporters are released and expelled in breath at levels detectable by mass spectrometry. These breath signals can identify diseased mice with high sensitivity as early as 10 min after nanosensor administration. Using these nanosensors, we performed serial breath tests to monitor dynamic changes in neutrophil elastase activity during lung infection and to assess the efficacy of a protease inhibitor therapy targeting neutrophil elastase for the treatment of alpha-1 antitrypsin deficiency.
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Affiliation(s)
- Leslie W Chan
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Melodi N Anahtar
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Harvard-MIT Division of Health Sciences and Technology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Ta-Hsuan Ong
- Biological and Chemical Technologies Group, Massachusetts Institute of Technology Lincoln Laboratory, Lexington, MA, USA
| | - Kelsey E Hern
- Harvard-MIT Division of Health Sciences and Technology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Roderick R Kunz
- Biological and Chemical Technologies Group, Massachusetts Institute of Technology Lincoln Laboratory, Lexington, MA, USA
| | - Sangeeta N Bhatia
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA.
- Harvard-MIT Division of Health Sciences and Technology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Broad Institute, Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA.
- Howard Hughes Medical Institute, Cambridge, MA, USA.
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Implications of a Change of Paradigm in Alpha1 Antitrypsin Deficiency Augmentation Therapy: From Biochemical to Clinical Efficacy. J Clin Med 2020; 9:jcm9082526. [PMID: 32764414 PMCID: PMC7465600 DOI: 10.3390/jcm9082526] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 12/18/2022] Open
Abstract
Ever since the first studies, restoring proteinase imbalance in the lung has traditionally been considered as the main goal of alpha1 antitrypsin (AAT) replacement therapy. This strategy was therefore based on ensuring biochemical efficacy, identifying a protection threshold, and evaluating different dosage regimens. Subsequently, the publication of the results of the main clinical trials showing a decrease in the progression of pulmonary emphysema has led to a debate over a possible change in the main objective of treatment, from biochemical efficacy to clinical efficacy in terms of lung densitometry deterioration prevention. This new paradigm has produced a series controversies and unanswered questions which face clinicians managing AAT deficiency. In this review, the concepts that led to the approval of AAT replacement therapy are reviewed and discussed under a new prism of achieving clinical efficacy, with the reduction of lung deterioration as the main objective. Here, we propose the use of current knowledge and clinical experience to face existing challenges in different clinical scenarios, in order to help clinicians in decision-making, increase interest in the disease, and stimulate research in this field.
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Abstract
Chronic obstructive pulmonary disease (COPD) is characterized by persistent respiratory symptoms and progressive airflow obstruction. Tobacco smoking is the leading cause but not the only one. A postbronchodilator FEV1-FVC ratio less than 0.70 is required for a diagnosis of COPD. Inhaler therapy is the backbone of treatment and should be complemented by a multifaceted management strategy that includes counseling and pharmacotherapy for smoking cessation, pulmonary rehabilitation, treatment of comorbidities, administration of influenza and pneumococcal immunizations, and prescription of long-term oxygen therapy in hypoxemic patients.
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Tumpara S, Martinez-Delgado B, Gomez-Mariano G, Liu B, DeLuca DS, Korenbaum E, Jonigk D, Jugert F, Wurm FM, Wurm MJ, Welte T, Janciauskiene S. The Delivery of α1-Antitrypsin Therapy Through Transepidermal Route: Worthwhile to Explore. Front Pharmacol 2020; 11:983. [PMID: 32719598 PMCID: PMC7348051 DOI: 10.3389/fphar.2020.00983] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/17/2020] [Indexed: 12/12/2022] Open
Abstract
Human α1-antitrypsin (AAT) is an abundant acute phase glycoprotein expressing anti-protease and immunomodulatory activities, and is used as a biopharmaceutical to treat patients with inherited AAT deficiency. The pleiotropic properties of AAT provide a rationale for using this therapy outside of inherited AAT deficiency. Therapy with AAT is administrated intravenously, yet the alternative routes are being considered. To examine the putative transepidermal application of AAT we used epiCS®, the 3D human epidermis equivalents reconstructed from human primary epidermal keratinocytes. We topically applied various concentrations of AAT protein with a constant volume of 50 µl, prepared in Hank's balance solution, HBSS, to epiCS cultured under bas\al condition or when culture medium supplemented with 100 µg/ml of a combined bacterial lipopolysaccharide (LPS) and peptidoglycan (PGN) mixture. AAT freely diffused across epidermis layers in a concentration and time-dependent manner. Within 18 h topically provided 0.2 mg AAT penetrated well the stratum corneum and localizes within the keratinocytes. The treatments with AAT did not induce obvious morphological changes and damages in keratinocyte layers. As expected, LPS/PGN triggered a strong pro-inflammatory activation of epiCS. AAT exhibited a limited capacity to neutralize the effect of LPS/PGN, but more importantly, it lowered expression of IL-18 and IL-8, and preserved levels of filaggrin, a key protein for maintaining the epidermal barrier integrity. Our findings suggest that the transepidermal route for delivering AAT is worthwhile to explore further. If successful, this approach may offer an easy-to-use therapy with AAT for skin inflammatory diseases.
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Affiliation(s)
- Srinu Tumpara
- Department of Internal Medicine, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Beatriz Martinez-Delgado
- Molecular Genetics Unit, Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Gema Gomez-Mariano
- Molecular Genetics Unit, Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Bin Liu
- Department of Internal Medicine, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - David S DeLuca
- Department of Internal Medicine, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Elena Korenbaum
- Research Core Unit for Structural Biochemistry, Hannover Medical School, Hannover, Germany
| | - Danny Jonigk
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - Frank Jugert
- Department of Dermatology, University Clinic Aachen, Aachen, Germany
| | - Florian M Wurm
- ExcellGene SA, Monthey, Switzerland.,Faculty of Life Sciences, Ecole Polytechnique Federale de Lausanne, Lausanne, Switzerland
| | | | - Tobias Welte
- Department of Internal Medicine, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Sabina Janciauskiene
- Department of Internal Medicine, Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
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Franciosi AN, Hobbs BD, McElvaney OJ, Molloy K, Hersh C, Clarke L, Gunaratnam C, Silverman EK, Carroll TP, McElvaney NG. Clarifying the Risk of Lung Disease in SZ Alpha-1 Antitrypsin Deficiency. Am J Respir Crit Care Med 2020; 202:73-82. [PMID: 32197047 PMCID: PMC7530947 DOI: 10.1164/rccm.202002-0262oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 03/20/2020] [Indexed: 12/14/2022] Open
Abstract
Rationale: The ZZ genotype of alpha-1 antitrypsin deficiency (AATD) is associated with chronic obstructive pulmonary disease (COPD), even among never-smokers. The SZ genotype is also considered severe; yet, its effect on lung health remains unclear.Objectives: To determine the effect of SZ-AATD on spirometry compared with a normal-risk population and to determine the effect of smoking cessation in this genotype.Methods: We prospectively enrolled 166 related individuals, removing lung index cases to reduce bias, and compared spirometry between 70 SZ and 46 MM/MS individuals (control subjects). The effect of AAT concentrations on outcomes was assessed in 82 SZ individuals (including lung index cases). Subsequently, we analyzed retrospective SZ registry data to determine the effect of smoking cessation on spirometry decline (n = 60) and plasma anti-neutrophil elastase capacity (n = 20).Measurements and Main Results: No difference between SZ and control never-smokers was seen. Ever smoking was associated with a lower FEV1% predicted (-14.3%; P = 0.0092) and a lower FEV1/FVC ratio (-0.075; P = 0.0041) in SZ-AATD. No association was found between AAT concentration and outcomes for SZ-AATD. Longitudinal analysis of 60 SZ individuals demonstrated that COPD at baseline, but not former smoking or AAT concentrations, predicted greater spirometry decline. Finally, anti-neutrophil elastase capacity did not differ between former smokers and never-smokers (P = 0.67).Conclusions: SZ never-smokers demonstrated no increased risk of COPD, regardless of AAT concentration. Smoking interacts with SZ-AATD to significantly increase airflow obstruction. Former smoking alone is not associated with greater spirometry decline in SZ-AATD, suggesting that cessation attenuates the obstructive process. We found no evidence that the putative protective threshold or AAT concentrations predict risk within the SZ genotype, raising further doubts over the need for intravenous AAT augmentation in this cohort.
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Affiliation(s)
| | - Brian D. Hobbs
- Channing Division of Network Medicine and
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Kevin Molloy
- Irish Centre for Genetic Lung Disease and
- Department of Medicine and
| | - Craig Hersh
- Channing Division of Network Medicine and
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Louise Clarke
- Department of Pulmonary Physiology, Beaumont Hospital, Dublin, Ireland; and
| | | | - Edwin K. Silverman
- Channing Division of Network Medicine and
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Tomás P. Carroll
- Irish Centre for Genetic Lung Disease and
- Alpha-1 Foundation Ireland, Royal College of Surgeons in Ireland, Dublin, Ireland
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Alpha-1 Antitrypsin Deficiency and Pulmonary Morbidity in Patients with Primary Immunodeficiency Disease: A Single-Center Experience. Can Respir J 2020; 2020:4019608. [PMID: 32566054 PMCID: PMC7273390 DOI: 10.1155/2020/4019608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 04/22/2020] [Accepted: 05/06/2020] [Indexed: 01/20/2023] Open
Abstract
Background Alpha-1 antitrypsin deficiency (AATD) is of importance in the pathogenesis of pulmonary emphysema, chronic obstructive pulmonary diseases (COPD), and bronchiectasis. Various pulmonary disorders are a typical feature of primary immunodeficiency disease (PID). This includes recurrent pulmonary infections, immunodysregulation, and autoinflammatory diseases. As a result, incidence of acute and chronic pulmonary diseases is higher. Interestingly, pulmonary morbidity in PID and AATD share similar features. To study the coexistence of AATD in patients suffering from PID, we performed the underlying investigation. Methods We evaluated a study group of 149 patients (n = 149) with PID. In total, serum AAT concentrations were available for 110 patients (n = 110). For the identified patients, we analyzed both clinical associations and interactions. Results Among the investigated patients, reduced serum AAT levels were detected in 7 patients. With regard to the genotype, PI∗ZZ was found in 2 patients, whereas PI∗MZ was observed in 5 patients. Independent of the underlying phenotype, obstructive lung diseases were found in 2 patients with PI∗ZZ and 2 patients with PI∗MZ. Conclusions In Germany, the estimated percentage for PI∗ZZ and PI∗MZ is 0.01% and 1.9%, respectively. As demonstrated, the ratio in our study group was even higher. We identified seven patients with AATD. Since AATD contributes to pulmonary morbidity in PID patients, systematic underdiagnosis of the coexistence might yield a strong clinical impact. Hence, AAT analysis should be offered to all patients with confirmed PID diagnoses. To strengthen this finding, we suggest the investigation of larger databases.
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McElvaney GN, Sandhaus RA, Miravitlles M, Turino GM, Seersholm N, Wencker M, Stockley RA. Clinical considerations in individuals with α 1-antitrypsin PI*SZ genotype. Eur Respir J 2020; 55:13993003.02410-2019. [PMID: 32165400 PMCID: PMC7301289 DOI: 10.1183/13993003.02410-2019] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/25/2020] [Indexed: 12/12/2022]
Abstract
α1-Antitrypsin deficiency (AATD), characterised by reduced levels or functionality of α1-antitrypsin (AAT), is a significantly underdiagnosed genetic condition that predisposes individuals to lung and liver disease. Most of the available data on AATD are based on the most common, severe deficiency genotype (PI*ZZ); therefore, treatment and monitoring requirements for individuals with the PI*SZ genotype, which is associated with a less severe AATD, are not as clear. Recent genetic data suggest the PI*SZ genotype may be significantly more prevalent than currently thought, due in part to less frequent identification in the clinic and less frequent reporting in registries. Intravenous AAT therapy, the only specific treatment for patients with AATD, has been shown to slow disease progression in PI*ZZ individuals; however, there is no specific evidence for AAT therapy in PI*SZ individuals, and it remains unclear whether AAT therapy should be considered in these patients. This narrative review evaluates the available data on the PI*SZ genotype, including genetic prevalence, the age of diagnosis and development of respiratory symptoms compared with PI*ZZ individuals, and the impact of factors such as index versus non-index identification and smoking history. In addition, the relevance of the putative 11 µM “protective threshold” for AAT therapy and the risk of liver disease in PI*SZ individuals is explored. The purpose of this review is to identify open research questions in this area, with the aim of optimising the future identification and management of PI*SZ individuals. Individuals with α1-antitrypsin (AAT) PI*SZ genotype appear to have an increased risk for lung and liver disease, although definitive evidence is lacking; smoking is a major risk factor for lung disease. The role of AAT therapy requires further study.http://bit.ly/2TxxFD0
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Affiliation(s)
- Gerard N McElvaney
- Dept of Respiratory Medicine, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Robert A Sandhaus
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
| | - Marc Miravitlles
- Pneumology Dept, Vall d'Hebron University Hospital/Vall d'Hebron Research Institute (VHIR), CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Gerard M Turino
- Dept of Medicine, Mt Sinai-St Luke's-Roosevelt Hospital, New York, NY, USA
| | - Niels Seersholm
- Dept of Respiratory Medicine, Gentofte Hospital, Hellerup, Denmark
| | | | - Robert A Stockley
- Lung Investigation Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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