151
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Affiliation(s)
- Pavel Strnad
- From the Department of Internal Medicine III, University Hospital RWTH (Rheinisch-Westfälisch Technische Hochschule) Aachen, Aachen, Germany (P.S.); the Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin (N.G.M.); and UCL Respiratory, Division of Medicine, Rayne Institute, University College London, London (D.A.L.)
| | - Noel G McElvaney
- From the Department of Internal Medicine III, University Hospital RWTH (Rheinisch-Westfälisch Technische Hochschule) Aachen, Aachen, Germany (P.S.); the Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin (N.G.M.); and UCL Respiratory, Division of Medicine, Rayne Institute, University College London, London (D.A.L.)
| | - David A Lomas
- From the Department of Internal Medicine III, University Hospital RWTH (Rheinisch-Westfälisch Technische Hochschule) Aachen, Aachen, Germany (P.S.); the Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin (N.G.M.); and UCL Respiratory, Division of Medicine, Rayne Institute, University College London, London (D.A.L.)
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152
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Genetic profiling for disease stratification in chronic obstructive pulmonary disease and asthma. Curr Opin Pulm Med 2020; 25:317-322. [PMID: 30762612 DOI: 10.1097/mcp.0000000000000568] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW In asthma and chronic obstructive pulmonary disease (COPD), the movement towards genetic profiling with a push towards 'personalized medicine' has been hindered by complex environment--gene interactions and lack of tools to identify clear causal genetic traits. In this review, we will discuss the need for genetic profiling in asthma and COPD, what methods are currently used in the clinics and the recent finding using new sequencing methods. RECENT FINDINGS Over the past 10-15 years, genome-wide association studies analysis of common variants has provide little in the way of new genetic profiling markers for asthma and COPD. Whole exome/genome sequencing has provided a new method to identify lowly abundant alleles, which might have a much higher impact. Although, low population numbers due to high costs has hindered early studies, recent studies have reached genome wide significance. SUMMARY The use of genetic profiling of COPD in the clinic is current limited to the identification of Alpha-1 antitrypsin deficiency, while being absent in asthma. Advances in sequencing technology provide new avenues to identify disease causes or therapy response altering variants that in the short-term will allow for the development of screening procedures for disease to identify patients at risk of developing asthma or COPD.
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153
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Aiello M, Fantin A, Longo C, Ferrarotti I, Bertorelli G, Chetta A. Clinical manifestations in patients with PI*MM Malton genotypes. A matter still unsolved in alpha-1 antitrypsin deficiency. Respirol Case Rep 2020; 8:e00528. [PMID: 32076552 PMCID: PMC7029433 DOI: 10.1002/rcr2.528] [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: 10/09/2019] [Revised: 12/05/2019] [Accepted: 12/22/2019] [Indexed: 11/08/2022] Open
Abstract
We report the genetic variants associated with alpha-1 antitrypsin deficiency (AATD) in 117 patients admitted to our outpatient clinic and characterized by a serum concentration of AAT lower than 113 mg/dL. We focused on the M-like heterozygous variant of the SERPINA1 gene called PI*MMMalton, and describe three patients with this variant. While the role of homozygous AATD in liver and pulmonary disease is well established, the association between heterozygous AATD and chronic liver and pulmonary disease is still under investigation. The PI*MMMalton genotype was found in 5.8% of patients with a pathological genotype of AATD and in 14.3% of the subjects when considering only those with intermediate AATD. There were no liver or renal abnormalities in patients with the PI*MMMalton genotype. The PI*MMMalton patients included here showed a normal liver function, and none had renal function abnormalities or abdominal aortic aneurysm. Only a prevalence of lung disease was detected.
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Affiliation(s)
- Marina Aiello
- Department of Medicine and Surgery, Respiratory Disease and Lung Function UnitUniversity of ParmaItaly
| | - Alberto Fantin
- Department of Medicine and Surgery, Respiratory Disease and Lung Function UnitUniversity of ParmaItaly
| | - Chiara Longo
- Department of Medicine and Surgery, Respiratory Disease and Lung Function UnitUniversity of ParmaItaly
| | - Ilaria Ferrarotti
- Center for the Diagnosis of Inherited Alpha1‐antitrypsin Deficiency, Department of Internal Medicine and Therapeutics, Pneumology UnitUniversity of PaviaItaly
| | - Giuseppina Bertorelli
- Department of Medicine and Surgery, Respiratory Disease and Lung Function UnitUniversity of ParmaItaly
| | - Alfredo Chetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function UnitUniversity of ParmaItaly
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154
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Alpha-1-Antitrypsin Deficiency and Bronchiectasis: A Concomitance or a Real Association? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17072294. [PMID: 32235324 PMCID: PMC7178111 DOI: 10.3390/ijerph17072294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/22/2020] [Accepted: 03/27/2020] [Indexed: 11/17/2022]
Abstract
Alpha-1-antitrypsin deficiency (AATd) is a hereditary disease, mainly characterized by early onset and the lower lobes' predominant emphysema. Bronchiectasis is characterized by dilatation of the bronchial wall and a clinical syndrome whose features are a cough, sputum production and frequent respiratory exacerbations. In the literature, there are many papers concerning these two clinical entities, but there is still a lot of debate about a possible association between them, in particular about the frequency of their association and causal links. The aim of this short communication is to show the literature reports about the association between AATd and bronchiectasis to establish the state of the art and possible future developments in this research field.
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155
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Knowledge of Rare Respiratory Diseases among Paediatricians and Medical School Students. J Clin Med 2020; 9:jcm9030869. [PMID: 32235794 PMCID: PMC7141530 DOI: 10.3390/jcm9030869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 03/15/2020] [Accepted: 03/18/2020] [Indexed: 12/05/2022] Open
Abstract
Alpha-1-antitrypsin deficiency (AATD) and primary ciliary dyskinesia (PCD) are underdiagnosed rare diseases showing a median diagnostic delay of five to ten years, which has negative effects on patient prognosis. Lack of awareness and education among healthcare professionals involved in the management of these patients have been suggested as possible causes. Our aim was to assess knowledge of these diseases among paediatricians and medical school students to determine which knowledge areas are most deficient. A survey was designed with questions testing fundamental aspects of the diagnosis and treatment of AATD and PCD. A score equal to or greater than 50% of the maximum score was set as the level necessary to ensure a good knowledge of both diseases. Our results indicate a profound lack of knowledge of rare respiratory diseases among paediatric professionals and medical students, suggesting that it is necessary to increase rare respiratory diseases training among all physicians responsible for suspecting and diagnosing them; this will allow early diagnosis and the setup of preventive measures and appropriate early-stage treatment. The first step in closing this knowledge gap could be to include relevant material in the medical syllabus.
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156
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Barrecheguren M, Torres-Duran M, Casas-Maldonado F, Miravitlles M. Spanish Implementation of the New International Alpha-1 Anitrypsin Deficiency International Registry: The European Alpha-1 Research Collaboration (EARCO). Arch Bronconeumol 2020; 57:81-82. [PMID: 32197815 DOI: 10.1016/j.arbres.2020.02.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 02/01/2020] [Accepted: 02/05/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Miriam Barrecheguren
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, Barcelona, España; Miembro de la European Alpha-1-Research Collaboration (EARCO)
| | - María Torres-Duran
- Servicio de Neumología, Hospital Álvaro Cunqueiro, EOXI Vigo, Vigo, Pontevedra, España; Coordinadora del Registro Español de Pacientes con Déficit de Alfa-1-Antitripsina (REDAAT)
| | - Francisco Casas-Maldonado
- Servicio de Neumología, Hospital Universitario San Cecilio, Granada, España; Coordinador del REDAAT entre 2016 y 2019
| | - Marc Miravitlles
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, Barcelona, España; Coordinador de la European Alpha-1-Research Collaboration (EARCO).
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157
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Ottaviani S, Barzon V, Buxens A, Gorrini M, Larruskain A, El Hamss R, Balderacchi AM, Corsico AG, Ferrarotti I. Molecular diagnosis of alpha1-antitrypsin deficiency: A new method based on Luminex technology. J Clin Lab Anal 2020; 34:e23279. [PMID: 32181528 PMCID: PMC7370739 DOI: 10.1002/jcla.23279] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/17/2020] [Accepted: 02/13/2020] [Indexed: 12/12/2022] Open
Abstract
Background Alpha1‐antitrypsin deficiency (AATD) is an under‐diagnosed hereditary disorder characterized by reduced serum levels of alpha1‐antitrypsin (AAT) and increased risk to develop lung and liver diseases at an early age. AAT is encoded by the highly polymorphic SERPINA1 gene. The most common deficiency alleles are S and Z, but more than 150 rare variants lead to low levels of the protein. To identify these pathological allelic variants, sequencing is required. Since traditional sequencing is expensive and time‐consuming, we evaluated the accuracy of A1AT Genotyping Test, a new diagnostic genotyping kit which allows to simultaneously identify and genotype 14 deficiency variants of the SERPINA1 gene based on Luminex technology. Methods A total of 418 consecutive samples with AATD suspicion and submitted to the Italian Reference laboratory between January and April 2016 were analyzed both by applying the diagnostic algorithm currently in use, and by applying A1AT Genotyping Test. Results The assay gave the following results: 101 samples (24.2%) were positive for at least one of the 14 deficiency variants, 316 (75.6%) were negative for all the variants analyzed. The identified mutations showed a 100% correlation with the results obtained with our diagnostic algorithm. Seventeen samples (4%) resulted negative for the assay but sequencing identified other rare pathological variants in SERPINA1 gene. Conclusion The A1AT Genotyping Test assay was highly reliable and robust and allowed shorter diagnostic times. In few cases, it has been necessary to sequence the SERPINA1 gene to identify other rare mutations not included in the kit.
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Affiliation(s)
- Stefania Ottaviani
- Center for Diagnosis of Inherited Alpha1-antitrypsin Deficiency, Laboratory of Biochemistry and Genetics, Institute for Respiratory Disease, Department of Internal Medicine and Therapeutics, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Valentina Barzon
- Center for Diagnosis of Inherited Alpha1-antitrypsin Deficiency, Laboratory of Biochemistry and Genetics, Institute for Respiratory Disease, Department of Internal Medicine and Therapeutics, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Amaya Buxens
- Progenika Biopharma, A Grifols Company, Derio, Spain
| | - Marina Gorrini
- Center for Diagnosis of Inherited Alpha1-antitrypsin Deficiency, Laboratory of Biochemistry and Genetics, Institute for Respiratory Disease, Department of Internal Medicine and Therapeutics, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | | | - Alice M Balderacchi
- Center for Diagnosis of Inherited Alpha1-antitrypsin Deficiency, Laboratory of Biochemistry and Genetics, Institute for Respiratory Disease, Department of Internal Medicine and Therapeutics, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Angelo G Corsico
- Center for Diagnosis of Inherited Alpha1-antitrypsin Deficiency, Laboratory of Biochemistry and Genetics, Institute for Respiratory Disease, Department of Internal Medicine and Therapeutics, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Ilaria Ferrarotti
- Center for Diagnosis of Inherited Alpha1-antitrypsin Deficiency, Laboratory of Biochemistry and Genetics, Institute for Respiratory Disease, Department of Internal Medicine and Therapeutics, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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158
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Greulich T, Altraja A, Barrecheguren M, Bals R, Chlumsky J, Chorostowska-Wynimko J, Clarenbach C, Corda L, Corsico AG, Ferrarotti I, Esquinas C, Gouder C, Hećimović A, Ilic A, Ivanov Y, Janciauskiene S, Janssens W, Kohler M, Krams A, Lara B, Mahadeva R, McElvaney G, Mornex JF, O'Hara K, Parr D, Piitulainen E, Schmid-Scherzer K, Seersholm N, Stockley RA, Stolk J, Sucena M, Tanash H, Turner A, Ulmeanu R, Wilkens M, Yorgancioğlu A, Zaharie A, Miravitlles M. Protocol for the EARCO Registry: a pan-European observational study in patients with α 1-antitrypsin deficiency. ERJ Open Res 2020; 6:00181-2019. [PMID: 32154291 PMCID: PMC7049712 DOI: 10.1183/23120541.00181-2019] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 12/04/2019] [Indexed: 12/31/2022] Open
Abstract
Rationale and objectives Alpha-1 antitrypsin deficiency (AATD) is a genetic condition that leads to an increased risk of emphysema and liver disease. Despite extensive investigation, there remain unanswered questions concerning the natural history, pathophysiology, genetics and the prognosis of the lung disease in association with AATD. The European Alpha-1 Clinical Research Collaboration (EARCO) is designed to bring together researchers from European countries and to create a standardised database for the follow-up of patients with AATD. Study design and population The EARCO Registry is a non-interventional, multicentre, pan-European, longitudinal observational cohort study enrolling patients with AATD. Data will be collected prospectively without interference/modification of patient's management by the study team. The major inclusion criterion is diagnosed severe AATD, defined by an AAT serum level <11 µM (50 mg·dL−1) and/or a proteinase inhibitor genotype ZZ, SZ or compound heterozygotes or homozygotes of other rare deficient variants. Assessments at baseline and during the yearly follow-up visits include lung function testing (spirometry, body plethysmography and diffusing capacity of the lung), exercise capacity, blood tests and questionnaires (symptoms, quality of life and physical activity). To ensure correct data collection, there will be designated investigator staff to document the data in the case report form. All data will be reviewed by the EARCO database manager. Summary The EARCO Registry aims to understand the natural history and prognosis of AATD better with the goal to create and validate prognostic tools to support medical decision-making. The EARCO Registry is a non-interventional, multicentre, pan-European, longitudinal observational cohort study enrolling patients with AATD to elucidate the natural history, pathophysiology, genetics and prognosis of this conditionhttp://bit.ly/369ScCc
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Affiliation(s)
- Timm Greulich
- University Medical Centre Giessen and Marburg, Philipps-University, Dept of Medicine, Pulmonary and Critical Care Medicine, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Alan Altraja
- Pneumology Dept, Tartu University, Tartu, Estonia.,Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - Miriam Barrecheguren
- Pneumology Dept, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Robert Bals
- Dept of Internal Medicine V - Pulmonology, Allergology, Intensive Care Medicine, Saarland University Hospital, Homburg, Germany
| | - Jan Chlumsky
- Dept of Pneumology, Thomayer Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Joanna Chorostowska-Wynimko
- Dept of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | | | - Luciano Corda
- Dept of Internal Medicine, Respiratory Disease Unit, Spedali Civili, Brescia, Italy
| | - Angelo Guido Corsico
- Dept of Internal Medicine and Therapeutics, Pneumology Unit IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Ilaria Ferrarotti
- Dept of Internal Medicine and Therapeutics, Pneumology Unit IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Cristina Esquinas
- Pneumology Dept, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Caroline Gouder
- Dept of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Ana Hećimović
- Dept of Respiratory Diseases "Jordanovac", University of Zagreb, School of Medicine, Zagreb, Croatia
| | - Aleksandra Ilic
- Clinic for Pulmology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Yavor Ivanov
- Pulmonary Clinic, University Hospital, Pleven, Bulgaria
| | | | - Wim Janssens
- Katholieke Universiteit Leuven, Laboratory of Respiratory Diseases, Dept of Chronic Disease, Metabolism and Ageing, Leuven, Belgium.,University Hospitals Leuven, Department of Respiratory Diseases, Leuven, Belgium
| | - Malcolm Kohler
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Alvils Krams
- Faculty of Medicine, University of Latvia, Riga, Latvia.,Riga East University Hospital, Riga, Latvia
| | - Beatriz Lara
- Dept of Respiratory Medicine, University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Ravi Mahadeva
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gerry McElvaney
- Irish Centre for Rare Lung Diseases, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Jean-François Mornex
- Hospices Civils de Lyon, Service de Pneumologie, Hôpital Louis Pradel, Lyon, France.,Université de Lyon, Université Lyon 1, UMR754, INRA, Lyon, France
| | - Karen O'Hara
- Alpha-1 UK Support Group, Droitwich, UK.,Alpha-1 Global, Miami, FL, USA
| | - David Parr
- Dept of Respiratory Medicine, University Hospitals of Coventry and Warwickshire, Coventry, UK
| | - Eava Piitulainen
- Dept of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Karin Schmid-Scherzer
- Dept of Internal Medicine II and Pulmonology, Wilhelminenspital, Medical University of Vienna, Vienna, Austria
| | - Niels Seersholm
- Dept of Internal Medicine, Herlev and Gentofte University Hospital, Hellerup, Denmark
| | - Robert A Stockley
- Lung Investigation Unit Medicine, University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Jan Stolk
- Dept of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maria Sucena
- Pulmonology Dept, Centro Hospitalar de São João, Porto, Portugal
| | - Hanan Tanash
- Dept of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Alice Turner
- Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Ruxandra Ulmeanu
- Marius Nasta Institute, Bucharest, Romania.,Faculty of Medicine, University of Medicine Oradea, Bucharest, Romania
| | - Marion Wilkens
- Patientenorganisation Alpha1 Deutschland e.V., Gernsheim, Germany
| | - Arzu Yorgancioğlu
- Dept of Pulmonary Diseases, Celal Bayar University, Faculty of Medicine (and the GARD Executive Committee), Manisa, Turkey
| | - Ana Zaharie
- Dept of Pneumophthisiology, University of Medicine and Pharmacy, "Marius Nasta" Institute of Pneumophthisiology, Bucharest, Romania
| | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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159
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Dummer J, Dobler CC, Holmes M, Chambers D, Yang IA, Parkin L, Smith S, Wark P, Dev A, Hodge S, Dabscheck E, Gooi J, Samuel S, Knowles S, Holland AE. Diagnosis and treatment of lung disease associated with alpha one-antitrypsin deficiency: A position statement from the Thoracic Society of Australia and New Zealand. Respirology 2020; 25:321-335. [PMID: 32030868 PMCID: PMC7078913 DOI: 10.1111/resp.13774] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/27/2019] [Accepted: 01/10/2020] [Indexed: 12/18/2022]
Abstract
AATD is a common inherited disorder associated with an increased risk of developing pulmonary emphysema and liver disease. Many people with AATD-associated pulmonary emphysema remain undiagnosed and therefore without access to care and counselling specific to the disease. AAT augmentation therapy is available and consists of i.v. infusions of exogenous AAT protein harvested from pooled blood products. Its clinical efficacy has been the subject of some debate and the use of AAT augmentation therapy was recently permitted by regulators in Australia and New Zealand, although treatment is not presently subsidized by the government in either country. The purpose of this position statement is to review the evidence for diagnosis and treatment of AATD-related lung disease with reference to the Australian and New Zealand population. The clinical efficacy and adverse events of AAT augmentation therapy were evaluated by a systematic review, and the GRADE process was employed to move from evidence to recommendation. Other sections address the wide range of issues to be considered in the care of the individual with AATD-related lung disease: when and how to test for AATD, changing diagnostic techniques, monitoring of progression, disease in heterozygous AATD and pharmacological and non-pharmacological therapy including surgical options for severe disease. Consideration is also given to broader issues in AATD that respiratory healthcare staff may encounter: genetic counselling, patient support groups, monitoring for liver disease and the need to establish national registries for people with AATD in Australia and New Zealand.
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Affiliation(s)
- Jack Dummer
- Department of Medicine, Dunedin School of MedicineUniversity of OtagoDunedinNew Zealand
| | - Claudia C. Dobler
- Institute for Evidence‐Based HealthcareBond University and Gold Coast University HospitalGold CoastQLDAustralia
- Department of Respiratory MedicineLiverpool HospitalSydneyNSWAustralia
| | - Mark Holmes
- Department of Thoracic MedicineRoyal Adelaide HospitalAdelaideSAAustralia
- Faculty of MedicineThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Daniel Chambers
- Faculty of MedicineThe University of QueenslandBrisbaneQLDAustralia
- Queensland Lung Transplant ProgramThe Prince Charles HospitalBrisbaneQLDAustralia
| | - Ian A. Yang
- Faculty of MedicineThe University of QueenslandBrisbaneQLDAustralia
- Department of Thoracic MedicineThe Prince Charles HospitalBrisbaneQLDAustralia
| | - Lianne Parkin
- Department of Preventive and Social Medicine, Dunedin School of MedicineUniversity of OtagoDunedinNew Zealand
| | - Sheree Smith
- School of Nursing and MidwiferyWestern Sydney UniversitySydneyNSWAustralia
| | - Peter Wark
- Centre for Healthy LungsUniversity of NewcastleNewcastleNSWAustralia
- Department of Respiratory and Sleep MedicineJohn Hunter HospitalNew LambtonNSWAustralia
| | - Anouk Dev
- Department of GastroenterologyMonash HealthMelbourneVICAustralia
| | - Sandra Hodge
- Department of Thoracic MedicineRoyal Adelaide HospitalAdelaideSAAustralia
- Faculty of MedicineThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Eli Dabscheck
- Department of Respiratory MedicineAlfred HospitalMelbourneVICAustralia
- Department of Allergy, Immunology and Respiratory Medicine, Central Clinical SchoolMonash UniversityMelbourneVICAustralia
| | - Julian Gooi
- Department of Cardiothoracic SurgeryAlfred HospitalMelbourneVICAustralia
| | - Sameh Samuel
- Department of Respiratory MedicineWollongong HospitalWollongongNSWAustralia
- School of Medicine, University of WollongongWollongongNSWAustralia
| | | | - Anne E. Holland
- Department of Allergy, Immunology and Respiratory Medicine, Central Clinical SchoolMonash UniversityMelbourneVICAustralia
- Department of PhysiotherapyAlfred HealthMelbourneVICAustralia
- Institute for Breathing and SleepMelbourneVICAustralia
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160
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Cazzola M, Stolz D, Rogliani P, Matera MG. α 1-Antitrypsin deficiency and chronic respiratory disorders. Eur Respir Rev 2020; 29:29/155/190073. [PMID: 32051168 DOI: 10.1183/16000617.0073-2019] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/28/2019] [Indexed: 01/09/2023] Open
Abstract
α1-antitrypsin deficiency (AATD) is a hereditary disorder associated with a risk of developing liver disease and pulmonary emphysema, and other chronic respiratory disorders (mainly asthma and bronchiectasis); Z variant is the commonest deficient variant of AAT. Determining AAT concentration in serum or plasma and identifying allelic variants by phenotyping or genotyping are fundamental in the diagnosis of AATD. Initial evaluation and annual follow-up measurement of lung function, including post-bronchodilator forced expiratory volume in 1 s and gas transfer inform on disease progression. Lung densitometry is the most sensitive measure of emphysema progression, but must not be use in the follow-up of patients in routine clinical practice. The exogenous administration of purified human serum-derived AAT is the only approved specific treatment for AATD in PiZZ. AAT augmentation therapy is not recommended in PiSZ, PiMZ or current smokers of any protein phenotype, or in patients with hepatic disease. Lung volume reduction and endoscopic bronchial valve placement are useful in selected patients, whereas the survival benefit of lung transplant is unclear. There are several new lines of research in AATD to improve the diagnosis and evaluation of the response to therapy and to develop genetic and regenerative therapies and other treatments.
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Affiliation(s)
- Mario Cazzola
- Unit of Respiratory Medicine, Dept Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Daiana Stolz
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital of Basel, Basel, Switzerland
| | - Paola Rogliani
- Unit of Respiratory Medicine, Dept Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Maria Gabriella Matera
- Unit of Pharmacology, Dept Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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161
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Chorostowska-Wynimko J, Barrecheguren M, Ferrarotti I, Greulich T, Sandhaus RA, Campos M. New Patient-Centric Approaches to the Management of Alpha-1 Antitrypsin Deficiency. Int J Chron Obstruct Pulmon Dis 2020; 15:345-355. [PMID: 32103933 PMCID: PMC7024807 DOI: 10.2147/copd.s234646] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/24/2020] [Indexed: 12/30/2022] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a rare and underdiagnosed genetic predisposition for COPD and emphysema and other conditions, including liver disease. Although there have been improvements in terms of awareness of AATD and understanding of its treatment in recent years, current challenges center on optimizing detection and management of patients with AATD, and improving access to intravenous (IV) AAT therapy – the only available pharmacological intervention that can slow disease progression. However, as an orphan disease with geographically dispersed patients, international cooperation is essential to address these issues. To achieve this, new European initiatives in the form of the European Reference Network for Rare Lung Diseases (ERN-LUNG) and the European Alpha-1 Research Collaboration (EARCO) have been established. These organizations are striving to address the current challenges in AATD, and provide a new platform for future research efforts in AATD. The first objectives of ERN-LUNG are to establish a quality control program for European AATD laboratories and create a disease management program for AATD, following the success of such programs in the United States. The main purpose of EARCO is to create a pan-European registry, with the aim of understanding the natural history of the disease and supporting the development of new treatment modalities in AATD and access to AAT therapy. Going further, other patient-centric initiatives involve improving the convenience of intravenous AAT therapy infusions through extended-interval dosing and self-administration. The present review will discuss the implementation of these initiatives and their potential contribution to the optimization of patient care in AATD.
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Affiliation(s)
- Joanna Chorostowska-Wynimko
- Department of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | | | - Ilaria Ferrarotti
- Department of Internal Medicine and Therapeutics, Pneumology Unit IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Timm Greulich
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps-University, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Robert A Sandhaus
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, 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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162
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Leung SS, Lee P, Most JE, Sundaram B. Images in COPD: Idiopathic Emphysema in a Never Smoker. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2020; 7:130-133. [PMID: 32324984 DOI: 10.15326/jcopdf.7.2.2020.0148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Stephan S Leung
- Division of Cardiothoracic Radiology, Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Patrick Lee
- Division of Cardiothoracic Radiology, Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jessica E Most
- Division of Pulmonology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Baskaran Sundaram
- Division of Cardiothoracic Radiology, Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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163
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Menga G, Fernandez Acquier M, Echazarreta AL, Sorroche PB, Lorenzon MV, Fernández ME, Saez MS. Prevalence of Alpha-1 Antitrypsin Deficiency in COPD Patients in Argentina. The DAAT.AR Study. Arch Bronconeumol 2019; 56:571-577. [PMID: 31889566 DOI: 10.1016/j.arbres.2019.11.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 10/25/2019] [Accepted: 11/01/2019] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Alpha-1 antitrypsin deficiency (AATD) is still underdiagnosed, despite the recommendation to determine AAT in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVE To estimate the prevalence of AATD in COPD patients adjusted according to the population of the COPD prevalence study in Argentina (EPOC.AR). MATERIAL AND METHODS This was a multicenter prospective cross-sectional study of a population aged≥30 years of age diagnosed with COPD, involving AAT quantification in dry blood spot and subsequent genotyping in subjects with<1.5mg/dL AAT in dry blood spot (<80mg/dL in serum). AAT was defined as the detection of variants ZZ or SZ on genotyping. The EPOC.AR study population was used to calculate local adjusted prevalence. RESULTS We included 3,254 patients (544 with AAT<80mg/dL) with a spirometric diagnosis of COPD. The prevalence of AATD in the total study population was 1.29% (95% CI 0.93-1.74), of which 0.92% (95% CI 0.62-1.31) were Pi*ZZ and 0.37% (95% CI 0.19-0.64) Pi*SZ. The adjusted prevalence of AATD in COPD patients≥40 years of age was 0.83% (95% CI 0.23-2.08). We found that AATD was negatively associated with age (OR 0.94; 95% CI 0.90-0.98; P=.006), smoking habit (OR 0.98; 95% CI 0.96-0.99; P=.009), and FEV1% (OR 0.95; 95% CI 0.91-0.99; P=.015). CONCLUSIONS The prevalence of AATD in the adult population with COPD in Argentina is estimated to be 0.83%, which could represent 17,000 cases in our country.
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Affiliation(s)
- Guillermo Menga
- Hospital Municipal de Rehabilitación Respiratoria María Ferrer, Buenos Aires, Argentina
| | | | - Andrés L Echazarreta
- Hospital Interzonal Especializado de Agudos y Crónicos San Juan de Dios, La Plata, Argentina
| | | | | | - Martin E Fernández
- Hospital Municipal de Rehabilitación Respiratoria María Ferrer, Buenos Aires, Argentina
| | - María S Saez
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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164
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Roohani S, Tacke F. Non-invasive assessment for alpha-1 antitrypsin deficiency-associated liver disease: new insights on steatosis and fibrosis in Pi*ZZ carriers. Transl Gastroenterol Hepatol 2019; 4:82. [PMID: 32039287 DOI: 10.21037/tgh.2019.11.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 11/15/2019] [Indexed: 12/12/2022] Open
Affiliation(s)
- Siyer Roohani
- Department of Hepatology & Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Tacke
- Department of Hepatology & Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
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165
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Abstract
Alpha-1 antitrypsin (AAT) protects the lung by inhibiting neutrophil proteinases, but AAT has many other non-proteolytic functions that are anti-inflammatory, antiviral and homeostatic. Approximately 1 in 1600 to 1 in 5000 people have the homozygous Z mutation, which causes AAT misfolding, accumulation in (predominantly) liver cells and low circulating levels of AAT, leading to AAT deficiency (AATD). AATD is classically a disease of neutrophilic inflammation, with an aggressive and damaging innate immune response contributing to emphysema and other pathologies. AATD is one of the most common genetic disorders but considerably under-recognised. Most patients are diagnosed later in life, by which time they may have accumulated significant lung, liver and multisystem damage. Disease presentation is heterogeneous and not fully explained by deficiency levels alone or exposure to cigarette smoking. This suggests other factors influence AATD-associated pathological processes. Aging itself is associated with organ dysfunction, including emphysema and airflow obstruction, inflammation, altered immune cell responses (termed immunosenescence) and a loss of proteostasis. Many of these processes are present in AATD but at an earlier age and more advanced stage compared with chronological aging alone. Augmentation therapy does not completely abrogate the manifold disease processes present in AATD. New approaches are needed. There is emerging evidence that both age- and AATD-related disease processes are amenable to correction by targeting proteostasis, autophagy, immunosenescence and epigenetic factors. This review explores the impact of the aging process on AATD presentation and discusses novel therapeutic strategies to mitigate low levels of AAT or misfolded AAT in an aging host.
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166
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Barrecheguren M, Miravitlles M. Treatment with inhaled α1-antitrypsin: a square peg in a round hole? Eur Respir J 2019; 54:54/5/1901894. [DOI: 10.1183/13993003.01894-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 09/27/2019] [Indexed: 11/05/2022]
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Veith M, Klemmer A, Anton I, El Hamss R, Rapun N, Janciauskiene S, Kotke V, Herr C, Bals R, Vogelmeier CF, Greulich T. Diagnosing Alpha-1-Antitrypsin Deficiency Using A PCR/Luminescence-Based Technology. Int J Chron Obstruct Pulmon Dis 2019; 14:2535-2542. [PMID: 31819391 PMCID: PMC6873957 DOI: 10.2147/copd.s224221] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 10/21/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose Alpha-1-antitrypsin deficiency (AATD) is a rare hereditary condition resulting from the mutations in the SERPINA1 (serine protease inhibitor) gene and is characterized by low circulating levels of the alpha-1 antitrypsin (AAT) protein. The traditional algorithm for laboratory testing of AATD involves the analysis of AAT concentrations (nephelometry), phenotyping (isoelectric focusing, IEF), and genotyping (polymerase chain reaction, PCR); in selected cases, full sequencing of the SERPINA1 gene can be undertaken. New technologies arise that may make diagnosis easier and faster. Methods We developed and evaluated a new diagnostic algorithm based on Luminex xMAP (multi-analyte profiling) technology using Progenika A1AT Genotyping Test. In an initial learning phase, 1979 samples from individuals suspected of having AATD were examined by both, a traditional and a "new" algorithm. In a second phase, 1133 samples were analyzed with the Luminex xMAP only. Results By introducing a Luminex xMAP based algorithm, we were able to simultaneously identify 14 mutations in SERPINA1 gene (instead of two- S and Z-by using our old algorithm). Although the quantity of IEF assays remained unchanged, the nephelometric measurements and sequencing were reduced by 79% and 63.4%, respectively. Conclusion The new method is convenient, fast and user-friendly. The application of the Luminex xMAP technology can simplify and shorten the diagnostic workup of patients with suspected AATD.
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Affiliation(s)
- Martina Veith
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research Marburg, University Medical Center Giessen And Marburg, Germany
| | - Andreas Klemmer
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research Marburg, University Medical Center Giessen And Marburg, Germany
| | - Iker Anton
- Progenika Biopharma, S.A. A Grifols Company, Derio, Bizkaia, Spain
| | - Rachid El Hamss
- Progenika Biopharma, S.A. A Grifols Company, Derio, Bizkaia, Spain
| | - Noelia Rapun
- Progenika Biopharma, S.A. A Grifols Company, Derio, Bizkaia, Spain
| | - Sabina Janciauskiene
- Department of Respiratory Medicine, Member of the German Center for Lung Research (DZL), Hannover Medical School, Biomedical Research in End Stage and Obstructive Lung Disease Hannover (BREATH), Hannover 30625, Germany
| | - Viktor Kotke
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research Marburg, University Medical Center Giessen And Marburg, Germany
| | - Christian Herr
- Department of Internal Medicine V, Pulmonology, Allergology, Respiratory and Intensive Care Medicine, Saarland Hospital, Homburg/Saar, Germany
| | - Robert Bals
- Department of Internal Medicine V, Pulmonology, Allergology, Respiratory and Intensive Care Medicine, Saarland Hospital, Homburg/Saar, Germany
| | - Claus Franz Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research Marburg, University Medical Center Giessen And Marburg, Germany
| | - Timm Greulich
- Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research Marburg, University Medical Center Giessen And Marburg, Germany
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168
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Hersh CP, Campbell EJ, Scott LR, Raby BA. Alpha-1 Antitrypsin Deficiency as an Incidental Finding in Clinical Genetic Testing. Am J Respir Crit Care Med 2019; 199:246-248. [PMID: 30359090 DOI: 10.1164/rccm.201809-1679le] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Craig P Hersh
- 1 Brigham and Women's Hospital Boston, Massachusetts
| | | | | | - Benjamin A Raby
- 1 Brigham and Women's Hospital Boston, Massachusetts.,3 Boston Children's Hospital Boston, Massachusetts
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169
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Pye A, Turner AM. Experimental and investigational drugs for the treatment of alpha-1 antitrypsin deficiency. Expert Opin Investig Drugs 2019; 28:891-902. [PMID: 31550938 DOI: 10.1080/13543784.2019.1672656] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Introduction: Alpha-1 antitrypsin deficiency (AATD) is most often associated with chronic lung disease, early onset emphysema, and liver disease. The standard of care in lung disease due to AATD is alpha-1 antitrypsin augmentation but there are several new and emerging treatment options under investigation for both lung and liver manifestations. Areas covered: We review therapeutic approaches to lung and liver disease in alpha-1 antitrypsin deficiency (AATD) and the agents in clinical development according to their mode of action. The focus is on products in clinical trials, but data from pre-clinical studies are described where relevant, particularly where progression to trials appears likely. Expert opinion: Clinical trials directed at lung and liver disease separately are now taking place. Multimodality treatment may be the future, but this could be limited by treatment costs. The next 5-10 years may reveal new guidance on when to use therapeutics for slowing disease progression with personalized treatment regimes coming to the forefront.
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Affiliation(s)
- Anita Pye
- Institute of Applied Health Research, University of Birmingham , Birmingham , UK
| | - Alice M Turner
- Institute of Applied Health Research, University of Birmingham , Birmingham , UK
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170
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Attaway A, Majumdar U, Sandhaus RA, Nowacki AS, Stoller JK. An analysis of the degree of concordance among international guidelines regarding alpha-1 antitrypsin deficiency. Int J Chron Obstruct Pulmon Dis 2019; 14:2089-2101. [PMID: 31564856 PMCID: PMC6734458 DOI: 10.2147/copd.s208591] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/01/2019] [Indexed: 11/23/2022] Open
Abstract
Background Practice guidelines (PGs) attempt to standardize practice to optimize care. For uncommon lung diseases like alpha-1 antitrypsin deficiency (AATD), a paucity of definitive studies and geographic variation in prevalence may hamper guideline generation. The current study assembled and assesses the degree of concordance among available PGs regarding AATD. Methods To assess concordance, 15 eligible guidelines focused on AATD were evaluated regarding recommendations surrounding 24 key clinical issues. A Delphi process achieved consensus on ratings for each statement among 3 reviewers. Agreement was quantified as the proportion of guideline comparisons with a matching rating. Results The overall level of agreement was 47% (1190/2520 comparisons). The overall “affirmative agreement percentage” (ie, when guidelines agreed in endorsing a practice), was 42% (501/1190 comparisons). The agreement for individual clinical statements ranged from 26% to 75%. A broad consensus was seen in the recommendation to test all patients with a history of fixed obstruction on pulmonary function testing (either from asthma or COPD). Given that AATD is an under-recognized disease and that diagnosis often occurs at a late stage, the authors are encouraged by this consensus. Where overall the guidelines were less explicit was when to refer to a specialist or AATD center. Deciding on a treatment strategy requires a thorough understanding of the alpha 1 serum level, genotype, pulmonary function testing, and imaging, and therefore the authors feel that all patients would benefit from a specialty referral if the diagnosis of AATD is being considered. Conclusion Available guidelines regarding AATD frequently disagreed in management recommendations. Possible explanations for discordance include differences in regional prevalence, availability of augmentation therapy, and insurance environments. Attempts to harmonize the various guidelines by empaneling a broadly representative international group of disease experts should be considered for AATD. Similar comparisons among guidelines for other diseases are recommended.
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Affiliation(s)
- Amy Attaway
- Cleveland Clinic Lerner School of Medicine, Cleveland, OH, USA.,Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Uddalak Majumdar
- Cleveland Clinic Lerner School of Medicine, Cleveland, OH, USA.,Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Robert A Sandhaus
- Alpha-1 Antitrypsin Deficiency Program, National Jewish Health, Denver, CO, USA.,Alpha-1 Foundation, Coral Gables, FL, USA
| | - Amy S Nowacki
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - James K Stoller
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Education Institute, Cleveland Clinic, Cleveland, OH, USA
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171
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Rahaghi F, Omert L, Clark V, Sandhaus RA. Managing the Alpha-1 patient in the ICU: Adapting broad critical care strategies in AATD. J Crit Care 2019; 54:212-219. [PMID: 31614323 DOI: 10.1016/j.jcrc.2019.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 07/17/2019] [Accepted: 08/27/2019] [Indexed: 10/26/2022]
Abstract
Alpha-1 Antitrypsin Deficiency (AATD) is a progressive pulmonary disease under-recognized or misdiagnosed by clinicians. Patients with AATD can develop a variety of organ-specific complications and as a result, often require hospitalization and treatment within critical care and ICU settings. Due to the complexity of AATD there are minimal guidelines in place to address the specific and highly variable needs of these patients in the critical care setting. This review presents clinical considerations with respect to the management of patients with AATD and provides treatment recommendations for these patients in the critical care setting. In addition, we have outlined certain aspects of the care of this patient population that may be of interest to critical care practitioners. With greater disease awareness and earlier diagnosis the onset of symptoms can be delayed, which will ultimately reduce the frequency of deleterious health consequences.
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Affiliation(s)
- Franck Rahaghi
- Pulmonary and Critical Care Division, Cleveland Clinic Florida, Weston, Florida, United States.
| | - Laurel Omert
- CSL Behring, King of Prussia, PA, United States.
| | - Virginia Clark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, United States.
| | - Robert A Sandhaus
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, United States.
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172
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Balbi B, Sangiorgi C, Gnemmi I, Ferrarotti I, Vallese D, Paracchini E, Delle Donne L, Corda L, Baderna P, Corsico A, Carone M, Brun P, Cappello F, Ricciardolo FL, Ruggeri P, Mumby S, Adcock IM, Caramori G, Di Stefano A. Bacterial load and inflammatory response in sputum of alpha-1 antitrypsin deficiency patients with COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:1879-1893. [PMID: 31686800 PMCID: PMC6709647 DOI: 10.2147/copd.s207203] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/10/2019] [Indexed: 01/18/2023] Open
Abstract
Background Airway inflammation may drive the progression of chronic obstructive pulmonary disease (COPD) associated with alpha-1 antitrypsin deficiency (AATD), but the relationship between airway microbiota and inflammation has not been investigated. Methods We studied 21 non-treated AATD (AATD-noT) patients, 20 AATD-COPD patients under augmentation therapy (AATD-AT), 20 cigarette smoke-associated COPD patients, 20 control healthy smokers (CS) and 21 non-smokers (CON) with normal lung function. We quantified sputum inflammatory cells and inflammatory markers (IL-27, CCL3, CCL5, CXCL8, LTB4, MPO) by ELISA, total bacterial load (16S) and pathogenic bacteria by qRT-PCR. Results AATD-AT patients were younger but had similar spirometric and DLCO values compared to cigarette smoke-associated COPD, despite a lower burden of smoking history. Compared to cigarette smoke-associated COPD, AATD-noT and AATD-AT patients had lower sputum neutrophil levels (p=0.0446, p=0.0135), total bacterial load (16S) (p=0.0081, p=0.0223), M. catarrhalis (p=0.0115, p=0.0127) and S. pneumoniae (p=0.0013, p=0.0001). Sputum IL-27 was significantly elevated in CS and cigarette smoke-associated COPD. AATD-AT, but not AATD-noT patients, had IL-27 sputum levels (pg/ml) significantly lower than COPD (p=0.0297) and these positively correlated with FEV1% predicted values (r=0.578, p=0.0307). Conclusions Compared to cigarette smoke-associated COPD, AATD-AT (COPD) patients have a distinct airway inflammatory and microbiological profile. The decreased sputum bacterial load and IL-27 levels in AATD-AT patients suggests that augmentation therapy play a role in these changes.
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Affiliation(s)
- Bruno Balbi
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
| | - Claudia Sangiorgi
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
| | - Isabella Gnemmi
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
| | - Ilaria Ferrarotti
- Department of Internal Medicine and Medical Therapy, University of Pavia , Pavia, Italy
| | - Davide Vallese
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
| | - Elena Paracchini
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
| | - Lorena Delle Donne
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
| | - Luciano Corda
- Medicina Respiratoria, Seconda Medicina Interna, Spedali Civili , Brescia, Italy
| | - Paolo Baderna
- Division of Pneumology, Aosta Hospital , Aosta, Italy
| | - Angelo Corsico
- Department of Internal Medicine and Medical Therapy, University of Pavia , Pavia, Italy
| | - Mauro Carone
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
| | - Paola Brun
- Department of Molecular Medicine, University of Padova , Padova, Italy
| | - Francesco Cappello
- Dipartimento di Biomedicina Sperimentale e Neuroscienze Cliniche, Sezione di Anatomia Umana, Università di Palermo, Palermo, Italy.,Euro-mediterranean Institute of Science and Technology (IEMEST) , Palermo, Italy
| | - Fabio Lm Ricciardolo
- Department of Clinical and Biological Sciences, A.O.U., San Luigi Gonzaga, Orbassano, University of Turin , Turin, Italy
| | - Paolo Ruggeri
- UOC Di Pneumologia, Dipartimento di Scienze Biomediche, Odontoiatriche e Delle Immagini Morfologiche e Funzionali (BIOMORF), Università di Messina, Messina, Italy
| | - Sharon Mumby
- Airways Disease Section, National Heart and Lung Institute, Imperial College London , UK
| | - Ian M Adcock
- Airways Disease Section, National Heart and Lung Institute, Imperial College London , UK
| | - Gaetano Caramori
- UOC Di Pneumologia, Dipartimento di Scienze Biomediche, Odontoiatriche e Delle Immagini Morfologiche e Funzionali (BIOMORF), Università di Messina, Messina, Italy
| | - Antonino Di Stefano
- Istituti Clinici Scientifici Maugeri, IRCCS, Division of Pneumology and Laboratory of Cytoimmunopathology of the Heart and Lung, Veruno, Italy
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173
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Chukowry PS, Edgar RG, Turner AM. Alpha 1 antitrypsin deficiency: a rare multisystem disease, predominantly affecting the lung. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1651640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Priya S Chukowry
- University Hospitals Birmingham NHS Foundation Trust, Heartlands Hospital, Birmingham, UK
| | - Ross Gareth Edgar
- University Hospitals Birmingham NHS Foundation Trust, Heartlands Hospital, Birmingham, UK
- Therapy Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alice M Turner
- University Hospitals Birmingham NHS Foundation Trust, Heartlands Hospital, Birmingham, UK
- Therapy Services, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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174
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Blair HA. Human α1-proteinase inhibitor (Respreeza®) in α1-antitrypsin deficiency emphysema: a profile of its use in the EU. DRUGS & THERAPY PERSPECTIVES 2019. [DOI: 10.1007/s40267-019-00648-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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175
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What Do Alpha-1 Antitrypsin Levels Tell Us About Chronic Inflammation in COPD? Arch Bronconeumol 2019; 56:72-73. [PMID: 31340890 DOI: 10.1016/j.arbres.2019.06.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/05/2019] [Accepted: 06/07/2019] [Indexed: 12/30/2022]
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176
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Franciosi AN, Carroll TP, McElvaney NG. Pitfalls and caveats in α1-antitrypsin deficiency testing: a guide for clinicians. THE LANCET RESPIRATORY MEDICINE 2019; 7:1059-1067. [PMID: 31324540 DOI: 10.1016/s2213-2600(19)30141-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/05/2019] [Accepted: 03/11/2019] [Indexed: 01/04/2023]
Abstract
α1-antitrypsin deficiency (AATD) remains the only readily identified genetic cause of chronic obstructive pulmonary disease (COPD). Furthermore, there is growing evidence that even a moderate deficiency increases the risk of lung disease among smokers. Despite these facts, the uptake of testing for AATD in at-risk populations remains low for many reasons, and a lack of clarity among clinicians regarding the most appropriate diagnostic techniques presents a major deterrent. This Personal View addresses the benefits of diagnosis, the technical basis of the available diagnostic methods, and possible clinical confounders for each test. We include a series of unusual cases encountered at our National Centre of Expertise to provide context. The topics covered should equip clinicians with the core knowledge required to confidently assess patients for AATD.
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Affiliation(s)
- Alessandro N Franciosi
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Medicine, Beaumont Hospital, Dublin, Ireland.
| | - Tomás P Carroll
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland; Alpha-1 Foundation Ireland, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Noel G McElvaney
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Medicine, Beaumont Hospital, Dublin, Ireland
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177
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Wells AD, Woods A, Hilleman DE, Malesker MA. Alpha-1 Antitrypsin Replacement in Patients With COPD. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2019; 44:412-415. [PMID: 31258312 PMCID: PMC6590928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Chronic obstructive pulmonary disease can be attributed to genetic conditions and predispositions, among other factors. Alpha-1 antitrypsin deficiency (AATD) is a significant risk factor for COPD development and progression, and aggressive screening for all patients with COPD or adult-onset asthma is encouraged.
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178
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Janciauskiene S, DeLuca DS, Barrecheguren M, Welte T, Miravitlles M. Serum Levels of Alpha1-antitrypsin and Their Relationship With COPD in the General Spanish Population. Arch Bronconeumol 2019; 56:76-83. [PMID: 31153743 DOI: 10.1016/j.arbres.2019.03.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/20/2019] [Accepted: 03/02/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Low plasma level of alpha1-antitrypsin (AAT) is an established risk factor for early-onset chronic obstructive lung disease (COPD). However, less attention is given to the levels of AAT in the general population. METHODS This is a part of a multicentre, population-based study conducted at 11 sites throughout Spain. Plasma levels of AAT were available for 837 persons with a mean (SD) age of 58.05 (11.3) years: 328-smokers, 272-ex-smokers and 237 non-smokers. Out of 837, 303 (36.2%) had a diagnosis of COPD, 222 (26.5%) had respiratory symptoms but no COPD, and 312 (37.3%) were healthy controls. RESULTS In the whole cohort, the mean level of plasma AAT was 1.51 (0.47)g/L. Levels were higher in COPD patients [1.55 (0.45)g/L] and individuals with respiratory symptoms [1.57 (0.47)g/L] than in controls [1.43 (0.47)g/L], p<0.001, a finding which persisted after correction for age and CRP. Plasma AAT levels were negatively associated with FEV1/FVC ratio, after adjustment for age, sex, smoking status, CRP, TNFα, fibrinogen and albumin. The risk for COPD was significantly associated with higher AAT levels in univariate and multivariate models, with odds ratios of 1.8 and 1.5, respectively. In the univariate and multivariate models smoking status, gender, and CRP levels were also associated with COPD probability, demonstrating that they act independently. CONCLUSION Increased circulating levels of AAT, similarly to CRP and other markers of systemic inflammation, is an important feature of COPD. Our results highlight a complex interrelationship between levels of AAT and health of respiratory system.
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Affiliation(s)
- Sabina Janciauskiene
- Department of Respiratory Medicine, Hannover Medical School, Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), Member of German Centre for Lung Research (DZL), Hannover, Germany
| | - David S DeLuca
- Department of Respiratory Medicine, Hannover Medical School, Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), Member of German Centre for Lung Research (DZL), Hannover, Germany
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), Member of German Centre for Lung Research (DZL), Hannover, Germany
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
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179
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Lopes AP, Mineiro MA, Costa F, Gomes J, Santos C, Antunes C, Maia D, Melo R, Canotilho M, Magalhães E, Vicente I, Valente C, Gonçalves BG, Conde B, Guimarães C, Sousa C, Amado J, Brandão ME, Sucena M, Oliveira MJ, Seixas S, Teixeira V, Telo L. Portuguese consensus document for the management of alpha-1-antitrypsin deficiency. Pulmonology 2019; 24 Suppl 1:1-21. [PMID: 30473034 DOI: 10.1016/j.pulmoe.2018.09.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/12/2018] [Accepted: 09/14/2018] [Indexed: 01/08/2023] Open
Abstract
Alpha-1-antitrypsin deficiency (AATD) is a genetic autosomal codominant disorder caused by mutations in SERPINA1 gene. It is one of the most prevalent genetic disorders, although it remains underdiagnosed. Whereas at international level there are several areas of consensus on this disorder, in Portugal, inter-hospital heterogeneity in clinical practice and resources available have been adding difficulties in reaching a diagnosis and in making therapeutic decisions in this group of patients. This raised a need to draft a document expressing a national consensus for AATD. To this end, a group of experts in this field was created within the Portuguese Pulmonology Society - Study group on AATD, in order to elaborate the current manuscript. The authors reviewed the existing literature and provide here general guidance and extensive recommendations for the diagnosis and management of AATD that can be adopted by Portuguese clinicians from different areas of Medicine. This article is part of a supplement entitled "Portuguese consensus document for the management of alpha-1-antitrypsin deficiency" which is sponsored by Sociedade Portuguesa de Pneumologia.
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Affiliation(s)
- A P Lopes
- Centro Hospitalar e Universitário de Coimbra (HUC); Alpha-1-antitrypsin deficiency study group coordinator.
| | | | - F Costa
- Centro Hospitalar e Universitário de Coimbra (HG)
| | | | | | | | - D Maia
- Centro Hospital Lisboa Central
| | - R Melo
- Hospital Prof. Doutor Fernando da Fonseca
| | | | | | | | | | | | - B Conde
- Centro Hospitalar de Trás os Montes e Alto Douro
| | | | - C Sousa
- Centro Hospitalar de São João
| | - J Amado
- Unidade Local de Saúde de Matosinhos
| | - M E Brandão
- Centro Hospitalar de Trás os Montes e Alto Douro
| | | | | | - S Seixas
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto (I3S); Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP)
| | - V Teixeira
- Serviço de Saúde da Região Autónoma da Madeira (SESARAM)
| | - L Telo
- Centro Hospitalar Lisboa Norte
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180
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Hersh CP. Pharmacogenomics of chronic obstructive pulmonary disease. Expert Rev Respir Med 2019; 13:459-470. [PMID: 30925849 PMCID: PMC6482089 DOI: 10.1080/17476348.2019.1601559] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/27/2019] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a heterogeneous condition, which presents the opportunity for precision therapy based on genetics or other biomarkers. Areas covered: Alpha-1 antitrypsin deficiency, a genetic form of emphysema, provides an example of this precision approach to diagnosis and therapy. To date, research in COPD pharmacogenomics has been limited by small sample sizes, lack of accessible target tissue, failure to consider COPD subtypes, and different outcomes relevant for various medications. There have been several published genome-wide association studies and other omics studies in COPD pharmacogenomics; however, clinical implementation remains far away. There is a growing evidence base for precision prescription of inhaled corticosteroids in COPD, based on clinical phenotypes and blood biomarkers, but not yet based on pharmacogenomics. Expert opinion: At this time, there is insufficient evidence for clinical implementation of COPD pharmacogenomics. Additional genome-wide studies will be required to discover predictors of drug response and to identify genomic biomarkers of COPD subtypes, which could be targeted with subtype-directed therapies.
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Affiliation(s)
- Craig P Hersh
- a Channing Division of Network Medicine and Division of Pulmonary and Critical Care Medicine , Brigham and Women's Hospital, Harvard Medical School , Boston , MA , USA
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181
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Perciaccante A, Charlier P, Negri C, Coralli A, Appenzeller O, Bianucci R. Lessons from the Past: Some Histories of Alpha-1 Antitrypsin Deficiency Before Its Discovery. COPD 2019; 15:1-3. [PMID: 29469675 DOI: 10.1080/15412555.2017.1421151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A1AT deficiency- a genetically inherited autosomal codominant disease with more than 120 identified alleles- was first identified by Laurell and Eriksson in 1963. The most common hereditary disorder in adults, A1AT causes an increased risk of developing pulmonary emphysema and liver disease. In A1AT patients, lung disease generally presents at a younger age than "usual" chronic obstructive pulmonary disease (COPD) and it may be misdiagnosed as asthma. Because A1AT deficiency patients can show the same clinical features as non-deficient COPD (including increased evidence of bronchiectasis, frequent exacerbations, impaired health status and a degree of reversibility of airflow obstruction), the World Health Organization recommend to test every patient with a diagnosis of COPD or adult-onset asthma for A1AT deficiency. Despite these recommendations, the epidemiology of A1AT deficiency remains uncertain. Although recently discovered A1AT deficiency has affected human populations since antiquity. By using scientific data and recently studied skeletons and historical cases, we show that it is now possible to reconstruct the natural history of pathological processes, whether due to genetic, infectious or environmental factors. We believe that the evolution of disease in patients and research to elucidate the relationship between social science and environmental are pertinent contemporaneous subjects.
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Affiliation(s)
- A Perciaccante
- a Department of Medicine , San Giovanni di Dio Hospital , Gorizia , Italy
| | - P Charlier
- b Section of Medical Anthropology, DANTE Laboratory EA 4498, Faculty of Health Sciences, University of Versailles Saint-Quentin-en-Yvelines , Montigny-Le-Bretonneux , France.,c Max Fourestier Hospital (CASH) and Institute of Precarity and Social Exclusion (IPES) , Nanterre , France
| | - C Negri
- a Department of Medicine , San Giovanni di Dio Hospital , Gorizia , Italy
| | - A Coralli
- d Basso Isontino District , Azienda per l'Assistenza Sanitaria Bassa Friulana-Isontina , Gorizia , Italy
| | - O Appenzeller
- e New Mexico Health Enhancement and Marathon Clinics Research Foundation , Albuquerque , NM , United States of America.,f New Mexico Museum of Natural History and Science , Albuquerque , NM , United States of America
| | - R Bianucci
- g Microbiology and Infection Unit, Warwick Medical School , The University of Warwick , Warwick , United Kingdom.,h Department of Public Health and Paediatric Sciences , Legal Medicine Section, University of Turin , Turin , Italy.,i Laboratoire d'Anthropologie bio-culturelle, Droit, Etique & Santé (Adés), Faculté de Médecine de Marseille , Marseille , France
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182
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Esteves Brandão M, Conde B, Seixas S, Clotilde Silva J, Fernandes A. Pulmonary Emphysema in a Child With Alpha-1 Antitrypsin Deficiency: Evaluation of 2 Years of Intravenous Augmentation Therapy. Arch Bronconeumol 2019; 55:502-504. [PMID: 30871819 DOI: 10.1016/j.arbres.2019.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 01/22/2019] [Accepted: 01/22/2019] [Indexed: 01/20/2023]
Affiliation(s)
- Maria Esteves Brandão
- Respiratory Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal.
| | - Bebiana Conde
- Respiratory Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Susana Seixas
- Institute of Molecular Pathology and Immunology of the University of Porto, Porto, Portugal; Instituto de Investigação e Inovação em Saúde (I3S), Porto, Portugal
| | - Joelma Clotilde Silva
- Respiratory Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Ana Fernandes
- Respiratory Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
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183
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Abstract
As NPs play an increasingly vital role in primary care, they must be well versed in a variety of conditions. Alpha-1 antitrypsin (AAT) deficiency is a respiratory disease for which there is particularly low awareness in both the nursing profession and the wider medical community. This article provides an overview of AAT deficiency and includes guidance for diagnosing the disease.
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184
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Abstract
IMPORTANCE There are 30 million adults (12%) in the United States who have chronic obstructive pulmonary disease (COPD). Chronic obstructive pulmonary disease accounts for 3.2% of all physician office visits annually and is the fourth leading cause of death (126 000 deaths per year). Most patients are diagnosed by their primary care clinicians who must address the highly variable clinical features and responses to therapy. The diagnosis and treatment of COPD is rapidly changing, so understanding recent advances is important for the delivery of optimal patient care. OBSERVATIONS Chronic obstructive pulmonary disease is characterized by incompletely reversible expiratory airflow limitation. Spirometry is the reference standard for diagnosing and assessing the severity of COPD. All patients should be counseled about and receive preventive measures such as smoking cessation and vaccination. Treatment should be guided by the severity of lung impairment, symptoms such as dyspnea, the amount of cough and sputum production, and how often a patient experiences an exacerbation. When dyspnea limits activity or quality of life, COPD should be treated with once- or twice-daily maintenance long-acting anticholinergic and β-agonist bronchodilators. Patients with acute exacerbations may benefit from the addition of inhaled corticosteroids, particularly those with elevated peripheral eosinophil levels. Pulmonary rehabilitation, which includes strength and endurance training and educational, nutritional, and psychosocial support, improves symptoms and exercise tolerance but is underutilized. Supplemental oxygen for patients with resting hypoxemia (defined as Spo2 <89%) improves survival. CONCLUSIONS AND RELEVANCE Chronic obstructive pulmonary disease is a complicated disease requiring intensive treatment. Appropriate use of long-acting maintenance bronchodilators, inhaled corticosteroids, and pulmonary rehabilitation decreases symptoms, optimizes functional performance, and reduces exacerbation frequency. Supplemental oxygen in patients with resting hypoxemia prolongs life, and other advanced treatments are available based on specific patient characteristics.
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Affiliation(s)
- Craig M Riley
- Division of Pulmonary, Department of Medicine, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Frank C Sciurba
- Division of Pulmonary, Department of Medicine, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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185
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Miravitlles M, Chorostowska-Wynimko J, Ferrarotti I, McElvaney N, O'Hara K, Stolk J, Stockley RA, Turner A, Wilkens M, Greulich T. The European Alpha-1 Research Collaboration (EARCO): a new ERS Clinical Research Collaboration to promote research in alpha-1 antitrypsin deficiency. Eur Respir J 2019; 53:53/2/1900138. [DOI: 10.1183/13993003.00138-2019] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 01/23/2019] [Indexed: 01/02/2023]
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186
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Horváth I, Canotilho M, Chlumský J, Chorostowska-Wynimko J, Corda L, Derom E, Ficker JH, Kneussl M, Miravitlles M, Sucena M, Thabut G, Turner AM, van ’t Wout E, McElvaney NG. Diagnosis and management of α 1-antitrypsin deficiency in Europe: an expert survey. ERJ Open Res 2019; 5:00171-2018. [PMID: 30863774 PMCID: PMC6409083 DOI: 10.1183/23120541.00171-2018] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 12/12/2018] [Indexed: 01/09/2023] Open
Abstract
Despite recent improvements, α1-antitrypsin deficiency (AATD) remains a rarely diagnosed and treated condition. To assess the variability of AATD diagnosis/treatment in Europe, and to evaluate clinicians' views on methods to optimise management, specialist AATD clinicians were invited to complete a web-based survey. Surveys were completed by 15 physicians from 14 centres in 13 European countries. All respondents perceived the AATD diagnosis rate to be low in their country; 77% of physicians believed that ∼15% of cases were diagnosed. Low awareness was perceived as the greatest barrier to diagnosis. Spirometry was considered more practical than quantitative computed tomography (QCT) for monitoring AATD patients in clinical practice; QCT was considered more useful in trials. AAT therapy provision was reported to be highly variable: France and Germany were reported to treat the highest proportion (∼60%) of diagnosed patients, in contrast to the UK and Hungary, where virtually no patients receive AAT therapy. Most clinicians supported self-administration and extended dosing intervals to improve convenience of AAT therapy. This survey indicates that AATD diagnosis and management are highly heterogeneous in Europe; European cooperation is essential to generate data to support access to AAT therapy. Improving convenience of AAT therapy is an ongoing objective.
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Affiliation(s)
- Ildikó Horváth
- Dept of Pulmonology, National Koranyi Institute for Pulmonology in Budapest, Budapest, Hungary
| | - Maria Canotilho
- Dept of Pneumology, Hospital of Santo Andre – Centro Hospitalar de Leiria, Leiria, Portugal
| | - Jan Chlumský
- Dept of Pneumology, Thomayer Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Joanna Chorostowska-Wynimko
- Dept of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - Luciano Corda
- Dept of Internal Medicine, Respiratory Disease Unit, Spedali Civili, Brescia, Italy
| | - Eric Derom
- Dept of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Joachim H. Ficker
- 3rd Medical Dept, Nuremberg General Hospital/Paracelsus Medical University, Nuremberg, Germany
| | - Meinhard Kneussl
- Dept of Internal Medicine II and Pneumology at Wilhelminenspital Wien, Vienna, Austria
| | - Marc Miravitlles
- Pulmonology Dept, University Hospital Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Maria Sucena
- Pulmonology Dept, Centro Hospitalar de São João, Porto, Portugal
| | - Gabriel Thabut
- Dept of Pneumology and Lung Transplantation, Bichat Hospital, Paris, France
| | - Alice M. Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Emily van ’t Wout
- Leiden University Medical Centre, Dept of Pulmonology, Leiden, Netherlands
| | - N. Gerard McElvaney
- Dept of Respiratory Medicine, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
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187
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Greulich T, Chlumsky J, Wencker M, Vit O, Fries M, Chung T, Shebl A, Vogelmeier C, Chapman KR, McElvaney NG. Safety of biweekly α 1-antitrypsin treatment in the RAPID programme. Eur Respir J 2018; 52:13993003.00897-2018. [PMID: 30237305 PMCID: PMC6557539 DOI: 10.1183/13993003.00897-2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 09/10/2018] [Indexed: 11/20/2022]
Abstract
α1-antitrypsin (α1-AT) deficiency is a hereditary disorder characterised by an abnormally low concentration of functional α1-AT in blood and tissues [1]. The primary role of α1-AT is to protect elastin-containing tissues, most notably the lung, against the destructive activity of proteolytic enzymes [2]. Patients with severe α1-AT deficiency present with serum α1-AT concentrations <11 μM and are prone to destruction of the lung tissue, often developing respiratory symptoms and emphysema in the fourth or fifth decade of life [3, 4]. Administration of 120 mg·kg−1 α1-antitrypsin on a biweekly basis was safe and well toleratedhttp://ow.ly/CVbz30lUBum
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Affiliation(s)
- Timm Greulich
- Dept of Medicine, Respiratory and Critical Care Medicine, Philipps-University Marburg, Member of the German Center for Lung Diseases (DZL), Marburg, Germany
| | - Jan Chlumsky
- Dept of Pulmonary Diseases, Charles University, Prague, Czech Republic
| | | | - Oliver Vit
- Clinical Research and Development, CSL Behring, Bern, Switzerland
| | - Michael Fries
- Clinical Strategy and Development, CSL Behring, King of Prussia, PA, USA
| | - Thomas Chung
- Statistics Dept, CSL Behring, King of Prussia, PA, USA
| | - Amgad Shebl
- Global Clinical Safety and Pharmacovigilance, CSL Behring, Marburg, Germany
| | - Claus Vogelmeier
- Dept of Medicine, Respiratory and Critical Care Medicine, Philipps-University Marburg, Member of the German Center for Lung Diseases (DZL), Marburg, Germany
| | | | - Noel G McElvaney
- Irish Centre for Genetic Lung disease, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland.,A list of the RAPID Trial Group members can be found in the study group information at the end of this article
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188
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Craig TJ, Henao MP. Advances in managing COPD related to α 1 -antitrypsin deficiency: An under-recognized genetic disorder. Allergy 2018; 73:2110-2121. [PMID: 29984428 PMCID: PMC6282978 DOI: 10.1111/all.13558] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 06/08/2018] [Accepted: 06/15/2018] [Indexed: 12/19/2022]
Abstract
α1 -Antitrypsin deficiency (AATD) predisposes individuals to chronic obstructive pulmonary disease (COPD) and liver disease. Despite being commonly described as rare, AATD is under-recognized, with less than 10% of cases identified. The following is a comprehensive review of AATD, primarily for physicians who treat COPD or asthma, covering the genetics, epidemiology, clinical presentation, screening and diagnosis, and treatments of AATD. For patients presenting with liver and/or lung disease, screening and diagnostic tests are the only methods to determine whether the disease is related to AATD. Screening guidelines have been established by organizations such as the World Health Organization, European Respiratory Society, and American Thoracic Society. High-risk groups, including individuals with COPD, nonresponsive asthma, bronchiectasis of unknown etiology, or unexplained liver disease, should be tested for AATD. Current treatment options include augmentation therapy with purified AAT for patients with deficient AAT levels and significant lung disease. Recent trial data suggest that lung tissue is preserved by augmentation therapy, and different dosing schedules are currently being investigated. Effective management of AATD and related diseases also includes aggressive avoidance of smoking and biomass burning, vaccinations, antibiotics, exercise, good diet, COPD medications, and serial assessment.
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Affiliation(s)
- Timothy J. Craig
- Department of Medicine and PediatricsCollege of MedicinePennsylvania State UniversityHersheyPennsylvania
| | - Maria Paula Henao
- Department of MedicineCollege of MedicinePennsylvania State UniversityHersheyPennsylvania
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189
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Gramegna A, Aliberti S, Confalonieri M, Corsico A, Richeldi L, Vancheri C, Blasi F. Alpha-1 antitrypsin deficiency as a common treatable mechanism in chronic respiratory disorders and for conditions different from pulmonary emphysema? A commentary on the new European Respiratory Society statement. Multidiscip Respir Med 2018; 13:39. [PMID: 30338069 PMCID: PMC6174569 DOI: 10.1186/s40248-018-0153-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/25/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The European Respiratory Society recently published an important statement reviewing available evidence on diagnosis and treatment of lung disease associated to alpha-1 antitrypsin deficiency (AATD). Several issues on this topic still remain unresolved and subject of interpretation according to different standard procedures and healthcare systems worldwide. The purpose of this commentary is to offer a critical contribution to most of these controversial issues in light of an Italian perspective for the management of this disease. MAIN BODY The clinical spectrum of AATD lung disease might include different manifestations and the traditional paradigm of a younger emphysematous patient has been revealing insufficient. Targeting with appropriate testing only COPD patients might be considered a limited approach leading to underestimation of the real prevalence of the disease. Several reports have suggested the association between AATD and other chronic respiratory conditions, as asthma and bronchiectasis. A deeper evaluation of clinical, radiological, microbiological and functional variables is, therefore, needed in order to investigate different phenotypes in AATD patients. In addition, a new line of translational research in AATD might focus on the development of personalized therapeutic regimens taking into account the patient clinical profile and needs. CONCLUSIONS Over the past years, AATD has been interpreted as a common mechanism of inflammatory disequilibrium and tissue damage across different conditions. Future research is gradually pointing toward this new paradigm by expanding the evidence of the role of AAT as a potent immunomodulatory and anti-inflammatory drug in conditions different from pulmonary emphysema.
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Affiliation(s)
- Andrea Gramegna
- Department of Pathophysiology and Transplantation, University of Milano; Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Stefano Aliberti
- Department of Pathophysiology and Transplantation, University of Milano; Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Marco Confalonieri
- Department of Medical Sciences, Respiratory Diseases Unit, University Hospital of Cattinara, Trieste, Italy
| | - Angelo Corsico
- Department of Internal Medicine and therapeutics, Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Luca Richeldi
- Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carlo Vancheri
- Regional Referral Centre for Rare Lung Diseases, Department of Clinical and Experimental Medicine, University of Catania, University–Hospital Policlinico “G. Rodolico”, Catania, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, University of Milano; Internal Medicine Department, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
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190
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Polverino E, Dimakou K, Hurst J, Martinez-Garcia MA, Miravitlles M, Paggiaro P, Shteinberg M, Aliberti S, Chalmers JD. The overlap between bronchiectasis and chronic airway diseases: state of the art and future directions. Eur Respir J 2018; 52:13993003.00328-2018. [PMID: 30049739 DOI: 10.1183/13993003.00328-2018] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 07/10/2018] [Indexed: 11/05/2022]
Abstract
Bronchiectasis is a clinical and radiological diagnosis associated with cough, sputum production and recurrent respiratory infections. The clinical presentation inevitably overlaps with other respiratory disorders such as asthma and chronic obstructive pulmonary disease (COPD). In addition, 4-72% of patients with severe COPD are found to have radiological bronchiectasis on computed tomography, with similar frequencies (20-30%) now being reported in cohorts with severe or uncontrolled asthma. Co-diagnosis of bronchiectasis with another airway disease is associated with increased lung inflammation, frequent exacerbations, worse lung function and higher mortality. In addition, many patients with all three disorders have chronic rhinosinusitis and upper airway disease, resulting in a complex "mixed airway" phenotype.The management of asthma, bronchiectasis, COPD and upper airway diseases has traditionally been outlined in separate guidelines for each individual disorder. Recognition that the majority of patients have one or more overlapping pathologies requires that we re-evaluate how we treat airway disease. The concept of treatable traits promotes a holistic, pathophysiology-based approach to treatment rather than a syndromic approach and may be more appropriate for patients with overlapping features.Here, we review the current clinical definition, diagnosis, management and future directions for the overlap between bronchiectasis and other airway diseases.
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Affiliation(s)
- Eva Polverino
- Pneumology Dept, Hospital Universitari Vall d'Hebron (HUVH), Barcelona, Spain.,Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain.,CIBER, Spain
| | | | - John Hurst
- UCL Respiratory, University College London, London, UK
| | | | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron (HUVH), Barcelona, Spain.,Institut de Recerca Vall d'Hebron (VHIR), Barcelona, Spain.,CIBER, Spain
| | - Pierluigi Paggiaro
- Dept of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, Pisa, Italy
| | - Michal Shteinberg
- Pulmonology Institute and Cystic Fibrosis Center, Carmel Medical Center, Haifa, Israel.,Technion-Israel Institute of Technology, The B. Rappaport Faculty of Medicine, Haifa, Israel
| | - Stefano Aliberti
- Dept of Pathophysiology and Transplantation, University of Milan Internal Medicine Dept, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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191
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Genotype is associated with smoking and other key health behaviors among individuals with alpha-1 antitrypsin deficiency-associated lung disease. Respir Med 2018; 143:48-55. [PMID: 30261992 DOI: 10.1016/j.rmed.2018.08.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/21/2018] [Accepted: 08/31/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine the association of genotype with smoking and other key health behaviors among individuals with alpha-1 antitrypsin deficiency (AATD) associated lung disease. METHODS Self-reported data were analyzed from 3506 individuals with AATD-associated lung disease. All data were collected upon enrollment in a disease management program designed for individuals who have been prescribed augmentation therapy. Multivariate logistic regression was utilized to examine the extent to which genotype was associated with smoking and other key health behaviors (i.e., getting a pneumonia vaccine, getting a flu vaccine, exercising, and maintaining a healthy weight). We hypothesized that MZs and SZs are more likely than ZZs to be current smokers, and that genotype is associated with additional health behaviors. RESULTS MZs and SZs had higher odds of being a current smoker than ZZs (MZ versus ZZ OR = 2.73, p < .001; SZ versus ZZ OR = 4.34, p < .001). For every additional health behavior examined, MZs had higher odds of unhealthy behavior than ZZs (ORs ranged from 1.35 to 1.98, p < .05). SZs had higher odds of unhealthy behavior than ZZs with regard to lack of exercise (OR = 1.52, p = .003) and failure to maintain a healthy weight (underweight OR = 1.93, p = .028; overweight OR = 1.43, p = .015). CONCLUSIONS Among individuals who have been prescribed augmentation therapy for lung disease due to AATD, genotype is associated with smoking and additional health behaviors that are central to managing lung disease.
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192
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Greulich T, Rodríguez-Frias F, Belmonte I, Klemmer A, Vogelmeier CF, Miravitlles M. Real world evaluation of a novel lateral flow assay (AlphaKit® QuickScreen) for the detection of alpha-1-antitrypsin deficiency. Respir Res 2018; 19:151. [PMID: 30103740 PMCID: PMC6090649 DOI: 10.1186/s12931-018-0826-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 06/08/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Alpha-1-Antitrypsin (AAT) deficiency (AATD) is a hereditary disorder that manifests primarily as pulmonary emphysema and liver cirrhosis. The clinically most relevant mutation causing AATD is a single nucleotide polymorphism Glu342Lys (Z-mutation). Despite the recommendation to test every COPD patient, the condition remains severely underdiagnosed with a delay of several years between first symptoms and diagnosis. The Grifols' AlphaKit® QuickScreen is a novel qualitative point-of-care (POC) in vitro screening test developed for the detection of the Z AAT protein in capillary whole blood. The objective of this prospective, international, multi-center, diagnostic, interventional real-world study was to assess the performance of this device for the detection of AATD in test-naïve COPD patients. METHODS 1044 test-naïve COPD patients were recruited from 9 centers in Spain and 10 centers in Germany, ranging from primary to tertiary care. To evaluate the performance of the test, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated compared with the gold standard (genotyping). RESULTS Genotyping and phenotyping of all 1019 evaluable samples revealed 4.12% of patients as carriers of at least one Z-allele, while 0.29% carried the homozygous genotype Pi*ZZ. The evaluation of the test's ability to detect the PiZ protein yielded the following results: specificity 97.8%, sensitivity 73.8%, negative predictive value 98.9%, and positive predictive value 58.5%. All false negatives (n = 11) were heterozygote Pi*MZ samples. CONCLUSIONS The tested device can be used as an appropriate tool to exclude AATD in primary care and in the overall COPD population, except in patients with a high a-priori- probability of AATD.
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Affiliation(s)
- Timm Greulich
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps-University, Marburg, Germany.
- German Centre for Lung Research (DZL), Marburg, Germany.
- Respiratory Medicine, University Hospital of Gießen and Marburg, 35043, Marburg, Germany.
| | - Francisco Rodríguez-Frias
- Liver Pathology Unit, Departments of Biochemistry and Microbiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- CIBER de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto Nacional de Salud Carlos III, Madrid, Spain
| | - Irene Belmonte
- Liver Pathology Unit, Departments of Biochemistry and Microbiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Andreas Klemmer
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps-University, Marburg, Germany
- German Centre for Lung Research (DZL), Marburg, Germany
| | - Claus F Vogelmeier
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps-University, Marburg, Germany
- German Centre for Lung Research (DZL), Marburg, Germany
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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193
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Abstract
α1-Antitrypsin deficiency (AATD) is an inherited metabolic disorder in which mutations in the coding sequence of the SERPINA1 gene prevent secretion of α1-antitrypsin (α1-AT) and cause predisposition to pulmonary and liver diseases. The heterogeneity of clinical manifestations in AATD is related to the complexity of biological function of α1-AT. The role of smoking is crucial in the natural history of lung damage progression in severe AATD individuals, even if it also partly explains the heterogeneity in lung disease. Lung damage progression in AATD can also be related to body mass index, exacerbation rate, sex, environmental exposure and specific mutations of SERPINA1. Recent randomised controlled trials, together with previous observational work, have provided compelling evidence for the importance of early detection and intervention in order to enable patients to receive appropriate treatment and preserve functional lung tissue. Early detection and intervention in cases of α1-antitrypsin deficiency are essential to enable appropriate treatment and preserve functional lung tissuehttp://ow.ly/Mr3P30jUEyn
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Affiliation(s)
- Ilaria Ferrarotti
- Center for Diagnosis of Inherited Alpha1-antitrypsin Deficiency, Dept of Internal Medicine and Therapeutics, Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Università di Pavia, Pavia, Italy
| | - Stefania Ottaviani
- Center for Diagnosis of Inherited Alpha1-antitrypsin Deficiency, Dept of Internal Medicine and Therapeutics, Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Università di Pavia, Pavia, Italy
| | | | - Angelo G Corsico
- Center for Diagnosis of Inherited Alpha1-antitrypsin Deficiency, Dept of Internal Medicine and Therapeutics, Pneumology Unit, Fondazione IRCCS Policlinico San Matteo, Università di Pavia, Pavia, Italy
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194
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Torres-Durán M, Lopez-Campos JL, Barrecheguren M, Miravitlles M, Martinez-Delgado B, Castillo S, Escribano A, Baloira A, Navarro-Garcia MM, Pellicer D, Bañuls L, Magallón M, Casas F, Dasí F. Alpha-1 antitrypsin deficiency: outstanding questions and future directions. Orphanet J Rare Dis 2018; 13:114. [PMID: 29996870 PMCID: PMC6042212 DOI: 10.1186/s13023-018-0856-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 06/26/2018] [Indexed: 12/14/2022] Open
Abstract
Background Alpha-1 antitrypsin deficiency (AATD) is a rare hereditary condition that leads to decreased circulating alpha-1 antitrypsin (AAT) levels, significantly increasing the risk of serious lung and/or liver disease in children and adults, in which some aspects remain unresolved. Methods In this review, we summarise and update current knowledge on alpha-1 antitrypsin deficiency in order to identify and discuss areas of controversy and formulate questions that need further research. Results 1) AATD is a highly underdiagnosed condition. Over 120,000 European individuals are estimated to have severe AATD and more than 90% of them are underdiagnosed. Conclusions 2) Several clinical and etiological aspects of the disease are yet to be resolved. New strategies for early detection and biomarkers for patient outcome prediction are needed to reduce morbidity and mortality in these patients; 3) Augmentation therapy is the only specific approved therapy that has shown clinical efficacy in delaying the progression of emphysema. Regrettably, some countries reject registration and reimbursement for this treatment because of the lack of larger randomised, placebo-controlled trials. 4) Alternative strategies are currently being investigated, including the use of gene therapy or induced pluripotent stem cells, and non-augmentation strategies to prevent AAT polymerisation inside hepatocytes.
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Affiliation(s)
- María Torres-Durán
- Pulmonary Department, Hospital Álvaro Cunqueiro EOXI, Vigo, Spain.,NeumoVigo I+i Research Group, IIS Galicia Sur, Vigo, Spain
| | - José Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio, Universidad de Sevilla, Sevilla, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Miriam Barrecheguren
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Pneumology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marc Miravitlles
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Pneumology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Beatriz Martinez-Delgado
- Molecular Genetics Unit, Instituto de Investigación de Enfermedades Raras (IIER), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Silvia Castillo
- Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, c/Menéndez y Pelayo, 4, 46010, Valencia, Spain.,School of Medicine, Department of Physiology, Research group on Rare Respiratory Diseases (ERR), University of Valencia, Valencia, Spain
| | - Amparo Escribano
- Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, c/Menéndez y Pelayo, 4, 46010, Valencia, Spain.,School of Medicine, Department of Paediatrics, Obstetrics and Gynaecology, University of Valencia, Valencia, Spain.,School of Medicine, Department of Physiology, Research group on Rare Respiratory Diseases (ERR), University of Valencia, Valencia, Spain
| | - Adolfo Baloira
- Pneumology Department, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - María Mercedes Navarro-Garcia
- Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, c/Menéndez y Pelayo, 4, 46010, Valencia, Spain.,School of Medicine, Department of Physiology, Research group on Rare Respiratory Diseases (ERR), University of Valencia, Valencia, Spain
| | - Daniel Pellicer
- Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, c/Menéndez y Pelayo, 4, 46010, Valencia, Spain.,School of Medicine, Department of Physiology, Research group on Rare Respiratory Diseases (ERR), University of Valencia, Valencia, Spain
| | - Lucía Bañuls
- Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, c/Menéndez y Pelayo, 4, 46010, Valencia, Spain.,School of Medicine, Department of Physiology, Research group on Rare Respiratory Diseases (ERR), University of Valencia, Valencia, Spain
| | - María Magallón
- Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, c/Menéndez y Pelayo, 4, 46010, Valencia, Spain.,School of Medicine, Department of Physiology, Research group on Rare Respiratory Diseases (ERR), University of Valencia, Valencia, Spain
| | - Francisco Casas
- Pneumology Department, Hospital Universitario San Cecilio, Granada, Spain
| | - Francisco Dasí
- Fundación Investigación Hospital Clínico Valencia, Instituto de Investigación Sanitaria INCLIVA, c/Menéndez y Pelayo, 4, 46010, Valencia, Spain. .,School of Medicine, Department of Physiology, Research group on Rare Respiratory Diseases (ERR), University of Valencia, Valencia, Spain.
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195
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Soriano JB, Lucas SJ, Jones R, Miravitlles M, Carter V, Small I, Price D, Mahadeva R. Trends of testing for and diagnosis of α 1-antitrypsin deficiency in the UK: more testing is needed. Eur Respir J 2018; 52:13993003.00360-2018. [PMID: 29853490 DOI: 10.1183/13993003.00360-2018] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/07/2018] [Indexed: 11/05/2022]
Abstract
α1-antitrypsin deficiency (AATD) significantly increases the risk of developing chronic obstructive pulmonary disease (COPD), and testing of all COPD patients for AATD is recommended by the World Health Organization, European Respiratory Society and Global Initiative for Chronic Obstructive Lung Disease (GOLD). We aimed to determine trends for testing and diagnosing AATD from 1990 to 2014.This study analysed all patients diagnosed with COPD from about 550 UK Optimum Patient Care Research Database general practices, including a subgroup of those diagnosed before the age of 60 years.We identified 107 024 COPD individuals, of whom 29 596 (27.6%) were diagnosed before 60 years of age. Of them, only 2.2% (95% CI 2.09-2.43%) had any record of being tested for AATD. Of those tested, 23.7% (95% CI 20.5-27.1%) were diagnosed with AATD. Between 1994 and 2013 the incidence of AATD diagnosis generally increased. A diagnosis of AATD was associated with being male, being an ex-smoker, more severe COPD with a lower forced expiratory volume in 1 s % pred and higher GOLD 2017 stages (all p<0.05).Despite an increase in the frequency of AATD testing since 1990, only 2.2% of patients diagnosed with COPD before the age of 60 years were tested. AATD prevalence was 23.7% in those tested. Thus, it appears that AATD remains markedly underdiagnosed in COPD patients.
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Affiliation(s)
- Joan B Soriano
- Instituto de Investigación Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid and SEPAR, Madrid, Spain
| | | | - Rupert Jones
- Plymouth University Peninsula School of Medicine and Dentistry, Plymouth, UK
| | - Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron and CIBERES, Barcelona, Spain
| | | | - Iain Small
- Peterhead Medical Practice, Peterhead, UK
| | - David Price
- Observational and Pragmatic Research Institute (OPRI) Pte Ltd, Singapore, Singapore.,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Ravi Mahadeva
- Dept of Respiratory Medicine, Cambridge NIHR BRC, Addenbrookes Hospital, Cambridge, UK
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196
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Calle Rubio M, Soriano JB, López- Campos JL, Soler-Cataluña JJ, Alcázar Navarrete B, Rodríguez González- Moro JM, Miravitlles M, Barrecheguren M, Fuentes Ferrer ME, Rodriguez Hermosa JL. Testing for alpha-1 antitrypsin in COPD in outpatient respiratory clinics in Spain: A multilevel, cross-sectional analysis of the EPOCONSUL study. PLoS One 2018; 13:e0198777. [PMID: 29953442 PMCID: PMC6023216 DOI: 10.1371/journal.pone.0198777] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 05/24/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Alpha-1 antitrypsin deficiency (AATD) is the most common hereditary disorder in adults, but is under-recognized. In Spain, the number of patients diagnosed with AATD is much lower than expected according to epidemiologic studies. The objectives of this study were to assess the frequency and determinants of testing serum α1-antitrypsin (AAT) levels in COPD patients, and to describe factors associated with testing. METHODS EPOCONSUL is a cross-sectional clinical audit, recruiting consecutive COPD cases over one year. The study evaluated serum AAT level determination in COPD patients and associations between individual, disease-related, and hospital characteristics. RESULTS A total of 4,405 clinical records for COPD patients from 57 Spanish hospitals were evaluated. Only 995 (22.5%) patients had serum AAT tested on some occasion. A number of patient characteristics (being male [OR 0.5, p < 0.001], ≤55 years old [OR 2.38, p<0.001], BMI≤21 kg/m2 [OR 1.71, p<0.001], FEV1(%)<50% [OR 1.35, p<0.001], chronic bronchitis [OR 0.79, p < 0.001], Charlson index ≥ 3 [OR 0.66, p < 0.001], or history or symptoms of asthma [OR 1.32, p<0.001]), and management at a specialized COPD outpatient clinic [OR 2.73,p<0.001] were identified as factors independently associated with ever testing COPD patients for AATD. Overall, 114 COPD patients (11.5% of those tested) had AATD. Of them, 26 (22.8%) patients had severe deficiency. Patients with AATD were younger, with a low pack-year index, and were more likely to have emphysema (p<0.05). CONCLUSION Testing of AAT blood levels in COPD patients treated at outpatient respiratory clinics in Spain is infrequent. However, when tested, AATD (based on the serum AAT levels ≤100 mg/dL) is detected in one in five COPD patients. Efforts to optimize AATD case detection in COPD are needed.
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Affiliation(s)
- Myriam Calle Rubio
- Pulmonary Department, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid, España
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, España
- * E-mail:
| | - Joan B. Soriano
- Instituto de Investigación Hospital Universitario de la Princesa (IISP), Consultant on Methodology and Research of SEPAR, Universidad Autónoma de Madrid, Madrid, España
| | - José Luis López- Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias. Instituto de Biomedicina de Sevilla (IBiS). Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, España
- CIBER de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Madrid. España
| | | | - Bernardino Alcázar Navarrete
- CIBER de Enfermedades Respiratorias (CIBERES). Instituto de Salud Carlos III, Madrid. España
- Pulmonary Department, Hospital de Alta Resolución de Loja, Granada, España
| | | | - Marc Miravitlles
- Pulmonary Department, Hospital Universitari Vall d’Hebron, Barcelona, España
- CIBER de Enfermedades Respiratorias (CIBERES). Barcelona, España
| | | | - Manuel E. Fuentes Ferrer
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, España
- UGC de Medicina Preventiva, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - Juan Luis Rodriguez Hermosa
- Pulmonary Department, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid, España
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, España
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197
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Esquinas C, Miravitlles M. Are There Differences Between the Available Treatments for Emphysema Associated with Alpha-1 Antitrypsin Deficiency? Arch Bronconeumol 2018; 54:451-452. [PMID: 29625713 DOI: 10.1016/j.arbres.2018.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/10/2018] [Accepted: 01/10/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Cristina Esquinas
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, España
| | - Marc Miravitlles
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, España.
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198
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Barrecheguren M, Miravitlles M. Augmentation therapy for emphysema due to alpha-1 antitrypsin deficiency: Pro. Arch Bronconeumol 2018; 54:S0300-2896(18)30056-5. [PMID: 29555450 DOI: 10.1016/j.arbres.2018.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 02/02/2018] [Accepted: 02/05/2018] [Indexed: 02/05/2023]
Affiliation(s)
| | - Marc Miravitlles
- Servicio de Neumología, Hospital Universitari Vall d́Hebron, Barcelona, España; CIBER de Enfermedades Respiratorias (CIBERES).
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