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Lemke J, Weigert A, Bagci S, Born M, Ganschow R, Katzer D. Alpha-1-Antitrypsin Deficiency in Children-Unmet Needs Concerning the Liver Manifestation. CHILDREN (BASEL, SWITZERLAND) 2024; 11:694. [PMID: 38929273 PMCID: PMC11202262 DOI: 10.3390/children11060694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/13/2024] [Accepted: 06/01/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES This study aimed to analyse the clinical course of 45 children with severe alpha-1-antitrypsin deficiency (AATD) registered in our clinic to detect possible predictors of poor outcomes. METHODS The clinical and biological data of 45 patients with homozygous or compound heterozygous AATD were analysed. The data were collected retrospectively going back to 2005 and prospectively from May 2020 until October 2021. It was based on questionnaires, laboratory values, sonography, and biopsy findings. Liver disease was classified into four grades depending on the grade of liver disease: mild or no liver disease, moderate disease, severe disease, and liver transplantation. RESULTS Thirty-nine patients (86.7%) had a Pi*ZZ and five (11.1%) a Pi*SZ genotype. One patient showed a new, not-yet-described compound heterozygous genotype (Pi*Z + Asp95Asn). A total of 66.7% of the cohort showed mild or no liver disease, 20% moderate, and 13.3% severe. AATD was diagnosed in most cases because of liver abnormalities, such as the elevation of transaminases (42.2%). A total of 29.4% of the patients with neonatal icterus prolongatus developed severe liver disease, and 25.7% were born small for their gestational age (SGA). Diseases of the atopic type were reported in 47.4% of the cases. CONCLUSIONS The presence of neonatal icterus prolongatus in the first weeks of life was significantly more likely in severe courses of liver disease (r = 0.371, p = 0.012). A tendency toward atopic comorbidity in AAT-deficient children needs to be further evaluated.
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Affiliation(s)
- Joelle Lemke
- Department of Pediatric Gastroenterology and Hepatology, University Hospital of Bonn Children’s Hospital, 53127 Bonn, Germany (A.W.); (R.G.)
| | - Alexander Weigert
- Department of Pediatric Gastroenterology and Hepatology, University Hospital of Bonn Children’s Hospital, 53127 Bonn, Germany (A.W.); (R.G.)
| | - Soyhan Bagci
- Department of Pediatric Gastroenterology and Hepatology, University Hospital of Bonn Children’s Hospital, 53127 Bonn, Germany (A.W.); (R.G.)
- Department of Neonatology and Pediatric Intensive Care Medicine, University Hospital of Bonn Children’s Hospital, 53127 Bonn, Germany
| | - Mark Born
- Department of Pediatric Radiology, University Hospital of Bonn Children’s Hospital, 53127 Bonn, Germany
| | - Rainer Ganschow
- Department of Pediatric Gastroenterology and Hepatology, University Hospital of Bonn Children’s Hospital, 53127 Bonn, Germany (A.W.); (R.G.)
| | - David Katzer
- Department of Pediatric Gastroenterology and Hepatology, University Hospital of Bonn Children’s Hospital, 53127 Bonn, Germany (A.W.); (R.G.)
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Fromme M, Schneider CV, Trautwein C, Brunetti-Pierri N, Strnad P. Alpha-1 antitrypsin deficiency: A re-surfacing adult liver disorder. J Hepatol 2022; 76:946-958. [PMID: 34848258 DOI: 10.1016/j.jhep.2021.11.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 11/05/2021] [Accepted: 11/18/2021] [Indexed: 12/21/2022]
Abstract
Alpha-1 antitrypsin deficiency (AATD) arises from mutations in the SERPINA1 gene encoding alpha-1 antitrypsin (AAT) that lead to AAT retention in the endoplasmic reticulum of hepatocytes, causing proteotoxic liver injury and loss-of-function lung disease. The homozygous Pi∗Z mutation (Pi∗ZZ genotype) is responsible for the majority of severe AATD cases and can precipitate both paediatric and adult liver diseases, while the heterozygous Pi∗Z mutation (Pi∗MZ genotype) is an established genetic modifier of liver disease. We review genotype-related hepatic phenotypes/disease predispositions. We also describe the mechanisms and factors promoting the development of liver disease, as well as approaches to evaluate the extent of liver fibrosis. Finally, we discuss emerging diagnostic and therapeutic approaches for the clinical management of this often neglected disorder.
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Affiliation(s)
- Malin Fromme
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
| | - Carolin V Schneider
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
| | - Christian Trautwein
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
| | - Nicola Brunetti-Pierri
- Telethon Institute of Genetics and Medicine, Pozzuoli, 80078 Naples, Italy; Department of Translational Medicine, Federico II University of Naples, Naples, Italy
| | - Pavel Strnad
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany.
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Burbaum B, Fromme M, Strnad P. [Alpha-1 antitrypsin deficiency: cause and cofactor for liver disease]. Dtsch Med Wochenschr 2021; 146:714-718. [PMID: 34062584 DOI: 10.1055/a-1277-9066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Alpha-1-antitrypsin deficiency (AATD) is a genetic disorder arising due to mutation in alpha1-antitrypsin (AAT). AAT mutations interfere with the AAT production/secretion, cause decreased AAT serum levels and accumulation of AAT in the liver. The excess AAT leads to a proteotoxic liver disease, while the lack of AAT in systemic circulation predisposes to lung injury. While AATD related lung disease is well understood, liver disease needs further awareness. Non-invasive liver stiffness measurement constitutes a useful method to estimate the extent of liver fibrosis. Significant liver fibrosis occurs in 20-35 % of individuals with the classic, severe genotype Pi*ZZ. Genotype Pi*SZ, also known as the compound heterozygous form, confers an increased risk of both liver fibrosis and liver neoplasia. Even the heterozygous genotype Pi*MZ increases the odds of fibrosis in presence of further risk factors such as obesity, male sex, metabolic syndrome and diabetes mellitus. In individuals with non-alcoholic fatty liver disease or alcohol misuse it promotes the development of liver cirrhosis. While no drug treatment exists for AATD-related liver disease, there are several compounds in clinical phase II/III-trials. These either silence the AAT production via siRNA or facilitate the secretion of AAT from the liver due to an improved folding.
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Affiliation(s)
- Barbara Burbaum
- Medizinische Klinik III, Gastroenterologie, Stoffwechselerkrankungen und Intensivmedizin, Uniklinik Aachen, Aachen, Deutschland
| | - Malin Fromme
- Medizinische Klinik III, Gastroenterologie, Stoffwechselerkrankungen und Intensivmedizin, Uniklinik Aachen, Aachen, Deutschland
| | - Pavel Strnad
- Medizinische Klinik III, Gastroenterologie, Stoffwechselerkrankungen und Intensivmedizin, Uniklinik Aachen, Aachen, Deutschland
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Pons M, Núñez A, Esquinas C, Torres-Durán M, Rodríguez-Hermosa JL, Calle M, Tubio-Pérez R, Belmonte I, Rodríguez-Frías F, Rodríguez E, Genescà J, Miravitlles M, Barrecheguren M. Utility of Transient Elastography for the Screening of Liver Disease in Patients with Alpha1-Antitrypsin Deficiency. J Clin Med 2021; 10:jcm10081724. [PMID: 33923569 PMCID: PMC8073267 DOI: 10.3390/jcm10081724] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 02/07/2023] Open
Abstract
Screening of liver disease in alpha-1 antitrypsin deficiency (AATD) is usually carried out with liver enzymes, with low sensitivity. We conducted a multicenter cross-sectional study aiming to describe the utility of transient elastography for the identification of liver disease in patients with AATD. A total of 148 AATD patients were included. Among these, 54.7% were Pi*ZZ and 45.3% were heterozygous for the Z allele. Between 4.9% and 16.5% of patients had abnormal liver enzymes, without differences among genotypes. Liver stiffness measurement (LSM) was significantly higher in Pi*ZZ individuals than in heterozygous Z (5.6 vs. 4.6 kPa; p = 0.001). In total, in 8 (5%) individuals LSM was >7.5 kPa, considered significant liver fibrosis, and ≥10 kPa in 3 (1.9%) all being Pi*ZZ. Elevated liver enzymes were more frequently observed in patients with LSM > 7.5 kPa, but in 5 out of 8 of these patients all liver enzymes were within normal range. In patients with AATD, the presence of abnormal liver enzymes is frequent; however, most of these patients do not present significant liver fibrosis. Transient elastography can help to identify patients with liver fibrosis even with normal liver enzymes and should be performed in all Z-allele carriers to screen for liver disease.
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Affiliation(s)
- Mònica Pons
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain; (M.P.); (J.G.)
| | - Alexa Núñez
- Pneumology Department, Hospital Universitari Vall d’Hebron/Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain; (A.N.); (C.E.); (I.B.); (E.R.); (M.B.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
| | - Cristina Esquinas
- Pneumology Department, Hospital Universitari Vall d’Hebron/Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain; (A.N.); (C.E.); (I.B.); (E.R.); (M.B.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
| | - María Torres-Durán
- Pneumology Department, University Hospital Complex of Vigo, Instituto de Investigación Biomédica Galicia Sur, 36213 Vigo, Spain; (M.T.-D.); (R.T.-P.)
| | - Juan Luis Rodríguez-Hermosa
- Pneumology Department, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Hospital Clínico de San Carlos, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain; (J.L.R.-H.); (M.C.)
| | - Myriam Calle
- Pneumology Department, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Hospital Clínico de San Carlos, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain; (J.L.R.-H.); (M.C.)
| | - Ramón Tubio-Pérez
- Pneumology Department, University Hospital Complex of Vigo, Instituto de Investigación Biomédica Galicia Sur, 36213 Vigo, Spain; (M.T.-D.); (R.T.-P.)
| | - Irene Belmonte
- Pneumology Department, Hospital Universitari Vall d’Hebron/Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain; (A.N.); (C.E.); (I.B.); (E.R.); (M.B.)
| | - Francisco Rodríguez-Frías
- Department of Clinical Biochemistry, Hospital Universitari Vall d’Hebron, Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain;
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), 28029 Madrid, Spain
| | - Esther Rodríguez
- Pneumology Department, Hospital Universitari Vall d’Hebron/Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain; (A.N.); (C.E.); (I.B.); (E.R.); (M.B.)
| | - Joan Genescà
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain; (M.P.); (J.G.)
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), 28029 Madrid, Spain
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron/Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain; (A.N.); (C.E.); (I.B.); (E.R.); (M.B.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), 28029 Madrid, Spain
- Correspondence:
| | - Miriam Barrecheguren
- Pneumology Department, Hospital Universitari Vall d’Hebron/Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain; (A.N.); (C.E.); (I.B.); (E.R.); (M.B.)
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Hamesch K, Strnad P. Non-Invasive Assessment and Management of Liver Involvement in Adults With Alpha-1 Antitrypsin Deficiency. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2020; 7:260-271. [PMID: 32697896 DOI: 10.15326/jcopdf.7.3.2019.0161] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a systemic disorder affecting mainly the lung and the liver and is caused by mutations in SERPINA1, the AAT gene. A homozygous "Pi*Z" mutation (Pi*ZZ genotype) may cause liver fibrosis on its own independently of pulmonary AATD manifestation, while heterozygous Pi*Z carriage (Pi*MZ genotype) is considered a strong risk factor for development of liver cirrhosis in patients with concomitant liver disease such as alcoholic and non-alcoholic liver disease. In Pi*ZZ homozygotes, liver disease constitutes the second leading cause of death and is highly heterogeneous. About 35% of Pi*ZZ individuals display significant liver fibrosis on biopsy (i.e., fibrosis stage ≥ 2 on scale 0-4). Among non-invasive methods for liver fibrosis assessment, liver stiffness measurement (LSM) via vibration-controlled transient elastography (VCTE) has been most widely evaluated. Based on these data, Pi*ZZ adults have 20x increased odds of developing advanced liver fibrosis (i.e., fibrosis stage ≥ 3) than adults without AAT mutation. Risk factors for accelerated fibrosis progression are male sex, age ≥ 50 years, alcohol misuse, obesity, diabetes mellitus, or metabolic syndrome. Unlike VCTE, other ultrasound- and magnetic resonance-based elastography methods have been assessed in small cohorts of Pi*ZZ individuals and remain to be comprehensively validated. Among blood-based fibrosis tests, AST-to-platelet ratio index (APRI) correlates moderately with histologic fibrosis stage and LSM. Given APRI's wide availability, it can be used for risk stratification as an adjunct to LSM or when LSM is not at hand. Despite recent efforts, AATD-related liver disease, especially for genotypes other than Pi*ZZ, remains greatly understudied. AATD individuals should be offered liver biochemistry, liver ultrasound, and non-invasive fibrosis assessment at the time of diagnosis to detect potential complications and for proper risk stratification. If signs of AATD-related liver disease occur (i.e., pathologic fibrosis test or repeatedly elevated liver enzymes), patients should be referred to a health care center specialized in AATD-related liver disease and be screened for potentially treatable comorbidities. To exclude the latter, they may need a liver biopsy. Moreover, every health care provider of an AATD individual should be aware of the potential liver manifestation, counsel their patient on modifiable hepatic risk factors, and offer them regular liver check-ups.
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Affiliation(s)
- Karim Hamesch
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany.,Coordinating Center for Alpha-1 Antitrypsin Deficiency-Related Liver Disease of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER) and the European Association for the Study of the Liver (EASL) Registry Group "Alpha-1 Liver"
| | - Pavel Strnad
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany.,Coordinating Center for Alpha-1 Antitrypsin Deficiency-Related Liver Disease of the European Reference Network on Hepatological Diseases (ERN RARE-LIVER) and the European Association for the Study of the Liver (EASL) Registry Group "Alpha-1 Liver"
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