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Kamuda K, Ronzoni R, Majumdar A, Guan FHX, Irving JA, Lomas DA. A novel pathological mutant reveals the role of torsional flexibility in the serpin breach in adoption of an aggregation-prone intermediate. FEBS J 2024; 291:2937-2954. [PMID: 38523412 DOI: 10.1111/febs.17121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/17/2024] [Accepted: 03/07/2024] [Indexed: 03/26/2024]
Abstract
Mutants of alpha-1-antitrypsin cause the protein to self-associate and form ordered aggregates ('polymers') that are retained within hepatocytes, resulting in a predisposition to the development of liver disease. The associated reduction in secretion, and for some mutants, impairment of function, leads to a failure to protect lung tissue against proteases released during the inflammatory response and an increased risk of emphysema. We report here a novel deficiency mutation (Gly192Cys), that we name the Sydney variant, identified in a patient in heterozygosity with the Z allele (Glu342Lys). Cellular analysis revealed that the novel variant was mostly retained as insoluble polymers within the endoplasmic reticulum. The basis for this behaviour was investigated using biophysical and structural techniques. The variant showed a 40% reduction in inhibitory activity and a reduced stability as assessed by thermal unfolding experiments. Polymerisation involves adoption of an aggregation-prone intermediate and paradoxically the energy barrier for transition to this state was increased by 16% for the Gly192Cys variant with respect to the wild-type protein. However, with activation to the intermediate state, polymerisation occurred at a 3.8-fold faster rate overall. X-ray crystallography provided two crystal structures of the Gly192Cys variant, revealing perturbation within the 'breach' region with Cys192 in two different orientations: in one structure it faces towards the hydrophobic core while in the second it is solvent-exposed. This orientational heterogeneity was confirmed by PEGylation. These data show the critical role of the torsional freedom imparted by Gly192 in inhibitory activity and stability against polymerisation.
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Affiliation(s)
- Kamila Kamuda
- Division of Medicine, UCL Respiratory, Rayne Institute, University College London, UK
- Institute of Structural and Molecular Biology, Birkbeck College, University College London, UK
| | - Riccardo Ronzoni
- Division of Medicine, UCL Respiratory, Rayne Institute, University College London, UK
- Institute of Structural and Molecular Biology, Birkbeck College, University College London, UK
| | - Avik Majumdar
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
- Victorian Liver Transplant Unit, Austin Health, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
| | - Fiona H X Guan
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - James A Irving
- Division of Medicine, UCL Respiratory, Rayne Institute, University College London, UK
- Institute of Structural and Molecular Biology, Birkbeck College, University College London, UK
| | - David A Lomas
- Division of Medicine, UCL Respiratory, Rayne Institute, University College London, UK
- Institute of Structural and Molecular Biology, Birkbeck College, University College London, UK
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Mulkareddy V, Roman J. Pulmonary manifestations of alpha 1 antitrypsin deficiency. Am J Med Sci 2024; 368:1-8. [PMID: 38599244 DOI: 10.1016/j.amjms.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 04/02/2024] [Indexed: 04/12/2024]
Abstract
Alpha 1 antitrypsin deficiency is a widely under recognized autosomal codominant condition caused by genetic mutations in the SERPINA 1 gene, which encodes for alpha 1 antitrypsin (AAT), a serine protease inhibitor. The SERPINA 1 gene contains 120 variants and mutations in the gene may decrease AAT protein levels or result in dysfunctional proteins. This deficiency leads to unopposed protease activity in tissues, thereby promoting pulmonary and hepatic disease. The most common genotype associated with pulmonary disease is the ZZ genotype, and the most frequent pulmonary manifestation is emphysema. Although its pathophysiology may differ from cigarette smoking related chronic obstructive pulmonary disease, smoking itself can hasten lung decline in alpha 1 antitrypsin deficiency (AATD). The diagnosis of AATD is made through AAT protein testing along with genotyping. AATD patients with obstructive airflow limitation may qualify for intravenous augmentation with AAT. However, there is ongoing research to allow for earlier detection and treatment. This review describes in general terms the genetic mechanisms of AATD; its pathogenesis and the impact of cigarette smoke; and its clinical manifestations, diagnosis, treatment, and prognosis. We hope to stimulate research in the field, but mostly we wish to enhance awareness to promote early diagnosis and treatment in those eligible for intervention.
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Affiliation(s)
- Vani Mulkareddy
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine and The Jane & Leonard Korman Respiratory Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jesse Roman
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine and The Jane & Leonard Korman Respiratory Institute, Thomas Jefferson University, Philadelphia, PA, USA.
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Scioscia G, Santacroce R, Tondo P, Hoxhallari A, Soccio P, Giuffreda E, D'Ambrosio MF, Leccese A, Paladini L, Natale MP, Moriondo G, Foschino Barbaro MP, Margaglione M, Lacedonia D. A Report on a Targeted Screening Population for Alpha-1-Antitrypsin Deficiency (AATD) in Central-Southern Italy. Arch Bronconeumol 2024:S0300-2896(24)00191-1. [PMID: 38876920 DOI: 10.1016/j.arbres.2024.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 05/27/2024] [Accepted: 05/27/2024] [Indexed: 06/16/2024]
Affiliation(s)
- Giulia Scioscia
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Department of Specialistic Medicine, Respiratory Care Unit, University-Hospital Policlinico of Foggia, Foggia, Italy
| | - Rosa Santacroce
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy; Medical Genetics Unit, University-Hospital Policlinico of Foggia, 71122 Foggia, Italy
| | - Pasquale Tondo
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy.
| | - Anela Hoxhallari
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Department of Specialistic Medicine, Respiratory Care Unit, University-Hospital Policlinico of Foggia, Foggia, Italy
| | - Piera Soccio
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Ernesto Giuffreda
- Department of Specialistic Medicine, Respiratory Care Unit, University-Hospital Policlinico of Foggia, Foggia, Italy
| | - Maria Francesca D'Ambrosio
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy; Medical Genetics Unit, University-Hospital Policlinico of Foggia, 71122 Foggia, Italy
| | - Angelica Leccese
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy; Medical Genetics Unit, University-Hospital Policlinico of Foggia, 71122 Foggia, Italy
| | - Luigi Paladini
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Department of Specialistic Medicine, Respiratory Care Unit, University-Hospital Policlinico of Foggia, Foggia, Italy
| | - Matteo Pio Natale
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Department of Specialistic Medicine, Respiratory Care Unit, University-Hospital Policlinico of Foggia, Foggia, Italy
| | - Giorgia Moriondo
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Maria Pia Foschino Barbaro
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Department of Specialistic Medicine, Respiratory Care Unit, University-Hospital Policlinico of Foggia, Foggia, Italy
| | - Maurizio Margaglione
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy; Medical Genetics Unit, University-Hospital Policlinico of Foggia, 71122 Foggia, Italy
| | - Donato Lacedonia
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Department of Specialistic Medicine, Respiratory Care Unit, University-Hospital Policlinico of Foggia, Foggia, Italy
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Blanco I, Miravitlles M. Genetic Epidemiology of Alpha-1 Antitrypsin Deficiency in Macaronesia. Respiration 2024; 103:368-377. [PMID: 38588657 DOI: 10.1159/000538293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/06/2024] [Indexed: 04/10/2024] Open
Abstract
INTRODUCTION The prevalence of alpha-1 antitrypsin deficiency (AATD) in Macaronesia (i.e., Azores, Madeira, Canary Islands, and Cape Verde archipelagos) is poorly known. Our goal was to update it by selecting the most reliable available articles. METHOD Literature search using MEDLINE, Embase (via Ovid), and Google Scholar, until December 2023, for studies on prevalence of AATD in the general population and in screenings, published in peer-reviewed journals. RESULTS Three studies carried out in the general population of Madeira, La Palma, and Cape Verde, and three screenings carried out in La Palma (2) and Gran Canaria (1) were selected. The frequencies of PI*S in the general population showed an ascending gradient, from South to North, with values (per thousand) of 35 in Cape Verde, 82 in La Palma, and 180 in Madeira. The PI*Z frequencies showed this same gradient, with values of 2 × 1,000 in Cape Verde, 21 in La Palma, and 25 in Madeira. Screenings detected high percentages of defective alleles, including several rare and null alleles, some unique to these islands. CONCLUSION The frequencies of PI*S and PI*Z in Madeira are comparable to the highest in the world. Those of the Canary Islands are similar to those of the peninsular population of Spain, and contrast with the low rates of Cape Verde. Screenings detected high numbers of deficient alleles. These results support the systematic investigation of AATD in clinically suspected patients and in relatives of index cases, to reduce underdiagnosis and apply early preventive and therapeutic measures in those affected.
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Affiliation(s)
- Ignacio Blanco
- Hospital Valle del Nalón, Pneumology Service (retired), Langreo, Spain
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
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Joshi D, Nayagam J, Clay L, Yerlett J, Claridge L, Day J, Ferguson J, Mckie P, Vara R, Pargeter H, Lockyer R, Jones R, Heneghan M, Samyn M. UK guideline on the transition and management of childhood liver diseases in adulthood. Aliment Pharmacol Ther 2024; 59:812-842. [PMID: 38385884 DOI: 10.1111/apt.17904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/15/2023] [Accepted: 02/03/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Improved outcomes of liver disease in childhood and young adulthood have resulted in an increasing number of young adults (YA) entering adult liver services. The adult hepatologist therefore requires a working knowledge in diseases that arise almost exclusively in children and their complications in adulthood. AIMS To provide adult hepatologists with succinct guidelines on aspects of transitional care in YA relevant to key disease aetiologies encountered in clinical practice. METHODS A systematic literature search was undertaken using the Pubmed, Medline, Web of Knowledge and Cochrane database from 1980 to 2023. MeSH search terms relating to liver diseases ('cholestatic liver diseases', 'biliary atresia', 'metabolic', 'paediatric liver diseases', 'autoimmune liver diseases'), transition to adult care ('transition services', 'young adult services') and adolescent care were used. The quality of evidence and the grading of recommendations were appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS These guidelines deal with the transition of YA and address key aetiologies for the adult hepatologist under the following headings: (1) Models and provision of care; (2) screening and management of mental health disorders; (3) aetiologies; (4) timing and role of liver transplantation; and (5) sexual health and fertility. CONCLUSIONS These are the first nationally developed guidelines on the transition and management of childhood liver diseases in adulthood. They provide a framework upon which to base clinical care, which we envisage will lead to improved outcomes for YA with chronic liver disease.
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Affiliation(s)
- Deepak Joshi
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Jeremy Nayagam
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Lisa Clay
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust, London, UK
| | - Jenny Yerlett
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust, London, UK
| | - Lee Claridge
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | - Jemma Day
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - James Ferguson
- National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Paul Mckie
- Department of Social Work, King's College Hospital NHS Foundation Trust, London, UK
| | - Roshni Vara
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust, London, UK
- Evelina London Children's Hospital, London, UK
| | | | | | - Rebecca Jones
- Leeds Liver Unit, St James's University Hospital, Leeds, UK
| | - Michael Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, UK
| | - Marianne Samyn
- Paediatric Liver, GI and Nutrition service, King's College Hospital NHS Foundation Trust, London, UK
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Calle Rubio M, Miravitlles M, López-Campos JL, Soler-Cataluña JJ, Alcazar Navarrete B, Fuentes-Ferrer ME, Rodriguez Hermosa JL. Detection of Alpha-1 Antitrypsin Levels in Chronic Obstructive Pulmonary Disease in Respiratory Clinics in Spain: Results of the EPOCONSUL 2021 Audit. J Clin Med 2024; 13:955. [PMID: 38398268 PMCID: PMC10889736 DOI: 10.3390/jcm13040955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 01/29/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Alpha-1 antitrypsin deficiency (AATD) is an underdiagnosed condition despite being one of the most common inherited disorders in adults that is associated with an increased risk of developing chronic obstructive pulmonary disease (COPD). The aim was to evaluate the frequency of performing AAT levels and associated factors in COPD patients in an audit conducted in 2021-2022, as well as to compare with a previous audit conducted in 2014-2015. METHODS EPOCONSUL 2021 is a cross-sectional audit that evaluated the outpatient care provided to COPD patients in respiratory clinics in Spain based on available data from medical registries. RESULTS 4225 patients with a diagnosis of COPD from 45 centers were audited in 2021. A total of 1670 (39.5%) patients underwent AAT determination. Being treated at a specialized COPD outpatient clinic (OR 1.88, p = 0.007), age ≤ 55 years old (OR 1.84, p = 0.007) and a FEV1 < 50% (OR 1.86, p < 0.001) were associated with a higher likelihood of being tested for AAT, while Charlson index ≥ 3 (OR 0.63, p < 0.001) and genotyping of AATD availability (OR 0.42, p < 0.001) showed a statistically significant negative association. The analysis of cases included in respiratory units that participated in both audits showed an increase in the proportion of cases with AAT serum level testing available (adjusted OR 2.81, p < 0.001). The percentage of individuals with serum AAT levels < 60 mg/dL (a severe AATD) was 4%. CONCLUSIONS Our analysis identifies significant improvements in adherence to the recommendation to test AAT levels in COPD patients, performed in 4 out of 10 patients, being more likely at younger ages and with higher COPD severity, and with a detection of severe AATD of 4% among those tested, suggesting that clinicians still perform AAT testing in COPD patients selectively. Therefore, efforts are still needed to optimize AATD screening and establish new early detection strategies to reduce morbidity and mortality in these patients.
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Affiliation(s)
- Myriam Calle Rubio
- Pulmonology Department, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain;
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Marc Miravitlles
- Pulmonary Department, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institut de Recerca (VHIR), Vall d’Hebron Barcelona Hospital Campus, 08035 Barcelona, Spain;
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain;
| | - José Luis López-Campos
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, 28029 Madrid, Spain;
- Respiratory Disease Medical-Surgical Unit, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, 41009 Sevilla, Spain
| | - Juan J. Soler-Cataluña
- Pulmonology Department, Hospital Arnau de Vilanova-Lliria, 46015 Valencia, Spain;
- Medicine Department, Valencia University, 46010 Valencia, Spain
| | - Bernardino Alcazar Navarrete
- Pulmonary Department, Hospital Universitario Virgen de las Nieves, Instituto Biosanitario de Granada, 18014 Granada, Spain;
| | - Manuel E. Fuentes-Ferrer
- Unidad de Investigación, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain;
| | - Juan Luis Rodriguez Hermosa
- Pulmonology Department, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain;
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
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Piloni D, Ottaviani S, Saderi L, Corda L, Baderna P, Barzon V, Balderacchi AM, Seebacher C, Balbi B, Albicini F, Corino A, Mennitti MC, Tirelli C, Spreafico F, Bosio M, Mariani F, Sotgiu G, Corsico AG, Ferrarotti I. Comparison among populations with severe and intermediate alpha1-antitrypsin deficiency and chronic obstructive pulmonary disease. Minerva Med 2024; 115:23-31. [PMID: 37021471 DOI: 10.23736/s0026-4806.22.08266-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
BACKGROUND Severe alpha1-antitrypsin (AAT) deficiency (AATD) is associated with a high risk of airflow obstruction and emphysema. The risk of lung disease in those with intermediate AAT deficiency is unclear. Our aims were to compare pulmonary function, time of onset of symptoms, and indicators of quality of life among patients with severe AATD (PI*ZZ), patients with intermediate AATD (PI*MZ) from the Italian Registry of AATD with a chronic obstructive pulmonary disease (COPD) cohort of patients without AATD (PI*MM). METHODS We considered a total of 613 patients: 330 with the PI*ZZ genotype, 183 with the PI*MZ genotype and 100 with the PI*MM genotype. Radiological exams, pulmonary function test, and measurement of quality of life have been performed on all cohorts of patients. RESULTS The three populations differ significantly in terms of age at COPD/AATD diagnosis (P=0.00001), respiratory function (FEV1, FVC, DLCO P<0.001), quality of life (P=0.0001) and smoking history (P<0.0001). PI*ZZ genotype had 24.9 times a higher likelihood of developing airflow obstruction. The MZ genotype is not associated with a significant early risk of airflow obstruction. CONCLUSIONS The comparison of populations with PI*ZZ, MZ and MM genotypes allows to delineate the role of alpha1-antitrypsin deficiency on respiratory function and on the impact on quality of life, in relation to other risk factors. These results highlight the crucial role of primary and secondary prevention on smoking habits in PI*MZ subjects and the importance of an early diagnosis.
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Affiliation(s)
- Davide Piloni
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
- Department of Internal Medicine, and Therapeutics, Center for Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | - Stefania Ottaviani
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
- Department of Internal Medicine, and Therapeutics, Center for Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | - Laura Saderi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Luciano Corda
- First Division of Medicine, ASST Spedali Civili, Brescia, Italy
| | | | - Valentina Barzon
- Department of Internal Medicine, and Therapeutics, Center for Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | - Alice M Balderacchi
- Department of Internal Medicine, and Therapeutics, Center for Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | | | - Bruno Balbi
- Division of Pneumology, IRCCS Maugeri Scientific Clinical Institutes, Veruno, Novara, Italy
| | - Federica Albicini
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Alessandra Corino
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Maria C Mennitti
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Claudio Tirelli
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Fabio Spreafico
- First Division of Medicine, ASST Spedali Civili, Brescia, Italy
| | - Matteo Bosio
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Francesca Mariani
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
- Department of Internal Medicine, and Therapeutics, Center for Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | - Giovanni Sotgiu
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Angelo G Corsico
- Section of Pneumology, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
- Department of Internal Medicine, and Therapeutics, Center for Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
- AATD Core Network of European Reference Network LUNG, Frankfurt am Main, Germany
| | - Ilaria Ferrarotti
- Department of Internal Medicine, and Therapeutics, Center for Diagnosis of Inherited Alpha-1 Antitrypsin Deficiency, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy -
- AATD Core Network of European Reference Network LUNG, Frankfurt am Main, Germany
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8
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Moll M, Silverman EK. Precision Approaches to Chronic Obstructive Pulmonary Disease Management. Annu Rev Med 2024; 75:247-262. [PMID: 37827193 DOI: 10.1146/annurev-med-060622-101239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. COPD heterogeneity has hampered progress in developing pharmacotherapies that affect disease progression. This issue can be addressed by precision medicine approaches, which focus on understanding an individual's disease risk, and tailoring management based on pathobiology, environmental exposures, and psychosocial issues. There is an urgent need to identify COPD patients at high risk for poor outcomes and to understand at a mechanistic level why certain individuals are at high risk. Genetics, omics, and network analytic techniques have started to dissect COPD heterogeneity and identify patients with specific pathobiology. Drug repurposing approaches based on biomarkers of specific inflammatory processes (i.e., type 2 inflammation) are promising. As larger data sets, additional omics, and new analytical approaches become available, there will be enormous opportunities to identify high-risk individuals and treat COPD patients based on their specific pathophysiological derangements. These approaches show great promise for risk stratification, early intervention, drug repurposing, and developing novel therapeutic approaches for COPD.
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Affiliation(s)
- Matthew Moll
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; ,
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Pulmonary, Critical Care, Sleep and Allergy, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Edwin K Silverman
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; ,
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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9
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Lafortune P, Zahid K, Ploszaj M, Awadalla E, Carroll TP, Geraghty P. Testing Alpha-1 Antitrypsin Deficiency in Black Populations. Adv Respir Med 2023; 92:1-12. [PMID: 38392031 PMCID: PMC10886060 DOI: 10.3390/arm92010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/11/2023] [Accepted: 12/15/2023] [Indexed: 02/24/2024]
Abstract
Alpha-1 antitrypsin (AAT) deficiency (AATD) is an under-recognized hereditary disorder and a significant cause of chronic obstructive pulmonary disease (COPD), a disease that contributes to global mortality. AAT is encoded by the SERPINA1 gene, and severe mutation variants of this gene increase the risk of developing COPD. AATD is more frequently screened for in non-Hispanic White populations. However, AATD is also observed in other ethnic groups and very few studies have documented the mutation frequency in these other ethnic populations. Here, we review the current literature on AATD and allele frequency primarily in Black populations and discuss the possible clinical outcomes of low screening rates in a population that experiences poor health outcomes and whether the low frequency of AATD is related to a lack of screening in this population or a truly low frequency of mutations causing AATD. This review also outlines the harmful SERPINA1 variants, the current epidemiology knowledge of AATD, health inequity in Black populations, AATD prevalence in Black populations, the clinical implications of low screening of AATD in this population, and the possible dangers of not diagnosing or treating AATD.
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Affiliation(s)
- Pascale Lafortune
- Department of Medicine, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA; (P.L.); (K.Z.); (M.P.); (E.A.)
| | - Kanza Zahid
- Department of Medicine, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA; (P.L.); (K.Z.); (M.P.); (E.A.)
| | - Magdalena Ploszaj
- Department of Medicine, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA; (P.L.); (K.Z.); (M.P.); (E.A.)
| | - Emilio Awadalla
- Department of Medicine, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA; (P.L.); (K.Z.); (M.P.); (E.A.)
| | - Tomás P. Carroll
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
- Alpha-1 Foundation Ireland, Royal College of Surgeons in Ireland, D02 YN77 Dublin, Ireland
| | - Patrick Geraghty
- Department of Medicine, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA; (P.L.); (K.Z.); (M.P.); (E.A.)
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10
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Denardo A, Ben Khlifa E, Bignotti M, Giuliani R, D'Acunto E, Miranda E, Irving JA, Fra A. Probing of the reactive center loop region of alpha-1-antitrypsin by mutagenesis predicts new type-2 dysfunctional variants. Cell Mol Life Sci 2023; 81:6. [PMID: 38087060 PMCID: PMC11073084 DOI: 10.1007/s00018-023-05059-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/25/2023] [Accepted: 11/22/2023] [Indexed: 12/18/2023]
Abstract
Lung disease in alpha-1-antitrypsin deficiency (AATD) mainly results from insufficient control of the serine proteases neutrophil elastase (NE) and proteinase-3 due to reduced plasma levels of alpha-1-antitrypsin (AAT) variants. Mutations in the specificity-determining reactive center loop (RCL) of AAT would be predicted to minimally affect protein folding and secretion by hepatocytes but can impair anti-protease activity or alter the target protease. These properly secreted but dysfunctional 'type-2' variants would not be identified by common diagnostic protocols that are predicated on a reduction in circulating AAT. This has potential clinical relevance: in addition to the dysfunctional Pittsburgh and Iners variants reported previously, several uncharacterized RCL variants are present in genome variation databases. To prospectively evaluate the impact of RCL variations on secretion and anti-protease activity, here we performed a systematic screening of amino acid substitutions occurring at the AAT-NE interface. Twenty-three AAT variants that can result from single nucleotide polymorphisms in this region, including 11 present in sequence variation databases, were expressed in a mammalian cell model. All demonstrated unaltered protein folding and secretion. However, when their ability to form stable complexes with NE was evaluated by western blot, enzymatic assays, and a novel ELISA developed to quantify AAT-NE complexes, substrate-like and NE-binding deficient dysfunctional variants were identified. This emphasizes the ability of the RCL to accommodate inactivating substitutions without impacting the integrity of the native molecule and demonstrates that this class of molecule violates a generally accepted paradigm that equates circulating levels with functional protection of lung tissue.
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Affiliation(s)
- Andrea Denardo
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Emna Ben Khlifa
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Mattia Bignotti
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Roberta Giuliani
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Emanuela D'Acunto
- Department of Biology and Biotechnologies 'Charles Darwin', Sapienza University of Rome, Rome, Italy
| | - Elena Miranda
- Department of Biology and Biotechnologies 'Charles Darwin', Sapienza University of Rome, Rome, Italy
| | - James A Irving
- UCL Respiratory and the Institute of Structural and Molecular Biology, University College London, London, UK
| | - Annamaria Fra
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy.
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11
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Roche S, Carroll TP, Mcelvaney NG. Provider Education in Alpha 1 Antitrypsin Deficiency: Try Again, Fail Again, Fail Better. ATS Sch 2023; 4:396-399. [PMID: 38196687 PMCID: PMC10773271 DOI: 10.34197/ats-scholar.2023-0128ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Affiliation(s)
- Suzanne Roche
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tomás P Carroll
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Noel G Mcelvaney
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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12
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Teckman J, Rosenthal P, Ignacio RV, Spino C, Bass LM, Horslen S, Wang K, Magee JC, Karpen S, Asai A, Molleston JP, Squires RH, Kamath BM, Guthery SL, Loomes KM, Shneider BL, Sokol RJ. Neonatal cholestasis in children with Alpha-1-AT deficiency is a risk for earlier severe liver disease with male predominance. Hepatol Commun 2023; 7:e0345. [PMID: 38055647 PMCID: PMC10984655 DOI: 10.1097/hc9.0000000000000345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/27/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Our objective was to better understand the natural history and disease modifiers of Alpha-1-antitrypsin deficiency (AATD), a common genetic liver disease causing hepatitis and cirrhosis in adults and children. The clinical course is highly variable. Some infants present with neonatal cholestasis, which can resolve spontaneously or progress to cirrhosis; others are well in infancy, only to develop portal hypertension later in childhood. METHODS The Childhood Liver Disease Research Network has been enrolling AATD participants into longitudinal, observational studies at North American tertiary centers since 2004. We examined the clinical courses of 2 subgroups of participants from the several hundred enrolled; first, those presenting with neonatal cholestasis captured by a unique study, enrolled because of neonatal cholestasis but before specific diagnosis, then followed longitudinally (n=46); second, separately, all participants who progressed to liver transplant (n=119). RESULTS We found male predominance for neonatal cholestasis in AATD (65% male, p=0.04), an association of neonatal gamma-glutamyl transpeptidase elevation to more severe disease, and a higher rate of neonatal cholestasis progression to portal hypertension than previously reported (41%) occurring at median age of 5 months. Participants with and without preceding neonatal cholestasis were at risk of progression to transplant. Participants who progressed to liver transplant following neonatal cholestasis were significantly younger at transplant than those without neonatal cholestasis (4.1 vs. 7.8 years, p=0.04, overall range 0.3-17 years). Neonatal cholestasis had a negative impact on growth parameters. Coagulopathy and varices were common before transplant, but gastrointestinal bleeding was not. CONCLUSIONS Patients with AATD and neonatal cholestasis are at risk of early progression to severe liver disease, but the risk of severe disease extends throughout childhood. Careful attention to nutrition and growth is needed.
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Affiliation(s)
- Jeffrey Teckman
- Department of Pediatrics and Biochemistry, Saint Louis University, Cardinal Glennon Children’s Hospital, Saint Louis, Missouri, USA
| | - Philip Rosenthal
- Department of Pediatrics and Surgery, University of California San Francisco, San Francisco, California, USA
| | | | - Cathie Spino
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Lee M. Bass
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Simon Horslen
- Department of Pediatric Gastroenterology and Hepatology, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kasper Wang
- Department of Pediatric Gastroenterology, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - John C. Magee
- Department of Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Saul Karpen
- Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Akihiro Asai
- Department of Gastroenterology, and Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jean P. Molleston
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Robert H. Squires
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Binita M. Kamath
- Division of Pediatric Gastroenterology, Department of Pediatrics, Hepatology and Nutrition, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Stephen L. Guthery
- Department of Pediatrics, University of Utah College of Medicine and Intermountain Primary Children’s Hospital, Salt Lake City, Utah, USA
| | - Kathleen M. Loomes
- Division of Pediatric Gastroenterology, Department of Pediatrics, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Benjamin L. Shneider
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, USA
| | - Ronald J. Sokol
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, Colorado, USA
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13
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Schumacher RC, Chiu CY, Lubarda J, Aboulsaoud P, Bomberger J, Wells JM. A Novel Provider Education Module to Enhance Detection of Alpha-1 Antitrypsin Deficiency. ATS Sch 2023; 4:490-501. [PMID: 38196685 PMCID: PMC10773490 DOI: 10.34197/ats-scholar.2023-0028oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/22/2023] [Indexed: 01/11/2024] Open
Abstract
Background Alpha-1 antitrypsin deficiency (AATD) is the most common genetic risk factor for early-onset emphysema. However, AATD continues to be underrecognized and underdiagnosed. Provider awareness about AATD, concerns with testing costs, and limited understanding about therapeutic options contribute to its underdiagnosis. We hypothesized that provider education would improve awareness of AATD and improve screening. Objective To evaluate the impact of a targeted provider education module on AATD screening. Methods We developed a web-based education module to address barriers to screening for AATD, deployed the education module using the Medscape Education platform, assessed perceived healthcare provider confidence in AATD screening, and conducted a prospective pre and postintervention study of AATD testing practices at a high-volume academic outpatient subspecialty pulmonary clinic. Results A total of 11,385 healthcare providers, including eight pulmonologists at our institution, completed the web-based education module. Confidence in identifying patients at high risk for AATD improved after completing the module ("not confident" in AATD screening was 7.7% postintervention compared with 19.4% preintervention). The rate of screening patients at high risk for AATD improved more than twofold (AATD screening rate 9.7% preintervention vs. 20.4% postintervention; P = 0.004). Among patients screened for AATD in our cohort, 27.2% had a genotype/phenotype or low alpha-1 antitrypsin concentration consistent with AATD. Conclusion Targeted healthcare provider education can improve the confidence in testing for AATD. Improvements in provider confidence corresponded to improvements in AATD screening in a subspecialty pulmonary clinic. More than one-fourth of screening tests suggested AATD, underpinning the value of testing in high-risk individuals.
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Affiliation(s)
- Ross C. Schumacher
- Division of Pulmonary, Allergy, and
Critical Care Medicine, Department of Medicine, and
- Lung Health Center, University of Alabama
at Birmingham, Birmingham, Alabama
| | - Chia-Ying Chiu
- Division of Pulmonary, Allergy, and
Critical Care Medicine, Department of Medicine, and
- Lung Health Center, University of Alabama
at Birmingham, Birmingham, Alabama
| | | | | | | | - J. Michael Wells
- Division of Pulmonary, Allergy, and
Critical Care Medicine, Department of Medicine, and
- Lung Health Center, University of Alabama
at Birmingham, Birmingham, Alabama
- Birmingham Veterans Affairs Healthcare
System, Birmingham, Alabama
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14
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Tural Onur S, Natoli A, Dreger B, Arınç S, Sarıoğlu N, Çörtük M, Karadoğan D, Şenyiğit A, Yıldız BP, Köktürk N, Argun Barıs S, Kodalak Cengiz S, Polatli M. An Alpha-1 Antitrypsin Deficiency Screening Study in Patients with Chronic Obstructive Pulmonary Disease, Bronchiectasis, or Asthma in Turkey. Int J Chron Obstruct Pulmon Dis 2023; 18:2785-2794. [PMID: 38046982 PMCID: PMC10693271 DOI: 10.2147/copd.s425835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/27/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose Alpha-1 antitrypsin deficiency (AATD) is a rare hereditary condition characterized by decreased serum alpha-1 antitrypsin (AAT) levels. We aim to identify AATD in patients with chronic obstructive pulmonary disease (COPD), bronchiectasis, or asthma and to report the frequency of AAT variants in Turkey. Patients and Methods This non-interventional, multicenter, prospective study was conducted between October 2021 and June 2022. Adult patients with COPD, bronchiectasis, asthma, liver symptoms, or family members with AATD were included. Demographic and clinical characteristics, pulmonary diagnosis, respiratory symptoms, and AAT serum levels were assessed. Whole blood samples were collected as dried blood spots, and the most common AATD mutations were simultaneously tested by allele-specific genotyping. Results A total of 1088 patients, mainly diagnosed with COPD (92.7%) and shortness of breath (78.7%), were assessed. Fifty-one (5%) were found to have AATD mutations. Fifteen (29.4%) patients had Pi*S or Pi*Z mutations, whereas 36 (70.6%) patients carried rare alleles Pi*M malton (n=18, 35.3% of mutations), Pi*I (n=8, 16%), Pi*P lowell (n=7, 14%), Pi*M heerlen (n=2, 4%), and Pi*S iiyama (n=1, 2%). The most common heterozygous combinations were Pi*M/Z (n=12, 24%), and Pi*M/M malton (n=11, 22%). Ten patients with severe AATD due to two deficiency alleles were identified, two with the Pi*Z/Z genotype, four with the genotype Pi*M malton/M malton, three with Pi*Z/M malton, and one with Pi*Z/M heerlen. Conclusion Our results identified AATD mutations as a genetic-based contributor to lung disease in patients with COPD or bronchiectasis and assessed their frequency in a population of Turkish patients.
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Affiliation(s)
- Seda Tural Onur
- Department of Pulmonology, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, University of Health Sciences, Istanbul, Türkiye
| | - Antonino Natoli
- Scientific and Medical Affairs, Scientific Innovation Office, Grifols, Frankfurt, Deutschland
| | - Bettina Dreger
- Scientific and Medical Affairs, Scientific Innovation Office, Grifols, Frankfurt, Deutschland
| | - Sibel Arınç
- Clinic of Chest Diseases, University of Health Sciences Turkey, S.B.Ü. Süreyyapaşa Chest Diseases and Thoracic Surgery Training and Research Hospital, İstanbul, Türkiye
| | - Nurhan Sarıoğlu
- Department of Pulmonology, Balıkesir University Faculty of Medicine, Pulmonology Clinic, Balıkesir, Türkiye
| | - Mustafa Çörtük
- Department of Pulmonology, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, University of Health Sciences, Istanbul, Türkiye
| | - Dilek Karadoğan
- Department of Chest Diseases, Recep Tayyip Erdoğan University, School of Medicine, Rize, Türkiye
| | - Abdurrahman Şenyiğit
- Department of Chest Diseases, Dicle University Faculty of Medicine Hospital, Diyarbakır, Türkiye
| | - Birsen Pınar Yıldız
- Department of Pulmonology, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, University of Health Sciences, Istanbul, Türkiye
| | - Nurdan Köktürk
- Department of Pulmonary Medicine, Gazi University, School of Medicine, Ankara, Türkiye
| | - Serap Argun Barıs
- Department of Pulmonary Diseases, Faculty of Medicine, Kocaeli University, Kocaeli, Türkiye
| | | | - Mehmet Polatli
- Faculty of Medicine, Aydin Adnan Menderes University, Aydin, Türkiye
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15
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Fraughen DD, Ghosh AJ, Hobbs BD, Funk GC, Meischl T, Clarenbach CF, Sievi NA, Schmid-Scherzer K, McElvaney OJ, Murphy MP, Roche AD, Clarke L, Strand M, Vafai-Tabrizi F, Kelly G, Gunaratnam C, Carroll TP, McElvaney NG. Augmentation Therapy for Severe Alpha-1 Antitrypsin Deficiency Improves Survival and Is Decoupled from Spirometric Decline-A Multinational Registry Analysis. Am J Respir Crit Care Med 2023; 208:964-974. [PMID: 37624745 PMCID: PMC10870866 DOI: 10.1164/rccm.202305-0863oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/24/2023] [Indexed: 08/27/2023] Open
Abstract
Rationale: Intravenous plasma-purified alpha-1 antitrypsin (IV-AAT) has been used as therapy for alpha-1 antitrypsin deficiency (AATD) since 1987. Previous trials (RAPID and RAPID-OLE) demonstrated efficacy in preserving computed tomography of lung density but no effect on FEV1. This observational study evaluated 615 people with severe AATD from three countries with socialized health care (Ireland, Switzerland, and Austria), where access to standard medical care was equal but access to IV-AAT was not. Objectives: To assess the real-world longitudinal effects of IV-AAT. Methods: Pulmonary function and mortality data were utilized to perform longitudinal analyses on registry participants with severe AATD. Measurements and Main Results: IV-AAT confers a survival benefit in severe AATD (P < 0.001). We uncovered two distinct AATD phenotypes based on an initial respiratory diagnosis: lung index and non-lung index. Lung indexes demonstrated a more rapid FEV1 decline between the ages of 20 and 50 and subsequently entered a plateau phase of minimal decline from 50 onward. Consequentially, IV-AAT had no effect on FEV1 decline, except in patients with a Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 2 lung index. Conclusions: This real-world study demonstrates a survival advantage from IV-AAT. This improved survival is largely decoupled from FEV1 decline. The observation that patients with severe AATD fall into two major phenotypes has implications for clinical trial design where FEV1 is a primary endpoint. Recruits into trials are typically older lung indexes entering the plateau phase and, therefore, unlikely to show spirometric benefits. IV-AAT attenuates spirometric decline in lung indexes in GOLD stage 2, a spirometric group commonly outside current IV-AAT commencement recommendations.
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Affiliation(s)
- Daniel D. Fraughen
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Auyon J. Ghosh
- Division of Pulmonary, Critical Care, and Sleep Medicine, SUNY Upstate University Hospital, Syracuse, New York
| | - Brian D. Hobbs
- Channing Division of Network Medicine and Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Georg-Christian Funk
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology and Department of Medicine II with Pneumology, Klinik Ottakring, Vienna, Austria
| | - Tobias Meischl
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology and Department of Medicine II with Pneumology, Klinik Ottakring, Vienna, Austria
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Noriane A. Sievi
- Department of Pneumology, University Hospital Zurich, Zurich, Switzerland
| | - Karin Schmid-Scherzer
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology and Department of Medicine II with Pneumology, Klinik Ottakring, Vienna, Austria
| | - Oliver J. McElvaney
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington
| | - Mark P. Murphy
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Adam D. Roche
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Louise Clarke
- Department of Respiratory Physiology, Beaumont Hospital, Dublin, Ireland; and
| | - Matthew Strand
- Division of Biostatistics and Bioinformatics, National Jewish Health, Denver, Colorado
| | - Florian Vafai-Tabrizi
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology and Department of Medicine II with Pneumology, Klinik Ottakring, Vienna, Austria
| | - Geraldine Kelly
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Cedric Gunaratnam
- Department of Respiratory Physiology, Beaumont Hospital, Dublin, Ireland; and
| | - Tomás P. Carroll
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Noel G. McElvaney
- Department of Medicine, Irish Center for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland
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16
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Wu T, Hagiwara M, Gnass E, Barman H, Sasson D, Treem W, Ren K, Marins EG, Karki C, Malhi H. Liver disease progression in patients with alpha-1 antitrypsin deficiency and protease inhibitor ZZ genotype with or without lung disease. Aliment Pharmacol Ther 2023; 58:1075-1085. [PMID: 37718576 DOI: 10.1111/apt.17715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/09/2023] [Accepted: 08/30/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Alpha-1 antitrypsin deficiency (AATD) is caused by mutations in SERPINA1, which encodes alpha-1 antitrypsin, a protease inhibitor (Pi). Individuals with AATD and the homozygous Pi*ZZ genotype have variable risk of progressive liver disease but the influence of comorbid lung disease is poorly understood. AIMS To characterise patients with AATD Pi*ZZ and liver disease (AATD-LD-Pi*ZZ) with or without lung disease and describe liver disease-related clinical events longitudinally. METHODS This was an observational cohort study of patients in the Mayo Clinic Healthcare System (January 2000-September 2021). Patients were identified using diagnosis codes and natural language processing. Fibrosis stage (F0-F4) was assessed using a hierarchical approach at baseline (90 days before or after the index date) and follow-up. Clinical events associated with liver disease progression were assessed. RESULTS AATD-LD-Pi*ZZ patients with lung disease had a longer median time from AATD diagnosis to liver disease diagnosis versus those without lung disease (2.2 vs. 0.2 years, respectively). Compared to those without lung disease, patients with lung disease had a longer time to liver disease-related clinical events (8.5 years and not reached, respectively). AATD-LD-Pi*ZZ patients without lung disease were more likely to undergo liver transplantation compared with those with lung disease. CONCLUSION In patients with AATD and lung disease, there is a delay in the diagnosis of comorbid liver disease. Our findings suggest that liver disease may progress more rapidly in patients without comorbid lung disease.
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Affiliation(s)
- Tiffany Wu
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - May Hagiwara
- Takeda Development Center Americas, Inc., Lexington, Massachusetts, USA
| | | | | | | | - William Treem
- Takeda Development Center Americas, Inc., Lexington, Massachusetts, USA
| | - Kaili Ren
- Takeda Development Center Americas, Inc., Lexington, Massachusetts, USA
| | - Ed G Marins
- Takeda Development Center Americas, Inc., Lexington, Massachusetts, USA
| | - Chitra Karki
- Takeda Development Center Americas, Inc., Lexington, Massachusetts, USA
| | - Harmeet Malhi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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17
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Bohn MK, Schneider R, Jung B, Adeli K. Pediatric reference interval verification for 16 biochemical markers on the Alinity ci system in the CALIPER cohort of healthy children and adolescents. Clin Chem Lab Med 2023; 61:2033-2040. [PMID: 37114851 PMCID: PMC10695436 DOI: 10.1515/cclm-2023-0256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVES Special chemistry parameters are useful in the diagnosis and management of inherited disorders, liver disease, and immunopathology. Evidence-based pediatric reference intervals (RIs) are required for appropriate clinical decision-making and need to be verified as new assays are developed. This study aimed to evaluate the applicability of pediatric RIs established for biochemical markers on the ARCHITECT for use on newer Alinity assays. METHODS An initial method validation was completed for 16 assays, including precision, linearity, and method comparison. Sera collected from approximately 100 healthy children and adolescents as part of the Canadian Laboratory Initiative on Pediatric Reference Intervals (CALIPER) were also analyzed on the Alinity c system. Percentage of results within established ARCHITECT RIs were calculated and considered verified if ≥90 % fell within established limits. New RIs were established for three electrolytes, glucose, and lactate wherein no data were previously reported. RESULTS Of the 11 assays for which CALIPER pediatric RIs were previously established on ARCHITECT assays, 10 met the verification criteria. Alpha-1-antitrypsin did not meet verification criterion and a new RI was established. For the other 5 assays, de novo RIs were derived following analysis of 139-168 samples from healthy children and adolescents. None required age- and sex-partitioning. CONCLUSIONS Herein, pediatric RIs were verified or established for 16 chemistry markers in the CALIPER cohort on Alinity assays. Findings support excellent concordance between ARCHITECT and Alinity assays with one exception (alpha-1-antitrypsin) as well as robustness of age- and sex-specific patterns originally reported by CALIPER in healthy Canadian children and adolescents.
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Affiliation(s)
- Mary Kathryn Bohn
- CALIPER Program, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | | | - Benjamin Jung
- CALIPER Program, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Khosrow Adeli
- CALIPER Program, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
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18
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Costa MP, Ferreira AR, Rodrigues AT, Fagundes EDT, Queiroz TCN. CLINICAL, LABORATORIAL AND EVOLUTIONARY ASPECTS OF PEDIATRIC PATIENTS WITH LIVER DISEASE DUE TO ALPHA 1-ANTITRYPSIN DEFICIENCY. ARQUIVOS DE GASTROENTEROLOGIA 2023; 60:438-449. [PMID: 38018549 DOI: 10.1590/s0004-2803.230402023-71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/12/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Alpha 1-antitrypsin deficiency (AATD) is a hereditary codominant autosomal disease. This liver disease ranges from asymptomatic cases to terminal illness, which makes early recognition and diagnosis challenging. It is the main cause of pediatric liver transplantation after biliary atresia. OBJECTIVE To describe the clinical characteristics, as well as those of histologic and laboratory tests, phenotypic and/or genetic evaluation and evolution of a cohort of pediatric patients with AATD. METHODS This is a retrospective observational study of 39 patients with confirmed or probable AATD (without phenotyping or genotyping, but with suggestive clinical features, low serum alpha 1-antitrypsin (AAT) level and liver biopsy with PAS granules, resistant diastasis). Clinical, laboratory and histological varia-bles, presence of portal hypertension (PH) and survival with native liver have been analyzed. RESULTS A total of 66.7% of 39 patients were male (26/39). The initial manifestation was cholestatic jaundice in 79.5% (31/39). Liver transplantation was performed in 28.2% (11/39) of patients. Diagnosis occurred at an average of 3.1 years old and liver transplantation at 4.1 years of age. 89.2% (25/28) of the patients with confirmed AATD were PI*ZZ or ZZ. The average AAT value on admission for PI*ZZ or ZZ patients was 41.6 mg/dL. All transplanted patients with phenotyping or genotyping were PI*ZZ (or ZZ). Those who were jaundiced on admission were earlier referred to the specialized service and had higher levels of GGT and platelets on admission. There was no significant difference in the survival curve when comparing cholestatic jaundiced to non-cholestatic jaundiced patients on admission. Comparing patients who did or did not progress to PH, higher levels of AST and APRI score at diagnosis (P=0.011 and P=0.026, respectively) were observed and in the survival curves patients with PH showed impairment, with 20.2% survival with native liver in 15 years. CONCLUSION Jaundice is an important clinical sign that motivates referral to a specialist, but it does not seem to compromise survival with native liver. Patients progressing to PH had higher AST, APRi score on admission and significantly impaired survival with native liver. It is important to pay attention to these signs in the follow-up of patients with AATD.
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Affiliation(s)
- Mariana Pena Costa
- Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
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Riley L, Sriram A, Brantly M, Lascano J. Testing Patterns and Disparities for Alpha-1 Antitrypsin Deficiency. Am J Med 2023; 136:1011-1017. [PMID: 37451388 DOI: 10.1016/j.amjmed.2023.06.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 04/06/2023] [Accepted: 06/16/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Alpha-1 antitrypsin deficiency is an under-recognized genetic cause of chronic lung and liver disease; it remains unclear what the testing frequency and disparities are for alpha-1 antitrypsin deficiency. METHODS This is a retrospective cohort study of people with newly diagnosed chronic obstructive pulmonary disease and liver disease identified at the University of Florida between January 1, 2012 and December 31, 2021. We performed incidence and prevalence analysis for alpha-1 antitrypsin (AAT) testing and point-biserial correlation analysis for tobacco use and AAT testing. We evaluated characteristics with AAT testing using adjusted multivariable logistic regression. RESULTS Among 75,810 subjects with newly diagnosed chronic obstructive pulmonary disease and liver disease between 2012 and 2021, 4248 (5.6%) were tested for AAT deficiency. All subjects had an AAT level performed, while 1654 (39%) had phenotype testing. Annual incidence of testing increased for subjects with newly diagnosed chronic obstructive pulmonary disease or liver disease from 2.8% and 5.4%, respectively, in 2012 to 4.1% and 11.3%, respectively, in 2021. Adjusted multivariable regression analysis showed factors favoring AAT testing were White race, and concomitant chronic obstructive pulmonary disease and liver disease. Increasing age, non-White race, current tobacco use, and being a male with chronic obstructive pulmonary disease had lower odds of AAT testing. CONCLUSION Although slowly improving, testing for AAT deficiency continues to have a low uptake in the clinical setting despite guidelines recommending broader testing. Individuals of White race and those with concomitant chronic obstructive pulmonary disease and liver disease are more likely to be tested, while older subjects, individuals of non-White race, current tobacco use, and men with chronic obstructive pulmonary disease are less favored to be tested.
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Affiliation(s)
- Leonard Riley
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Kansas City Veterans Affairs Medical Center, Mo.
| | | | - Mark Brantly
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville
| | - Jorge Lascano
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville
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Cuenca I, Botella C, Moya-Quiles MR, Jimenez-Coll V, Galian JA, Martinez-Banaclocha H, Muro-Pérez M, Minguela A, Legaz I, Muro M. Genotypic Frequencies of Mutations Associated with Alpha-1 Antitrypsin Deficiency in Unrelated Bone Marrow Donors from the Murcia Region Donor Registry in the Southeast of Spain. Diagnostics (Basel) 2023; 13:2845. [PMID: 37685383 PMCID: PMC10486455 DOI: 10.3390/diagnostics13172845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
Alpha-1 antitrypsin (AAT1) deficiency (AAT1D) is an inherited disease with an increased risk of chronic obstructive pulmonary disease (COPD), liver disease, and skin and blood vessel problems. AAT1D is caused by mutations in the SERPINE1 gene (Serine Protease Inhibitor, group A, member 1). Numerous variants of this gene, the Pi system, have been identified. The most frequent allelic variants are Pi*M, Pi*S, and Pi*Z. The development of COPD requires both a genetic predisposition and the contribution of an environmental factor, smoking being the most important. Studies on this deficiency worldwide are very scarce, and it is currently considered a rare disease because it is underdiagnosed. The aim of this study was to analyze the genotypic frequencies of mutations associated with AAT1 deficiency in unrelated bone marrow donors from the donor registry of the Region of Murcia in southeastern Spain due to the high risk of presenting with different pathologies and underdiagnosis in the population. A total of 112 DNA-healthy voluntary unrelated bone marrow donors from different parts of the Region of Murcia were analyzed retrospectively. AAT1 deficiency patient testing involved an automated biochemical screening routine. The three main variants, Pi*M, Pi*Z, and Pi*S, were analyzed in the SERPINE1 gene. Our results showed a frequency of 3.12% of the Pi*Z (K342) mutation in over 224 alleles tested in the healthy population. The frequency of Pi*S (V264) was 11.1%. The frequency of the haplotype with the most dangerous mutation, EK342 EE264, was 4.46%, and the frequency of EK342 EV264 was 1.78% in the healthy population. Frequencies of other EE342 EV264-mutated haplotypes accounted for 18.7%. As for the EE342 VV264 haplotype, 0.89% of the total healthy population presented heterozygous for the EV264 mutation and one individual presented homozygous for the VV264 mutation. In conclusion, the frequencies of Pi mutations in the healthy population of the Region of Murcia were not remarkably different from the few studies reported in Spain. The genotype and haplotype frequencies followed the usual pattern. Health authorities should be aware of this high prevalence of the Pi*S allelic variant and pathological genotypes such as Pi*MZ and Pi*SZ in the healthy population if they consider screening the smoking population.
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Affiliation(s)
- Irene Cuenca
- Immunology Service, University Clinical Hospital “Virgen de la Arrixaca”, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Carmen Botella
- Immunology Service, University Clinical Hospital “Virgen de la Arrixaca”, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - María Rosa Moya-Quiles
- Immunology Service, University Clinical Hospital “Virgen de la Arrixaca”, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Víctor Jimenez-Coll
- Immunology Service, University Clinical Hospital “Virgen de la Arrixaca”, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - José Antonio Galian
- Immunology Service, University Clinical Hospital “Virgen de la Arrixaca”, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Helios Martinez-Banaclocha
- Immunology Service, University Clinical Hospital “Virgen de la Arrixaca”, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Manuel Muro-Pérez
- Immunology Service, University Clinical Hospital “Virgen de la Arrixaca”, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Alfredo Minguela
- Immunology Service, University Clinical Hospital “Virgen de la Arrixaca”, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Isabel Legaz
- Department of Legal and Forensic Medicine, Biomedical Research Institute of Murcia (IMIB), Regional Campus of International Excellence “Campus Mare Nostrum”, Faculty of Medicine, University of Murcia (UMU), 30100 Murcia, Spain
| | - Manuel Muro
- Immunology Service, University Clinical Hospital “Virgen de la Arrixaca”, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
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Riley EL, Brunson JC, Eydgahi S, Brantly ML, Lascano JE. Development of a risk score to increase detection of severe alpha-1 antitrypsin deficiency. ERJ Open Res 2023; 9:00302-2023. [PMID: 37727673 PMCID: PMC10505949 DOI: 10.1183/23120541.00302-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/20/2023] [Indexed: 09/21/2023] Open
Abstract
Background Alpha-1 antitrypsin deficiency (AATD) is an under-recognised genetic cause of chronic obstructive lung disease, and many fewer cases than estimated have been identified. Can a reported respiratory and hepatic disease history from a large AATD testing database be used to stratify a person's risk of severe AATD? Methods We analysed data extracted from the AATD National Detection Program. Demographics and medical history were evaluated to predict AATD PI*ZZ genotype. Logistic regression and integer programming models identified predictors and obtained risk scores. These were internally validated on a subset of the data. Results Out of 301 343 subjects, 1529 (0.5%) had PI*ZZ genotype. Predictors of severe AATD were asthma, bronchitis, emphysema, allergies, bronchiectasis, family history of AATD, cirrhosis, hepatitis and history of abnormal liver function tests. The derived model establishes a subject's risk of severe AATD, and scores ≥0 had an estimated risk of 0.41%, sensitivity 84.62% and specificity 24.32%. A model simulating guideline recommendations had an estimated risk of 0.51% with a sensitivity of 37.98% and specificity 46.60%. By recommending screening for scores ≥0, we estimate that more subjects would be screened (75.7% versus 53.4%) and detected (84.6% versus 58.2%) compared to a guideline-simulated model. Conclusion This medical history risk model is a useful predictive tool to detect subjects at greater risk of having severe AATD and improves sensitivity of detection. Scores <0 are at lower risk and may need not be screened; testing is recommended for scores ≥0 and consistent with current guidelines.
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Affiliation(s)
- E. Leonard Riley
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Kansas City Veterans Affairs Medical Center, Kansas City, MO, USA
| | - J. Cory Brunson
- Laboratory for Systems Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Soroush Eydgahi
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Mark L. Brantly
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jorge E. Lascano
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL, USA
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Schuler BA, Bastarache L, Wang J, He J, Van Driest SL, Denny JC. Population genetic testing and SERPINA1 sequencing identifies unidentified alpha-1 antitrypsin deficiency alleles and gene-environment interaction with hepatitis C infection. PLoS One 2023; 18:e0286469. [PMID: 37651384 PMCID: PMC10470904 DOI: 10.1371/journal.pone.0286469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/16/2023] [Indexed: 09/02/2023] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD), a relatively common autosomal recessive genetic disorder, is underdiagnosed in symptomatic individuals. We sought to compare the risk of liver transplantation associated with hepatitis C infection with AATD heterozygotes and homozygotes and determine if SERPINA1 sequencing would identify undiagnosed AATD. We performed a retrospective cohort study in a deidentified Electronic Health Record (EHR)-linked DNA biobank with 72,027 individuals genotyped for the M, Z, and S alleles in SERPINA1. We investigated liver transplantation frequency by genotype group and compared with hepatitis C infection. We performed SERPINA1 sequencing in carriers of pathogenic AATD alleles who underwent liver transplantation. Liver transplantation was associated with the Z allele (ZZ: odds ratio [OR] = 1.31, p<2e-16; MZ: OR = 1.02, p = 1.2e-13) and with hepatitis C (OR = 1.20, p<2e-16). For liver transplantation, there was a significant interaction between genotype and hepatitis C (ZZ: interaction OR = 1.23, p = 4.7e-4; MZ: interaction OR = 1.11, p = 6.9e-13). Sequencing uncovered a second, rare, pathogenic SERPINA1 variant in six of 133 individuals with liver transplants and without hepatitis C. Liver transplantation was more common in individuals with AATD risk alleles (including heterozygotes), and AATD and hepatitis C demonstrated evidence of a gene-environment interaction in relation to liver transplantation. The current AATD screening strategy may miss diagnoses whereas SERPINA1 sequencing may increase diagnostic yield for AATD, stratify risk for liver disease, and inform clinical management for individuals with AATD risk alleles and liver disease risk factors.
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Affiliation(s)
- Bryce A. Schuler
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Janey Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Jing He
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Sara L. Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Joshua C. Denny
- All of Us Research Program, National Institutes of Health, Bethesda, Maryland, United States of America
- National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, United States of America
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Fernández-Gomez B, Menao-Guillén S, Fernandez Gonzalez A, Arruebo Muñio M, Ramos Alvarez M, Inda Landaluce M, Castillo Arce MA, Torralba-Cabeza MÁ. Utility of the Serum Protein Electrophoresis in the Opportunistic Screening for the Deficiency of Alpha-1 Antitrypsin. Diagnostics (Basel) 2023; 13:2778. [PMID: 37685316 PMCID: PMC10486943 DOI: 10.3390/diagnostics13172778] [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: 07/22/2023] [Revised: 08/20/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND A deficiency in alpha-1 antitrypsin (AAT1) is a rare disorder that represents a significant health threat and early diagnostic priority issue. We investigated the usefulness of the serum protein electrophoresis (SPE) as an opportunistic screening tool for AAT1 deficiency. METHODS For 6 months, all SPE carried out for any reasons were evaluated in our center. In those with less than 3% of alpha-1 globulins, AAT1 concentrations were studied. The SERPINA1 gene was subsequently sequenced in those patients displaying concentrations below 100 mg/dL. RESULTS Out of the total, 14 patients (0.3%) were identified with low AAT1 concentrations, with 11 of them agreeing to enter the study. Of those, mutations in the SERPINA1 gene were discovered in 10 patients (91%). Heterozygous mutations were detected in seven patients; three had the c.1096G>A mutation (p.Glu366Lys; Pi*Z), two had the c.863A>T mutation (p.Glu288Val; Pi*S), one had the c.221_223delTCT mutation (p.Phe76del; Pi*Malton), and the last one had the c.1066G>A (p.Ala356Thr) mutation, which was not previously described. Finally, one patient had the c.863A>T mutation in homozygosis, whereas two double heterozygous patients c.863A>T/c.1096G>A were detected. CONCLUSIONS An altered result in the concentration of AAT1 anticipates a mutation in the SERPINA1 gene in a manner close to 91%. The relationship between a decrease in the alpha-1 globulin band of the SPE and an alteration in the AAT1 concentration is direct in basal states of health. The SPE is presented as a highly sensitive test for opportunistic screening of AAT1 deficiency.
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Affiliation(s)
| | - Sebastian Menao-Guillén
- Department of Biochemistry, “Lozano Blesa” University Hospital, 50009 Zaragoza, Spain; (S.M.-G.); (A.F.G.); (M.A.M.); (M.R.A.); (M.I.L.); (M.A.C.A.)
- Instituto de Investigación Sanitaria de Aragon, 13th San Juan Bosco Avenue, 50009 Zaragoza, Spain
| | - Ayla Fernandez Gonzalez
- Department of Biochemistry, “Lozano Blesa” University Hospital, 50009 Zaragoza, Spain; (S.M.-G.); (A.F.G.); (M.A.M.); (M.R.A.); (M.I.L.); (M.A.C.A.)
| | - Maria Arruebo Muñio
- Department of Biochemistry, “Lozano Blesa” University Hospital, 50009 Zaragoza, Spain; (S.M.-G.); (A.F.G.); (M.A.M.); (M.R.A.); (M.I.L.); (M.A.C.A.)
| | - Monica Ramos Alvarez
- Department of Biochemistry, “Lozano Blesa” University Hospital, 50009 Zaragoza, Spain; (S.M.-G.); (A.F.G.); (M.A.M.); (M.R.A.); (M.I.L.); (M.A.C.A.)
| | - Mercedes Inda Landaluce
- Department of Biochemistry, “Lozano Blesa” University Hospital, 50009 Zaragoza, Spain; (S.M.-G.); (A.F.G.); (M.A.M.); (M.R.A.); (M.I.L.); (M.A.C.A.)
| | - Maria Angeles Castillo Arce
- Department of Biochemistry, “Lozano Blesa” University Hospital, 50009 Zaragoza, Spain; (S.M.-G.); (A.F.G.); (M.A.M.); (M.R.A.); (M.I.L.); (M.A.C.A.)
| | - Miguel Ángel Torralba-Cabeza
- Faculty of Medicine, University of Zaragoza, 50009 Zaragoza, Spain;
- Instituto de Investigación Sanitaria de Aragon, 13th San Juan Bosco Avenue, 50009 Zaragoza, Spain
- Unit or Rare Disorders, Department of Internal Medicine, “Lozano Blesa” University Hospital, 15th San Juan Bosco Avenue, 50009 Zaragoza, Spain
- Working Group on Minority Diseases of the Spanish Society of Internal Medicine (GTEM-SEMI), 50009 Zaragoza, Spain
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Craig TJ, Corbett ML, Meadows JA. Improving Detection of Alpha-1 Antitrypsin Deficiency: Role of the Allergist. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2348-2354. [PMID: 37146883 DOI: 10.1016/j.jaip.2023.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 03/24/2023] [Accepted: 04/10/2023] [Indexed: 05/07/2023]
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a genetic disorder that manifests as lung and/or liver disease. Because symptoms of AATD overlap with those of common pulmonary and hepatic conditions, AATD is often misdiagnosed, which has resulted in substantial underdiagnosis of AATD worldwide. Although screening patients for AATD is recommended, the lack of procedures to facilitate testing remains a barrier to accurate diagnosis of AATD. Delays in AATD diagnosis can worsen outcomes for patients by postponing appropriate disease-modifying treatments. Patients with AATD-related lung disease experience symptoms similar to other obstructive lung disorders and are often misdiagnosed for years. In addition to existing screening guidelines, we recommend that screening for AATD become a standard part of allergists' workups of patients with asthma and fixed obstructive disease, chronic obstructive pulmonary disease, bronchiectasis without known origin, and patients under consideration for treatment with biologics. This Rostrum article reviews screening and diagnostic tests available in the United States and emphasizes evidence-based strategies to increase testing frequency and improve AATD detection rates. We underscore the pivotal role of allergists in managing care for patients with AATD. Finally, we urge health care providers to be aware of potentially poor clinical outcomes among patients with AATD during the coronavirus disease 2019 pandemic.
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Affiliation(s)
- Timothy J Craig
- Penn State Health Allergy, Asthma, and Immunology, Hershey, Pa.
| | | | - J Allen Meadows
- Alabama College of Osteopathic Medicine, AllerVie Health, Montgomery, Ala
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Önür ST. Initial alpha-1 antitrypsin screening in Turkish patients with chronic obstructive pulmonary disease. Turk J Med Sci 2023; 53:1012-1018. [PMID: 38031954 PMCID: PMC10760586 DOI: 10.55730/1300-0144.5665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 08/18/2023] [Accepted: 06/04/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Alpha-1 antitrypsin (AAT) deficiency is associated with several types of pathology, and the reported effects of mutations in the ATT-encoding gene vary worldwide. No Turkish study has yet appeared. We thus explored the AAT status of Turkish patients with chronic obstructive pulmonary disease (COPD). METHODS This prospective cross-sectional study included outpatients and inpatients treated from June 2021 to June 2022. Serum AAT levels were checked, and dry blood samples were subjected to genetic analysis. RESULTS : Genetic mutations were found in 21 (3.52%) of 596 patients with prior and new COPD diagnoses treated in our pneumonology outpatient department. The mean serum AAT level was 114.80 mg/dL (minimum 19, maximum 209; standard deviation 27.86 mg/dL). The most frequent mutation was M/Plowell (23.8%, n = 5), followed by M/S (23.8%, n = 5), M/I (19%, n = 4), M/Malton (14.3%, n = 3), Z/Z (9.5%, n = 2), M/Z (4.8%, n = 1), and Kayseri/Kayseri (4.8%, n = 1). Thoracic computed tomography revealed that 85.7% (n = 18) of all patients had emphysema, 28.5% (n = 6) had bronchiectasis, and 28.5% (n = 6) had mass lesions. Of the emphysema patients, 55% (n = 10) had only upper lobe emphysema, and 83.3% (n = 15) had emphysema in additional areas, but statistical significance was lacking (p > 0.05). DISCUSSION In patients with emphysema and normal serum AAT levels, genetic analyses may reveal relevant heterozygous mutations, which are commonly ignored. Most clinicians focus on lower lobe emphysema. Evaluations of such patients might reveal AAT mutations that are presently overlooked because they are not considered to influence COPD status.
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Affiliation(s)
- Seda Tural Önür
- Department of Pulmonology, Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, University of Health Sciences, İstanbul, Turkiye
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Khan MZ, Klepper C, Orkin S, Arce-Clachar AC, Bramlage K, Fei L, Miethke A, Kohli R, Xanthakos S, Mouzaki M. Presence of Alpha 1 Antitrypsin Risk Variants is Not Associated With Histologic Severity of Pediatric NAFLD. J Pediatr Gastroenterol Nutr 2023; 77:166-170. [PMID: 37229749 PMCID: PMC10524978 DOI: 10.1097/mpg.0000000000003845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Among adults with nonalcoholic fatty liver disease (NAFLD), alpha-1-antitrypsin (A1AT) heterozygosity has been linked to advanced liver disease; pediatric data remain unclear. OBJECTIVE The objective of this study is to determine whether A1AT PiZ or PiS variants are associated with liver disease severity in youth with NAFLD. METHODS Retrospective study of youth with confirmed NAFLD. Multivariable logistic regression used to determine independent associations between A1AT risk variants and histologic severity [NAFLD activity score (NAS) ≥5 and/or significant fibrosis (stage ≥2)]. RESULTS The cohort included 269 patients, mean age 12 [±3] years with NAFLD and A1AT phenotyping (n = 260) and/or A1AT levels (n = 261). The mean NAS of the cohort was 4.2 [±1.5]; 50% had any, and 18% had significant fibrosis. Most (86%) had the MM A1AT phenotype, while 7% had the MS and 3% the MZ phenotype (the rest had other, nonpathogenic variants). Mean A1AT level was 123 mg/dL [±20]. A1AT levels did not differ by low versus high NAS (122 ± 2 vs 126 ± 19 mg/dL, P = 0.12) or by no/mild versus significant fibrosis (123 ± 20 vs 126 ± 20 mg/dL, P = 0.23, respectively). Carriers and noncarriers of the PiS or PiZ variants had similar NAS (mean NAS 3.8 ± 1.6 vs 4.2 ± 1.4; P = 0.25, respectively). Fibrosis severity did not differ by carrier vs noncarrier group: 38% versus 52% had any fibrosis ( P = 0.17) and 14% versus 18% had significant fibrosis ( P = 0.80, respectively). Multivariable modeling showed no association between A1AT risk variants and histologic severity. CONCLUSION While not uncommon, carriage of the A1AT PiZ or PiS risk variants was not associated with histologic severity in children with NAFLD.
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Affiliation(s)
- Maya Zahid Khan
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Corie Klepper
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Sarah Orkin
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- University of Cincinnati College of Medicine
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- University of Cincinnati College of Medicine
| | - Kristen Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- University of Cincinnati College of Medicine
| | - Lin Fei
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- University of Cincinnati College of Medicine
| | - Alexander Miethke
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- University of Cincinnati College of Medicine
| | - Rohit Kohli
- Department of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Los Angeles, Los Angeles, CA, United States
| | - Stavra Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- University of Cincinnati College of Medicine
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- University of Cincinnati College of Medicine
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Campos M, Hagenlocker B, Lascano J, Riley L. Impact of a Computerized Clinical Decision Support System to Improve Chronic Obstructive Pulmonary Disease Diagnosis and Testing for Alpha-1 Antitrypsin Deficiency. Ann Am Thorac Soc 2023; 20:1116-1123. [PMID: 36989247 DOI: 10.1513/annalsats.202211-954oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/29/2023] [Indexed: 03/30/2023] Open
Abstract
Rationale: Chronic obstructive pulmonary disease (COPD) and alpha-1 antitrypsin deficiency (AATD) are underrecognized diseases. This is in part due to the underdiagnosis and lack of confirmation of COPD but also from poor adherence to AATD screening recommendations. Objectives: A clinical decision support system (CDSS) to guide primary care providers improves spirometry testing and confirmation of COPD diagnosis in subjects at risk and improves AATD screening in patients with confirmed COPD. Methods: A CDSS was created to be applied to all Veterans attending single-center Veterans Affairs primary care clinics. The CDSS had an algorithmic dialogue with components executed in phases during different clinic visits: screening for COPD risk using the COPD population screening (COPD-PS) questionnaire, spirometry recommendation, and ordering tool for subjects with a prior diagnosis of COPD or subjects considered high risk by the COPD-PS, dialogue to confirm or discard the diagnosis of COPD, and recommendations for AATD screening in subjects with confirmed COPD. The latter was performed by ordering alpha-1 antitrypsin (AAT) serum levels. Each step of the CDSS algorithm approach was recorded and available to be retrieved at a later date for analysis. Results: Over 6 years, a total of 6,235 Veterans >40 years of age completed the CDSS. According to the COPD-PS questionnaire, 962 (18.5%) subjects were identified as high risk for COPD. An additional 579 subjects with a prior diagnosis of COPD also entered the subsequent steps of the CDSS algorithm. Of the high-risk cohort, the CDSS led to an increase in spirometry testing from 24% to 83% and led to a new diagnosis of COPD in 342 (43%). In the prior COPD diagnosis group, spirometry testing increased from 58% to 84%, leading to COPD reconfirmation in only 326 (67%). A total of 489 (68%) subjects with confirmed COPD completed AAT testing prompted by the CDSS, with 23 subjects identified with AATD and one with severe AATD. Conclusions: In the Veterans Affairs system, the use of a clinical decision support system algorithm that incorporates screening for COPD and AATD improves COPD over- and underdiagnosis and screening rates of AATD in a primary care setting.
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Affiliation(s)
- Michael Campos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Miami, Miami, Florida
- Pulmonary Section, Department of Medicine, and
| | - Brian Hagenlocker
- Department of Primary Care Medicine, Miami Veterans Affairs Medical Center, Miami, Florida
| | - Jorge Lascano
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Florida, Gainesville, Florida; and
| | - Leonard Riley
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Kansas City Veterans Affairs Medical Center, Kansas City, Missouri
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Feitosa PH. Diagnosis and augmentation therapy for alpha-1 antitrypsin deficiency: current knowledge and future potential. Drugs Context 2023; 12:2023-3-1. [PMID: 37521109 PMCID: PMC10379007 DOI: 10.7573/dic.2023-3-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/19/2023] [Indexed: 08/01/2023] Open
Abstract
The underdiagnosis of alpha-1 antitrypsin (AAT) deficiency (AATD) has been recognized for many years, yet little progress has been made in treatment of the disease. In this review, we summarize the AATD disease process as well as its diagnosis and treatment by AAT augmentation therapy. AATD is a rare autosomal disease that primarily affects the lungs and liver. AATD is associated with an increased susceptibility to developing pulmonary emphysema. The specific pharmacological treatment for AATD is intravenous administration of exogenous AAT. Augmentation therapy with AAT increases serum and pulmonary epithelial AAT levels, restores anti-elastase capacity, and decreases inflammatory mediators in the lung. Augmentation therapy reduces the loss of lung density over time, thus slowing progression of the disease. The effects of augmentation therapy on outcomes, such as frequency/duration of flare-ups, quality of life, lung function decline and mortality, are assessed. Wider testing for AATD, potentially through primary care physicians, could result in earlier treatment and better outcomes for individuals with AATD-induced lung respiratory disease.
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Reincke M, Thimme R. [Elevated liver enzymes: A diagnostic challenge]. Dtsch Med Wochenschr 2023; 148:809-817. [PMID: 37364575 DOI: 10.1055/a-1871-6459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
The differential diagnosis of elevated liver enzymes is a key aspect of hepatology and a diagnostic challenge for many. Elevated liver enzymes may mostly indicate liver damage but also physiologic elevations or extrahepatic causes are possible. A rational approach to the differential diagnosis of elevated liver enzymes is necessary to avoid overdiagnosis while not missing rare causes of liver disease.
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Strnad P, San Martin J. RNAi therapeutics for diseases involving protein aggregation: fazirsiran for alpha-1 antitrypsin deficiency-associated liver disease. Expert Opin Investig Drugs 2023; 32:571-581. [PMID: 37470509 DOI: 10.1080/13543784.2023.2239707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/23/2023] [Accepted: 07/19/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Therapeutic agents that prevent protein misfolding or promote protein clearance are being studied to treat proteotoxic diseases. Among them, alpha-1 antitrypsin deficiency (AATD) is caused by mutations in the alpha-1 antitrypsin (SERPINA1) gene. Fazirsiran is a small interfering RNA (siRNA) that is intended to address the underlying cause of liver disease associated with AATD through the RNA interference (RNAi) mechanism. AREAS COVERED This article describes the role of misfolded proteins and protein aggregates in disease and options for therapeutic approaches. The RNAi mechanism is discussed, along with how the siRNA therapeutic fazirsiran for the treatment of AATD was developed. We also describe the implications of siRNA therapeutics in extrahepatic diseases. EXPERT OPINION Using RNAi as a therapeutic approach is well suited to treat disease in conditions where an excess of a protein or the effect of an abnormal mutated protein causes disease. The results observed for the first few siRNA therapeutics that were approved or are in development provide an important promise for the development of future drugs that can address such conditions in a specific and targeted way. Current developments should enable the use of RNAi therapeutics outside the liver, where there are many more possible diseases to address.
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Affiliation(s)
- Pavel Strnad
- Department of Internal Medicine III, University Hospital RWTH (Rheinisch-Westfälisch Technische Hochschule) Aachen, Aachen, Germany
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Alí-Munive A, Leidy P, Proaños NJ, Pedrozo-Pupo J, Giraldo A, Cano D, Diaz-Bossa C, Mosquera R, Paul H, Gonzalez-García M, Aguirre-Franco C, López-Campos JL, Casas-Herrera A. Prevalence of genetic mutations in alpha-1 antitrypsin deficiency (aatd) in patients with chronic obstructive pulmonary disease in Colombia. BMC Pulm Med 2023; 23:156. [PMID: 37143026 PMCID: PMC10158008 DOI: 10.1186/s12890-023-02453-0] [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: 02/14/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Alpha-1 antitrypsin deficiency (AATD) is an underrecognized genetic disorder associated mainly with pulmonary emphysema and Chronic Obstructive Pulmonary Disease (COPD). All individuals with COPD regardless of age or ethnicity should be tested for AATD, but in Colombia its prevalence in unknown. MAIN OBJECTIVE To determine the prevalence of the genetic mutations, present in AATD in adult patients with COPD in Colombia, using a genotyping test on cells from the oral mucosa. METHODS This was a multicentre, observational, cross-sectional study which included adult patients attending seven COPD care centres in Colombia. Demographic data, medical history, including history of exposure to smoking and biomass smoke, most recent spirometry, pharmacological and non-pharmacological treatment received, serum AAT levels, and mutations detected by the genotyping test were recorded for all the recruited patients. For the comparison of variables between the groups with and without mutation, we used the X2 test for the qualitative variables and the Student's t-test or Mann-Whitney U test according to their distribution. MAIN FINDINGS We collected a sample of 1,107 patients, the median age was 73.8 years (87.6-79.9). Mutations were documented in 144 patients (13.01%), the majority had the M/S mutation (78.50%), followed by M/Z (9.72%). One patient had a ZZ mutation and two patients had null alleles. In total, 23 patients had mutations associated with serum AAT deficiency (levels below 60 mg/dl). CONCLUSIONS Genetic mutations were documented in 13.01% of patients with COPD in Colombia and 2.07% were AATD-related, showing that there is a significant number of underdiagnosed patients.
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Affiliation(s)
- Abraham Alí-Munive
- Fundación Neumológica Colombiana, Cra. 13 B # 161 - 85, Bogota, Colombia.
| | - Prada Leidy
- Universidad de La Sabana, Campus del puente del común, Km 7 Autopista Norte de Bogotá, Chía, Chía- Cundinamarca, Colombia
| | - Nadia Juliana Proaños
- Universidad de La Sabana, Campus del puente del común, Km 7 Autopista Norte de Bogotá, Chía, Chía- Cundinamarca, Colombia
| | - John Pedrozo-Pupo
- Respire Instituto para el Cuidado Respiratorio (Previcare Ltda), Cra 21 # 18 - 27., Santa Marta, Colombia
| | - Angela Giraldo
- CardioSalud Eje Cafetero SAS, Cra. 13 # 3B ? 12, Pereira, Colombia
| | - Diana Cano
- Instituto Neumologico del Oriente S.A. Calle, 53 No. 31 - 30. Bucaramanga, Santander, Spain
| | | | - Ricardo Mosquera
- , Clínica Neumológica del Pacífico S.A.S. Calle 5 A No. 42A - 18. Cali, Valle, Barranquilla, Colombia
| | - Hector Paul
- , Promotores de la salud de la costa S.A.S. Cra 54 No 54 ? 01, Barranquilla, Colombia
| | | | | | - José Luis López-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Avda de Manuel Siurot s/n, Sevilla, 41013, España
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Di Mambro T, Pellielo G, Agyapong ED, Carinci M, Chianese D, Giorgi C, Morciano G, Patergnani S, Pinton P, Rimessi A. The Tricky Connection between Extracellular Vesicles and Mitochondria in Inflammatory-Related Diseases. Int J Mol Sci 2023; 24:ijms24098181. [PMID: 37175888 PMCID: PMC10179665 DOI: 10.3390/ijms24098181] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/21/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023] Open
Abstract
Mitochondria are organelles present in almost all eukaryotic cells, where they represent the main site of energy production. Mitochondria are involved in several important cell processes, such as calcium homeostasis, OXPHOS, autophagy, and apoptosis. Moreover, they play a pivotal role also in inflammation through the inter-organelle and inter-cellular communications, mediated by the release of mitochondrial damage-associated molecular patterns (mtDAMPs). It is currently well-documented that in addition to traditional endocrine and paracrine communication, the cells converse via extracellular vesicles (EVs). These small membrane-bound particles are released from cells in the extracellular milieu under physio-pathological conditions. Importantly, EVs have gained much attention for their crucial role in inter-cellular communication, translating inflammatory signals into recipient cells. EVs cargo includes plasma membrane and endosomal proteins, but EVs also contain material from other cellular compartments, including mitochondria. Studies have shown that EVs may transport mitochondrial portions, proteins, and/or mtDAMPs to modulate the metabolic and inflammatory responses of recipient cells. Overall, the relationship between EVs and mitochondria in inflammation is an active area of research, although further studies are needed to fully understand the mechanisms involved and how they may be targeted for therapeutic purposes. Here, we have reported and discussed the latest studies focused on this fascinating and recent area of research, discussing of tricky connection between mitochondria and EVs in inflammatory-related diseases.
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Affiliation(s)
- Tommaso Di Mambro
- Department of Medical Sciences, Section of Experimental Medicine, Laboratory for Technologies of Advanced Therapies, University of Ferrara, 44121 Ferrara, Italy
| | - Giulia Pellielo
- Department of Medical Sciences, Section of Experimental Medicine, Laboratory for Technologies of Advanced Therapies, University of Ferrara, 44121 Ferrara, Italy
| | - Esther Densu Agyapong
- Department of Medical Sciences, Section of Experimental Medicine, Laboratory for Technologies of Advanced Therapies, University of Ferrara, 44121 Ferrara, Italy
| | - Marianna Carinci
- Department of Medical Sciences, Section of Experimental Medicine, Laboratory for Technologies of Advanced Therapies, University of Ferrara, 44121 Ferrara, Italy
| | - Diego Chianese
- Department of Medical Sciences, Section of Experimental Medicine, Laboratory for Technologies of Advanced Therapies, University of Ferrara, 44121 Ferrara, Italy
| | - Carlotta Giorgi
- Department of Medical Sciences, Section of Experimental Medicine, Laboratory for Technologies of Advanced Therapies, University of Ferrara, 44121 Ferrara, Italy
| | - Giampaolo Morciano
- Department of Medical Sciences, Section of Experimental Medicine, Laboratory for Technologies of Advanced Therapies, University of Ferrara, 44121 Ferrara, Italy
| | - Simone Patergnani
- Department of Medical Sciences, Section of Experimental Medicine, Laboratory for Technologies of Advanced Therapies, University of Ferrara, 44121 Ferrara, Italy
| | - Paolo Pinton
- Department of Medical Sciences, Section of Experimental Medicine, Laboratory for Technologies of Advanced Therapies, University of Ferrara, 44121 Ferrara, Italy
- Center of Research for Innovative Therapies in Cystic Fibrosis, University of Ferrara, 44121 Ferrara, Italy
| | - Alessandro Rimessi
- Department of Medical Sciences, Section of Experimental Medicine, Laboratory for Technologies of Advanced Therapies, University of Ferrara, 44121 Ferrara, Italy
- Center of Research for Innovative Therapies in Cystic Fibrosis, University of Ferrara, 44121 Ferrara, Italy
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Toumpanakis D, Usmani OS. Small airways disease in patients with alpha-1 antitrypsin deficiency. Respir Med 2023; 211:107222. [PMID: 36965591 DOI: 10.1016/j.rmed.2023.107222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 03/27/2023]
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a genetic disorder, characterized by panacinar emphysema mainly in the lower lobes, and predisposes to chronic obstructive pulmonary disease (COPD) at a younger age, especially in patients with concomitant cigarette smoking. Alpha-1 antitrypsin (a1-AT) is a serine protease inhibitor that mainly blocks neutrophil elastase and maintains protease/antiprotease balance in the lung and AATD is caused by mutations in the SERPINA1 gene that encodes a1-AT protein. PiZZ is the most common genotype associated with severe AATD, leading to reduced circulating levels of a1-AT. Besides its antiprotease function, a1-AT has anti-inflammatory and antioxidative effects and AATD results in defective innate immunity. Protease/antiprotease imbalance affects not only the lung parenchyma but also the small airways and recent studies have shown that AATD is associated with small airway dysfunction. Alterations in small airways structure with peripheral ventilation inhomogeneities may precede emphysema formation, providing a unique opportunity to detect early disease. The aim of the present review is to summarize the current evidence for the contribution of small airways disease in AATD-associated lung disease.
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Affiliation(s)
- Dimitrios Toumpanakis
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; General State Hospital for Thoracic Diseases of Athens "Sotiria", Greece.
| | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Hidden Comorbidities in Asthma: A Perspective for a Personalized Approach. J Clin Med 2023; 12:jcm12062294. [PMID: 36983294 PMCID: PMC10059265 DOI: 10.3390/jcm12062294] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/05/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
Bronchial asthma is the most frequent inflammatory non-communicable condition affecting the airways worldwide. It is commonly associated with concomitant conditions, which substantially contribute to its burden, whether they involve the lung or other districts. The present review aims at providing an overview of the recent acquisitions in terms of asthma concomitant systemic conditions, besides the commonly known respiratory comorbidities. The most recent research has highlighted a number of pathobiological interactions between asthma and other organs in the view of a shared immunological background underling different diseases. A bi-univocal relationship between asthma and common conditions, including cardiovascular, metabolic or neurodegenerative diseases, as well as rare disorders such as sickle cell disease, α1-Antitrypsin deficiency and immunologic conditions with hyper-eosinophilia, should be considered and explored, in terms of diagnostic work-up and long-term assessment of asthma patients. The relevance of that acquisition is of utmost importance in the management of asthma patients and paves the way to a new approach in the light of a personalized medicine perspective, besides targeted therapies.
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McElvaney OF, Fraughen DD, McElvaney OJ, Carroll TP, McElvaney NG. Alpha-1 antitrypsin deficiency: current therapy and emerging targets. Expert Rev Respir Med 2023; 17:191-202. [PMID: 36896570 DOI: 10.1080/17476348.2023.2174973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
INTRODUCTION Alpha1 antitrypsin deficiency (AATD), a common hereditary disorder affecting mainly lungs, liver and skin has been the focus of some of the most exciting therapeutic approaches in medicine in the past 5 years. In this review, we discuss the therapies presently available for the different manifestations of AATD and new therapies in the pipeline. AREAS COVERED We review therapeutic options for the individual lung, liver and skin manifestations of AATD along with approaches which aim to treat all three. Along with this renewed interest in treating AATD come challenges. How is AAT best delivered to the lung? What is the desired level of AAT in the circulation and lungs which therapeutics should aim to provide? Will treating the liver disease increase the potential for lung disease? Are there treatments to target the underlying genetic defect with the potential to prevent all aspects of AATDrelated disease? EXPERT OPINION With a relatively small population able to participate in clinical studies, increased awareness and diagnosis of AATD is urgently needed. Better, more sensitive clinical parameters will assist in the generation of acceptable and robust evidence of therapeutic effect for current and emerging treatments.
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Affiliation(s)
- Oisín F McElvaney
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Medicine, Beaumont Hospital, Dublin, Ireland
| | - Daniel D Fraughen
- Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Medicine, Beaumont Hospital, Dublin, Ireland
| | - Oliver J McElvaney
- 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.,Department of Medicine, Beaumont Hospital, 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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Höger P, Veith M, Greulich T, Limen E, Brock J, Schlamp K, Buschulte K, Presotto MA, Schäfer JC, Herth F, Trudzinski FC. Characterization of three new SERPINA1 variants PiQ0Heidelberg II, PiQ0Heidelberg III and PiQ0Heidelberg IV in patients with severe alpha-1 antitrypsin deficiency. Respir Med Case Rep 2023; 43:101838. [PMID: 37021142 PMCID: PMC10068255 DOI: 10.1016/j.rmcr.2023.101838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 03/16/2023] Open
Abstract
Background The clinical and molecular characteristics of three patients with previously unreported SERPINA1 mutations associated with severe alpha-1 antitrypsin deficiency (AATD) are described. The pathophysiology of the chronic obstructive pulmonary disease (COPD) present in these patients was characterized through clinical, biochemical, and genetic examinations. Case presentations Case 1: A 73-year-old male with bilateral centri-to panlobular emphysema and multiple increasing ventrobasal bullae and incomplete fissures, COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) grade III B), progressive dyspnea on exertion (DOE), AAT level of 0.1-0.2 g/L. Genetic testing revealed a unique SERPINA1 mutation: Pi*Z/c.1072C > T. This allele was designated PiQ0Heidelberg II. Case 2: A 47-year-old male with severely heterogenous centri-to panlobular emphysema concentrated in the lower lobes, COPD GOLD IV D with progressive DOE, AAT <0.1 g/L. He also had a unique Pi*Z/c.10del mutation in SERPINA1. This allele was named PiQ0Heidelberg III. Case 3: A 58-year-old female with basally accentuated panlobular emphysema, GOLD II B COPD, progressive DOE. AAT 0.1 g/L. Genetic analysis revealed Pi*Z/c.-5+1G > A and c.-472G > A mutations in SERPINA1. This variant allele was named PiQ0Heidelberg IV. Conclusions Each of these patients had a unique and previously unreported SERPINA1 mutation. In two cases, AATD and a history of smoking led to severe lung disease. In the third case, timely diagnosis, and institution of AAT replacement stabilized lung function. Wider screening of COPD patients for AATD could lead to faster diagnosis and earlier treatment of AATD patients with AATD which could slow or prevent progression of their disease.
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Wauthier L, Jacques S, Delanghe J, Favresse J. Optimizing the screening of alpha-1 antitrypsin deficiency using serum protein electrophoresis. Clin Chem Lab Med 2023; 61:427-434. [PMID: 36420543 DOI: 10.1515/cclm-2022-0967] [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: 09/27/2022] [Accepted: 11/10/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Alpha-1 antitrypsin (A1AT) deficiency was first identified in patients with emphysema by the absence of the α1 band on serum protein electrophoresis (SPE). Today, capillary zone electrophoresis is widely performed in laboratories. Here, we compared two SPE systems to detect decreased A1AT concentrations to optimize their use as a screening tool for A1AT deficiency. METHODS Serum protein electrophoresis was performed on 200 samples on the Capillarys 2 and the V8 Nexus. The latter presents two α1 bands (α1 band 1 and 2) while the Capillarys 2 has only one (Capillarys 2 total α1). The measures of A1AT and α1 acid glycoprotein (AAG) were performed as well as the phenotyping of M, S and Z alleles. RESULTS At a A1AT cutoff of 0.80 g/L, a cutoff of 1.21 g/L using the V8 Nexus α1 band 2 corresponded to a 100% sensitivity and a 92.4% specificity while a 1.69% cutoff corresponded to a 100% sensitivity and a 92.4% specificity. The performance of the α1 band 1 was suboptimal and rather corresponded to AAG. On the Capillarys 2, a cutoff of 2.0 g/L corresponded to a 75.0% sensitivity and a 86.6% specificity, while a 3.2% cutoff showed a 96.4% sensitivity and a 67.4% specificity. The V8 Nexus α1 band 2 was the method the most correlated with A1AT (r=0.90-0.94). CONCLUSIONS The V8 Nexus α1 band 2 was the best predictor of A1AT deficiency, probably owing to a better resolution. The use of SPE was however unable to predict each phenotype. Phenotype or genotype studies are therefore still advisable in case of A1AT deficiency.
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Affiliation(s)
- Loris Wauthier
- Department of Laboratory Medicine, Clinique St-Luc Bouge, Namur, Belgium
| | - Stéphanie Jacques
- Department of Laboratory Medicine, Clinique St-Luc Bouge, Namur, Belgium
| | - Joris Delanghe
- Department of Clinical Chemistry, Ghent University Hospital, Gent, Belgium
| | - Julien Favresse
- Department of Laboratory Medicine, Clinique St-Luc Bouge, Namur, Belgium.,Department of Pharmacy, Namur Research Institute for LIfes Sciences, University of Namur, Namur, Belgium
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Rosenberg JB, De BP, Greco A, Gorman N, Kooner V, Chen A, Yost-Bido M, Munoz-Zuluaga C, Kaminsky SM, Rostami M, Monette S, Crystal RG, Sondhi D. Safety of Intravenous Administration of an AAV8 Vector Coding for an Oxidation-Resistant Human α1-Antitrypsin for the Treatment of α1-Antitrypsin Deficiency. Hum Gene Ther 2023; 34:139-149. [PMID: 36606685 PMCID: PMC9963503 DOI: 10.1089/hum.2022.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/18/2022] [Indexed: 01/07/2023] Open
Abstract
α1-antitrypsin (AAT) deficiency is a common autosomal recessive hereditary disorder, with a high risk for the development of early-onset panacinar emphysema. AAT, produced primarily in the liver, functions to protect the lung from neutrophil protease; with AAT deficiency, unimpeded neutrophil proteases destroy the lung parenchyma. AAT is susceptible to oxidative damage resulting in an inability to inhibit its target proteases, neutrophil elastase, and cathepsin G. The major sites of oxidative modification on the AAT molecule are methionine residues 351 and 358. We have previously demonstrated that an engineered variant of AAT that resists oxidation by modifying both protein surface methionines (M351V and M358L) provides antiprotease protection, despite oxidative stress. In mice, intravenous delivery of the modified AAT(AVL) variant by AAV serotype 8, AAV8hAAT(AVL), primarily to the liver resulted in long-term expression of an AAT that resists oxidative inactivation. In this study, we evaluated the safety of intravenous administration of AAV8hAAT(AVL) in a dose-escalating, blinded, placebo-controlled toxicology study in wild-type mice. The study assessed organ histology and clinical pathology findings of mice, intravenously administered AAV8hAAT(AVL) at three doses (5.0 × 1011, 5.0 × 1012, and 5.0 × 1013 genome copies [gc]/kg), compared to control mice injected intravenously with phosphate-buffered saline. As previously demonstrated, administration of AAV8hAAT(AVL) resulted in dose-dependent expression of high, potentially therapeutic, levels of serum human AAT protein that persist for at least 6 months. Antibodies against the AAV8 capsid were elicited as expected, but there was no antibody detected against the AAT(AVL) protein generated by the AAV8hAAT(AVL) vector. There was no morbidity or mortality observed in the study. The data demonstrate that intravenous administration of AAV8hAAT(AVL) is safe with no significant adverse effect attributed to AAV8hAAT(AVL) vector at any dose. This study demonstrates that AAV8hAAT(AVL) has a safety profile consistent with the requirements for proceeding to a clinical study.
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Affiliation(s)
| | - Bishnu P. De
- Department of Genetic Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Alessandria Greco
- Department of Genetic Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Nicholas Gorman
- Department of Genetic Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Vikrum Kooner
- Department of Genetic Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Alvin Chen
- Department of Genetic Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Melissa Yost-Bido
- Department of Genetic Medicine, Weill Cornell Medicine, New York, New York, USA
| | | | - Stephen M. Kaminsky
- Department of Genetic Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Mahboubeh Rostami
- Department of Genetic Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Sébastien Monette
- Laboratory of Comparative Pathology, Weill Cornell Medicine, Memorial Sloan Kettering Cancer Center, The Rockefeller University, New York, New York, USA
| | - Ronald G. Crystal
- Department of Genetic Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Dolan Sondhi
- Department of Genetic Medicine, Weill Cornell Medicine, New York, New York, USA
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Fung C, Wilding B, Schittenhelm RB, Bryson-Richardson RJ, Bird PI. Expression of the Z Variant of α1-Antitrypsin Suppresses Hepatic Cholesterol Biosynthesis in Transgenic Zebrafish. Int J Mol Sci 2023; 24:ijms24032475. [PMID: 36768797 PMCID: PMC9917206 DOI: 10.3390/ijms24032475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/20/2023] [Accepted: 01/21/2023] [Indexed: 01/31/2023] Open
Abstract
Individuals homozygous for the Pi*Z allele of SERPINA1 (ZAAT) are susceptible to lung disease due to insufficient α1-antitrypsin secretion into the circulation and may develop liver disease due to compromised protein folding that leads to inclusion body formation in the endoplasmic reticulum (ER) of hepatocytes. Transgenic zebrafish expressing human ZAAT show no signs of hepatic accumulation despite displaying serum insufficiency, suggesting the defect in ZAAT secretion occurs independently of its tendency to form inclusion bodies. In this study, proteomic, transcriptomic, and biochemical analysis provided evidence of suppressed Srebp2-mediated cholesterol biosynthesis in the liver of ZAAT-expressing zebrafish. To investigate the basis for this perturbation, CRISPR/Cas9 gene editing was used to manipulate ER protein quality control factors. Mutation of erlec1 resulted in a further suppression in the cholesterol biosynthesis pathway, confirming a role for this ER lectin in targeting misfolded ZAAT for ER-associated degradation (ERAD). Mutation of the two ER mannosidase homologs enhanced ZAAT secretion without inducing hepatic accumulation. These insights into hepatic ZAAT processing suggest potential therapeutic targets to improve secretion and alleviate serum insufficiency in this form of the α1-antitrypsin disease.
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Affiliation(s)
- Connie Fung
- Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Melbourne 3800, Australia
- Correspondence: (C.F.); (P.I.B.)
| | - Brendan Wilding
- Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Melbourne 3800, Australia
| | - Ralf B. Schittenhelm
- Monash Proteomics and Metabolomics Facility, Monash University, Melbourne 3800, Australia
| | | | - Phillip I. Bird
- Department of Biochemistry and Molecular Biology, Biomedicine Discovery Institute, Monash University, Melbourne 3800, Australia
- Correspondence: (C.F.); (P.I.B.)
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Conde B, Costa F, Gomes J, Lopes AP, Mineiro MA, Rodrigues O, Santos C, Semedo L, Sucena M, Guimarães C. Expert Perspectives on the Management of Alpha 1-Antitrypsin Deficiency. ACTA MEDICA PORT 2023; 36:49-54. [PMID: 35848753 DOI: 10.20344/amp.18497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 01/05/2023]
Abstract
Alpha 1-antitrypsin deficiency is an inherited autosomal codominant disorder, which predisposes patients to lung and/or liver disease. Even though it is considered rare, it is one of the most frequent genetic disorders worldwide, albeit remaining underdiagnosed. Several organizations and societies, including the Portuguese Society of Pulmonology have been elaborating guidelines and recommendations for the diagnosis and management of alpha 1-antitrypsin deficiency. Nevertheless, some important matters are yet to be included in those, mainly due to lack of robust scientific evidence, and continue to represent a point of discussion. This article reviews some important scientific publications and expresses the perspectives of a group of Portuguese experts regarding the management of alpha 1-antitrypsin deficiency, namely in terms of the pre and neonatal diagnosis, the impact of the COVID-19 pandemic, the validity of replacement therapy in lung transplant-receiving, and finally, alternative strategies of alpha 1-antitrypsin deficiency treatment to improve the patients' quality of life.
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Affiliation(s)
- Bebiana Conde
- Centro Hospitalar Trás-os-Montes e Alto Douro. Vila Real; Universidade de Trás-os-Montes e Alto Douro. Vila Real. Portugal
| | - Filipa Costa
- Serviço de Pneumologia. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
| | - Joana Gomes
- Serviço de Pneumologia. Centro Hospitalar e Universitário do Porto. Porto. Portugal
| | - António Paulo Lopes
- Serviço de Pneumologia. Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
| | | | - Orlando Rodrigues
- Serviço de Genética Médica. Hospital Pediátrico do Centro Hospitalar e Universitário de Coimbra. Coimbra. Portugal
| | - Cristina Santos
- Serviço de Pneumologia. Centro Hospitalar e Universitário Lisboa Norte. Lisboa. Portugal
| | - Luísa Semedo
- Serviço de Pneumologia. Centro Hospitalar Universitário Lisboa Central. Lisboa. Portugal
| | - Maria Sucena
- Serviço de Pneumologia. Centro Hospitalar e Universitário do Porto. Porto. Portugal
| | - Catarina Guimarães
- Serviço de Pneumologia. Hospital Senhora da Oliveira. Guimarães. Portugal
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Meischl T, Schmid-Scherzer K, Vafai-Tabrizi F, Wurzinger G, Traunmüller-Wurm E, Kutics K, Rauter M, Grabcanovic-Musija F, Müller S, Kaufmann N, Löffler-Ragg J, Valipour A, Funk GC. The impact of diagnostic delay on survival in alpha-1-antitrypsin deficiency: results from the Austrian Alpha-1 Lung Registry. Respir Res 2023; 24:34. [PMID: 36707810 PMCID: PMC9881325 DOI: 10.1186/s12931-023-02338-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 01/18/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Alpha-1-antitrypsin (AAT) deficiency (AATD) is a genetic disorder that can manifest as lung disease. A delay between onset of symptoms and diagnosis of AATD is common and associated with worse clinical status and more advanced disease stage but the influence on survival is unclear. OBJECTIVE We aimed to investigate the impact of diagnostic delay on overall survival (OS) and transplant-free survival (TS) in AATD patients. METHODS We analysed 268 AATD patients from the prospective multi-centre Austrian Alpha-1 Lung (AAL) Registry, employing descriptive statistics, Chi-square-test as well as univariable (Kaplan-Meier plots, log-rank test) and multivariable survival analysis (Cox regression). RESULTS The predominant phenotype was Pi*ZZ (82.1%). At diagnosis, 90.2% had an AAT level below 0.6 g/L. At inclusion, 28.2% had never smoked, 68.0% had quit smoking and 3.8% continued to smoke. Lung disease was diagnosed in 98.5%, thereof most patients were diagnosed with emphysema (63.8%) and/or chronic obstructive pulmonary disease (44.0%). Median diagnostic delay was 5.3 years (inter-quartile range [IQR] 2.2-11.5 years). In multivariable analysis (n = 229), a longer diagnostic delay was significantly associated with worse OS (hazard ratio [HR] 1.61; 95% CI 1.09-2.38; p = 0.016) and TS (HR 1.43; 95% CI 1.08-1.89; p = 0.011), independent from age, smoking status, body mass index (BMI), forced expiratory volume in one second (FEV1) and long-term oxygen treatment. Furthermore, BMI, age and active smoking were significantly associated with worse OS as well as BMI, active smoking and FEV1 were with worse TS. CONCLUSIONS A delayed diagnosis was associated with significantly worse OS and TS. Screening should be improved and efforts to ensure early AATD diagnosis should be intensified.
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Affiliation(s)
- Tobias Meischl
- grid.487248.50000 0004 9340 1179Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Montleartstraße 37, 1160 Vienna, Austria ,grid.22937.3d0000 0000 9259 8492Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Karin Schmid-Scherzer
- grid.487248.50000 0004 9340 1179Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Montleartstraße 37, 1160 Vienna, Austria ,Department of Medicine II With Pneumology, Klinik Ottakring, Vienna, Austria
| | - Florian Vafai-Tabrizi
- grid.487248.50000 0004 9340 1179Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Montleartstraße 37, 1160 Vienna, Austria ,Department of Medicine II With Pneumology, Klinik Ottakring, Vienna, Austria
| | - Gert Wurzinger
- Center of Pulmology, LKH Graz II, Standort Enzenbach, Gratwein-Strassengel, Austria
| | - Eva Traunmüller-Wurm
- grid.459707.80000 0004 0522 7001Department of Pulmology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Kristina Kutics
- grid.459707.80000 0004 0522 7001Department of Pulmology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Markus Rauter
- grid.415431.60000 0000 9124 9231Department of Pulmonology, Klinikum Klagenfurt Am Woerthersee, Klagenfurt, Austria
| | | | - Simona Müller
- Department of Pulmonology, Landeskrankenhaus Hohenems, Hohenems, Austria
| | - Norbert Kaufmann
- Division of Gastroenterology, Infectiology and Pneumology, Department of Medicine, LKH Graz II, Graz, Austria
| | - Judith Löffler-Ragg
- grid.5361.10000 0000 8853 2677Department of Medicine II, Medical University of Innsbruck, Innsbruck, Austria
| | - Arschang Valipour
- grid.487248.50000 0004 9340 1179Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Montleartstraße 37, 1160 Vienna, Austria ,Department of Respiratory and Critical Care Medicine, Klinik Floridsdorf, Vienna, Austria
| | - Georg-Christian Funk
- grid.487248.50000 0004 9340 1179Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Montleartstraße 37, 1160 Vienna, Austria ,Department of Medicine II With Pneumology, Klinik Ottakring, Vienna, Austria
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Extracellular Vesicles' Role in the Pathophysiology and as Biomarkers in Cystic Fibrosis and COPD. Int J Mol Sci 2022; 24:ijms24010228. [PMID: 36613669 PMCID: PMC9820204 DOI: 10.3390/ijms24010228] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/03/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022] Open
Abstract
In keeping with the extraordinary interest and advancement of extracellular vesicles (EVs) in pathogenesis and diagnosis fields, we herein present an update to the knowledge about their role in cystic fibrosis (CF) and chronic obstructive pulmonary disease (COPD). Although CF and COPD stem from a different origin, one genetic and the other acquired, they share a similar pathophysiology, being the CF transmembrane conductance regulator (CFTR) protein implied in both disorders. Various subsets of EVs, comprised mainly of microvesicles (MVs) and exosomes (EXOs), are secreted by various cell types that are either resident or attracted in the airways during the onset and progression of CF and COPD lung disease, representing a vehicle for metabolites, proteins and RNAs (especially microRNAs), that in turn lead to events as such neutrophil influx, the overwhelming of proteases (elastase, metalloproteases), oxidative stress, myofibroblast activation and collagen deposition. Eventually, all of these pathomechanisms lead to chronic inflammation, mucus overproduction, remodeling of the airways, and fibrosis, thus operating a complex interplay among cells and tissues. The detection of MVs and EXOs in blood and biological fluids coming from the airways (bronchoalveolar lavage fluid and sputum) allows the consideration of EVs and their cargoes as promising biomarkers for CF and COPD, although clinical expectations have yet to be fulfilled.
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Kaserman JE, Werder RB, Wang F, Matte T, Higgins MI, Dodge M, Lindstrom-Vautrin J, Bawa P, Hinds A, Bullitt E, Caballero IS, Shi X, Gerszten RE, Brunetti-Pierri N, Liesa M, Villacorta-Martin C, Hollenberg AN, Kotton DN, Wilson AA. Human iPSC-hepatocyte modeling of alpha-1 antitrypsin heterozygosity reveals metabolic dysregulation and cellular heterogeneity. Cell Rep 2022; 41:111775. [PMID: 36476855 PMCID: PMC9780780 DOI: 10.1016/j.celrep.2022.111775] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/28/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
Individuals homozygous for the "Z" mutation in alpha-1 antitrypsin deficiency are known to be at increased risk for liver disease. It has also become clear that some degree of risk is similarly conferred by the heterozygous state. A lack of model systems that recapitulate heterozygosity in human hepatocytes has limited the ability to study the impact of a single Z alpha-1 antitrypsin (ZAAT) allele on hepatocyte biology. Here, we describe the derivation of syngeneic induced pluripotent stem cells (iPSCs) engineered to determine the effects of ZAAT heterozygosity in iPSC-hepatocytes (iHeps). We find that heterozygous MZ iHeps exhibit an intermediate disease phenotype and share with ZZ iHeps alterations in AAT protein processing and downstream perturbations including altered endoplasmic reticulum (ER) and mitochondrial morphology, reduced mitochondrial respiration, and branch-specific activation of the unfolded protein response in cell subpopulations. Our model of MZ heterozygosity thus provides evidence that a single Z allele is sufficient to disrupt hepatocyte homeostatic function.
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Affiliation(s)
- Joseph E. Kaserman
- Center for Regenerative Medicine (CReM) of Boston University and Boston Medical Center, Boston, MA 02118, USA,The Pulmonary Center and Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Rhiannon B. Werder
- Center for Regenerative Medicine (CReM) of Boston University and Boston Medical Center, Boston, MA 02118, USA
| | - Feiya Wang
- Center for Regenerative Medicine (CReM) of Boston University and Boston Medical Center, Boston, MA 02118, USA
| | - Taylor Matte
- Center for Regenerative Medicine (CReM) of Boston University and Boston Medical Center, Boston, MA 02118, USA
| | - Michelle I. Higgins
- Center for Regenerative Medicine (CReM) of Boston University and Boston Medical Center, Boston, MA 02118, USA
| | - Mark Dodge
- Center for Regenerative Medicine (CReM) of Boston University and Boston Medical Center, Boston, MA 02118, USA
| | - Jonathan Lindstrom-Vautrin
- Center for Regenerative Medicine (CReM) of Boston University and Boston Medical Center, Boston, MA 02118, USA
| | - Pushpinder Bawa
- Center for Regenerative Medicine (CReM) of Boston University and Boston Medical Center, Boston, MA 02118, USA
| | - Anne Hinds
- The Pulmonary Center and Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Esther Bullitt
- Department of Physiology and Biophysics, Boston University, Boston, MA 02118, USA
| | - Ignacio S. Caballero
- Center for Regenerative Medicine (CReM) of Boston University and Boston Medical Center, Boston, MA 02118, USA
| | - Xu Shi
- Division of Cardiovascular Medicine, Beth Israel Deaconess Hospital, Boston, MA 02118, USA
| | - Robert E. Gerszten
- Division of Cardiovascular Medicine, Beth Israel Deaconess Hospital, Boston, MA 02118, USA
| | - Nicola Brunetti-Pierri
- Telethon Institute of Genetics and Medicine, 80078 Pozzuoli, Naples, Italy,Department of Translational Medicine, Federico II University, 80131 Naples, Italy
| | - Marc Liesa
- Departments of Medicine, Endocrinology, and Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA,Institut de Biologia Molecular de Barcelona (IBMB-CSIC), 08028 Barcelona, Catalonia, Spain
| | - Carlos Villacorta-Martin
- Center for Regenerative Medicine (CReM) of Boston University and Boston Medical Center, Boston, MA 02118, USA
| | - Anthony N. Hollenberg
- Joan and Sanford I. Weill Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Weill Cornell Medicine, 1300 York Avenue, New York, NY 10065, USA
| | - Darrell N. Kotton
- Center for Regenerative Medicine (CReM) of Boston University and Boston Medical Center, Boston, MA 02118, USA,The Pulmonary Center and Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
| | - Andrew A. Wilson
- Center for Regenerative Medicine (CReM) of Boston University and Boston Medical Center, Boston, MA 02118, USA,The Pulmonary Center and Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA,Lead contact,Correspondence:
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Jiménez-Rodríguez BM, Triviño-Ibáñez EM, Gutiérrez-Fernández J, Romero-Ortiz AD, Ramos-Urbina EM, Morales-García C. Abnormal Alpha-1 Antitrypsin Levels and Other Risk Factors Associated with Lung Function Impairment at 6 and 12 Months after Hospitalization Due to COVID-19: A Cohort Study. Healthcare (Basel) 2022; 10:healthcare10122341. [PMID: 36553867 PMCID: PMC9777719 DOI: 10.3390/healthcare10122341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/11/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022] Open
Abstract
Respiratory function deficits are common sequelae for COVID-19. In this study, we aimed to identify the medical conditions that may influence lung function impairment at 12 months after SARS-CoV2 infection and to analyze the role of alpha-1 antytripsin (AAT) deficiciency (AATD). A cohort study was conducted on hospitalized COVID-19 pneumonia patients in Granada (Spain) during the first infection wave who were referred to a post-COVID-19 hospital clinic. The patients were monitored with three follow-up visits from May 2020 to May 2021. Previous medical history, hospital admission data, baseline parameters and physical examination data were collected at the first visit. Pulmonary function tests were performed at 6 and 12 months together with the determination of AAT level and AATD genotype. After 12 months, 49 out of 157 patients (31.2%) continued to have lung function impairment. A multivariate analysis showed a statistically significant association of lung function impairment with: higher Charlson index; pneumonia with a central and/or mixed distribution; anemia on admission; time in intensive care; need for corticosteroid boluses; abnormal respiratory sounds at 6 months; elevated lactate dehydrogenase at 12 months; abnormal AAT; and MZ genotype. Our results suggest that these medical conditions predispose COVID-19 patients to develop long-term lung function sequelae.
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Affiliation(s)
- Beatriz María Jiménez-Rodríguez
- Department of Pneumology, University Hospital Virgen de las Nieves, 18014 Granada, Spain
- Department of Microbiology, School of Medicine and PhD Program in Clinical Medicine and Public Health, University of Granada-IBS, 18010 Granada, Spain
- Correspondence: ; Tel.: +34-958020246
| | - Eva Maria Triviño-Ibáñez
- Biomedical Research Institute of Granada-IBS, 18012 Granada, Spain
- Department of Nuclear Medicine, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain
| | - José Gutiérrez-Fernández
- Department of Microbiology, School of Medicine and PhD Program in Clinical Medicine and Public Health, University of Granada-IBS, 18010 Granada, Spain
- Biomedical Research Institute of Granada-IBS, 18012 Granada, Spain
- Department of Microbiology, University Hospital Virgen de las Nieves, 18014 Granada, Spain
| | - Ana Dolores Romero-Ortiz
- Department of Pneumology, University Hospital Virgen de las Nieves, 18014 Granada, Spain
- Biomedical Research Institute of Granada-IBS, 18012 Granada, Spain
| | | | - Concepción Morales-García
- Department of Pneumology, University Hospital Virgen de las Nieves, 18014 Granada, Spain
- Biomedical Research Institute of Granada-IBS, 18012 Granada, Spain
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45
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Çerçi B, Uzay IA, Kara MK, Dinçer P. Clinical trials and promising preclinical applications of CRISPR/Cas gene editing. Life Sci 2022; 312:121204. [PMID: 36403643 DOI: 10.1016/j.lfs.2022.121204] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/03/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022]
Abstract
Treatment of genetic disorders by genomic manipulation has been the unreachable goal of researchers for many decades. Although our understanding of the genetic basis of genetic diseases has advanced tremendously in the last few decades, the tools developed for genomic editing were not efficient and practical for their use in the clinical setting until now. The recent advancements in the research of Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) and CRISPR-associated protein (Cas) systems offered an easy and efficient way to edit the genome and accelerated the research on their potential use in the treatment of genetic disorders. In this review, we summarize the clinical trials that evaluate the CRISPR/Cas systems for treating different genetic diseases and highlight promising preclinical research on CRISPR/Cas mediated treatment of a great diversity of genetic disorders. Ultimately, we discuss the future of CRISPR/Cas mediated genome editing in genetic diseases.
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Affiliation(s)
- Barış Çerçi
- Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey.
| | - Ihsan Alp Uzay
- Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
| | | | - Pervin Dinçer
- Department of Medical Biology, Faculty of Medicine, Hacettepe University, Ankara 06100, Turkey
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46
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Seyama K, Suzuki M, Tasaka S, Nukiwa T, Sato T, Konno S, Sorrells S, Chen J, Aragonés ME, Minamino H. Long-term safety of Prolastin®-C, an alpha1-proteinase inhibitor, in Japanese patients with alpha1-antitrypsin deficiency. Respir Investig 2022; 60:831-839. [PMID: 35970714 DOI: 10.1016/j.resinv.2022.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/21/2022] [Accepted: 07/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Safety and pharmacokinetics (PK) of alpha1-proteinase inhibitor, modified process (Alpha-1 MP), was evaluated in a clinical trial of Japanese patients with alpha1-antitrypsin deficiency (AATD). The present study aimed to evaluate the long-term safety of weekly intravenous infusions of 60 mg/kg Alpha-1 MP in Japanese patients with AATD. METHODS This was a multi-center, open-label extension (OLE) study that enrolled adult patients with AATD, who had completed the preceding safety and PK clinical trial. Patients were administered with Alpha-1 MP (60 mg/kg) weekly, for 52 weeks, and this could be renewed annually. Alpha1-MP trough levels (Cmin) were evaluated, and safety endpoints include: treatment-emergent adverse events (TEAEs), serious adverse events (SAEs), TEAEs potentially related to Alpha-1 MP, chronic obstructive pulmonary disease (COPD) exacerbations, laboratory parameters, vital signs, and pulmonary function tests (forced expiration volume in 1 s [FEV1] and forced vital capacity [FVC]). RESULTS Four patients underwent Alpha-1 MP intravenous infusions at a mean (SD) of 210.8 (9.54) for 213 weeks (four years), with a Cmin of 55.73 (4.99) mg/dL. A total of fifty-four TEAEs were reported in four patients, in which most of them were mild (n = 52, 96.3%). Two patients had five SAEs, and all were unrelated to treatment. Three mild TEAEs were potentially related to treatment with Alpha-1 MP. No clinically significant findings in laboratory parameters, COPD exacerbations, or vital signs were observed. There were no identifiable differences in FEV1 and FVC throughout the study period. CONCLUSIONS Long-term weekly intravenous infusions of 60 mg/kg Alpha-1 MP are generally safe and well-tolerated in Japanese patients with AATD. CLINICALTRIALS GOV: NCT02870348; JAPIC CTI: JapicCTI-163194.
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Affiliation(s)
- Kuniaki Seyama
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan.
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | | | - Tadashi Sato
- Division of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Susan Sorrells
- Grifols Bioscience Research Group, Grifols, Research Triangle Park, NC, USA
| | - Junliang Chen
- Grifols Bioscience Research Group, Grifols, Research Triangle Park, NC, USA
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Disease Status at Diagnosis in Danish Children with α 1 -antitrypsin Deficiency. J Pediatr Gastroenterol Nutr 2022; 75:629-634. [PMID: 36070551 DOI: 10.1097/mpg.0000000000003604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The aim of this cross-sectional study was to assess the state of disease at the time of diagnosis in Danish children with α 1 -antitrypsin deficiency as Denmark has a high prevalence of ZZ-homozygosity. METHODS Children either heterozygous, compound heterozygous, or homozygous for Z- and S-variants in the SERPINA1 -gene were included. Clinical characteristics, SERPINA1 -genotype, and blood serum (S) concentrations were recorded concurrently with genetic testing. Serum liver marker concentrations were compared using T tests and Wilcoxon-Mann-Whitney tests. Generalized estimating equation (GEE) linear regression models, both univariable and multivariable adjusted for age and sex, were applied to identify correlations with serum α 1 -antitrypsin (S-AAT). The relationship between S-AAT concentration and genotype was assessed using logistic regression with GEE. RESULTS The study included 183 of 225 children genetically tested for alpha-1-antitrypsin deficiency (AATD). Of these, 36.6% were homozygous for the Z-variant. Of the heterozygotes, 89.7% had a ZM genotype and the remaining had either an MS genotype or were compound heterozygous. At diagnosis, ZZ-homozygous children had higher serum concentrations of liver enzymes and conjugated bilirubin, but lower concentrations of S-AAT compared with heterozygotes. Serum concentrations of conjugated bilirubin and liver enzymes were negatively associated with S-AAT. Children under 6 months of age had higher total S-bilirubin concentrations than children over 6 months of age. CONCLUSIONS A low S-AAT concentration is a strong indicator of homozygosity, and homozygous children have higher enzymatic and cholestatic parameters compared with heterozygous children at diagnosis. This underlines the importance of measuring the S-AAT concentration in children with prolonged neonatal jaundice.
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48
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Meng L, Treem W, Heap GA, Chen J. A stacking ensemble machine learning model to predict alpha-1 antitrypsin deficiency-associated liver disease clinical outcomes based on UK Biobank data. Sci Rep 2022; 12:17001. [PMID: 36220873 PMCID: PMC9554039 DOI: 10.1038/s41598-022-21389-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 09/27/2022] [Indexed: 12/29/2022] Open
Abstract
Alpha-1 antitrypsin deficiency associated liver disease (AATD-LD) is a rare genetic disorder and not well-recognized. Predicting the clinical outcomes of AATD-LD and defining patients more likely to progress to advanced liver disease are crucial for better understanding AATD-LD progression and promoting timely medical intervention. We aimed to develop a tailored machine learning (ML) model to predict the disease progression of AATD-LD. This analysis was conducted through a stacking ensemble learning model by combining five different ML algorithms with 58 predictor variables using nested five-fold cross-validation with repetitions based on the UK Biobank data. Performance of the model was assessed through prediction accuracy, area under the receiver operating characteristic (AUROC), and area under the precision-recall curve (AUPRC). The importance of predictor contributions was evaluated through a feature importance permutation method. The proposed stacking ensemble ML model showed clinically meaningful accuracy and appeared superior to any single ML algorithms in the ensemble, e.g., the AUROC for AATD-LD was 68.1%, 75.9%, 91.2%, and 67.7% for all-cause mortality, liver-related death, liver transplant, and all-cause mortality or liver transplant, respectively. This work supports the use of ML to address the unanswered clinical questions with clinically meaningful accuracy using real-world data.
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Affiliation(s)
- Linxi Meng
- Florida State University, Tallahassee, USA
| | - Will Treem
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Graham A Heap
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Jingjing Chen
- Takeda Development Center Americas, Inc., Cambridge, MA, USA.
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49
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Mornex JF, Balduyck M, Bouchecareilh M, Cuvelier A, Epaud R, Kerjouan M, Le Rouzic O, Pison C, Plantier L, Pujazon MC, Reynaud-Gaubert M, Toutain A, Trumbic B, Willemin MC, Zysman M, Brun O, Campana M, Chabot F, Chamouard V, Dechomet M, Fauve J, Girerd B, Gnakamene C, Lefrançois S, Lombard JN, Maitre B, Maynié-François C, Moerman A, Payancé A, Reix P, Revel D, Revel MP, Schuers M, Terrioux P, Theron D, Willersinn F, Cottin V, Mal H. [French clinical practice guidelines for the diagnosis and management of lung disease with alpha 1-antitrypsin deficiency]. Rev Mal Respir 2022; 39:633-656. [PMID: 35906149 DOI: 10.1016/j.rmr.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/31/2022] [Indexed: 11/18/2022]
Affiliation(s)
- J-F Mornex
- Université de Lyon, université Lyon 1, INRAE, EPHE, UMR754, IVPC, 69007 Lyon, France; Centre de référence coordonnateur des maladies pulmonaires rares, hospices civils de Lyon, hôpital Louis-Pradel, service de pneumologie, 69500 Bron, France.
| | - M Balduyck
- CHU de Lille, centre de biologie pathologie, laboratoire de biochimie et biologie moléculaire HMNO, faculté de pharmacie, EA 7364 RADEME, université de Lille, service de biochimie et biologie moléculaire, Lille, France
| | - M Bouchecareilh
- Université de Bordeaux, CNRS, Inserm U1053 BaRITon, Bordeaux, France
| | - A Cuvelier
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU de Rouen, Rouen, France; Groupe de recherche sur le handicap ventilatoire et neurologique (GRHVN), université Normandie Rouen, Rouen, France
| | - R Epaud
- Centre de références des maladies respiratoires rares, site de Créteil, Créteil, France
| | - M Kerjouan
- Service de pneumologie, CHU Pontchaillou, Rennes, France
| | - O Le Rouzic
- CHU Lille, service de pneumologie et immuno-allergologie, Lille, France; Université de Lille, CNRS, Inserm, institut Pasteur de Lille, U1019, UMR 9017, CIIL, OpInfIELD team, Lille, France
| | - C Pison
- Service de pneumologie physiologie, pôle thorax et vaisseaux, CHU de Grenoble, Grenoble, France; Université Grenoble Alpes, Saint-Martin-d'Hères, France
| | - L Plantier
- Service de pneumologie et explorations fonctionnelles respiratoires, CHRU de Tours, Tours, France; Université de Tours, CEPR, Inserm UMR1100, Tours, France
| | - M-C Pujazon
- Service de pneumologie et allergologie, pôle clinique des voies respiratoires, hôpital Larrey, Toulouse, France
| | - M Reynaud-Gaubert
- Service de pneumologie, centre de compétence pour les maladies pulmonaires rares, AP-HM, CHU Nord, Marseille, France; Aix-Marseille université, IHU-Méditerranée infection, Marseille, France
| | - A Toutain
- Service de génétique, CHU de Tours, Tours, France; UMR 1253, iBrain, université de Tours, Inserm, Tours, France
| | | | - M-C Willemin
- Service de pneumologie et oncologie thoracique, CHU d'Angers, hôpital Larrey, Angers, France
| | - M Zysman
- Service de pneumologie, CHU Haut-Lévèque, Bordeaux, France; Université de Bordeaux, centre de recherche cardiothoracique, Inserm U1045, CIC 1401, Pessac, France
| | - O Brun
- Centre de pneumologie et d'allergologie respiratoire, Perpignan, France
| | - M Campana
- Service de pneumologie, CHR d'Orléans, Orléans, France
| | - F Chabot
- Département de pneumologie, CHRU de Nancy, Vandœuvre-lès-Nancy, France; Inserm U1116, université de Lorraine, Vandœuvre-lès-Nancy, France
| | - V Chamouard
- Service pharmaceutique, hôpital cardiologique, GHE, HCL, Bron, France
| | - M Dechomet
- Service d'immunologie biologique, centre de biologie sud, centre hospitalier Lyon Sud, HCL, Pierre-Bénite, France
| | - J Fauve
- Cabinet médical, Bollène, France
| | - B Girerd
- Université Paris-Saclay, faculté de médecine, Le Kremlin-Bicêtre, France; AP-HP, centre de référence de l'hypertension pulmonaire, service de pneumologie et soins intensifs respiratoires, hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - C Gnakamene
- Service de pneumologie, CH de Montélimar, GH Portes de Provence, Montélimar, France
| | | | | | - B Maitre
- Service de pneumologie, centre hospitalier intercommunal, Créteil, France; Inserm U952, UFR de santé, université Paris-Est Créteil, Créteil, France
| | - C Maynié-François
- Université de Lyon, collège universitaire de médecine générale, Lyon, France; Université Claude-Bernard Lyon 1, laboratoire de biométrie et biologie évolutive, UMR5558, Villeurbanne, France
| | - A Moerman
- CHRU de Lille, hôpital Jeanne-de-Flandre, Lille, France; Cabinet de médecine générale, Lille, France
| | - A Payancé
- Service d'hépatologie, CHU Beaujon, AP-HP, Clichy, France; Filière de santé maladies rares du foie de l'adulte et de l'enfant (FilFoie), CHU Saint-Antoine, Paris, France
| | - P Reix
- Service de pneumologie pédiatrique, allergologie, mucoviscidose, hôpital Femme-Mère-Enfant, HCL, Bron, France; UMR 5558 CNRS équipe EMET, université Claude-Bernard Lyon 1, Villeurbanne, France
| | - D Revel
- Université Claude-Bernard Lyon 1, Lyon, France; Hospices civils de Lyon, Lyon, France
| | - M-P Revel
- Université Paris Descartes, Paris, France; Service de radiologie, hôpital Cochin, AP-HP, Paris, France
| | - M Schuers
- Université de Rouen Normandie, département de médecine générale, Rouen, France; Sorbonne université, LIMICS U1142, Paris, France
| | | | - D Theron
- Asten santé, Isneauville, France
| | | | - V Cottin
- Université de Lyon, université Lyon 1, INRAE, EPHE, UMR754, IVPC, 69007 Lyon, France; Centre de référence coordonnateur des maladies pulmonaires rares, hospices civils de Lyon, hôpital Louis-Pradel, service de pneumologie, 69500 Bron, France
| | - H Mal
- Service de pneumologie B, hôpital Bichat-Claude-Bernard, AP-HP, Paris, France; Inserm U1152, université Paris Diderot, site Xavier Bichat, Paris, France
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Strnad P, Mandorfer M, Choudhury G, Griffiths W, Trautwein C, Loomba R, Schluep T, Chang T, Yi M, Given BD, Hamilton JC, San Martin J, Teckman JH. Fazirsiran for Liver Disease Associated with Alpha 1-Antitrypsin Deficiency. N Engl J Med 2022; 387:514-524. [PMID: 35748699 DOI: 10.1056/nejmoa2205416] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Alpha1-antitrypsin (AAT) deficiency results from carriage of a homozygous SERPINA1 "Z" mutation (proteinase inhibitor [PI] ZZ). The Z allele produces a mutant AAT protein called Z-AAT, which accumulates in hepatocytes and can lead to progressive liver disease and fibrosis. This open-label, phase 2 trial investigated the safety and efficacy of fazirsiran, an RNA interference therapeutic, in patients with liver disease associated with AAT deficiency. METHODS We assigned adults with the PI ZZ genotype and liver fibrosis to receive fazirsiran at a dose of 200 mg (cohorts 1 [4 patients] and 2 [8 patients]) or 100 mg (cohort 1b [4 patients]) subcutaneously on day 1 and week 4 and then every 12 weeks. The primary end point was the change from baseline to week 24 (cohorts 1 and 1b) or week 48 (cohort 2) in liver Z-AAT concentrations, which were measured by means of liquid chromatography-mass spectrometry. RESULTS All the patients had reduced accumulation of Z-AAT in the liver (median reduction, 83% at week 24 or 48). The nadir in serum was a reduction of approximately 90%, and treatment was also associated with a reduction in histologic globule burden (from a mean score of 7.4 [scores range from 0 to 9, with higher scores indicating a greater globule burden] at baseline to 2.3 at week 24 or 48). All cohorts had reductions in liver enzyme concentrations. Fibrosis regression was observed in 7 of 15 patients and fibrosis progression in 2 of 15 patients after 24 or 48 weeks. There were no adverse events leading to trial or drug discontinuation. Four serious adverse events (viral myocarditis, diverticulitis, dyspnea, and vestibular neuronitis) resolved. CONCLUSIONS In this small trial, fazirsiran was associated with a strong reduction of Z-AAT concentrations in the serum and liver and concurrent improvements in liver enzyme concentrations. (Funded by Arrowhead Pharmaceuticals; AROAAT-2002 ClinicalTrials.gov number, NCT03946449.).
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Affiliation(s)
- Pavel Strnad
- From the Department of Internal Medicine III, University Hospital, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-LIVER), Aachen, Germany (P.S., C.T.); the Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, ERN RARE-LIVER, Vienna (M.M.); the Department of Respiratory Medicine, Royal Infirmary of Edinburgh University Hospital, University of Edinburgh, Edinburgh (G.C.), and the Department of Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge (W.G.) - both in the United Kingdom; the Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla (R.L.), and Arrowhead Pharmaceuticals, Pasadena (T.S., T.C., M.Y., B.D.G., J.C.H., J.S.M.) - both in California; and the Departments of Pediatrics and Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis (J.H.T.)
| | - Mattias Mandorfer
- From the Department of Internal Medicine III, University Hospital, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-LIVER), Aachen, Germany (P.S., C.T.); the Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, ERN RARE-LIVER, Vienna (M.M.); the Department of Respiratory Medicine, Royal Infirmary of Edinburgh University Hospital, University of Edinburgh, Edinburgh (G.C.), and the Department of Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge (W.G.) - both in the United Kingdom; the Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla (R.L.), and Arrowhead Pharmaceuticals, Pasadena (T.S., T.C., M.Y., B.D.G., J.C.H., J.S.M.) - both in California; and the Departments of Pediatrics and Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis (J.H.T.)
| | - Gourab Choudhury
- From the Department of Internal Medicine III, University Hospital, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-LIVER), Aachen, Germany (P.S., C.T.); the Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, ERN RARE-LIVER, Vienna (M.M.); the Department of Respiratory Medicine, Royal Infirmary of Edinburgh University Hospital, University of Edinburgh, Edinburgh (G.C.), and the Department of Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge (W.G.) - both in the United Kingdom; the Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla (R.L.), and Arrowhead Pharmaceuticals, Pasadena (T.S., T.C., M.Y., B.D.G., J.C.H., J.S.M.) - both in California; and the Departments of Pediatrics and Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis (J.H.T.)
| | - William Griffiths
- From the Department of Internal Medicine III, University Hospital, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-LIVER), Aachen, Germany (P.S., C.T.); the Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, ERN RARE-LIVER, Vienna (M.M.); the Department of Respiratory Medicine, Royal Infirmary of Edinburgh University Hospital, University of Edinburgh, Edinburgh (G.C.), and the Department of Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge (W.G.) - both in the United Kingdom; the Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla (R.L.), and Arrowhead Pharmaceuticals, Pasadena (T.S., T.C., M.Y., B.D.G., J.C.H., J.S.M.) - both in California; and the Departments of Pediatrics and Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis (J.H.T.)
| | - Christian Trautwein
- From the Department of Internal Medicine III, University Hospital, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-LIVER), Aachen, Germany (P.S., C.T.); the Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, ERN RARE-LIVER, Vienna (M.M.); the Department of Respiratory Medicine, Royal Infirmary of Edinburgh University Hospital, University of Edinburgh, Edinburgh (G.C.), and the Department of Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge (W.G.) - both in the United Kingdom; the Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla (R.L.), and Arrowhead Pharmaceuticals, Pasadena (T.S., T.C., M.Y., B.D.G., J.C.H., J.S.M.) - both in California; and the Departments of Pediatrics and Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis (J.H.T.)
| | - Rohit Loomba
- From the Department of Internal Medicine III, University Hospital, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-LIVER), Aachen, Germany (P.S., C.T.); the Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, ERN RARE-LIVER, Vienna (M.M.); the Department of Respiratory Medicine, Royal Infirmary of Edinburgh University Hospital, University of Edinburgh, Edinburgh (G.C.), and the Department of Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge (W.G.) - both in the United Kingdom; the Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla (R.L.), and Arrowhead Pharmaceuticals, Pasadena (T.S., T.C., M.Y., B.D.G., J.C.H., J.S.M.) - both in California; and the Departments of Pediatrics and Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis (J.H.T.)
| | - Thomas Schluep
- From the Department of Internal Medicine III, University Hospital, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-LIVER), Aachen, Germany (P.S., C.T.); the Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, ERN RARE-LIVER, Vienna (M.M.); the Department of Respiratory Medicine, Royal Infirmary of Edinburgh University Hospital, University of Edinburgh, Edinburgh (G.C.), and the Department of Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge (W.G.) - both in the United Kingdom; the Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla (R.L.), and Arrowhead Pharmaceuticals, Pasadena (T.S., T.C., M.Y., B.D.G., J.C.H., J.S.M.) - both in California; and the Departments of Pediatrics and Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis (J.H.T.)
| | - Ting Chang
- From the Department of Internal Medicine III, University Hospital, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-LIVER), Aachen, Germany (P.S., C.T.); the Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, ERN RARE-LIVER, Vienna (M.M.); the Department of Respiratory Medicine, Royal Infirmary of Edinburgh University Hospital, University of Edinburgh, Edinburgh (G.C.), and the Department of Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge (W.G.) - both in the United Kingdom; the Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla (R.L.), and Arrowhead Pharmaceuticals, Pasadena (T.S., T.C., M.Y., B.D.G., J.C.H., J.S.M.) - both in California; and the Departments of Pediatrics and Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis (J.H.T.)
| | - Min Yi
- From the Department of Internal Medicine III, University Hospital, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-LIVER), Aachen, Germany (P.S., C.T.); the Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, ERN RARE-LIVER, Vienna (M.M.); the Department of Respiratory Medicine, Royal Infirmary of Edinburgh University Hospital, University of Edinburgh, Edinburgh (G.C.), and the Department of Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge (W.G.) - both in the United Kingdom; the Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla (R.L.), and Arrowhead Pharmaceuticals, Pasadena (T.S., T.C., M.Y., B.D.G., J.C.H., J.S.M.) - both in California; and the Departments of Pediatrics and Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis (J.H.T.)
| | - Bruce D Given
- From the Department of Internal Medicine III, University Hospital, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-LIVER), Aachen, Germany (P.S., C.T.); the Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, ERN RARE-LIVER, Vienna (M.M.); the Department of Respiratory Medicine, Royal Infirmary of Edinburgh University Hospital, University of Edinburgh, Edinburgh (G.C.), and the Department of Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge (W.G.) - both in the United Kingdom; the Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla (R.L.), and Arrowhead Pharmaceuticals, Pasadena (T.S., T.C., M.Y., B.D.G., J.C.H., J.S.M.) - both in California; and the Departments of Pediatrics and Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis (J.H.T.)
| | - James C Hamilton
- From the Department of Internal Medicine III, University Hospital, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-LIVER), Aachen, Germany (P.S., C.T.); the Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, ERN RARE-LIVER, Vienna (M.M.); the Department of Respiratory Medicine, Royal Infirmary of Edinburgh University Hospital, University of Edinburgh, Edinburgh (G.C.), and the Department of Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge (W.G.) - both in the United Kingdom; the Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla (R.L.), and Arrowhead Pharmaceuticals, Pasadena (T.S., T.C., M.Y., B.D.G., J.C.H., J.S.M.) - both in California; and the Departments of Pediatrics and Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis (J.H.T.)
| | - Javier San Martin
- From the Department of Internal Medicine III, University Hospital, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-LIVER), Aachen, Germany (P.S., C.T.); the Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, ERN RARE-LIVER, Vienna (M.M.); the Department of Respiratory Medicine, Royal Infirmary of Edinburgh University Hospital, University of Edinburgh, Edinburgh (G.C.), and the Department of Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge (W.G.) - both in the United Kingdom; the Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla (R.L.), and Arrowhead Pharmaceuticals, Pasadena (T.S., T.C., M.Y., B.D.G., J.C.H., J.S.M.) - both in California; and the Departments of Pediatrics and Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis (J.H.T.)
| | - Jeffery H Teckman
- From the Department of Internal Medicine III, University Hospital, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-LIVER), Aachen, Germany (P.S., C.T.); the Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, ERN RARE-LIVER, Vienna (M.M.); the Department of Respiratory Medicine, Royal Infirmary of Edinburgh University Hospital, University of Edinburgh, Edinburgh (G.C.), and the Department of Hepatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge (W.G.) - both in the United Kingdom; the Division of Gastroenterology, University of California San Diego School of Medicine, La Jolla (R.L.), and Arrowhead Pharmaceuticals, Pasadena (T.S., T.C., M.Y., B.D.G., J.C.H., J.S.M.) - both in California; and the Departments of Pediatrics and Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis (J.H.T.)
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