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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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2
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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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3
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Afsharinasab M, Akbari AH, Mirzaei V, Mahmoodi M, Hajizadeh MR, Amri J, Khoshdel A. The investigation of the frequency of the alpha-1-antitrypsin phenotype in patients with liver cirrhosis. Horm Mol Biol Clin Investig 2022; 43:397-403. [PMID: 35973212 DOI: 10.1515/hmbci-2022-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 05/23/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Alpha-1-antitrypsin (AAT) has different phenotypes. Evidence suggests that the abundance of each of these phenotypes may be associated with a disease. The purpose of this study was to evaluate the frequency of AAT phenotypes in patients with liver cirrhosis as well as in healthy individuals. METHODS In this study, 42 patients with liver cirrhosis were selected. The results of the previous research done by the researcher on healthy individuals were used to construct the control group. After obtaining informed consent, 5 mL of fasting venous blood sample was taken, and phenotypes were analyzed by isoelectric focusing. Data were analyzed using Chi-square and Fisher's exact tests at a significant level of 0.05. RESULTS The results of this study indicated that all 42 healthy subjects had an MM allele (100%). However, among 42 patients, 35 (83.3%) had an MM allele, 5 (11.9%) had an MS allele, and 2 (4.8%) had MZ allele. The difference between the two groups was significant (p=0.02). There was no difference between men and women in the allele type (p=0.557). CONCLUSIONS This study revealed that MS and MZ alleles were observed only in patients with liver cirrhosis, and none of these alleles were found in healthy subjects. Therefore, MS and MZ alleles can be further investigated as risk factors for liver cirrhosis.
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Affiliation(s)
- Mehdi Afsharinasab
- Department of Clinical Biochemistry, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran.,Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Akbari
- Molecular Medicine Research Center, Institute of Basic Medical Sciences Research, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Vahid Mirzaei
- Department of Internal Medicine, School of Medicine, and Physiology-Pharmacology Research Center, Ali Ibn Abitaleb Educational and Tretment Hospital, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Mehdi Mahmoodi
- Molecular Medicine Research Center, Institute of Basic Medical Sciences Research, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.,Department of Clinical Biochemistry, Afzalipoor Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Reza Hajizadeh
- Molecular Medicine Research Center, Institute of Basic Medical Sciences Research, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.,Department of Clinical Biochemistry, Faculty of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Jamal Amri
- Department of Clinical Biochemistry, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran.,Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Khoshdel
- Department of Clinical Biochemistry, Nervous System Stem Cells Research Center, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran.,Department of Clinical Biochemistry, Faculty of Medicine, and Pistachio Safety Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
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Ghosh AJ, Hobbs BD, Moll M, Saferali A, Boueiz A, Yun JH, Sciurba F, Barwick L, Limper AH, Flaherty K, Criner G, Brown KK, Wise R, Martinez FJ, Lomas D, Castaldi PJ, Carey VJ, DeMeo DL, Cho MH, Silverman EK, Hersh CP. Alpha-1 Antitrypsin MZ Heterozygosity Is an Endotype of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2022; 205:313-323. [PMID: 34762809 PMCID: PMC8886988 DOI: 10.1164/rccm.202106-1404oc] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 11/09/2021] [Indexed: 02/03/2023] Open
Abstract
Rationale: Multiple studies have demonstrated an increased risk of chronic obstructive pulmonary disease (COPD) in heterozygous carriers of the AAT (alpha-1 antitrypsin) Z allele. However, it is not known if MZ subjects with COPD are phenotypically different from noncarriers (MM genotype) with COPD. Objectives: To assess if MZ subjects with COPD have different clinical features compared with MM subjects with COPD. Methods: Genotypes of SERPINA1 were ascertained by using whole-genome sequencing data in three independent studies. We compared outcomes between MM subjects with COPD and MZ subjects with COPD in each study and combined the results in a meta-analysis. We performed longitudinal and survival analyses to compare outcomes in MM and MZ subjects with COPD over time. Measurements and Main Results: We included 290 MZ subjects with COPD and 6,184 MM subjects with COPD across the three studies. MZ subjects had a lower FEV1% predicted and greater quantitative emphysema on chest computed tomography scans compared with MM subjects. In a meta-analysis, the FEV1 was 3.9% lower (95% confidence interval [CI], -6.55% to -1.26%) and emphysema (the percentage of lung attenuation areas <-950 HU) was 4.14% greater (95% CI, 1.44% to 6.84%) in MZ subjects. We found one gene, PGF (placental growth factor), to be differentially expressed in lung tissue from one study between MZ subjects and MM subjects. Conclusions: Carriers of the AAT Z allele (those who were MZ heterozygous) with COPD had lower lung function and more emphysema than MM subjects with COPD. Taken with the subtle differences in gene expression between the two groups, our findings suggest that MZ subjects represent an endotype of COPD.
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Affiliation(s)
- Auyon J. Ghosh
- Channing Division of Network Medicine and
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Brian D. Hobbs
- Channing Division of Network Medicine and
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Matthew Moll
- Channing Division of Network Medicine and
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Adel Boueiz
- Channing Division of Network Medicine and
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Jeong H. Yun
- Channing Division of Network Medicine and
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Frank Sciurba
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Andrew H. Limper
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kevin Flaherty
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Gerard Criner
- Department of Thoracic Medicine and Surgery, Temple University, Philadelphia, Pennsylvania
| | - Kevin K. Brown
- Department of Medicine, National Jewish Health, Denver, Colorado
| | - Robert Wise
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Fernando J. Martinez
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York; and
| | - David Lomas
- University College London Respiratory Division of Medicine, University College London, London, United Kingdom
| | - Peter J. Castaldi
- Channing Division of Network Medicine and
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Vincent J. Carey
- Channing Division of Network Medicine and
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Dawn L. DeMeo
- Channing Division of Network Medicine and
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Michael H. Cho
- Channing Division of Network Medicine and
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Edwin K. Silverman
- Channing Division of Network Medicine and
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Craig P. Hersh
- Channing Division of Network Medicine and
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
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5
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Bhattacharya PT, Fox AN, Marboe CC, Lagana SM, Remotti HE, D'Armiento JM, Goldklang MP, Eisenberger AB, Griffin JM, Maurer MS. Can lightning strike twice? Wild-type transthyretin cardiac amyloidosis associated with rare liver disease. Oxf Med Case Reports 2021; 2021:omab113. [PMID: 34858627 PMCID: PMC8633595 DOI: 10.1093/omcr/omab113] [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: 07/09/2021] [Revised: 08/17/2021] [Accepted: 10/14/2021] [Indexed: 11/24/2022] Open
Abstract
Wild-type ATTR cardiac amyloidosis (ATTRwt-CA) is not as rare as previously thought to be. Patients with infiltrative cardiac amyloidosis often present with right-sided heart failure (HF) symptomatology. Clinically significant liver disease and cirrhosis has not been reported in ATTRwt-CA. We present two cases of ATTRwt-CA with right-sided HF and abnormal liver function tests initially thought to be secondary to congestive hepatopathy but found to have rare and unrelated liver disease. These cases highlight the importance of developing a broad differential diagnosis and leveraging a multidisciplinary team approach in evaluating patients for unusual causes of cirrhosis/other chronic liver diseases when ATTR cardiac amyloidosis patients present with congestive hepatopathy.
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Affiliation(s)
| | - Alyson N Fox
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Charles C Marboe
- Department of Pathology & Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Stephen M Lagana
- Department of Pathology & Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Helen E Remotti
- Department of Pathology & Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jeanine M D'Armiento
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Monica P Goldklang
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Andrew B Eisenberger
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Jan M Griffin
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Mathew S Maurer
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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6
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Martinez-González C, Blanco I, Diego I, Bueno P, Miravitlles M. Estimated Prevalence and Number of PiMZ Genotypes of Alpha-1 Antitrypsin in Seventy-Four Countries Worldwide. Int J Chron Obstruct Pulmon Dis 2021; 16:2617-2630. [PMID: 34556982 PMCID: PMC8455519 DOI: 10.2147/copd.s327803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 09/03/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The α-1 antitrypsin (AAT) protease inhibitor PiMZ is a moderately deficient genotype, until recently considered of little or negligible risk. However, a growing number of studies show that MZ carriers have an increased risk of developing lung and liver diseases, if exposed to smoking or other airborne or industrial pollutants, and hepatotoxic substances. METHODS We used the epidemiological studies performed to determine the frequencies of PiM and PiZ worldwide, based on the following criteria: 1) samples representative of the general population; 2) AAT phenotyping or genotyping characterized by adequate methods, including isoelectric focusing and polymerase chain reaction; and 3) studies with reliable results assessed with a coefficient of variation calculated from the sample size and 95% confidence intervals, to measure the precision of the results in terms of dispersion of the data around the mean. RESULTS The present review reveals an impressive number of MZs of more than 35 million in 74 countries of the world with available data. Seventy-five percent of them are people of Caucasian European heritage, mostly living in Europe, America, Australia and New Zealand. Twenty percent of the remaining MZs live in Asia, with the highest concentrations in the Middle East, Eastern¸ Southern, and South-eastern regions of the Asian continent. The remaining five percent are Africans residing in Western and Eastern Africa. CONCLUSION Considering the high rate of smoking, the outdoor and the indoor air pollution from solid fuels used in cooking and heating, and the exposure to industrial dusts and chemicals in many of these countries, these figures are very worrying, and hence the importance of adequately assessing MZ subjects, recommending them rigorous preventive measures based on the adoption of healthy lifestyles, including avoidance of smoking and alcohol.
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Affiliation(s)
- Cristina Martinez-González
- Pulmonology Department, University Central Hospital of Asturias, Universidad de Oviedo, Instituto de Investigación del Principado de Asturias (ISPA), Oviedo, Spain
| | - Ignacio Blanco
- Alpha1-Antitrypsin Deficiency Spanish Registry (REDAAT), Spanish Society of Pneumology and Thoracic Surgery (SEPAR), Barcelona, Spain
| | - Isidro Diego
- Materials and Energy Department, School of Mining Engineering, Oviedo University, Oviedo, Spain
| | - Patricia Bueno
- Internal Medicine Department, County Hospital of Jarrio, Jarrio, Spain
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall d’Hebron/Vall d’Hebron Research Institute (VHIR), Vall d’Hebron Barcelona Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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7
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Abu Rmilah A, Fencl R, Watt K, Krowka M, Wiesner R, Murray D, Nyberg S, Leise M. Association of α 1 Antitrypsin Phenotype and Development of Advanced Liver Disease and Pulmonary Complications Before and After Liver Transplantation. Transplantation 2021; 105:1576-1584. [PMID: 32732616 DOI: 10.1097/tp.0000000000003390] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The role of MZ phenotype of α 1 antitrypsin (α1AT) deficiency as a potential cofactor in advanced liver disease arising from other primary causes is not widely understood. In the general population, MZ phenotype accounts for 2%-4% in Europe and 2%-7.1% in North America. The aim of this study was to determine the prevalence of the MZ phenotype among various causes of cirrhosis in the United States in the modern era and its impact on pulmonary function before and after liver transplantation. METHODS This retrospective study included adult patients with cirrhosis who underwent liver transplantation at Mayo Clinic. Participants' data including pathogenesis of cirrhosis, model for end-stage liver disease-Na score, α1AT phenotype, liver decompensation events, and pulmonary outcomes was determined by retrospective review of the liver transplantation database. RESULTS One hundred thirty of 1341 adult patients with cirrhosis (9.7%) were α1AT MZ carriers. When comparing the distribution of protease inhibitor (PI) MZ among different pathogenesis, the prevalence of MZ was significantly increased in nonalcoholic steatohepatitis (NASH), alcoholic liver disease (ALD), and cryptogenic cirrhosis compared with other causes. Thirty-seven of 171 with NASH (22%), 37 of 187 with ALD (20%), and 9 of 39 with cryptogenic cirrhosis (23.1%) were identified as PI MZ, while in other subgroups; we detected 18 of 320 with viral hepatitis, and 11 of 339 with primary biliary cholangitis/primary sclerosing cholangitis. Also, MZ patients were more likely to develop preoperative chronic obstructive lung disease, and postoperative pulmonary hypertension and pulmonary embolism than MM patients. CONCLUSIONS The rates of preoperative and postoperative pulmonary complications were found to be higher in PI MZ patients than in PI MM patients. The MZ phenotype was significantly enriched in NASH, ALD, and cryptogenic cirrhosis.
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Affiliation(s)
- Anan Abu Rmilah
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine, Rochester, MN
| | - Robert Fencl
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN
| | - Kymberly Watt
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine, Rochester, MN
| | - Michael Krowka
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine, Rochester, MN
| | - Russell Wiesner
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine, Rochester, MN
| | - David Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN
| | - Scott Nyberg
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine, Rochester, MN
| | - Michael Leise
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine, Rochester, MN
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Barjaktarevic I, Miravitlles M. Alpha-1 antitrypsin (AAT) augmentation therapy in individuals with the PI*MZ genotype: a pro/con debate on a working hypothesis. BMC Pulm Med 2021; 21:99. [PMID: 33757485 PMCID: PMC7989144 DOI: 10.1186/s12890-021-01466-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 03/15/2021] [Indexed: 11/20/2022] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a significantly under-diagnosed genetic condition caused by reduced levels and/or functionality of alpha-1 antitrypsin (AAT), predisposing individuals to lung, liver or other systemic diseases. The management of individuals with the PI*MZ genotype, characterized by mild or moderate AAT deficiency, is less clear than of those with the most common severe deficiency genotype (PI*ZZ). Recent genetic data suggest that the PI*MZ genotype may be significantly more prevalent than currently thought. The only specific treatment for lung disease associated with severe AATD is the intravenous infusion of AAT augmentation therapy, which has been shown to slow disease progression in PI*ZZ individuals. There is no specific evidence for the clinical benefit of AAT therapy in PI*MZ individuals, and the risk of emphysema development in this group remains controversial. As such, current guidelines do not support the use of AAT augmentation in PI*MZ individuals. Here, we discuss the limited data on the PI*MZ genotype and offer pro and con perspectives on pursuing an AAT-specific therapeutic strategy in PI*MZ individuals with lung disease. Ultimately, further research to demonstrate the safety, risk/benefit balance and efficacy of AAT therapy in PI*MZ individuals is needed.
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Affiliation(s)
- Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitari Vall D'Hebron, Vall D'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Campus, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.
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Alpha-1 Antitrypsin Deficiency and Pulmonary Morbidity in Patients with Primary Immunodeficiency Disease: A Single-Center Experience. Can Respir J 2020; 2020:4019608. [PMID: 32566054 PMCID: PMC7273390 DOI: 10.1155/2020/4019608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 04/22/2020] [Accepted: 05/06/2020] [Indexed: 01/20/2023] Open
Abstract
Background Alpha-1 antitrypsin deficiency (AATD) is of importance in the pathogenesis of pulmonary emphysema, chronic obstructive pulmonary diseases (COPD), and bronchiectasis. Various pulmonary disorders are a typical feature of primary immunodeficiency disease (PID). This includes recurrent pulmonary infections, immunodysregulation, and autoinflammatory diseases. As a result, incidence of acute and chronic pulmonary diseases is higher. Interestingly, pulmonary morbidity in PID and AATD share similar features. To study the coexistence of AATD in patients suffering from PID, we performed the underlying investigation. Methods We evaluated a study group of 149 patients (n = 149) with PID. In total, serum AAT concentrations were available for 110 patients (n = 110). For the identified patients, we analyzed both clinical associations and interactions. Results Among the investigated patients, reduced serum AAT levels were detected in 7 patients. With regard to the genotype, PI∗ZZ was found in 2 patients, whereas PI∗MZ was observed in 5 patients. Independent of the underlying phenotype, obstructive lung diseases were found in 2 patients with PI∗ZZ and 2 patients with PI∗MZ. Conclusions In Germany, the estimated percentage for PI∗ZZ and PI∗MZ is 0.01% and 1.9%, respectively. As demonstrated, the ratio in our study group was even higher. We identified seven patients with AATD. Since AATD contributes to pulmonary morbidity in PID patients, systematic underdiagnosis of the coexistence might yield a strong clinical impact. Hence, AAT analysis should be offered to all patients with confirmed PID diagnoses. To strengthen this finding, we suggest the investigation of larger databases.
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Cortes-Lopez R, Barjaktarevic I. Alpha-1 Antitrypsin Deficiency: a Rare Disease? Curr Allergy Asthma Rep 2020; 20:51. [PMID: 32572624 DOI: 10.1007/s11882-020-00942-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Commonly categorized as a rare disease, alpha-1 antitrypsin deficiency (AATD) is neither rare, when compared to many other genetic disorders, nor an actual disease, but rather a predisposition toward a wide variety of diseases. It is one of the most common genetic disorders which can lead to a spectrum of clinical manifestations, ranging from no symptoms to progressively debilitating systemic disease, most commonly affecting the lung and liver. It is therefore imperative for clinicians to recognize and be familiar with the spectrum of presentations, methods of diagnosis, and clinical management of AATD. It is also imperative for scientists to recognize the potential for progress in the management of this disorder. RECENT FINDINGS This review focuses on the current state of knowledge of AATD, including the wide range of presentations, diagnosis, and clinical management. In addition to the clinical implications of severe AATD, we discuss the relevance of heterozygous state with mild or moderate AATD in the development of both lung and liver disease. While our understanding of the multiple roles of alpha-1 antitrypsin (AAT) is on the rise, with appreciation of its immunomodulatory, anti-infective, and anti-inflammatory properties, this knowledge has yet to impact our ability to predict outcomes. We discuss nuances of augmentation therapy and review novel therapeutic approaches currently under investigation. With the expanding knowledge about the complexities of AAT function and its clinical relevance, and with the increasing ability to diagnose early and intervene on AATD, it should be our goal to change the perception of AATD as a correctable inherited disorder rather than a fatal disease.
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Affiliation(s)
- Roxana Cortes-Lopez
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, CHS, Los Angeles, CA, 90095, USA
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, CHS, Los Angeles, CA, 90095, USA.
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Dummer J, Dobler CC, Holmes M, Chambers D, Yang IA, Parkin L, Smith S, Wark P, Dev A, Hodge S, Dabscheck E, Gooi J, Samuel S, Knowles S, Holland AE. Diagnosis and treatment of lung disease associated with alpha one-antitrypsin deficiency: A position statement from the Thoracic Society of Australia and New Zealand. Respirology 2020; 25:321-335. [PMID: 32030868 PMCID: PMC7078913 DOI: 10.1111/resp.13774] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/27/2019] [Accepted: 01/10/2020] [Indexed: 12/18/2022]
Abstract
AATD is a common inherited disorder associated with an increased risk of developing pulmonary emphysema and liver disease. Many people with AATD-associated pulmonary emphysema remain undiagnosed and therefore without access to care and counselling specific to the disease. AAT augmentation therapy is available and consists of i.v. infusions of exogenous AAT protein harvested from pooled blood products. Its clinical efficacy has been the subject of some debate and the use of AAT augmentation therapy was recently permitted by regulators in Australia and New Zealand, although treatment is not presently subsidized by the government in either country. The purpose of this position statement is to review the evidence for diagnosis and treatment of AATD-related lung disease with reference to the Australian and New Zealand population. The clinical efficacy and adverse events of AAT augmentation therapy were evaluated by a systematic review, and the GRADE process was employed to move from evidence to recommendation. Other sections address the wide range of issues to be considered in the care of the individual with AATD-related lung disease: when and how to test for AATD, changing diagnostic techniques, monitoring of progression, disease in heterozygous AATD and pharmacological and non-pharmacological therapy including surgical options for severe disease. Consideration is also given to broader issues in AATD that respiratory healthcare staff may encounter: genetic counselling, patient support groups, monitoring for liver disease and the need to establish national registries for people with AATD in Australia and New Zealand.
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Affiliation(s)
- Jack Dummer
- Department of Medicine, Dunedin School of MedicineUniversity of OtagoDunedinNew Zealand
| | - Claudia C. Dobler
- Institute for Evidence‐Based HealthcareBond University and Gold Coast University HospitalGold CoastQLDAustralia
- Department of Respiratory MedicineLiverpool HospitalSydneyNSWAustralia
| | - Mark Holmes
- Department of Thoracic MedicineRoyal Adelaide HospitalAdelaideSAAustralia
- Faculty of MedicineThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Daniel Chambers
- Faculty of MedicineThe University of QueenslandBrisbaneQLDAustralia
- Queensland Lung Transplant ProgramThe Prince Charles HospitalBrisbaneQLDAustralia
| | - Ian A. Yang
- Faculty of MedicineThe University of QueenslandBrisbaneQLDAustralia
- Department of Thoracic MedicineThe Prince Charles HospitalBrisbaneQLDAustralia
| | - Lianne Parkin
- Department of Preventive and Social Medicine, Dunedin School of MedicineUniversity of OtagoDunedinNew Zealand
| | - Sheree Smith
- School of Nursing and MidwiferyWestern Sydney UniversitySydneyNSWAustralia
| | - Peter Wark
- Centre for Healthy LungsUniversity of NewcastleNewcastleNSWAustralia
- Department of Respiratory and Sleep MedicineJohn Hunter HospitalNew LambtonNSWAustralia
| | - Anouk Dev
- Department of GastroenterologyMonash HealthMelbourneVICAustralia
| | - Sandra Hodge
- Department of Thoracic MedicineRoyal Adelaide HospitalAdelaideSAAustralia
- Faculty of MedicineThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Eli Dabscheck
- Department of Respiratory MedicineAlfred HospitalMelbourneVICAustralia
- Department of Allergy, Immunology and Respiratory Medicine, Central Clinical SchoolMonash UniversityMelbourneVICAustralia
| | - Julian Gooi
- Department of Cardiothoracic SurgeryAlfred HospitalMelbourneVICAustralia
| | - Sameh Samuel
- Department of Respiratory MedicineWollongong HospitalWollongongNSWAustralia
- School of Medicine, University of WollongongWollongongNSWAustralia
| | | | - Anne E. Holland
- Department of Allergy, Immunology and Respiratory Medicine, Central Clinical SchoolMonash UniversityMelbourneVICAustralia
- Department of PhysiotherapyAlfred HealthMelbourneVICAustralia
- Institute for Breathing and SleepMelbourneVICAustralia
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Sandford AJ. Alpha-1 Antitrypsin Mutations: Is One Too Many? Am J Respir Crit Care Med 2020; 201:505-506. [PMID: 31810377 PMCID: PMC7047447 DOI: 10.1164/rccm.201911-2209ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Andrew J Sandford
- Centre for Heart Lung InnovationUniversity of British Columbia and St. Paul's HospitalVancouver, British Columbia, Canada
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Williams MS, Taylor CO, Walton NA, Goehringer SR, Aronson S, Freimuth RR, Rasmussen LV, Hall ES, Prows CA, Chung WK, Fedotov A, Nestor J, Weng C, Rowley RK, Wiesner GL, Jarvik GP, Del Fiol G. Genomic Information for Clinicians in the Electronic Health Record: Lessons Learned From the Clinical Genome Resource Project and the Electronic Medical Records and Genomics Network. Front Genet 2019; 10:1059. [PMID: 31737042 PMCID: PMC6830110 DOI: 10.3389/fgene.2019.01059] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 10/03/2019] [Indexed: 01/05/2023] Open
Abstract
Genomic knowledge is being translated into clinical care. To fully realize the value, it is critical to place credible information in the hands of clinicians in time to support clinical decision making. The electronic health record is an essential component of clinician workflow. Utilizing the electronic health record to present information to support the use of genomic medicine in clinical care to improve outcomes represents a tremendous opportunity. However, there are numerous barriers that prevent the effective use of the electronic health record for this purpose. The electronic health record working groups of the Electronic Medical Records and Genomics (eMERGE) Network and the Clinical Genome Resource (ClinGen) project, along with other groups, have been defining these barriers, to allow the development of solutions that can be tested using implementation pilots. In this paper, we present “lessons learned” from these efforts to inform future efforts leading to the development of effective and sustainable solutions that will support the realization of genomic medicine.
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Affiliation(s)
- Marc S Williams
- Genomic Medicine Institute, Geisinger, Danville, PA, United States
| | - Casey Overby Taylor
- Genomic Medicine Institute, Geisinger, Danville, PA, United States.,Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Nephi A Walton
- Genomic Medicine Institute, Geisinger, Danville, PA, United States
| | | | | | - Robert R Freimuth
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States
| | - Luke V Rasmussen
- Department of Preventive Medicine, Northwestern University, Chicago, IL, United States
| | - Eric S Hall
- Department of Pediatrics, University of Cincinnati College of Medicine, and Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Cynthia A Prows
- Divisions of Human Genetics and Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University, New York, NY, United States
| | - Alexander Fedotov
- Irving Institute for Clinical and Translational Research, Columbia University, New York, NY, United States
| | - Jordan Nestor
- Department of Medicine, Division of Nephrology, Columbia University, New York, NY, United States
| | - Chunhua Weng
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Robb K Rowley
- National Human Genome Research Institute, Bethesda, MD, United States
| | - Georgia L Wiesner
- Division of Genetic Medicine, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Gail P Jarvik
- Departments of Medicine (Medical Genetics) and Genome Sciences, University of Washington, Seattle, WA, United States
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
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