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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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Loomba R, Clark G, Teckman J, Ajmera V, Behling C, Brantly M, Brenner D, D'Armiento J, Fried MW, Iyer JS, Mandorfer M, Rockey DC, Tincopa M, Vuppalanchi R, Younossi Z, Krag A, Turner AM, Strnad P. Review article: New developments in biomarkers and clinical drug development in alpha-1 antitrypsin deficiency-related liver disease. Aliment Pharmacol Ther 2024; 59:1183-1195. [PMID: 38516814 DOI: 10.1111/apt.17967] [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: 12/18/2023] [Revised: 01/04/2024] [Accepted: 03/12/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Alpha-1 antitrypsin liver disease (AATLD) occurs in a subset of patients with alpha-1 antitrypsin deficiency. Risk factors for disease progression and specific pathophysiologic features are not well known and validated non-invasive assessments for disease severity are lacking. Currently, there are no approved treatments for AATLD. AIMS To outline existing understanding of AATLD and to identify knowledge gaps critical to improving clinical trial design and development of new treatments. METHODS This report was developed following a multi-stakeholder forum organised by the Alpha-1 Antitrypsin Deficiency Related Liver Disease Expert Panel in which experts presented an overview of the available literature on this topic. RESULTS AATLD results from a 'gain of toxic function' and primarily manifests in those with the homozygous Pi*ZZ genotype. Accumulation of misfolded 'Z' AAT protein in liver cells triggers intracellular hepatocyte injury which may ultimately lead to hepatic fibrosis. Male gender, age over 50 years, persistently elevated liver tests, concomitant hepatitis B or C virus infection, and metabolic syndrome, including obesity and type 2 diabetes mellitus, are known risk factors for adult AATLD. While the gold standard for assessing AATLD disease activity is liver histology, less invasive measures with low intra- and inter-observer variability are needed. Measurement of liver stiffness shows promise; validated thresholds for staging AATLD are in development. Such advances will help patients by enabling risk stratification and personalised surveillance, along with streamlining the development process for novel therapies. CONCLUSIONS This inaugural forum generated a list of recommendations to address unmet needs in the field of AATLD.
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Affiliation(s)
- Rohit Loomba
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Ginger Clark
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jeff Teckman
- Pediatrics and Biochemistry, St. Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Veeral Ajmera
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Cynthia Behling
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California San Diego, San Diego, California, USA
- Pacific Rim Pathology Lab, San Diego, California, USA
| | - Mark Brantly
- Division of Pulmonary, Critical Care & Sleep Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - David Brenner
- Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California, USA
| | - Jeanine D'Armiento
- Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | | | | | - Mattias Mandorfer
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Don C Rockey
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Monica Tincopa
- University of California San Diego, San Diego, California, USA
| | - Raj Vuppalanchi
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | | | - Pavel Strnad
- University Hospital RWTH Aachen, Healthcare Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany
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Mornex JF, Traclet J, Guillaud O, Dechomet M, Lombard C, Ruiz M, Revel D, Reix P, Cottin V. Alpha1-antitrypsin deficiency: An updated review. Presse Med 2023; 52:104170. [PMID: 37517655 DOI: 10.1016/j.lpm.2023.104170] [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: 03/17/2023] [Revised: 05/07/2023] [Accepted: 07/19/2023] [Indexed: 08/01/2023] Open
Abstract
Alpha1-antitrypsin deficiency (AATD) is a rare autosomal recessive disease associated with the homozygous Z variant of the SERPINA1 gene. Clinical expression of AATD, reported 60 years ago associate a severe deficiency, pulmonary emphysema and/or liver fibrosis. Pulmonary emphysema is due to the severe alpha1-antitrypsin deficiency of the ZZ homozygous status and is favored by smoking. Liver fibrosis is due to the ZZ homozygous status and is favored by obesity and excessive chronic alcohol intake, with a risk of liver cancer. Diagnosis is based on serum level and either isoelectric focusing determination of the biochemical phenotype or PCR detection of some variants. SERPINA1 gene sequencing is necessary in case of discrepancies between the results of these tests. No treatment is available for the liver disease in AATD. Although no specific trial has been performed, COPD in AATD should be treated as per COPD recommendations. Based on a randomized clinical trial, augmentation therapy is indicated in non-smoking adults less than 70 years of age with emphysema at chest CT, confirmed homozygous AATD, and FEV1 between 35% and 70% of predicted. In contrast Z heterozygosis (MZ or SZ) brings a risk of lung or liver disease only in association with further risk factors. Early detection, in all patients with COPD and chronic liver disease, is critical for the correct information of Z variant carriers. News ways of correcting the liver production of alpha1-antitrypsin will modify the care of AATD patients.
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Affiliation(s)
- Jean-François Mornex
- Université de Lyon, université Lyon 1, INRAE, EPHE, UMR754, IVPC, F-69007 Lyon, France; Centre de référence des maladies pulmonaires rares, Orphalung, RESPIFIL, ERN-LUNG, F-69500 Bron, France; Hospices civils de Lyon, hôpital Louis-Pradel, service de pneumologie, F-69500 Bron, France; Inserm, hospices civils de Lyon, CIC 1407, F-69500 Bron, France.
| | - Julie Traclet
- Centre de référence des maladies pulmonaires rares, Orphalung, RESPIFIL, ERN-LUNG, F-69500 Bron, France; Hospices civils de Lyon, hôpital Louis-Pradel, service de pneumologie, F-69500 Bron, France
| | - Olivier Guillaud
- Ramsay générale de santé, clinique de la Sauvegarde, F-69009 Lyon, France; Hospices civils de Lyon, hôpital Edouard Herriot, Fédération des spécialités digestives, F-69003 Lyon, France
| | - Magali Dechomet
- Hospices civils de Lyon, hôpital Lyon sud, service d'immunologie biologique, F-69495 Pierre Bénite, France
| | - Christine Lombard
- Hospices civils de Lyon, hôpital Lyon sud, service d'immunologie biologique, F-69495 Pierre Bénite, France
| | - Mathias Ruiz
- Centre de référence de l'atrésie des voies biliaires et des cholestases génétiques, FILFOIE, F-69500 Bron, France; Hospices civils de Lyon, hôpital femme mère enfant, service d'hépatologie, gastroentérologie et nutrition pédiatrique, F-69500 Bron, France
| | - Didier Revel
- Hospices civils de Lyon, hôpital Louis Pradel, service d'imagerie, F-69500 Bron, France
| | - Philippe Reix
- Service de pneumologie, allergologie pédiatrique. Hôpital Femme Mère Enfant. Hospices civils de Lyon, F-69500 Bron, France; Université de Lyon, université Lyon, CNRS, UMR 5558, équipe EMET, F-69100 Villeurbanne, France
| | - Vincent Cottin
- Université de Lyon, université Lyon 1, INRAE, EPHE, UMR754, IVPC, F-69007 Lyon, France; Centre de référence des maladies pulmonaires rares, Orphalung, RESPIFIL, ERN-LUNG, F-69500 Bron, France; Hospices civils de Lyon, hôpital Louis-Pradel, service de pneumologie, F-69500 Bron, France
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Roche SM, Carroll TP, Fraughen DD, McElvaney NG. Alpha-1 Antitrypsin Deficiency and Smoking Cessation: Tackling the Burden of COPD One Test at a Time? Chest 2023; 163:e197. [PMID: 37031997 DOI: 10.1016/j.chest.2022.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 10/14/2022] [Indexed: 04/11/2023] Open
Affiliation(s)
- Suzanne M Roche
- Department of Medicine, Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland; National Centre for Expertise in AATD, Beaumont Hospital, Dublin, Ireland.
| | - Tomás P Carroll
- Department of Medicine, Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland; National Centre for Expertise in AATD, Beaumont Hospital, Dublin, Ireland
| | - Daniel D Fraughen
- Department of Medicine, Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland; National Centre for Expertise in AATD, Beaumont Hospital, Dublin, Ireland
| | - Noel G McElvaney
- Department of Medicine, Irish Centre for Genetic Lung Disease, Royal College of Surgeons in Ireland, Dublin, Ireland; National Centre for Expertise in AATD, Beaumont Hospital, Dublin, Ireland
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Stoller JK, Ashenhurst JR, Nhan H, Shelton JF, Wu S, Tung JY, Elson SL. Response. Chest 2023; 163:e198. [PMID: 37031998 DOI: 10.1016/j.chest.2022.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 12/09/2022] [Indexed: 04/11/2023] Open
Affiliation(s)
- James K Stoller
- Education Institute and Respiratory Institute, Cleveland Clinic, Cleveland, OH.
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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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Mornex JF. [Alpha 1-antitrypsin deficiency]. Rev Mal Respir 2022; 39:698-707. [PMID: 35715315 DOI: 10.1016/j.rmr.2022.02.062] [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: 05/23/2021] [Accepted: 02/26/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pulmonary emphysema and liver disease are the clinical expressions of alpha 1-antitrypsin deficiency, an autosomal recessive genetic disease. STATE OF THE ART Alpha 1-antitrypsin deficiency is usually associated with the homozygous Z variant of the SERPINA1 gene. Its clinical expression always consists in a substantial reduction of alpha 1-antitrypsin serum concentration and its variants are analyzed by isoelectric focalization or molecular techniques. Assessed by CO transfer alteration and CT scan, risk of pulmonary emphysema is increased by tobacco consumption. Assessed by transient elastography and liver ultrasound, risk of liver disease is increased by alcohol consumption or obesity. Treatment of COPD-associated alpha 1-antitrypsin deficiency does not differ from that of other forms of COPD. In patients presenting with severe deficiency, augmentation therapy with plasma-derived alpha 1-antitrypsin reduces the progression of emphysema, as shown in terms of CT-based lung density metrics. Patients with alpha 1-antitrypsin deficiency with a ZZ genotype should refrain from alcohol or tobacco consumption, and watch their weight; so should their close relatives. PERSPECTIVES Modulation of alpha 1-antitrypsin liver production offers an interesting new therapeutic perspective. CONCLUSION Homozygous (Z) variants of the SERPINA1 gene confer an increased risk of pulmonary emphysema and liver disease, particularly among smokers, drinkers and obese persons.
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Affiliation(s)
- J-F Mornex
- Université de Lyon, université Lyon 1, INRAE, EPHE, UMR754, IVPC, Lyon, France; Centre de référence des maladies respiratoires rares, Orphalung, RESPIFIL, 69500 Bron, Bron, France; Service de pneumologie, hôpital Louis-Pradel, hospices civils de Lyon, 69500 Bron, France.
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Miravitlles M, Herepath M, Priyendu A, Sharma S, Vilchez T, Vit O, Haensel M, Lepage V, Gens H, Greulich T. Disease burden associated with alpha-1 antitrypsin deficiency: systematic and structured literature reviews. Eur Respir Rev 2022; 31:210262. [PMID: 35321931 PMCID: PMC9488933 DOI: 10.1183/16000617.0262-2021] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/24/2022] [Indexed: 12/14/2022] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a rare genetic disorder characterised by reduced levels of circulating alpha-1 antitrypsin and an increased risk of lung and liver disease. Recent reviews of AATD have focused on diagnosis, epidemiology and clinical management; comprehensive reviews examining disease burden are lacking. Therefore, we conducted literature reviews to investigate the AATD disease burden for patients, caregivers and healthcare systems. Embase, PubMed and Cochrane libraries were searched for AATD publications from database inception to June 2021, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Most published AATD studies were small and short in duration, with variations in populations, designs, measures and outcomes, complicating cross-study comparisons. AATD was associated with significant pulmonary and hepatic morbidity. COPD, emphysema and bronchiectasis were common lung morbidities, where smoking was a key risk factor. Fibrosis and steatosis were the most common liver complications reported in patients with a PiZ allele. Health status analyses suggested a poorer quality of life for AATD patients diagnosed with COPD versus those with non-AATD-associated COPD. The burden for caregivers included loss of personal time due to caring responsibilities, stress and anxiety. AATD was also associated with high direct medical costs and healthcare resource utilisation.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Dept, Hospital Universitari Vall d'Hebron/Vall d'Hebron Research Institute (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | | | - Asim Priyendu
- Access Consulting, HEOR, Parexel International, Mohali, India
| | - Sheetal Sharma
- Access Consulting, HEOR, Parexel International, Mohali, India
| | | | | | | | | | | | - Timm Greulich
- Dept of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps-University, Centre for Lung Research (DZL), Marburg, Germany
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Ghosh AJ, Hobbs BD. Recent advancements in understanding the genetic involvement of alpha-1 antitrypsin deficiency associated lung disease: a look at future precision medicine approaches. Expert Rev Respir Med 2022; 16:173-182. [PMID: 35025710 PMCID: PMC8983484 DOI: 10.1080/17476348.2022.2027755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Alpha-1 antitrypsin deficiency occurs in individuals with deleterious genetic mutations on both chromosomes (maternal and paternal) in SERPINA1, the gene encoding the alpha-1 antitrypsin protein. There has been substantial progress in understanding the genetic variation that underlies the heterogeneous penetrance of lung disease in alpha-1 antitrypsin deficiency. AREAS COVERED This review will cover SERPINA1 gene structure and genetic variation, population genetics, genome-wide genetic modifiers of lung disease, alternative mechanisms of disease, and emerging therapeutics - including gene and cell therapy - related to alpha-1 antitrypsin deficiency-associated lung disease. EXPERT OPINION There remains ample opportunity to employ precision medicine in the diagnosis, prognosis, and therapy of alpha-1 antitrypsin deficiency-associated lung disease. In particular, a genome-wide association study and subsequent polygenic risk score is an important first step in identifying genome-wide genetic modifiers contributing to the variability of lung disease in severe alpha-1 antitrypsin deficiency.
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Affiliation(s)
- Auyon J. Ghosh
- Assistant Professor of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, SUNY Upstate Medical University, 750 E. Adams St, Syracuse, NY, 13210
| | - Brian D. Hobbs
- Assistant Professor of Medicine, Channing Division of Network Medicine, Brigham and Women’s Hospital, 181 Longwood Ave, Boston, MA, 02115,Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital,Harvard Medical School
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Hiller AM, Piitulainen E, Tanash H. The Clinical Course of Severe Alpha-1-Antitrypsin Deficiency in Patients Identified by Screening. Int J Chron Obstruct Pulmon Dis 2022; 17:43-52. [PMID: 35023912 PMCID: PMC8743380 DOI: 10.2147/copd.s340241] [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: 09/20/2021] [Accepted: 12/06/2021] [Indexed: 11/23/2022] Open
Abstract
Background Severe alpha-1-antitrypsin deficiency (AATD) is a genetic condition predisposing to chronic obstructive pulmonary disease (COPD) and liver disease. Its natural course is not well known. Our aim was to study the natural course of AATD by analyzing the clinical course in individuals with severe AATD identified by screening. Materials and Methods Of the 1585 individuals included in the Swedish AATD register, 377 (24%) were identified by screening and included in this retrospective study. The follow-up time was from the date of inclusion in the register to the first lung transplantation, death or the termination of the study on June 1st, 2016. The risk factors for having a diagnosis of COPD were investigated through a proportional hazards model, adjusted for sex, diagnosis before the age of 14 years, smoking habits, occupational exposure to airway irritants and respiratory symptoms or diseases. Results At inclusion, 71% of the individuals were asymptomatic, ie, without any respiratory symptoms. Compared to the 156 (41%) ever-smokers, the 221 (59%) never-smokers had better lung function (mean FEV1 98 (SD 18) vs 85 (SD 28) % predicted; p < 0.001), and fewer of them were symptomatic, ie, with respiratory symptoms, at inclusion (20% vs 42%; p < 0.001). They also had a lower annual decline in FEV1 (mean 42 (95% CI 36-47) vs 53 (95% CI 47-60) mL·yr-1; p = 0.011) and better survival than the ever-smokers. The risk factors for having a diagnosis of COPD were the identification of severe AATD at an age of ≥14 years and the presence of respiratory symptoms or diseases. Conclusion Never-smoking individuals with severe AATD identified by screening have better lung function, fewer symptoms, and better survival compared with the ever-smokers. Screening for AATD at an early age may improve the prognosis of AATD.
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Affiliation(s)
- Adriana-Maria Hiller
- Department of Respiratory Medicine and Allergology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Eeva Piitulainen
- Department of Respiratory Medicine and Allergology, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Hanan Tanash
- Department of Respiratory Medicine and Allergology, Lund University, Skåne University Hospital, Malmö, Sweden
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11
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Schramm GR, Mostafavi B, Piitulainen E, Wollmer P, Tanash HA. Lung Function and Health Status in Individuals with Severe Alpha-1-Antitrypsin Deficiency at the Age of 42. Int J Chron Obstruct Pulmon Dis 2022; 16:3477-3485. [PMID: 34992356 PMCID: PMC8711559 DOI: 10.2147/copd.s335683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 11/14/2021] [Indexed: 11/23/2022] Open
Abstract
Background Severe hereditary alpha-1-antitrypsin deficiency (AATD) is a known risk factor for the early development of pulmonary emphysema and COPD, especially in smokers. By the Swedish national screening programme carried out from 1972 to 1974, a cohort of individuals with severe (PiZZ) AATD was identified and has been followed up regularly. The aim of this study was to investigate health status, quality of life and lung function in this cohort at the age of 42 years compared with an age-matched control group randomly selected from the population registry. Methods All study participants answered a questionnaire on smoking habits, symptoms, occupation, exposure to airway irritants and quality of life using Saint George’s Respiratory Questionnaire (SGRQ). They underwent complete pulmonary function tests (PFT) and forced oscillation technique (FOT) for the measurement of airway resistance and reactance. Blood samples were taken for allergies and IgG-subclasses as an indicator of increased risk of airway infections. Results The residual volume (RV), total lung capacity (TLC) and RV/TLC ratio were significantly higher in the PiZZ ever-smokers compared to the PiMM ever-smokers and PiZZ never-smokers (p < 0.05). The resistance in the upper, small and total airways was significantly lower in PiZZ subjects compared to PiMM subjects (p < 0.05). A greater proportion of PiZZ never-smokers had an FEV1/VC ratio <0.7 than PiMM never-smokers (p = 0.043). PiZZ subjects with occupational exposure to airway irritants showed a significantly lower FEV1, VC and higher RV/TLC ratio than PiMM individuals with exposure (p < 0.05). Conclusion At the age of 42, ever-smoking PiZZ individuals have signs of COPD, and also PiZZ never-smokers have early, physiological signs of emphysema.
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Affiliation(s)
- Georg Rüdiger Schramm
- Department of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Behrouz Mostafavi
- Department of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Eeva Piitulainen
- Department of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Per Wollmer
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Hanan A Tanash
- Department of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Malmö, Sweden
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12
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Steele L, Mitchell CD, Shipman AR, Shipman KE. <<Alpha-1 antitrypsin deficiency-associated panniculitis>> A potentially challenging diagnosis but an important one for patients. J Am Acad Dermatol 2021; 86:e67-e68. [PMID: 34343603 DOI: 10.1016/j.jaad.2021.06.897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Lloyd Steele
- Department of Dermatology, The Royal London Hospital, Barts Health NHS Trust, London, UK; Centre for Cell Biology and Cutaneous Research, Blizard Institute, Queen Mary University of London, UK.
| | - C D Mitchell
- Dermatology Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - A R Shipman
- Dermatology Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - K E Shipman
- Department of Clinical Chemistry Pathology, St Richard's Hospital, Chichester, UK
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13
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Lange P, Ahmed E, Lahmar ZM, Martinez FJ, Bourdin A. Natural history and mechanisms of COPD. Respirology 2021; 26:298-321. [PMID: 33506971 DOI: 10.1111/resp.14007] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 12/17/2022]
Abstract
The natural history of COPD is complex, and the disease is best understood as a syndrome resulting from numerous interacting factors throughout the life cycle with smoking being the strongest inciting feature. Unfortunately, diagnosis is often delayed with several longitudinal cohort studies shedding light on the long 'preclinical' period of COPD. It is now accepted that individuals presenting with different COPD phenotypes may experience varying natural history of their disease. This includes its inception, early stages and progression to established disease. Several scenarios regarding lung function course are possible, but it may conceptually be helpful to distinguish between individuals with normal maximally attained lung function in their early adulthood who thereafter experience faster than normal FEV1 decline, and those who may achieve a lower than normal maximally attained lung function. This may be the main mechanism behind COPD in the latter group, as the decline in FEV1 during their adult life may be normal or only slightly faster than normal. Regardless of the FEV1 trajectory, continuous smoking is strongly associated with disease progression, development of structural lung disease and poor prognosis. In developing countries, factors such as exposure to biomass and sequelae after tuberculosis may lead to a more airway-centred COPD phenotype than seen in smokers. Mechanistically, COPD is characterized by a combination of structural and inflammatory changes. It is unlikely that all patients share the same individual or combined mechanisms given the heterogeneity of resultant phenotypes. Lung explants, bronchial biopsies and other tissue studies have revealed important features. At the small airway level, progression of COPD is clinically imperceptible, and the pathological course of the disease is poorly described. Asthmatic features can further add confusion. However, the small airway epithelium is likely to represent a key focus of the disease, combining impaired subepithelial crosstalk and structural/inflammatory changes. Insufficient resolution of inflammatory processes may facilitate these changes. Pathologically, epithelial metaplasia, inversion of the goblet to ciliated cell ratio, enlargement of the submucosal glands and neutrophil and CD8-T-cell infiltration can be detected. Evidence of type 2 inflammation is gaining interest in the light of new therapeutic agents. Alarmin biology is a promising area that may permit control of inflammation and partial reversal of structural changes in COPD. Here, we review the latest work describing the development and progression of COPD with a focus on lung function trajectories, exacerbations and survival. We also review mechanisms focusing on epithelial changes associated with COPD and lack of resolution characterizing the underlying inflammatory processes.
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Affiliation(s)
- Peter Lange
- Department of Internal Medicine, Section of Respiratory Medicine, Copenhagen University Hospital - Herlev, Herlev, Denmark.,Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
| | - Engi Ahmed
- IRMB, University of Montpellier, INSERM, CHU Montpellier, Montpellier, France.,Department of Respiratory Diseases, University of Montpellier, CHU Montpellier, INSERM, Montpellier, France
| | - Zakaria Mohamed Lahmar
- Department of Respiratory Diseases, University of Montpellier, CHU Montpellier, INSERM, Montpellier, France
| | - Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Arnaud Bourdin
- Department of Respiratory Diseases, University of Montpellier, CHU Montpellier, INSERM, Montpellier, France.,PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France
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14
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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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15
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McElvaney GN, Sandhaus RA, Miravitlles M, Turino GM, Seersholm N, Wencker M, Stockley RA. Clinical considerations in individuals with α 1-antitrypsin PI*SZ genotype. Eur Respir J 2020; 55:13993003.02410-2019. [PMID: 32165400 PMCID: PMC7301289 DOI: 10.1183/13993003.02410-2019] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/25/2020] [Indexed: 12/12/2022]
Abstract
α1-Antitrypsin deficiency (AATD), characterised by reduced levels or functionality of α1-antitrypsin (AAT), is a significantly underdiagnosed genetic condition that predisposes individuals to lung and liver disease. Most of the available data on AATD are based on the most common, severe deficiency genotype (PI*ZZ); therefore, treatment and monitoring requirements for individuals with the PI*SZ genotype, which is associated with a less severe AATD, are not as clear. Recent genetic data suggest the PI*SZ genotype may be significantly more prevalent than currently thought, due in part to less frequent identification in the clinic and less frequent reporting in registries. Intravenous AAT therapy, the only specific treatment for patients with AATD, has been shown to slow disease progression in PI*ZZ individuals; however, there is no specific evidence for AAT therapy in PI*SZ individuals, and it remains unclear whether AAT therapy should be considered in these patients. This narrative review evaluates the available data on the PI*SZ genotype, including genetic prevalence, the age of diagnosis and development of respiratory symptoms compared with PI*ZZ individuals, and the impact of factors such as index versus non-index identification and smoking history. In addition, the relevance of the putative 11 µM “protective threshold” for AAT therapy and the risk of liver disease in PI*SZ individuals is explored. The purpose of this review is to identify open research questions in this area, with the aim of optimising the future identification and management of PI*SZ individuals. Individuals with α1-antitrypsin (AAT) PI*SZ genotype appear to have an increased risk for lung and liver disease, although definitive evidence is lacking; smoking is a major risk factor for lung disease. The role of AAT therapy requires further study.http://bit.ly/2TxxFD0
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Affiliation(s)
- Gerard N McElvaney
- Dept of Respiratory Medicine, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Robert A Sandhaus
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
| | - Marc Miravitlles
- Pneumology Dept, Vall d'Hebron University Hospital/Vall d'Hebron Research Institute (VHIR), CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Gerard M Turino
- Dept of Medicine, Mt Sinai-St Luke's-Roosevelt Hospital, New York, NY, USA
| | - Niels Seersholm
- Dept of Respiratory Medicine, Gentofte Hospital, Hellerup, Denmark
| | | | - Robert A Stockley
- Lung Investigation Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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16
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Chorostowska-Wynimko J, Wencker M, Horváth I. The importance of effective registries in pulmonary diseases and how to optimize their output. Chron Respir Dis 2020; 16:1479973119881777. [PMID: 31645111 PMCID: PMC6811757 DOI: 10.1177/1479973119881777] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Randomized controlled trials (RCTs) are essential for the approval of new
therapies; however, because of their design, they provide little insight
concerning disease epidemiology/etiology and current clinical practice.
Particularly, in lung disease, rigid inclusion/exclusion criteria can limit the
generalizability of pivotal trial data. Noninterventional studies (NIS),
conducted through the well-established mechanism of patient registries, are
undervalued as a means to close data gaps left by RCTs by providing essential
data that can guide patient care at different levels from clinical
decision-making to health-care policy. While NIS contribute valuable data in all
disease areas, their importance in rare diseases cannot be underestimated. In
respiratory disease, registries have been essential in understanding the natural
history and different phenotypes of rare conditions, such as alpha 1 antitrypsin
deficiency, cystic fibrosis, and idiopathic pulmonary fibrosis. Importantly,
additional therapeutic outcome data were generated. While measures for enhancing
data quality in RCTs have evolved significantly, the approach and effectiveness
of registries is variable. Within this article, we review the contribution of
registries to pulmonary disease and make recommendations for their effective
management. Additionally, we assess limitations of registry data as well as
challenges to registry operation, including the impact of the European Union
General Data Protection Regulation.
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Affiliation(s)
- Joanna Chorostowska-Wynimko
- Department of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | | | - Ildikó Horváth
- Department of XIV, National Koranyi Institute for Pulmonology, Budapest, Hungary.,Department of Public Health, Semmelweis University, Budapest, Hungary
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17
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Li LSK, Williams MT, Johnston KN, Frith P, Hyppönen E, Paquet C. Parental and life-course influences on symptomatic airflow obstruction. ERJ Open Res 2020; 6:00343-2019. [PMID: 32154293 PMCID: PMC7049733 DOI: 10.1183/23120541.00343-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 12/17/2019] [Indexed: 12/31/2022] Open
Abstract
Few studies have examined the contribution of life-course factors in explaining familial aggregation of chronic lung conditions. Using data from the 1958 British Birth Cohort, a life-course approach was used to examine whether, and how, exposure to risk factors through one's life explained the association between parental respiratory disease history and symptomatic airflow obstruction (AO). Cohort participants (n=6212) were characterised in terms of parental respiratory disease history and symptomatic AO at 45 years. Life-course factors (e.g. smoking, asthma and early-life factors) were operationalised as life period-specific and cumulative measures. Logistic regression and path analytic models predicting symptomatic AO adjusted for parental respiratory disease history were used to test different life-course models (critical period, accumulation- and chain-of-risks models). While some life-course factors (e.g. childhood passive smoking and occupational exposure) were individually associated with parental respiratory disease history and symptomatic AO, asthma (OR 6.44, 95% CI 5.01–8.27) and persistent smoking in adulthood (OR 5.42, 95% CI 4.19–7.01) had greater impact on the association between parental respiratory disease history and symptomatic AO. A critical period model provided a better model fit compared with an accumulation-of-risk model and explained 57% of the effect of parental respiratory disease history on symptomatic AO. Adulthood asthma and smoking status explained around half of the effect of parental respiratory disease history on chronic obstructive pulmonary disease. Beyond smoking history, the combination of parental respiratory disease history and adulthood asthma may provide an opportunity for early diagnosis and intervention. Adulthood asthma and smoking explain half of the effect of parental respiratory disease history on symptomatic airflow obstruction. Use of a life-course approach and models may help clarify mechanisms behind associations in intergenerational lung health.http://bit.ly/2PIzGf4
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Affiliation(s)
- Lok Sze Katrina Li
- School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Marie T Williams
- School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Kylie N Johnston
- School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Peter Frith
- School of Health Sciences, University of South Australia, Adelaide, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Elina Hyppönen
- School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Catherine Paquet
- School of Health Sciences, University of South Australia, Adelaide, Australia
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18
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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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19
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Chorostowska-Wynimko J, Barrecheguren M, Ferrarotti I, Greulich T, Sandhaus RA, Campos M. New Patient-Centric Approaches to the Management of Alpha-1 Antitrypsin Deficiency. Int J Chron Obstruct Pulmon Dis 2020; 15:345-355. [PMID: 32103933 PMCID: PMC7024807 DOI: 10.2147/copd.s234646] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/24/2020] [Indexed: 12/30/2022] Open
Abstract
Alpha-1 antitrypsin deficiency (AATD) is a rare and underdiagnosed genetic predisposition for COPD and emphysema and other conditions, including liver disease. Although there have been improvements in terms of awareness of AATD and understanding of its treatment in recent years, current challenges center on optimizing detection and management of patients with AATD, and improving access to intravenous (IV) AAT therapy – the only available pharmacological intervention that can slow disease progression. However, as an orphan disease with geographically dispersed patients, international cooperation is essential to address these issues. To achieve this, new European initiatives in the form of the European Reference Network for Rare Lung Diseases (ERN-LUNG) and the European Alpha-1 Research Collaboration (EARCO) have been established. These organizations are striving to address the current challenges in AATD, and provide a new platform for future research efforts in AATD. The first objectives of ERN-LUNG are to establish a quality control program for European AATD laboratories and create a disease management program for AATD, following the success of such programs in the United States. The main purpose of EARCO is to create a pan-European registry, with the aim of understanding the natural history of the disease and supporting the development of new treatment modalities in AATD and access to AAT therapy. Going further, other patient-centric initiatives involve improving the convenience of intravenous AAT therapy infusions through extended-interval dosing and self-administration. The present review will discuss the implementation of these initiatives and their potential contribution to the optimization of patient care in AATD.
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Affiliation(s)
- Joanna Chorostowska-Wynimko
- Department of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | | | - Ilaria Ferrarotti
- Department of Internal Medicine and Therapeutics, Pneumology Unit IRCCS San Matteo Hospital Foundation, University of Pavia, Pavia, Italy
| | - Timm Greulich
- Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps-University, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Robert A Sandhaus
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO, USA
| | - Michael Campos
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami School of Medicine, Miami, FL, USA
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20
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Abstract
As NPs play an increasingly vital role in primary care, they must be well versed in a variety of conditions. Alpha-1 antitrypsin (AAT) deficiency is a respiratory disease for which there is particularly low awareness in both the nursing profession and the wider medical community. This article provides an overview of AAT deficiency and includes guidance for diagnosing the disease.
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21
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Mostafavi B, Piitulainen E, Tanash HA. Survival in the Swedish cohort with alpha-1-antitrypsin deficiency, up to the age of 43-45 years. Int J Chron Obstruct Pulmon Dis 2019; 14:525-530. [PMID: 30880942 PMCID: PMC6400233 DOI: 10.2147/copd.s183205] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background Alpha-1-antitrypsin deficiency (AATD) is a hereditary disorder. AATD is a known risk factor for the development of emphysema and liver disease. A cohort of severe (PiZZ) and moderate (PiSZ) AAT-deficient newborn infants was identified by the Swedish national neonatal AAT screening in 1972-1974 and has been followed up since birth. Our aim was to study survival in this cohort up to 43-45 years of age in comparison with the general Swedish population. Methods Data from 127 PiZZ, 2 PiZnull, 54 PiSZ, and 1 PiSnull subjects, who were identified by the neonatal screening in 1972-1974, were included in the study. To compare death rates in the PiZZ and PiSZ individuals with the general Swedish population, a standardized mortality ratio (SMR) was calculated as the ratio of observed to expected deaths. Results Seven PiZZ subjects died during the follow-up, to be compared with an expected 3.66 deaths for the general population, giving an SMR of 1.91 (95% CI 0.77-3.94). Four PiSZ subjects died compared to an expected 1.53 deaths, giving an SMR of 2.61 (95% CI 0.71-6.71). The cumulative probability of survival up to the age of 45 years was 94% (95% CI 90%-98%) for the study population. Six deaths occurred before the age of 8 years. Conclusion Up to 43-45 years of age, there was no difference in survival between PiZZ and PiSZ individuals in comparison with the Swedish general population. The majority of deaths occurred during childhood.
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Affiliation(s)
- Behrouz Mostafavi
- Department of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Malmö, Sweden,
| | - Eeva Piitulainen
- Department of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Malmö, Sweden,
| | - Hanan A Tanash
- Department of Respiratory Medicine and Allergology, Skåne University Hospital, Lund University, Malmö, Sweden,
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22
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Horváth I, Canotilho M, Chlumský J, Chorostowska-Wynimko J, Corda L, Derom E, Ficker JH, Kneussl M, Miravitlles M, Sucena M, Thabut G, Turner AM, van ’t Wout E, McElvaney NG. Diagnosis and management of α 1-antitrypsin deficiency in Europe: an expert survey. ERJ Open Res 2019; 5:00171-2018. [PMID: 30863774 PMCID: PMC6409083 DOI: 10.1183/23120541.00171-2018] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 12/12/2018] [Indexed: 01/09/2023] Open
Abstract
Despite recent improvements, α1-antitrypsin deficiency (AATD) remains a rarely diagnosed and treated condition. To assess the variability of AATD diagnosis/treatment in Europe, and to evaluate clinicians' views on methods to optimise management, specialist AATD clinicians were invited to complete a web-based survey. Surveys were completed by 15 physicians from 14 centres in 13 European countries. All respondents perceived the AATD diagnosis rate to be low in their country; 77% of physicians believed that ∼15% of cases were diagnosed. Low awareness was perceived as the greatest barrier to diagnosis. Spirometry was considered more practical than quantitative computed tomography (QCT) for monitoring AATD patients in clinical practice; QCT was considered more useful in trials. AAT therapy provision was reported to be highly variable: France and Germany were reported to treat the highest proportion (∼60%) of diagnosed patients, in contrast to the UK and Hungary, where virtually no patients receive AAT therapy. Most clinicians supported self-administration and extended dosing intervals to improve convenience of AAT therapy. This survey indicates that AATD diagnosis and management are highly heterogeneous in Europe; European cooperation is essential to generate data to support access to AAT therapy. Improving convenience of AAT therapy is an ongoing objective.
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Affiliation(s)
- Ildikó Horváth
- Dept of Pulmonology, National Koranyi Institute for Pulmonology in Budapest, Budapest, Hungary
| | - Maria Canotilho
- Dept of Pneumology, Hospital of Santo Andre – Centro Hospitalar de Leiria, Leiria, Portugal
| | - Jan Chlumský
- Dept of Pneumology, Thomayer Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Joanna Chorostowska-Wynimko
- Dept of Genetics and Clinical Immunology, National Institute of Tuberculosis and Lung Diseases, Warsaw, Poland
| | - Luciano Corda
- Dept of Internal Medicine, Respiratory Disease Unit, Spedali Civili, Brescia, Italy
| | - Eric Derom
- Dept of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Joachim H. Ficker
- 3rd Medical Dept, Nuremberg General Hospital/Paracelsus Medical University, Nuremberg, Germany
| | - Meinhard Kneussl
- Dept of Internal Medicine II and Pneumology at Wilhelminenspital Wien, Vienna, Austria
| | - Marc Miravitlles
- Pulmonology Dept, University Hospital Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Maria Sucena
- Pulmonology Dept, Centro Hospitalar de São João, Porto, Portugal
| | - Gabriel Thabut
- Dept of Pneumology and Lung Transplantation, Bichat Hospital, Paris, France
| | - Alice M. Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Emily van ’t Wout
- Leiden University Medical Centre, Dept of Pulmonology, Leiden, Netherlands
| | - N. Gerard McElvaney
- Dept of Respiratory Medicine, Beaumont Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
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23
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Mostafavi B, Diaz S, Piitulainen E, Stoel BC, Wollmer P, Tanash HA. Lung function and CT lung densitometry in 37- to 39-year-old individuals with alpha-1-antitrypsin deficiency. Int J Chron Obstruct Pulmon Dis 2018; 13:3689-3698. [PMID: 30510411 PMCID: PMC6231508 DOI: 10.2147/copd.s167497] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Alpha-1-antitrypsin (AAT) deficiency is a hereditary disorder that predisposes to emphysema. A cohort of severe (PiZZ) and moderate (PiSZ) AAT-deficient newborn infants was identified by the Swedish national neonatal AAT screening program in 1972-1974 and has been followed-up since birth. Our aim was to study whether the cohort has signs of emphysema in pulmonary function tests (PFTs) and computed tomography (CT) densitometry at 38 years of age in comparison with an age-matched control group, randomly selected from the population registry. METHODS Forty-one PiZZ, 18 PiSZ, and 61 control subjects (PiMM) underwent complete PFTs, measurement of resistance and reactance in the respiratory system by impulse oscillometry (IOS)/forced oscillation technique (FOT), and CT densitometry. The results were related to self-reported smoking habits. RESULTS The total lung capacity (TLC) % of the predicted value was significantly higher in the PiZZ ever-smokers than in the PiZZ never-smokers (P<0.05), PiSZ never-smokers (P=0.01) and the PiMM never-smokers (P=0.01). The residual volume (RV) % of the predicted value was significantly higher in the PiZZ ever-smokers compared to the PiMM never-smokers (P<0.01). The PiZZ ever-smokers had a significantly lower carbon monoxide transfer coefficient (Kco) than the PiSZ never-smokers (P<0.01) and PiMM never-smokers (P<0.01). Respiratory system resistance at 5 Hz (P<0.01), at 20 Hz (P<0.01), and the area of low reactance (Alx; P<0.05) were significantly lower and respiratory system reactance at 5 Hz (P<0.05) was significantly higher in PiZZ subjects compared to the PiMM subjects. No statistically significant differences in the CT densitometry parameters were found between the Pi subgroups. CONCLUSION The physiological parameters in the PiZZ ever-smokers showed evidence of hyperinflation and emphysema before the age of 40 years.
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Affiliation(s)
- Behrouz Mostafavi
- Department of Respiratory Medicine and Allergology Malmö, Skåne University Hospital, Lund University, Malmö, Sweden,
| | - Sandra Diaz
- Department of Clinical Physiology Malmö, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Eeva Piitulainen
- Department of Respiratory Medicine and Allergology Malmö, Skåne University Hospital, Lund University, Malmö, Sweden,
| | - Berend C Stoel
- Division of Image Processing, Department of Radiology, Leiden University Medical, Leiden, the Netherlands
| | - Per Wollmer
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Hanan A Tanash
- Department of Respiratory Medicine and Allergology Malmö, Skåne University Hospital, Lund University, Malmö, Sweden,
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24
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Stockley RA, Edgar RG, Starkey S, Turner AM. Health status decline in α-1 antitrypsin deficiency: a feasible outcome for disease modifying therapies? Respir Res 2018; 19:137. [PMID: 30029692 PMCID: PMC6053712 DOI: 10.1186/s12931-018-0844-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 07/13/2018] [Indexed: 12/24/2022] Open
Abstract
Background Trials of disease modifying therapies in Chronic Obstructive Pulmonary Disease (COPD) provide challenges for detecting physiological and patient centred outcomes. The purpose of the current study was to monitor decline in health status in Alpha-1 antitrypsin deficiency (AATD) and determine its’ relationship to conventional physiology. Methods Patients recruited to the UK-AATD database with a median follow up of 7 years (IQR 5–10) were studied to determine annual change in St George’s Respiratory Questionnaire (SGRQ), FEV1, gas transfer and their feasibility of use in future trials. Results Annual decline in SGRQ had a wide range, was greater for patients with established COPD and correlated with decline in FEV1 (p < 0.0001). Total score decline was greater (p < 0.05) for those with accelerated FEV1 decline (median = 1.07 points/year) compared to those without (median = 0.51). Power calculations indicated effective intervention would not achieve MCID for the SGRQ unless the timeframe was extended for up to 8 years. More than 5000 patients/arm would be required for a statistically significant modest effect over 3 years even in those with rapid FEV1 decline. Conclusion Despite AATD being a rapidly declining form of COPD, deterioration in SGRQ was slow consistent with ageing and the chronic nature of disease progression. Power calculations indicate the numbers needed to detect a difference with disease modifying therapies would be prohibitive especially in this rare cause of COPD. These data have important implications for future study design of disease modifying therapies even in COPD not associated with AATD. Electronic supplementary material The online version of this article (10.1186/s12931-018-0844-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Robert A Stockley
- Lung Investigation Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK.
| | - Ross G Edgar
- Therapy Services, University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Sian Starkey
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - Alice M Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK.,Heart of England NHS Foundation Trust, Respiratory Medicine, Bordesley Green East, Birmingham, B9 5SS, UK
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25
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Miravitlles M, Dirksen A, Ferrarotti I, Koblizek V, Lange P, Mahadeva R, McElvaney NG, Parr D, Piitulainen E, Roche N, Stolk J, Thabut G, Turner A, Vogelmeier C, Stockley RA. European Respiratory Society statement: diagnosis and treatment of pulmonary disease in α1-antitrypsin deficiency. Eur Respir J 2017; 50:50/5/1700610. [DOI: 10.1183/13993003.00610-2017] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 08/16/2017] [Indexed: 11/05/2022]
Abstract
α1-antitrypsin deficiency (AATD) is the most common hereditary disorder in adults. It is associated with an increased risk of developing pulmonary emphysema and liver disease. The pulmonary emphysema in AATD is strongly linked to smoking, but even a proportion of never-smokers develop progressive lung disease. A large proportion of individuals affected remain undiagnosed and therefore without access to appropriate care and treatment.The most recent international statement on AATD was published by the American Thoracic Society and the European Respiratory Society in 2003. Since then there has been a continuous development of novel, more accurate and less expensive genetic diagnostic methods. Furthermore, new outcome parameters have been developed and validated for use in clinical trials and a new series of observational and randomised clinical trials have provided more evidence concerning the efficacy and safety of augmentation therapy, the only specific treatment available for the pulmonary disease associated with AATD.As AATD is a rare disease, it is crucial to organise national and international registries and collect information prospectively about the natural history of the disease. Management of AATD patients must be supervised by national or regional expert centres and inequalities in access to therapies across Europe should be addressed.
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