1
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Akbasheva OE, Spirina LV, Dyakov DA, Masunova NV. Proteolysis and Deficiency of α1-Proteinase Inhibitor in SARS-CoV-2 Infection. BIOCHEMISTRY (MOSCOW) SUPPLEMENT. SERIES B, BIOMEDICAL CHEMISTRY 2022; 16:271-291. [PMID: 36407837 PMCID: PMC9668222 DOI: 10.1134/s1990750822040035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/30/2022] [Accepted: 04/11/2022] [Indexed: 11/17/2022]
Abstract
The SARS-CoV-2 pandemic had stimulated the emergence of numerous publications on the α1-proteinase inhibitor (α1-PI, α1-antitrypsin), especially when it was found that the regions of high mortality corresponded to the regions with deficient α1-PI alleles. By analogy with the data obtained in the last century, when the first cause of the genetic deficiency of α1-antitrypsin leading to elastase activation in pulmonary emphysema was proven, it can be supposed that proteolysis hyperactivation in COVID-19 may be associated with the impaired functions of α1-PI. The purpose of this review was to systematize the scientific data and critical directions for translational studies on the role of α1-PI in SARS-CoV-2-induced proteolysis hyperactivation as a diagnostic marker and a therapeutic target. This review describes the proteinase-dependent stages of viral infection: the reception and penetration of the virus into a cell and the imbalance of the plasma aldosterone-angiotensin-renin, kinin, and blood clotting systems. The role of ACE2, TMPRSS, ADAM17, furin, cathepsins, trypsin- and elastase-like serine proteinases in the virus tropism, the activation of proteolytic cascades in blood, and the COVID-19-dependent complications is considered. The scientific reports on α1-PI involvement in the SARS-CoV-2-induced inflammation, the relationship with the severity of infection and comorbidities were analyzed. Particular attention is paid to the acquired α1-PI deficiency in assessing the state of patients with proteolysis overactivation and chronic non-inflammatory diseases, which are accompanied by the risk factors for comorbidity progression and the long-term consequences of COVID-19. Essential data on the search and application of protease inhibitor drugs in the therapy for bronchopulmonary and cardiovascular pathologies were analyzed. The evidence of antiviral, anti-inflammatory, anticoagulant, and anti-apoptotic effects of α1-PI, as well as the prominent data and prospects for its application as a targeted drug in the SARS-CoV-2 acquired pneumonia and related disorders, are presented.
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Affiliation(s)
| | - L. V. Spirina
- Siberian State Medical University, 634050 Tomsk, Russia
- Cancer Research Institute, Tomsk National Research Medical Center, 634009 Tomsk, Russia
| | - D. A. Dyakov
- Siberian State Medical University, 634050 Tomsk, Russia
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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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Akbasheva OE, Spirina LV, Dyakov DA, Masunova NV. [Proteolysis and deficiency of α1-proteinase inhibitor in SARS-CoV-2 infection]. BIOMEDITSINSKAIA KHIMIIA 2022; 68:157-176. [PMID: 35717581 DOI: 10.18097/pbmc20226803157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The SARS-CoV-2 pandemia had stimulated the numerous publications emergence on the α1-proteinase inhibitor (α1-PI, α1-antitrypsin), primarily when it was found that high mortality in some regions corresponded to the regions with deficient α1-PI alleles. By analogy with the last century's data, when the root cause of the α1-antitrypsin, genetic deficiency leading to the elastase activation in pulmonary emphysema, was proven. It is evident that proteolysis hyperactivation in COVID-19 may be associated with α1-PI impaired functions. The purpose of this review is to systematize scientific data, critical directions for translational studies on the role of α1-PI in SARS-CoV-2-induced proteolysis hyperactivation as a diagnostic marker and a target in therapy. This review describes the proteinase-dependent stages of a viral infection: the reception and virus penetration into the cell, the plasma aldosterone-angiotensin-renin, kinins, blood clotting systems imbalance. The ACE2, TMPRSS, ADAM17, furin, cathepsins, trypsin- and elastase-like serine proteinases role in the virus tropism, proteolytic cascades activation in blood, and the COVID-19-dependent complications is presented. The analysis of scientific reports on the α1-PI implementation in the SARS-CoV-2-induced inflammation, the links with the infection severity, and comorbidities were carried out. Particular attention is paid to the acquired α1-PI deficiency in assessing the patients with the proteolysis overactivation and chronic non-inflammatory diseases that are accompanied by the risk factors for the comorbidities progression, and the long-term consequences of COVID-19 initiation. Analyzed data on the search and proteases inhibitory drugs usage in the bronchopulmonary cardiovascular pathologies therapy are essential. It becomes evident the antiviral, anti-inflammatory, anticoagulant, anti-apoptotic effect of α1-PI. The prominent data and prospects for its application as a targeted drug in the SARS-CoV-2 acquired pneumonia and related disorders are presented.
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Affiliation(s)
| | - L V Spirina
- Siberian State Medical University, Tomsk, Russia; Cancer Research Institute, Tomsk National Research Medical Center, Tomsk, Russia
| | - D A Dyakov
- Siberian State Medical University, Tomsk, Russia
| | - N V Masunova
- Siberian State Medical University, Tomsk, Russia
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Forrest IS, Nadkarni GN, Do R. Penetrance of Deleterious Clinical Variants-Reply. JAMA 2022; 327:1927. [PMID: 35579644 PMCID: PMC9423129 DOI: 10.1001/jama.2022.4634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Iain S. Forrest
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Medical Scientist Training Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- The BioMe Phenomics Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Girish N. Nadkarni
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- The BioMe Phenomics Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- The Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ron Do
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- The BioMe Phenomics Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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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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Fawcett KA, Song K, Qian G, Farmaki AE, Packer R, John C, Shrine N, Granell R, Ring S, Timpson NJ, Yerges-Armstrong LM, Eastell R, Wain LV, Scott RA, Tobin MD, Hall IP. Pleiotropic associations of heterozygosity for the SERPINA1 Z allele in the UK Biobank. ERJ Open Res 2021; 7:00049-2021. [PMID: 33981765 PMCID: PMC8107350 DOI: 10.1183/23120541.00049-2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 02/20/2021] [Indexed: 11/20/2022] Open
Abstract
Homozygosity for the SERPINA1 Z allele causes α1-antitrypsin deficiency, a rare condition that can cause lung and liver disease. However, the effects of Z allele heterozygosity on nonrespiratory phenotypes, and on lung function in the general population, remain unclear. We conducted a large, population-based study to determine Z allele effects on >2400 phenotypes in the UK Biobank (N=303 353). Z allele heterozygosity was strongly associated with increased height (β=1.02 cm, p=3.91×10-68), and with other nonrespiratory phenotypes including increased risk of gall bladder disease, reduced risk of heart disease and lower blood pressure, reduced risk of osteoarthritis and reduced bone mineral density, increased risk of headache and enlarged prostate, as well as with blood biomarkers of liver function. Heterozygosity was associated with higher height-adjusted forced expiratory volume in 1 s (FEV1) (β=19.36 mL, p=9.21×10-4) and FEV1/forced vital capacity (β=0.0031, p=1.22×10-5) in nonsmokers, whereas in smokers, this protective effect was abolished. Furthermore, we show for the first time that sex modifies the association of the Z allele on lung function. We conclude that Z allele heterozygosity and homozygosity exhibit opposing effects on lung function in the UK population, and that these associations are modified by smoking and sex. In exploratory analyses, heterozygosity for the Z allele also showed pleiotropic associations with nonrespiratory health-related traits and disease risk.
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Affiliation(s)
| | - Kijoung Song
- Human Genetics, GlaxoSmithKline, Collegeville, PA, USA
| | - Guoqing Qian
- Dept of General Internal Medicine, Ningbo First Hospital, Ningbo City, Zhejiang Province, China
- Division of Respiratory Medicine, University of Nottingham, and NIHR Nottingham BRC, NUH NHS Trust, Nottingham, UK
| | - Aliki-Eleni Farmaki
- MRC Unit for Lifelong Health and Ageing, Institute of Cardiovascular Science, University College London, London, UK
| | - Richard Packer
- Dept of Health Sciences, University of Leicester, Leicester, UK
| | - Catherine John
- Dept of Health Sciences, University of Leicester, Leicester, UK
| | - Nick Shrine
- Dept of Health Sciences, University of Leicester, Leicester, UK
| | - Raquel Granell
- Medical Research Council Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sue Ring
- Medical Research Council Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicholas J. Timpson
- Medical Research Council Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Richard Eastell
- Dept of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - Louise V. Wain
- Dept of Health Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research, Leicester Respiratory Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Robert A. Scott
- Human Genetics – R&D, GSK Medicines Research Centre, Stevenage, UK
| | - Martin D. Tobin
- Dept of Health Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research, Leicester Respiratory Biomedical Research Centre, Glenfield Hospital, Leicester, UK
- These authors contributed equally
| | - Ian P. Hall
- Division of Respiratory Medicine, University of Nottingham, and NIHR Nottingham BRC, NUH NHS Trust, Nottingham, UK
- These authors contributed equally
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Nakanishi T, Forgetta V, Handa T, Hirai T, Mooser V, Lathrop GM, Cookson WOCM, Richards JB. The undiagnosed disease burden associated with alpha-1 antitrypsin deficiency genotypes. Eur Respir J 2020; 56:13993003.01441-2020. [PMID: 32675199 PMCID: PMC7726845 DOI: 10.1183/13993003.01441-2020] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/25/2020] [Indexed: 12/16/2022]
Abstract
Alpha-1 antitrypsin deficiency (AATD), mainly due to the PI*ZZ genotype in SERPINA1, is one of the most common inherited diseases. Since it is associated with a high disease burden and partially prevented by smoking cessation, identification of PI*ZZ individuals through genotyping could improve health outcomes. We examined the frequency of the PI*ZZ genotype in individuals with and without diagnosed AATD from UK Biobank, and assessed the associations of the genotypes with clinical outcomes and mortality. A phenome-wide association study (PheWAS) was conducted to reveal disease associations with genotypes. A polygenic risk score (PRS) for forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio was used to evaluate variable penetrance of PI*ZZ. Among 458 164 European-ancestry participants in UK Biobank, 140 had the PI*ZZ genotype and only nine (6.4%, 95% CI 3.4–11.7%) of them were diagnosed with AATD. Those with PI*ZZ had a substantially higher odds of COPD (OR 8.8, 95% CI 5.8–13.3), asthma (OR 2.0, 95% CI 1.4–3.0), bronchiectasis (OR 7.3, 95%CI 3.2–16.8), pneumonia (OR 2.7, 95% CI 1.5–4.9) and cirrhosis (OR 7.8, 95% CI 2.5–24.6) diagnoses and a higher hazard of mortality (2.4, 95% CI 1.2–4.6), compared to PI*MM (wildtype) (n=398 424). These associations were stronger among smokers. PheWAS demonstrated associations with increased odds of empyema, pneumothorax, cachexia, polycythaemia, aneurysm and pancreatitis. Polygenic risk score and PI*ZZ were independently associated with FEV1/FVC <0.7 (OR 1.4 per 1-sd change, 95% CI 1.4–1.5 and OR 4.5, 95% CI 3.0–6.9, respectively). The important underdiagnosis of AATD, whose outcomes are partially preventable through smoking cession, could be improved through genotype-guided diagnosis. Only 6.4% of those with genotype-defined alpha-1 antitrypsin deficiency had been diagnosed with this serious disease in UK Biobank. Genotype-guided diagnosis could help to identify the thousands of people in the UK with this partially preventable disease. https://bit.ly/3dMu5Ng
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Affiliation(s)
- Tomoko Nakanishi
- Dept of Human Genetics, McGill University, Montréal, QC, Canada.,Centre for Clinical Epidemiology, Dept of Medicine, Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada.,Kyoto-McGill International Collaborative School in Genomic Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Dept of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Research Fellow of Japan Society for the Promotion of Science, Tokyo, Japan
| | - Vincenzo Forgetta
- Centre for Clinical Epidemiology, Dept of Medicine, Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Tomohiro Handa
- Dept of Advanced Medicine for Respiratory Failure, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toyohiro Hirai
- Dept of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Vincent Mooser
- Dept of Human Genetics, McGill University, Montréal, QC, Canada.,Canada Excellence Research Chair in Genomic Medicine, McGill University, Montréal, QC, Canada
| | - G Mark Lathrop
- McGill University and Genome Québec Innovation Centre, Montréal, QC, Canada
| | - William O C M Cookson
- National Heart and Lung Institute, Imperial College London, London, UK.,Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - J Brent Richards
- Dept of Human Genetics, McGill University, Montréal, QC, Canada .,Centre for Clinical Epidemiology, Dept of Medicine, Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montréal, QC, Canada.,Division of Endocrinology, Depts of Medicine, Human Genetics, Epidemiology and Biostatistics, Jewish General Hospital, McGill University, Montréal, QC, Canada
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8
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Rangaraju M, Turner AM. Why is Disease Penetration so Variable in Alpha-1 Antitrypsin Deficiency? The Contribution of Environmental Factors. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2020; 7:280-289. [PMID: 32698254 DOI: 10.15326/jcopdf.7.3.2019.0177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Environmental influences on clinical phenotype in alpha-1 antitrypsin deficiency (AATD) include cigarette smoke, occupational exposures, airway/sputum bacteria and outdoor air pollution. This narrative review describes the impact of the major environmental exposures and summarizes their effect on clinical phenotype and outcomes. In general, patients with AATD are more susceptible to pulmonary damage as a result of the relatively unopposed action of neutrophil elastase, in the context of neutrophilic inflammation stimulated by environmental factors. However, the amount of phenotypic variability explicable by environmental factors is insufficient to account for the wide range of clinical presentations observed, suggesting that a combination of genetic and environmental factors is likely to be responsible.
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Affiliation(s)
- Madhu Rangaraju
- University Hospitals, Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Alice M Turner
- University Hospitals, Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom.,Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
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9
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Hobbs BD, Cho MH. Why is Disease Penetration So Variable? Role of Genetic Modifiers of Lung Function in Alpha-1 Antitrypsin Deficiency. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2020; 7:214-223. [PMID: 32621460 DOI: 10.15326/jcopdf.7.3.2019.0159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Individuals with alpha-1 antitrypsin deficiency (AATD) have marked heterogeneity in lung function, suspected to be related to a combination of both environmental (e.g., cigarette smoking) and genetic factors. Lung function is heritable in the general population and in persons with severe AATD. Several genetic modifiers of lung function in persons with AATD have been described; however, replication is lacking. A genome-wide association study (GWAS) of lung function in persons with AATD has yet to be performed and may inform whether genetic determinants of lung function are overlapping in persons with AATD and in the general population. As GWASs require large sample sizes for adequate power, genetic risk scores offer an alternate approach to assess the overlap of genetic determinants of lung function in the general population in persons with AATD. Where GWASs are limited to common genetic variant discovery, whole genome sequencing (for rare variant discovery) and integrative genomic studies (examining the influence of genetic variants on gene, protein, and metabolite levels) offer potential for an expanded discovery of genetic modifiers of lung function in AATD. In the following review we examine past descriptions of genetic modifiers of lung function in AATD and describe a path forward to further investigate and define the likely genetic modifiers of lung function in AATD.
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Affiliation(s)
- Brian D Hobbs
- Channing Division of Network Medicine and Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael H Cho
- Channing Division of Network Medicine and Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Lopes AP, Mineiro MA, Costa F, Gomes J, Santos C, Antunes C, Maia D, Melo R, Canotilho M, Magalhães E, Vicente I, Valente C, Gonçalves BG, Conde B, Guimarães C, Sousa C, Amado J, Brandão ME, Sucena M, Oliveira MJ, Seixas S, Teixeira V, Telo L. Portuguese consensus document for the management of alpha-1-antitrypsin deficiency. Pulmonology 2019; 24 Suppl 1:1-21. [PMID: 30473034 DOI: 10.1016/j.pulmoe.2018.09.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/12/2018] [Accepted: 09/14/2018] [Indexed: 01/08/2023] Open
Abstract
Alpha-1-antitrypsin deficiency (AATD) is a genetic autosomal codominant disorder caused by mutations in SERPINA1 gene. It is one of the most prevalent genetic disorders, although it remains underdiagnosed. Whereas at international level there are several areas of consensus on this disorder, in Portugal, inter-hospital heterogeneity in clinical practice and resources available have been adding difficulties in reaching a diagnosis and in making therapeutic decisions in this group of patients. This raised a need to draft a document expressing a national consensus for AATD. To this end, a group of experts in this field was created within the Portuguese Pulmonology Society - Study group on AATD, in order to elaborate the current manuscript. The authors reviewed the existing literature and provide here general guidance and extensive recommendations for the diagnosis and management of AATD that can be adopted by Portuguese clinicians from different areas of Medicine. This article is part of a supplement entitled "Portuguese consensus document for the management of alpha-1-antitrypsin deficiency" which is sponsored by Sociedade Portuguesa de Pneumologia.
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Affiliation(s)
- A P Lopes
- Centro Hospitalar e Universitário de Coimbra (HUC); Alpha-1-antitrypsin deficiency study group coordinator.
| | | | - F Costa
- Centro Hospitalar e Universitário de Coimbra (HG)
| | | | | | | | - D Maia
- Centro Hospital Lisboa Central
| | - R Melo
- Hospital Prof. Doutor Fernando da Fonseca
| | | | | | | | | | | | - B Conde
- Centro Hospitalar de Trás os Montes e Alto Douro
| | | | - C Sousa
- Centro Hospitalar de São João
| | - J Amado
- Unidade Local de Saúde de Matosinhos
| | - M E Brandão
- Centro Hospitalar de Trás os Montes e Alto Douro
| | | | | | - S Seixas
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto (I3S); Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP)
| | - V Teixeira
- Serviço de Saúde da Região Autónoma da Madeira (SESARAM)
| | - L Telo
- Centro Hospitalar Lisboa Norte
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Blanchette CM, Zacherle E, Noone JM, Van Doren BA, Roy D, Howden R. One-year Prevalence, Comorbidities, and Cost of Hospitalizations for Alpha-1 Antitrypsin Deficiency among Patients with Chronic Obstructive Pulmonary Disease in the United States. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2017; 5:65-74. [PMID: 37664693 PMCID: PMC10471378 DOI: 10.36469/9799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Objectives: Little is known about severe chronic obstructive pulmonary disease (COPD) exacerbations among patients with Alpha-1 Antitrypsin Deficiency (AATD). We assessed inpatients with AATD and COPD among a sample of COPD inpatients to ascertain demographic, clinical and economic differences in the course of disease and treatment. Methods: Using data from the 2009 Nationwide Inpatient Sample (NIS), we identified COPD (ICD-9-CM: 491.xx, 492.xx, or 496.xx) patients with AATD (273.4). We compared patient demographics and healthcare outcomes (eg, length of stay, inpatient death, type and number of procedures, and cost of care) between COPD patients with and without alpha-1 antitrypsin deficiency. Frequencies and percentages for patient demographics were compared using bivariate statistics (eg, chi-square test). Recognizing the non-parametric nature of length of stay and cost, we calculated median values and interquartile ranges for these variables for each group of patients. Finally, the risk of inpatient death was estimated using logistic regression. Results: Of 840 242 patients with COPD (10.8% of the NIS sample population), 0.08% (684) had a primary or secondary diagnosis code for AATD. COPD+AATD were younger (56 vs 70, p<0.0001) and as a result, less likely to be covered by Medicare (44% vs 62%, p<0.0001). AATD patients were also more likely to have comorbid non-alcoholic liver disease (7% vs 2%, p<0.0001), depression (17% vs 13%, p=0.0328), and pulmonary circulation disorders (7% vs 4%, p=0.0299). Patients with AATD had a 14% longer length of stay (IRR = 1.14, 95% CI 1.07, 1.21) and a mean cost of $1487 (p=0.0251) more than COPD inpatients without AATD. Conclusions: AATD is associated with increased mean length of stay and cost, as well as higher frequency of comorbid non-alcoholic liver disease, depression, and pulmonary circulation disorders. Future research should assess other differences between AATD and the general COPD population such as natural history of disease, treatment responsiveness and disease progression.
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Alpha-1 Antitrypsin Deficiency: Beyond the Protease/Antiprotease Paradigm. Ann Am Thorac Soc 2016; 13 Suppl 4:S305-10. [DOI: 10.1513/annalsats.201510-671kv] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Topic A, Nagorni-Obradovic L, Francuski D, Ljujic M, Malic Z, Radojkovic D. Oxidative Stress and Polymorphism of Xenobiotic-Metabolizing Enzymes in Two Patients with Severe Alpha-1-Antitrypsin Deficiency. Biochem Genet 2016; 54:746-52. [PMID: 27271084 DOI: 10.1007/s10528-016-9748-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 05/27/2016] [Indexed: 11/29/2022]
Abstract
Alpha-1-antitrypsin deficiency (AATD) and tobacco smoke play a key role in the pathogenesis of early-onset emphysema. Differences in AATD-related chronic obstructive pulmonary disease stages imply the existence of modifying factors associated with disease severity. We present two male patients with emphysema caused by severe AATD (PiZZ genotype). Both are former smokers and have epoxide hydrolase low-activity phenotype. Extremely high level of oxidative stress (high urinary 8-oxo-7,8-dihydro-2'-deoxyguanosine), increased inflammation (high serum CRP), and GSTP1 105Val mutation were found in patient with a worse lung function and prognosis. These data provide more evidence that oxidative stress-related gene variants and inflammation are associated with worse symptoms of AATD-related emphysema. Therefore, prevention against severe stage of AATD-related emphysema would include early identification of the risk gene variants, cessation or never smoking, and treatment with anti-inflammatory and anti-oxidant drugs. Additionally, urinary 8-oxodG could be a candidate for predictive biomarker for routine assessment of the oxidative stress level in AATD patients.
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Affiliation(s)
- Aleksandra Topic
- Department of Medical Biochemistry, Faculty of Pharmacy, University of Belgrade, Vojvode Stepe, 450, Belgrade, 11221, Serbia.
| | - Ljudmila Nagorni-Obradovic
- School of Medicine, Clinic for Pulmonary Diseases Clinical Centre of Serbia, University of Belgrade, Belgrade, Serbia
| | - Djordje Francuski
- Institute of Molecular Genetics and Genetic Engineering, University of Belgrade, Belgrade, Serbia
| | - Mila Ljujic
- Institute of Molecular Genetics and Genetic Engineering, University of Belgrade, Belgrade, Serbia
| | - Zivka Malic
- Faculty of Pharmacy, University of Bijeljina, Bijeljina, Bosnia and Herzegovina
| | - Dragica Radojkovic
- Institute of Molecular Genetics and Genetic Engineering, University of Belgrade, Belgrade, Serbia
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Baraldo S, Balestro E, Bazzan E, Tiné ME, Biondini D, Turato G, Cosio MG, Saetta M. Alpha-1 Antitrypsin Deficiency Today: New Insights in the Immunological Pathways. Respiration 2016; 91:380-5. [PMID: 27164860 DOI: 10.1159/000445692] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 03/17/2016] [Indexed: 11/19/2022] Open
Abstract
More than 50 years ago, the observation that absence of the α1 band from protein electrophoresis is associated with severe emphysema established the link between α1-antitrypsin deficiency (AATD) and lung damage. From this discovery, the classic paradigm of protease/antiprotease imbalance was derived, linking lung destruction in patients with AATD to the unopposed effect of proteases. By extension, this paradigm was also applied to patients with 'common' chronic obstructive pulmonary disease, in whom large increases in smoke-induced proteases could overwhelm the antiprotease capability of AAT. However, it has become increasingly evident that AAT has important anti-inflammatory and immunoregulatory activities which, beside its antiprotease function, may be critically involved in lung destruction. From this perspective, we will consider recent evidence, based on epidemiological, clinical and immunopathological studies, suggesting that it is time to move on from the original protease/antiprotease paradigm toward a more complex view of the condition, which embraces its immunomodulating functions. Of importance, the potent immunoregulatory, tolerogenic role of AAT may support its therapeutic use in a number of diseases other than AATD, particularly in immune-related disorders.
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Affiliation(s)
- Simonetta Baraldo
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova and Padova City Hospital, Padova, Italy
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miR-1343 attenuates pathways of fibrosis by targeting the TGF-β receptors. Biochem J 2015; 473:245-56. [PMID: 26542979 DOI: 10.1042/bj20150821] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 11/05/2015] [Indexed: 12/18/2022]
Abstract
Irreversible respiratory obstruction resulting from progressive airway damage, inflammation and fibrosis is a feature of several chronic respiratory diseases, including cystic fibrosis (CF), idiopathic pulmonary fibrosis (IPF) and chronic obstructive pulmonary disease (COPD). The cytokine transforming growth factor β (TGF-β) has a pivotal role in promoting lung fibrosis and is implicated in respiratory disease severity. In the present study, we show that a previously uncharacterized miRNA, miR-1343, reduces the expression of both TGF-β receptor 1 and 2 by directly targeting their 3'-UTRs. After TGF-β exposure, elevated intracellular miR-1343 significantly decreases levels of activated TGF-β effector molecules, pSMAD2 (phosphorylated SMAD2) and pSMAD3 (phosphorylated SMAD3), when compared with a non-targeting control miRNA. As a result, the abundance of fibrotic markers is reduced, cell migration into a scratch wound impaired and epithelial-to-mesenchymal transition (EMT) repressed. Mature miR-1343 is readily detected in human neutrophils and HL-60 cells and is activated in response to stress in A549 lung epithelial cells. miR-1343 may have direct therapeutic applications in fibrotic lung disease.
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Campos MA, Lascano J. α1 Antitrypsin deficiency: current best practice in testing and augmentation therapy. Ther Adv Respir Dis 2014; 8:150-61. [PMID: 25013223 DOI: 10.1177/1753465814542243] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
α1 Antitrypsin deficiency (AATD) increases the risk of chronic obstructive pulmonary disease (COPD), liver disease and other conditions. Although it is not a rare disease, it is a condition rarely diagnosed because of unawareness by most healthcare providers who manage subjects at risk. Testing recommendations have been published and strongly suggest testing all subjects with confirmed COPD, cryptogenic liver cirrhosis, subjects with incompletely reversible airflow obstruction and siblings of affected individuals. Testing strategies usually imply a combination of measures of α1 antitrypsin (AAT) levels, phenotyping and genotyping, techniques that have been facilitated for in-office use by development of testing kits using dried blood spots. Early detection of subjects is crucial to apply effective preventive measures and early institution of therapy. The only specific Food and Drug Administration - approved therapy for this condition is lifelong weekly intravenous AAT replacement (augmentation therapy). Observational studies strongly suggest a beneficial effect of augmentation therapy in slowing lung function decline and randomized trials suggest a beneficial effect in slowing the progression of emphysema over time as measured by computed tomography. In addition, augmentation therapy has been shown to modulate systemic inflammatory responses and affect markers of elastin degradation. As new markers of disease progression are discovered, new doses of AAT replacement are tested and sub-phenotypes of disease are described, treatment recommendations are likely to change towards a more individualized therapeutic approach.
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Affiliation(s)
- Michael A Campos
- Associate Professor of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami School of Medicine, PO Box 016960 (R-47), Miami, FL 33101, USA
| | - Jorge Lascano
- Assistant Professor, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA
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Ward H, Turner AM, Stockley RA. Spirometric and Gas Transfer Discordance in α 1 -Antitrypsin Deficiency. Chest 2014; 145:1316-1324. [DOI: 10.1378/chest.13-1886] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Manca S, Rodriguez E, Huerta A, Torres M, Lazaro L, Curi S, Pirina P, Miravitlles M. Usefulness of the CAT, LCOPD, EQ-5D and COPDSS Scales in Understanding the Impact of Lung Disease in Patients with Alpha-1 Antitrypsin Deficiency. COPD 2014; 11:480-8. [DOI: 10.3109/15412555.2014.898030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Longer telomere length in COPD patients with α1-antitrypsin deficiency independent of lung function. PLoS One 2014; 9:e95600. [PMID: 24763308 PMCID: PMC3998943 DOI: 10.1371/journal.pone.0095600] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 03/28/2014] [Indexed: 01/22/2023] Open
Abstract
Oxidative stress is involved in the pathogenesis of airway obstruction in α1-antitrypsin deficient patients. This may result in a shortening of telomere length, resulting in cellular senescence. To test whether telomere length differs in α1-antitrypsin deficient patients compared with controls, we measured telomere length in DNA from peripheral blood cells of 217 α1-antitrypsin deficient patients and 217 control COPD patients. We also tested for differences in telomere length between DNA from blood and DNA from lung tissue in a subset of 51 controls. We found that telomere length in the blood was significantly longer in α1-antitrypsin deficient COPD patients compared with control COPD patients (p = 1×10−29). Telomere length was not related to lung function in α1-antitrypsin deficient patients (p = 0.3122) or in COPD controls (p = 0.1430). Although mean telomere length was significantly shorter in the blood when compared with the lungs (p = 0.0078), telomere length was correlated between the two tissue types (p = 0.0122). Our results indicate that telomere length is better preserved in α1-antitrypsin deficient COPD patients than in non-deficient patients. In addition, measurement of telomere length in the blood may be a suitable surrogate for measurement in the lung.
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Stockley RA, Miravitlles M, Vogelmeier C. Augmentation therapy for alpha-1 antitrypsin deficiency: towards a personalised approach. Orphanet J Rare Dis 2013; 8:149. [PMID: 24063809 PMCID: PMC3852071 DOI: 10.1186/1750-1172-8-149] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 09/13/2013] [Indexed: 11/28/2022] Open
Abstract
Background Intravenous augmentation therapy is the only specific treatment available for emphysema associated with alpha-1 antitrypsin deficiency. Despite large observational studies and limited interventional studies there remains controversy about the efficacy of this treatment due to the impracticality of conducting adequately powered studies to evaluate the rate of decline in lung function, due to the low prevalence and the slow progression of the disease. However, measurement of lung density by computed tomography is a more specific and sensitive marker of the evolution of emphysema and two small placebo-controlled clinical trials have provided evidence supporting a reduction in the rate of decline in lung density with augmentation therapy. The problem Where augmentation therapy has become available there has been little consideration of a structured approach to therapy which is often introduced on the basis of functional impairment at diagnosis. Data from registries have shown a great variability in the evolution of lung disease according to patient acquisition and the presence of recognised risk factors. Avoidance of risk factors may, in many cases, stabilise the disease. Since augmentation therapy itself will at best preserve the presenting level of lung damage yet require intravenous administration for life with associated costs, identification of patients at risk of continued rapid or long term progression is essential to select those for whom this treatment can be most appropriate and hence generally more cost-effective. This represents a major reconsideration of the current practice in order to develop a consistent approach to management world wide. Purpose of this review The current review assesses the evidence for efficacy of augmentation therapy and considers how the combination of age, physiological impairment, exacerbation history and rate of decline in spirometry and other measures of emphysema may be used to improve therapeutic decision making, until a reliable predictive biomarker of the evolution of lung impairment can be identified. In addition, individual pharmacokinetic studies may permit the selection of the best regimen of administration for those who need it. Summary The rarity and variable characteristics of the disease imply the need for an individualised approach to therapy in specialised centres with sufficient experience to apply a systematic approach to monitoring and management.
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Affiliation(s)
- Robert A Stockley
- Lung Investigation Unit, Queen Elizabeth Hospital Birmingham, Mindelsohn way, Edgbaston, Birmingham B15 2WB, UK.
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Abstract
Although much remains to be done, recent advances and the advent of new methodologies are promising and should yield increased understanding of the genetic and epigenetic mechanisms influencing the pathogenesis of COPD, both related and unrelated to severe AAT deficiency. Such understanding should ultimately be translated into novel approaches to prevent, diagnose, and treat COPD.
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Affiliation(s)
- Marilyn Foreman
- Division of Pulmonary and Critical Care Medicine, Dept. of Medicine, Morehouse School of Medicine
| | - Michael Campos
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept. of Medicine, University of Miami Miller School of Medicine
| | - Juan C. Celedón
- Division of Pediatric Pulmonary Medicine, Allergy and Immunology, Dept. of Pediatrics, Children’s Hospital of Pittsburgh of UPMC
- Division of Pulmonary, Allergy and Critical Care Medicine, Dept. of Medicine, University of Pittsburgh School of Medicine
- Corresponding author: Juan C. Celedón, M.D., Dr.P.H., F.A.C.P., F.C.C.P., Division of Pediatric Pulmonary Medicine, Allergy and Immunology, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Pittsburgh, PA 15224, Phone: 412.692.8429; Fax: 412.692.7636,
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Barros-Tizón JC, Torres ML, Blanco I, Martínez MT. Reduction of severe exacerbations and hospitalization-derived costs in alpha-1-antitrypsin-deficient patients treated with alpha-1-antitrypsin augmentation therapy. Ther Adv Respir Dis 2012; 6:67-78. [DOI: 10.1177/1753465812438387] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: Severe exacerbations in alpha-1-antitrypsin (AAT)-deficient patients with chronic obstructive pulmonary disease (COPD) and/or emphysema are a major cause of hospitalization. A multicentre, observational, retrospective study was undertaken to evaluate the effect of continuous AAT augmentation therapy in reducing the incidence of exacerbations in these patients. Methods: Patients treated with Trypsone® or Prolastin® for at least 18 months were recruited if their medical records for 18 months before starting augmentation therapy were available. The number of mild and severe exacerbations in the two periods was compared and hospitalization-related costs were analysed. Results: A total of 127 patients were recruited; 75 of them experienced at least one exacerbation in the period prior to augmentation. In the treatment period, the mean number of exacerbations per patient was reduced in both the total population and the population with exacerbations (mean ± SD: 1.2 ± 1.6 versus 1.0 ± 2.2 and 2.0 ± 1.6 versus 1.4 ± 2.7, respectively; p < 0.01). The percentage of patients experiencing exacerbations was reduced in the total population (59.1% versus 44.1%; p < 0.05). In the patient subgroup of the total population who experienced a change in their number of exacerbations between the two periods, 43.7% had a reduction and 21.4% had an increase ( p < 0.01). The number of severe exacerbations diminished in 42.9% of this subgroup and increased in 12.0% ( p < 0.001). Most adverse events were nonserious or not related to treatment. Hospitalization costs savings per patient associated with treatment ranged from approximately €400 to €900 ( p < 0.05). Conclusions: Augmentation therapy with AAT concentrates was associated with a reduction in the incidence and severity of exacerbations in AAT-deficient patients, which resulted in lower hospitalization expenditures.
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Abstract
Common lung diseases such as asthma, COPD, and pulmonary fibrosis cause significant morbidity and mortality in the U.S. and worldwide. Research investigating the mechanisms of disease etiology has clearly indicated that genetic attributes and environmental exposures each play important roles in the development of these diseases. Emerging evidence underscores the importance of the interplay between genetic predisposition and environmental factors in fully understanding the development of lung disease. Herein we discuss recent advances in knowledge and technology surrounding the role of genetics, the environment, and gene-environment interactions in these common lung diseases.
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Affiliation(s)
- Max A Seibold
- Center for Genes, Environment, and Health, National Jewish Health, Denver, Colorado 80206, USA.
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Wang D, Wang W, Dawkins P, Paterson T, Kalsheker N, Sallenave JM, Houghton AM. Deletion of Serpina1a, a murine α1-antitrypsin ortholog, results in embryonic lethality. Exp Lung Res 2011; 37:291-300. [PMID: 21574874 DOI: 10.3109/01902148.2011.554599] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States Approximately 1% to 2% of COPD patients suffer from α(1)-antitrypsin (A1AT) deficiency, the major inheritable predisposition to COPD/emphysema. To further study the role of A1AT deficiency in the pathogenesis of COPD/emphysema, the authors attempted to generate null-mutant mice for Serpina1a, 1 of 2 A1AT orthologs in mice. Here the authors show that targeted deletion of Serpina1a results in embryonic lethality prior to 8.5 days post conception (dpc). The results are surprising given that A1AT-null humans exist and therefore do not require this gene product for normal development. The Serpina1 gene cluster is substantially different between mouse and man. Through gene duplication, mice have 3 to 5 (depending on the strain) highly homologous proteinase inhibiting (Pi) genes, 2 of which inhibit neutrophil elastase. Despite the abundance of Pi genes in mice, Serpina1a serves a critical, nonredundant function during early mouse development. A1AT-deficient mice have been highly sought after to study emphysema, cancer, and liver disease, and as a model to perfect gene replacement therapy. These results highlight important differences between human and murine serpins and point to the difficulty inherent to using gene-targeted mice to study this common human genetic disease.
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Affiliation(s)
- Dongmei Wang
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Abboud RT, Nelson TN, Jung B, Mattman A. Alpha1-antitrypsin deficiency: a clinical-genetic overview. Appl Clin Genet 2011; 4:55-65. [PMID: 23776367 PMCID: PMC3681178 DOI: 10.2147/tacg.s10604] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Severe α1-antitrypsin deficiency (AATD) is an inherited disorder, leading to development of emphysema in smokers at a relatively young age with disability in their forties or fifties. The emphysema results from excessive elastin degradation by neutrophil elastase as a result of the severe deficiency of its major inhibitor α1-antitrypsin (AAT). The AAT expression is determined by the SERPINA1 gene which expresses codominant alleles. The three most common alleles are the normal M, the S with plasma levels of 60% of normal, and the severely deficient Z with levels of about 15% of normal. Homozygosity for the Z mutant allele is associated with retention of abnormal AAT in the liver, which may lead to neonatal hepatitis, liver disease in children, and liver disease in adults. Regular intravenous infusions of purified human AAT (AAT augmentation therapy) have been used to partially correct the biochemical defect and protect the lung against further injury. Two randomized controlled trials showed a trend of slower progression of emphysema by chest computerized tomography. Integrated analysis of these two studies indicated significantly slower progression of emphysema. AAT is quantified by immunologic measurement of AAT in serum, the phenotype characterized by isoelectric focusing, the common genotypes by targeted DNA analysis, and by sequencing the coding region of the gene when the AAT abnormality remains undefined. AATD is often unrecognized, and diagnosis delayed. Testing for AATD is recommended in patients with chronic irreversible airflow obstruction, especially in those with early onset of disease or positive family history. Testing is also recommended for immediate family members of those with AATD, asthmatics with persistent airflow obstruction, and infants and older subjects with unexplained liver disease. There are over 100 different AAT gene variants; most are rare and only some are associated with clinical disease.
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Affiliation(s)
- Raja T Abboud
- Department of Medicine, Respiratory Division, University of British Columbia, Vancouver, BC, Canada
| | - Tanya N Nelson
- Department of Pathology and Laboratory Medicine, Children’s and Women’s Health Centre of British Columbia, University of British Columbia, Vancouver, BC, Canada
| | - Benjamin Jung
- Department of Pathology and Laboratory Medicine, Children’s and Women’s Health Centre of British Columbia, University of British Columbia, Vancouver, BC, Canada
| | - Andre Mattman
- Department of Pathology and Laboratory Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada
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Tonelli AR, Brantly ML. Augmentation therapy in alpha-1 antitrypsin deficiency: advances and controversies. Ther Adv Respir Dis 2010; 4:289-312. [DOI: 10.1177/1753465810373911] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Alpha-1 antitrypsin (AAT) deficiency is a hereditary condition characterized by low levels of AAT in plasma and hence diffusion into tissues. One of the most relevant characteristics of the disease is the development of panacinar emphysema due to an imbalance between proteases and antiproteases in the presence of environmental triggers. Left untreated, severe obstructive lung disease may develop. Avoidance of environmental triggers such as cigarette smoking constitutes a critical component of AAT deficiency treatment. Intravenous augmentation therapy is the only specific therapy for the condition that has been approved by the US Food and Drug Administration (FDA). While this therapy likely slows the rate of progression of emphysema and may improve survival in selected individuals with severe AAT deficiency, the gold standard for proof of efficacy is lacking. Areas where controversy exists regarding the use of AAT augmentation therapy include: (1) indications for treatment, (2) selection of specific AAT augmentation therapy, (3) appropriate dose and interval of administration, (4) cost effectiveness, (5) frequency and mode of follow up of treated patients, (6) use of augmentation therapy after lung transplantation, (7) use of recombinant AAT supplementation, (8) alternative delivery routes, and (9) genetic therapy. In this review we describe the advances in treatment and try to address some of the current controversies in AAT deficiency management.
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Affiliation(s)
- Adriano R. Tonelli
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Mark L. Brantly
- Molecular Genetics and Microbiology, Alpha One Foundation Research Professor, Pulmonary, Critical Care, and Sleep Medicine, University of Florida College of Medicine, JHMHC PO Box 100225, Gainesville, FL 32610, USA,
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Alpha1-Antitrypsin-Mangel in Österreich: Auswertung der österreichischen Datenbank des internationalen Alpha1-Antitrypsin Registers. Wien Klin Wochenschr 2010; 122:390-6. [DOI: 10.1007/s00508-010-1399-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Accepted: 04/26/2010] [Indexed: 11/26/2022]
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Sørheim IC, Bakke P, Gulsvik A, Pillai SG, Johannessen A, Gaarder PI, Campbell EJ, Agustí A, Calverley PMA, Donner CF, Make BJ, Rennard SI, Vestbo J, Wouters EFM, Paré PD, Levy RD, Coxson HO, Lomas DA, Hersh CP, Silverman EK. α₁-Antitrypsin protease inhibitor MZ heterozygosity is associated with airflow obstruction in two large cohorts. Chest 2010; 138:1125-32. [PMID: 20595457 DOI: 10.1378/chest.10-0746] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Severe α₁-antitrypsin deficiency is a known genetic risk factor for COPD. Heterozygous (protease inhibitor [PI] MZ) individuals have moderately reduced serum levels of α₁-antitrypsin, but whether they have an increased risk of COPD is uncertain. METHODS We compared PI MZ and PI MM individuals in two large populations: a case-control study from Norway (n = 1,669) and a multicenter family-based study from Europe and North America (n = 2,707). We sought to determine whether PI MZ was associated with the specific COPD-related phenotypes of lung function and quantitative CT scan measurements of emphysema and airway disease. RESULTS PI MZ was associated with a 3.5% lower FEV₁/FVC ratio in the case-control study (P = .035) and 3.9% lower FEV₁/vital capacity (VC) ratio in the family study (P = .009). In the case-control study, PI MZ also was associated with 3.7% more emphysema on quantitative analysis of chest CT scans (P = .003). The emphysema result was not replicated in the family study. PI MZ was not associated with airway wall thickness or COPD status in either population. Among subjects with low smoking exposure (< 20 pack-years), PI MZ individuals had more severe emphysema on chest CT scan than PI MM individuals in both studies. CONCLUSIONS Compared with PI MM individuals, PI MZ heterozygotes had lower FEV₁/(F)VC ratio in two independent studies. Our results suggest that PI MZ individuals may be slightly more susceptible to the development of airflow obstruction than PI MM individuals.
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Affiliation(s)
- Inga-Cecilie Sørheim
- Channing Laboratory, Brigham and Women's Hospital and Harvard Medical School, 181 Longwood Ave, Boston, MA 02115, USA
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Tanash HA, Nilsson PM, Nilsson JA, Piitulainen E. Survival in severe alpha-1-antitrypsin deficiency (PiZZ). Respir Res 2010; 11:44. [PMID: 20420704 PMCID: PMC2867977 DOI: 10.1186/1465-9921-11-44] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Accepted: 04/26/2010] [Indexed: 11/22/2022] Open
Abstract
Background Previous studies of the natural history of alpha-1-antitrypsin (AAT) deficiency are mostly based on highly selected patients. The aim of this study was to analyse the mortality of PiZZ individuals. Methods Data from 1339 adult PiZZ individuals from the Swedish National AAT Deficiency Registry, followed from 1991 to 2008, were analysed. Forty-three percent of these individuals were identified by respiratory symptoms (respiratory cases), 32% by liver diseases and other diseases (non-respiratory cases) and 25% by screening (screened cases). Smoking status was divided into two groups: smokers 737 (55%) and 602 (45%) never-smokers. Results During the follow-up 315 individuals (24%) died. The standardised mortality rate (SMR) for respiratory cases was 4.70 (95% Confidence Interval (CI) 4.10-5.40), 3.0 (95%CI 2.35-3.70) for the non-respiratory cases and 2.30 (95% CI 1.46-3.46) for the screened cases. The smokers had a higher mortality risk than never-smokers, with a SMR of 4.80 (95%CI 4.20-5.50) for the smokers and 2.80(95%CI 2.30-3.40) for the never-smokers. The Rate Ratio (RR) was 1.70 (95% CI 1.35-2.20). Also among the screened cases, the mortality risk for the smokers was significantly higher than in the general Swedish population (SMR 3.40 (95% CI 1.98-5.40). Conclusion Smokers with severe AAT deficiency, irrespective of mode of identification, have a significantly higher mortality risk than the general Swedish population.
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Affiliation(s)
- Hanan A Tanash
- Department of Respiratory Medicine, Malmö University Hospital, Lund University, Malmö, 205 02, Sweden.
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Abstract
COPD is a highly prevalent disorder that results from the interplay of genetic susceptibility and environmental exposures. Over the past 2 decades, significant technological advances have been made in genetic investigations of complex diseases, yet limited progress has been made in the identification of additional COPD susceptibility genes. Genetic and phenotypic heterogeneity, limited power due to modest study population sizes, and significant modification of genetic effects by environmental factors pose significant challenges in COPD and emphysema genetic studies. More refined characterization of the emphysema and airway components of COPD can now be obtained through the systematic use of CT scans. These improved phenotypes can be applied in genome-wide association studies and will likely lead to the discovery of additional susceptibility loci and therapeutic targets.
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Affiliation(s)
- Emily S Wan
- Channing Laboratory and the Pulmonary and Critical Care Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Edwin K Silverman
- Channing Laboratory and the Pulmonary and Critical Care Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA.
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Abstract
α1-Antitrypsin (AAT), a 52 kDa plasma protein, is produced mainly in the liver. It is the most abundant circulating serine proteinase inhibitor (serpin). It has also previously been called protease inhibitor to reflect its function as a general inhibitor of serine proteases. Its main physiological role is to inhibit neutrophil elastase and it contributes to the innate immune system as an anti-inflammatory protein. Severe AAT deficiency is most prevalent in northern Europeans affecting about 1 in 3000 of the population. AAT deficiency predisposes individuals who smoke to developing pulmonary emphysema in the fourth–fifth decade of adult life and to childhood cirrhosis in about 10% of cases, with the initial presentation being prolonged neonatal jaundice. The mean interval from presentation with symptoms to diagnosis in adults is about 8 years. The condition is under-recognised and under-diagnosed. The only effective current treatment for the severe liver disease that occurs in childhood currently is liver transplantation. Replacement therapy with purified AAT from human plasma is being used in clinical practice for the lung disease though it is not known whether this influences the outcome of this chronic condition. The liver pathology arises from intracellular polymerisation of mutant protein, and attenuation of polymerisation is a potential target for therapy.
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Bossé Y. Genetics of chronic obstructive pulmonary disease: a succinct review, future avenues and prospective clinical applications. Pharmacogenomics 2009; 10:655-67. [PMID: 19374520 DOI: 10.2217/pgs.09.10] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is influenced by genetic and environmental factors. A large number of candidate gene-association studies and genome-wide linkage scans have been conducted to elucidate the genetic architecture underlying this disease. The compilation of these studies clearly revealed the complex genetic nature of COPD. Multiple genes acting on specific environmental backgrounds are likely to be the tenet of this multifactorial disorder. Encouragingly, reproducible susceptibility genes, such as SERPINE2, were recently identified. Advances in genomic research offer unprecedented capabilities to interrogate the human genome and are likely to accelerate the discovery of new genes. A comprehensive catalogue of genes implicated in the pathogenesis of COPD has great potential to lead to the development of new therapies and explain interindividual response to treatment.
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Affiliation(s)
- Yohan Bossé
- Institut universitaire de cardiologie et de pneumologie de Québec, Pavillon Margeritte-d'Youville, Y4190, 2725, Chemin Sainte-Foy, Quebec City, Quebec, G1V 4G5, Canada.
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Wood AM, Needham M, Simmonds MJ, Newby PR, Gough SC, Stockley RA. Phenotypic Differences in Alpha 1 Antitrypsin-Deficient Sibling Pairs May Relate to Genetic Variation. COPD 2009; 5:353-9. [DOI: 10.1080/15412550802522320] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Campos MA, Alazemi S, Zhang G, Salathe M, Wanner A, Sandhaus RA, Baier H. Clinical characteristics of subjects with symptoms of alpha1-antitrypsin deficiency older than 60 years. Chest 2008; 135:600-608. [PMID: 19017884 DOI: 10.1378/chest.08-1129] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The clinical characteristics of elderly subjects with alpha(1)-antitrypsin deficiency (AATD)-associated COPD have not been described. METHODS The clinical, demographic, health-related quality of life (HRQoL) characteristics and 1-year exacerbation rates of 275 subjects with AATD and COPD receiving augmentation therapy aged > 59 years (mean [+/- SD] age, 66.3 +/- 5.7 years) were compared to those of 354 subjects aged 50 to 59 years (mean age, 54.3 +/- 2.8 years) and 293 subjects < 50 years (mean age, 43.9 +/- 3.8 years). RESULTS Older subjects received diagnoses later in life (mean age at diagnosis, 55.0 +/- 8.5 years) and had a longer diagnostic delay (mean age at diagnosis, 12.9 +/- 14.3 years) than subjects in the other two age groups. Although the proportion of lifetime nonsmokers was higher in the older group, the majority (64%) had significant tobacco exposure but with a longer interval of tobacco abstinence. The mean FEV(1) values (n = 641) were similar between the three age groups, suggesting a slower disease progression in the oldest group. Subjects in the older group were less symptomatic, had less concomitant asthma, and had significantly better scores in most domains of two HRQoL instruments. During follow-up, older subjects had fewer acute exacerbations. CONCLUSIONS Subjects with AATD-associated COPD who reach an older age exhibit a more indolent clinical course than younger affected individuals, possibly related in part to differences in tobacco exposure. This finding supports current guidelines that recommend screening of all patients with COPD for AATD, regardless of their age and prior smoking history.
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Affiliation(s)
| | - Saleh Alazemi
- Miller School of Medicine, University of Miami, Miami, FL
| | | | | | - Adam Wanner
- Miller School of Medicine, University of Miami, Miami, FL
| | | | - Horst Baier
- Miller School of Medicine, University of Miami, Miami, FL
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Detection of alpha-1 antitrypsin deficiency: a review. Respir Med 2008; 103:335-41. [PMID: 19013782 DOI: 10.1016/j.rmed.2008.10.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 10/02/2008] [Accepted: 10/04/2008] [Indexed: 10/21/2022]
Abstract
Screening studies reveal a much larger number of individuals expected to have alpha-1 antitrypsin deficiency than is clinically recognized, with estimates that only about 2-10% of such individuals have been diagnosed. In the context that recognition of alpha-1 antitrypsin may prompt specific interventions (e.g., smoking avoidance, testing of family members, genetic counseling, and consideration of augmentation therapy), diagnosis is important, inviting much attention for efforts to identify affected individuals. Strategies to identify affected individuals include both population-based screening and targeted detection, and available studies have employed both approaches, though large-scale population-based screening is challenging. As reviewed in this paper, targeted-detection studies have generally produced a higher rate of detecting disease, and tend to be more successful with easier sampling techniques. Strategies to enhance detection in targeted studies have included awareness campaigns, easy testing techniques (such as evaluation of dried blood spots and home, confidential testing), and inclusive criteria for testing which span the full spectrum of clinical manifestations of alpha-1 antitrypsin deficiency.
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Abstract
Alpha 1-antitrypsin deficiency is an inherited metabolic disorder that predisposes the affected individual to chronic pulmonary disease, in addition to chronic liver disease, cirrhosis, and hepatocellular carcinoma. Just over one-third of genetically susceptible adult patients with the most severe phenotype, PiZZ, develop clinically significant liver injury. The clinical presentation of liver disease is variable, and the genetic and environmental factors that predispose some individuals to liver disease while sparing others are unknown. The mechanisms of liver and lung disease are distinct and unique. This article reviews the liver disease associated with alpha 1-antitrypsin deficiency, emphasizing the genetic defect, molecular pathogenesis, natural history, and promising therapies.
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Affiliation(s)
- Kyrsten D Fairbanks
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Alpha-1 antitrypsin Null mutations and severity of emphysema. Respir Med 2008; 102:876-84. [DOI: 10.1016/j.rmed.2008.01.009] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2007] [Revised: 01/06/2008] [Accepted: 01/12/2008] [Indexed: 11/17/2022]
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Greene CM, Miller SDW, Carroll T, McLean C, O'Mahony M, Lawless MW, O'Neill SJ, Taggart CC, McElvaney NG. Alpha-1 antitrypsin deficiency: a conformational disease associated with lung and liver manifestations. J Inherit Metab Dis 2008; 31:21-34. [PMID: 18193338 DOI: 10.1007/s10545-007-0748-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Revised: 11/30/2007] [Accepted: 12/07/2007] [Indexed: 12/20/2022]
Abstract
Alpha-1 antitrypsin (A1AT) is a serine anti-protease produced chiefly by the liver. A1AT deficiency is a genetic disorder characterized by serum levels of less than 11 mumol/L and is associated with liver and lung manifestations. The liver disease, which occurs in up to 15% of A1AT-deficient individuals, is a result of toxic gain-of-function mutations in the A1AT gene, which cause the A1AT protein to fold aberrantly and accumulate in the endoplasmic reticulum of hepatocytes. The lung disease is associated with loss-of-function, specifically decreased anti-protease protection on the airway epithelial surface. The so-called 'Z' mutation in A1AT deficiency encodes a glutamic acid-to-lysine substitution at position 342 in A1AT and is the most common A1AT allele associated with disease. Here we review the current understanding of the molecular pathogenesis of A1AT deficiency and the best clinical management protocols.
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Affiliation(s)
- C M Greene
- Respiratory Research Division, Department of Medicine, Royal College of Surgeons in Ireland, Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland.
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Abstract
Alpha1-antitrypsin deficiency is a genetic disorder which contributes to the development of chronic obstructive pulmonary disease, bronchiectasis, liver cirrhosis and panniculitis. The discovery of alpha1-antitrypsin and its function as an antiprotease led to the protease-antiprotease hypothesis, which goes some way to explaining the pathogenesis of emphysema. This article will review the clinical features of alpha1-antitrypsin deficiency, the genetic mutations known to cause it, and how they do so at a molecular level. Specific treatments for the disorder based on this knowledge will be reviewed, including alpha1-antitrypsin replacement, gene therapy and possible future therapies, such as those based on stem cells.
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Affiliation(s)
- Alice M Wood
- Department of Medical Sciences, University of Birmingham, Birmingham, UK
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American Thoracic Society/European Respiratory Society statement: standards for the diagnosis and management of individuals with alpha-1 antitrypsin deficiency. Am J Respir Crit Care Med 2007; 168:818-900. [PMID: 14522813 DOI: 10.1164/rccm.168.7.818] [Citation(s) in RCA: 627] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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45
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Demeo DL, Sandhaus RA, Barker AF, Brantly ML, Eden E, McElvaney NG, Rennard S, Burchard E, Stocks JM, Stoller JK, Strange C, Turino GM, Campbell EJ, Silverman EK. Determinants of airflow obstruction in severe alpha-1-antitrypsin deficiency. Thorax 2007; 62:806-13. [PMID: 17389752 PMCID: PMC2117297 DOI: 10.1136/thx.2006.075846] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Severe alpha(1)-antitrypsin (AAT) deficiency is an autosomal recessive genetic condition associated with an increased but variable risk for chronic obstructive pulmonary disease (COPD). A study was undertaken to assess the impact of chronic bronchitis, pneumonia, asthma and sex on the development of COPD in individuals with severe AAT deficiency. METHODS The AAT Genetic Modifier Study is a multicentre family-based cohort study designed to study the genetic and epidemiological determinants of COPD in AAT deficiency. 378 individuals (age range 33-80 years), confirmed to be homozygous for the SERPINA1 Z mutation, were included in the analyses. The primary outcomes of interest were a quantitative outcome, forced expiratory volume in 1 s (FEV(1)) percentage predicted, and a qualitative outcome, severe airflow obstruction (FEV(1) <50% predicted). RESULTS In multivariate analysis of the overall cohort, cigarette smoking, sex, asthma, chronic bronchitis and pneumonia were risk factors for reduced FEV(1 )percentage predicted and severe airflow obstruction (p<0.01). Index cases had lower FEV(1) values, higher smoking histories and more reports of adult asthma, pneumonia and asthma before age 16 than non-index cases (p<0.01). Men had lower pre- and post-bronchodilator FEV(1) percentage predicted than women (p<0.0001); the lowest FEV(1) values were observed in men reporting a history of childhood asthma (26.9%). This trend for more severe obstruction in men remained when index and non-index groups were examined separately, with men representing the majority of non-index individuals with airflow obstruction (71%). Chronic bronchitis (OR 3.8, CI 1.8 to 12.0) and a physician's report of asthma (OR 4.2, CI 1.4 to 13.1) were predictors of severe airflow obstruction in multivariate analysis of non-index men but not women. CONCLUSION In individuals with severe AAT deficiency, sex, asthma, chronic bronchitis and pneumonia are risk factors for severe COPD, in addition to cigarette smoking. These results suggest that, in subjects severely deficient in AAT, men, individuals with symptoms of chronic bronchitis and/or a past diagnosis of asthma or pneumonia may benefit from closer monitoring and potentially earlier treatment.
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Affiliation(s)
- Dawn L Demeo
- Channing Laboratory, 181 Longwood Avenue, Boston, Massachusetts 02115, USA.
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de la Roza C, Lara B, Vilà S, Miravitlles M. [Alpha1-antitrypsin deficiency: situation in Spain and development of a screening program]. Arch Bronconeumol 2006; 42:290-8. [PMID: 16827978 DOI: 10.1016/s1579-2129(06)60145-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Studies undertaken in Spain indicate that 9% of the general population aged between 40 and 70 years is affected by chronic obstructive pulmonary disease (COPD). Although tobacco smoke is the causative factor in more than 90% of cases, it is estimated that only 10% to 20% of smokers develop COPD. This may be explained by the existence of genetic or environmental factors that modulate the toxic effects of tobacco. The best known genetic factor is alpha1-antitrypsin deficiency, which is associated with an increased risk of developing pulmonary emphysema in smokers. The most recent guidelines from both the World Health Organization and the American Thoracic Society/European Respiratory Society recommend the establishment of screening programs for the detection of alpha1-antitrypsin deficiency in patients with COPD. This strategy is crucial in Spain, where the disease is under diagnosed, mainly due to a low index of suspicion among doctors.
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Affiliation(s)
- Cristian de la Roza
- Servicio de Neumología, Institut Clínic del Tórax, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Red Respira RTIC 03/11 ISCIII, Hospital Clínic, Barcelona, España.
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Vidal R, Blanco I, Casas F, Jardí R, Miravitlles M. Guidelines for the Diagnosis and Management of α1-Antitrypsin Deficiency. ACTA ACUST UNITED AC 2006; 42:645-59. [PMID: 17178069 DOI: 10.1016/s1579-2129(07)60007-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Rafael Vidal
- Servicio de Neumología, Hospital Universitari Vall d'Hebron, Barcelona, España.
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Vidal R, Blanco I, Casas F, Jardí R, Miratvilles M. Diagnóstico y tratamiento del déficit de alfa-1-antitripsina. Arch Bronconeumol 2006. [DOI: 10.1157/13095974] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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de la Roza C, Lara B, Vilà S, Miravitlles M. Déficit de alfa-1-antitripsina. Situación en España y desarrollo de un programa de detección de casos. Arch Bronconeumol 2006. [DOI: 10.1157/13089541] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Mayer AS, Stoller JK, Vedal S, Ruttenber AJ, Strand M, Sandhaus RA, Newman LS. Risk factors for symptom onset in PI*Z alpha-1 antitrypsin deficiency. Int J Chron Obstruct Pulmon Dis 2006; 1:485-92. [PMID: 18044105 PMCID: PMC2707814 DOI: 10.2147/copd.2006.1.4.485] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In an early study of highly symptomatic patients with PI*Z alpha-1 antitrypsin deficiency (AAT), tobacco smoking was identified as a risk factor by comparing the age of symptom onset in smokers and nonsmokers. Age of symptom onset has not been well studied in relationship to other environmental exposures. METHODS Environmental exposures were assessed in 313 PI*Z adults through retrospective self-administered questionnaire. Age of onset of symptoms with and without these exposures were analyzed through survival analysis. RESULTS Personal smoking was the most important risk factor, associated with earlier onset of cough and wheeze, and showed a dose-dependent relationship with the onset of dyspnea. Childhood environmental tobacco smoke (ETS) exposure was independently associated with younger age of onset of cough. Earlier onset of wheeze was also associated with childhood respiratory infections and family history of emphysema. The report of childhood respiratory infections was associated with childhood ETS exposure, but no statistically significant interactions were noted. CONCLUSIONS We conclude that both personal and secondhand exposure to tobacco smoke in childhood are likely to accelerate the onset of symptoms in AAT deficient patients. Respiratory infections in childhood may also contribute to this risk.
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Affiliation(s)
- Annyce S Mayer
- Division of Environmental and Occupational Health Sciences National Jewish Medical and Research Center, Denver, CO 80206, USA.
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