Long-term therapy of alpha 1-antitrypsin-deficiency-associated pulmonary emphysema with human alpha 1-antitrypsin

alpha 1-antitrypsin (alpha 1-AT) deficiency is a genetic disorder characterized by low serum levels of alpha 1-AT and a high risk of pulmonary emphysema at a young age. The resulting surplus of proteases, mainly of neutrophil elastase, can be balanced by i.v. augmentation with alpha 1-AT. However, it is not clear if affected patients benefit from long-term augmentation therapy and no long-term safety data are available. We examined 443 patients with severe alpha 1-AT deficiency and pulmonary emphysema receiving weekly i.v. infusions of 60 mg/kg body weight alpha 1-AT in addition to their regular medication. The progression of the disease was assessed by repeated lung function measurements, particularly the decline in forced expiratory volume in 1 second (delta FEV1). 443 patients with alpha 1-AT deficiency tolerated augmentation therapy well with few adverse reactions. The delta FEV1 in 287 patients with available follow-up data was 57.1 +/- 31.1 ml per year. Stratified for baseline FEV1, the decline was 35.6 +/- 21.3 ml in the 108 patients with an initial FEV1 < 30% and 64.0 +/- 26.4 ml in the 164 with 30% < FEV1 < or = 65% of predicted normal (p = 0.0008). The remaining 15 patients had an initial FEV1 > 65%. Long-term treatment with i.v. alpha 1-antitrypsin in patients with severe alpha 1-Pi deficiency is feasible and safe. The decline in forced expiratory volume in one second is related to the initial forced expiratory volume in one second as in alpha 1-antitrypsin deficient patients not receiving augmentation therapy.     

Host response to initial and challenge infections, following treatment, of Gyrodactylus bullatarudis and G. turnbulli (Monogenea) on the guppy (Poecilia reticulata)

Patients homozygous for the Z allele of alpha-1-antitrypsin (alpha 1AT) have very low serum levels and are predisposed to emphysema. There have also been reports of emphysema being associated with the heterozygous phenotype FZ. To investigate whether F alpha 1AT was dysfunctional, the inhibitory activity of F alpha 1AT against human neutrophil elastase (HNE) was compared with that of common alpha 1AT phenotypes. Time-dependent inhibition of HNE by alpha 1AT was used to calculate the association rate constant (k assoc) for M, MZ, FM, FZ, F (partially purified from FZ or FS), Z and S alpha 1AT phenotypes in human sera. The results for k assoc at 25 degrees C were 9.1 (SD 0.9), 9.7 (SD 0.9), 8.0 (SD 0.8), 4.0 (SD 0.4), 4.2 (SD 0.8), 5.1 (SD 0.6) and 8.6 (SD 0.6) x 10(6) M-1s-1 respectively. F was found to have reduced activity much like that of Z, the alpha 1AT most commonly associated with emphysema. MZ (low risk for disease) and FZ heterozygotes had similar intermediate alpha 1AT levels. However the in vivo inhibition time for FZ was almost three times longer than for MZ, indicating greater exposure to proteolytic damage from free elastase for FZ than MZ individuals. In conclusion, F alpha 1AT is expressed in serum at low normal levels but is dysfunctional in its ability to inhibit HNE. Individuals who coinherit the F and a deficiency allele such as Z or Null, are likely to have a high risk for the development of emphysema. The disease risk for F homozygotes remains to be determined.     

Alpha-1-antitrypsin PLowell: a normally functioning variant present in low concentration

BACKGROUND: Alpha-1-antitrypsin deficiency is associated with a high risk for the development of emphysema, particularly for phenotype Pi ZZ, which is both deficient and an abnormal inhibitor of the powerful proteolytic enzyme, human neutrophil elastase. The rare variant PLowell is also expressed at abnormally low levels, but its anti-elastase activity has not been described. AIM: To study the anti-elastase activity of alpha-1-antitrypsin PLowell and compare it to the common M, S and Z proteins. METHOD: Alpha-1-antitrypsin from a female patient aged 75 years with the rare genotype PLowell NullBellingham was studied for its ability to inhibit human neutrophil elastase in a time dependent manner. RESULTS: PLowell has near normal function as an inhibitor of human neutrophil elastase with an association rate constant of 7.4 x 10(6) M-1 S-1 at 25 degrees C, similar to that of M and S. CONCLUSION: Alpha-1-antitrypsin PLowell is associated with a severe deficiency of alpha-1-antitrypsin similar to Z, but unlike that protein it has near normal function as an anti-elastase.     

New insights into the structural basis of alpha 1-antitrypsin deficiency

The serpin superfamily of serine proteinase inhibitors contains many members but the best-characterized is the plasma protein alpha 1-antitrypsin. its genetic deficiency is associated, in the homozygote, with hepatic damage that may progress to cirrhosis and hepatocellular carcinoma. Low levels of circulating alpha 1-antitrypsin fail to protect the lungs against proteolytic attack and predispose the homozygote to early onset pan-lobular emphysema, bronchiectasis and asthma. The major cause of alpha 1-antitrypsin deficiency, the Z mutation (Glu342Lys), results in the accumulation of protein in the endoplasmic reticulum of the liver. Using a structural approach, we have shown that the hepatic inclusions result from a protein-protein interaction between the reactive centre loop of one molecule and the beta-pleated sheet of a second. This loop-sheet polymerization is now also recognized to be the basis of deficiencies associated with mutations of C1-inhibitor, antithrombin and alpha 1-antichymotrypsin. Our recent solution of a crystal structure of a thermostable mutant of alpha 1-antitrypsin shows the detailed interactions that result in loop-sheet linkage and helps to explain the mechanism of action of this family of proteinase inhibitors.     

NaF potentiates a K(+)-selective ion channel in G292 osteoblastic cells

In a previous study, isoelectrofocusing of serum from liver-diseased and healthy dogs revealed three different types of the acute phase protein, alpha-1-antitrypsin: Pi (protease inhibitor) F, Pi I and Pi S. Moreover, accumulated alpha-1-antitrypsin was found immunohistochemically in liver sections from dogs with chronic liver disease, predominantly in association with Pi I in serum. The present study was made to further the relationship between alpha-1-antitrypsin and the pathogenesis of chronic liver disease in dogs. Aliquots of samples of purified canine Pi F, Pi I and Pi S were examined for elastase inhibitory capacity, the main function of alpha-l-antitrypsin, and for polymerization tendency, a possible cause of accumulation of alpha-1-antitrypsin in the liver. These parameters were studied after incubation of the proteins at different temperatures (4, 37 and 42 degrees C) and pH values (6.8, 7.8 and 8.5) and for different periods (< or = 24 h and 5 days). In contrast to findings with Pi Z, the human alpha-1-antitrypsin variant associated with liver disease, polymers of canine Pi F, Pi I or Pi S could not be detected under any of the conditions tested. However, Pi I was sensitive to pH, as was demonstrated by reduced elastase inhibitory capacity after incubation at pH 6.8 for < or = 24 h or 5 days, or at pH 8.5 for 5 days. However, after incubation at pH 7.8 for < or = 24 h or 5 days at 4, 37 or 42 degrees C, Pi I was completely stable. Pi F retained its elastase inhibitory capacity, even after prolonged incubation, at all pH values and temperatures tested. Due to low yield, Pi S was tested only after incubation for < or = 24 h at pH 6.8 and at 4 degrees C; under these conditions its elastase inhibitory capacity was equal to that of Pi F. Taken together, these findings indicate molecular and functional differences between Pi I and Pi F and further support a role for alpha-1-antitrypsin in the pathogenesis of canine liver disease.     

Hyperplasia of pulmonary neuroendocrine cells in a case of childhood pulmonary emphysema

Pulmonary emphysema is very uncommon in children in the first decade of life. The few cases documented in the literature were all due to alpha1-antitrypsin deficiency. We present the case of a 6-year-old white boy with chronic cough and dyspnea on exertion. Lung biopsy showed panacinar type emphysema with patent airways and diffuse hyperplasia of pulmonary neuroendocrine cells revealed after immunostaining for bombesin, a peptide produced by these cells. We speculate that idiopathic diffuse hyperplasia of bombesin-producing pulmonary neuroendocrine cells may contribute to the pathogenesis of unusual COPD in childhood.     

Severe alpha1-antitrypsin deficiency (PiZ homozygosity) with membranoproliferative glomerulonephritis and nephrotic syndrome, reversible after orthotopic liver transplantation

BACKGROUND/AIMS: Nephropathy associated with alpha1-antitrypsin deficiency is assumed to be an unusual entity. We describe the case of a 23-year-old woman with severe alpha1-antitrypsin (PiZ homozygosity) deficiency who developed hepatic cirrhosis in childhood, and glomerulonephritis and nephrotic syndrome in adult life. METHODS/RESULTS: A renal biopsy was consistent with membranoproliferative glomerulonephritis. An immunofluorescence study revealed the presence of alpha1-antitrypsin (PiZ) in the subendothelial region of the glomerular basement membrane. The renal disease was reversible after orthotopic liver transplantation. CONCLUSIONS: The presence of abnormal PiZ protein in the subendothelial region of the glomerular basement membrane may suggest a possible role for this protein in the pathogenesis of glomerulonephritis. The case should add impetus to the search for alpha1-antitrypsin deficiency in any patient presenting with combined liver and renal disease, in the absence of evidence of hepato-renal syndrome, and illustrates that liver transplantation alone may reverse the nephropathy associated with alpha1-antitrypsin deficiency.     

Latent alpha1-antichymotrypsin. A molecular explanation for the inactivation of alpha1-antichymotrypsin in chronic bronchitis and emphysema

alpha1-Antichymotrypsin is an acute phase protein that protects the tissues from damage by proteolytic enzymes, but previous studies have shown that alpha1-antichymotrypsin within the lungs of patients with chronic bronchitis and emphysema is intact but inactive as an inhibitor. Ammonium sulfate fractionation followed by blue Sepharose and DNA-Sepharose chromatography was used to isolate small amounts of intact, monomeric but inactive alpha1-antichymotrypsin from the plasma of 30 healthy blood donors. This species had a higher DNA binding affinity with more anodal electrophoretic mobility than native alpha1-antichymotrypsin and was conformationally stable against thermal denaturation, 8 M urea, and 7 M guanidinium chloride. The protein was unable to accept synthetic reactive loop peptides, and the reactive loop was resistant to proteolytic cleavage at the P5-P4 bond but could be cleaved between P1' and P3'. These data suggest that this new alpha1-antichymotrypsin species was in a conformation similar to those of the crystallographically determined latent serpins, plasminogen activator inhibitor-1 and antithrombin. alpha1-Antichymotrypsin from lung lavage migrated with the same electrophoretic mobility as the putative latent alpha1-antichymotrypsin, suggesting that this is the inactive conformation described previously in the lungs of patients with chronic bronchitis and emphysema. This conformational transition of alpha1-antichymotrypsin, from an active to an inactive state, within the lung may play an important role in the pathogenesis of chronic lung disease.     

Pathophysiology and treatment of alpha 1-antitrypsin deficiency

The pathophysiology of alpha 1-antitrypsin (AAT) deficiency and the use of alpha 1-proteinase inhibitor therapy in the management of emphysema caused by AAT deficiency are described. AAT deficiency is the most common genetic cause of liver disease in children and emphysema in adults. However, not all patients with AAT deficiency develop hepatic or pulmonary involvement. Changes in the composition of the AAT molecule have been associated with AAT dysfunction in liver disease, whereas lung disease occurs when AAT concentrations are reduced. A definitive diagnosis can be made through serum AAT phenotype determination. Therapy for liver disease induced by AAT deficiency consists of supportive measures. Therapy for pulmonary disease due to AAT deficiency includes AAT augmentation therapy along with supportive measures. The available product, alpha 1-proteinase inhibitor, is derived from fractionated plasma and has similar biological activity to native serum AAT. Clinical trials have demonstrated a positive effect on serum and lung concentrations of AAT with few adverse events. Two recombinant forms of AAT have also been developed; however, few trials have been published evaluating their safety and efficacy in AAT-deficient patients. Many questions remain unanswered concerning AAT deficiency and replacement therapy. AAT augmentation therapy appears to reduce the progression of emphysema in some AAT-deficient patients.     

Divergent expression of alpha1-protease inhibitor genes in mouse and human

The alpha1-protease inhibitor proteins of laboratory mice are homologous in sequence and function to human alpha1-antitrypsin and are encoded by a highly conserved multigene family comprised of five members. In humans, the inhibitor is expressed in liver and in macrophages and decreased expression or inhibitory activity is associated with a deficiency syndrome which can result in emphysema and liver disease in affected individuals. It has been proposed that macrophage expression may be an important component of the function of human alpha1-antitrypsin. Clearly, it is desirable to develop a mouse model of this deficiency syndrome, however, efforts to do this have been largely unsuccessful. In this paper, we report that aside from the issues of potentially redundant gene function, the mouse may not be a suitable animal for such studies, because there is no significant expression of murine alpha1-protease inhibitor in the macrophages of mice. This difference between the species appears to result from an absence of a functional macrophage-specific promoter in mice.     

Alpha1-antitrypsin phenotypes in patients with cryptogenic fibrosing alveolitis: a case-control study

Cryptogenic fibrosing alveolitis (CFA) is an interstitial lung disease, which by definition is of unknown aetiology. Recent evidence has suggested that smoking and occupational exposure to dusts may be environmental risk factors for the disease, but there has been little research into potential host risk factors. One previous study has suggested that the prevalence of abnormal alpha1-antitrypsin phenotypes may be increased in patients with CFA. Since alpha1-antitrypsin is important in regulating inflammation within the lung in response to environmental exposures, such abnormalities may be of aetiological importance in this disease. We have compared the alpha1-antitrypsin phenotypes of 189 patients with CFA with 189 age-, sex-, and community-matched controls. This sample size was sufficient to provide more than 95% power to detect an odds ratio (OR) of 2.5. Alpha1-antitrypsin phenotype was established by isoelectric focusing, and the prevalence of abnormal phenotypes in cases and controls was compared by conditional logistic regression. Personal smoking histories were obtained by postal questionnaire. The prevalence of abnormal alpha1-antitrypsin phenotypes was similar in cases and controls (12.7 versus 15.3%; OR 0.88; 95% confidence interval 0.49-1.57; p=0.66). No interaction was found between the presence of abnormal alpha1-antitrypsin phenotypes and a history of smoking. We conclude that cryptogenic fibrosing alveolitis is not associated with abnormal alpha1-antitrypsin phenotypes.     

Cystadenolymphoma of the parotid gland an immunohistochemical study of the epithelial component of twenty cases

Carcinoembryonic antigen, epithelial membrane antigen, Keratin, Desmin, Vimentin, CD30, lysozyme, alpha 1-antitrypsin, alpha 1-antichymotrypsin, S-100 protein, somatostatin and glucagon were looked for using immunohistochemical methods in the epithelial component of 20 parotid gland cystadenolymphomas and 20 normal parotid glands. Carcino-embryonic antigen, ephithelial membrane antigen, S-100 protein, and somatostatin were found in the epithelial cells of most of the cystadenolymphomas. In normal parotid tissue, carcinoembryonic antigen, epithelial membrane antigen, Keratin, alpha 1-antitrypsin, alpha 1-antichymotrypsin, and S-100 protein were found in all three types of ductal cells, somatostatin only in intercalated and striated ductal cells, and lysozyme only in acinar and intercalated ductal cells. Desmin and CD30 were found in the epithelial component of seven of the 20 tumors versus none of the 20 normal parotid glands. Glucagon and Vimentin were negative both in tumor epithelial cells and in normal parotid ductal cells. Our results support the theory that cystadenolymphomas arise from epithelial cells. The presence of lysozyme in the epithelial tumor cells and in the intercalated ductal cells of normal parotid tissue suggest that cystadenolymphomas may arise from the intercalated ducts. The presence of S-100 and somatostatin may indicate that the tumor derives from neuroendocrine structures, but further studies are needed to clarify this point.     

Current issues in the management of chronic obstructive pulmonary diseases

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality, especially among smokers. Many guidelines that have recently been issued emphasize that COPD is not inaccessible to therapeutic measures: although few interventions are capable of affecting its natural history (i.e. smoking cessation and, in patients with severe resting hypoxaemia, oxygen therapy), several others have a demonstrated effect on symptoms and, thereby, quality of life. The effects of inhaled corticosteroids, and alpha 1-antitrypsin replacement therapy in emphysema due to alpha 1-antitrypsin deficiency are currently being studied. When there is a marked increase in mucus production, chest physiotherapy using controlled expiration and directed cough may be useful. Inhaled bronchodilators are frequently effective on dyspnoea, anticholinergic agents being more suitable for continuous symptoms. Rehabilitation, which includes education and psychosocial care, chest physiotherapy, nutritional care and exercise training, also improves quality of life. When there is persistent severe alveolar hypoventilation despite oxygen therapy, long-term mechanical ventilation may be considered. Surgical options in the treatment of emphysema include resection of giant bullae and lung volume reduction surgery. Lung transplantation should be proposed only in patients with end-stage disease, the difficulty here being to define what 'end-stage' means. Finally, all preventive and some therapeutic interventions are likely to be more effective early in the course of the disease. Thus, efforts should be made to detect airways obstruction early in subjects at risk, such as smokers.     

Use of polymerase chain reaction in clinical diagnostic laboratories in viral hepatitis B and C]

alpha 1-Antitrypsin deficiency has been associated with a variety of vascular disorders including arterial aneurysms, spontaneous extracranial arterial dissections, and arterial fibromuscular dysplasia. We determined the distribution of alpha 1-antitrypsin phenotypes in patients with intracranial arterial dissections, a rare cause of subarachnoid hemorrhage. The study population consisted of 4 consecutive patients with subarachnoid hemorrhage due to spontaneous intracranial arterial dissections. The vertebral artery was involved in 3 patients and the posterior inferior cerebellar artery in 1 patient. Three of these 4 patients were found to have a heterozygous alpha 1-antitrypsin deficiency (PiMZ or PiMS phenotypes). These data support previous studies suggesting that patients with alpha 1-antitrypsin deficiency may be at an increased risk of developing spontaneous arterial dissections.     

Pulp exposure after stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth

Serum levels of alpha 1-antichymotrypsin (alpha 1-ACT), macroglobulin, alpha 1-antitrypsin, ceruloplasmin, acid glycoprotein, transferrin, and C-reactive protein were measured in patients with probable late onset dementia of Alzheimer type (I-AD), patients with vascular dementia (VD), healthy elderly (HC), and patients with chronic or acute inflammation. Three blood samples were taken at 10-15 day intervals. Serum alpha 1-ACT levels from first and second serum samples were elevated in one out of 11 I-AD patients. Serpin serum levels from the third sample were increased in four out of 11 I-AD patients. None of these patients showed increased levels of other acute phase proteins measured in the three serum samples. VD patients did not show abnormal serum levels of alpha 1-ACT. Serum levels of alpha 1-ACT along with those of other acute phase proteins were altered in patients with inflammation. This investigation showed that in I-AD patients with increased alpha 1-ACT and no concomitant elevation of other acute phase proteins, serum levels of alpha 1-ACT varied with time. Based on our results, serum alpha 1-ACT does not appear to be a useful biomarker for clinical diagnosis of probable I-AD, but it might be associated with the clinical history of the disease.     

Nonsmoking, non-alpha 1-antitrypsin deficiency-induced emphysema in nonsmokers with healed spontaneous pneumothorax, identified by computed tomography of the lungs

This case-control study is based on an investigation of 27 nonsmoking patients with radiologically verified spontaneous pneumothorax (SP) and ten healthy never-smoker control subjects. The posteroanterior and lateral radiographs of patients and control subjects were normal. They were all submitted to the same clinical, laboratory, and radiologic examinations, including computed tomography (CT) of the lungs, with the aim of detecting any parenchymatous lung changes. Emphysema-like changes (ELCs) were detected on CT in 22 (81 percent) of the 27 patients, and if the ELC cases detected during interventional surgery are added, the frequency increases to 24/27 (89 percent). In 20 patients with unilateral SP, at least one ELC was found in 13 of the 20 SP-affected lungs, but only in five of the 20 lungs that were not diagnosed as having SP (p < 0.05). ELCs were found more frequently in the upper than in the lower lung regions (p < 0.05) and more frequently in the radiologically peripheral than in central regions (p < 0.001). No ELC was detected in the control group on CT. No alpha 1-antitrypsin deficiency was found in the 27 nonsmoking patients with radiologically verified SP who had ELCs despite the absence of these known promoters of emphysema.     

Cigarette smoking: CT and pathologic findings of associated pulmonary diseases

The health risks associated with cigarette smoking are well known. Cigarette smoking is the most important causative factor in the development of bronchogenic carcinoma. Pulmonary diseases such as chronic bronchitis, centrilobular and panacinar emphysema, respiratory bronchiolitis-associated interstitial lung disease (RB-ILD), and pulmonary Langerhans cell histiocytosis are also related to cigarette smoking. In adenocarcinoma and squamous cell carcinoma, the most common manifestation at computed tomography (CT) is a solitary pulmonary nodule; in small cell carcinoma, hilar and mediastinal adenopathy secondary to metastases; and in large cell carcinoma, a mass with central necrosis or cavitation in the lung periphery. For chronic bronchitis, the most common CT finding is bronchial wall thickening, but this finding is nonspecific. Emphysema, both centrilobular and panacinar associated with alpha-1-antitrypsin deficiency, usually manifests as areas of decreased attenuation and may involve bullous changes. However, centrilobular emphysema more commonly involves the upper lungs, whereas panacinar emphysema more commonly involves the lower lungs. Most patients with RB-ILD have normal high-resolution CT scans; however, abnormalities may be present, the most common of which are areas of ground-glass attenuation. CT appearance of pulmonary Langerhans cell histiocytosis varies depending on the disease stage: In the early stage, typical CT findings include multiple nodules, usually accompanied by cystic spaces with thin, well-defined walls. As the disease progresses, the cystic spaces become more numerous and the number of nodules decreases.     

Characterization of a human alpha1-antitrypsin variant that is as stable as ovalbumin

The metastability of inhibitory serpins (serine proteinase inhibitors) is thought to play a key role in the facile conformational switch and the insertion of the reactive center loop into the central beta-sheet, A-sheet, during the formation of a stable complex between a serpin and its target proteinase. We have examined the folding and inhibitory activity of a very stable variant of human alpha1-antitrypsin, a prototype inhibitory serpin. A combination of seven stabilizing single amino acid substitutions of alpha1-antitrypsin, designated Multi-7, increased the midpoint of the unfolding transition to almost that of ovalbumin, a non-inhibitory but more stable serpin. Compared with the wild-type alpha1-antitrypsin, Multi-7 retarded the opening of A-sheet significantly, as revealed by the retarded unfolding and latency conversion of the native state. Surprisingly, Multi-7 alpha1-antitrypsin could form a stable complex with a target elastase with the same kinetic parameters and the stoichiometry of inhibition as the wild type, indicating that enhanced A-sheet closure conferred by Multi-7 does not affect the complex formation. It may be that the stability increase of Multi-7 alpha1-antitrypsin is not sufficient to influence the rate of loop insertion during the complex formation.     

Fibromuscular dysplasia of the internal carotid artery associated with alpha1-antitrypsin deficiency

OBJECTIVE: A deficiency of alpha1-antitrypsin has been implicated in the development of various disorders affecting medium-sized arteries, including intracranial aneurysms, cervicocephalic arterial dissections, and fibromuscular dysplasia (FMD). We performed alpha1-antitrypsin phenotyping in three consecutive patients who underwent bypass surgery for FMD of the extracranial internal carotid artery to test the hypothesis that alpha1-antitrypsin deficiency is a genetic risk factor for the development of FMD. METHODS: The study population consisted of three women (aged 37, 49, and 53 years, respectively) who had bilateral internal carotid artery stenosis caused by FMD. The indications for surgery included ocular or cerebral ischemic symptoms in two patients and progressive stenosis in one patient. The diagnosis of FMD was confirmed by histological examination of the resected segment of artery. The alpha1-antitrypsin phenotype was determined by isoelectric focusing in polyacrylamide gels. RESULTS: Two of the three patients had a heterozygous alpha1-antitrypsin deficiency (PiMZ phenotype). Pathological examination of the resected arterial segment showed typical medial FMD with focal intimal fibroplasia in both patients with the PiMZ phenotype. CONCLUSION: These findings suggest that a heterozygous alpha1-antitrypsin deficiency may be a genetic risk factor for the development of FMD of the internal carotid artery.