Aspectos clínicos, laboratoriais e evolutivos de pacientes pediátricos com doença hepática por deficiência de alfa 1-antitripsina / Clinical, laboratorial and evolutionary aspects of pediatric patients with liver disease due to alpha 1-antitrypsin deficiency

ABSTRACT Background: Alpha 1-antitrypsin deficiency (AATD) is a hereditary codominant autosomal disease. This liver disease ranges from asymptomatic cases to terminal illness, which makes early recognition and diagnosis challenging. It is the main cause of pediatric liver transplantation after biliary atresia. Objective: To describe the clinical characteristics, as well as those of histologic and laboratory tests, phenotypic and/or genetic evaluation and evolution of a cohort of pediatric patients with AATD. Methods: This is a retrospective observational study of 39 patients with confirmed or probable AATD (without phenotyping or genotyping, but with suggestive clinical features, low serum alpha 1-antitrypsin (AAT) level and liver biopsy with PAS granules, resistant diastasis). Clinical, laboratory and histological varia­bles, presence of portal hypertension (PH) and survival with native liver have been analyzed. Results: A total of 66.7% of 39 patients were male (26/39). The initial manifestation was cholestatic jaundice in 79.5% (31/39). Liver transplantation was performed in 28.2% (11/39) of patients. Diagnosis occurred at an average of 3.1 years old and liver transplantation at 4.1 years of age. 89.2% (25/28) of the patients with confirmed AATD were PI*ZZ or ZZ. The average AAT value on admission for PI*ZZ or ZZ patients was 41.6 mg/dL. All transplanted patients with phenotyping or genotyping were PI*ZZ (or ZZ). Those who were jaundiced on admission were earlier referred to the specialized service and had higher levels of GGT and platelets on admission. There was no significant difference in the survival curve when comparing cholestatic jaundiced to non-cholestatic jaundiced patients on admission. Comparing patients who did or did not progress to PH, higher levels of AST and APRI score at diagnosis (P=0.011 and P=0.026, respectively) were observed and in the survival curves patients with PH showed impairment, with 20.2% survival with native liver in 15 years. Conclusion: Jaundice is an important clinical sign that motivates referral to a specialist, but it does not seem to compromise survival with native liver. Patients progressing to PH had higher AST, APRi score on admission and significantly impaired survival with native liver. It is important to pay attention to these signs in the follow-up of patients with AATD.

RESUMO Contexto: Deficiência de alfa 1-antitripsina (DAAT) é uma doença hereditária, de caráter autossômico codominante. A apresentação da doença hepática varia desde casos assintomáticos até doença terminal, o que dificulta reconhecimento e diagnóstico precoces. É a principal causa de transplante hepático pediátrico após atresia de vias biliares. Objetivo: Descrever as características clínicas, de exames laboratoriais, histológicos, avaliação fenotípica e/ou genética e sobrevida de uma coorte de pacientes pediátricos com DAAT. Métodos: Estudo observacional retrospectivo de 39 pacientes com diagnóstico de DAAT confirmada ou provável (sem fenotipagem ou genotipagem, mas com clínica sugestiva, baixo nível sérico de alfa 1-antitripsina (A1AT) e biópsia hepática com grânulos PAS, diástase resistentes). Variáveis clínicas, laboratoriais, histológicas, presença de hipertensão portal (HP) e sobrevida com fígado nativo foram analisadas. Resultados: Dos 39 pacientes, 66,7% eram do sexo masculino (26/39). A manifestação inicial foi icterícia colestática em 79,5% (31/39). Em 28,2% (11/39) houve necessidade de transplante hepático. O diagnóstico ocorreu com uma idade média de 3,1 anos e, o transplante hepático, 4,1 anos. Dos pacientes com DAAT confirmada, 89,2% (25/28) eram PI*ZZ ou ZZ. O valor médio de A1AT na admissão de pacientes PI*ZZ ou ZZ foi 41,6 mg/dL. Todos os transplantados com fenotipagem ou genotipagem eram PI*ZZ (ou ZZ). Os ictéricos à admissão foram referenciados mais cedo ao serviço especializado e apresentaram níveis mais elevados de GGT e plaquetas à admissão. Não houve diferença significativa na curva de sobrevida ao compararmos icterícia colestática ou não à admissão. Ao comparar os pacientes que progrediram ou não para HP, observou-se níveis mais elevados de AST e APRI escore ao diagnóstico (P=0,011 e P=0,026, respectivamente) e, nas curvas de sobrevida, pacientes com HP apresentaram comprometimento, com 20,2% de sobrevida com fígado nativo em 15 anos. Conclusão: Icterícia é um sinal clínico importante que motiva o encaminhamento ao especialista, mas parece não comprometer a sobrevida com fígado nativo. Pacientes com evolução para HP tiveram AST e escore APRi mais elevados à admissão e comprometimento significativo da sobrevida com fígado nativo. Importante atentar a esses sinais no seguimento de pacientes com DAAT.

Selective decrease in alpha1-antitrypsin levels in diabetic retinopathy: Could the levels of it be playing a role in the pathophysiology of diabetic retinopathy?

Background & objectives: Type 2 diabetes mellitus (T2DM) is known to induce inflammation and activation of neutrophils causing the release of neutrophil elastase (NE), a pro-inflammatory proteinase. The activity of NE is regulated by endogenous inhibitors alpha1-antitrypsin (?1-AT) and alpha2- macroglobulin (?2-MG). Disrupted proteolytic homeostasis in T2DM patients is one of the causes for vascular complications. This study was carried out for evaluating the levels of plasma NE, ?1-AT, ?2-MG and NE-?1-AT complex to understand their roles in the pathophysiology of diabetic nephropathy (DN) and diabetic retinopathy (DR). Methods: A total of 240 participants (Control, n=60; T2DM, n=60; DN, n=60; and DR, n=60) were recruited after recording history, clinical examination and laboratory investigations. Retinopathy was confirmed by fundoscopy and nephropathy by urinary albumin excretion and serum creatinine levels. NE was measured using STANA. ?1-AT, ?2-MG and NE-?1-AT complex were estimated by ELISA. Results: Baseline clinical and laboratory findings were confirmatory to the study groups. The mean elastase activity was higher (P<0.0005) in diabetes groups (T2DM=0.73±0.31, DN=0.87±0.35, DR=0.76±0.41) than controls (0.35±0.20). The levels of ?1-AT were lower in DR (8.77±2.85) than DN (26.26±6.16) and T2DM (41.13±14.06) when juxtaposed with controls (122.95±25.71). The approximate fold decrease of ?1-AT levels was 15 for DR and four for DN compared to controls. The levels of ?2-MG were lowered in T2DM (167.29±30.45), DN (144.66±13.72), and DR (104.67±11.47) than controls (208.87±31.16). The NE-?1-AT complex levels were: controls (215.83±13.61), T2DM (98.85±23.85), DN (129.26±20.40) and DR (153.25±17.11). Interpretation & conclusions: Homeostasis of NE, ?1-AT and ?2-MG is disrupted in T2DM, DN and DR. Strikingly reduced levels of ?1-AT observed in DR are indicative of its possible role in the pathophysiology of retinopathy and emphasizes ?1-AT as a plausible therapeutic target.

Obstructive Spirometeric Patterns and Its reversibility against Short acting ß-2 Agonist in Patients with Bronchiectasis

Objectives: To determine the frequency of obstructive pattern of spirometry in bronchiectasis patients. Material and methods: This case series study was conducted at Department of Pulmonology, Jinnah Hospital Lahore. Total 143 patients with bronchiectasis having age 30-60 years either male or female and having duration of symptoms ?1 years were selected for this study. Results: Total 143 patients with Bronchiectasis were selected for this study. Mean age of the patients was 47.56 ± 9.11 years, mean weight, mean height and mean BMI was 68.01 12.22, 59.63 ± 4.21 and 29.84 5.71 respectively. Out of 143 patients of Bronchiectasis, Positive obstructive pattern was noted in 80 (55.9%) patients and reversibility was noted in 45 (56.25%) patients. Conclusion:Results of this study showed a higher number of positive obstructive pattern in patients of bronchiectasis and percentage reversibility is also very high. Reversibility was significantly associated with age of the patients and duration of disease.

Update on and future perspectives for the diagnosis of alpha-1 antitrypsin deficiency in Brazil / Atualização e perspectivas futuras para o diagnóstico da deficiência de alfa-1 antitripsina no Brasil

ABSTRACT Alpha-1 antitrypsin deficiency (AATD) is a rare genetic disorder caused by a mutation in the SERPINA1 gene, which encodes the protease inhibitor alpha-1 antitrypsin (AAT). Severe AATD predisposes individuals to COPD and liver disease. Early diagnosis is essential for implementing preventive measures and limiting the disease burden. Although national and international guidelines for the diagnosis and management of AATD have been available for 20 years, more than 85% of cases go undiagnosed and therefore untreated. In Brazil, reasons for the underdiagnosis of AATD include a lack of awareness of the condition among physicians, a racially diverse population, serum AAT levels being assessed in a limited number of individuals, and lack of convenient diagnostic tools. The diagnosis of AATD is based on laboratory test results. The standard diagnostic approach involves the assessment of serum AAT levels, followed by phenotyping, genotyping, gene sequencing, or combinations of those, to detect the specific mutation. Over the past 10 years, new techniques have been developed, offering a rapid, minimally invasive, reliable alternative to traditional testing methods. One such test available in Brazil is the A1AT Genotyping Test, which simultaneously analyzes the 14 most prevalent AATD mutations, using DNA extracted from a buccal swab or dried blood spot. Such advances may contribute to overcoming the problem of underdiagnosis in Brazil and elsewhere, as well as being likely to increase the rate detection of AATD and therefore mitigate the harmful effects of delayed diagnosis.

RESUMO A deficiência de alfa-1 antitripsina (DAAT) é um distúrbio genético raro causado por uma mutação no gene SERPINA1, que codifica o inibidor de protease alfa-1 antitripsina (AAT). A DAAT predispõe os indivíduos a DPOC e doença hepática. O diagnóstico precoce é essencial para a implementação de medidas preventivas e para limitar a carga da doença. Embora diretrizes nacionais e internacionais para o diagnóstico e manejo da DAAT estejam disponíveis há 20 anos, mais de 85% dos casos não são diagnosticados e, portanto, não são tratados. No Brasil, os motivos para o subdiagnóstico da DAAT incluem o desconhecimento dos médicos sobre a condição, a diversidade racial da população, o fato de os níveis séricos de AAT serem avaliados em um número limitado de indivíduos e a falta de ferramentas diagnósticas convenientes. O diagnóstico da DAAT baseia-se em resultados de exames laboratoriais. A abordagem diagnóstica padrão envolve a avaliação dos níveis séricos de AAT, seguida de fenotipagem, genotipagem, sequenciamento gênico ou suas combinações para detecção da mutação específica. Nos últimos 10 anos, novas técnicas foram desenvolvidas, oferecendo uma alternativa rápida, minimamente invasiva e confiável aos métodos tradicionais de teste. Um desses testes disponíveis no Brasil é o teste de genotipagem A1AT, que analisa simultaneamente as 14 mutações mais prevalentes da DAAT usando DNA extraído de swab bucal ou de sangue em papel-filtro. Esses avanços podem contribuir para a superação do problema do subdiagnóstico no Brasil e em outros países, bem como podem aumentar a taxa de detecção da DAAT e, portanto, mitigar os malefícios do diagnóstico tardio.

Research of the correlation between α1-antitrypsin and acute kidney injury after cardiopulmonary bypass / 中华胸心血管外科杂志

Objective:To figure out variety of the plasma level of Alpha-1-Antitrypsin(α1-AT) in patients who undergo AKI following cardiopulmonary bypass(CPB), and whether this biomarker serve as a competent predictor.Methods:We recruited 75 patients undergoing cardiac surgery with CPB from January 2018 to January 2019. Patients were categorized into two groups according to the development of AKI. The relationship between plasma concentration of α1-AT and renal injury in two groups was analyzed.Results:27 patients in the AKI group were aged (54.3±12.2)years old, including 15 males and 12 females, the time of cardiopulmonary bypass was(133.5±34.7)min. In the non-AKI group, 48 cases were aged(47.7±11.3)years old, including 26 males and 22 females, and the time of cardiopulmonary bypass was(133.5±34.7)min. α1-AT was significantly decreased in AKI group at 1 h after operation[(0.53±0.53)g/L vs. (1.46±0.91)g/L, P<0.05]compared with the non-AKI group. The sensitivity and specificity of α1-antitrypsin level at 1h after operation was the highest when α1-AT was 0.675 g/L. CPB time ( OR=5.890, 95% CI: 1.078-32.173) and age ( OR=4.427, 95% CI: 1.113-17.614) were independent risk factors for AKI after surgery, and α1-AT at 1h after CPB ( OR=0.084, 95% CI: 0.021-0.333) were protective factors after operation. Conclusion:Increased concentration of α1-AT after cardiopulmonary bypass at early time is a protective factor for AKI and the concentration of α1-AT in plasma could be used as an early biomarker of AKI after CPB.

Deficiencia de alfa-1 antitripsina y neumotórax espontáneo. ¿Solo una coincidencia? / Alpha-1 antitrypsin deficiency and spontaneous pneumothorax. Just a coincidence?

Resumen La deficiencia de alfa-1 antitripsina (AAT) es uno de los trastornos hereditarios más frecuentes y con mayor incidencia en pacientes con enfermedad pulmonar obstructiva crónica (EPOC). Se desconoce su prevalencia en aquellos con neumotórax espontáneo. El objetivo fue estimar la prevalencia de deficiencia de AAT en sujetos con neumotórax espontáneo. El estudio fue prospectivo y de corte transversal en pacientes con neumotórax espontáneo primario. Se excluyeron aquellos con neumotórax secundario. Se realizó cuantificación de AAT en suero por nefelometría y posterior genotipificación rápida (PCR en tiempo real) para detectar los alelos de deficiencia más prevalentes (Z y S) en aquellos con concentraciones séricas ≤ 120 mg/dl. Se incluyeron 58 pacientes con neumotórax espontáneo primario. La edad promedio fue de 34 ± 13 años con predominio de sexo masculino (72%) y alta prevalencia de tabaquismo actual y pasado (60%). Del total, el 26% (IC95%: 15-39) presentó concentraciones de AAT ≤ 120mg/dl. Encontramos 7 formas deficitarias (12%; IC 95%: 5-23%). Un paciente presentó una forma grave Pi*ZZ (1.7%), 3 fueron heterocigotos Z (5.2%) y 3 heterocigotos S (5.2%). La prevalencia de variantes deficitarias de AAT fue alta en este grupo con neumotórax espontáneo.

Abstract Alpha-1 antitrypsin (AAT) deficiency is one of the most common inherited disorders with a higher incidence in patients with chronic obstructive pulmonary disease (COPD). Its prevalence in patients with spontaneous pneumothorax is unknown. The objective was to estimate the prevalence of AAT deficiency in patients with spontaneous pneumothorax. This was a prospective cross-sectional study, in patients with spontaneous pneumothorax, where those with secondary pneumothorax were excluded. Quantification of serum AAT by nephelometry and subsequent rapid genotyping (real time PCR) was performed, in order to detect the most prevalent deficiency alleles (Z and S) in those subjects with serum AAT concentrations ≤ 120 mg/dl. Fifty-eight patients with primary spontaneous pneumothorax were included. The average age was 34 ± 13 years with male predominance (72%) and high prevalence of current and past smoking (60%). Twenty six percent of them (95% CI: 15-39) presented AAT serum concentrations ≤ 120mg/dl. We found 7 deficiency variants (12%; IC 95%: 5-23%). One patient presented a severe Pi*ZZ form (1.7%), 3 were heterozygotes Z (5.2%) and 3 heterozygotes S (5.2%). The prevalence of AAT deficient variants was high in patients with spontaneous pneumothorax.

Liver Involvement in Children with Alpha-1 Antitrypsin Deficiency: A Multicenter Study / 대한소아소화기영양학회지

PURPOSE: Alpha-1 antitrypsin deficiency (A1ATD) in one of the most common genetic causes of liver disease in children. We aimed to analyze the clinical characteristics and outcomes of patients with A1ATD.METHODS: This study included patients with A1ATD from five pediatric hepatology units. Demographics, clinical findings, genetics, and outcome of the patients were recorded (n=25).RESULTS: Eight patients (32.0%) had homozygous PiZZ genotype while 17 (68.0%) had heterozygous genotype. Patients with PiZZ genotype had lower alpha-1 antitrypsin levels than patients with PiMZ genotype (37.6±7.7 mg/dL vs. 66.5±22.7 mg/dL, p=0.0001). Patients with PiZZ genotype were diagnosed earlier than patients with PiMZ genotype, but this was not significant (13±6.8 months vs. 23.7±30.1 months, p=0.192). Follow-up revealed the death of one patient (12.5%) with a homozygous mutation, and revealed that one patient had child A cirrhosis, five patients (62.5%) had chronic hepatitis, and one patient (12.5%) was asymptomatic. Nine of the 17 patients with a heterozygous mutation had chronic hepatitis (52.9%), two (11.7%) had child A cirrhosis, and six (35.2%) were asymptomatic. Overall, 18 (72%) of the 25 children had liver pathology in the long-term.CONCLUSION: Although prevalence is rare, patients with liver disorders should be checked for alpha-1 antitrypsin levels. Moreover, long-term follow-up is essential because most patients have a liver pathology.

Expression and clinical significance of α1-antitrypsin in thyroid-associated ophthalmopathy / 上海交通大学学报（医学版）

Objective : To investigate the expression and clinical significance of α1-antitrypsin (α1-AT) in tears of thyroid-associated ophthal-mopathy (TAO) patients. Methods ¡¤ Patients diagnosed with TAO at Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine from January to December 2019 were included and divided into active TAO group (n=33) and inactive TAO group (n=22). Thirty eyes of 30 healthy volunteers were included (n=30). Unstimulated tear samples were collected from all subjects and the concentration of α1-AT was analyzed by enzyme-linked immunosorbent assay (ELISA). Difference of α1-AT concentration among 3 groups was compared by using Kruskal-Wallis H test. Mann-Whitney U test was performed for further comparison between each 2 groups. Correlationship between α1-AT con-centration and clinical activity score (CAS) was analyzed by Spearman relation. Statistical significance was accepted at a value of P<0.05. Re-sults ¡¤ α1-AT was significantly higher in active TAO group than that in inactive TAO group and control group (both P<0.05). There was no significant difference in α1-AT between inactive TAO group and control group. Tear α1-AT level was significantly correlated with CAS (r=0.846, P=0.000). ROC curve showed that the optimal diagnostic cut off value of α1-AT was 939.48 ng/mL, and the sensitivity and specificity were 81.8% and 100% (AUC=0.959, P<0.05). Conclusion ¡¤ α1-AT is significantly elevated in the tears of active TAO patients. Tear α1-AT level has important value in the diagnosis of clinical activity of TAO.

An unusual cause of edema in a child with congenital heart disease post Fontan procedure

Protein Losing Enteropathy Post Fontan procedure. Protein Losing Enteropathy (PLE) is an uncommon cause of edema in children with congenital heart disease. Protein-Losing Enteropathy may be defined as excessive loss of proteins across the intestinal mucosa and is due to either a primary gastrointestinal abnormality or secondary to cardiac disease. Protein-losing enteropathy (PLE) is a rare complication of the Fontan palliation for functional single-ventricle. Although PLE occurs in about 3.5% of patients post-Fontan, it confers marked morbidity and high mortality within 5 years of diagnosis. The pathogenesis of Fontan-related PLE is not completely understood, and it is unclear why it develops in some patients post-Fontan and not others. We describe a child with Double Inlet Right Ventricle who had undergone Fontan procedure, and presented to us with generalised oedema. The child had hypoproteinaemia, the common causes for which were ruled out and was diagnosed as Protein Losing Enteropathy (PLE) related to his surgical intervention. Though, not frequently encountered it should be kept in mind as one of the causes of anasarca.

Laboratory diagnosis of inherited metabolic liver disease in children / 中华检验医学杂志

Children with inherited metabolic liver disease appear liver damage caused by metabolic disorders and accumulation of substrate or abnormal metabolite in liver due to genetic defects . Because of complex clinical manifestations and non-specificity of routine examination, its definite diagnosis depends on laboratory special examinations. Early treatment is closely related to the prognosis of children so that the importance of early diagnosis of inherited metabolic liver disease is emphasized. This article described the laboratory diagnosis of three common inherited metabolic liver diseases and screening for childhood with inherited metabolic liver disease.

Effect of Tangnaikang on Imbalance Between NE and α1-AT in Spontaneous Type 2 Diabetic Mouse / 中国实验方剂学杂志

Objective: To observe the regulatory effect of Tangnaikang (TNK) on imbalance between neutrophil elastase (NE) and α1-antitrypsin (α1-AT) in ob/ob mice with type 2 diabetes mellitus (T2DM). Method: Thirty-two male SPF ob/ob mice were randomly divided into model group (DM, normal saline) and high-dose TNK group (TNKH, TNK solution 16.04 g·kg-1), middle-dose TNK group (TNKM, TNK solution 8.02 g·kg-1) and low-dose TNK group (TNKL, TNK solution 4.01 g·kg-1). Another 8 C57BL/6J mice were included in normal group (Con, saline). The experiment lasted for four weeks. The general state, body weight (BW) and fasting blood glucose (FBG) of the mice were recorded weekly, the oral glucose tolerance (OGTT) test was performed on the 25th day, the insulin tolerance (ITT) test was performed on the 27th day, and the area under the curve (AUC) was calculated. After the end of the experiment, serum was used to detect the level of fasting insulin (Fins), insulin resistance index (HOMA-IR), total triglyceride (TG), total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), NE and α1-AT. Adipose tissue was used to detect the expressions of NE, α1-AT, phosphor-insulin receptor substrate 1 antibody (p-IRS1) and glucose transporter 4 (GLUT4) proteins. Result: Compared with the Con group, the BW of the ob/ob mice of the model group increased significantly, the glucose and lipid metabolism indexes showed diabetes, the serum and adipose tissue NE increased significantly (Pα1-AT decreased significantly (PPPogtt and AUCITT were significantly decreased (PPα1-AT increased significantly (PPConclusion: TNK can reduce the BW of ob/ob mice, improve glycolipid metabolism, increase α1-AT level, decrease NE level, and regulate IRS1-GLUT4 signaling pathway, which may be one of its mechanisms in improving IR of adipose tissue mediated by neutrophil.

Analysis of the effect of siRNA silencing α1 antitrypsin on rheumatoid arthritis fibroblasts / 中华风湿病学杂志

Objective@#To investigate the effect of siRNA silencing α1 antitrypsin (α1-AT) gene on the biological behavior of rheumatoid arthritis fibroblast-like synoviocytes (RA-SFs).@*Methods@#Primary culture of knee synovial tissue from 5 patients with rheumatoid arthritis (RA) was performed. The artificially synthesized silencing α1-AT siRNA specifically inhibits the expression of α1-AT in RA-SFs. After 24 and 36 hours of transient transfection, the inhibition efficiency was detected by Quantitative reverse transcription polymerase chain reaction (RT-qPCR), and the expression of related genes after α1-AT gene silencing was detected.Furthermore, ethyl thiazolyl tetrazolium (MTT) assay, Trans-well chamber, cell scratch and enzyme-linked immunosorbent assay (ELISA) were used to detect the effects of interfering α1-AT expression on cell proliferation, invasion and migration, and secretion of interleukin (IL)-17, Tumor necrosis factor (TNF)-α, IL-1α, IL-1β and other related inflammatory factors. At the same time, when the pathway inhibitor (ERK inhibitor, signal transducer and activator of transcription 3 (STAT3) inhibitor, NF-κB inhibitor) stimulated cells, the effect on α1-AT was changed. One-way analysis of variance was used for comparison between the two groups; further pairwise comparison using LSD-t test; The count data was checked by χ2 test.@*Results@#Compared with the negative control group, the siRNA α1-AT group was transfected for 24 hours, the α1-AT mRNA level was significantly inhibited (P<0.05), and the proliferation rate of RA-SFs was not affected (P>0.05), and the invasion and migration ability of cells decreased significantly (P<0.05). The secretion of IL-17 and IL-1β was slightly decreased (P>0.05), while TNF-α and IL-1α were not affected (P>0.05). In addition, the expression of α1-AT downstream genes Matrix metallop roteinases (MMP)-2 169, Hu-Bax1, MMP-9, Hu Bax and Hu Bcl-xl were significantly decreased (P<0.05). Moreover, the signaling pathway inhibitors ERK inhibitor (PD98059) and NF-κB inhibitor (PDTC) had significant effects on α1-AT (P<0.05).@*Conclusion@#The α1-AT gene silencing has potential effect on the biological behavior of RA SFs. Further study of this mechanism is helpful to provide evidence for the treatment of RA.

Analysis of the effect of siRNA silencing α1 antitrypsin on rheumatoid arthritis fibroblasts / 中华风湿病学杂志

Objective To investigate the effect of siRNA silencing α1 antitrypsin (α1-AT) gene on the biological behavior of rheumatoid arthritis fibroblast-like synoviocytes (RA-SFs).Methods Primary culture of knee synovial tissue from 5 patients with rheumatoid arthritis (RA) was performed.The artificially synthesized silencing α1-AT siRNA specifically inhibits the expression of α1-AT in RA-SFs.After 24 and 36 hours of transient transfection,the inhibition efficiency was detected by Quantitative reverse transcription polymerase chain reaction (RT-qPCR),and the expression of related genes after α1-AT gene silencing was detected.Furthermore,ethyl thiazolyl tetrazolium (MTT) assay,Trans-well chamber,cell scratch and enzyme-linked immunosorbent assay (ELISA) were used to detect the effects of interfering α1-AT expression on cell proliferation,invasion and migration,and secretion of interleukin (IL)-17,Tumor necrosis factor (TNF)-α,IL-1α,IL-1β and other related inflammatory factors.At the same time,when the pathway inhibitor (ERK inhibitor,signal transducer and activator of transcription 3 (STAT3) inhibitor,NF-κB inhibitor) stimulated cells,the effect on α1-AT was changed.One-way analysis of variance was used for comparison between the two groups;further pairwise comparison using LSD-t test;The count data was checked by x2 test.Results Compared with the negative control group,the siRNA α1-AT group was transfected for 24 hours,the α1-AT mRNA level was significantly inhibited (P＜0.05),and the proliferation rate of RA-SFs was not affected (P＞0.05),and the invasion and migration ability of cells decreased significantly (P＜0.05).The secretion of IL-17 and IL-1β was slightly decreased (P＞0.05),while TNF-α and IL-1α were not affected (P＞0.05).In addition,the expression of α1-AT downstream genes Matrix metallop roteinases (MMP)-2 169,Hu-Bax1,MMP-9,Hu Bax and Hu Bcl-xl were significantly decreased (P＜0.05).Moreover,the signaling pathway inhibitors ERK inhibitor (PD98059) and NF-κB inhibitor (PDTC) had significant effects on α1-AT (P＜0.05).Conclusion The α1-AT gene silencing has potential effect on the biological behavior of RA SFs.Further study of this mechanism is helpful to provide evidence for the treatment of RA.

The patient profile of individuals with Alpha-1 antitrypsine gene mutations at a referral center in Brazil / Perfil dos pacientes com mutação no gene da alfa-1 antitripsina em um centro de referência no Brasil

ABSTRACT Objective: The clinical, functional, radiological and genotypic descriptions of patients with an alpha-1 antitrypsin (A1AT) gene mutation in a referral center for COPD in Brazil. Methods: A cross-sectional study of patients with an A1AT gene mutation compatible with deficiency. We evaluated the A1AT dosage and genotypic, demographic, clinical, tomographic, and functional characteristics of these patients. Results: Among the 43 patients suspected of A1AT deficiency (A1ATD), the disease was confirmed by genotyping in 27 of them. The A1AT median dosage was 45 mg/dL, and 4 patients (15%) had a normal dosage. Median age was 54, 63% of the patients were male, and the respiratory symptoms started at the age of 40. The median FEV1 was 1.37L (43% predicted). Tomographic emphysema was found in 77.8% of the individuals. The emphysema was panlobular in 76% of them and 48% had lower lobe predominance. The frequency of bronchiectasis was 52% and the frequency of bronchial thickening was 81.5%. The most common genotype was Pi*ZZ in 40.7% of participants. The other genotypes found were: Pi*SZ (18.5%), PiM1Z (14.8%), Pi*M1S (7.4%), Pi*M2Z (3.7%), Pi*M1I (3.7%), Pi*ZMnichinan (3.7%), Pi*M3Plowell (3.7%), and Pi*SF (3.7%). We did not find any significant difference in age, smoking load, FEV1, or the presence of bronchiectasis between the groups with a normal and a reduced A1AT dosage, neither for 1 nor 2-allele mutation for A1ATD. Conclusions: Our patients presented a high frequency of emphysema, bronchiectasis and bronchial thickening, and early-beginning respiratory symptoms. The most frequent genotype was Pi*ZZ. Heterozygous genotypes and normal levels of A1AT also manifested significant lung disease.

RESUMO Objetivo: Caracterização clínica, funcional, radiológica e genotípica dos pacientes portadores de mutações do gene da alfa-1 antitripsina (A1AT) em um centro de referência em doença pulmonar obstrutiva crônica (DPOC) no Brasil. Métodos: Estudo transversal de pacientes com mutação no gene da A1AT compatível com deficiência. Foram avaliadas características genotípicas, demográficas, clínicas, tomográficas, de função pulmonar, e dosagem de A1AT. Resultados: De 43 pacientes suspeitos para deficiência de alfa-1 antitripsina (DA1AT), a doença foi confirmada por genotipagem em 27. A mediana da dosagem de A1AT foi de 45 mg/dL, e 4 pacientes (15%) apresentavam dosagens normais. A idade mediana foi de 54 anos, 63% dos participantes eram do sexo masculino e a idade do início dos sintomas prevalente foi aos 40 anos. A mediana do volume expiratório forçado no primeiro segundo (VEF1) foi de 1,37 L (43% do previsto). Enfisema tomográfico foi encontrado em 77,8% dos indivíduos, sendo panlobular em 76% e de predomínio em lobos inferiores em 48%. A frequência de bronquiectasias foi de 52%, e a de espessamento brônquico, de 81,5%. O genótipo mais encontrado foi Pi*ZZ (40,7%). Os demais genótipos foram: Pi*SZ (18,5%), Pi*M1Z (14,8%), Pi*M1S (7,4%), Pi*M2Z (3,7%), Pi*M1I (3,7%), Pi*ZMnichinan (3,7%), Pi*M3Plowell (3,7%) e Pi*SF (3,7%). Não encontramos diferença significativa para idade, carga tabágica, VEF1 e presença de bronquiectasias entre os grupos com dosagem de A1AT normal versus alterada, nem entre 1 alelo versus 2 alelos com mutação para DA1AT. Conclusões: Nossos pacientes apresentaram alta frequência de enfisema, bronquiectasias e espessamento brônquico, com início precoce dos sintomas respiratórios. O genótipo mais frequente foi Pi*ZZ, embora genótipos heterozigotos e níveis normais de A1AT também tenham se manifestado com doença pulmonar significativa.

Therapeutic potential of alpha-1 antitrypsin in human disease

Alpha-1 antitrypsin (AAT), an alpha globulin glycoprotein, is a member of the serine protease inhibitor (serpin) superfamily. The clinical significance of AAT is highlighted by AAT deficiency. Genetic deficiency of AAT can present as several neutrophilic diseases associated with emphysema, liver cirrhosis, panniculitis, and systemic vasculitis. Recently, animal and human studies have shown that AAT can control inflammatory, immunological, and tissue-protective responses. In addition, AAT treatment can prevent overt hyperglycemia, increase insulin secretion, and reduce cytokine-mediated apoptosis of pancreatic β-cells in diabetes. These multifunctional roles of AAT draw attention to the glycoprotein's therapeutic potential for many inflammatory and autoimmune diseases beyond AAT deficiency. As underlying mechanisms, recent studies have suggested the importance of serine protease inhibitory activity of AAT in obesity-associated insulin resistance, chronic obstructive pulmonary disease, and cystic fibrosis. In this review, we explore the multiple functions of AAT, in particular, the anti-inflammatory and serine protease inhibitory functions, and AAT's therapeutic potential in a variety of human diseases through published literature.

Alpha-1-antitrypsin deficiency / 中华实用儿科临床杂志

Alpha-1-antitrypsin deficiency (AATD) is a rare genetic metabolic disease,characterized by a lack of alpha-1-antitrypsin,which can lead to chronic lung and liver disease.The lung disease is thought to be caused primarily by a lack of effective protection against the harmful effects of elastase due to the low AAT levels in the lung.Patients may also develop liver disease due to polymerisation of AAT within hepatocytes.Measuring the AAT serum level,AAT protein phenotyping,and SERPINA1 allele genotyping can help to diagnose AATD.The prognosis of AATD has been improved by AAT augmentation therapy in patients with lung disease,which can prevent or delay lung tissue destruction.

Associations of Polymorphism of rs9944155, rs1051052, and rs1243166 Locus Allele in Alpha-1-antitrypsin with Chronic Obstructive Pulmonary Disease in Uygur Population of Kashgar Region / 中华医学杂志(英文版)

<p><b>Background</b>Previous studies conducted in various geographical and ethnical populations have shown that Alpha-1-antitrypsin (Alpha-1-AT) expression affects the occurrence and progression of chronic obstructive pulmonary disease (COPD). We aimed to explore the associations of rs9944155AG, rs1051052AG, and rs1243166AG polymorphisms in the Alpha-1-AT gene with the risk of COPD in Uygur population in the Kashgar region.</p><p><b>Methods</b>From March 2013 to December 2015, a total of 225 Uygur COPD patients and 198 healthy people were recruited as cases and controls, respectively, in Kashgar region. DNA was extracted according to the protocol of the DNA genome kit, and Sequenom MassARRAY single-nucleotide polymorphism technology was used for genotype determination. Serum concentration of Alpha-1-AT was detected by enzyme-linked immunosorbent assay. A logistic regression model was used to estimate the associations of polymorphisms with COPD.</p><p><b>Results</b>The rs1243166-G allele was associated with a higher risk of COPD (odds ratio [OR] = 2.039, 95% confidence interval [CI]: 1.116-3.725, P = 0.019). In cases, Alpha-1-AT levels were the highest among participants carrying rs1243166 AG genotype, followed by AA and GG genotype (χ = 11.89, P = 0.003). Similarly, the rs1051052-G allele was associated with a higher risk of COPD (OR = 19.433, 95% CI: 8.783-43.00, P < 0.001). The highest Alpha-1-AT levels were observed in cases carrying rs1051052 AA genotype, followed by cases with AG and GG genotypes (χ = 122.45, P < 0.001). However, individuals with rs9944155-G allele exhibited a lower risk of COPD than those carrying the rs9944155-A allele (OR = 0.121, 95% CI: 0.070-0.209, P < 0.001). In both cases and controls, no significant difference in Alpha-1-AT levels was observed among various rs9944115 genotypes.</p><p><b>Conclusions</b>rs1243166, rs9944155, and rs1051052 sites of Alpha-1-AT may be associated with the COPD morbidity in Uygur population. While rs1243166-G allele and rs1051052-G allele are associated with an increased risk of developing COPD, rs9944155-G allele is a protect locus in Uygur population. Alpha-1-AT levels in Uygur COPD patients were lower than those in healthy people and differed among patients with different rs1051052 AG and rs1243166 AG genotypes.</p>

Alpha-1-antitrypsin deficiency screening program at the Pneumonology Department of Hospital Tránsito Cáceres de Allende

Alpha-1-antitrypsin deficiency (AATD) is a rare genetic disease associated with an increased risk of suffering from pulmonary emphysema and chronic hepatopathy in children and adults alike. It is often underdiagnosed, with long periods elapsing between the onset of symptoms and a definite diagnosis. Alpha-1-antitrypsin (AAT) is the most abundant protease inhibitor in the human body. Scientific literature considers severe deficiency to be associated with the following phenotypes: SZ, ZZ and Null. Screening programs are required for early detection, this is why an easy and specific method has been described and validated. Through this method, AAT values are quantified using nephelometry in blood drop samples on blotting paper, then genotyping of the Z and S variants is quickly performed. Objectives: To determine the number of individuals with AATD within a population of patients with chronic respiratory diseases. To identify and define those with AAT deficiency. Materials and Method: Observational, descriptive and cross-sectional study of AAT deficiency screening, between January 2nd, 2014 and March 30th, 2015. Out of 80 individuals who fulfilled the inclusion criteria and who spontaneously attended or were referred to the Pneumonology Department of Hospital Tránsito Cáceres de Allende, Córdoba, Argentina, 62 patients who agreed to the study were analyzed. A test to determine the concentration of alpha-1-antitrypsin was performed to the patients who met all the inclusion criteria using blood drops on blotting paper. Only patients with alpha-1-antitrypsin levels < 1.8 mg/dL were requested a spirometry, a high-resolution computed tomography of the chest and quick genotyping tests. Results: A total of 62 patients was evaluated in this study, 28 (45.2%) were females and 34 (54.8%) were males, 37 (59.7%) had alpha-1-antitrypsin levels ≥ 1.8 mg/dL and 25 (40.3%) < 1.8 mg/dL. Genotype elicitation using the dried-droplet method in 25 (40.3%; 25:62) patients with values < 1.8 mg/dL showed that: 22 (88%; 22:25) were Non-S Non-Z, 2 (8%; 2:25) were heterozygote for Z and 1 (4%; 1:25) was heterozygote for S. According to ATS/ERS criteria, the predominant spirometric pattern was obstructive (88%). The HRCT pattern corresponded to emphysema in 22 patients (88%): 7 (31.8%) centrilobular, 8 (36.4%) paraseptal, 7 (31.8%) panlobular. There were 2 patients (8%) with bronchiectasis and 1 (4%) was normal. Conclusion: In a population selected by symptoms and/or history, patients with AATD can be identified using the dried-droplet method. Severe AATD is uncommon in Argentina, probably because it is underdiagnosed, and the amount of heterozygote PIS and PIZ carriers is higher. Early AATD diagnosis is uncommon. It is difficult to draw conclusions about the alpha-1-antitrypsin group below 1.8 mg/dL without severe deficiencies in connection with the variables analyzed in the sample due to the lack of studies and bibliography on this subject. We consider that patients with non-S non-Z genotypes and the ones with discrepancies must be quantitatively confirmed and their phenotype defined in serum samples using isoelectric focusing and, occasionally, they must have a molecular gene analysis to look for uncommon, new or null allelic variants.

Deficiência de alfa-1 antitripsina: uma condição subdiagnosticada / Alpha-1 antitrypsin deficiency: an underdiagnosed condition

A deficiência de alfa-1-antitripsina (AAT) é associada ao desenvolvimento de doenças hepáticas graves e enfisema pulmonar precoce. Em todo o mundo, considera-se que apenas 2% dos casos estimados da deficiência de AAT tenham sido diagnosticados. A disciplina de Pneumologia da Universidade do Estado do Rio de Janeiro vem realizando testes de varredura para deficiência de AAT através da técnica de nefelometria em papel filtro em todos os pacientes com diagnóstico de DPOC. A prevalência de mutações graves encontradas nos genes da AAT em pacientes com DPOC foi de 2,4% e não difere dos dados existentes previamente na literatura, mas o número de outros pacientes com mutações leves é bastante elevado (4%). As autoras sugerem que a dosagem sistemática de AAT em todos os pacientes com DPOC possa ser uma estratégia eficiente para captura dos pacientes com deficiência enzimática, permitindo que medidas preventivas como a suspensão do fumo e o aconselhamento genético seja efetivadas.

Alpha-1-antitrypsin deficiency (AAT) is associated with the development of severe liver disease and early pulmonary emphysema. Around the world, only 2% of the estimated cases of AAT deficiency are believed to have been diagnosed. The discipline of Pulmonology of the University of the State of Rio de Janeiro has been conducting tests for AAT deficiency by filter nephelometry technique in all patients diagnosed with COPD. The prevalence of severe mutations found in AAT genes in patients with COPD was 2.4% and does not differ from previous data in the literature, but the number of other patients with mild mutations is quite high (4%). The authors suggest that the systematic dosing of AAT in all patients with COPD may be an effective strategy to capture patients with enzyme deficiency, allowing preventive measures such as smoking cessation and genetic counseling to be effective.

α1-antitrypsin Pittsburg mutations: report of two cases in the same family / 中华血液学杂志

Objective@#To analyze the clinical and laboratory abnormalities of two patients with α1-antitrypsin (α1-AT) Pittsburgh in a family and review the literatures.@*Methods@#Both plasma clotting time and factor activities were performed using clotting or substrate methods. Platelet aggregation was evaluated using an optical aggregometer. The serum protein electrophoresis was performed on Sebia HYDRASYS by using Agarose gel. The exons of α1-AT were amplified by using polymerase chain reaction (PCR) and then sequenced and compared with NCBI GenBank records.@*Results@#The proband had several ruptures of corpus luteum and bleeding after operation, while her daughter had no bleeding history. Both of them showed prolonged coagulation tests which could not be corrected by mixing with the normal plasma. They also showed low levels of plasma coagulation factors, undetected protein C and S activity and abnormal bands of α1-globulin. The results of gene sequencing demonstrated that they were heterozygous for g.T17132G (p.Met358Arg) mutation of α1-antitrypsin gene (NG_008290.1) .@*Conclusions@#Comparing with the data of previously reported cases, our results confirmed the obvious abnormality of coagulation test and the discrepancy of bleeding tendency of α1-antitrypsin Pittsburgh patients, and suggested that the rupture of corpus luteum would be a specific characteristic in women of child-bearing age.