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A number of genetic polymorphisms can cause AATD&#44; with the normal allele known as M and the most common deficiency alleles being S and Z&#59; individuals with 2 abnormal alleles are at higher risk of developing emphysema and COPD&#44; and those who are MZ heterozygotes have increased risk in the presence of environmental risk factors such as smoking&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> Similar to CRP and fibrinogen&#44; AAT is also a positive acute phase protein where hepatic synthesis of AAT is augmented by interleukin 6 &#40;IL-6&#41; in response to tissue inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> It is considered a reliable marker of systemic inflammation although it&#39;s role in this capacity is less well studied in relation to COPD&#44; where pulmonary inflammation is a definite feature&#44; and systemic inflammation a potential poor prognostic marker&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Janciauskiene et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> conducted a post hoc analysis of the relationship between serum AAT levels in patients with COPD &#40;defined as post bronchodilator FEV1&#47;FVC ratio<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;7&#41;&#44; those with respiratory symptoms and no COPD and healthy participants&#46; Data was collected from the EPI-SCAN study&#44; a multicentre&#44; cross sectional&#44; observational study of the Spanish population with the primary objective of establishing the national prevalence of COPD in individuals between 40 and 80 years old&#46; Of the 3802 patients enrolled&#44; 837 had a plasma AAT level available and were included in the analysis reported in this journal&#46; Those with COPD and respiratory symptoms had higher adjusted serum levels of AAT compared to control &#40;1&#46;55<span class="elsevierStyleHsp" style=""></span>g&#47;L&#44; 1&#46;57<span class="elsevierStyleHsp" style=""></span>g&#47;L and 1&#46;43<span class="elsevierStyleHsp" style=""></span>g&#47;L respectively&#41;&#46; Though these results meet the generally accepted level of statistical significance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; the clinical impact of these findings is less clear&#46; The authors plausibly propose that AAT could serve as a surrogate marker of chronic inflammation and as a biomarker for long-term outcomes in COPD&#46; Given the small actual differences in AAT level between groups it seems logical that it could form one part of a composite score with inclusion of other relevant biomarkers&#44; rather than a standalone test&#44; to risk stratify COPD patients and allow targeted therapy&#46; Certainly&#44; inclusion of an AAT level for all patients with a new COPD diagnosis would simultaneously screen for AATD and is therefore a worthwhile area of further scientific exploration&#46; The authors add to data collected from the Copenhagen General Population study which characterised the SERPINA1 genotype and AAT level of 13&#44;405 individuals with and without COPD which found increased inflammatory markers including AAT in smokers and patients with COPD compared with control&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">It is worth mentioning that there is significant overlap in serum AAT levels between genotypes for AATD&#44; and variation in level alone is therefore not adequate to diagnose MZ or other intermediate deficiencies&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> in part due to the impact of inflammation at the time of sampling&#46; Simultaneous measurement of CRP is one proposed strategy to recognise falsely elevated AAT level as a result of an acute phase protein response&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> Further genotyping could be reserved for those with levels lower than 24&#46;4<span class="elsevierStyleHsp" style=""></span>&#956;M&#47;L &#40;1&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;L&#41; to detect known common deficiencies &#40;SZ&#44; ZZ&#44; etc&#46;&#41; or gene sequencing for those suspected to have rarer variants&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> The study by Janciauskiene et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> reported 57 patients with low levels of AAT which may represent an underlying AAT deficiency&#46; Unfortunately&#44; specific patient genotypes were not available in this study which means that we cannot be certain of either AATD prevalence in Spanish patients who have COPD&#44; or of the degree to which systemic inflammation in COPD is masking underlying AATD&#46; For example&#44; an undetected PiZ heterozygote would have significantly lower serum AAT levels compared with a patient homozygous for the M allele&#46; In addition&#44; patients in the study were not assessed for symptoms of a pulmonary exacerbation at the time of biological sampling&#46; Since AAT is an acute phase protein&#44; AAT could have been falsely elevated in some cases&#46; Both of these scenarios would alter the validity of any of the study conclusions and is a limitation of the study design acknowledged by the authors&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The authors raise an interesting discussion regarding chronic inflammation associated with COPD&#46; It is commonly observed that patients with COPD are multimorbid with increased incidence of disease with similar inflammatory aetiologies&#46; These include cardiovascular disease&#44; osteoporosis&#44; diabetes mellitus and skeletal muscle dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> A recent systematic review concluded that patients with stable COPD have raised markers of systemic inflammation including CRP&#44; fibrinogen and WCC with associated increased risk of mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The observation that AAT levels are higher in patients with COPD supports the presence of chronic systemic inflammation&#46; It remain unclear whether inflammation is the result of a primary systemic problem &#40;such as might result from a genetic cause&#44; like AATD&#41;&#44; spill over of inflammatory cytokines from the lungs or secondary to co-morbidity observed in COPD &#40;such as inflammation associated with ischaemic heart disease&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> Attempts to manage inflammation as a primary pathology in COPD have had varying degrees of success&#46; Early trials of anti-tumour necrosis factor therapy reported no benefit in symptom outcomes<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> despite its effectiveness in the treatment of other inflammatory disease such as rheumatoid arthritis and inflammatory bowel disease&#46; However monoclonal antibodies targeting eosinophilic inflammation have had greater impact&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> In addition inhaled steroids appear increasingly likely to only benefit patients with relatively high blood eosinophils&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> This may simply indicate that neutrophilic COPD has a more complex underlying inflammatory phenotype with interaction of multiple cytokines that cannot be addressed by targeting individual molecules&#46; Further trials are needed to explore the usefulness of specific therapies against implicated inflammatory cytokines&#44; to delineate the contribution of AATD to inflammatory pathologies and to elucidate whether serum AAT level is a useful biomarker for chronic inflammation in COPD beyond its role as an indicator of deficiency genotypes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0030" class="elsevierStylePara elsevierViewall">No specific funding was received for this article&#46; PRE is supported by a research grant from the <span class="elsevierStyleGrantSponsor" id="gs1">Alpha 1 Foundation</span>&#46; AMT has current funding from the ATS Foundation&#44; Alpha 1 Foundation&#44; NIHR&#44; Chiesi&#44; AstraZeneca and CSL Behring</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">Alice Turner research grant received within the last 3 years from Grifols biotherapeutics and CSL Behring</p></span></span>"
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Editorial
What Do Alpha-1 Antitrypsin Levels Tell Us About Chronic Inflammation in COPD?
¿Qué nos dicen los niveles de alfa-1 antitripsina sobre la inflamación crónica en EPOC?
Paul Ellis, Alice Turner
Corresponding author
a.m.turner@bham.ac.uk

Corresponding author.
Institute of Applied Health Research, University of Birmingham, UK
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Alpha 1-antitrypsin&#44; a member of the serine proteinase inhibitor or serpin super family&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> is a potent inhibitor of neutrophil elastase and other proteases&#46; Patients with serum deficiency of AAT &#40;alpha-1 antitrypsin deficiency&#59; AATD&#41; due to mutations in the SERPINA1 gene locus have early onset panacinar emphysema that typically has a bibasal predominance&#46; It was this observation that led to the protease-antiprotease hypothesis in COPD&#46; AATD is a clinically relevant phenotype of respiratory disease&#44; with specific treatment available in the form of intravenous augmentation therapy which elevates AAT levels closer to normal and reduces progression of emphysema&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> Case finding for AATD in symptomatic respiratory patients is recommended by the World Health Organisation and by experts in AATD in Europe&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> consequently measurement of AAT level in clinical practice would usually be done to identify and then manage such patients&#46; A number of genetic polymorphisms can cause AATD&#44; with the normal allele known as M and the most common deficiency alleles being S and Z&#59; individuals with 2 abnormal alleles are at higher risk of developing emphysema and COPD&#44; and those who are MZ heterozygotes have increased risk in the presence of environmental risk factors such as smoking&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> Similar to CRP and fibrinogen&#44; AAT is also a positive acute phase protein where hepatic synthesis of AAT is augmented by interleukin 6 &#40;IL-6&#41; in response to tissue inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> It is considered a reliable marker of systemic inflammation although it&#39;s role in this capacity is less well studied in relation to COPD&#44; where pulmonary inflammation is a definite feature&#44; and systemic inflammation a potential poor prognostic marker&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Janciauskiene et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> conducted a post hoc analysis of the relationship between serum AAT levels in patients with COPD &#40;defined as post bronchodilator FEV1&#47;FVC ratio<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;7&#41;&#44; those with respiratory symptoms and no COPD and healthy participants&#46; Data was collected from the EPI-SCAN study&#44; a multicentre&#44; cross sectional&#44; observational study of the Spanish population with the primary objective of establishing the national prevalence of COPD in individuals between 40 and 80 years old&#46; Of the 3802 patients enrolled&#44; 837 had a plasma AAT level available and were included in the analysis reported in this journal&#46; Those with COPD and respiratory symptoms had higher adjusted serum levels of AAT compared to control &#40;1&#46;55<span class="elsevierStyleHsp" style=""></span>g&#47;L&#44; 1&#46;57<span class="elsevierStyleHsp" style=""></span>g&#47;L and 1&#46;43<span class="elsevierStyleHsp" style=""></span>g&#47;L respectively&#41;&#46; Though these results meet the generally accepted level of statistical significance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; the clinical impact of these findings is less clear&#46; The authors plausibly propose that AAT could serve as a surrogate marker of chronic inflammation and as a biomarker for long-term outcomes in COPD&#46; Given the small actual differences in AAT level between groups it seems logical that it could form one part of a composite score with inclusion of other relevant biomarkers&#44; rather than a standalone test&#44; to risk stratify COPD patients and allow targeted therapy&#46; Certainly&#44; inclusion of an AAT level for all patients with a new COPD diagnosis would simultaneously screen for AATD and is therefore a worthwhile area of further scientific exploration&#46; The authors add to data collected from the Copenhagen General Population study which characterised the SERPINA1 genotype and AAT level of 13&#44;405 individuals with and without COPD which found increased inflammatory markers including AAT in smokers and patients with COPD compared with control&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">It is worth mentioning that there is significant overlap in serum AAT levels between genotypes for AATD&#44; and variation in level alone is therefore not adequate to diagnose MZ or other intermediate deficiencies&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> in part due to the impact of inflammation at the time of sampling&#46; Simultaneous measurement of CRP is one proposed strategy to recognise falsely elevated AAT level as a result of an acute phase protein response&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> Further genotyping could be reserved for those with levels lower than 24&#46;4<span class="elsevierStyleHsp" style=""></span>&#956;M&#47;L &#40;1&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;L&#41; to detect known common deficiencies &#40;SZ&#44; ZZ&#44; etc&#46;&#41; or gene sequencing for those suspected to have rarer variants&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> The study by Janciauskiene et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> reported 57 patients with low levels of AAT which may represent an underlying AAT deficiency&#46; Unfortunately&#44; specific patient genotypes were not available in this study which means that we cannot be certain of either AATD prevalence in Spanish patients who have COPD&#44; or of the degree to which systemic inflammation in COPD is masking underlying AATD&#46; For example&#44; an undetected PiZ heterozygote would have significantly lower serum AAT levels compared with a patient homozygous for the M allele&#46; In addition&#44; patients in the study were not assessed for symptoms of a pulmonary exacerbation at the time of biological sampling&#46; Since AAT is an acute phase protein&#44; AAT could have been falsely elevated in some cases&#46; Both of these scenarios would alter the validity of any of the study conclusions and is a limitation of the study design acknowledged by the authors&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The authors raise an interesting discussion regarding chronic inflammation associated with COPD&#46; It is commonly observed that patients with COPD are multimorbid with increased incidence of disease with similar inflammatory aetiologies&#46; These include cardiovascular disease&#44; osteoporosis&#44; diabetes mellitus and skeletal muscle dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> A recent systematic review concluded that patients with stable COPD have raised markers of systemic inflammation including CRP&#44; fibrinogen and WCC with associated increased risk of mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The observation that AAT levels are higher in patients with COPD supports the presence of chronic systemic inflammation&#46; It remain unclear whether inflammation is the result of a primary systemic problem &#40;such as might result from a genetic cause&#44; like AATD&#41;&#44; spill over of inflammatory cytokines from the lungs or secondary to co-morbidity observed in COPD &#40;such as inflammation associated with ischaemic heart disease&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> Attempts to manage inflammation as a primary pathology in COPD have had varying degrees of success&#46; Early trials of anti-tumour necrosis factor therapy reported no benefit in symptom outcomes<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a> despite its effectiveness in the treatment of other inflammatory disease such as rheumatoid arthritis and inflammatory bowel disease&#46; However monoclonal antibodies targeting eosinophilic inflammation have had greater impact&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> In addition inhaled steroids appear increasingly likely to only benefit patients with relatively high blood eosinophils&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> This may simply indicate that neutrophilic COPD has a more complex underlying inflammatory phenotype with interaction of multiple cytokines that cannot be addressed by targeting individual molecules&#46; Further trials are needed to explore the usefulness of specific therapies against implicated inflammatory cytokines&#44; to delineate the contribution of AATD to inflammatory pathologies and to elucidate whether serum AAT level is a useful biomarker for chronic inflammation in COPD beyond its role as an indicator of deficiency genotypes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0030" class="elsevierStylePara elsevierViewall">No specific funding was received for this article&#46; PRE is supported by a research grant from the <span class="elsevierStyleGrantSponsor" id="gs1">Alpha 1 Foundation</span>&#46; AMT has current funding from the ATS Foundation&#44; Alpha 1 Foundation&#44; NIHR&#44; Chiesi&#44; AstraZeneca and CSL Behring</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">Alice Turner research grant received within the last 3 years from Grifols biotherapeutics and CSL Behring</p></span></span>"
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ISSN: 03002896
Original language: English
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