This report describes family members with alpha-1 antitrypsin (AAT) deficiency arising from two rare alleles of SERPINA1 - p.(Phe76del) and p.(Asp280Val) along with the more common deficiency allele, Pi*Z. The index case, a 51-year-old female presented with cough, bloody sputum, fever, weight loss and night sweats. In addition to a respiratory infection, scans revealed bronchiectasis and bronchiolitis without emphysema. Her AAT level was 30 mg/dL and genetic testing revealed a Pi*Z/p.(Phe76del) genotype. Follow up testing of her relatives revealed the rare p.(Asp280Val) variant as well. AAT deficiency remains underdiagnosed. Early detection and intervention could improve quality of life and outcomes.

Background:The clinical and molecular characteristics of three patients with previously unreported SERPINA1 mutations associated with severe alpha-1 antitrypsin deficiency (AATD) are described. The pathophysiology of the chronic obstructive pulmonary disease (COPD) present in these patients was characterized through clinical, biochemical, and genetic examinations. Case presentations:Case 1: A 73-year-old male with bilateral centri-to panlobular emphysema and multiple increasing ventrobasal bullae and incomplete fissures, COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) grade III B), progressive dyspnea on exertion (DOE), AAT level of 0.1-0.2 g/L. Genetic testing revealed a unique SERPINA1 mutation: Pi*Z/c.1072C > T. This allele was designated PiQ0Heidelberg II. Case 2: A 47-year-old male with severely heterogenous centri-to panlobular emphysema concentrated in the lower lobes, COPD GOLD IV D with progressive DOE, AAT <0.1 g/L. He also had a unique Pi*Z/c.10del mutation in SERPINA1. This allele was named PiQ0Heidelberg III. Case 3: A 58-year-old female with basally accentuated panlobular emphysema, GOLD II B COPD, progressive DOE. AAT 0.1 g/L. Genetic analysis revealed Pi*Z/c.-5+1G > A and c.-472G > A mutations in SERPINA1. This variant allele was named PiQ0Heidelberg IV. Conclusions:Each of these patients had a unique and previously unreported SERPINA1 mutation. In two cases, AATD and a history of smoking led to severe lung disease. In the third case, timely diagnosis, and institution of AAT replacement stabilized lung function. Wider screening of COPD patients for AATD could lead to faster diagnosis and earlier treatment of AATD patients with AATD which could slow or prevent progression of their disease.

Diffuse panniculitis is a rare manifestation of α1-ATD, albeit perhaps the most fulminant and life-threatening complication, associated usually with ZZ phenotype. Intravenous α1-AT treatment is lifesaving. https://bit.ly/3EDmCzT.

Alpha-1-antitrypsin deficiency (AATD) is a rare cause of noncystic fibrosis (CF) bronchiectasis. The benefits of augmentation therapy in patients with chronic obstructive pulmonary disease (COPD) and pulmonary emphysema are well established. The role of augmentation therapy in AATD bronchiectasis in patients without pulmonary emphysema is not clear. We present the case of a 53-year-old woman (never smoker) who presented with increased susceptibility to infection, productive cough, and intermittent hemoptysis. Pulmonary function testing revealed restrictive impairment [VC 2,7 l (83% of pred.), FEV1 2,3 l (86% of pred.)]. A CT scan of the chest showed marked basal bronchiectasis with mucoid impaction, surrounding consolidation, and no emphysema. Despite frequent use of inhalation therapy, a satisfactory control of symptoms and exacerbations was not achieved. In the course of extended diagnostics regarding the genesis of bronchiectasis, a reduced alpha-1-antitrypsin (AAT) serum level was detected, and a genetic test revealed a homozygous Pi*ZZ genotype. We started augmentation therapy with AAT (Respreeza®, CLS Behring) at the dose of 60 mg/kg per week; the therapy was well tolerated by the patient, and she reported clinical improvement with a reduction in exacerbation frequency. AAT is a serine protease inhibitor and plays a major role in regulating inflammatory activities, in particular by inhibiting neutrophil elastase (NE). The present case illustrates the positive effect of augmentation therapy, including patients without airway obstruction. Among other causes, AATD should be considered as a possible cause of bronchiectasis, and the effects of augmentation therapy for this indication need to be prospectively studied.

The clinical characterization of a null variant of SERPINA1 – PiQ0Heidelberg – resulting in alpha1antitrypsin (AAT) deficiency is described. This rare mutation (c.-5+5 G > A) has been previously identified but not clinically described. The 77 year-old female patient had GOLD-3, Group B COPD, severe destructive panlobular emphysema and newly observed respiratory failure on exertion at the time the genetic analysis was performed. Serum AAT level was 0.1 g/L (reference 0.9–2.0 g/L). Isoelectric focusing showed only the Z-protein indicating that this was a null mutation. The patient has started AAT replacement. Early screening and identification of AAT deficiency would allow for earlier intervention.

Background: AATD is a genetic disorder frequently under/misdiagnosed. The lack of specific reference materials available for genetic and biochemical tests for AATD prevents systematized external quality control of lab testing. Objectives: We designed, organized and implemented the EQA program for AATD laboratory diagnostic procedures in seven leading European laboratories in the period of 2018-2020. Methods: Pilot validation rounds involved Warsaw and Pavia labs, alternately acting as referral unblinded center responsible for sample collection, shipping and report verification. Subsequent rounds involved all participating labs that performed analysis according to routine internal protocols and reported results to referral lab for verification. Each half-yearly round consisted of five blinded samples of serum and Dried Blood Spots (DBS), appropriately stored and shipped. Results: Validation rounds provided important evidences for the technicalities of safe and effective organization of sample delivery and DBSs stability. Regarding AAT concentration in the EQA, we observed variations of mean deviation rates in values measured in plasma (from 11,0 to 9,6 %) and DBS (from 7,8 to 15,7 %), respectively. Normal (PiM) and deficient (PiZ, PiS) SERPINA1 variants were assessed by geno/phenotyping with 100% inter-lab concordance. Conclusions: This EQA program provides a robust and customable tool for effective quality control applicable for routine AATD diagnosis. Excellent inter-lab concordance was observed confirming the reliability of AATD diagnostics provided by the participating laboratories.

Background: Numerous studies have reported positive effects of exercise training in patients with interstitial lung disease (ILD) on physical capacity and quality of life. However, evidence is rare on the effects of specific forms of training and further pathophysiological mechanisms in these patients. Objectives: In this multicenter study we aimed to explore the clinical effects of whole-body vibration training (WBVT) in patients with ILD on various outcome measures, including proinflammatory cytokines and myostatin. Methods: We randomly assigned 26 patients with different forms of multidisciplinary confirmed fibrotic ILDs either to the WBVT group (n = 11; 55% male, 61 ± 14 years old, forced vital capacity 83.2 ± 29.3% predicted, 6-min walking distance [6MWD] 478 ± 79 m) performing 3 months of a standardized training (3 times per week), or to a control training group (CTG, n = 15; 60% male, 63 ± 9 years old, FVC 74.6 ± 20.5% predicted, 6MWD 455 ± 85 m) performing sham WBV training. Training in the two groups was performed on a GalileoTM vibration plate (6–20 vs. 5 Hz). The functional assessments before and after the intervention period included pulmonary function, 6MWD test, chair rise test, ultrasonographic measurement of quadriceps muscle thickness (cross-sectional area), quality of life questionnaires, and serum samples. Results: We observed a significant increase in 6MWD (∆Training = 30 m [12–67], p = 0.024) and a decrease of myostatin (∆Training = –465 pg/mL [–713 to –166], p = 0.008) in the WBVT group. In contrast, no significant differences were observed in the CTG. Conclusions: The present study demonstrates that WBVT is able to significantly increase 6MWD and decrease myostatin in patients with fibrotic ILDs. Therefore, WBVT seems to be a beneficial and feasible training modality in ILD patients. Clinical Trial Registry: German Clinical Trials Registry (DRKS00012930).

Purpose:Alpha-1-antitrypsin deficiency (AATD) is a rare hereditary condition characterized by low circulating levels of alpha-1antitrypsin (AAT). While the association between AATD and COPD/emphysema is undisputed, the association between AATD and asthma or bronchiectasis is still a matter of debate.Aims and Objectives:Our study aimed to investigate the distribution of AAT genotypes between patients with COPD/emphysema, asthma and bronchiectasis. To back up the diagnostic labels, we described symptoms associated with the diagnosis.Methods:Between September 2003 and March 2020, 29,465 testing kits (AlphaKit®) were analyzed in the AAT laboratory, University of Marburg, Germany. The diagnosis of AATD has been made based on the measurements of AAT serum levels, followed by genotyping, phenotyping or whole gene sequencing depending on the availability and/or the need for more detailed interpretation of the results. The respiratory symptoms were recorded as well.Results:Regarding the distribution of the wild type allele M and the most frequent mutations S (E264V) and Z (E342K), no significant differences could be found between COPD/emphysema [Pi*MM (58.24%); Pi*SZ (2.49%); Pi*ZZ (9.12%)] and bronchiectasis [Pi*MM (59.30%) Pi*SZ (2.81%); Pi*ZZ (7.02%)]. When COPD/emphysema and bronchiectasis were recorded in the same patient, the rate of Pi* ZZ (14.78%) mutations was even higher. Asthma patients exhibited significantly less deficient genotypes [Pi*MM (54.81%); Pi*SZ (2%); Pi*ZZ (2.77%)] than two other groups. Associated respiratory symptoms confirmed the diagnosis.Conclusion:COPD/emphysema and bronchiectasis, but not asthma patients, exhibit higher frequency of AATD genotypes. Our data suggest that AATD testing should be offered to patients with COPD/emphysema and bronchiectasis.

Introduction: Alpha-1-antitrypsin deficiency (AATD) is a rare hereditary disease resulting from mutations in the SERPINA1 (serine protease inhibitor) gene and is characterized by low AAT serum levels. Among the more than 100 known mutations of SERPINA1, the Z- and the S-Allele are the most frequent mutations leading to AATD. Different PCR-based methods can be used in laboratory practice. Aims and Objectives: The study provides a comparison of the results (AATD laboratory of the University of Marburg) after the introduction of a new diagnostic genotyping kit (Progenika A1AT Genotyping Test) as compared to the conventional PCR-based algorithm before the introduction of the test. Methods: In July 2016, a new method has been established (Luminex xMAP-based multiplex PCR), allowing the detection of 14 SERPINA1 mutations, while in the time period before July 2016, genotyping was performed with a PCR-analysis for the presence of the S- and Z-mutation only. Isoelectric focusing (IEF) of serum or “dried-blood-spot” (DBS) and/or sequencing was used to diagnose unclear cases. We compared the AAT-genotypes of all 8,137 patients diagnosed by Luminex-based multiplex PCR to the same number of patients before July 2016. Results: Using multiplex PCR, we found 8,056 genotypes without sequencing, including 392 rare (of the 14 mutations) and 68 other (rare or new). In 8,137 individuals, analyzed before the introduction of the new test, only 7,836 could be diagnosed directly, and 301 had to be sequenced (finding 270 rare and 25 new mutations). Conclusion: The introduction of a new Luminex-based multiplex PCR leads to a marked reduction of samples that need to be sequenced, thus simplifies the diagnostic algorithm.

Introduction: Alpha-1-antitrypsin deficiency (AATD) is a rare hereditary condition, which is characterized by low alpha-1 antitrypsin (AAT) serum levels. While the association between AATD and COPD/emphysema is indisputed, the association to bronchiectasis and asthma is a matter of debate. Aims and Objectives: We compared the distribution of AAT genotypes between patients with COPD/emphysema, bronchiectasis and asthma. Methods: Between 2003 and 2019, 27,223 testing kits (AlphaKit©) were analyzed in the German AAT laboratory, University of Marburg. The diagnosis of AATD was made through a measurement of AAT serum levels, followed by genotyping, phenotyping or whole gene sequencing depending on availability and/or the need for more detailed interpretation of the AAT results. Respiratory symptoms were additionally recorded on the kit. Results: The distribution of the wild type (Pi*MM) was roughly comparable between the three groups. A higher percentage of COPD/emphysema and bronchiectasis patients exhibited the Pi*ZZ genotype as compared to asthma patients. In patients with bronchiectasis only, the distribution of alleles was as follows: M/M (59.4%), M/S (4%), M/Z (19.5%), S/S (0.8%), S/Z (2.8%), Z/Z (7.2%). Figure 1: Distribution of AAT alleles among patients with COPD/emphysema, bronchiectasis and asthma Conclusions: Not only patients with COPD/emphysema, but also patients with bronchiectasis (and asthma) should be screened for AATD.

1Department of Medicine, Pulmonary and Critical Care Medicine, Member of the German Center for Lung Research Marburg, University Medical Center Giessen And Marburg, Germany; 2Progenika Biopharma, S.A. A Grifols Company, Derio, Bizkaia, Spain; 3Department of Respiratory Medicine, Member of the German Center for Lung Research (DZL), Hannover Medical School, Biomedical Research in End Stage and Obstructive Lung Disease Hannover (BREATH), Hannover 30625, Germany; 4Department of Internal Medicine V, Pulmonology, Allergology, Respiratory and Intensive Care Medicine, Saarland Hospital, Homburg/Saar, Germany Purpose: Alpha-1-antitrypsin deficiency (AATD) is a rare hereditary condition resulting

Purpose Alpha-1-antitrypsin deficiency (AATD) is a rare hereditary condition resulting from the mutations in the SERPINA1 (serine protease inhibitor) gene and is characterized by low circulating levels of the alpha-1 antitrypsin (AAT) protein. The traditional algorithm for laboratory testing of AATD involves the analysis of AAT concentrations (nephelometry), phenotyping (isoelectric focusing, IEF), and genotyping (polymerase chain reaction, PCR); in selected cases, full sequencing of the SERPINA1 gene can be undertaken. New technologies arise that may make diagnosis easier and faster. Methods We developed and evaluated a new diagnostic algorithm based on Luminex xMAP (multi-analyte profiling) technology using Progenika A1AT Genotyping Test. In an initial learning phase, 1979 samples from individuals suspected of having AATD were examined by both, a traditional and a “new” algorithm. In a second phase, 1133 samples were analyzed with the Luminex xMAP only. Results By introducing a Luminex xMAP based algorithm, we were able to simultaneously identify 14 mutations in SERPINA1 gene (instead of two- S and Z-by using our old algorithm). Although the quantity of IEF assays remained unchanged, the nephelometric measurements and sequencing were reduced by 79% and 63.4%, respectively. Conclusion The new method is convenient, fast and user-friendly. The application of the Luminex xMAP technology can simplify and shorten the diagnostic workup of patients with suspected AATD.

Background: A large number of training programs and methods have shown that COPD patients of all severities can benefit from their performance and quality of life over a period of up to 3 months. The results of high-intensity training provide remarkable gains for patients. There is less evidence about the long-term effect of such training program. The aim of the study was to examine the impact of high-intensity training over a period of 6 years. Methods: A grand total of 49 patients agreed to participate (31 in the training group and 18 in the control groupwho underwent no training). The training group exercised twice a week for 90 minutes with increased loads. A subgroup of 10 patients continued the training program over a period of 6 years. At the time of enrolment (T0), after 3 (T1), 6 (T2) months and 6 (T3) years was performed a 6-minute walk test, health-related quality of life questionnaire, analysis of serum markers and lung function. Results: The training group remained constant in 6-MWT (T2= 457±122 m vs T3= 430±172 m), leg squats (T2= 56.4±21.6 kg vs T3= 55.7±27.7 kg), cable pulldown (T2= 112±20.7 kg vs T3= 90.5±32.6 kg) and in SGRQ score (T2= 34.9±13.8 vs T3= 52.6±19.5). They improved in cable row (T2= 56.9±12.5 kg vs T3= 108.9±19.8 kg; p<0.05) and Tiffeneau Index (T2= 49.5±16.4 % vs T3= 62.6±13.6 %). Conclusion: High-intensity training twice a week over a period of 6 years is possible for patients with COPD and leads to a preservation of performance, lung function and quality of life.

Introduction: Effects of training therapy on functional and physical performance in interstitial lung disease patients (ILD) has been reported. While there is evidence that whole body vibration therapy (WBVT) increases physical capacity in COPD patients, effects of this therapy in ILD are unknown. The aim of the three-center study was to investigate clinical and biological effects of WBVT in patients with ILD. Methods: 25 consecutive stable ILD patients were recruited; 11 (50% male: age 60.5 years) were randomized to the training group (WBVT 20 Hz, Novotec Medical GmbH, Germany) for three months, 3x/week. 16 ILD patients (62% male; age: 62.7 years) were randomized to the control group (CTG) and performed sham training at 5Hz. Functional tests (6 MWT, lung function, Chair rising test), ultrasound of the cross-section area of M. quadriceps, and serum samples were performed at the beginning and end of the study. Results: Patients in the training group had a significant increase in their the 6-MWT distance (∆Training = 34.82m, p=0.024) and presented a decrease of myostatin levels (∆Training = -409.79pg/ml, p=0.008). No differences in ultrasound and lung function was obeserved. Conclusion: The present study demonstrates for the 1st time significant effects of WBVT in patients with ILD. The influence on muscle mass and quality regulating could be explained as training success. WBV training seems to be an alternative to classical endurance and strength training for patients with ILD.

Background: Various exercise training programs are used for patients with chronic obstructive pulmonary disease (COPD) of different severity. Objectives: To investigate the impact of individualized high-intensity training on exercise capacity with COPD. Methods: A total of 49 patients agreed to participate. Of these, 31 were assigned to the training group and 18 served as controls. The training group exercised twice a week for 90 min with consecutively increasing loads. At the time of enrollment (T0), as well as after 3 (T1) and 6 (T2) months, a 6-min walk test (6-MWT) was performed and data on health-related quality of life, femoral muscle thickness, and various serum markers were obtained. Results: The training group improved in their 6-MWT results (T0 = 407 ± 152 m vs. T1 = 459 ± 127 m, p = 0.002, vs. T2 = 483.2 ± 130.1 m, p = 0.004), in their cross-sectional area of the musculus rectus femoris (T0 = 6.2 ± 1.2 cm2 vs. T1 = 6.9 ± 1.2 cm2, p = 0.003, vs. 7.5 ± 1.6 cm2, p = 0.002), and in their St. George's Respiratory Questionnaire (SGRQ) score (T0 = 43.3 ± 18.0 vs. T1 = 36.0 ± 18.4, p = 0.001, vs. T2 = 34.7 ± 18. 0, p = 0.004). Serum levels of myostatin, irisin, resistin, and α-Klotho did not change significantly within the training period. Of note, the exercise group showed an inverse relationship between serum levels of resistin and those of α-Klotho after 6 months (r = -0.608, p = 0.021). Conclusions: COPD patients undergoing an individualized, structured, high-intensity training program improved their exercise capacity, gained muscle mass, and improved their quality of life.