Replacement therapy for alpha-1-protease inhibitor deficiency in PiZ subjects with chronic obstructive lung disease.

In a six-month multicenter feasibility and safety study, 20 patients, who all had a congenital deficiency of alpha-1-protease inhibitor (A1PI) of the PiZ phenotype accompanied by a chronic obstructive lung disease, were treated with human-plasma-derived A1PI. A weekly dose of 60 mg/kg, administered intravenously, was shown to be sufficient to maintain patient serum levels above the threshold limit of 35 percent, the serum level of healthy persons of the MZ phenotype. This is supposed to be the minimal effective level for protection against the elastolytic attack of the lung and, therefore, satisfies one of the most important criteria of feasibility of long-term replacement therapy. The global concentration in serum or bronchiolar lavage fluid A1PI including active and inactivated A1PI was measured immunologically by rate nephelometry and radial immunodiffusion. The functional activity of A1PI, expressed as free inhibitor activity against trypsin and leukocyte elastase, confirmed that the infused A1PI remained mostly in its active form in the circulation. Reported adverse reactions were moderate and did not require alteration to the schedule of the infusions and/or the dose and rate of administration. Antibodies to A1PI as measured by the Ouchterlony method did not develop. Laboratory and physical signs of possible hepatitis virus contamination were not observed. The long-term replacement therapy, therefore, appears to be safe.

Inhibitor activity against elastolytic enzymes in the bronchial area. A contribution to the pathogenesis of chronic airway obstruction.

In the bronchial mucus of patients with long-term airway obstruction free elastolytic activities are observed. These originate from leucocytes with polymorphous nuclei and may cause the digestion of lung tissue and thus an emphysematous lung metaplasia. It is known that the supersensitivity of bronchial musculature increases due to the influence of proteolytic ferments. For the inhibition of elastolytic enzymes, specific, acid-proof, low-molecular inhibitory substances are available. We were able to measure three of them in bronchial mucus against different substrates; i.e. against substrates for trypsin, pancreas elastase and leucocyte elastase. Our results show that the free inhibitor preparation decreases if free elastolytic activity in bronchial mucus is measured and is no longer available if the concentration decreases. It was also found that the concentration of secretory IGA decreases if the elastolytic activity increases. Thus, it is possible that the secretory IGA molecule is attacked by proteolytic enzymes. It is known that in case of chronic obstructive airway diseases lysozyme is released from leucocytes with polymorphous nuclei; in case of silicosis, from macrophages as well. In this study, the lysozyme concentration served as measurement for cell decomposition. The observation showed that in spite of the same lysozyme levels the elastolytic activity in patients can be very different. It is in strong connection with the available inhibitor capacity. Regarding the clinical evaluation can be concluded that some patients show a lack of secretory inhibitors. On a long-term basis, this lack can lead to the formation of emphysemata.

[The "IgA secretory component complex" in bronchial mucus in patients with chronic obstructive lung disease under different therapy (author's transl)]. / Der "IgA-Secretory-Component-Complex" im Bronchialschleim bei chronischer Atemwegsobstruktion unter verschiedenen Therapieformen.

The concentration of "IgA secretory component complex" in the bronchial mucus was measured under different therapeutical influences. The "IgA secretory component complex" is a most important factor of the exogenous immunodefense. The formation of the "IgA secretory component complex" was independent from the age of the patients and from the intensity of their airway obstruction. Therapy with glucocorticosteroids and antibiotics had no certain influence on the formation of the immunocomplex. We did not find any certain influence of gammaglobulin therapy in adult patients with chronic airway obstruction, neither on the "IgA secretory component complex" nor on the immunoglobulin G, A and M. Furthermore, the clinical course of the disease was not influence by this therapy.

[Serum-concentrations of the immunoglobulins iga, ige and igm in children with different age and diseases with different aetiologies (author's transl)]. / Serumkonzentrationen der Immunglobuline IgG, IgA und IgM bei Kindern verschiedener Altersstufen mit Erkrankungen verschiedener Atiologien.

Normal values of the immunoglobulins, G, A and M in the serum were measured with the immunodiffusion-method by Mancini et al., (1965) (immunodiffusion-plates: Hyland-Travenol) for children in the age between 0-15 years. Moreover, we measured the course of the immunoglobulin development of some babies during hospitalisation. Here we found a wide individual range in synthesis of immunoglobulins.

[The role of inter-alpha-trypsin-inhibitor (concentration of serum of childhood) (author's transl)]. / Uber die Bedeutung des Inter-Alpha-Trypsininhibitors (Serumkonzentrationen bei Kindern verschiedener Altersstufen).

The feeble monovalent, humoral protease inhibitor inter-alpha-trypsin inhibitor has to be regarded as inhibitogen for different secretory, low-molecular, polyvalent inhibitors. Kallikreine acts as inhibitor-releasing enzyme. The inhibitor levels in the serum were determined for children of different ages. Contrary to adult patients not showing a lack of inhibitogen as consequence of the disease, inhibitogen insufficiencies are rather frequent, particularly for prematures and newborns with respiratory distress and inflammatory diseases. Obviously, in early childhood the production of inhibitogen is not yet in full progress. In case of increased inhibitor consumption or excessive kallikrein consumption this condition results in an inhibitogen insufficiency.

[The protease inhibitor system in children (in diseases of the lung, liver and hereditary alpha 1-antitrypsin deficiency)]. / Das Proteasen-Inhibitorsystem bei Kindern (bei Erkrankungen der Lunge, der Leber und beim hereditären alpha 1-Antitrypsinmangel).

The balance of the protease inhibitor system is decisive for the pulmonary conditions of children. Our investigations showed that an imbalance of this system can be interpreted as manifestation of a severe pulmonary inflammation (e.g. deficit of inter-alpha-antitrypsin inhibitor in case of dyspnoe) or it can be regarded itself as a severe disease (alpha 1 antitrypsin deficit). A largely normal protease inhibitor system in children with pulmonary diseases is a point in favour of a clinically bland progression (for instance no protease inhibitor depression in group II = lung diseases). The efforts to compensate for existing inhibitor deficits are distinct (e.g. by the compensatory mechanism of alpha 2 macroglobulin). How and to which extent hepatopathies or the still immature liver in early childhood, for instance by synthesis disturbances, have an effect on the protease inhibitor system cannot be regarded as clarified. For characterization pulmonary inflammatory diseases and alpha 1 antitrypsin deficiency analysis of inhibitors can be efficient.

Comparison of three methods for the determination of serum alpha-1-antitrypsin in patients with pulmonary diseases.

In patients with pulmonary diseases, serum alpha 1-antitrypsin (AAT) was measured by three methods: radial immunodiffusion (RID), trypsin inhibitory capacity assay (TIC) and by rate nephelometry with the immunosystem (NIA) in a total of 369 subjects (sarcoidosis, n = 35; asthma, n = 41; chronic obstructive bronchitis, n = 62; bronchogenic carcinoma, n = 93; pneumonia, n = 24; tuberculosis, n = 43; fibrosis, n = 22; healthy controls, n = 49). Considering all patients, AAT was found to be significantly elevated (p less than 0.01-0.001) in all methods (RID: 3.3 +/- 1.0 g/l; TIC: 2.7 +/- 0.4 g/l; NIA: 2.1 +/- 0.8 g/l) compared to healthy controls (RID: 2.1 +/- 0.3 g/l; TIC: 2.1 +/- 0.4 g/l; NIA: 1.2 +/- 0.3 g/l). The lowest mean values were found by means of the NIA method. The best correlation coefficient (R) was evaluated between the TIC and the NIA method (R = 0.96) in healthy controls, but the best correlated methods were the RID and the NIA (R = 0.93) in patients with pulmonary disease.

Allergen-specific histamine release from whole blood in flour-sensitive bakers.

We have studied the allergen-specific in vitro histamine release (HR) in 38 flour-sensitive bakers and in 10 controls without occupational exposure after whole blood incubation with native wheat and rye flour and compared the results with the findings in RAST, skin and bronchial provocation tests. The mean in vitro HR from whole blood after incubation with rye flour amounted to 38.1% (range 0-100%) in flour-sensitive bakers and to 8.2% in the controls (p less than 0.005). Concerning the quantity of HR, no significant differences were found when bakers with meal rhinitis or those with flour-induced asthma were compared. Qualitative analysis, however, showed a close correlation between the frequency of positive HR and the severity of the allergic disorder (rhinitis versus asthma). Comparison of in vitro HR with the findings in RAST and skin tests gave a strong correlation of concordant results with the severity of the underlying disease. The highest coincidence of tests was found in patients with flour-induced asthma. The sensitivity of HR was very high when compared with RAST, skin and provocation tests. Although the assay of HR from whole blood may be a very specific indicator of cell sensitivity in the field of allergy research, the present findings indicate that the conventional methods for diagnosing flour allergy in bakers such as inhalative provocation tests cannot be replaced by this in vitro technique.

Long term effect on lung function of alpha 1-protease inhibitor substitution therapy in COPD patients with Pi ZZ phenotype.

Eight patients suffering from alpha 1-protease inhibitor (alpha 1-PI) deficiency (Pi ZZ phenotype) and chronic obstructive lung disease received substitution therapy (60 mg.kg-1 weekly) for a period of up to 30 months. Intrathoracic gas volume, airway resistance and arterial oxygen tension were followed once every three months. There was no trend for these indices to deteriorate or improve over the period of observation.

[Protease inhibitors, serum endotoxin and serum immunoglobulins following portacaval end-to-side anastomosis in animal experiments]. / Proteaseninhibitoren, Serum-Endotoxin und Serum-Immunglobuline nach portokavaler End-zu-Seit-Anastomose im Tierexperiment.

In order to clarify the pathophysiological mechanism of certain biochemical and immunological changes (endotoxin in serum, protease inhibitors, immunoglobulins) found in a former study on human cirrhosis of the liver the porto-caval end-to-side anastomosis of rats with unaffected livers was chosen as test model. With the aid of this bypass the "spill-over" phenomenon of the liver can be completely imitated. In this study, 7 operated and 5 or 14 control animals resp. are referred to. Serum endotoxin, acid-stable and acid-unstable protease inhibitors and immunoglobulins IgG, IgA and IgM were determined 20 months after operation. For the determination of potential hemodynamically or toxically induced effects on these organs, morphologic liver and lung examinations were performed. On the average, the operated rats showed a weight loss of 8 percent, i.e. from 378.4 +/- 9.2 g to 348.4 +/- 17 g. Compared to control rats, their relative liver weights were significantly lower (34%) (mean = 2.23 +/- 0.2 compared to 3.4 +/- 0.44 g, p less than 0.0005). Serum immunoglobulins IgG, IgA and IgM in operated animals were significantly higher (p less than 0.005 or p less than 0.025 resp. and 0.0025). Endotoxin in serum could be identified in 4 out of 7 operated animals (57, 1%), but in none of the control animals. While there was no difference in serum levels of acid-unstable protease inhibitors between the two groups levels of acid-stable protease inhibitors were in operated animals by 24% higher than in control animals (mean = 35.3 +/- 3.3 compared to 28.5 +/- 2.3 mU/ml, p less than 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)

[Mucous membrane specific protease inhibitors in bronchial mucus in severe chronic obstructive bronchitis and in alpha 1-antitrypsin deficiency syndrome]. / Schleimhautspezifische Proteaseinhibitoren im Bronchialschleim bei schwerer chronisch obstruktiver Bronchitis und bei alpha1-Antitrypsinmangelsyndrom

In the bronchial mucus of 40 patients with chronic obstructive airway diseases we measured proteolytic activities, the total protein concentrations, alpha1-antitrypsin, alpha1-antichymotrypsin, and the free and bound proteinase inhibitors together with the total proteinase inhibition against trypsin and chymotrypsin. Without exception we always found free proteinase inhibitors together with proteolytic activities. The free-to-bound inhibitor rate was approximately 1:1 alpha1-Antitrypsin and alpha1-antichymotrypsin was measured in sputum only in very low concentrations. One patient with alpha1-anti-trypsin deficiency had no alpha1-antitrypsin, but high concentrations of total proteinase inhibitor-free and bound being in the same relation - in his bronchial mucus. In the alveolar part of the lung, the humoral proteinase inhibitors were effective. In the bronchial part of the lung the specific mucosal inhibitors had the decided importance. The proteinase inhibition of the mucosa-specific inhibitors is probably of great importance for the pathogenesis of airway obstruction, while the humoral proteinase inhibitors are responsible for the pathogenesis of emphysema.

[Effect of the protease inhibitor aprotinin on pulmonary function and on the inhibitory activity of sputum in patients with chronic obstructive bronchitis]. / Uber die Wirkung des Proteaseinhibitors Aprotinin auf die Lungenfunktion sowie die inhibitorische Aktivatt des Sputums bei Patienten mit chronisch-obstruktiver Bronchitis

It has been investigated whether a substitution of protease inhibitor deficiency is indicated in case of chronic obstructive airway disease. As a therapeutic possibility, apronitin isolated from bovine organs (tyasylol), which in vitro inhibits sputum proteases up to 80 per cent was tested. Besides infusion, inhalation was chosen for application by which a protease inhibition could be attained. We observed an inhibition of the course of illness associated with a good tolerance of the preparation. Whether a therapy applying the addition of protease inhibitor is reasonable in the long run in chronic diseases cannot yet be concluded from these investigations.

Plasma catecholamines in exercise induced bronchoconstriction.

Plasma nor-epinephrine (NE) and epinephrine (E) levels at rest and immediately after exercise were estimated in 8 patients with asymptomatic extrinsic allergic bronchial asthma. The patients had a normal airway resistance at rest and developed a marked bronchoconstriction (EIB) during exercise, which could be prevented by previous alpha-adrenergic blockade with phentolamine. In 7 control persons NE and E levels were measured also after beta-adrenergic blockade with propranolol. The following results were obtained: 1. At rest NE levels showed no significant differences between the groups. After exercise an increase of NE was observed in all groups, but in patients, even after phentolamine, and in normals after propranolol the increase was significantly higher than in the normal group within the control test. 2. No significant differences between the groups were found in E levels at rest and after exercise. Exercise caused no significant increase of E levels, except in the normals after propranolol application. 3. No significant correlation existed between NE levels and the increase of airway resistance after exercise. It is concluded that during exercise in asthmatics the sympathetic activity is enhanced, but the provocation of an EIB does not seem to be mediated by enhanced plasma NE levels.

[Clinical-functional emphysema diagnostics and immunological correlations (author's transl)]. / Klinisch-funktionelle Emphysemdiagnostik und immunologische Korrelationen.

By application of the correlation flow resistance/intrathoracic gas volume the lung emphysema is differentiated in quality within the scope of chronic obstructive lung diseases. For these groups immunoglobulins, the alpha1-trypsin activity in serum and the activity of further protease inhibitors were determined. There are no substantial variables in the different groups with regard to immunoglobulins. In the emphysema group alpha1-antitrypsin was a little reduced. This group included 2 patients with an alpha1-antitrypsin deficit. The two-dimensional separation of the inter-alpha-trypsin big inhibitor shows 3 areas which decrease significantly in case of severe emphysemata. The irritation of the inter-alpha-trypsin big inhibitor, i.e. in its turnover, parallel to the increasing degree of emphysema formation, is discussed.

An elastase-specific inhibitor from human bronchial mucus. Isolation and characterization.

It was shown previously that human bronchial mucus contains an acid-stable proteinase inhibitor directed against trypsin and chymotrypsin, polymorphonuclear granulocyte elastase and cathepsin G. In addition to this well-characterized inhibitor, designated here as BSI-ATE (identical with the inhibitor HUSI-I from human seminal plasma or antileucoprotease), another acid-stable inhibitor BSI-E is present in the mucus which exerts inhibitory activity towards porcine pancreatic and human granulocytic elastase, but not against trypsin, chymotrypsin, or granulocytic cathepsin G. This elastase-specific inhibitor was isolated by affinity chromatography. Its molecular mass and its amino acid composition are very similar to those of BSI-TE. An immunological cross-reactivity between both inhibitor species was not observed. In the mucus of patients suffering from obstructive airway disease the elastase-specific inhibitor is not present in the free form but can be liberated by acidification.

An elastase-specific inhibitor from human bronchial mucus. Pathogenesis in lung emphysema.

Under physiological conditions human bronchial mucus contains an elastase-specific inhibitor which is quite different from hitherto known inhibitors: alpha 1-antitrypsin, HI-30, and BSI-TE. In bronchial mucus of 100 patients suffering from obstructive airway disease the amount of this inhibitor specific against elastase from both pancreas and polymorphonuclear neutrophilic leucocytes was measured. A group of 18 patients showed no inhibitor in their native mucus rather than free elastolytic activity. Another group of 82 patients had no elastolytic activity in their native mucus but free anti-elastolytic activity together with varying amounts of elastase-specific inhibitor bound to proteases. In a total of 20 cases from both groups the inhibitor was not detectable, neither in a free nor in a complexed form. Presuming that there is no hereditary deficiency involved, a strong importance of inactivating reactions such as oxidation is concluded.

Biochemical reaction of alpha 1 antitrypsin during the substitution therapy of patients with homozygote PI-ZZ deficit.

The homozygote deficit of alpha 1 antitrypsin (alpha 1 PI-ZZ) in patients frequently results in a premature development of emphysema in the lung due to incomplete protection against proteases. An active inhibitor substitution appears to be useful. The presented study proves the biological effect of alpha 1 antitrypsin infused into 8 patients. The results were an activity increase of leukocyte elastase and trypsin inhibition in serum as well as doubling of alpha 1 antitrypsin in sputum. This therapeutical conception (with a dose of 60 mg/kg body weight/week) results in an efficient protection. Inhibitors specific for mucosa are not influenced. An improvement of lung function during 6 weeks of intravenous therapy was not achieved. The progressive destruction of lung parenchyma can be probably prevented, however.

[Substitution therapy with alpha-1-Pi in patients with alpha-1-Pi deficiency and progressive pulmonary edema]. / Substitutionstherapie mit Alpha-1-Pi bei Patienten mit Alpha-1-Pi-Mangel und progredientem Lungenemphysem.

In a multi-centre study 20 patients with severe congenital alpha-1-Pi deficiency and progressive pulmonary emphysema received infusions of alpha-1-Pi concentrate from human plasma once weekly for six months, at an initial dosage of 60 mg/kg body-weight, in some instances slightly increased to achieve a minimum serum level above 70 mg/100 ml. The immunologically measured serum level of alpha-1-Pi rose 30 min after start of the infusion by a mean of 130% of normal, at an initial level of 13%. An exponential fall followed this rise. The lowest level occurred at the end of the first week, immediately before the next infusion, to 35% of normal, a serum level which is assumed still to provide an effective protection against elastases in the lung. There was also a definite increase of free inhibitors against both trypsin and leucocyte-elastase in serum of all patients, with a minimal level which for both was many times that of the initial value. There were no side-effects in more than 500 infusions and no dose reduction was necessary. During the entire course there were no significant changes in haematological, coagulation and biochemical test results, and lung function means remained constant. No antibodies against alpha-1-Pi were demonstrated, nor transmission of hepatitis B.

[Influence of vagus nerve, histamine, prostaglandin and catecholamine on airway obstruction]. / Bedeutung des Nervus vagus, des Histamins, der Prostaglandine und der Katecholamine für die Atemwegsobstruktion.

In three series of experiments, aerosols of acetylcholine, histamine, and Ascaris were administered in a maximal concentration before and after bilateral vagus transection. Vagotomy induced a clear reduction of the dynamic elastance increase by maintaining a constant breath volume. The persisting reaction of the dynamic elastance after vagotomy depends on the intensity of the reaction before vagus transection. Acetylcholine induced the largest reaction. Changes in epinephrine and norepinephrine were found to be variable, but an increase related to dynamic elastance increase could be assumed. Acetylcholine induced a maximal increase in thromboxane B2, and Ascaris induced preferentially a maximal increase in the prostaglandin F2 alpha metabolite 15-Keto-13, 14-dihydro-PGF2 alpha. Vagotomy showed no influence on changes of thromboxane B2, prostaglandin F2 alpha metabolite, or histamine in arterial plasma. The variability in changes of these metabolites may be the cause of the clinical differences in obstructive airway diseases.