Gut: first published as 10.1136/gut.15.7.573 on 1 July 1974. Downloaded from Gut, 1974, 15, 573-580

Progress report Antitrypsin and the liver While genetic influences may be of considerable importance in determining susceptibility to only rarely is a simple direct genetic cause identifiable. At most only some 2-3 % of patients with can be shown to have single-gene disease such as Wilson's disease or haemochromatosis'. With rapidly progressive disease in infancy, however, the proportion is very much higher2. Recently an inherited trait-deficiency of alpha-l-antitrypsin (alAT)-has been shown to be an important cause of neonatal and cirrhosis3'4'5 and also a cause ofadult cirrhosis6. In addition, partial deficiency may increase susceptibility to cirrhosis associated with other causes6'7. Protease Inhibitors Human plasma is known to contain at least six inhibitors of enzymes acting on proteins (proteases)8 whose wide-ranging functions are not yet completely defined but include, among others, inhibition of trypsin and other serum proteases as well as forming an integral part of the fibrinolytic and kallikrein/ kinin systems. Jacobsson9 showed nearly 20 years ago that the trypsin inhibitory capacity of serum related predominantly to the alpha-i-globulin band of the electrophoretic strip. This band consists almost entirely of a http://gut.bmj.com/ glycoprotein of molecular weight approximately 540008 called variously 'alpha-l-trypsin inhibitor'"0, 'alpha-l-glycoprotein"'l, and finally 'alpha-l- antitrypsin'2. Itconstitutes some 3 % of the plasma proteins'3 and is produced in the liver'4'5. Several methods of estimating the trypsin inhibitory capacity exist'6, most of them estimating the inhibition of a given amount of trypsin by a given amount ofthe test serum by 'back-titrating' the uninhibited trypsin with an artificial substrate such as BAPNA (benzoyl-d-1-arginine-p-nitro- on October 2, 2021 by guest. Protected copyright. anilide). Approximately 90% of the trypsin inhibitory capacity is due to alpha-l-antitrypsin (alAT). Estimation is routinely carried out using a radial immunodiffusion method'7. Levels of oclAT and therefore of trypsin inhibitory capacity tend to vary somewhat in health'8,". They rise in many inflamma- tory states, in pregnancy, and also while taking 'the pill'; as might be expected they disappear following hepatectomyl5. In many liver diseases the levels of oclAT are normal or raised3"5'20. Antitrypsin and Lung Disease By an almost chance observation Laurell2' in 1963, while scanning routine electrophoretic strips from a sanatorium, noted two patients with emphysema who lacked the alpha-l-globulin band. The association of almost complete absence of alAT and panacinar emphysema of early onset rapidly became established22 first in Sweden then throughout Europe, America, South Africa, and elsewhere23. With increasing awareness the frequency of the deficiency in emphysema is seen to be rising in different surveys24 and is now recognized in children as well as in young adults25'26'27. The lung bases are predominantly 573 Gut: first published as 10.1136/gut.15.7.573 on 1 July 1974. Downloaded from 574 Peter W. Brunt affected and the disease is usually severe24. Lung involvement in alAT deficiency has recently been reviewed by Lieberman28. Genetics of the Pi System Hard on the discovery of the association with emphysema came the observa- tion that the deficiency state was a genetic disease which appeared to behave as an autosomal recessive trait'6'22'29. Numerous instances of affected siblings were recorded. Homozygotes had a mean trypsin inhibitory capacity of 0.24 mg trypsin inhibited per ml of serum compared with the normal of approxi- mately 1-10 mg16. Obligate heterozygotes were found to have an intermediate range of activity, about 0-67 mg, but were felt to be free of disease. Recently they also have been shown to be more susceptible to both emphysema24'30'31 and liver disease6 7. Unfortunately, owing to the fluctuation in levels of the trypsin inhibitory capacity under various physiological and pathological situations heterozygotes are not reliably detected by determining the serum trypsin inhibitory capacity24'32. Erikssonl' calculated the gene frequency to be 0.024 (1 in 42) in Sweden with a carrier (heterozygote) frequency of 0047 (1 in 21). The homozygote frequency would therefore be approximately 1 in 1800. In Britain the homozygote frequency is thought to be about 1 in 3410 which would mean something like 230 homozygote births per year33. Concepts changed radically in 1965 when Fagerhol and Braend34 discovered by using acid starch gel electrophoresis, which gives higher resolution35, that not one but eight separate bands were detectable in the pre-albumin zone. These can be defined and quantitated by antigen-antibody crossed electro- phoresis into several patterns corresponding to the products of several genes http://gut.bmj.com/ 36,37,38. This system has been termed the Pi (Protease inhibitor) system35. Subtypes have been designated by letters according to their electrophoretic mobility, as Pi M (medium), Pi F (fast), Pi S (slow), Pi Z (ultra slow), and so on'8. Since each fully penetrant gene determines physicochemical properties of a protein the genetic behaviour is really codominant rather than recessive. Each Pi Z 7 gene consistently codes about % of the normal amount of oclAT on October 2, 2021 by guest. Protected copyright. and the homozygous genotype Pi ZZ corresponds to the originally described 'homozygous' deficiency state'8'37. Most people (about 86 %) are Pi MM, ie, normal, and about 3% are heterozygous Pi MZ. Approximately 9% in Britain have the genotype Pi MS31 although frequencies of these genotypes vary in different communities'8. So far some 19 genes, most of them very rare, have been identified with 171 possible combinations although only about 35 have been recognized33. The evidence suggests that the genes are all alleles, ie, share the same locus on a chromosome'8'39'40, and recently evidence for linkage with the GM (immunoglobulin heavy chain) locus on the same autosome has been reported41. A gene coding no alAT-Pi 0-has recently been described42. Only the Pi Z gene has been unequivocally associated with lung and liver disease. Its racial prevalence seems to vary and to be higher for instance in north European stock such as English, Irish, and German and much lower in some ethnic groups such as Jewish, Italian, and Negro'82843. liver Involvement The first report of liver disease associated with a1AT deficiency seems to have been in 1967 by Ganrot and his colleagues44 who noted, without particular Gut: first published as 10.1136/gut.15.7.573 on 1 July 1974. Downloaded from Antitrypsin and the liver 575 comment, that two of their series had died of cirrhosis and another of liver carcinoma. Liver disease had not been previously expected or detected and indeed Eriksson (1964) had performed bromsulphalein tests on some of his patients with normal results16. In 1968 Sharp and his coworkers first drew attention to the association with infantile cirrhosis45'46. As with the lung disease discovery four years earlier the observation was fortuitous-while surveying electrophoretic patterns47. In all, this group discovered six families with seven affected individuals plus a further three children with liver disease who had died before studies were begun48. Johnson and Alper49 described four infants with low antitrypsin levels and liver disease (neonatal hepatitis). In two of these the hepatitis was progressive and led to cirrhosis. Additional cases of infantile liver disease were reported by Sharp in 197115650 and by Porter and his colleagues in 19723. The latter detected five alAT-deficient infants out of a total of 28 with neonatal hepatitis picked up in a survey of the South East Metropolitan Hospital Region, England. Two of the five infants appeared to recover completely. Aagenaes and his colleagues4 reported a further five infants with hepatitis and stressed the cholestatic characteristics. Thus the hepatic manifestations of oclAT deficiency appeared to be predomin- antly neonatal hepatitis and cirrhosis but recently an association with adult disease is becoming recognized6, both cirrhosis5l1 525354 and hepatoma44'51. In the light of early experience the view became general that in homozygous alAT deficiency (Pi ZZ) the patient, if not entirely normal, develops either liver disease or obstructive lung disease but probably not both. This is now known to be erroneous. Aminotransferases have been noted to be elevated in patients with emphysema5'56. In addition there are now a number of well documented cases with both lung and liver disease4'2752M54,57. Nevertheless the fact that they occur more often in isolation suggests that the mechanisms for http://gut.bmj.com/ development of liver and lung disease may be totally unrelated (vide infra). Both lung and liver disease in alAT deficiency is essentially associated with the homozygous Pi ZZ phenotype. It seems possible, however, that hetero- zygous Pi MZ individuals may be more susceptible to emphysema5"'59 and neonatal hepatitis60. Furthermore, individuals heterozygous for another gene

and with associated disease have been reported such as Pi SZ with emphy- on October 2, 2021 by guest. Protected copyright. sema,' and cirrhosis7. Other genotypes have been looked at, such as FZ62, but no disease pattern has yet emerged.

NEONATAL HEPATITIS Instances of familial hepatitis have been reported for many years63'64'65 although in many of these no cause is demonstrable. The evidence suggests that antitrypsin deficiency may be a major cause of neonatal hepatitis5. In the small series reported by Aagenaes and his colleagues from Oslo, 40% of infants with intrahepatic were of Pi ZZ phenotype4. In 1971 the King's College Hospital Group began a survey in south east England3, which has a birth rate of 40 thousand yearly in a population of approximately 2.5 million. At the latest tally, two and a half years later, there were 13 cases of alAT deficiency among some 100 cases of neonatal hepatitis66. Results of other surveys throughout the world will be awaited with interest. The clinical picture of aolAT hepatitis is not distinctive. Jaundice is usually evident in the first week or two of life although sometimes as late as two months3'4'48 49. Cholestasis may be marked with pale stools and dark urine and biliary atresia may be suspected,4 48. Bleeding may be prominent. Gut: first published as 10.1136/gut.15.7.573 on 1 July 1974. Downloaded from 576 Peter W. Brunt The histological features are not uniform but variable4. Necrosis and infiltration with plasma cells, lymphocytes, and eosinophils are usual; cholestasis with bile ductular proliferation and increase in connective tissue common3"4'15. In contrast giant cell formation is not common27'50. Brownish- grey pigment may be seen in the periportal cells4. Most infants are of low birth weight suggesting a pathogenesis in utero"°. Cholestasis gradually subsides in some three weeks to three months66. The prognosis is said to be poor with cirrhosis a usual outcome50'60. However, only four of the 13 King's College series", have thus far developed cirrhosis, nine remaining well, although it will be interesting to follow their progress to adult life. In other series infants have subsequently been shown to develop hepatosplenomegaly and some years after the initial jaundice has cleared27"48'50.

ADULT LIVER DISEASE In adults oclAT deficiency produces a less well defined picture. Liver changes vary from mild to moderate fibrosis50'67 through to advanced cirrhosis which is not infrequently found incidentally or only at necropsy44'5152'53'54'67'68. In contrast to the infant disease cholestasis is not a feature of adult disease although a biliary cirrhosis type of histological picture has been described54 and also cholangiocellular carcinoma57. A history of previous infantile hepatitis is strikingly lacking in these adult patients but this may simply reflect, in part at least, the inadequacy of retrospective information. As already stated, primary liver cell carcinoma has been reported in several instances44"'5 and in Lund a large survey ofhepatoma has revealed nearly 10%/ with evidence suggestive of alAT deficiency51. Whether this is a primary http://gut.bmj.com/ feature of the disease or simply a consequence of chronic liver disease is not yet clear. Pathogenesis of Antitrypsin Liver Disease

It seems that only two organs show pathological changes in alAT deficiency- on October 2, 2021 by guest. Protected copyright. the lungs and the liver-and other tissues are strikingly spared60 although glomerulonephritis has been described in association68. Patients with severe deficiency (Pi ZZ) fall into one of three pathological categories: (1) no clinical disease; (2) emphysema in early adult life, without and with liver disease; (3) childhood hepatitis and cirrhosis. Aagenaes4 has estimated the 'risk' for these three groups of the Pi ZZ phenotype as 10-20, 50-60, and 20-30 % respectively. The pathological mechanisms involved are still not understood but the fact that some people escape clinical disease altogether suggests that some additional factor or 'trigger' is involved. For emphysema, infection and smoking have been suggested24'28. For neonatal hepatitis and cirrhosis B has been postulated, notably by Porter and his colleagues3, three out of five of whose patients had detectable Australia antigen in the acute phase. It should be noted, however, that in other series this was reportedly absent47'69. An important fact that has emerged in the last two years is that the livers of virtually all individuals carrying the Pi Z gene have a detectable microscopic abnormality. Globules staining with periodic acid Schiff (PAS) and resistant to diastase (therefore not glycogen) were first reported in 197170,71. Numerous studies since then have confirmed these findings both in heterozygotes and Antitrypsin and the liver 577 Gut: first published as 10.1136/gut.15.7.573 on 1 July 1974. Downloaded from homozygotes, with or without frank liver disease4'7'13'27'50'51'52'53'4'62'72. This suggests that the finding is a primary feature of the deficiency state. There is ample evidence from the studies mentioned to suggest that the globules are in fact accumulations of alAT itself. Although not proven to be chemically or enzymatically identical6 '73, they do seem to be antigenically identical as can be shown by specific immunofluorescence using fluorescein-tagged antihuman alpha-l-antitrypsin"71. This latter is now available commercially. The globules vary in size up to 30,u diameter and are often multiple within cells or coalescent53. They tend to lie within dilated endoplasmic reticulum4'27'67'71. Groups of globule-containing cells tend to congregate in the periportal areas4'71. They are best identified by immunofluorescence and can easily be missed on light microscopy with haematoxylin and eosin8. The amount of fluorescence correlates with the gene dose (one or two Pi Z genes) but not with the severity of the liver disease which again suggests some additional trigger factor at play. Such specific fluorescence has not been found in normal controls4 or in patients with other liver diseases52. The reason for this cyto- plasmic inclusion of olAT is not known although a recent theory ties this to abnormality or deficiency of the sialic acid radical of the glycoprotein which in turn may influence membrane transport and thus impair release74'75. The gene Pi Z may thus be a structural gene coding for the sialic acid component. Clearly, however, failure of release of alAT cannot, of itself, explain the liver disease since it occurs in otherwise normal livers. It may, however, account for the emphysema component of this disease28. There is evidence that, in addition to trypsin, aLAT also inhibits collagenase69'78, elastase77'78, chymo- trypsin78, and leucocyte proteases78'79'80. Serum deficient in alAT may thus fail to counteract destructive proteases produced during pulmonary infec- tion80'81'82. The same arguments could clearly not apply for the hepatocytes. http://gut.bmj.com/ One possible explanation is that intracellular accumulations of excess and active ocAT may inhibit the normally protective proteolysis of absorbed intestinal toxins. Another possibility advanced by Gans83 and based on animal models is that defective intestinal barriers allow toxins to reach the Kupffer cells where during detoxication lysozomal enzymes are released;

deficiency of circulating olAT may thus allow these enzymes to effect liver on October 2, 2021 by guest. Protected copyright. damage. Further studies in these areas are currently under way. Treatment Other than general measures specific treatment of alAT deficiency liver disease has thus far proved ofno avail. The administration of exogenous alAT would require such large plasma volumes as to be totally impracticable"M. The half- life of injected alAT is only approximately six days84. Attempted enzyme induction (using phenobarbitone) has failed3. An unsuccessful liver transplant has been carried out in one homozygous child with cirrhosis; it is of interest that his serum trypsin inhibitory capacity levels rose to normal within two days after operation and remained so until his death50. Conclusions Alpha-l-antitrypsin deficiency is an important predisposing cause of infantile liver disease. In some individuals it may act in conjunction with some addi- tional factors such as viral hepatitis. Enzyme levels are readily measurable by Gut: first published as 10.1136/gut.15.7.573 on 1 July 1974. Downloaded from 578 Peter W. Brunt immunodiffusion methods, which are now available in commercially prepared kits (Behringwerke Partigen plates, Hoechst Pharmaceuticals), and simple electrophoresis85. It should be considered in all infants with hepatitis, prolonged cholestasis, or cirrhosis. Partial deficiency of the enzyme is less easily measured and ideally demands determination of the Pi phenotype by special electrophoretic methods. The importance of its role in predisposing the liver to other toxic agents is not yet known. It is, for instance, possible that it may be one of the factors explaining why only a small proportion of alcohol abusers develop cirrhosis. So far only sporadic cases of partial deficiency with liver disease have been reported but larger surveys are currently underway. PETER W. BRUNT Department ofMedicine, University ofAberdeen, and the Aberdeen Hospitals References 'Brunt, P. W. (1973). Genetics of liver disease. Clin. Gastroent., 2, 615-637. 'Danks, D. M., and Campbell, P. E. (1972). Frequencies of certain liver diseases and abnormalities in Victoria, Australia. Birth Defects, Original Article Series, 8 (2), 119-121. 'Porter, C. A., Mowat, A. P., Cook, P. J. L., Haynes, D. W. G., Shilkin, K. B., and Williams, R. (1972). Alpha- I-antitrypsin deficiency and neonatal hepatitis. Brit. med. J., 3, 435-439. 'Aagenaes, 0., Matlary, A., Elgjo, K., Munthe, E., and Fagerhol, M. (1972). Neonatal cholestasis in alpha-l- antitrypsin deficient children. Acta paediat. scand., 61, 632-642. "Alper, C. A. (1973). Deficiency of alpha-l-antitrypsin. Ann. intern. Med., 78, 298-299. 'Lancet (1973). Leader. Antitrypsin deficiency and adult cirrhosis. Lancet, 1, 925. 7Campra, J. L., Craig, J. R., Peters, R. L., and Reynolds, T. B. (1973). Cirrhosis associated with partial deficiency of alpha-l-antitrypsin in an adult. Ann. intern. Med., 78, 233-238. 8Heimburger, N. (1972). Introductory remarks: proteinase inhibition in human serum: identification, concen- tration, chemical properties, enzymatic specificity. In Pulmonary Emphysema and Proteolysis, edited by C. Mittman, pp. 307-310. Academic Press, London. 'Jacobsson, K. (1955). Studies on the trypsin and plasmin inhibitors in human serum. Scand. J. clin. Lab. Invest., http://gut.bmj.com/ Suppl., 14, 57-102. "Bundy, H. F., and Mehl, J. W. (1959). Trypsin inhibitors of human serum. II. Isolation of the a,-inhibitor and its partial characterization. J. biol. Chem., 234, 1124-1128. "Hirschfeld, J. (1960). Characterization of precipitating components in normal human sera obtained by an immuno-electrophoretic technique. Acta path. microbiol. scand., 49, 255-269. "Schultze, H. F., Heide, K., and Haupt, H. (1962). a1-Antitrypsin aus Humanserum. Klin. Wschr., 40, 427-429. "Gordon, H. W., Dixon, J., Rogers, J. C., Mittman, C., and Lieberman, J. (1972). Alpha-l-antitrypsin accumulation in livers of emphysematous patients with alpha-l-antitrypsin deficiency. Hum. Path., 3, 361-370. "Asofsky, R., and Thorbecke, G. J. (1961). Sites of formation of immune globulins and of a component of C',. II. Production of immuno-electrophoretically identified serum proteins by human and monkey tissues on October 2, 2021 by guest. Protected copyright. in vitro. J. exp. Med., 114, 471-483. "Sharp, H. L. (1971). Alpha-l-antitrypsin deficiency. Hosp. Pract., 6, 83-96. "Eriksson, S. (1965). Studies in a1-antitrypsin deficiency. Acta med. scand., Suppl. 432, 1-85. 7Mancini, G., Carbonara, A. O., and Heremans, J. F. (1965). Immunochemical quantitation of antigens by single radial immunodiffusion. Immunochemistry, 2, 235-254. "Fagerhol, M. K., and Laurell, G. B. (1970). The Pi system-inherited variants of serum alpha-l-antitrypsin. Progr. med. Genet., 7, 96-111. "Pierce, J. (1972). More on antitrypsin. New Engl. J. Med., 287, 1095-1096. 2OMowat, N. A. G., Brunt, P. W., and Ogston, D. (1974). The fibrinolytic enzyme system in acute and chronic liver injury. Acta haemat. (Basel), in press. 2'Laurell, C-B., and Eriksson, S. (1963). The electrophoretic aplha-l-globulin pattern of serum in alpha-l- antitrypsin deficiency. Scand. J. clin. Lab. Invest., 15, 132-140. "Eriksson, S. (1964). Pulmonary emphysema and alpha-l-antitrypsin deficiency. Acta med. scand., 175, 197-205 23British Medical Journal (1971). Leader. Enzyme-deficiency and emphysema. Brit. med. J., 3, 655. 24British Medical Journal (1973). Leader. Enzymes and emphysema. Brit. med. J., 1-2. "Glasgow, J. F. T., Hercz, A., Levison, H., Lynch, M. J., and Sass-Kortsak, A. (1971). Alpha-l-antitrypsin (AT) deficiency with both cirrhosis and chronic obstructive lung disease in two sibs (Abstr.). Pediat. Res., 5, 427. "Talamo, R. C., Levison, H., Lynch, M. J., Hercz, A., Hyslop, N. E., Jr., and Bain, H. W. (1971). Symptomatic pulmonary emphysema in childhood associated with hereditary alpha-l-antitrypsin and elastase inhibitor deficiency. J. Pediat., 79, 20-26. '"Glasgow, J. F. T., Lynch, M. J., Hercz, A., Levison, H., and Sass-Kortsak, A. (1973). Alpha-l-antitrypsin deficiency in association with both cirrhosis and chronic obstructive lung disease in two sibs. Amer. J. Med., 54, 181-194. "'Lieberman, J. (1973). Alpha-l-antitrypsin deficiency. Med. Clin. N. Amer., 57, 691-706. 2'Kueppers, F., Briscoe, W. A., and Bearn, A. G. (1965). Hereditary deficiency of serum alpha-l-antitrypsin. Science, 146, 1678-1679. "Kueppers, F. (1971). Alpha-l-antitrypsin: 1. Evidence for two genes causing low concentration in serum. 2. Association of heterozygosity and chronic obstructive lung disease. Chest, Suppl., 59, 15S-16S. Antitrypsin and the liver 579 Gut: first published as 10.1136/gut.15.7.573 on 1 July 1974. Downloaded from "Kueppers, F., Fallat, R., and Larson, R. K. (1969). Obstructive lung disease and alpha-l-antitrypsin deficiency gene heterozygosity. Science, 165, 899. "Talamo, R. C., Langley, C. E., Levine, B. W., and Kazemi, H. (1972). Genetic versus quantitative analysis of serum alpha-l-antitrypsin. New Engi. J. Med., 287, 1067-1069. "Cook, P. J. L. (1973). Genetic aspects-the Pi system. Alpha-l-antitrypsin deficiency and liver disease in childhood. (Symposium to be published). "Fagerhol, M. K., and Braend, M. (1965). Serum pre-albumin: polymorphism in man. Science, 149, 986-987. "Fagerhol, M. K., and Laurell, C-B. (1967). The polymorphism of 'prealbumins' and alpha-l-antitrypsin in human sera. Clin. chim. Acta, 16, 199-203. "Kueppers, F., and Beam, A. G. (1966). Inherited variations of human serum alpha-l-antitrypsin. Science, 154, 407-408. "Fagerhol, M. K. (1969). Quantitative studies on the inherited variants of serum alpha-l-antitrypsin. Scand. J. clin. Lab. Invest., 23, 97-103. 3"Kueppers, F. (1972). Antigen-antibody crossed electrophoresis for typing of alpha-l-antitrypsin. In Pulmonary Emphysema and Proteolysis, edited by C. Mittman, pp. 151-153. Academic Press, London. 3"Fagerhol, M. K., and Gedde-Dahl, T., Jr. (1969). Genetics ofthe Pi serum types. Human Heredity, 19, 354-359. "Kueppers, F. (1969). Identification of the heterozygous state for the alpha-l-antitrypsin deficiency gene in man. Blochem. Genet., 3, 283-288. '"Gedde-Dahl, T., Jr., Fagerhol, M. K., Cook, P. J. L., and Noades, J. (1972). Autosomal linkage between Gm and Pi loci in man. Ann. hum. Genet., 35, 393-399. "Talamo, R. C., Langley, C. E., Reed, C. E., and Makino, S. (1973). Alpha-l-antitrypsin deficiency: a variant with no detectable alpha-l-antitrypsin. Science, 181, 70-71. "Fagerhol, M. K., and Tenfjord, 0. W. (1968). Serum Pi types in some European, American, Asian and African populations. Acta path. microbiol. scand., 72, 601-608. "Ganrot, P. O., Laurell, C-B., and Eriksson, S. (1967). Obstructive lung disease and trypsin inhibitors in alpha-l- antitrypsin deficiency. Scand. J. clin. Lab. Invest., 19, 205-208. "Sharp, H., Freier, E., and Bridges, R. (1968). Alpha-l-globulin deficiency in a familial infantile liver disease. Pediat. Res., 2, 298. "Freier, E., Sharp, H. L., and Bridges, R. A. (1968). Alpha-l-antitrypsin deficiency associated with familial infantile liver disease. Clin. Chem.. 14, 782. "7Sharp, H. L., Bridges, R. A., Krivit, W., and Freier, E. F. (1969). Cirrhosis associated with alpha-l-antitrypsin deficiency-a previously unrecognised inherited disorder. J. Lab. clin. Med., 73, 934-939. "Gans, H., Sharp, H. L., and Tan, B. H. (1969). Antiprotease deficiency and familial infantile liver cirrhosis. Surg. Gynec. Obstet., 129, 289-299. "Johnson, A. M., and Alper, C. A. (1970). Deficiency ofalpha-l-antitrypsin in childhood liver disease. Pediatrics, 46,921-925. "Sharp, H., and Freier, E. (1972). Familial cirrhosis. In Pulmonary Emphysema and Proteolysis, edited by C. Mittman, pp. 101-113. Academic Press, London. "Berg, N. O., and Eriksson, S. (1972). Liver disease in adults with alpha-l-antitrypsin deficiency. New Engl. J. Med.. 287, 1264-1267. "Cohen, K. L., Rubin, P. E., Echevarria, R. A., Sharp, H. L., and Teague, P. 0. (1973). Alpha-l-antitrypsin deficiency, emphysema and cirrhosis in an adult. Ann. intern. Med., 78, 227-232. http://gut.bmj.com/ "Palmer, P. E., Wolfe, H. J., and Gherardi, G. J. (1973). Hepatic changes in adult alpha-l-antitrypsin deficiency. Gastroenterology, 65, 284-293. "Gherardi, G. J. (1971). Alpha-l-antitrypsin deficiency and its effect on the liver. Hum. Path., 2, 173-175. "Aagenaes, 0. (1971). Personal communication quoted by Porter, C. A., Mowat, A. P., Cook, P. J. L., Haynes, D. W. G., Shilkin, K. B., and Williams, R. (1972). Brit. med. J., 3, 435-439. "Delellis, R. A., Balogh, K., Merk, F. B., and Chirife, A. M. (1972). Distinctive hepatic cell globules in adult alpha-l-antitrypsin deficiency. Arch. Path., 94, 308-316. "Pedersen, J. T., Weeke, B., and George, J. (1969). Lung disease and alpha, antitrypsin deficiency. Danish med. Bull., 16, 283-288.

"Lieberman, J. (1969). Heterozygous and homozygous alpha-l-antitrypsin deficiency in patients with pulmonary on October 2, 2021 by guest. Protected copyright. emphysema. New Engt. J. Med., 281, 279-284. "Mittman, C., Lieberman, J., Miranda, A., and Marasso, F. (1972). Pulmonary disease in intermediate Alpha-l- antitrypsin deficiency. In Pulmonary Emphysema and Proteolysis, edited by C. Mittman, pp. 33-43. Academic Press, London. "'Aagenaes, 0 (1973). Pathogenesis of liver disease in alpha-l-antitrypsin deficiency. Alpha-l-antitrypsin deficienc.y and liver disease in childhood. (Symposium to be published). 'Fagerhol, M. K., and Hauge, H. E. (1969). Serum Pi types in patients with pulmonary diseases. Acta allerg. (Kbh.). 24, 107-114. "Feldman, G., Bignon, J., and Chahinian, P. (1973). Antitrypsin deficiency. Lancet, 1, 1515. "Hsia, D. Y-Y., Boggs, J. D., Driscoll, S. G., and Gellis, S. S. (1958). Prolonged obstructive jaundice in infancy. V. The genetic components in neonatal hepatitis. Amer. J. Dis. Child., 95, 485. "Danks, D., and Bodian, M. (1963). A genetic study of neonatal obstructive jaundice. Arch. Dis. Childh., 38, 378-387. "Cassady, G., Morris, A. B., and Cohen, M. M. (1964). Familial 'giant-cell hepatitis' in infancy. Amer. J. Dis. Child., 107,456-469. "Cottrall, K. (1973). Neonatal hepatitis and alpha-l-antitrypsin deficiency-An epidemiological study in S.E. England. Alpha-l-antitrypsin deficiency and liver disease in childhood. (Symposium to be published). "Ishak, K. G., Jenis, E. H., Marshall, M. L., Bolton, B. H., and Battistone, G. C. (1972). Cirrhosis of the liver associated with alpha-l-antitrypsin deficiency. Arch. Path., 94, 445-455. "Miller, F., and Kuschner, M. (1969). Alpha-l-antitrypsin deficiency, emphysema, necrotizing angiitis and glomerulonephritis. Amer. J. Med., 46, 615-623. "Alper, C. A., and Johnson, A. M. (1970). Alpha-l-antitrypsin deficiency and disease. Pediatrics, 46, 837-840. 7"Gordon, H. W. (1971). Letter. Hum. Path., 2, 463. "Sharp, H. L., Mathis, R., Krivit, W., and Freier, E. (1971). The liver in non-cirrhotic alpha-l-antitrypsin deficiency. J. Lab. clin. Med., 78, 1012-1013. "Lieberman, J., Mittman, C., and Gordon, H. W. (1972). Alpha-l-antitrypsin in the livers of patients with emphysema. Science, 175, 63-65. '"Favara, B. E., Franciosi, R. A.. and Silverman, A. (1972). Serum alpha-l-antitrypsin deficiency and infantile Gut: first published as 10.1136/gut.15.7.573 on 1 July 1974. Downloaded from 580 Peter W. Brunt

liver disease. (Abstr.) Pediat. Res., 6, 378. 7'Bell, 0. F., and Carrell, R. W. (1973). Basis ofthe defect in alpha-l-antitrypsin deficiency. Nature (Lond.), 243, 410-411. ?'Cox, D. W. (1973). Defect in alpha-l-antitrypsin deficiency. Lancet, 2, 844-845. 7'0hlsson, K. (1971). Interaction between human or dog leucocyte proteases and plasma protease inhibitors. Scand. J. clin. Lab. Invest., 28, 226-230. 77Turino, G. M., Senior, R. M., Garg, B. D., Keller, S., Levi, M. M., and Mandl, I. (1969). Serum elastase inhibitor deficiency and alpha-l-antitrypsin deficiency in patients with obstructive emphysema. Science, 165, 709-711. '0hlsson, K. (1971). Neutral leucocyte proteases and elastase inhibited by plasma alpha-l-antitrypsin. Scand. J. clin. Lab. Invest., 28, 251-253. "Hermann, G., and Miescher, P. A. (1965). Differentiation of leukocytic fibrinolytic enzymes from plasmin by the use of plasmatic proteolytic inhibitors. Int. Arch. Allergy, 27, 346-354. '°Kueppers, F., and Beam, A. G. (1966). A possible experimental approach to the association of hereditary alpha-l-antitrypsin deficiency and pulmonary emphysema. Proc. Soc. exp. Biol. (N. Y.), 121, 1207-1209. "Lieberman, J., Mohamed, M., and Mittman, C. (1970). Inhibition of leucocytic proteases in purulent sputum by alpha-l-antitrypsin. J. clin. Invest., 49, 58a. "Laurell, C-B. (1971). Is emphysema in alpha-l-antitrypsin deficiency a result of autodigestion? Scand. J. clin. Lab. Invest., 28, 1-3. "Gans, H. (1972). Considerations on the etiology of the hepatic injury observed in patients with homozygous alpha-l-antitrypsin deficiency. In Pubnonary Emphysema and Proteolysis, edited by C. Mittman, pp. 115-119. Academic Press, London. 'Makino, S., and Reed, C. E. (1970). Distribution and elimination of exogenous alpha-l-antitrypsin. J. Lab. clin. Med., 75, 742-746. "Laurell, C-B. (1972). A screening test for alpha-l-antitrypsin deficiency. Scand. J. clin. Lab. Invest., 29,247-248.

Addendum Since preparation of this review further homozygous and heterozygous (FZ) patients with liver disease have been described. See: Brand, B., Bezahler, G. H., and Gould, R. (1974). Cirrhosis and heterozygous (FZ) alpha-1-antitrypsin deficiency in an adult. Case report and review of the literature. Gastroenterology, 66, 264-268.

Kumar, P., Lancaster-Smith, M., Cook, P., Stansfield, A., Clark, M. L., and http://gut.bmj.com/ Dawson, A. M. (1974). Alpha-l-antitrypsin deficiency in chronic liver disease, and a report of cirrhosis and emphysema in adult members of a family. Brit. med. J., 1, 366-367. on October 2, 2021 by guest. Protected copyright.