The genetics of chronic obstructive pulmonary disease
© BioMed Central Ltd 2001
Received: 21 November 2000
Accepted: 11 December 2000
Published: 11 January 2001
Chronic obstructive pulmonary disease (COPD) is a significant cause of global morbidity and mortality. Previous studies have shown that COPD aggregates in families, suggesting a genetic predisposition to airflow obstruction. Many candidate genes have been assessed, but the data are often conflicting. We review the genetic factors that predispose smokers to COPD and highlight the future role of genomic scans in identifying novel susceptibility genes.
Keywordsassociation studies chronic obstructive pulmonary disease emphysema genetics lungs
Chronic obstructive pulmonary disease (COPD) is defined as airflow obstruction that does not change appreciably over a period of several months . It is a syndrome composed of chronic bronchitis, small airways disease (bronchiolitis) and emphysema, which vary in proportion between affected individuals. COPD is a major cause of global morbidity and mortality, and affected 44 million people in 1990. Indeed, 14 million people suffer from COPD in the United States alone, where this condition resulted in nearly 92 thousand deaths in 1995 . It is estimated that 2.88 million people in the world will die from COPD this year and the numbers are growing . COPD is becoming more prevalent amongst Western women and is set to explode in developing countries such as India, Mexico, Cuba, Egypt, South Africa and China . Severe α1-antitrypsin deficiency is the only proven genetic risk factor for the development of COPD. Here we review the evidence from human studies that other genetic determinants are also important in the pathogenesis of this condition. Although genetic studies using animal models may be very useful [5,6,7], they are beyond the scope of this review.
Environmental factors that predispose to COPD
The major environmental risk factor for the development of COPD is cigarette smoking. In non-smokers, the forced expiratory volume in 1s (FEV1) declines at a mean rate of approximately 20–30 ml per year during adult life. In most smokers, this mean rate of decline is increased to 30–45 ml per year, but in the subset of cigarette smokers who are susceptible to developing COPD the rate of decline is 80–100 ml per year. There is evidence of a dose–response relationship between the severity of lung disease and the pack-years of cigarettes smoked [8,9,10,11], but only 15% of the variability in FEV1 is accounted for by smoking history. It remains unclear whether susceptible smokers represent a discrete subset of individuals, or if susceptibility to COPD is a continuous trait. Postmortem studies of smokers have demonstrated substantial variability in the severity of emphysema, but most heavy smokers had at least some pathological evidence of disease [12,13].
Other environmental factors have also been implicated in the development of chronic irreversible airflow obstruction. There has been an association of COPD with environmental pollution since the great London smogs of the 1950s . Domestic and cooking fumes may also be important risk factors, especially in regions where indoor wood stoves are used with poor ventilation . In certain cities in China, non-smoker emphysema death rates are almost 100 times greater than those of the non-smoker in the USA . Exposure to dust in the coal and gold mining industries, and to gas in cadmium mining, has been linked to the development of airflow obstruction [16,17,18]. Exposure to dust and gases by underground tunnel workers has similarly been associated with respiratory symptoms and COPD, as well as with an accelerated decline in FEV1, compared to matched controls who worked above ground . COPD is more common in individuals of lower socio-economic status  and has a poorer prognosis when associated with low body-mass index  and with bronchial hyper-reactivity [21,22]. There is also evidence that previous viral infections predispose smokers to COPD , and an increasing awareness that diet  and factors involved during in utero [25,26] and adolescent lung development  may be important for the subsequent predisposition to obstructive lung disease. These other environmental factors are likely to be much less important than cigarette smoking, but they may interact with smoking to increase the risk of COPD [28,29].
Familial clustering of COPD
The observation that only a minority of cigarette smokers develop COPD suggests that additional factors contribute to the impact of smoking on the development of chronic airflow obstruction. The most important genetic factor in the development of emphysema is the Z allele of α1-antitrypsin, which results in plasma levels of this protein that are 10–15% of that produced by the normal M allele . The levels are low because 85% of the synthesised mutant Z α1-antitrypsin is retained as polymers within hepatocyte [31,32]. Homozygotes for the Z allele (denoted PI Z) are greatly predisposed to developing emphysema if they smoke [33,34]. However, severe PI Z α1-antitrypsin deficiency makes up only 1–2% of all cases of COPD and there is considerable variability in FEV1 between current and ex-smokers with the same PI Z genotype . This suggests that other coexisting genetic factors must predispose to lung disease in PI Z individuals.
A logical follow-on from the association of α1-antitrypsin deficiency with emphysema is an assessment of the risk of COPD in heterozygotes who carry an abnormal Z allele and a normal M allele. These individuals have plasma α1-antitrypsin levels that are approximately 65% of normal. A population-based study demonstrated that PI MZ heterozygotes do not have a clearly increased risk of lung damage . However, if groups of patients are collected who already have COPD, then the prevalence of PI MZ individuals appears to be increased [37,38]. In addition, a longitudinal study has demonstrated that among COPD patients (most of whom were smokers), the PI MZ heterozygotes have a more rapid decline in lung function . These data suggest that either all PI MZ individuals are at slightly increased risk for the development of COPD, or that a subset of the PI MZ subjects are at substantially increased risk of pulmonary damage if they smoke. An alternative explanation is that the apparent increased risk among PI MZ subjects reflects ascertainment bias and the elevated rate of PI MZ subjects among COPD cases reflects the influence of other, as yet unidentified, factors.
Several previous studies have suggested that genetic factors other than α1-antitrypsin deficiency may be involved in the susceptibility of cigarette smokers to chronic airflow obstruction. These studies have demonstrated a significantly higher prevalence of COPD amongst relatives of index patients than amongst control groups [40,41,42]. The findings have been confirmed recently in a study of 44 patients with severe COPD (FEV1 <40% predicted) aged 52 or less . The prevalence of airflow obstruction in smoking siblings was approximately 3-fold greater than in smoking control subjects.
Candidate genes that have been associated with COPD in case–control studies
PI MZα1-antitrypsin deficiency
Tumour necrosis factor α
Microsomal epoxide hydrolase
Taq-1 polymorphism of α1-antitrypsin
Vitamin D binding protein
ABO Blood Group
ABH Secretor Status
Cystic fibrosis transmembrane regulator
The first genetic association studies in the 1970s used the small number of genetic polymorphisms that were then known: largely blood group antigens . Subsequently, candidate genes thought to be involved in the pathophysiology of COPD have been examined. For instance, polymorphisms in the proteins that protect the lungs against proteolytic attack have been assessed. A polymorphism that predisposed smokers to develop COPD (Taq-1 G→A)  was detected by the restriction enzyme Taq-1 in the 3' non-coding region of the α1-antitrypsin gene. The Taq-1 (G→A) allele, conferring the absence of this Taq-1 site, was present in 18% of a population of emphysema patients, but in only 5% of blood donor control subjects. This association was confirmed by a second European group ; further studies revealed that the polymorphism was in a regulatory sequence, and that the Taq-1 (G→A) allele reduced the production of α1-antitrypsin in response to the inflammatory cytokine interleukin-6 (IL-6) . Subsequent studies by other groups refuted the association with COPD [49,50]. Moreover, although the Taq-1 (G→A) allele reduced the production of α1-antitrypsin in vitro , it had no effect on the plasma level of α1-antitrypsin in vivo or on the rise in levels of this protein during the inflammatory response [51,52,53]. Thus the role of this polymorphism in the pathogenesis of COPD remains unproven.
The logical follow-on from this work was the assessment of mutations in another plasma proteinase inhibitor, α1-antichymotrypsin, to explain the susceptibility of smokers to COPD. No patients who are homozygotes for α1-antichymotrypsin deficiency have ever been described, but two point mutations that alter the amino acid sequence (229Pro → Ala  and 55Leu → Pro ) in the α1-antichymotrypsin gene have been associated with COPD. The 55Leu → Pro point mutation causes a conformational change within the protein , resulting in low circulating levels of the inhibitor and its retention within hepatocytes. The retention of this protein has been associated with intracellular hepatic inclusions of α1-antichymotrypsin and cirrhosis  analogous to that associated with α1-antitrypsin deficiency . However, the association of these two polymorphisms with COPD was not replicated in a study of 168 COPD patients and 61 control subjects . Moreover, the mutations are uncommon, making it unlikely that they are a frequent contributor to the pathogenesis of COPD [50,57].
Two other plasma serine proteinase inhibitors, secretory leukoprotease inhibitor and elafin, are also potential candidates, as mutations in these genes may reduce the anti-proteinase screen and predispose smokers to airflow obstruction. No polymorphisms were detected in the secretory leukoprotease inhibitor gene in 10 patients with early onset irreversible airflow obstruction . Moreover, although polymorphisms have been described in the elafin gene , they have not been assessed in patients with COPD. Similarly, no polymorphisms have yet been described in tissue inhibitor of metalloproteinase genes in patients with COPD.
The cytokine tumour necrosis factor α (TNF-α) plays an important role in the inflammatory response. Approximately 10% of the population have a polymorphism (G→A) at position -308 in the 5' promoter region of the gene. This variant is known as tumour necrosis factor 2 and results in a 2-fold increase in the plasma concentration of TNF-α following gene activation . The -308 polymorphism was found to be more prevalent in a group of Taiwanese patients with COPD, when compared to controls matched for age, sex and smoking who did not have airflow obstruction . It is plausible that smokers who have a higher level of TNF-α in the bronchial mucosa have more bronchitis and more airflow obstruction. However, these findings have been refuted by others who have assessed the association between this polymorphism and airflow obstruction in Caucasian populations [62,63].
Each puff of a cigarette contains 1017 free radicals, which can cause lung damage. Thus defects in the detoxification of these reactive species may predispose smokers to airflow obstruction and emphysema. Indeed the proportion of patients with slow microsomal epoxide hydrolase activity was significantly higher in patients with COPD and emphysema, when compared to healthy blood donor controls . The smoking history of the blood donor control group was not recorded. These findings have been supported by Paré and colleagues, who have assessed a well-characterised cohort of patients from the Lung Health Study . These patients were all smokers and had spirometric signs of early COPD. They were followed up for five years as part of a longitudinal study and then stratified into two groups: those smokers whose lung function showed a significant decline and those whose did not. Association analysis demonstrated a significantly higher prevalence of the slow-detoxifying epoxide hydrolase in those patients who showed a progressive decline in lung function compared to those who did not. These findings were not reproduced by another group who assessed the polymorphism in a Korean population .
More recently, Yamada and colleagues reported an association between COPD and a short tandem repeat polymorphism in the heme oxygenase-1 gene promoter . The protein that this gene encodes also plays an important antioxidant role in the lung, and there is in vitro evidence that the polymorphism in the gene promoter region reduces the upregulation of heme oxygenase-1 in response to reactive oxygen species in cigarette smoke. Although the possibility that microsomal epoxide hydrolase and heme oxygenase-1 might be associated with obstructive lung disease is biologically appealing, further association studies are required in other well-characterised COPD populations with matched control subjects or, ideally, with family-based association study designs.
Finally, mutations in enzymes that generate protective antioxidants have also been associated with the development of COPD. The glutathione S1-transferases (GSTs) are a family of enzymes that catalyse the conjugation of reduced glutathione with various electrophilic compounds. They are divided into the alpha (GSTA), mu (GSTM), pi (GSTP), theta, sigma, and kappa subclasses . A polymorphism in exon 5 (Ile105) of GST P1 is located in the substrate binding pocket and has considerable effects on catalytic activity. It was significantly more common in men with irreversible airflow obstruction than in controls who were current smokers, but who had no evidence of COPD .
What do candidate gene association studies tell us about disease processes in COPD?
This complex picture is starting to show similarities to the quagmire that bedevils the field of asthma genetics. However, unlike asthma genetics, linkage studies in COPD have not been performed to identify regions of the genome likely to contain susceptibility genes, in which association studies with candidate genes may be more productive. The inconsistent results from case–control association studies are likely to relate to differences between study populations and the relatively small sizes of the populations under consideration. In addition, failure to account for population stratification differences between cases and controls within a particular study, and failure to correct adequately for the multiple comparisons involved in studying multiple polymorphisms with multiple phenotypes, is also likely to be problematic. However, several messages can be drawn from the association studies that have been undertaken to date. It is clear that many researchers continue to focus on the well-established hypotheses of lung damage: proteinase–anti-proteinase and oxidant–antioxidant imbalance. At least some smokers with a MZ α1-antitrypsin phenotype may be more likely to develop COPD than smoking matched controls, but the Taq-1 polymorphism in the 3' non-coding region of the PI locus has not been proven to confer an increased risk of lung disease. Heterozygote deficiency of α1-antichymotrypsin is so uncommon that even if it is ultimately shown to have a pathophysiological effect, it will contribute to the development of airflow obstruction in only a few smokers. There is growing evidence for the role of antioxidant imbalance in the pathogenesis of airflow obstruction, which is supported by association studies between COPD and variants in epoxide hydrolase and GSTs that detoxify free radicals and other tobacco products. Before these associations are generally accepted, they must be subjected to scrutiny with further association studies.
Genomic scans to identify genes that predispose smokers to COPD
The association studies described above have all been conducted with variants in known candidate genes. Clearly our understanding of COPD would be revolutionised if a new gene or genes could be discovered that explained the predisposition of a minority of smokers to develop COPD. An alternative approach to this problem is to detect novel genes using linkage analysis in families of COPD patients, using polymorphic markers throughout the genome. If a marker segregates with COPD in affected relatives, then it indicates that this marker is located near to one or more genes that cause this disease. In order for this approach to be successful, it requires a large number of well-characterised affected relatives; either extended pedigrees or nuclear families can be used.
One of our research groups (EKS) has been focusing on linkage analysis of extended pedigrees of patients with severe, early-onset COPD. A genome screen of 72 extended pedigrees (600 individuals) has been performed by the National Heart, Lung, and Blood Institute (NHLBI) Mammalian Genotyping Service; analysis of this data is currently underway. However, the sample size is modest and it is unclear how far generalisations can be made from this population to older COPD subjects.
To study the genetics of COPD in subjects at ages more typical for the development of this disease, a large number of families will be required. The magnitude and organisation of a network to recruit the thousands of patients that are required for such studies is extremely expensive. A pharmaceutical company (Glaxo-Wellcome) has funded a consortium that spans 10 centres in seven North American and European countries. The consortium, which is led by the authors, involves collaboration between universities and industry designed to recruit nuclear families of COPD patients. This consortium has started to recruit 3000 families in order to identify 1500 affected sib pairs with COPD. The index cases (probands) and their siblings are being screened with respiratory questionnaires, spirometry and high resolution chest CT scans. The collection of this data from 3000 patients with COPD and their siblings will provide unique insights into the pathophysiology of airflow obstruction and, most importantly, the genetics of this condition. The search for new genes that predispose smokers to COPD will be undertaken using linkage analysis of COPD with genomic scan data from DNA-based polymorphisms throughout the genome. Strong linkage between regions of the genome and COPD-related phenotypes will identify locations on chromosomes that need to be assessed in more detail. Clearly, the rapidly advancing project to fully sequence the human genome will provide a 'road map' of the genes in the regions of interest, thereby rapidly accelerating the identification of genes that result in COPD.
Benefits of cloning genes that predispose smokers to COPD
Why have so many workers put so much effort and resources into searching for genes that predispose to COPD? There are several answers. The identification of new genes would greatly improve our understanding of a condition that has for 37 years rested largely on the observation that deficiency of a protective anti-proteinase (α1-antitrypsin) is associated with emphysema. Novel genes would allow the assessment of new mechanisms and pathways in disease and provide new therapeutic opportunities. At-risk individuals could be identified by screening and strongly advised to abstain from smoking and avoid occupations where there are high loads of environmental dusts. Finally, new genes may help to explain other diseases. There is epidemiological evidence that COPD and lung cancer share a common familial component other than smoking [69,70]. The discovery of novel genes that predispose to COPD may therefore have a major impact on our understanding of the pathogenesis of cancer.
COPD is an enormous cause of global morbidity and mortality that is becoming an even greater health problem with the growing use of cigarettes around the world. Mutations in the anti-proteinase and antioxidant screen are currently the best candidates to explain part of the genetic risk of COPD. However, new candidates need to be assessed in order to improve our understanding of the development of this disease. The recruitment of large numbers of affected siblings with COPD will provide the basis for whole genome scans to discover novel genes that predispose smokers to airflow obstruction. This will be greatly aided by the rapid completion of the human genome project. Taken together, it is a very exciting time for all those interested in the pathogenesis of this all too common disabling condition.
DAL is supported by the Medical Research Council (UK) and the Wellcome Trust; EKS is supported in part by grant HL-61575 from the National Institutes of Health.
- British Thoracic Society: BTS guidelines for the management of chronic obstructive pulmonary disease. Thorax. 1997, 52: Supplement 5-
- Wise RA: Changing smoking patterns and mortality from chronic obstructive pulmonary disease. Prev Med. 1997, 26: 418-421. 10.1006/pmed.1997.0181.View ArticleGoogle Scholar
- Murray CJL, Lopez AD: Global health statistics: a compendium of incidence, prevalence, and mortality estimates for over 200 conditions. Global burden of disease and injury series volume II: Harvard School of Public Health, Harvard University Press. 1999Google Scholar
- Peto R, Chen Z-M, Boreham J: Tobacco: the growing epidemic. Nature Med. 1999, 5: 15-17. 10.1038/4691.View ArticleGoogle Scholar
- D'armiento J, Dalal SS, Okada Y, Berg RA, Chada K: Collagenase expression in the lungs of transgenic mice causes pulmonary emphysema. Cell. 1992, 71: 955-961.View ArticleGoogle Scholar
- Hautamaki RD, Kobayashi DK, Senior RM, Shapiro S: Requirement for macrophage elastase for cigarette smoke-induced emphysema in mice. Science. 1997, 277: 2002-2004. 10.1126/science.277.5334.2002.View ArticleGoogle Scholar
- Zheng T, Zhu Z, Wang Z, Homer RJ, Ma B, Riese RJ, Chapman HA, Shapiro SD, Elias JA: Inducible targeting of IL-13 to the adult lung causes matrix metalloproteinase- and cathepsin-dependent emphysema. J Clin Invest. 2000, 106: 1081-1093.View ArticleGoogle Scholar
- Fletcher C, Peto R: The natural history of chronic airflow obstruction. Br Med J. 1977, 1: 1645-1648.View ArticleGoogle Scholar
- Burrows B, Knudson RJ, Cline MG, Lebowitz MD: Quantitative relationships between cigarette smoking and ventilatory function. Am Rev Respir Dis. 1977, 115: 195-205.Google Scholar
- Dockery DW, Speizer FE, Ferris BG, Ware JH, Louis TA, Spiro A: Cumulative and reversible effects of lifetime smoking on simple tests of lung function in adults. Am Rev Respir Dis. 1988, 137: 286-292.View ArticleGoogle Scholar
- Peat JK, Woolcock AJ, Cullen K: Decline of lung function and development of chronic airflow limitation: a longitudinal study of non-smokers and smokers in Busselton, Western Australia. Thorax. 1989, 45: 32-37.View ArticleGoogle Scholar
- Auerbach O, Hammond EC, Garfinkel L, Benante C: Relation of smoking and age to emphysema. Whole lung section study. N Eng J Med. 1972, 286: 853-857.View ArticleGoogle Scholar
- Petty TL, Ryan SF, Mitchell RS: Cigarette smoking and the lungs. Relation to postmortem evidence of emphysema, chronic bronchitis, and black lung pigmentation. Arch Environ Health. 1967, 14: 172-177.View ArticleGoogle Scholar
- Holland WW, Reid DD: The urban factor in chronic bronchitis. Lancet. 1965, i: 445-448.View ArticleGoogle Scholar
- Pandey MR: Domestic smoke pollution and chronic bronchitis in a rural community of the Hill region of Nepal. Thorax. 1984, 39: 337-339.View ArticleGoogle Scholar
- Kauffmann F, Drouet D, Lellouch J, Brille D: Twelve years spirometric changes among Paris area workers. Int J Epidemiol. 1979, 8: 201-212.View ArticleGoogle Scholar
- Oxman AD, Muir DCF, Shannon HS, Stock SR, Hnizdo E, Lange HJ: Occupational dust exposure and chronic obstructive pulmonary disease. A systematic overview of the evidence. Am Rev Respir Dis. 1993, 148: 38-48.View ArticleGoogle Scholar
- Davison AG, Fayers PM, Newman Taylor AJ, Venables KM, Darbyshire J, Pickering CAC, Chettle DR, Franklin D, Guthrie CJG, Scott MC, O'Malley D, Holden H, Mason HJ, Wright AL, Gompertz D: Cadmium fume inhalation and emphysema. Lancet. 1988, March 26: 663-667. 10.1016/S0140-6736(88)91474-2.View ArticleGoogle Scholar
- Ulvestad B, Bakke B, Melbostad E, Fuglerud P, Kongerud J, Lund MB: Increased risk of obstructive pulmonary disease in tunnel workers. Thorax. 2000, 55: 277-282. 10.1136/thorax.55.4.277.View ArticleGoogle Scholar
- Landbo C, Prescott E, Lange P, Vestbo J, Almdal TP: Prognostic value of nutritional status in chronic obstructive pulmonary disease. Am J Resp Crit Care Med. 1999, 160: 1856-1861.View ArticleGoogle Scholar
- Rijcken B, Schouten JP, Xu X, Rosner B, Weiss ST: Airway hyper-responsiveness to histamine associated with accelerated decline in FEV1. Am J Respir Crit Care Med. 1995, 151: 1377-1382.View ArticleGoogle Scholar
- Eden E, Mitchell D, Mehlman B, Khouli H, Nejat M, Grieco MH, Turino GM: Atopy, asthma, and emphysema in patients with severe alpha-1-antitrypsin deficiency. Am J Respir Crit Care Med. 1997, 156: 68-74.View ArticleGoogle Scholar
- Matsuse T, Hayashi S, Kuwano K, Keunecke H, Jefferies WA, Hogg JC: Latent adenoviral infection in the pathogenesis of chronic airways obstruction. Am Rev Respir Dis. 1992, 146: 177-184.View ArticleGoogle Scholar
- Sargeant LA, Jaeckel A, Wareham NJ: Interaction of vitamin C on the relation between smoking and obstructive airways disease in EPIC-Norfolk. Eur Respir J. 2000, 16: 397-403. 10.1034/j.1399-3003.2000.016003397.x.View ArticleGoogle Scholar
- Barker DJP, Osmond C: Childhood respiratory infection and adult chronic bronchitis in England and Wales. Br Med J. 1986, 293: 1271-1275.View ArticleGoogle Scholar
- Barker DJP, Godfrey KM, Fall C, Osmond C, Winter PD, Shaheen SO: Relation of birth weight and childhood respiratory infection to adult lung function and death from chronic obstructive airways disease. Br Med J. 1991, 303: 671-674.View ArticleGoogle Scholar
- Tager IB, Segal MR, Speizer FE, Weiss ST: The natural history of forced expiratory volumes. Effect of cigarette smoking and respiratory symptoms. Am Rev Respir Crit Care Med. 1988, 138: 837-849.Google Scholar
- Silverman EK, Speizer FE: Risk factors for the development of chronic obstructive pulmonary disease. Med Clinics N Am. 1996, 80: 501-522.View ArticleGoogle Scholar
- Sandford AJ, Weir TD, Paré PD: Genetic risk factors for chronic obstructive pulmonary disease. Eur Respir Dis. 1997, 10: 1380-1391. 10.1183/09031936.97.10061380.View ArticleGoogle Scholar
- Eriksson S: Studies in α1-antitrypsin deficiency. Acta Med Scand. 1965, Suppl 432: 1-85.Google Scholar
- Lomas DA, Evans DL, Finch JT, Carrell RW: The mechanism of Z α1-antitrypsin accumulation in the liver. Nature. 1992, 357: 605-607. 10.1038/357605a0.View ArticleGoogle Scholar
- Mahadeva R, Chang W-SW, Dafforn T, Oakley DJ, Foreman RC, Calvin J, Wight D, Lomas DA: Heteropolymerisation of S, I and Z α1-antitrypsin and liver cirrhosis. J Clin Invest. 1999, 103: 999-1006.View ArticleGoogle Scholar
- Larsson C: Natural history and life expectancy in severe alpha1-antitrypsin deficiency, PiZ. Acta Med Scand. 1978, 204: 345-351.View ArticleGoogle Scholar
- Piitulainen E, Eriksson S: Decline in FEV1 related to smoking status in individuals with severe alpha1-antitrypsin deficiency. Eur Respir J. 1999, 13: 247-251. 10.1183/09031936.99.13224799.View ArticleGoogle Scholar
- Silverman EK, Province MA, Campbell EJ, Pierce JA, Rao DC: Biochemical intermediates in α1-antitrypsin deficiency: residual family resemblance for total α1-antitrypsin, oxidised α1-antitrypsin, and immunoglobulin E after adjustment for the effect of the Pi locus. Genet Epidem. 1989, 7: 137-149.View ArticleGoogle Scholar
- Bruce RM, Cohen BH, Diamond EL, Fallet RJ, Knudson RJ, Lebowitz MD, Mittman C, Patterson CD, Tockman MS: Collaborative study to assess risk of lung disease in Pi MZ phenotype subjects. Am Rev Respir Dis. 1984, 130: 386-390.Google Scholar
- Lieberman J, Winter B, Sastre A: Alpha1-antitrypsin Pi-types in 965 COPD patients. Chest. 1986, 89: 370-373.View ArticleGoogle Scholar
- Janus ED: Alpha1-antitrypsin Pi types in COPD patients. Chest. 1988, 92: 446-447.View ArticleGoogle Scholar
- Tarján E, Magyar P, Váczi Z, Lantos Å, Vaszár L: Longitudinal lung function study in heterozygous PiMZ phenotype subjects. Eur Respir J. 1994, 7: 2199-2204. 10.1183/09031936.94.07122199.View ArticleGoogle Scholar
- Larson RK, Barman ML, Kueppers F, Fudenberg HH: Genetic and environmental determinants of chronic obstructive pulmonary disease. Ann Intern Med. 1970, 72: 627-632.View ArticleGoogle Scholar
- Kueppers F, Miller RD, Gordon H, Hepper NG, Offord K: Familial prevalence of chronic obstructive pulmonary disease in a matched pair study. Am J Med. 1977, 63: 336-342.View ArticleGoogle Scholar
- Rybicki BA, Beaty TH, Cohen BH: Major genetic mechanisms in pulmonary function. J Clin Epidemiol. 1990, 43: 667-675.View ArticleGoogle Scholar
- Silverman EK, Chapman HA, Drazen JM, Weiss ST, Rosner B, Campbell EJ, O'Donnell WJ, Reilly JJ, Ginns L, Mentzer S, Wain J, Speizer FE: Genetic epidemiology of severe, early-onset chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1998, 157: 1770-1778.View ArticleGoogle Scholar
- Silverman EK, Palmer LJ: Case–control association studies for the genetics of complex respiratory diseases. Am J Resp Cell Mol Biol. 2000, 22: 645-648.View ArticleGoogle Scholar
- Cohen BH: Chronic obstructive pulmonary disease: a challenge in genetic epidemiology. Am J Epidemiol. 1980, 112: 274-288.Google Scholar
- Kalsheker NA, Hodgson IJ, Watkins GL, White JP, Morrison HM, Stockley RA: Deoxyribonucleic acid (DNA) polymorphism of the α1-antitrypsin gene in chronic lung disease. Br Med J. 1987, 294: 1511-1514.View ArticleGoogle Scholar
- Poller W, Meisen C, Olek K: DNA polymorphisms of the α1-antitrypsin gene region in patients with chronic obstructive pulmonary disease. Eur J Clin Invest. 1990, 20: 1-7.Google Scholar
- Morgan K, Scobie G, Marsters P, Kalsheker NA: Mutation in an α1-antitrypsin enhancer results in an interleukin-6 deficient acute phase response due to loss of cooperativity between transcription factors. Biochim Biophys Acta. 1997, 1362: 67-76. 10.1016/S0925-4439(97)00064-1.View ArticleGoogle Scholar
- Sandford AJ, Spinelli JJ, Weir TD, Paré PD: Mutation in the 3' region of the α-1-antitrypsin gene and chronic obstructive pulmonary disease. J Med Genet. 1997, 34: 874-875.View ArticleGoogle Scholar
- Benetazzo MG, Gile LS, Bombieri C, Malerba G, Massobrio M, Pignatti PF, Luisetti M: α1-antitrypsin TAQ I polymorphism and α1-antichymotrypsin mutations in patients with obstructive pulmonary disease. Respir Med. 1999, 93: 648-654.View ArticleGoogle Scholar
- Green SL, Gaillard MC, Dewae B, Ludewick H, Song E, Feldman C: Differences in the prevalence of a Taq-1 RFLP in the 3' flanking region of the α1-proteinase inhibitor gene between asthmatic and non-asthmatic black and white South Africans. Clin Genet. 1997, 52: 162-166.View ArticleGoogle Scholar
- Mahadeva R, Westerbeek R, Perry DJ, Whitehouse D, Carroll N, Ross-Russell R, Webb K, Bilton D, Lomas DA: α1-antitrypsin deficiency alleles and the Taq-1 G→A allele in cystic fibrosis lung disease. Eur Resp J. 1998, 11: 873-879. 10.1183/09031936.98.11040873.View ArticleGoogle Scholar
- Sandford AJ, Chagani T, Spinelli J, Paré PD: α1-antitrypsin genotypes and the acute-phase response to open heart surgery. Am J Respir Crit Care Med. 1999, 159: 1624-1628.View ArticleGoogle Scholar
- Faber J-P, Poller W, Olek K, Baumann U, Carlson J, Lindmark B, Eriksson S: The molecular basis of α1-antichymotrypsin deficiency in a heterozygote with liver and lung disease. J Hepatology. 1993, 18: 313-321.View ArticleGoogle Scholar
- Poller W, Faber J-P, Weidinger S, Tief K, Scholz S, Fischer M, Olek K, Kirchgesser M, Heidtmann H-H: A leucine-to-proline substitution causes a defective α1-antichymotrypsin allele associated with familial obstructive lung disease. Genomics. 1993, 17: 740-743. 10.1006/geno.1993.1396.View ArticleGoogle Scholar
- Gooptu B, Hazes B, Chang W-SW, Dafforn TR, Carrell RW, Read R, Lomas DA: Inactive conformation of the serpin α1-antichymotrypsin indicates two stage insertion of the reactive loop; implications for inhibitory function and conformational disease. Proc Natl Acad Sci USA. 2000, 97: 67-72. 10.1073/pnas.97.1.67.View ArticleGoogle Scholar
- Sandford AJ, Chagani T, Weir TD, Paré PD: α1-antichymotrypsin mutations in patients with chronic obstructive pulmonary disease. Dis Markers. 1998, 13: 257-260.View ArticleGoogle Scholar
- Abe T, Kobayashi N, Yoshimura K, Trapnell BC, Kim H, Hubbard RC, Brewer MT, Thompson R, Crystal RG: Expression of the secretory leukoprotease inhibitor gene in epithelial cells. J Clin Invest. 1991, 87: 2207-2215.View ArticleGoogle Scholar
- Kuijpers ALA, Pfundt R, Zeeuwen PLJM, Molhuizen HOF, Mariman ECM, van de Kerkhof PCM, Schalkwijk J: SKALP/elafin gene polymorphisms are not associated with pustular forms of psoriasis. Clin Genet. 1998, 54: 96-101.View ArticleGoogle Scholar
- Wilson AG, Symons JA, McDowell TL, McDevitt HO, Duff GW: Effects of a polymorphism in the human tumor necrosis factor-α promoter on transcriptional activation. Proc Natl Acad Sci U S A. 1997, 94: 3195-3199. 10.1073/pnas.94.7.3195.View ArticleGoogle Scholar
- Huang S-L, Su C-H, Chang S-C: Tumor necrosis factor-α gene polymorphism in chronic bronchitis. Am J Respir Crit Care Med. 1997, 156: 1436-1439.View ArticleGoogle Scholar
- Patuzzo C, Gile LS, Zorzetto M, Trabetti E, Malerba G, Pignatti PF, Luisetti M: Tumor necrosis factor gene complex in COPD and disseminated bronchiectasis. Chest. 2000, 117: 1353-1358. 10.1378/chest.117.5.1353.View ArticleGoogle Scholar
- Higham MA, Pride NB, Alikhan A, Morrell NW: Tumour necrosis factor-α gene promoter polymorphism in chronic obstructive pulmonary disease. Eur Respir J. 2000, 15: 281-284. 10.1183/09031936.00.15228100.View ArticleGoogle Scholar
- Smith CAD, Harrison DJ: Association between polymorphism in gene for microsomal epoxide hydrolase and susceptibility to emphysema. Lancet. 1997, 350: 630-633. 10.1016/S0140-6736(96)08061-0.View ArticleGoogle Scholar
- Sandford AJ, Chagani T, Weir TD, Connett JE, Anthonisen NR, Paré PD: Association of genetic polymorphisms with rate of decline of lung function. Am J Respir Crit Care Med. 2000, 159: A800-Google Scholar
- Yim J-J, Park GY, Lee C-T, Kim YW, Han SK, Shim Y-S, Yoo C-G: Genetic susceptibility to chronic obstructive pulmonary disease in Koreans: combined analysis of polymorphic genotypes for microsomal epoxide hydrolase and glutathione S-transferase M1 and T1. Thorax. 2000, 55: 121-125. 10.1136/thorax.55.2.121.View ArticleGoogle Scholar
- Yamada N, Yamaya M, Okinaga S, Nakayama K, Sekizawa K, Shibahara S, Sasaki H: Microsatellite polymorphism in the heme oxygenase-1 gene promoter is associated with susceptibility to emphysema. Am J Hum Genet. 2000, 66: 187-195. 10.1086/302729.View ArticleGoogle Scholar
- Ishii T, Matsuse T, Teramoto S, Matsui H, Miyao M, Hosoi T, Takahashi H, Fukuchi Y, Ouchi Y: Glutathione S-transferase P1 (GSTP1) polymorphism in patients with chronic obstructive pulmonary disease. Thorax. 1999, 54: 693-696.View ArticleGoogle Scholar
- Cohen BH, Diamond EL, Graves CG, Kreiss P, Levy DA, Menkes HA, Permutt S, Quaskey S, Tockman MS: A common familial component in lung cancer and chronic obstructive pulmonary disease. Lancet. 1977, ii: 523-526. 10.1016/S0140-6736(77)90663-8.View ArticleGoogle Scholar
- Tockman MS, Anthonisen NR, Wright EC, Donithan MG: Airways obstruction and the risk for lung cancer. Ann Intern Med. 1987, 106: 512-518.View ArticleGoogle Scholar