Pavel Strnad

Summary Background Alpha‐1 antitrypsin liver disease (AATLD) occurs in a subset of patients with alpha‐1 antitrypsin deficiency. Risk factors for disease progression and specific pathophysiologic features are not well known and validated non‐invasive assessments for disease severity are lacking. Currently, there are no approved treatments for AATLD. Aims To outline existing understanding of AATLD and to identify knowledge gaps critical to improving clinical trial design and development of new treatments. Methods This report was developed following a multi‐stakeholder forum organised by the Alpha‐1 Antitrypsin Deficiency Related Liver Disease Expert Panel in which experts presented an overview of the available literature on this topic. Results AATLD results from a ‘gain of toxic function’ and primarily manifests in those with the homozygous Pi*ZZ genotype. Accumulation of misfolded ‘Z’ AAT protein in liver cells triggers intracellular hepatocyte injury which may ultimately lead to hepatic fibrosis. Male gender, age over 50 years, persistently elevated liver tests, concomitant hepatitis B or C virus infection, and metabolic syndrome, including obesity and type 2 diabetes mellitus, are known risk factors for adult AATLD. While the gold standard for assessing AATLD disease activity is liver histology, less invasive measures with low intra‐ and inter‐observer variability are needed. Measurement of liver stiffness shows promise; validated thresholds for staging AATLD are in development. Such advances will help patients by enabling risk stratification and personalised surveillance, along with streamlining the development process for novel therapies. Conclusions This inaugural forum generated a list of recommendations to address unmet needs in the field of AATLD.