Alpha 1-antitrypsin (alAT) deficiency resulting from homozygous inheritance of the Z-type alAT gene is associated with serum alAT levels of < 50 mg/dl and the development of emphysema in the third to fourth decades. Despite the overwhelming evidence that the emphysema of PiZZ individuals develops because of a "deficiency" of alAT and hence an insufficient antineutrophil elastase defense of the lung, epidemiologic evidence has shown that levels of alAT of only 80 mg/dl protect the lung from an increased risk of emphysema. With this background, we hypothesized that homozygous inheritance of the Z-type may confer an added risk beyond a simple deficiency of alAT by virtue of an inability of the Z-type alAT molecule to inhibit neutrophil elastase as effectively as the common Ml-type molecule. To evaluate this hypothesis, the functional status of alAT from PiZZ individuals (n = 10) was compared with that of alAT from PiMlMl individuals (a = 7) for its ability to inhibit neutrophil elastase (percent inhibition) as well as its association rate constant for neutrophil elastase (K association). Plasma alAT concentration, measured by radial immunodiffusion, was 34±1 mg/dl in PiZZ patients vs. 237±14 mg/dl for PiMlMl plasma, a sevenfold difference. When titrated against neutrophil elastase, the present inhibition of PiZZ plasma was significantly less than Pi MIMl plasma (ZZ 78±1% vs. MlMl 95±1%, P < 0.001) as was purified Z type alAT (ZZ, 63±2% vs. MlMl 86±2%, P < 0.001). Sodium dodecyl sulfate (SDS) gel comparisons of the complexes formed with Ml-type alAT and Z-type alAT with elastase demonstrated the Z alAT-elastase complexes were less stable than the Ml alAT-elastase complexes, thus releasing some of the enzyme to continue to function as a protease. Consistent with these observations, the K association of purified Z-type alAT for neutrophil elastase was lower than that of Ml-type alAT (ZZ 4.5±0i3 X 106 M-1s-' vs. MlMl 9.7±OA X 106 M-Is-1, P < 0.001), suggesting that for the population of alAT molecules, the active Z-type molecules take more than twice as long as the active Ml-type alAT to inhibit neutrophil elastase. Consequently, not only is there less alAT in PiZZ individuals, but the population of Z-type alAT molecules is less competent as an inhibitor of neutrophil elastase than Ml-type alAT molecules. This combination of defects suggests that PiZZ individuals have far less functional antielastase protection than suggested by the reduced concenAddress reprint requests to Dr. Crystal, Pulmonary Branch, Building