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Tarawneh R. YKL-40 as a New Plasma Biomarker for Dementia Risk: Are We There Yet? Neurology 2024; 102:e209145. [PMID: 38546014 DOI: 10.1212/wnl.0000000000209145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/16/2023] [Indexed: 05/09/2024] Open
Affiliation(s)
- Rawan Tarawneh
- From the Department of Neurology, University of New Mexico, Albuquerque
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Tarawneh R, Pankratz VS. The search for clarity regarding "clinically meaningful outcomes" in Alzheimer disease clinical trials: CLARITY-AD and Beyond. Alzheimers Res Ther 2024; 16:37. [PMID: 38365811 PMCID: PMC10870501 DOI: 10.1186/s13195-024-01412-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/06/2024] [Indexed: 02/18/2024]
Abstract
CLARITY-AD is an 18-month, double-blinded, placebo-controlled, phase 3 trial which examined the safety and efficacy of the anti-amyloid agent, lecanemab, in mild cognitive impairment and mild dementia due to Alzheimer disease (AD). Lecanemab effectively reduced mean brain amyloid burden and was associated with statistically significant favorable effects, reflected by moderately less decline in the primary and secondary clinical outcomes, at 18 months compared to placebo. However, there is controversy within the AD community regarding the clinical significance of these results and whether they translate into clinically meaningful and tangible benefits on cognition or daily functions.We here review the primary and secondary clinical outcomes of CLARITY-AD and present our interpretation of the potential clinical meaningfulness of the group-level differences in study outcomes in the context of the 18-month study duration. We propose that the validation of stage-appropriate group-level thresholds for clinical meaningfulness of AD trial outcomes in biologically confirmed cohorts will allow objective interpretation of trial results and guide clinical decision-making. Further, in accordance with FDA guidance which emphasizes patient-focused drug development, the contextualization of AD clinical trial outcomes can be facilitated by supplementary individual-level data analyses which measure the risk of disease progression or summarize intraindividual change, using prespecified thresholds of clinically meaningful change, in each of the study groups over the trial period. The concepts of "time-saved" and "time-based" slowing in disease progression can be used to communicate clinical outcomes associated with emerging disease-modifying AD therapies to various stakeholders. We also describe several factors that need to be considered when evaluating outcomes of emerging AD therapies, including disease stage, the neuropathologic complexity of AD, time-based effects of disease-modifying therapies, and the possible influence of individual factors on treatment response and/or risk for adverse events. The consideration of these factors in the design and reporting of future trials of emerging AD therapies will guide clinicians regarding their appropriateness for use in various patient populations.Finally, we emphasize that data from clinical cohorts with longer durations of treatment and follow-up, including extension studies and patient registries, is needed to evaluate the long-term safety and efficacy of lecanemab in early symptomatic AD.
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Affiliation(s)
- Rawan Tarawneh
- Department of Neurology and Center for Memory and Aging, University of New Mexico, Albuquerque, NM, USA.
| | - Vernon S Pankratz
- Department of Internal Medicine, Division of Epidemiology, Biostatistics, and Preventive Medicine, University of New Mexico, Albuquerque, NM, USA
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Mayer AR, Dodd AB, Robertson-Benta CR, Zotev V, Ryman SG, Meier TB, Campbell RA, Phillips JP, van der Horn HJ, Hogeveen J, Tarawneh R, Sapien RE. Multifaceted neural and vascular pathologies after pediatric mild traumatic brain injury. J Cereb Blood Flow Metab 2024; 44:118-130. [PMID: 37724718 PMCID: PMC10905640 DOI: 10.1177/0271678x231197188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/01/2023] [Accepted: 07/25/2023] [Indexed: 09/21/2023]
Abstract
Dynamic changes in neurodevelopment and cognitive functioning occur during adolescence, including a switch from reactive to more proactive forms of cognitive control, including response inhibition. Pediatric mild traumatic brain injury (pmTBI) affects these cognitions immediately post-injury, but the role of vascular versus neural injury in cognitive dysfunction remains debated. This study consecutively recruited 214 sub-acute pmTBI (8-18 years) and age/sex-matched healthy controls (HC; N = 186), with high retention rates (>80%) at four months post-injury. Multimodal imaging (functional MRI during response inhibition, cerebral blood flow and cerebrovascular reactivity) assessed for pathologies within the neurovascular unit. Patients exhibited increased errors of commission and hypoactivation of motor circuitry during processing of probes. Evidence of increased/delayed cerebrovascular reactivity within motor circuitry during hypercapnia was present along with normal perfusion. Neither age-at-injury nor post-concussive symptom load were strongly associated with imaging abnormalities. Collectively, mild cognitive impairments and clinical symptoms may continue up to four months post-injury. Prolonged dysfunction within the neurovascular unit was observed during proactive response inhibition, with preliminary evidence that neural and pure vascular trauma are statistically independent. These findings suggest pmTBI is characterized by multifaceted pathologies during the sub-acute injury stage that persist several months post-injury.
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Affiliation(s)
- Andrew R Mayer
- The Mind Research Network/LBERI, Albuquerque, NM, USA
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
- Department of Psychiatry & Behavioral Sciences, University of New Mexico, Albuquerque, NM, USA
| | - Andrew B Dodd
- The Mind Research Network/LBERI, Albuquerque, NM, USA
| | | | - Vadim Zotev
- The Mind Research Network/LBERI, Albuquerque, NM, USA
| | | | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Richard A Campbell
- Department of Psychiatry & Behavioral Sciences, University of New Mexico, Albuquerque, NM, USA
| | - John P Phillips
- The Mind Research Network/LBERI, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | | | - Jeremy Hogeveen
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
| | - Rawan Tarawneh
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Robert E Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, USA
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Ryman SG, Shaff N, Dodd A, Nitschke S, Wertz C, Julio K, Suarez Cedeno G, Deligtisch A, Erhardt E, Lin H, Vakhtin A, Poston KL, Tarawneh R, Pirio Richardson S, Mayer A. Reduced and Delayed Cerebrovascular Reactivity in Patients with Parkinson's Disease. Mov Disord 2023; 38:1262-1272. [PMID: 37157056 PMCID: PMC10524339 DOI: 10.1002/mds.29429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/17/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Cerebrovascular dysfunction in Parkinson's disease (PD) is heterogeneous and may contribute to disease pathophysiology or progression. There is a need to understand the mechanisms by which cerebrovascular dysfunction is altered in participants with PD. OBJECTIVES The objective of this study is to test the hypothesis that participants with PD exhibit a significant reduction in the ability of the cerebral vessels to dilate in response to vasoactive challenges relative to healthy controls (HC). METHODS The current study uses a vasodilatory challenge while participants undergo functional magnetic resonance imaging to quantify the amplitude and delay of cerebrovascular reactivity in participants with PD relative to age and sex-matched HC. An analysis of covariance was used to evaluate differences in cerebrovascular reactivity amplitude and latency between PD participants and HC. RESULTS A significant main effect of group was observed for whole-brain cerebrovascular reactivity amplitude (F(1, 28) = 4.38, p = 0.046, Hedge's g = 0.73) and latency (F(1, 28) = 16.35, p < 0.001, Hedge's g = 1.42). Participants with PD exhibited reduced whole-brain amplitude and increased latencies in cerebrovascular reactivity relative to HC. The evaluation of regional effects indicates that the largest effects were observed in the cuneus, precuneus, and parietal regions. CONCLUSIONS PD participants exhibited reduced and delayed cerebrovascular reactivity. This dysfunction may play an important role in chronic hypoxia, neuroinflammation, and protein aggregation, mechanisms that could lead to disease progression. Cerebrovascular reactivity may serve as an important biomarker and target for future interventions. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Sephira G Ryman
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Nicholas Shaff
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Andrew Dodd
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Stephanie Nitschke
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Christopher Wertz
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Kayla Julio
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Gerson Suarez Cedeno
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Amanda Deligtisch
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Erik Erhardt
- Department of Mathematics and Statistics, University of New Mexico, Albuquerque, New Mexico, USA
| | - Henry Lin
- Department of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
- Neurology|Medicine, New Mexico VA Health Care System, Albuquerque, New Mexico, USA
| | - Andrei Vakhtin
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
| | - Kathleen L Poston
- Movement Disorders Division in the Department of Neurology and Neurological Sciences, Stanford University, Stanford, California, USA
| | - Rawan Tarawneh
- Memory and Aging Center, Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Sarah Pirio Richardson
- Nene and Jamie Koch Comprehensive Movement Disorder Center, Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
- Neurology|Medicine, New Mexico VA Health Care System, Albuquerque, New Mexico, USA
| | - Andrew Mayer
- Department of Translational Neuroscience, The Mind Research Network, Albuquerque, New Mexico, USA
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Tarawneh R. Microvascular Contributions to Alzheimer Disease Pathogenesis: Is Alzheimer Disease Primarily an Endotheliopathy? Biomolecules 2023; 13:830. [PMID: 37238700 PMCID: PMC10216678 DOI: 10.3390/biom13050830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/07/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
Alzheimer disease (AD) models are based on the notion that abnormal protein aggregation is the primary event in AD, which begins a decade or longer prior to symptom onset, and culminates in neurodegeneration; however, emerging evidence from animal and clinical studies suggests that reduced blood flow due to capillary loss and endothelial dysfunction are early and primary events in AD pathogenesis, which may precede amyloid and tau aggregation, and contribute to neuronal and synaptic injury via direct and indirect mechanisms. Recent data from clinical studies suggests that endothelial dysfunction is closely associated with cognitive outcomes in AD and that therapeutic strategies which promote endothelial repair in early AD may offer a potential opportunity to prevent or slow disease progression. This review examines evidence from clinical, imaging, neuropathological, and animal studies supporting vascular contributions to the onset and progression of AD pathology. Together, these observations support the notion that the onset of AD may be primarily influenced by vascular, rather than neurodegenerative, mechanisms and emphasize the importance of further investigations into the vascular hypothesis of AD.
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Affiliation(s)
- Rawan Tarawneh
- Department of Neurology, Center for Memory and Aging, University of New Mexico, Albuquerque, NM 87106, USA
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Tarawneh R, Kasper RS, Sanford J, Phuah C, Hassenstab J, Cruchaga C. Vascular endothelial-cadherin as a marker of endothelial injury in preclinical Alzheimer disease. Ann Clin Transl Neurol 2022; 9:1926-1940. [PMID: 36342663 PMCID: PMC9735377 DOI: 10.1002/acn3.51685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/02/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE Endothelial dysfunction is an early and prevalent pathology in Alzheimer disease (AD). We here investigate the value of vascular endothelial-cadherin (VEC) as a cerebrospinal fluid (CSF) marker of endothelial injury in preclinical AD. METHODS Cognitively normal participants (Clinical Dementia Rating [CDR] 0) from the Knight Washington University-ADRC were included in this study (n = 700). Preclinical Alzheimer's Cognitive Composite (PACC) scores, CSF VEC, tau, p-tau181, Aβ42/Aβ40, neurofilament light-chain (NFL) levels, and magnetic resonance imaging (MRI) assessments of white matter injury (WMI) were obtained from all participants. A subset of participants underwent brain amyloid imaging using positron emission tomography (amyloid-PET) (n = 534). Linear regression examined associations of CSF VEC with PACC and individual cognitive scores in preclinical AD. Mediation analyses examined whether CSF VEC mediated effects of CSF amyloid and tau markers on cognition in preclinical AD. RESULTS CSF VEC levels significantly correlated with PACC and individual cognitive scores in participants with amyloid (A+T±N±; n = 558) or those with amyloid and tau pathologies (A+T+N±; n = 259), after adjusting for covariates. CSF VEC also correlated with CSF measures of amyloid, tau, and neurodegeneration and global amyloid burden on amyloid-PET scans in our cohort. Importantly, our findings suggest that CSF VEC mediates associations of CSF Aβ42/Aβ40, p-tau181, and global amyloid burden with cognitive outcomes in preclinical AD. INTERPRETATION Our results support the utility of CSF VEC as a marker of endothelial injury in AD and highlight the importance of endothelial injury as an early pathology that contributes to cognitive impairment in even the earliest preclinical stages.
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Affiliation(s)
- Rawan Tarawneh
- Department of NeurologyUniversity of New MexicoAlbuquerqueNew MexicoUSA,Center for Memory and AgingUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Rachel S. Kasper
- Department of NeurologyUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Jessie Sanford
- Department of PsychiatryWashington University in St LouisSt. LouisMissouriUSA,NeuroGenomics and Informatics CenterWashington University in St LouisMissouriUSA
| | - Chia‐Ling Phuah
- NeuroGenomics and Informatics CenterWashington University in St LouisMissouriUSA,Department of NeurologyWashington University in St LouisSt. LouisMissouriUSA
| | - Jason Hassenstab
- Department of PsychologyWashington University in St LouisSt. LouisMissouriUSA
| | - Carlos Cruchaga
- Department of PsychiatryWashington University in St LouisSt. LouisMissouriUSA,NeuroGenomics and Informatics CenterWashington University in St LouisMissouriUSA
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Hershey L, Tarawneh R. Women Need to Be Advised About the Risks of Long-term Hormone Replacement Therapy. Neurology 2022; 99:733-734. [PMID: 36240090 DOI: 10.1212/wnl.0000000000201337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Linda Hershey
- From the University of Oklahoma Health Sciences Center (L.H.); and Department of Neurology (R.T.), Center for Memory and Aging, University of New Mexico, Albuquerque, NM.
| | - Rawan Tarawneh
- From the University of Oklahoma Health Sciences Center (L.H.); and Department of Neurology (R.T.), Center for Memory and Aging, University of New Mexico, Albuquerque, NM
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Tarawneh R, Penhos E. The gut microbiome and Alzheimer's disease: Complex and bidirectional interactions. Neurosci Biobehav Rev 2022; 141:104814. [PMID: 35934087 PMCID: PMC9637435 DOI: 10.1016/j.neubiorev.2022.104814] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 07/16/2022] [Accepted: 08/01/2022] [Indexed: 11/20/2022]
Abstract
Structural and functional alterations to the gut microbiome, referred to as gut dysbiosis, have emerged as potential key mediators of neurodegeneration and Alzheimer disease (AD) pathogenesis through the "gut -brain" axis. Emerging data from animal and clinical studies support an important role for gut dysbiosis in mediating neuroinflammation, central and peripheral immune dysregulation, abnormal brain protein aggregation, and impaired intestinal and brain barrier permeability, leading to neuronal loss and cognitive impairment. Gut dysbiosis has also been shown to directly influence various mechanisms involved in neuronal growth and repair, synaptic plasticity, and memory and learning functions. Aging and lifestyle factors including diet, exercise, sleep, and stress influence AD risk through gut dysbiosis. Furthermore, AD is associated with characteristic gut microbial signatures which offer value as potential markers of disease severity and progression. Together, these findings suggest the presence of a complex bidirectional relationship between AD and the gut microbiome and highlight the utility of gut modulation strategies as potential preventative or therapeutic strategies in AD. We here review the current literature regarding the role of the gut-brain axis in AD pathogenesis and its potential role as a future therapeutic target in AD treatment and/or prevention.
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Affiliation(s)
- Rawan Tarawneh
- Department of Neurology, Center for Memory and Aging, Alzheimer Disease Research Center, The University of New Mexico, Albuquerque, NM 87106, USA.
| | - Elena Penhos
- College of Medicine, The Ohio State University, Columbus, OH, USA 43210
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Merino JG, Ciccarelli O, Worrall BB, Amato AA, Burch R, Clardy SL, Hedera P, Hershey LA, Jobst BC, Shellhaas RA, Silbermann E, Strowd RE, Tarawneh R. Message From the Editors to Our Reviewers. Neurology 2022. [DOI: 10.1212/wnl.0000000000013044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Affiliation(s)
- Linda A Hershey
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, OK and
| | - Rawan Tarawneh
- Department of Neurology, The Ohio State University, Columbus, OH
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Abstract
Over the last decade, biomarkers have significantly improved our understanding of
the pathophysiology of Alzheimer disease (AD) and provided valuable tools to
examine different disease mechanisms and their progression over time. While
several markers of amyloid, tau, neuronal, synaptic, and axonal injury,
inflammation, and immune dysregulation in AD have been identified, there is a
relative paucity of biomarkers which reflect other disease mechanisms such as
oxidative stress, mitochondrial injury, vascular or endothelial injury, and
calcium-mediated excitotoxicity. Importantly, there is an urgent need to
standardize methods for biomarker assessments across different centers, and to
identify dynamic biomarkers which can monitor disease progression over time
and/or response to potential disease-modifying treatments. The updated research
framework for AD, proposed by the National Institute of Aging- Alzheimer’s
Association (NIA-AA) Work Group, emphasizes the importance of incorporating
biomarkers in AD research and defines AD as a biological construct consisting of
amyloid, tau, and neurodegeneration which spans pre-symptomatic and symptomatic
stages. As results of clinical trials of AD therapeutics have been
disappointing, it has become increasingly clear that the success of future AD
trials will require the incorporation of biomarkers in participant selection,
prognostication, monitoring disease progression, and assessing response to
treatments. We here review the current state of fluid AD biomarkers, and discuss
the advantages and limitations of the updated NIA-AA research framework.
Importantly, the integration of biomarker data with clinical, cognitive, and
imaging domains through a systems biology approach will be essential to
adequately capture the molecular, genetic, and pathological heterogeneity of AD
and its spatiotemporal evolution over time.
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Affiliation(s)
- Rawan Tarawneh
- Department of Neurology, The Ohio State University, Columbus, OH, USA
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Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, Matsumoto M, Mustafa RA, Pai M, Rock G, Russell L, Tarawneh R, Valdes J, Peyvandi F. Good practice statements (GPS) for the clinical care of patients with thrombotic thrombocytopenic purpura. J Thromb Haemost 2020; 18:2503-2512. [PMID: 32914535 PMCID: PMC7880820 DOI: 10.1111/jth.15009] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Despite advances in treatment options for thrombotic thrombocytopenic purpura (TTP), there are still limited high quality data to inform clinicians regarding its management. METHODS In June 2018, the ISTH formed a multidisciplinary guideline panel to issue recommendations about treatment of TTP. The panel discussed 12 treatment questions related to both immune-mediated TTP (iTTP) and hereditary/congenital TTP (cTTP). The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including evidence-to-decision frameworks, to appraise evidence and formulate recommendations. RESULTS The panel agreed on eleven recommendations based on evidence ranging from very low to moderate certainty. For first episode and relapses of acute iTTP, the panel made a strong recommendation for the addition of corticosteroids to therapeutic plasma exchange (TPE), and a conditional recommendation for addition of rituximab and caplacizumab. For asymptomatic iTTP with low ADAMTS13, the panel made a conditional recommendation for rituximab outside of pregnancy, and for prophylactic TPE during pregnancy. For asymptomatic cTTP, the panel made a strong recommendation for prophylactic plasma infusion during pregnancy, but a conditional recommendation for plasma infusion or a wait and watch approach outside of pregnancy. CONCLUSIONS The panel's recommendations are based on all the available evidence for the treatment effects of various approaches including suppressing inflammation, blocking platelet clumping, replacing the missing and/or inhibited ADAMTS13, and suppressing ADAMTS13 antibody production. There was insufficient evidence for further comparison of different treatment approaches, for which future high-quality studies in iTTP (e.g., rituximab, corticosteroids, recombinant ADAMTS13, and caplacizumab) and in cTTP (eg, recombinant ADAMTS13) are needed.
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Affiliation(s)
- X. Long Zheng
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sara K. Vesely
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Service d’Hématologie, Hôpital Saint-Antoine, Sorbonne Université, Assistance Publique, Hôpitaux de Paris, Paris, France
| | | | - Alfonso Iorio
- Department of Health Research Methods, Research, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Reem A. Mustafa
- Department of Medicine, The University of Kansas Mediccal Center, Kansas City, KS, USA
| | - Menaka Pai
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gail Rock
- University of Ottawa, Ottawa, ON, Canada
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rawan Tarawneh
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, Matsumoto M, Mustafa RA, Pai M, Rock G, Russell L, Tarawneh R, Valdes J, Peyvandi F. ISTH guidelines for treatment of thrombotic thrombocytopenic purpura. J Thromb Haemost 2020; 18:2496-2502. [PMID: 32914526 PMCID: PMC8091490 DOI: 10.1111/jth.15010] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Despite advances in treatment options for thrombotic thrombocytopenic purpura (TTP), there are still limited high quality data to inform clinicians regarding its appropriate treatment. METHODS In June 2018, the ISTH formed a multidisciplinary guideline panel to issue recommendations about treatment of TTP. The panel discussed 12 treatment questions related to immune-mediated TTP (iTTP) and hereditary or congenital TTP (cTTP). The panel used the Grading of Recommendations Assessment, Development, and Evaluation approach, including evidence-to-decision frameworks, to appraise evidence and formulate recommendations. RESULTS The panel agreed on 11 recommendations based on evidence ranging from very low to moderate certainty. For first acute episode and relapses of iTTP, the panel made a strong recommendation for adding corticosteroids to therapeutic plasma exchange (TPE) and a conditional recommendation for adding rituximab and caplacizumab. For asymptomatic iTTP with low plasma ADAMTS13 activity, the panel made a conditional recommendation for the use of rituximab outside of pregnancy, but prophylactic TPE during pregnancy. For asymptomatic cTTP, the panel made a strong recommendation for prophylactic plasma infusion during pregnancy, and a conditional recommendation for plasma infusion or a wait and watch approach outside of pregnancy. CONCLUSIONS The panel's recommendations are based on all the available evidence for the effects of an individual component of various treatment approaches, including suppressing inflammation, blocking platelet clumping, replacing the missing and/or inhibited ADAMTS13, and suppressing the formation of ADAMTS13 autoantibody. There was insufficient evidence for further comparing different treatment approaches (eg, TPE, corticosteroids, rituximab, and caplacizumab, etc.), for which high quality studies are needed.
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Affiliation(s)
- X. Long Zheng
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sara K. Vesely
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Service d’Hématologie, Hôpital Saint-Antoine, Sorbonne Université, Assistance Publique, Hôpitaux de Paris, Paris, France
| | | | - Alfonso Iorio
- Department of Health Research Methods, Research, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Reem A. Mustafa
- Department of Medicine, University of Kansas Mediccal Center, Kansas City, KS, USA
| | - Menaka Pai
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gail Rock
- University of Ottawa, Ottawa, ON, Canada
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rawan Tarawneh
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, Matsumoto M, Mustafa RA, Pai M, Rock G, Russell L, Tarawneh R, Valdes J, Peyvandi F. ISTH guidelines for the diagnosis of thrombotic thrombocytopenic purpura. J Thromb Haemost 2020; 18:2486-2495. [PMID: 32914582 PMCID: PMC8146131 DOI: 10.1111/jth.15006] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Despite an increase in our understandings of pathogenesis of thrombotic thrombocytopenic purpura (TTP), the approaches for initial diagnosis and management of TTP vary significantly. OBJECTIVE The evidence-based guidelines of the International Society on Thrombosis and Haemostasis (ISTH) are intended to support patients, clinicians, and other health care professionals in their decisions about the initial diagnosis and management of acute TTP. METHODS In June 2018, ISTH formed a multidisciplinary panel that included hematologists, an intensive care physician, nephrologist, clinical pathologist, biostatistician, and patient representatives, as well as a methodology team from McMaster University. The panel composition was designed to minimize the potential conflicts of interests. The panel used the Grading of Recommendations Assessment, Development, and Evaluation approach and the Population, Intervention, Comparison, Outcome framework to develop and grade their recommendations. Public comments were sought and incorporated in the final document. RESULTS The panel agreed on three recommendations covering the initial diagnosis with emphasis on the importance of ADAMTS13 testing (eg, activity, anti-ADAMTS13 IgG or inhibitor) and assessment of the pretest probability of TTP by clinical assessment and/or the risk assessment models like the PLASMIC or French score. The panel noted how availability and turnaround time of ADAMTS13 test results might affect early diagnosis and management, in particular the use of caplacizumab. CONCLUSIONS There is a lack of high-quality evidence to support strong recommendations for the initial diagnosis and management of a suspected TTP. The panel emphasized the importance of obtaining ADAMTS13 testing in a proper clinical context. Future research should focus on how to monitor and act on ADAMTS13 levels during remission.
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Affiliation(s)
- X. Long Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Sara K. Vesely
- Hudson College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Spero R. Cataland
- Department of Medicine, The Ohio State University, Columbus, OH, USA
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Service d’Hématologie, Hôpital Saint-Antoine, Assistance Publique, Hôpitaux de Paris, Sorbonne Université, Paris, France
| | | | - Alfonso Iorio
- Department of Health Research Methods, Research, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Reem A. Mustafa
- Department of Medicine, The University of Kansas Mediccal Center, Kansas City, KS, USA
| | - Menaka Pai
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gail Rock
- University of Ottawa, Ottawa, CA, USA
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rawan Tarawneh
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Flora Peyvandi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Tarawneh R. Cerebrospinal Fluid Markers of Synaptic Injury and Functional Connectivity in Alzheimer Disease: Protocol for a Cross-Sectional Study. JMIR Res Protoc 2019; 8:e14302. [PMID: 31271547 PMCID: PMC6668296 DOI: 10.2196/14302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 06/23/2019] [Accepted: 06/27/2019] [Indexed: 12/30/2022] Open
Abstract
Background Synaptic loss is the best surrogate for cognitive decline in Alzheimer disease (AD) and is more closely associated with cognitive function than amyloid or tau pathologies. Neurogranin (Ng) and synaptosome–associated protein-25 (SNAP-25) have demonstrated utility as cerebrospinal fluid (CSF) markers of synaptic injury in presymptomatic and symptomatic AD. While these synaptic markers have been shown to correlate with cognitive impairment and whole brain or regional atrophy in previous studies of AD, to our knowledge, the relationship between fluid markers of synaptic injury and functional brain imaging has not been previously investigated. Objective The main objective of this study is to examine the relationship between CSF markers of synaptic injury (Ng and SNAP-25) and functional connectivity (FC) in the default mode and semantic memory networks in individuals with mild cognitive impairment (MCI) and mild dementia due to AD (Clinical Dementia Rating [CDR] 0.5-1) and cognitively normal controls (CDR 0), adjusting for age, gender, and the apolipoprotein E4 (APOE4) genotype. Secondary objectives include investigating the associations between CSF markers of amyloid and tau pathology (CSF tau, p-tau181, and Aβ42) and FC in the default mode and semantic memory networks in AD (CDR 0.5-1) and controls (CDR 0), adjusting for age, gender, and the APOE4 genotype. Methods This is a cross-sectional study of individuals with MCI or mild dementia due to AD (CDR 0.5-1; n=20), and cognitively normal controls (CDR 0; n=20). Participants will undergo detailed clinical and neuropsychological assessments, CSF biomarker assessments (CSF Ng, SNAP-25, tau, p-tau181, and Aβ42 levels) and functional magnetic resonance imaging assessments, using a Siemens 3.0 Tesla Prisma scanner, during resting state and during the performance of a semantic memory task. All study procedures will be completed within 4 months of enrollment. Partial correlation analyses will examine associations of CSF biomarker measures with FC in the default mode and semantic memory networks in AD and controls. Results This study was funded by the Chronic Brain Injury Discovery Themes of the Ohio State University College of Medicine. Study enrollment began in April 2018. Study procedures and data analysis are currently underway. Results are expected by December 2019. Conclusions Findings from this study will further support the utility of CSF Ng and SNAP-25 as markers of synaptic injury by examining their associations with functional alterations in cortical networks affected by early AD pathology. International Registered Report Identifier (IRRID) DERR1-10.2196/14302
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Affiliation(s)
- Rawan Tarawneh
- Department of Neurology, College of Medicine, The Ohio State University, Columbus, OH, United States
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Tarawneh R, Schnell P. P4-214: CSF BIOMARKERS OF NEURONAL AND SYNAPTIC INJURY CORRELATE WITH AMYLOID LOAD IN COGNITIVELY NORMAL INDIVIDUALS. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.06.3877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tarawneh R, D'Angelo G, Crimmins D, Herries E, Griest T, Fagan AM, Zipfel GJ, Ladenson JH, Morris JC, Holtzman DM. Diagnostic and Prognostic Utility of the Synaptic Marker Neurogranin in Alzheimer Disease. JAMA Neurol 2017; 73:561-71. [PMID: 27018940 DOI: 10.1001/jamaneurol.2016.0086] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Synaptic loss is an early pathologic substrate of Alzheimer disease (AD). Neurogranin is a postsynaptic neuronal protein that has demonstrated utility as a cerebrospinal fluid (CSF) marker of synaptic loss in AD. OBJECTIVE To investigate the diagnostic and prognostic utility of CSF neurogranin levels in a large, well-characterized cohort of individuals with symptomatic AD and cognitively normal controls. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional and longitudinal observational study of cognitive decline in patients with symptomatic AD and cognitively normal controls was performed. Participants were individuals with a clinical diagnosis of early symptomatic AD and cognitively normal controls who were enrolled in longitudinal studies of aging and dementia at the Charles F. and Joanne Knight Alzheimer Disease Research Center, Washington University School of Medicine, from January 21, 2000, through March 21, 2011. Data analysis was performed from November 1, 2013, to March 31, 2015. MAIN OUTCOMES AND MEASURES Correlations between baseline CSF biomarker levels and future cognitive decline in patients with symptomatic AD and cognitively normal controls over time. RESULTS A total of 302 individuals (mean [SE] age, 73.1 [0.4] years) were included in this study (95 patients [52 women and 43 men] with AD and 207 controls [125 women and 82 men]). The CSF neurogranin levels differentiated patients with early symptomatic AD from controls with comparable diagnostic utility (mean [SE] area under the receiver operating characteristic curve, 0.71 [0.03]; 95% CI, 0.64-0.77) to the other CSF biomarkers. The CSF neurogranin levels correlated with brain atrophy (normalized whole-brain volumes: adjusted r = -0.38, P = .02; hippocampal volumes: adjusted r = -0.36, P = .03; entorhinal volumes: adjusted r = -0.46, P = .006; and parahippocampal volumes: adjusted r = -0.47, P = .005, n = 38) in AD and with amyloid load (r = 0.39, P = .02, n = 36) in preclinical AD. The CSF neurogranin levels predicted future cognitive impairment (adjusted hazard ratio, 1.89; 95% CI, 1.29-2.78; P = .001 as a continuous measure, and adjusted hazard ratio, 2.78; 95% CI, 1.13-5.99; P = .02 as a categorical measure using the 85th percentile cutoff value) in controls and rates of cognitive decline (Clinical Dementia Rating sum of boxes score: β estimate, 0.29; P = .001; global composite scores: β estimate, -0.11; P = .001; episodic memory scores: β estimate, -0.18; P < .001; and semantic memory scores: β estimate, -0.06; P = .04, n = 57) in patients with symptomatic AD over time, similarly to the CSF proteins VILIP-1, tau, and p-tau181. CONCLUSIONS AND RELEVANCE The CSF levels of the synaptic marker neurogranin offer diagnostic and prognostic utility for early symptomatic AD that is comparable to other CSF markers of AD. Importantly, CSF neurogranin complements the collective ability of these markers to predict future cognitive decline in cognitively normal individuals and, therefore, will be a useful addition to the current panel of AD biomarkers.
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Affiliation(s)
- Rawan Tarawneh
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri2Hope Center for Neurological Disorders, Washington University School of Medicine, St Louis, Missouri3Charles F. and Joanne Knight Alzheimer Disease Research Center, Wash
| | - Gina D'Angelo
- Charles F. and Joanne Knight Alzheimer Disease Research Center, Washington University School of Medicine, St Louis, Missouri5Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri
| | - Dan Crimmins
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
| | - Elizabeth Herries
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
| | - Terry Griest
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
| | - Anne M Fagan
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri2Hope Center for Neurological Disorders, Washington University School of Medicine, St Louis, Missouri3Charles F. and Joanne Knight Alzheimer Disease Research Center, Wash
| | - Gregory J Zipfel
- Hope Center for Neurological Disorders, Washington University School of Medicine, St Louis, Missouri7Department of Neurosurgery, Washington University School of Medicine, St Louis, Missouri
| | - Jack H Ladenson
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
| | - John C Morris
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri2Hope Center for Neurological Disorders, Washington University School of Medicine, St Louis, Missouri3Charles F. and Joanne Knight Alzheimer Disease Research Center, Wash
| | - David M Holtzman
- Department of Neurology, Washington University School of Medicine, St Louis, Missouri2Hope Center for Neurological Disorders, Washington University School of Medicine, St Louis, Missouri3Charles F. and Joanne Knight Alzheimer Disease Research Center, Wash
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Deming Y, Black K, Carrell D, Cai Y, Del-Aguila JL, Fernandez MV, Budde J, Ma S, Saef B, Howells B, Bertelsen S, Huang KL, Sutphen CL, Tarawneh R, Fagan AM, Holtzman DM, Morris JC, Goate AM, Dougherty JD, Cruchaga C. Chitinase-3-like 1 protein (CHI3L1) locus influences cerebrospinal fluid levels of YKL-40. BMC Neurol 2016; 16:217. [PMID: 27832767 PMCID: PMC5105244 DOI: 10.1186/s12883-016-0742-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 11/03/2016] [Indexed: 11/27/2022] Open
Abstract
Background Alzheimer’s disease (AD) pathology appears several years before clinical symptoms, so identifying ways to detect individuals in the preclinical stage is imperative. The cerebrospinal fluid (CSF) Tau/Aβ42 ratio is currently the best known predictor of AD status and cognitive decline, and the ratio of CSF levels of chitinase-3-like 1 protein (CHI3L1, YKL-40) and amyloid beta (Aβ42) were reported as predictive, but individual variability and group overlap inhibits their utility for individual diagnosis making it necessary to find ways to improve sensitivity of these biomarkers. Methods We used linear regression to identify genetic loci associated with CSF YKL-40 levels in 379 individuals (80 cognitively impaired and 299 cognitively normal) from the Charles F and Joanne Knight Alzheimer’s Disease Research Center. We tested correlations between YKL-40 and CSF Tau/Aβ42 ratio, Aβ42, tau, and phosphorylated tau (ptau181). We used studentized residuals from a linear regression model of the log-transformed, standardized protein levels and the additive reference allele counts from the most significant locus to adjust YKL-40 values and tested the differences in correlations with CSF Tau/Aβ42 ratio, Aβ42, tau, and ptau181. Results We found that genetic variants on the CH13L1 locus were significantly associated with CSF YKL-40 levels, but not AD risk, age at onset, or disease progression. The most significant variant is a reported expression quantitative trait locus for CHI3L1, the gene which encodes YKL-40, and explained 12.74 % of the variance in CSF YKL-40 in our study. YKL-40 was positively correlated with ptau181 (r = 0.521) and the strength of the correlation significantly increased with the addition of genetic information (r = 0.573, p = 0.006). Conclusions CSF YKL-40 levels are likely a biomarker for AD, but we found no evidence that they are an AD endophenotype. YKL-40 levels are highly regulated by genetic variation, and by including genetic information the strength of the correlation between YKL-40 and ptau181 levels is significantly improved. Our results suggest that studies of potential biomarkers may benefit from including genetic information. Electronic supplementary material The online version of this article (doi:10.1186/s12883-016-0742-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuetiva Deming
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave. B8134, St. Louis, MO, 63110, USA
| | - Kathleen Black
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave. B8134, St. Louis, MO, 63110, USA
| | - David Carrell
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave. B8134, St. Louis, MO, 63110, USA
| | - Yefei Cai
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave. B8134, St. Louis, MO, 63110, USA
| | - Jorge L Del-Aguila
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave. B8134, St. Louis, MO, 63110, USA
| | - Maria Victoria Fernandez
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave. B8134, St. Louis, MO, 63110, USA
| | - John Budde
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave. B8134, St. Louis, MO, 63110, USA
| | - ShengMei Ma
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave. B8134, St. Louis, MO, 63110, USA
| | - Benjamin Saef
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave. B8134, St. Louis, MO, 63110, USA
| | - Bill Howells
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave. B8134, St. Louis, MO, 63110, USA
| | - Sarah Bertelsen
- Ronald M. Loeb Center for Alzheimer's disease, Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kuan-Lin Huang
- Department of Genetics, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
| | - Courtney L Sutphen
- Department of Neurology, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
| | - Rawan Tarawneh
- Department of Neurology, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA.,Knight Alzheimer's Disease Research Center, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, 660 S. Euclid Ave. B8111, St. Louis, MO, 63110, USA
| | - Anne M Fagan
- Department of Neurology, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA.,Knight Alzheimer's Disease Research Center, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, 660 S. Euclid Ave. B8111, St. Louis, MO, 63110, USA
| | - David M Holtzman
- Department of Neurology, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA.,Knight Alzheimer's Disease Research Center, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, 660 S. Euclid Ave. B8111, St. Louis, MO, 63110, USA.,Department of Developmental Biology, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
| | - John C Morris
- Department of Neurology, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA.,Knight Alzheimer's Disease Research Center, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA.,Hope Center for Neurological Disorders, Washington University School of Medicine, 660 S. Euclid Ave. B8111, St. Louis, MO, 63110, USA.,Department of Developmental Biology, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
| | - Alison M Goate
- Ronald M. Loeb Center for Alzheimer's disease, Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joseph D Dougherty
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave. B8134, St. Louis, MO, 63110, USA.,Department of Genetics, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, 63110, USA
| | - Carlos Cruchaga
- Department of Psychiatry, Washington University School of Medicine, 660 S. Euclid Ave. B8134, St. Louis, MO, 63110, USA. .,Hope Center for Neurological Disorders, Washington University School of Medicine, 660 S. Euclid Ave. B8111, St. Louis, MO, 63110, USA.
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Tarawneh R, Head D, Allison S, Buckles V, Fagan AM, Ladenson JH, Morris JC, Holtzman DM. Cerebrospinal Fluid Markers of Neurodegeneration and Rates of Brain Atrophy in Early Alzheimer Disease. JAMA Neurol 2015; 72:656-65. [PMID: 25867677 DOI: 10.1001/jamaneurol.2015.0202] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE Measures of neuronal loss are likely good surrogates for clinical and radiological disease progression in Alzheimer disease (AD). Cerebrospinal fluid (CSF) markers of neuronal injury or neurodegeneration may offer usefulness in predicting disease progression and guiding outcome assessments and prognostic decisions in clinical trials of disease-modifying therapies. Visinin-like protein 1 (VILIP-1) has demonstrated potential usefulness as a marker of neuronal injury in AD. OBJECTIVE To investigate the usefulness of CSF VILIP-1, tau, p-tau181, and Aβ42 levels in predicting rates of whole-brain and regional atrophy in early AD and cognitively normal control subjects over time. DESIGN, SETTING, AND PARTICIPANTS Longitudinal observational study of brain atrophy in participants with early AD and cognitively normal controls. Study participants had baseline CSF biomarker measurements and longitudinal magnetic resonance imaging assessments for a mean follow-up period of 2 to 3 years. Mixed linear models assessed the ability of standardized baseline CSF biomarker measures to predict rates of whole-brain and regional atrophy over the follow-up period. The setting was The Charles F. and Joanne Knight Alzheimer's Disease Research Center, Washington University School of Medicine in St Louis. Participants (mean age, 72.6 years) were individuals with a clinical diagnosis of very mild AD (n = 23) and cognitively normal controls (n = 64) who were enrolled in longitudinal studies of healthy aging and dementia. The study dates were 2000 to 2010. MAIN OUTCOMES AND MEASURES Correlations between baseline CSF biomarker measures and rates of whole-brain or regional atrophy in the AD and control cohorts over the follow-up period. RESULTS Baseline CSF VILIP-1, tau, and p-tau181 levels (but not Aβ42 levels) predicted rates of whole-brain and regional atrophy in AD over the follow-up period. Baseline CSF VILIP-1 levels predicted whole-brain (P = .006), hippocampal (P = .01), and entorhinal (P = .001) atrophy rates at least as well as tau and p-tau181 in early AD. Cognitively normal controls whose CSF VILIP-1, tau, or p-tau181 levels were in the upper tercile had higher rates of whole-brain (P = .02, P = .003, and P = .02, respectively), hippocampal (P = .001, P = .01, and P = .02, respectively), and entorhinal (P = .007, P = .01, and P = .01, respectively) atrophy compared with those whose levels were in the lower 2 terciles. CONCLUSIONS AND RELEVANCE Cerebrospinal fluid VILIP-1 levels predict rates of whole-brain and regional atrophy similarly to tau and p-tau181 and may provide a useful CSF biomarker surrogate for neurodegeneration in early symptomatic and preclinical AD.
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Affiliation(s)
- Rawan Tarawneh
- Department of Neurology, Washington University School of Medicine in St Louis, St Louis, Missouri2Hope Center for Neurological Disorders, Washington University School of Medicine in St Louis, St Louis, Missouri3The Charles F. and Joanne Knight Alzheimer's
| | - Denise Head
- The Charles F. and Joanne Knight Alzheimer's Disease Research Center, Washington University School of Medicine in St Louis, St Louis, Missouri5Department of Radiology, Washington University School of Medicine in St Louis, St Louis, Missouri6Department of
| | - Samantha Allison
- Department of Psychology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Virginia Buckles
- Department of Neurology, Washington University School of Medicine in St Louis, St Louis, Missouri3The Charles F. and Joanne Knight Alzheimer's Disease Research Center, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Anne M Fagan
- Department of Neurology, Washington University School of Medicine in St Louis, St Louis, Missouri2Hope Center for Neurological Disorders, Washington University School of Medicine in St Louis, St Louis, Missouri3The Charles F. and Joanne Knight Alzheimer's
| | - Jack H Ladenson
- Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - John C Morris
- Department of Neurology, Washington University School of Medicine in St Louis, St Louis, Missouri3The Charles F. and Joanne Knight Alzheimer's Disease Research Center, Washington University School of Medicine in St Louis, St Louis, Missouri7Department of
| | - David M Holtzman
- Department of Neurology, Washington University School of Medicine in St Louis, St Louis, Missouri2Hope Center for Neurological Disorders, Washington University School of Medicine in St Louis, St Louis, Missouri3The Charles F. and Joanne Knight Alzheimer's
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Abstract
Alzheimer disease (AD) is the most common cause of dementia in the elderly. Clinicopathological studies support the presence of a long preclinical phase of the disease, with the initial deposition of AD pathology estimated to begin approximately 10-15 years prior to the onset of clinical symptoms. The hallmark clinical phenotype of AD is a gradual and progressive decline in two or more cognitive domains, most commonly involving episodic memory and executive functions, that is sufficient to cause social or occupational impairment. Current diagnostic criteria can accurately identify AD in the majority of cases. As disease-modifying therapies are being developed, there is growing interest in the identification of individuals in the earliest symptomatic, as well as presymptomatic, stages of disease, because it is in this population that such therapies may have the greatest chance of success. The use of informant-based methods to establish cognitive and functional decline of an individual from previously attained levels of performance best allows for the identification of individuals in the very mildest stages of cognitive impairment.
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Affiliation(s)
- Rawan Tarawneh
- Department of Neurology, Washington University School of Medicine, St. Louis, St. Louis,Missouri, USA; Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis,St. Louis, Missouri, USA; The Knight Alzheimer’s Disease Research Center, Washington University School of Medicine,St. Louis, St. Louis, Missouri, USA
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Macy EM, Crimmins DL, McQuillan JJ, Griest TA, Brada NA, Tarawneh R, Lee JM, Ladenson JH. Reversal of EDTA Interference in the Measurement of Visinin-Like Protein 1. Clin Chem 2012:clinchem.2011.181768. [PMID: 22490377 DOI: 10.1373/clinchem.2011.181768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Elizabeth M Macy
- Departments of Pathology and ImmunologyDivision of Laboratory and GenomicMedicine, and
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Abstract
OBJECTIVE Measures of neuronal damage/dysfunction are likely good surrogates for disease progression in Alzheimer disease (AD). CSF markers of neuronal injury may offer utility in predicting disease progression and guiding prognostic and outcome assessments in therapeutic trials. Visinin-like protein-1 (VILIP-1) has demonstrated potential utility as a marker of neuronal injury. We here investigate the utility of VILIP-1 and VILIP-1/Aβ42 in predicting rates of cognitive decline in early AD. METHODS Individuals with a clinical diagnosis of very mild or mild AD (n = 60) and baseline CSF measures of VILIP-1, tau, p-tau181, and Aβ42 were followed longitudinally for an average of 2.6 years. Annual assessments included the Clinical Dementia Rating (CDR), CDR-sum of boxes (CDR-SB), and global composite scores. Mixed linear models assessed the ability of CSF biomarker measures to predict rates of cognitive decline over time. RESULTS Baseline CSF VILIP-1 and VILIP-1/Aβ42 levels predicted rates of future decline in CDR-SB and global composite scores over the follow-up period. Individuals with CSF VILIP-1 ≥560 pg/mL (corresponding to the upper tercile) progressed much more rapidly in CDR-SB (1.61 boxes/year; p = 0.0077) and global scores (-0.53 points/year; p = 0.0002) than individuals with lower values (0.85 boxes/year and -0.15 points/year, respectively) over the follow-up period. CSF tau, p-tau181, tau/Aβ42, and p-tau181/Aβ42 also predicted more rapid cognitive decline in CDR-SB and global scores over time. CONCLUSION These findings suggest that CSF VILIP-1 and VILIP-1/Aβ42 predict rates of global cognitive decline similarly to tau and tau/Aβ42, and may be useful CSF surrogates for neurodegeneration in early AD.
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Affiliation(s)
- R Tarawneh
- Department of Neurology, Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
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Tarawneh R, D'Angelo G, Macy E, Xiong C, Carter D, Cairns NJ, Fagan AM, Head D, Mintun MA, Ladenson JH, Lee JM, Morris JC, Holtzman DM. Visinin-like protein-1: diagnostic and prognostic biomarker in Alzheimer disease. Ann Neurol 2011; 70:274-85. [PMID: 21823155 DOI: 10.1002/ana.22448] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE There is a growing need to identify cerebrospinal fluid (CSF) markers that can detect Alzheimer's disease (AD) pathology in cognitively normal individuals because it is in this population that disease-modifying therapies may have the greatest chance of success. While AD pathology is estimated to begin ~10-15 years prior to the onset of cognitive decline, substantial neuronal loss is present by the time the earliest signs of cognitive impairment appear. Visinin-like protein-1 (VILIP-1) has demonstrated potential utility as a marker of neuronal injury. Here we investigate CSF VILIP-1 and VILIP-1/amyloid-β42 (Aβ42) ratio as diagnostic and prognostic markers in early AD. METHODS We assessed CSF levels of VILIP-1, tau, phosphorylated-tau181 (p-tau181), and Aβ42 in cognitively normal controls (CNC) (n = 211), individuals with early symptomatic AD (n = 98), and individuals with other dementias (n = 19). Structural magnetic resonance imaging (n = 192) and amyloid imaging with Pittsburgh Compound-B (n = 156) were obtained in subsets of this cohort. Among the CNC cohort, 164 individuals had follow-up annual cognitive assessments for 2-3 years. RESULTS CSF VILIP-1 levels differentiated individuals with AD from CNC and individuals with other dementias. CSF VILIP-1 levels correlated with CSF tau, p-tau181, and brain volumes in AD. VILIP-1 and VILIP-1/Aβ42 predicted future cognitive impairment in CNC over the follow-up period. Importantly, CSF VILIP-1/Aβ42 predicted future cognitive impairment at least as well as tau/Aβ42 and p-tau181/Aβ42. INTERPRETATION These findings suggest that CSF VILIP-1 and VILIP-1/Aβ42 offer diagnostic utility for early AD, and can predict future cognitive impairment in cognitively normal individuals similarly to tau and tau/Aβ42, respectively.
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Affiliation(s)
- Rawan Tarawneh
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
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Tarawneh R, Ohlendorf MF, Macy EM, McQuillan J, Head D, Cairns NJ, Fagan AM, Mintun MA, Ladenson JH, Lee JM, Morris JC, Holtzman DM. P4‐060: The Novel Neuronal Injury Marker, Visinin‐like Protein‐1 (VILIP‐1), as a Diagnostic and Prognostic Marker in Alzheimer's Disease. Alzheimers Dement 2010. [DOI: 10.1016/j.jalz.2010.08.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Rawan Tarawneh
- Washington University School of MedicineSaint Louis MO USA
| | | | | | - Jay McQuillan
- Washington University School of MedicineSaint Louis MO USA
| | - Denise Head
- Washington University School of MedicineSaint Louis MO USA
| | | | - Anne M. Fagan
- Washington University School of MedicineSaint Louis MO USA
| | - Mark A. Mintun
- Washington University School of MedicineSaint Louis MO USA
| | | | - Jin-Moo Lee
- Washington University School of MedicineSaint Louis MO USA
| | - John C. Morris
- Washington University School of MedicineSaint Louis MO USA
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Tarawneh R, Holtzman DM. Biomarkers in translational research of Alzheimer's disease. Neuropharmacology 2010; 59:310-22. [PMID: 20394760 DOI: 10.1016/j.neuropharm.2010.04.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2009] [Revised: 03/14/2010] [Accepted: 04/07/2010] [Indexed: 10/19/2022]
Abstract
The identification and characterization of amyloid-beta (Abeta) and tau as the main pathological substrates of Alzheimer's disease (AD) have driven many efforts in search for suitable biomarkers for AD. In the last decade, research in this area has focused on developing a better understanding of the principles that govern protein deposition, mechanisms that link aggregation to toxicity and neuronal death, and a better understanding of protein dynamics in brain tissue, interstitial fluid and CSF. While Abeta and tau represent the two key pathological mediators of disease, other aspects of this multifaceted disease (e.g. oxidative stress, calcium-mediated toxicity, and neuroinflammation) are being unraveled, with the hope to develop a more comprehensive approach in exploring disease mechanisms. This has not only expanded possible areas for disease-modifying therapies, but has also allowed the introduction of novel, and potentially useful, fluid and radiological markers for the presence and progression of AD pathology. There is no doubt that the identification of several fluid and imaging biomarkers that can reliably detect the early stages of AD will have great implications in the design of clinical trials, in the selection of homogenous research populations, and in the assessment of disease outcomes. Markers with good diagnostic specificity will aid researchers in differentiating individuals with preclinical and probable AD from individuals who do not have AD pathology or have other dementing disorders. Markers that change with disease progression may offer utility in assessing the rates of disease progression and the efficacy of potential therapeutic agents on AD pathology. For both of these purposes, CSF Abeta42, amyloid imaging, and CSF tau appear to be very good markers of the presence of AD pathology as well as predictive of who will progress from MCI to AD. Volumetric MRI is also good at separating individuals with MCI and AD from controls and is predictive of who will progress from MCI to AD. Perhaps the most important role biomarkers will have, and the most needed at this time, lies in the identification of individuals who are cognitively normal, and yet have evidence of AD pathology (i.e. preclinical AD). Such individuals, it appears, can be identified with CSF Abeta42, amyloid imaging, and CSF tau. Such individuals are the most likely to benefit from future disease modifying/prevention therapies as they become available, and therefore represent the population in which the field can make the biggest therapeutic impact.
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Affiliation(s)
- Rawan Tarawneh
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Abstract
The cellular mechanisms underlying neuronal loss and neurodegeneration have been an area of interest in the last decade. Although neurodegenerative diseases such as Alzheimer disease, Parkinson disease, and Huntington disease each have distinct clinical symptoms and pathologies, they all share common mechanisms such as protein aggregation, oxidative injury, inflammation, apoptosis, and mitochondrial injury that contribute to neuronal loss. Although cerebrovascular disease has different causes from the neurodegenerative disorders, many of the same common disease mechanisms come into play following a stroke. Novel therapies that target each of these mechanisms may be effective in decreasing the risk of disease, abating symptoms, or slowing down their progression. Although most of these therapies are experimental, and require further investigation, a few seem to offer promise.
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Affiliation(s)
- Rawan Tarawneh
- Alzheimer Disease Research Center, Washington University School of Medicine, St Louis, MO, 63108
- Department of Neurology, Washington University School of Medicine, St Louis, MO, 63108
| | - James E. Galvin
- Alzheimer Disease Research Center, Washington University School of Medicine, St Louis, MO, 63108
- Department of Neurobiology, Washington University School of Medicine, St Louis, MO, 63108
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Tarawneh R, Holtzman DM. Critical issues for successful immunotherapy in Alzheimer's disease: development of biomarkers and methods for early detection and intervention. CNS Neurol Disord Drug Targets 2009; 8:144-59. [PMID: 19355934 DOI: 10.2174/187152709787847324] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Over the last 10 years, promising data has emerged from both animal and human studies that both active immunization with amyloid-beta (Abeta) as well as passive immunization with anti-Abeta antibodies offer promise as therapies for Alzheimer's disease (AD). Data from animal models suggests that antibodies to Abeta through several mechanisms can decrease Abeta deposition, decrease Abeta -associated damage such as dystrophic neurite formation, and improve behavioral performance. Data from human studies suggests that active immunization can result in plaque clearance and that passive immunotherapy might result in slowing of cognitive decline. Despite this, a recent analysis from a phase I trial that involved active immunization with Abeta42, while not powered to determine efficacy, suggested no large effect of active immunization despite the fact that plaque clearance was very prominent in some subjects. An important issue to consider is when active or passive immunization targeting Abeta has the chance to be most effective. Clinico-pathological and biomarker studies have shown that in terms of the time course of AD, Abeta deposition probably begins about 10-15 years prior to symptom onset (preclinical AD) and that tau aggregation in tangles and in neurites does not begin to accelerate and build up in larger amounts in the neocortex until just prior to symptom onset. By the time the earliest clinical signs of AD emerge, Abeta deposition may be close to reaching its peak and tangle formation and neuronal cell loss is substantial though still not at its maximal extent. Since immunization targeting Abeta does not appear to have major effects on tangle pathology, for immunization to have the most chance for success, performing clinical trials in individuals who are cognitively only very mildly impaired or even in those with preclinical AD would likely offer a much better chance for success. Current work with AD biomarkers suggests that such individuals can now be identified and it seems likely that targeting this population with immunization strategies targeting Abeta would offer the best chance of success.
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Affiliation(s)
- Rawan Tarawneh
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
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Abstract
Lewy body dementia (LBD) is the second most common dementia after Alzheimer's disease (AD). LBD is characterized clinically by visual hallucinations, extrapyramidal symptoms, cognitive fluctuations and neuroleptic sensitivity. LBD and AD share many common features in pathology, genetics and biochemical alterations; however, correct clinical distinction between these disorders has prognostic and therapeutic implications. There are currently no definitive radiological or biological markers for LBD, but studies suggest that premorbid differences in cognitive domains and personality traits, differences in clinical presentation, and alterations in autonomic function and sleep may improve diagnosis. Cholinergic dysfunction plays a major role in both AD and LBD; however, dysfunction is greater in LBD. This may account for the more prominent hallucinations, and offers the possibility of a greater response to cholinesterase inhibitors in LBD. The treatment of LBD is symptomatic and is based on a limited number of clinical trials and extension of results from trials in AD. Current research is focused on the role of synuclein aggregation with possible roles for synuclein-derived peptides as aggregation inhibitors. Other approaches target amyloid, neuroinflammation, oxidative injury, proteolysis, lipid peroxidation and immunotherapies with variable results. Improved understanding of disease mechanisms may open new therapeutic avenues for LBD in the future.
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Affiliation(s)
- Rawan Tarawneh
- Department of Neurology, Washington University School of Medicine, St Louis, MO 63108, USA.
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