A precision medicine initiative for Alzheimer's disease: the road ahead to biomarker-guided integrative disease modeling

After intense scientific exploration and more than a decade of failed trials, Alzheimer’s disease (AD) remains a fatal global epidemic. A traditional research and drug development paradigm continues to target heterogeneous late-stage clinically phenotyped patients with single 'magic bullet' drugs. Here, we propose that it is time for a paradigm shift towards the implementation of precision medicine (PM) for enhanced risk screening, detection, treatment, and prevention of AD. The overarching structure of how PM for AD can be achieved will be provided through the convergence of breakthrough technological advances, including big data science, systems biology, genomic sequencing, blood-based biomarkers, integrated disease modeling and P4 medicine. It is hypothesized that deconstructing AD into multiple genetic and biological subsets existing within this heterogeneous target population will provide an effective PM strategy for treating individual patients with the specific agent(s) that are likely to work best based on the specific individual biological make-up. The Alzheimer’s Precision Medicine Initiative (APMI) is an international collaboration of leading interdisciplinary clinicians and scientists devoted towards the implementation of PM in Neurology, Psychiatry and Neuroscience. It is hypothesized that successful realization of PM in AD and other neurodegenerative diseases will result in breakthrough therapies, such as in oncology, with optimized safety profiles, better responder rates and treatment responses, particularly through biomarker-guided early preclinical disease-stage clinical trials

A Knowledge-based Integrative Modeling Approach for <em>In-Silico</em> Identification of Mechanistic Targets in Neurodegeneration with Focus on Alzheimer’s Disease

Dementia is the progressive decline in cognitive function due to damage or disease in the body beyond what might be expected from normal aging. Based on neuropathological and clinical criteria, dementia includes a spectrum of diseases, namely Alzheimer's dementia, Parkinson's dementia, Lewy Body disease, Alzheimer's dementia with Parkinson's, Pick's disease, Semantic dementia, and large and small vessel disease. It is thought that these disorders result from a combination of genetic and environmental risk factors. Despite accumulating knowledge that has been gained about pathophysiological and clinical characteristics of the disease, no coherent and integrative picture of molecular mechanisms underlying neurodegeneration in Alzheimer’s disease is available. Existing drugs only offer symptomatic relief to the patients and lack any efficient disease-modifying effects. The present research proposes a knowledge-based rationale towards integrative modeling of disease mechanism for identifying potential candidate targets and biomarkers in Alzheimer’s disease. Integrative disease modeling is an emerging knowledge-based paradigm in translational research that exploits the power of computational methods to collect, store, integrate, model and interpret accumulated disease information across different biological scales from molecules to phenotypes. It prepares the ground for transitioning from ‘descriptive’ to “mechanistic” representation of disease processes. The proposed approach was used to introduce an integrative framework, which integrates, on one hand, extracted knowledge from the literature using semantically supported text-mining technologies and, on the other hand, primary experimental data such as gene/protein expression or imaging readouts. The aim of such a hybrid integrative modeling approach was not only to provide a consolidated systems view on the disease mechanism as a whole but also to increase specificity and sensitivity of the mechanistic model by providing disease-specific context. This approach was successfully used for correlating clinical manifestations of the disease to their corresponding molecular events and led to the identification and modeling of three important mechanistic components underlying Alzheimer’s dementia, namely the CNS, the immune system and the endocrine components. These models were validated using a novel in-silico validation method, namely biomarker-guided pathway analysis and a pathway-based target identification approach was introduced, which resulted in the identification of the MAPK signaling pathway as a potential candidate target at the crossroad of the triad components underlying disease mechanism in Alzheimer’s dementia

Simulating the outcome of amyloid treatments in Alzheimer's Disease from multi-modal imaging and clinical data

International audienceIn this study we investigate a novel quantitative instrument for the development of intervention strategies for disease modifying drugs in Alzheimer's disease. Our framework is based on the modeling of the spatio-temporal dynamics governing the joint evolution of imaging and clinical biomarkers along the history of the disease, and allows the simulation of the effect of intervention time and drug dosage on the biomarkers' progression. When applied to multi-modal imaging and clinical data from the Alzheimer's Disease Neuroimaging Initiative our method enables to generate hypothetical scenarios of amyloid lowering interventions. The results quantify the crucial role of intervention time, and provide a theoretical justification for testing amyloid modifying drugs in the pre-clinical stage. Our experimental simulations are compatible with the outcomes observed in past clinical trials, and suggest that anti-amyloid treatments should be administered at least 7 years earlier than what is currently being done in order to obtain statistically powered improvement of clinical endpoints

QUANTITATIVE PROTEOMIC ANALYSES OF HUMAN PLASMA: APPLICATION OF MASS SPECTROMETRY FOR THE DISCOVERY OF CLINICAL DELIRIUM BIOMARKERS

The biomarker discovery pipeline is a multi-step endeavor to identify potential diagnostic or prognostic markers of a disease. Although the advent of modern mass spectrometers has revolutionized the initial discovery phase, a significant bottleneck still exists when validating discovered biomarkers. In this doctoral research, I demonstrate that the discovery, verification and validation of biomarkers can all be performed using mass spectrometry and apply the biomarker pipeline to the context of clinical delirium. First, a systematic review of recent literature provided a birds-eye view of untargeted, discovery proteomic attempts for biomarkers of delirium in the geriatric population. Here, a comprehensive search from five databases yielded 1172 publications, from which eight peer-reviewed studies met our defined inclusion criteria. Despite the paucity of published studies that applied systems- biology approaches for biomarker discovery on the subject, lessons learned and insights from this review was instrumental in the study designing and proteomics analyses of plasma sample in our cohort. We then performed a targeted study on four biomarkers for their potential mediation role in the occurrence of delirium after high-dose intra-operative oxygen treatment. Although S100B calcium binding protein (S100B), gamma enolase (ENO2), chitinase-3-like protein 1 (CHI3L1) and ubiquitin carboxyl-terminal hydrolase isozyme L1 (UCHL1) have well-documented associations with delirium, we did not find any such associations in our cohort. Of note, this study demonstrates that the use of targeted approaches for the purposes of biomarker discovery, rather than an untargeted, systems-biology approach, is unavoidably biased and may lead to misleading conclusions. Lastly, we applied lessons learned and comprehensively profiled the plasma samples of delirium cases and non-delirium cases, at both pre- and post-surgical timepoints. We found 16 biomarkers as signatures of cardiopulmonary bypass, and 11 as potential diagnostic candidates of delirium (AuROC = 93%). We validated the discovered biomarkers on the same mass spectrometry platform without the use of traditional affinity-based validation methods. Our discovery of novel biomarkers with no know association with delirium such as serum amyloid A1 (SAA1) and A2 (SAA2), pepsinogen A3 (PEPA3) and cathepsin B (CATB) shed new lights on possible neuronal pathomechanisms

Integrative Analysis to Investigate Complex Interaction in Alzheimer’s Disease

Alzheimer’s disease (AD) is a neurodegenerative disorder featuring progressive cognitive and functional deficits. Pathologically, AD is characterized by tau and amyloid β protein deposition in the brain. As the sixth leading cause of death in the U.S., the disease course usually last from 7 to 10 years on average before the consequential death. In 2019 there are estimated 5.8 million Americans living with AD affecting 16 million family members. At certain stage of the disease course, patients with inability of maintaining their daily functioning highly depend on caregivers, primarily family caregivers, that incur estimated 18.4 billion unpaid hours of cares, which is equivalent to 232 billion dollars. These huge economic burdens and inevitable emotional distress on the family and the society would also increase as the number of AD affected population could triple by 2050. Altered cellular composition is associated with AD progression and decline in cognition, such as neuronal loss and astrocytosis, which is a key feature in neurodegeneration but has often been overlooked in transcriptome research. To explore the cellular composition changes in AD, I developed a deconvolution pipeline for bulk RNA-Seq to account for cell type specific effects in brain tissues. I found that neuronal and astrocyte relative proportions differ between healthy and diseased brains and also among AD cases that carry specific genetic risk variants. Brain carriers of pathogenic mutations in APP, PSEN1, or PSEN2 presented lower neuron and higher astrocyte relative proportions compared to sporadic AD. Similarly, the APOE ε4 allele also showed decreased neuronal and increased astrocyte relative proportions compared to AD non-carriers. In contrast, carriers of variants in TREM2 risk showed a lower degree of neuronal loss compared to matched AD cases in multiple independent studies. These findings suggest that genetic risk factors associated with AD etiology have a specific effect on the cellular composition of AD brains. The digital deconvolution approach provides an enhanced understanding of the fundamental molecular mechanisms underlying neurodegeneration, enabling the analysis of large bulk RNA-sequencing studies for cell composition. It also suggests that correcting for the cellular structure when performing transcriptomic analysis will lead to novel insights of AD. With deconvolution methods to delineate cell population changes in disease condition, it would help interpret transcriptomics results and reveal transcriptional changes in a cell type specific manner. One application demonstrated in this dissertation work is to use cell type proportion as quantitative trait to identify genetic factors associated with cellular composition changes. I performed cell type QTL analysis and identified a common pathway associated with neuronal protection underlying aging brains in the presence or absence of neurodegenerative disease symptoms. A protective variant of TMEM106B, which was previously identified with a protective effect in FTD, was identified to be associated with neuronal proportion in aging brains, suggesting a common pathway underlying neuronal protection and cognitive reservation in elderly. This extended analysis yield from deconvolution results demonstrated one promising direction of using deconvolution followed by cell type QTL analysis in identifying new genes or pathways underlying neurodegenerative or aging brains. To understand the complexity of the brain under disease condition, network analysis as a large-scale system-level approach provides unbiased and data-driven view to identify gene-gene interactions altered by disease status. Using network analysis, I replicated and reconfirmed the co-expression pattern between MS4A gene cluster and TREM2 in sporadic AD, from which further evidence was inferred from Bayesian network analysis to show that MS4A4A might be a potential regulator of TREM2 that is validated by in-vitro experiments. In Autosomal Dominant AD (ADAD) cohort, disrupted and acquired genes were identified from PSEN1 mutation carriers. Among these genes, previously identified AD risk genes and pathways were revealed along with novel findings. These results demonstrated the great potential of applying network approach in identifying disease associated genes and the interactions among them. To conclude the dissertation work from methodological, empirical, and theoretical levels, deconvolution pipeline for bulk RNA-Seq, cell type QTL analysis, and network analysis approaches were applied to understand transcriptome changes underlying disease etiology. From which previous AD related findings were replicated that validated the methods, and novel genes and pathways were identified as potential new therapeutic targets. Based on prior knowledge and empirical evidence observed from this dissertation work, a model is proposed to explain how genetic factors are assembled as a highly interconnected interactome network to affect proteinopathy observed in neurodegenerative disorders, that cause cellular composition changes in the brain, which ultimately leads to cognitive and functional deficits observed in AD patients

Deep Multilayer Brain Proteomics Identifies Molecular Networks in Alzheimer\u27s Disease Progression

Alzheimer\u27s disease (AD) displays a long asymptomatic stage before dementia. We characterize AD stage-associated molecular networks by profiling 14,513 proteins and 34,173 phosphosites in the human brain with mass spectrometry, highlighting 173 protein changes in 17 pathways. The altered proteins are validated in two independent cohorts, showing partial RNA dependency. Comparisons of brain tissue and cerebrospinal fluid proteomes reveal biomarker candidates. Combining with 5xFAD mouse analysis, we determine 15 Aβ-correlated proteins (e.g., MDK, NTN1, SMOC1, SLIT2, and HTRA1). 5xFAD shows a proteomic signature similar to symptomatic AD but exhibits activation of autophagy and interferon response and lacks human-specific deleterious events, such as downregulation of neurotrophic factors and synaptic proteins. Multi-omics integration prioritizes AD-related molecules and pathways, including amyloid cascade, inflammation, complement, WNT signaling, TGF-β and BMP signaling, lipid metabolism, iron homeostasis, and membrane transport. Some Aβ-correlated proteins are colocalized with amyloid plaques. Thus, the multilayer omics approach identifies protein networks during AD progression

Unconventional markers of Alzheimer Disease

Although typically conceptualized as a cortical disease, recent neuropathological and neuroimaging investigations on Alzheimer Disease suggest that other brain structures play an important role in the pathogenesis and progression of this devastating condition. In this thesis, we explored novel markers of Alzheimer Disease beyond the classical cortical pathology measures of amyloid, tau, and neurodegeneration. We focused on the role of white matter abnormalities, assessed with magnetic resonance imaging but also with amyloid positron emission tomography, in predicting early pathologic changes and disease progression, as well as on the added value of cognition to amyloid, tau, and neurodegeneration biomarkers. Overall, we found that these unconventional markers provide useful information to detect the earliest pathological changes of the disease, providing a better understanding of the mechanisms that lead to amyloid deposition and cognitive decline

Discovering lesser known molecular players and mechanistic patterns in Alzheimer's disease using an integrative disease modelling approach

Convergence of exponentially advancing technologies is driving medical research with life changing discoveries. On the contrary, repeated failures of high-profile drugs to battle Alzheimer's disease (AD) has made it one of the least successful therapeutic area. This failure pattern has provoked researchers to grapple with their beliefs about Alzheimer's aetiology. Thus, growing realisation that Amyloid-β and tau are not 'the' but rather 'one of the' factors necessitates the reassessment of pre-existing data to add new perspectives. To enable a holistic view of the disease, integrative modelling approaches are emerging as a powerful technique. Combining data at different scales and modes could considerably increase the predictive power of the integrative model by filling biological knowledge gaps. However, the reliability of the derived hypotheses largely depends on the completeness, quality, consistency, and context-specificity of the data. Thus, there is a need for agile methods and approaches that efficiently interrogate and utilise existing public data. This thesis presents the development of novel approaches and methods that address intrinsic issues of data integration and analysis in AD research. It aims to prioritise lesser-known AD candidates using highly curated and precise knowledge derived from integrated data. Here much of the emphasis is put on quality, reliability, and context-specificity. This thesis work showcases the benefit of integrating well-curated and disease-specific heterogeneous data in a semantic web-based framework for mining actionable knowledge. Furthermore, it introduces to the challenges encountered while harvesting information from literature and transcriptomic resources. State-of-the-art text-mining methodology is developed to extract miRNAs and its regulatory role in diseases and genes from the biomedical literature. To enable meta-analysis of biologically related transcriptomic data, a highly-curated metadata database has been developed, which explicates annotations specific to human and animal models. Finally, to corroborate common mechanistic patterns — embedded with novel candidates — across large-scale AD transcriptomic data, a new approach to generate gene regulatory networks has been developed. The work presented here has demonstrated its capability in identifying testable mechanistic hypotheses containing previously unknown or emerging knowledge from public data in two major publicly funded projects for Alzheimer's, Parkinson's and Epilepsy diseases

Tau pathology in Alzheimer's disease and other dementias : translational approach from in vitro autoradiography to in vivo PET imaging

Tauopathies, including Alzheimer's disease (AD), corticobasal degeneration (CBD), and progressive supranuclear palsy (PSP), are complex neurodegenerative disorders characterized by the pathological accumulation of tau proteins in the brain. These often overlapping disorders, with intricate pathologies and growing prevalence, lack definitive treatments, highlighting the necessity for advanced research. Positron emission tomography (PET) imaging aids in the diagnosis and monitoring of diseases, by providing in vivo insights into pathological features. This thesis focused on deciphering the binding properties and brain regional distribution of PET tracers for accurate disease differentiation. Spanning four studies, we aimed to bridge in vitro and in vivo PET data to investigate tau pathology and its association with dementia-related markers such as reactive astrogliosis, peripheral inflammation, and dopaminergic dysfunction. The 2nd generation tau PET tracers, 3H-MK6240 and 3H-PI2620, demonstrated high affinity and specificity in AD post-mortem brain tissues, especially in early-onset AD, compared to controls. 3H-PI2620, 3H-MK6240, and 3HRO948 displayed similar binding patterns in AD tissue, with multiple binding sites and equivalent high affinities (Papers I and II). 3H-PI2620 showed specificity in CBD and PSP tissues, in contrast to 3H-MK6240. However, differentiating CBD from PSP brains with 3H-PI2620 remained challenging in multiple brain regions, potentially due to complex tracer-target interactions (Papers II and III). Reactive astrogliosis PET tracers 3H-Deprenyl and 3H-BU99008 bound primarily to stable distinct high-affinity binding sites in AD, CBD and PSP, but also to transient binding sites, differing by brain region and condition. This pattern implied that these tracers may interact with similar or diverse subtypes or populations of astrocytes, expressing varying ratios of transient sites, which may vary depending on the brain location and the disease (Paper III). Using 3H-FEPE2I, we delineated a reduction in dopamine transporter (DAT) levels within the putamen across CBD, PSP and Parkinson's Disease (PD) brains. Concomitantly, elevated 3H-Raclopride binding reflected higher dopamine D2 receptor (D2R) levels in PSP and PD. Nonetheless, our observations underscored the heterogeneity inherent to these neurodegenerative pathologies, emphasizing the criticality of individual variability in neuropathological manifestations (Paper III). Lastly, we investigated late middle-aged cognitively unimpaired Hispanic individuals, in dichotomous groups of in vivo amyloid-β (Aβ) PET (18F-Florbetaben) and plasma neurofilament light (NfL) biomarkers. Our findings suggest that elevated plasma inflammation and tau burden as measured by 18FMK6240, can be detected at early preclinical stages of AD, offering potential for early diagnosis (Paper IV). This thesis underscored the importance of PET imaging in advancing our understanding of tauopathies. The innovative use of multiple PET tracers provided crucial insights into their potential use in clinics to distinguish pathological features of AD, CBD and PSP. The findings emphasized the need for more studies applying a multifaceted approach to studying and managing these complex neurodegenerative disorders, combining advanced imaging techniques with a broad spectrum of biological markers