Amyotrophic Lateral Sclerosis Progression Research Articles

CO202 Effect of an Oral, Fixed-Dose Combination of Sodium Phenylbutyrate and Taurursodiol on Long-Term Tracheostomy/Ventilation-Free Survival and Hospitalization in Amyotrophic Lateral Sclerosis: Final Results from Centaur

Assisted ventilation and hospitalization are significant drivers of aggregate annual costs and overall health burden in amyotrophic lateral sclerosis (ALS). An oral, fixed-dose combination of sodium phenylbutyrate and taurursodiol (PB&TURSO) slowed functional decline in people living with ALS in the 6-month randomized, placebo-controlled phase of the CENTAUR trial. Here, we report final analyses of ALS progression events in CENTAUR inclusive of the long-term, follow-up open-label extension phase.

Seeding the aggregation of TDP-43 requires post-fibrillization proteolytic cleavage

Despite the strong evidence linking the transactive response DNA-binding protein 43 (TDP-43) aggregation to the pathogenesis of frontotemporal lobar degeneration with TDP-43, amyotrophic lateral sclerosis and several neurodegenerative diseases, our knowledge of the sequence and structural determinants of its aggregation and neurotoxicity remains incomplete. Herein, we present a new method for producing recombinant full-length TDP-43 filaments that exhibit sequence and morphological features similar to those of brain-derived TDP-43 filaments. We show that TDP-43 filaments contain a β-sheet-rich helical amyloid core that is fully buried by the flanking structured domains of the protein. We demonstrate that the proteolytic cleavage of TDP-43 filaments and exposure of this amyloid core are necessary for propagating TDP-43 pathology and enhancing the seeding of brain-derived TDP-43 aggregates. Only TDP-43 filaments with exposed amyloid core efficiently seeded the aggregation of endogenous TDP-43 in cells. These findings suggest that inhibiting the enzymes mediating cleavage of TDP-43 aggregates represents a viable disease-modifying strategy to slow the progression of amyotrophic lateral sclerosis and other TDP-43 proteinopathies.

Live Cell Imaging of ATP Levels Reveals Metabolic Compartmentalization within Motoneurons and Early Metabolic Changes in FUS ALS Motoneurons.

Motoneurons are one of the most energy-demanding cell types and a primary target in Amyotrophic lateral sclerosis (ALS), a debilitating and lethal neurodegenerative disorder without currently available effective treatments. Disruption of mitochondrial ultrastructure, transport, and metabolism is a commonly reported phenotype in ALS models and can critically affect survival and the proper function of motor neurons. However, how changes in metabolic rates contribute to ALS progression is not fully understood yet. Here, we utilize hiPCS-derived motoneuron cultures and live imaging quantitative techniques to evaluate metabolic rates in fused in sarcoma (FUS)-ALS model cells. We show that differentiation and maturation of motoneurons are accompanied by an overall upregulation of mitochondrial components and a significant increase in metabolic rates that correspond to their high energy-demanding state. Detailed compartment-specific live measurements using a fluorescent ATP sensor and FLIM imaging show significantly lower levels of ATP in the somas of cells carrying FUS-ALS mutations. These changes lead to the increased vulnerability of diseased motoneurons to further metabolic challenges with mitochondrial inhibitors and could be due to the disruption of mitochondrial inner membrane integrity and an increase in its proton leakage. Furthermore, our measurements demonstrate heterogeneity between axonal and somatic compartments, with lower relative levels of ATP in axons. Our observations strongly support the hypothesis that mutated FUS impacts the metabolic states of motoneurons and makes them more susceptible to further neurodegenerative mechanisms.

Role of NCKAP1 in the Defective Phagocytic Function of Microglia-Like Cells Derived from Rapidly Progressing Sporadic ALS

Microglia plays a key role in determining the progression of amyotrophic lateral sclerosis (ALS), yet their precise role in ALS has not been identified in humans. This study aimed to identify a key factor related to the functional characteristics of microglia in rapidly progressing sporadic ALS patients using the induced microglia model, although it is not identical to brain resident microglia. After confirming that microglia-like cells (iMGs) induced by human monocytes could recapitulate the main signatures of brain microglia, step-by-step comparative studies were conducted to delineate functional differences using iMGs from patients with slowly progressive ALS [ALS(S), n = 14] versus rapidly progressive ALS [ALS(R), n = 15]. Despite an absence of significant differences in the expression of microglial homeostatic genes, ALS(R)-iMGs preferentially showed defective phagocytosis and an exaggerated pro-inflammatory response to LPS stimuli compared to ALS(S)-iMGs. Transcriptome analysis revealed that the perturbed phagocytosis seen in ALS(R)-iMGs was closely associated with decreased NCKAP1 (NCK-associated protein 1)-mediated abnormal actin polymerization. NCKAP1 overexpression was sufficient to rescue impaired phagocytosis in ALS(R)-iMGs. Post-hoc analysis indicated that decreased NCKAP1 expression in iMGs was correlated with the progression of ALS. Our data suggest that microglial NCKAP1 may be an alternative therapeutic target in rapidly progressive sporadic ALS.

Boosting Mitochondrial Potential: An Imperative Therapeutic Intervention in Amyotrophic Lateral Sclerosis.

Amyotrophic Lateral Sclerosis (ALS) is a progressive and terminal neurodegenerative disorder. Mitochondrial dysfunction, imbalance of cellular bioenergetics, electron chain transportation and calcium homeostasis are deeply associated with the progression of this disease. Impaired mitochondrial functions are crucial in rapid neurodegeneration. The mitochondria of ALS patients are associated with deregulated Ca2+ homeostasis and elevated levels of reactive oxygen species (ROS), leading to oxidative stress. Overload of mitochondrial calcium and ROS production leads to glutamatereceptor mediated neurotoxicity. This implies mitochondria are an attractive therapeutic target. The aim of this review is to brief the latest developments in the understanding of mitochondrial pathogenesis in ALS and emphasize the restorative capacity of therapeutic candidates. In ALS, mitochondrial dysfunction is a well-known phenomenon. Various therapies targeted towards mitochondrial dysfunction aim at decreasing ROS generation, increasing mitochondrial biogenesis, and inhibiting apoptotic pathways. Some of the therapies briefed in this review may be categorized as synthetic, natural compounds, genetic materials, and cellular therapies. The overarching goals of mitochondrial therapies in ALS are to benefit ALS patients by slowing down the disease progression and prolonging overall survival. Despite various therapeutic approaches, there are many hurdles in the development of a successful therapy due to the multifaceted nature of mitochondrial dysfunction and ALS progression. Intensive research is required to precisely elucidate the molecular pathways involved in the progression of mitochondrial dysfunctions that ultimately lead to ALS. Because of the multifactorial nature of ALS, a combination therapy approach may hold the key to cure and treat ALS in the future.

Non-Invasive Mechanical Ventilation slows motor decline in Amyotrophic Lateral Sclerosis: a population-based study (P10-8.003)

<h3>Objective:</h3> To test whether Non-Invasive Mechanical Ventilation (NIMV) use improved the rate of motor decline among ALS patients. <h3>Background:</h3> The efficacy of NIMV in improving Amyotrophic Lateral Sclerosis (ALS) survival and quality of life is well established. However, data regarding its effect on disease progression are still lacking. <h3>Design/Methods:</h3> This population-based cohort study included 630 patients with ALS from the Piemonte and Valle d’Aosta Register for ALS (PARALS) who were followed up after NIV initiation. Motor function was evaluated with the ALS Functional Rating Score – Revised (ALSFRS-R). Mixed-effect models for longitudinal data were performed to assess change in the rate of functional decline after NIMV initiation. <h3>Results:</h3> NIMV was associated with a ~30% reduction in the ΔALSFRS-R (post-NIMV difference in ΔALSFRS-R −0.46, 97.5% CI −0.43 to −0.49, p&lt;0.0001). The NIMV-related slowing was present on bulbar symptoms (post-NIMV difference in ΔALSFRS-R −0.08, 97.5% CI −0.065 to −0.010, p &lt; 0.0001) and even greater on spinal function (post-NIMV difference in ΔALSFRS-R −0.42, 97.5% CI −0.39 to −0.46, p &lt; 0.0001). All patients benefitted from NIMV usage, regardless of age, site of symptoms onset and presence of cognitive impairment. <h3>Conclusions:</h3> We demonstrate that NIMV significantly improves the rate of disease progression in ALS, regardless of age at symptoms onset, disease duration, presence of bulbar dysfunction or cognitive impairment. Our results reinforce the importance of not delaying NIMV initiation. In addition, NIMV-induced slowing of disease progression should also be accounted for when evaluating clinical trial outcomes. Further studies are required to optimize the effectiveness of respiratory care on disease progression in ALS. <b>Disclosure:</b> Mr. Grassano has nothing to disclose. Dr. Koumantakis has nothing to disclose. Cristina Moglia has nothing to disclose. Antonio Canosa has nothing to disclose. Dr. Manera has nothing to disclose. Dr. Vasta has nothing to disclose. Francesca Palumbo has nothing to disclose. Mr. Callegaro has nothing to disclose. Dr. Marchese has nothing to disclose. Paolina Salamone has nothing to disclose. Dr. Fuda has nothing to disclose. Federico Casale has nothing to disclose. Dr. Calvo has nothing to disclose. Dr. Mora has nothing to disclose. Dr. Chio has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Cytokinetics. Dr. Chio has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Mitsubishi. Dr. Chio has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Biogen.

Weight Loss and Disease Progression in Amyotrophic Lateral Sclerosis and Primary Lateral Sclerosis (P2-8.009)

<h3>Objective:</h3> We studied the association of changes in body mass index (BMI) with disease progression among amyotrophic lateral sclerosis (ALS) and primary lateral sclerosis (PLS) Multicenter Cohort Study of Oxidative Stress (COSMOS) study participants, prospectively followed up to 24 months. <h3>Background:</h3> Weight loss is a poor prognostic factor in ALS. However, less is known about weight change in PLS. <h3>Design/Methods:</h3> Participants had a confirmed diagnosis of ALS or PLS and completed baseline and at least one follow-up visit. The rate of BMI change (ΔBMI) and total revised ALS functional rating scale change (ΔALSFRS-r) were calculated between baseline and the first follow-up. Correlation between ΔBMI and ΔALSFRS-r were assessed using Pearson correlation among ALS and PLS participants separately. The demographics and proportion of participants with swallowing dysfunction at baseline and significant weight loss were compared between ALS and PLS groups using chi-square test. Cox proportional hazard models examined the association between significant weight loss (ΔBMI&lt;−1kg/m2/year) and survival in ALS, adjusted for other prognostic factors. <h3>Results:</h3> 279 ALS and 37 PLS participants were included. Mean age of ALS and PLS were both 60 years and 61% male. At baseline, swallowing dysfunction was more frequent in the PLS (78% vs 48%, p&lt;0.001) while significant weight loss was more frequent in the ALS (53% vs 19%, p&lt;0.001). ΔBMI and ΔALSFRS-r correlated significantly in ALS (r=0.3, p&lt;0.0001) but not in PLS (r= −0.21, p=0.2). Significant weight loss was associated with increased risk of death (hazard ratio 2.08, p&lt;0.0001) in ALS after adjusting for age, disease-duration, bulbar-onset, diagnostic-certainty, riluzole-intake, forced vital capacity, baseline BMI, baseline ALSFRS-r and ΔALSFRS-r. <h3>Conclusions:</h3> In ALS, significant weight loss is a strong independent prognostic factor for survival and rate of BMI change correlates with faster functional decline. In contrast, significant weight loss is infrequent in PLS despite a high prevalence of swallowing dysfunction. <b>Disclosure:</b> Dr. Lee has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Alexion. Dr. Lee has received personal compensation in the range of $0-$499 for serving as a Consultant for Amylyx. Dr. Lee has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for Regeneron. The institution of Dr. Lee has received research support from Myasthenia Gravis Foundation of America. The institution of Dr. Lee has received research support from CReATe consortium/American Brain Foundation. Dr. Mitsumoto has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Eli Lilly. Pam Factor-Litvak has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for ICF. Pam Factor-Litvak has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Frontiers Publishing. The institution of Pam Factor-Litvak has received research support from NIH. Prof. Nieves has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Bone Health and Osteoporosis Foundation. The institution of Prof. Nieves has received research support from Radius Pharmaceuticals. Prof. Nieves has received personal compensation in the range of $0-$499 for serving as a DSMB member with NIH.

Structural and functional connectome alterations across King’s stages in amyotrophic lateral sclerosis (S33.006)

<h3>Objective:</h3> To explore the rearrangements of structural and functional connectivity within and among brain networks underlying the clinical spreading of amyotrophic lateral sclerosis (ALS), as described by the King’s staging system, in order to suggest objective, continuous measures mirroring disease progression. <h3>Background:</h3> The identification of quantitative and reproducible markers of disease progression in ALS is of paramount importance for study design and inclusion of homogenous patient cohorts into clinical trials, as there is currently no validated disease-stage biomarker for ALS. <h3>Design/Methods:</h3> 104 patients with ALS and 61 age- and sex-matched healthy controls underwent clinical and brain magnetic resonance imaging (MRI) on a 3T scanner. Patients were stratified into four groups, according to the King’s staging system. No patient had comorbid frontotemporal dementia. Structural and functional connectivity values within and between different anatomical brain regions were obtained using diffusion tensor and resting-state functional MRI data, respectively. Comparisons between groups were performed using age- and sex-adjusted ANOVA models. Correlations were tested using Pearson’s coefficient. <h3>Results:</h3> Compared with controls, a significant, progressive reduction of structural connectivity within brain nodes of the sensorimotor network was observed in ALS patients across King’s stages 2, 3 and 4 (p&lt;0.006). Patients in stages 3 and 4 also showed significant loss of structural connectivity between frontal and sensorimotor regions (p=0.001). A significant disruption of functional connectivity within frontotemporal regions was found only in stage 4 (p=0.025). Sensorimotor structural connectivity showed a strong correlation with ALSFRS-r scores (r=0.31, p=0.001). <h3>Conclusions:</h3> Brain MRI allows to demonstrate and quantify increasing disruption of structural connectivity involving the sensorimotor and frontal networks in ALS, mirroring disease progression. Frontotemporal functional disconnection seems to characterize only advanced disease stages. Our findings demonstrate the utility of MRI connectomics to stratify patients and stage brain pathology in ALS in a reproducible way, which mirrors clinical progression. <b>Disclosure:</b> Dr. Spinelli has nothing to disclose. Miss Ghirelli has nothing to disclose. Silvia Basaia has nothing to disclose. Ms. Cividini has nothing to disclose. Nilo Riva has nothing to disclose. Dr. Russo has nothing to disclose. The institution of Elisa Canu has received research support from Italian Ministry of Health . Dr. Castelnovo has nothing to disclose. Dr. Filippi has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Bayer, Biogen Idec, Merck-Serono, Novartis, Roche, Sanofi Genzyme, Takeda, and Teva Pharmaceutical Industries. Dr. Filippi has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Bayer, Biogen Idec, Merck-Serono, Novartis, Roche, Sanofi Genzyme, Takeda, and Teva Pharmaceutical Industries. Dr. Filippi has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Springer Nature. The institution of Dr. Filippi has received research support from Biogen Idec, Merck-Serono, Novartis, Roche, Teva Pharmaceutical Industries, Italian Ministry of Health, Fondazione Italiana Sclerosi Multipla, and ARiSLA (Fondazione Italiana di Ricerca per la SLA). Federica Agosta has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Philips. Federica Agosta has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Elsevier INC.

Masitinib Shows Prolonged Survival in Amyotrophic Lateral Sclerosis (ALS) Patients with Mild or Moderate Disease Severity at Baseline (S33.003)

<h3>Objective:</h3> To assess the long-term overall survival (OS) of study AB10015, in particular, testing whether a signal in OS is evident in an enriched patient population similar to that prospectively defined for ongoing confirmatory study AB19001 (NCT03127267). <h3>Background:</h3> A randomized, placebo-controlled study (AB10015, NCT02588677) previously demonstrated that masitinib (4.5 mg/kg/d), administered orally as an add-on to standard riluzole over 48 weeks, slowed the rate of functional decline in ALS patients having an ALSFRS-R progression rate from disease-onset to baseline (ΔFS) of &lt;1.1 points/month. <h3>Design/Methods:</h3> Survival status of all patients originally randomized in AB10015 was collected from participating investigational sites (75 months average follow-up from diagnosis). Survival analysis (using the multivariate log-rank test and Cox proportional-hazards model, with stratification factors as covariates) was performed on the intention-to-treat population and enriched subgroups, which were defined according to initial randomization, ΔFS and baseline disease severity. <h3>Results:</h3> In ALS patients with mild or moderate disease severity at baseline (i.e., patients with ≥2 on each ALSFRS-R individual component) and ΔFS &lt;1.1 points/month (i.e., exclusion of faster progressors), masitinib 4.5mg/kg/d (n=45) prolonged survival by 25 months relative to those treated with riluzole alone (n=62) (median OS of 69 versus 44 months, respectively, P=0.037) with a 47% reduced risk of death (Hazard Ratio 0.53 (95%CI[0.31–0.92]); P=0.025). Significant treatment-effect for this cohort was also observed for ΔALSFRS-R at week-48 and time-to-event analysis (PFS). Conversely, no long-term survival advantage was observed for the overall masitinib 4.5 mg/kg/d cohort of study AB10015 (regardless of baseline disease severity or ΔFS) or for the low-dose (3.0 mg/kg/d) masitinib treatment-arm. <h3>Conclusions:</h3> Taken together, a consistently significant treatment effect in terms of median OS, hazard ratio of death, ΔALSFRS-R and PFS, provides evidence that oral masitinib (4.5 mg/kg/d) can slow ALS progression, provided that patients have not suffered severe impairment of ALSFRS-related functionality at the time of treatment initiation. <b>Disclosure:</b> Dr. Ludolph has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Novartis. Dr. Ludolph has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Biogen . Dr. Ludolph has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Roche Pharma AG . Dr. Ludolph has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Biogen. Dr. Ludolph has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Roche Pharma. Dr. Ludolph has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Biologix FZCo.. Dr. Ludolph has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Biologix FZCo.. Dr. Ludolph has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Biologix FZCo.. Dr. Ludolph has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Biogen. Dr. Ludolph has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Biogen. Dr. Ludolph has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Biogen. Dr. Ludolph has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Teva. Olivier Hermine has received personal compensation in the range of $500-$4,999 for serving as a Consultant for AB science. The institution of Olivier Hermine has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Gilead. The institution of Olivier Hermine has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for BMS. Olivier Hermine has stock in AB science. Olivier Hermine has stock in Inatherys. The institution of Olivier Hermine has received research support from BMS. The institution of Olivier Hermine has received research support from Roche. The institution of Olivier Hermine has received research support from Takeda. Olivier Hermine has received intellectual property interests from a discovery or technology relating to health care. Olivier Hermine has received intellectual property interests from a discovery or technology relating to health care.

Molecular and Physiological Determinants of Amyotrophic Lateral Sclerosis: What the DJ-1 Protein Teaches Us.

Amyotrophic lateral sclerosis (ALS) is an adult-onset disease which causes the progressive degeneration of cortical and spinal motoneurons, leading to death a few years after the first symptom onset. ALS is mainly a sporadic disorder, and its causative mechanisms are mostly unclear. About 5-10% of cases have a genetic inheritance, and the study of ALS-associated genes has been fundamental in defining the pathological pathways likely also involved in the sporadic forms of the disease. Mutations affecting the DJ-1 gene appear to explain a subset of familial ALS forms. DJ-1 is involved in multiple molecular mechanisms, acting primarily as a protective agent against oxidative stress. Here, we focus on the involvement of DJ-1 in interconnected cellular functions related to mitochondrial homeostasis, reactive oxygen species (ROS) levels, energy metabolism, and hypoxia response, in both physiological and pathological conditions. We discuss the possibility that impairments in one of these pathways may affect the others, contributing to a pathological background in which additional environmental or genetic factors may act in favor of the onset and/or progression of ALS. These pathways may represent potential therapeutic targets to reduce the likelihood of developing ALS and/or slow disease progression.

Basal ganglia alterations in amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) has traditionally been associated with brain damage involving the primary motor cortices and corticospinal tracts. In the recent decades, most of the research studies in ALS have focused on extra-motor and subcortical brain regions. The aim of these studies was to detect additional biomarkers able to support the diagnosis and to predict disease progression. The involvement of the frontal cortices, mainly in ALS cases who develop cognitive and/or behavioral impairment, is amply recognized in the field. A potential involvement of fronto-temporal and fronto-striatal connectivity changes in the disease evolution has also been reported. On this latter regard, there is still a shortage of studies which investigated basal ganglia (BG) alterations and their role in ALS clinical manifestation and progression. The present review aims to provide an overview on the magnetic resonance imaging studies reporting structural and/or functional BG alterations in patients with ALS, to clarify the role of BG damage in the disease clinical evolution and to propose potential future developments in this field.

Neurofilament light-chain response during therapy with antisense oligonucleotide tofersen in SOD1-related ALS: Treatment experience in clinical practice.

In amyotrophic lateral sclerosis (ALS) caused by superoxide dismutase 1 (SOD1) gene mutations (SOD1-ALS), the antisense oligonucleotide tofersen had been investigated in a phase III study (VALOR) and subsequently introduced in an expanded access program. In this study we assess neurofilament light chain (NfL) before and during tofersen treatment. In six SOD1-ALS patients treated with tofersen at three specialized ALS centers in Germany, NfL in cerebrospinal fluid (CSF-NfL) and/or serum (sNfL) were investigated using the ALS Functional Rating Scale Revised (ALSFRS-R) and ALS progression rate (ALS-PR), defined by monthly decline of ALSFRS-R. Three of the six SOD1-ALS patients reported a negative family history. Three patients harbored a homozygous c.272A > C, p.(Asp91Ala) mutation. These and two other patients showed slower progressing ALS (defined by ALS-PR <0.9), whereas one patient demonstrated rapidly progressing ALS (ALS-PR = 2.66). Mean treatment duration was 6.5 (range 5 to 8) months. In all patients, NfL decreased (mean CSF-NfL: -66%, range -52% to -86%; mean sNfL: -62%, range -36% to -84%). sNfL after 5 months of tofersen treatment was significantly reduced compared with the nearest pretreatment measurement (P = .017). ALS-PR decreased in two patients, whereas no changes in ALSFRS-R were observed in four participants who had very low ALS-PR or ALSFRS-R values before treatment. In this case series, the significant NfL decline after tofersen treatment confirmed its value as response biomarker in an expanded clinical spectrum of SOD1-ALS. Given the previously reported strong correlation between sNfL and ALS progression, the NfL treatment response supports the notion of tofersen having disease-modifying activity.

Integrative analysis of metabolomics and proteomics unravels purine metabolism dysregulation in the SOD1G93A mouse model of amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease with progressive paralysis of limbs and bulb in patients, the cause of which remains unclear. Accumulating studies suggest that motor neuron degeneration is associated with systemic metabolic impairment in ALS. However, the metabolic reprogramming and underlying mechanism in the longitudinal progression of the disease remain poorly understood. In this study, we aimed to investigate the molecular changes at both metabolic and proteomic levels during disease progression to identify the most critical metabolic pathways and underlying mechanisms involved in ALS pathophysiological changes. Utilizing liquid chromatography-mass spectrometry-based metabolomics, we analyzed the metabolites' levels of plasma, lumbar spinal cord, and motor cortex from SOD1G93A mice and wildtype (WT) littermates at different stages. To elucidate the regulatory network underlying metabolic changes, we further analyzed the proteomics profile in the spinal cords of SOD1G93A and WT mice. A group of metabolites implicated in purine metabolism, methionine cycle, and glycolysis were found differentially expressed in ALS mice, and abnormal expressions of enzymes involved in these metabolic pathways were also confirmed. Notably, we first demonstrated that dysregulation of purine metabolism might contribute to the pathogenesis and disease progression of ALS. Furthermore, we discovered that fatty acid metabolism, TCA cycle, arginine and proline metabolism, and folate-mediated one‑carbon metabolism were also significantly altered in this disease. The identified differential metabolites and proteins in our study could complement existing data on metabolic reprogramming in ALS, which might provide new insight into the pathological mechanisms and novel therapeutic targets of ALS.

Early electroacupuncture intervention delays progression of disease in mice with amyotrophic lateral sclerosis by down-regulating TLR4/NF-κB signaling

To observe the effect of early electroacupuncture (EA) intervention on Toll-like receptor 4 (TLR4)/nuclear factor-κB (NF-κB) signaling pathway in mice with amyotrophic lateral sclerosis (ALS), so as to explore its mechanisms underlying alleviation of ALS. Fifty-four ALS (ALS-SOD1G93A) mice with SOD1G93A gene mutation identified by PCR were randomly divided into model group, 60 day(d) EA group and 90 d EA group(n=18 mice in each group), and other 18 ALS-SOD1G93A negative mice were used as the control group. At the age of 60 and 90 days, mice of the two EA groups received EA (2 Hz, 1 mA) stimulation of bilateral "Jiaji" (EX-B2) of L1-L2 and L5-L6 for 20 min, twice a week for 4 weeks,respectively. When being 60 days old, the mice in the model and control groups were subjected to the same binding as that in the two EA groups but without EA intervention. The tail suspension test was used to judge the onset time of disease and the survival period, and rotary rod fatigue test was used to evaluate the hind limb motor function. Nissl staining method was used to observe the content of Nissl bodies in the anterior horn of the lumbar spinal cord. Immunohistochemical staining was used to observe the expression of ionized calcium binding adaptor molecule-1 (Iba-1) in the anterior horn of the lumbar spinal cord, and Western blot was used to detect the relative expression of TLR4, NF-κB and tumor necrosis factor-α (TNF-α) in the lumbar spinal cord. The disease onset time apparently delayed in the 60 d EA group than in the model group (P<0.01). The survival time was apparently shorter in the model group than in the control group (P<0.01), and obviously prolonged in the 60 d EA and 90 d EA groups than in the model group (P<0.01). The rotatory rod time was obviously shorter in the model group than in the control group (P<0.05), and apparently longer in the 60 d EA group than in the model group and 90 d EA group (P<0.05). Compared with the control group, the model group had a decrease in the number of Nissl bodies in the anterior horn of the lumbar spinal cord (P<0.01), and an increase in the expression levels of Iba-1, TLR4, NF-κB and TNF-α in the lumbar spinal cord (P<0.01). In contrast to the model group, both 60 d EA and 90 d EA groups had an apparent increase in the number of Nissl bodies and a marked decrease in the expression levels of Iba-1, TLR4, NF-κB and TNF-α in the lumbar spinal cord (P<0.05, P<0.01). The therapeutic effects of 60 d EA group were evidently superior to those of 90 d EA group in delaying the onset time of disease, prolonging the survival time and rotatory rod time, increasing the number of Nissl bodies, and in down-regulating the expression of Iba-1, TLR4, NF-κB and TNF-α (P<0.05, P<0.01). The early intervention of EX-B2 EA is more effective in delaying the progression of ALS than post-onset intervention in ALS-SOD1G93A mice, which may be related to its functions in inhibiting the excessive activation of microglia, and down-regulating TLR4/NF-κB signaling.

Effect of mesenchymal stromal cell transplantation on long-term survival in amyotrophic lateral sclerosis

Background aimsThanks to their immunomodulatory, tissue-protective and regenerative properties, mesenchymal stromal cells (MSCs) are a promising approach for amyotrophic lateral sclerosis (ALS); however, trials are limited and few follow-up studies have been published. This post-hoc analysis aims to describe the potential long-term effects of MSCs in ALS, analyzing data from two phase 1 clinical trials in ALS patients conducted by our group in 2002 and 2006. MethodsWe conducted two consecutive phase 1 prospective, open, pilot clinical trials, enrolling a total of 19 ALS patients. We followed patients for the duration of the disease. For each patient, we used the European Network to Cure ALS (ENCALS) survival prediction model to retrospectively calculate the expected survival at diagnosis. We then compared the predicted disease duration with the observed survival, analyzing patients at a single-patient level. ResultsUsing the ENCALS model, we predicted short survival in one patient, intermediate survival in three patients, long survival in three patients and very long survival in 12 patients. The difference between predicted and observed survival for the whole group was significant and demonstrated a mean predicted survival of 70.79 months (standard deviation [SD], 27.53) and a mean observed survival of 118.8 months (SD, 89.26) (P = 0.016). Based on the monthly ALS Functional Rating Scale–Revised progression rate (median, 0.64/month), we considered 10 of 19 patients slow progressors and nine of 19 patients fast progressors. Of the slow progressors, eight of 10 (80%) had significantly increased disease duration compared with predicted, and only two (20%) had decreased estimated disease duration. By contrast, five of nine (55%) fast progressors had increased disease duration, whereas four (45%) had decreased disease duration. To date, four patients are still alive. ConclusionsThe current study represents the first very long-term analysis of survival as an effect of MSC focal transplantation in the central nervous system of ALS patients, demonstrating that MSC transplantation could potentially slow down ALS progression and improve survival. Due to the interindividual variability in clinical course, at the current state of our knowledge, we cannot generalize the results, but these data provide new insights for planning the next generation of efficacy MSC clinical trials in ALS.

Motor unit number index (MUNIX) loss of 50% occurs in half the time of 50% functional loss according to the D50 disease progression model of ALS

Capturing disease progression in amyotrophic lateral sclerosis (ALS) is challenging and refinement of progression markers is urgently needed. This study introduces new motor unit number index (MUNIX), motor unit size index (MUSIX) and compound muscle action potential (CMAP) parameters called M50, MUSIX200 and CMAP50. M50 and CMAP50 indicate the time in months from symptom onset an ALS patient needs to lose 50% of MUNIX or CMAP in relation to the mean values of controls. MUSIX200 represents the time in months until doubling of the mean MUSIX of controls. We used MUNIX parameters of Musculi abductor pollicis brevis (APB), abductor digiti minimi (ADM) and tibialis anterior (TA) of 222 ALS patients. Embedded in the D50 disease progression model, disease aggressiveness and accumulation were analyzed separately. M50, CMAP50 and MUSIX200 significantly differed among disease aggressiveness subgroups (p < 0.001) regardless of disease accumulation. ALS patients with a low M50 had a significantly shorter survival compared to high M50 (median 32 versus 74 months). M50 preceded the loss of global function (median of about 14 months). M50, CMAP50 and MUSIX200 characterize the disease course in ALS in a new way and may be applied as early measures of disease progression.

Wearable device and smartphone data quantify ALS progression and may provide novel outcome measures

Amyotrophic lateral sclerosis (ALS) therapeutic development has largely relied on staff-administered functional rating scales to determine treatment efficacy. We sought to determine if mobile applications (apps) and wearable devices can be used to quantify ALS disease progression through active (surveys) and passive (sensors) data collection. Forty ambulatory adults with ALS were followed for 6-months. The Beiwe app was used to administer the self-entry ALS functional rating scale-revised (ALSFRS-RSE) and the Rasch Overall ALS Disability Scale (ROADS) surveys every 2–4 weeks. Each participant used a wrist-worn activity monitor (ActiGraph Insight Watch) or an ankle-worn activity monitor (Modus StepWatch) continuously. Wearable device wear and app survey compliance were adequate. ALSFRS-R highly correlated with ALSFRS-RSE. Several wearable data daily physical activity measures demonstrated statistically significant change over time and associations with ALSFRS-RSE and ROADS. Active and passive digital data collection hold promise for novel ALS trial outcome measure development.

Ultrasound–enhanced brain delivery of edaravone provides additive amelioration on disease progression in an ALS mouse model

BackgroundAlthough amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disease and unfortunately incurable yet, incremental attention has been drawn to targeting the health of corticospinal motor neurons. Focused ultrasound combined with systemically circulating microbubbles (FUS/MB) is an emerging modality capable of site-specific molecular delivery temporarily and noninvasively within a range of appropriate parameters. ObjectiveTo investigate the effect of FUS/MB–enhanced delivery of therapeutics to the motor cortex on the disease progression by using a transgenic mouse model of ALS. MethodsMultiple FUS/MB–enhanced deliveries of Edaravone (Eda) to the motor cortex were performed on the SOD1G93A mouse model of ALS. The motor function of the animals was evaluated by gait analysis, grip strength and wire hanging tests. Corticospinal and spinal motor neuronal health, misfolded SOD1 protein and neuroinflammation after treatments were evaluated by histological examination. ResultsUltrasound–enhanced delivery of Eda in the targeted motor cortex was achieved by a two-fold increase without gross tissue damage. Compared with the ALS mice administered Eda treatments only, the animals given additionally FUS/MB–enhanced brain delivery of Eda (FUS/MB + Eda) exhibited further improvements in neuromuscular functions characterized by gait patterns, muscular strength, and motor coordination along with rescued muscle atrophy. FUS/MB + Eda treatments conferred remarkable neuroprotection to both upper and lower motor neurons revealed by normalized neuronal morphology with increasing cell body size and profoundly alleviated neuroinflammation and misfolded SOD1 protein in the brains and lumbar spinal cords. ConclusionWe report a pilot study that non-invasive ultrasound–enhanced brain delivery of Eda provides additive amelioration on disease progression of ALS and suggest that broadening the target from spinal to cortical network functions using the FUS/MB–enhanced delivery can be a rational therapeutic strategy of this debilitating disorder.

Endogenous retroviruses and TDP-43 proteinopathy form a sustaining feedback driving intercellular spread of Drosophila neurodegeneration

Inter-cellular movement of “prion-like” proteins is thought to explain propagation of neurodegeneration between cells. For example, propagation of abnormally phosphorylated cytoplasmic inclusions of TAR-DNA-Binding protein (TDP-43) is proposed to underlie progression of amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). But unlike transmissible prion diseases, ALS and FTD are not infectious and injection of aggregated TDP-43 is not sufficient to cause disease. This suggests a missing component of a positive feedback necessary to sustain disease progression. We demonstrate that endogenous retrovirus (ERV) expression and TDP-43 proteinopathy are mutually reinforcing. Expression of either Drosophila mdg4-ERV (gypsy) or the human ERV, HERV-K (HML-2) are each sufficient to stimulate cytoplasmic aggregation of human TDP-43. Viral ERV transmission also triggers TDP-43 pathology in recipient cells that express physiological levels of TDP-43, whether they are in contact or at a distance. This mechanism potentially underlies the TDP-43 proteinopathy-caused neurodegenerative propagation through neuronal tissue.

Protein-RNA condensates: Complementary or competing interactions in ALS progression?

Membraneless organelles within cells provide organization of the intracellular environment through the process of liquid liquid phase separation (LLPS). The fused in sarcoma (FUS) protein is an RNA binding protein that undergoes LLPS with RNA as part of normal activity in healthy cells. PolyPR and polyGR, dipeptide repeat proteins (DPRs) caused by C9orf72 repeat expansion disorders, have been shown to promote protein aggregation of RNA binding proteins, including FUS. This aggregation contributes to the progression of ALS (amyotrophic lateral sclerosis) and FTD (frontotemporal dementia), which have ineffective treatments and no cure. The pathway towards protein aggregation, and away from stable condensates, is poorly understood, but has been linked to changes in condensate behavior induced by the addition of DPRs. Here we investigate the effect of DPR and RNA on the stability of FUS condensates through molecular dynamics simulations.