Periodic Reporting for period 3 - MegaALS (Unravelling the Interplay between Metabolism, Gut Microbiome and Adaptive Immunity in Amyotrophic Lateral Sclerosis)
Berichtszeitraum: 2021-11-01 bis 2023-04-30
1. What is the problem/issue being addressed?
Amyotrophic lateral sclerosis (ALS) is today recognized as a systemic disease affecting not only the central nervous system (CNS) but the whole-body physiology. A strategy of investigating the interaction between CNS and other aspects of the physiology is therefore needed to better understand its etiology. An emerging hypothesis that is gaining momentum concerns defects in energy metabolism and immune responses, both of which are clinically distinct and targetable for therapeutic interventions. The MegaALS research program therefore aims to understand how the alterations in energy metabolism and immune responses contribute to the disease development of ALS, and subsequently, whether modulations of such alterations could serve as potential therapeutic candidates for ALS.
2. Why is it important for society?
ALS is a fatal neurodegenerative disease that affects the motor neurons in the brain and spinal cord and subsequently the ability of the brain to initiate and control muscle movement. As a result of the progressive loss of voluntary muscle action, patients with ALS lose the ability to speak, eat, move, and breathe. The vast majority of patients with ALS die within 1-3 years after diagnosis, often due to failure in respiratory function. Currently, there is neither cure nor effective treatment for ALS. Undisputedly, ALS is one of the worst diagnoses for doctors to give, and for patients to receive, due to its rapid progression and the current lack of effective treatments.
The current lack of successful therapeutics for ALS is mainly due to our limited understanding about disease etiology. Although an increasing number of susceptibility genes have been reported, the overall genetic contribution to ALS still appears weak. Today, the only established risk factors are older age, male sex, and family history. Identification of additional contributors to disease development is therefore of paramount importance in providing new knowledge for disease prevention and identifying novel therapeutic targets.
3. What are the overall objectives?
With the ultimate goal of providing important new knowledge for disease prevention among high risk individuals and identifying novel therapeutic targets, the overarching aim of the MegaALS research program is to explore the interplay between metabolism, gut microbiome and adaptive immunity in ALS, and to assess the effectiveness of a novel treatment regimen that specifically targets the diet-microbiota interactions. MegaALS has two specific aims as follows:
I. To reveal the complex interplay between metabolism, gut microbiome, and adaptive immunity in ALS, using comprehensive proteomic, metagenomic and immune-response profiling, through contrasting ALS patients of different clinical phenotypes with their disease-free full siblings, spouses and population-controls.
II. To test the effectiveness of an intervention - a high-caloric diet in combination with fecal microbiota transplant from healthy donors - in delaying disease onset and ameliorating progression, and to test if immune modulation contributes to such effect, using an established transgenic ALS mouse model.
Amyotrophic lateral sclerosis (ALS) is today recognized as a systemic disease affecting not only the central nervous system (CNS) but the whole-body physiology. A strategy of investigating the interaction between CNS and other aspects of the physiology is therefore needed to better understand its etiology. An emerging hypothesis that is gaining momentum concerns defects in energy metabolism and immune responses, both of which are clinically distinct and targetable for therapeutic interventions. The MegaALS research program therefore aims to understand how the alterations in energy metabolism and immune responses contribute to the disease development of ALS, and subsequently, whether modulations of such alterations could serve as potential therapeutic candidates for ALS.
2. Why is it important for society?
ALS is a fatal neurodegenerative disease that affects the motor neurons in the brain and spinal cord and subsequently the ability of the brain to initiate and control muscle movement. As a result of the progressive loss of voluntary muscle action, patients with ALS lose the ability to speak, eat, move, and breathe. The vast majority of patients with ALS die within 1-3 years after diagnosis, often due to failure in respiratory function. Currently, there is neither cure nor effective treatment for ALS. Undisputedly, ALS is one of the worst diagnoses for doctors to give, and for patients to receive, due to its rapid progression and the current lack of effective treatments.
The current lack of successful therapeutics for ALS is mainly due to our limited understanding about disease etiology. Although an increasing number of susceptibility genes have been reported, the overall genetic contribution to ALS still appears weak. Today, the only established risk factors are older age, male sex, and family history. Identification of additional contributors to disease development is therefore of paramount importance in providing new knowledge for disease prevention and identifying novel therapeutic targets.
3. What are the overall objectives?
With the ultimate goal of providing important new knowledge for disease prevention among high risk individuals and identifying novel therapeutic targets, the overarching aim of the MegaALS research program is to explore the interplay between metabolism, gut microbiome and adaptive immunity in ALS, and to assess the effectiveness of a novel treatment regimen that specifically targets the diet-microbiota interactions. MegaALS has two specific aims as follows:
I. To reveal the complex interplay between metabolism, gut microbiome, and adaptive immunity in ALS, using comprehensive proteomic, metagenomic and immune-response profiling, through contrasting ALS patients of different clinical phenotypes with their disease-free full siblings, spouses and population-controls.
II. To test the effectiveness of an intervention - a high-caloric diet in combination with fecal microbiota transplant from healthy donors - in delaying disease onset and ameliorating progression, and to test if immune modulation contributes to such effect, using an established transgenic ALS mouse model.
The main milestones and results reached so far are the following:
Aim I
Until April 30, 2021, we have recruited 289 patients with ALS and 195 controls, with questionnaire data, medical journals, and biospecimens. As a result of the COVID-19 pandemic, the recruitment of controls has been delayed since the beginning of 2020, but the recruitment of cases has not been affected much. We have also performed the clinical follow-up of all recruited patients. We have performed proteomics, immune response, and single-cell RNA sequencing analyses for ALS cases and controls. We have also constructed the study database and performed data cleaning throughout the grant period.
Results:
1) We found that ALS patients with higher levels of LDL-C and apolipoprotein B at the time of diagnosis had a longer survival, compared with ALS patients with lower levels of these biomarkers. This study has been published in Neurology (Ingre C, et al).
2) We found that ALS patients did not seem to have a different profile of inflammatory biomarkers such as CRP, cell counts, and immunoglobins, during the 20 years before diagnosis, compared with individuals free of ALS. This study has been published in Annals of Neurology (Yazdani S, et al).
3) We performed a systematic review to summarize the existing literature on microbiome research (both human and experimental research) in ALS. We found that there is substantial inconsistency in the findings of human and animal studies, partly attributable to the differential study design and the small sample size. We discussed a few critical steps with the aim to perform higher quality studies in microbiome research of ALS. This study is published in the Journal of Internal Medicine (Sun J, et al).
Aim II
Because the core facility for germ-free animal research at the Karolinska Institutet was closed in 2019, it is no longer possible to perform the proposed research for Aim II in Karolinska Institutet as planned. We therefore looked for alternative solutions. We have identified a collaboration with a team in the Italian National Institute of Health and developed the study protocol jointly. However, due to the current COVID-19 pandemic, it has not been possible to initiate the research work yet. We will discuss the detailed research plan (manpower, timeline, etc.) in September 2021 when the situation of COVID-19 is clearer, thanks to the ongoing vaccination.
Aim I
Until April 30, 2021, we have recruited 289 patients with ALS and 195 controls, with questionnaire data, medical journals, and biospecimens. As a result of the COVID-19 pandemic, the recruitment of controls has been delayed since the beginning of 2020, but the recruitment of cases has not been affected much. We have also performed the clinical follow-up of all recruited patients. We have performed proteomics, immune response, and single-cell RNA sequencing analyses for ALS cases and controls. We have also constructed the study database and performed data cleaning throughout the grant period.
Results:
1) We found that ALS patients with higher levels of LDL-C and apolipoprotein B at the time of diagnosis had a longer survival, compared with ALS patients with lower levels of these biomarkers. This study has been published in Neurology (Ingre C, et al).
2) We found that ALS patients did not seem to have a different profile of inflammatory biomarkers such as CRP, cell counts, and immunoglobins, during the 20 years before diagnosis, compared with individuals free of ALS. This study has been published in Annals of Neurology (Yazdani S, et al).
3) We performed a systematic review to summarize the existing literature on microbiome research (both human and experimental research) in ALS. We found that there is substantial inconsistency in the findings of human and animal studies, partly attributable to the differential study design and the small sample size. We discussed a few critical steps with the aim to perform higher quality studies in microbiome research of ALS. This study is published in the Journal of Internal Medicine (Sun J, et al).
Aim II
Because the core facility for germ-free animal research at the Karolinska Institutet was closed in 2019, it is no longer possible to perform the proposed research for Aim II in Karolinska Institutet as planned. We therefore looked for alternative solutions. We have identified a collaboration with a team in the Italian National Institute of Health and developed the study protocol jointly. However, due to the current COVID-19 pandemic, it has not been possible to initiate the research work yet. We will discuss the detailed research plan (manpower, timeline, etc.) in September 2021 when the situation of COVID-19 is clearer, thanks to the ongoing vaccination.
The MegaALS research program has made significant contribution to the literature on ALS research. These contributions are described above and have been published:
1. Peripheral immune biomarkers and neurodegenerative diseases: A prospective cohort study with 20 years of follow-up. Yazdani S, Mariosa D, Hammar N, Andersson J, Ingre C, Walldius G, Fang F. Ann Neurol. 2019 Dec;86(6):913-926. PMID: 31604369
2. Lipids, apolipoproteins, and prognosis of amyotrophic lateral sclerosis. Ingre C, Chen L, Zhan Y, Termorshuizen J, Yin L, Fang F. Neurology. 2020 Apr 28;94(17):e1835-e1844. PMID: 32221024
3. Cardiac Troponin T is elevated and increases longitudinally in ALS patients. Kläppe U, Chamoun S, Shen Q, Finn A, Evertsson B, Zetterberg H, Blennow K, Press R, Samuelsson K, Månberg A, Fang F, Ingre C. Amyotroph Lateral Scler Frontotemporal Degener. In press.
4. Gut microbiome and amyotrophic lateral sclerosis: A systematic review of current evidence. Sun J, Huang T, Debelius J, Fang F. J Intern Med. 2021 Jun 3. Online ahead of print.
Below is a brief description of the prospective work in the coming years:
Aim I
Recruitment and data/sample collections: We will continue to recruit cases and controls, with more efforts made to the controls to complement the delay caused by the COVID-19 pandemic. We will also continue the clinical follow-up of all cases. We will make an amendment to the original grant agreement to prolong the grant period with the aim to complement the delayed enrolment of controls.
Aim II
We will discuss the plan for the research of Aim II in September 2021 when the situation of the COVID-19 pandemic is clearer.
1. Peripheral immune biomarkers and neurodegenerative diseases: A prospective cohort study with 20 years of follow-up. Yazdani S, Mariosa D, Hammar N, Andersson J, Ingre C, Walldius G, Fang F. Ann Neurol. 2019 Dec;86(6):913-926. PMID: 31604369
2. Lipids, apolipoproteins, and prognosis of amyotrophic lateral sclerosis. Ingre C, Chen L, Zhan Y, Termorshuizen J, Yin L, Fang F. Neurology. 2020 Apr 28;94(17):e1835-e1844. PMID: 32221024
3. Cardiac Troponin T is elevated and increases longitudinally in ALS patients. Kläppe U, Chamoun S, Shen Q, Finn A, Evertsson B, Zetterberg H, Blennow K, Press R, Samuelsson K, Månberg A, Fang F, Ingre C. Amyotroph Lateral Scler Frontotemporal Degener. In press.
4. Gut microbiome and amyotrophic lateral sclerosis: A systematic review of current evidence. Sun J, Huang T, Debelius J, Fang F. J Intern Med. 2021 Jun 3. Online ahead of print.
Below is a brief description of the prospective work in the coming years:
Aim I
Recruitment and data/sample collections: We will continue to recruit cases and controls, with more efforts made to the controls to complement the delay caused by the COVID-19 pandemic. We will also continue the clinical follow-up of all cases. We will make an amendment to the original grant agreement to prolong the grant period with the aim to complement the delayed enrolment of controls.
Aim II
We will discuss the plan for the research of Aim II in September 2021 when the situation of the COVID-19 pandemic is clearer.