阿尔茨海默病的预防与治疗:乐观的理由
Alzheimer's Disease Prevention and Treatment: Case for Optimism.
作者信息
Volloch Vladimir, Olsen Bjorn, Rits Sophia
机构信息
Department of Developmental Biology, Harvard School of Dental Medicine, USA.
Division of Molecular Medicine, Children's Hospital, Boston, USA.
出版信息
Ann Integr Mol Med. 2020;2(1):115-130. doi: 10.33597/aimm.02-1008.
A paradigm shift is under way in the Alzheimer's field. A view of Alzheimer's disease, AD, prevailing until now, the old paradigm, maintains that it is initiated and driven by the overproduction and extracellular accumulation of beta-amyloid, Aβ; a peptide assumed to be derived, both in health and disease, solely by proteolysis of its large precursor, βAPP. In AD, according to this view, Aβ overproduction-associated neurodegeneration begins early, accumulates throughout the lifespan, and manifests symptomatically late in life. A number of drugs, designed within the framework of exceptionality of the βAPP proteolytic/secretory pathway in Aβ production in Alzheimer's disease, achieved spectacular successes in treatment, even the reversal, of AD symptoms in animal models. Without exception, they all exhibited equally spectacular failures in human clinical trials. This paradigm provides few causes for optimism with regard to prevention and treatment of AD. In its context, the disease is considered untreatable in the symptomatic phase; even prodromal cases are assumed too advanced for treatment because Aβ-triggered damages have been accumulating for preceding decades, presumably starting in the early twenties and, to be effective, this is when therapeutic intervention should commence and continue for life. The new paradigm does not dispute the seminal role of Aβ in AD but posits that beta-amyloid produced in the βAPP proteolytic/secretory pathway causes AD in humans no more than it does in non-human mammals that share this pathway with humans, accumulate Aβ as they age, but do not develop the disease. Alzheimer's disease, according to this outlook, is driven by the AD-specific pathway of Aβ production, independent of βAPP and absent in animals. Its activation, late in life, occurs through accumulation, via both cellular uptake of secreted Aβ and neuronal retention of a fraction of beta-amyloid produced in the βAPP proteolytic pathway, of intraneuronal Aβ, which triggers mitochondrial dysfunction. Cellular stresses associated with mitochondrial dysfunction, or, probably, the integrated stress response, ISR, elicited by it, activate an AD-specific Aβ production pathway. In it, every conventionally produced βAPP mRNA molecule potentially serves repeatedly as a template for production of severely 5'-truncated mRNA encoding C99 fragment of βAPP, the immediate precursor of Aβ that is processed in a non-secretory pathway, apparently in a neuron-specific manner. The resulting intraneuronally retained Aβ augments mitochondrial dysfunction, which, in turn, sustains the activity of the βAPP mRNA amplification pathway. These self-propagating Aβ overproduction/mitochondrial dysfunction mutual feedback cycles constitute the engine that drives AD and ultimately triggers neuronal death. In this paradigm, preventive treatment can be initiated any time prior to commencement of βAPP mRNA amplification. Moreover, there are good reasons to believe that with a drug blocking the amplification pathway, it would be possible not only to preempt the disease but also stop and reverse it even when early AD symptoms are already manifested. Thus, the new paradigm introduces a novel theory of Alzheimer's disease. It explains the observed discordances, determines defined therapeutic targets, provides blueprints for a new generation of conceptually distinct AD models and specifies design of a reporter for the mRNA amplification pathway. Most importantly, it offers detailed guidance and tangible hope for prevention of the disease and its treatment at the early symptomatic stages.
阿尔茨海默病领域正在发生范式转变。直到现在,一种关于阿尔茨海默病(AD)的观点,即旧范式,一直盛行,该观点认为它是由β淀粉样蛋白(Aβ)的过量产生和细胞外积累引发和驱动的;人们认为,无论在健康还是疾病状态下,这种肽都仅由其大型前体β淀粉样前体蛋白(βAPP)的蛋白水解产生。根据这种观点,在AD中,与Aβ过量产生相关的神经退行性变很早就开始了,在整个生命周期中积累,并在生命后期出现症状。一些在阿尔茨海默病中Aβ产生的βAPP蛋白水解/分泌途径具有特殊性的框架内设计的药物,在动物模型中成功治疗甚至逆转了AD症状。无一例外,它们在人体临床试验中都同样遭遇了惨败。就AD的预防和治疗而言,这种范式几乎没有给人带来乐观的理由。在这种背景下,该疾病在症状期被认为无法治疗;即使是前驱病例也被认为病情太严重而无法治疗,因为Aβ引发的损害已经积累了几十年,大概从二十出头就开始了,而要想有效,治疗干预应该在这个时候开始并持续终身。新范式并不质疑Aβ在AD中的关键作用,但认为在βAPP蛋白水解/分泌途径中产生的β淀粉样蛋白在人类中引发AD的程度,并不比在与人类共享该途径、随着年龄增长积累Aβ但不患该病的非人类哺乳动物中更高。根据这种观点,阿尔茨海默病是由AD特异性的Aβ产生途径驱动的,该途径独立于βAPP且在动物中不存在。它在生命后期通过神经元内Aβ的积累而被激活,这种积累是通过分泌的Aβ的细胞摄取以及βAPP蛋白水解途径中产生的一部分β淀粉样蛋白在神经元中的保留实现的,而神经元内Aβ会触发线粒体功能障碍。与线粒体功能障碍相关的细胞应激,或者可能是由它引发的综合应激反应(ISR),激活了AD特异性的Aβ产生途径。在这个途径中,每个常规产生的βAPP mRNA分子都有可能反复作为模板,用于产生严重5'端截短的mRNA,该mRNA编码βAPP的C99片段,即Aβ的直接前体,它在非分泌途径中被加工,显然是以神经元特异性的方式。由此产生的神经元内保留的Aβ会加剧线粒体功能障碍,而线粒体功能障碍反过来又维持了βAPP mRNA扩增途径的活性。这些自我传播的Aβ过量产生/线粒体功能障碍相互反馈循环构成了驱动AD并最终引发神经元死亡的引擎。在这个范式中,预防性治疗可以在βAPP mRNA扩增开始之前的任何时间启动。此外,有充分的理由相信,使用一种阻断扩增途径的药物,不仅有可能预防疾病,而且即使在早期AD症状已经出现时,也有可能阻止并逆转疾病。因此,新范式引入了一种关于阿尔茨海默病的新理论。它解释了观察到的不一致现象,确定了明确的治疗靶点,为新一代概念上不同的AD模型提供了蓝图,并指定了mRNA扩增途径报告基因的设计。最重要的是,它为疾病的预防及其早期症状阶段的治疗提供了详细的指导和切实的希望。