Olsson B, Legros L, Guilhot F, Strömberg K, Smith J, Livesey FJ, Wilson DH, Zetterberg H, Blennow K.
Imatinib treatment and Aβ42 in humans.
Alzheimers Dement. 2013 Dec 10;
PubMed.
We welcome a discussion on the problem with irreproducibility of published research that we recently encountered, as outlined in the Alzforum news story. In this context, the recent editorial guidelines from Nature might represent one step to reduce this problem. A checklist for methodological and statistical information, together with unlimited space for methods, statistical description, and access to raw data, are commendable. In our mind, however, at least two problems remain. One is related to the difference in the requirement of independent replication between clinical and preclinical research, another to the technical requirements on the methods used for quantifying biochemical changes. Due to the issue with poor replication of results, Nature Genetics stipulated that novel genetic associations must be verified in at least two independent cohorts. Correspondingly, replication in independent cohorts is a core feature of any high-quality publication in clinical biomarker research (Bossuyt et al., 2004). In contrast, in high-impact basic research journals, publication is common with very small numbers of inbred animals or cell experiments, without replication in independent sets. One example is the imatinib/GSAP paper (He et al., 2010), in which many critical conclusions were based on n=3 experiments, a number that actually is too low to do statistical calculations. We appreciate that the variability in animal models may be lower than in clinical samples, but at the same time these models may be highly skewed and not representative of the clinical disease they are supposed to reflect (Begley et al., 2012). To reduce the problem with irreproducibility, any finding should be replicated in two independent disease models, or at least two independent experiments with a number of cell cultures or animals that allows proper statistical testing. Another bias is related to the methodology used for quantification. Clinical studies often include validated methods and provide data on assay performance, e.g., between-run variability. In contrast, it is common in basic research to use non-validated semi-quantitative methods, e.g., Western blot, without presenting any information on method precision, variability, or specificity. For this, again, the imatinib/GSAP paper can serve as an example (He et al.). In our view, such low-quality quantitative data may underlie irreproducibility, yet high-impact journals are full of them. We believe that addressing these two problems, in addition to the actions presented in the recent editorial, will solve a large part of the problem with irreproducible data from preclinical research.
Framework for a fully powered risk engine.
Nat Genet. 2005 Nov;37(11):1153.
PubMed.
Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig LM, Lijmer JG, Moher D, Rennie D, de Vet HC, STARD Group.
Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative.
Fam Pract. 2004 Feb;21(1):4-10.
PubMed.
He G, Luo W, Li P, Remmers C, Netzer WJ, Hendrick J, Bettayeb K, Flajolet M, Gorelick F, Wennogle LP, Greengard P.
Gamma-secretase activating protein is a therapeutic target for Alzheimer's disease.
Nature. 2010 Sep 2;467(7311):95-8.
PubMed.
Begley CG, Ellis LM.
Drug development: Raise standards for preclinical cancer research.
Nature. 2012 Mar 28;483(7391):531-3.
PubMed.
I have not tried to replicate He et al. 2010 myself, so I can only comment based on my readings about this topic. I am particularly interested in the regulation of γ-secretase, and carefully followed the research about GSAP. Two papers report a lack of interaction between GSAP and APP-CTFβ, also called C99 (Hussain et al., 2013, and Deatherage et al., 2012). Moreover, Hussain et al. report that GSAP has no effect on γ-secretase mediated ε cleavages of both APP and Notch (Fig. 5 and 6). Finally, Hussain et al. report that imatinib does not lower Aβ in rats in vivo. However, while we were particularly interested in the findings by He et al., we mentioned in a recent review (Barthet et al., 2012) some discrepancies found in the paper. Most notably, the authors reported that GSAP stimulates production of Aβ while it reduces AICD, the product of γ-secretase cleavage of APP at the ε site, a phenomenon that is difficult to conceive. Finally, the paper by Olsson et al. in Alzheimer’s & Dementia reports that imatinib does not reduce Aβ in humans. All together, three independent groups report evidence that raises doubts about the effects of imatinib and GSAP on γ-secretase.
References:
Hussain I, Fabrègue J, Anderes L, Ousson S, Borlat F, Eligert V, Berger S, Dimitrov M, Alattia JR, Fraering PC, Beher D.
The Role of γ-Secretase Activating Protein (GSAP) and Imatinib in the Regulation of γ-Secretase Activity and Amyloid-β Generation.
J Biol Chem. 2013 Jan 25;288(4):2521-31.
PubMed.
Deatherage CL, Hadziselimovic A, Sanders CR.
Purification and characterization of the human γ-secretase activating protein.
Biochemistry. 2012 Jun 26;51(25):5153-9.
PubMed.
Barthet G, Georgakopoulos A, Robakis NK.
Cellular mechanisms of γ-secretase substrate selection, processing and toxicity.
Prog Neurobiol. 2012 Aug;98(2):166-75.
PubMed.
Olsson B, Legros L, Guilhot F, Strömberg K, Smith J, Livesey FJ, Wilson DH, Zetterberg H, Blennow K.
Imatinib treatment and Aβ42 in humans.
Alzheimers Dement. 2013 Dec 10;
PubMed.
I did not try to reproduce He et al. 2010 myself but agree with the shortcomings of this data as reported in this story. If patient data suggest there will be no efficacy, I question whether it is worth resolving the remaining data discrepancies at this point.
Unfortunately, many studies in the AD field have failed to be replicated and it is then difficult to get these data published. Journals tend to be reluctant to publish out of concern that failed replication studies might tarnish their image. I have been moderately successful in publishing failed replications, but it takes an enormous effort. Without such publication, however, the original paper continues to get cited, often with a reference to the effect of “but these findings are somewhat controversial." We should also acknowledge a real fear of retaliation in our community. Given very competitive NIH funding and promotions on the line, not everyone wants to antagonize a colleague who might be a future reviewer, even if it is the right thing to do.
The irreproducibility of the literature data also impacts the speed and cost of discovering new therapies. The commitment to start an industry drug-discovery program is an expensive proposition, and risky if based only on the scientific literature because of the knowledge gaps created by the bias against publishing negative and contradictory findings. The biology is rarely as straightforward as presented in the first few publications on a new target. Thus, companies have to conduct internal research to fill in the knowledge gaps, and for competitive reasons, that knowledge is not made public immediately.
The shrinking of industry drug-discovery groups results in fewer scientists working on target identification and a movement toward well-documented targets, which in turn results in homogenization of industry pipelines. Innovation and the discovery of game-changing therapies slows.
Journals could help to address this problem by acknowledging the value of work that both replicates the data of others as well as work that may bring into question conclusions of previous papers. With the societal costs and human suffering that results from Alzheimer's disease, this field in particular needs to acknowledge the issue of publication biases.
Co-authored by William Netzer and Paul Greengard, The Rockefeller University; Yueming Li and Darren Veach, Memorial Sloan-Kettering Cancer Center; Wenjie Luo, Weill Cornell Medical College; Fred Gorelick, Yale University School of Medicine; and Dongming Cai and Sam Gandy, Icahn School of Medicine at Mount Sinai, New York.
Madolyn Rogers’ news article, and some of the comments in response to that article, draw attention to interlaboratory variability in the replication of two studies published by our research group. In our original paper on this topic (Netzer et al., 2003), we reported that Gleevec (imatinib) reduced Aβ generation in cell culture and in vivo in guinea pig brain. In the second paper (He et al., 2010), we described the identification of γ–secretase-activating protein (GSAP), an endogenous regulator of Aβ formation. Here we focus primarily on studies published subsequent to Netzer et al. that have evaluated the Aβ-lowering effects of imatinib.
Studies of imatinib in intact cell systems
Netzer et al. reported that imatinib lowered Aβ40 levels in rat primary neurons and lowered Aβ40 and 42 in N2a (mouse neuroblastoma) cells stably transfected with APP 695 or PS1ΔE9/APP Swe. Subsequent to that publication, we tested imatinib in Chinese hamster ovary cells transfected with wild-type human APP695 (CHO-hAPP), in 3T3 fibroblasts transfected with wild-type human APP695, and in mouse embryonic fibroblasts (MEFs) transfected with Swedish mutant human APP695. In each of these three cell lines, imatinib reduced total Aβ by 40 to 80 percent (Netzer, unpublished results). The observation that imatinib reduces Aβ generation in five different cell types—namely rat primary neurons, N2a, CHO, 3T3, and MEF cells—does not exclude the possibility that some cell types or cell lines might be resistant to imatinib-induced reduction in Aβ generation (see below).
Independent confirmation of the imatinib effect in the cell types used by Netzer et al. (2003)
Hussain et al. confirmed in N2a cells our published observations (in that same cell line) that imatinib causes a 50 to 60 percent reduction in Aβ40 and 42 secretion.
Arslanova et al. tested 100 μM imatinib in CHO-hAPP cells in culture and demonstrated that secretion of Aβ40 and 42 was reduced by 30 percent and 80 percent, respectively. The published results of Arslanova et al. were confirmed in the unpublished studies of Netzer mentioned above.
Extension of the studies of Netzer et al. (2003) to three additional cell types
Eisele et al. extended the list of imatinib-responsive cells to include H4-APPwt cells in their demonstration of an effect of imatinib on Aβ generation over a drug concentration range of 3.7 to 20μM. A 50 percent reduction in secretion of Aβ40 and 42 was observed in the presence of 10μM imatinib.
Hussain et al. tested imatinib in SHSY5Y-SPA4CT cells and found that 10μM imatinib reduced secretion of Αβ40 and 42 by about 40 percent, adding yet another cell line to the roster of those that display imatinib-responsive Αβ generation.
Mertens et al. reported that 10μΜ imatinib lowered Aβ40 and 42 secretion by 70 percent and 75 percent, respectively, in human differentiated neurons in culture, consistent with our observations using rat primary neuronal cultures.
Failure to replicate the imatinib effect in three previously untested cell types
Olsson et al. reported the only published failure to reproduce the imatinib effect in intact cells. They reported that imatinib does not lower Aβ42 secretion from either: (i) HEK293 cells (stably transfected with human APP Swe); (ii) human Down’s syndrome embryonic stem cell-derived cortical projection neurons; or (iii) mouse primary cortical neurons. The protocol published by Olsson et al. provided no obvious explanation for why their results differed from those derived from multiple other cell types in the hands of multiple other investigators. As of this writing, we are unaware of any other laboratory that has tested any of the cell types used by Olsson et al. At present, we cannot determine whether the Olsson results are technical in nature or whether all the cell types they studied are imatinib-resistant.
In summary, four of the five studies published since Netzer et al. have confirmed the Aβ-lowering effect of imatinib in cell culture. We have been unable to identify any obvious explanation for this disparity in careful scrutiny of the published protocols from those failing to replicate the imatinib effect. In an effort to resolve the issue as efficiently as possible, we would welcome visits to our laboratory by any scientists seeking a detailed demonstration of our methods of measuring the effect of imatinib on Aβ secretion by cultured cells.
Demonstration of the imatinib effect in a cell-free system
In addition to the results obtained in intact cell systems, a study by Fraering et al. reported that 75μM imatinib reduced Aβ40 and 42 formation by 50 percent in a cell-free γ–secretase assay.
Studies of imatinib in intact rodents and in humans
Netzer et al. reported that continuous intrathecal infusion of imatinib by osmotic pump reduced Aβ levels in the intact guinea pig brain. Intrathecal infusion was chosen as the route of administration because imatinib is rapidly pumped out of the brain by the p-glycoprotein pump (PGP) at the blood-brain-barrier (see Dai et al., 2003). As a result of robust PGP action, imatinib that is peripherally injected or ingested will appear in brain only to a negligible extent (Leis et al.). For this reason, Netzer et al. explicitly stated that imatinib administered peripherally would not be useful as a therapeutic for Alzheimer’s disease (AD). Nevertheless, both Hussain et al. (i.p. imatinib in rats) and Olsson et al. (oral imatinib in humans) studied the effects of peripherally injected or orally ingested imatinib. Since most plasma Αβ is derived from the CNS (DeMattos et al., 2002; Ghersi-Egea et al., 1996; Shibata et al., 2000), the failures of Hussain et al. and Olsson et al. to observe Αβ–reducing effects of peripherally injected or orally ingested imatinib on brain or plasma Aβ levels were the predicted results. Therefore, the data of Hussain et al. and Olsson et al. are irrelevant to any assessment of the potential for therapeutic success using a CNS imatinib-like compound or a GSAP-modulating compound.
Since we remain interested in developing an AD therapeutic based on imatinib, the Olsson et al. study in humans merits particular attention. These investigators measured plasma Aβ42 levels in chronic myelogenous leukemia patients (n = 51) before and during treatment with imatinib. They estimated that plasma concentrations of imatinib in these patients was 1.46 μM (the concentration of imatinib in the brain would have been much lower). We have only observed reductions in Aβ secretion by imatinib for imatinib concentrations of 5μΜ or greater (Netzer, unpublished results). Thus, the dose employed by Olsson et al. would not be expected to have an impact on peripheral generation of Aβ (if any such Aβ generation exists).
Studies of GSAP
With respect to GSAP, four members of our laboratory and one publication from another laboratory (Hussain et al., 2013) have confirmed the observation reported in He et al. that GSAP knockdown reduces Aβ secretion by cells in culture. There have been no contradictory publications reporting a failure of GSAP knockdown to lower Aβ secretion in intact cells. Two additional groups reported higher expression levels of GSAP in human tissues (including AD brain) that correlated with increased expression of γ-secretase components and increased Aβ deposition (Satoh et al., 2011; Nogalska et al., 2012). We continue to actively investigate the molecular mechanism(s) by which GSAP modulates Aβ accumulation.
Two research groups (Hussain et al., 2013, and Deatherage et al., 2012) have reported failure to reproduce some of the results reported by He et al. We are investigating the basis for these discrepancies.
References:
Netzer WJ, Dou F, Cai D, Veach D, Jean S, Li Y, Bornmann WG, Clarkson B, Xu H, Greengard P.
Gleevec inhibits beta-amyloid production but not Notch cleavage.
Proc Natl Acad Sci U S A. 2003 Oct 14;100(21):12444-9.
PubMed.
He G, Luo W, Li P, Remmers C, Netzer WJ, Hendrick J, Bettayeb K, Flajolet M, Gorelick F, Wennogle LP, Greengard P.
Gamma-secretase activating protein is a therapeutic target for Alzheimer's disease.
Nature. 2010 Sep 2;467(7311):95-8.
PubMed.
Hussain I, Fabrègue J, Anderes L, Ousson S, Borlat F, Eligert V, Berger S, Dimitrov M, Alattia JR, Fraering PC, Beher D.
The Role of γ-Secretase Activating Protein (GSAP) and Imatinib in the Regulation of γ-Secretase Activity and Amyloid-β Generation.
J Biol Chem. 2013 Jan 25;288(4):2521-31.
PubMed.
Arslanova D, Yang T, Xu X, Wong ST, Augelli-Szafran CE, Xia W.
Phenotypic analysis of images of zebrafish treated with Alzheimer's gamma-secretase inhibitors.
BMC Biotechnol. 2010;10:24.
PubMed.
Eisele YS, Baumann M, Klebl B, Nordhammer C, Jucker M, Kilger E.
Gleevec increases levels of the amyloid precursor protein intracellular domain and of the amyloid-beta degrading enzyme neprilysin.
Mol Biol Cell. 2007 Sep;18(9):3591-600.
PubMed.
Mertens J, Stüber K, Wunderlich P, Ladewig J, Kesavan JC, Vandenberghe R, Vandenbulcke M, van Damme P, Walter J, Brüstle O, Koch P.
APP Processing in Human Pluripotent Stem Cell-Derived Neurons Is Resistant to NSAID-Based γ-Secretase Modulation.
Stem Cell Reports. 2013;1(6):491-8. Epub 2013 Dec 5
PubMed.
Olsson B, Legros L, Guilhot F, Strömberg K, Smith J, Livesey FJ, Wilson DH, Zetterberg H, Blennow K.
Imatinib treatment and Aβ42 in humans.
Alzheimers Dement. 2013 Dec 10;
PubMed.
Fraering PC, Ye W, LaVoie MJ, Ostaszewski BL, Selkoe DJ, Wolfe MS.
gamma-Secretase substrate selectivity can be modulated directly via interaction with a nucleotide-binding site.
J Biol Chem. 2005 Dec 23;280(51):41987-96.
PubMed.
Dai H, Marbach P, Lemaire M, Hayes M, Elmquist WF.
Distribution of STI-571 to the brain is limited by P-glycoprotein-mediated efflux.
J Pharmacol Exp Ther. 2003 Mar;304(3):1085-92.
PubMed.
Leis JF, Stepan DE, Curtin PT, Ford JM, Peng B, Schubach S, Druker BJ, Maziarz RT.
Central nervous system failure in patients with chronic myelogenous leukemia lymphoid blast crisis and Philadelphia chromosome positive acute lymphoblastic leukemia treated with imatinib (STI-571).
Leuk Lymphoma. 2004 Apr;45(4):695-8.
PubMed.
Demattos RB, Bales KR, Parsadanian M, O'Dell MA, Foss EM, Paul SM, Holtzman DM.
Plaque-associated disruption of CSF and plasma amyloid-beta (Abeta) equilibrium in a mouse model of Alzheimer's disease.
J Neurochem. 2002 Apr;81(2):229-36.
PubMed.
Ghersi-Egea JF, Gorevic PD, Ghiso J, Frangione B, Patlak CS, Fenstermacher JD.
Fate of cerebrospinal fluid-borne amyloid beta-peptide: rapid clearance into blood and appreciable accumulation by cerebral arteries.
J Neurochem. 1996 Aug;67(2):880-3.
PubMed.
Shibata M, Yamada S, Kumar SR, Calero M, Bading J, Frangione B, Holtzman DM, Miller CA, Strickland DK, Ghiso J, Zlokovic BV.
Clearance of Alzheimer's amyloid-ss(1-40) peptide from brain by LDL receptor-related protein-1 at the blood-brain barrier.
J Clin Invest. 2000 Dec;106(12):1489-99.
PubMed.
Satoh J, Tabunoki H, Ishida T, Saito Y, Arima K.
Immunohistochemical characterization of gamma-secretase activating protein expression in Alzheimer's disease brains.
Neuropathol Appl Neurobiol. 2011 Jun 30;
PubMed.
Nogalska A, D'Agostino C, Engel WK, Askanas V.
Activation of the γ-secretase complex and presence of γ-secretase-activating protein may contribute to Aβ42 production in sporadic inclusion-body myositis muscle fibers.
Neurobiol Dis. 2012 Oct;48(1):141-9.
PubMed.
Deatherage CL, Hadziselimovic A, Sanders CR.
Purification and characterization of the human γ-secretase activating protein.
Biochemistry. 2012 Jun 26;51(25):5153-9.
PubMed.
We read with interest the response by Netzer, Greengard, and colleagues. It is clear that we have different views not only on the biological effect of GSAP but also on Αβ (patho)physiology in general.
There are some strong claims in the response, e.g., "that most plasma Αβ is derived from the CNS." Netzer and Greengard cite some papers, which they claim support this statement. One of these (Ghersi-Egea et al., 1996) showed that a large portion of Αβ40 injected into lateral ventricle CSF of normal rats ends up in blood, while another (Shibata et al., 2000) showed that Αβ40 injected into brains of mice is cleared from it by the LRP-1 receptor. Although interesting in themselves, these articles do not tell us whether or not most plasma Αβ is derived from the CNS.
There are many additional papers, not cited by Netzer and Greengard, that are highly relevant for the question of whether plasma Αβ is CNS-derived. Walker and co-workers showed that intravenous administration of a fusion protein of the Aβ-degrading enzyme neprilysin (NEP), which resembles the orientation of the native NEP in membranes, in mice resulted in a fast and very marked dose-dependent reduction in plasma Aβ without affecting either soluble or formic acid-extractable brain Aβ levels, or CSF Aβ levels (Walker et al., 2013). These results also have been confirmed using NEP engineered to have an extended plasma half-life and an increased Aβ degradation activity. In long-term studies on mice, rats, and monkeys, a marked decrease of Aβ was found in plasma without any change in brain or CSF Aβ levels (Henderson et al., 2014). This paper was also commented on at the AlzForum website.
Further, pharmacodynamic studies in man on BACE1 inhibitors also show that the decrease in plasma Aβ is much faster, and also more pronounced, than the decrease in CSF Aβ (May et al., 2011). Similar results were found in a Phase 2 trial on a gamma-secretase inhibitor (Fleisher et al., 2008).
Taken together, neither the NEP studies in animals nor the clinical trials in man support the existence of any robust peripheral Aβ efflux sink, and thus do not support "that most plasma Αβ is derived from the CNS."
Last, it well known that Aβ is generated in considerable amounts in many organs and cell types outside the CNS, such as platelets, the neuromuscular junctions of skeletal muscle, and arterial walls (Li et al., 1998; Kuo et al., 2000; Roher et al., 2009). Undoubtedly, these peripheral organs contribute to the pool of circulating Aβ in plasma.
In summary, the literature suggests that there is a (large) pool of Αβ in the plasma that is not derived from the CNS, and that compounds that suppress amyloidogenic processing of APP can shrink that pool. We found no such effect in patients treated with imatinib. We are happy to see continued discussion on the important topic of validating data from cell and animal experiments by translational studies in humans. However, the statement by Netzer and Greengard that "the data of Hussain et al. and Olsson et al. are irrelevant to any assessment of the potential for therapeutic success using a CNS imatinib-like compound or a GSAP-modulating compound" seems to be based on a misconception due to selective referencing of available data. Instead, an unbiased literature review tells us that the forecast of imatinib-like or GSAP-modifying compounds as Aβ-lowering therapies in AD does not look bright.
References:
Walker JR, Pacoma R, Watson J, Ou W, Alves J, Mason DE, Peters EC, Urbina HD, Welzel G, Althage A, Liu B, Tuntland T, Jacobson LH, Harris JL, Schumacher AM.
Enhanced proteolytic clearance of plasma Aβ by peripherally administered neprilysin does not result in reduced levels of brain Aβ in mice.
J Neurosci. 2013 Feb 6;33(6):2457-64.
PubMed.
Henderson SJ, Andersson C, Narwal R, Janson J, Goldschmidt TJ, Appelkvist P, Bogstedt A, Steffen AC, Haupts U, Tebbe J, Freskgård PO, Jermutus L, Burrell M, Fowler SB, Webster CI.
Sustained peripheral depletion of amyloid-β with a novel form of neprilysin does not affect central levels of amyloid-β.
Brain. 2014 Feb;137(Pt 2):553-64. Epub 2013 Nov 20
PubMed.
May PC, Dean RA, Lowe SL, Martenyi F, Sheehan SM, Boggs LN, Monk SA, Mathes BM, Mergott DJ, Watson BM, Stout SL, Timm DE, Smith Labell E, Gonzales CR, Nakano M, Jhee SS, Yen M, Ereshefsky L, Lindstrom TD, Calligaro DO, Cocke PJ, Greg Hall D, Friedrich S, Citron M, Audia JE.
Robust central reduction of amyloid-β in humans with an orally available, non-peptidic β-secretase inhibitor.
J Neurosci. 2011 Nov 16;31(46):16507-16.
PubMed.
Fleisher AS, Raman R, Siemers ER, Becerra L, Clark CM, Dean RA, Farlow MR, Galvin JE, Peskind ER, Quinn JF, Sherzai A, Sowell BB, Aisen PS, Thal LJ.
Phase 2 safety trial targeting amyloid beta production with a gamma-secretase inhibitor in Alzheimer disease.
Arch Neurol. 2008 Aug;65(8):1031-8.
PubMed.
Kuo YM, Kokjohn TA, Watson MD, Woods AS, Cotter RJ, Sue LI, Kalback WM, Emmerling MR, Beach TG, Roher AE.
Elevated abeta42 in skeletal muscle of Alzheimer disease patients suggests peripheral alterations of AbetaPP metabolism.
Am J Pathol. 2000 Mar;156(3):797-805.
PubMed.
Li QX, Whyte S, Tanner JE, Evin G, Beyreuther K, Masters CL.
Secretion of Alzheimer's disease Abeta amyloid peptide by activated human platelets.
Lab Invest. 1998 Apr;78(4):461-9.
PubMed.
Roher AE, Esh CL, Kokjohn TA, Castaño EM, Van Vickle GD, Kalback WM, Patton RL, Luehrs DC, Daugs ID, Kuo YM, Emmerling MR, Soares H, Quinn JF, Kaye J, Connor DJ, Silverberg NB, Adler CH, Seward JD, Beach TG, Sabbagh MN.
Amyloid beta peptides in human plasma and tissues and their significance for Alzheimer's disease.
Alzheimers Dement. 2009 Jan;5(1):18-29.
PubMed.
Ghersi-Egea JF, Gorevic PD, Ghiso J, Frangione B, Patlak CS, Fenstermacher JD.
Fate of cerebrospinal fluid-borne amyloid beta-peptide: rapid clearance into blood and appreciable accumulation by cerebral arteries.
J Neurochem. 1996 Aug;67(2):880-3.
PubMed.
Shibata M, Yamada S, Kumar SR, Calero M, Bading J, Frangione B, Holtzman DM, Miller CA, Strickland DK, Ghiso J, Zlokovic BV.
Clearance of Alzheimer's amyloid-ss(1-40) peptide from brain by LDL receptor-related protein-1 at the blood-brain barrier.
J Clin Invest. 2000 Dec;106(12):1489-99.
PubMed.
Comments
University of Goteborg, Sahlgrenska University Hospital
University of Gothenburg
University of Gothenburg
We welcome a discussion on the problem with irreproducibility of published research that we recently encountered, as outlined in the Alzforum news story. In this context, the recent editorial guidelines from Nature might represent one step to reduce this problem. A checklist for methodological and statistical information, together with unlimited space for methods, statistical description, and access to raw data, are commendable. In our mind, however, at least two problems remain. One is related to the difference in the requirement of independent replication between clinical and preclinical research, another to the technical requirements on the methods used for quantifying biochemical changes. Due to the issue with poor replication of results, Nature Genetics stipulated that novel genetic associations must be verified in at least two independent cohorts. Correspondingly, replication in independent cohorts is a core feature of any high-quality publication in clinical biomarker research (Bossuyt et al., 2004). In contrast, in high-impact basic research journals, publication is common with very small numbers of inbred animals or cell experiments, without replication in independent sets. One example is the imatinib/GSAP paper (He et al., 2010), in which many critical conclusions were based on n=3 experiments, a number that actually is too low to do statistical calculations. We appreciate that the variability in animal models may be lower than in clinical samples, but at the same time these models may be highly skewed and not representative of the clinical disease they are supposed to reflect (Begley et al., 2012). To reduce the problem with irreproducibility, any finding should be replicated in two independent disease models, or at least two independent experiments with a number of cell cultures or animals that allows proper statistical testing. Another bias is related to the methodology used for quantification. Clinical studies often include validated methods and provide data on assay performance, e.g., between-run variability. In contrast, it is common in basic research to use non-validated semi-quantitative methods, e.g., Western blot, without presenting any information on method precision, variability, or specificity. For this, again, the imatinib/GSAP paper can serve as an example (He et al.). In our view, such low-quality quantitative data may underlie irreproducibility, yet high-impact journals are full of them. We believe that addressing these two problems, in addition to the actions presented in the recent editorial, will solve a large part of the problem with irreproducible data from preclinical research.
References:
Announcement: Reducing our irreproducibility. Nature 496, 398 (2013).
Framework for a fully powered risk engine. Nat Genet. 2005 Nov;37(11):1153. PubMed.
Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig LM, Lijmer JG, Moher D, Rennie D, de Vet HC, STARD Group. Towards complete and accurate reporting of studies of diagnostic accuracy: the STARD initiative. Fam Pract. 2004 Feb;21(1):4-10. PubMed.
He G, Luo W, Li P, Remmers C, Netzer WJ, Hendrick J, Bettayeb K, Flajolet M, Gorelick F, Wennogle LP, Greengard P. Gamma-secretase activating protein is a therapeutic target for Alzheimer's disease. Nature. 2010 Sep 2;467(7311):95-8. PubMed.
Begley CG, Ellis LM. Drug development: Raise standards for preclinical cancer research. Nature. 2012 Mar 28;483(7391):531-3. PubMed.
View all comments by Bob OlssonFrench National Centre for Scientific Research
I have not tried to replicate He et al. 2010 myself, so I can only comment based on my readings about this topic. I am particularly interested in the regulation of γ-secretase, and carefully followed the research about GSAP. Two papers report a lack of interaction between GSAP and APP-CTFβ, also called C99 (Hussain et al., 2013, and Deatherage et al., 2012). Moreover, Hussain et al. report that GSAP has no effect on γ-secretase mediated ε cleavages of both APP and Notch (Fig. 5 and 6). Finally, Hussain et al. report that imatinib does not lower Aβ in rats in vivo. However, while we were particularly interested in the findings by He et al., we mentioned in a recent review (Barthet et al., 2012) some discrepancies found in the paper. Most notably, the authors reported that GSAP stimulates production of Aβ while it reduces AICD, the product of γ-secretase cleavage of APP at the ε site, a phenomenon that is difficult to conceive. Finally, the paper by Olsson et al. in Alzheimer’s & Dementia reports that imatinib does not reduce Aβ in humans. All together, three independent groups report evidence that raises doubts about the effects of imatinib and GSAP on γ-secretase.
References:
Hussain I, Fabrègue J, Anderes L, Ousson S, Borlat F, Eligert V, Berger S, Dimitrov M, Alattia JR, Fraering PC, Beher D. The Role of γ-Secretase Activating Protein (GSAP) and Imatinib in the Regulation of γ-Secretase Activity and Amyloid-β Generation. J Biol Chem. 2013 Jan 25;288(4):2521-31. PubMed.
Deatherage CL, Hadziselimovic A, Sanders CR. Purification and characterization of the human γ-secretase activating protein. Biochemistry. 2012 Jun 26;51(25):5153-9. PubMed.
Barthet G, Georgakopoulos A, Robakis NK. Cellular mechanisms of γ-secretase substrate selection, processing and toxicity. Prog Neurobiol. 2012 Aug;98(2):166-75. PubMed.
Olsson B, Legros L, Guilhot F, Strömberg K, Smith J, Livesey FJ, Wilson DH, Zetterberg H, Blennow K. Imatinib treatment and Aβ42 in humans. Alzheimers Dement. 2013 Dec 10; PubMed.
View all comments by Gael BarthetUniversity of Cincinnati College of Medicine
I did not try to reproduce He et al. 2010 myself but agree with the shortcomings of this data as reported in this story. If patient data suggest there will be no efficacy, I question whether it is worth resolving the remaining data discrepancies at this point.
View all comments by Raphael KopanThe University of Chicago
Unfortunately, many studies in the AD field have failed to be replicated and it is then difficult to get these data published. Journals tend to be reluctant to publish out of concern that failed replication studies might tarnish their image. I have been moderately successful in publishing failed replications, but it takes an enormous effort. Without such publication, however, the original paper continues to get cited, often with a reference to the effect of “but these findings are somewhat controversial." We should also acknowledge a real fear of retaliation in our community. Given very competitive NIH funding and promotions on the line, not everyone wants to antagonize a colleague who might be a future reviewer, even if it is the right thing to do.
View all comments by Sangram SisodiaArmada TX
The irreproducibility of the literature data also impacts the speed and cost of discovering new therapies. The commitment to start an industry drug-discovery program is an expensive proposition, and risky if based only on the scientific literature because of the knowledge gaps created by the bias against publishing negative and contradictory findings. The biology is rarely as straightforward as presented in the first few publications on a new target. Thus, companies have to conduct internal research to fill in the knowledge gaps, and for competitive reasons, that knowledge is not made public immediately.
The shrinking of industry drug-discovery groups results in fewer scientists working on target identification and a movement toward well-documented targets, which in turn results in homogenization of industry pipelines. Innovation and the discovery of game-changing therapies slows.
Journals could help to address this problem by acknowledging the value of work that both replicates the data of others as well as work that may bring into question conclusions of previous papers. With the societal costs and human suffering that results from Alzheimer's disease, this field in particular needs to acknowledge the issue of publication biases.
View all comments by Barbara TateThe Rockefeller University
Co-authored by William Netzer and Paul Greengard, The Rockefeller University; Yueming Li and Darren Veach, Memorial Sloan-Kettering Cancer Center; Wenjie Luo, Weill Cornell Medical College; Fred Gorelick, Yale University School of Medicine; and Dongming Cai and Sam Gandy, Icahn School of Medicine at Mount Sinai, New York.
Madolyn Rogers’ news article, and some of the comments in response to that article, draw attention to interlaboratory variability in the replication of two studies published by our research group. In our original paper on this topic (Netzer et al., 2003), we reported that Gleevec (imatinib) reduced Aβ generation in cell culture and in vivo in guinea pig brain. In the second paper (He et al., 2010), we described the identification of γ–secretase-activating protein (GSAP), an endogenous regulator of Aβ formation. Here we focus primarily on studies published subsequent to Netzer et al. that have evaluated the Aβ-lowering effects of imatinib.
Studies of imatinib in intact cell systems
Netzer et al. reported that imatinib lowered Aβ40 levels in rat primary neurons and lowered Aβ40 and 42 in N2a (mouse neuroblastoma) cells stably transfected with APP 695 or PS1ΔE9/APP Swe. Subsequent to that publication, we tested imatinib in Chinese hamster ovary cells transfected with wild-type human APP695 (CHO-hAPP), in 3T3 fibroblasts transfected with wild-type human APP695, and in mouse embryonic fibroblasts (MEFs) transfected with Swedish mutant human APP695. In each of these three cell lines, imatinib reduced total Aβ by 40 to 80 percent (Netzer, unpublished results). The observation that imatinib reduces Aβ generation in five different cell types—namely rat primary neurons, N2a, CHO, 3T3, and MEF cells—does not exclude the possibility that some cell types or cell lines might be resistant to imatinib-induced reduction in Aβ generation (see below).
Independent confirmation of the imatinib effect in the cell types used by Netzer et al. (2003)
Hussain et al. confirmed in N2a cells our published observations (in that same cell line) that imatinib causes a 50 to 60 percent reduction in Aβ40 and 42 secretion.
Arslanova et al. tested 100 μM imatinib in CHO-hAPP cells in culture and demonstrated that secretion of Aβ40 and 42 was reduced by 30 percent and 80 percent, respectively. The published results of Arslanova et al. were confirmed in the unpublished studies of Netzer mentioned above.
Extension of the studies of Netzer et al. (2003) to three additional cell types
Eisele et al. extended the list of imatinib-responsive cells to include H4-APPwt cells in their demonstration of an effect of imatinib on Aβ generation over a drug concentration range of 3.7 to 20μM. A 50 percent reduction in secretion of Aβ40 and 42 was observed in the presence of 10μM imatinib.
Hussain et al. tested imatinib in SHSY5Y-SPA4CT cells and found that 10μM imatinib reduced secretion of Αβ40 and 42 by about 40 percent, adding yet another cell line to the roster of those that display imatinib-responsive Αβ generation.
Mertens et al. reported that 10μΜ imatinib lowered Aβ40 and 42 secretion by 70 percent and 75 percent, respectively, in human differentiated neurons in culture, consistent with our observations using rat primary neuronal cultures.
Failure to replicate the imatinib effect in three previously untested cell types
Olsson et al. reported the only published failure to reproduce the imatinib effect in intact cells. They reported that imatinib does not lower Aβ42 secretion from either: (i) HEK293 cells (stably transfected with human APP Swe); (ii) human Down’s syndrome embryonic stem cell-derived cortical projection neurons; or (iii) mouse primary cortical neurons. The protocol published by Olsson et al. provided no obvious explanation for why their results differed from those derived from multiple other cell types in the hands of multiple other investigators. As of this writing, we are unaware of any other laboratory that has tested any of the cell types used by Olsson et al. At present, we cannot determine whether the Olsson results are technical in nature or whether all the cell types they studied are imatinib-resistant.
In summary, four of the five studies published since Netzer et al. have confirmed the Aβ-lowering effect of imatinib in cell culture. We have been unable to identify any obvious explanation for this disparity in careful scrutiny of the published protocols from those failing to replicate the imatinib effect. In an effort to resolve the issue as efficiently as possible, we would welcome visits to our laboratory by any scientists seeking a detailed demonstration of our methods of measuring the effect of imatinib on Aβ secretion by cultured cells.
Demonstration of the imatinib effect in a cell-free system
In addition to the results obtained in intact cell systems, a study by Fraering et al. reported that 75μM imatinib reduced Aβ40 and 42 formation by 50 percent in a cell-free γ–secretase assay.
Studies of imatinib in intact rodents and in humans
Netzer et al. reported that continuous intrathecal infusion of imatinib by osmotic pump reduced Aβ levels in the intact guinea pig brain. Intrathecal infusion was chosen as the route of administration because imatinib is rapidly pumped out of the brain by the p-glycoprotein pump (PGP) at the blood-brain-barrier (see Dai et al., 2003). As a result of robust PGP action, imatinib that is peripherally injected or ingested will appear in brain only to a negligible extent (Leis et al.). For this reason, Netzer et al. explicitly stated that imatinib administered peripherally would not be useful as a therapeutic for Alzheimer’s disease (AD). Nevertheless, both Hussain et al. (i.p. imatinib in rats) and Olsson et al. (oral imatinib in humans) studied the effects of peripherally injected or orally ingested imatinib. Since most plasma Αβ is derived from the CNS (DeMattos et al., 2002; Ghersi-Egea et al., 1996; Shibata et al., 2000), the failures of Hussain et al. and Olsson et al. to observe Αβ–reducing effects of peripherally injected or orally ingested imatinib on brain or plasma Aβ levels were the predicted results. Therefore, the data of Hussain et al. and Olsson et al. are irrelevant to any assessment of the potential for therapeutic success using a CNS imatinib-like compound or a GSAP-modulating compound.
Since we remain interested in developing an AD therapeutic based on imatinib, the Olsson et al. study in humans merits particular attention. These investigators measured plasma Aβ42 levels in chronic myelogenous leukemia patients (n = 51) before and during treatment with imatinib. They estimated that plasma concentrations of imatinib in these patients was 1.46 μM (the concentration of imatinib in the brain would have been much lower). We have only observed reductions in Aβ secretion by imatinib for imatinib concentrations of 5μΜ or greater (Netzer, unpublished results). Thus, the dose employed by Olsson et al. would not be expected to have an impact on peripheral generation of Aβ (if any such Aβ generation exists).
Studies of GSAP
With respect to GSAP, four members of our laboratory and one publication from another laboratory (Hussain et al., 2013) have confirmed the observation reported in He et al. that GSAP knockdown reduces Aβ secretion by cells in culture. There have been no contradictory publications reporting a failure of GSAP knockdown to lower Aβ secretion in intact cells. Two additional groups reported higher expression levels of GSAP in human tissues (including AD brain) that correlated with increased expression of γ-secretase components and increased Aβ deposition (Satoh et al., 2011; Nogalska et al., 2012). We continue to actively investigate the molecular mechanism(s) by which GSAP modulates Aβ accumulation.
Two research groups (Hussain et al., 2013, and Deatherage et al., 2012) have reported failure to reproduce some of the results reported by He et al. We are investigating the basis for these discrepancies.
References:
Netzer WJ, Dou F, Cai D, Veach D, Jean S, Li Y, Bornmann WG, Clarkson B, Xu H, Greengard P. Gleevec inhibits beta-amyloid production but not Notch cleavage. Proc Natl Acad Sci U S A. 2003 Oct 14;100(21):12444-9. PubMed.
He G, Luo W, Li P, Remmers C, Netzer WJ, Hendrick J, Bettayeb K, Flajolet M, Gorelick F, Wennogle LP, Greengard P. Gamma-secretase activating protein is a therapeutic target for Alzheimer's disease. Nature. 2010 Sep 2;467(7311):95-8. PubMed.
Hussain I, Fabrègue J, Anderes L, Ousson S, Borlat F, Eligert V, Berger S, Dimitrov M, Alattia JR, Fraering PC, Beher D. The Role of γ-Secretase Activating Protein (GSAP) and Imatinib in the Regulation of γ-Secretase Activity and Amyloid-β Generation. J Biol Chem. 2013 Jan 25;288(4):2521-31. PubMed.
Arslanova D, Yang T, Xu X, Wong ST, Augelli-Szafran CE, Xia W. Phenotypic analysis of images of zebrafish treated with Alzheimer's gamma-secretase inhibitors. BMC Biotechnol. 2010;10:24. PubMed.
Eisele YS, Baumann M, Klebl B, Nordhammer C, Jucker M, Kilger E. Gleevec increases levels of the amyloid precursor protein intracellular domain and of the amyloid-beta degrading enzyme neprilysin. Mol Biol Cell. 2007 Sep;18(9):3591-600. PubMed.
Mertens J, Stüber K, Wunderlich P, Ladewig J, Kesavan JC, Vandenberghe R, Vandenbulcke M, van Damme P, Walter J, Brüstle O, Koch P. APP Processing in Human Pluripotent Stem Cell-Derived Neurons Is Resistant to NSAID-Based γ-Secretase Modulation. Stem Cell Reports. 2013;1(6):491-8. Epub 2013 Dec 5 PubMed.
Olsson B, Legros L, Guilhot F, Strömberg K, Smith J, Livesey FJ, Wilson DH, Zetterberg H, Blennow K. Imatinib treatment and Aβ42 in humans. Alzheimers Dement. 2013 Dec 10; PubMed.
Fraering PC, Ye W, LaVoie MJ, Ostaszewski BL, Selkoe DJ, Wolfe MS. gamma-Secretase substrate selectivity can be modulated directly via interaction with a nucleotide-binding site. J Biol Chem. 2005 Dec 23;280(51):41987-96. PubMed.
Dai H, Marbach P, Lemaire M, Hayes M, Elmquist WF. Distribution of STI-571 to the brain is limited by P-glycoprotein-mediated efflux. J Pharmacol Exp Ther. 2003 Mar;304(3):1085-92. PubMed.
Leis JF, Stepan DE, Curtin PT, Ford JM, Peng B, Schubach S, Druker BJ, Maziarz RT. Central nervous system failure in patients with chronic myelogenous leukemia lymphoid blast crisis and Philadelphia chromosome positive acute lymphoblastic leukemia treated with imatinib (STI-571). Leuk Lymphoma. 2004 Apr;45(4):695-8. PubMed.
Demattos RB, Bales KR, Parsadanian M, O'Dell MA, Foss EM, Paul SM, Holtzman DM. Plaque-associated disruption of CSF and plasma amyloid-beta (Abeta) equilibrium in a mouse model of Alzheimer's disease. J Neurochem. 2002 Apr;81(2):229-36. PubMed.
Ghersi-Egea JF, Gorevic PD, Ghiso J, Frangione B, Patlak CS, Fenstermacher JD. Fate of cerebrospinal fluid-borne amyloid beta-peptide: rapid clearance into blood and appreciable accumulation by cerebral arteries. J Neurochem. 1996 Aug;67(2):880-3. PubMed.
Shibata M, Yamada S, Kumar SR, Calero M, Bading J, Frangione B, Holtzman DM, Miller CA, Strickland DK, Ghiso J, Zlokovic BV. Clearance of Alzheimer's amyloid-ss(1-40) peptide from brain by LDL receptor-related protein-1 at the blood-brain barrier. J Clin Invest. 2000 Dec;106(12):1489-99. PubMed.
Satoh J, Tabunoki H, Ishida T, Saito Y, Arima K. Immunohistochemical characterization of gamma-secretase activating protein expression in Alzheimer's disease brains. Neuropathol Appl Neurobiol. 2011 Jun 30; PubMed.
Nogalska A, D'Agostino C, Engel WK, Askanas V. Activation of the γ-secretase complex and presence of γ-secretase-activating protein may contribute to Aβ42 production in sporadic inclusion-body myositis muscle fibers. Neurobiol Dis. 2012 Oct;48(1):141-9. PubMed.
Deatherage CL, Hadziselimovic A, Sanders CR. Purification and characterization of the human γ-secretase activating protein. Biochemistry. 2012 Jun 26;51(25):5153-9. PubMed.
View all comments by William NetzerUniversity of Goteborg, Sahlgrenska University Hospital
University of Gothenburg
University of Gothenburg
We read with interest the response by Netzer, Greengard, and colleagues. It is clear that we have different views not only on the biological effect of GSAP but also on Αβ (patho)physiology in general.
There are some strong claims in the response, e.g., "that most plasma Αβ is derived from the CNS." Netzer and Greengard cite some papers, which they claim support this statement. One of these (Ghersi-Egea et al., 1996) showed that a large portion of Αβ40 injected into lateral ventricle CSF of normal rats ends up in blood, while another (Shibata et al., 2000) showed that Αβ40 injected into brains of mice is cleared from it by the LRP-1 receptor. Although interesting in themselves, these articles do not tell us whether or not most plasma Αβ is derived from the CNS.
There are many additional papers, not cited by Netzer and Greengard, that are highly relevant for the question of whether plasma Αβ is CNS-derived. Walker and co-workers showed that intravenous administration of a fusion protein of the Aβ-degrading enzyme neprilysin (NEP), which resembles the orientation of the native NEP in membranes, in mice resulted in a fast and very marked dose-dependent reduction in plasma Aβ without affecting either soluble or formic acid-extractable brain Aβ levels, or CSF Aβ levels (Walker et al., 2013). These results also have been confirmed using NEP engineered to have an extended plasma half-life and an increased Aβ degradation activity. In long-term studies on mice, rats, and monkeys, a marked decrease of Aβ was found in plasma without any change in brain or CSF Aβ levels (Henderson et al., 2014). This paper was also commented on at the AlzForum website.
Further, pharmacodynamic studies in man on BACE1 inhibitors also show that the decrease in plasma Aβ is much faster, and also more pronounced, than the decrease in CSF Aβ (May et al., 2011). Similar results were found in a Phase 2 trial on a gamma-secretase inhibitor (Fleisher et al., 2008).
Taken together, neither the NEP studies in animals nor the clinical trials in man support the existence of any robust peripheral Aβ efflux sink, and thus do not support "that most plasma Αβ is derived from the CNS."
Last, it well known that Aβ is generated in considerable amounts in many organs and cell types outside the CNS, such as platelets, the neuromuscular junctions of skeletal muscle, and arterial walls (Li et al., 1998; Kuo et al., 2000; Roher et al., 2009). Undoubtedly, these peripheral organs contribute to the pool of circulating Aβ in plasma.
In summary, the literature suggests that there is a (large) pool of Αβ in the plasma that is not derived from the CNS, and that compounds that suppress amyloidogenic processing of APP can shrink that pool. We found no such effect in patients treated with imatinib. We are happy to see continued discussion on the important topic of validating data from cell and animal experiments by translational studies in humans. However, the statement by Netzer and Greengard that "the data of Hussain et al. and Olsson et al. are irrelevant to any assessment of the potential for therapeutic success using a CNS imatinib-like compound or a GSAP-modulating compound" seems to be based on a misconception due to selective referencing of available data. Instead, an unbiased literature review tells us that the forecast of imatinib-like or GSAP-modifying compounds as Aβ-lowering therapies in AD does not look bright.
References:
Walker JR, Pacoma R, Watson J, Ou W, Alves J, Mason DE, Peters EC, Urbina HD, Welzel G, Althage A, Liu B, Tuntland T, Jacobson LH, Harris JL, Schumacher AM. Enhanced proteolytic clearance of plasma Aβ by peripherally administered neprilysin does not result in reduced levels of brain Aβ in mice. J Neurosci. 2013 Feb 6;33(6):2457-64. PubMed.
Henderson SJ, Andersson C, Narwal R, Janson J, Goldschmidt TJ, Appelkvist P, Bogstedt A, Steffen AC, Haupts U, Tebbe J, Freskgård PO, Jermutus L, Burrell M, Fowler SB, Webster CI. Sustained peripheral depletion of amyloid-β with a novel form of neprilysin does not affect central levels of amyloid-β. Brain. 2014 Feb;137(Pt 2):553-64. Epub 2013 Nov 20 PubMed.
May PC, Dean RA, Lowe SL, Martenyi F, Sheehan SM, Boggs LN, Monk SA, Mathes BM, Mergott DJ, Watson BM, Stout SL, Timm DE, Smith Labell E, Gonzales CR, Nakano M, Jhee SS, Yen M, Ereshefsky L, Lindstrom TD, Calligaro DO, Cocke PJ, Greg Hall D, Friedrich S, Citron M, Audia JE. Robust central reduction of amyloid-β in humans with an orally available, non-peptidic β-secretase inhibitor. J Neurosci. 2011 Nov 16;31(46):16507-16. PubMed.
Fleisher AS, Raman R, Siemers ER, Becerra L, Clark CM, Dean RA, Farlow MR, Galvin JE, Peskind ER, Quinn JF, Sherzai A, Sowell BB, Aisen PS, Thal LJ. Phase 2 safety trial targeting amyloid beta production with a gamma-secretase inhibitor in Alzheimer disease. Arch Neurol. 2008 Aug;65(8):1031-8. PubMed.
Kuo YM, Kokjohn TA, Watson MD, Woods AS, Cotter RJ, Sue LI, Kalback WM, Emmerling MR, Beach TG, Roher AE. Elevated abeta42 in skeletal muscle of Alzheimer disease patients suggests peripheral alterations of AbetaPP metabolism. Am J Pathol. 2000 Mar;156(3):797-805. PubMed.
Li QX, Whyte S, Tanner JE, Evin G, Beyreuther K, Masters CL. Secretion of Alzheimer's disease Abeta amyloid peptide by activated human platelets. Lab Invest. 1998 Apr;78(4):461-9. PubMed.
Roher AE, Esh CL, Kokjohn TA, Castaño EM, Van Vickle GD, Kalback WM, Patton RL, Luehrs DC, Daugs ID, Kuo YM, Emmerling MR, Soares H, Quinn JF, Kaye J, Connor DJ, Silverberg NB, Adler CH, Seward JD, Beach TG, Sabbagh MN. Amyloid beta peptides in human plasma and tissues and their significance for Alzheimer's disease. Alzheimers Dement. 2009 Jan;5(1):18-29. PubMed.
Ghersi-Egea JF, Gorevic PD, Ghiso J, Frangione B, Patlak CS, Fenstermacher JD. Fate of cerebrospinal fluid-borne amyloid beta-peptide: rapid clearance into blood and appreciable accumulation by cerebral arteries. J Neurochem. 1996 Aug;67(2):880-3. PubMed.
Shibata M, Yamada S, Kumar SR, Calero M, Bading J, Frangione B, Holtzman DM, Miller CA, Strickland DK, Ghiso J, Zlokovic BV. Clearance of Alzheimer's amyloid-ss(1-40) peptide from brain by LDL receptor-related protein-1 at the blood-brain barrier. J Clin Invest. 2000 Dec;106(12):1489-99. PubMed.
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