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Neuron, Vol.

32, 181184, October 25, 2001, Copyright 2001 by Cell Press

New Frontiers in
Alzheimers Disease Genetics
Rudolph E. Tanzi1 and Lars Bertram
Genetics and Aging Research Unit
Center for Aging, Genetics, and Neurodegeneration
Department of Neurology
Massachusetts General Hospital
114 16th Street
Charlestown, Massachusetts 02129

Alzheimers disease (AD) is a genetically complex disorder that accounts for the majority of dementia in
the elderly population. Over 100 rare, highly penetrant
mutations have been described in three genes (APP,
PSEN1, PSEN2) for early-onset familial AD. In the more
common late-onset form, a polymorphism in the apolipoprotein E gene has been associated with increased
susceptibility. However, recent studies suggest that
these four genes account for less than 30% of the
genetic variance for AD and that more genetic factors
remain to be identified. In this review, we present a
brief history of AD genetics and preview some of the
next frontiers in Alzheimer gene discovery primarily
focusing on chromosomes 12, 10, and 9.
Introduction
Alzheimers disease (AD) is the most common form of
age-related dementia and one of the most serious health
problems in the U.S. AD is a progressive and insidious
neurodegenerative disorder of the central nervous system characterized by global deficits in cognition ranging
from loss of memory to impaired judgment and reasoning. Autopsy of AD patients brains reveals abundant
amounts of neurofibrillary tangles and -amyloid in the
form of senile plaques and blood vessel deposits, both
prerequisites for a confirmed diagnosis of AD (Price et
al., 1998). While the complete etiological picture of AD
remains unresolved, the inheritance of predisposing genetic factors appears to play a major role. After age,
family history is the second greatest risk factor for AD.
There is also an emerging consensus that AD is a complex and genetically heterogeneous disorder that is best
explained by an age-dependent dichotomous model
(Tanzi, 1999). AD is considered to be complex because
there is no single (or simple) mode of inheritance that
accounts for its heritability; heterogeneous because mutations and polymorphisms in multiple genes are involved together with nongenetic factors; dichotomous
because early-onset familial AD (EOFAD) mutations are
rare, highly penetrant, and transmitted in an autosomaldominant fashion, while increased risk for late-onset AD
is conferred by common polymorphisms with relatively
low penetrance (but high prevalence). Adding to the
complexity and heterogeneity of AD genetics are currently ill-defined and difficult-to-model gene-to-gene
and gene-to-environment interactions.
Despite these complexities, tremendous progress has
been made over the past two decades in deciphering AD
1

Correspondence: tanzi@helix.mgh.harvard.edu

Minireview

genetics, which has laid the foundation for our current


understanding of the etiological and pathogenic mechanisms underlying AD as well as for the development
of novel approaches for treatment and prevention. As
therapeutic strategies become more effective and our
grasp of AD genetics is strengthened, reliable and comprehensive genetic risk profiling will eventually enable
systematic early-prediction/early-prevention procedures.
In this minireview, we will present a brief history of AD
genetics and discuss its current and future status, focusing on recent findings suggesting the existence of novel
and potentially important AD genes on chromosomes
12, 10, and 9.
Genetics of AD: The Early Days
Initial attempts to understand the role of genetics in AD
in the early 1980s focused on rare multigenerational
families with early-onset (60), autosomal-dominant,
fully penetrant forms of the disease (EOFAD) using conventional linkage analysis (i.e., measuring cosegregation
of a genetic marker with disease phenotype) and subsequent positional cloning. Although the initial findings
showing significant linkage of EOFAD to chromosome
21 in 1987 were later found to be false positive findings
(the same families were actually linked to another AD
locus on chromosome 14, see below), the implied region
harbored a compelling candidate gene for AD mutations:
the gene encoding the amyloid precursor protein (APP).
In 1990, the first APP mutation was discovered in a
pedigree with Dutch type hereditary cerebral hemorrhage with amyloidosis shortly followed by a missense
mutation occurring in the same APP exon (exon 17) in
patients with EOFAD (reviewed in Hardy, 1997; Price et
al., 1998; Tanzi, 1999). Since then, 11 different pathogenetic mutations have been identified in APP, all of which
are missense mutations lying within or close to the domain encoding the A peptide, the major component of
-amyloid in AD (for an overview of all EOFAD mutations,
see the AD Mutation Database at http://molgen-www.
uia.ac.be/ADMutations). Although the APP mutations
account for less than 0.1% of all AD cases (Tanzi, 1999),
they carry virtually complete penetrance leading to AD
between the fourth and seventh decades of life.
Only a year after the first EOFAD mutation was found
in APP, a second EOFAD locus was linked to chromosome 14, and the gene was later identified and named
presenilin 1 (PSEN1; reviewed in Hardy 1997; Price et
al., 1998; St George Hyslop, 2000; Tanzi, 1999). PSEN1
encodes a highly conserved polytopic membrane protein that is required for -secretase activity necessary
to liberate A from APP (Haass and De Strooper, 1999).
EOFAD mutations in this gene as well as those in APP
and PSEN2 lead to an increase of secreted A42, the
primary component of -amyloid plaques in the brain
(reviewed in Price et al., 1998; Haass and De Strooper,
1999; Figure 1). Over the last 5 years, it has become
clear that the majority of EOFAD mutations identified to
date reside in PSEN1. Six other EOFAD mutations occur
in a gene encoding a second member of the presenilin
family called presenilin 2 (PSEN2) on chromosome 1.

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Figure 1. Possible Pathogenetic Routes of A Production, Clearance, and Degradation


Early-onset AD genes APP, PSEN1, and PSEN2 along with BACE
(-secretase) are involved in the production of A. The late-onset
AD gene APOE and the putative AD gene -1-antichymotrypsin
(ACT) have been proposed to play roles in the aggregation and
fibrillogenesis of A. APOE and putative AD genes LRP and A2M
may play roles in the clearance of A as follows. Once 2M-A or
apoE-A complexes are internalized by LRP, they may be targeted
for endosomal recycling, lysosomal degradation, or undergo trancytosis across the blood-brain barrier to the plasma. Membrane
APP containing an alternatively spliced Kunitz protease inhibitor
(KPI) domain may also undergo internalization by LRP and generate
A (dotted arrows) via the endocytic pathway. (Note: APP has also
been shown to undergo LRP-independent endocytosis.) Extracellular degradation of A can occur via binding of the peptide to 2M
followed by degradation by an active protease (e.g., trypsin) bound
to the bait region of 2M. Alternatively, A may be degraded by
free proteases, such as the insulin-degrading enzyme (IDE) or
neprilysin (MME). Asterisk (*) denotes established AD genes.

On average, EOFAD mutations in PSEN2 exhibit a later


age of onset than those in APP or PSEN1.
The genetics of late-onset AD (LOAD) is considerably
more difficult to address, because for this form of the
disease even linkage studies performed with arguably
reasonable sample sizes (i.e., 5001000 families) may
not be sufficiently powerful to identify genetic factors
of small or modest effect. Rather, these loci stand a
better chance of detection through studies of association or linkage disequilibrium, i.e., testing for cosegregation of a particular allele(s) and disease phenotype
across individual cases and families, ideally in regions
of established or, at least, suggestive linkage (Figure 2).
It was this type of positional candidate gene strategy
that in 1993 led to the discovery of a common variant,
4, of the gene encoding apolipoprotein E (APOE) as a
risk factor for AD (Strittmatter et al., 1993). In contrast
to all other association-based findings in AD, the association with APOE-4 has been consistently replicated in
a large number of studies across many ethnic groups
and has also been found in early-onset sporadic AD
(for a recent meta-analysis, see Farrer et al., 1997). In
addition to the increased risk exerted by the 4 allele,
several studies have also reported a weak, albeit significant, protective effect for the least frequent allele, 2.
Despite its established association, the APOE-4 allele is neither necessary nor sufficient to cause AD, but
instead operates as a genetic risk modifier by decreas-

ing the age of onset in a dose-dependent manner


(Blacker et al, 1997; Meyer et al., 1998). Some have
estimated that APOE-4 accounts for 50% of the predicted total genetic effect in AD based simply on the
prevalence of this allele in the patient population (versus
the control population where it is closer to 25%). However, a recent and more systematic study on over 700
AD cases from 75 families estimates the actual contribution of this polymorphism to onset of AD to be only
7%9% (Daw et al., 2000). The pathophysiological consequences of APOE-4 in AD include the enhanced accumulation of A in the brains of carriers as well as in
transgenic mice expressing the human 4 allele and
mutant APP (Poirier, 2000; St. George Hyslop, 2000;
Figure 1). Apolipoprotein E normally plays a role in cholesterol transport and lipid metabolism. High plasma
cholesterol, in turn, has been firmly correlated with increased -amyloid deposition in the brain. Interestingly,
cholesterol has also been shown to both increase A
production and to stabilize the peptide in the brains of
transgenic AD mice (Poirier, 2000). Thus, it is possible
that APOE-4 confers risk for AD via a mechanism that
is shared in common with its effect on cardiovascular
disease by increasing a carriers risk for hypercholesterolemia, as this would also elevate accumulation of A.
The Search for Novel AD Genes
Over the last decade, more than three dozen associations have been reported between AD and candidate
genes on nearly every chromosome in the genome.
However, with the exception of APOE, none of these
findings has been consistently replicated (Tanzi, 1999;
Bertram and Tanzi, 2001). A recent study modeling AD
as a quantitative trait locus (i.e., using a continuous
[age of onset] rather than a binary [affected/unaffected]
phenotype definition) reported evidence for the existence of four to seven additional AD susceptibility loci
(or genetic risk factors) besides APOE, and at least one
of these loci was predicted to exert a much greater
effect on AD than APOE (Daw et al., 2000). In addition
to association studies of AD with candidate genes chosen on the basis of pathobiological arguments, complete genome screens have been performed in attempts
to find genetic linkage to novel AD loci. These studies
have revealed candidate AD regions on several different
chromosomes, most notably on chromosomes 12, 10,
and 9 (Kehoe et al., 1999; Pericak-Vance et al., 1997).
Because these latter genomic regions meet the critical
criteria (1) of having been replicated in subsequent, independent studies and (2) of being characterized by both
positive linkage and positive association findings, they
are more likely to represent authentic signals for novel
AD genes and merit further investigation.
Chromosome 12. In the late nineties, genetic linkage
studies from three independent laboratories described
evidence for a putative AD locus on the short arm and
in the vicinity of the centromeric region of chromosome
12 (St. George Hyslop, 2000; Bertram and Tanzi, 2001).
Two of these associated genes encode 2-macroglobulin (A2M) and its receptor, the low-density lipoprotein
receptor-related protein (LRP1), both of which have
been shown to play roles in mediating the clearance
and degradation of A (Tanzi, 1999; Figure 1). LRP also
serves as a receptor for apolipoprotein E and certain
secreted forms of APP. The original association between
A2M was demonstrated using family-based association

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183

Figure 2. Strategy for Identifying Novel AD Genes


Candidate genes are chosen as either positional candidates from
chromosomal regions implicated by genetic linkage studies and/or
as biological candidates implicated by pathobiological studies of
AD. DNA variants (e.g., SNPs) in these candidate genes are tested
for association using either case control or family-based studies.
For those yielding positive association, independent samples are
tested for confirmation. If confirmatory studies are consistently positive, the variant is likely to be pathogenic. If the association cannot
be replicated, the initial results most likely represent a false positive
finding. If confirmation is inconsistent, the possibility of linkage disequilibrium, a minor gene effect (or a false positive finding) must be
considered.

methods (Blacker et al., 1998; Figure 2). However, most


subsequent independent attempts to corroborate this
finding in independent laboratories using mainly the
classical case control design, were negative. In fact, a
recent meta analysis concluded that A2M is not genetically associated with LOAD in white patients or mixed
populations as found in the United States (Koster et
al., 2000). On the other hand, at least nine separate
studies have reported significant association between
polymorphisms in A2M and AD across various ethnic
groups, using either case control or family-based methods (reviewed in Bertram and Tanzi, 2001). Although the
combination of numerous confirmations makes it seem
unlikely that the initial findings were due to type I error
alone, this scenario cannot yet be excluded. However,
an alternative explanation is the presence of linkage
disequilibrium, i.e., cosegregation of the actual (and as
yet undefined) disease predisposing DNA variant and
the originally associated polymorphism(s) in A2M. These
considerations are supported by the results of a haplotype-based study of A2M, showing a firm association
of this locus with AD in the absence of APOE-4 (Verpillat
et al., 2000).
Roughly 50 Mb proximal to A2M lie two additional
candidate AD genes: LRP1 and TFCP2, the latter being
a transcriptional factor located near LRP1. Polymorphisms in these genes have been associated with AD
in case control studies and have been followed by both
replications and refutations (reviewed in Bertram and
Tanzi, 2001). Collectively, the presence of significant
linkage and association in both chromosomal regions
may indicate the existence of two distinct AD genes on
chromosome 12, one being A2M (or a gene nearby) and
the other being LRP1 (or a gene nearby, e.g., TFCP2).
The known interaction of the proteins encoded by A2M

and LRP1, and their demonstrated role in clearing cerebral A (Figure 1) further support the candidacy of these
genes as novel AD loci.
Chromosome 10. Recently, three laboratories reported
significant linkage of LOAD to two regions of the long
arm of chromosome 10 (Bertram et al., 2000; ErtekinTaner et al., 2000; Myers et al., 2000). One study followed
up suggestive linkage results on this chromosome using an affected sibling pair method resulting in significant linkage near 67 Mb. Using a different methodology, a second study (Ertekin-Taner et al., 2000)
performed multipoint linkage analyses in five late-onset
AD families using A plasma levels as a quantitative
phenotype and found significant linkage very close to
the same chromosomal region. The third report (Bertram
et al., 2000) was a candidate gene-driven linkage analysis of 435 families using six genetic markers in a region
of chromosome 10 that lies 40 Mb distal to the one
implicated by the former two studies. The candidate
gene of interest encodes the insulin-degrading enzyme
(IDE) that, together with neprilysin and other proteases,
has been previously suggested to play a major role in
the degradation and clearance of A in brain (see Selkoe,
2001, in this issue of Neuron; Figure 1). Two of the six
markers in this region showed significant linkage to AD.
In addition, one marker, D10S583, displayed significant
association with AD through an under representation of
one of its alleles in affecteds versus unaffecteds, possibly indicating linkage disequilibrium with a disease modifying DNA variant nearby.
Similar to the situation with A2M and LRP on chromosome 12, a large genomic distance (40 Mb) separates
the two linked regions on chromosome 10, and presently
it remains unclear as to whether there are one or two
AD loci on this chromosome. Additional studies of linkage and association/linkage disequilibrium are needed
to identify the putative underlying AD gene(s) (Figure
2). This will also require the identification of sequence
variants in IDE and other candidate genes (e.g. the gene
encoding the urokinase type plasminogen activator
[PLAU], which has been shown to be involved in A
degradation) in families that are strongly linked to this
region as well as those linked to the more proximal
region of chromosome 10 implicated by the two other
linkage studies. Systematic linkage-disequilibrium mapping using high-throughput SNP genotyping should effectively narrow down these candidate gene regions
and eventually lead to the identification of potentially
pathogenic DNA variants in either or both linked sections
of this chromosome (Figure 2).
Chromosome 9. As early as 1995, a case control study
revealed significant association with a common polymorphism in the gene encoding the very low-density
lipoprotein receptor (VLDL-R), which also serves as a
receptor for apolipoprotein E containing lipoproteins,
located at the telomere of the short arm on chromosome
9. As for the other proposed AD risk factors outlined
above, this report was followed by a series of both replications and refutations. Four years later, the genome
scan by Kehoe et al. (1999) reported suggestive evidence of linkage in two regions on chromosome 9: one
25 Mb and the other 100 Mb away from the telomere
of the short arm of this chromosome and VLDL-R. More
recently, significant linkage was reported in autopsy
confirmed AD cases using an overlapping set of families

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184

for the more proximal locus (Pericak-Vance et al., 2000).


Again, the situation on chromosome 9 is reminiscent of
that which has evolved on chromosomes 10 and 12: two
separate linkage signals in two distinct regions of the
same chromosome, which may indicate the presence
of two separate AD genes, but may also be caused by
the same locus. At this point, it remains unclear whether
or not VLDL-R is responsible for the linkage observed
on the short arm of chromosome 9. However, the
strength of the linkage signal(s) observed in two differentalthough not entirely independentstudies clearly
warrant the evaluation of additional candidate genes
and markers on this chromosome.
Conclusion
Genetic analyses of AD over the last two decades have
led to the discovery and firm establishment of roughly
100 rare, highly penetrant, autosomal-dominantly transmitted mutations in three EOFAD genes, as well as to
the identification of one genetic risk-modifying gene for
LOAD. Yet, recent estimates suggest that these four
established AD genes account for less than 30% of the
genetic variance in age of onset for AD and predict that
numerous additional AD genes may exist. According to
the latest findings from various independent laboratories, the most promising locations to search for these
novel AD genes are on chromosomes 12, 10, and 9.
Furthermore, a dichotomy with respect to the impact of
any given genetic variant is emerging from the established data: all EOFAD gene mutations known to date
exhibit low prevalence but nearly complete penetrance,
while, conversely, LOAD DNA variants (located in susceptibility genes) exhibit high prevalence but relatively
low penetrance. This situation is similar to that found in
other common diseases, like breast cancer or diabetes.
It will be crucial to the understanding and further application of AD genetics to see whether or not this dichotomous trend continues as more bona fide AD gene alterations are identified.
Unfortunately, the successful identification of novel
AD genes is facing several major obstacles, in particular
for the more common late-onset form of the disease.
First, AD is a complex and heterogeneous genetic disorder in which numerous genetic factors of only minor
to moderate effect are likely to play simultaneous and
possibly interdependent roles. Thus, lack of power due
to insufficient sample sizes becomes a major concern
while trying to uncover novel AD genes. Second, these
power issues are aggravated by the currently ill-defined
and difficult-to-model effects owing to gene-to-gene
and gene-to-environment interactions in AD etiology and
pathogenesis. Consequently, analytic methodologies that
would allow for incorporation of these interactions stand
the greatest chance of identifying novel and genuine
genetic risk factors for AD. Third, it is important to minimize the chance of false positive findings that occur
in linkage and association studies, alike. Appropriate
measures include: (1) accounting for spurious results
due to population admixture when using case control
designs (e.g. by quantifying the degree of population
admixture or using family-based designs), (2) carefully
adjusting significance thresholds according to the number of tests performed, (3) placing more emphasis on the
consistency of positive results across adjacent markers/
loci when multiple polymorphisms are investigated, and,

most importantly, (4) replicating positive findings in independent datasets.


Fortunately, access to sufficiently large family samples will allow the simultaneous evaluation of linkage
and association, without being subject to the possible
drawbacks of the more classical case control design.
Furthermore, the development of increasingly powerful
and sophisticated genotyping and analytic methodologies will greatly facilitate the large-scale identification
of novel AD genes. This knowledge will eventually engender reliable genetic risk profiling protocols for the
early prediction of AD, and foster the development of
effective therapeutic strategies for the early prevention
and treatment of this devastating disorder.
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