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Original Investigation
July 22, 2019

Lifetime Risk and Heritability of Amyotrophic Lateral Sclerosis

Author Affiliations
  • 1Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
  • 2Smurfit Institute of Genetics, Trinity College Dublin, Dublin, Ireland
JAMA Neurol. 2019;76(11):1367-1374. doi:10.1001/jamaneurol.2019.2044
Key Points

Question  How much do genetic factors contribute to the variation in lifetime risk of developing amyotrophic lateral sclerosis?

Findings  This population-based parent-offspring heritability study found that genetic factors account for half of the variance in the risk of developing amyotrophic lateral sclerosis overall and close to 40% in a population devoid of known gene mutations. Heritability estimates are higher in female-specific pairings, suggesting that the C9orf72 repeat expansion may be transmitted in a sex-dependent manner.

Meaning  Inherited and noninherited factors contribute approximately equally toward amyotrophic lateral sclerosis; even in a population devoid of known gene mutations, amyotrophic lateral sclerosis heritability remains high, supporting ongoing efforts to identify causative genes.


Importance  Heritability describes the proportion of variance in the risk of developing a condition that is explained by genetic factors. Although amyotrophic lateral sclerosis (ALS) is known to have a complex genetic origin, disease heritability remains unclear.

Objectives  To determine the extent of ALS heritability and assess the association of sex with disease transmission.

Design, Setting, and Participants  A prospective population-based parent-offspring heritability study was conducted from January 1, 2008, to December 31, 2017 to assess ALS heritability, and was the first study to assess heritability in the context of known gene mutations of large effect. A total of 1123 incident cases of ALS, diagnosed according to the El Escorial criteria and recorded on the Irish ALS register, were identified. Ninety-two individuals were excluded (non-Irish parental origin [n = 86] and familial ALS [n = 6]), and 1117 patients were included in the final analysis.

Main Outcomes and Measures  Annual age-specific and sex-specific standardized ALS incidence and mortality-adjusted lifetime risk were determined. Sex-specific heritability estimates were calculated for the overall study cohort, for those known to carry the C9orf72 (OMIM 614260) variant, and for those with no known genetic risk.

Results  A total of 32 parent-child ALS dyads were identified during the study period. Affected offspring were younger at the onset of disease (mean age, 52.0 years; 95% CI, 48.8-55.3 years) compared with their parents (mean age, 69.6 years; 95% CI, 62.4-76.9 years; P = .008). Lifetime risk of developing ALS in first-degree relatives of individuals with ALS was increased compared with the general population (1.4% [32 of 2234] vs 0.3% [2.6 of 1000]; P < .001). Mean lifetime heritability of ALS for the overall study cohort was 52.3% (95% CI, 42.9%-61.7%) and 36.9% (95% CI, 19.8%-53.9%) for those with no known genetic risk. Heritability estimates were highest in mother-daughter pairings (66.2%; 95% CI, 58.5%-73.9%).

Conclusions and Relevance  This population-based study confirms that up to 50% of variance in ALS has a genetic basis, and that the presence of the C9orf72 variant is an important determinant of heritability. First-degree relatives of individuals with ALS without a known genetic basis remain at increased risk of developing ALS compared with the general population. A higher heritability estimate in mother-daughter pairings points to a sex-mediated effect that has been previously unrecognized.