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Original Investigation
April 13, 2020

Association of Klotho-VS Heterozygosity With Risk of Alzheimer Disease in Individuals Who Carry APOE4

Author Affiliations
  • 1Department of Neurology and Neurological Sciences, Functional Imaging in Neuropsychiatric Disorders (FIND) Lab, Stanford University, Stanford, California
  • 2Department of Neurosurgery, Stanford University, Stanford, California
  • 3Quantitative Sciences Unit, Stanford Medicine, Stanford, California
JAMA Neurol. Published online April 13, 2020. doi:10.1001/jamaneurol.2020.0414
Key Points

Question  Does Klotho-VS heterozygosity protect against Alzheimer disease (AD) in individuals who carry APOE4?

Findings  In this study, associations were evaluated across 22 AD cohorts (n = 20 928), 3 longitudinal cohorts (n = 3008), and 4 cohorts collecting β-amyloid measurements (cerebrospinal fluid, n = 556; brain, n = 251). In individuals who carry APOE4, Klotho-VS heterozygosity was associated with reduced AD risk and more favorable β-amyloid profiles in the brain and cerebrospinal fluid of older control participants. Klotho-VS heterozygosity was also associated with reduced AD conversion risk in individuals who carry APOE4.

Meaning  Pathways associated with KL merit exploration for novel AD drug targets, and the KL-VS genotype should be considered in conjunction with APOE genotype to refine prediction models used in clinical trial enrichment.


Importance  Identification of genetic factors that interact with the apolipoprotein e4 (APOE4) allele to reduce risk for Alzheimer disease (AD) would accelerate the search for new AD drug targets. Klotho-VS heterozygosity (KL-VSHET+ status) protects against aging-associated phenotypes and cognitive decline, but whether it protects individuals who carry APOE4 from AD remains unclear.

Objectives  To determine if KL-VSHET+ status is associated with reduced AD risk and β-amyloid (Aβ) pathology in individuals who carry APOE4.

Design, Setting, and Participants  This study combined 25 independent case-control, family-based, and longitudinal AD cohorts that recruited referred and volunteer participants and made data available through public repositories. Analyses were stratified by APOE4 status. Three cohorts were used to evaluate conversion risk, 1 provided longitudinal measures of Aβ CSF and PET, and 3 provided cross-sectional measures of Aβ CSF. Genetic data were available from high-density single-nucleotide variant microarrays. All data were collected between September 2015 and September 2019 and analyzed between April 2019 and December 2019.

Main Outcomes and Measures  The risk of AD was evaluated through logistic regression analyses under a case-control design. The risk of conversion to mild cognitive impairment (MCI) or AD was evaluated through competing risks regression. Associations with Aβ, measured from cerebrospinal fluid (CSF) or brain positron emission tomography (PET), were evaluated using linear regression and mixed-effects modeling.

Results  Of 36 530 eligible participants, 13 782 were excluded for analysis exclusion criteria or refusal to participate. Participants were men and women aged 60 years and older who were non-Hispanic and of Northwestern European ancestry and had been diagnosed as being cognitively normal or having MCI or AD. The sample included 20 928 participants in case-control studies, 3008 in conversion studies, 556 in Aβ CSF regression analyses, and 251 in PET regression analyses. The genotype KL-VSHET+ was associated with reduced risk for AD in individuals carrying APOE4 who were 60 years or older (odds ratio, 0.75 [95% CI, 0.67-0.84]; P = 7.4 × 10−7), and this was more prominent at ages 60 to 80 years (odds ratio, 0.69 [95% CI, 0.61-0.79]; P = 3.6 × 10−8). Additionally, control participants carrying APOE4 with KL-VS heterozygosity were at reduced risk of converting to MCI or AD (hazard ratio, 0.64 [95% CI, 0.44-0.94]; P = .02). Finally, in control participants who carried APOE4 and were aged 60 to 80 years, KL-VS heterozygosity was associated with higher Aβ in CSF (β, 0.06 [95% CI, 0.01-0.10]; P = .03) and lower Aβ on PET scans (β, −0.04 [95% CI, −0.07 to −0.00]; P = .04).

Conclusions and Relevance  The genotype KL-VSHET+ is associated with reduced AD risk and Aβ burden in individuals who are aged 60 to 80 years, cognitively normal, and carrying APOE4. Molecular pathways associated with KL merit exploration for novel AD drug targets. The KL-VS genotype should be considered in conjunction with the APOE genotype to refine AD prediction models used in clinical trial enrichment and personalized genetic counseling.

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