• Alzheimer's Disease and Tau

    Pathogenic Mechanisms and Therapeutic Approaches

    Alzheimer's Disease and Tau

    Pathogenic Mechanisms and Therapeutic Approaches

    Organizers: Robert Martone (St. Jude Children's Research Hospital) and Sonya Dougal (The New York Academy of Sciences)Presented by the Brain Dysfunction Discussion Group
    Reported by Caitlin McOmish | Posted February 2, 2016


    Microtubule-associated protein tau helps maintain the stability and flexibility of microtubules in neuronal axons. Alternative splicing of the tau gene, MAPT, produces 6 isoforms of tau in the brain and many more in the peripheral nervous system. Tau can be phosphorylated at over 30 sites, and it undergoes many posttranslational modifications to operate as a substrate for multiple enzymes. However, tau also mediates pathological functions including neuroinflammatory response, seizure, and amyloid-β (Aβ) toxicity, and tau pathology is a hallmark of conditions including frontotemporal dementia, traumatic brain injury (TBI), Down syndrome, focal cortical dysplasia, and Alzheimer's disease (AD), as well as some tumors and infections. On September 18, 2015, speakers at the Brain Dysfunction Discussion Group's Alzheimer's Disease and Tau: Pathogenic Mechanisms and Therapeutic Approaches symposium discussed the mechanisms by which tau becomes pathological and how the pathology spreads. They also described emerging therapeutic strategies for AD focused on tau.

    Microtubule-associated protein tau has a complex biology, including multiple splice variants and phosphorylation sites. Tau is a key component of microtubules, which contribute to neuronal stability. In AD, tau changes, causing microtubules to collapse, and tau proteins clump together to form neurofibrillary tangles. (Image presented by Robert Martone courtesy of the National Institute on Aging)

    Tau is ubiquitous in the brain, with widespread effects, but has historically been overlooked as a driving force in AD. In his introduction to the symposium, Robert Martone from St. Jude Children's Research Hospital highlighted tau's activity and emergence as a treatment target for this devastating disorder. Hyperphosphorylated tau (p-tau) has long been recognized as a principle component of neurofibrillary tangles in AD; tau monomers are misfolded into oligomers that form tau filaments. As Hartmuth Kolb from Johnson & Johnson explained, the development in 2012 of a tau-specific positron emission tomography (PET) tracer led to important insights into the presence and spread of tau pathology over the course of tauopathies, including AD, in humans. Notably, researchers demonstrated that tau pathology propagates through the brain in a predictable pattern, corresponding to the Braak stages of AD.

    Tau pathology spreads through the brain in a predictable pattern. Abnormal tau protein is first observed in the transentorhinal region (stages I and II) and spreads to the limbic regions in stages III and IV, when early signs of AD begin to be observed. Pathology subsequently extends throughout the neocortex, driving fully developed AD. This staging was first described by Braak and Braak in 1991. (Image courtesy of Hartmuth Kolb)

    It is likely that the symptoms of AD are produced by the combined effects of tau and Aβ pathologies. George Bloom from the University of Virginia described how Aβ and tau interact to cause mature neurons to reenter the cell cycle, leading to cell death. In a healthy brain, insulin acts as a gatekeeper that maintains adult neurons in the G0 phase after the cells permanently exit the cell cycle. In AD, amyloid oligomers sequester neuronal insulin receptors, causing insulin resistance. In parallel, tau phosphorylation at key sites—pY18 (fyn site), pS409 (PKA site), pS416 (CAM Kinase site), and pS262—drives mTOR signaling at the plasma membrane but not at the lysosome, resulting in cell cycle reentry. In a normal cell, activation of mTOR at the lysosome overrides the cell cycle reentry signal—creating an important regulatory mechanism for maintaining healthy neurons. However, lysosomal activation of mTOR is insulin dependent and thus affected by Aβ-induced insulin insensitivity. Amyloid oligomers, via insulin regulation, release the brakes on a cascade of events driven by p-tau that leads to cell cycle reentry and cell death.

    Hallmark dysfunction produced by Aβ is dependent on tau. Pathological Aβ drives the formation of p-tau in the brain, resulting in synaptic dysfunction, cell death, and broad neurocognitive symptoms. This process can be influenced by a range of factors including genetic predisposition, environmental risk factors, and biochemical signaling pathways. (Image courtesy of George Bloom)

    Khalid Iqbal from the New York State Institute for Basic Research in Developmental Disabilities described research showing that p-tau spreads through the brain in a rodent model, well beyond the injection site, in a prion-like manner, and that the spread of pathology can be mitigated by the addition of PP2A—a phosphatase known to be decreased in gray and white matter in AD. PP2A regulation is affected in AD, stroke, and brain acidosis, providing a link between these disorders and tau pathology.

    Discussion of the pathophysiology of AD commonly focuses on Aβ plaques and neurofibrillary tangles (NFTs) composed of misassembled hyperphosphorylated tau; it has generally been thought that these plaques and tangles are the primary causes of symptoms. However, recent evidence indicates that oligomeric variants of tau are actually far more toxic than the form of tau present in NFTs. Michael Hutton from Eli Lilly and Company studies the properties needed for tau to become pathological. He used animal models to show that the abnormal p-tau "seed," from which a prion-like spread develops, must be of a high molecular weight (with at minimum three tau units) and highly phosphorylated to induce healthy tau to become pathological. These characteristics are necessary but not sufficient for effective seeding. There is also evidence that tau pathology propagates via an autocatalytic cycle of seeded aggregation and fragmentation.

    Propagation, in addition to requiring a large number of p-tau units in aggregates, may be affected by the isomerization of those monomers. Kun Ping Lu from Harvard Medical School provided data suggesting that cis but not trans pT231-tau is a precursor of tauopathy, linking TBI to the later development of neurodegenerative diseases such as chronic traumatic encephalopathy and AD. He demonstrated a role for Pin1, a phosphorylation-specific prolyl isomerase, in this process using animal models of TBI and AD. Pin1, which is regulated in response to stress, prevents the accumulation of toxic cis p-tau by converting it to the trans isoform, but this process is inhibited in AD and TBI. Lu showed that cis p-tau’s ability to cause and spread neurodegeneration can be blocked by a cis p-tau monoclonal antibody in vitro and in animal models, pointing to the therapeutic potential of targeting cis p-tau for treatment of TBI and AD.

    Culturing p-tau seeds in vitro produces a broad array of tau aggregate structures. Marc Diamond from the University of Texas Southwestern Medical Center discussed the diverse structures produced by different tau seeds, which his team has studied in a series of experiments using in vitro models, animal models, and human postmortem analyses. His lab showed that distinct conformations of aggregate seeds propagate stably, infecting normal cells and leading them to acquire abnormal tau aggregates with distinct, reproducible structures and different biochemical properties. In another study, the team showed that the morphology of the p-tau aggregates was related to diagnosis. Seeds sourced from postmortem human tissue produced reliable phenotypes in culture, which tracked with different diagnoses, retroactively predicting biological outcome. Thus, the characteristics of the p-tau seed have a large influence on the biological outcome, providing a new prospect for presymptomatic diagnosis.

    Tau seeds obtained from postmortem brain tissue from AD, argyrophilic grain disease (AGD), corticobasal degeneration (CBD), Pick's disease (PiD), and progressive supranuclear palsy (PSP) produce unique aggregate pathologies in cell culture, including toxic, mosaic, ordered, disordered, and speckled. AD-derived seeds largely produce the speckled phenotype. (Images courtesy of Marc Diamond)

    With the mechanisms by which p-tau forms, converts healthy tau, and seeds dysfunction established, the question of how p-tau exits the cell and moves through the brain arises. The pattern of spread and the speed with which the pathology progresses suggests that p-tau propagates trans-synaptically. Nicole Leclerc from the University of Montreal provided evidence to support this view. It is likely, her lab has shown, that tau is secreted and taken up by neurons in an active process, in response to neuronal activity. Tau secretion in vitro increases under conditions such as starvation and lysosomal dysfunction, phenomena found in the early stages of AD. Moreover, hyperphosphorylation appears to increase the targeting of tau to the secretory pathway, potentially accelerating the spread of p-tau. Intriguingly, however, the extracellular tau is hypophosphorylated, suggesting large-scale dephosphorylation during the secretory process. This hypo-tau may activate muscarinic acetylcholine receptors, increasing intracellular Ca2+ and promoting cell death.

    These findings suggest that the synapse plays a critical role in the development of AD; the extrasynaptic environment is known to be exquisitely regulated by microglia. The focus of studies into neurodegenerative disorders is often neurons, but genetic studies have repeatedly identified changes in expression of microglial genes in AD, including in one of the leading AD candidate genes, TREM2, demonstrating a fundamental contribution of these cells to AD. Richard Ransohoff of Biogen discussed the importance of this cell type. Microglia enter the brain at around embryonic day (E) 9.5 in rodents and are crucially involved in maintaining brain health. During development the cells play a major role in large-scale synaptic pruning required for effective neural maturation. They are also highly responsive to the environment, and stress in adulthood can reengage microglial synaptic pruning—a process that is adaptive during development but maladaptive in adulthood. The process is regulated by complement system cascades. TGF-β expressed by astrocytes drives neurons to express C1q presynaptically, initiating complement elements to accumulate at the site, ultimately activating microglia to prune the synaptic connection. In AD, inappropriate activation of this cascade may lead to the removal of otherwise healthy connections. Ransohoff described a role for CXCR3, the fractalkine receptor, in regulating reactivity of microglia, and thus mitigating pruning of adult synapses. Regulation of microglia reactivity is driven by epigenetically induced changes in inflammatory response genes. Correspondingly, in the absence of CXCR3, tau pathology is aggravated in htau mice (which express human tau isoforms), suggesting a protective effect of the CXCR3 pathway. Ransohoff closed with the caveat that microglia are not intrinsically helpful or harmful; their properties are context dependent and must be unraveled by empirical observations in appropriate models.

    Peter Davies from the Feinstein Institute for Medical Research discussed the need to better incorporate current knowledge into research model design, particularly to develop monoclonal antibodies for the treatment of AD. Monoclonal antibodies are a promising strategy, but translating preclinical findings into successful clinical outcomes will require careful consideration of the context of the early research. Most transgenic animal models for AD express p-tau in all neurons, but such extensive p-tau spread is not found in human AD brains. There are several hurdles to determine the drugs' efficacy and safety in humans; it is difficult to assess specificity and find appropriate dosages. In a series of studies with a focus on external reproducibility, Davies presented evidence from animal models showing that immunotherapy can block the spread of p-tau but cannot undo pathology already present in the brain. In the htau mouse model several putative antibodies lacked efficacy and in some cases appeared to worsen pathology. These findings underscore the need for both better models and improved understanding of mechanisms of action before moving drugs to the clinic.

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    Presentations available from:
    George S. Bloom, PhD (University of Virginia)
    Peter Davies, PhD (Feinstein Institute for Medical Research)
    Marc I. Diamond, MD (University of Texas Southwestern Medical Center)
    Khalid Iqbal, PhD (New York State Institute for Basic Research in Developmental Disabilities)
    Magdalena J. Kiprowska, MS (Hunter College and Graduate Center, CUNY)
    Hartmuth C. Kolb, PhD (Johnson & Johnson, Janssen R&D)
    Nicole Leclerc, PhD (Université de Montréal, Canada)
    Kun Ping Lu, MD, PhD (Harvard Medical School)
    Robert L. Martone (St. Jude Children's Research Hospital)
    Natura Myeku, PhD (Taub Institute for Alzheimer's Disease Research, Columbia University)
    Richard M. Ransohoff, MD (Biogen)

    The Brain Dysfunction Discussion Group is proudly supported by

    • Acorda Therapeutics

    How to cite this eBriefing

    The New York Academy of Sciences. Alzheimer's Disease and Tau: Pathogenic Mechanisms and Therapeutic Approaches. Academy eBriefings. 2016. Available at:

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