Brain | August 16, 2021

Beerepoot S, Heijst H, Roos B, Wamelink MMC, Boelens JJ, Lindemans CA, van Hasselt PM, Jacobs EH, van der Knaap MS, Teunissen CE and Wolf NI

Brain : a journal of neurology. 2021

https://doi.org/10.1093/brain/awab304

Abstract

Metachromatic leukodystrophy is a lethal metabolic leukodystrophy, with emerging treatments for early disease stages. Biomarkers to measure disease activity are required for clinical assessment and treatment follow-up. This retrospective study compared neurofilament light chain and glial fibrillary acidic protein levels in CSF (n =11) and blood (n =92) samples of 40 patients with metachromatic leukodystrophy (aged 0–42 years) with 38 neurologically healthy children (aged 0–17 years) and 38 healthy adults (aged 18–45 years), and analyzed the associations between these levels with clinical phenotype and disease evolution in untreated and transplanted patients. Metachromatic leukodystrophy subtype was determined based on the (expected) age of symptom onset. Disease activity was assessed by measuring gross motor function deterioration and brain MRI. Longitudinal analyses with measurements up to 23 years after diagnosis were performed using linear mixed models. CSF and blood neurofilament light chain and glial fibrillary acidic protein levels in pediatric controls were negatively associated with age (all P <0.001). Blood neurofilament light chain level at diagnosis (median, interquartile range; picogram per milliliter) was significantly increased in both pre-symptomatic (14.7, 10.6–56.7) and symptomatic patients (136, 40.8–445) compared to controls (5.6, 4.5–7.1), and highest amongst patients with late-infantile (456, 201–854) or early-juvenile MLD (291.0, 104–445) and those ineligible for treatment based on best practice (291, 57.4–472). Glial fibrillary acidic protein level (median, interquartile range; picogram per milliliter) was only increased in symptomatic patients (591, 224–1150) compared to controls (119, 78.2–338) and not significantly associated with treatment eligibility (P =0.093). Higher blood neurofilament light chain and glial fibrillary acidic protein levels at diagnosis were associated with rapid disease progression in late-infantile (P =0.006 and P =0.051, respectively) and early-juvenile patients (P =0.048 and P =0.039, respectively). Finally, blood neurofilament light chain and glial fibrillary acidic protein levels decreased during follow-up in untreated and transplanted patients but remained elevated compared with controls. Only neurofilament light chain levels were associated with MRI deterioration (P <0.001). This study indicates that both proteins may be considered as non-invasive biomarkers for clinical phenotype and disease stage at clinical assessment, and that neurofilament light chain might enable neurologists to make better informed treatment decisions. In addition, neurofilament light chain holds promise assessing treatment response. Importantly, both biomarkers require pediatric reference values, given that their levels first decrease before increasing with advancing age.