Quantitative Measurement of Cerebrospinal Fluid Amyloid-β Species by Mass Spectrometry

Seino, Yusuke; Nakamura, Takumi; Harada, Tomoo; Nakahata, Naoko; Kawarabayashi, Takeshi; Ueda, Tetsuya; Takatama, Masamitsu; Shoji, Mikio

doi:10.3233/JAD-200987

Quantitative Measurement of Cerebrospinal Fluid Amyloid-β Species by Mass Spectrometry

Article type: Research Article

Authors: Seino, Yusuke^a | Nakamura, Takumi^b | Harada, Tomoo^c | Nakahata, Naoko^d | Kawarabayashi, Takeshi^e | Ueda, Tetsuya^c | Takatama, Masamitsu^e | Shoji, Mikio^{e; *}

Affiliations: [a] Department of Neurology, Hirosaki National Hospital, Hirosaki, Aomori, Japan | [b] Department of Neurology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan | [c] Bioanalysis Department, LSI Medience Corporation, Itabashi-ku, Tokyo, Japan | [d] Department of Speech-Language-Hearing Therapy, Hirosaki University of Health and Welfare, Hirosaki, Aomori, Japan | [e] Dementia Center, Geriatrics Research Institute and Hospital, Maebashi, Gunma, Japan

Correspondence: [*] Correspondence to: Mikio Shoji, MD, PhD, Director, Dementia Center, Geriatrics Research Institute and Hospital, 3-26-8 Ootomo-machi, Maebashi, Gunma, 371-0847 Japan. Tel.: +81 27 253 3311; Fax: +81 27 252 7575; E-mail: [email protected].

Keywords: Aβ_1-38, Aβ_1-40, Aβ_1-42 Aβ_1-43, cerebrospinal fluid, ELISA, liquid chromatography mass spectrometry

DOI: 10.3233/JAD-200987

Journal: Journal of Alzheimer's Disease, vol. 79, no. 2, pp. 573-584, 2021

Accepted 26 October 2020

Published: 19 January 2021

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Abstract

Background:

High sensitivity liquid chromatography mass spectrometry (LC-MS/MS) was recently introduced to measure amyloid-β (Aβ) species, allowing for a simultaneous assay that is superior to ELISA, which requires more assay steps with multiple antibodies.

Objective:

We validated the Aβ_1-38, Aβ_1-40, Aβ_1-42, and Aβ_1-43 assay by LC-MS/MS and compared it with ELISA using cerebrospinal fluid (CSF) samples to investigate its feasibility for clinical application.

Methods:

CSF samples from 120 subjects [8 Alzheimer’s disease (AD) with dementia (ADD), 2 mild cognitive dementia due to Alzheimer’s disease (ADMCI), 14 cognitively unimpaired (CU), and 96 neurological disease subjects] were analyzed. Aβ species were separated using the Shimadzu Nexera X2 system and quantitated using a Qtrap 5500 LC-MS/MS system. Aβ_1-40 and Aβ_1-42 levels were validated using ELISA.

Results:

CSF levels in CU were 666±249 pmol/L in Aβ_1-38, 2199±725 pmol/L in Aβ_1-40, 153.7±79.7 pmol/L in Aβ_1-42, and 9.78±4.58 pmol/L in Aβ_1-43. The ratio of the amounts of Aβ_1-38, Aβ_1-40, Aβ_1-42, and Aβ_1-43 was approximately 68:225:16:1. Linear regression analyses showed correlations among the respective Aβ species. Both Aβ_1-40 and Aβ_1-42 values were strongly correlated with ELISA measurements. No significant differences were observed in Aβ_1-38 or Aβ_1-40 levels between AD and CU. Aβ_1-42 and Aβ_1-43 levels were significantly lower, whereas the Aβ_1-38/1-42, Aβ_1-38/1-43, and Aβ_1-40/Aβ_1-43 ratios were significantly higher in AD than in CU. The basic assay profiles of the respective Aβ species were adequate for clinical usage.

Conclusion:

A quantitative LC-MS/MS assay of CSF Aβ species is as reliable as specific ELISA for clinical evaluation of CSF biomarkers for AD.

INTRODUCTION

Cerebrospinal fluid (CSF) amyloid-β (Aβ)_1-42 is a definite biomarker of Alzheimer’s disease (AD). A decrease in the Aβ_1-42 level, which begins 25 years earlier, allows the prediction of the onset and progression of Aβ amyloidosis in the AD brain. CSF Aβ_1-42 is the earliest and most reliable biomarker for the prediction and diagnosis of AD [1–3]. Low CSF Aβ_1-42 and cortical amyloid PET ligand binding have been adopted as biomarkers of Aβ plaques (labeled “A”) in the ATN classification system of the NIA-AA research framework and have been proposed as diagnostic criteria based on the biological definition of AD for observational and interventional research [4].

γ-Secretase cleaves the β-carboxyl terminal fragment (β-CTF) of the amyloid-β protein precursor (AβPP) at the ɛ-site into long Aβs (Aβ_1-49 and Aβ_1-48), which are ultimately converted from Aβ_1-43 to Aβ_1-40 and from Aβ_1-42 to Aβ_1-38, respectively, by the successive cleavage of tripeptides and tetrapeptides [5, 6]. The half-life of Aβ in the brain is approximately 9 hours. However, the faster turnover of Aβ_1-42 than Aβ_1-38 and Aβ_1-40 in CSF has been reported with aging and AD [7, 8]. γ-Secretase activity in AD is enhanced by the conversion of Aβ_1-43 to Aβ_1-40 and Aβ_1-42 to Aβ_1-38, leading to low CSF levels of Aβ_1-42 and Aβ_1-43 [9]. Aβ_1-38 and Aβ_1-40 have been shown to attenuate Aβ_1-42 toxicity [10]. Aβ_1-43 is known to be enriched in the AD brain [11–13] and promotes the rates and extent of protofibril aggregation [14]. CSF Aβ_1-43 is of similar diagnostic accuracy to Aβ_1-42 [15, 16]. The quantification of Aβ_1-38, Aβ_1-40, and Aβ_1-42 in CSF using mass spectrometry and ELISA has already revealed that the Aβ_1-42/1-40 and Aβ_1-42/1-38 ratios are superior to CSF Aβ_1-42 alone for the detection of amyloid deposition in AD and the differentiation of AD dementia (ADD) from non-AD dementias [17–19]. However, Aβ_1-40 and Aβ_1-38 have lower discriminative powers [20–23]. Collectively, these findings imply that the precise quantitation of these Aβ species, including Aβ_1-38, Aβ_1-40, Aβ_1-42, and Aβ_1-43, is relevant to biomarkers for observational and interventional research.

However, antibody-based immunoassays, such as ELISA, have several disadvantages [24, 25]. Currently available ELISA systems using antibodies against different epitopes or the conformation of Aβ species measure the levels of various forms of Aβ species. The specific characteristics of Aβ with self-aggregation, binding to tubes, post-translational modifications, and cross-reactions with endogenous components of CSF decrease assay sensitivity and lead to variable results depending on the ELISA systems. Therefore, discrepant findings have been reported across each assay procedure and laboratory. This variability represents a major issue for global clinical observational and interventional studies. Commercial ELISA kits and systems are expensive, time-consuming (often include overnight incubations), and indicate the variation of measured values due to the different lots of the ELISA kits.

An approach based on liquid chromatography mass spectrometry (LC-MS/MS) has been developed to overcome these methodological issues [26–29]. The direct confirmation of Aβ_1-38, Aβ_1-40, Aβ_1-42, and Aβ_1-43 is possible, and detailed comparisons can be made with advanced LC-MS/MS equipment [8, 17–19]. However, the lower sensitivity and intra-assay variability of this system compared to immunological methods have yet to be reliably improved [26–29]. Therefore, we herein developed and validated a novel LC-MS/MS method to assay CSF Aβ_1-38, Aβ_1-40, Aβ_1-42, and Aβ_1-43, and further confirm their contribution as biomarkers for AD pathological changes by comparing the results obtained by the conventional ELISA system for Aβ_1-40 and Aβ_1-42.

MATERIALS AND METHODS

Subjects

One hundred and twenty CSF samples from 106 patients with neurological diseases and 14 cognitively unimpaired subjects (CU) were examined. The AD group consisted of 4 cases of autosomal inherited ADD with PSEN-1 mutations, 4 of ADD, and 2 of AD due to mild cognitive impairment (ADMCI) based on the criteria of NIA-AA [4, 30, 31]. They were all defined by positive A+T+N+biomarker changes. Clinically diagnosed neurological diseases by the respective recent criteria included 17 cases of amyotrophic lateral sclerosis [32], 9 of corticobasal degeneration [33], 6 of encephalopathy, 3 of frontotemporal dementia [34, 35], 14 of multiple sclerosis and related disorders, 6 of multiple system atrophy [36], 11 of Parkinson’s disease [37], 4 of peripheral neuropathy, 11 of progressive supranuclear palsy [38], and 15 of spinocerebellar degeneration. Basic profiles are summarized in Table 1 and no significant differences were observed in age among the disease groups. CSF samples were taken in polypropylene vials by lumber puncture in the morning. Cell numbers and protein levels were examined in the first 1 mL of CSF. Each 1 mL of remaining CSF sample was transferred into polypropylene vials after centrifugation at 1,500×g for 10 min and stored at –80°C until analysis.

Table 1

Subject profiles. Subjects consisted of 10 cases of Alzheimer’s disease with dementia (ADD) and AD due to MCI (ADMCI), 17 of amyotrophic lateral sclerosis (ALS), and 9 of corticobasal degeneration (CBD). Six cases of encephalopathy (ENC) consisted of meningoencephalitis, Creutzfeldt-Jacob disease, leukoencephalopathy, superficial siderosis, or cerebral angiitis. Three cases of frontotemporal dementia (FTD), 14 cognitively unimpaired healthy controls (CU), 14 cases of multiple sclerosis (MS) and related disorders including neuromyelitis optica in the multiple sclerosis group, 6 of multiple system atrophy (MSA), 11 of Parkinson’s disease (PD), 4 of peripheral neuropathy (PN), 11 of progressive supranuclear palsy (PSP), and 15 of spinocerebellar degeneration (SCD) were analyzed. No significant differences were observed in age among the CU and other groups

Disease	Number			Mean age	Age range
	Total	Males	Females
ADD/ADMCI	10	5	5	59	41-80
ALS	17	13	4	67	53-83
CBD	9	4	5	72	67-78
ENC	6	1	5	60	41-78
FTD	3	2	1	73	70-75
CU	14	5	9	61	22-80
MS	14	3	11	40	19-75
MSA	6	2	4	66	58-81
PD	11	6	5	65	49-79
PN	4	2	2	51	30-62
PSP	11	6	5	74	67-82
SCD	15	7	8	64	39-80
Total	120	56	64	62	19–83

LC-MS/MS chemicals and reagents

Synthetic human Aβ_1-38, Aβ_1-40, Aβ_1-42, and Aβ_1-43 were purchased from the Peptide Institute (Osaka, Japan). Uniformly stable isotope-labeled peptides manufactured by rPeptide (Watkinsville, GA, USA), corresponding to each peptide (Aβ_1-38, Aβ_1-40, Aβ_1-42, and Aβ_1-43), were used as internal standards (ISs). Artificial CSF was purchased from Tocris Bioscience (Bristol, UK), and rat plasma was purchased from Charles River Laboratories Japan (Yokohama, Japan). Other materials and reagents were purchased from Kanto Chemical (Tokyo, Japan), Kokusan Chemical (Tokyo, Japan), and Sigma-Aldrich (St. Louis, MO, USA). Ultrapure water was prepared using Milli-Q Integral 10 (Merck, Darmstadt, Germany).

LC-MS/MS sample preparation by solid-phase extraction

Human CSF samples (300μL) and IS solution were mixed in 1500μL of water/propionic acid (PA)/ trifluoroacetic acid (TFA) (950:50:1) and loaded onto an Oasis HLB 96-well plate (Waters Corporation, MA, USA). After loading, the plate was washed with 1000μL of water/Methanol (MeOH)/PA/TFA (900:50:50:1) and then analytes and ISs were eluted with 100μL of EtOH/2,2,2-trifluoroethanol (TF-EtOH)/PA/Ethylene glycol (1:1:1:0.1) twice. Eluates from individual samples were evaporated to dryness at approximately 40°C under nitrogen. The resulting residue was re-dissolved with 100μL of water/MeOH/TF-EtOH/PA (85:5:5:5). Calibration standards were also prepared by spiking standard solutions to 300μL of artificial CSF containing 0.25% rat plasma, with concentration ranges of 50–5000 pmol/L for Aβ_1-38, 100–10000 pmol/L for Aβ_1-40, 10–1000 pmol/L for Aβ_1-42, and 2–200 pmol/L for Aβ_1-43.

LC-MS/MS analysis

Chromatographic separation was performed using the Shimadzu Nexera X2 system (Shimadzu Corporation, Kyoto, Japan) with a column of Acquity UPLC BEH C8 (1.7μm, 2.1×100 mm, Waters Corporation, MA, USA) set at 50°C. The mobile phases of (A) water/acetic acid (AA) (8:2) and (B) MeOH/AA (8:2) were used with a linear gradient program as follows (Time – B conc.): 0 min-25%, 3.5 min-55%, 4.0 min-100%, 6.0 min-100%, 6.1 min-25%, and 8.0 min-25%. The flow rate was set at 0.4 mL/min. Mass spectra were obtained by a Qtrap 5500 system (AB Sciex, CA, USA) with the positive electrospray ionization and multiple reaction monitoring (MRM) mode. MRM transitions are shown in Table 2. MS/MS conditions were as follows: ion spray voltage at 5500 V, temperature at 600°C, curtain gas at 10 psi, ion source gas 1 at 90 psi, ion source gas 2 at 90 psi, and collision gas at level 11. Quantification was performed using Analyst 1.6.2 (AB Sciex, Redwood City, CA, USA). Calibration curves were constructed by analyzing calibration standards. The peak area ratios of analytes to the corresponding ISs were plotted against analyte concentrations, and the curves were fit by a linear least-squares regression method (a weighting factor of 1/X2).

Table 2

MRM transitions. Mass spectra were obtained by the Qtrap 5500 system with the positive electrospray ionization (ESI) and multiple reaction monitoring (MRM) mode. MRM transitions are shown, respectively

Analyte and IS	Precursor ion [M + 5H]^5 +(m/z)	Product ion (m/z)
Aβ_1-38	827.3	801.1
[¹⁵N₅₁]-Aβ_1-38	837.2	810.6
Aβ_1-40	867.0	843.8
[¹⁵N₅₃]-Aβ_1-40	877.2	853.6
Aβ_1-42	903.7	863.2
[¹⁵N₅₅]-Aβ_1-42	914.7	873.7
Aβ_1-43	924.1	1000.9
[¹⁵N₅₆]-Aβ_1-43	935.1	1012.8

ELISA

Sandwich ELISA was used to quantify Aβ_1-40 and Aβ_1-42 levels using Human β Amyloid (1-40) ELISA Kit Wako II and a Human/Rat β Amyloid (1-42) ELISA Kit Wako, High-Sensitive according to the manufacturer’s instructions (Wako Pure Chemical Industries, Ltd., Osaka, Japan). Microplates were pre-coated with monoclonal BAN-50 (IgG, anti-Aβ1-16) and sequentially incubated with 25μL of samples followed by horseradish-peroxidase-conjugated BA27 (anti-Aβ_1-40 (Fab’)2, specific for Aβ₄₀) or BC05 (anti-_Aβ35-43 (Fab’)2, specific for Aβ_42/43) [39]. Sensitivities were 0.019 pmol/L (assay range 1.0–100 pmol/L) in the Aβ_1-40 assay and 0.06 pmol/L (assay range 0.01–20.0 pmol/L) in the Aβ_1-42 assay. Intra- and inter-assay coefficients of variation were less than 10% in both assay systems.

Data analysis

Simple linear regression models were used in statistical analyses. The linear regression line was drawn by the method of least squares. Comparisons among the groups of assay values were performed using the Kruskal-Wallis test with multiple comparison tests for non-parametric data. Two-tailed p-values less than 0.05 were considered to be significant. These analyses were performed with IBM SPSS Statistics, version 24 (IBM Japan, Tokyo) and GraphPad Prism, version 8 (GraphPad Software, San Diego, CA, USA).

RESULTS

The minimal to maximal LC-MS/MS assay ranges of Aβ_1-38, Aβ_1-40, Aβ_1-42, and Aβ_1-43 were 193.231∼1,224.771, 391.624∼3,560.087, 29.326∼328.450, and 0.714∼20.624 pmol/L, respectively (Table 3). CSF levels as mean±standard deviation values of CU were 666±249 pmol/L in Aβ_1-38, 2199±725 pmol/L in Aβ_1-40, 153.7±79.66±79.7 pmol/L in Aβ_1-42, and 9.78±4.58 pmol/L in Aβ_1-43. The ratios of Aβ_1-38_/_1-42, Aβ_1-38_/_1-43, Aβ_1-40_/_1-42, Aβ_1-40/1-₄₃, and Aβ₍_1-40_/_1-43₎/Aβ₍_1-38_/_1-42₎ were 4.66±0.94, 71.7±15.8, 15.7±3.7, 241±58, and 53±13, respectively. The ratio of the amounts of Aβ_1-38, Aβ_1-40, Aβ_1-42, and Aβ_1-43 was approximately 68:225:16:1 (Table 4).

Table 3

Basic profile of the LC-MS/MS analysis. The minimal to maximal assay ranges, median, mean, and standard deviations of Aβ_1-38, Aβ_1-40, Aβ_1-42, and Aβ_1-43 values measured by LC-MS/MS assay and ELISA

Item	Aβ_1-38	Aβ_1-40		Aβ_1-42		Aβ_1-43
	LC-MS/MS	LC-MS/MS	ELISA	LC-MS/MS	ELISA	LC-MS/MS
Max	1224.771	3560.087	3401.273	328.450	306.233	20.624
Min	193.231	391.624	634.258	29.326	41.120	0.714
Median	506.495	1739.419	1555.430	100.789	122.838	5.798
Mean	546.038	1771.370	1619.538	111.056	126.683	6.267
SD	198.920	600.511	561.217	54.778	50.425	3.559

Table 4

Assay data obtained by LC-MS/MS. Mean±standard values (pmol/L) of Aβ_1-38, Aβ_1-40, Aβ_1-42, and Aβ_1-43, and the ratios of Aβ_1-38/1-42, Aβ_1-38/1-43, Aβ_1-40/1-42, Aβ_1-40/1-43, and Aβ(_1-40/1-43)/Aβ(_1-38/1-42) in respective disease groups including with ADD and ADMCI, ALS, CBD, 6 ENC, 3 FTD, MS, MSA, PD, PN, PSP, and SCD

Disease	mean level±standard deviation pmol/L				ratio±standard deviation
	Aβ_1-38	Aβ_1-40	Aβ_1-42	Aβ_1-43	Aβ_1-38/1-42	Aβ_1-38/1-43	Aβ_1-40/1-42	Aβ_1-40/Aβ_1-42 ₊ Aβ_1-43	Aβ_1-40/_1-43	Aβ_1-42/1-43	Aβ(_1-40/1-43)/(_1-38/1-42)
ADD/	498±166	1552±527	71.93±27.7^**a	3.15±2.66^****b	7.38±2.28^*e	250.2±184.2^***f	22.5±6.8	21.6±6.6	759±520^**g	32.5±19.8	101±61
ADMCI
ALS	647±260	1986±615	115.8±44.6	6.68±2.75	6.06±2.55	107.4±48.3	19.1±8.3	18.0±7.8	333±138	18.0±4.8	57±13
CBD	474±160	1634±526	90.4±50.1	4.82±2.65	6.24±2.54	125.1±71.2	22.0±10.5	20.6±9.1	452±324	21.7±11.4	78±50
ENC	503±156	1571±405	107.8±54.4	4.39±2.49^*c	5.05±1.19	133.7±53.2	15.9±3.7	15.3±3.6	429±199	26.2±2.1^*h	85±30
FTD	671±62	2132±438	146.4±63.1	9.07±4.46	5.26±2.36	91.4±53.0	16.2±5.9	15.3±5.6	279±134	16.8±2.1	53±3
CU	666±249	2199±725	153.7±79.7	9.78±4.58	4.66±0.94	71.7±15.8	15.7±3.7	114.7±3.3	241±58	15.7±3.4	53±13
MS	468±138	1604±554	97.2±37.6	5.58±3.07	5.27±2.14	120.2±121.7	17.8±6.6	16.9±6.4	393±352	20.6±8.5	69±26
MSA	498±191	1531±702	83.2±33.9	5.41±1.61	6.42±2.72	93.6±33.2	19.5±7.9	18.2±7.1	282±82	15.3±4.0	46±13
PD	489±127	1702±518	97.6±33.9	4.98±2.17^*d	5.29±1.23	110.7±49.1	18.2±4.2	17.3±3.9	385±181	21.2±8.7	74±34
PN	464±165	1546±491	114.4±48.7	7.54±1.94	4.30±1.04	60.7±10.3	14.3±2.9	13.3±2.5	202±17	14.7±4.2	50±14
PSP	537±260	1729±830	129.6±87.4	7.07±5.31	4.61±1.42	106.5±81.3	14.8±4.0	14.0±3.8	342±262	22.6±15.1	73±49
SCD	550±124	1759±352	118.1±27.2	6.67±2.15	4.71±0.60	86.4±17.8	15.2±2.3	14.3±2.2	284±96	18.6±4.7	62±29
total	546±199	1771±601	111.1±54.8	6.27±3.56	5.44±1.96	111.2±89.1	17.7±6.3	16.7±5.9	370±272	20.45±10.2	67±35

^**ap = 0.0066; ^****bp < 0.0001; ^*cp = 0.0297; ^*dp = 0.0281; ^*ep = 0.021; ^***fp = 0.0004; ^**gp = 0.0033; ^*hp = 0.0123. ADD, Alzheimer’s disease with dementia; ADMCI, AD due to MCI; ALS, amyotrophic lateral sclerosis; CBD, corticobasal degeneration; ENC, encephalopathy; FTD, frontotemporal dementia;), CU, cognitively unimpaired; MS, multiple sclerosis; MSA, multiple system atrophy; PD, Parkinson’s disease; PN, peripheral neuropathy; PSP, progressive supranuclear palsy; SCD, spinocerebellar degeneration.

First order regression analysis showed a correlation between Aβ_1-38 and Aβ_1-40 (Y = 0.3035*X + 8.409; r² = 0.8395; p < 0.0001, Fig. 1a), between Aβ_1-38 and Aβ_1-42 (Y = 2.686*X + 247.8; r² = 0.547; p <0.0001, Fig. 1b), between Aβ_1-38 and Aβ_1-43 (Y = 36.4*X + 317.9; r² = 0.424; p < 0.0001, Fig. 1c), between Aβ_1-40 and Aβ_1-42 (Y = 8.204*X + 860.3; r² = 0.5601; p < 0.0001, Fig. 1d), between Aβ_1-40 and Aβ_1-43 (Y = 112.8*X + 1064; r² = 0.4469; p < 0.0001, Fig. 1e), and between Aβ_1-42 and Aβ_1-43 (Y = 13.4*X + 27.09; r² = 0.7576; p < 0.0001, Fig. 1f).

Fig.1

Correlation among Aβ species measured by LC-MS/MS. First order regression analysis between Aβ_1-38 and Aβ_1-40 (a), between Aβ_1-38 and Aβ_1-42 (b), between Aβ_1-38 and Aβ_1-43 (c), between Aβ_1-40 and Aβ_1-42 (d), between Aβ_1-40 and Aβ_1-43 (e), and between Aβ_1-42 and Aβ_1-43 (f).

Aβ_1-40 and Aβ_1-42 values measured by LC-MS/MS were strongly correlated with those obtained by ELISA. The first order regression analysis was Y = 0.9726*X + 165.9 (r² = 0.8127, p < 0.0001) for Aβ_1-40 values measured by LC-MS/MS and ELISA (Fig. 2a). Regarding Aβ_1-42 values, the regression curve was Y = 0.8584*X + 2.545 (r² = 0.6207, p < 0.0001) between LC-MS/MS and ELISA (Fig. 2b). Thus, these quantitative assays of Aβ_1-40 and Aβ_1-42 by LC-MS/MS were equivalent to those by specific ELISA. Comparisons between Aβ_1-42 ₊ Aβ_1-43 levels by LC-MS/MS and Aβ_1-42 values by ELISA showed the same relationship as those between LC-MS/MS Aβ_1-42 levels and Aβ_1-42 by ELISA (Y = 0.9100*X + 2.389, r² = 0.6245, p < 0.0001; Fig. 2c). These results show that conventional ELISA using BCO5 for Aβ42/43 measures both Aβ_1-42 and Aβ_1-43 in CSF.

Fig.2

Correlation between LC-MS/MS and ELISA. Aβ_1-40, Aβ_1-42, and Aβ_1-42 + Aβ_1-43 values measured by LC-MS/MS were strongly correlated with those obtained by ELISA (a: Y = 0.9726*X + 165.9, r² = 0.8127, p < 0.0001 for Aβ_1-40 values; b: Y = 0.8584*X+2.545, r² = 0.6207, p < 0.0001 for Aβ_1-42; and c: comparisons between Aβ_1-42 + Aβ_1-43 levels by LC-MS/MS and Aβ_1-42 values by ELISA: Y = 0.9100*X + 2.389, r² = 0.6245, p < 0.0001). The regression curve between the Aβ_1-38/_1-42 ratio and Aβ_1-40/Aβ_1-43 ratio measured by LC-MS/MS was almost constant. The ratios of 8 out of 10 AD patients were outside the linear regression curve (d: Red circles represent sporadic ADD, red triangles represent sporadic ADMCI, brown circles represent familial AD). Correlation analysis between measured levels by LC-MS/MS and ELISA in Aβ_1-40/Aβ_1-42 and Aβ_1-40/Aβ_1-42 + Aβ_1-43 showed close relationships, but most values were present in the leftmost regression curve (e and f).

The regression curve between the Aβ_1-38/1-42 ratio and Aβ_1-40/Aβ_1-43 ratio measured by LC-MS/MS was Y = 0.003858*X+4.017 (r² = 0.2857, p < 0.0001; Fig. 2d), suggesting that this ratio is almost constant. The ratios of 8 out of 10 AD patients were outside the linear regression curve (Fig. 2d: Red circles indicate ADD and triangles indicate ADMCI). Although correlation analysis between measured levels by LC-MS/MS and ELISA in Aβ_1-40/Aβ_1-42 and Aβ_1-40/Aβ_1-42 + Aβ_1-43 showed close relationships, most values were present in the leftmost regression curve (Fig. 1e, f).

We then examined the efficacy of LC-MS/MS assay values as biomarkers for AD by comparisons with assay values among ADD/ADMCI, CU, and other neurogenerative diseases. No significant differences were observed in Aβ_1-38 and Aβ_1-40 levels among ADD/ADMCI and other neurological diseases and CU (Fig. 3a, b). Aβ_1-42 levels were significantly lower in ADD/ADMCI than in CU (p =0.0066; Fig. 3c). CSF Aβ_1-43 values were significantly lower in ADD/ADMCI (Fig. 3d; p < 0.0001), encephalopathy (p = 0.0297), and Parkinson’s disease (p = 0.0281) than in CU. The Aβ_1-38/Aβ_1-42 and Aβ_1-38/Aβ_1-43 ratios were significantly higher in ADD/ADMCI than in CU (p = 0.021 in Aβ_1-38/1-42, Fig. 3e; p = 0.0004 in Aβ_1-38/1-43, Fig. 3f). Increased ratios of Aβ_1-40/Aβ_1-42 and Aβ_1-40/Aβ_1-42 ₊ Aβ_1-43 were not significant (p = 0.1226 in Aβ_1-40/ Aβ_1-42 ratio, Fig. 3g; p = 0.0895 in Aβ_1-40/Aβ_1-42 ₊ Aβ_1-43 ratio). The Aβ_1-40/Aβ_1-43 ratio was significantly increased (p = 0.0033, Fig. 3h). The Aβ(_1-40_/_1-43)/Aβ(_1-38_/_1-42) ratio was not significantly changed in ADD/ADMCI and other diseases. These results imply that successive cleavage from Aβ_1-43 to Aβ_1-40 and from Aβ_1-42 to Aβ_1-38 was enhanced in parallel in AD.

Fig.3

Values of CSF Aβ species and ratios among neurological diseases and controls. No significant differences were observed in Aβ_1-38 and Aβ_1-40 levels among ADD/ADMCI and other neurological diseases and CU (a, b). Aβ_1-42 levels were significantly lower in ADD/ADMCI than in CU (p = 0.0066; c). CSF Aβ_1-43 values were significantly lower in ADD/ADMCI (d; p < 0.0001), ENC (p = 0.0297), and PD (p = 0.0281) than in CU. The Aβ_1-38/Aβ_1-42 and Aβ_1-38/Aβ_1-43 ratios were significantly higher in ADD/ADMCI than in CU (e: p = 0.021; f: p = 0.0004). Ratios of Aβ_1-40/Aβ_1-42 and Aβ_1-40/Aβ_1-42 + Aβ_1-43 were not significant (g: p = 0.1226 in Aβ_1-40/Aβ_1-42 ratio; p = 0.0895 in Aβ_1-40/Aβ_1-42 ₊ Aβ_1-43 ratio). The Aβ_1-40/Aβ_1-43 ratio was significantly increased (h: p = 0.0033). The Aβ (_1-40/_1-43)/Aβ (_1-38/_1-42) ratio was not significantly changed in ADD/ADMCI and other diseases (i). (a: Blue circles represent sporadic ADD and ADMCI, cyan circles represent familial AD).

DISCUSSION

Mass spectrometry is a device that is capable of detecting the masses of various substances, as well as accurate peptide sequence lengths. Due to advances in the operability and analytical devices for extremely small amounts, this method has been clinically applied to the measurement of various substances in recent years. MS/MS is the combination of two mass analyzers in one mass spectrometric instrument. The combination with a highly selective separation method by LC allows for more accurate and reliable quantification for clinical application. Therefore, the LC-MS/MS technique has been used to measure Aβ peptides [7–9, 17–19, 26–29]. This method eliminates time-consuming immune assays with a large number of steps and multiple antibodies or immunoprecipitation steps for pre-clinical studies. This approach also allows for performance of a single assay to measure several different Aβ species simultaneously in one sample with selectivity, specificity, and in a high-throughput format, while still achieving the high sensitivity required for low level endogenous Aβ peptides (such as CSF Aβ_1-43), plasma Aβ species, and modified tau products.

Comparative assays using the same samples between the LC-MS/MS assay and commonly used ELISA systems for Aβ_1-40, Aβ_1-42, and Aβ_1-42 ₊ Aβ_1-43 confirmed a strong correlation (Y = 0.9726* X + 165.9 for Aβ_1-40; Y = 0.8584*X + 2.545 for Aβ_1-42; Y = 0.9100*X + 2.389 for Aβ_1-42 ₊ Aβ₄₃; Fig. 2a–c). These results suggest that this LC-MS/MS assay is as reliable and reproducible a system as conventional ELISA systems. We did not validate Aβ_1-38 or Aβ_1-43 assay values by comparisons with ELISA systems. This LC-MS/MS assay requires further improvements in sensitivity for lower Aβ_1-43 values. However, studies on relationships with the respective Aβ species showed strong linear correlations among Aβ_1-38, Aβ_1-40, Aβ_1-42, and Aβ_1-43 (Fig. 1). Reliable ELISA for Aβ_1-38 and Aβ_1-43 are not commonly available. The present results support the application of the LC-MS/MS assay system for clinical usage, similar to conventional ELISA systems.

We previously proposed that Aβ_1-38/1-42 and Aβ_1-40/1-43 were distinct product/precursor pairs and reflected γ-secretase activity [9]. Significantly decreased CSF levels of Aβ_1-42 and Aβ_1-43 accompanied by increased Aβ_1-38/1-42 and Aβ_1-40/1-43 ratios and an enhanced proportional ratio of Aβ_1-40/1-43 versus Aβ_1-38/1-42 suggested altered successive cleavage by γ-secretase in AD. In the present study, strong correlations between Aβ_1-38 and Aβ_1-40 (r² = 0.8395) and between Aβ_1-42 and Aβ_1-43 (r² = 0.7576) also support this cleavage being processed in parallel. The processing ratio from Aβ_1-42 to Aβ_1-38 was 2.686 (Fig. 1b), and that from Aβ_1-43 to Aβ_1-40 was 112.8 (Fig. 1f). The accurate ratios of Aβ_1-38/1-42 were 4.66 in CU and 7.38 in AD whereas those of Aβ_1-40/1-43 were 241 in CU and 795 in AD. Both cleavage processes appear to have been enhanced in parallel twice in AD (Fig. 2d). Recent studies revealed that CNS-derived Aβ is cleared into the CSF [7] and peripheral blood [40], and that the clearance rate decreases in late onset AD [8] and is differently regulated by age, APOE isoforms, and the presence of Aβ amyloidosis [41–44]. Therefore, the measurement of precise amounts of Aβ_1-38, Aβ_1-40, Aβ_1-42, and Aβ_1-43 is relevant for clinical application of biomarkers and understanding of the processing of Aβ species in AD.

Comparisons between 66 cases of early-onset AD and 25 of late-onset AD by ELISA showed that CSF Aβ_1-43 significantly varied with age in AD. However, Aβ_1-43 levels were not superior to Aβ_1-42 for diagnostic accuracy [15]. CSF Aβ_1-43, but not Aβ_1-42, differentiated between patients with amnestic MCI who progressed to AD during a 2-year follow-up [16]. Goda and Kobayashi evaluated dog CSF Aβ_1-38, Aβ_1-40, Aβ_1-42, and Aβ_1-43 using peptide adsorption-controlled LC-MS/MS and showed that the Aβ assay was reproducible [17]. Aβ quantitation by LC-MS/MS showed satisfactory intra- and inter-day reproducibility as well as freeze-thaw and room temperature stability [17, 18]. The findings of a recent large study by Janelidze et al. using three different immunoassays revealed that the CSF Aβ₄₂/Aβ₄₀ and Aβ_42/₃₈ ratios were significantly better than CSF Aβ₄₂ alone for the detection of brain amyloid deposition in prodromal AD and differentiating AD dementia from non-AD dementias [20]. Widely used ELISA for the quantitation of Aβ_1-42/total tau, Aβ_1-42/Aβ_1-40, Aβ_1-42/Aβ_1-38, and Aβ_1-42 showed the greatest accuracy for identifying amyloid-positive subjects. Aβ_1-40 and Aβ_1-38 showed significantly lower discriminative powers [21]. The first report of ELISA assays for Aβ_1-38, Aβ_1-40, and Aβ_1-42 showed only decreased levels of Aβ_1-42 compared with Aβ_1-38 and Aβ_1-40 in CSF from AD [22]. CSF Aβ_1-42/Aβ_1-40 and Aβ_1-42/Aβ_1-43 were positively correlated with in gait variability and ADL in mild ADD [23]. A UPLC-MS-MS assay of CSF Aβ_1-42 showed equivalent diagnostic utility to those of commonly used AlzBio3 ELISA systems [26]. Oe et al. reported that the validated methods had limits of quantitation of 44 fmol/mL for Aβ_1-42 and 92 fmol/mL for Aβ_1-40 in CSF. A strong correlation was observed between LC/MS/MS and ELISA for Aβ_1-42 (r² = 0.915), and those correlations were weak for Aβ_1-40 (r² = 0.644) [27]. The accuracy and precision of LC-MS/MS will contribute to the clinical diagnosis and monitoring of therapeutic interventions [27].

The present results suggest that the quantitative LC-MS/MS assay for CSF Aβ species is as reliable as specific ELISA for the clinical evaluation of CSF biomarkers for AD. Since the present study was not a large scale or prospective control study, further large-scale studies are necessary. However, the reliable and convenient LC-MS/MS multiple assay of Aβ species is equivalent to specific multiple ELISA assays. Therefore, the LC-MS/MS multiple assay of Aβ species may be applicable and contribute to kinetic [7, 8] and drug monitoring [44] studies on Aβ species. The establishment of a multiple Aβ and tau species assay by LC-MS/MS is warranted.

ACKNOWLEDGMENTS

We thank Yasuhito Wakasaya for his research assistance. This study was supported by the Amyloidosis Research Committee Surveys and Research on Special Diseases, the Longevity Science Committee of the Ministry of Health and Welfare of Japan; Scientific Research (C) (18K07385 MS, 19K07989 T.K.) from the Ministry of Education, Science, and Culture of Japan, the Hirosaki University Institutional Research Grant, and the Center of Innovation Science and Technology-based Radical Innovation and Entrepreneurship Program from the Japan Science and Technology Agency. This study was approved by the Ethics Committee of Hirosaki University (2017-112) and Geriatrics Research Institute and Hospital (2019-78). All participants provided written informed consent.

Authors’ disclosures available online (https://www.j-alz.com/manuscript-disclosures/20-0987r1).

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