Received: 17 August 2023 Revised: 8 February 2024 Accepted: 15 February 2024

DOI: 10.1002/alz.13789

RESEARCH ARTICLE

Glymphatic system dysfunction predicts amyloid deposition,

neurodegeneration, and clinical progression in Alzheimer’s
disease

Shu-Yi Huang1 Ya-Ru Zhang1 Yu Guo1 Jing Du2 Peng Ren3

Bang-Sheng Wu1 Jian-Feng Feng3,4,5 Alzheimer’s Disease Neuroimaging Initiative
Wei Cheng1,3,4,5,6 Jin-Tai Yu1
1
Department of Neurology and National Center for Neurological Disorders, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers
Center for Brain Science, Shanghai Medical College, Fudan University, Shanghai, China
2
Centre for Healthy Brain Ageing (CHeBA), Discipline of Psychiatry and Mental Health, School of Clinical Medicine, UNSW, Sydney, New South Wales, Australia
3
Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
4
Key Laboratory of Computational Neuroscience and Brain-Inspired Intelligence (Fudan University), Ministry of Education, Shanghai, China
5
Fudan ISTBI—ZJNU Algorithm Centre for Brain-Inspired Intelligence, Zhejiang Normal University, Jinhua, China
6
Shanghai Medical College and Zhongshan Hospital Immunotherapy Technology Transfer Center, Fudan University, Shanghai, China

Correspondence
Jin-Tai Yu, National Center for Neurological Abstract
Disorders and Department of Neurology,
Huashan Hospital, Fudan University, 12th
INTRODUCTION: Although glymphatic function is involved in Alzheimer’s disease
Wulumuqi Zhong Road, Shanghai 200040, (AD), its potential for predicting the pathological and clinical progression of AD and
China.
Email: [email protected]
its sequential association with core AD biomarkers is poorly understood.
METHODS: Whole-brain glymphatic activity was measured by diffusion tensor image
Data used in preparation for this article were
analysis along the perivascular space (DTI-ALPS) in participants with AD dementia
obtained from the Alzheimer’s Disease
Neuroimaging Initiative (ADNI) database (n = 47), mild cognitive impairment (MCI; n = 137), and normal controls (n = 235) from
(adni.loni.usc.edu). As such, the investigators
the Alzheimer’s Disease Neuroimaging Initiative.
within the ADNI contributed to the design and
implementation of ADNI and/or provided data RESULTS: ALPS index was significantly lower in AD dementia than in MCI or con-
but did not participate in the analysis or
trols. Lower ALPS index was significantly associated with faster changes in amyloid
writing of this report. A complete listing of
ADNI investigators can be found at: positron emission tomography (PET) burden and AD signature region of interest vol-
http://adni.loni.usc.edu/wp-
ume, higher risk of amyloid-positive transition and clinical progression, and faster rates
ontent/uploads/how_to_apply/
16ADNI_Acknowledgement_List.pdf. of amyloid- and neurodegeneration-related cognitive decline. Furthermore, the associ-
ations of the ALPS index with cognitive decline were fully mediated by amyloid PET and
Funding information
Science and Technology Innovation 2030 brain atrophy.
Major Projects, Grant/Award Number: DISCUSSION: Glymphatic failure may precede amyloid pathology, and predicts amy-
2022ZD0211600; National Natural Science
Foundation of China, Grant/Award Number: loid deposition, neurodegeneration, and clinical progression in AD.

Shu-Yi Huang and Ya-Ru Zhang contributed equally to the present work.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2024 The Authors. Alzheimer’s & Dementia published by Wiley Periodicals LLC on behalf of Alzheimer’s Association.

Alzheimer’s Dement. 2024;20:3251–3269. wileyonlinelibrary.com/journal/alz 3251

 15525279, 2024, 5, Downloaded from https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.13789 by CAPES, Wiley Online Library on [30/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
3252 HUANG ET AL .

82071201 82071997; Shanghai Municipal

Science and Technology Major Project, KEYWORDS
Grant/Award Number: 2018SHZDZX01; Alzheimer’s disease, amyloid, analysis along the perivascular space, cognitive decline, glymphatic,
Research Start-up Fund of Huashan Hospital, neurodegeneration, progression
Grant/Award Number: 2022QD002;
Excellence 2025 Talent Cultivation Program at
Fudan University, Grant/Award Number: Highlights
3030277001; Shanghai Talent Development
Funding for The Project, Grant/Award
∙ The analysis along the perivascular space (ALPS) index is reduced in patients with
Number: 2019074; Shanghai Rising-Star Alzheimer’s disease (AD) dementia, prodromal AD, and preclinical AD.
Program, Grant/Award Number:
21QA1408700; ZHANGJIANG LAB; Tianqiao
∙ Lower ALPS index predicted accelerated amyloid beta (Aβ) positron emission
and Chrissy Chen Institute; State Key tomography (PET) burden and Aβ-positive transition.
Laboratory of Neurobiology and Frontiers
Center for Brain Science of Ministry of
∙ The decrease in the ALPS index occurs before cerebrospinal fluid Aβ42 reaches the
Education, Fudan University positive threshold.
∙ ALPS index predicted brain atrophy, clinical progression, and cognitive decline.
∙ Aβ PET and brain atrophy mediated the link of ALPS index with cognitive decline.

1 BACKGROUND angiography-based method.11 The ALPS index provides an opportu-

nity for the non-invasive investigation of the human glymphatic system.
The glymphatic system is an essential fluid-clearance system in the It has been studied in various neurological disorders.11–14 In the field
brain that has been identified in the rodent brain.1 The highly orga- of AD, previous studies have observed a decreased ALPS index in AD
nized cerebrospinal fluid (CSF) transport system subserves the influx patients compared to controls.15–17 The ALPS index is also associated
of CSF into the brain parenchyma along the arterial perivascular spaces with cognitive performance in AD10,15 and is negatively associated
and subsequent transfer to the brain interstitial space. The system then with amyloid and tau deposition on positron emission tomography
directs the clearance of brain interstitial fluid along the venous perivas- (PET) images.15,18 However, to our knowledge, no prior attempts have
cular into the meningeal and cervical lymphatic drainage vessels to been made to investigate the potential of glymphatic activity in pre-
remove waste. The accumulation of amyloid beta (Aβ) plaques and dicting the pathological and clinical progression of AD in longitudinal
neurofibrillary tangles of hyperphosphorylated tau have been impli- cohorts, or to determine whether it is a cause or a consequence of AD
cated in the cognitive dysfunction of Alzheimer’s disease (AD).2 Aβ pathological and clinical progression.
is transported and removed from the central nervous system along In the present study, we used the ALPS index to investigate the
the glymphatic pathways.1,3 Although tau is an intracellular pathol- cross-sectional and longitudinal associations between glymphatic
ogy characterized in AD, intracellular tau can release into extracellular activity and clinical and pathological features of AD, including diag-
space and be cleared from the brain along the glymphatic system.4–7 nosis, cognitive scores, and CSF and neuroimaging biomarkers.
Therefore, impaired brain clearance mechanisms may be an essential Taking advantage of the large-scale and longitudinal measurements
factor contributing to the deposition of pathological proteins in AD.8 of the ALPS index and AD hallmarks in the Alzheimer’s Disease
The novel fluid transport system provides a promising target for the Neuroimaging Initiative (ADNI) cohort, we further investigated the
prevention or treatment of AD. sequential relationship between glymphatic dysfunction, as measured
Magnetic resonance imaging (MRI) tracer-based studies have by the ALPS index, and markers of AD pathology in the development
demonstrated the existence of a glymphatic system in the human of AD.
brain9 as previously discovered in rodents, through the intrathe-
cal administration of gadolinium-based contrast agent. This approach
can detect glymphatic function directly. However, its invasive nature 2 METHODS
restricts the comprehensive human studies of the glymphatic system.
Recently, a measure of perivascular clearance activity in the human 2.1 Participants and study design
brain using diffusion MRI called diffusion tensor image analysis along
the perivascular space (DTI-ALPS) has been proposed by Taoka et al.,10 This study included two longitudinal follow-up cohorts, the ADNI and
which is calculated from the diffusivity along the deep medullary the UK Biobank (UKB) study. The ADNI database was used for the main
vein at the level of the lateral ventricular body. The reliability of the analyses, which included examining the relationship of the ALPS index
ALPS index as a measure of glymphatic activity was supported in a with clinical and pathological features of AD, as well as its sequence
recent study that found a significant correlation between the ALPS association with core AD biomarkers. The UKB was used as a repli-
index and glymphatic clearance function evaluated by the intrathecal cation cohort for analyzing the role of the ALPS index in predicting
 15525279, 2024, 5, Downloaded from https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.13789 by CAPES, Wiley Online Library on [30/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HUANG ET AL . 3253

clinical progression. A general scheme of the current study is depicted

in Figure 1. RESEARCH IN CONTEXT

1. Systematic review: We reviewed literature in PubMed

and found studies of glymphatic activity measured by
2.1.1 ADNI cohort for main analysis
analysis along the perivascular space (ALPS) index in
Alzheimer’s disease (AD) were all conducted in cross-
Data used in the main analysis were obtained from the ADNI
sectional cohorts. No prior attempts have been made to
database (http://adni.loni.usc.edu/). For the present study, we used
investigate the potential of glymphatic activity in track-
data accessed from the ADNI database in March 2023. The ADNI was
ing the pathological and clinical progression of AD and
launched in 2003 as a public–private partnership and is led by prin-
its sequential relationship with core AD biomarkers in
cipal investigator Michael W. Weiner, MD. The primary goal of ADNI
longitudinal cohorts.
is to test whether serial MRI, PET, and various clinical, biological, and
2. Interpretation: The ALPS index decreased in AD demen-
neuropsychological markers can be combined to measure the progres-
tia, prodromal, and preclinical AD patients. We for the
sion of mild cognitive impairment (MCI) and early AD dementia. The
first time suggested the predictive effect of the ALPS
ADNI study was approved by the local institutional review boards
index on longitudinal changes in amyloid positron emis-
of all participating centers. All study participants provided written
sion tomography (PET) and AD signature region of inter-
informed consent. Inclusion and exclusion criteria have been described
est volume, risk of amyloid-positive transition and clinical
previously.19 ADNI participants were included in this study if they
progression, and cognitive decline. Amyloid PET and brain
possessed available DTI and necessary covariate data (i.e., age, sex,
atrophy mediated the associations of ALPS index with
education, and apolipoprotein E [APOE] ε4 genotype). Patients with
cognitive decline.
AD dementia were diagnosed according to the National Institute of
3. Future directions: The ALPS index provides a rough mea-
Neurological and Communication Disorders/Alzheimer’s Disease and
sure of the global glymphatic activity and cannot reflect
Related Disorders Association criteria, reported a Mini-Mental State
its regional heterogeneity. Developing and improving a
Examination (MMSE) score of between 20 and 26, a global Clinical
precise and non-invasive measure of regional glymphatic
Dementia Rating from 0.5 to 1.0, and a sum-of-boxes Clinical Demen-
function is a promising future direction.
tia Rating (CDR-SB) of 1.0 to 9.0. Patients diagnosed with MCI had an
MMSE score between 24 and 30, objective memory loss as assessed
by delayed recall of the Wechsler Memory Scale Logical Memory II, a
CDR-SB score of at least 0.5, preserved activities of daily living, and
absence of dementia. Cognitively normal (CN) controls were defined
as those with an MMSE score of at least 24 and a CDR-SB score of 0 or (Fields 131036-131037 and 130836-130837), algorithmically defined
0.5. To sum up, a total of 47 AD dementia patients, 137 MCI patients, AD outcomes (Field 42020), hospital inpatient data summaries (Fields
and 235 CN controls were included in the primary analysis. 41270 and 41280), and death registry data (Fields 40001 and 40002).
Self-reported AD records were excluded from the study. Detailed infor-
mation about the data used for AD definitions in the UKB is provided
2.1.2 Replication cohort in Table S1 in supporting information. Participants were considered
at risk for AD from the first imaging visit (Field 53, instance 2) and
The UKB study was approved by the National Information Gover- were followed up until the date of first AD diagnosis, death, or the last
nance Board for Health and Social Care and the National Health recorded date (September 2023), whichever came first. Analyses were
Service North West Multicenter Research Ethics Committee.20 It is a performed under UK Biobank application number 19542.
population-based cohort of > 500,000 participants aged 37 to 73 years
recruited across the United Kingdom between 2006 and 2010.20 All
participants provided electronic informed consent at baseline assess- 2.2 CSF biomarkers
ment. To assess the relationship between baseline ALPS index and the
risk of progression from non-demented to AD, 36,050 non-demented CSF was collected by lumbar puncture from a subset of ADNI partic-
participants with available DTI data at the first imaging visit in UKB ipants. Each sample was aliquoted to 500 µL in polypropylene tubes,
were screened. After excluding participants with missing follow-up shipped on dry ice to the ADNI Biomarker Core laboratory, and stored
data, missing covariate data, and without incident AD within the at −80◦ C. CSF Aβ42, phosphorylated tau 181 (p-tau181), and total
first 3 years of follow-up, 36,050 eligible participants were finally tau (t-tau) concentrations were measured using Roche Elecsys and
included in the replication analyses (Figure S1 in supporting informa- cobas e 601 automated immunoassay analyzer systems as previously
tion). Incident AD events were recorded using codes F00 and G30 described.21 All CSF biomarker assays were performed in duplicate
of the International Classification of Diseases system. AD diagnosis and averaged. Coefficients of variation for CSF analytes within and
data were ascertained by combining records from first occurrence data between lots were <15%. The cutoffs for CSF Aβ42, p-tau181, and
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3254 HUANG ET AL .

t-tau were previously set at 1098 pg/mL,22,23 26.64 pg/mL,23 and (right-left), y axis (anterior-posterior), z axis (inferior-superior), and
300 pg/ml,24,25 respectively. color-coded FA maps for all participants were also warped to the MNI
space. The diffusivity in the directions of the x axis (Dx), y axis (Dy), and
z axis (Dz) of the ROIs on the projection and association fibers were cal-
2.3 MRI imaging culated for each participant within the ROI templates and recorded as
Dxproj, Dyproj, Dzproj, Dxassoc, Dyassoc, Dzassoc, respectively. The
Mean(Dxproj + Dxassoc)
In ADNI, T1-weighted imaging, fluid-attenuated inversion recovery ALPS index was calculated as follows: ALPS index = .
Mean(Dyproj + Dzassoc)
(FLAIR) imaging, and DTI data were acquired for each participant using The ALPS indexes of the left and right hemispheres were calculated
3T scanners. Details of the imaging protocol can be found in the open- separately, and then we used the average ALPS index of the bilateral
source document (https://adni.loni.usc.edu/methods/documents/mri- sides in the main analysis. A higher ALPS index represented better
protocols/). Brain structural measures were derived from quality- glymphatic activity. Two neurologists blinded to clinical data indepen-
controlled T1-weighted neuroimaging data. FreeSurfer was used to dently placed ROIs for inter-observer reliability analysis. To exclude
quantify the regional volumes according to the 2010 Desikan–Killiany the potential influence of white matter integrity, we also calculated the
atlas. We used volumetric data for the hippocampus and AD signature whole-brain white matter mean FA and mean diffusivity (MD) of ADNI
region of interest (ROI) composed of the entorhinal, inferior temporal, individuals according to the prior work.29
middle temporal, and fusiform areas.26 We then calculated the resid-
ual hippocampal volume and the residual AD signature ROI volume
from a linear regression of the imaging measure (y) against the intracra- 2.5 PET imaging
nial volume (ICV; x) among CN subjects, as previously described.27
The adjusted imaging measure is interpreted as the deviation from the A subset of ADNI participants provided eligible PET data. The Aβ
value expected in a healthy individual with the observed ICV. Unless (florbetapir, or [18 F]AV45; florbetaben, or FBB), tau (flortaucipir, or
otherwise noted, “hippocampal volume” and “AD signature ROI vol- [18 F]AV1451), and fluorodeoxyglucose (FDG) PET data were prepro-
ume” in the following refer to their residual metrics. White matter cessed using the ADNI pipeline (http://adni.loni.usc.edu/datasamples/
hyperintensities (WMH) and gray matter (GM) volume were automati- pet/). Briefly, each participant’s MRI image from the nearest avail-
cally segmented by the ADNI core laboratory using the ADNI pipeline able visit was segmented and parcellated using FreeSurfer (version
(https://files.alz.washington.edu/documentation/adni-proto.pdf). 7.1.1) to define ROIs in native space. The mean standard uptake
In UKB, all brain MRI were acquired on the standard 3T Siemens value ratio (SUVR) of each scan for targeted ROIs was calculated by
Skyra scanner with a 32-channel head coil, according to a freely avail- dividing the tracer uptake in these regions by the value in a pre-
able protocol (https://www.fmrib.ox.ac.uk/ukbiobank/protocol/ defined reference region. For Aβ PET, the SUVRs were generated
V4_23092014.pdf), document (https://biobank.ndph.ox.ac.uk/ by averaging uptake ratios across AD summarized cortical regions
showcase/showcase/docs/brain_mri.pdf), and publication.28 Fur- (frontal, anterior/posterior cingulate, lateral parietal, and lateral tem-
ther information on the image processing and quality control pipeline poral regions) and then normalized by a composite reference region
are available elsewhere.28 (whole cerebellum, brainstem/pons, and eroded subcortical white mat-
ter). This composite reference region had more reliable longitudinal
AV45 results in ADNI compared to using only the cerebellum as a ref-
2.4 ALPS index calculation erence region.30 For note, Aβ PET in the following text refers only to
AV45 PET, unless otherwise specified. For tau PET, a composite SUVR
In both ADNI and UKB cohorts, the ALPS index was calculated from was calculated by referring AV1451 uptake in a weighted composite
DTI using a semi-automated and highly reliable pipeline developed and (MetaROI) of regions (bilateral entorhinal, amygdala, fusiform, infe-
validated by Taoka et al.10 Diffusivity maps along the x axis (right-left), rior and middle temporal cortices) to the mean uptake of the inferior
y axis (anterior-posterior), z axis (inferior-superior), and color-coded cerebellar GM. The tau PET SUVR values in Braak stage ROIs were
fractional anisotropy (FA) maps were processed using the FMRIB Soft- extracted, including three Braak region groups (Braak I, Braak III–IV,
ware Library (https://fsl.fmrib.ox.ac.uk/fsl/fslwiki). To make the ROI and Braak V–VI) in the present study. The Braak II region (hippocam-
templates, we randomly selected 100 ADNI participants and 150 UKB pus) was not included because this region is known to be contaminated
participants with age and sex matched. At the location where the direc- by off-target binding in the choroid plexus. In addition, cortical uptake
tion of the deep medullary veins was perpendicular to the ventricular of AV45 and AV1451 in 68 ROIs defined by the Desikan–Killiany
body, four spherical ROIs with a radius of 4 mm were placed on the atlas31 were also extracted from each PET scan that was coregistered
bilateral projection (superior and posterior corona radiata) and associ- with the corresponding individual structural MRI scan. For FDG PET
ation (superior longitudinal fasciculus) fibers on the FA map template. images, a composite SUVR of each scan was calculated as the mean
The ROI maps were non-linearly warped to the Montreal Neurolog- uptake of predefined MetaROIs (bilateral angular, posterior cingulate,
ical Institute (MNI) space using FNIRT (https://fsl.fmrib.ox.ac.uk/fsl/ and inferior temporal gyrus) relative to the mean of a pons/vermis ref-
fslwiki/FNIRT) and the probability maps were then generated and bina- erence region. Cutoffs for brain Aβ, tau, and FDG PET categories were
rized as the templates. After that, the diffusivity maps along the x axis as follows: 0.78 for AV45 SUVR, 0.74 for FBB SUVR, 1.37 for AV1451
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HUANG ET AL . 3255

MetaROI SUVR,23 and 1.21 for FDG PET.32 The cut points used in the 2.8 Statistical analysis
present study are based on published articles or ADNI proposals.
All statistical analyses were performed using R software (version 4.2.3).
Data were initially screened for outliers and those that fell outside
2.6 Cognitive assessments three standard deviations (SDs) were removed. Raw data are pre-
sented in tables as mean (±SD) or number (%) unless otherwise noted.
Previously validated Preclinical Alzheimer’s Cognitive Composite Normality tests were performed using the Shapiro–Wilk test and visual
(PACC) scores were used to represent global cognition in the present inspection of histograms. The ALPS index was normalized using the
study. The PACC score has been associated with the detection of early Box–Cox transformation. Z transformation was performed on the nor-
cognitive decline in patients with AD.33 In ADNI, the PACC score mally transformed ALPS index and AD variables when comparability
is the average of four z scored cognitive tests: Alzheimer’s Disease of effect sizes was required. Non-parametric Kruskal–Wallis tests,
Assessment Scale delayed recall word list test, MMSE, Logical Mem- chi-squared tests, and Spearman rank correlation were used to com-
ory Delayed Recall test, and Digit Symbol coding test. Specific cognitive pare baseline characteristics between diagnostic groups, or to test
domains were also assessed using composite measures developed by associations between ALPS index and demographic factors. Group
ADNI that reflect memory and executive function (EF).34,35 For each comparisons of the ALPS index were examined using analysis of covari-
of the three cognitive measures, higher scores indicate more normal ance (ANCOVA) controlling for age, sex, education, and APOE ε4 carrier
cognition and lower scores indicate more impaired cognition. status (Model 1). Baseline diagnosis was also adjusted for comparing
the ALPS index in different biological groups. A false discovery rate
(FDR) of 0.05 was applied using the Benjamini–Hochberg approach for
2.7 Biological status definition and AD profiles correction of multiple comparisons when appropriate.
Linear regression models were used to examine the cross-sectional
Participants were classified into different amyloid (A) statuses accord- associations of the ALPS index with core AD biomarkers (including
ing to the abnormal status of CSF Aβ42 and Aβ PET (AV45 and FBB). CSF, PET, and MRI indicators of amyloid pathology, tau pathology,
If any one of the three biomarkers indicates an abnormal level of amy- and neurodegeneration) and cognition in Model 1. We then exam-
loid pathology, the individual would be considered A+ status. Based on ined how the ALPS index correlated with these core AD biomarkers
the CSF p-tau181 levels and tau PET and the cutoffs described above, in participants stratified by CSF Aβ42 status (positive or negative), the
participants were classified into the aggregated AD-tau positive (T+) established earliest biomarker of AD,39 according to the predefined
group if either of these two biomarkers indicated the presence of tau cutoffs. We also calculated the linear regression slopes for core AD
pathology. Similarly, CSF t-tau and FDG PET were used to determine biomarkers in CSF Aβ42 defined A± groups and tested whether the
neurodegeneration (N) status. Table S2 in supporting information lists slopes were statistically significantly different. To investigate the lon-
detailed definitions of biological status. Unless otherwise noted, A/T/N gitudinal relationship among the ALPS index, core AD biomarkers, and
statuses hereinafter refer to A/T/N statuses jointly defined by CSF or cognition, we examined whether the baseline ALPS index could predict
PET, respectively. To maximize the use of data, for participants who did the longitudinal change rates of AD biomarkers and cognition. Addi-
not have a CSF assessment or PET scan at baseline (first ALPS index tionally, we examined whether baseline levels of AD biomarkers and
measurement), the corresponding measurements within the last 12 cognition could predict longitudinal changes in the ALPS index using
months before the baseline ALPS index measurement were used for linear regression in Model 1. We derived the slopes of each core AD
imputation. For sensitivity analysis, we also used the biological status biomarker (including CSF, PET, and MRI measures) and ALPS index
(A± , T± , and N±) defined separately by CSF or PET. using linear mixed-effect (LME) models for all the participants with cor-
According to the clinical diagnosis and A status, participants were responding longitudinal data, adjusting for age and sex, and including a
classified into five groups, including the A–CN, A+CN (preclinical random slope and intercept. The slope of each cognitive score was cal-
AD36 ), A–MCI, A+MCI (prodromal AD37 ), and A+AD dementia. Then, culated in a similar manner, but adjusted for age, sex, and education.
aggregated tau and neurodegeneration groups were merged as a “TN” As an additional analysis, we examined the interaction effect of base-
group according to the National Institute on Aging–Alzheimer’s Asso- line ALPS index with core AD variables on the longitudinal changes in
ciation criteria for preclinical AD.36 If any of the biomarkers indicate PACC scores using linear regression in Model 1.
an abnormal level of tau or neurodegeneration pathology, the individ- To further explore the sequential changes between the ALPS index
ual would be considered a TN+ status. Combining TN with A status, and Aβ biomarkers, we first applied robust local weighted regression
we subdivided CN participants into three biomarker subgroups, stage models to visualize the relationships among the ALPS index, CSF Aβ42,
0 (A–TN–), stage 1 (A+TN–), and stage 2 (A+TN+). Participants were Aβ PET, and PACC score. The data above was scaled from 0% to 100%,
accordingly classified into normal control (stage 0), preclinical AD with 0% representing minimal abnormalities and 100% representing
(stage 1 and stage 2), prodromal AD (A+MCI), and A+AD demen- maximal abnormalities, as performed elsewhere.15 The CSF Aβ42 level
tia, following the AD continuum category.36–38 Table S3 in supporting and PACC score were modeled as the proxies for disease progression.
information provides detailed definitions of AD biological profiles. Subsequently, we examined the relationship between ALPS index and
 15525279, 2024, 5, Downloaded from https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.13789 by CAPES, Wiley Online Library on [30/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
3256 HUANG ET AL .

the risk of A status progression from A– to A+ in baseline A–CN sub- index correlated with age (Spearman ρ = −0.253, P = 1.81×10−7 ), sex
jects using Kaplan–Meier curve and multivariable Cox proportional (median, 1.30 for females and 1.20 for males; P = 1.38×10−7 ), mean
hazards regression adjusted for covariates in Model 1. In the Cox FA (ρ = 0.203, P = 3.63×10−5 ) and MD (ρ = −0.276, P = 1.11×10−8 ),
model, the baseline ALPS index was treated as a continuous variable WMHVF (ρ = −0.200, P = 8.20×10−5 ), and GMVF (ρ = 0.260,
and categorized as a dichotomous variable by the median level (< 1.25 P = 1.94×10−7 ), but not with education (ρ = −0.089, P = 0.070) and
and ≥1.25). Time variable in this Cox model was time to progression to APOE ε4 carrier status (P = 0.222). In addition, we tested whether
A+ or the maximum follow-up duration. the assessment location influence the ALPS index by using ANCOVA
To assess whether baseline ALPS index could predict the risk of clin- controlling for age, sex, education, and APOE ε4 genotype. The results
ical conversion to AD dementia or MCI in ADNI participants and the showed a significant difference in the ALPS index across different
risk of progression from non-demented to incident AD in UKB baseline assessment sites (F-value = 1.477, P = 0.027). A general scheme of the
non-demented participants, we constructed Kaplan–Meier curve and current study is depicted in Figure 1.
multivariable Cox proportional hazards regression in Model 1. In this
section, baseline ALPS index was modeled as a continuous variable and
categorized by tertiles (thresholds in ADNI: < 1.17, 1.17–1.34, ≥ 1.34; 3.2 Comparisons of ALPS index among different
thresholds in UKB: < 1.30, 1.30–1.41, ≥ 1.41). The time variable was diagnostic and biological groups
defined in the ADNI as the time to progression to MCI or AD dementia,
or the maximum follow-up duration. In the UKB, the time variable was After correction for age, sex, education, and APOE ε4 carrier status
measured as the time from the first imaging visit to the first AD diagno- (Model 1), patients with AD dementia had significantly lower base-
sis, death, or until the last recorded date (September 2023), whichever line ALPS index compared to CN controls and MCI patients after FDR
came first. correction (PFDR = 1.39×10−4 and 0.010, respectively; Figure 2A). We
After the preliminary result and previous studies,39 mediation then compared the ALPS index between different biological diagnos-
analyses based on structural equation modeling were further used tic groups (Figure 2B). Baseline characteristics of the study population
to investigate the directional dependencies among the ALPS index, stratified by diagnosis and A status are shown in Table S4 in support-
amyloid (CSF Aβ42 and Aβ PET), neurodegeneration (AD signature ing information. When the A status was defined by CSF Aβ42 and
ROI volume, hippocampal volume, or FDG PET), and cognitive func- Aβ PET (AV45 and FBB), patients with A+CN, A+MCI, and A+AD
tion (PACC; implemented in the R package lavaan 0.6-1.1). We first dementia showed significantly decreased ALPS index compared to the
constructed simple mediation models to specify the mediation associ- A–CN controls (PFDR = 0.018, 0.001, and 2.02×10−4 , respectively).
ations between ALPS index and AD biomarkers. Subsequently, three Patients with A+AD dementia had a lower ALPS index compared to the
multiple mediation models including ALPS index, AD biomarkers, and A+CN individuals (PFDR = 0.031). The ALPS index was also decreased
cognition were constructed to examine the potential pathological path- in patients with A+MCI compared to patients with A–MCI subjects at
ways by which glymphatic function, assessed by the ALPS index, affects the very edge of significance after multiple correction (PFDR = 0.051).
cognition (see eMethods in supporting information for more details). When the A status was defined by CSF Aβ42 or Aβ PET (AV45 and
Covariates comprised age, sex, education, and APOE ε4 carrier status FBB) separately, the stepwise descending trend from A–CN, A+CN,
(Model 1). through A+MCI to A+AD dementia remained (Figure S2A-B in sup-
In sensitivity analyses, we examined the influence of white matter porting information). In addition, when the CN individuals were divided
pathology, the assessment location, and GM atrophy on the measure- into the preclinical AD stages 0 to 2, participants in the stage 1,
ments of the glymphatic system by including WMH volume fraction A+MCI, and A+AD dementia groups had significantly more decreased
(WMHVF; Model 2), mean FA and MD (Model 3), assessment site ALPS index than those in the stage 0 group (PFDR = 0.033, 3.55×10−4 ,
(Model 4), or GM volume fraction (GMVF; Model 5) as confounding fac- 3.04×10−5 , respectively; Figure 2C). The A+MCI and A+AD dementia
tors in addition to the covariates in Model 1. For note, Model 5 was not groups also had significantly lower ALPS index than the stage 2 group
applied in analyses involved in brain structure measures. (PFDR = 0.033 and 0.002, respectively).
We further examined the ALPS index in different biological groups.
After correcting for age, sex, education, APOE ε4 carrier status, and
3 RESULTS baseline diagnosis, participants in the A+ group had a significantly
lower ALPS index than the A– group (P = 2.92×10−4 ; Figure 2D),
3.1 Cohort characteristics regardless of the definition of A status (Figure S2C-D). No differ-
ences in ALPS index were observed between T± groups or N± groups
Table 1 summarizes the clinical and demographic characteristics of the (Figure 2E-F and Figure S2E-G). However, participants in the FDG
study population from ADNI at baseline. Among 419 participants, 229 PET defined N+ group had a significantly lower ALPS index than the
(54.7%) were female, 204 (48.7%) were APOE ε4 carriers (ε4 +/- and corresponding N– group (P = 6.25×10−5 ; Figure S2H). When includ-
ε4 +/+), and the mean (±SD) of age and education were 68.5 (±4.50) ing WMHVF (Model 2), mean FA and MD (Model 3), assessment site
and 16.3 (±2.42), respectively. Longitudinal data of ALPS index and AD (Model 4), or GMVF (Model 5) as covariates in addition to those
variables are also illustrated in Table 1. In the whole cohort, the ALPS of Model 1 in sensitivity analyses, the group difference results align
 15525279, 2024, 5, Downloaded from https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.13789 by CAPES, Wiley Online Library on [30/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HUANG ET AL . 3257

TA B L E 1 Characteristics of the study population in ADNI.

CN MCI AD dementia Total

(N = 235) (N = 137) (N = 47) (N = 419) P value
Age (years) 68.7 (±3.85) 68.2 (±5.17) 68.0 (±5.36) 68.5 (±4.50) 0.980
Female 150 (63.8%) 54 (39.4%) 25 (53.2%) 229 (54.7%) 2.95×10−5
Education (years) 16.7 (±2.27) 16.1 (±2.54) 15.5 (±2.57) 16.3 (±2.42) 0.004
APOE ε4 carrier status
ε4−/− 149 (63.4%) 58 (42.3%) 8 (17.0%) 215 (51.3%) 5.31×10−12
ε4+/− 82 (34.9%) 55 (40.1%) 30 (63.8%) 167 (39.9%)
ε4+/+ 4 (1.7%) 24 (17.5%) 9 (19.1%) 37 (8.8%)
ALPS index 1.28 (±0.187) 1.24 (±0.198) 1.17 (±0.143) 1.26 (±0.189) 3.16×10−4
PACC score 0.748 (±2.52) −5.50 (±4.89) −15.7 (±3.76) −3.02 (±6.29) <2.22×10−16
ADNI-MEM 1.19 (±0.558) 0.308 (±0.649) −0.816 (±0.490) 0.690 (±0.874) <2.22×10−16
ADNI-EF 1.21 (±0.799) 0.504 (±0.869) −0.859 (±1.07) 0.758 (±1.07) <2.22×10−16
CSF Aβ42 (pg/ml) 1270 (±563) 1050 (±534) 636 (±332) 1110 (±568) 2.85×10−12
CSF p-tau181 (pg/ml) 20.2 (±8.32) 25.3 (±13.1) 34.3 (±14.6) 23.7 (±11.9) 1.34×10−8
CSF t-tau (pg/ml) 226 (±80.8) 266 (±117) 344 (±130) 254 (±108) 4.19×10−7
AV45 PET SUVR 0.759 (±0.100) 0.836 (±0.155) 1.03 (±0.114) 0.821 (±0.152) 4.42×10−15
FBB PET SUVR 0.748 (±0.114) 0.759 (±0.105) 1.01 (±0.207) 0.778 (±0.147) 0.001
AV1451 PET SUVR 1.18 (±0.114) 1.29 (±0.235) 1.52 (±0.299) 1.24 (±0.193) 3.48×10−7
FDG PET SUVR 1.32 (±0.119) 1.26 (±0.130) 1.01 (±0.149) 1.23 (±0.168) <2.22×10−16
Hippocampal volume (cm ) 3
0.0235 (±0.705) −0.494 (±0.993) −1.76 (±0.757) −0.321 (±0.972) <2.22×10−16
AD signature ROI volume (cm3 ) 65.5 (±7.77) 65.6 (±8.19) 55.3 (±9.47) 64.4 (±8.70) 5.39×10−8
WMHVF 0.002 (±0.003) 0.003 (±0.004) 0.004 (±0.004) 0.003 (±0.003) 3.00×10−5
GMVF 0.431 (±0.021) 0.420 (±0.026) 0.402 (±0.025) 0.424 (±0.025) <2.22×10−16
Mean FA 0.243 (±0.017) 0.237 (±0.016) 0.228 (±0.017) 0.239 (±0.017) <2.22×10−16
Mean MD 0.00119 (±0.0001) 0.00123 (±0.0001) 0.00130 (±0.0001) 0.00121 (±0.0001) <2.22×10−16
Longitudinal data (median, IQR, range)
ALPS index N = 133 N = 89 N = 29 N = 251
Visits 3 (1, 2−8) 3 (2, 2−13) 3 (1, 2−4) 3 (2, 2−13) 0.006
Duration (years) 2.1 (2, 0.45−9.5) 2 (2, 0.21−11.11) 1 (0.3, 0.18−2.26) 2 (2, 0.2−11.1) 1.68×10−8
CSF Aβ42 N = 77 N = 31 N=6 N = 114
Visits 2 (1, 2−6) 2 (1, 2−6) 2 (0, 2−2) 2 (1, 2−6) 0.066
Duration (years) 2.3 (2, 1.95−9.92) 3 (2, 1.77−11.11) 2 (0.1, 1.95−2.26) 2.2 (2, 1.8−11.1) 0.096
CSF p-tau181 N = 77 N = 28 N=5 N = 110
Visits 2 (1, 2−6) 3 (1, 2−6) 2 (0, 2−2) 2 (1, 2−6) 0.042
Duration (years) 2.3 (2, 1.95−9.92) 3.8 (2, 1.97−11.11) 2 (0.1, 1.95−2.26) 2.3 (2, 2−11.1) 0.067
CSF t-tau N = 78 N = 28 N=5 N = 111
Visits 2 (1, 2−6) 2.5 (1, 2−6) 2 (0, 2−2) 2 (1, 2−6) 0.067
Duration (years) 2.3 (2, 1.95−9.92) 3.3 (2, 1.97−11.11) 2 (0.1, 1.95−2.26) 2.3 (2, 2−11.1) 0.087
AV45 PET imaging N = 118 N = 64 N=7 N = 189
Visits 3 (2, 2−6) 2.5 (1, 2−6) 2 (0, 2−2) 3 (2, 2−6) 0.010
Duration (years) 4 (4.3, 1.54−9.92) 3.8 (2, 1.72−9.98) 2 (0, 1.95−2.26) 4 (3.9, 1.5−10) 5.65×10−4
AV1451 PET imaging N = 97 N = 26 N = 10 N = 133
Visits 2 (1, 2−4) 2.5 (1, 2−6) 2 (1, 2−3) 2 (1, 2−6) 0.605
Duration (years) 4 (3.1, 0.97−9.92) 2.9 (5.7, 0.88−11.11) 1.6 (1, 0.95−2.34) 4 (3.2, 0.9−11.1) 5.41×10−4

(Continues)
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3258 HUANG ET AL .

TA B L E 1 (Continued)

CN MCI AD dementia Total

(N = 235) (N = 137) (N = 47) (N = 419) P value
FDG PET imaging N = 22 N = 28 N=4 N = 54
Visits 2 (0, 2−3) 2 (1, 2−3) 2 (0, 2−2) 2 (0, 2−3) 0.135
Duration (years) 2 (0.1, 1.76−6.58) 2 (3.9, 1.77−6.98) 2 (0, 1.95−2.03) 2 (1.9, 1.8−7) 0.222
Structural MRI N = 157 N = 97 N = 30 N = 284
Visits 3 (2, 2−8) 3 (3, 2−11) 3 (1, 2−4) 3 (2, 2−11) 4.32×10−4
Duration (years) 2.2 (2.3, 0.46−9.22) 2.9 (2.2, 0.21−9.1) 1 (1, 0.18−2.34) 2.2 (2.1, 0.2−9.2) 5.61×10−10

Notes: Raw data were presented as mean (± standard deviation [SD]) or number (percentage, %) in tables unless otherwise noted. Data were compared using
two-tailed Kruskal–Wallis tests or chi-square tests.
Abbreviations: Aβ, amyloid beta; AD, Alzheimer’s disease; ADNI, Alzheimer’s Disease Neuroimaging Initiative; APOE, apolipoprotein E; ALPS, analysis along
the perivascular space; AV45, florbetapir; AV1451, flortaucipir; CN, cognitively normal; CSF, cerebrospinal fluid; EF, executive function composite score;
FA, fractional anisotropy; FBB, florbetaben; FDG, fluorodeoxyglucose; GMVF, gray matter volume fraction; IQR, interquartile range; MCI, mild cognitive
impairment; MD, mean diffusivity; MEM, memory composite score; MRI, magnetic resonance imaging; p-tau181, phosphorylated tau 181; PACC, Preclinical
Alzheimer’s Cognitive Composite; PET, positron emission tomography; ROI, region of interest; SUVR, standard uptake value ratio; t-tau, total tau; WMLVF,
white matter hyper hyperintensity volume fraction.

with those of the primary analysis (Model 1; Table S5 in supporting in the MetaROI regions (Table S6) or in different Braak regions (Table
information). S8). In sensitivity analyses, the inclusion of WMHVF (Model 2), mean
FA and MD (Model 3), assessment site (Model 4), or GMVF (Model 5)
as confounding factors in addition to the covariates of Model 1 also
3.3 Association of ALPS index with core AD resulted in significant longitudinal associations between ALPS index
biomarkers and slope of Aβ PET burden (Table S9 in supporting information).
Across 68 FreeSurfer-defined brain regions, baseline ALPS index
At baseline, the ALPS index was significantly correlated with Aβ was negatively associated with baseline Aβ PET SUVR in 29 regions
biomarkers, including a positive correlation with CSF Aβ42 (β = 0.22, (Figure 3D). Baseline ALPS index was also negatively associated with
P = 1.85×10−5 ) and a negative correlation with Aβ PET burden rates of increase in Aβ PET SUVR in 26 regions (Figure 3E and Table
(β = −0.20, P = 1.94×10−4 ; Table S6 in supporting information and S10 in supporting information). Regionally significant associations with
Figure 3A). When participants were divided into two subgroups based both baseline and slope of Aβ PET burden included bilateral rostral
on CSF Aβ42 status, a significant difference in the association of middle frontal, right superior frontal, and bilateral frontal pole, and so
ALPS index with CSF Aβ42 was observed in the two subgroups (P for on. As for tau PET, baseline ALPS index was negatively associated with
interaction = 0.003; Table S7 in supporting information), where the baseline tau PET SUVR in 14 regions and with faster rates of increase
cross-sectional association between ALPS index and CSF Aβ42 was in tau PET SUVR in 10 regions (Figure S3 and Table S11 in supporting
maintained in the CSF A– subgroup (β = 0.32, P = 2.66×10−4 ) but not information). The overlapping significant regions include left superior
in the CSF A+ subgroup (β = 0.06, P = 0.434). Regarding tau biomark- parietal, inferior parietal, paracentral, and so on. Regarding the regional
ers, ALPS index was negatively correlated with tau PET in the MetaROI MRI measures, baseline ALPS index was negatively correlated with
regions (β = −0.14, P = 0.039), Braak III and IV (β = −0.14, P = 0.049), cortical volume in 41 regions. The strongest associations were found
and Braak V and VI (β = −0.17, P = 0.017) regions, but not in Braak I in the inferior parietal region (Figure 3F and Table S12 in supporting
region (β = −0.08, P = 0.241; Table S8 in supporting information). The information). Despite the significant correlation between the base-
ALPS index was also positively correlated with neuroimaging markers line ALPS-index and the slope of the AD-signature ROI volume, we
of neurodegeneration, that is, FDG PET, hippocampal volume, and AD observed no positive correlation between the baseline ALPS-index and
signature ROI volume. There was no correlation of ALPS index with the slope of the cortical volume in any of the 68 ROI regions separately
CSF p-tau181 and CSF t-tau levels. (Figure 3G).
Longitudinally, lower baseline ALPS indexes were related to faster
rates of increase in Aβ PET burden (β = −0.17, P = 0.013) and faster
rates of decrease in AD signature ROI volume (β = 0.13, P = 0.029; 3.4 ALPS index reduction may occur prior to Aβ
Figure 3B). In contrast, the baseline levels of Aβ PET burden did not pre- and predict Aβ-positive transition
dict longitudinal changes in ALPS index (Figure 3C), but higher baseline
levels of AD signature ROI volume were associated with faster rates of To explore the sequential changes in glymphatic activity and Aβ
decline in the ALPS index (β = −0.17, P = 0.014). As for tau PET, base- biomarkers, the trajectories of ALPS index, Aβ PET deposition, and
line ALPS index was not related to the slope of the tau PET SUVR either PACC score were modeled using CSF Aβ42 as a proxy for AD
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HUANG ET AL . 3259

F I G U R E 1 Overview of the study. A, amyloid; Aβ, amyloid beta; AD, Alzheimer’s disease; ADNI, Alzheimer’s Disease Neuroimaging Initiative;
ALPS, analysis along the perivascular space; AV45, florbetapir; AV1451, flortaucipir; CN, cognitively normal; CSF, cerebrospinal fluid; FBB,
florbetaben; FDG, fluorodeoxyglucose; MCI, mild cognitive impairment; MRI, magnetic resonance imaging; PACC, Preclinical Alzheimer’s
Cognitive Composite; PET, positron emission tomography; p-tau181, phosphorylated tau 181; ROI, region of interest; SUVR, standard uptake
value ratio; t-tau, total tau.
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3260 HUANG ET AL .

F I G U R E 2 ALPS indexes by diagnosis and biological stages. The graphs display the 95% CIs around the median of raw values of each plasma
biomarker. ALPS indexes were Box–Cox transformed for normalization prior to the analysis. Statistical analyses were conducted using analyses of
covariance controlling for age, sex, education, and APOE ε4 carrier status (A–C). Comparing ALPS indexes in different biological groups, covariates
include age, sex, education, APOE ε4 carrier status, and baseline diagnoses (D–F). A status was defined by CSF Aβ42 and amyloid PET (AV45 and
FBB PET) (D). T status was defined by CSF p-tau181 and AV1451 PET (E). N status was defined by CSF t-tau and FDG PET (F). Significant P values
after FDR corrected post hoc pairwise comparisons are marked with ***P < 0.001, *P<0.05, **P<0.01, ***P<0.001. “–” indicates negative; “+”
indicates positive. A, amyloid; Aβ, amyloid beta; AD, Alzheimer’s disease; ALPS, analysis along the perivascular space; APOE, apolipoprotein E;
AV45, florbetapir; AV1451, flortaucipir; CI, confidence interval; CN, cognitively normal; CSF, cerebrospinal fluid; FBB, florbetaben; FDG,
fluorodeoxyglucose; FDR, false discovery rate; MCI, mild cognitive impairment; N, neurodegeneration; PET, positron emission tomography;
p-tau181, phosphorylated tau 181; T, tau pathology; t-tau, total tau.

progression (Figure 4A). We observed that the abnormality of ALPS group. Subjects who converted to A+ status had a significantly lower
index prominently increased before the threshold of CSF Aβ42 positiv- ALPS index at baseline compared to non-converters (P = 0.016; Figure
ity and then plateaued. The abnormality curves of Aβ PET SUVR and S4 in supporting information). In A–CN participants, those with higher
PACC score were initially flat and began to increase when the ALPS ALPS index at baseline had a reduced risk of converting to A+ status
index approached the plateau (i.e., almost near the threshold for CSF (hazard ratio [HR; 95% confidence interval (CI)] = 0.36 [0.19–0.71],
Aβ42 positivity). When regarding PACC score as a surrogate for AD P = 0.003 when ALPS index was considered a continuous variable; HR
progression, the fitted curves for the abnormality of the ALPS index [95% CI] = 0.27 [0.09–0.84], P = 0.024 when ALPS index was consid-
apparently increased before the fitted curves for the Aβ biomarkers ered a binary variable; Figure 4C and Figure S5). Significant results
(CSF Aβ42 and Aβ PET) increased markedly, then reached a plateau, remained when the A status was defined by either CSF Aβ42 levels or
and then gradually increased again (Figure 4B). Aβ PET (AV45 and FBB PET) separately (Figure 4D and Figure S4-5).
We further investigated whether the baseline ALPS index could Sensitivity analyses yielded similar results for the ALPS index in pre-
predict A+ conversion in baseline A–CN subjects. Among A–CN par- dicting Aβ-positive transition as in the primary analysis (Table S13 in
ticipants at baseline, when A status was defined by CSF Aβ42 or Aβ supporting information).
PET (AV45 and FBB PET), 19 (30.6%) participants converted to the
corresponding A+ status within the median (interquartile range [IQR])
follow-up period of 4.17 years (3.98–5.80), and 43 remained A– sta- 3.5 ALPS index predicts clinical progression in AD
tus after at least 3 years of follow-up. A total of 39 CN participants in
the A– group did not convert to A+ status during follow-up, but were In ADNI, among baseline non-demented participants in the whole
followed for < 3 years and were not included in the non-converter cohort, 45 (23.0%) participants experienced clinical progression
 15525279, 2024, 5, Downloaded from https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.13789 by CAPES, Wiley Online Library on [30/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HUANG ET AL . 3261

F I G U R E 3 Association of ALPS indexes with core AD biomarkers. A, Cross-sectional association between ALPS index and core AD variables. B,
Prediction of longitudinal changes of core AD variables by baseline ALPS index. C, Association between baseline core AD variables and
longitudinal slope of ALPS index. The points (red, CN; blue, MCI; yellow, AD dementia) and solid lines represent the individuals and regression
lines, respectively. The regression coefficients (β) and P values were computed using a linear model across all participants, adjusting for age, sex,
education, APOE ε4 carrier status. Association of baseline ALPS index with baseline and slope of regional Aβ PET SUVR (D–E) and cortical volume
(F–G). The strength of associations with neuroimaging measures is shown in color scales representing the t value. Aβ, amyloid beta; AD,
Alzheimer’s disease; ALPS, analysis along the perivascular space; APOE, apolipoprotein E; CN, cognitively normal; FDG, fluorodeoxyglucose; MCI,
mild cognitive impairment; p-tau181, phosphorylated tau 181; PET, positron emission tomography; ROI, region of interest; SUVR, standard uptake
value ratio; t-tau, total tau.

(including 22 participants who progressed from CN to MCI, 20 partic- non-demented participants did not show clinical progression during
ipants who progressed from MCI to AD dementia, and three partici- follow-up, but were followed for < 3 years and were not included
pants who progressed from CN to AD dementia) over a median (IQR) in the non-converters group. Subjects who converted to MCI or AD
follow-up of 4.12 years (3.92–6.23), and 151 participants remained dementia had a significantly lower ALPS index at baseline compared
clinically stable after at least 3 years of follow-up. A total of 98 to non-converters (P = 0.028; Figure S6 in supporting information). In
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3262 HUANG ET AL .

F I G U R E 4 ALPS index reduction may occur prior to amyloid and predict amyloid-positive transition. Trajectories of ALPS index, CSF Aβ42, Aβ
PET (AV45 PET), and PACC score were modeled using CSF Aβ42 (A) or PACC score (B) as proxy of disease progression. The values of Aβ PET (AV45
PET) and PACC score were scaled to 0% to 100%, with 0% representing the minimal value and 100% representing the maximal value. The original
ALPS index and CSF Aβ42 were reversed, with 100% representing the minimal value and 0% representing the maximal value. This normalization
procedure made the higher values of abnormalities in ALPS index, CSF Aβ42, Aβ PET (AV45 PET), and PACC score represent the more severe
disease state. C–D, The Kaplan–Meier curves showing cumulative probability of amyloid status progression. Results of multivariable Cox
regression treating the ALPS index as a continuous variable after adjustment for age, sex, education, and APOE ε4 genotype are shown in the lower
left. The table under the curve illustrates number at risk (%) at 2-year intervals, to facilitate interpretation of the curves. A, amyloid; Aβ, amyloid
beta; AD, Alzheimer’s disease; APOE, apolipoprotein E; ALPS, analysis along the perivascular space; AV45, florbetapir; CN, cognitively normal; CSF,
cerebrospinal fluid; CI, confidence interval; MCI, mild cognitive impairment; HR, hazard ratio; PACC, Preclinical Alzheimer’s Cognitive Composite;
PET, positron emission tomography.

the multivariable Cox regression, after the allowance for covariates in [0.11–0.96], P = 0.043 for median vs. low baseline ALPS group, and (HR
Model 1, we found that a higher baseline ALPS index was significantly [95% CI] = 0.20 [0.06–0.62], P = 0.005 for high vs. low baseline ALPS
associated with a lower risk of progression to MCI or AD dementia group; Figure S7). In addition, the associations between ALPS index and
when the ALPS index was treated as a continuous variable (HR [95% risk of clinical progression remained significant in sensitivity analyses
CI] = 0.64 [0.47–0.88], P = 0.006; Figure 5A) or categorized by ter- (Table S14 in supporting information).
tile (HR [95% CI] = 0.24 [0.11–0.56], P = 9.67×10−4 for high vs. low
baseline ALPS group; Figure S7 in supporting information). These anal-
yses were then repeated in baseline CN participants, and the results 3.6 Replication for research of clinical
remained similar. A higher baseline ALPS index was significantly asso- progression
ciated with a lower risk of progression from CN to MCI or AD dementia
when treated as a continuous variable (HR [95% CI] = 0.54 [0.34–0.88], In the UKB, among the 36,050 non-demented participants included
P = 0.013; Figure 5B) or categorized by tertile (HR [95% CI] = 0.32 in the first imaging visit (which was considered the baseline for our
 15525279, 2024, 5, Downloaded from https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.13789 by CAPES, Wiley Online Library on [30/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HUANG ET AL . 3263

F I G U R E 5 Associations of ALPS indexes with risk of clinical progression. The Kaplan–Meier curves of clinical progression to MCI/AD
dementia in non-demented participants (A), progression to MCI/AD dementia in CN participants (B), or progression to AD in UKB participants (C).
Results of multivariable Cox regression treating the ALPS index as a continuous variable after adjustment for age, sex, education, and APOE ε4
carrier status are shown in the lower left. The table under the curve illustrates number at risk (%) at 2-year intervals, to facilitate interpretation of
the curves. AD, Alzheimer’s disease; ALPS, analysis along the perivascular space; APOE, apolipoprotein E; CN, cognitively normal; CI, confidence
interval; MCI, mild cognitive impairment; HR, hazard ratio; UKB, UK Biobank.

analysis), 40 incident AD events were recorded during a median 3.8 Interaction of ALPS index with amyloid and
(IQR) follow-up period of 5.34 years (4.54–6.83; Table S15 in sup- neurodegeneration on cognitive decline
porting information). The significant associations of the ALPS index
with risk of clinical progression were successfully replicated in the Based on the significant association of ALPS index with Aβ biomark-
UKB cohort. Participants with clinical progression had a significantly ers (CSF Aβ42 and Aβ PET), neurodegeneration markers (AD signature
lower baseline ALPS index than non-converters (P = 1.88×10−4 ; ROI volume, hippocampal volume, and FDG PET), and cognitive func-
Figure S6). Participants with a higher baseline ALPS index had a tion, we then tested whether the ALPS index had an interaction effect
lower risk of AD when the ALPS index was either treated as a con- with these biomarkers in predicting longitudinal cognitive decline as
tinuous variable (HR [95% CI] = 0.55 [0.39–0.77], P = 4.44×10−4 ; measured by the PACC score. We found that baseline ALPS index sig-
Figure 5C) or categorized by tertile (HR [95% CI] = 0.26 [0.09–0.76], nificantly interacted with baseline CSF Aβ42 (β = −0.26, P = 0.027),
P = 0.013 for high vs. low baseline ALPS group; HR [95% CI] = 0.35 AD signature ROI volume (β = −0.35, P = 0.001), hippocampal volume
[0.15–0.81], P = 0.014 for median vs. low baseline ALPS group; (β = −0.21, P = 0.026), and FDG PET SUVR (β = −0.30, P = 0.017)
Figure S7). in predicting longitudinal cognitive decline, showing that individuals
with low ALPS index had more pronounced positive associations of
CSF Aβ42, AD signature ROI volume, hippocampal volume, and FDG
3.7 Association of ALPS index with cognitive PET with slopes of PACC scores than individuals with high ALPS index
function (Figure S8 in supporting information). Baseline ALPS index interacted
with baseline Aβ PET SUVR with a strong trend toward statistical sig-
Figure 6 shows the cross-sectional and longitudinal associations of the nificance (β = 0.20, P = 0.051), indicating that negative associations of
ALPS index with PACC, memory, and EF composite scores. At base- Aβ PET SUVR with slopes of PACC scores may be modified by ALPS
line, all three of these cognitive tests were positively associated with index. However, baseline ALPS index did not show an interaction asso-
baseline ALPS index (Figure 6A). Longitudinally, a higher baseline ALPS ciation with the slope of any of these biomarkers in predicting cognitive
index was significantly associated with faster rates of decline in PACC decline.
(β = 0.19, P = 4.24×10−4 ), memory (β = 0.11, P = 0.038), and EF com-
posite score (β = 0.16, P = 0.005; Figure 6B). In contrast, the baseline
PACC, memory, and EF composite scores did not predict longitudinal 3.9 Mediation among ALPS index, amyloid, and
changes in the ALPS index (Figure 6C). In sensitivity analyses, the longi- neurodegeneration
tudinal associations between baseline ALPS index and slope of decline
in PACC were still statistically significant in all three sensitivity models The AD signature ROI volume is a robust neurodegeneration marker
(Table S16 in supporting information). associated with the ALPS index and was therefore selected in the
 15525279, 2024, 5, Downloaded from https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.13789 by CAPES, Wiley Online Library on [30/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
3264 HUANG ET AL .

F I G U R E 6 Associations of ALPS indexes with cognitive performance. A, Cross-sectional association between ALPS and cognitive
performance. B, Association between baseline ALPS and longitudinal slope of cognitive performance. C, Association between baseline cognitive
performance and longitudinal slope of ALPS. The points (red, CN; blue, MCI; yellow, AD dementia) and solid lines represent the individuals and
regression lines, respectively. The regression coefficients (β) and P values were computed using a linear model across all participants, adjusting for
age, sex, education, APOE ε4 carrier status. AD, Alzheimer’s disease; ALPS, analysis along the perivascular space; APOE, apolipoprotein E; CN,
cognitively normal; EF, executive function composite score; PACC, Preclinical Alzheimer’s Cognitive Composite; MCI, mild cognitive impairment;
MEM, memory composite score.

following simple mediation models, namely (1) ALPS → CSF Aβ42 P = 0.009) and CSF Aβ42 was associated with Aβ PET (β = −0.563,
→ Aβ PET → AD signature ROI volume, (2) ALPS → CSF Aβ42 → Aβ P = 2.27×10−11 ), and in addition, Aβ PET was associated with brain vol-
PET, (3) ALPS → CSF Aβ42 → AD signature ROI volume, and (4) ALPS ume (β = −0.273, P = 0.001). The indirect pathway of the effect of ALPS
→ Aβ PET → AD signature ROI volume (Figure S9A in supporting index on AD signature ROI volume via CSF Aβ42 and Aβ PET nearly
information). Results of the first model showed that ALPS index had a reached a significant level (path β = 0.030, P = 0.071). CSF Aβ42 was
significant positive effect on the AD signature ROI volume (β = 0.284, a significant mediator for the association of ALPS index with Aβ PET
P = 2.99×10−6 ), ALPS index was associated with CSF Aβ42 (β = 0.192, (path β = 0.105, P = 0.027) or AD signature ROI volume (path β = 0.059,
 15525279, 2024, 5, Downloaded from https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.13789 by CAPES, Wiley Online Library on [30/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HUANG ET AL . 3265

P = 0.033). Aβ PET significantly mediated the association between suggesting that glymphatic failure or impairment may occur in the early
ALPS index and AD signature ROI volume (path β = 0.050, P = 0.018). stages of AD. Moreover, glymphatic dysfunction may even occur prior
When the hippocampal volume or FDG PET was used to represent to amyloid pathology. Using the PACC score as a proxy for disease pro-
neurodegeneration instead of AD signature ROI volume, the indirect gression, we observed that changes in glymphatic activity were present
pathway of the association of ALPS index on hippocampal volume before the increase in Aβ PET burden and even before CSF Aβ42
(path β = 0.079, P = 0.003) or FDG PET (path β = 0.071, P = 0.025) via reached the positive threshold (Figure 4B). Nevertheless, a recent
Aβ PET were both significant (Figure S10 in supporting information). study yielded inconsistent results. Using the Consortium to Establish a
Registry for Alzheimer’s Disease Neuropsychological Assessment Bat-
tery (CERAD-NAB) total score as a surrogate for AD progression in
3.10 Potential pathological pathways by which a non-linear curve-fitting model, they suggested that the accelerating
ALPS index affects cognition turning point of ALPS index abnormality might occur after the changes
in Aβ deposition.15 Different findings can result from various reasons.
In the multiple mediation model comprised of baseline ALPS index, Aβ One possible explanation is that although both this previous work and
PET, AD signature ROI volume, and slope of PACC score (Figure 7), ours used cognitive score as a proxy for disease progression to visualize
ALPS index was significantly associated with Aβ PET (β = −0.162, the sequential changes of ALPS index and Aβ biomarkers in AD,15 we
P = 0.014), and AD signature ROI volume (β = 0.268, P = 5.80×10−4 ). used the PACC score, which is sensitive to cognitive decline in preclin-
ALPS index showed no direct effect on the slope of PACC score ical AD.33,40 Our analysis can therefore more sensitively capture the
(β = −0.028, P = 0.627), but its indirect effect was significant (β = 0.197, sequential relationship between Aβ biomarkers and ALPS index in the
P= 3.85×10−4 ). The indirect pathway of the effect of ALPS index on early stages of AD, as the CERAD-NAB total score is highly sensitive
the slope of PACC score via Aβ PET (path β = 0.079, P = 0.020) or AD to cognitive decline in the late stages of AD.41,42 From the perspective
signature ROI volume (path β = 0.100, P = 0.007) was significant. The of late stages of AD, however, ours corroborates previous findings.15
proportion mediated by Aβ PET or AD signature ROI volume of the The abnormalities in the ALPS index lagging Aβ deposition observed
total mediation effect was 40.1% and 50.8%, respectively. There were by Hsu et al. may reflect the further impairment of the glymphatic sys-
no significant differences between the effects mediated by Aβ PET or tem caused by Aβ deposition in late stages of AD.15 Consistently, we
AD trait ROI volume (P = 0.691). Two additional hypothetical structural found that the abnormality of the ALPS index gradually increased dur-
equation models are shown in Figure S9B-C, both indicating that the ing the late stages of AD after the plateau, at which point Aβ pathology
ALPS index indirectly affects cognitive performance via Aβ pathology had accumulated to a certain level. Moreover, previous animal studies
or brain volume. Results of the corresponding models when hippocam- revealed that long-term exposure to Aβ pathology can further com-
pal volume or FDG PET was used to represent neurodegeneration are promise the glymphatic system.43 Nonetheless, it cannot be ruled out
shown in Figure S10 in supporting information. The sensitivity models that white matter damage unrelated to glymphatic function could be
yielded consistent results with the primary model, as shown in Figure responsible for the alterations in the ALPS index after the plateau.
S11 in supporting information. Another explanation for the discrepancy between our study and
the previous one is that our study provides multiple longitudinal evi-
dences supporting the determinant role of glymphatic activity in Aβ
4 DISCUSSION deposition. This strengthens the reliability of our conclusion compared
to the previous cross-sectional study.15 We found that a lower base-
In the current study, we used the ALPS index representing glymphatic line ALPS index predicted an accelerated rate of increase in Aβ PET
activity and investigated its cross-sectional and longitudinal relation- burden with adjustment for age, sex, education, and APOE ε4 carrier
ships with clinical and pathological features of AD. We observed a status. Even after further correction for white matter pathology, this
significantly reduced ALPS index in AD dementia, and in the preclinical finding remained robust. In contrast, Aβ PET showed no apparent influ-
and prodromal stages of AD. Lower ALPS index predicts acceler- ence on the rate of ALPS index decline. When examined in 68 cortical
ated Aβ PET burden and AD signature ROI volume, higher risk of regions, the atlas of cortical regions associated with ALPS index in
amyloid-positive transition and clinical progression, and faster cogni- cross-sectional and longitudinal Aβ PET closely resembled those of
tive decline. The associations of ALPS index with cognitive decline were brain regions considered to be particularly sensitive to early Aβ accu-
fully mediated by Aβ PET and brain atrophy. Synthesizing our and for- mulation (i.e., posterior cingulate, superior frontal, and rostral middle
mer findings,39 one hypothetical cascade model of AD can be inferred frontal lobes).44,45 This suggests that glymphatic activity may influence
(Figure 7A). Our findings suggest that glymphatic impairment indicated the progression of Aβ deposition in the early stages of AD. Addition-
by the ALPS index may occur before significant Aβ deposits, and predict ally, lower baseline ALPS index predicted a higher risk of Aβ status
amyloid deposition, neurodegeneration, and clinical progression in AD. progression, especially the CSF Aβ42 status progression. Together, one
The ALPS index is reduced in AD patients,15–17 but few studies have of the most critical findings of this study is that glymphatic failure
examined it at different biological stages of AD. Our results filled the may precede and contribute to the development of brain parenchy-
knowledge gap by showing that ALPS index decreased as early as the mal Aβ deposits. This is concordant with animal studies demonstrating
preclinical and prodromal stages of AD compared to A–CN controls, that glymphatic transport is significantly reduced before extensive Aβ
 15525279, 2024, 5, Downloaded from https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.13789 by CAPES, Wiley Online Library on [30/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
3266 HUANG ET AL .

F I G U R E 7 ALPS index predicts cognition change through amyloid and neurodegeneration. A, A model integrating the findings in the present
study, together with previous studies,39 depicts an approximative order of ALPS and AD core biomarkers in the AD continuum. B, Mediation
analysis based on structural equation modeling. We computed the standardized coefficients (β) of each association. P values are visualized with
*P<0.05, **P<0.01, ***P<0.001. The horizontal gray line in lollipop chart represents the absolute value of β, and the color of the circle represents
the positive (orange) or negative (blue) direction of β. Aβ, amyloid beta; AD, Alzheimer’s disease; ALPS, analysis along the perivascular space; AV45,
florbetapir; CSF, cerebrospinal fluid; PACC, preclinical Alzheimer cognitive composite; IE, indirect effect; PET, positron emission tomography; ROI,
region of interest.

deposition in brains of the AD mouse model.43 Enhanced glymphatic the decline of the ALPS index precedes the brain atrophy and exhibits
activity in the early period can reduce Aβ burden and improve memory early acceleration followed by deceleration. Therefore, in the advanced
in an AD mice model.46 While validation with pathophysiological stud- stages of AD with a certain degree of brain atrophy, glymphatic activity
ies is needed, our findings provide clues to the timing of interventions may have already undergone a period of rapid decline, while brain atro-
for the prevention and treatment of AD that target the glymphatic phy continues to change substantially. There is no proposed mechanism
system. whereby impaired glymphatic function directly affects brain structure.
In addition to Aβ biomarkers, the ALPS index predicted accelerated Yet, our mediation analysis suggests that glymphatic activity may pre-
rates of brain atrophy in AD signature ROI regions, representing neu- dict brain atrophy by affecting amyloid in AD. This is theoretically
rodegeneration downstream of Aβ in AD.2 An interesting finding is justifiable because the Aβ burden in early stages of AD is highly cor-
that higher baseline levels of AD signature ROI volume were associ- related with brain atrophy, and downstream pathologic events of Aβ
ated with faster decline in the ALPS index with adjustment for age, sex, accumulation may be responsible for the ongoing atrophy as disease
education, and APOE ε4 carrier status. One possible explanation is that progresses.47
 15525279, 2024, 5, Downloaded from https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.13789 by CAPES, Wiley Online Library on [30/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HUANG ET AL . 3267

Consistent with previous study, we observed an association is cross-sectional and may not accurately reflect the exact sequence of
between the ALPS index and tau PET burden,15 particularly pro- events. When interpreting the findings of this paper, it is important to
nounced in Braak III and VI regions. However, the longitudinal asso- note that our research conclusion is based not only on cross-sectional
ciation was insignificant. The weaker ALPS associations with tau than findings but also on multiple longitudinal evidence. Besides, the predic-
amyloid may be attributed to the intracellular nature of AD tau pathol- tive effect of the ALPS index on amyloid and brain atrophy is clearly
ogy. Recent studies suggest that the extracellular space, which is demonstrated here, but we cannot definitively conclude their causal
cleared by the glymphatic system, serves as a conduit for the neuron- relationship from an observational cohort. Moreover, due to the lack
to-neuron propagation.48,49 Therefore, a possible explanation of our of MCI diagnostic records and AD biomarker data in UKB, replication
findings is that the removal of extracellular tau may not be sufficient to was not possible for some analyses.
affect tau deposition, but it may contribute somewhat to the spreading
of tau throughout the brain.
Despite the mounting cross-sectional evidence linking the glym- 5 CONCLUSIONS
phatic system to cognitive performance in AD,10,15,16,50 we present the
first preliminary evidence that lower ALPS index predicts faster cogni- In summary, we used the ALPS index to investigate the glymphatic sys-
tive decline and higher risk of clinical progression in AD adjusting for tem and suggested that the ALPS index reduction parallels CSF Aβ42
age, sex, education, and APOE ε4 carrier status. And the effects of white levels and may occur prior to amyloid pathology and neurodegener-
matter pathology or GM atrophy on the ALPS index were not sufficient ation in the early stages of AD. This study demonstrates for the first
to shake our main conclusions. Because our findings support that ALPS time the predictive effect of the ALPS index on amyloid deposition,
index alterations occur before apparent Aβ pathology and neurodegen- brain atrophy, clinical progression, and cognitive decline in AD, and the
eration, both of which contribute to cognitive dysfunction in AD,2,39 mediating effect of amyloid and neurodegeneration on the glymphatic–
we further examined the potential pathological pathways by which the cognitive decline association. These findings extend the understanding
ALPS index affects cognitive decline. Our study supports the previ- of the relationships among glymphatic activity, AD pathology, and
ous finding that brain volume fully mediates the relationship between cognitive decline, and provide evidence for targeting the glymphatic
ALPS index and cognition.50 Nonetheless, our novel contributions lie in system at an early stage to diminish glymphatic dysfunction and sub-
the longitudinal design, the inclusion of Aβ biomarkers, and the use of sequent amyloid deposition, neurodegenerative process, and cognitive
the multiple mediation model. We found that the glymphatic function, impairment in AD.
assessed by the ALPS index, may protect against AD-related cognitive
decline mediated not only by brain volume but also by Aβ burden. And AUTHOR CONTRIBUTIONS
the mediation effects of the two were not significantly different. Differ- Jin-Tai Yu had full access to all of the data in the study and takes
ent from the simple mediation model, we obtained the mediating effect responsibility for the integrity of the data and the accuracy of the data
of Aβ burden (or brain volume) in the association between the ALPS analysis. Conceptualization: Jin-Tai Yu; methodology: Shu-Yi Huang, Ya-
index and cognition controlling for brain volume (or Aβ burden) by con- Ru Zhang, Yu Guo; acquisition, analysis, or interpretation of data: all
structing a multiple mediation model. This could explain why the beta authors; writing—original draft: Shu-Yi Huang, Jing Du; critical revision
of the indirect effect is not that high in our study. of the manuscript for important intellectual content: Shu-Yi Huang, Ya-
This is a pioneering study investigating the sequential associations Ru Zhang, Yu Guo, Jin-Tai Yu; data curation and formal analysis: Shu-Yi
of the ALPS index with AD biomarkers and their influence on cognitive Huang, Jing Du, Peng Ren, Bang-Sheng Wu; obtained funding: Jin-Tai
decline in large-scaled and longitudinal cohorts, which provides novel Yu; administrative, technical, or material support: Jian-Feng Feng, Wei
insights into the underlying mechanism and role of glymphatic activ- Cheng, Jin-Tai Yu; all authors read and approved the final manuscript.
ity in AD. However, several caveats should be noted. First, the efficacy
of the ALPS index in detecting human glymphatic function has not yet ACKNOWLEDGMENTS
been substantially and rigorously validated by pathophysiological stud- The authors want to acknowledge the study participants and all the
ies. While the ALPS index has been confirmed by glymphatic MRI11 and investigators involved in the Alzheimer’s Disease Neuroimaging Ini-
has been extensively studied in various diseases,14,15,51 it should be tiative (ADNI) and UK Biobank for their helpful contributions to data
interpreted with caution. Second, the ALPS index was used to assess collection. Data used in preparation for this paper were obtained from
the global glymphatic activity and cannot reflect regional glymphatic the ADNI database (http://adni.loni.usc.edu/). As such, the investiga-
dysfunction. Given the regional heterogeneity of glymphatic activity tors within the ADNI contributed to the design and implementation
and the potentially heterogeneous effects of aggregated protein tox- of ADNI and/or provided data but did not participate in analysis or
icity throughout the brain, studies investigating regional glymphatic writing of this report. A complete listing of ADNI investigators can be
function in AD-susceptible networks are needed. Third, caution should found at: http://adni.loni.usc.edu/wp-content/uploads/how_to_apply/
be taken when interpreting the temporal sequence of glymphatic dys- ADNI_Acknowledgement_List.pdf. Data collection and sharing for
function and amyloid pathology. Although the trajectory plot with this project was funded by the ADNI (National Institutes of Health
cognitive scores as proxy is an intuitive indication of that the ALPS Grant U01 AG024904) and DOD ADNI (Department of Defense
index reduction may occur before Aβ deposition, this single evidence award number W81XWH-12-2-0012). ADNI is funded by the National
 15525279, 2024, 5, Downloaded from https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.13789 by CAPES, Wiley Online Library on [30/09/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
3268 HUANG ET AL .

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& Development LLC; Lumosity; Lundbeck; Merck & Co., Inc.; Meso way function promotes tau pathology after traumatic brain injury. J
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CONFLICTS OF INTEREST STATEMENT
Alzheimer disease. Ann Neurol. 2023;93:164-174.
The authors declare no conflict of interest related to this work. Author
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disclosures are available in the supporting information. indices of glymphatic system with amyloid deposition and cogni-
tion in mild cognitive impairment and Alzheimer disease. Neurology.
2022;99:e2648-2660.
CONSENT STATEMENT 17. Steward CE, Venkatraman VK, Lui E, et al. Assessment of the DTI-
ADNI was approved by the institutional review boards of all partic- ALPS parameter along the perivascular space in older adults at risk of
ipating institutions. All ADNI participants provided written informed dementia. J Neuroimaging. 2021;31:569-578.
consent according to the Declaration of Helsinki before study 18. Ota M, Sato N, Nakaya M, et al. Relationships between the deposi-
tion of amyloid-β and tau protein and glymphatic system activity in
enrollment. The UK Biobank has research tissue bank approval
Alzheimer’s disease: diffusion tensor image study. J Alzheimers Dis.
from the North West Multi-centre Research Ethics Committee 2022;90:295-303.
(Ref 21/NW/0157) (https://www.ukbiobank.ac.uk/learn-more-about- 19. Petersen RC, Aisen PS, Beckett LA, et al. Alzheimer’s disease
uk-biobank/about-us/ethics) and provided oversight for this study. neuroimaging initiative (ADNI): clinical characterization. Neurology.
2010;74:201-209.
All UK Biobank participants provided electronic informed consent at
20. Sudlow C, Gallacher J, Allen N, et al. UK biobank: an open access
baseline assessment. resource for identifying the causes of a wide range of complex diseases
of middle and old age. PLoS Med. 2015;12:e1001779.
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