1. The Worldwide Epidemic of Senile Dementias- Challenges of Pre-Clinical Treatment Evolving Diagnostic Approaches Dimitrios Kapogiannis AAAS 2015 Annual Meeting

2. Biomarkers in Alzheimer’s disease AD Age Successful aging MCI Modified disease Primary prevention interventions Preclinical predictors Disease modifying interventions Cognition & function Diagnostic biomarkers Predictors of MCI conversion Biomarker outcomes

3. Exosomes: a window into the cell Bellingham et al. Frontiers Physiology. 2012 Pathogenic proteins for neurodegenerative diseases

4. Plasma Exosome isolation Selection of neuronal exosomes with antibodies A novel methodology for exosome isolation and neuronal enrichment Exosome expressing neuronal markers Ab for neuronal markers “Breaking”of exosomes Protein quantification Capture of sub-population of exosomes

5. Nelson PT, et al. Neuropathology and Cognitive Impairment in Alzheimer Disease: a complex but coherent relationship. J Neuropathol Exp Neurol. 2009; 68: 1-14. Aβ 42 (+) plaques Tau (+) tangles Alzheimer’s disease pathogenic proteins

6. Exosomal p-181-tau (pg/ml) Exosomal Aβ 42 (pg/ml) 57 AD patients vs. 57 Controls All differences: p < 0.001 Fiandaca M, Kapogiannis D, et al. Alzheimer’s & Dementia, 2014 ControlsAD patients ControlsAD patients Exosomes: a source for near-perfect diagnostic biomarkers?

7. Distinguishing AD patients from cognitively intact elderly Fiandaca M, Kapogiannis D, et al. Alzheimer’s & Dementia, 2014 Near-perfect discrimination!

8. Willette and Kapogiannis; Psychiatry Research Neuroimaging, 2014 …better than MRI and CSF combined

9. Exosomal biomarkers predict AD diagnosis AP, AD vs. AC: p < 0.001 AP vs. AD: N.S. AP, AD vs. AC: p < 0.001 AP vs. AD: P < 0.001 Fiandaca M, Kapogiannis D, et al. Alzheimer’s & Dementia, 2014 Diagnosis √ Prognosis √ Biomarker outcomes for clinical trials? ControlsPreclinical ADClinical ADControlsPreclinical ADClinical AD

10. Exosome biomarkers Besides the obvious targets…Besides the obvious targets… Helping us understand everything that goes wrong with the disease…Helping us understand everything that goes wrong with the disease…

11. Insulin resistance (IR): reduced cellular responsiveness to insulin  type 2 diabetes. Patients with Diabetes show: o impaired cognitive performance (slightly, but measurably…) o greater age-related decline Type 2 diabetes and IR are independent risk factors for AD (Ott et al., 1999; Luchsinger et al., 2001; Arvanitakis et al., 2004; Luchsinger et al., 2007; Toro et al., 2009) Diabetes/IR and AD

12. Bomfim et al., JCI, 2012 Brain Insulin Resistance in AD Talbot et al., JCI, 2012 Saline Control MCI AD p-Ser-IRS-1

13. CN, DM vs. AD: p < 0.001 CN vs. DM: P < 0.001 Kapogiannis D, et al. FASEB J, 2014 Total IRS-1 (pg/ml) P-Ser-IRS-1 (pg/ml) P-Tyr-IRS-1 (pg/ml) P-Ser/P-Tyr-IRS-1 (pg/ml)

14. Brain IR markers also distinguish AD patients from cognitively intact elderly …

15. Bomfim et al., JCI, 2012 Moving forward: targeting brain IR in clinical trials (Exendin-4)

16. Abnormal lysosomes in AD

17. Lysosomal proteins in exosomes Goetzl et al., Neurology, 2015 ControlsAD patients The hallmark of a good biomarker: little to no overlap!

18. Exosomal biomarkers for AD prognosis diagnosis, therapeutics! AD Age MCI Preclinical predictors Exosomal p-Tau, p- IRS-1, lysosomal proteins Cognition & function Biomarker outcomes Exosomal Aβ42, p- Tau, p-IRS-1, lysosomal proteins MCI conversion predictors

19. Thank you!