Ignite Creation Date:
2024-05-11 @ 8:31 AM
Last Modification Date:
2024-10-26 @ 3:29 PM
Study NCT ID:
NCT06403189
Status:
NOT_YET_RECRUITING
Last Update Posted:
2024-05-07
First Post:
2024-04-25
Brief Title:
Choroid Plexus Dysfunction in Neurological Diseases
Sponsor:
Assistance Publique - Hôpitaux de Paris
Organization:
Assistance Publique - Hôpitaux de Paris
Study Overview
Official Title:
Profound Cerebral Folate Deficiency as a Clinical Model for Identification of MRI and Biochemical Signatures of Choroid Plexus Dysfunction
Status:
NOT_YET_RECRUITING
Status Verified Date:
2024-05
Last Known Status:
None
Delayed Posting:
No
If Stopped, Why?:
Not Stopped
Has Expanded Access:
False
If Expanded Access, NCT#:
N/A
Has Expanded Access, NCT# Status:
N/A
Acronym:
PLEXFOLD
Brief Summary:
Cerebral folate deficiency CFD a partially treatable condition defined by a low folate cerebrospinal fluid CSF concentration can be linked to genetic defects of folate metabolism or be secondary to various diseases without clear causal link The team identified a neurological syndrome named LHIPFOLFD characterized by deep CFD and a specific leukoencephalopathy related to several possible gene defects never involving folate metabolism The team hypothesize that CFD in LHIPFOLD is due to a Choroid Plexus CP dysfunction a brain organ that expresses transporters regulating flux between blood and CSF of numerous metabolites including folate and secretes CSF and specific proteins Consequently other potentially treatable biochemical abnormalities due to PC dysfunction may exist in LHIPFOLD beyond CFD Currently there is no available clinical explorations to evaluate CP functions whereas the team consider LHIPFOLD a very useful model to validate the capacity of some relevant diagnostic tools to do so The objectives are to identify a CP-related MRI and biochemical signature in LHIPFOLD patients using morphological and functional imaging CP capillary permeability and CP macrovascular perfusion and metabolomicsproteomics approaches untargeted then targeted validation of candidate biomarkers related to CP physiology and to set-up imaging and biochemical diagnostic tests for clinical practice For this brain MRI data and bloodCSF samples will be collected during 2 years from LHIPFOLD patients and controls Some experimental data indicate that the innovative concept of generalized PC dysfunction as part of a more global pathophysiology has the potential to be applied to other neurological diseases like Alzheimers disease Therefore efficient diagnostic tools exploring CP function will be of great utility not only in LHIPFOLD but also in more common neurological diseases potentially leading to original therapeutic approaches
Detailed Description:
Cerebral folate deficiency CFD is a condition defined by low concentration 41 nM of 5-methyltetrahydrofolate 5MTHF the biologically active form of folate in the cerebrospinal fluid CSF 1 CFD is considered to be of primary origin if it is associated with several genetic diseases involving folate metabolism leading to severe motor and cognitive manifestations CFD can also be secondary ie associated with various definite diseases such as genetic mitochondrial diseases and also unidentified diseases In secondary CFD the cause of CFD is not understood In the center the team identified 16 CFD patients with common characteristics deep secondary CFD 5MTHF10nM whereas blood folate is normal high protein CSF 1gL N05 and a specific involvement of brain white matter hyperintense on T2-weighted MRI The team called this syndrome LHIPFOLD for Leukoencephalopathy with CSF HIgh Protein and FOLate Deficiency confidential planned submission in end of 2022 Within the French metabolic biochemistry labs network the team identified 6 additional LHIPFOLDpat LHIPFOLD patients They have a mean age of 42 to 14 years min 15 max 77 and a sex ratio of 18 MF 922 had either a large mitochondrial DNA deletion Kearns-Sayre or bi-allelic POLG mutations mitochondrial DNA replication defect The other 13 patients were all undiagnosed until recently but the team found in a research context and validated in vitro bi-allelic variants in 47 tested patients within genes from MRPS family coding for sub-units of the mitoribosome
LHIPFOLD patients clearly have a defect of intracerebral 5MTHF transport but without mutation of the brain folate transporters Since folate is exclusively transported from blood to the brain by the choroid plexus CP2 the team hypothesize that CFD in LHIPFOLD is due to CP dysfunction CP localized in the brain ventricles is a vascularized epithelial organ that acts as a blood-CSF barrier expressing numerous transporters for molecules transfer from the blood to the CSF and vice versa removing waste products from brain cells CP also secretes CSF and expresses CSF-secreted proteins related to various functions3
High protein CSF due to a blood brain barrier alteration and reported abnormal CP morphology from brain autopsy in two Kearns-Sayre patients are also in favor of CP dysfunction in LHIPFOLD 4 In addition in two LHIPFOLDpat the team found very high concentrations of CSF sialic acid without the involvement of sialic acid-related genes whereas CP strongly expresses the sialic acid efflux transporter The team also recently measured strongly decreased CP size after automatic segmentation in two other LHIPFOLD pat All these data strongly argue for CP dysfunction in LHIPFOLD
If the hypothesis is correct it means that beyond CFD other CSF abnormalities probably exist as a consequence of generalized CP dysfunction This may be very interesting in terms of therapeutic approach as folate supplementation has a clear but limited therapeutic effect especially in some patients Unfortunately to assess our hypothesis there is no available clinical exploration to evaluate CP functions whereas CP dysfunctionalteration is suggested as a potential pathogenesis contributor in several common neurological diseases for the following text the team will use dysfunction for both dysfunction and alteration As the team think that in LHIPFOLD the CP dysfunction is particularly severe as suggested by the deep CFD the team consider LHIPFOLD syndrome a very useful clinical model to validate the capacity of some relevant diagnostic tools to evaluate CP function Therefore the objectives of the project are
1 Prove CP dysfunction in LHIPFOLD through the identification of specific and CP-related MRI and biochemical signatures using CP-centered imaging and metabolomics and proteomics approaches
2 Identify CP-related biochemical biomarkers in LHIPFOLD directly amenable to treatment
3 Set-up imaging and biochemical diagnostic tests for evaluating CP function in clinical practice biomarkers-based CP-dysfunction score
Methodology To reach the objectives the team will conduct a monocentric diagnostic phase 1 case-control study based on descriptive deterministic statistic and multidimensional clustering approach supported by complementary diagnostic tools specifically designed for CP exploration of LHIPFOLDpat versus healthy volunteers HV and neurological control patients NCpat NCpat will be used to assess the specificity of the CP-related signatures identified in LHIPFOLDpat The team expect that findings will be similar to HV in some NCpat but will reflect slight to moderate CP dysfunction in others With AP-HP as the study sponsor the team will obtain approval of the Research Ethics Committee for a Jardé 1 study in accordance with the legislation and regulatory requirements in force
-Patients and controls selection and recruitment Subjects will be prospectively recruited during a two-year period 1LHIPFOLDpat will be selected as previously described 2HV will be recruited by the usual advertisement procedure and will be matched for age and sex with LHIPFOLDpat 3 NCpat will be age and sex matched patients with definite common brain diseases frequently explored in the Neurology department multiple sclerosis amyotrophic lateral sclerosis alzheimers disease frontotemporal dementia idiopathic intracranial hypertension and normal pressure hydrocephalus The diagnosis of these diseases will be made according to the newest guidelines by the neurologists specialised in each disease Concerning the sample to be recruited the team took into account two constraints the number of LHIPFOLDpat is limited the study is not a simple deterministic comparison vs a control group but more a multidimensional analysis leading to the identification of CP-related signatures through homogeneous patient clusters Consequently the strategy was to identify a global sample size that would lead to a homogeneous classification of patients based on 5 or 6 biomarkers According to Donicars formula5 26 patients properly selected by a stratified sampling technique should allow this These 64 patients will include 15 LHIPFOLDpat and an equal number of 25 HV and 25 NCpat Furthermore keeping the deterministic approach and based on a simulation study integrating mean and standard deviation of CSF 5MTHF in LHIPFOLDpat and NCpat 385 - 267 and 4953 - 1335 respectively with respectively 15 and 25 subjects this sample size provides a power greater than 95 to demonstrate a difference with a Wilcoxon Rank Sum test between these two groups of note values in HV are currently unknown
The team will acquire brain MRI data with blood gadolinium injection blood and CSF samples from all subjects LHIPFOLDpat and NCpat will undergo these procedures as part of standard care in the Neurology Department of Pitié-Salpêtrière Hospital HV will be hospitalized one day in our Clinical Investigation Center All subjects will sign informed consent and agree to undergo MRI examination and blood and CSF sampling for research purpose for HV and additional MRI time acquisition and sample volumes for patients
Brain MRI study Brain MRI will be performed at 3 TESLA Siemens PRISMA at the Centre for Neuroimaging Research CENIR the imaging platform of the Paris Brain Institute ICM The team will assess both CP morphology and function 1for CP morphological analysis the team will measure CP volumes and extract textural parameters CP segmentation will be performed using automated software developed at the site Texture analysis will be performed using the MP2RAGE MRI sequence 2CP function assessment will include quantitative measurements of the capillary permeability and macrovascular perfusion To explore CP permeability dynamic T1 perfusion sequence with gadolinium enhancement will be used t-TRANS and other regional values will be extracted Post processing will be performed using Syngovia Siemens software To explore CP macrovascular perfusion the team will use a shorter version of the dynamic Arterial Spin Labeling perfusion without gadolinium published previously 6 With this sequence the team will be able to appreciate the arterial transit time and apparent blood flow Data analysis will be performed at CENIR
Discovery of CP dysfunction biomarker candidates in CSFblood compartments Two mixed approaches will be used to select the top 10 biomarkers candidates a priori 5 metabolites and 5 proteins that will be investigated by a targeted and fully quantitative analysis iuntargeted metabolomics and proteomics the findings will be reviewed to assess a possible link with CP function and iihypothesis-driven approach in addition to 5MTHF based on data from the literature and publicly available biological database the team also identified metabolites including ascorbic acid and sialic acid that seem to be specifically transported by the CP and proteins specifically expressed by the CP including TRPM3 and Klotho As blood concentrations can influence CSF concentrations for some molecules the team plan to analyze blood and CSF sampled at the same time with calculation of a CSFBlood ratio of concentrations
For untargeted metabolomics metabolic extracts of CSF and plasma samples will be obtained following methanol-assisted protein precipitation and analysed by liquid chromatography coupled to high resolution mass spectrometry LC-HRMS as the team routinely perform 7 A combination of two complementary LC-HRMS platforms will be used to profile both hydrophobic and polar metabolites8 Data pre-treatment and statistical analyses will be achieved by using Workflow4Metabolomics W4M which is an open-source collaborative online platform for computational metabolomics Annotation of data sets and identification of biologically relevant signals will be performed by using in-house spectral libraries and MSMS tandem mass spectrometry experiments Relative quantification of 250 metabolites will be achieved thanks to normalization using quality control samples For targeted metabolomics CSF 5MTHF is routinely measured in Necker laboratory specialized in Neurometabolism using very sensitive and specific analytical methods liquid chromatography hyphenated to tandem MS The team are in the process to include in the same run ascorbic acid and sialic acid measures Depending on the chemical nature of the metabolite biomarker candidates identified in the untargeted study one or few new methods for robust quantification using stable isotopes will be developed
A preliminary proteomic study on the CSF of a patient with high CSF protein and a control will allow us to establish a sample preparation protocol select a mass spectrometry analysis method and data analyses workflow The objective is twofold to optimize the extraction of proteins and to allow the comparison of very different CSFs in order to develop an analytical strategy that will allow us to identify biomarkers The study will be carried out by using a label-free approach to minimize variability the number of steps and especially not to restrict the dynamic range of the sample All bioinformatics analyses will be performed with myProMS9 our proteomic data management and analysis software developed at the Institut Curie in collaboration with the INSERM U900 bioinformatics platform directed by Dr E Barillot For the targeted proteomic approach the team will use the expertise on targeted MS with stable isotope-labeled internal standard peptides the gold standard approach for protein quantification in biological fluid resulting in high robustness high sensitivity and multiplex analysis10
-Cross data analysis The team will centrally manage analyze and integrate clinical and biological datasets and knowledge generated by the MRI and biological samples analysis to identify a global CP-related signature in LHIPFOLD patients With these data the team will establish a CP-dysfunction score for use in routine clinical practice intended to be used to explore CP in neurological patients
LHIPFOLD patients clearly have a defect of intracerebral 5MTHF transport but without mutation of the brain folate transporters Since folate is exclusively transported from blood to the brain by the choroid plexus CP2 the team hypothesize that CFD in LHIPFOLD is due to CP dysfunction CP localized in the brain ventricles is a vascularized epithelial organ that acts as a blood-CSF barrier expressing numerous transporters for molecules transfer from the blood to the CSF and vice versa removing waste products from brain cells CP also secretes CSF and expresses CSF-secreted proteins related to various functions3
High protein CSF due to a blood brain barrier alteration and reported abnormal CP morphology from brain autopsy in two Kearns-Sayre patients are also in favor of CP dysfunction in LHIPFOLD 4 In addition in two LHIPFOLDpat the team found very high concentrations of CSF sialic acid without the involvement of sialic acid-related genes whereas CP strongly expresses the sialic acid efflux transporter The team also recently measured strongly decreased CP size after automatic segmentation in two other LHIPFOLD pat All these data strongly argue for CP dysfunction in LHIPFOLD
If the hypothesis is correct it means that beyond CFD other CSF abnormalities probably exist as a consequence of generalized CP dysfunction This may be very interesting in terms of therapeutic approach as folate supplementation has a clear but limited therapeutic effect especially in some patients Unfortunately to assess our hypothesis there is no available clinical exploration to evaluate CP functions whereas CP dysfunctionalteration is suggested as a potential pathogenesis contributor in several common neurological diseases for the following text the team will use dysfunction for both dysfunction and alteration As the team think that in LHIPFOLD the CP dysfunction is particularly severe as suggested by the deep CFD the team consider LHIPFOLD syndrome a very useful clinical model to validate the capacity of some relevant diagnostic tools to evaluate CP function Therefore the objectives of the project are
1 Prove CP dysfunction in LHIPFOLD through the identification of specific and CP-related MRI and biochemical signatures using CP-centered imaging and metabolomics and proteomics approaches
2 Identify CP-related biochemical biomarkers in LHIPFOLD directly amenable to treatment
3 Set-up imaging and biochemical diagnostic tests for evaluating CP function in clinical practice biomarkers-based CP-dysfunction score
Methodology To reach the objectives the team will conduct a monocentric diagnostic phase 1 case-control study based on descriptive deterministic statistic and multidimensional clustering approach supported by complementary diagnostic tools specifically designed for CP exploration of LHIPFOLDpat versus healthy volunteers HV and neurological control patients NCpat NCpat will be used to assess the specificity of the CP-related signatures identified in LHIPFOLDpat The team expect that findings will be similar to HV in some NCpat but will reflect slight to moderate CP dysfunction in others With AP-HP as the study sponsor the team will obtain approval of the Research Ethics Committee for a Jardé 1 study in accordance with the legislation and regulatory requirements in force
-Patients and controls selection and recruitment Subjects will be prospectively recruited during a two-year period 1LHIPFOLDpat will be selected as previously described 2HV will be recruited by the usual advertisement procedure and will be matched for age and sex with LHIPFOLDpat 3 NCpat will be age and sex matched patients with definite common brain diseases frequently explored in the Neurology department multiple sclerosis amyotrophic lateral sclerosis alzheimers disease frontotemporal dementia idiopathic intracranial hypertension and normal pressure hydrocephalus The diagnosis of these diseases will be made according to the newest guidelines by the neurologists specialised in each disease Concerning the sample to be recruited the team took into account two constraints the number of LHIPFOLDpat is limited the study is not a simple deterministic comparison vs a control group but more a multidimensional analysis leading to the identification of CP-related signatures through homogeneous patient clusters Consequently the strategy was to identify a global sample size that would lead to a homogeneous classification of patients based on 5 or 6 biomarkers According to Donicars formula5 26 patients properly selected by a stratified sampling technique should allow this These 64 patients will include 15 LHIPFOLDpat and an equal number of 25 HV and 25 NCpat Furthermore keeping the deterministic approach and based on a simulation study integrating mean and standard deviation of CSF 5MTHF in LHIPFOLDpat and NCpat 385 - 267 and 4953 - 1335 respectively with respectively 15 and 25 subjects this sample size provides a power greater than 95 to demonstrate a difference with a Wilcoxon Rank Sum test between these two groups of note values in HV are currently unknown
The team will acquire brain MRI data with blood gadolinium injection blood and CSF samples from all subjects LHIPFOLDpat and NCpat will undergo these procedures as part of standard care in the Neurology Department of Pitié-Salpêtrière Hospital HV will be hospitalized one day in our Clinical Investigation Center All subjects will sign informed consent and agree to undergo MRI examination and blood and CSF sampling for research purpose for HV and additional MRI time acquisition and sample volumes for patients
Brain MRI study Brain MRI will be performed at 3 TESLA Siemens PRISMA at the Centre for Neuroimaging Research CENIR the imaging platform of the Paris Brain Institute ICM The team will assess both CP morphology and function 1for CP morphological analysis the team will measure CP volumes and extract textural parameters CP segmentation will be performed using automated software developed at the site Texture analysis will be performed using the MP2RAGE MRI sequence 2CP function assessment will include quantitative measurements of the capillary permeability and macrovascular perfusion To explore CP permeability dynamic T1 perfusion sequence with gadolinium enhancement will be used t-TRANS and other regional values will be extracted Post processing will be performed using Syngovia Siemens software To explore CP macrovascular perfusion the team will use a shorter version of the dynamic Arterial Spin Labeling perfusion without gadolinium published previously 6 With this sequence the team will be able to appreciate the arterial transit time and apparent blood flow Data analysis will be performed at CENIR
Discovery of CP dysfunction biomarker candidates in CSFblood compartments Two mixed approaches will be used to select the top 10 biomarkers candidates a priori 5 metabolites and 5 proteins that will be investigated by a targeted and fully quantitative analysis iuntargeted metabolomics and proteomics the findings will be reviewed to assess a possible link with CP function and iihypothesis-driven approach in addition to 5MTHF based on data from the literature and publicly available biological database the team also identified metabolites including ascorbic acid and sialic acid that seem to be specifically transported by the CP and proteins specifically expressed by the CP including TRPM3 and Klotho As blood concentrations can influence CSF concentrations for some molecules the team plan to analyze blood and CSF sampled at the same time with calculation of a CSFBlood ratio of concentrations
For untargeted metabolomics metabolic extracts of CSF and plasma samples will be obtained following methanol-assisted protein precipitation and analysed by liquid chromatography coupled to high resolution mass spectrometry LC-HRMS as the team routinely perform 7 A combination of two complementary LC-HRMS platforms will be used to profile both hydrophobic and polar metabolites8 Data pre-treatment and statistical analyses will be achieved by using Workflow4Metabolomics W4M which is an open-source collaborative online platform for computational metabolomics Annotation of data sets and identification of biologically relevant signals will be performed by using in-house spectral libraries and MSMS tandem mass spectrometry experiments Relative quantification of 250 metabolites will be achieved thanks to normalization using quality control samples For targeted metabolomics CSF 5MTHF is routinely measured in Necker laboratory specialized in Neurometabolism using very sensitive and specific analytical methods liquid chromatography hyphenated to tandem MS The team are in the process to include in the same run ascorbic acid and sialic acid measures Depending on the chemical nature of the metabolite biomarker candidates identified in the untargeted study one or few new methods for robust quantification using stable isotopes will be developed
A preliminary proteomic study on the CSF of a patient with high CSF protein and a control will allow us to establish a sample preparation protocol select a mass spectrometry analysis method and data analyses workflow The objective is twofold to optimize the extraction of proteins and to allow the comparison of very different CSFs in order to develop an analytical strategy that will allow us to identify biomarkers The study will be carried out by using a label-free approach to minimize variability the number of steps and especially not to restrict the dynamic range of the sample All bioinformatics analyses will be performed with myProMS9 our proteomic data management and analysis software developed at the Institut Curie in collaboration with the INSERM U900 bioinformatics platform directed by Dr E Barillot For the targeted proteomic approach the team will use the expertise on targeted MS with stable isotope-labeled internal standard peptides the gold standard approach for protein quantification in biological fluid resulting in high robustness high sensitivity and multiplex analysis10
-Cross data analysis The team will centrally manage analyze and integrate clinical and biological datasets and knowledge generated by the MRI and biological samples analysis to identify a global CP-related signature in LHIPFOLD patients With these data the team will establish a CP-dysfunction score for use in routine clinical practice intended to be used to explore CP in neurological patients
Study Oversight
Has Oversight DMC:
None
Is a FDA Regulated Drug?:
False
Is a FDA Regulated Device?:
False
Is an Unapproved Device?:
None
Is a PPSD?:
None
Is a US Export?:
None
Is an FDA AA801 Violation?:
None