How is ALS initiated?
Much evidence implicates mitochondrial dysfunction in ALS. Mitochondrial shape and positioning in cells is crucial for bioenergetics [
11]. Morphological changes observed in ALS mitochondria in the anterior horn of the spinal cord include smaller size, disrupted crests and edema, crystolysis and vacuolisation, indicating metabolic disturbances [
73]. These changes were unlikely to be the artefacts due to ageing or post mortem process because they were significantly different from 15 age-matched control samples. Interestingly, similar changes can be found in liver and muscle cells [
74,
75], supporting the concept that mitochondrial defects are inherited from either mitochondrial or nuclear genomes [
74,
75] (Fig.
1).
Mitochondrial mutations are maternally inherited or result from somatic changes. These mutations can progressively increase with age through neural clonal expansion [
76] (Fig.
1). High metabolic rate and ATP consumption make the human motor system particularly vulnerable to energy deficiency. Included in the 126 ALS genes in the Amyotrophic Lateral Sclerosis Online genetics Database (v6) are one mitochondrial gene (MT-ND2) and 10 nuclear genome-coded mitochondrial genes (
ATXN2, CHCHD10, GARS, MAOB, OGG1, OMA1, PARK7, SOD1 SOD2 and
SPG7), found when ALS genes are cross-over with MitoCarta [
5,
15]. Other mitochondrial variants, particularly nuclear genome coded ones, could be misinterpreted as variants of unknown significance due to their population frequencies or less clear-cut functionality. A study of 44 ALS case-unaffected parents trios found that ALS can be transmitted in an autosomal recessive way by homozygous or compound heterozygous changes [
6] (Table
1). The frequencies of ALS-related recessive alleles could therefore be higher than expected and be adversely filtered out due to the cut-off values used in the whole exome or whole genome studies.
The finding that mitochondria can be transferred from astrocytes to neurons supports the critical role of mitochondria in neurons, and the possible involvement of astrocytes in ALS pathogenesis [
17,
77]. This is of interest since mercury, long suspected in the pathogenesis of ALS, first enters the CNS via uptake by perivascular astrocytes, and is found predominantly within mitochondria [
78]; any transfer of mercury-laden mitochondria from astrocytes into motor neurons could result in neurotoxic damage to these neurons. Furthermore, reduced mitochondrial content with age and somatic changes in post-mitotic neurons could lead to a decline of mitochondrial function [
79].
ALS-susceptible mitochondrial variants are unlikely to remain ‘switched off’ until mid- to late-adulthood, although they may not be sufficient to cause any overt mitochondrial disease in early life. The motor neuron system in these individuals could be in a delicate balance with a constant struggle to compensate for such a defect or defects (Fig.
1). Compensatory capacity diminishes with ageing and the compromised mitochondrial function may finally collapse. Environmental insults could further affect the mitochondria, particularly in the presence of susceptibility alleles of the interacting genes, and trigger the decompensation process in ALS susceptible individuals (Figs.
1 and
2). It is also possible that astrocytes with mitochondrial defects may be the target cells for the harmful action of some environmental insults (such as mercury, see above), while neuronal death may be a secondary event following the initial insult to astrocytes closely related with motor neurons [
10,
77].
Persistent viral infection, organophosphates, heavy metals and intense physical exercise could put metabolic loads on defective mitochondria and exhaust any compensatory capacity (Fig.
1). Other mechanisms including excitotoxins, oxidative stress, or altered calcium homeostasis could participate in cell damage [
77]. Disease triggers could be disguised as the root cause of ALS, and generate conflicting results in environmental studies, since these initial insults may be necessary but not sufficient for the pathogenesis of ALS. Environmental insults, even with similar intensity and exposure time, are unlikely to have similar impacts on non-susceptible individuals.
ALS spread
Any loss of motor neurons would put extra stress on surviving motor neurons that innervate the same muscle and increase the metabolic needs to compensate for the loss. Astrocytes at this stage may fail to perform the normal maintenance to axons or neuronal cell bodies since they would divert their resources in attempts to rescue decompensating neurons. As a consequence, more neurons would enter the decompensating process. A decrease in motor unit number and an increase in cortical excitability is found before symptom onset in
SOD1 mutation carriers [
80,
81]. Such excitatory compensation may not be helpful, but instead initiate a chain reaction of mitochondrial crisis and neuronal apoptosis. Excitotoxicity can increase calcium flow into the neuron, initiate oxidative stress, and result in neuronal death. A mitochondrial crisis could also influence proteasomal or autophagic protein degradation and amplify the cellular stress. Environmental risk factors such as muscle-stored heavy metals released during muscle wasting [
46] could further accelerate the deterioration. Of note, a recent study has shown how human spinal interneurons, which normally inhibit motor neurons, take up heavy metals during ageing; any mercury within the mitochondria of these interneurons could lead to interneuron malfunction with subsequent excitotoxicity to motor neurons [
82].
This proposed model could explain the well-known clinical and pathological pattern of ALS starting in one CNS region and ‘spreading’ to other adjacent region [
83]. This spread may be due to a cascade of decompensating neurons. This model therefore avoids the presumption that any environmental agent travels from one neuron to another through their synapses, extracellular vesicles, or membrane contacts. The proposed model provides a unique mechanism involving a decompensation process for spreading and “gain of toxic strength” for the subsequent accelerated progression of ALS.
Association of the proposed model with known ALS features
The development of ALS has been considered as involving a six-step process [
84]. Further identification of these steps could lead to novel preventive or therapeutic avenues. Our proposed model is consistent with the gene-time-environment hypothesis [
1] and entails multiple steps (Fig.
1). It offers a potential single root of ALS pathogenesis, with environmental insults being a trigger for ALS initiation. The available evidence has suggested that primary inherited defect(s) could cause mitochondrial dysfunction that establishes the susceptibility of motor neurons to ALS (Fig.
1). Environmental insults then upset the delicate balance of mitochondrial function, followed by propagation and acceleration due to an ineffective compensating process. Metal homeostasis is intimately coupled to the oxidative stress response in many cell types [
71]. The depletion of microtubules and neurofilaments in ALS motor neurons could result from the genetic predisposition. Consequently, it would impair normal transport and affect mitochondrial function due to lack of sufficient nutrients [
85]. Environmental insults can also trigger adverse responses such as neuroinflammation that include activation of astrocytes and microglia, as well as direct motor neuron toxicity.
Persistent viral infection could be one environmental trigger of the decompensation process. It is unlikely that the relevant virus could be isolated, or any serological reaction be sufficiently generated, though microbiome studies of CNS tissue and muscle would be of interest. The model explains the paradox of the concept of virus spreading from one neuron to another with no evidence of any viral presence. Rather, the cellular stress of one neuron could be spread to activate the endogenous retrovirus in the neighbouring neurons via the expression of the env protein [
31].
As suggested by Mendelian randomisation analyses, some ALS patients would have less efficient abilities to detoxify heavy metals, which could be enough to tip motor neurons beyond the point of sustained viability, resulting in the initiation of motor neuron loss and the decompensation process. Interestingly, loss of mobility and innervated nerve stimulation to muscle can accelerate the decompensation process, since more heavy metal such as lead can be released due to osteoporosis and loss of muscle bulk [
46].
The proposed model emphasises gene-environment interactions, which involves multiple steps. Some crucial environmental insults might have arisen in early development, which makes them difficult to identify. For example, subclinical enterovirus or poliovirus infection, or heavy metal exposure, could occur early in life and only play a role in the initiation or acceleration stage of the disease in later life. Differently-susceptible individuals could inherit different genetic defects with different impacts on mitochondrial function and require different intensities of environmental triggers. Major inherited defects in mitochondria-related genes may only need occult or mild triggers, while other inherited variants may require a combination of environmental insults, e.g., military deployment, to evoke the onset of ALS.