Background
Alzheimer’s disease (AD) is the most common form of dementia and an age-related neurodegenerative disease characterized by extracellular amyloid plaques, intracellular neurofibrillary tangles, and neuroinflammation triggered by activated microglia and reactive astrocytes [
1,
2]. Accumulating evidence supports the idea that an imbalance between the production and elimination of amyloid beta (Aβ) is a very early sign of AD pathogenesis [
3,
4]. Familial AD (early-onset AD), which is caused by the overproduction of Aβ due to mutations in the amyloid precursor protein (APP) and PSEN1 (PS1) genes, accounts for only 1% of all AD cases [
5,
6]. However, in sporadic AD (late-onset AD), which represents 99% of all AD patients, impaired Aβ clearance is thought to be the leading cause of Aβ accumulation. Metabolic labelling studies have shown that Aβ clearance is impaired while Aβ production remains unchanged in sporadic late-onset AD [
7]. Therefore, exploring dysfunctional molecular and cellular mechanisms involved in the clearance of Aβ will enhance the understanding of AD pathophysiology and promote the development of new clinical interventions.
Aβ is the product of the proteolytic cleavage of APP and is mainly expressed in neurons [
8,
9]. Traditionally, Aβ has been thought to be cleared primarily by cells in the brain [
10,
11]. For instance, microglia, the major type of innate immune cell in the brain, can eliminate various forms of Aβ through cell-mediated phagocytosis and extracellular enzymatic degradation [
12,
13]. However, convincing evidence has indicated that the peripheral system plays a role in the clearance of Aβ [
14‐
17]. Approximately 40–60% of brain-derived Aβ is estimated to be transported to the peripheral system for clearance [
17,
18]. Blood monocytes are the counterparts of microglia in the periphery [
19,
20]. Monocytes/macrophages are vital members of the peripheral innate immune system and act as the first line of host defence through multiple effector functions [
21]. Blood monocytes clear Aβ that is transported from the brain and slow the progression of AD [
22]. Some studies have shown that monocytes are more effective than resident microglia at providing neuroprotection, regulating neuroinflammation, and clearing Aβ in AD [
18,
19,
23‐
25]. However, monocytes derived from patients with AD display an unexplainable degree of phagocytic dysfunction; for example, macrophages from the majority of AD patients fail to transport Aβ into endosomes and lysosomes [
25,
26], monocytes inefficiently clear Aβ from regions of the AD brain [
27], and the expression of phagocytosis-related receptors was decreased in monocytes from AD patients [
28]. Therefore, the determinants of Aβ elimination by monocytes may be potential interventional targets for the peripheral clearance of Aβ.
Cystatin F, encoded by the
Cst 7 gene, is a secreted protein that is specifically expressed in immune cells such as monocytes/macrophages, lymphocytes, and neutrophils in the peripheral circulation and exclusively in microglia in the central nervous system. Cystatin F is most likely involved in the immune response [
29‐
34]. When cystatin F is synthesized or taken up intracellularly, it enters the endosome-lysosome compartment, where it acts as an endogenous inhibitor of cysteine proteases such as cathepsin L and C [
35]. Recently, cystatin F has been regarded as a disease-associated microglia (DAM) signature in AD that regulates microglial phagocytosis via an unclear mechanism [
36,
37]. However, the role of cystatin F, especially its secreted form in peripheral monocytes, remains largely unknown.
Here, we identified increased mRNA expression of cystatin F in monocytes isolated from patients with AD. Monocyte-derived cystatin F exacerbate Aβ deposition in the brain and cognitive impairment in APP/PS1 mice. Mechanistically, we found that cystatin F was released by monocytes as a dimer into the plasma and physically interacted with Aβ to inhibit its internalization by monocytes. High-level cystatin F dimers in plasma rapidly aggravate cognitive impairment in 5XFAD transgenic mice, suggesting that circulatory cystatin F inhibits peripheral Aβ clearance and leads to deteriorated Aβ deposition in the brain, providing us with a potential therapeutic target for the elimination of Aβ in the periphery.
Methods
Patients and clinical assessment
Age-matched controls and AD patients were recruited from Xuanwu Hospital of Capital Medical University and First Hospital of China Medical University (sTable 1). The National Institute of Neurological and Communication Disorders and the Stroke and Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA) were used as the basis for the patient selection criteria, and patients with other types of dementia were excluded from this study [
38]. All of the healthy control individuals had no substantial comorbidities that could impair brain function and no family history of dementia, and the patients with AD did not have immunological illnesses or vascular risk factors [
39]. The Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA) [
40], and the Clinical Dementia Rating (CDR) [
41,
42] were all used to measure cognitive function and the degree of impairment in all subjects. To evaluate object recognition memory, the Rey Auditory Verbal Learning Test (RAVLT) was used as described previously [
43]. All participants (or their legal guardians) provided written informed consent.
Isolation of plasma, monocytes, lymphocytes and neutrophils
Approximately 5 mL of peripheral whole blood was extracted from each individual by venipuncture. The plasma was extracted from the whole blood by centrifuging for 10 min at 800 ×g. The monocytes and lymphocytes were separated by using Dynabeads Isolation Reagent (Invitrogen, Carlsbad, CA, Cat No. 11145D;11149D) according to the manufacturer’s instructions. Neutrophils were isolated by using Percoll (Sigma Aldrich, MO, USA, Cat No. P1644) density gradient centrifugation.
RNA sequencing and data analysis
The RNA of the primary monocytes from the AD patients and age-matched controls was extracted by using TRIzol reagent (Invitrogen, Carlsbad, CA, Cat No. 15596026CN) according to the instructions. RNA sequencing analysis was carried out by Biomarker Technologies Company (Beijing, China). For data analysis, the fold change (FC), an absolute fold change between the two groups for each transcript, was calculated when comparing the two groups with distinct profiles. A Student's t test was used to determine the statistical significance of the differences between groups. The significantly differentially expressed transcripts had a FC of at least 4 and p values less than 0.05. By dividing the total number of genes in the Gene Ontology (GO) category by the total number of differentially expressed genes, enrichment factors were computed. Gene Set Enrichment Analysis (GSEA) v2.0.14 software was used to perform GSEA analysis.
Mice
APP/PS1 transgenic mice were obtained from China Medical University. 5 × FAD transgenic mice were generous gifts from Professor Chao Wang of Chongqing Medical University. Monocyte-specific human cystatin F-overexpressing transgenic mice were generated as described in previous reports [
44,
45]. Briefly, the open reading frame (ORF) of human cystatin F was obtained and subcloned and inserted into pBluescript SK (-) under the control of the human CD68 promoter. The fragment was removed and injected into fertilized C57BL/6 mice to construct transgenic mice named Hmo-cys F
+ mice. Hmo-cys F
+ and APP/PS1 AD model mice were bred to produce APP/PS1/Hmo-cys F
+ double transgenic mice. All transgenic lines were backcrossed to the C57BL/6J strain. Mice were housed under specific pathogen-free conditions on a 12 h light/12 h dark cycle with free access to water and food and no more than five mice per cage. The temperature and humidity were 18–29 °C and 45–55%, respectively. In this study, only male 9-month-old APP/PS1 mice and 3-month-old 5XFAD mice were included. All the animal experimental procedures were approved by the Animal Experimentation Ethics Committee of China Medical University (CMU20240091).
Morris water maze (MWM) test
The spatial memory and learning abilities of the mice were assessed by the MWM test. One day before the experiment, the mice were allowed to become accustomed to the water maze (100 cm in diameter). The pool was filled with water that was rendered opaque, which was drained every day, and the temperature of the water was maintained at 19 °C to 22 °C. During the training period, the mice were permitted to swim freely for 60 s to locate the platform (9 cm in diameter), which was fixed at a depth of 1 cm below the surface of the water. Mice that did not find the platform were directed to it and allowed to rest for 30 s. The mice were trained four times per day for six days. On day seven, the platform was removed, and the swimming activity of each mouse, including the latency, number of platform crossings and velocity within 1 min, was recorded. All the processes were monitored by using a video camera mounted overhead and automatically recorded via ANY-maze behavioural tracking software (Stoelting, Wood Dale, IL, USA).
Novel object recognition (NOR) test
The NOR test was conducted as described previously [
46]. Initially, the mice were acclimated to the testing room for five days before testing. Then, the mice were allowed to explore freely in the empty arena (40 × 40 × 40 cm) for 10 min. For the training session, two identical cylinders (6 cm in diameter) were placed in the arena 5 cm away from the wall. The mice were individually placed in the arena and allowed to freely explore for 10 min. Twenty-four hours after the training session, the NOR test was carried out. One of the familiar cylinders was replaced with a cube (with a side length of 6 cm). The mice were allowed to explore for 10 min, and a camera tracking system (TopScan Suite, CleverSys Inc., Reston, VA, USA) was used to record the amount of time the mice spent exploring the objects. The recognition index = time spent exploring the new object/(time spent exploring the new object + time spent exploring the familiar object) × 100%.
Tail intravenous injections
Three-month-old 5xFAD mice were given tail intravenous injections of murine cystatin F dimer protein at a dose of 200 μg/kg every three days for one month. The experiments were performed 48 h after the last injection.
Tissue preparation and immunofluorescence
Briefly, mice were transcardially perfused with phosphate-buffered saline (PBS) followed by ice-cold 4% paraformaldehyde (PFA) in PBS (pH 7.4). After perfusion, the brain was removed and postfixed in 4% PFA in PBS at 4 °C overnight and then transferred to 30% sucrose for 2-3 days until it sank to the bottom of the container. Coronal sections of the brain (30 μm) were cut using a cryostat (Minux FS800A, RWD Inc., China), collected serially on coated glass slides, and stored at − 20 °C until use. Six sections obtained from each brain containing the cortex and CA1 area of the hippocampus were chosen for immunofluorescence staining. The brain sections were incubated with PBS containing 0.5% Triton X-100 for 10 min and 5% BSA for 1 h at room temperature. The brain sections were sequentially incubated overnight at 4 °C with primary antibodies recognizing Aβ (1:800; Cell Signaling Technology, MA, USA, Cat No. 8243S), His tag (1:500; ABclonal Technology, Wuhan, China, Cat No. AE003) and IBAI (1:1000; Abcam, Cambs, UK, Cat No. ab178846). Then, the sections were incubated with Alexa Fluor 488-conjugated donkey-anti-rabbit IgG (1:200; Invitrogen, CA, USA, Cat No. A-21206) for 3 h in the dark at room temperature. After counterstaining with 4′,6-diamidino-2-phenylindole (DAPI) (Sigma Aldrich, MO, USA, Cat No. 28718-90-3) for 5 min, the coverslips were mounted and the slides were analysed under a laser scanning confocal microscope (LSCM).
Enzyme-linked immunosorbent assay (ELISA)
The levels of soluble and insoluble Aβ in the prefrontal cortex were measured by ELISA method. Briefly, fresh brain tissues from the mice were homogenized in RIPA buffer [50 mM Tris (pH 7.4), 150 mM NaCl, 1% NP-40, and 0.5% sodium deoxycholate] supplemented with protease inhibitor cocktail, followed by centrifugation at 12,000 × g for 30 min at 4 °C. The supernatant was collected as the RIPA fraction, and the pellet was solubilized in 2% SDS and 25 mM Tris-HCl (pH 7.4) followed by centrifugation at 12,000 × g for 30 min at 4 °C as the SDS fraction. The concentrations of Aβ40 and Aβ42 were measured using ELISA kits (Elabscience Biotechnology Company, Wuhan, China, Cat No. E-EL-M3009; E-EL-M3010) according to the manufacturer’s instructions. The Aβ40 and Aβ42 in human plasma were also determined by the ELISA kits (Elabscience Biotechnology Company, Wuhan, China, Cat No. E-EL-H0542; E-EL-H0543). In addition, the levels of cystatin F in the plasma of patients with AD or AD mice were quantitatively analysed by ELISA kits (CUSABIO Company, Wuhan, China, Cat No. CSB-E17504h; CSB-EL006095MO). The data were normalized to the total protein concentration.
Real-time polymerase chain reaction (RT-qPCR)
M-MLV reverse transcriptase was used to reverse transcribe the total RNA from the cells. RT-qPCR was conducted using a SYBR Premix Ex Taq Kit (Vazyme,Nanjing,China, Cat No. Q321-02) and an ABI 7500 RT-PCR instrument. Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) was selected as the reference gene. The conditions for PCR were 95 °C for 10 s, followed by 40 cycles of 95 °C for 30 s and 60 °C for 30 s. Standard curves were established to calculate target gene transcript quantities in each sample.
Western blot analysis
The plasma protein concentrations were determined by using a nondenaturing gel. Briefly, the plasma was diluted with 1X PBS, and nondenaturing loading buffer (50% glycerol, 0.3 mol/L pH = 6.8 Tris-HCl, 10% SDS, 0.01% bromophenol blue) was added to the samples. To detect the monomeric form of cystatin F, loading buffer with 20% dithiothreitol (DTT) (Sangon biotech, shanghai, China, Cat No. A620058) was used, and the samples were boiled at 95 °C for 10 min. Coomassie Brilliant Blue (CBB) staining of the plasma proteins served as an internal control. Cells were lysed with radioimmunoprecipitation assay lysis buffer (Beyotime Biotech, Beijing, China, Cat No. P0013B) containing 1 mM PMSF (Beyotime Biotech, Beijing, China, Cat No.ST506). Then, the protein samples were separated on 12% SDS polyacrylamide gels. For western blot detection, the primary antibody against cystatin F (ABclonal Technology, Wuhan, China, Cat No. A8164) was diluted 1:1000, and Horseradish Peroxidase (HRP) goat anti-rabbit IgG (ABclonal Technology, Wuhan, China, Cat No. AS014) was diluted 1:10,000. Immunoreactive bands were visualized with the SuperSignal West Pico chemiluminescent substrate (Pierce, IL, USA) using an LAS-3000 mini (Fujifilm, Tokyo, Japan). For quantitative analysis, the mean density of each band was measured by ImageJ software.
Recombinant protein expression and purification
The ORF of cystatin F was subcloned and inserted into the pcDNA3.1 (+) myc-His A vector, and the recombinant plasmids were transfected into 293T cells with polyethylenimine (PEI) (Polysciences, IL, USA, Cat No. 02371-500) at a ratio of 1 µg of DNA to 2.5 µg of PEI [
47,
48]. The cell culture supernatant was collected after 48 and 72 h of transfection, and the secreted cystatin F protein was purified by using His-tag Purification Resin (Beyotime, Shanghai, China, Cat No. P2210).
Aβ internalization assay
The Aβ internalization by monocytes were assessed by flow cytometry analysis (FCM), ELISA and LSCM methods. For FCM and ELSIA assay, 3 × 105 cells per well were cultured in 24-well plates, and the cystatin F dimer protein was added at final concentrations of 0 ng/mL, 50 ng/mL, 250 ng/mL, and 1000 ng/mL for 30 min. Then a final concentration of 1 μg/mL Aβ42-Alexa Fluor 647 (Kaneka Eurogentec, Liege Province, Belgium, Cat No. AS-64161) or soluble Aβ42 was added for a further incubation for 30 min at 37 °C, after which the cells were subjected to FCM and ELISA analysis, respectively. For LSCM analysis, cells were pretreated with the cystatin F dimer at a final concentration of 250 ng/mL for 30 min and then cells were incubated with Aβ42-Alexa Fluor 555 (Kaneka Eurogentec, Liege Province, Belgium, Cat No. AS-60480-01) for an additional 30 min at 37 °C. To analysis the binding ability of cystatin F dimer to Aβ at the cell membrane by FCM and ELISA methods, cells were pretreated with the cystatin F dimer at a final concentration of 250 ng/mL for 30 min at 37 °C, and then cells were incubated with Aβ42-Alexa Fluor 647 or soluble Aβ42 for an additional 30 min at 0 °C, after which the cells were subjected to FCM and ELISA analysis, respectively. For LSCM analysis, cells were pretreated with the cystatin F dimer at a final concentration of 250 ng/mL for 30 min at 37 °C, and then cells were incubated with Aβ42-Alexa Fluor 555 for an additional 30 min at 0 °C. The coverslips were labelled with 15 μg/mL 3,3′-dioctadecyloxacarbocyanine perchlorate (DiOC18(3), Beyotime, Shanghai, China, Cat No. C1038) in 4% PFA solution for 15 min, and stained with DAPI at a final concentration of 1 μg/mL for 4 min.
For the uptake inhibition assay, cytochalasin D (GLPBIO, CA, USA, Cat No. D22914GC13440) or EIPA (MedChemExpress, NJ, USA, Cat No. HY-101840) at final concentrations of 5 μg/mL or 40 μM were added to the cells to pretreat for 30 min and 1 h, respectively. The cells were incubated with the cystatin F dimer at a final concentration of 250 ng/mL for 30 min. Aβ42-Alexa Fluor 647 at a final concentration of 1 μg/mL was added to the cells, which were incubated for 30 min and analysed via FCM method. The data were analysed with InCyte software (Millipore, Darmstadt, Germany) and visualized using FlowJo software (Tree Star, Inc., CA, USA).
Total internal reflection fluorescence microscopy (TIRFM)
Monocytes were cultured on coverslips, and after treatment with 250 ng/mL cystatin F protein for 30 min, the cells were incubated with 1 μg/mL soluble Aβ42-Alexa Fluor 555 for 30 min at 0 °C and washed three times with PBS. The monocytes on the coverslips were fixed with 4% PFA solution for 15 min and were analysed under a TIRFM.
Binding assay
The 96-well ELISA plates were coated with 4 ng/μL of dissolved Aβ1-40, Aβ1-42, Aβ40-1, or Aβ42-1 for 16 h at 4 °C. Bull serum albumin at a 5% concentration was used as a blocking agent and incubated for 2 h at 37 °C. Recombinant cystatin F dimer protein was added to the plates for 3 h at various concentrations (18.75 ng/mL, 37.5 ng/mL, 75 ng/mL, 150 ng/mL, and 300 ng/mL). Cystatin F antibody (R&D Systems, MN, USA, Cat No. MAB1889) was used to identify the binding of the two proteins. A secondary antibody coupled to HRP and 3,3′,5,5′-Tetramethylbenzidine reagent was used to induce a colour reaction, and the absorbance was read at 450 nm.
Molecular docking
Protein Aβ42 (PDB ID: 6SZF) and cystatin F dimer (PDB ID: 2CH9) crystal structures were retrieved from the RCSB Protein Data Bank (
http://www.rcsb.org/). The protein cystatin F was set as the receptor before docking, while Aβ42 was set as the ligand. Cluspro1, HDOCK2, and MOE3 were utilized to determine the binding mechanism of Aβ42 and the cystatin F dimer using three molecular docking tools.
Pull-down assay
Purified GST-Aβ protein (Abcam, Cambridge, UK) and His-tag cystatin F were co-incubated overnight at 4 °C. The purification resin (Beyotime, Shanghai, China, Cat No. P2251; P2210) for the GST-tag or His-tag was added to the protein mixture and incubated for 2 h at 4 °C. The resins were centrifuged for 5 min at 1000 ×g and the precipitate was mixed with loading buffer, then the samples were subjected to Western blot analysis. Rabbit anti-His-tag and mouse anti-GST-tag (ABclonal Technology, Wuhan, China, Cat No. AE086; AE001) were diluted 1:1000. Goat anti-rabbit IgG or goat anti-mouse IgG conjugated with HRP was diluted 1:10,000 (ABclonal Technology, Wuhan, China, Cat No. AS070; AS066).
Bimolecular fluorescence complementation assay (BiFC)
The BiFC was carried out as previously reported with modifications [
49]. Briefly, full-length ORF of cystatin F conjugated with the N-terminal fragment Venus and of Aβ conjugated with the C-terminal fragment Venus were constructed. The recombinant plasmids were transfected into 293T cells, and the protein supernatants were purified. The two proteins were incubated at 200 ng/mL for 2 h at 37 °C, and the fluorescence intensity was detected at 529 nm.
Statistical analysis
Data were presented as mean ± standard deviation (SD). Student’s t test was used to compare two groups while one-way ANOVA was used to compare more than two groups. A receiver operating characteristic (ROC) curve was generated to evaluate the diagnostic value of the cystatin F in AD monocytes. Correlations were assessed by using Pearson correlation coefficient. All data were analysed by GraphPad Prism 8.0 statistical software. Statistical significance was indicated by a probability (p) value of less than or equal to 0.05.
Discussion
The mechanism underlying the dysfunctional peripheral clearance of Aβ by monocytes derived from AD patients is unclear. Herein, we demonstrated that aberrantly elevated expression of the cystatin F dimer released by AD monocytes is a determinant of dysfunctional Aβ clearance in the periphery and contributes to AD pathology.
Monocytes and macrophages are capable of physiologically removing circulating Aβ that originates in the brain through multiple means. Similar to glial cells in the brain, monocytes/macrophages in the periphery express phagocytic receptors for Aβ and produce Aβ-degrading enzymes to recognize and degrade Aβ [
59,
60]. Mounting evidence suggests that gene expression changes in peripheral immune cells can affect brain function and animal behaviour [
61]. We demonstrated that cystatin F expression was specifically elevated in the monocytes of sporadic AD patients and that in vivo, human cystatin F aggravated Aβ deposition in the brain and cognitive impairment in APP/PS1 mice. Cystatin F was first identified in samples from AD patients by Keren-Shaul H et al. [
62] and was reported to be significantly upregulated in microglia as an amyloid plaque’s indicator [
63]. Cystatin F exhibited similarly elevated expression and functions in contributing AD development in both peripheral and central innate immune cells. This may be a result of meningeal macrophages penetrating the brain during embryonic development to form microglia, and even brain parenchymal microglia could also be derived from blood monocytes, which are regarded as the counterparts of microglia in the periphery [
64,
65]. Our findings verified the importance of defects in peripheral monocytes in AD progression and that cystatin F may be a potential risk factor.
Bone marrow-derived monocytes have been studied often in AD for their ability to infiltrate the brain and engage in the phagocytosis of Aβ [
66]. Since cystatin F is unable to cross the BBB and has no impact on resident microglia and transendothelial migration of monocytes, it may play a major role in Aβ clearance in the periphery. We determined that cystatin F was released as a dimer into the plasma. Additionally, the cystatin F dimer specifically impaired Aβ internalization by hindering its adhesion to the surface of monocytes. This finding not only confirms that abnormal levels of cystatin F in plasma can directly affect the phagocytosis of Aβ by monocytes but also challenges the previous view that cystatin F is inactive in its dimeric form until it is reduced into monomers [
67].
Cystatin F belongs to the type II cystatin gene family, which shares approximately 38% homology with its family member cystatin C [
68]. The role that Cystatin C plays in AD progression is controversial, however Cystatin C has been found to inhibit the expression of cathepsin B to degrade Aβ [
69]. Moreover, cystatin C can bind to Aβ to inhibit further oligomerization and fibrosis of Aβ to protect against neuronal cell death and limit the course of AD [
70,
71]. Although cystatin F is especially expressed in the microglia around Aβ plaques [
72] and is regarded as a sensitive indicator of Aβ plaques in AD [
31], the link between cystatin F to Aβ has not been explored. We found that the cystatin F dimer is able to physically interact with Aβ through specific amino acids. Among these amino acids, arginine and lysine, which are located at positions 77 and 119, respectively, are also found in the homologous region of cystatin F and cystatin C. The direct interaction between the cystatin F dimer and Aβ is the dominant force that inhibits the recognition and internalization of Aβ by monocytes, as weakening the interaction by destruction of the interacting amino acids restored the uptake of Aβ by monocytes. Several secreted proteins are able to alter the metabolism of Aβ by binding to Aβ in the extracellular fluid. For instance, β2M markedly accelerated Aβ42 aggregation and oligomer formation by coaggregation with Aβ [
73]. Whether the binding of cystatin F to Aβ results in structural changes that affect Aβ recognition by pattern receptors on monocyte membranes is worth exploring in depth.
Sporadic AD is a progressive disorder that typically starts in midlife, decades before symptom onset. Aβ accumulation precedes the onset of other AD pathologies and a decrease in cognitive impairment [
2]. Strategies targeting Aβ are thus promising disease-modifying approaches for the treatment and prevention of AD [
74]. Cystatin F dimers especially rapidly exacerbated the deposition of Aβ in the brain and cognitive deficits in 5XFAD transgenic mice, suggesting that this protein is a promising target in peripheral blood. An important reason for the uncontrollability of AD progression is the lack of early noninvasive diagnostic biomarkers. Considerable research has focused on changes in certain signature proteins of AD in the plasma because these proteins are easily accessible and noninvasive [
75,
76]. The increase in the cystatin F dimer level in plasma from patients with AD patients was closely correlated with the Aβ level and clinical mental score of patients with AD, suggesting that the cystatin F dimer level in plasma from patients with AD might be useful for assessing AD severity.
There are several limitations to this study. First, the interaction of the cystatin F dimer with Aβ likely occurs through multiple amino acids; thus, it is difficult to use genetic or pharmacological approaches to disrupt this interaction to enhance the recognition and phagocytosis of Aβ by monocytes. Second, sex differences exist in clinical AD, and preclinical model animals also exhibit sexual dimorphisms in AD-like behaviours. In particular, Daniels MJD et al. recently reported that cystatin F plays a sexually dimorphic role in regulating microglia in
Cst7-deficient AD mice and that the microglia of female mice have a greater Aβ burden in vivo [
77]. To avoid the potential confounding effects of sex, only male mice were used in this study. Thus, our findings in male mice may not be completely recapitulated in female mice. Finally, although cystatin F may be a potential target, reducing or eliminating cystatin F from the periphery is a challenge for the future.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.