**5. Conclusion**

The field of ALS research has progressed significantly in recent years with the identification of glial cells as an active contributor to the disease process. Specifically, astrocytes and microglia have been recognized as glial cell types which undeniably influence survival in rodent models of ALS. Efforts are underway to test therapies aimed at modifying the glial cell population in hopes of slowing ALS disease progression and extending patient survival. While rodent models of ALS have been key in revealing glial cells as a disease contributor in SOD1 fALS, it still remains to be determined to what extent glial cells are involved in disease processes in other patient populations. New genes have been recently linked ALS including TDP43 and FUS, suggesting a possible role for RNA metabolism in disease pathogenesis. Creation of both rodent and *in vitro* models mimicking these forms of ALS is underway and will hopefully reveal whether glial cells are also a target in patients harboring these mutations.

Although glial cell targets have been identified, much work remains to elucidate the mechanisms behind their neural toxicity. Several groups have been able to model the glialmotor neuron interface *in vitro* using unique stem-cell based models to study the effects of diseased glia on motor neurons. While these studies have yet to identify relevant mechanisms involved in glial-mediated toxicity, *in vitro* models present the opportunity to study human patient-derived glial cells from both fALS and sALS patients. With the development of iPSC technology, there exists potential to study patient-specific glial cells and evaluate therapies in a high-throughput fashion.

Discovery of mechanisms involved in glial pathogenicity will likely lead to the development of promising therapeutic interventions. Detection of additional pathways of importance will hopefully shed light on new compounds which may be capable of targeting glialmediated motor neuron damage. Furthermore, stem cell and gene-based therapies have reached evaluation in clinical trials, creating excitement and optimism in the field. As new knowledge of disease mechanisms arises, there is great hope for novel interventions to target glial cells and significantly change the ALS disease course.

### **6. References**

468 Amyotrophic Lateral Sclerosis

from an ALS patient. A phase I clinical trial has been initiated in fALS patients with SOD1 mutations testing intrathecal infusion of this same antisense oligonucleotide against SOD1. This dose-escalation trial will evaluate safety, tolerability, and pharmacokinetics in patients treated with antisense oligonucleotide infusion for 12 hours. If proven safe, this strategy

While a great deal of progress has been made in the development of anti-SOD1 therapies, additional work needs to be focused on advancing novel treatments for non-SOD1 ALS patient populations. As additional genetic mutations are linked to ALS, these genes might present new targets for gene-based therapeutic approaches. However, in the case of TDP43 and FUS mutations, a great deal of basic research is still required to evaluate whether a lossof-function or gain-of-function mechanism is responsible for disease caused by these mutations and whether glial cells are also a target in these cases. Until these crucial questions are answered, it will be difficult to develop RNAi or gene therapy treatments for these patients. Efforts to reach a broad ALS patient population may benefit most from the design of therapies which interfere with downstream mechanisms prevalent in most patients, such as glial-mediated glutamate excitotoxicity or neuroinflammation. Many of the siRNA and antisense oligonucleotide approaches can be amenable to inhibit potentially damaging genes involved in these glial responses. Additionally, viral vectors have been developed that can deliver gene therapies to glial cells in the CNS, allowing for potential immune modulation. With increasingly innovative developments in RNAi and gene therapy, the door is open for novel gene-based therapies to alter the ALS disease process.

The field of ALS research has progressed significantly in recent years with the identification of glial cells as an active contributor to the disease process. Specifically, astrocytes and microglia have been recognized as glial cell types which undeniably influence survival in rodent models of ALS. Efforts are underway to test therapies aimed at modifying the glial cell population in hopes of slowing ALS disease progression and extending patient survival. While rodent models of ALS have been key in revealing glial cells as a disease contributor in SOD1 fALS, it still remains to be determined to what extent glial cells are involved in disease processes in other patient populations. New genes have been recently linked ALS including TDP43 and FUS, suggesting a possible role for RNA metabolism in disease pathogenesis. Creation of both rodent and *in vitro* models mimicking these forms of ALS is underway and will hopefully reveal whether glial cells are also a target in patients

Although glial cell targets have been identified, much work remains to elucidate the mechanisms behind their neural toxicity. Several groups have been able to model the glialmotor neuron interface *in vitro* using unique stem-cell based models to study the effects of diseased glia on motor neurons. While these studies have yet to identify relevant mechanisms involved in glial-mediated toxicity, *in vitro* models present the opportunity to study human patient-derived glial cells from both fALS and sALS patients. With the development of iPSC technology, there exists potential to study patient-specific glial cells

Discovery of mechanisms involved in glial pathogenicity will likely lead to the development of promising therapeutic interventions. Detection of additional pathways of importance will hopefully shed light on new compounds which may be capable of targeting glial-

holds considerable promise to treat SOD1 fALS patients.

**5. Conclusion** 

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**21** 

*The Netherlands* 

**Genetics of Amyotrophic Lateral Sclerosis** 

*2Deparment of Neuroscience and Pharmacology, University Medical Center Utrecht,* 

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by progressive muscle weakness caused by loss of central and peripheral motor neurons. Symptoms typically have a localized limb or bulbar onset and progress to other muscle groups of the body. Denervation of respiratory muscles and dysphagia leading to respiratory complications are the most common causes of death. There is no cure for this

Approximately 5% of patients have a family history of ALS (fALS) (Byrne et al., 2011). All other cases are considered to have a sporadic form of the disease (sALS). A twin study of sALS patients has estimated hereditability to be considerable (0.38-0.76), indicating an important genetic component in disease etiology (Al-Chalabi et al., 2010). sALS, therefore, is considered to be a disease of complex etiology with both genetic and environmental factors

This chapter will provide an overview of the current knowledge of the genetics of both fALS and sALS. There will be, however, particular emphasis on two sALS associated regions identified in a large genome wide association study namely, chromosomal region 9p21.2 and 19p13.11. Evidence for the association with these regions as well as the function of the

Familial ALS is a genetically heterogeneous group of diseases for which linkage has been found for over 13 different loci (Table 1). These loci account for approximately 25-30% of all fALS cases. In addition, variants in several other genes have been implicated in fALS but most of these data are still inconclusive. All currently known fALS loci and the genes

Linkage analysis in autosomal-dominant fALS pedigrees associated the copper-zinc superoxide dismutase (*SOD1*) gene on chromosome 21q to ALS. Several point mutations in

**1. Introduction** 

**2.1 ALS1 (SOD1)** 

Corresponding authors

 \*

rapidly progressive disease.

contributing to disease susceptibility.

relevant genes in these regions will be discussed.

involved will be briefly discussed in this section.

**2. Genetics of familial amyotrophic lateral sclerosis** 

Max Koppers1, 2, Michael van Es1, Leonard H. van den Berg1,

*1Departments of Neurology, University Medical Center Utrecht,* 

Jan H. Veldink1\* and R. Jeroen Pasterkamp1, 2\*
