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Recently, increasing evidence has suggested the association between gut dysbiosis and Alzheimer’s disease (AD) progression, yet
the role of gut microbiota in AD pathogenesis remains obscure. Herein, we provide a potential mechanistic link between gut
microbiota dysbiosis and neuroinflammation in AD progression. Using AD mouse models, we discovered that, during AD
progression, the alteration of gut microbiota composition leads to the peripheral accumulation of phenylalanine and isoleucine,
which stimulates the differentiation and proliferation of pro-inflammatory T helper 1 (Th1) cells. The brain-infiltrated peripheral Th1
immune cells are associated with the M1 microglia activation, contributing to AD-associated neuroinflammation. Importantly, the
elevation of phenylalanine and isoleucine concentrations and the increase of Th1 cell frequency in the blood were also observed in
two small independent cohorts of patients with mild cognitive impairment (MCI) due to AD. Furthermore, GV-971, a sodium
oligomannate that has demonstrated solid and consistent cognition improvement in a phase 3 clinical trial in China, suppresses gut
dysbiosis and the associated phenylalanine/isoleucine accumulation, harnesses neuroinflammation and reverses the cognition
impairment. Together, our findings highlight the role of gut dysbiosis-promoted neuroinflammation in AD progression and suggest
a novel strategy for AD therapy by remodelling the gut microbiota.
1
Shanghai Green Valley Pharmaceutical Co., Ltd, Shanghai 201203, China; 2State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of
Sciences, Shanghai 201203, China; 3Department of Geriatric Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine; Alzheimer’s Disease
and Related Disorders Center, Shanghai Jiao Tong University, Shanghai 200025, China and 4Institutional Technology Service Center, Shanghai Institute of Materia Medica, Chinese
Academy of Sciences, Shanghai 201203, China
Correspondence: Meiyu Geng (mygeng@simm.ac.cn)
These authors contributed equally: Xun Huang, Tao Wang, Zuoquan Xie
These authors contributed equally as co-first authors: Xinyi Wang, Guangqiang Sun, Teng Feng, Jing Zhang
microbiota. The elucidation of the mechanisms underlying the stage of 2-3-month old, both M1 and M2 microglia increased,
neuroimmune regulation by microbiota may hold promise for while in the following months, M1 subtype continued to increase
developing novel therapeutics for AD patients. and peaked at 7-9 months, whereas M2 type microglia declined
from 3 to 5 month and maintained a low level thereafter (Fig. 1g).
In addition to microglia activation, AD-associated neuroinflam-
RESULTS mation is known to involve the infiltration of peripheral immune
AD progression is associated with the alteration of gut microbiota cells.34–36 We therefore also analyzed the infiltrating peripheral
and immune cell infiltration immune cells in the brain during AD progression. It was observed
To assess the role of gut microbiota alteration in AD pathogenesis, that the frequency of CD45high cells in the brain was significantly
we used the 5XFAD transgenic (Tg) mouse model, which is widely higher in Tg mice than that in WT mice, similar to the result of
used in AD study for faithfully recapitulating AD-associated IBA1 staining (Fig. 1f, h). We further profiled changes of CD45high
pathological features including the severely accelerated cognitive cell subtypes at a series of time points during AD progression
impairment, amyloid deposition in the 2nd postnatal month, (Fig. 1i). Using the k-means clustering (see Materials and methods),
synaptic degeneration in the 4th postnatal month, and behavioural we revealed that the alteration of CD4+ T cells, as the major
changes in the 6th month.20–23 Consistent with these reports,24–27 proportion of CD45high cells, closely recapitulated the change of
we observed rapid accumulation of Aβ plaque deposition in the M1 cells (Fig. 1i, j). Infiltrating Th1 and Th2 cells, two major
cortex and hippocampus beginning from the 3rd postnatal month subtypes of CD4+ cells, exhibited similar dynamics to that of M1
in Tg mice compared to the age-paired wild-type (WT) mice and M2 microglial cells over the period that we examined (Fig. 1k).
(Supplementary information, Fig. S1a). Tau phosphorylation in the It appeared to us that, as the pattern of the gut microbiota shifted,
brain of Tg mice was first found in the 5th month and increased the immune cell population tended to change to a Th1- and M1-
gradually compared to the age-paired WT mice (Supplementary dominated state. Similar results were also found in the APP/PS1
information, Fig. S1b). The synaptophysin expression level in the model (Supplementary information, Fig. S1i, j) and other AD
hippocampus significantly decreased from the 7th to the 9th mouse models by querying public databases (Supplementary
months, indicative of synaptic degeneration (Fig. 1a), while the information, Fig. S2).37,38
behavioural test in Tg mice showed a significant decline in We also analyzed the correlation between gut microbiota
discrimination learning at 9 months of age (Fig. 1b). abundance and brain immune cell frequency at both early and
We then compared the enterotypes of Tg mice and WT mice at late stages of AD progression. We noted that the abundance
different stages in AD progression using 16S ribosomal RNA (rRNA) changes of bacteria were aligned with the alterations of Th2 and
gene amplicon sequencing. The sequences were grouped into M2 cells at the early stage (2–3 months) (Fig. 1l, top), but
provisional clusters as operational taxonomic units (OTUs). correlated with those of Th1 and M1 cells at the late stage
Enterotype analysis revealed a notable clustering effect in the (7–9 months) (Fig. 1l, bottom). The bacteria that were significantly
gut microbiome, with Tg mice clustered into a norank genus interrelated with immune cells were listed in the right panel of
under the family of Muribaculaceae and WT mice clustered into Fig. 1l (list of the full names is in Supplementary information,
the Lactobacillus genus (Fig. 1c). Using principal component Table S2). Overall, these results indicated that gut bacteria were
analysis (PCA), which simplifies the complexity in high- associated with the infiltration of peripheral immune cells and
dimensional data while retaining trends and patterns upon a neuroinflammation occurrence during AD progression.
series of time points (also see Materials and methods28), we
revealed a remarkable shift in the gut microbiota composition Gut microbiota is required for immune cell infiltration and
during AD progression in Tg mice. Hardly any changes were microglial activation in the brain
observed in WT mice (Fig. 1d; Supplementary information, To determine whether the gut microbiota change is required for
Fig. S1c). Using OTUs to track the dynamics of the abundance of driving peripheral immune cell infiltration and in turn neuroin-
different bacterial phyla in Tg mice, we found two distinct changes flammation in AD progression, we used an antibiotic cocktail
of gut microbiota profiles in Tg mice during disease progression. containing ampicillin (0.1 mg/mL), streptomycin (0.5 mg/mL), and
colistin (0.1 mg/mL) to ablate gut microbiota. Antibiotic treatment information, Fig. S3a). Analysis of the gut microbiota change in
in Tg mice resulted in a marked reduction in microbial abundance these mice indicated that the composition of the gut microbiota
in the gut (Fig. 2a; Supplementary information, Table S3). Along was quite similar between co-housed WT mice and Tg mice, but
with this change, we observed a reduction in both infiltrating pro- significantly different from that of WT mice of the same age under
inflammatory Th1 cells (Fig. 2b) and M1 cells (Fig. 2c) in the brain. separate housing (Fig. 2d). Moreover, infiltrating Th1 cells between
Further, these findings were confirmed by a co-housing co-housed WT and Tg mice were comparable as well, which were
experiment, in which WT mice were co-housed with Tg mice of both significantly higher than that of separately housed WT mice
the same age for 7 months since birth. The co-housed WT mice (Fig. 2e). Meanwhile, M1 cells were only slightly increased in the
displayed the decline in discrimination learning, comparable to co-housed WT mice (Fig. 2f), suggesting that microbiota alteration
that of Tg mice, indicating that the long-term exposure to the mainly influenced the infiltrating immune cells rather than the
Tg bacteria could cause cognitive impairment (Supplementary resident immune cells. In line with the immune cell change,
cytokine expression in the brain showed a marked similarity cognition impairment in AD patients in a 36-week multi-center,
between co-housed WT and Tg mice, but distinct from those of randomized, double-blind, placebo-controlled Phase 3 clinical trial
WT mice (Fig. 2g; Supplementary information, Table S4). in China. Given that carbohydrates, in the forms of monosacchar-
We also performed faecal microbiota transplantation (FMT) ide or oligosaccharide, are the primary nutrient source for bacteria
experiments using C57BL/6 WT mice. For C57 WT mice with and have shown diverse modulatory effects on bacteria,39–42 we
hippocampal Aβ injection, oral administration of faecal microbiota were interested to explore whether GV-971 could affect the gut
from 7-month Tg mice resulted in a marked increase in Th1 cells microbiota.
and a reduction in Th2 cells in the brain (Supplementary
information, Fig. S3b). Reversely, transplantation of WT feces GV-971 alleviates neuroinflammation by shaping the gut
decreased brain Th1 cells in the recipient Tg mice (Supplementary microbiota
information, Fig. S3c). Together, these findings suggest that the Intriguingly, one-month oral administration of GV-971 in Tg mice
gut microbiota alteration drives peripheral immune cell infiltration beginning from 7-month-old age markedly altered the composi-
and neuroinflammatory activation in AD progression. tion of gut microbiota in a bi-directional way (Fig. 4a, b;
Supplementary information, Fig. S4a and Table S2). In line with the
GV-971 exhibits ameliorative effects on cognitive impairment gut microbiota alteration, GV-971 treatment in Tg mice disrupted
The essential role of gut microbiota in AD progression revealed the correlation previously seen between brain lymphocytes and
herein may suggest the therapeutic implications by the interven- gut bacterial change (Fig. 4c; Supplementary information, Fig. S4b,
tion of gut microbiota. To test this hypothesis, we took advantage c and Table S2), decreased brain Th1 cells (Fig. 4d), significantly
of GV-971 (Fig. 3a). In 9-month-old APP/PS1 mice treated with GV- reduced microglial activation (Fig. 4e), and decreased multiple
971 for three months until 13-month old, GV-971 exhibited brain cytokines levels (Fig. 4f; Supplementary information,
significant ameliorative effect on the cognitive impairment, as Table S4). In parallel, GV-971 treatment significantly reduced the
shown by the enhanced spatial learning and memory perfor- Aβ plaque deposition, tau phosphorylation, and ameliorated the
mance of APP/PS1 mice in both training trial (Fig. 3b) and probe decline in discrimination learning in Tg mice (Fig. 4g–i; Supple-
trial (Fig. 3c) in the Morris Water Maze (MWM) task. GV-971 also mentary information, Fig. S4d).
significantly improved the mice performance in Y maze (Fig. 3d). Further, we did FMT, transplanting feces of GV-971-treated
Recently, GV-971 has shown the therapeutic effect on reversing Tg mice to the recipient C57BL/6 WT mice which were
Fig. 2 The gut microbiota is required for immune cell infiltration and microglial activation. a The effects of five-month oral gavage of
antibiotics on the relative abundance of gut microbes in 7-month-old 5XFAD transgenic (Tg) mice (n = 5–7). ABX, a cocktail of mixed
antibiotics composed of ampicillin (0.1 mg/mL), streptomycin (0.5 mg/mL) and colistin (0.1 mg/mL). Different genera of gut microbes are
coloured differently, and their changes in relative abundance are presented on the barplot. The abundance of Bacteroides in Tg mice is below
0.01 and was thus not shown in both groups. b-c The effects of five-month oral gavage of antibiotics on the frequency of Th1 cells (b) and M1-
type microglia (c) in the brain homogenate of 7-month-old 5XFAD transgenic (Tg) mice. Cell counts of Th1 cells (CD45highCD4+CXCR3+) are
presented relative to the frequency of CD45high cells (b), while those of M1-type microglia (CD45lowCD11b+CX3CR1+Siglec-H+CD86+) are
presented relative to the frequency of CD45low cells (c). Both are detected by flow cytometry, n = 7, the data are presented as mean ± standard
error of the mean (mean ± SEM). d The relative abundance of gut microbes at the genus level in WT, co-housed WT and 5XFAD transgenic (Tg)
mice (n = 6–7). All three groups of mice were at 7-month old. Different colours represent different genera. Co-housed WT: WT mice that were
housed with Tg mice. e-f Changes in the frequency of Th1 cells (e) and M1 type microglia (f) in the brain homogenates of 7-month-old WT, co-
housed WT and 5XFAD transgenic (Tg) mice (n = 4–7). Th1 cells (CD45highCD4+CXCR3+) are presented relative to the frequency of CD45high
cells (e), while the frequency of M1-type microglia (CD45lowCD11b+CX3CR1+Siglec-H+CD86+) are presented relative to the frequency
of CD45lowCD11b+ cells (f). Both are detected by flow cytometry. The data are presented as mean ± standard error of the mean (mean ± SEM).
*P < 0.05, **P < 0.01 by Student’s t-test. g Levels of cytokine proteins in the brain homogenates of WT, co-housed WT and 5XFAD transgenic
(Tg) mice at 7-month old as detected by a cytokine antibody array (n = 5–6). Colours in the heatmap indicate relative cytokine levels; red
indicates cytokines that are upregulated, and blue indicates cytokines that are downregulated
Fig. 3 The effects of GV-971 on behaviour changes in APP/PS1 mice models. a Structure of GV-971. GV-971 is a mixture of acidic linear
oligosaccharides with degrees of polymerization ranging from dimers to decamers with an average molecular weight of approximately 1 kDa.
b The escape latency time results of the Morris Water Maze (MWM) test as a measurement of spatial learning and memory in APP/PS1 mice.
Nine-month-old APP/PS1 mice were treated with 50 mpk and 100 mpk of GV-971 for 3 months until 13-month old. Then, the MWM test for
spatial learning and memory abilities were conducted for 6 additional days. During the test, GV-971 was continuously administrated. The
escape latency time starting (seconds) was measured as one of the final readouts of the test (see Materials and methods). Higher escape
latency time shows that these mice will spend more time to reach the target, which indicates a more severely impaired spatial learning and
memory ability (n = 11–14). The data are presented as mean ± standard error of the mean (mean ± SEM). Black asterisk indicates the
comparison between WT and APP/PS1 group. Blue asterisk indicates the comparison between GV-971(100 mpk) treatment and APP/PS1
group. *P < 0.05, ***P < 0.001 by two-way ANOVA. c The number of platform-site crossovers in MWM test as a measurement of spatial learning
and memory in APP/PS1 mice. Nine-month-old APP/PS1 mice were treated with 50 mpk and 100 mpk of GV-971 for 3 months until 13-month
old. Then, the MWM test for spatial learning and memory abilities were conducted for 6 additional days. During the test, GV-971 was
continuously administrated. The number of platform-site crossovers was measured as the other readout of the test (see Materials and
methods). Larger numbers of platform-site crossovers indicate less severely impaired spatial learning and memory ability (n = 11–17). *P <
0.05, ***P < 0.001 by one-way ANOVA (F (3, 55) = 6.542). d The accuracy of spatial working memory as tested using the Y maze in APP/PS1
mice. Nine-month-old APP/PS1 mice were treated with 50 mpk and 100 mpk of GV-971 for 3 months until 12-month old. Then the Y maze test
was conducted. During the test, GV-971 was continuously administrated. The accuracy of the Y maze was the ratio between the
correct alternation and the total alternation (see “Materials and methods”). Higher accuracy indicates less severely inpaired working memory
abilities. (n = 17–20). The data are presented as mean ± standard error of the mean (mean ± SEM). **P < 0.01, ***P < 0.001 by one-way ANOVA
(F (3, 71) = 12.39)
intraventricularly injected with aggregated Aβ. Feces of GV-971- with the Human Metabolome Database (HMDB) and the Kyoto
treated Tg mice resulted in decreased Th1 cells in the brain of Encyclopaedia of Genes and Genomes (KEGG), yielding a total of
recipient mice as compared to that of Tg mice without GV-971 31 metabolites that were differentially regulated among WT, Tg
treatment (Supplementary information, Fig. S4e). Consistently, and GV-971-treated Tg mice, which could be matched to all three
antibiotic treatment impaired the effect of GV-971 on gut databases (Supplementary information, Fig. S5g). Pathway enrich-
microbiota, Th1 cells, IBA1 levels and cytokine expression in the ment analysis of these metabolites using MBROLE or
APP/PS1 mouse model (Supplementary information, Fig. S4f-j). In MetaboAnalyst47,48 further revealed significant changes in amino
addition, treatment with oligo-guluronic acid (PG), an epimer of acid-related metabolic pathways and enzymes, especially
GV-971, or with polymannuronate sulfate, polyguluronate sulfate, phenylalanine-related pathways (Fig. 5a).
heparin, heparan sulfate did not show the therapeutic effects We therefore chose to focus on amino acids for further study.
(data not shown), indicating that the sugar backbone of GV-971 Plasma concentrations of a total of 36 amino acids were screened
may account for its specific impact on gut microbiota. All these in both WT and Tg mice (Supplementary information, Table S6).
data suggested that GV-971 could alleviate neuroinflammation Classification of these amino acids using a random forest
and cognition decline via modulating gut dysbiosis. algorithm49 ranked phenylalanine as the top hit that was different
between WT and Tg, followed by isoleucine, serotonin, histidine
GV-971 inhibits neuroinflammation by regulating amino acid and acetylornithine (Fig. 5b; Supplementary information, Fig. S5h),
metabolism suggested their strong correlation with the disease progression.
Emerging evidence has highlighted the role of gut microbiota- We then examined the concentration of the selected amino acids
associated metabolites in influencing the host immune system.43 in the faecal and blood samples in GV-971-treated or untreated Tg
To test the possible involvement of metabolites in immune mice, and compared it with that of WT mice. We found that the
modulation, the supernatant of in vitro-cultured feces from 7- concentrations of phenylalanine and isoleucine were significantly
month-old Tg mice44–46 was added to naïve CD4+ T cell culture higher in the feces of Tg mice than those of WT mice, and GV-971
(see Materials and methods), which stimulated the differentiation treatment significantly reduced their concentrations to a level
of naïve CD4+ T cells to Th1 and Th2 cells. In contrast, fecal comparable to that of WT mice (Fig. 5c). A similar change in the
supernatant of Tg mice treated with GV-971 inhibited Th1 concentration of phenylalanine and isoleucine was detected in
differentiation and promoted Th2 differentiation (Supplementary blood (Fig. 5d). To test whether the elevation of these amino acids
information, Fig. S5a). resulted from gut microbiota change, we examined the concen-
We next employed a non-targeted metabolomics technique to tration of amino acids in FMT study. Feces from 2-month-old WT
characterize the fecal metabolome. A total of 11289 metabolites mice could significantly reduce the concentration of phenylala-
were identified in faecal samples from WT, Tg and GV-971-treated nine and isoleucine in Tg mice (Supplementary information,
Tg mice (Supplementary information, Fig. S5b-c). Among those Fig. S5i). Likewise, in co-housed WT mice across various months of
metabolites matched to database (Supplementary information, age, phenylalanine and isoleucine concentrations in blood were
Fig. S5d-e), the abundance of 124 metabolites, as annotated by also elevated, comparable to that of Tg mice (Supplementary
METLIN database, was significantly changed in Tg mice as information, Fig. S5j).
compared to that in WT mice (Supplementary information, Fig. S5f Amino acids could be taken by immune cells through
and Table S5). These altered metabolites were further annotated specific transporters, driving immune cell differentiation and
proliferation.50 We examined the expression levels of Slc7a5, the To assess the direct effects of phenylalanine and isoleucine on T
transporter of phenylalanine and isoleucine, in Th1 cells and found cell differentiation, naïve CD4+ T cells were exposed to either
that Slc7a5 was expressed in Th1 cells (data not shown). phenylalanine or isoleucine with or without GV-971 for 4 days and
Furthermore, incubation of Th1 cells with 13C-labelled phenylala- Th1 cells were assessed by Flow cytometry (FACS). We observed
nine revealed the uptake of phenylalanine by Th1 cells, which the significantly enhanced Th1 cell differentiation exposed to
could be blocked by a pharmacological inhibitor of SLC7A5 either phenylalanine or isoleucine, which was inhibited by GV-971
(Supplementary information, Fig. S5k), suggesting that Th1 cells treatment (Fig. 5e). Next, we evaluated the direct influence of
are prone to phenylalanine and isoleucine uptake. phenylalanine and isoleucine on Th1 cell proliferation. We found
that the proliferation of Th1 cells was significantly promoted by infiltration and M1 microglia activation in WT mice, while reverse
phenylalanine and isoleucine, and GV-971 treatment inhibited FMT of WT mice feces into Tg mice reduced Th1 cells of the
phenylalanine-induced Th1 cell proliferation, but barely changed recipient Tg mice. Our findings collectively highlighted the gut
isoleucine’s effect (Fig. 5f, blue column). Furthermore, we treated microbiota as a driving factor in promoting Th1/M1 microglia-
WT mice with intraperitoneal injection of phenylalanine and predominated neuroinflammation in AD progression. Interest-
isoleucine and observed that Th1 cell frequency in the blood was ingly, gut-derived inflammatory immune cells such as Treg
significantly increased (Fig. 5g). and γδT were also reported to play roles in ischemic brain injury52
Finally, we explored whether the above findings could be and dietary salt-induced cognitive impairment,53 which further
recapitulated in MCI due to AD (see “Materials and methods” for supports the functional link between gut microbiota and
definition of MCI used in this study) patients. Indeed, phenylala- neuroinflammation and brain functions.
nine and isoleucine concentrations as well as Th1 cell frequency in In our study, we did not observe any sex-dependent changes in
the blood of MCI due to AD subjects were significantly higher than terms of gut microbiota composition or brain M1/Th1 cell
those in the age-matched healthy counterparts (Fig. 5h, i). abundance, which seemed different from recent findings showing
Moreover, the increased levels of both phenylalanine and sex-dependent changes of microglia and Aβ deposition under
isoleucine in the blood were also confirmed in another small antibiotic treatment.54 We speculate that this discrepancy might
MCI due to AD cohort (Fig. 5j), indicating that the abnormal result from the different experimental settings, including mouse
accumulation of phenylalanine and isoleucine and elevation of models (APP/PS1-21 vs. 5XFAD), antibiotic treatment periods at
Th1 frequency in the blood might function as a signature to different ages of mice and readout parameters.
differentiate the MCI due to AD patients from the healthy subjects. The mechanistic relationship regarding gut microbiota dysbiosis
and neuroinflammation in AD remains unclear, though advance-
ments have recently been made in other neurological disorders
DISCUSSION including Parkinson’s disease (PD). Previous studies suggest the
In this study, we revealed that dysbiosis of the gut microbiota is direct or indirect involvement of bacterial metabolites, in
required for the infiltration of various peripheral immune cells, particular, short-chain fatty acid (SCFA) and bile acids32,55 in some
including CD4+ and CD8+ T cells, B cells, natural killer (NK) cells, neurological disorders. In this study, we detected many metabo-
neutrophil, dendritic cells (DCs) and monocytes, to the brain. lites significantly altered in AD mice compared to WT mice.
Among them, Th1 cells were particularly noted for the close Among them, the most significant change occurred in amino
association with the M1 microglia activation during AD progres- acids, particularly those in phenylalanine-related pathways. We
sion. Given the well-recognized functional crosstalk between Th1 confirmed that the abundance of phenylalanine and isoleucine
and M1 microglia in the brain,51 we propose that gut dysbiosis was increased in the feces and blood of AD mice compared to that
promotes Th1 cell infiltration to allow their local crosstalk with the of WT mice. Functional assessment both in vitro and in vivo
M1 microglia and in turn triggers the microglia differentiation revealed the role of phenylalanine and isoleucine in promoting
towards a pro-inflammatory state. both differentiation and proliferation of peripheral inflammatory
This mechanistic insight is strengthened by a series of findings Th1 cells. These findings highlight the role of the abnormal
obtained in this study. Firstly, a dynamic shift of gut microbiota production of phenylalanine and isoleucine by gut microbiota in
composition during AD progression is significantly correlated with provoking Th1 cell-dominated neuroinflammation. Consistent
the elevation of Th1 cell infiltration. Secondly, ablation of the gut with this notion, we detected higher concentration of phenyla-
microbiota by antibiotic treatment blocked Th1 cells infiltration lanine/isoleucine and Th1 cell frequency in the blood of MCI due
and M1 microglia activation in AD mice. Thirdly, both long-term to AD patients compared with that of the healthy control cohort.
exposure to faecal bacteria (co-housing experiment) and FMT of All these findings allowed us to propose a conceptual
faecal bacteria from AD mice markedly enhanced Th1 cell advancement in understanding the mechanism of AD
pathogenesis. AD is not only an Aβ-driven brain disease. Its Emerging data have shown that poly- or oligosaccharides
development also requires the systematic interaction between have advantages to modulate gut microbiota.56 The oligoman-
gut, brain and the intermediate inflammatory factors. In the nate sodium GV-971 is a carbohydrate-based anti-AD drug that
context of Aβ deposition, the altered gut microbiota composition has been demonstrated to reverse cognitive impairment in mild-
during AD progression causes an abnormal elevation of amino to-moderate AD patients in a recently completed phase 3
acids, phenylalanine and isoleucine in particular. These amino clinical trial in China. GV-971 is well tolerated with a safety
acids promote the infiltration of peripheral Th1 cells into the brain profile comparable to the placebo control. In this study, we
via blood circulation. The infiltrating peripheral Th1 cells may found that GV-971 effectively reconditioned gut microbiota,
locally crosstalk with M1 microglial cells in the brain, resulting in decreased the concentration of phenylalanine and isoleucine in
pathological neuroinflammation and cognitive impairment (Fig. 6). the feces and blood, and reduced Th1-related neuroinflamma-
These mechanistic insights into AD pathogenesis may provide a tion in the brain. Of note, GV-971-treated Tg feces could largely
novel therapeutic solution by reconstituting the gut microbiota to mimic the therapeutic effects of GV-971 treatment per se, while
favour anti-neuroinflammation responses. antibiotic treatment abrogated the therapeutic effects of GV-
Fig. 6 Schematic diagram of gut-brain axis in AD progression and the intervention strategy. Along with Aβ deposition and tau
phosphorylation, the alteration of the gut microbiota during AD progression causes metabolic disorder. The abnormal metabolites production
provoke peripheral inflammation, increases the brain infiltration of immune cells which crosstalk with M1 microglial cells in the brain, resulting
in pathological neuroinflammation and cognitive impairment (left panel). Oral administration of GV-971 reconditions the gut microbiota,
normalizes disordered metabolites, reduces the peripheral immune cell infiltration to the brain, resolves neuroinflammation, and reduces Aβ
deposition and tau phosphorylation, leading to ultimate improvement of cognitive functions (right panel)
Uptake of phenylalanine
Th1 cell staining in human samples Naïve CD4+ T cells were separated from the splenocytes of 8-
Two milliliters of peripheral blood from healthy people or patients month-old C57BL/6 female mice using the Naïve CD4+ T cell
were treated with red blood cells lysis buffer. A total of 1 × 106 Isolation Kit (Stem Cell, Cat No. 19765) and were induced to Th1
cells were collected and incubated in 100 μL of PBS containing differentiation by 20 ng/mL IL-12. After 3 days, a total of 5 × 105
Zombie Yellow Dye (Biolegend, #423104) for 15 min to label live cells/well Th1 cells in 0.5 mL of RPMI-1640 medium were plated
cells. After washing, samples were stained with APC/Cy7- into 48-well plates. 13C-labelled phenylalanine and 5 mM amino
conjugated anti-human CD45 (Biolegend, #304014), Alexa Fluor transporter inhibitor BCH (CAS:20448-79-7) were added into
700-conjugated anti-human CD3 (Biolegend, #344822), FITC- indicated wells. After 0.5 h, cells were collected and washed twice
conjugated anti-human CD4 (Biolgend, #300506), Brilliant Violet with ice-cold D-PBS. Then, 50 µL deionized water was added and
421-conjugated anti-human CXCR3 (Biolgend, #353716) and APC- cells were lysed through freezing and thawing twice at −80 °C.
conjugated anti-human CCR6 (Biolgend, #353416) for 30 min. The cell lysate was centrifuged at 12000 × g for 10 min and 13C-
Stained cells were washed twice with PBS. Cells were acquired labelled phenylalanine in the supernatant was analyzed by Mass
using FACS Fortessa X-20 flow cytometer (BD Biosciences, San spectrometry.
Jose, CA). Live CD45+CD3+CD4+CXCR3+CCR6- cells were gated as
Th1 subsets as previously described.59 Data analysis were Antibiotic treatments
performed with flowjo software (version 10.5, LLC) Mice were treated by adding an antibiotic solution (ABX) contain-
ing ampicillin (0.1 mg/mL, final concentration in drinking water),
In vitro differentiation induced by phenylalanine and isoleucine streptomycin (0.5 mg/mL, final concentration in drinking water),
As previously described,60 naïve CD4+ T cells were enriched from and colistin (0.1 mg/mL, final concentration in drinking water)
the splenocytes of 8-month-old C57BL/6 female mice using the (Sigma-Aldrich) to sterile drinking water. Solutions and bottles
Naïve CD4+ T cell Isolation Kit (Stem Cell, #19765). For cell were changed 3 times and once weekly, respectively. The antibiotic
differentiation assay, a total of 1 × 105 cells/well in 0.2 mL of RPMI- activity was confirmed by 16S rRNA gene sequencing. Types of
1640 medium were plated in anti-CD3/CD28-coated 96-well plates bacteria with a relative abundance of less than 0.01 are deleted in
(anti-CD3, 2 μg/mL; anti-CD28, 1 μg/mL), and the culture medium the Tg group. The duration of ABX treatment was slightly different
was supplemented with cytokines or blocking antibodies. Th0: based on the experimental settings. In the context of faecal
mIL-2 (10 ng/mL); Th1: mIL-2 (10 ng/mL) and 11B11 (5000 ng/mL). microbia transplantation experiments, mice received 3 days of ABX
Phenylalanine (final concentration, 1 mmol/L), isoleucine (final before undergoing faecal microbia transplantation the next day by
concentration, 1 mmol/L) and GV-971 (final concentration, 100 µg/ oral gavage using animal feeding needles.
mL) were added into the indicated wells, respectively. After
incubation at 37 °C in 5% CO2 for 5 days, cells were stimulated FMT experiments
with Cell Activation Cocktail (Thermo fisher, #00-4975-03) in 5% FMT was performed by thawing faecal material. Then, 200 μL of
CO2 at 37 °C for 4 h, washed twice with PBS, and labeled with the suspension was transferred by oral gavage into each ABX-
zombie yellow (Biolegend, #423104) to exclude dead cells. Non- pretreated recipient. Twelve-month-old C57 mice were first
specific binding of immunoglobulin to the Fc receptors was treated with an antibiotic cocktail in drinking water for 3 days,
blocked with anti-CD16/32 (Biolegend, #101320). Intracellular and then 40 mg of the mixed stool suspended in PBS was inserted
staining was performed with anti-CD4 (Biolegend, #100406) and by gavage into each mouse 3 times with a 2-day break in
anti-IFNγ (Biolegend, #505830) according to the manufactures’ between. After 3 days, 4.2 µg Aβ 1–40 oligomer was injected into
protocal. Cells were acquired on a BD Fortessa cytometer, and both sides of the hippocampus. The mice were sacrificed 3 days
data were analyzed using FlowJo software. later and used for different analyses.