RESEARCH ARTICLE

Association of Plasma Biomarkers of Alzheimer

Disease With Cognition and Medical Comorbidities
in a Biracial Cohort
Vijay K. Ramanan, MD, PhD, Jonathan Graff-Radford, MD, Jeremy Syrjanen, MS, Dror Shir, MD, Correspondence
Alicia Algeciras-Schimnich, PhD, John Lucas, PhD, Yuka A. Martens, PhD, Minerva M. Carrasquillo, PhD, Dr. Ramanan
Gregory S. Day, MD, Nilüfer Ertekin-Taner, MD, PhD, Christian Lachner, MD, Floyd B. Willis, MD, ramanan.vijay@mayo.edu
David S. Knopman, MD, Clifford R. Jack, Jr., MD, Ronald C. Petersen, MD, PhD, Prashanthi Vemuri, PhD,
Neill Graff-Radford, MBBCh,* and Michelle M. Mielke, PhD*

®
Neurology 2023;101:e1402-e1411. doi:10.1212/WNL.0000000000207675

Abstract
Background and Objectives
Recent advances in blood-based biomarkers offer the potential to revolutionize the diagnosis and
management of Alzheimer disease (AD), but additional research in diverse populations is critical.
We assessed the profiles of blood-based AD biomarkers and their relationships to cognition and
common medical comorbidities in a biracial cohort.

Methods
Participants were evaluated through the Mayo Clinic Jacksonville Alzheimer Disease Research
Center and matched on age, sex, and cognitive status. Plasma AD biomarkers (β-amyloid
peptide 1–42 [Aβ42/40], plasma tau phosphorylated at position 181 [p-tau181], glial fibrillary
acidic protein [GFAP], and neurofilament light) were measured using the Quanterix SiMoA
HD-X analyzer. Cognition was assessed with the Mini-Mental State Examination. Wilcoxon
rank sum tests were used to assess for differences in plasma biomarker levels by sex. Linear
models tested for associations of self-reported race, chronic kidney disease (CKD), and vascular
risk factors with plasma AD biomarker levels. Additional models assessed for interactions
between race and plasma biomarkers in predicting cognition.

Results
The sample comprised African American (AA; N = 267) and non-Hispanic White (NHW; N =
268) participants, including 69% female participants and age range 43–100 (median 80.2) years.
Education was higher in NHW participants (median 16 vs 12 years, p < 0.001) while APOE e4
positivity was higher in AA participants (43% vs 34%; p = 0.04). We observed no differences in
plasma AD biomarker levels between AA and NHW participants. These results were unchanged
after stratifying by cognitive status (unimpaired vs impaired). Although the p-tau181-cognition
association seemed stronger in NHW participants while the Aβ42/40-cognition association
seemed stronger in AA participants, these findings did not survive after excluding individuals with
CKD. Female participants displayed higher GFAP (177.5 pg/mL vs 157.73 pg/mL; p = 0.002)
and lower p-tau181 (2.62 pg/mL vs 3.28 pg/mL; p = 0.001) levels than male participants. Diabetes
was inversely associated with GFAP levels (β = −0.01; p < 0.001).

Discussion
In a biracial community-based sample of adults, we observed that sex differences, CKD, and
vascular risk factors, but not self-reported race, contributed to variation in plasma AD bio-
markers. Although some prior studies have reported primary effects of race/ethnicity, our

*These authors contributed equally to this work as co-senior authors.

From the Department of Neurology (V.K.R., J.G.-R., D.S., D.S.K., R.C.P.), Department of Quantitative Health Sciences (J.S., R.C.P.), and Department of Laboratory Medicine and
Pathology (A.A.-S.), Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology (J.L., C.L.), Department of Neuroscience (Y.A.M., M.M.C., G.S.D., N.E.-T.), Department of
Neurology (N.E.-T., C.L., N.G.-R.), and Department of Family Medicine (F.B.W.), Mayo Clinic, Jacksonville, FL; Department of Radiology (C.R.J., P.V.), Mayo Clinic, Rochester, MN; and
Department of Epidemiology and Prevention (M.M.M.), Wake Forest University School of Medicine, Winston-Salem, NC.

Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

e1402 Copyright © 2023 American Academy of Neurology

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Glossary
AA = African American; Aβ = β-amyloid; Aβ40 = Aβ peptide 1–40; Aβ42 = Aβ peptide 1–42; AD = Alzheimer disease; ADRC =
Alzheimer Disease Research Center; BMI = body mass index; CAD = coronary artery disease; CKD = chronic kidney disease;
CU = cognitively unimpaired; DEM = dementia; GFAP = glial fibrillary acidic protein; MCI = mild cognitive impairment;
MMSE = Mini-Mental State Examination; NfL = neurofilament light; NHW = non-Hispanic White; p-tau181 = plasma tau
phosphorylated at position 181; SiMoA = single-molecule array.

results reinforce the need to account for broad-based medical and social determinants of health (including sex, systemic
comorbidities, and other factors) in effectively and equitably deploying plasma AD biomarkers in the general population.

Introduction In this study, we analyzed a large, biracial, community-based

Several promising blood-based biomarkers of Alzheimer disease
(AD) pathophysiology have emerged in research studies,1–5 and
there is increasing use of these biomarkers for enrollment
screening and treatment monitoring in interventional trials.6,7
These developments have created optimism that blood-based
biomarkers may revolutionize diagnosis and management para-
digms for AD, including facilitating noninvasive, cost-effective,
and infrastructure-efficient deployment to augment existing
tools for evaluation of cognitive impairment in the general
population.8,9 However, there is a strong consensus that addi-
tional research is needed to guide appropriate use of blood-based
AD biomarkers outside of selective research studies and spe-
cialized memory clinics.9
A major priority for additional research includes broader study
of blood-based biomarkers in diverse, heterogeneous pop-
ulations that are more representative of real-world clinical
practice. Some prior studies have reported that race/ethnicity
may be associated with differences in plasma AD biomarker
levels. One cross-sectional study of individuals with normal
cognition or mild cognitive impairment (MCI) described lower
levels of plasma tau phosphorylated at position 181 (p-tau181),
β-amyloid (Aβ) peptide 1–42 (Aβ42), and Aβ peptide 1–40
(Aβ40) in African American (AA) individuals compared with
those in non-Hispanic White (NHW) individuals.10 A different
study reported lower plasma Aβ40 and higher total tau in
cognitively normal Mexican American individuals compared
with those in NHW individuals.11 However, no plasma bio-
marker differences (total tau, p-tau181, p-tau217, Aβ42/Aβ40, and
neurofilament light [NfL]) by self-reported race were observed
in analyses of a separate multiethnic, community-based co-
hort.12 Another study found that select plasma AD biomarkers
may perform inconsistently (in predicting brain amyloidosis)
across AA and NHW individuals, although sample size and
characteristics (e.g., cognitive status, medical comorbidities,
social determinants of health) may have influenced the re-
sults.13 Furthermore, among the general population with AD,
there is wide heterogeneity in social determinants of health and
medical comorbidities, all of which may affect the interpretation
of AD biomarkers11,14,15 and thus motivate additional study.
sample with the primary objective to determine whether race/
ethnicity, sex differences, and medical comorbidities would be
associated with differential profiles of ultrasensitive single-
molecule array (SiMoA)–based plasma AD biomarkers. We
also assessed whether self-reported race would modify the
associations between plasma AD biomarkers and cognition.
Methods
Sample Characteristics
Older adults residing in Jacksonville, Florida, and surrounding
communities were recruited from patient visits in local clinic
practice and through outreach into the community. Enrolled
participants were seen annually through Mayo Clinic Alz-
heimer Disease Research Center (ADRC) resources and have
been included in several prior cohort studies.16–18 Study visits
included interviews for medical history, detailed neurologic and
general physical examination, cognitive assessments (described
further), and blood sample collection. Participants or their
surrogates provided written informed consent to participate in
research. Study protocols were approved by the Mayo Clinic
Institutional Review Board. Cognitive status for each partici-
pant (cognitively unimpaired [CU], MCI, and dementia
[DEM]) was determined by a multidisciplinary consensus
panel incorporating all available information and referencing
established diagnostic criteria.19
Demographic, Clinical, and Genetic Data
Race (AA vs NHW participants) and sex (male vs female par-
ticipants) were determined by self-report on a free-response
question posed during an in-person interview. Age and years of
education were also ascertained for each participant. The partici-
pant’s Mini-Mental State Examination (MMSE)20 score was used
as a measure of cognitive functioning. APOE ɛ4 allele status was
assessed through Taqman genotyping assays on stored blood
samples, as previously described.21 Height (in centimeters) and
weight (in kilograms) for each participant was measured and used
to calculate body mass index (BMI; kg/m2). Cardiovascular
risk factors (hypertension, diabetes, tobacco usage [current,
former, and never], stroke, coronary artery disease [CAD])

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 were determined primarily by medical record abstraction with
supplementing from research charts and National Alzheimer
Coordinating Center database forms when available. Presence
or absence of chronic kidney disease (CKD) was determined
by medical record abstraction; specifically, chart search was
performed for the terms “chronic kidney disease,” “renal fail-
ure,” “renal,” and “kidney,” and for those participants whose
records included those terms, clinical notes and laboratory data
were reviewed to ensure this was a chronic diagnosis rendered
by health providers before the plasma draw for research.
SiMoA-Based Plasma AD Biomarker Data
Blood samples were collected for all participants. EDTA
plasma fractions were aliquoted after centrifuge and stored at
−80°C. Plasma AD biomarkers were measured on these stored
samples using the Quanterix SiMoA HD-X analyzer (Quan-
terix Corp., Lexington, MA) according to manufacturer’s in-
structions. Plasma β-amyloid (Aβ) peptide 1–42 (Aβ42), Aβ
peptide 1–40 (Aβ40), glial fibrillary acidic protein (GFAP),
and NfL were assessed using the Simoa Neurology 4-Plex E
Advantage kit (N4PE, item #103670). p-tau181 was measured
using the Simoa p-tau181 Advantage V2 kit (item #103714),
which uses a mouse monoclonal antibody (AT270) specific
for the threonine-181 phosphorylation site of human tau
protein.22 Samples were analyzed over 57 runs spanning ap-
proximately 4 months using the same kit lot numbers
throughout. Interassay variability assessed by the coefficient of
variation was <13% for all analytes based on 2 levels of
manufacturer-provided quality controls run in duplicate with
each sample batch.
Statistical Analyses
For this study, AA and NHW participants were matched 1:1
on age, sex, and cognitive status; 1 AA participant was ex-
cluded because of failure of their plasma sample run. Log
transformations were applied to plasma p-tau181, GFAP, and
NfL to lessen the skew in their distributions; the ratio of
plasma Aβ42/40 (primarily analyzed based on prior work23)
did not require log transformation. When used as predictors
in models, all plasma markers were also z standardized to
assist with interpretation. For any statistical outliers in plasma
biomarker measures (≥3 SDs from the sample mean), anal-
yses were repeated after excluding outliers to ensure no undue
influence on the results. For unadjusted comparisons of var-
iables by sex and race, Wilcoxon rank sum tests were used for
continuous measures, and Pearson chi-squared tests were
used for categorical measures. Linear models were analyzed
with plasma biomarkers as outcomes and race, CKD, and
vascular disease risk factors (BMI [modeled as a continuous
measure] and presence of hypertension, diabetes, tobacco
usage, stroke, or CAD) as independent predictors in separate
models, covarying for age and sex. Linear models were also
used to assess the association of plasma biomarkers as pre-
dictors of cognition (MMSE score) and to test for statistical
interactions between the plasma biomarkers and race in pre-
dicting cognitive performance. For these analyses, age, sex,
and education were included as covariates, and MMSE scores
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were flipped (i.e., 30 − MMSE) and log transformed (1 was
added to everyone’s MMSE score to avoid taking the log of 0,
which is undefined) to assist with interpretation and to reduce
skew in variable distribution. For interaction-based analyses,
the primary measure of interest was the p value for the bio-
marker × race term within a full factorial model (i.e., including
the base terms for the biomarker of interest and race along with
all covariates). Data preparation and analyses were conducted
using SAS version 9.4 (SAS Institute, Cary, NC) and R version
3.6.2 (R Foundation for Statistical Computing, Vienna, Aus-
tria). Statistical significance was defined as p < 0.05.
Data Availability
Anonymized data will be available on reasonable request from
a qualified investigator in accordance with the Mayo ADRC
data sharing protocol.
Results
Among the 535 adults in the study sample, the median age was
80.2 years (range 43.2–100.1 years), and 69.3% (N = 371)
were female participants (Table 1). Most of the participants
were cognitively unimpaired (61.3%), while 9.3% of partici-
pants had a clinical diagnosis of MCI and 29.3% had a clinical
diagnosis of DEM. Hypertension (71%) was common within
the sample. Diabetes (19.3%) and CKD (14.3%) were rela-
tively less common but observed at frequencies similar to
those documented in older adults overall.24,25 Presence of
APOE e4 was more common among AA participants (43.2%
vs 34.1%; p = 0.04), while median education levels were
higher in NHW participants (16 years vs 12 years; p < 0.001).
Hypertension (83.1% vs 58.6%) and diabetes (29.4 vs 9.3%)
were more frequent among AA participants when compared
with NHW participants (p < 0.001). The frequencies of CAD
or prior stroke were not different between NHW and AA
participants. Although hypertension was more common in
female (74.6%) than male (62.7%) participants within the
sample (p = 0.006), there were no sex differences in the
frequencies of diabetes, CAD, prior stroke, or APOE e4 allele
presence. Male participants displayed a higher frequency of
CKD than female participants (19.0% vs 12.2%), but this
difference was not statistically significant (p = 0.08).
As expected, age had robust associations with plasma bio-
marker levels in all models (βNfL = 0.37; βGFAP = 0.26; βp-tau181
= 0.19; βAβ42/40 = −0.004; all p < 0.001). We also observed that
sex, but not self-reported race/ethnicity, was associated with
plasma biomarker levels (Figure). Specifically, female partici-
pants displayed higher GFAP (177.5 pg/mL vs 157.73 pg/mL;
p = 0.002) and lower p-tau181 (2.62 pg/mL vs 3.28 pg/mL; p =
0.001) levels than male counterparts. These differences per-
sisted when the sample was stratified by cognitive status
(cognitively unimpaired vs MCI/DEM) and within a sensitivity
analysis after removing individuals with CKD. There were no
differences in plasma biomarker (Aβ42/40, p-tau181, GFAP,
NfL) levels between AA and NHW participants within the
Neurology.org/N
 sample overall or after stratifying by cognitive status (cogni-
Table 1 Sample Characteristics tively unimpaired vs MCI/DEM). The lack of association of
AA (N = 267) NHW (N = 268)
self-reported race with plasma biomarker levels was confirmed
with linear models including age and sex as covariates
Age (y) 80.2 (44.0–100.1) 80.1 (43.2–99.7)
(Table 2). In post hoc models stratifying by APOE e4 allele
Sex status, marginally nonsignificant associations with race were
Male 82 (30.7) 82 (30.6)
observed among those with an e4 allele, where plasma p-tau181
(β = 0.16, p = 0.09) and GFAP (β = 0.12, p = 0.08) levels were
Female 185 (69.3) 186 (69.4)
higher in NHW participants when compared with those in AA
Education (y) a
12 (2–20) 16 (7–20) participants.
Clinical diagnosis
Several systemic medical comorbidities were associated with
CU 164 (61.4) 164 (61.2)
the plasma biomarkers (Table 2). Presence of diabetes (β =
DEM 78 (29.2) 79 (29.5) −0.19, p < 0.001) and higher BMI values (β = −0.02, p < 0.001)
MCI 25 (9.4) 25 (9.3)
were associated with lower GFAP levels. Higher BMI values
were also associated with lower NfL levels (β = −0.01, p =
b
Presence of an APOE «4 allele
0.007). CKD was associated with higher p-tau181 (β = 0.33, p <
Negative 138 (56.8) 145 (65.9) 0.001) and NfL (β = 0.35, p < 0.001) levels, while prior stroke
Positive 105 (43.2) 75 (34.1)
was associated with higher NfL levels (β = 0.25, p = 0.003). We
observed no association of hypertension, CAD, or tobacco use
BMIc 27.4 (17.0–47.3) 25.4 (17.2–50.0)
(current or former) with plasma AD biomarker profiles. These
CKDd results were similar when imputation was used to account for
Absent 127 (81.9) 208 (88.1)
missing data in some participants.

Present 28 (18.1) 28 (11.9)

We next investigated relationships between the plasma bio-
Diabetes e markers and cognition and whether self-reported race modified
Absent 180 (70.6) 233 (90.7)
these relationships. In the overall sample, higher plasma GFAP
was most strongly associated with worse MMSE (flipped and
Present 75 (29.4) 24 (9.3)
log transformed) score (β = 0.38, p < 0.001), followed by
Hypertensionf p-tau181 (β = 0.29, p < 0.001) and NfL (β = 0.24, p < 0.001).
Absent 45 (16.9) 108 (41.4)
The plasma Aβ42/40 ratio was not associated with cognition in
the overall sample (β = −0.06, p = 0.13). We observed a modest
Present 221 (83.1) 153 (58.6) interaction (p = 0.01) between self-reported race and plasma
Tobacco use g p-tau181 on cognition, wherein the p-tau181-cognition association
seemed stronger in NHW participants (β = 0.41) than in AA
Current 12 (4.8) 6 (2.3)
participants (β = 0.22). However, these findings were attenuated
Former 87 (34.9) 93 (36.2) (p = 0.38) after excluding individuals with CKD. Similarly,
Never 150 (60.2) 158 (61.5) although the Aβ42/40-cognition association seemed stronger in
h
AA participants than in NHW participants (β = −0.19 vs β =
Stroke
−0.002), the statistical interaction between plasma Aβ42/40 and
Absent 195 (89.4) 224 (93.3) self-reported race was attenuated (p = 0.02 vs p = 0.15) after
Present 23 (10.6) 16 (6.7) excluding individuals with CKD. This interaction was also no
longer statistically significant if an Aβ42/40 outlier was removed.
CADi

Absent 130 (82.3) 200 (83.3)

Present 28 (17.7) 40 (16.7) Discussion

Abbreviations: AA = African American; BMI = body mass index; CAD = cor- Developments in blood-based biomarkers have great po-
onary artery disease; CKD = chronic kidney disease; CU = cognitively
unimpaired; DEM = dementia; MCI = mild cognitive impairment; NHW = non- tential for noninvasive and resource-efficient utilization in
Hispanic White. the general population. A major barrier to wider deployment
Values displayed as median (range) or n (%).
a
Missing for 23 participants (16 AA, 7 NHW). of available assays at this time involves the relative paucity of
b
Missing for 72 participants (24 AA, 48 NHW). data on how these blood-based biomarkers perform in rep-
c
Missing for 221 participants (159 AA, 62 NHW).
d
Missing for 144 participants (112 AA, 32 NHW). resentative populations that better reflect real-world clinical
e
Missing for 23 participants (12 AA, 11 NHW).
f
Missing for 8 participants (1 AA, 7 NHW).
practice. In such settings, systemic medical conditions and
g
h
Missing for 29 participants (18 AA, 11 NHW). social determinants of health would be expected to have
Missing for 77 participants (49 AA, 27 NHW).
i
Missing for 137 participants (109 AA, 28 NHW). different profiles compared with selective research studies
and specialty memory clinics.9 This study of a large, biracial,

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 Figure Profiles of Plasma Biomarkers of Alzheimer Disease by Sex and Self-Reported Race

Analyses were performed on a biracial sample matched on age, sex, and clinical diagnosis. Box plots display the distributions of plasma biomarker (Aβ42/40, GFAP,
NfL, and p-tau181) levels among female vs male participants (A) and among AA vs NHW participants (B). Female participants displayed higher GFAP and lower p-
tau181 levels than male participants, differences that persisted after excluding individuals with CKD. No differences by self-reported race were observed for any
plasma biomarker. AA = African American; Aβ = β-amyloid; Aβ40 = Aβ peptide 1–40; Aβ42 = Aβ peptide 1–42; CKD = chronic kidney disease; GFAP = glial fibrillary
acidic protein; NfL = neurofilament light; NHW = non-Hispanic White; p-tau181 = plasma tau phosphorylated at position 181.

community-based sample of adults provides evidence that AD biomarkers and therefore need to be accounted for in the
sex differences and systemic medical comorbidities, but not development of reference ranges and guidance on clinical
self-reported race/ethnicity, influence variation in plasma interpretation.

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Table 2 Linear Models Predicting Plasma Alzheimer Disease Biomarkers
Biomarker Independent variablea Nb Model R2 β (95% CI) p Value

Aβ42/40 Race (self-reported) 531 0.05 0.0002 (−0.003 to 0.003) 0.91

Aβ42/40 BMI 311 0.04 0.0003 (0.0001 to 0.0006) 0.02

Aβ42/40 CKD 388 0.06 0.004 (−0.001 to 0.009) 0.12

Aβ42/40 Diabetes 508 0.05 −0.001 (−0.004 to 0.003) 0.65

Aβ42/40 Hypertension 523 0.05 −0.00003 (−0.003 to 0.003) 0.99

Aβ42/40 Tobacco use (current) 503 0.05 0.001 (−0.007 to 0.008) 0.77

Aβ42/40 Tobacco use (former) 503 0.05 −0.001 (−0.009 to 0.007) 0.84

Aβ42/40 CAD 395 0.06 0.001 (−0.004 to 0.005) 0.75

Aβ42/40 Stroke 455 0.06 0.001 (−0.005 to 0.006) 0.85

GFAPc Race (self-reported) 534 0.22 −0.03 (−0.11 to 0.05) 0.49

GFAP BMI 314 0.29 −0.02 (−0.03 to −0.01) <0.001

GFAP CKD 391 0.23 0.10 (−0.04 to 0.24) 0.16

GFAP Diabetes 511 0.23 −0.19 (−0.29 to −0.08) <0.001

GFAP Hypertension 526 0.22 −0.01 (−0.10 to 0.08) 0.90

GFAP Tobacco use (current) 506 0.23 0.03 (−0.20 to 0.26) 0.78

GFAP Tobacco use (former) 506 0.23 0.10 (−0.12 to 0.33) 0.37

GFAP CAD 398 0.23 0.05 (−0.08 to 0.17) 0.47

GFAP Stroke 458 0.22 0.02 (−0.13 to 0.17) 0.80

c
NfL Race (self-reported) 534 0.30 −0.03 (−0.11 to 0.06) 0.57

NfL BMI 314 0.37 −0.01 (−0.02 to −0.004) 0.007

NfL CKD 391 0.36 0.35 (0.21 to 0.49) <0.001

NfL Diabetes 511 0.29 0.11 (−0.002 to 0.22) 0.05

NfL Hypertension 526 0.30 0.06 (−0.04 to 0.16) 0.22

NfL Tobacco use (current) 506 0.30 −0.08 (−0.33 to 0.17) 0.52

NfL Tobacco use (former) 506 0.30 −0.11 (−0.35 to 0.14) 0.40

NfL CAD 398 0.33 0.05 (−0.08 to 0.18) 0.43

NfL Stroke 458 0.32 0.25 (0.08 to 0.41) 0.003

p-tau181c Race (self-reported) 532 0.10 0.03 (−0.07 to 0.13) 0.54

p-tau181 BMI 312 0.12 −0.01 (−0.02 to 0.003) 0.14

p-tau181 CKD 389 0.15 0.33 (0.17 to 0.49) <0.001

p-tau181 Diabetes 509 0.10 0.02 (−0.11 to 0.15) 0.76

p-tau181 Hypertension 524 0.10 0.08 (−0.03 to 0.19) 0.16

p-tau181 Tobacco use (current) 503 0.10 0.04 (−0.24 to 0.32) 0.80

p-tau181 Tobacco use (former) 503 0.10 0.10 (−0.18 to 0.37) 0.50

p-tau181 CAD 396 0.13 0.14 (−0.01 to 0.28) 0.07

p-tau181 Stroke 456 0.11 0.07 (−0.12 to 0.26) 0.50

Abbreviations: Aβ = β-amyloid; Aβ40 = Aβ peptide 1–40; Aβ42 = Aβ peptide 1–42; BMI = body mass index; CAD = coronary artery disease; CKD = chronic kidney
disease; GFAP = glial fibrillary acidic protein; NfL = neurofilament light; p-tau181 = plasma tau phosphorylated at position 181.
a
All models included age and sex as covariates, and the outcome measures (plasma biomarkers) were log transformed (except for Aβ42/40); models for
tobacco use had a reference level of never.
b
Number of participants included (having nonmissing data for all variables) in each independent model.
c
Unit of measure pg/mL.

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 A prior study of adults from the greater Atlanta metropolitan
area reported lower levels of plasma Aβ40, Aβ42, p-tau181, and
NfL in AA individuals compared with those in NHW individ-
uals.10 That study sample consisted predominantly of individ-
uals with MCI and those in a younger age range than ours. In
addition, that study did not match on age (AA participants were
younger than NHW participants) and did not consider CKD,
which is known to elevate plasma biomarker levels.11,14,26 An-
other study identified lower plasma Aβ42/40 levels in Mexican
American participants compared with those in NHW partici-
pants, but included similar limitations of clinical diagnostic
range (analyzing only cognitively unimpaired individuals),
without age or sex matching.11 We previously identified ele-
vated plasma total tau levels in AA individuals with AD com-
pared with cognitively unimpaired control participants, similar
to findings reported in other ethnoracial groups.21
Despite identifying strong associations with demographic
factors (age and sex) and medical comorbidities (e.g., CKD
and diabetes), we observed no differences in plasma AD
biomarker levels between AA and NHW participants in our
sample. These findings did not differ based on cognitive sta-
tus. We also examined for APOE e4–specific effects given the
existence of population-level variation in this allele (i.e., more
common but less penetrant among AA individuals compared
with NHW individuals27,28) and its association with plasma
biomarker levels in previous studies.21,29 Among APOE e4
carriers in our study, there was a trend toward lower plasma p-
tau181 and GFAP levels among AA participants, mirroring
data on CSF biomarkers from an independent sample30 and
parallel literature on amyloid PET.31 Taken together with
findings from Schindler et al.13 and Brickman et al.,12 our
results suggest that inconsistencies in plasma AD biomarker
performance in the population have multiple underlying
contributors, including meaningful differences by biomarker
assay, variation in systemic medical and social determinants of
health, and individualized profiles of AD genetic risk factors.
In our study, individuals with diabetes had lower plasma GFAP
levels compared with those without. There are some limitations
to interpreting this association, including the relatively lower
frequency of diabetes in NHW participants (9%) compared with
that in AA participants (29%) in this cohort and the fact that we
did not distinguish between types of diabetes (e.g., type 1 vs type
2). Blood-based measures of GFAP are hypothesized to be
markers of CNS inflammation and reactive astrogliosis.32 Several
studies have demonstrated associations of plasma GFAP with
brain amyloidosis3,33 and vascular disease pathology.32,34 Al-
though the mechanism behind the diabetes-GFAP association
cannot be determined directly from our dataset, rodent models
have demonstrated decreased brain GFAP expression in un-
treated diabetic rats,35 suggesting insulin dysregulation may
plausibly influence GFAP levels. In addition, a recent study in a
small cohort identified a similar negative correlation between
BMI and plasma levels of GFAP and NfL.36 More broadly,
these results support that accounting for the presence of di-
abetes and other vascular risk factors and systemic medical
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comorbidities11,14 will be critical in developing reference ranges
and cut points for plasma AD biomarkers.
This study has several limitations. We analyzed self-reported
biological sex as a variable of interest in relation to plasma
biomarker levels. However, the participant data in this study
may not be able to fully disambiguate sex from gender and
may not adequately delineate individuals who are transgender
or gender nonbinary. In addition, the information on self-
reported race obtained for study participants may be in-
sufficient for individuals who have multiracial backgrounds or
who originate from geographic areas where different racial/
ethnic descriptors are used. While it is advantageous that the
SiMoA platform used in this study is available commer-
cially now, other emerging plasma assays including mass
spectrometry–based measures of Aβ42/405,37,38 and assess-
ments of alternative isoforms of p-tau (e.g., p-tau217 and p-
tau231)2,3,26,39 may have superior accuracy in reflecting the
presence of AD pathophysiology, which could affect analyses
of race/ethnicity differences. It is also possible that the ap-
proaches we used to obtain diagnoses of CKD and cardio-
vascular risk factors may not match the true frequency of these
conditions assessed by other methods. Relevant for CKD, one
prior study found associations of plasma creatinine (as a
quantitative measure of renal function) with plasma GFAP,
NfL, and p-tau levels, though observed only a modest impact
of creatinine levels toward prediction of other outcomes (e.g.,
corresponding CSF protein levels, subsequent development
of dementia).40 However, that study sample was lacking in
racial and ethnic diversity and did not include individuals with
dementia. Additional medical comorbidities not assessed in
our analyses may also influence plasma biomarker profiles.
The cross-sectional nature of this study is also a limitation
because our analyses were not designed to assess the down-
stream longitudinal consequences of plasma biomarker levels.
Furthermore, although the use of MMSE score as the target
cognitive outcome in this work facilitated maximizing of our
sample size (for optimal statistical power) and is reflective of a
cognitive test administered in typical clinical practice, we
cannot rule out that more detailed measures from a neuro-
psychological test battery restricted to specific etiologic di-
agnoses (e.g., Alzheimer dementia vs vascular dementia) may
have yielded different results. The associations of diabetes and
BMI with GFAP levels will additionally benefit from valida-
tion in larger independent samples. Future work is also
planned in this cohort to add complementary in vivo bio-
markers (neuroimaging and CSF) and postmortem neuro-
pathology along with longitudinal clinical and biomarker
measures. In summary, this study of a biracial sample rein-
forces the need to systematically account for medical and
social determinants of health to maximize the clinical utility of
plasma AD biomarkers in the general population.
Acknowledgment
The authors thank the study participants and the staff for
the Mayo Clinic Alzheimer Disease Research Center (ADRC)
Neurology.org/N
and the community advisory board and action network of the
Mayo Clinic Florida ADRC for their assistance in neighbor-
hood outreach and engagement in support of participant
recruitment.
Study Funding
This work was supported by NIH grants RF1 AG069052, RF1
AG077386, RF1 AG079397, U01 AG006786, R01 NS097495,
R01 AG56366, P50 AG016574, P30 AG062677, R37
AG011378, R01 AG041851, C06 RR018898, RF AG051504,
U01 AG046139, AG061796, and R01 AG034676; the GHR
Foundation; the Alexander Family Alzheimer Disease Research
Professorship of the Mayo Clinic; the Alzheimer Association;
the Mayo Foundation for Medical Education and Research; the
Liston Award; the Elsie and Marvin Dekelboum Family
Foundation; the Schuler Foundation; and grants from the
Florida Department of Health Ed and Ethel Moore Alzheimer
Disease Research Program (FL 8AZ08, 5AZ03, and 7AZ07).
speaker fees from Miller Medical Communications, Inc.
and receives research support from the NIH. N. Graff-
Radford receives research support from the NIH. M.M.
Mielke has served on scientific advisory boards and/or has
consulted for Biogen, LabCorp, Lilly, Merck, Siemens
Healthineers, and Sunbird Bio and receives grant support
from the NIH and Department of Defense. The other au-
thors report no disclosures. Go to Neurology.org/N for full
disclosures.
Publication History
Received by Neurology February 3, 2023. Accepted in final form
June 6, 2023. Submitted and externally peer reviewed. The handling
editor was Associate Editor Linda Hershey, MD, PhD, FAAN.
Appendix Authors
Name Location Contribution

Vijay K. Department of Neurology, Drafting/revision of the

Disclosure Ramanan, Mayo Clinic, Rochester, MN
V.K. Ramanan receives research support from the NIH and MD, PhD
the Mangurian foundation for Lewy body disease research. J.
Graff-Radford receives research support from the NIH. G.S.
Day’s research is supported by the NIH (K23AG064029, Jonathan Department of Neurology,
U01AG057195, and U19AG032438), the Alzheimer Associ- Graff- Mayo Clinic, Rochester, MN
Radford, MD
ation, and Chan Zuckerberg Initiative; he serves as a consul-
tant for Parabon Nanolabs Inc., as a Topic Editor (Dementia)
for DynaMed (EBSCO), and as the Clinical Director of the
Anti-NMDA Receptor Encephalitis Foundation (Inc., Can-
ada; uncompensated); he is the coproject PI for a clinical trial
Jeremy Department of Quantitative Drafting/revision of the
in anti-NMDAR encephalitis, which receives support from Syrjanen, MS Health Sciences, Mayo Clinic, article for content, including
Horizon Pharmaceuticals; he has developed educational ma- Rochester, MN
terials for PeerView Media, Inc., and Continuing Education,
Inc.; he owns stock in ANI pharmaceuticals; and his in-
Dror Shir, MD Department of Neurology,
stitution has received support from Eli Lilly for his de- Mayo Clinic, Rochester, MN
velopment and participation in an educational event
promoting early diagnosis of symptomatic Alzheimer disease.
N. Ertekin-Taner receives research support from the NIH. C.
Alicia Department of Laboratory
Lachner receives research support from the NIH (P30- Algeciras- Medicine and Pathology,
AG062677 Research and Education Core). D.S. Knopman Schimnich, Mayo Clinic, Rochester, MN
PhD
serves on a Data Safety Monitoring Board for the DIAN study,
serves on a Data Safety Monitoring Board for Biogen but
receives no personal compensation, is an investigator in John Lucas, Department of Psychiatry
PhD and Psychology, Mayo Clinic, article for content, including
clinical trials sponsored by Biogen, Lilly Pharmaceuticals, and Jacksonville, FL
the University of Southern California, and serves as a con-
sultant for Roche, Samus Therapeutics, Third Rock, and
Alzeca Biosciences but receives no personal compensation. Yuka A. Department of
Martens, Neuroscience, Mayo Clinic,
C.R. Jack serves on an independent data monitoring board for PhD Jacksonville, FL
Roche, has served as a speaker for Eisai, and consulted for
Biogen, but he receives no personal compensation from any
commercial entity; he receives research support from the Minerva M. Department of
Carrasquillo, Neuroscience, Mayo Clinic,
NIH and the Alexander Family Alzheimer Disease Re- PhD Jacksonville, FL
search Professorship of the Mayo Clinic. R.C. Petersen
serves as a consultant for Roche, Inc., Merck Inc., and Gregory S. Department of
Biogen, Inc., serves on the Data Safety Monitoring Board Day, MD Neuroscience, Mayo Clinic,
for Genentech, Inc., and receives royalty from Oxford Jacksonville, FL
University Press and UpToDate. P. Vemuri received
Neurology.org/N Neurology | Volume 101, Number 14 | October 3, 2023
Copyright © 2023 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
article for content, including
medical writing for content;
study concept or design; and
analysis or interpretation of
data
Drafting/revision of the
article for content,
including medical writing for
content; major role in the
acquisition of data; study
concept or design; and
analysis or interpretation of
data
medical writing for content;
analysis or interpretation of
data
Drafting/revision of the
article for content, including
medical writing for content;
major role in the acquisition
of data
Drafting/revision of the
article for content, including
medical writing for content;
major role in the acquisition
of data
Drafting/revision of the
medical writing for content;
major role in the acquisition
of data
Drafting/revision of the
article for content, including
medical writing for content;
major role in the acquisition
of data
Drafting/revision of the
article for content,
including medical writing for
content
Drafting/revision of the
article for content,
including medical writing
for content
Continued
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