Amyotrophic lateral sclerosis (ALS) is an adult-onset neurodegenerative disorder characterized by the premature loss of upper and lower motor neurons. The progression of ALS is marked by fatal paralysis and respiratory failure with a typical disease course of 1–5 years. Most incidences of ALS are sporadic but ~10% of patients have a familial history. Dominant mutations in the copper/zinc superoxide dismutase 1 (
SOD1) gene (
1) account for ~20% of the familial ALS forms and ~1% of sporadic cases. Other rare familial cases with atypical forms of ALS are due to mutations in multiple genes; however, a large majority of ALS cases do not have a known genetic component (reviewed in
2–
4). The identification of SOD1 mutations initiated the molecular era of ALS research and significant insights into ALS pathogenesis were provided through the identification of pathways directly affected by the toxicity of mutant SOD1 (reviewed in
2,
3,
5).
A major shift in our understanding of ALS pathogenesis started in 2006 (
6,
7) with the identification of the 43 kDa transactive response (TAR) DNA-binding protein (TDP-43) as the main component of ubiquitinated protein aggregates found in sporadic ALS patients and in patients with frontotemporal lobar degeneration (FTLD), a neurodegenerative disease characterized by behavioral and language disorders (
8). Motor neuron disease and cognitive deficits of variable severity can be concomitant in patients or within families (
9–
12), and the identification of a common pathological hallmark defined by TDP-43- and ubiquitin-positive, α-synuclein- and tau-negative, cytoplasmic inclusions (
6,
7) suggested that ALS and FTLD were part of a broad disease continuum, a point now proven by mutations in TDP-43 as causative of either (see below).
Mislocalization of TDP-43 observed by pathology motivated direct sequencing of the gene encoding it (
TARDBP) in cohorts of patients with motor neuron disease and/or frontotemporal dementia. In early 2008, the successful identification of dominant mutations as a primary cause of ALS provided evidence that aberrant TDP-43 can directly trigger neurodegeneration (
13–
17). A total of 38 mutations (Fig. ) have now been described in ALS patients with or without apparent family history, corresponding to ~4% of familial ALS (and <1% of sporadic ALS) (
13–
33). Most patients with TDP-43 mutation develop a classical ALS phenotype without cognitive deficit, with some variability within families in the site and age of onset. Although initial studies failed to find
TARDBP mutations in FTLD patients, rare TDP-43 mutations in patients displaying FTLD, with or without motor neuron disease, were reported in 2009 (
34–
37).
TDP-43 is a 414 amino acid protein encoded by six exons and containing two RNA recognition motifs (RRM1 and 2) and a C-terminal glycine-rich region (
38–
40). Most of the mutations identified are localized in the glycine-rich region encoded by exon 6 (Fig. ). All the mutations are dominant missense changes with the exception of a truncating mutation at the extreme C-terminal of the protein (Y374X) (
20). Several variants lying in the non-coding regions of the
TARDBP gene have been identified in patients but further studies are necessary to prove their pathogenic effect (
29,
35).
Postmortem analysis of patients with TDP-43 mutations found a pattern similar to the TDP-43 pathology described in sporadic ALS and FTLD patients. TDP-43 inclusions are not restricted to motor neurons but can be widespread in brain in ALS patients with or without dementia (
16,
17,
31,
41,
42). Under normal conditions, TDP-43 is mainly localized within the nucleus, but abnormal TDP-43 distribution such as neuronal cytoplasmic or intranuclear inclusions and dystrophic neurites (
6,
7), as well as glial cytoplasmic inclusions (
7,
31,
43–
45) have been reported. A very curious, and mechanistically unexplained, aspect of TDP-43 pathology is a significant TDP-43 nuclear clearance in a proportion of neurons containing cytoplasmic aggregates, suggesting that pathogenesis may be driven, at least in part, by loss of one or more nuclear TDP-43 functions (
6,
17,
43,
46,
47). Some ‘pre-inclusions’ have been proposed to arise from diffuse granular cytoplasmic staining and nuclear clearing (
17,
31,
42,
43,
47–
52). Although a plethora of early reports did not establish how prominent this nuclear clearing was and whether it escalates in frequency during disease progression, further efforts, especially the work of Giordana
et al. (
42), have established that the cytoplasmic redistribution of TDP-43 appears to be an early event in ALS. The pre-inclusions and the larger TDP-43 inclusions are only partially labeled with anti-ubiquitin antibodies (
42,
52), whereas intranuclear and cytoplasmic inclusions are strongly recognized by phosphorylation-specific antibodies to TDP-43 (
33,
53–
57).
Immunoblotting of detergent-insoluble protein extracts from affected brain and spinal cord has defined a biochemical signature of disease that includes hyperphosphorylation and ubiquitination of TDP-43, and the production of several C-terminal fragments (CTFs) around 25 kDa (
6,
7). The extent of this pathologic signature correlates with the density of TDP-43 inclusions detected by immunohistochemistry (
58,
59). Interestingly, the composition of TDP-43 inclusions seems to differ between cortical brain and spinal cord in ALS patients, as inclusions from cortical regions are preferentially labeled by C-terminal antibodies, whereas spinal cord inclusions display equivalent immunoreactivity between N- and C-terminal-specific antibodies (
46). In accordance with this, spinal cord extracts showed an absence or only weak accumulation of ~25 kDa CTFs compared with brain extracts (
54).