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Calcium hypothesis of Alzheimer’s disease

Article in Pflügers Archiv - European Journal of Physiology · October 2009

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Pflugers Arch - Eur J Physiol
DOI 10.1007/s00424-009-0736-1
SIGNALING AND CELL PHYSIOLOGY
Calcium hypothesis of Alzheimer’s disease
Michael J. Berridge
Received: 20 August 2009 / Revised: 4 September 2009 / Accepted: 5 September 2009
# Springer-Verlag 2009
Abstract Alzheimer's disease (AD) is a progressive neu-
rodegenerative disorder caused by an increase in amyloid
metabolism. The calcium hypothesis of AD explores how
activation of the amyloidogenic pathway may function to
remodel the neuronal Ca2+ signaling pathways responsible
for cognition. Hydrolysis of the β-amyloid precursor
protein (APP) yields two products that can influence Ca2+
signaling. Firstly, the amyloids released to the outside form
oligomers that enhance the entry of Ca2+ that is pumped
into the endoplasmic reticulum (ER). An increase in the
luminal level of Ca2+ within the ER enhances the sensitivity
of the ryanodine receptors (RYRs) to increase the amount
of Ca2+ being released from the internal stores. Secondly,
the APP intracellular domain may alter the expression of
key signaling components such as the RYR. It is proposed
that this remodeling of Ca2+ signaling will result in the
learning and memory deficits that occur early during the
onset of AD. In particular, the Ca2+ signaling remodeling
may erase newly acquired memories by enhancing the
mechanism of long-term depression that depends on
activation of the Ca2+-dependent protein phosphatase
calcineurin. The alteration in Ca2+ signaling will also
contribute to the neurodegeneration that characterizes the
later stages of dementia.
Keywords Inositol 1,4,5-trisphosphate . Aging . AMPA
receptor . Memory . Ca2+ mobilization . Ca2+ stores . Synaptic
plasticity . Calcineurin . Calbindin . Calcium signaling
Alzheimer's disease (AD) is a progressive neurodegenera-
tive disorder characterized by the appearance of amyloid
M. J. Berridge (*)
The Babraham Institute,
Cambridge CB22 3AT, UK
e-mail: michael.berridge@bbsrc.ac.uk
fibrils and plaques [32]. These plaques, which tend to build
up outside nerve terminals, are formed by the polymeriza-
tion of the β-amyloid (Aβ) proteins that are derived from
the β-amyloid precursor protein (APP) that is hydrolysed
by β-secretase and the γ-secretase complex. The amyloid
cascade hypothesis suggests that AD arises when the
amount or the nature of this amyloid is abnormally altered
to disrupt neural function to bring about memory loss and
neuronal cell death.
The mild cognitive decline that occurs normally during
aging is dramatically enhanced in AD. There are two forms
of AD: sporadic AD, which accounts for most cases, is
characterized by a severe progressive decline in cognition
and increased neuronal cell death (Fig. 1). The other form is
familial AD (FAD) that develops much faster and is caused
by mutations in components of the amyloid pathway such
as APP, apolipoprotein E4 (ApoE4), presenilin-1 and
presenilin-2 (PS1 and PS2) and sortilin-related receptor 1
(SORL1). The rapid onset of AD caused by these mutations
has been an important component of the amyloid cascade
hypothesis that links amyloid metabolism to AD. While the
biochemical mechanisms responsible for amyloid accumu-
lation is reasonably well understood, it is still not clear why
this leads to the progressive neurodegeneration and cell
death that characterizes AD. The calcium hypothesis of
Alzheimer's disease [24, 27, 51] is beginning to feature
prominently as a potential mechanisms for linking amyloid
metabolism to neuronal dysfunction and neurodegeneration
(Fig. 1).
There is a bidirectional relationship between Ca2+
signaling and the amyloidogenic pathway (Fig. 1) [2, 14].
An increase in Ca2+ can stimulate the metabolism of APP
[38–40]. The calcium homeostasis modulator 1
(CALHM1), which promotes the entry of external Ca2+,
may have a specific role in regulating amyloid metabolism

Fig. 1 Ca2+ signaling remodeling and Alzheimer's disease (AD).
During aging, there is a moderate degree of Ca2+ signaling remodeling
that may cause a small decline in cognition. This cognitive decline
during normal aging is greatly enhanced in sporadic AD by activation
of the amyloidogenic pathway. A reciprocal interaction between
amyloid metabolism and Ca2+ signaling may result in the severe
[10]. Of particular interest was the observation that a
polymorphism in the CALHM1 gene, which reduced Ca2+
entry, increased amyloid formation. One possibility is that
the entry through the CALHM1 channel normally activates
the nonamyloidogenic pathway and thus prevents the
conversion of APP to amyloids (Fig. 3). In contrast to this
ability of Ca2+ to influence amyloid metabolism, there is
considerable evidence that various AD mutations can
induce changes in Ca2+ signaling [27, 49]. Such a two-
way interaction between these two processes introduces an
element of positive feedback that might be critical for the
onset and progression of both AD and FAD. In addition, it
raises an interesting question as to which one of these
processes is the primary cause of AD [14]. Is it the
activation of the amyloidogenic pathway that occurs first or
is it a change in Ca2+ signaling? At this stage, it is difficult
to decide between these two alternatives, but what is
abundantly clear from the studies on FAD is that an
increase in amyloid metabolism can bring about a remodel-
ing of the Ca2+ signaling system and this may be critical for
the onset of both AD and FAD.
In this review, I wish to explore how amyloid metabo-
lism might remodel neuronal Ca2+ signaling leading to both
the early stages of memory loss and then the later stages of
cell death.
Pflugers Arch - Eur J Physiol
remodeling of the Ca2+ signaling system which leads to the severe
cognitive decline and neuronal cell death that characterizes sporadic
AD. In the case of familial Alzheimer's disease (FAD), various
mutations induce an early activation of the amyloidogenic pathway
and Ca2+ signaling that triggers an early onset of cognitive decline and
cell death
Amyloid cascade hypothesis
The amyloid cascade hypothesis considers that AD is
caused by the abnormal processing of β-amyloid [18]. This
hypothesis is supported by the fact that mutations in some
of the components of the amyloid pathway, such as APP,
ApoE4, presenilin-1 and presenilin-2 (PS1 and PS2), and
SORL1 are responsible for autosomal-dominant early onset
familial Alzheimer's disease (Fig. 1). The gene for APP is
also carried on the extra chromosome in Down's syndrome,
and this may account for the early plaque formation and
onset of dementia associated with this disease [18]. There is
thus strong evidence that AD is caused by the formation
and accumulation of β-amyloid. The latter are formed from
APP, which is synthesized and transferred to the plasma
membrane by the endoplasmic reticulum-Golgi secretory
pathway (see step 1 in Fig. 2). This membrane APP can
then be processes by two main pathways, the nonamyloi-
dogenic and amyloidogenic pathways.
Nonamyloidogenic pathway
In the nonamyloidogenic pathway, APP is processed
without giving rise to the β amyloids. First, APP is cleaved
by α-secretases resulting in the shedding of soluble APPα
Pflugers Arch - Eur J Physiol
Fig. 2 Nonamyloidogenic and amyloidogenic pathways. The amyloid
cascade hypothesis proposes that Alzheimer's disease (AD) is caused
by an increase in the formation of the amyloid β peptides Aβ40 and
Aβ42. In the nonamyloidogenic pathway (steps 1–3), the amyloid
precursor protein (APP) that is inserted into the plasma membrane is
either recycled through the endosomal pathway or is cleaved by α-
secretase without forming the amyloids. During the amyloidogenic
pathway (steps 4–8), APP enters the late endosome where it is cleaved
to form the Aβ40 and Aβ42, which are released to the outside. The
APP intracellular domain (AICD) functions as a transcription factor.
(sAPPα) leaving the C-terminal fragment α (CTFα) in the
membrane. The CTFα is then hydrolyzed by the γ-
secretase complex to release the APP intracellular domain
(AICD). Secondly, the APP that associates with various
low-density lipoprotein receptors (LDLRs), such as
SORL1, can be internalized and enters the recycling
endosomes and thus can be returned to the membrane
[41]. These two nonamyloidogenic pathways do not result
in release of the β-amyloids that cause AD.
Amyloidogenic pathways
In the amyloidogenic pathway, APP is processed to release
the β-amyloids responsible for AD [32, 45]. Internalized
APP that ends up in the late endosomes is hydrolysed by
β-secretase (also known as BACE) that sheds the N-
terminal sAPPβ region leaving the C-terminal fragment β
(CTFβ) in the membrane (Fig. 2). As outlined below, both
fragments (sAPPβ and CTFβ) have been implicated in the
neurodegeneration responsible for AD. CTFβ is hydro-
lysed by the γ-secretase complex that contains the
The calcium hypothesis of Alzheimer's disease (steps 9 and 10)
proposes that these various processes may act to enhance Ca2+
signaling. The Aβ42 oligomerizes to enhance Ca2+ entry perhaps by
binding to the cellular prion protein (PrPC). By altering the expression
of components such as the ryanodine receptor (RYR), the AICD may
contribute to the remodeling of the Ca2+ signaling system that leads
first to a decrease in learning and memory and then later to apoptosis.
Apoptosis may also be induced by activating the orphan receptor DR6
(steps 11 and 12)
presenilin enzymes, either the PS1 or PS2 isoforms. This
γ-secretase cleaves CTFβ at two sites to yield either
amyloid β 40 (Aβ40) or amyloid β 42 (Aβ42), which are
released to the inside of the vesicle, and the APP
intracellular domain (AICD) that is released to the
cytoplasm. The amyloids are transported and released to
the surface via the constitutive secretory pathway, whereas
the AICD enters the nucleus where it functions as a
transcription factor. Amyloids can be removed by two
mechanisms. Firstly, the amyloids formed in the late
endosomes can be transferred to lysosomes where they
are removed. Autophagy is also an efficient mechanism
for removing amyloids [34]. During the onset of AD,
autophagy is increased but the transfer of autophagic
vesicles to the lysosomes is impeded and this may
contribute to the accumulation of amyloids. Secondly,
the amyloid β monomers that are released to the outside of
the neuron can be removed by the microglia, which
release insulin-degrading enzyme (IDE) that destroys the
Aβ monomers. The microglial cells also remove the
amyloid plaques and fibrils by a process of phagocytosis.

Apolipoprotein E (ApoE) has a major role in influencing
how amyloid β is formed and hydrolysed [22]. It can
increase the degradation of the β amyloids by functioning
as a chaperone to shepherd them to the insulin-degrading
enzyme. ApoE can also bind to various members of the
low-density lipoprotein receptor family that control the
endocytosis of lipoproteins such as apoE. Some of these
LDLRs such as SORL1 interact with APP to influence its
subsequent processing once it enters the endocytic path-
ways [36]. In particular, SOLR1 directs APP to the
recycling endosome and thus redirects it back to the surface
and prevents it from being hydrolysed by the β-secretase
pathway. In this way, ApoE protects neurons by reducing
both the formation of the Aβ monomers and by enhancing
their degradation. Polymorphism of the APOE gene
markedly increases the susceptibility of developing AD.
The APOE gene encodes three isoforms ApoE2, ApoE3,
and ApoE4. The risk of developing AD is markedly
increased in individuals that inherit the ApoE4 isoforms.
On the basis of the mechanisms outlined in Fig. 2, it would
seem that this isoforms enhances the onset of AD by
increasing the conversion of APP into the amyloids and by
reducing their clearance by the degradation pathway.
In summary, the main tenet of the amyloid cascade
hypothesis is that an alteration in the processing of APP,
which culminates in an accumulation of β amyloids, is
responsible for the onset of AD. The next aspect to consider
is how this change in amyloid processing remodels
neuronal Ca2+ signaling pathways to disrupt the mecha-
nisms of learning and memory.
Calcium hypothesis of Alzheimer’s disease
The calcium hypothesis attempts to explain how amyloid
formation and accumulation might account for both the
progressive decline in memory and increase in neuronal cell
apoptosis [24, 27, 49, 51]. There are clear indications that
AD is a progressive disease where a decline in cognitive
function becomes apparent before there is any significant
neuronal loss [21, 55]. Animal models of AD have revealed
how the calcium hypothesis has the subtleties necessary to
explain both the early cognitive decline and the later cell
death. The basic idea is that activation of the amyloidogenic
pathway results in a remodeling of the neuronal Ca2+
signaling pathway (Fig. 1). This remodeling normally
appears as an upregulation of signaling although a down-
regulation has also been described in some cases. When
Ca2+ is measured in the spines and dendrites of pyramidal
neurons in the neocortex, there was a higher than normal
resting level in those neurons located close to amyloid
deposits [26]. Similarly, the resting level of Ca2+ in the
cortical neurons of 3xTg-AD animals was 247 nmol/L,
Pflugers Arch - Eur J Physiol
which was twice that found in the nonTg controls
(110 nmol/L) [31]. These measurements are consistent with
the hypothesis that Ca2+ signaling is upregulated in AD.
This remodeling then functions to distort the normal Ca2+-
dependent mechanisms responsible for learning and mem-
ory. Remodeling of Ca2+ signaling changes both the entry
of external Ca2+ and release from internal stores.
Amyloid accumulation and Ca2+ entry
One mechanism for the upregulation of Ca2+ signaling is
for the amyloids to enhance Ca2+ entry [1, 26, 44, 45]
(Fig. 3). While much previous attention focused on the
plaques within these deposits, there is increasing evidence
that the peptides themselves have a more important role to
play in disease progression [17, 30]. These β-amyloid
peptides aggregate to form complexes of different sizes,
starting with dimers and oligomers and then the larger
protofibrils and plaques. It is the Aβ42 oligomers that seem
to be responsible for the pathological changes in neuronal
function. The cellular prion protein (PrPC), which is
tethered to the outside of the membrane through a
glycosylphosphatidylinositol anchor, functions as an amy-
loid β receptor [28] and may thus carry out some of the
pathological actions of Aβ42. These Aβ42 oligomers may
increase Ca2+ entry by either functioning as channels or by
activating channels in the plasma membrane. With regard to
the latter, the Aβ oligomers, perhaps in association with
PrPC, may enhance Ca2+ entry through various receptor-
operated channels such as the NMDA receptors. Any Ca2+
that enters through these amyloid-dependent mechanisms
will contribute to the remodeling of the Ca2+ signaling
system that occurs during AD.
Amyloid processing and Ca2+ release from internal stores
One of the main consequence of Ca2+ signaling remodel-
ing is an increase in the amount of Ca2+ being released
from the ER [15, 48, 50]. For example, there is a large
increase in the amount of Ca2+ released by InsP3 in
neurons from mice expressing the presenilin 1 mutation
(PS1) [7, 48]. By contrast, the response to depolarization
was not changed [48]. A number of mechanisms have
been proposed for this enhanced Ca2+ sensitivity (Fig. 3).
There is evidence that the mutated PS1 interacts with the
InsP3 receptor to enhance its sensitivity [7]. This hyper-
sensitivity of the internal release mechanism may also be
caused by the amyloidogenic pathway triggering a
remodeling of the Ca2+ signaling system. One of the
consistent changes is an increase in the expression of the
ryanodine receptor (RYR) [5, 6, 46, 48] and particularly
the RYR3 isoform [50]. Since one of the functions of these
RYRs is to amplify the InsP3-mediated release of Ca2+
Pflugers Arch - Eur J Physiol
Fig. 3 The calcium hypothesis of Alzheimer's disease. Amyloid
metabolism may influence synaptic plasticity and neuronal apoptosis
by remodeling the Ca2+ signaling system through two main pathways.
1 The release of amyloid β (Aβ) and the formation of Aβ oligomers
may enhance Ca2+ entry. The cellular prion protein (PrPC) may be a
receptor for the Aβ oligomers. 2 Release of the APP intracellular
domain (AICD) may remodel the Ca2+ signaling system by altering
the expression of components such as the ryanodine receptor (RYR)
and the buffer calbindin. 3 In most cases, this remodeling results in
[48], this remodeling of the ER release channels can
markedly enhance neuronal Ca2+ signals.
Release of Ca2+ can also be altered by changing the Ca2+
content of the internal stores. In most cases, there appears to
be an increase in the level of Ca2+, which depends on the
balance between the activity of the SERCA pump and the
passive leak of Ca2+ back into the cytoplasm (Fig. 3).
Presenilins have been shown to alter both activities. For
example, the activity of the SERCA pump is enhanced by
the presenilins [13]. The channels responsible for the
passive leak remain to be properly characterized. One
possibility is that the CALHM1 channel, which is located in
both the plasma membrane and ER [10], may function as a
leak channel. The CALHM1 polymorphism that increases
the risk of developing AD has a reduced Ca2+ permeability
and this would increase the level of stored Ca2+ by reducing
this putative leak pathway. There also is increasing
evidence that presenilins may be leak channels [1, 53].
The level of Ca2+ within the lumen and the amount of Ca2+
being released in response to InsP3 is markedly reduced in
cells that over express PS1. Conversely, the mutated forms
of PS1 that give rise to early onset familial Alzheimer's
disease reduced the passive leak resulting in enhanced Ca2+
upregulation of Ca2+ signaling. Mutations of presenilin may enhance
signaling through various mechanisms: reduction in the leak pathway,
activation of the SERCA pump and sensitization of the InsP3 receptor.
Bcl-2 may reduce this sensitization by inhibiting the activity of the
InsP3 receptor. 4 The remodeled Ca2+ signaling system disrupts the
synaptic mechanisms responsible for learning and memory. Excess
Ca2+ also stimulates the mitochondria to release cytochrome C to
trigger apoptosis
signals [53]. However, the opposite was found when these
two presenilins were removed from hippocampal neurons
[56]. A similar observation was found in mouse embryonic
fibroblasts where removal of both presenilins resulted in an
increase in the passive leak that was caused by an
upregulation of the type 1 InsP3 receptor [23]. It is not
clear why the outcome of interfering with the presenilins
should have such divergent consequences in the different
experimental models. One possibility is that the divergent
observation may depend on the fact that the manipulations
were carried out on different cell types that may develop
different compensatory mechanisms. A case in point is the
compensatory upregulation of InsP3 receptors when pre-
senilins were removed from mouse embryonic fibroblasts
[23]. What is clear, however, is that interfering with the
presenilins can have a profound effect on the internal store
of Ca2+ and this supports the idea that Ca2+ signaling
remodeling might be one of the causative mechanisms of
AD.
In addition to enhancing the Ca2+ content of the ER, the
mutated presenilins may also contribute to Ca2+ signaling
remodeling by altering the expression levels of various
components of the Ca2+ signaling toolkit. While in the ER,

the presenilin holoenzyme controls the passive leak of Ca2+
as described above. However, when these presenilins are
processed and enter the endosomes and Golgi, they
contribute to the γ-secretase complex responsible for
forming the amyloid β 42 (Aβ42), which may enhance
Ca2+ entry as described earlier (Fig. 2). In addition, γ-
secretase releases the APP intracellular domain (AICD),
which is a transcription factor [4] that may result in a
significant remodeling of the Ca2+ signaling system [29]. The
targets for AICD have not been fully established, but the
increased expression of the RYR described earlier [5, 46, 48,
50], could be explained by an increased production of AICD.
Another important remodeling event associated with AD
is a downregulation of the Ca2+ buffer calbindin [37]. It has
been known for some time that during normal aging there
are gradual changes in certain Ca2+ signaling components
that increase neuronal vulnerability to cell death stimuli.
For example, there is a decline in the level of the Ca2+
buffer calbindin D-28 k (CB) that normally functions to
restrict the amplitude of Ca2+ signals [12]. The number and
size of calbindin immunoreactive neurons in the cerebral
cortex areas were significantly reduced in AD patients
when compared with age-matched controls [20]. Converse-
ly, expression of CB reduced the Ca2+ signals induced by
Aβ42 especially when these Ca2+ signals are enhanced by
the presence of mutant presenilin [16]. A decline in this
buffer may also increase the onset of AD because mice
expressing mutant APP also display a decline in the level of
calbindin D-28 k (CB) especially in the dentate gyrus
region of the hippocampus [37], which functions in
learning and memory. Just how the decrease in the
expression of calbindin D-28 k (CB) occurs during normal
aging is not known, but the fact that it is exacerbated by
mutant APP that results in the formation of AICD, suggest
that this transcription factor may play some role. This
remodeling of key components of the Ca2+ signaling
system that alters how much Ca2+ is released from the
internal store has a significant effect on the mechanisms
responsible for synaptic plasticity.
In summary, a close linkage between amyloid processing
and remodeling of the Ca2+ signaling system may be a
significant early step in the development and progression of
AD.
Remodeling Ca2+ signaling mechanisms disrupts
synaptic plasticity and induces cell death
Any explanation of AD, particularly sporadic AD, has to
account for the slow progression of the disease and for the
fact that the changes in synaptic physiology and onset of
memory loss often precedes any evidence for the massive
cell loss that characterizes the later stages of AD [19, 50].
Pflugers Arch - Eur J Physiol
These two phases of early memory loss and subsequent
cell death are well accommodated by the Ca2+ hypothesis
of AD.
Remodeling Ca2+ signaling and disruption of learning
and memory in AD
The appearance of amyloids has been linked to a decline in
both neural activity and the mechanisms responsible for
learning and memory. For example, neurons located near
amyloid plaques have enhanced neural activity that may
result from a decrease in synaptic inhibition [3]. Similarly,
the appearance of amyloid oligomers or the acute applica-
tion of such oligomers has been correlated with a decline in
learning mechanisms such as LTP [35, 52, 54]. Further-
more, these acute effects can be reversed by Aβ antibodies
[25].
These learning mechanisms, which are carefully orches-
trated by neuronal Ca2+ signaling systems, are complicated
by the fact that Ca2+ can either increase or decrease the
strength of central glutamatergic synapses. This bimodal
action is revealed physiologically as either long-term
potentiation (LTP) or long-term depression (LTD) of the α-
amino-3-hydroxy-5-methyl-4-isoxazolepropionic (AMPA)
receptors responsible for fast excitatory neurotransmission
[8]. LTP is triggered by high levels of Ca2+ whereas LTD is
driven by lower levels of Ca2+. There already are indications
that remodeling of the Ca2+ signaling system caused by an
increase in amyloid metabolism can upset this delicate
balance between the induction of LTP and LTD leading to
severe memory loss. The addition of Aβ oligomers to
hippocampal slices can inhibit the induction of LTP. LTP was
also reduced in the presenilin knock out mouse where there
appeared to be a selective decrease in presynaptic transmitter
release [56]. In the 3xTg-AD mouse model, there is a
fivefold increase in the expression of the type 2 RYR and
this resulted in subtle changes in both synaptic transmission
and plasticity especially when neurons were challenged with
drugs such as dantrolene and caffeine [5].
The remodeling of the Ca2+ signaling system may have a
major impact on the process of LTD that is used to erase
memories [9, 19, 26]. Since LTD is driven by small
elevations in Ca2+, any upregulation of Ca2+ signaling will
selectively enhance LTD to continuously erase any mem-
ories initiated by LTP. Since one of the mechanisms for
inducing LTD is the activation of metabotropic glutamater-
gic receptors that generate InsP3 to release Ca2+ from
internal stores [8], the enhanced memory loss seen in AD
could well be explained by an increased activation of LTD.
The changes in synaptic strength responsible for the
formation (LTP) or removal (LTD) of memories are
controlled by varying the level of Ca2+. High levels of
Ca2+, which cause LTP, activate processes such as AMPA
Pflugers Arch - Eur J Physiol
receptor phosphorylation, remodeling of the cytoskeleton
and the trafficking and insertion of AMPA receptors. These
are dynamic processes that are readily reversible by lower
levels of Ca2+ to cause LTD. This LTD mechanism, which
erases putative memories, appears to depend on activation
of the Ca2+-dependent protein phosphatase calcineurin
(CN). For example, CN activates the removal of both
NMDA and AMPA receptors by a process of endocytosis
[19, 47]. In aged rats and in APP transgenic mice, which
show defects in cognition, there is an upregulation of CN
[9, 11]. The associative learning disorder in transgenic mice
could be reversed by treatment with the CN inhibitor
FK506 thus supporting the notion that an increase in the
activity of CN and the inappropriate activation of LTD
might be one of the main consequence of remodeling the
Ca2+ signaling system in the early phase of AD.
Ca2+ signaling remodeling and neuronal cell death
A number of mechanisms have been proposed to account
for how activation of the amyloidogenic pathway leads to
neuronal cell death. One mechanism depends on the
formation of N-terminal sAPPβ when APP is hydrolysed
by β-secretase (also known as BACE; see step 4 in Fig. 2).
The sAPPβ is cleaved by an unknown enzyme to form an
N-terminal APP (N-APP) fragment that may be a ligand for
the orphan DR6 receptor [33]. DR6 is a member of the
superfamily of tumor necrosis factor (TNF) receptors. One
of the functions of such receptors is to activate caspase 3
that then triggers apoptosis. An increase in the amyloido-
genic pathway resulting in an increase in the formation of
sAPPβ may thus contribute to the increase in cell death
associated with Alzheimer's disease.
With regard to the calcium hypothesis of Alzheimer's
disease, the increased output of Ca2+ due to the hypersen-
sitivity of the Ca2+ signaling system may activate the
mitochondria to initiate the intrinsic pathway of Ca2+-
induced apoptosis (Fig. 3). There is an ER/mitochondrial
Ca2+ shuttle that functions to modulate Ca2+ signals. When
Ca2+ stored within the ER lumen is released into the
cytoplasm by the InsP3Rs to generate a Ca2+ signal, a
proportion is taken up by the mitochondria that thus
function as cytosolic buffers. During the recovery phase,
this sequestered Ca2+ is released back into the cytoplasm
and can be returned to the ER. The upregulation of Ca2+
that occurs during AD, will distort this normal ebb and flow
of Ca2+ by increasing the amount of Ca2+ being taken up by
the mitochondria. Such an excessive uptake of mitochon-
drial Ca2+ results in opening of the mitochondrial perme-
ability transition pore (MTP), collapse of the mitochondrial
membrane potential and the release of factors such as
cytochrome c that activate the caspase cascade responsible
for apoptosis. A build up of matrix Ca2+ will also increase
the production of reactive oxygen species, which contribute
to the activation of the MTP that is responsible for Ca2+-
induced apoptosis.
The anti-apoptotic Bcl-2 superfamily may reduce cell
death by reducing the release of Ca2+ from the internal store
[43]. This control seems to be exerted through Bcl-2 that
binds to the InsP3R to reversibly inhibit InsP3-dependent
channel opening (Fig. 3). In a mouse model of AD,
overexpression of Bcl-2 was found to prevent early
apoptotic events, such as caspase activation [42]. Bcl-2
was also found to improve cognition before there were any
signs of neurodegeneration, which is consistent with the
proposal that the upregulation of Ca2+ signaling in AD can
influence both the early deficits in learning and memory as
well as the subsequent onset of neuronal cell death.
Conclusion
The Ca2+ hypothesis attempts to explain how amyloid
formation and accumulation might account for Alzheimer's
disease. The central tenet of the hypothesis is that amyloid
metabolism results in an upregulation of Ca2+ signaling by
enhancing both the entry of external Ca2+ and the sensitivity
of the channels (InsP3 and ryanodine receptors) that release
Ca2+ from the internal stores. This alteration may also
depend on a change in the expression of key components of
the Ca2+ signaling system induced by the transcription factor
APP intracellular domain, which is released during amyloid
formation. Upregulation of Ca2+ signaling may account for
both the progressive decline in memory and the increase in
neuronal cell apoptosis that occurs during AD. Of particular
interest is the possibility that Ca2+ signaling remodeling may
have a major impact on the process of long-term depression
that is used to erase memories. In effect, the change in Ca2+
signaling in AD may switch the brain from a system of
memory storage to one of memory loss. Since this proposed
defect in memory storage occurs before there is any sign of
cell death, it holds out the promise of being able to arrest the
slow progression of AD by developing drugs to normalize
the subtle changes in Ca2+ signaling.
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Two very recent reports have identified new AD susceptibility genes
(CLU, CR1 and PICALM) [57, 58], which provide further support for
the hypotheses outlined in this review. CLU encodes the protein
clustrin, which function like ApoE (see Fig. 2) to bind soluble
amyloids to regulate their toxicity [57, 58]. CR1 is the gene for the
complement component (3b/4b) receptor 1, which functions in the
complement system to clear soluble amyloids [58]. PICALM encodes
a phosphatidylinositol-binding clathrin assembly protein, which is
located in pre- and post-synaptic neuronal endings where it plays a
role in clathrin-mediated endocytosis [57]. The genetic modifications
to PICALM may function to divert APP to the late endosomes to
promote the formation of soluble amyloids (see step 4 in Figure 2). In
addition, mutated PICALM may contribute to the decline in synaptic
plasticity seen in AD by increasing the rate of endocytosis. Such an
action would thus mirror the effect of elevated Ca2+ by enhancing the
process of long-term depression (LTD), which might be one of the
major defects responsible for early memory loss in AD.