Developmental brain programmes and biomarker activation in Alzheimer's disease

Recent studies show that serum glial fibrillary acidic protein (GFAP) is highest in healthy infancy and early childhood and then declines steadily with age, while plasma tau protein phosphorylated at position 217 is strikingly elevated in healthy newborns and can exceed values observed in Alzheimer's disease (AD). Additional evidence indicates that soluble phosphorylated tau forms are not specific to AD, as increased tau protein phosphorylated-217 has been reported in MAPT R406W carriers without amyloid pathology and in Niemann-Pick disease type C, where plasma tau protein phosphorylated-217 is associated with disease progression and lysosomal enlargement. These observations invite a broader review of biomarker biology across development, physiological remodelling and neurodegeneration. We hypothesize that, at least in part, increases of GFAP, tau protein phosphorylated-217 and related biomarkers in AD reflect a chronic attempt of the ageing brain to reactivate multicellular programmes that are physiologically engaged during development, repair and circuit refinement. In this framework, biomarker elevation does not necessarily indicate that the reactive programme is intrinsically toxic. Rather, persistent elevation may index the duration and intensity of unresolved metabolic, inflammatory, vascular, proteostatic, mitochondrial or infectious stressors that keep repair and homeostatic systems engaged until their compensatory capacity is exceeded. Protein precipitation is therefore positioned as a downstream consequence of persistent stress, chronic compensatory activation, increased protein turnover, secretion or processing and impaired clearance or proteostasis. This Review summarizes the developmental biomarker evidence, examines alternative interpretations and discusses therapeutic implications focused on upstream stressors and failed resolution rather than biomarker lowering alone.