Cited by 320Alzheimer's disease research and treatmentsDementia and Cognitive Impairment ResearchGenetic Associations and Epidemiology

APOE Genotype and Alzheimer Disease Risk Across Age, Sex, and Population Ancestry

Open access
Belloy, Michael E., Andrews, Shea J., Le Guen, Yann, Cuccaro, Michael, Farrer, Lindsay A., Napolioni, Valerio, Greicius, Michael D.·2023·JAMA Neurology

Abstract

Importance: Apolipoprotein E (APOE)*2 and APOE*4 are, respectively, the strongest protective and risk-increasing, common genetic variants for late-onset Alzheimer disease (AD), making APOE status highly relevant toward clinical trial design and AD research broadly. The associations of APOE genotypes with AD are modulated by age, sex, race and ethnicity, and ancestry, but these associations remain unclear, particularly among racial and ethnic groups understudied in the AD and genetics research fields. Objective: To assess the stratified associations of APOE genotypes with AD risk across sex, age, race and ethnicity, and global population ancestry. Design, Setting, Participants: This genetic association study included case-control, family-based, population-based, and longitudinal AD-related cohorts that recruited referred and volunteer participants. Data were analyzed between March 2022 and April 2023. Genetic data were available from high-density, single-nucleotide variant microarrays, exome microarrays, and whole-exome and whole-genome sequencing. Summary statistics were ascertained from published AD genetic studies. Main Outcomes and Measures: The main outcomes were risk for AD (odds ratios [ORs]) and risk of conversion to AD (hazard ratios [HRs]), with 95% CIs. Risk for AD was evaluated through case-control logistic regression analyses. Risk of conversion to AD was evaluated through Cox proportional hazards regression survival analyses. Results: Among 68 756 unique individuals, analyses included 21 852 East Asian (demographic data not available), 5738 Hispanic (68.2% female; mean [SD] age, 75.4 [8.8] years), 7145 non-Hispanic Black (hereafter referred to as Black) (70.8% female; mean [SD] age, 78.4 [8.2] years), and 34 021 non-Hispanic White (hereafter referred to as White) (59.3% female; mean [SD] age, 77.0 [9.1] years) individuals. There was a general, stepwise pattern of ORs for APOE*4 genotypes and AD risk across race and ethnicity groups. Odds ratios for APOE*34 and AD risk attenuated following East Asian (OR, 4.54; 95% CI, 3.99-5.17),White (OR, 3.46; 95% CI, 3.27-3.65), Black (OR, 2.18; 95% CI, 1.90-2.49) and Hispanic (OR, 1.90; 95% CI, 1.65-2.18) individuals. Similarly, ORs for APOE*22+23 and AD risk attenuated following White (OR, 0.53, 95% CI, 0.48-0.58), Black (OR, 0.69, 95% CI, 0.57-0.84), and Hispanic (OR, 0.89; 95% CI, 0.72-1.10) individuals, with no association for Hispanic individuals. Deviating from the global pattern of ORs, APOE*22+23 was not associated with AD risk in East Asian individuals (OR, 0.97; 95% CI, 0.77-1.23). Global population ancestry could not explain why Hispanic individuals showed APOE associations with less pronounced AD risk compared with Black and White individuals. Within Black individuals, decreased global African ancestry or increased global European ancestry showed a pattern of APOE*4 dosage associated with increasing AD risk, but no such pattern was apparent for APOE*2 dosage with AD risk. The sex-by-age–specific interaction effect of APOE*34 among White individuals (higher risk in women) was reproduced but shifted to ages 60 to 70 years (OR, 1.48; 95% CI, 1.10-2.01) and was additionally replicated in a meta-analysis of Black individuals and Hispanic individuals (OR, 1.72; 95% CI, 1.01-2.94). Conclusion and Relevance: Through recent advances in AD-related genetic cohorts, this study provided the largest-to-date overview of the association of APOE with AD risk across age, sex, race and ethnicity, and population ancestry. These novel insights are critical to guide AD clinical trial design and research.

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Integrity signals

Registry

Crossref · 10.1001/jamaneurol.2023.3599

Cites

35 of 38 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The protective effect of APOEε2 is attenuated in Black versus white people, whereas in Hispanic and East Asian individuals, the APOEε2 allele confers essentially no protection against Alzheimer disease relative to APOEε3 homozygosis, and only in the presence of APOEε4 does APOEε2 confer protection in Hispanic people.

    “Even more puzzling than these differences in APOEε4-linked AD risk are those associated with the APOEε2 allele; this study found that the protective effect of APOEε2 is attenuated in Black versus white people, whereas in Hispanic and East Asian individuals, the APOEε2 allele confers essentially no protection against AD relative to APOEε3 homozygosis, and only in the presence of APOEε4 does APOEε2”

    From Multifaceted roles of APOE in Alzheimer disease (2024) · cites this paper as [10]

    Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured
  • The risk associated with the APOEε3/ε4 genotype is highest in women of ages 60-70 years (or 70-80 years according to ref. 6) but decreases in older women and equalizes to that of non-Hispanic White, Black and Hispanic men of the same age.

    “Rather, age and sex moderate the effects of the APOE genotype on AD risk so that the risk associated with the APOEε3/ε4 genotype is highest in women of ages 60–70 years (or 70–80 years according to ref. 6) but decreases in older women and equalizes to that of non-Hispanic White, Black and Hispanic men of the same age10.”

    From Multifaceted roles of APOE in Alzheimer disease (2024) · cites this paper as [10]

    The Results (Race and Ethnicity Analyses; page unavailable) find greater APOE ε3/ε4-associated AD risk in women than men at ages 60–70, including a replicated association in Black and Hispanic individuals. The Discussion likewise identifies this age-specific finding, but our copy does not establish that risk decreases in older women or equalizes with that of men of the same age across all three groups. (LLM, conf=0.84)

    Experimental — accuracy not yet measured
  • APOE allele frequencies for East Asian, white, Black and Hispanic people are: APOEε2 carriers 5.6%, 11.1%, 19.7% and 10.6%; APOEε3 homozygotes 72.8%, 50.6%, 43.3% and 61.3%; and APOEε4 carriers 21.6%, 40.6%, 41.6% and 29.9%, respectively.

    “In the analysis, APOE allele frequencies for East Asian, white, Black and Hispanic people were as follows: APOEε2 carriers 5.6%, 11.1%, 19.7% and 10.6%; APOEε3 homozygotes 72.8%, 50.6%, 43.3% and 61.3% and APOEε4 carriers 21.6%, 40.6%, 41.6% and 29.9%, respectively10.”

    From Multifaceted roles of APOE in Alzheimer disease (2024) · cites this paper as [10]

    The Results table (Race and Ethnicity Analyses; page unavailable) gives carrier counts and sample sizes that yield the quoted percentages for White, Black, and Hispanic participants after rounding. Our copy does not give the three quoted East Asian percentages; it says East Asian genotype assessment was limited to results from prior studies. The figures are proportions of people in genotype or carrier categories, not allele frequencies. (LLM, conf=0.88)

    Experimental — accuracy not yet measured
  • Compared with E3, E4 confers up to a 13-fold increase in risk for AD in homozygous carriers.

    “Compared with E3, E4 confers up to a 13-fold increase in risk for AD in homozygous carriers1.”
  • The degree of risk and protection afforded by E4 and E2 respectively vary according to ancestry.

    “First, the degree of risk and protection afforded by E4 and E2 respectively vary according to ancestry1,59–62.”

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The self-check needs the paper’s full text.

Cites

Flagged first, then by citations

Cited by

Sorted by citations

Authors
Belloy, M. E., Andrews, S. J., Le Guen, Y., Cuccaro, M., Farrer, L. A., Napolioni, V., & Greicius, M. D.
Affiliations
  • Department of Neurology and Neurological Sciences, Stanford University, Stanford, California
  • University of California, San Francisco (US)
  • University of Miami (US)
  • Boston University (US)
  • Università di Camerino (IT)
  • Stanford University (US)
Venue
JAMA Neurology
Published
2023-12-01
Volume
80
Issue
12
Pages
1284
ISSN
2168-6149 (ISSN-L)
OpenAlex
W4388410342
Cited by
320
References
38
Citations by year
2026: 120 · 2025: 149 · 2024: 47 · 2023: 4
FWCI
56.83
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • JAMA Neurology (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Unicam Scientific Publications (University of Camerino) (submittedVersion, cc-by)
  • Digital Commons@Becker (Washington University School of Medicine) (submittedVersion, cc-by)
Funders
  • Alzheimer's Association (AARF-20-683984)
  • European Commission (890650)
  • National Institute on Aging (R01AG060747, P50AG047366, K99AG075238, U24AG021886, R00AG075238)
  • H2020 Marie Skłodowska-Curie Actions
Topics
  • Health Sciences › Medicine › Physiology › Alzheimer's disease research and treatments
  • Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Genetic Associations and Epidemiology
Keywords
apolipoprotein E, APOE ε4, late-onset Alzheimer's disease, Alzheimer's disease risk, sex differences, age effects, population ancestry, racial and ethnic disparities, East Asian populations, Hispanic population, non-Hispanic Black population, non-Hispanic whites, genetic risk stratification, clinical trial design
MeSH terms
Aged, Alzheimer Disease, Antibodies, Monoclonal, Apolipoproteins E, Female, Genotype, Humans, Male, Middle Aged, Amyloid beta-Peptides, White People, Apolipoprotein E4

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review