Adrenoleukodystrophy—Neuroendocrine pathogenesis and redefinition of natural history
Open accessAbstract
X-Linked adrenoleukodystrophy (ALD) is a peroxisomal metabolic disorder with a highly complex clinical presentation. ALD is caused by mutations in the ABCD1 gene, which leads to the accumulation of very long-chain fatty acids in plasma and tissues. Virtually all men with ALD develop adrenal insufficiency and myelopathy. Approximately 60% of men develop progressive cerebral white matter lesions (known as cerebral ALD). However, one cannot identify these individuals until the early changes are seen using brain imaging. Women with ALD also develop myelopathy, but generally at a later age than men and adrenal insufficiency or cerebral ALD are very rare. Owing to the multisystem symptomatology of the disease, patients can be assessed by the paediatrician, general practitioner, endocrinologist or a neurologist. This Review describes current knowledge on the clinical presentation, diagnosis and treatment of ALD, and highlights gaps in our knowledge of the natural history of the disease owing to an absence of large-scale prospective cohort studies. Such studies are necessary for the identification of new prognostic biomarkers to improve care for patients with ALD, which is particularly relevant now that newborn screening for ALD is being introduced.
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ALD has no established genotype-phenotype relationship.
“The disease is characterized by a striking clinical spectrum and is unpredictable in disease course and severity, with no established genotype–phenotype relationship [8,9].”
From Structure and Function of the ABCD1 Variant Database: 20 Years, 940 Pathogenic Variants, and 3400 Cases of Adrenoleukodystrophy (2022) · cites this paper as [9]
At diagnosis, 80% of boys or adolescents with cALD and 70% of AMN patients have hormonal evidence of clinically silent adrenal insufficiency.
“At diagnosis, 80% of boys or adolescents with cALD and 70% of AMN patients have hormonal evidence of clinically silent adrenal insufficiency [65,66,67,68,69].”
From Revisiting the Pathogenesis of X-Linked Adrenoleukodystrophy (2025) · cites this paper as [67]
Cerebral ALD causes severe disability and death.
“Cerebral ALD causes severe disability and death.1”
From International Recommendations for the Diagnosis and Management of Patients With Adrenoleukodystrophy (2022) · cites this paper as [1]
It is currently not possible to predict the individual disease course of ALD.
“Currently, it is not possible to predict the individual disease course.1”
From International Recommendations for the Diagnosis and Management of Patients With Adrenoleukodystrophy (2022) · cites this paper as [1]
ALD has a variable and unpredictable clinical course.
“Adrenoleukodystrophy (ALD) has a variable and unpredictable clinical course.1”
From International Recommendations for the Diagnosis and Management of Patients With Adrenoleukodystrophy (2022) · cites this paper as [1]
Adrenal insufficiency is characterized by low or normal early morning cortisol levels with high levels of ACTH.
“Adrenal insufficiency is characterized by low or normal early morning cortisol levels with high levels of ACTH.1,33”
From International Recommendations for the Diagnosis and Management of Patients With Adrenoleukodystrophy (2022) · cites this paper as [1]
The risk of developing cerebral disease is highest in childhood but remains present throughout life.
“The risk of developing cerebral disease is highest in childhood but remains present throughout life.1,29,33-39”
From International Recommendations for the Diagnosis and Management of Patients With Adrenoleukodystrophy (2022) · cites this paper as [1]
Erectile dysfunction may reflect primary gonadal insufficiency or can be caused by spinal cord disease.
“For instance, erectile dysfunction may reflect primary gonadal insufficiency or can be caused by spinal cord disease.1”
From International Recommendations for the Diagnosis and Management of Patients With Adrenoleukodystrophy (2022) · cites this paper as [1]
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ω-Oxidation of Very Long-chain Fatty Acids in Human Liver Microsomes
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Assessment of Adrenal Function in Women Heterozygous for Adrenoleukodystrophy1
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Self-citationTopology of ATP-Binding Domain of Adrenoleukodystrophy Gene Product in Peroxisomes
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Late-onset adrenoleukodystrophy associated with long-standing psychiatric symptoms
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Testicular dysfunction in adrenomyeloneuropathy
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FAMILIAL ADDISON'S DISEASE WITH SPASTIC PARAPLEGIA
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High prevalence of primary adrenal insufficiency in Zellweger spectrum disorders
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Self-citationMonozygotic twins with X-linked adrenoleukodystrophy and different phenotypes
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Myelopathy but normal MRI: where next?
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Enzymatic characterization of ELOVL1, a key enzyme in very long-chain fatty acid synthesis
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ALDP expression in fibroblasts of patients with X-linked adrenoleukodystrophy
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Very‐late‐onset adrenoleukodystrophy: Possible precipitation of demyelination by cerebral contusion
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Bezafibrate for X-Linked Adrenoleukodystrophy
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Lorenzo's Oil -- Hope and Disappointment
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Self-citationX-linked adrenoleukodystrophy: are signs of hypogonadism always due to testicular failure?
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Self-citationAdult cerebral adrenoleukodystrophy and Addison's disease in a female carrier
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Inflammasome signalling in brain function and neurodegenerative disease
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The physiological functions of human peroxisomes
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International Recommendations for the Diagnosis and Management of Patients With Adrenoleukodystrophy
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“The risk of developing cerebral disease is highest in childhood but remains present throughout life.(1,29,33-39) The age for the baseline MRI was set at 2 years because cerebral ALD before the age of 3 years is rare, and MRI scans obtained before the age of 2 years are difficult to interpret because of incomplete myel…”
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Disease progression in women with X-linked adrenoleukodystrophy is slow
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Thyroid Hormone Analogues: An Update
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The role of the clinician in the multi‐omics era: are you ready?
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Self-citationThe changing face of adrenoleukodystrophy
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Primary adrenal insufficiency in children: Diagnosis and management
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A report on state-wide implementation of newborn screening for X-linked Adrenoleukodystrophy
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Self-citationHow the brain fights fatty acids’ toxicity
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Self-citationTreatment of cerebral adrenoleukodystrophy: allogeneic transplantation and lentiviral gene therapy
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Self-citationEvaluation of X-Linked Adrenoleukodystrophy Newborn Screening in North Carolina
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Self-citationProgression of myelopathy in males with adrenoleukodystrophy: towards clinical trial readiness
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Self-citationAdrenoleukodystrophy Newborn Screening in the Netherlands (SCAN Study): The X-Factor
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- Authors
- Kemp, S., Huffnagel, I. C., Linthorst, G. E., Wanders, R. J., & Engelen, M.
- Affiliations
- Amsterdam UMC Location University of Amsterdam (NL)
- Corresponding author
- Kemp, Stephan
- Venue
- Nature Reviews Endocrinology
- Published
- 2016-06-17
- Volume
- 12
- Issue
- 10
- Pages
- 606-615
- ISSN
- 1759-5029 (ISSN-L)
- 1759-5037
- OpenAlex
- W2438153122
- Cited by
- 275
- References
- 149
- Citations by year
- 2026: 23 · 2025: 28 · 2024: 35 · 2023: 17 · 2022: 30 · 2021: 39 · 2020: 39 · 2019: 23 · 2018: 21 · 2017: 16 · 2016: 3
- FWCI
- 2.24
- Type
- journal article
- Language
- en
- Open access
- green
- pure.amsterdamumc.nl
- Licence
- other-oa
- www.springer.com/tdm (tdm)
- Locations
- Nature Reviews Endocrinology (publishedVersion)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion, other-oa)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Topics
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Clinical Biochemistry › Metabolism and Genetic Disorders
- Health Sciences › Medicine › Physiology › Lysosomal Storage Disorders Research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
- Keywords
- adrenoleukodystrophy, ABCD1 gene, very long chain fatty acids, adrenal insufficiency, myelopathy, cerebral adrenoleukodystrophy, white matter lesions, natural history (disease), diagnosis, treatment, newborn screening, prognostic factors, sex differences
- MeSH terms
- ATP Binding Cassette Transporter, Subfamily D, Member 1, Adrenal Insufficiency, Adrenoleukodystrophy, Brain, Fatty Acids, Female, Glucocorticoids, Humans, Male, Peripheral Nervous System Diseases, Spinal Cord Diseases, Disease Progression, ATP-Binding Cassette Transporters, Hormone Replacement Therapy, Leukoencephalopathies
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 ›
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