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Plasma neurofilament light reflects more severe manifestation of Alzheimer’s disease in men

Molecular Psychiatry volume 30, pages 5615–5624 (2025)Cite this article

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Abstract

Plasma neurofilament light (NfL) protein is a promising non-invasive biomarker for detecting neuronal damage in Alzheimer’s disease (AD). However, its clinical utility is limited by the lack of standardized threshold values. Sex is an important factor that should be considered when setting these thresholds, but only a few studies have examined sex differences in plasma NfL levels in AD, with inconsistent findings. Even fewer have explored whether sex influences the relationship between plasma NfL levels and disease severity. To investigate this, we first analyzed data from 860 participants in the Alzheimer’s Disease Neuroimaging Initiative (ADNI) database. Linear regression models were used to assess sex differences in the correlation between plasma NfL levels, cognitive deficits, and neuroimaging metrics. A Cox model with bootstrap resampling was used to evaluate sex differences in dementia risk, calculating the hazard ratio for men versus women for a given increase in plasma NfL. Our results showed that, compared to women, men with higher plasma NfL levels exhibited more severe cognitive defects and brain hypometabolism, along with smaller hippocampal volume. These findings were validated using data from 619 participants in the Chinese Preclinical Alzheimer’s Disease Study (C-PAS) cohort and 86 participants from a publicly available dataset. In addition, we found that increase in plasma NfL levels were predictive of faster cognitive decline and a higher likelihood of AD progression in men compared to women. In conclusion, sex differences influence the relationship between plasma NfL levels and AD symptoms. Men exhibit greater cognitive and neuropathological defects with rising plasma NfL levels, underscoring the need for considering sex when using NfL as a biomarker for neuronal damage in AD.

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Fig. 1: Increased plasma NfL levels reflect more severe cognitive deficit in men.
Fig. 2: Increased plasma NfL levels indicate more pronounced AD-related neuropathology in men.
Fig. 3: Increased plasma NfL levels predict higher risks of converting to dementia in men.
Fig. 4: Increased plasma NfL levels reflect more severe cognitive deficit and more substantial reduction in hippocampus volume in men in the C-PAS cohort.

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Data availability

ADNI data are publicly available at: https://adni.loni.usc.edu. Data from C-PAS study will be shared by request from a qualified academic investigator for the sole purpose of replicating procedures and results presented in the article. The third longitudinal open dataset can be download at: https://www.nature.com/articles/s41467-020-14612-6#Sec16. Analysis code used in this study is available upon reasonable request.

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Acknowledgements

Data used in preparation of this article were partially obtained from the Alzheimer’s Disease Neuroimaging Initiative (ADNI) database (adni.loni.usc.edu). As such, the investigators within the ADNI contributed to the design and implementation of ADNI and/or provided data but did not participate in analysis or writing of this report. A complete listing of ADNI investigators can be found at: http://adni.loni.usc.edu/wpcontent/uploads/how_to_apply/ADNI_Acknowledgement_List.pdf. Data collection and sharing for this project was funded by the Alzheimer’s Disease Neuroimaging Initiative (ADNI) (National Institutes of Health Grant U01 AG024904) and DOD ADNI (Department of Defense award number W81XWH-12-2-0012). ADNI is funded by the National Institute on Aging, the National Institute of Biomedical Imaging and Bioengineering, and through generous contributions from the following: AbbVie, Alzheimer’s Association; Alzheimer’s Drug Discovery Foundation; Araclon Biotech; BioClinica, Inc.; Biogen; Bristol-Myers Squibb Company; CereSpir, Inc.; Cogstate; Eisai Inc.; Elan Pharmaceuticals, Inc.; Eli Lilly and Company; EuroImmun; F. Hoffmann-La Roche Ltd and its affiliated company Genentech, Inc.; Fujirebio; GE Healthcare; IXICO Ltd.; Janssen Alzheimer Immunotherapy Research & Development, LLC.; Johnson & Johnson Pharmaceutical Research & Development LLC.; Lumosity; Lundbeck; Merck & Co., Inc.; Meso Scale Diagnostics, LLC.; NeuroRx Research; Neurotrack Technologies; Novartis Pharmaceuticals Corporation; Pfizer Inc.; Piramal Imaging; Servier; Takeda Pharmaceutical Company; and Transition Therapeutics. The Canadian Institutes of Health Research is providing funds to support ADNI clinical sites in Canada. Private sector contributions are facilitated by the Foundation for the National Institutes of Health (www.fnih.org). The grantee organization is the Northern California Institute for Research and Education, and the study is coordinated by the Alzheimer’s Therapeutic Research Institute at the University of Southern California. ADNI data are disseminated by the Laboratory for Neuro Imaging at the University of Southern California. We thank Dr. Wei Cheng (Fudan University) for his guidance on the bootstrap resample method for survival analysis.

Funding

This work was supported by the National Key Research and Development Program of China (2023YFC3603200, 2016YFC1306305, 2018YFE0203600), Shanghai Pilot Program for Basic Research - FuDan University 21TQ1400100 (22TQ019), Shanghai Municipal Science and Technology Major Project, the Lingang Laboratory (grant no. LG-QS-202203-09), Shanghai Natural Science Foundation (22ZR1415000), and STI2030-Major Projects (2022ZD0213800).

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  1. These authors contributed equally: Xiaoqin Cheng, Zhenghong Wang, Kun He, Yingfeng Xia.

Authors and Affiliations

  1. Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China

    Xiaoqin Cheng

  2. Department of Rehabilitation Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Institute for Translational Brain Research, MOE Frontiers Center for Brain Science, MOE Innovative Center for New Drug Development of Immune Inflammatory Diseases, Fudan University, Shanghai, China

    Zhenghong Wang & Peng Yuan

  3. Department of Nuclear Medicine & PET Center, Huashan Hospital, Fudan University, Shanghai, China

    Kun He & Fang Xie

  4. Department of Neurology, Zhongnan Hospital, Wuhan University, Wuhan, China

    Yingfeng Xia

  5. Department of Gerontology, Shanghai Jiaotong University Affiliated Sixth People’s Hospital, Shanghai, China

    Ying Wang & Qihao Guo

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Contributions

PY, XQC designed the study. ZHW and YFX carried out the analysis. KH, YW, QHG,and FX directed the data collection in the validation cohort. PY, ZHW and YFX made the graphs. PY, XQC and FX wrote and edited the manuscript. PY directed the study.

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Correspondence to Fang Xie or Peng Yuan.

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The study of C-PAS cohort was approved by the Independent Ethics Committee “Huashan Hospital Institutional Review Board (HIRB), Fudan University” (approval number: KY-2017-406), and all participants gave written informed consent. All methods were performed in accordance with the relevant guidelines and regulations.

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Cheng, X., Wang, Z., He, K. et al. Plasma neurofilament light reflects more severe manifestation of Alzheimer’s disease in men. Mol Psychiatry 30, 5615–5624 (2025). https://doi.org/10.1038/s41380-025-03149-z

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