BACKGROUND: KLOTHO-VS (KL-VS) heterozygosity, a variant of the KLOTHO gene, and its encoded protein, α-Klotho, are associated with brain health and show neuroprotective potential against Alzheimer's disease (AD). We aimed to assess whether KL-VS heterozygosity, cerebrospinal fluid (CSF) and serum soluble α-Klotho (sαKl) levels, would be associated with a lower likelihood of AD and better performance on memory and other cognitive domains in individuals with AD dementia, amnestic mild cognitive impairment (aMCI) due to AD, and cognitively unimpaired controls. METHODS: In this cross-sectional study, we analyzed two partially overlapping subsamples derived from 296 participants from the Czech Brain Aging Study. The first subsample included 196 participants with KL-VS haplotype data: 71 with AD dementia, 84 with aMCI due to AD, and 41 cognitively unimpaired controls. The second subsample included 147 participants with CSF and/or serum sαKl measurements, including 58 with AD dementia, 59 with aMCI due to AD, and 30 cognitively unimpaired controls. Diagnoses of aMCI and AD dementia were confirmed by positive CSF biomarkers and/or amyloid PET imaging. Logistic regression assessed how KL-VS heterozygosity influenced the odds of aMCI or dementia due to AD. Linear regression investigated associations between cognitive performance and either KL-VS heterozygosity or CSF/serum sαKl levels. Analysis of variance and analysis of covariance with post-hoc tests were used to compare sαKl levels across study groups. RESULTS: KL-VS heterozygosity carriers showed a consistent trend towards lower odds of being classified with aMCI and dementia due to AD, with similar patterns in both Apolipoprotein E ε4 (APOE ε4) allele carriers and non-carriers, although none of the associations reached statistical significance despite moderate (rather than small) effect sizes. Among individuals with aMCI due to AD, KL-VS heterozygotes displayed better memory performance (β = 0.61, p = .008), particularly those who also carried the APOE ε4 allele (β = 0.64, p = .042). Results with other cognitive domains were non-significant. No significant differences in sαKl levels were found between study groups, and soluble α-Klotho levels did not associate with memory performance. CONCLUSIONS: KL-VS heterozygosity may be linked to lower likelihood of classification as aMCI or dementia due to AD, and its association with memory might be specific to the aMCI stage of AD and modulated by APOE ε4 status.

Department of Clinical Biochemistry Hematology and Immunology Homolka Hospital Prague Czech Republic

Edson College of Nursing and Health Innovation Arizona State University Phoenix AZ USA

Memory Clinic Department of Neurology 2nd Faculty of Medicine Charles University and Motol University Hospital Prague Czech Republic

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Kuro-o M, Matsumura Y, Arawa H, Kawaguchi H, Suga T, Utsugi T, et al. Mutation of the mouse Klotho gene leads to a syndrome resembling ageing. Chemtracts. 1999;12:703–7. PubMed

Xu Y, Sun Z. Molecular basis of klotho: from gene to function in aging. Endocr Rev. 2015;36:174–93. PubMed PMC

Kuro-O M, Matsumura Y, Aizawa H, Kawaguchi H, Suga T, Utsugi T, et al. Mutation of the mouse Klotho gene leads to a syndrome resembling ageing. Nature. 1997;390:45–51. PubMed

Nagai T, Yamada K, Kim HC, Kim YS, Noda Y, Imura A, et al. Cognition impairment in the genetic model of aging Klotho gene mutant mice: a role of oxidative stress. FASEB J. 2003;17:50–2. PubMed

Shiozaki M, Yoshimura K, Shibata M, Koike M, Matsuura N, Uchiyama Y, et al. Morphological and biochemical signs of age-related neurodegenerative changes in Klotho mutant mice. Neuroscience. 2008;152:924–41. PubMed

Dubal DB, Yokoyama JS, Zhu L, Broestl L, Worden K, Wang D, et al. Life extension factor Klotho enhances cognition. Cell Rep. 2014;7:1065–76. PubMed PMC

Zeng CY, Yang TT, Zhou HJ, Zhao Y, Kuang X, Duan W, et al. Lentiviral vector–mediated overexpression of Klotho in the brain improves alzheimer’s disease–like pathology and cognitive deficits in mice. Neurobiol Aging. 2019;78:18–28. PubMed

Zhao Y, Zeng CY, Li XH, Yang TT, Kuang X, Du JR. Klotho overexpression improves amyloid-β clearance and cognition in the APP/PS1 mouse model of alzheimer’s disease. Aging Cell. 2020;19:1–17. PubMed PMC

Kurosu H, Yamamoto M, Clark JD, Pastor JV, Nandi A, Gurnani P, et al. Suppression of aging in mice by the hormone Klotho. Science. 2005;309:1829–33. PubMed PMC

Erickson CM, Schultz SA, Oh JM, Darst BF, Ma Y, Norton D, et al. KLOTHO heterozygosity attenuates APOE4-related amyloid burden in preclinical AD. Neurology. 2019;92:E1878–89. PubMed PMC

Belloy ME, Napolioni V, Han SS, Le Guen Y, Greicius MD. Association of Klotho -VS heterozygosity with risk of alzheimer disease in individuals who carry APOE4. JAMA Neurol. 2020;77:849–62. PubMed PMC

Belloy ME, Eger SJ, Le Guen Y, Napolioni V, Deters KD, Yang HS, et al. KL∗VS heterozygosity reduces brain amyloid in asymptomatic at-risk APOE∗4 carriers. Neurobiol Aging. 2021;101:123–9. PubMed PMC

Driscoll I, Ma Y, Gallagher CL, Johnson SC, Asthana S, Hermann BP, et al. Age-related Tau burden and cognitive deficits are attenuated in Klotho KL-vs heterozygotes. J Alzheimer’s Disease. 2021;79:1297–305. PubMed PMC

Neitzel J, Franzmeier N, Rubinski A, Dichgans M, Brendel M, Weiner M, et al. KL-VS heterozygosity is associated with lower amyloid-dependent Tau accumulation and memory impairment in alzheimer’s disease. Nat Commun. 2021;12:1–12. PubMed PMC

Ali M, Sung YJ, Wang F, Fernández MV, Morris JC, Fagan AM, et al. Leveraging large multi-center cohorts of alzheimer disease endophenotypes to understand the role of Klotho heterozygosity on disease risk. PLoS ONE. 2022;17:1–16. PubMed PMC

Chen XR, Shao Y, Sadowski MJ. Interaction between KLOTHO-VS heterozygosity and APOE ε4 allele predicts rate of cognitive decline in Late-Onset alzheimer’s disease. Genes (Basel). 2023;14. PubMed PMC

Eger SJ, Belloy ME, Guen Y, Le, Napolioni V, Deters KD, Mormino EC, et al. Klotho-VS decreases probability of amyloid pet positivity in APOE4 + controls. Alzheimer’s Dement. 2020;16:2–4.

Grøntvedt GR, Sando SB, Lauridsen C, Bråthen G, White LR, Salvesen Ø, et al. Association of Klotho protein levels and KL-VS heterozygosity with alzheimer disease and amyloid and Tau burden. JAMA Netw Open. 2022;5:e2243232. PubMed PMC

Yokoyama JS, Marx G, Brown JA, Bonham LW, Wang D, Coppola G, et al. Systemic Klotho is associated with KLOTHO variation and predicts intrinsic cortical connectivity in healthy human aging. Brain Imaging Behav. 2017;11:391–400. PubMed PMC

Linghui D, Simin Y, Zilong Z, Yuxiao L, Shi Q, Birong D. The relationship between serum Klotho and cognitive performance in a nationally representative sample of US adults. Front Aging Neurosci. 2023;15:1–8. PubMed PMC

Shardell M, Semba RD, Rosano C, Kalyani RR, Bandinelli S, Chia CW et al. Plasma Klotho and cognitive decline in older adults: findings from the InCHIANTI Study. Journals of Gerontology - Series A biological sciences and medical sciences. 2016;71:677–82. PubMed PMC

Semba RD, Moghekar AR, Hu J, Sun K, Turner R, Ferrucci L, et al. Klotho in the cerebrospinal fluid of adults with and without alzheimer’s disease. Neurosci Lett. 2014;558:37–40. PubMed PMC

Kundu P, Zimmerman B, Quinn JF, Kaye J, Mattek N, Westaway SK, et al. Serum levels of α-Klotho are correlated with cerebrospinal fluid levels and predict measures of cognitive function. J Alzheimer’s Disease. 2022;86:1471–81. PubMed PMC

Brombo G, Bonetti F, Ortolani B, Morieri ML, Bosi C, Passaro A, et al. Lower plasma Klotho concentrations are associated with vascular dementia but not Late-Onset alzheimer’s disease. Gerontology. 2018;64:414–21. PubMed

Ren JR, Wang Z, Cheng Y, He CY, Jian JM, Fan DY, et al. Associations between plasma Klotho with renal function and cerebrospinal fluid Amyloid-β levels in alzheimer’s disease: the Chongqing ageing dementia study. J Alzheimer’s Disease. 2023;92:477–85. PubMed

Sheardova K, Vyhnalek M, Nedelska Z, Laczo J, Andel R, Marciniak R, et al. Czech brain aging study (CBAS): prospective multicentre cohort study on risk and protective factors for dementia in the Czech Republic. BMJ Open. 2019;9:e030379. PubMed PMC

Yesavage JA. Geriatric depression scale. Psychopharmacol Bull. 1988;24:709–11. PubMed

Fazekas F, Chawluk J, Alavi A, Hurtig H, Zimmerman R. MR signal abnormalities at 1.5 T in alzheimer’s dementia and normal aging. Am J Roentgenol. 1987;149:351–6. PubMed

McKhann GM, Knopman DS, Chertkow H, Hyman BT, Jack CR, Kawas CH, et al. The diagnosis of dementia due to alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s association workgroups on diagnostic guidelines for alzheimer’s disease. Alzheimer’s Dement. 2011;7:263–9. PubMed PMC

Albert MS, DeKosky ST, Dickson D, Dubois B, Feldman HH, Fox NC, et al. The diagnosis of mild cognitive impairment due to alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s association workgroups on diagnostic guidelines for alzheimer’s disease. Alzheimer’s Dement. 2011;7:270–9. PubMed PMC

Jessen F, Amariglio RE, Van Boxtel M, Breteler M, Ceccaldi M, Chételat G, et al. A conceptual framework for research on subjective cognitive decline in preclinical alzheimer’s disease. Alzheimer’s Dement. 2014;10:844–52. PubMed PMC

Laczó J, Andel R, Vlček K, Mat’oška V, Vyhnálek M, Tolar M, et al. Spatial navigation and APOE in amnestic mild cognitive impairment. Neurodegener Dis. 2011;8:169–77. PubMed

Hixson JE, Vernier DT. Restriction isotyping of human Apolipoprotein E by gene amplification and cleavage with HhaI. J Lipid Res. 1990;31:545–8. PubMed

Stepankova H, Nikolai T, Lukavsky J, Bezdicek O, Vrajova M, Kopecek M. Mini-Mental state Examination – Czech normative study. Ceska Slov Neurologie Neurochirurgie. 2015;78/111:57–63.

Nikolai T, Stepankova H, Kopecek M, Sulc Z, Vyhnalek M, Bezdicek O. Normative Data in Older Adults from an International Perspective. J Alzheimer’s disease. 2018;61:1233. The Uniform Data Set, Czech Version:. PubMed PMC

Bezdicek O, Motak L, Axelrod BN, Preiss M, Nikolai T, Vyhnalek M, et al. Czech version of the trail making test: normative data and clinical utility. Arch Clin Neuropsychol. 2012;27:906–14. PubMed

Bezdicek O, Rosická AM, Mana J, Libon DJ, Kopeček M, Georgi H. The 30-item and 15-item Boston naming test Czech version: item response analysis and normative values for healthy older adults. J Clin Exp Neuropsychol. 2021;43:890–905. PubMed

Nikolai T, Štěpánková H, Michalec J, Bezdíček O, Horáková K, Marková H, et al. Verbal fluency Tests – Czech normative study for older persons. Ceska Slov Neurologie Neurochirurgie. 2015;78:292–9.

Meyers JE, Meyers KR. Rey complex figure test and recognition trial: professional manual. Odessa: Psychological Assessment Resources. 1995.

Mazancova AF, Nikolai T, Stepankova H, Kopecek M, Bezdicek O. The reliability of clock drawing test scoring systems modeled on the normative data in healthy aging and nonamnestic mild cognitive impairment. Assessment. 2016;24:945–57. PubMed

Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Introduction to Meta-Analysis. Wiley. 2009.

Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd Edition. illsdale, NJ: Lawrence Erlbaum Associates, Publishers. 1988.

Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39:175–91. PubMed

RStudio Team. RStudio: Integrated Development for R 2020.

Driscoll I, Ma Y, Lose SR, Gallagher CL, Johnson SC, Asthana S, et al. AD-associated CSF biomolecular changes are attenuated in KL-VS heterozygotes. Alzheimer’s Dementia: Diagnosis Assess Disease Monit. 2022;14:1–8. PubMed PMC

Yokoyama JS, Sturm VE, Bonham LW, Klein E, Arfanakis K, Yu L, et al. Variation in longevity gene KLOTHO is associated with greater cortical volumes. Ann Clin Transl Neurol. 2015;2:215–30. PubMed PMC

Müller BW, Hinney A, Scherbaum N, Weimar C, Kleinschnitz C, Peters T, et al. Klotho KL-VS haplotype does not improve cognition in a population-based sample of adults age 55–87 years. Sci Rep. 2021;11:13852. PubMed PMC

Tank R, Ward J, Celis-Morales C, Smith DJ, Flegal KE, Lyall DM. Testing for interactions between APOE and Klotho genotypes on Cognitive, Dementia, and brain imaging metrics in UK biobank. J Alzheimer’s Disease. 2021;83:51–5. PubMed

Porter T, Burnham SC, Milicic L, Savage G, Maruff P, Lim YY, et al. Klotho allele status is not associated with Aβ and APOE ε4–related cognitive decline in preclinical alzheimer’s disease. Neurobiol Aging. 2019;76:162–5. PubMed

Mengel-From J, Soerensen M, Nygaard M, McGue M, Christensen K, Christiansen L. Genetic variants in KLOTHO associate with cognitive function in the oldest old group. Journals Gerontol - Ser Biol Sci Med Sci. 2016;71:1151–9. PubMed PMC

de Vries CF, Staff RT, Noble KG, Muetzel RL, Vernooij MW, White T, et al. Klotho gene polymorphism, brain structure and cognition in early-life development. Brain Imaging Behav. 2020;14:213–25. PubMed PMC

Castner SA, Gupta S, Wang D, Moreno AJ, Park C, Chen C, et al. Longevity factor Klotho enhances cognition in aged nonhuman primates. Nat Aging. 2023;3:931–7. PubMed PMC

Li D, Jing D, Liu Z, Chen Y, Huang F, Behnisch T. Enhanced expression of secreted α-klotho in the hippocampus alters nesting behavior and memory formation in mice. Front Cell Neurosci. 2019;13:133. PubMed PMC

Zhou HJ, Zeng CY, Yang TT, Long FY, Kuang X, Du JR. Lentivirus-mediated Klotho up-regulation improves aging-related memory deficits and oxidative stress in senescence-accelerated mouse prone-8 mice. Life Sci. 2018;200:56–62. PubMed

Massó A, Sánchez A, Bosch A, Giménez-Llort L, Chillón M. Secreted αKlotho isoform protects against age-dependent memory deficits. Mol Psychiatry. 2018;23:1937–47. PubMed

Katonova A, Andel R, Jurasova V, Veverova K, Angelucci F, Matoska V et al. Associations of KLOTHO-VS heterozygosity and α-Klotho protein with cerebrospinal fluid Alzheimer’s disease biomarkers. Journal of Alzheimer’s Disease. 2025; Available from: https://journals.sagepub.com/doi/10.1177/13872877251326199 PubMed PMC