genetic influences on disease course and severity, 30 years after a clinically isolated syndrome

Multiple sclerosis risk has a well-established polygenic component, yet the genetic contribution to disease course and severity remains unclear and difficult to examine. Accurately measuring disease progression requires long-term study of clinical and radiological outcomes with sufficient follow-up duration to confidently confirm disability accrual and multiple sclerosis phenotypes. In this retrospective study, we explore genetic influences on long-term disease course and severity; in a unique cohort of clinically isolated syndrome patients with homogenous 30-year disease duration, deep clinical phenotyping and advanced MRI metrics. Sixty-one clinically isolated syndrome patients [41 female (67%): 20 male (33%)] underwent clinical and MRI assessment at baseline, 1-, 5-, 10-, 14-, 20- and 30-year follow-up (mean age ± standard deviation: 60.9 ± 6.5 years). After 30 years, 29 patients developed relapsing-remitting multiple sclerosis, 15 developed secondary progressive multiple sclerosis and 17 still had a clinically isolated syndrome. Twenty-seven genes were investigated for associations with clinical outcomes [including disease course and Expanded Disability Status Scale (EDSS)] and brain MRI (including white matter lesions, cortical lesions, and brain tissue volumes) at the 30-year follow-up. Genetic associations with changes in EDSS, relapses, white matter lesions and brain atrophy (third ventricular and medullary measurements) over 30 years were assessed using mixed-effects models. -positive ( = 26) patients showed faster white matter lesion accrual [+1.96 lesions/year (0.64-3.29), = 3.8 × 10], greater 30-year white matter lesion volumes [+11.60 ml, (5.49-18.29), = 1.27 × 10] and higher annualized relapse rates [+0.06 relapses/year (0.005-0.11), = 0.031] compared with -negative patients ( = 35). -positive patients ( = 41) had more cortical lesions (+0.83 [0.08-1.66], = 0.042), faster EDSS worsening [+0.06 points/year (0.02-0.11), = 0.010], greater 30-year EDSS [+1.72 (0.49-2.93), = 0.013; multiple sclerosis cases: +2.60 (1.30-3.87), = 2.02 × 10], and greater risk of secondary progressive multiple sclerosis [odds ratio (OR) = 12.25 (1.15-23.10), = 0.031] than -negative patients ( = 18). In contrast, -positive ( = 30) patients had preserved 30-year grey matter fraction [+0.76% (0.28-1.29), = 8.4 × 10], lower risk of cortical lesions [OR = 0.22 (0.05-0.99), = 0.049] and lower 30-year EDSS [-1.35 (-0.87,-3.44), = 0.026; multiple sclerosis cases: -2.12 (-0.87, -3.44), = 5.02 × 10] than -negative patients ( = 30). In multiple sclerosis cases, -positive patients also had slower EDSS worsening [-0.07 points/year (-0.01,-0.13), = 0.015] and lower risk of secondary progressive multiple sclerosis [OR = 0.19 (0.04-0.92), = 0.042]. These exploratory findings support diverse genetic influences on pathological mechanisms associated with multiple sclerosis disease course. influenced white matter inflammation and relapses, while (protective) and (adverse) were associated with grey matter pathology (cortical lesions and atrophy), long-term disability worsening and the risk of developing secondary progressive multiple sclerosis.