NAD salvage pathway machinery expression in normal and glaucomatous retina and optic nerve
Acta Neuropathologica Communications volume 11, Article number: 18 (2023)
Glaucoma is the leading cause of irreversible blindness and is a major health and economic burden. Current treatments do not address the neurodegenerative component of glaucoma. In animal models of glaucoma, the capacity to maintain retinal nicotinamide adenine dinucleotide (NAD) pools declines early during disease pathogenesis. Treatment with nicotinamide, an NAD precursor through the NAD salvage pathway, robustly protects against neurodegeneration in a number of glaucoma models and improves vision in existing glaucoma patients. However, it remains unknown in humans what retinal cell types are able to process nicotinamide to NAD and how these are affected in glaucoma. To address this, we utilized publicly available RNA-sequencing data (bulk, single cell, and single nucleus) and antibody labelling in highly preserved enucleated human eyes to identify expression of NAD synthesizing enzyme machinery. This identifies that the neural retina favors expression of the NAD salvage pathway, and that retinal ganglion cells are particularly enriched for these enzymes. NMNAT2, a key terminal enzyme in the salvage pathway, is predominantly expressed in retinal ganglion cell relevant layers of the retina and declines in glaucoma. These findings suggest that human retinal ganglion cells can directly utilize nicotinamide and could maintain a capacity to do so in glaucoma, showing promise for ongoing clinical trials.
Age is the major risk factor for neurodegenerative disease. There is a pressing need to elucidate the underlying molecular mechanisms that drive retinal susceptibility to age. Metabolic decline may be a critical, and treatable, pathogenic component of aging and neurodegenerative disease. Neurons are highly bioenergetic and are intrinsically susceptible to mitochondrial dysfunction and metabolic failure . During normal neuronal aging, there is a decrease in metabolic activity and a concomitant increase in mitochondrial stress, which, when combined with other cofactors, leads to neurodegenerative disease. Glaucoma is one of the most common neurodegenerative diseases affecting ~ 80 million patients worldwide . It is characterized by the progressive dysfunction and death of retinal ganglion cells resulting in irreversible blindness. Current strategies to manage glaucoma only target a risk factor; elevated intraocular pressure, and do not address the neurodegenerative components of the disease.
We have previously identified metabolic dysfunction and mitochondrial abnormalities occurring prior to neurodegeneration in glaucoma. This has been demonstrated both in multiple animal models of glaucoma and in glaucoma patients [3,4,5,6]. Further work by other groups has identified mitochondrial and metabolic changes in cells derived from glaucoma patients (e.g. Tenon’s fibroblasts [7, 8]). A major finding has been that the capacity to maintain nicotinamide adenine dinucleotide (NAD, an essential metabolite in neurons) declines in the retina in an age-dependent manner and renders retinal ganglion cells susceptible to neurodegeneration . Preventing NAD depletion via administration of nicotinamide (a precursor to NAD through the NAD salvage pathway; Fig. 1) robustly prevents glaucoma in multiple animal models [3, 5, 6, 9]. Supporting a hypothesis in which age-related, pathogenically low NAD leads to glaucoma susceptibility, glaucoma patients have been demonstrated to have systemically low levels of nicotinamide (in sera)  and recent preliminary clinical trials have demonstrated that oral nicotinamide can improve visual function in existing glaucoma patients [11, 12]. This has initiated a large scale, multicenter randomized controlled trial (RCT) exploring nicotinamide for glaucoma prevention which is taking place in Sweden, Australia, Singapore, and the UK. Even though these preliminary studies have been successful and RCTs are now on-going, it is currently unknown if the target neurons in the retina contain or express the enzymatic machinery to utilize nicotinamide in its current form, and how this might change during glaucoma pathogenesis.
To address this, we assessed expression of NAD synthesizing enzymes in human retina in publicly available bulk, single cell, and single nucleus RNA-sequencing data. We compare this to protein expression by utilizing highly preserved enucleated eyes from St. Eriks Eye Hospital, Stockholm (i.e. from living donors having their eye removed due to painful glaucoma not post mortem tissue, and corresponding controls). Histological staining of high quality, tightly controlled, glaucomatous tissue from living donors identifies the enzymatic machinery in the NAD salvage pathway in the retina and optic nerve. We demonstrate that the inner retina is well-endowed with the enzymatic machinery to utilize nicotinamide directly, and identify changes in this expression profile in severe disease.
Materials and methods
Access to histopathology archive samples was fully covered through biobank #366 (St Erik Eye Hospital). The study adhered to the tenets of the Declaration of Helsinki and the ethics protocols were approved by the Swedish Ethical Review Authority (2020-01525 and 2021-01036).
We previously utilized the Ophthalmic Pathology archive at St. Erik Eye Hospital in Stockholm, Sweden, to identify a cohort of enucleated eyes from glaucoma patients and age-matched controls . Donor details are outlined in Additional file 1: Table S1. This cohort consisted of 13 control eyes and 7 glaucoma eyes. New 3 μm sections through the optic nerve head (ONH) were cut from these eyes (whole eyes embedded in paraffin wax). Sections were placed on glass slides and baked at 60 °C for 1 h. All samples labelled with the same antibody were processed as a single batch to avoid batch effects from staining. Chromogenic immunohistochemistry was performed in an automated IHC machine (Leica). Sections were deparaffinization in Bond DeWax solution, rehydrated through an ethanol gradient, prior to antigen retrieval in 1 mM EDTA buffer (pH 8.9–9.1) for 30 min at 100 °C. Sections were then washed and incubated in primary antibody for 15 min. Primary Antibodies used were: rabbit anti-NAMPT/Visfatin (Abcam, ab45890; used at 9 µg/mL), mouse anti-NMNAT1 (R&D systems, MAB5865; used at 6.7 µg/mL), mouse anti-NMNAT2 (Abcam, ab56980; used at 10 µg/mL). Slides were washed again and incubated in a polymer conjugated secondary antibody (BOND Polymer Refine Red Detection) for 50 min at room temperature followed by color development for 15 min. Two sections per eye were processed in this way with one section counterstained with hematoxylin (used only for example images to allow reference to retinal layers). Sections were dehydrated through an ethanol gradient, cleared in xylene, mounted in PERTEX, and covered with a coverslip.
Slides were scanned using a Nano Zoomer s60 (Hamamatsu Photonics KK) to acquire tiled color images (40 × objective). All samples labelled with the same antibody were imaged as a single batch with imaging parameters kept constant. Semi-quantitative image analysis was performed using a protocol based on methods described previously . Using NDP view2 software (Hamamatsu Photonics KK) image crops were acquired of the ONH, and the retina 2 mm (central) and 6 mm (mid-peripheral) from the center of the ONH (to the left and right). Control samples were eyes with uveal melanoma (since healthy eyes are not enucleated). In these eyes the tumor did not infringe on the central retina or optic nerve. We previously identified that the retina on the side of the tumor had significantly greater immune cell density. For the current analysis, we did not analyze the retina on the side of the tumor to avoid potential influence on metabolism. Images were exported to FIJI and deconvoluted using a vector for DAB/FastBlue/FastRed; the channel corresponding to FastRed was retained (the same chromogen as Polymer Refine Red). Retinal layers were isolated using the polygon selection tool and the mean pixel intensity was measured. The results were averaged between the left and right retina at each distance in glaucoma samples. Inner limiting membrane (ILM), nerve fiber layer (NFL), ganglion cell layer (GCL), inner plexiform layer (IPL), inner nuclear layer (INL), and the inner and outer segments of the photoreceptor layer (PS) were analyzed. Due to degenerative changes observed in glaucomatous tissue the ILM, NFL, and GCL were cropped as the ganglion cell complex (GCC), as is typically performed for in vivo clinical analysis using OCT , for both control and glaucoma samples when comparing these. The ONH was divided and analyzed as 5 regions of 500 µm long (in the majority of samples, there is only ~ 2–2.5 mm of ON protruding from the globe due to enucleation), beginning from a line drawn through Bruch’s membrane opening. Pixel intensity was inverted for presentation so that 0 = no signal, and 255 = maximal signal intensity.
RNA-seq analysis of human retina
We accessed whole retina bulk RNA-sequencing data from The Genotype-Tissue Expression (GTEx) Project through The Human Protein Atlas [accessed 11/22/2022]. Data are expressed as normalized transcripts per million (nTPM) where normalization uses trimmed mean of M values to allow for between-sample comparisons. The human retina NucSeq dataset  was accessed through NCBI GEO (GSE135133) and imported into Seurat v4 for analysis. Using metadata provided by the authors we retained 100,055 high quality nuclei following QC filtering. Normalization was performed using the NormalizeData() function. Features with high cell–cell variation were identified using the FindVariableFeatures() function using the VST method, using default setting to return 2000 features. And linear transformation was applied to the dataset using ScaleData() function. Principal components were computed using the variable features and UMAP dimensional reduction was performed with the first 20 dimensions. Clustering and cell annotation ID provided by the authors were used to identify the major cell types in the retina, and unidentified subpopulations were removed from further analysis. Similarly, the human retina scRNAseq dataset  was available through the NCBI GEO (GSE147979) and imported into Seurat v4 for analysis. QC filtering was performed to remove low-quality cells and doublets, and the data was normalized and scaled as previously described . Metadata provided by the authors were used for annotation for retinal cell types. For both NucSeq and scRNAseq, visualization of gene expression was generated using the Dotplot(), Ridgeplot() and Vlnplot() functions in the Seurat package.
Statistical analyses of antibody labelling were performed in R using an unpaired Student’s t-test. Unless otherwise stated, * = P < 0.05, ** = P < 0.01. For box plots, the center hinge represents the median with upper and lower hinges representing the first and third quartiles; whiskers represent 1.5 times the interquartile range.
RNA-sequencing indicates that the neural retina favors the NAD-salvage pathway for NAD synthesis
To determine which NAD-synthesizing enzymes are present in the retina we queried publicly available RNA-sequencing data to determine which genes are transcribed. We first examined whole retina bulk RNA-sequencing data from The Genotype-Tissue Expression (GTEx) Project through The Human Protein Atlas project portal, allowing for an assessment of transcripts in human retina across a sample of 105 individuals. NAD-salvage pathway transcripts (NAMPT, NMNAT1, NMNAT2, NMNAT3) were expressed in whole retina from all individuals as was NMRK1, but not NMRK2 (detected in only 32 individuals, of which all had negligible expression of < 0.5 normalized transcript per million (nTPM)). NAMPT and NMNAT3 were highly variable between individuals. The Preiss-Handler pathway transcript NAPRT was lowly expressed and only detected in 21 individuals (< 20%) but NADSYN1 was well expressed (Fig. 1B).
Next, we determined which cells express these transcripts by examining publicly available single cell sequencing data from human retina. We examined two independent datasets: a single cell RNA-sequencing dataset (scRNAseq) from 4 individual postmortem normal retina (~ 15,000 cells) and single nucleus RNA-sequencing dataset (NucSeq) from 4 individual postmortem normal retina (~ 100,000 nuclei in total). These allowed for identification of expression in retinal neurons (cones, rods, horizontal cells (HCs), bipolar cells (BPs), amacrine cells (ACs), retinal ganglion cells (RGCs)), and non-neuronal retinal cells (myeloid/microglia and Müller glia, and additionally astrocyte, vascular cells, and retinal pigment epithelial cells (RPE cells) in the NucSeq; Fig. 2). NAPRT was lowly expressed in only a small percentage of neurons in the scRNAseq and NucSeq (Fig. 2A). In contrast, NAMPT expression was greater in all retinal neurons (Fig. 2A) indicating a preference for the NAD-salvage pathway over the Preiss-Handler pathway. Likewise, NADSYN1, the terminal enzyme of the Preiss-Handler pathway, was expressed in very few retinal neurons compared to NMNAT1-3 (Fig. 2A). NMRK1 expression was detected in very few neurons, and NMRK2 was almost entirely absent, indicating a preference for nicotinamide (NAM) as a substrate over nicotinamide riboside (NR) in retinal neurons (Fig. 2A). Of these, RGCs had both the highest average expression and highest percentage of cells expressing NAD-salvage pathway transcripts (Fig. 2A). NAMPT and NMNAT1 appear to be particularly important in RGCs over other retinal neurons, while NMNAT2 expression was exclusive to RGCs in the scRNAseq, with NucSeq demonstrating that other retinal neurons do express NMNAT2, but to a lesser extent (Fig. 2B). Examining the distribution of expression (Fig. 2C, ridgeplots) revealed NAMPT and NMNAT1 expression to be normally distributed, whereas NMNAT2 had a greater variance, perhaps indicating RGC-subtype specific variation in NMNAT2. NMNAT3 expression was greatest in rods and cones, followed by RGCs (Fig. 2A–C), given that NMNAT3 mRNA has a mitochondrial targeting sequence this would appear to fit with the high density of mitochondria in these neurons. However, NMNAT3 is known to be translationally repressed due to an upstream open reading frame in the mRNA 5′UTR region and mature protein has only been identified in cells following over-expression through plasmid transfection . Although rods, cones, and RGCs express NMNAT3 it is, therefore, unlikely to have a functional role at a protein level in these cells.
In the non-neuronal cells of the retina, all transcripts were expressed in a lower percentage of cells than in neuronal cells, with the exception of NAMPT and NMNAT3 (Fig. 2A–C), perhaps reflecting the lower metabolic demands of these cell types relative to neurons. NAMPT was expressed by a higher percentage of microglia/myeloid cells, astrocytes, Müller glia, vascular cells, and RPEs than in neuronal cell types; its average expression was greatest in microglia/myeloid cells (Fig. 2A, B). Expression of NAPRT, NMRK1, and NADSYN1 was generally greater than in retinal neurons (except RGCs) demonstrating that non-neuronal cells in the retina may have a greater flexibility in NAD production by utilizing more substrates and pathways (Fig. 2A, B). Supporting this, when we expanded our examination to other cell types of the eye in the scRNAseq (e.g. corneal epithelial cells, ciliary body cells) we identified that NMRK1 and NADSYN1 average expression and percentage of expressing cells is far greater in the anterior chamber of the eye (Additional file 2: Fig. S1). This suggests that while the retina favors the NAD-salvage pathway, the anterior chamber favors the Preiss-Handler pathway and nicotinamide riboside as an alternative substrate to the NAD-salvage pathway.
Antibody labelling identifies the presence of NAD salvage pathway machinery in normal retina and optic nerve
Identification of transcript expression does not determine that a mature protein is expressed since cells employ multiple mechanisms of translational regulation. No protein data is available from the Human Protein Atlas project for any of the NAD-producing enzymes. We therefore utilized a unique resource of enucleated human eyes from the St. Erik Eye Hospital Ophthalmic Pathology archive. We previously identified and characterized 6 glaucoma and 12 control (uveal melanoma, since healthy eyes are not enucleated) eyes from this archive . Importantly, since these eyes are live enucleations and fixed immediately, there are no post-mortem degenerative confounders. We used immunohistochemistry to determine localized protein expression across the retina. We focused on the NAD-salvage pathway since this was the predominant pathway identified through RNA-sequencing. NAMPT was distributed across all layers of the central and mid-peripheral retina, but was greatest in the nuclear layers, particularly the INL (n = 11 control eyes; Fig. 3A). NMNAT1 was clearly confined to the nuclear layers and overlapped with hematoxylin, consistent with its known nuclear localization (n = 11 control eyes; Fig. 3B). Conversely, NMNAT2 labelling was largely uniform across nuclear and plexiform layers and had the highest relative intensity in the RNFL compared to the rest of the retina of all the antibodies tested. NMNAT2 labelling was greatest in the GCL, this was more pronounced in the central, compared to mid-peripheral, retina where RGC density is higher (n = 11 control eyes; Fig. 3C).
NAMPT labelling was present in the both the axon and glial compartments of the optic nerve but was more intense in the latter; the labelling was highly uniform along the optic nerve length (n = 11 control eyes; Fig. 3D). NMNAT1 (n = 10 control eyes) and NMNAT2 (n = 8 control eyes) labelling demonstrated contrasted localization with NMNAT1 located only in nuclei (particularly high in glia compartments; Fig. 3E) and NMNAT2 only in axons (no labeling within or around nuclei, as can be seen in Fig. 3F inset). While NMNAT1 labelling was highly uniform along the optic nerve (Fig. 3E), NMNAT2 was significantly greater in the initial 500 µm (representing the pre-lamina, lamina cribrosa and initial pos-laminar region; Fig. 3F). This may reflect the increased density of axons relative to glia and connective tissue here, as well as the optic nerve head representing a particularly metabolically active portion of the optic nerve where axons first become myelinated.
NAD salvage pathway machinery labelling is reduced in glaucoma
To determine if the expression patterns of these NAD salvage pathway machinery are altered in glaucoma, we compared the control eyes with 7 glaucoma eyes. Since the glaucoma tissue is from late-stage disease, we accounted for remodeling of the inner retinal layers by delineating the whole ganglion cell complex (GCC; combined RNFL, GCL, and IPL) as is common for in vivo OCT imaging studies. NAMPT labelling in the central retina was significantly reduced in the GCC in glaucomatous samples relative to controls and was not significantly altered in the INL or outer retina (n = 11 control eyes, 7 glaucoma eyes; Fig. 4A). NMNAT1 was significantly reduced in the GCC and INL in both central and mid-peripheral retina, with no detectable difference in the outer retina (n = 11 control eyes, 7 glaucoma eyes; Fig. 4B). NMNAT2 labelling was significantly reduced only in the central retina GCC in glaucomatous samples (n = 11 control eyes, 7 glaucoma eyes; Fig. 4C). These changes likely reflect the loss of RGC axons, cell somas, and dendrites, and potential subsequent structural and metabolic remodeling of the INL. In the ONH NAMPT was significantly reduced in the first 500 µm and was otherwise unchanged across the remaining nerve (n = 11 control eyes, 5 glaucoma eyes; Fig. 4D). This pattern was also evident for NMNAT1 (n = 10 control eyes, 5 glaucoma eyes) and NMNAT2 (n = 8 control eyes, 5 glaucoma eyes; Fig. 4E, F). These changes are predominantly a reflection of the loss of neural content through cupping and excavation of the ONH in this late stage of disease.
Taken together, these findings demonstrate that the inner retina and proximal optic nerve/optic nerve head is highly enriched with the machinery to directly utilize nicotinamide through the salvage pathway. However, while the ability to utilize nicotinamide remains in glaucoma, the capacity to do so may be lower during disease.
Vision loss from glaucoma is a significant health and economic burden. However, the only current strategies to manage glaucoma target a risk factor; elevated intraocular pressure, and do not address the neurodegenerative components of the disease. Development of neuroprotective therapies and a clear understanding of their potential mechanisms of action is of crucial importance. NAD production is an ideal target for neuroprotection in glaucoma and other age-related ophthalmic diseases. In mammals, NAD is produced through 3 primary pathways: de novo from tryptophan, the Preiss-Handler pathway from niacin, and the NAD salvage pathway from nicotinamide (and an alternate entry route in from nicotinamide riboside) . The maintenance of NAD pools in neurons is most critically controlled by the NAD salvage pathway (Fig. 1). We demonstrate that the retina, as a whole, has a greater transcript abundance for the NAD salvage pathway over the Preiss-Handler pathway. Single cell/nucleus RNA sequencing data confirmed that this preference is also reflected in transcript abundance in all neuronal types of the retina. NAPRT was below expression cut-off in ~ 80% of retina in the bulk RNA-sequencing data and below expression cut-off in > 90% of all cells in the single cell and single nucleus sequencing data. These data suggest that the Preiss-Handler pathway has a very limited role in the retina. The NAD salvage pathway starts with nicotinamide and goes through a two-step reaction to become NAD. The first step to NMN is catalyzed by NAMPT, likely to be the rate limiting enzyme in this pathway. The final step of NAD production in neurons is controlled through two terminal enzymes; NMNAT1 (localized to the nucleus) and NMNAT2 (localized in the cytoplasm) . This distribution is particularly evident in our retinal histology, with NMNAT1 colocalizing to hematoxylin within the retinal nuclear layers and NMNAT2 present in the cytoplasm throughout the retinal neuropil of the nuclear and plexiform layers. This is most apparent in the optic nerve where NMNAT1 is found only within glia (the only nucleated cells in the nerve) and NMNAT2 in the axonal component (RGC axons only). We have previously used the compartmentalized nature of these enzymes to identify neuroprotective mechanisms at the level of the soma (NMNAT1)  or axon (NMNAT2 and the WLDS fusion protein) . As such, both NMNAT1 and NMNAT2 may be valid treatment targets in the context of glaucoma and optic neuropathies. NAMPT was distributed across all retinal layers and localized to both nuclei and cytoplasm reflecting its need for localized NMN production at the site of both NMNAT1 and NMNAT2.
As a neuron-specific, cytosolically expressed protein, NMNAT2 is emerging as an extremely important NAD producing enzyme in axons, protecting from axon degeneration. NMNAT2 expression is decreased in brains with Alzheimer's disease and has a highly variable expression in aged postmortem human brains . We have previously demonstrated that there is down-regulation of Nmnat2 in rodent RGCs in both an age- and disease-dependent manner [3, 21] and we hypothesized that NMNAT2 expression levels may be a potential risk factor in human glaucoma. We expand this knowledge by demonstrating that RGCs are the predominant NMNAT2 gene expressing neurons of the retina (reflecting the fact that they are the only retinal neuron with a true axon i.e. a large cytoplasmic volume), and that NMNAT2 protein is greatest in the RGC relevant layers of the retina and localizes to RGC axons in the optic nerve. NMNAT2 expression was variable in the retina and optic nerve head, which could potentially contribute to the variability of glaucoma progression. NMNAT2 has a rapid turnover time in vivo . Importantly, since we used eyes that are live enucleations and fixed immediately, there are no post-mortem degenerative confounders or potential for loss of protein through rapid turnover. It is important to note, that these glaucoma eyes represent a more severe disease stage than might be first identified in the clinic and that this loss of NMNAT2 might be due to the loss of neuronal content in the retina.
There was visible variability in the labeling intensity of NMNAT1 between nuclei in the retinal nuclear layers. The single cell/nuclear sequencing data reflects this, with low percentage expression across cell types (i.e. expression below cut-off in the majority of cells). Co-labelling with specific cell markers would be needed to identify whether this variability reflects inter- or intra- cell type variability. It is worth noting that the expression-cut offs in the single cell/nucleus sequencing have a high threshold for detection; in the NucSeq, on average only 2266 genes per nucleus were detected (of the ~ 10,000 transcribed genes typical in a cell type). The true percentage of cells expressing these genes is likely much higher.
Non-neuronal cells in the retina and eye had greater expression of Preiss-Handler pathway genes than neuronal cells, suggesting a lower reliance on the NAD-salvage pathway. Non neuronal cells also had greater expression of NMRK1, suggesting a greater ability to utilize nicotinamide riboside as an alternative NAD substrate. NAMPT gene expression was also proportionally higher in non-neuronal cells in the retina (microglia/myeloid, astrocytes, vascular cells, and RPEs), however protein labelling appears greater in the round nuclei of the GCL and INL than in non-uniform nuclei in the IPL (typically microglia/myeloid) or in small capillary vascular walls. Conversely, there was intense labelling surrounding nuclei in the glial framework of the optic nerve head and the vasculature of the central retinal vessels (intense labelling in the RPE is also apparent in ONH overview image, Fig. 3D), which better matched the single cell/nuclear sequencing. The high expression of NAMPT in microglia and monocytes may reflect its importance in immune responses. NAMPT is a metabolic regulator of immune states, especially as a negative regulator of Sirtuins through NMN:NAD ratio [23, 24]. NAMPT is up-regulated in microglia in immune activation and NAMPT is secreted via exosomes into the extracellular space where is functions as both an enzyme regulating extracellular NAD, but also directly as a cytokine (e.g. as a toll-like receptor-4 ligand) . The NAMPT inhibitor FK866, ameliorates pro-inflammatory responses in cultured microglia and in the brain following injury . NAMPT was also well labelled in the axonal portion of the optic nerve matching the known role of local NMN in axonal degeneration . That NAMPT labeling was largely stable relative to controls in the glaucomatous optic nerves, suggests that changes in NAMPT at least, may not be directly associated to any NMN mediated axonal degeneration.
Supplementation of high dose nicotinamide has demonstrated robust neuroprotection in glaucoma across multiple animal species and models [3, 6] and has demonstrated improvements to retinal visual function in short-term clinical trials [11, 12]. It is important to understand whether nicotinamide can be used natively within the retina, or whether metabolic changes to the molecular structure need to occur for it to be fully utilized by retinal neurons. In this study, we demonstrate that NAD salvage machinery is well-expressed in the inner retina suggesting that retinal ganglion cells have the ability to utilize nicotinamide directly. This is supported by our earlier mouse studies demonstrating that isolated retinal neurons and optic nerve cells can utilize nicotinamide directly to generate high levels of NAD . Taken together, this provides strong evidence that human retinal neurons can use nicotinamide directly and gives confidence into the ongoing clinical trials. Our finding that NAMPT, NMNAT1, and NMNAT2 labelling decreases in the inner retina with severe disease might limit this NAD synthesis in more severe glaucoma patients, however, these enzymes remain detectable at 32%, 49%, and 46% respectively, supporting the ability to generate NAD even in more diseased retina. This is consistent with the known deleterious effects of complete loss of NAD production e.g. spontaneous knockdown of Nmnat2 triggers Wallerian degeneration in mouse neurons  and reduction of function mutations in NMNAT1 cause Leber’s congenital amaurosis  (a rapid photoreceptor degenerative disease resulting in blindness). Considering that glaucoma patients have reduced nicotinamide in sera , reduced substrate may compound this loss of NAD salvage enzymes resulting in low NAD production or a lower and less responsive dynamic range of NAD production, acting as a critical pathomechanism. These results should also aid in the design of clinical trials for other retinal diseases affecting other retinal cells (e.g. the high expression of NMNAT1 in photoreceptors in the outer retina).
These findings demonstrate that the inner retina and optic nerve head is highly enriched with the machinery to directly utilize nicotinamide through the salvage pathway and that the ability to do so is maintained, but the capacity to do so may be lower in glaucoma.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. The whole retina, bulk RNA-sequencing data was available from The Genotype-Tissue Expression (GTEx) Project accessed through The Human Protein Atlas. The human retina NucSeq dataset was accessed through NCBI GEO (GSE135133) and the scRNAseq dataset was available through the NCBI GEO (GSE147979).
Ganglion cell complex
Ganglion cell layer
Inner limiting membrane
Inner nuclear layer
Inner plexiform layer
Nicotinamide adenine dinucleotide
Nerve fiber layer
Normalized transcripts per million
Single nucleus RNA-sequencing
Optical coherence tomography
Optic nerve head
Inner and outer segments of the photoreceptor layer
Randomized controlled trial
Retinal ganglion cell
Single cell RNA-sequencing
Verdin E (2015) NAD+ in aging, metabolism, and neurodegeneration. Science 350:1208–1213
Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY (2014) Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology 121:2081–2090
Williams PA, Harder JM, Foxworth NE, Cochran KE, Philip VM, Porciatti V et al (2017) Vitamin B-3 modulates mitochondrial vulnerability and prevents glaucoma in aged mice. Science 355:756–760
Tribble JR, Vasalauskaite A, Redmond T, Young RD, Hassan S, Fautsch MP et al (2019) Midget retinal ganglion cell dendritic and mitochondrial degeneration is an early feature of human glaucoma. Brain Commun 1:fcz035
Harder JM, Guymer C, Wood JPM, Daskalaki E, Chidlow G, Zhang C, et al. Disturbed glucose and pyruvate metabolism in glaucoma with neuroprotection by pyruvate or rapamycin. Proc Natl Acad Sci U S A 2020
Tribble JR, Otmani A, Sun S, Ellis SA, Cimaglia G, Vohra R et al (2021) Nicotinamide provides neuroprotection in glaucoma by protecting against mitochondrial and metabolic dysfunction. Redox Biol 43:101988
Vallabh NA, Armstrong J, Czanner G, McDonagh B, Choudhary A, Criddle DN et al (2022) Evidence of impaired mitochondrial cellular bioenergetics in ocular fibroblasts derived from glaucoma patients. Free Radic Biol Med 189:102–110
Want A, Gillespie SR, Wang Z, Gordon R, Iomini C, Ritch R et al (2016) Autophagy and mitochondrial dysfunction in Tenon fibroblasts from exfoliation glaucoma patients. PLoS ONE 11:e0157404
Chou TH, Romano GL, Amato R, Porciatti V (2020) Nicotinamide-rich diet in DBA/2J mice preserves retinal ganglion cell metabolic function as assessed by PERG adaptation to flicker. Nutrients 12
Kouassi Nzoughet J, Chao de la Barca JM, Guehlouz K, Leruez S, Coulbault L, Allouche S et al (2019) Nicotinamide deficiency in primary open-angle glaucoma. Invest Ophthalmol Vis Sci 60:2509–2514
Hui F, Tang J, Williams PA, McGuinness MB, Hadoux X, Casson RJ et al (2020) Improvement in inner retinal function in glaucoma with nicotinamide (vitamin B3) supplementation: a crossover randomized clinical trial. Clin Exp Ophthalmol 48:903–914
De Moraes CG, John SWM, Williams PA, Blumberg DM, Cioffi GA, Liebmann JM (2022) Nicotinamide and pyruvate for neuroenhancement in open-angle glaucoma: a phase 2 randomized clinical trial. JAMA Ophthalmol 140:11–18
Rutigliani C, Tribble JR, Hagström A, Lardner E, Jóhannesson G, Stålhammar G et al (2022) Widespread retina and optic nerve neuroinflammation in enucleated eyes from glaucoma patients. Acta Neuropathol Commun 10:118
Scuderi G, Fragiotta S, Scuderi L, Iodice CM, Perdicchi A (2020) Ganglion cell complex analysis in glaucoma patients: What can it tell us? Eye Brain 12:33–44
Orozco LD, Chen HH, Cox C, Katschke KJ, Arceo R, Espiritu C et al (2020) Integration of eQTL and a single-cell atlas in the human eye identifies causal genes for age-related macular degeneration. Cell Rep 30:1246–59.e6
Gautam P, Hamashima K, Chen Y, Zeng Y, Makovoz B, Parikh BH et al (2021) Multi-species single-cell transcriptomic analysis of ocular compartment regulons. Nat Commun 12:5675
Felici R, Lapucci A, Ramazzotti M, Chiarugi A (2013) Insight into molecular and functional properties of NMNAT3 reveals new hints of NAD homeostasis within human mitochondria. PLoS ONE 8:e76938
Lautrup S, Sinclair DA, Mattson MP, Fang EF (2019) NAD. Cell Metab 30:630–655
Williams PA, Harder JM, Foxworth NE, Cardozo BH, Cochran KE, John SWM (2017) Nicotinamide and WLDS act together to prevent neurodegeneration in glaucoma. Front Neurosci 11
Ali YO, Allen HM, Yu L, Li-Kroeger D, Bakhshizadehmahmoudi D, Hatcher A et al (2016) NMNAT2:HSP90 complex mediates proteostasis in proteinopathies. PLoS Biol 14:e1002472
Williams PA, Harder JM, Cardozo BH, Foxworth NE, John SWM (2018) Nicotinamide treatment robustly protects from inherited mouse glaucoma. Commun Integr Biol 11:e1356956
Gilley J, Coleman MP (2010) Endogenous Nmnat2 is an essential survival factor for maintenance of healthy axons. PLoS Biol 8:e1000300
Skokowa J, Lan D, Thakur BK, Wang F, Gupta K, Cario G et al (2009) NAMPT is essential for the G-CSF-induced myeloid differentiation via a NAD(+)-sirtuin-1-dependent pathway. Nat Med 15:151–158
Vachharajani VT, Liu T, Wang X, Hoth JJ, Yoza BK, McCall CE (2016) Sirtuins link inflammation and metabolism. J Immunol Res 2016:8167273
Lu YB, Chen CX, Huang J, Tian YX, Xie X, Yang P et al (2019) Nicotinamide phosphoribosyltransferase secreted from microglia via exosome during ischemic injury. J Neurochem 150:723–737
Chen CX, Huang J, Tu GQ, Lu JT, Xie X, Zhao B et al (2017) NAMPT inhibitor protects ischemic neuronal injury in rat brain via anti-neuroinflammation. Neuroscience 356:193–206
Di Stefano M, Nascimento-Ferreira I, Orsomando G, Mori V, Gilley J, Brown R et al (2015) A rise in NAD precursor nicotinamide mononucleotide (NMN) after injury promotes axon degeneration. Cell Death Differ 22:731–742
Koenekoop RK, Wang H, Majewski J, Wang X, Lopez I, Ren H et al (2012) Mutations in NMNAT1 cause Leber congenital amaurosis and identify a new disease pathway for retinal degeneration. Nat Genet 44:1035–1039
The authors would like to thank St. Erik Eye Hospital for financial support for research and clinical histopathology space. We used data from the The Genotype-Tissue Expression (GTEx) Project, which is supported by the Common Fund of the Office of the Director of the National Institutes of Health, and by NCI, NHGRI, NHLBI, NIDA, NIMH, and NINDS.
Open access funding provided by Karolinska Institutet. PAW is supported by Karolinska Institutet in the form of a Board of Research Faculty Funded Career Position, by St. Erik Eye Hospital philanthropic donations, Vetenskapsrådet 2018-02124 and 2022-00799, and Ögonfonden. PAW is an Alcon Research Institute Young Investigator. RCBW is supported by the National Health and Medical Research Council (Ideas grant) and Centre for Eye Research Australia Foundation.
Ethical approval and consent to participate
Access to histopathology archive samples was fully covered through biobank #366 (St Erik Eye Hospital). The study adhered to the tenets of the Declaration of Helsinki and the ethics protocols were approved by the Swedish Ethical Review Authority (2020-01525 and 2021-01036).
Consent for publication
PAW is an inventor on an awarded US patent held by The Jackson Laboratory for nicotinamide treatment in glaucoma (“Treatment and prevention of ocular neurodegenerative disorder”, US11389439B2). All other authors declare that they have no competing interests.
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The single cell RNA-sequencing dataset also contains annotated cell types from other tissues of the eye. Cells in the anterior of the eye (e.g. corneal epithelial cells, ciliary body cells) had high average expression in a high percentage of cells for NMRK1, and to a lesser extent NADSYN1. This is greater in comparison to retinal cells, suggesting that while the retina favors the NAD-salvage pathway, the anterior chamber favors the Preiss-Handler pathway and nicotinamide riboside as an alternative substrate to the NAD-salvage pathway.
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Tribble, J.R., Hagström, A., Jusseaume, K. et al. NAD salvage pathway machinery expression in normal and glaucomatous retina and optic nerve. acta neuropathol commun 11, 18 (2023). https://doi.org/10.1186/s40478-023-01513-0