Pyruvate and Related Energetic Metabolites Modulate Resilience Against High Genetic Risk for Glaucoma

Reviewer #1 (Public review):

Summary:

The authors explore associations between plasma metabolites and glaucoma, a primary cause of irreversible vision loss worldwide. The study relies on measurements of 168 plasma metabolites in 4,658 glaucoma patients and 113,040 controls from the UK Biobank. The authors show that metabolites improve the prediction of glaucoma risk based on polygenic risk score (PRS) alone, albeit weakly. The authors also report a "metabolomic signature" that is associated with a reduced risk (or "resilience") for developing glaucoma among individuals in the highest PRS decile (reduction of risk by an estimated 29%). The authors highlight the protective effect of pyruvate, a product of glycolysis, for glaucoma development and show that this molecule mitigates elevated intraocular pressure and optic nerve damage in a mouse model of this disease.

Strengths:

This work provides additional evidence that glycolysis may play a role in the pathophysiology of glaucoma. Previous studies have demonstrated the existence of an inverse relationship between intraocular pressure and retinal pyruvate levels in animal models (Hader et al. 2020, PNAS 117(52)) and pyruvate supplementation is currently being explored for neuro-enhancement in patients with glaucoma (De Moraes et al. 2022, JAMA Ophthalmology 140(1)). The study design is rigorous and relies on validated, standard methods. Additional insights gained from a mouse model are valuable.

Weaknesses:

Caution is warranted when examining and interpreting the results of this study. Among all participants (cases and controls) glaucoma status was self-reported, determined on the basis of ICD codes or previous glaucoma laser/surgical therapy. This is problematic as it is not uncommon for individuals in the highest PRS decile to have undiagnosed glaucoma (as shown in previous work by some of the authors of this article). The authors acknowledge a "relatively low glaucoma prevalence in the highest decile group" but do not explore how undiagnosed glaucoma may affect their results. This also applies to all controls selected for this study. The authors state that "50 to 70% of people affected [with glaucoma] remain undiagnosed". Therefore, the absence of self-reported glaucoma does not necessarily indicate that the disease is not present. Validation of the findings from this study in humans is, therefore, critical. This should ideally be performed in a well-characterized glaucoma cohort, in which case and control status has been assessed by qualified clinicians.

The authors indicate that within the top decile of PRS participants with glaucoma are more likely to be of white ethnicity, while they are more likely to be of Black and Asian ethnicity if they are in the bottom half of PRS. Have the authors explored how sensitive their predictions are to ethnicity? Since their cohort is predominantly of European ancestry (85.8%), would it make sense to exclude other ethnicities to increase the homogeneity of the cohort and reduce the risk for confounders that may not be explicitly accounted for?

The authors discuss the importance of pyruvate, and lactate for retinal ganglion cell survival, along with that of several lipoproteins for neuroprotection. However, there is a distinction to be made between locally produced/available glycolysis end products and lipoproteins and those circulating in the blood. It may be useful to discuss this in the manuscript, and for the authors to explore if plasma metabolites may be linked to metabolism that takes place past the blood-retinal barrier.

Reviewer #2 (Public review):

Summary:

The authors have used the UK Biobank data to interrogate the association between plasma metabolites and glaucoma.

(1) They initially assessed plasma metabolites as predictors of glaucoma: The addition of NMR-derived metabolomic data to existing models containing clinical and genetic data was marginal.

(2) They then determined whether certain metabolites might protect against glaucoma in individuals at high genetic risk: Certain molecules in bioenergetic pathways (lactate, pyruvate, and citrate) conferred protection.

(3) They provide support for protection conferred by pyruvate in a murine model.

Strengths:

(1) The huge sample size supports a powerful statistical analysis and the opportunity for the inclusion of multiple covariates and interactions without overfitting the models.

(2) The authors have constructed a robust methodology and statistical design.

(3) The manuscript is well written, and the study is logically presented.

(4) The figures are of good quality.

(5) Broadly, the conclusions are justified by the findings.

Weaknesses:

(1) Although it is an invaluable treasure trove of data, selection bias and self-reporting are inescapable problems when using the UK Biobank data for glaucoma research. The high-impact glaucoma-related GWAS publications (references 26 and 27) referenced in support of the method suffer the same limitations. This doesn't negate the conclusions but must be taken into consideration. The authors might note that it is somewhat reassuring that the proportion of glaucoma cases (4%) is close to what would be expected in a population-based study of 40-69-year-olds of predominantly white ethnicity.

(2) As noted by the authors, a limitation is the predominantly white ethnicity profile that comprises the UK Biobank.

(3) Also as noted by the authors, the study is cross-sectional and is limited by the "correlation does not imply causation" issue.

(4) The optimal collection, transport, and processing of the samples for NMR metabolite analysis is critical for accurate results. Strict policies were in place for these procedures, but deviations from protocol remain an unknown influence on the data.

(5) In addition, all UK Biobank blood samples had unintended dilution during the initial sample storage process at UK Biobank facilities. (Julkunen, H. et al. Atlas of plasma NMR biomarkers for health and disease in 118,461 individuals from the UK Biobank. Nat Commun 14, 604 (2023) Samples from aliquot 3, used for the NMR measurements, suffered from 5-10% dilution. (Allen, Naomi E., et al. Wellcome Open Research 5 (2021): 222.) Julkunen et al. report that "The dilution is believed to come from mixing of participant samples with water due to seals that failed to hold a system vacuum in the automated liquid handling systems. While this issue is likely to have an impact on some of the absolute biomarker concentration values, it is expected to have limited impact on most epidemiological analyses."

Impact:

The findings advance personalized prognostics for glaucoma that combine metabolomic and genetic data. In addition, the protective effect of certain metabolites influences further research on novel therapeutic strategies.