Systematic evaluation of multifactorial causal associations for Alzheimer’s disease and an interactive platform based on Mendelian randomization analysis — MRAD

Reviewer #1 (Public Review):

Summary:

An online database called MRAD has been developed to identify the risk or protective factors for AD.

Strengths:

This study is a very intriguing study of great clinical and scientific significance that provided a thorough and comprehensive evaluation with regard to risk or protective factors for AD. It also provided physicians and scientists with a very convenient, free as well as user-friendly tool for further scientific investigation.

Weaknesses:

(1) The paper mentions that the MRAD database currently contains data only from European populations, with no mention of data from other populations or ethnicities. Given potential differences in Alzheimer's Disease (AD) across different populations, the limitations of the data should be emphasized in the discussion, along with plans to expand the database to include data from more racial and geographic regions.

(2) Sufficient information should be provided to clarify the data sources, sample selection, and quality control methods used in the MRAD database. Readers may expect more detailed information about the data to ensure data reliability, representativeness, and research applicability.

(3) While the authors mention that the MRAD database offers interactive visualization interfaces, the paper lacks detailed information on how to interpret and understand these visual results. Guidelines on effectively using these visualization tools to help researchers better comprehend the data are essential.

(4) In the conclusion section of the paper, it is advisable to explicitly emphasize the practical applications and potential clinical significance of the MRAD database. The paper should articulate how MRAD can contribute to the early identification, diagnosis, prevention, and treatment of AD and its potential societal and clinical value more clearly.

(5) Grammar and Spelling Errors: There are several spelling and grammar errors in the paper. Referring to a scientific editing service is recommended.

Reviewer #2 (Public Review):

Summary:

This MR study by Zhao et al. provides a comprehensive hypothesis-free approach to identifying risk and protective factors causal to Alzheimer's Disease (AD).

Strengths:

The study employs a comprehensive, hypothesis-free approach, which is novel over traditional hypothesis-driven studies. Also, causal associations between risk/protective factors and AD were addressed using genetic instruments and analysis.

Major comments:

(1) The authors used the inverse-variance weighted (IVW) model as the primary method and other MR methods (MR-Egger, weighted mean, etc.) for sensitivity analysis. However, each method has its own assumption, and IVW is only robust when pleiotropy and heterogeneity are not severe. Rather than using IVW imprudently across all associations, it would be more appropriate to choose the best MR method for each association based on heterogeneity/Egger intercept tests. This customized approach, based on tests of MR assumption violations, yields more stable and reliable results. For reference, please follow up on work by Milad et al. (EHJ - "Plasma lipids and risk of aortic valve stenosis: a Mendelian randomization study"). This study selected the best MR model for each association based on pleiotropy and heterogeneity tests. Given the large number of tests in this work, I suggest initially screening significant signals using IVW, as done, and then validating the results using multiple MR methods for those signals. It is common for MR estimates from different methods to vary significantly (with some being statistically significant and others not), and in such cases, the MR estimates from the best-fitted model should be trusted and highlighted.

(2) Lines 157-160 mentioned "But to date, AD has been reported as hypothesis-driven MR study based on a single factor, ignoring the potential role of a huge number of other risk factors. Also, due to the high degree of heterogeneity present in AD subtypes, which have different biological and genetic characteristics. Thus, the previous studies cannot offer a systematic and complete viewpoint.". This statement overlooks a similar study published in Molecular Psychiatry ("A Phenome-wide Association and Mendelian Randomization Study for Alzheimer's Disease: A Prospective Cohort Study of 502,493"), which rigorously assessed the effects of 4171 factors spanning 10 different categories on AD using observational analysis and MR. The authors should revise their statement on the novelty of their study type throughout the manuscript and discuss how their work differs from and potentially strengthens previous studies.

(3) Given the large number of tests, the multiple testing issue is concerning. To mitigate potential false positives, I recommend employing the Bonferroni threshold or FDR. The authors should only interpret exposures that are significant at the Bonferroni threshold.

(4) In the discussion, the authors should interpret or highlight exposures that remain significant after multiple testing corrections.