A Comprehensive Head-to-Head Comparison of Key Plasma Phosphorylated Tau 217 Biomarker Tests
Authors: Warmenhoven Noëlle , Salvadó Gemma , Janelidze Shorena , Mattsson-Carlgren Niklas , Bali Divya , Dolado Anna Orduña , Kolb Hartmuth , Triana-Baltzer Gallen , Barthélemy Nicolas R. , Schindler Suzanne E. , Aschenbrenner Andrew J. , Raji Cyrus A. , Benzinger Tammie L.S. , Morris John C. , Ibanez Laura , Timsina Jigyasha , Cruchaga Carlos , Bateman Randall J. , Ashton Nicholas , Arslan Burak , Zetterberg Henrik , Blennow Kaj , Binette Alexa Pichet , Hansson Oskar 
Published: July 2024

Plasma phosphorylated-tau 217 (p-tau217) is currently the most promising biomarkers for reliable detection of Alzheimer’s disease (AD) pathology. Various p-tau217 assays have been developed, but their relative performance is unclear. We compared key plasma p-tau217 tests using cross-sectional and longitudinal measures of amyloid-β (Aβ)-PET, tau-PET, and cognition as outcomes, and benchmarked them against cerebrospinal fluid (CSF) biomarker tests.

Samples from 998 individuals (mean[range] age 68.5[20.0-92.5], 53% female) from the Swedish BioFINDER-2 cohort were analyzed. Plasma p-tau217 was measured with mass spectrometry (MS) assays (the ratio between phosphorylated and non-phosphorylated [%p-tau217WashU]and p-tau217WashU) as well as with immunoassays (p-tau217Lilly, p-tau217Janssen, p-tau217ALZpath). CSF biomarkers included p-tau217Lilly, and the FDA-approved p-tau181/Aβ42Elecsysand p-tau181Elecsys.

All plasma p-tau217 tests exhibited high ability to detect abnormal Aβ-PET (AUC range: 0.91-0.96) and tau-PET (AUC range: 0.94-0.97). Plasma %p-tau217WashUhad the highest performance, with significantly higher AUCs than all the immunoassays (Pdiff<0.007). For detecting Aβ-PET status, %p-tau217WashUhad an accuracy of 0.93 (immunoassays: 0.83-0.88), sensitivity of 91% (immunoassays: 84-87%), and a specificity of 94% (immunoassays: 85-89%). Among immunoassays, p-tau217Lillyand plasma p-tau217ALZpathhad higher AUCs than plasma p-tau217Janssenfor Aβ-PET status (Pdiff<0.006), and p-tau217Lillyoutperformed plasma p-tau217ALZpathfor tau-PET status (Pdiff=0.025). Plasma %p-tau217WashUexhibited higher associations with all PET load outcomes compared to immunoassays; baseline Aβ-PET load (R2: 0.72; immunoassays: 0.47-0.58; Pdiff<0.001), baseline tau-PET load (R2: 0.51; immunoassays: 0.38-0.45; Pdiff<0.001), longitudinal Aβ-PET load (R2: 0.53; immunoassays: 0.31-0.38; Pdiff<0.001) and longitudinal tau-PET load (R2: 0.50; immunoassays: 0.35-0.43; Pdiff<0.014). Among immunoassays, plasma p-tau217Lillywas more strongly associated with Aβ-PET load than plasma p-tau217Janssen(Pdiff<0.020) and with tau-PET load than both plasma p-tau217Janssenand plasma p-tau217ALZpath(allPdiff<0.010). Plasma %p-tau217 also correlated more strongly with baseline cognition (Mini-Mental State Examination[MMSE]) than all immunoassays (R2%p-tau217WashU: 0.33; immunoassays: 0.27-0.30;Pdiff<0.024). The main results were replicated in an external cohort from Washington University in St Louis (n=219). Finally, p-tau217Nulisashowed similar performance to other immunoassays in subsets of both cohorts.

In summary, both MS-and immunoassay-based p-tau217 tests generally perform well in identifying Aβ-PET, tau-PET, and cognitive abnormalities, but %p-tau217WashUperformed significantly better than all the examined immunoassays. Plasma %p-tau217 may be considered as a stand-alone confirmatory test for AD pathology, while some immunoassays might be better suited as triage tests where positive results are confirmed with a second test.