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Condition report · Neurological

X-Linked Adrenoleukodystrophy (ALD)

Whole genome sequencing identifies ABCD1 pathogenic variants, enabling hematopoietic stem cell transplantation or gene therapy enrollment before the MRI changes that define the narrow treatment window close.

A condition report looks for rare variants known to cause the conditions it covers.

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About this condition

An inherited peroxisomal condition caused by changes in the ABCD1 gene, in which very long chain fatty acids build up in the brain, spinal cord and adrenal glands. It includes childhood cerebral ALD, adrenomyeloneuropathy and adrenal insufficiency, and is part of newborn screening in many places.

X-linked adrenoleukodystrophy (X-ALD) is an X-linked peroxisomal disorder caused by pathogenic variants in ABCD1 (ATP-binding cassette subfamily D member 1) on chromosome Xq28, encoding the adrenoleukodystrophy protein (ALDP). ALDP transports very-long-chain fatty acids (VLCFA) into peroxisomes for beta-oxidation; its deficiency leads to VLCFA accumulation in the nervous system and adrenal cortex. X-ALD is the most common peroxisomal disorder, affecting approximately 1 in 17,000 males. Carrier females may develop adrenomyeloneuropathy (AMN), a slowly progressive spinal cord disease, in adulthood, but rarely develop the severe cerebral form.

X-ALD manifests as a spectrum of clinical phenotypes in males. Childhood cerebral ALD (ccALD), the most feared form, presents between ages 4-10 with behavioral changes, cognitive decline, visual and auditory disturbances, and rapidly progressive neurological deterioration leading to a vegetative state and death within 2-5 years without treatment. Onset is unpredictable; any hemizygous male with ABCD1 pathogenic variant has approximately a 35-40% lifetime risk of developing ccALD, with onset most often in childhood or early adolescence. Adrenomyeloneuropathy (AMN), in adults, causes slowly progressive spastic paraparesis and peripheral neuropathy. Adrenal insufficiency (Addison disease) occurs in approximately 70-80% of affected males and may be the first manifestation.

The treatment window for cerebral ALD is narrow and MRI-defined: hematopoietic stem cell transplantation (HSCT) and gene therapy (elivaldogene tavalentivec/Lenti-D, approved 2022) halt disease progression but only when MRI lesions are early (Loes score ≤9) and neurological function is preserved. Once significant neurological disability develops, transplantation provides no benefit. This creates intense urgency around early identification, boys with ABCD1 pathogenic variants need brain MRI surveillance every 6 months from ages 4-12, with immediate transplant referral when early MRI changes are detected. X-ALD is now included in newborn screening programs in many U.S. states. Carrier female relatives of affected boys can be identified by ABCD1 testing and counseled about their 35-40% risk of having an affected son.

Genotype-phenotype correlation in X-ALD is poor, the same ABCD1 variant can produce childhood cerebral ALD in one family member and adrenomyeloneuropathy in another. Phenotype cannot be predicted from the genotype, making ongoing surveillance essential for all hemizygous males.

The condition we analyse

X-linked adrenoleukodystrophy (including adrenomyeloneuropathy)

X-linked recessive

ABCD1 changes cause a range of presentations in males, from adrenal insufficiency and slowly progressive spinal cord disease (adrenomyeloneuropathy) to a rapidly progressive cerebral form in childhood; many female carriers develop milder spinal cord symptoms in adulthood.

What a diagnosis changes

Boys with an ABCD1 change are offered regular brain MRI and adrenal testing so that stem cell transplantation or gene therapy can be considered while cerebral disease is still early, and adrenal insufficiency can be treated.

Genes analysed

Also known as

ABCD1 deficiency; X-Linked Adrenoleukodystrophy; adrenoleukodystrophy, X-linked recessive; adrenomyeloneuropathy, adult; adrenomyeloneuropathy, adult, X-linked recessive; ALD; Bronze-Schilder disease; diffuse cerebral sclerosis of Schilder; Siemerling-Creutzfeldt disease; X-ALD; X-linked ALD

Includes 3 related subtypes ↓
  • adrenomyeloneuropathy
  • isolated adrenal insufficiency
  • X-linked cerebral adrenoleukodystrophy
MONDO:0018544OMIM 300100Orphanet 43MedGen 57667

Why whole genome sequencing

ABCD1 has over 900 documented pathogenic variants with no hotspot, complete gene sequencing is required. Newborn screening plasma VLCFA measurement requires confirmatory ABCD1 sequencing, which whole genome sequencing provides.

Over 900 ABCD1 variants exist with no hotspot, only complete gene sequencing detects them all

Unlike genes with a small number of common recurrent variants, ABCD1 has over 900 distinct pathogenic variants distributed throughout the gene with no single hotspot accounting for more than a few percent of cases. This private variant distribution means that a limited ABCD1 panel would have unacceptably low sensitivity. Newborn screening programs that detect elevated VLCFA on dried blood spot require confirmatory ABCD1 molecular testing to confirm the diagnosis and identify the specific pathogenic variant for family cascade testing. Whole genome sequencing provides complete ABCD1 sequence data, covering all 10 exons and flanking intronic regions, with simultaneous copy number variant analysis.

Cascade testing of at-risk male relatives must happen before the MRI surveillance window opens

When a boy is diagnosed with X-ALD, his mother is an obligate carrier. Her other sons, the patient's brothers, each have a 50% probability of being hemizygous for the ABCD1 variant. If an unidentified brother reaches age 4 without ABCD1 confirmation, he enters the childhood cerebral ALD risk window without the MRI surveillance that would detect early lesions while curative treatment remains possible. Cascade ABCD1 testing of all at-risk male relatives, using the specific familial variant identified by whole genome sequencing, allows all boys to enter the surveillance protocol before the onset window begins, providing the maximum opportunity for curative intervention.

Limitations

  • Parts of ABCD1 have closely similar copies elsewhere in the genome, which can make some variants harder to map and call with short read sequencing. Results in these regions may need confirmation by a targeted method.

Other neurological conditions

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