Axonopathy in Duchenne Muscular Dystrophy limits microdystrophin gene therapy efficacy

Abstract

Duchenne muscular dystrophy (DMD) is classically defined as a primary myopathy, and current AAV-mediated microdystrophin gene therapies are shown to successfully preserve muscle integrity. However, their efficacy in recovering functional outcomes remains to improve. We hypothesized that this limitation stems from an unaccounted vulnerability within the peripheral nerve. Here, we demonstrate that the mdx mouse model exhibits a peripheral axonopathy independently of muscle necrosis. Using single-nucleus RNA sequencing and structural analyses, we have identified an active denervation program and a profound failure of neural repair pathways. Importantly, we revealed that the full-length dystrophin isoform Dp427c is expressed in the healthy peripheral nerve, intimately following the cytoskeletal organization and accumulating at regions of high biomechanical stress, including Schmidt-Lanterman incisures and Nodes of Ranvier. In its absence, nerves of mdx mice loss an essential scaffolding support, leading to localized structural collapse. Furthermore, we showed that muscle-restricted microdystrophin gene therapy rescues sarcolemmal integrity but failed to restore nerve-muscle connectivity or resolved neurotransmission defects. These findings fundamentally redefine DMD as an integrated motor unit pathology, thereby underscoring the absolute necessity of implementing combined therapeutic strategies that target both the muscle and the peripheral nervous system.