Patient-derived Granulocyte/Macrophage Colony-Stimulating Factor Autoantibodies Reproduce Pulmonary Alveolar Proteinosis in Nonhuman Primates

• Published in: American journal of respiratory and critical care medicine 2010-07, Vol.182 (1), p.49-61
• Main Authors: SAKAGAMI, Takuro, BECK, David, WHITSETT, Jeffrey A, LUISETTI, Maurizio, DAVIES, Stella, KRISCHER, Jeffrey P, BRODY, Alan, RYCKMAN, Fred, TRAPNELL, Bruce C, UCHIDA, Kanji, SUZUKI, Takuji, CAREY, Brenna C, NAKATA, Koh, KELLER, Gary, WOOD, Robert E, WERT, Susan E, IKEGAMI, Machiko
• Format: Article
• Language: English
• Subjects: Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Animals; Autoantibodies - adverse effects; Biological activity; Biological and medical sciences; Biomarkers; Bronchoalveolar Lavage Fluid - immunology; C. Critical Care; Disease Models, Animal; Female; Granulocyte-Macrophage Colony-Stimulating Factor - immunology; Granulocytes; Humans; Immunoglobulins; Intensive care medicine; Lavage; Leukocytes; Lipids; Lungs; Macaca fascicularis; Macrophages, Alveolar - diagnostic imaging; Macrophages, Alveolar - immunology; Medical sciences; Medical screening; Neutrophils; Pathogenesis; Patients; Pneumology; Proteins; Pulmonary Alveolar Proteinosis - immunology; Pulmonary Alveolar Proteinosis - pathology; Pulmonary hypertension. Acute cor pulmonale. Pulmonary embolism. Pulmonary vascular diseases; Surfactants; Ultrasonography
• ISSN: 1073-449X; 1535-4970
• DOI: 10.1164/rccm.201001-0008oc

Granulocyte/macrophage colony-stimulating factor (GM-CSF) autoantibodies (GMAb) are strongly associated with idiopathic pulmonary alveolar proteinosis (PAP) and are believed to be important in its pathogenesis. However, levels of GMAb do not correlate with disease severity and GMAb are also present at low levels in healthy individuals. Our primary objective was to determine whether human GMAb would reproduce PAP in healthy primates. A secondary objective was to determine the concentration of GMAb resulting in loss of GM-CSF signaling in vivo (i.e., critical threshold). Nonhuman primates (Macaca fascicularis) were injected with highly purified, PAP patient-derived GMAb in dose-ranging (2.2-50 mg) single and multiple administration studies, and after blocking antihuman immunoglobulin immune responses, in chronic administration studies maintaining serum levels greater than 40 microg/ml for up to 11 months. GMAb blocked GM-CSF signaling causing (1) a milky-appearing bronchoalveolar lavage fluid containing increased surfactant lipids and proteins; (2) enlarged, foamy, surfactant-filled alveolar macrophages with reduced PU.1 and PPARgamma mRNA, and reduced tumor necrosis factor-alpha secretion; (3) pulmonary leukocytosis; (4) increased serum surfactant protein-D; and (5) impaired neutrophil functions. GM-CSF signaling varied inversely with GMAb concentration below a critical threshold of 5 microg/ml, which was similar in lungs and blood and to the value observed in patients with PAP. GMAb reproduced the molecular, cellular, and histopathologic features of PAP in healthy primates, demonstrating that GMAb directly cause PAP. These results have implications for therapy of PAP and help define the therapeutic window for potential use of GMAb to treat other disorders.