Use of induced pluripotent stem cells to recapitulate pulmonary alveolar proteinosis pathogenesis

Am J Respir Crit Care Med. 2014 Jan 15;189(2):183-93. doi: 10.1164/rccm.201306-1039OC.


Rationale: In patients with pulmonary alveolar proteinosis (PAP) syndrome, disruption of granulocyte/macrophage colony-stimulating factor (GM-CSF) signaling is associated with pathogenic surfactant accumulation from impaired clearance in alveolar macrophages.

Objectives: The aim of this study was to overcome these barriers by using monocyte-derived induced pluripotent stem (iPS) cells to recapitulate disease-specific and normal macrophages.

Methods: We created iPS cells from two children with hereditary PAP (hPAP) caused by recessive CSF2RA(R217X) mutations and three normal people, differentiated them into macrophages (hPAP-iPS-Mφs and NL-iPS-Mφs, respectively), and evaluated macrophage functions with and without gene-correction to restore GM-CSF signaling in hPAP-iPS-Mφs.

Measurements and main results: Both hPAP and normal iPS cells had human embryonic stem cell-like morphology, expressed pluripotency markers, formed teratomas in vivo, had a normal karyotype, retained and expressed mutant or normal CSF2RA genes, respectively, and could be differentiated into macrophages with the typical morphology and phenotypic markers. Compared with normal, hPAP-iPS-Mφs had impaired GM-CSF receptor signaling and reduced GM-CSF-dependent gene expression, GM-CSF- but not M-CSF-dependent cell proliferation, surfactant clearance, and proinflammatory cytokine secretion. Restoration of GM-CSF receptor signaling corrected the surfactant clearance abnormality in hPAP-iPS-Mφs.

Conclusions: We used patient-specific iPS cells to accurately reproduce the molecular and cellular defects of alveolar macrophages that drive the pathogenesis of PAP in more than 90% of patients. These results demonstrate the critical role of GM-CSF signaling in surfactant homeostasis and PAP pathogenesis in humans and have therapeutic implications for hPAP.

MeSH terms

  • Case-Control Studies
  • Cell Differentiation
  • Cells, Cultured
  • Child
  • Gene Transfer Techniques
  • Genetic Diseases, X-Linked / physiopathology*
  • Granulocyte-Macrophage Colony-Stimulating Factor / genetics
  • Granulocyte-Macrophage Colony-Stimulating Factor / physiology
  • Humans
  • Induced Pluripotent Stem Cells / metabolism*
  • Macrophages, Alveolar / metabolism
  • Pulmonary Alveolar Proteinosis / physiopathology*
  • Pulmonary Surfactants / metabolism*
  • Receptors, Granulocyte-Macrophage Colony-Stimulating Factor / deficiency*
  • Receptors, Granulocyte-Macrophage Colony-Stimulating Factor / genetics
  • Receptors, Granulocyte-Macrophage Colony-Stimulating Factor / therapeutic use
  • Signal Transduction


  • CSF2RA protein, human
  • Pulmonary Surfactants
  • Receptors, Granulocyte-Macrophage Colony-Stimulating Factor
  • Granulocyte-Macrophage Colony-Stimulating Factor

Supplementary concepts

  • Surfactant Metabolism Dysfunction, Pulmonary, 4