Research ArticleLung Disease

Modeling pulmonary alveolar microlithiasis by epithelial deletion of the Npt2b sodium phosphate cotransporter reveals putative biomarkers and strategies for treatment

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Science Translational Medicine  11 Nov 2015:
Vol. 7, Issue 313, pp. 313ra181
DOI: 10.1126/scitranslmed.aac8577

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Casting the first stone for lung disease

Pulmonary alveolar microlithiasis (PAM) is a rare lung disease characterized by spherical deposits of calcium phosphate. PAM is thought to be a genetic disorder, and mutations in the gene encoding the NPT2b sodium-dependent phosphate cotransporter have been implicated. Now, Saito et al. delete Npt2b in epithelial cells in mice and observe a disease that mimics human PAM. Whole-lung EDTA can reduce the burden of stones in the lungs, and a low-phosphate diet prevents stone formation. These data support a causative role of Npt2b in PAM and suggest strategies for treatment.


Pulmonary alveolar microlithiasis (PAM) is a rare, autosomal recessive lung disorder associated with progressive accumulation of calcium phosphate microliths. Inactivating mutations in SLC34A2, which encodes the NPT2b sodium-dependent phosphate cotransporter, has been proposed as a cause of PAM. We show that epithelial deletion of Npt2b in mice results in a progressive pulmonary process characterized by diffuse alveolar microlith accumulation, radiographic opacification, restrictive physiology, inflammation, fibrosis, and an unexpected alveolar phospholipidosis. Cytokine and surfactant protein elevations in the alveolar lavage and serum of PAM mice and confirmed in serum from PAM patients identify serum MCP-1 (monocyte chemotactic protein 1) and SP-D (surfactant protein D) as potential biomarkers. Microliths introduced by adoptive transfer into the lungs of wild-type mice produce marked macrophage-rich inflammation and elevation of serum MCP-1 that peaks at 1 week and resolves at 1 month, concomitant with clearance of stones. Microliths isolated by bronchoalveolar lavage readily dissolve in EDTA, and therapeutic whole-lung EDTA lavage reduces the burden of stones in the lungs. A low-phosphate diet prevents microlith formation in young animals and reduces lung injury on the basis of reduction in serum SP-D. The burden of pulmonary calcium deposits in established PAM is also diminished within 4 weeks by a low-phosphate diet challenge. These data support a causative role for Npt2b in the pathogenesis of PAM and the use of the PAM mouse model as a preclinical platform for the development of biomarkers and therapeutic strategies.

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