Mechanisms of acetylcholine receptor loss from the neuromuscular junction

At the normal mammalian neuromuscular junction the half-life of the acetylcholine receptor (AChR) ranges from 6 to 13 days (estimates from seven different laboratories). Indirect evidence suggests that the internalized receptor is degraded by a lysosomal mechanism. We have now traced the fate of the AChR labelled in vivo with peroxidase-alpha-bungarotoxin. Segments of junctional folds bearing AChRs are internalized by endocytosis. The endocytosed vesicles are engulfed by tubules and larger vesicles which, by electron cytochemical criteria, represent secondary lysosomes. Pathological mechanisms increased AChR loss from the end-plate. These include destruction of junctional folds, formation of immature junctions with a few or no junctional folds, accelerated internalization of AChR, impaired membrane insertion of new AChR and, possibly decreased AChR synthesis. The common mechanism for destruction of the junctional folds is an altered subsynaptic ionic milieu, and especially focal calcium excess. This can be induced by antibody and complement, too frequent or prolonged openings of the acetylcholine (ACh)-induced ion channel, and other membrane defects. In acquired autoimmune myasthenia gravis there is (a) antibody-dependent complement-mediated lysis of the junctional folds, (b) accelerated internalization of AChR cross-linked by antibody and (c) decreased insertion of AChR into the postsynaptic membrane. The last mechanism is attributed to lack of membrane patches available for tight packing and secure anchoring of the receptor. In acute, but not in chronic, experimental autoimmune myasthenia gravis, and infrequently in human myasthenia gravis, macrophages destroy junctional folds opsonized by antibody and C3. In a recently recognized congenital syndrome attributed to a prolonged open time of the ACh-induced ion channel, and to a lesser extent in congenital end-plate acetylcholinesterase deficiency, AChR is lost with degradation of junctional folds. In other, less well-defined, congenital syndromes there is deficiency or abnormal function of AChR. This could arise from decreased synthesis or membrane insertion or accelerated degradation of AChR, or from a structurally abnormal AChR with reduced affinity for ACh or with a diminished conductance or open time of its ion channel.