NMDA-receptor-Fc-fusion constructs neutralize anti- NMDA receptor antibodies

Abstract

N-methyl-D-aspartate receptor (NMDAR) encephalitis is the most common subtype of autoimmune encephalitis characterized by a complex neuropsychiatric syndrome ranging from memory impairment and psychosis to coma. Patients develop an intrathecal immune response against NMDARs with antibodies that presumably bind to the amino-terminal domain (ATD) of the GluN1 subunit. The therapeutic response to immunotherapy is often delayed and does not directly interfere with intrathecal synthesis of pathogenic antibodies. Therefore, new therapeutic approaches for fast neutralization of NMDAR antibodies are needed. Here, we developed fusion constructs consisting of the Fc part of immunoglobulin G and the ATDs of either GluN1 or GluN2B or both, GluN1 and GluN2B, subunits. Surprisingly, both subunits were required to generate high-affinity epitopes. The construct with both subunits efficiently prevented NMDAR binding of patient-derived monoclonal antibodies and of patient cerebrospinal fluid containing high-titer NMDAR antibodies. Furthermore, it inhibited the internalization of NMDARs in rodent dissociated neurons and human induced pluripotent stem cells (iPSC)-derived neurons. Finally, the construct stabilized NMDAR currents recorded in rodent neurons. Our results demonstrate that both GluN1 and GluN2B subunits contribute to the main immunogenic region of the NMDAR and provide a promising strategy for fast and specific treatment of NMDAR encephalitis, which can complement immunotherapy.