Progressive accumulation of lipid-laden macrophages is a hallmark of the acid sphingomyelinase (ASM)-deficient forms of Niemann-Pick disease (i.e. Types A and B NPD). To investigate the mechanisms underlying enzyme replacement therapy for this disorder, we studied the uptake of recombinant, human ASM (rhASM) by alveolar macrophages from ASM knock-out (ASMKO) mice. The recombinant enzyme used for these studies was produced in Chinese hamster ovary cells and contained complex type, N-linked oligosaccharides. Binding of radiolabeled, rhASM to the ASMKO macrophages was enhanced as compared with normal macrophages, consistent with their larger size and increased surface area. However, internalization of the enzyme by the ASMKO cells was markedly reduced when compared with normal cells. Studies using receptor-specific ligands to inhibit enzyme uptake revealed that in normal cells rhASM was taken up by a combination of mannose and mannose 6-phosphate receptors (MR and M6PR, respectively), whereas in the ASMKO cells the M6PR had a minimal role in rhASM uptake. Expression of M6PR mRNA was normal in the ASMKO cells, although Western blotting revealed more receptors in these cells when compared with normal. We therefore hypothesized that lipid accumulation in ASMKO macrophages led to abnormalities in M6PR trafficking and/or degradation, resulting in reduced enzyme uptake. Consistent with this hypothesis, we also found that, when rhASM was modified to expose terminal mannose residues and target mannose receptors, the uptake of this modified enzyme form by ASMKO cells was Ïł10-fold greater when compared with the "complex" type rhASM. These findings have important implications for NPD enzyme replacement therapy, particularly in the lung.Types A and B Niemann-Pick disease (NPD) 1 are lysosomal storage disorders resulting from an inherited deficiency of acid sphingomyelinase (ASM) activity (EC 3.1.4.12) (1). ASM is responsible for hydrolyzing the lipid, sphingomyelin, to ceramide and phosphocholine, and both forms of the disease are characterized by extensive lipid storage in various cells and tissues. Patients with Type A NPD follow a rapid, neurodegenerative course that leads to death by about 3 years of age, whereas Type B NPD patients have a less severe form of the disease with little or no neurological involvement. This latter form is characterized mainly by visceral organ complications, including hepatosplenomegaly and progressive pulmonary compromise (1, 2). Intermediate forms also have been described (e.g. Ref.3), revealing that ASM deficiency can lead to a wide spectrum of disease.Enzyme replacement therapy was first suggested as an approach for the treatment of lysosomal storage disorders over 30 years ago (4), although difficulties in purifying the human enzymes limited its early evaluation (5-7). However, during the past decade the isolation of genes encoding most lysosomal enzymes and the development of expression systems that produced large quantities of recombinant proteins led to the successful treatment of sev...