Myasthenia gravis (MG) is caused by the failure of neuromuscular transmission mediated by pathogenic autoantibodies (Abs) against the acetylcholine receptor (AChR), muscle-specific receptor tyrosine kinase (MuSK), and unknown autoantibodies. The seropositivity rates for routine AChR binding Ab and MuSK Ab in MG are 85% and a few % for MG patients in Japan, respectively. The autoimmune target in the remaining patients is unknown. In 2001, Hoch et al. reported that a proportion of AChR-Ab-negative MG patients had serum IgG antibodies against MuSK, shedding new light on the pathogenesis of the disease. This idea has been recently supported by many clinical studies, including neonatal myasthenic syndrome and animal model studies. In 2011, autoantibodies against low-density lipoprotein receptor-related protein 4(Lrp4) were identified in Japanese MG patients and, thereafter, have been reported in Germany and the USA. We developed a simple technique termed Gaussia luciferase immunoprecipitation for detecting antibodies to Lrp4. As a result, nine generalized MG patients out of 300 lacking AChR Ab were found to be positive for Lrp4 antibodies. Thymoma was not observed in any of these patients. These antibodies inhibit the binding of Lrp4 to its ligand and are predominantly of the IgG1 subclass. In other reports of Lrp4 ab, Lrp4 ab-positive sera inhibited the agrin-induced aggregation of AChRs in cultured myotubes, suggesting a pathogenic role regarding the dysfunction of the neuromuscular endplate. These results indicate that Lrp4 is the third autoantigen in patients with MG, and anti-Lrp4 autoantibodies may be pathogenic. Further studies including neuromuscular junction biopsy are needed to clarify the pathomechanism of Lrp4 ab-positive MG.