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Archive for the ‘Nephrology’ Category

Resistance Hypertension: Renal Artery Intervention using Stenting

Reporter: Aviva Lev-Ari, PhD, RN

UPDATED 2/4/2014

Stenting and Medical Therapy for Atherosclerotic Renal-Artery Stenosis

Christopher J. Cooper, M.D., Timothy P. Murphy, M.D., Donald E. Cutlip, M.D., Kenneth Jamerson, M.D., William Henrich, M.D., Diane M. Reid, M.D., David J. Cohen, M.D., Alan H. Matsumoto, M.D., Michael Steffes, M.D., Michael R. Jaff, D.O., Martin R. Prince, M.D., Ph.D., Eldrin F. Lewis, M.D., Katherine R. Tuttle, M.D., Joseph I. Shapiro, M.D., M.P.H., John H. Rundback, M.D., Joseph M. Massaro, Ph.D., Ralph B. D’Agostino, Sr., Ph.D., and Lance D. Dworkin, M.D. for the CORAL Investigators

N Engl J Med 2014; 370:13-22 January 2, 2014DOI: 10.1056/NEJMoa1310753

BACKGROUND

Atherosclerotic renal-artery stenosis is a common problem in the elderly. Despite two randomized trials that did not show a benefit of renal-artery stenting with respect to kidney function, the usefulness of stenting for the prevention of major adverse renal and cardiovascular events is uncertain.

METHODS

We randomly assigned 947 participants who had atherosclerotic renal-artery stenosis and either systolic hypertension while taking two or more antihypertensive drugs or chronic kidney disease to medical therapy plus renal-artery stenting or medical therapy alone. Participants were followed for the occurrence of adverse cardiovascular and renal events (a composite end point of death from cardiovascular or renal causes, myocardial infarction, stroke, hospitalization for congestive heart failure, progressive renal insufficiency, or the need for renal-replacement therapy).

RESULTS

Over a median follow-up period of 43 months (interquartile range, 31 to 55), the rate of the primary composite end point did not differ significantly between participants who underwent stenting in addition to receiving medical therapy and those who received medical therapy alone (35.1% and 35.8%, respectively; hazard ratio with stenting, 0.94; 95% confidence interval [CI], 0.76 to 1.17; P=0.58). There were also no significant differences between the treatment groups in the rates of the individual components of the primary end point or in all-cause mortality. During follow-up, there was a consistent modest difference in systolic blood pressure favoring the stent group (−2.3 mm Hg; 95% CI, −4.4 to −0.2; P=0.03).

CONCLUSIONS

Renal-artery stenting did not confer a significant benefit with respect to the prevention of clinical events when added to comprehensive, multifactorial medical therapy in people with atherosclerotic renal-artery stenosis and hypertension or chronic kidney disease. (Funded by the National Heart, Lung and Blood Institute and others; ClinicalTrials.gov number, NCT00081731.)

SOURCE

http://www.nejm.org/doi/full/10.1056/NEJMoa1310753

based on

What Do CORAL and ERASE Mean for Peripheral Intervention?

Seth Bilazarian, MD, Mark A. Creager, MD

November 27, 2013

Seth Bilazarian, MD: Hi. I’m Seth Bilazarian from the heart.org on Medscape. I’m here at the American Heart Association Scientific Sessions in Dallas with Dr. Mark Creager, Director of Vascular Medicine at Brigham and Women’s Hospital in Boston. Dr. Creager was the moderator of a session enriched with peripheral vascular disease topics yesterday. And I’m fortunate to be with him to unpack 2 of those studies: the ERASE study,[1] a study of peripheral artery disease in the lower extremities and exercise; and the CORAL study,[2] a study of renal artery intervention using stenting.

As a practicing endovascular medicine physician, I’m excited to get Dr. Creager’s take on this. The CORAL study, to start with, was a study that was sponsored by the NHLBI (National Heart, Lung, and Blood Institute), -looking at patients who had greater than 60% stenosis who had resistant hypertension or renal insufficiency and were optimally treated with medical therapy. The patients were given free antihypertensive therapies and statin therapy. And that alone was compared with medical therapy plus renal artery intervention with stenting.

Dr. Creager, can you summarize the take-home message and the results for our audience?

Mark A. Creager, MD: Thank you, Seth. This was an important study. The CORAL study compared these 2 groups, and the primary endpoints were cardiovascular and renal death, hospitalization for congestive heart failure, stroke, myocardial infarction, progressive renal insufficiency, and renal replacement therapy. The trial found that there was no significant difference in this primary composite endpoint between the 2 groups.

That’s an important message: that if we treat our patients with hypertension and renal insufficiency who have concomitant renal artery stenosis with appropriate medical therapy, they will do as well — in terms of cardiovascular and renal endpoints — as those who undergo renal artery stenting.

Dr. Bilazarian: A very strong message that stenting adds nothing, if we take home the short answer that renal stenting adds nothing on top of optimal medical therapy. Previously, enthusiasts for renal stenting criticized studies such as ASTRAL[3] and STAR[4] that the patients may not have been optimally chosen and may not have had significant enough renal artery stenosis.

In the CORAL study, we saw yesterday that in a subgroup analysis looking at patients who had greater or less than 80% stenosis, the average was 72% in the whole trial. But those at greater than 80% did not seem to fare any better from this study. They were the same as those at less than 80%. So does this largely close the door to renal stenting for atherosclerotic disease?

Dr. Creager: As implied by your question, one might have anticipated that those individuals with the most severe renal artery stenosis would have been those most likely to benefit. But as you stated, there was no difference between the patients who had a greater than 80% stenosis and those who did not. That really continues to raise questions about the efficacy of renal artery stenting in this population in general.

But it doesn’t entirely close the door. I think it still is very important for all physicians to deal with their patients individually and inform their decisions by the evidence that’s available. But there will be patients who have hypertension and remain refractory despite aggressive and appropriate medical therapy. And in those individuals, one might consider looking for the presence of renal artery stenosis, and if found, treat them.

But keep in mind that in this trial, the group randomized to medical therapy did demonstrate benefit. In fact, they demonstrated a 15-mm Hg (on average) decrease in systolic blood pressure, indicating that before enrollment in the trial they probably were being treated as aggressively as they should be.

My take-home message is: If you have a patient with significant hypertension, make sure you’re implementing guideline-based therapies to bring their blood pressure into appropriate control. And if one is not successful in that case, then consider other options.

Dr. Bilazarian: One of the findings in the study was that at the end of the trial, there was a 2.5-mm Hg blood pressure difference between those with renal stenting and those without renal stenting (both on optimal medical therapy). Did that result surprise you?

Dr. Creager: It did surprise me for the very reason I just alluded to. I think that prior to enrollment in the trial, many of these patients who were treated with 2 or more antihypertensive drugs still might not have been treated aggressively enough with the right doses of these drugs or the right number of drugs to bring their blood pressure down.

In fact, I was pleased to see that an intensive medical regimen could be effective in these patients. And it sends another important message to our medical community that we can do more for these patients.

Dr. Bilazarian: You mentioned in this last answer that there may still be a role for identifying patients with renal artery stenosis. Can you help clarify that for me as a director of the vascular lab at Brigham and Women’s Hospital? As a teacher of postgraduate physicians, help me understand in what situation patients should be evaluated.

Currently, patients who may not have frank resistant hypertension get referrals to duplex ultrasound for assessment. Should that bar be moved up? Or is it only the most refractory patients who should be investigated? Or is it still valuable to know whether a patient has renal artery stenosis with noninvasive testing?

Dr. Creager: The bar does need to be moved without question. But there are several situations. I’ll give you 2 examples. One I mentioned: The patient who continues to have resistant hypertension despite aggressive medical therapy will be one such patient where I’ll be looking for secondary causes. And one of those secondary causes could be renal artery stenosis. So in that individual, duplex ultrasound would be appropriate, and if renal artery stenosis is found, continue the evaluation and treat that patient as the renal artery stenosis is confirmed.

Another example might be an individual who has recurrent acute pulmonary edema that cannot be explained by coronary artery disease or severe left ventricular dysfunction. That’s a patient I would consider working up for bilateral renal artery stenosis. And if found, I would treat. That patient population was really not the type that was included in the CORAL trial. So those are 2 examples.

Dr. Bilazarian: Our current guidelines say that there is a role for renal artery intervention for resistant hypertension, acute pulmonary edema, and declining renal function. It seems like the first of those has been taken off the table. Is there a role in the patient with declining renal function?

Dr. Creager: Well, that’s an important subset of patients, indeed. And I would be evaluating them for the potential causes of declining renal function. If they have renal artery stenosis, I would then initiate aggressive risk factor modification, antiplatelet therapy, and if they’re hypertensive, treat that as well.

But if in spite of that there still is evidence of declining renal function, then there’s a situation of someone who has failed medical therapy, and I would consider evaluating them for a renal artery stenosis. If one were to find, for example, bilateral renal artery stenosis in that patient or a severe stenosis to a single functioning kidney, then, yes, I would consider renal artery stenting in that individual.

Dr. Bilazarian: Great. Thank you for that summary on the trial called CORAL. Let’s move on to the second trial that you moderated. That trial is called ERASE, a study looking at supervised exercise therapy — an abbreviation I wasn’t familiar with: SET — supervised exercise therapy alone or supervised exercise therapy plus intervention of lower-extremity peripheral arterial disease. And that study was called ERASE. It built on an earlier study called CLEVER.[5] Please summarize the take-home message for the audience in that trial.

Dr. Creager: These were patients with peripheral artery disease and intermittent claudication, and the peripheral artery disease could have affected the aortoiliac system or the femoropopliteal system. The bottom line is that those patients who were randomized to both endovascular intervention and supervised exercise training had a much greater improvement in their walking time as assessed by treadmill testing, and also in quality of life as assessed by a number of instruments, compared with those patients who were just treated with supervised exercise training.

It adds incrementally to what we’ve previously understood. We know that supervised exercise training is extremely effective in improving walking time in patients with intermittent claudication. And as was shown with CLEVER, compared with medical therapy, endovascular intervention — at least in the aortoiliac area — is also associated with improvement in walking time.

So perhaps it’s no surprise that if you put the two together, they’re going to do better. And that’s what the ERASE trial showed.

Dr. Bilazarian: I agree with you. Many times, studies compare one or the other. And, of course, both is better than one or the other. I was happy to see that this trial looked at both.

There is one part of the trial that I had difficulty getting a take-home message from, and I’d love your input. As endovascular medicine physicians, we think in terms of the 3 zones of lower-extremity vascular disease: above the inguinal ligament, the fem-pop system, and then below the knee. Each becomes increasingly difficult, both for acute result as well as for durability. In this trial, half the patients had aortoiliac disease and half had fem-pop disease. Am I right to say that that might make it somewhat difficult to interpret whether the effects of supervised exercise therapy might be different for fem-pop disease or, say, aortoiliac disease, and that the bar for intervention might be lower for aortoiliac disease?

Dr. Creager: That’s a very important question. We don’t know yet what the subset analysis will be between those patients who had aortoiliac disease and underwent randomization and those who had femoropopliteal artery disease. And I’m sure we all await that analysis when it’s available.

Having said that, however, the studies show several things. It underscores the fact that no matter where the lesion is, patients still do better when exercise training is included in their therapeutic interventions. I think those of us who practice vascular medicine recognize the fact that endovascular intervention in the iliac arteries has been extremely successful and durable. And those patients really do benefit. d Our practice pattern and standard of care is to do endovascular intervention in patients with disabling claudication who have aortoiliac disease.

Superficial femoral artery disease, as you implied, is a little bit of a different situation. Those lesions are sometimes more difficult to treat and the durability is not as great. Within the context of this study, durability was pretty good in terms of restenosis. But I still think we need to see the subset analysis to make sure that those patients benefited as much as the entire group.

Dr. Bilazarian: Help us with a take-home message for US-based physicians. This was supervised exercise therapy in-home. We don’t have that available in the United States. Other than adding to our knowledge base, which is, of course, valuable, and being able to impart this knowledge to our patients and show them that this is of value, what other things can we do as a change in our practice to integrate this?

Dr. Creager: Currently we do need changes in healthcare policy, at least as it applies to supervised exercise training. We need reimbursement from CMS (Centers for Medicare & Medicaid Services). We need reimbursement from other third-party payers to provide additional incentive for physicians to recommend supervised exercise training for their patients. Unfortunately, that’s not available. And that’s one reason why patients in this country are not being referred for supervised exercise training. It’s an extremely effective intervention in patients with intermittent claudication.

Dr. Bilazarian: Great. Mark, thanks for joining me and for helping unpack these 2 trials for our audience: the ERASE trial of lower-extremity exercise in PAD patients, and the CORAL trial of renal artery stenting. I think they will add to our knowledge base and hopefully make practice changes in both areas. Thank you again for joining. And thank you for joining us for this program.

SOURCE

http://www.medscape.com/viewarticle/815029?src=emailthis#1

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Transthyretin and Lean Body Mass in Stable and Stressed State

Curator: Larry H Bernstein, MD, FCAP

Chapter 20
Plasma Transthyretin Reflects the Fluctuations
of Lean Body Mass in Health and Disease
Yves Ingenbleek
Abstract

Transthyretin (TTR) is a 55-kDa protein secreted mainly by the choroid plexus and the liver. Whereas its intracerebral production appears as a stable secretory process allowing even distribution of intrathecal thyroid hormones, its hepatic synthesis is influenced by nutritional and inflammatory circumstances working concomitantly. Both morbid conditions are governed by distinct pathogenic mechanisms leading to the reduction in size of lean body mass (LBM). The liver production of TTR integrates the dietary and stressful components of any disease spectrum, explaining why it is the sole plasma protein whose evolutionary patterns closely follow the shape outlined by LBM fluctuations. Serial measurement of TTR therefore provides unequalled information on the alterations affecting overall protein nutritional status. Recent advances in TTR physiopathology emphasize the detecting power and preventive role played by the protein in hyperhomocysteinemic states, acquired metabolic disorders currently ascribed to dietary restriction in water-soluble vitamins. Sulfur (S)-deficiency is proposed as an additional causal factor in the sizeable proportion of hyperhomocysteinemic patients characterized by adequate vitamin intake but experiencing varying degrees of nitrogen (N)-depletion. Owing to the fact that N and S coexist in plant and animal tissues within tightly related concentrations, decreasing LBM as an effect of dietary shortage and/or excessive hypercatabolic losses induces proportionate S-losses. Regardless of water-soluble vitamin status, elevation of homocysteine plasma levels is negatively correlated with LBM reduction and declining TTR plasma levels. These findings occur as the result of impaired cystathionine-b-synthase activity, an enzyme initiating the transsulfuration pathway and whose suppression promotes the upstream accumulation and remethylation of homocysteine molecules. Under conditions of N- and S-deficiencies,the maintenance of methionine homeostasis indicates high metabolic priority.
Y. Ingenbleek
Laboratory of Nutrition, University Louis Pasteur Strasbourg
e-mail: yves.ingenbleek@wanadoo.fr
S.J. Richardson and V. Cody (eds.), Recent Advances in Transthyretin Evolution, 329
Structure and Biological Functions,
DOI: 10.1007/978‐3‐642‐00646‐3_20, # Springer‐Verlag Berlin Heidelberg 2009

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Renal Function Biomarker, β-trace protein (BTP) as a Novel Biomarker for Cardiac Risk Diagnosis in Patients with Atrial Fibrilation

Curator: Aviva Lev-Ari, PhD, RN

Original Research | November 2013

β-Trace Protein and Prognosis in Patients With Atrial Fibrillation Receiving Anticoagulation Treatment

Juan Antonio Vílchez, BSc Pharm, PhD; Vanessa Roldán, MD, PhD; Sergio Manzano-Fernández, MD, PhD; Hermógenes Fernández, MD; Francisco Avilés-Plaza, MD, PhD; Pedro Martínez-Hernández, BSc Pharm, PhD; Vicente Vicente, MD, PhD; Mariano Valdés, MD, PhD; Francisco Marín, MD, PhD; Gregory Y. H. Lip, MD

From the University of Birmingham Centre for Cardiovascular Sciences (Drs Apostolakis and Lip), City Hospital, Birmingham, England; and the Division of Cardiovascular Medicine (Drs Sullivan and Olshansky), University of Iowa Hospitals and Clinics, Iowa City, IA.

Correspondence to: Gregory Y. H. Lip, MD, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Dudley Rd, Birmingham, B18 7QH, England; e-mail: g.y.h.lip@bham.ac.uk

Abstract

Background:  Atrial fibrillation (AF) is associated with a high risk of mortality and morbidity and it commonly coexists with chronic kidney disease. A biomarker of renal function, β-trace protein (BTP), has been implicated in the progression of cardiovascular disease. The aim of our study was to evaluate the association of BTP with adverse cardiovascular events, bleeding, and mortality in patients with AF.

Methods:  In a consecutive cohort of patients with nonvalvular AF receiving anticoagulation treatment, plasma BTP was determined using an automated nephelometer BN ProSpec System (Siemens) and related to estimated glomerular filtration rate (eGFR). We recorded adverse cardiovascular events (stroke, acute coronary syndrome, and acute pulmonary edema), major bleeding, and mortality.

Results:  We included 1,279 patients (48.6% men), aged 76 years (IQR, 71-81 years), who were followed up for 996 days (IQR, 802-1,254 days). During the follow-up, there were 150 cardiovascular events (annual rate, 3.99%), 57 embolisms (annual rate, 1.54%), and 114 major bleeding events (annual rate, 3.04%), and 161 patients died (annual rate, 4.32%). BTP levels were inversely associated with eGFR (P < .001). High BTP concentrations were significantly associated with embolic events (hazard ratio [HR], 4.64 [1.98-10.86]; P < .001), composite adverse cardiovascular events (HR, 1.93 [1.31-2.85]; P = .001), and mortality (HR, 2.08 [1.49-2.90]; P < .001), even after adjusting for CHAD2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years [doubled], diabetes mellitus, stroke [doubled], vascular disease, age 65 to 74 years, sex category) score and renal function. High BTP was associated with major bleeding events (HR, 1.88 [1.18-3.00]; P = .008), even after adjusting for the HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or redisposition, labile international normalized ratio, elderly [> 65 years], drugs/alcohol concomitantly) score.

Conclusions:  We suggest that BTP, a proposed renal damage biomarker, may be a novel predictor of adverse cardiovascular events, major bleeding, and mortality in patients with AF. BTP may help refine clinical risk stratification in these patients.

SOURCE

http://journal.publications.chestnet.org/article.aspx?articleid=1730537

Editorials | November 2013

Predicting the Quality of Anticoagulation During Warfarin Therapy:The Basis for an Individualized Approach

Giuseppe Boriani, MD, PhD

From the Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna.

Correspondence to: Giuseppe Boriani, MD, PhD, Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; e-mail: giuseppe.boriani@unibo.it

Chest. 2013;144(5):1437-1438. doi:10.1378/chest.13-1285

In medicine, there is an emerging tendency toward individualized medicine, that is, an approach to medicine based on available evidence, but enriched by the awareness of the inherent limitations of any “one size fits all” approach. As a matter of fact, diseases show individual differences with regard to onset and course, and individuals show different responses to drugs and interventions, thus suggesting the rationale for an individualized approach to disease treatments, able to predict individual responses. The most sophisticated approach to individualization and tailoring of medicine is personalized medicine, a broad and rapidly advancing field of health care that is informed by each person’s unique clinical, genetic, genomic, and environmental information.1 Treatment with vitamin K antagonists (VKAs) has been one of the traditional settings for individualization of treatment. The concept of personalized medicine specifically applies to warfarin dosing, a setting where knowledge of the complex polymorphic variants in the gene encoding cytochrome 2C9 (CYP2C9) and of the genetic variants in the gene encoding vitamin K epoxide reductase complex 1 (VKORC 1) may help to predict the interindividual variability in warfarin pharmacokinetics and pharmacodynamics, as well as warfarin-associated events and costs.2 However, it is still uncertain and unproven whether management of warfarin dosing guided by pharmacogenetics may improve patient outcomes.3

Biomarker Can Predict Events in Afib Patients

Published: Nov 6, 2013 | Updated: Nov 7, 2013

By Todd Neale, Senior Staff Writer, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Beta-trace protein (BTP), a biomarker that has been associated with both kidney damage and an increased cardiovascular risk, may help identify high-risk atrial fibrillation patients, researchers found.

Among patients with atrial fibrillation who were on stable oral anticoagulant therapy, high plasma levels of the protein were associated with significantly elevated risks of embolic events, adverse cardiovascular events, death, and major bleeding, according to Gregory Lip, MD, of the University of Birmingham in England, and colleagues.

Also, adding information about BTP levels modestly improved the predictive ability of models that included two established risk scores — CHAD2DS2-VASc and HAS-BLED — as indicated by higher C-statistics, they reported in the Nov. 5 issue of CHEST.

“This raises the possibility that BTP may help refine the clinical risk stratification for thrombotic or hemorrhagic events and mortality in these patients,” they wrote.

BTP has been proposed has a marker of renal damage, and it has also been associated with inflammation, atherogenesis, angina, vasomotor reactivity, and hypertension. Previous studies have also identified a relationship between BTP and the progression of cardiovascular disease.

In the current study, Lip and colleagues explored whether BTP levels were related to outcomes in 1,279 patients with nonvalvular atrial fibrillation who were on stable oral anticoagulant therapy with an international normalized ratio (INR) of 2.0 to 3.0. Their average age was 76.

The median estimated glomerular filtration rate at baseline was 71.28 mL/min/1.73 m2; BTP levels and renal function were inversely related (P<0.001).

The BTP cut-offs with the best sensitivity and specificity for predicting each of the endpoints varied — 0.561 mg/L for adverse cardiovascular events, 0.556 mg/L for embolic events, 0.670 mg/L for mortality, and 0.573 mg/L for major bleeds.

During a median follow-up of 2.7 years, cardiovascular events occurred at a rate of 3.99% per year, embolisms at 1.54% per year, deaths at 4.32% per year, and major bleeds at 3.04% per year.

After adjustment for renal function and the CHAD2DS2-VASc risk score — which incorporates congestive heart failure, hypertension, age, diabetes, stroke, vascular disease, and sex — a BTP level above the cutoff was associated with increased risks of cardiovascular events (HR 1.93, 95% CI 1.31-2.85), embolic events (HR 4.64, 95% CI 1.98-10.86), and mortality (HR 2.08, 95% CI 1.49-2.90).

Also, after adjustment for the HAS-BLED risk score — which takes into account hypertension, abnormal renal and liver function, stroke, bleeding history or predisposition, labile INR, age over 65, and concomitant use of drugs and alcohol — a high BTP level was associated with a greater risk of major bleeding (HR 1.88, 95% CI 1.18-3.00).

“We suggest that BTP, a proposed renal damage biomarker, may be a novel predictor of adverse cardiovascular events, major bleeding, and mortality in patients with atrial fibrillation,” the authors wrote.

They acknowledged some limitations of the analysis, however, including possible selection bias because all of the patients were on stable oral anticoagulant therapy, the measurement of renal function and BTP levels at a single time point only, and the exclusion of patients with end-stage renal disease.

SOURCE

http://www.medpagetoday.com/Cardiology/Arrhythmias/42751

These are promising early results, but the data include plenty of limitations. As the article notes, the researchers themselves acknowledge that their work only looked at patients on a regular oral anticlotting drug at a certain point in time. Further research must include a broader class of patients to determine if BTP can be a reliable biomarker to help identify atrial fibrillation patients with an added risk of other health problems.

As hard as it might be to spot atrial fibrillation patients at risk of more problems, doctors struggle to definitively identify the condition in the first place and apply targeted treatments. The med tech industry, meanwhile, is trying to fill the gap. Topera, a 2013 Fierce 15 winner, recently won U.S. and EU approval for a 3-D device and mapping tool designed to better detect cardiac rhythm problems such as atrial fibrillation in order to enable more targeted and accurate treatment. In late August, St. Jude Medical ($STJ) snatched up Endosense, which makes a cutting-edge irrigated ablation catheter designed to treat atrial fibrillation, and rival companies are developing or promoting electrophysiology treatments and other devices for the condition.

 SOURCE

From: FierceBiomarkers <editors@fiercebiomarkers.com>
Reply-To: <editors@fiercebiomarkers.com>
Date: Wednesday, November 13, 2013 10:31 AM
To: AvivaLev-Ari@alum.berkeley.edu
Subject: | 11.13.13 | Investigators flag new biomarkers for atrial fib

Articles related to Diagnosis of Atrial Fibrilation published on this Open Access Online Scientific Journal include the following:

Genetic Analysis of Atrial Fibrillation, Larry H Bernstein, MD, FCAP  and Aviva-Lev Ari, PhD, RN

http://pharmaceuticalintelligence.com/2013/10/27/genetic-analysis-of-atrial-fibrillation/

Cardiac Contractility & Myocardium Performance: Ventricular Arrhythmiasand Non-ischemic Heart Failure – Therapeutic Implications for Cardiomyocyte Ryanopathy (Calcium Release-related Contractile Dysfunction) and Catecholamine Responses
Justin Pearlman, MD, PhD, FACC, Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/08/28/cardiac-contractility-myocardium-performance-ventricular-arrhythmias-and-non-ischemic-heart-failure-therapeutic-implications-for-cardiomyocyte-ryanopathy-calcium-release-related-contractile/

Oxidized Calcium Calmodulin Kinase and Atrial Fibrillation, Larry H. Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN
http://pharmaceuticalintelligence.com/2013/10/26/oxidized-calcium-calmodulin-kinase-and-atrial-fibrillation/

Genetics of Conduction Disease: Atrioventricular (AV) Conduction Disease (block): Gene Mutations – Transcription, Excitability, and Energy Homeostasis, Aviva Lev-Ari, PhD, RN

http://pharmaceuticalintelligence.com/2013/04/28/genetics-of-conduction-disease-atrioventricular-av-conduction-disease-block-gene-mutations-transcription-excitability-and-energy-homeostasis/

On Devices and On Algorithms: Prediction of Arrhythmia after Cardiac Surgery and ECG Prediction of an Onset of Paroxysmal Atrial Fibrillation, Justin D. Pearlman, MD, PhD, FACC and Aviva Lev-Ari, PhD, RN

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The Role of Tight Junction Proteins in Water and Electrolyte Transport

 

Reviewer and Curator: Larry H. Bernstein, MD, FCAP 

 

This article is Part II of a series that explores the physiology, genomics, and the proteomics of water and electrolytes in human and mammalian function in health and disease.  In this portion of curation, we examine the role of special proteins at the tight junctions of cells, including the claudins.  Consistent with the exploration of cation homeostasis, the last featured article is one of the altered handling of calcium (Ca2+) in CHF, and the closely regulated calcium efflux by the sodium-calcium exchanger (NCX).

The Role of Aquaporin and Tight Junction Proteins in the Regulation of Water Movement in Larval Zebrafish (Danio rerio).

Kwong RW, Kumai Y, Perry SF.
Department of Biology, University of Ottawa, Ottawa, Ontario, Canada.
PLoS One. 2013 Aug 14;8(8):e70764.
http://dx.doi.org/10.1371/journal.pone.0070764   eCollection 2013.

Teleost fish living in freshwater are challenged by passive water influx; however the molecular mechanisms regulating water influx in fish are not well understood. The potential involvement of aquaporins (AQP) and epithelial tight junction proteins in the regulation of transcellular and paracellular water movement was investigated in larval zebrafish (Danio rerio).

We observed that the half-time for saturation of water influx (K u) was 4.3±0.9 min, and reached equilibrium at approximately 30 min. These findings suggest a high turnover rate of water between the fish and the environment. Water influx was reduced by the putative AQP inhibitor phloretin (100 or 500 μM). Immunohistochemistry and confocal microscopy revealed that AQP1a1 protein was expressed in cells on the yolk sac epithelium. A substantial number of these AQP1a1-positive cells were identified as ionocytes, either H(+)-ATPase-rich cells or Na(+)/K(+)-ATPase-rich cells. AQP1a1 appeared to be expressed predominantly on the basolateral membranes of ionocytes, suggesting its potential involvement in regulating ionocyte volume and/or water flux into the circulation.

Additionally, translational gene knockdown of AQP1a1 protein reduced water influx by approximately 30%, further indicating a role for AQP1a1 in facilitating transcellular water uptake. On the other hand, incubation with the Ca(2+)-chelator EDTA or knockdown of the epithelial tight junction protein claudin-b significantly increased water influx. These findings indicate that the epithelial tight junctions normally act to restrict paracellular water influx. Together, the results of the present study provide direct in vivo evidence that water movement can occur through transcellular routes (via AQP); the paracellular routes may become significant when the paracellular permeability is increased.

PMID:  23967101  PMCID: PMC3743848    http://www.ncbi.nlm.nih.gov/pubmed/23967101

The tight junction protein claudin-b regulates epithelial permeability and sodium handling in larval zebrafish, Danio rerio.

Kwong RW, Perry SF.
Department of Biology, University of Ottawa, Ottawa, Ontario, Canada. wkwong@uottawa.ca
Am J Physiol Regul Integr Comp Physiol. Apr 1, 2013; 304(7):R504-13. http://dx.doi.org/10.1152/ajpregu.00385.2012  Epub 2013 Jan 30.

The functional role of the tight junction protein claudin-b in larval zebrafish (Danio rerio) was investigated. We showed that claudin-b protein is expressed at epithelial cell-cell contacts on the skin. Translational gene knockdown of claudin-b protein expression caused developmental defects, including edema in the pericardial cavity and yolk sac.

Claudin-b morphants exhibited an increase in epithelial permeability to the paracellular marker polyethylene glycol (PEG-4000) and fluorescein isothiocyanate-dextran (FD-4). Accumulation of FD-4 was confined mainly to the yolk sac and pericardial cavity in the claudin-b morphants, suggesting these regions became particularly leaky in the absence of claudin-b expression.

Additionally, Na(+) efflux was substantially increased in the claudin-b morphants, which contributed to a significant reduction in whole-body Na(+) levels. These results indicate that claudin-b normally acts as a paracellular barrier to Na(+). Nevertheless, the elevated loss of Na(+) in the morphants was compensated by an increase in Na(+) uptake.

Notably, we observed that the increased Na(+) uptake in the morphants was attenuated in the presence of the selective Na(+)/Cl(-)-cotransporter (NCC) inhibitor metolazone, or during exposure to Cl(-)-free water. These results suggested that the increased Na(+) uptake in the morphants was, at least in part, mediated by NCC. Furthermore, treatment with an H(+)-ATPase inhibitor bafilomycin A1 was found to reduce Na(+) uptake in the morphants, suggesting that H(+)-ATPase activity was essential to provide a driving force for Na(+) uptake. Overall, the results suggest that claudin-b plays an important role in regulating epithelial permeability and Na(+) handling in zebrafish.
PMID: 23364531   http://www.ncbi.nlm.nih.gov/pubmed/23364531

Evidence for a role of tight junctions in regulating sodium permeability in zebrafish (Danio rerio) acclimated to ion-poor water.

Kwong RW, Kumai Y, Perry SF.
Department of Biology, University of Ottawa, Ottawa, ON, Canada. wkwong@uottawa.ca
J Comp Physiol B. Feb 2013 ;183(2):203-13.
http://dx.doi.org/10.1007/s00360-012-0700-9  Epub 2012 Jul 29.

Freshwater teleosts are challenged by diffusive ion loss across permeable epithelia including gills and skin. Although the mechanisms regulating ion loss are poorly understood, a significant component is thought to involve paracellular efflux through pathways formed via tight junction proteins. The mammalian orthologue (claudin-4) of zebrafish (Danio rerio) tight junction protein, claudin-b, has been proposed to form a cation-selective barrier regulating the paracellular loss of Na(+).

The present study investigated the cellular localization and regulation of claudin-b, as well as its potential contribution to Na(+) homeostasis in adult zebrafish acclimated to ion-poor water. Using a green fluorescent protein-expressing line of transgenic zebrafish, we found that claudin-b was expressed along the lamellar epithelium as well as on the filament in the inter-lamellar regions. Co-localization of claudin-b and Na(+)/K(+)-ATPase was observed, suggesting its interaction with mitochondrion-rich cells. Claudin-b also appeared to be associated with other cell types, including the pavement cells. In the kidney, claudin-b was expressed predominantly in the collecting tubules. In addition,

exposure to ion-poor water caused a significant increase in claudin-b abundance as well as a decrease in Na(+) efflux, suggesting a possible role for claudin-b in regulating paracellular Na(+) loss. Interestingly, the whole-body uptake of a paracellular permeability marker, polyethylene glycol-400, increased significantly after prolonged exposure to ion-poor water, indicating that an increase in epithelial permeability is not necessarily coupled with an increase in passive Na(+) loss. Overall, our study suggests that in ion-poor conditions, claudin-b may contribute to a selective reduction in passive Na(+) loss in zebrafish.
PMID: 22843140   http://www.ncbi.nlm.nih.gov/pubmed/22843140

Claudin-16 and claudin-19 function in the thick ascending limb.

Hou J, Goodenough DA.
Washington University School of Medicine, Div Renal Diseases, St Louis, Missouri
Curr Opin Nephrol Hypertens. Sep 2010; 19(5):483-8. http://dx.doi.org/10.1097/MNH.0b013e32833b7125.

The thick ascending limb (TAL) of the loop of Henle is responsible for reabsorbing 25–40% of filtered Na+, 50–60% of filtered Mg2+ and 30–35% of filtered Ca2+. The dissociation of salt and water reabsorption in the TAL serves both to dilute the urine and to establish the corticomedullary osmolality gradient. Active transcellular salt reabsorption results in a lumen-positive transepithelial voltage that drives passive paracellular reabsorption of divalent cations. Claudins are the key components of the paracellular channel. The paracellular channels in the tight junction have properties of ion selectivity, pH dependence and anomalous mole fraction effects, similar to conventional transmembrane channels. Genetic mutations in claudin-16 and claudin-19 cause an inherited human renal disorder, familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC).

In the TAL of Henle’s loop, the epithelial cells form a water-impermeable barrier, actively transport Na+ and Cl− via the transcellular route, and provide a paracellular pathway for the selective absorption of cations. Na+ K+ and Cl− enter the cell through the Na-K-2Cl cotransporter (NKCC2) in the luminal membrane. Na+ exits the cell through the Na+/K+-ATPase, in exchange for K+ entry. K+ is secreted into the lumen through the renal outer medullary potassium channel. Cl− leaves the cell through the basolateral Cl− channel, made up of two subunits, ClCKb and barttin. The polarized distribution of luminal K+ versus basolateral Cl− conductance generates a spontaneous voltage source (Vsp) of +7−8mV , depending on active transcellular NaCl reabsorption. With continuous NaCl reabsorption along the axis of the TAL segment, the luminal fluid is diluted to 30–60mmol/l  and a large NaCl transepithelial chemical gradient develops at the end of the TAL. Because the paracellular permeability of the TAL is cation-selective (with a PNa/PCl value between 2 and 4), the diffusion voltage (Vdi) is superimposed onto the active transport voltage (Vsp) and becomes the major source of the transepithelial voltage (Vte), which now increases up to +30mV.

Early in-vivo micropuncture studies have shown that approximately 50–60% of the filtered Mg2+ is reabsorbed in the TAL. The flux–voltage relationship indicates that Mg2+ is passively reabsorbed from the lumen to the peritubular space through the paracellular pathway in this segment, driven by a lumen positive Vte.  Vte is made of the sum of Vsp and Vdi. There are two prerequisites required for the paracellular Mg2+ reabsorption in the TAL: the lumen-positive Vte as the driving force and the paracellular permeability for the divalent cation Mg2+.

Claudin-16 and claudin-19 underlie familial hypercalciuric hypomagnesemia with nephrocalcinosis

Claudin-16 and claudin-19 play a major role in the regulation of magnesium reabsorption in the thick ascending limb (TAL). This review describes recent findings of the physiological function of claudin-16 and claudin-19 underlying normal transport function for magnesium reabsorption in the TAL. Mutations in the genes encoding the tight junction proteins claudin-16 and claudin-19 cause the inherited human renal disorder familial hypomagnesemia with hypercalciuria and nephrocalcinosis. FHHNC, OMIM #248250, is a rare autosomal recessive tubular disorder. As a consequence of excessive renal Mg2+ and Ca2+ wasting, patients develop the characteristic triad of hypomagnesemia, hypercalciuria and nephrocalcinosis. Recurrent urinary tract infections and polyuria/polydipsia are frequent initial symptoms. Other clinical symptoms include nephrolithiasis, abdominal pain, convulsions, muscular tetany, and failure to thrive. Additional laboratory findings include elevated serum parathyroid hormone levels before the onset of chronic renal failure, incomplete distal tubular acidosis, hypocitraturia, and hyperuricemia. In contrast to hypomagnesemia and secondary hypocalcemia (HSH, OMIM #602014), FHHNC is generally complicated by end-stage renal failure in early childhood or adolescence.

Simon et al. used the positional cloning strategy and identified claudin-16 (formerly known as paracellin-1), which is mutated in patients with FHHNC. Most mutations reported to date in claudin-16 are missense mutations clustering in the first extracellular loop composing the putative ion selectivity filter. Konrad et al. have found mutations in another tight junction gene encoding claudin-19 from new cohorts of FHHNC patients (OMIM #248190). The renal tubular phenotypes are indistinguishable between patients with mutations in claudin-16 and those with mutations in claudin-19. Although claudin-16 and claudin-19 underlie FHHNC and paracellular Mg2+ reabsorption in the TAL, the transient receptor potential channel melastatin 6 (TRPM6) regulates the apical entry of Mg2+ into the distal convoluted tubule epithelia. Mutations in TRPM6 cause the HSH syndrome.

These above data suggested the hypothesis that claudin-16 and/or claudin-19 forms a selective paracellular Mg2+/Ca2+ channel, which was tested in a number of in-vitro studies. Ikari et al. transfected low-resistance Madin-Darby canine kidney (MDCK) cells with claudin-16 and reported that the Ca2+ flux in these cells was increased in the apical to basolateral direction, whereas the Ca2+ flux in the opposite direction remained unchanged. The Mg2+ flux was without any noticeable change. Kausalya et al.  transfected the high-resistance MDCK-C7 cell line and found that claudin-16 only moderately increased Mg2+ permeability without any directional preference. The effects of claudin-16 on Mg2+/Ca2+ permeation appeared so small (<50%) that the Mg2+/Ca2+ channel theory incompletely explains the dramatic effect of mutations in claudin-16 on Mg2+ and Ca2+ homoeostasis in FHHNC patients. However, , Hou et al.  transfected the anion-selective LLC-PK1 cell line with claudin-16 and found a large increase in Na+ permeability (PNa) accompanied by a moderately enhanced Mg2+ permeability (PMg). The permeability of claudin-16 to other alkali metal cations was found to be: K+ > Rb+ > Na+.  Yu et al. emphasized that these residue replacements can influence protein structures that may have impacts on ion permeability independent of amino acid charge.

The cation selectivity of the tight junction is vital for generating the lumen positive transepithelial potential in the TAL, which drives paracellular absorption of magnesium. Claudin-16 and claudin-19 require each other for assembly into tight junctions in the TAL. Heteromeric claudin-16 and claudin-19 interaction forms a cation selective tight junction paracellular channel. Loss of either claudin-16 or claudin-19 in the mouse kidney abolishes the cation selectivity for the TAL paracellular pathway, leading to excessive renal wasting of magnesium.

Claudins interact with each other both intracellularly and intercellularly: they copolymerize linearly within the plasma membrane of the cell, together with the integral protein occludin, to form the classical intramembrane fibrils or strands visible in freeze-fracture replicas. These intramembrane interactions (side-to-side) can involve one claudin protein (homomeric or homopolymeric) or different claudins (heteromeric or heteropolymeric). In the formation of the intercellular junction, claudins may interact head-to-head with claudins in an adjacent cell, generating both homotypic and heterotypic claudin–claudin interactions. Using the split-ubiquitin yeast 2-hybrid assay, Hou et al. found strong claudin-16 and claudin-19 heteromeric interaction. The point mutations in claudin-16 (L145P, L151F, G191R, A209T, and F232C) or claudin-19 (L90P and G123R) that are known to cause human FHHNC disrupted the claudin-16 and claudin-19 heteromeric interaction. In mammalian cells such as the human embryonic kidney 293 cells, claudin-16 can be coimmunoprecipitated with claudin-19. Freeze-fracture replicas revealed the assembly of tight junction strands in L cells coexpressing claudin-16 and claudin-19, supporting their heteromeric interaction.

Coexpression of claudin-16 and claudin-19 in LLC-PK1 cells resulted in a dramatic upregulation of PNa and down-regulation of PCl, generating a highly cation-selective paracellular pathway. Certain FHHNC mutations in claudin-16 (L145P, L151F, G191R, A209T, and F232C) or claudin-19 (L90P and G123R) that disrupted their heteromeric interaction abolished this physiological change. As claudin-16 colocalizes with claudin-19 in the TAL epithelia of the kidney, claudin-16 and claudin-19 association through heteromeric interactions confers cation selectivity to the tight junction in the TAL. Human FHHNC mutations in claudin-16 or claudin-19 that abolish the cation selectivity diminish the lumen-positive Vdi as the driving force for Mg2+ and Ca2+ reabsorption, readily explaining the devastating phenotypes in FHHNC patients.  Hou et al. generated claudin-16 deficient mouse models using lentiviral transgenesis of siRNA to knock down claudin-16 expression by more than 99% in mouse kidneys. Claudin-16 knockdown mice show significantly reduced plasma Mg2+ levels and excessive urinary excretions (approximately four-fold) of Mg2+ and Ca2+. Calcium deposits are observed in the basement membranes of the medullary tubules and the interstitium in the kidney of claudin-16 knockdown mice. These phenotypes of claudin-16 knockdown mice recapitulate the symptoms in human FHHNC patients.

The paracellular reabsorption of Mg2+ and Ca2+ is driven by a lumen-positive Vte made up of two components: Vsp and Vdi. When isolated TAL segments were perfused ex vivo with symmetrical NaCl solutions, there was no difference in Vsp between claudin-16 knockdown and wild-type mice, indicating Vsp was normal in claudin-16 knockdown. Blocking the NKCC2 channel with furosemide (thus dissipating VSP), the cation selectivity (PNa/PCl) was significantly reduced from3.1 ± 0.3 in wild type to 1.5 ± 0.1 in claudin-16 knockdown, resulting in the loss of Vdi. When perfused with a NaCl gradient of 145mmol/l (bath) versus 30mmol/l (lumen), the resulting Vdi was +18mV in wild type, but only +6.6mV in claudin-16 knockdown. Thus, the reduction in Vdi accounted for a substantive loss of the driving force for Mg2+ and Ca2+ reabsorption.

Renal handling of Na+ in claudin-16 knockdown mice is more complex. In the early TAL segment, the transcellular and paracellular pathways form a current loop in which the currents traversing the two pathways are of equal size but opposite direction. Net luminal K+ secretion and basolateral Cl− absorption polarize the TAL epithelium and generate Vsp. As the paracellular pathway is cation selective (PNa/PCl=2–4 , the majority of the current driven by Vsp through the paracellular pathway is carried by Na+ moving from the lumen to the interstitium. Hebert et al. estimated that, for each Na+ absorbed through the trans-cellular pathway, one Na+ is absorbed through the paracellular pathway. With the loss of claudin-16 and the concomitant loss of paracellular cation selectivity, Na+ absorption through the paracellular pathway is reduced.  In the late TAL segment, dilution of NaCl in the luminal space creates an increasing chemical transepithelial gradient; back diffusion of Na+ through the cation-selective tight junction generates a lumen-positive Vdi across the epithelium. The paracellular absorption of Na+ will be diminished when Vdi equals Vsp, and reversed when Vdi exceeds Vsp. As an equilibrium potential, Vdi blocks further Na+ backleak into the lumen. Without claudin-16, Vdi will be markedly reduced well below normal, providing a driving force for substantial Na+ secretion. Indeed, claudin-16 knockdown mice had increased fractional excretion of Na+ (FENa) and developed hypotension and secondary hyperaldosteronism. The observed Na+ and volume loss are consistent with human FHHNC phenotypes. For example, polyuria and polydipsia are the most frequently reported symptoms from FHHNC patients.

Epithelial paracellular channels are increasingly understood to be formed from claudin oligomeric complexes. In the mouse TAL, claudin-16 and claudin-19 cooperate to form cation-selective paracellular channels required for normal levels of magnesium reabsorption. Different subsets of the claudin family of tight junction proteins are found distributed throughout the nephron, and understanding their roles in paracellular ion transport will be fundamental to understanding renal ion homeostasis.

Keywords: claudin; hypomagnesemia; thick ascending limb; tight junction; transepithelial voltage.     PMID: 20616717  PMCID: PMC3378375  http://www.ncbi.nlm.nih.gov/pubmed/20616717

Function and regulation of claudins in the thick ascending limb of Henle.

Günzel D, Yu AS.
Depart Clin Physiol, Charité, Campus Benjamin Franklin, Berlin, Germany.
Pflugers Arch. May 2009; 458(1):77-88.
http://dx.doi.org/10.1007/s00424-008-0589-z  Epub 2008 Sep 16.

The thick ascending limb (TAL) of Henle mediates transcellular reabsorption of NaCl while generating a lumen-positive voltage that drives passive paracellular reabsorption of divalent cations. Disturbance of paracellular reabsorption leads to Ca(2+) and Mg(2+) wasting in patients with the rare inherited disorder of familial hypercalciuric hypomagnesemia with nephrocalcinosis (FHHNC). Recent work has shown that the claudin family of tight junction proteins form paracellular pores and determine the ion selectivity of paracellular permeability. Importantly, FHHNC has been found to be caused by mutations in two of these genes, claudin-16 and claudin-19, and mice with knockdown of claudin-16 reproduce many of the features of FHHNC. Here, we review the physiology of TAL ion transport, present the current view of the role and mechanism of claudins in determining paracellular permeability, and discuss the possible pathogenic mechanisms responsible for FHHNC.

Tight junctions form the paracellular barrier in epithelia. Claudins are ~22 kDa proteins that were first identified by Mikio Furuse in the laboratory of the late Shoichiro Tsukita as proteins that copurified in a tight junction fraction from the chicken liver [23]. The observation that they were transmembrane proteins with 4 predicted membrane domains and 2 extracellular domains raised early on the possibility that they could play a key role in intercellular adhesion and formation of the paracellular barrier. In 1999, Richard Lifton’s group identified mutations in a novel gene, which they called paracellin, as the cause of familial hypercalciuric hypomagnesemia, an inherited disorder believed to be due to failure of paracellular reabsorption of divalent cations in the thick ascending limb of the renal tubule. Paracellin turned out to be a claudin family member (claudin-16). This suggested that claudins in general might be directly involved in regulating paracellular transport in all epithelia. This is now supported by numerous studies demonstrating that overexpressing or ablating expression of various claudin isoforms in cultured cell lines or in mice affects both the degree of paracellular permeability and its selectivity (vide infra). Furthermore, in mammals alone there are ~24 claudin genes and each exhibits a distinct tissue-specific, pattern of expression. Thus, the specific claudin isoform(s) expressed in each tissue might explain its paracellular permeability properties.

Each nephron segment expresses a unique set of multiple claudin isoforms, and each isoform is expressed in multiple segments, thus making a complicated picture which even varies between different species. The role of combinations of claudins in determining paracellular permeability properties has hardly been studied yet. In mouse, rabbit and cattle, the thick ascending limb of Henle’s loop is thought to express claudins 3, 10, 11, 16  in adulthood, and, at least in mouse, additionally claudin-6 during development. In addition, claudin-4 has been found in cattle and claudin-8 in rabbit. To date, the distribution of Claudin-19 has been investigated in mouse, rat, and man where its presence in the TAL was demonstrated.

The thick ascending limb (TAL) of Henle’s loop, working as “diluting segment” of the nephron, is characterized by two major properties: high transepithelial, resorptive transport of electrolytes and low permeability to water. Major players to achieve electrolyte transport are the apical Na+-K+-2Cl−symporter (NKCC2), the apical K+ channel ROMK, the basolateral Cl− channel (CLC-Kb) together with its subunit barttin and the basolateral Na+/K+-ATPase . The combined actions of these transport systems have been extensively reviewed and are therefore only briefly summarized here. Na+ and Cl− are resorbed by entering the cells apically through NKCC2 and leaving the cells basolaterally through the Na+/K+-ATPase and CLC-Kb, respectively. In contrast, K+ is either recycled across the apical membrane as it is entering through NKCC2 and leaving through ROMK, or even secreted, as it is also entering the cells basolaterally through the Na+/K+-ATPase. Taking these ion movements together, there is a net movement of positive charge from the basolateral to the apical side of the epithelium, giving rise to a lumen positive voltage (3 – 9 mV [11]; about 5 – 7 mV [30,31]; 7 – 8 mV [57]). Over the length of the TAL, luminal NaCl concentration decreases gradually to concentrations of 30 – 60 mM at the transition to the distal tubule, depending on the flow rate within the tubule (low flow rates resulting in low concentrations).

To keep up such a high gradient, the TAL epithelium has to be tight to water and various studies summarized by Burg and Good report water permeability values from 28 µm/s down to values indistinguishable from zero. Tight junctions of the TAL are, however, highly permeable to cations with PNa being about 2 – 2.7 fold, 2.5 fold or even up to 6 fold that of PCl. Amongst the monovalent cations, a permeability sequence of PK > PNa > PRb = PLi > PCs > Porganic cation was observed which is similar to Eisenman sequence VIII or IX, indicating a strong interaction between the permeating ion and the paracellular pore that enables at least partial removal of the hydration shell (see below). As reviewed by Burg and Good, the transepithelial sodium and chloride permeabilities, estimated from radioisotope fluxes, are high (in the range of 10 – 63·10−6 cm/s) and the transepithelial electrical resistance is correspondingly low (21 – 25 W cm2 ; 30 – 40 W cm2 ; 11 – 34 W cm2 . Blocking active transport by the application of furosemide or ouabain increases transepithelial resistance only slightly, indicating that the low values are primarily due to a very high paracellular permeability. Due to these properties of TAL epithelial cells, Na+ ions leak back into the lumen of the tubule, creating a diffusion (dilution) potential that adds another 10 – 15 mV to the lumen positive potential, so that considerable potential differences (25 mV ; 30 mV; cTAL 23 mV, mTAL 17 mV ) may be reached at very slow flow rates.

Considerable proportions of the initially filtrated Mg2+ (50 – 60%; 50 – 70%; 65 – 75%) and Ca2+ (20%; 30 – 35% are resorbed in the TAL. The transepithelial potential is considered to provide the driving force for the predominantly paracellular resorption of Mg2+ and Ca2+ as in many studies, transport of both divalent ions in the TAL has been found to be strictly voltage dependent (resorbtive at lumen positive potentials, zero at 0 mV and secretory at lumen negative potentials) and permeability considerable (PCa 7.7·10−6 cm/s, i.e. approximately 25% of PNa). There is however, some conflicting evidence, e.g. by Suki et al. and Friedman. Both studies used cTAL (cortical TAL) and found that decreasing the transepithelial potential by applying furosemide did either not alter the unidirectional lumen to bath Ca2+ flux (rabbit) or left a substantial net Ca2+ resorption (mouse). Similarly, Rocha et al. found that bath application of ouabain almost abolished the transepithelial potential, but hardly affected net Ca2+ resorption and conclude that (a) all segments of Henle’s loop are relatively impermeable to calcium and (b) net calcium resorption occurs in the thick ascending limb which cannot be explained by passive mechanisms.  Mandon et al. conclude that both Mg2+ and Ca2+ are transported in the cTAL but not in the mTAL (medullary TAL) of rat and mouse, although transepithelial potential differences were similar in both segments, and even if the transepithelial potential was experimentally elevated to values above 20 mV. Wittner et al. even found evidence that in mouse mTAL the passive permeability to divalent cations is very low and that Ca2+ and Mg2+ can be secreted into the luminal fluid under conditions which elicit large lumen-positive transepithelial potential differences. They conclude that this Ca2+ and Mg2+ transport is most probably of cellular origin. In contrast, in rabbit, both ions are transported along the whole length of the TAL.

Both, Mg2+ and Ca2+ resorption are modulated through the action of the basolateral Ca (and Mg) sensing receptor (CaSR) which is found along the entire nephron but especially in the loop of Henle, distal convoluted tubule (DCT) and the inner medullary collecting duct. Different modes of action on Ca2+ and Mg2+ homeostasis exist, such as an indirect action through the modulation of PTH secretion or direct effects on the cells expressing CaSR. In the TAL the latter model is based on the assumptions depicted above, i.e. that Mg2+ and Ca2+ are resorbed paracellularly, driven by the lumen positive potential, so that a reduction in NaCl resorption causes a reduction in driving force for Mg2+ and Ca2+ resorption. As reviewed by Hebert and Ward, CaSR is activated through an increase in basolateral Ca2+ and/or Mg2+ concentration which triggers an increase in the intracellular Ca2+ concentration. This reduces the activity of the adenylate cyclase which, in turn, inhibits transcellular transport of Na+ and Cl−. In addition, the increase in intracellular Ca2+ activates phospholipase A2 (PLA2) and thus increases the intracellular concentration of arachidonic acid and its derivative, 20-HETE. 20-HETE inhibits NKCC2, ROMK and the Na+/K+-ATPase and by this Mg2+ and Ca2+ resorption. In keeping with this hypothesis, mutations in CaSR affect Ca/Mg resorption. Inactivating mutations cause hypercalcemia, hypocalciuria, hypomagnesiuria and, in some patients hypermagnesemia. Conversely, activating mutations (gain of function mutations) lead to hypocalcemia, hypercalciuria, hypermagnesiuria and in up to 50% of the patients mild hypomagnesemia.

Bartter syndrome type I (mutations in NKCC2), and type II (mutations in ROMK) lead to hypercalciuria and thus cause nephrocalcinosis, but no hypomagnesemia is observed. Reports on hypermagnesiuria are conflicting: while Kleta and Bockenhauer link it to nephrocalcinosis seen in these patients, Rodriguez-Soriano states that patients with neonatal Bartter syndrome (i.e. type I or II) show a lack of hypermagnesiuria that may be explained by compensation in the DCT. Hypomagnesemia is occationally present in Bartter type III (CLC-Kb). However, here it is believed to be mainly due to effects on DCT, where CLC-Kb shows highest expression. Patients with Bartter syndrome IV (CLC-Kbsubunit barttin) may or may not present nephrocalcinosis, while Mg2+ homeostasis appears undisturbed. Interestingly, the largest effects on Mg2+-homeostasis are observed in Gitelman syndrome, a defect in the Na+/Cl− symport (NCC) predominantly found in the DCT, where Mg2+ is transported along the transcellular route. Affected patients suffer from hypomagnesemia, hypermagnesuria and hypocalciuria. The effect on Mg2+ in Gitelman syndrome is still poorly understood and possibly due to a concomitant down-regulation of TRPM6, the apical Mg2+ uptake channel in DCT.

More than 30 different claudin-16 mutations have now been reported in families with FHHNC. Because of the large number of unique mutations, it has not been possible to identify any clear qualitative correlation between the phenotype and individual mutations, although certain mutations are associated with greater severity of disease. In 2006, a second locus was identified, CLDN19, which encodes claudin-19. In the initial report, the phenotype appeared similar to that due to claudin-16 mutations, with the exception that there was a high prevalence of ocular abnormalities, including macular colobomata, nystagmus and myopia. Claudin-19 is normally expressed at high levels in the retina, but why it causes these ocular disorders is unknown.

In vitro studies of claudin function comprise inducible or non-inducible transfection of various cells lines with cDNA for claudins that are not endogenously expressed by the cell line used. Alternatively, cells can be transfected with siRNA directed against an endogenous claudin. In both cases, cells are then grown to confluence on permeable filter supports that allow measurement of transepithelial permeabilities. Before the results of permeability studies can be interpreted, however, several parameters have to be controlled.

First, special care has to be taken to make sure that the exogenous claudin is correctly inserted into the tight junction. This can be achieved e.g. by confocal laser scanning microscopy, colocalizing the claudin of interest  with a tight junction marker protein such as occludin.

Second, it has to be ensured that endogenous claudin expression remains unaffected, as permeability changes always result from the combined effects of alterations in endogenous and exogenous claudins.

Third, it has to be kept in mind that, typically, epithelia express several different claudins that act together to produce tissue specific permeability properties. Thus, ideally, a cell line should be chosen that provides a claudin background resembling that usually experienced by the claudin investigated. The latter two points may be the reason for contradicting results obtained in permeability studies expressing a specific claudin in different cell lines.

Studies of paracellular permeabilities can be divided into two groups, those employing electrophysiological measurements (e.g. determination of diffusion potentials), and those measuring ion or solute flux, using either radioactive isotopes or various analytical methods to determine the amount transported.

Although transepithelial conductances depend on paracellular permeabilities of the predominant ions in the bath solution, conductance changes alone cannot be used to predict ion permeabilities.

Firstly, conductances always depend on both ion and counter-ion, not on one ion species alone.

Secondly, transepithelial conductances are the sum of the conductances of the transcellular and paracellular pathways.

Thus, they only reflect paracellular permeability, if paracellular conductance dominates transepithelial conductance and if transcellular conductance remains constant throughout the experiment. This, however, is often not the case, as concentration changes of the ions investigated may affect transcellular conductance, e.g. by activating ion transporters or by inhibiting ion channels. Thirdly, the specific conductance of each solution employed may differ and has therefore to be assessed and taken into account. Thus, comparison of results from diffusion potential measurements or flux studies and conductance measurements may even yield contradicting results. For the same reasons, other methods based on pure conductance/resistance measurements, including the more sophisticated conductance scanning method or one-path impedance spectroscopy are not ion specific and do not allow the measurement of paracellular permeabilities to single ions.

In contrast to electrophysiological measurements, flux measurements are not limited to ions but can also be extended to uncharged molecules.  Flux measurements per se do not distinguish between transcellular or paracellular transport. Therefore, to estimate paracellular permeabilities, inhibition or at least estimation of the transcellular flux is necessary. Assuming that transcellular flux for energetic reasons is not easily reversible while paracellular flux is passive and thus generally assumed to be symmetric, the transcellular proportion is often estimated by calculating the difference between apical to basolateral and basolateral to apical fluxes. All flux measurements are very sensitive to the development of diffusion zones (“unstirred layers”) near the cells. These layers are depleted/enriched in the compound transported and thus alter the driving forces acting on these compounds, if bath solutions are not continually circulated. If ionic fluxes are investigated, transepithelial potentials may develop that diminish or completely inhibit the flux investigated.

All the techniques described above have been employed to investigate the function of claudin-16 and -19, especially with respect to their ability to increase paracellular permeability to divalent cations. The hypothesis, that claudin-16 (then called paracellin-1) may be a paracellular Mg2+ and Ca2+ pore was originally expressed by Simon et al. It was based on the findings that mutations in claudin-16 were the cause of the severe disturbance in Mg2+ and Ca2+ homeostasis in FHHNC patients together with the observations that claudin-16 is a tight junction protein located in the TAL, i.e. the nephron segment responsible for bulk Mg2+ resoption along the paracellular pathway. When, recently, it was found that claudin-19 mutations were underlying hitherto unexplained cases of FHHNC and that claudin-19 co-localized with claudin-16, the hypothesis was extended to claudin-19.

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  5. Schlingmann KP, Konrad M, Seyberth HW. Genetics of hereditary disorders of magnesium homeostasis. Pediatr Nephrol 2004;19:13–25. [PubMed: 14634861]  
  6. Simon DB, Lu Y, Choate KA, et al. Paracellin-1, a renal tight junction protein required for paracellular Mg2+ resorption. Science 1999;285:103–106. [PubMed: 10390358]

PMID: 18795318  PMCID:  PMC2666100  http://www.ncbi.nlm.nih.gov/pubmed/18795318

Deletion of claudin-10 (Cldn10) in the thick ascending limb impairs paracellular sodium permeability and leads to hypermagnesemia and nephrocalcinosis.

Breiderhoff T, Himmerkus N, Stuiver M, Mutig K, Will C, Meij IC et al.
Max Delbrück Center for Molec Med, Berlin, Germany. t.breiderhoff@mdc-berlin.de

Erratum in Proc Natl Acad Sci. 2012 Sep 11;109(37):15072.
Proc Natl Acad Sci. Aug 28, 2012; 109(35):14241-6.   http://dx.doi.org/10.1073/pnas.1203834109. Epub 2012 Aug 13.

In the kidney, tight junction proteins contribute to segment specific selectivity and permeability of paracellular ion transport. In the thick ascending limb (TAL) of Henle’s loop, chloride is reabsorbed transcellularly, whereas sodium reabsorption takes transcellular and paracellular routes. TAL salt transport maintains the concentrating ability of the kidney and generates a transepithelial voltage that drives the reabsorption of calcium and magnesium. Thus, functionality of TAL ion transport depends strongly on the properties of the paracellular pathway. To elucidate the role of the tight junction protein claudin-10 in TAL function, we generated mice with a deletion of Cldn10 in this segment. We show that claudin-10 determines paracellular sodium permeability, and that its loss leads to hypermagnesemia and nephrocalcinosis. In isolated perfused TAL tubules of claudin-10-deficient mice, paracellular permeability of sodium is decreased, and the relative permeability of calcium and magnesium is increased. Moreover, furosemide-inhibitable transepithelial voltage is increased, leading to a shift from paracellular sodium transport to paracellular hyperabsorption of calcium and magnesium. These data identify claudin-10 as a key factor in control of cation selectivity and transport in the TAL, and deficiency in this pathway as a cause of nephrocalcinosis.

Whereas regulation of transporters and channels involved in trans-cellular ion transport has been characterized in much detail, the functional and molecular determinants of paracellular ion trans­port in the kidney remain incompletely understood. In the thick ascending limb (TAL) of Henle’s loop, both trans-cellular and paracellular ion transport pathways contribute to reabsorption of Na+, Cl, Mg2+, and Ca2+. Na+ and Clare reabsorbed mostly transcellularly by the concerted action of chan­nels and transporters. Mutations in five of the genes involved lead to Bartter syndrome, a disorder characterized by salt wasting and polyuria. Whereas Clis transported exclusively transcellularly, 50% of the Na+ load, as well as Ca2+ and Mg2+, are reabsorbed via paracellular pathways. In the TAL, this paracellular route is highly cation-selective. The paracellular passage is largely controlled by the tight junction (TJ), a supramolecular structure of membrane-spanning proteins, their intracellular adapters, and scaffolding proteins. Claudins, a family comprising 27 members, are the main components of the TJ defining the permeability properties. They interact via their extracellular loops with corre­sponding claudins of the neighboring cell to allow or restrict pas­sage of specific solutes (5, 6). In the kidney, their expression pattern is closely related to the corresponding segment-specific solute reabsorption profile. Several claudins are expressed in the TAL, including claudin-16, -19, -10, -3, and -18 The importance of claudin-16 and -19 in this tissue is documented by mutations in CLDN16 and CLDN19, which cause familial hypomagnesemia, hypercalciuria, and nephrocalcinosis, an autosomal recessive dis­order that leads to end-stage renal disease. The relevance of CLDN16 for paracellular reabsorption of Mg2+ and Ca2+ was confirmed in mouse models with targeted gene disruption. In addition, claudin-14, expressed in the TAL of mice on a high-calcium diet, was identified as negative regulator of claudin-16 function (15), and sequence variants in CLDN14 have been asso­ciated with human kidney stone disease. The functional significance of claudin-10, which is also ex­pressed in the TAL, remains unclear. This TJ protein is expressed in two isoforms, claudin-10a and claudin-10b, which differ in their first extracellular loop. In cultured epithelial cells, heter-ologous expression of claudin-10a increases paracellular anion transport, whereas claudin-10b expression increases paracellular cation transport. Both isoforms are expressed differentially along the nephron, with claudin-10a found predominantly in cortical segments, whereas claudin-10b is enriched in the medullary region.  In the present study we generated a mouse model with a TAL-specific Cldn10 gene defect to query the role of this protein in renal paracellular in transport in vivo. We found that claudin-10 is crucial to paracellular Na+ handling in the TAL, and that its absence leads to a shift from paracellular sodium transport to paracellular hyperreabsorption of Ca2+ and Mg2+.

Analysis of claudin-10 expression in the kidney. (A) Western blot analysis of kidney membrane extracts from control (ctr) and cKO mice. A dramatic reduction in claudin-10 protein can be seen in kidneys of cKO mice. Levels of the TJ marker occludin are unchanged. (B) Gene expression analysis of Cldn10 variants on cDNA from isolated segments of the nephron. (C) Immunohistological detection of claudin-10 and markers for PCT (NHE3) and TAL (NKCC2) on sections from control mice (ctr) and cKO mice demonstrates no difference in the signal for claudin-10 in the PCT between WT and cKO. Claudin-10 is expressed in TAL tubules positive for NKCC2. No specific clau-din-10 staining is evident in the TAL of cKO mice. Claudin-10 is detected in TJs positive for ZO-1. This signal is absent in cKO mice, whereas ZO-1 staining is unchanged. (Scale bar: 25 μm.)

In control animals, claudin-10 is located mainly in the TAL, as documented by coimmunostaining with the Na+K+2Clcotrans-porter (NKCC2). In this segment, a large portion of the claudin-10 immunofluorescence signal is located outside of the TJ; however, claudin-10 is present in the TJ, as demonstrated by colocalization with the TJ protein ZO-1. PCTs positive for the sodium-proton exchanger NHE-3 showed a considerably weaker signal restricted to the TJ area. Claudin-10 immunoreactivity was virtually absent in NKCC2-positive tubules of cKO mice, in line with the activity of Cre recombinase in this cell type. The immu-noreactivity of claudin-10 in PCTs of cKOs remained unchanged, however. ZO-1 staining in TAL sections of cKOs was unchanged compared with controls, indicating no unspecific effect on TJ structures. The TJ localization of claudin-16 and claudin-19 in medullary rays was similar in cKOs and controls.   To investigate the phenotypic consequences of renal claudin-10 deficiency, we per­formed a histological examination of the kidneys of 10-wk-old cKO mice and their respective controls. Kidneys from cKO mice contained extensive medullary calcium deposits, as revealed by von Kossa and alizarin red S staining. The deposits were found along the outer stripe of the outer medulla. The detection of extensive calcification suggests alterations in renal ion homeostasis in mice deficient for claudin-10.  Serum Na+ and Cllevels and their renal FE excretion rates were not different be­tween genotypes. In addition, serum creatinine and glomerular filtration rate were not altered compared with controls. Taken together, these findings indicate that calcium deposition does not nonpecifically affect overall glomerular or tubular function.

Fig 4. Gene expression analysis of renal claudins (A) and representative renal ion transporters and channels (B) by real-time PCR. Cldn10 deficiency results in differential gene expression of several genes. Values from cKO animals are shown relative to control mice (mean ± SEM). Wnk1, Wnk1-KS, Kcnj1, and Trpm6, n = 5/4; all other genes, n = 10/10. *P < 0.05; **P < 0.01; ***P < 0.001.    The thiazide-sensitive NaCl cotransporter NCC (Slc12a3), the protein involved in NaCl absorption in the DCT, and the respective inhibitory, kidney-specific kinase-defective KS-WNK1 were expressed at lower levels in the cKO mice. Taken together, these data suggest specific compensatory alterations in components of both paracellular and transcellular renal ion transport mechanisms in mice deficient in claudin-10 in the TAL.

Urinalysis demonstrated that the inhibition of TAL tubular transport by furosemide resulted in a completely differ­ent pattern of tubular Ca2+ and Mg2+ handling that identifies the TAL as the major nephron segment affected by claudin-10 deficiency.  Interestingly, the different effects on plasma Mg2+ and Ca2+ levels reflect the different major reabsorption sites of these ions. Some 60% of the filtered Mg2+ is reabsorbed in the TAL, compared with only 20% of the filtered Ca2+ load (20). Ca2+ hyperreabsorption in TAL seems to be balanced by reduced (proximal and) distal tubular Ca2+ transport. The hyperreabsorption of divalent cations in mice deficient in claudin-10 is in opposition to the loss of divalent cations seen in mouse models of claudin-16 deficiency and in human patients with mutation in CLDN16 or CLDN19. This finding indicates that claudins in the TAL have functions that differentially affect paracellular cation transport in this segment. Mice deficient for claudin-10b in the TAL exhibit decreased permeability for Na+ and increased permeability for Ca2+ and Mg2+, whereas in mice with claudin-16 or claudin-19 deficiency, decreased sodium per­meability in the TAL is paralleled by decreased reabsorption of Ca2+ and Mg2+.

1. Greger R (1981) Cation selectivity of the isolated perfused cortical thick ascending limb of Henle’s loop of rabbit kidney. Pflugers Arch 390:30–37.
2. Furuse M (2010) Molecular basis of the core structure of tight junctions. Cold Spring Harb Perspect Biol 2:a002907.
3. Konrad M, et al. (2006) Mutations in the tight-junction gene claudin 19 (CLDN19) are associated with renal magnesium wasting, renal failure, and severe ocular in­volvement. Am J Hum Genet 79:949–957.
4.  Simon DB, et al. (1999) Paracellin-1, a renal tight junction protein required for par-acellular Mg2+ resorption. Science 285:103–106.
5. Hou J, et al. (2007) Transgenic RNAi depletion of claudin-16 and the renal handling of magnesium. J Biol Chem 282:17114–17122.
6. Himmerkus N, et al. (2008) Salt and acid-base metabolism in claudin-16 knockdown mice: Impact for the pathophysiology of FHHNC patients. Am J Physiol Renal Physiol 295:F1641–F1647.

 PMID: 22891322  PMCID: PMC3435183   http://www.ncbi.nlm.nih.gov/pubmed/22891322

Paracellin-1 is critical for magnesium and calcium reabsorption in the human thick ascending limb of Henle.

Blanchard A, Jeunemaitre X, Coudol P, Dechaux M, Froissart M, et al.
Université Pierre et Marie Curie, INSERM and Laboratoire de Génétique Moléculaire, Hôpital Universitaire Européen Georges Pompidou, Paris, France. blanch@ccr.jussieu.fr
Kidney Int. 2001 Jun; 59(6):2206-15.

A new protein, named paracellin 1 (PCLN-1), expressed in human thick ascending limb (TAL) tight junctions, possibly plays a critical role in the control of magnesium and calcium reabsorption, since mutations of PCLN-1 are present in the hypomagnesemia hypercalciuria syndrome (HHS).
No functional experiments have demonstrated that TAL magnesium and calcium reabsorption were actually impaired in patients with HHS.
Genetic studies were performed in the kindred of two unrelated patients with HHS.

We found two yet undescribed mutations of PCLN-1 (Gly 162 Val, Ala 139 Val). In patients with HHS, renal magnesium and calcium reabsorptions were impaired as expected; NaCl renal conservation during NaCl deprivation and NaCl tubular reabsorption in diluting segment were intact. Furosemide infusion in CS markedly increased NaCl, Mg, and Ca urinary excretion rates. In HHS patients, furosemide similarly increased NaCl excretion, but failed to increase Mg and Ca excretion. Acute MgCl(2) infusion in CS and ERH patient provoked a dramatic increase in urinary calcium excretion without change in NaCl excretion. When combined with MgCl(2) infusion, furosemide infusion remained able to induce normal natriuretic response, but was unable to increase urinary magnesium and calcium excretion further. In HHS patients, calciuric response to MgCl(2) infusion was blunted.

In patients with HHS, levels of circulating renin and aldosterone were normal, suggesting normal blood and extracellular volume. In addition, HHS patient 2 was normally able to lower her sodium excretion below 10 mmol/day during sodium deprivation, and in HHS pa­tient 1, sodium reabsorption in the diluting segment was normal as assessed by hypotonic saline infusion.  After oral NH4Cl load: Minimal urinary pH was 5.8 (normal value <5.4), and maximal net acid excretion reached only 24 pmol/min (normal value >80). Both subjects had hypocitraturia. The latter data suggested in the two probands distal defect of urinary acidification, probably related to nephrocalcinosis.

Because the filtered load of calcium but not the filtered load of magnesium remains unchanged during acute magnesium infusion in humans, the increase in calcium excretion is a better index of the inhibitory effect of peritubular magnesium on renal tubular divalent cation transport.  Urinary sodium excretion remained almost constant in both subjects during MgCl2 infusion (data not shown). Accordingly, the FECa/FENa ratio, which should remain constant if sodium reabsorption was primarily affected, increased in the CS and EHR patient.  Before the furosemide infusion, serum ultrafilterable (UF) Ca concentrations were similar in patients with HHS and the controls. However, Ca excretion markedly differed and was approximately five times higher in HHS patients than in controls.

In the two patients with homozygous mutations in the PCLN-1 gene, an impairment in renal tubular magne­sium and calcium reabsorption with normal NaCl recla­recla­mation was demonstrated. Accordingly, comparative studies performed under baseline condition in one pa­tient with ERH and in HHS patients demonstrated that the magnesium and calcium excretion in HHS patients were inappropriately high when compared with serum magnesium and calcium concentrations. However, renal NaCl reabsorption in HHS patients was intact. There was no clinical evidence of extracellular fluid volume  contraction. Furthermore, basal circulating renin and aldosterone concentrations were normal and adapted to the normal Na intake. Finally, abnormal NaCl reclama­tion in the diluting segment of the nephron was excluded in one patient, while the other was able to adapt normally to a sodium deprived diet.

This study is the first to our knowledge to demonstrate that homozygous mutations of PCLN-1 result in a selective defect in paracellular Mg and Ca reabsorption in the TAL, with intact NaCl reabsorption ability at this site. In addition, the study supports a selective physiological effect of basolateral Mg(2+) and Ca(2+) concentration on TAL divalent cation paracellular permeability, that is, PCLN-1 activity.   PMID: 11380823   http://www.ncbi.nlm.nih.gov/pubmed/11380823

Development of a Novel Sodium-Hydrogen Exchanger Inhibitor for Heart Failure

Elizabeth Juneman*, Reza Arsanjani, Hoang M Thai, Jordan Lancaster, Jeffrey B Madwed, Steven Goldman
Citation: Elizabeth Juneman, et al. (2013) Development of a Novel Sodium-Hydrogen Exchanger Inhibitor for Heart Failure. J Cardio Vasc Med 1: 1-6

This study was designed to determine the potential therapeutic effects of a new sodium-hydrogen exchanger (NHE-1) inhibitor in the rat coronary artery ligation model of chronic heart failure. After the induction of acute myocardial infarction, rats were entered randomly dose dranging from 0.3 mg/kg, 1.0 mg/kg, and 3.0 mg/kg. Solid state micrometer hemodynamics, echocardiographic, and pressure-volume relationships were measured after 6 weeks of treatment. Treatment with this NHE- 1 inhibitor at 3 mg/kg increased (P< 0.05) ejection fraction from 23±3% (N=6) to 33±2% (N=13) while the 1 mg/kg dose decreased (P< 0.05) the infarct size in CHF rats from 21.7±1.4% (N=7) to 15.9±0.7% (N=3) and prevented (P< 0.05) dilatation of the left ventricle in CHF rats in diastole (1.0±0.1 cm, N=6) to 0.9±0.1 cm, N=10) and in systole (0.9±0.1 cm, N=6) to 0.8±0.1, N=10). These study results suggest that this new NHE-1 inhibitor may be potentially useful in treating CHF with an improvement in maladaptive left ventricule remodeling. Because the mechanism of action of this agent is entirely different than the currently applied approach in treating CHF that focuses on aggressive neurohormonal blockade and because this agent does not adversely affect important hemodynamic variables, further investigations with this agent may be warranted.

Keywords: Congestive heart failure; Sodium/hydrogen exchange; Cardiovascular disease; Cardiovascular drugs; CHF: Chronic Heart Failure; NHE-1: Sodium-Hydrogen Exchanger; NCX: Sodium-Calcium Exchanger; Ca2+: Calcium; Na+: Sodium; Na+-K+ATPase: Sodium-Potassium ATPase; NKCC: Sodium-Potassium-Chloride co-transporter; MI: Myocardial Infarction; BI: Boehringer Ingelheim; LV: left Ventricle; EF: Ejection Fraction; LVD: left ventricular dysfunction; PV: Pressure-Volume; SE: Standard Error; ARB: Angiotensin Receptor Blocker; ACE: Angiotensin Converting Enzyme

Without reviewing the pathophysiology of CHF here, altered calcium (Ca2+) handling is a hallmark of CHF. Intracellular Ca2+ concentration is closely regulated by sodium-calcium exchanger (NCX) and Ca2+ efflux is dependent on the intracellular sodium (Na+) concentration and trans-sarcolemmal Na gradient. Multiple channels including sodium-potassium ATPase (Na+-K+ ATPase), sodium-hydrogen exporter (NHE), sodium-bicarbonate co-transporter, sodium-potassium-chloride co-transporter (NKCC), and sodium-magnesium exchanger are responsible for regulation of intracellular sodium in cardiac myocytes. The intracellular concentration of Na+ is significantly increased in heart failure, primarily due to influx of Na+. The NHE plays an integral part in rise of intracellular Na+ concentration and development of hypertrophy in heart failure. Because of its multifaceted role in myocardial function, there has been interest in examining the effects of NHE-1 inhibitors in heart failure.

In this study we report the physiologic responses of a new NHE-1 inhibitor, in a rodent model of heart failure. Previous evaluation of the pharmacokinetic properties of this agent in rat and dog revealed low clearance and robust oral bioavailability, suggesting a potential for once daily oral administration. This new compound was found to be potentially effective in preventing ischemic injury in isolated cells systems and in ischemic injury in isolated cells systems and in a Langendorff isolated heart preparation. Based on these encouraging a pharmacokinetic data, and the established preclinical roof of principle, the next step in new drug development was to test this inhibitor in an appropriate disease-relevant animal model. For this, we chose the rat coronary ligation model of CHF, which is the established model of chronic ischemic heart failure and well performed in our laboratory. The model with permanent occlusion of the left coronary artery is important because this model a similar to the clinical syndrome of CHF. This rat coronary artery model of CHF is the same model used in the classic study defining the beneficial use of angiotensin converting enzyme inhibition with captopril in the treatment of CHF. Thus results in this model have the potential to be predictive of the clinical response seen in patients.

Results

In vivohemodynamic effect of NHE1: As noted previously by our laboratory, rats with severe CHF compared to Sham had changes (P< 0.05) in right ventricular weight, mean arterial pressure, tau, the time constant of LV relaxation, LV systolic pressure, LV end-diastolic pressure, +LVdP/dt, -LVdP/dt, dead volume and peak developed pressure. In this study, treatment resulted in no changes in body weight, chamber weight or hemodynamics. Because we stopped the lowest dose (0.3 mg/kg) there are only hemodynamic data with this dose in rats with CHF.

Echocardiographic changes in LV function and Dimensions with NHE1: Rats with CHF have decreases in EF accompanied by increases in LV systolic and diastolic dimensions. There was no change in anterior wallsystolic displacement. These data are consistent with other reports in this model showing that at 6 weeks after left coronary artery ligation, rats with large MIs have dilated left ventricles with LV remodeling and poor LV function (14,15). Treatment with the highest dose of 3 mg/kg increased (P< 0.05) ejection fraction from 23±3% (N=6) to 33±2% (N=13). Treatment with 1 mg/kg prevented maladaptive LV remodeling, it prevented (P< 0.05) dilatation of the LV in CHF rats in diastole (1.0±0.1 cm, N=6) to 0.9±0.1 cm, N=10) and in systole (0.9±0.1 cm, N=6) to 0.8±0.1, N=10) with no change anterior wall thickening.

Pressure-Volume relationships:  Although there are no significant changes in the PV relationships for either the Sham or CHF rats, there is a trend for the PV loop in CHF to be shifted toward the pressure axis with treatment. These data are consistent with the trend toward decreases in LV dimensions seen with treatment in CHF rats.

Discussion

This study can be viewed as a corollary of a pilot Phase II clinical trial to look for a signal of a beneficial physiologic effect of this new NHE-1 inhibitor in CHF. In terms of drug development, this is an appropriate approach, i.e., take an agent with a therapeutic focus, with an acceptable toxicology profile, alter its pharmacokinetics to improve its oral delivery and bioavailability and then study the drug in an appropriate animal model. The administration of this agent to rats with CHF after left coronary artery ligation resulted in a therapeutic benefit with an increase in EF and a decrease in infarct size in rats with the largest infarcts. There is a suggestion of the prevention of LV remodeling with decreases in LV end-diastolic and end-systolic dimensions accompanied by a similar trend in the PV loop with a shift toward the pressure axis. There were no changes in hemodynamics.

Importantly, the decrease in infarct size with no changes in hemodynamicswould positively affect LV remodeling by minimizing LV dilatation without changes in LV afterload. From a therapeutic perspective, an agent like this may be advantageous in the treatment of heart failure after MI. The lack of hemodynamic changes is not a clinical problem because we already have agents that decrease afterload and lower LV end-diastolic pressure such as angiotensin converting enzyme (ACE) inhibitors and angiotens in receptor blockers (ARBs). In treating CHF, we also have diuretics to control blood volume, which in turn reduces LV end-diastolic pressure. The other potential advantage of an NHE-1 inhibitor is that as opposed to our current use of aggressive neurohormonal blockade, this represents a different approach to treating CHF. This is attractive because we essentially have exhausted or maximized our effects of neurohumoral blockade and with no real new treatments for CHF introduced in the last 10-15 years, need to look for other approaches to treat CHF.

Drug development is obviously a complicated and expensive undertaking. In exploring this agent, we would proposea stepwise approach. In this case with an agent whose analogs have been studied extensively, our thought would be to perform a larger dose ranging study in CHF rats to define dose response curves for systolic function as well as obtain more information on pharmacokinetics, as well as diastolic function and structural changes.

An attractive aspect of this work is that we are examining an agent with a different mechanisms of action that current treatments for heart failure. The stimulus to study the agent in an animal model of heart failure was based on multifaceted roles of sodium-hydrogen exchangers on myocardial function. Nine isoforms of NHE have currently been identified, with NHE- 1 being the predominant isoform in the plasma membrane of the myocardium [3,24]. Because NHE is activated by intracellular acidosis, angiotensin II, and catecholamines, its activity is expectedly increased in heart failure. Inhibition of NHE-1 has previously been associated with decreased fibrosis, apoptosis, preserved contractility, and attenuation of hypertrophy and development of heart failure.

1. Baartscheer A, van Borren MMGJ (2008) Sodium Ion Transporters as New Therapeutic Targets in Heart Failure. Cardiovasc Hematol Agents Med Chem 6: 229-236.
2. Murphy E, Eisner DA (2009) Regulation of Intracellular and Mitochondrial Sodium in Health and Disease. Circ Res 104: 292-303
3. Despa S, Islam MA, Weber CR, Pogwizd SM, Bers DM (2002) Intracellular Na(+) Concentration is Elevated in Heart Failure but Na/K Pump Function is Unchanged. Circulation 105: 2543-2548.
4. Baartscheer A, Schumacher CA, van Borren MMGJ, Belterman CNW, Coronel R, et al. (2003) Increased Na+/H+-Exchange Activity is the Cause of Increased [Na+]i and Underlies Disturbed Calcium Handling in the Rabbit Pressure and Volume Overload Heart Failure Model. Cardiovasc Res 57: 1015-1024.
5.  Pieske B, Houser SR (2003) [Na+]i Handling in the Failing Human Heart. Cardiovasc Res 57: 874-886.
6.  Engelhardt S, Hein L, Keller U, Klämbt K, Lohse MJ (2002) Inhibition of Na(+)-H(+) Exchange Prevents Hypertrophy, Fibrosis, and Heart Failure in Beta(1)- Adrenergic Receptor Transgenic Mice. Circ Res 90: 814-819.
7.  Chen L, Chen CX, Gan XT, Beier N, Scholz W, et al. (2004) Inhibition and Reversal of Myocardial Infarction-Induced Hypertrophy and Heart Failure by NHE-1 Inhibition. Am J Physiol Heart Circ Physiol 286: 381-387.
8.  Marano G, Vergari A, Catalano L, Gaudi S, Palazzesi S, et al. (2004) Na+/ H+ Exchange Inhibition Attenuates Left Ventricular Remodeling and Preserves Systolic Function in Pressure-Overloaded Hearts. Br J Pharmacol 141: 526-532.
9. Goldman S, Raya TE (1995) Rat Infarct Model of Myocardial Infarction and Heart Failure. J Card Fail 1: 169-177.
10. Gaballa MA, Goldman S (2002) Ventricular Remodeling in Heart Failure. J Card Fail. 8: 476-485.
11. Pfeffer MA, Pfeffer JM, Steinberg C, Finn P (1985) Survival After Experimental Myocardial Infarction: Beneficial Effects of Long-Term Therapy with Captopril. Circulation 72: 406-412.
12. Raya TE, Gay RG, Aguirre M, Goldman S (1989) Importance of Venodilatation in Prevention of Left Ventricular Dilatation after Chronic Large Myocardial Infarction in Rats: A Comparison of Captopril and Hydralazine. Circ Res 64: 330-337.

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pone.0070764.g006  Morpholino knockdown of aquaporin-1a1 reduces water influx.       NIHMS262281.html

nihms81087f1  Localization of claudin proteins in mammalian kidney.      F1.medium  intracellular Mg2+ in normal and Mg2+ depleted immortalized mouse distal convoluted tubule (MDCT) cells

F2.small  membrane voltage influences Mg2+ uptake in MDCT cells    pnas.1203834109fig04  Gene expression analysis of renal claudins

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Translational Research on the Mechanism of Water and Electrolyte Movements into the Cell

Reviewer and Curator: Larry H. Bernstein, MD, FACP

Introduction

This article is the first in a three part curation covering work that has great importance to our understanding of hydration and possibly the effects of dehydration in cell physiology, and studied effects on renal function and brain, with possible implications for heart failure, myocardial contraction, heart rate, and arrhythmiagenesis.  The discovery of aquaporins and the elucidation of potassium channels and selective ion conduction was jointly awarded the Nobel Prize in Chemistry in 2003 to Peter Agre, at the Johns Hopkins School of Medicine, Baltimore, and Roderick Mac Kinnon, at the Howard Hughes Medical Institute, Laboratory of Molecular Neurobiology and Biophysics, Rockefeller University, New York, NY.  The transport of water, it was assumed, is associated with the movements of Na(+), K(+), Ca(2+), Mg(2+).  The calmodulin kinase, rhyanodine, and calcium sparks in the Ca(2+) release from sarcolemma is covered elsewhere in cardiac contraction, skeletal muscle, smooth muscle, and neural stimulation of muscle and adrenergic release.  The sodium/potassium exchange is depicted in diagrams, but not discussed.  In traditional chemistry we would think in terms of a cationic and anionic balance that has to be maintained in charge equivalents on both sides of a membrane.  However, the intricacies of membrane structure as well as active transporters has been delineated and has been a transformative factor in our understanding of organ function in health and disease.

Aquaporin Water Channels

AQUAPORIN WATER CHANNELS: Nobel Lecture, Dec 8, 2003, by Peter Agre. http://www.nobelprize.org/nobel_prizes/chemistry/laureates/2003/agre-lecture.pdfagre-lecture Fig1 Membrane orientation of AQP1

We have studied the aquaporin water channels for several years, and we now understand that they explain how water crosses biological membranes. Our bodies are 70% water, and all other vertebrates, invertebrates, microbes, and plants are also primarily water. The organization of water within biological compartments is fundamental to life, and the aquaporins serve as the plumbing systems for cells. Aquaporins explain how our
brains secrete and absorb spinal fluid, how we can generate aqueous humor within our eyes, how we can secrete tears, saliva, sweat, and bile, and how our kidneys can concentrate urine so effectively. These proteins are fundamental to mammalian physiology, but they are also very important in the lives of microorganisms and plants.
It was correctly proposed  in the 1920’s that water could move through the cell membrane simply by diffusing through the lipid bilayer. The current view is that the lipid bilayer has a finite permeability for water, but, in addition, a set of proteins exists that we now refer to as “aquaporins.” Their existence was suggested by a group of pioneers in the water transport field who preceded us by decades – people including Arthur K. Solomon in Boston, Alan Finkelstein in New York, Robert Macey in Berkeley, Gheorghe Benga in Romania, Guillermo Whittembury in Venezuela, Mario Parisi in Argentina – who by biophysical methods predicted that water channels must exist in certain cell types with high water permeability such as renal tubules, salivary glands, and red cells (reviewed by Finkelstein, 1987).
The difference between diffusional and channel-mediated water perme-ability is fairly distinct. Diffusion is a low capacity, bidirectional movement of water that occurs in all cell membranes, whereas the membranes of a subset of cells with aquaporin proteins have very high capacity for permeation by water.
This permeability is selective, since water (H O) crosses through the membranes with almost no resistance, while acid, the hydronium ion (H O ) does not permeate the proteins. This distinction is essential to life. The movement of water is directed by osmotic gradients, so aquaporins are not pumps or exchangers. They form a simple pore that allows water to rapidly pass through membranes by osmosis. There are also other differences between diffusion and channel-mediated water transport. No inhibitors are known for simple diffusion. In contrast, mercurials were discovered by Robert Macey to inhibit water transport in red cells but water permeability was restored by treatment with reducing agents (Macey and Farmer, 1970). These observations predicted that water channels must be proteins with sulfhydryls and characteristically low Arrhenius activation energy.
A number of investigators using ver y logical approaches attempted to identify the water channel molecule; identification proved a very difficult prolem. Isotopic mercurials labeled several membrane proteins – the anion exchanger (band 3). Solomon and a group of several proteins (band 4.5) by Benga. None of the proteins were isolated, reconstituted, and shown  to transport watter (reviewed by Agre et al., 1993a).

DISCOVERY OF AQP1

The field was essentially stuck, but following the well known scientific approach known as “sheer blind luck,” we stumbled upon the protein. Looking through our notebooks for the earliest studies that showed there was such a protein water channel. We were at that time attempting to raise antibodies in rabbits to the denatured partially purified Rh polypeptide.  The rabbits vigorously produced antibodies, but we failed to recognize initially that our antibody did not react with the core Rh polypeptide that migrated at 32 kDa, seen clearly by silver staining of sodium dodecyl sulfate polyacryamide electrophoresis gels (SDS-PAGE). Instead, our antibodies reacted only with a 28 kDa polypeptide. The 28 kDa was an unrelated protein.  Silver staining of SDS-PAGE migration of the isolated protein revealed a discrete band of 28 kDa in detergent insoluble extracts (it failed to stain with the conventional protein stains such as Coomassie blue). The protein was then purified in large amounts from human red cell membranes (Denker et al., 1988; Smith and Agre, 1991).  The 28 kDa protein was strikingly abundant. With approximately  copies per red cell, it was one of the major proteins in the membrane. The protein had features suggesting that it was a tetrameric membrane-spanning protein – suggesting that it was a channel, but a channel for what? The purified protein also provided us the N-terminal amino acid sequence that we used for cDNA cloning. Using our antibody, we looked at several other tissues and found the protein is also strikingly abundant in human kidney. We observed staining over the apical and basolateral membranes of proximal renal tubules and the descending thin limb of the loops of Henle, but we were still frustrated by our failure to recognize what the protein’s function might be.  My clinical mentor, John C. Parker (1935–1993) at the University of North Carolina at Chapel Hill, was the first to suggest to me that red cells and renal tubules were exceedingly permeable to water. He recommended that we consider a role in membrane water transport. While John did not live to see our later studies, he did live to see our initial discovery and we celebrated together.
Postdoctoral fellow Gregor y Preston cloned the cDNA from an erythroid brary (Preston and Agre, 1991). The coding region corresponded to a 269 amino acid polypeptide, predicted by hydropathy analysis to have six bilayer-spanning domains. Interestingly, the amino terminal half (repeat-1) and the carboxy terminal half of the molecule (repeat-2) were genetically related – about 20% identical. Two loops B and E were more highly related to each other, and each contained the signature motif – asparagine, proline, alanine (NPA) [Fig. 1]. Examining the genetics database, we recognized several sequence-related DNAs from diverse sources: lens of cow eyes, brains of fruit flies, bacteria, and plants. Nevertheless, none was functionally defined.
Figure 1. Membrane orientation of AQP1 predicted from primary amino acid sequence. Two tandem repeats each have three bilayer-spanning domains; the repeats are oriented 180˚ with respect to each other. The loops B and E each contain the conser ved motif, Asn- Pro-Ala (NPA)
These clues heightened our suspicion that the 28 kDa protein was a transporter, so we tested for possible water transport function with our colleague Bill Guggino at Johns Hopkins. We used oocytes the frog Xenopus laevis, a useful model, since frog oocytes have very low water permeability. Control oocytes were injected with water alone; oocytes were injected with 2 ng of cRNA encoding our protein. After days of protein synthesis, the oocytes appeared essentially identical. Then we stressed the oocytes by transferring them to distilled water, and an amazing difference was immediately apparent. Having exceedingly low water perme-
ability, the control oocytes failed to swell. In contrast, the test oocytes were highly permeable to water and exploded like popcorn [Fig. 2] (Preston et al., 1992).  The protein was christened “aquaporin” and is now officially designated “AQP1,” the first functionally defined water channel protein (Agre et al., 1993b).
Figure 2. Functional expression of AQP1 water channels in Xenopus laevis oocytes. Control oocyte (left) was injected with water; AQP1 oocyte (right) was injected with cRNA. The oocytes were transferred to hypotonic buffer. After 30 seconds (top) the AQP1 oocyte has begun to swell; after 3 minutes (bottom), the AQP1 oocyte has exploded. Modified and reprinted from Science with permission (Preston et al., 1992).
We  confirmed the function of this protein by studying the purified AQP1 reconstituted into synthetic lipid vesicles of ~0.1 micron diameter prepared by our colleague Suresh Ambudkar at Johns Hopkins (Zeidel et al., 1992). These simple membrane vesicles were examined by freeze fracture electron microscopy by our colleague Arvid Maunsbach, from the University of Aarhus. When lipid was reconstituted without protein, the membrane surfaces were smooth; however, membranes reconstituted with AQP1 contained many intramembraneous particles 0.01 micron diameter (Zeidel et al., 1994). We tested the membranes for water permeability in collaboration with Mark Zeidel at Har vard Medical School. Using stopped flow transfer to hypertonic buffer, the simple liposomes shrank, reaching equilibrium in about one half
second; this is believed to represent the baseline water permeability. When membranes reconstituted with AQP1 were examined, the shrinking occurred much more rapidly, reaching equilibrium in about 20 milliseconds. The channel-mediated flow of water was confirmed, since it was inhibited with mercurials. We calculated the Arrhenius activation energy (<5 kcal/mol), and we determined the unit permeability to be ~3×10 water molecules per subunit per second. Importantly, we attempted to measure proton permeation of AQP1, but despite massive water permeability, acid permeation was not detected. These studies verified that we had, in fact, isolated the long-sought water channel protein.

STRUCTURE OF AQP1

Subsequent efforts were devoted to identifying the mercurial inhibitory site predicted by the studies of Macey. Mercurials react with free sulfhydryls in the amino acid cysteine. Four cysteines are found in the AQP1 polypeptide, but only the residue in loop E (Cys-189 proximal to the second NPA motif) is inhibited by mercurials. We altered the AQP1 sequence by site-directed mutagenesis and expressed the recombinants in oocytes for water permeability studies. Mutation of this residue to serine (Cys-189-Ser) resulted in full water permeability without mercurial inhibition. When we then replaced the alanine in the corresponding position of loop B with a cysteine (Ala-73-Cys), the protein exhibited mercurial sensitive water permeability (Preston et al., 1993). Substitutions elsewhere in the AQP1 failed to produce this behavior. This suggested to us that loops B and E in opposite parts of the molecule must somehow form the aqueous pore. The model that we concocted turned out to be schematically correct and was termed “the hourglass.” The ancient timepiece allows sand to run from upper chamber to lower chamber; if inverted, the sand will flow in the opposite direction. Six bilayer spanning domains were predicted to surround a central domain containing loop B, dipping into the membrane from the cytoplasmic surface, and loop E, dipping into the membrane from the extracellular surface [Fig. 3 left and right].
Figure 3. Hourglass model for membrane topology of AQP1 subunit.
Left panel – Schematic folding of loops B and E overlap within the lipid bilayer to form a single aqueous pathway.
Right panel – Ribbon model of three dimensional structure of AQP1 subunit confirms hourglass with single aqueous pathway. Modified and reprinted with permission from Jour-
nal of Biological Chemistr y (Jung et al., 1994b) and Journal of Clinical Investigation (Kozono et al., 2002).
The overlap of loops B and E was predicted to form a single aqueous pore through the center of the molecule with the NPA motifs juxtaposed and mercurial inhibitory site alongside (Jung et al., 1994b). The AQP1 protein tetrameric with a central pore in each subunit. Thus, AQP1 is structurally like ion channel proteins where four subunits surround a single central as discussed by Rod MacKinnon in his lecture.
We  then sought to establish the high resolution structure of AQP1 in collaboration with Andreas Engel and his group at the Biozentrum in Basel. We were later joined with Yoshinori Fujiyoshi and his group at Kyoto University. Human red cell AQP1 protein was purified by Barb Smith in our lab; Andreas’s student Tom Walz reconstituted it into synthetic membranes at very high protein concentrations. Under these conditions, the AQP1 protein forms remarkably symmetrical arrays referred to as membrane crystals. By measuring the water permeability, we confirmed that the function was 100% retained, giving us confidence that the structure we deduced would be the biologically relevant structure (Walz et al., 1994).
Figure 4. Functional representation for selective water flow through AQP1 subunit and residues involved in human disease.
Left panel – Schematic of sagittal cross-section of AQP1 reveals bulk water in extracellu- lar and intracellular vestibules of hourglass. These are separated by a 20Å span where water passes in single file with transient interactions with pore-lining residues that prevent hy- drogen bonding between water molecules (bold colors). Two structures are believed to pre- vent permeation by protons (H O ): electrostatic repulsion is created by a fixed positive
charge from pore-lining arginine (R195) at a 2.8Å narrowing in the channel; water dipole reorientation occurs from simultaneous hydrogen bonding of water molecule with side chains of two asparagines residues in NPA motifs (N192 and N76). Two partial positive charges at the center of the channel result from orientation of two non-membrane span- ning alpha helices distal to the NPA motifs

THE AQUAPORIN AND AQUAGLYCEROPORIN PROTEIN FAMILY

While we were pursuing studies of AQP1, several other research groups from around the world became interested in what is now known to be a large family of related proteins. The combined efforts of these labs have led to the molecular identification of 12 mammalian aquaporin homologs, and several hundred related proteins have been recognized in other vertebrates as well as invertebrates, plants, and unicellular micro-organisms. The mammalian homologs may be loosely clustered into two subsets [Fig. 5]. The first is referred to as “classical aquaporins”, since they were initially considered to be exclusive water pores. The second is referred to as “aquaglyceroporins”, since they are permeated by water plus glycerol. Interestingly, E. coli has one member of
each – AqpZ (Calamita et al., 1995), and GlpF, isolated by other investigators much earlier. Together, the mammalian aquaporins and aquaglyceroporins are now known to contribute to multiple physiological processes that occur during our daily lives.
Figure 5. Human aquaporin gene family contains two subsets. Homologs freely permeated by water (classical aquaporins, blue) or water and glycerol (aquaglyceroporins, yellow) are represented. E. coli has one aquaporin (AqpZ) and one aquaglyceroporin (GlpF). Reprinted with permission from Journal of Physiology (Agre et al., 2002)
 The remainder of the Nobel Lecture (2003) can be found at the Nobel Prize site.  This portion is sufficient to cover the genesis and advancement of the water transport discovery.

Urinary Excretion of Aquaporin-2 Water Channel Differentiates Psychogenic Polydipsia from Central Diabetes Insipidus

T Saito, San-e Ishikawa, T Ito, H Oda, F Ando, … and T Saito Division of Endocrinology and Metabolism (Ta.S., S.I., F.A., Mi.H., S.N., To.S.), Department of Medicine, Jichi Medical School, Tochigi 329-0498; and Departments of Medicine and Psychiatry (T.I., H.O., Ma.H.), Tokyo Metropolitan Matsuzawa Hospital, Tokyo, Jp 
correspondence to: San-e Ishikawa, M.D., Division of Endocrinology and Metabolism, Department of Medicine, Jichi Medical School, Tochigi 329-0498, Japan. E-mail: saneiskw@jichi.ac.jp. http://jcem.endojournals.org/full/84/6/2235
The present study was undertaken to determine whether urinary excretion of aquaporin-2 (AQP-2) water channel under ad libitum water intake is of value to differentiate polyuria caused by psychogenic polydipsia from central diabetes insipidus. A 30-min urine collection was made at 0900 h in 3 groups of: 11 patients with central diabetes insipidus (22–68 yr old), 10 patients with psychogenic polydipsia (28–60 yr old), and 15 normal subjects (21–38 yr old). In the patients with central diabetes insipidus, the plasma arginine vasopressin level was low despite hyperosmolality, resulting in hypotonic urine. Urinary excretion of AQP-2 was 37 ± 15 fmol/mg creatinine, a value one-fifth less than that in the normal subjects. In the patients with psychogenic polydipsia, plasma arginine vasopressin and urinary osmolality were as low as those in the patients with central diabetes insipidus. However, urinary excretion of AQP-2 of 187 ± 45 fmol/mg creatinine was not decreased, and its excretion was equal to that in the normal subjects. These results indicate that urinary excretion of AQP-2, under ad libitum water drinking, participates in the differentiation of psychogenic polydipsia from central diabetes insipidus. 
PSYCHOGENIC polydipsia causes a marked polyuria with hypotonic urine (1, 2). Arginine vasopressin (AVP) secretion is suppressed by hypoosmolality caused by excess intake of water. Suppression of AVP release obliges us to differentiate psychogenic polydipsia from central diabetes insipidus. Osmotic stimulation tests have been carried out to determine the reserve function of the posterior pituitary gland. Plasma AVP levels increase in response to an increase in plasma osmolality (Posm) in patients with psychogenic polydipsia but not in those with central diabetes insipidus.
In response to AVP, concentrated urine is produced by water reabsorption across the renal collecting duct (3, 4). Aquaporin-2 (AQP-2) is an AVP-regulated water channel of the collecting duct; it is translocated from the cytoplasmic vesicles to the apical plasma membranes by shuttle trafficking when the cells are stimulated by AVP (5, 6, 7), and it is again redistributed into the cytoplasmic vesicles after removal of AVP stimulation (8). Also, AQP-2 is, in part, excreted into the urine (9, 10). We demonstrated that urinary excretion of AQP-2 is of great value in diagnosing central diabetes insipidus in the hypertonic saline infusion test and impaired water excretion in the acute oral water load test (11, 12).   The present study was undertaken to determine whether urinary excretion of AQP-2, under ad libitum water intake, is a useful tool for diagnosing psychogenic polydipsia.

Subjects and study design

Three groups of subjects were examined in the present study.
[1]  11 patients who had been diagnosed as having idiopathic central diabetes insipidus. They had taken 1-deamino-8-D-AVP (DDAVP) intranasally, twice a day, and discontinued the DDAVP therapy 24 h before the study.
[2] 10 patients were diagnosed as having psychogenic polydipsia. They had been treated for psychiatric disorders, including schizophrenia, atypical psychiatric disorder, and chronic alcoholism.
[3] 15 normal volunteers, with ages ranging from 21–38 yr. (the age range of [1] and [2] reached 60)
All the subjects drank water ad libitum, and 30-min urine collection was made and blood drawn at 0900 h. Urine samples were subjected to measurements of urinary osmolality (Uosm) and urinary excretion of creatinine and AQP-2. Blood samples were used to measure Posm and plasma AVP levels. Uosm and Posm were measured by freezing-point depression (Model 3W2, Advanced Instruments, Needham Height, MA). Urinary creatinine was measured with an automatic clinical analyzer (Model 736, Hitachi Co., Tokyo, Jp). Plasma AVP levels were determined by RIA using AVP RIA kits (Mitsubishi Chemistry, Tokyo, Jp) (13). Urinary excretion of AQP-2 was measured as described below.

RIA of AQP-2

The RIA of urinary AQP-2 was performed by the method described in our previous reports (11, 12). Urinary AQP-2-like immunoreactivity was measured by a specific RIA that used the polyclonal antibody against a synthetic portion (Tyr0-AQP-2[ V257-A271]) of the C-terminal of human AQP-2 raised in rabbits. A synthetic peptide [Tyr0-AQP-2 (V257-A271)] was radioiodinated with iodine-125 (New England Nuclear, Boston, MA) by the chloramine-T method.  All samples were analyzed in duplicate. The intra- and interassay coefficients of variation were less than 10%. The minimal detectable quantity of AQP-2 was 0.86 pmol/tube, and an amount equivalent to 6.9 pmol/tube caused 50% inhibition of binding of the radiolabeled ligand.

Results

In the patients with central diabetes insipidus, the plasma AVP level was low despite hyperosmolality of 297.8 ± 3.4 mosmol/kg H2O, resulting in hypotonic urine (Fig. 1⇓). Urinary excretion of AQP-2 was one-fifth less in the patients with central diabetes insipidus than in the normal subjects. AQP-2 is the AVP-dependent water channel of collecting duct cells and is recycling between the cytoplasmic vesicles and the apical plasma membranes in the cells (5, 6, 7, 8). AQP-2 is partly excreted into the urine, which is approximately 3% of AQP-2 in the collecting duct cells (14). In normal subjects, urinary excretion of AQP-2 is changeable in a wide range in physiological conditions (11). Because urinary excretion of AQP-2 has a positive correlation with plasma AVP levels in normal subjects (11), the reduced urinary excretion of AQP-2 was in concert with the impaired secretion of AVP in central diabetes insipidus.
Figure 1.
Posm, plasma AVP (Pavp), Uosm, and urinary excretion of AQP-2 (UAQP-2), under ad libitum water drinking, in 15 normal subjects (NL, •), 11 patients with central diabetes insipidus (CDI, ○) and 10 patients with psychogenic polydipsia (PP, □). *, P < 0.01; **, P < 0.05 vs. the normal subjects. Value are means ± sem.
In the patients with psychogenic polydipsia, Uosm was as low as that in the patients with central diabetes insipidus (Fig. 1⇑). The plasma AVP level was low because of the reduced Posm, which was derived from an exaggerated intake of water. Urinary excretion of AQP-2, however, was not decreased; and rather, its excretion kept the normal range. The relationship between plasma AVP levels and urinary excretion of AQP-2 is shown in Fig. 2⇓. The urinary excretion of AQP-2 in the patients with psychogenic polydipsia was dissociated from the positive correlation between plasma AVP and urinary excretion of AQP-2 in the normal subjects.
Figure 2.
Relationship between plasma AVP levels and UAQP-2. •, Normal subjects (n = 15); ○, patients with central diabetes insipidus (n = 11); □, patients with psychogenic polydipsia (n = 10). Values are means ± sem.

Discussion

The present study demonstrated the clinical tool, of urinary excretion of AQP-2, in differentiating psychogenic polydipsia from central diabetes insipidus. What is involved in the marked difference in urinary excretion of AQP-2 in these two disorders? There is a possibility that, as patients with psychogenic polydipsia reduce water intake during sleep, antidiuresis may occur periodically at night and the production of AQP-2 be somewhat restored. Because approximately 3% of AQP-2 in collecting duct cells is excreted into the urine, urinary excretion of AQP-2 may keep relatively high, despite hypotonic urine. The difference may come from the periodicity of water intake in a day, in the patients with psychogenic polydipsia. As a whole, these changes may disrupt the positive relationship between urinary excretion of AQP-2 and plasma AVP levels. At the present time, however, other factors involved in urinary excretion of AQP-2 remain undetermined.
In conclusion, urinary excretion of AQP-2, under ad libitum water drinking, participates in the differentiation of polyuria caused by psychogenic polydipsia from central diabetes insipidus.

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Comparison of cardiovascular aquaporin-1 changes during water restriction between 25- and 50-day-old rats.

Netti VA, Vatrella MC, Chamorro MF, Rosón MI, Zotta E, Fellet AL, Balaszczuk AM.
Cátedra de Fisiología, Facultad de Farmacia y Bioquímica, Universidad de Buenos Aires, IQUIMEFA, CONICET, Junín 956, C1113AAD, Buenos Aires, Argentina, vnetti@conicet.gov.ar.
Eur J Nutr. Apr 27, 2013
Aquaporin-1 (AQP1) is the predominant water channel in the heart, linked to cardiovascular homeostasis. Our aim was to study cardiovascular AQP1 distribution and protein levels during osmotic stress and subsequent hydration during postnatal growth.
Rats aged 25 and 50 days were divided in: 3d-WR: water restriction 3 days; 3d-WAL: water ad libitum 3 days; 6d-WR+ORS: water restriction 3 days + oral rehydration solution (ORS) 3 days; and 6d-WAL: water ad libitum 6 days. AQP1 was evaluated by immunohistochemistry and western blot in left ventricle, right atrium and thoracic aorta.
Water restriction induced a hypohydration state in both age groups (40 and 25 % loss of body weight in 25- and 50-day-old rats, respectively), reversible with ORS therapy. Cardiac AQP1 was localized in the endocardium and endothelium in both age groups, being evident in cardiomyocytes membrane only in 50-day-old 3d-WR group, which presented increased protein levels of AQP1; no changes were observed in the ventricle of pups. In vascular tissue, AQP1 was present in the smooth muscle of pups; in the oldest group, it was found in the endothelium, increasing after rehydration in smooth muscle. No differences were observed between control groups 3d-WAL and 6d-WAL of both ages.
Our findings suggest that cardiovascular AQP1 can be differentially regulated in response to hydration status in vivo, being this response dependent on postnatal growth. The lack of adaptive mechanisms of mature animals in young pups may indicate an important role of this water channel in maintaining fluid balance during hypovolemic state.

 Clinical application of aquaporin research: aquaporin-1 in the peritoneal membrane

Nishino T, Devuyst O.
Division of Renal Care Unit, Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Jp
Peritoneal dialysis (PD) is an established mode of renal replacement therapy based on the exchange of fluid and solutes between blood and a dialysate that has been instilled in the peritoneal cavity. The dialysis process involves osmosis, as well as diffusive and convective transports through the highly vascularized peritoneal membrane. The membrane contains ultrasmall pores responsible for the selective transport of water across the capillary endothelium. The distribution of the water channel aquaporin-1 (AQP1), as well as its molecular structure ensuring an exquisite selectivity for water, fit with the characteristics of the ultrasmall pore. Peritoneal transport studies using AQP1 knockout mice demonstrated that the osmotic water flux across the peritoneal membrane is mediated by AQP1. This water transport accounts for 50% of the ultrafiltration during PD. Treatment with high-dose corticosteroids upregulates the expression of AQP1 in peritoneal capillaries, resulting in increased water transport and ultrafiltration in rats. These data illustrate the potential of the peritoneal membrane as an experimental model in the investigation of the role of AQP1 in the endothelium. They emphasize the critical role of AQP1 during PD and suggest that manipulating AQP1 expression could be clinically useful in PD patients.

Corticosteroids induce expression of aquaporin-1 and increase transcellular water transport in rat peritoneum

Stoenoiu MS, Ni J, Verkaeren C, Debaix H, Jonas JC, Lameire N, Verbavatz JM, Devuyst O.
Division of Nephrology and ENDO Unit, Université Catholique de Louvain Medical School, Brussels, Belgium
J Am Soc Nephrol. Mar 2003; 14(3):555-565.
The water channel aquaporin-1 (AQP1) is the molecular counterpart of the ultrasmall pore responsible for transcellular water permeability during peritoneal dialysis (PD). This water permeability accounts for up to 50% of ultrafiltration (UF) during a hypertonic dwell, and its loss can be a major clinical problem for PD patients. By analogy with the lung, the hypothesis was tested that corticosteroids may increase AQP1 expression in the peritoneal membrane (PM) and improve water permeability and UF in rats. First, the expression and distribution of the glucocorticoid receptor (GR) in the PM and capillary endothelium was documented. Time-course and dose-response analyses showed that a daily IM injection of dexamethasone (1 or 4 mg/kg) for 5 d induced an approximately twofold increase in the expression of AQP1 at the mRNA and protein levels. The GR antagonist RU-486 completely inhibited the dexamethasone effect. The functional counterpart of the increased AQP1 expression was a significant increase in sodium sieving and net UF across the PM, contrasting with a lack of effect on the osmotic gradient and permeability for small solutes. The latter observation reflected the lack of effect of corticosteroids on nitric oxide synthase (NOS) activity and endothelial NOS isoform expression in the PM. In conclusion, corticosteroids induce AQP1 expression in the capillary endothelium of the PM, which is reflected by increased transcellular water permeability and UF. These data emphasize the critical role of AQP1 during PD and suggest that pharmacologic regulation of AQP1 may provide a target for manipulating water permeability across the PM.

Aquaporins: relevance to cerebrospinal fluid physiology and therapeutic potential in hydrocephalus

Owler BK, Pitham T, Wang D.
Kids Neurosurgical Research Unit, Children’s Hospital at Westmead, Westmead NSW 2145, Australia. brian@sydneyneurosurgeon.com.au.
Cerebrospinal Fluid Res.  Sep 22, 2010; 7:15.  http://dx.doi.org/10.1186/1743-8454-7-15.
The discovery of a family of membrane water channel proteins called aquaporins, and the finding that aquaporin 1 was located in the choroid plexus, has prompted interest in the role of aquaporins in cerebrospinal fluid (CSF) production and consequently hydrocephalus. While the role of aquaporin 1 in choroidal CSF production has been demonstrated, the relevance of aquaporin 1 to the pathophysiology of hydrocephalus remains debated. This has been further hampered by the lack of a non-toxic specific pharmacological blocking agent for aquaporin 1. In recent times aquaporin 4, the most abundant aquaporin within the brain itself, which has also been shown to have a role in brain water physiology and relevance to brain oedema in trauma and tumours, has become an alternative focus of attention for hydrocephalus research. This review summarises current knowledge and concepts in relation to aquaporins, specifically aquaporin 1 and 4, and hydrocephalus. It also examines the relevance of aquaporins as potential therapeutic targets in hydrocephalus and other CSF circulation disorders.
PMID: 20860832  PMCID:  PMC2949735

Pathophysiology of the aquaporin water channels

King LS, Agre P.
Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA.
Annu Rev Physiol. 1996; 58:619-48.
Discovery of aquaporin water channel proteins has provided insight into the molecular mechanism of membrane water permeability. The distribution of known mammalian aquaporins predicts roles in physiology and disease.
Aquaporin-1 mediates proximal tubule fluid reabsorption, secretion of aqueous humor and cerebrospinal fluid, and lung water homeostasis.
Aquaporin-2 mediates vasopressin-dependent renal collecting duct water permeability; mutations or downregulation can cause nephrogenic diabetes insipidus.
Aquaporin-3 in the basolateral membrane of the collecting duct provides an exit pathway for reabsorbed water.
Aquaporin-4 is abundant in brain and probably participates in reabsorption of cerebrospinal fluid, osmoregulation, and regulation of brain edema.
Aquaporin-5 mediates fluid secretion in salivary and lacrimal glands and is abundant in alveolar epithelium of the lung.
Specific regulation of membrane water permeability will likely prove important to understanding edema formation and fluid balance in both normal physiology and disease.

Discovery of aquaporins: a breakthrough in research on renal water transport

van Lieburg AF, Knoers NV, Deen PM.
Department of Pediatrics, University of Nijmegen, The Netherlands.
Pediatr Nephrol. Apr 1995; 9(2):228-34.
Several membranes of the kidney are highly water permeable, thereby enabling this organ to retain large quantities of water. Recently, the molecular identification of water channels responsible for this high water permeability has finally been accomplished. At present, four distinct renal water channels have been identified, all members of the family of major intrinsic proteins.
Aquaporin 1 (AQP1), aquaporin 2 (AQP2) and the mercury-insensitive water channel (MIWC) are water-selective channel proteins, whereas the fourth,
Aquaporin 3 (AQP3), permits transport of urea and glycerol as well. Furthermore, a putative renal water channel (WCH3) has been found.
AQP1 is expressed in apical and basolateral membranes of proximal tubules and descending limbs of Henle,
AQP2 predominantly in apical membranes of principal and inner medullary collecting duct cells and
AQP3 in basolateral membranes of kidney collecting duct cells.
MIWC is expressed in the inner medulla of the kidney and has been suggested to be localised in the vasa recta.
The human genes encoding AQP1 and AQP2 have been cloned, permitting deduction of their amino acid sequence, prediction of their two-dimensional structure by hydropathy analysis, speculations on their way of functioning and DNA analysis in patients with diseases possibly caused by mutant aquaporins. Mutations in the AQP1 gene were recently detected in clinically normal individuals, a finding which contradicts the presumed vital importance of this protein. Mutations in the AQP2 gene were shown to cause autosomal recessive nephrogenic diabetes insipidus. The renal unresponsiveness to arginine vasopressin, which characterises this disease, is in accordance with the assumption that AQP2 is the effector protein of the renal vasopressin pathway.(ABSTRACT TRUNCATED AT 250 WORDS)

Selectivity of the renal collecting duct water channel aquaporin-3

Echevarría M, Windhager EE, Frindt G.
Depart Physiol Biophys, Cornell University Medical College, New York, NY
J Biol Chem. Oct 11, 1996; 271(41):25079-82.
Aquaporin-3 (AQP3) is a water channel found in the basolateral cell membrane of principal cells of the renal collecting tubule as well as in other epithelia. To examine the selectivity of AQP3, the permeability to water (Pf), urea (Pur), and glycerol (Pgly) of Xenopus oocytes injected with cRNA encoding AQP3 was measured. Oocytes injected with cRNA encoding either human or rat aquaporin-1 (AQP1) were used as controls. Although both aquaporins permit water flow across the cell membrane, only AQP3 was permeable to glycerol and urea (Pgly > Pur). The uptake of glycerol into oocytes expressing AQP3 was linear up to 165 mM. For AQP3 the Arrhenius energy of activation for Pf was 3 kcal/mol, whereas for Pgly and Pur it was >12 kcal/mol. The sulfhydryl reagent p-chloromercuriphenylsulfonate (1 mM) abolished Pf of AQP3, whereas it did not affect Pgly. In addition, phloretin (0.1 mM) inhibited Pf of AQP3 by 35%, whereas it did not alter Pgly or Pur. We conclude that water does not share the same pathway with glycerol or urea in AQP3 and that this aquaporin, therefore, forms a water-selective channel.

The aquaporin family of water channels in kidney

Agre P, Nielsen S.
Depart of Med, Johns Hopkins University School of Medicine, Baltimore, MD
Nephrologie. 1996;17(7):409-15.
The longstanding puzzle of membrane water-permeability was advanced by discovery of a new class of proteins known as the “aquaporins” (AQPs). First identified in red blood cells, AQP1 was shown to function as a water channel when expressed in Xenopus oocytes or when pure AQP1 protein was reconstituted into synthetic membranes. Analysis of the primary sequence revealed that the two halves of the AQP1 polypeptide are tandem repeats; site directed mutagenesis studies indicate that the repeats may fold into an obversely symmetric structure which resembles an hourglass. Electron crystallography elucidated the tetrameric organization of AQP1, and functional studies suggest that each tetramer contains multiple functionally independent aqueous pores.
AQP1 is abundant in the apical and basolateral membranes of renal proximal tubules and descending thin limbs, and is also present in multiple extra renal tissues.
AQP2 is expressed only in the principal cells of renal collecting duct where it is the predominant vasopressin (ADH, antidiuretic hormone) regulated water channel. AQP2 is localized in the apical membrane and in intracellular vesicles which are targeted to the apical plasma membranes when stimulated by ADH. Humans with mutations in genes encoding AQP1 and AQP2 exhibit contrasting clinical phenotypes.
AQP3 resides in the basolateral membranes of renal collecting duct principal cells providing an exit pathway for water;
AQP4 is abundant in brain where it may function as the hypothalamic osmoreceptor responsible for secretion of ADH. Continued analysis of the aquaporins is providing detailed molecular insight into the fundamental physiological problems of water balance and disorders of water balance.

Aquaporins in the kidney: from molecules to medicine

Nielsen S, Frøkiaer J, Marples D, Kwon TH, Agre P, Knepper MA.
The Water and Salt Res Center, Anatomy and Exper Clin Res Institutes, University of Aarhus, Aarhus, Denmark. sn@ana.au.dk
Physiol Rev. Jan 2002; 82(1):205-44.  http://dx.doi.org/10.1152/physrev.00024.2001

The molecular identity of membrane water channels long-standing biophysical question of how water crosses long remained elusive until the pioneering discovery of biological membranes specifically, and provided insight, at the molecular level, of AQP1 by Agre and colleagues around 1989 –1991,  The discovery of aquaporin-1 (AQP1) answered the long-standing biophysical question of how water specifically crosses biological membranes. In the kidney, at least seven aquaporins are expressed at distinct sites. AQP1 is extremely abundant in the proximal tubule and descending thin limb and is essential for urinary concentration. AQP2 is exclusively expressed in the principal cells of the connecting tubule and collecting duct and is the predominant vasopressin-regulated water channel. AQP3 and AQP4 are both present in the basolateral plasma membrane of collecting duct principal cells and represent exit pathways for water reabsorbed apically via AQP2. Studies in patients and transgenic mice have demonstrated that both AQP2 and AQP3 are essential for urinary concentration.

Since the discovery of aquaporins, major efforts have been aimed at elucidating their structural organization. Hydropathy analysis of the deduced amino acid sequence of AQP1 led to the prediction that the protein resides primarily within the lipid bilayer (191), consistent with the initial studies of AQP1 in red cell membranes (46). AQP1 contains an internal repeat with the NH – and the first provided a molecular answer to the long-standing COOH-terminal halves being sequence related and each
containing the signature motif Asn-Pro-Ala (NPA) (181,252). This is consistent with earlier observations on the homologous major intrinsic protein from lens, (MIP, nowreferred to as AQP0). When evaluated by hydropathy analysis, six bilayer-spanning domains are apparent (Fig.1); however, the apparent interhelical loops B and E also exhibit significant hydrophobicity. Critical to the topology is the location of loop C which connects the two halves of the molecule. Preston et al. (194) demonstrated that loop C resides at the extracellular surface of the oocytes, confirming the obverse sym-metry of the NH – and COOH-terminal halves of the mol-lar surface of the oocytes, confirming the obverse symmetry of the NH – and COOH-terminal halves of the mol-ecule.The structural organization of other aquaporins such as bacterial aquaporin-Z and plant aquaporins have also been deduced. How can water channels avoid passage of protons (H O )? As predicted, loops B and E are associated by Van der Waals interactions between the two NPA motifs. Free hydrogen bonding occurs in the column of water within the pore, except at the very center where a single water molecule transiently reorients to bond with the two asparagines residues of the NPA motif. This results in minimum resistance to the flow of water, thus permitting kidneys to perform their important physiological roles of reabsorbing water while excreting acid.

FIG. 1. A: schematic representation of the structural organization of aquaporin-1 (AQP1) monomers in the membrane (top and bottom). Aquaporins have six membrane-spanning regions, both intracellular NH and COOH termini, and internal tandem repeats that, presumably, are due to an ancient gene duplication (top). The topology is consistent with an obverse symmetry for the two similar NH – and COOH- 2 terminal halves (bottom). The tandem repeat structure with two asparagine-proline-alanine (NPA) sequences has been proposed to form tight turn structures that interact in the membrane to form the pathway for translocation of water across the plasma membrane. Of the five loops in AQP1, the B and E loops dip into the lipid bilayer, and it has been proposed that they form “hemichannels” that connect between the leaflets to form a single aqueous pathway within a symmetric structure that resembles an “hourglass.” B: AQP1 is a multisubunit oligomer that is organized as a tetrameric assembly of four identical polypeptide subunits with a large glycan attached to only one.

Discovery and Biophysical Characterization of the First Molecular Water Channel AQP1 Expression of AQP1 in X. laevis oocytes by Preston et al. (192) demonstrated that AQP1-expressing oocytes exhibited remarkably high osmotic water permeability (P
cm/s), causing the cells to swell rapidly and explode in hypotonic buffer. The osmotically induced swelling of oocytes expressing AQP1 occurs with a low activation energy and is reversibly inhibited by HgCl or other mercurials. Only inward water flow (swelling) was examined, but it was predicted that the direction of water flow through AQP1 is determined by the orientation of the osmotic gradient. Consistent with this, it was later demonstrated that AQP1-expressing oocytes swell in hyposmolar buffers but shrink in hyperosmolar buffers (160).  Swelling of oocytes expressing AQP1 occurs with a low activation energy and is reversibly inhibited by HgCl or other mercurials. Only inward water flow (swelling) was examined, but it was predicted that the direction of water flow through AQP1 is determined by the orientation of the osmotic gradient. Consistent with this, it was later demonstrated that AQP1-expressing oocytes swell in hyposmolar buffers but shrink in hyperosmolar buffers (160).

Over the past 4 years a series of studies have explored the issues of selectivity and polytransport function of aquaporins. This has led to a division of aquaporins (4) into a group that transports water relatively selectively (the “orthodox” set or “aquaporins”) and a group of water channels that also conduct glycerol and other small solutes in addition to water (the “cocktail” set or aquaglyceroporins). This appears to represent an ancient phylogenetic divergence between glycerol transporters and pure water channels (185). Recently, it has become clear that transport properties are even more diverse, since AQP6 has been demonstrated to conduct anions as well (263), and it has also been demonstrated that aquaporins can be regulated by gating, as discussed below.

The signal transduction pathways have been de­scribed thoroughly in previous reviews. cAMP levels in collecting duct principal cells are in­creased by binding of vasopressin to V2 receptors. The synthesis of cAMP by adenylate cyclase is stim­ulated by a V2 receptor-coupled heterotrimeric GTP-bind-ing protein, Gs. Gs interconverts between an inactive responses to vasopressin. In this study it was demon­strated that changes in AQP2 labeling density of the apical plasma membrane correlated closely with the water per­meability in the same tubules, while there were reciprocal changes in the intracellular labeling for AQP2. In vivo studies using normal rats or vasopressin-deficient Brattleboro rats also showed a marked increase in apical plasma membrane labeling of AQP2 in response to vasopressin or dDAVP treatment.  The acute treatment of rats with vasopressin V2-receptor antagonist or acute water loading (to reduce endogenous vasopressin levels, both re­ducing vasopressin action, resulted in a prominent inter­nalization of AQP2 from the apical plasma membrane to small intracellular vesicles further underscoring the role of AQP2 trafficking in the regulation of collecting duct water permeability.

PGE2 inhibits vasopressin-induced water permeabil­ity by reducing cAMP levels. In preliminary studies, Zelenina et al. investigated the effect of PGE2 on PKA phosphorylation of AQP2 in kidney papilla, and the results suggest that the action of prostaglandins is associated with retrieval of AQP2 from the plasma membrane, but that this appears to be independent of AQP2 phosphorylation by PKA.  Phosphorylation of AQP2 by other kinases, e.g., pro­tein kinase C or casein kinase II, may potentially partici­pate in regulation of AQP2 trafficking (Fig. 9C). Phosphorylation of other cytoplasmic or vesicular regulatory proteins may also be involved. These issues remain to be investigated directly.

Since the fundamentals of the shuttle hypothesis have been confirmed, interest has turned to the cellular mechanisms mediating the vasopressin-induced transfer of AQP2 to the apical plasma membrane. The shuttle hypothesis has a number of features whose molecular basis remains poorly understood. First, AQP2 is delivered in a relatively rapid and coordinated fashion, and vesicles move from a distribution throughout the cell to the apical region of the cell in response to vasopressin stimulation. Furthermore, AQP2 is delivered specifically to the apical plasma membrane. Finally, AQP2-bearing vesicles fuse with the apical plasma membrane in response to vasopressin, but not to a significant degree in the absence of stimulation (e.g., in vasopressin-deficient Brattleboro rats where < 5% of total AQP2 is present in the apical plasma membrane. Thus there must be some kind of a “clamp” preventing fusion in the unstimulated state and/or a “trigger” when activation occurs.

The coordinated delivery of AQP2-bearing vesicles to the apical part of the cell appears to depend on the translocation of the vesicles along the cytoskeletal ele­ments. In particular, the microtubular network has been implicated in this process, since chemical disruption of microtubules inhibits the increase in permeability both in the toad bladder and in the mammalian collecting duct. Because microtubule-disruptive agents inhibit the development of the hydrosmotic response to vaso-pressin, but have no effect on the maintenance of an established response, and because they have been re­ported to slow the development of the response without affecting the final permeability in toad bladders , it has been deduced that microtubules appear to be involved in the coordinated delivery of water channels, without being involved in the actual insertion process.

In addition to increasing cAMP levels in collecting duct principal cells, vasopressin acting through the V2 receptor has also been demonstrated to transiently in­crease intracellular Ca2+. The increase occurs in the absence of activation of the phosphoinositide signaling pathway and has recently been dem­onstrated to be due to activation of ryanodine-sensitive calcium release channels in the collecting duct cells. Buffering intracellular calcium with BAPTA or inhibition of calmodulin completely blocked the water permeability response to vasopressin in isolated perfused inner med­ullary collecting ducts, suggesting a critical role for cal­cium at some step in the process of AQP2 vesicle traffick­ing.

In addition to the acute regulation of collecting duct water permeability brought about by the trafficking of AQP2 described above, it is now clear that there are longer term adaptational changes that modulate this acute response. These occur during prolonged changes in body hydration status and form an appropriate physiolog­ical response to such challenges. However, similar long ­term changes also appear to be important in a wide variety of pathological conditions,  and an understanding of the mechanisms involved in these adaptational responses may provide the basis both for a better understanding of, and for potential therapeutic ap­proaches to, pathological disorders of water balance.  Microtubules are polar structures, arising from microtubule organizing centers (MTOCs), at which their minus ends are anchored, and with the plus ends growing away “into” the cell. In fibroblastic cells, there is a single MTOC in the perinuclear region, and the plus ends project to the periphery of the cell. However, there is increasing evidence that in polarized epithelia microtubules arise from multiple MTOCs in the apical region, with their plus ends projecting down toward the basolateral membrane. If this is the case in collecting duct cells, and there is some evidence that it is , then a minus end-directed motor protein such as dynein would be expected to be involved in the movement of vesicles toward the apical plasma membrane.  Recently, it has been shown that dynein is present in the kidney of several mammalian spe­cies and that both dynein and dynactin, a protein complex believed to mediate the interaction of dynein with vesicles, associate with AQP2-bearing vesicles. It seems likely that dynein may drive the microtubule-dependent delivery of AQP2-bearing vesicles toward the apical plasma mem­brane.

The apical part of the collecting duct principal cells contains a prominent terminal web made up of actin filaments. These also appear to be involved in the hydrosmotic response, since disruption of microfilaments with cytochalasins inhibits the response in the toad bladder. Cytochalasins can also inhibit an estab­lished response, and even the offset of the response. From this it has been concluded that microfilaments are probably involved in the final movement of vesicles through the terminal web, their fusion with the plasma membrane, and the subsequent endocytic retrieval of the water channels. Interestingly, vasopressin itself causes actin depolymerization, suggesting that reor­ganization of the terminal web is an important part of the cellular response to vasopressin, a conclusion reached on morphological grounds by DiBona.

The problem of delivering vesicles to a particular domain and allowing them to fuse when, and only when, a signal arrives is conceptually very similar to the situa­tion in the neuronal synapse. It therefore seemed possible that a molecular apparatus similar to the SNAP/SNARE system described there might be present in the collecting duct principal cells.  There are specific proteins on the vesicles (vSNAREs) and the target plasma membrane (tSNAREs) that interact with components of a fusion complex to induce fusion of the vesicles only with the required target membrane. The process is thought to be regulated by other protein com­ponents that sense the signal for fusion (i.e., increased calcium in the synapse). Several groups have now shown that vSNAREs such as VAMP-2 are present in the collect­ing duct principal cells and colocalize with AQP2 in the same vesicles .

A putative tSNARE, SNAP23, has been found in collecting duct principal cells both in the apical plasma membrane and in AQP2-bearing vesicles. Some soluble components of the fusion complex, including NEM-sensitive factor (NSF) and a-soluble NSF-associated protein (SNAP), have also been identified in these cells. Thus it seems likely that the exocytic insertion of AQP2 is indeed controlled by a set of proteins similar to those involved in synaptic transmission, al­though considerable work remains to be done in isolating and characterizing the components, their regulation, and prime physiological function.

 Body water balance is tightly regulated by vasopressin, and multiple studies now have underscored the essential roles of AQP2 in this.
Vasopressin regulates acutely the water permeability of the kidney collecting duct by trafficking of AQP2 from intracellular vesicles to the apical plasma membrane.
The long-term adaptational changes in body water balance are controlled in part by regulated changes in AQP2 and AQP3 expression levels. Lack of functional AQP2 is seen in primary forms of diabetes insipidus, and reduced expression and targeting are seen in several diseases associated with urinary concentrating defects such as acquired nephrogenic diabetes insipidus, postobstructive polyuria, as well as acute and chronic renal failure. In contrast, in conditions with water retention such as severe congestive heart failure, pregnancy, and syndrome of inappropriate antidiuretic hormone secretion, both AQP2 expression levels and apical plasma membrane targetting are increased, suggesting a role for AQP2 in the development of water retention. Continued analysis of the aquaporins is providing detailed molecular insight into the fundamental physiology and pathophysiology of water balance and water balance disorders.
Three additional aquaporins are present in the kidney. AQP6 is present in intracellular vesicles in collecting duct intercalated cells, and AQP8 is present intracellularly at low abundance in proximal tubules and collecting duct principal cells, but the physiological function of these two channels remains undefined. AQP7 is abundant in the brush border of proximal tubule cells and is likely to be involved in proximal tubule water reabsorption.

Fluid transport across leaky epithelia: central role of the tight junction and supporting role of aquaporins.

Fischbarg J.
Institute of Cardiology Research , A. C. Taquini, University of Buenos Aires and National Council for Scientific and Technical Investigations, Buenos Aires, Argentina. jf20@columbia.edu
Physiol Rev. Oct 2010; 90(4):1271-90. http://dx.doi.org/10.1152/physrev.00025.2009.
The mechanism of epithelial fluid transport remains unsolved, which is partly due to inherent experimental difficulties. However, a preparation with which our laboratory works, the corneal endothelium, is a simple leaky secretory epithelium in which we have made some experimental and theoretical headway. As we have reported, transendothelial fluid movements can be generated by electrical currents as long as there is tight junction integrity. The direction of the fluid movement can be reversed by current reversal or by changing junctional electrical charges by polylysine. Residual endothelial fluid transport persists even when no anions (hence no salt) are being transported by the tissue and is only eliminated when all local recirculating electrical currents are.   The notion that transepithelial movement of water depends on the movement of electrolytes arises from a finding by Peter Curran and Arthur K. Solomon that transintestinal water flow (“solvent” flow) depended on the transport of NaCl (“solute” flux) by that layer. That gave birth to the question of how the flow of solute (or “salt”) is linked to the movement of solvent (or “fluid”), or in the short jargon of the field, how solute-solvent cou­pling arises. 
To be noted, gradientless flow is different from transepithelial osmosis a` la Dutrochet. In this last one, in the presence of an osmotic gradient across an epithelial layer, water obligingly traverses the layer. This is well exempli­fied by the kidney collecting duct, a tight epithelium for which we accept nowadays that the water goes across both cell plasma membranes in series, traversing their aquaporins.  There is also the special case of the anuran skin epithelia, whose intercellular junctions are tight, and which water also appears to traverse through cell membrane aquaporins. As a rule, epithelia specialized to transport fluid do so in the absence of any external osmotic gradient across their layers; that is, fluid is transported between compartments of similar osmolarity.  That gave birth to the question of how the flow of solute (or “salt”) is linked to the movement of solvent (or “fluid”), or in the short jargon of the field, how solute-solvent cou­pling arises.
The progression of the ideas on fluid transport is linked to those in a parallel field, that of water channels.  After early advances in their characterization and isolation, they were molecularly identified by Peter Agre and co-workers in the early 1990s, who termed them aquaporins (AQPs). It was subsequently de­termined that AQPs were present in many fluid transport­ing epithelia  and were also present in water-perme­able kidney segments while absent in relatively water-impermeable ones . By then, the measurements of osmotic permeabilities of epithelial cell membranes had been refined using video microscopy techniques. The lab­oratories of Kenneth Spring (working on gallbladders)  and of the Welling brothers (working on kidney proximal tubule) found rather high osmotic perme­ability (or “filtration” permeability, Pf) values (Persson and Spring: 550 and 1,200 pm/s for the apical and baso-lateral membranes, respectively; Welling: -300 pm/s). Both laboratories suggested that, given such high Pf values, a few milliosmoles of osmotic pressure difference across the cell boundaries would suffice to drive the transported fluids through the cells.

There had been all along experimental evidence for the diverging view that fluid transport across leaky epi­thelia took place via paracellular, transjunctional water flow. That contrary evidence came from the laboratories of Adrian Hill using gallbladder, John Pappenheimer and his fellow James Madara using intestine, and Guillermo Whittembury and Gerhard Malnic using kidney proximal tubule. The contrary view of paracellular flow had remained a minority opinion. Still and all, these “rebels” stood their ground, led by an utterly unconvinced Adrian Hill. Con­sidering the divergent views, Kenneth Spring and col­leagues decided to take the bull by the horns and use confocal microscopy to look for evidence for or against transjunctional water flow in epithelia.
Paracellular, transjunctional fluid flow in an absorbing epithelium would lead to significant dilution of a paracellular fluorescent marker trapped in the inter­cellular spaces, which in turn would be detectable by the optical sectioning methods they mastered; all very ele­gant, for sure.

And so we come to the paper Spring and colleagues published in May of 1998  reporting that they had found no transjunctional water flow in cultured Madin-Darby canine kidney (MDCK) cell layers. Understandably, their statement had a very large impact. And yet, only some months afterwards, this notion had to be revised as it became clear that the preparation they had chosen presumably transported little if any water. By Spring’s own admission in October of the same 1998, “ . . . the fluid transport rate of MDCK cells is only about 1% of that of the renal proximal tubule… ”  To spell out the obvious, little or no fluid transport means no transjunctional (or trans-cellular) water flow either, so in perspective, the findings of Spring and colleagues (“absence of junctional flow”) bring no surprise and have no bearing on the issue of the route of fluid flow in general.

After the demise of the 1998 paper above, doubts about local osmosis continued to be fueled. Adrian Hill had been joined in his criticism of it by Thomas Zeuthen and Ernest Wright. In particular, Zeuthen and co-workers had developed an alternative model for transcellular water transfer based on molecular cotransport through transporters. Predictably, Hill’s views were newly sought out. In a thorough review written with his wife and colleague Bruria Shachar-Hill, they restated the evidence from theirs and collaborating laboratories for junctional flow for Necturus and rabbit gallbladder, Necturus intestine, Rhodnius Malpighian tubule, and rat and rabbit salivary gland. In addition, they gave a convincing account of the evidence consistent with junctional water flow for renal proximal tubule, exocrine gland (salivary, lacrimal), and small intestine. Here we will simply call attention to those arguments and will concentrate on other arguments plus additional evidence of our own.

By the end of the 1990s, Alan Verkman’s laboratory had been investigating the physiological effects of knock­ing out AQPs in mice.  The dele­tion of AQPs resulted in drastic decreases of cell mem­brane osmotic permeability, but only in rather mild decreases in rates of fluid transport, and this last to boot only in tissues that transported fluid at high rates. Verkman and colleagues generally discuss those results in a guarded manner, underlining the role of aquaporins as routes for cell water permeability without making pro­nouncements on the mechanism of transtissue fluid trans­port. Yet, paraphrasing the comments by Hill and col­leagues in another cogent review, the effects seen in the AQP knockouts are sometimes difficult to explain, and not commensurate with the deletion of what would be hypothetically a major route for transcellular transtissue water transfer.

Perhaps the existence and the location of electrogenic transporters and channels are telling us something very fundamental about the function of these layers. There does not seem to be an explanation of why epithelia in general, and specifically leaky epithelia, would have evolved to have an electrical potential difference across the layer. In principle, salts could simply be transported neutrally. In a similar vein, apical Na channels that allow Na to leak back into the cell would not make sense if the task of an epithelial cell would be to transport salt from the serosal (basal) to the luminal (apical) side. However, both of these apparent incongruencies suddenly make sense if the raison d’être of these epithelia is to perform tasks such as electro-osmosis. The electrical potential might not be an evolutionary leftover but a central fea­ture. The Na channel would not be apical by accident but to help build up the local current meant for electro-osmosis. As mentioned above, aside from the corneal endothelium , there is evidence for electro-osmosis in small intestine, kidney proximal tubule, and frog skin glands. Hence, it would be desirable if the presence of electro-osmosis would be explored in other fluid-transporting epithelia.

Electro-osmotic coupling would result in somewhat (perhaps 30%) hypotonic emerging fluid. This entails that the fluid left behind at the intercellular spaces might be correspondingly hypertonic. Such osmolarity difference in turn might be sensed by the cell and trigger mechanisms that would affect sites for regulation at basolateral and apical sites for HCO3  and Na transports, and perhaps also at the junction so as to modify the characteristics of the coupling. It is conceivable that such regulation might take place with some degree of period­icity. There may be a role for AQP1 in this regulation, which would explain the mild effects seen on fluid trans­port in this and other preparations in experiments done with AQP1 null cells. This would explain what has been noted by Verkman and colleagues, namely, that effects of AQP deletion are more pronounced in epithelia that gen­erate higher rates of fluid transport. Thus AQP deletion reduced near-isosmolar fluid transport in kidney proximal tubule and salivary gland, where fluid transport is rapid, but not in lung, lacrimal gland, sweat gland, or corneal endothelium where fluid trans­port is relatively slow.

Aquaporin (AQP) 1 is the only AQP present in these cells, and its deletion in AQP1 null mice significantly affects cell osmotic permeability (by > 40%) but fluid transport much less ( > 20%), which militates against the presence of sizable water movements across the cell. In contrast, AQP1 null mice cells have reduced regulatory volume decrease (only 60% of control), which suggests a possible involvement of AQP1 in either the function or the expression of volume-sensitive membrane channels/transporters. A mathematical model of corneal endothelium we have developed correctly predicts experimental results only when paracellular electro-osmosis is assumed rather than transcellular local osmosis. Our evidence therefore suggests that the fluid is transported across this layer via the paracellular route by a mechanism that we attribute to electro-osmotic coupling at the junctions. From our findings we have developed a novel paradigm for this preparation that includes

1) paracellular fluid flow;
2) a crucial role for the junctions;
3) hypotonicity of the primary secretion; and
4) an AQP role in regulation rather than as a significant water pathway.
These elements are remarkably similar to those proposed by the laboratory of Adrian Hill for fluid transport across other leaky epithelia.

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Part V: Heart, Vascular Smooth Muscle, Excitation-Contraction Coupling (E-CC), Cytoskeleton, Cellular Dynamics and Ca2 Signaling

Larry H Bernstein, MD, FCAP, Justin Pearlman, MD, PhD, FACC and Aviva Lev-Ari, PhD, RN

http://pharmaceuticalintelligence.com/2013/08/26/heart-smooth-muscle-excitation-contraction-coupling-cytoskeleton-cellular-dynamics-and-ca2-signaling/

Part VI: Calcium Cycling (ATPase Pump) in Cardiac Gene Therapy: Inhalable Gene Therapy for Pulmonary Arterial Hypertension and Percutaneous Intra-coronary Artery Infusion for Heart Failure: Contributions by Roger J. Hajjar, MD

Aviva Lev-Ari, PhD, RN

http://pharmaceuticalintelligence.com/2013/08/01/calcium-molecule-in-cardiac-gene-therapy-inhalable-gene-therapy-for-pulmonary-arterial-hypertension-and-percutaneous-intra-coronary-artery-infusion-for-heart-failure-contributions-by-roger-j-hajjar/

Part VII: Cardiac Contractility & Myocardium Performance: Ventricular Arrhythmiasand Non-ischemic Heart Failure – Therapeutic Implications for Cardiomyocyte Ryanopathy (Calcium Release-related Contractile Dysfunction) and Catecholamine Responses

Justin Pearlman, MD, PhD, FACC, Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

http://pharmaceuticalintelligence.com/2013/08/28/cardiac-contractility-myocardium-performance-ventricular-arrhythmias-and-non-ischemic-heart-failure-therapeutic-implications-for-cardiomyocyte-ryanopathy-calcium-release-related-contractile/

Part VIII: Disruption of Calcium Homeostasis: Cardiomyocytes and Vascular Smooth Muscle Cells: The Cardiac and Cardiovascular Calcium Signaling Mechanism

Justin Pearlman, MD, PhD, FACC, Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

http://pharmaceuticalintelligence.com/2013/09/12/disruption-of-calcium-homeostasis-cardiomyocytes-and-vascular-smooth-muscle-cells-the-cardiac-and-cardiovascular-calcium-signaling-mechanism/

Part IX: Calcium-Channel Blockers, Calcium Release-related Contractile Dysfunction (Ryanopathy) and Calcium as Neurotransmitter Sensor

Justin Pearlman, MD, PhD, FACC, Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

Part X: Synaptotagmin functions as a Calcium Sensor: How Calcium Ions Regulate the fusion of vesicles with cell membranes during Neurotransmission

Larry H Bernstein, MD, FCAP and Aviva Lev-Ari, PhD, RN

 1743-8454-7-15-1  Distribution in brain of aquaporin-1 (AQP1, blue) and AQP4 (orange), schematically illustrated on a sagittal section of a human brain
centralpore-small  Tetrameric Pore                     AQP-highlight
Created with The GIMP                           Gating of aquaporins
AQP-thumbnail  Gas Molecules Commute into Cell      aqpz-glpf  water channels
GlpF-ABF  Molecular Obstacle Course              nihms365271f1   Roles of water-selective aquaporins (AQPs, shown in purple).
building_a_model-02-full     nihms365271f2  Roles of water-glycerol-transporting aquaporins (aquaglyceroporins).

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Sunitinib brings Adult Acute Lymphoblastic Leukemia (ALL) to Remission – RNA Sequencing – FLT3 Receptor Blockade

Curator: Aviva Lev-Ari, PhD, RN

Article ID #1: Sunitinib brings Adult Acute Lymphoblastic Leukemia (ALL) to Remission – RNA Sequencing – FLT3 Receptor Blockade. Published on 7/9/2012

WordCloud Image Produced by Adam Tubman

Sunitinib brings Adult Acute Lymphoblastic Leukemia (ALL) to Remission – RNA Sequencing – FLT3 Receptor Blockade

Word Cloud by Daniel Menzin

Updated 11/13/2013

Pazopanib versus Sunitinib in Renal Cancer

N Engl J Med 2013; 369:1968-1970November 14, 2013DOI: 10.1056/NEJMc1311795

Article

To the Editor:

Cancer treatments are expensive. The estimation of the total cost can be challenging because of several factors such as efficacy, toxicity, and the costs and duration of supportive care and end-of-life care. Motzer et al. (Aug. 22 issue)1 report similar efficacy but a favorable safety and quality-of-life profile and less medical resource utilization with pazopanib as compared with sunitinib in first-line therapy for metastatic renal cancer. Since oncology is becoming an increasingly value-based specialty, we wanted to highlight another important aspect of this trial. Pazopanib appears to be favorable not only in terms of safety and quality of life, but also in terms of overall cost. A 30-day supply of pazopanib (at a dose of 800 mg daily) ranges from $3,500 to $8,556, whereas a 30-day supply of sunitinib (at a dose of 50 mg daily) ranges from $4,500 to $13,559.2 The total cost of pazopanib during the median progression-free survival of 8.4 months is $29,400 to $71,870, and the total cost of sunitinib during the median progression-free survival of 9.5 months is $42,750 to $127,454. Less toxicity and less medical resource utilization with pazopanib will most likely further lower the overall costs of treatment with this agent. Comparative-effectiveness trials hold great promise for maximizing patient safety, improving treatment outcomes, and reducing costs.

Ryan Ramaekers, M.D.
Mark Tharnish, Pharm.D.
M. Sitki Copur, M.D.
Saint Francis Cancer Treatment Center, Grand Island, NE
mcopur@sfmc-gi.org

No potential conflict of interest relevant to this letter was reported.

2 References

To the Editor:

Motzer et al. report a combined analysis of two open-label noninferiority trials (927 patients in the original trial and 183 patients in a second trial), each of which compared pazopanib with sunitinib with respect to progression-free survival in renal-cell carcinoma. Quality-of-life outcomes were subjective.

Analysis of noninferiority trials is notoriously difficult.1,2 The authors’ analysis of the trials, which was open-label because of the different administration schedules of the drugs, presents problems in interpreting progression-free survival and quality of life. The studies define disease progression differently. The larger study defined progression-free survival according to independent review. The protocol for the smaller study states that progression-free survival “will be summarized . . . based on the investigator assessment.” Inference from subjective outcomes in unmasked trials (e.g., quality of life in both studies and progression-free survival in the smaller study and therefore in the combined analysis) is subject to well-known bias. Moreover, the article does not state how many of the 379 participants (34%) who discontinued the intervention before death or disease progression (see Fig. S2 in the Supplementary Appendix, available with the full text of the article at NEJM.org) were assessed for progression-free survival. A fair comparison must use rigorous methods to handle missing data.3 Since the article did not deal appropriately with missing data, its conclusions regarding noninferiority are uninterpretable.

Janet Wittes, Ph.D.
Statistics Collaborative, Washington, DC
janet@statcollab.com

Dr. Wittes reports that her company, Statistics Collaborative, has consulting agreements with both GlaxoSmithKline and Pfizer, the manufacturers of the drugs discussed in the article by Motzer et al. In addition, Statistics Collaborative has contracts with several other companies that produce drugs for patients with cancer. No other potential conflict of interest relevant to this letter was reported.

3 References

To the Editor:

Motzer et al. state that “the results of the progression-free survival analysis in the per-protocol population were consistent with the results of the primary analysis.” However, the predefined margin of noninferiority (<1.25) was not met. The upper limit of the confidence interval (1.255) was clearly above the defined threshold.1 In a noninferiority trial, the use of the intention-to-treat population is generally nonconservative,2 the full analysis set and the per-protocol analysis set are considered to have equal importance, and the use of the intention-to-treat population should lead to similar conclusions for a robust interpretation.3 Thus, it is surprising that the authors did not come to or discuss the same conclusions as that of the French National Authority for Health4: “serious doubt exists about the noninferiority result of pazopanib compared to sunitinib” and “the clinical significance of the noninferiority threshold defined in the protocol was an efficacy loss of 2.2 months in the median progression-free survival. This is too large for patients.”

Jochen Casper, M.D.
Silke Schumann-Binarsch, M.D.
Claus-Henning Köhne, M.D.
Klinikum Oldenburg, Oldenburg, Germany
casper.jochen@klinikum-oldenburg.de

Dr. Casper reports receiving consulting fees from Bayer, Novartis, and Pfizer and speaking fees from Novartis and Pfizer. No other potential conflict of interest relevant to this letter was reported.

4 References

The authors reply: In reply to Ramaekers et al.: we agree that decisions regarding the provision of health care include economic evaluations to identify treatments that provide the best clinical benefit at an acceptable cost.

To clarify a point in the letter by Wittes: the primary end point of this phase 3 trial was progression-free survival evaluated by an independent review committee; these data were assessed for all 1110 patients from both trials. This is specified in the protocol. The consistency of the quality-of-life results with the observed differences in the safety profiles for the two drugs speaks to the absence of bias in the quality-of-life outcome. The number of patients in whom follow-up ended before progression was assessed by the independent review committee was balanced between the two groups: 156 patients in the pazopanib group (28%) and 168 patients in the sunitinib group (30%). To Wittes’s final point regarding rigorous methods to handle missing data: the algorithm for assigning disease-progression and censoring dates followed the Guidance for Industry of the Food and Drug Administration1 and is included in the protocol of our article.

In reply to Casper et al.: there is no consensus regarding whether the per-protocol population is more conservative than the intention-to-treat population for the noninferiority analysis.2,3Reviews of noninferiority trials indicate that the per-protocol population is not generally more conservative than the intention-to-treat population, and there are scenarios in which the per-protocol analysis itself could introduce bias.3 A systematic review indicated that more than 70% of published findings from noninferiority trials in oncology show results in only the intention-to-treat population and not in the per-protocol population.4 Our phase 3 trial had a single primary analysis in the intention-to-treat population, with the per-protocol population included as a key sensitivity analysis, as supported by Fleming et al.5 No formal hypothesis testing was planned for the per-protocol population, nor was the trial powered for this. Consistency of the point estimates was desired to show an absence of bias due to the analysis population. This absence of bias was shown by the consistency of the hazard ratios (1.07 in the per-protocol analysis vs. 1.05 in the primary analysis). For an underpowered per-protocol comparison, it is inappropriate for Casper et al. to interpret that the upper bound that barely exceeded 1.25 in our per-protocol analysis is an indication of inconsistency of results across the two populations. The noninferiority margin was selected in consultation with oncology experts, and justification of the margin is in the protocol.

Robert J. Motzer, M.D.
Memorial Sloan-Kettering Cancer Center, New York, NY
motzerr@mskcc.org

Lauren McCann, Ph.D.
Keith Deen, M.S.
GlaxoSmithKline, Collegeville, PA

Since publication of their article, the authors report no further potential conflict of interest.

REFERENCES

Food and Drug Administration. Guidance for industry: clinical trial endpoints for the approval of cancer drugs and biologics. May 2007 (http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm071590.pdf).
Jones B, Jarvis P, Lewis JA, Ebbutt AF. Trials to assess equivalence: the importance of rigorous methods. BMJ 1996;313:36-39[Erratum, BMJ 1996;313:550.]
CrossRef | Web of Science | Medline
Brittain E, Lin D. A comparison of intent-to-treat and per-protocol results in antibiotic non-inferiority trials. Stat Med 2005;24:1-10
CrossRef | Web of Science | Medline
Tanaka S, Kinjo Y, Kataoka Y, Yoshimura K, Termukai S. Statistical issues and recommendations for noninferiority trials in oncology: a systematic review. Clin Cancer Res 2012;18:1837-1847
CrossRef | Web of Science | Medline
Fleming TR, Odem-Davis K, Rothmann MD, Li Shen Y. Some essential considerations in the design and conduct of non-inferiority trials. Clin Trials2011;8:432-439
CrossRef | Web of Science | Medline
SOURCE

Original Article Published on 7/9/2012

July 6, 2012 NY Times reports on a new approach based on DNA and RNA sequencing and a cancer drug for kidney cancer to bring REMISSION to Adult acute lymphoblastic leukemia (ALL).

On the lower left corner of this page – Watch the VIDEO

second-chance.html

Dr. Lukas Wartman, is a Cancer Researcher specializing in Leukemia. He suspected he had Leukemia, the very disease he had devoted his medical career to studying.

After years of treatment and two relapses of ALL, he has exhaused all conventional approaches to his disease. At Washington University in St. Louis, his colleagues in the lab, decoded Dr. Wartman’s genetic information by genome sequencing techniques t determine the genetic cause of his ALL. The team found an overactive gne, FLT3 on Chromosome 13. The gene was treated with pfizer’s Suntinib drug for advanced kidney cancer.

Blood samples free of ALL found in days after using the drug. As results were very promising, Pfizer, the drug’s maker who has turned down Dr. Wartman’s request for the drug under their compassionate use program, though he explained that his entire salary was only enough to pay for 7 1/2 months of Sutent (Suntinib). While he does not know why Pfizer gave him the drug finally, he suspects it was the plea of his Nurse Practitioner, Stephanie Bauer, NP.

Identification of the genetic cause for his ALL, thus discovering a breakthough in understanding and treatment for ALL in other patients, involved the following steps:

SAMPLE

two tissue samples taken from Dr. Wartman’s Bone marrow and skin cells

SEQUENCE

Extracts of DNA and RNA from Dr. Wartman’s cells, two types of genetic material tested

COMPARISON

DNA sequesnces showed genetic mutations possibly related to his ALL, none seemed treatable. However, RNA sequencing revealed that a normal Gene, FLT3, on cheomozome 13, was overactive in his leukemia cells

TARGETING

The FLT3 gene helps create new white blod cells in the bone marrow. Dr. Wartman’s marrow bone cells were covered with an extreme number of FLT3 receptors which possibly caused the growth of his leukemia.

TREATMENT – Receptor Blockade 

Drug known to block FLT3 receptor, Sunitinib, used for kedney cancer treatment, was given to Dr. Wartman. Two weeks after Dr, Wartman began taking the drug, tests revealed that his leukenia was in remission.

NEW MARKETS FOR FLT3  GENE BLOCKADE DRUG  – KIDNEY CANCER AND LEUKEMIA

Pfizer has NOW a NEW market for Sunitinib — All CANCER PATIENTS DIAGNOSED WITH Adult acute lymphoblastic leukemia (ALL) where an overactive FLT3 gene on chomosome 13 is found.

NEW TREATMENT OPTIONS FOR Adult acute lymphoblastic leukemia (ALL)

Thus, any (ALL) diagnosed patient needs to be tested for Chromosome 13, ONLY rather then the entire genome sequencing of the Patient. If FLT3 is not found overactive, THEN proceed with entire genome sequencing of the Patient. IF another gene is overactive FIND DRUG FOR RECEPTOR BLOCKADE.

SIZING THE MARKET FOR FLT3 BLOCKADE DRUGS: KIDNEY CANCER vs LEUKEMIA

The Market for Adult ALL is much bigger than the market for kidney cancer. Thus, this discovery regarding the remission of Dr. Wartman’s remission following two relapses is so significant for Pfizer and for any patient with the diagnosis of Adult ALL.

I recommend the reader to click on the links and follow the reactions of the public to this article in The New York Times.

http://www.nytimes.com/2012/07/08/health/in-gene-sequencing-treatment-for-leukemia-glimpses-of-the-future.html?pagewanted=all

Read HUNDREDS of Comments by Cancer Patients and the readers of The New York Times Health Section

http://www.nytimes.com/2012/07/08/health/in-gene-sequencing-treatment-for-leukemia-glimpses-of-the-future.html?pagewanted=all#commentsContainer

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