First published online May 15, 2009
Journal of Experimental Biology 212, 1707-1715 (2009)
Published by The Company of Biologists 2009
doi: 10.1242/jeb.024125
Aquaporins: translating bench research to human disease
A. S. Verkman
Departments of Medicine and Physiology, Cardiovascular Research
Institute, University of California, San Francisco, CA 94143, USA
e-mail:
alan.verkman{at}ucsf.edu
Accepted 16 December 2008

Summary
There is considerable potential for translating knowledge of
aquaporin
structure, function and physiology to the clinic.
One area is in
aquaporin-based diagnostics. The discovery of
AQP4 autoantibodies as a marker
of the neuromyelitis optica
form of multiple sclerosis has allowed precise
diagnosis of
this disease. Other aquaporin-based diagnostics are possible.
Another
area is in aquaporin-based genetics. Genetic diseases caused
by
loss-of-function mutations in aquaporins include nephrogenic
diabetes
insipidus and cataracts, and functionally significant
aquaporin polymorphisms
are beginning to be explored. Perhaps
of greatest translational potential is
aquaporin-based therapeutics.
Information largely from aquaporin knockout mice
has implicated
key roles of aquaporin-facilitated water transport in
transepithelial
fluid transport (urinary concentrating, gland fluid
secretion),
water movement into and out of the brain, cell migration
(angiogenesis,
tumor metastasis, wound healing) and neural function (sensory
signaling,
seizures). A subset of aquaporins that transport both water
and
glycerol, the `aquaglyceroporins', regulate glycerol content
in epidermal, fat
and other tissues, and are involved in skin
hydration, cell proliferation,
carcinogenesis and fat metabolism.
Aquaporin-based modulator drugs are
predicted to be of broad
potential utility in the treatment of edematous
states, cancer,
obesity, wound healing, epilepsy and glaucoma. These exciting
possibilities
and their associated challenges are reviewed.
Key words: aquaporin, AQP, water transport, cell migration, angiogenesis, cancer, diuretic epidermis, brain swelling

Introduction
There are 13 mammalian aquaporins (AQPs), constituting a family
of small,
hydrophobic, membrane proteins. There is a considerable
body of information
about AQP structure from electron and x-ray
crystallography (reviewed by
Fujiyoshi et al., 2002

),
showing
AQP monomers (

30 kDa) containing six membrane-spanning helical
domains
surrounding a narrow aqueous pore. AQP monomers are super-assembled
in
membranes as tetramers. While the primary function of most
AQPs is in
facilitating water movement across cell membranes
in response to osmotic
gradients, a subset of AQPs, called aquaglyceroporins,
also transport glycerol
and possibly other small polar molecules.
There is controversial evidence that
some AQPs may transport
gases and ions across membranes. The mammalian AQPs
are expressed
in various epithelia and endothelia involved in fluid transport,
such
as kidney tubules and glandular epithelia, as well as in other
cell types
such as brain glial cells, epidermis and adipocytes.
Much of our understanding
of AQP functions in mammalian physiology
has come from phenotype analysis of
mice lacking each of the
AQPs (reviewed by
Verkman, 2005

). Mouse
phenotype studies have
confirmed the anticipated involvement of AQPs in the
urinary-concentrating
mechanism and glandular fluid secretion, and led to the
discovery
of unanticipated roles of AQPs in brain water balance, cell
migration,
cell proliferation, neural activity, epidermal hydration and
ocular
function.
This review focuses on translational aspects of AQP research. What AQPs do
and don't do in mammalian physiology is reviewed, followed by consideration of
AQP-based diagnostics, genetics and therapeutics.

Functions of aquaporins in cell and organ physiology
Anticipated roles of AQPs in urinary-concentrating function and gland fluid secretion
Water transport across kidney tubules and microvessels is important
for
reabsorption of water filtered by the glomerulus and for
the formation of a
concentrated urine, which involves countercurrent
multiplication and exchange
mechanisms and vasopressin-regulated
water permeability in the collecting
duct. AQP1 is expressed
at cell plasma membranes in proximal tubule and thin
descending
limb of Henle epithelia, and in descending vasa recta endothelia
(reviewed
by Verkman, 2008

).
AQP2, the vasopressin-regulated water channel,
is expressed in collecting duct
apical membrane and intracellular
vesicles, and AQPs 3 and 4 are expressed
constitutively at the
basolateral membrane of collecting duct epithelia. As
anticipated,
defective urinary-concentrating function was found in mice
lacking
AQPs 1–4 (Ma et al.,
1997

; Ma et al.,
1998

; Ma et al.,
2000b

;
Yang et al.,
2001

) and in humans with mutations in AQP1
(King
et al., 2001

) or AQP2
(Deen et al., 1994

).
Transepithelial water
permeability and near-isosmolar fluid absorption in
proximal
tubule are impaired in mice lacking AQP1
(Schnermann et al.,
1998

).
AQP1 deletion also reduces water permeability in thin
descending limb of Henle
(Chou et al., 1999

) and vasa
recta
microvessels (Pallone et al.,
2000

), impairing the generation
of a hyperosmolar medullary
interstitium. Deletion or mutation
of AQPs 2–4 reduces collecting duct
water permeability,
impairing osmotic equilibration between urinary fluid in
the
collecting duct lumen and the renal interstitium, as illustrated
in
Fig. 1A. AQP inhibitors are
thus predicted to have `aquaretic'
activity, producing a water>salt
diuresis.
The other anticipated role of AQPs is in active fluid transport across
epithelia. AQP5 deletion in mice impairs fluid secretion by salivary
(Ma et al., 1999
) and airway
submucosal (Song and Verkman,
2001
) glands, resulting in reduced secretion of a relatively
hyperosmolar fluid. Impaired fluid secretion has also been found in AQP1
knockout mice in choroid plexus (Oshio et
al., 2005
), where cerebrospinal fluid is produced, and in ciliary
epithelium (Zhang et al.,
2002
), where ocular aqueous fluid is produced. AQP1 is involved in
the regulation of intracranial and intraocular pressure in these closed fluid
compartments. As shown in Fig.
1B, active, near-isosmolar fluid transport involves water movement
across a highly water permeable epithelium in response to osmotic gradients
produced by salt transport. Reduced epithelial cell water permeability results
in the secretion of a relatively low volume of a hyperosmolar fluid. In the
various epithelia mentioned above the rates of transepithelial fluid secretion
normalized to epithelial surface area are very high, such that the reduced
water permeability in AQP deficiency impairs transepithelial osmotic
equilibration. In other epithelia having much lower rates of fluid absorption
or secretion, including lacrimal gland
(Moore et al., 2000
), sweat
gland (Song et al., 2002
),
alveolus (Bai et al., 1999
;
Ma et al., 2000a
), and airways
(Song et al., 2001
), AQP
deletion does not impair transepithelial fluid transport. Transepithelial
water transport is not rate limiting for fluid secretion when rates of fluid
secretion are low.
Unanticipated roles of AQP-facilitated water transport in brain function and cell migration
The main water channel in brain is AQP4, which is expressed in glial cells
at fluid–parenchymal interfaces at the blood–brain and
ependymal–CSF barriers. In cytotoxic brain edema, water moves into the
brain through an intact blood–brain barrier in response to osmotic
driving forces. Mice lacking AQP4 showed improved outcome and reduced brain
water accumulation compared with wild-type mice in models of cytotoxic brain
edema, including water intoxication and ischemic stroke
(Manley et al., 2000
) and
bacterial meningitis (Papadopoulos et al., 2005). Recent results show a
remarkably improved outcome in AQP4 null mice following spinal cord injury
(Saadoun et al., 2008
), which
was attributed to reduced spinal cord edema early after injury. AQP deletion
also influences tissue water accumulation in stress-induced corneal
(Thiagarajah and Verkman,
2002
) and retinal (Da and
Verkman, 2004
) edema, as well as cataract formation
(Ruiz-Ederra and Verkman,
2006
).
In vasogenic, or `leaky-vessel' brain edema, excess water moves into the
brain by a bulk fluid flow mechanism through a leaky blood–brain
barrier, and exits the brain by movement into the CSF through the AQP4-rich
glia limitans lining brain ventricles and the brain surface
(Fig. 1C). When these water
exit routes are blocked in obstructive hydrocephalus, water also moves out of
the brain back into microvessels through the blood–brain barrier. Mice
lacking AQP4 have a worse clinical outcome and greater brain water
accumulation in models of vasogenic brain edema, including cortical-freeze
injury and brain tumor (Papadopoulos et
al., 2004
) and brain abscess
(Bloch et al., 2005
). AQP4 null
mice also manifest an accelerated course of brain swelling in obstructive
hydrocephalus (Bloch et al.,
2006
). We concluded that AQP4 facilitates removal of excess brain
water in vasogenic brain edema and hydrocephalus. AQP4 inhibitors are thus
predicted to reduce brain swelling in cytotoxic edema, whereas AQP4 enhancers
(activators or upregulators) are predicted to reduce brain swelling in
vasogenic edema.
Another unanticipated role of AQPs related to their water-transporting
function is in cell migration. Involvement of AQPs in cell migration was
discovered following the observation of impaired tumor angiogenesis in AQP1
null mice and subsequent characterization of endothelial cell cultures derived
from wild-type and AQP1 null mice (Saadoun
et al., 2005a
). Based on findings of slowed lamellipodial dynamics
in AQP deficiency and AQP polarization to the leading edge of migrating cells,
a mechanism of AQP-facilitated cell migration was proposed in which actin
cleavage and ion uptake at the tip of a lamellipodium create local osmotic
gradients that drive water influx, facilitating lamellipodial extension and
cell migration (Fig. 1D)
(reviewed by Papadopoulos et al.,
2008
). AQP-faciliated cell migration has also been found in brain
astroglial cells (Saadoun et al.,
2005b
; Auguste et al.,
2007
), kidney proximal tubule cells
(Hara-Chikuma and Verkman,
2006
), corneal epithelial cells
(Levin and Verkman, 2006
),
skin cells (Hara-Chikuma and Verkman,
2008b
) and tumor cells (Hu and
Verkman, 2006
). AQP-facilitated cell migration thus appears to be
important in tumor angiogenesis, tumor cell metastasis and spread, and wound
healing. These observations offer an explanation for the expression of AQPs in
many tumor cell types, and for correlations in some tumors between AQP
expression and tumor grade (reviewed by
Verkman et al., 2008a
).
An additional unexpected role of AQPs is in neural function. AQP4 is
expressed in supportive cells adjacent to electrically excitable cells, as in
glia vs neurons in brain, Müller vs bipolar cells in
retina, hair vs supportive cells in the inner ear, and olfactory
receptor neurons vs supportive cells in olfactory epithelium.
Electrophysiological measurements have demonstrated impaired vision, hearing
and olfaction in AQP4 null mice, as demonstrated by increased auditory
brainstem response thresholds (Li and
Verkman, 2001
), reduced electroretinogram potentials
(Li et al., 2002
), and reduced
electro-olfactogram potentials (Lu et al.,
2008
). In brain, seizure threshold is reduced and seizure duration
prolonged in AQP4 deficiency (Binder et
al., 2004a
). Possible mechanisms for altered neuroexcitation in
AQP4 deficiency include impaired K+ reuptake into glial cells
following neuroexcitation, and extracellular space expansion
(Fig. 1E). Delayed
K+ uptake from brain extracellular space in AQP4 deficiency has
been found (Binder et al.,
2006
; Padmawar et al.,
2005
), which may account for their prolonged seizures
(Fig. 1D). It has been proposed
that AQP4 associates with the inwardly rectifying K+ channel
Kir4.1, such that reduced K+ channel function in AQP4 deficiency
might account for the delay in K+ clearance. However, patch-clamp
studies in Müller cells (Ruiz-Ederra
et al., 2007
) and brain astroglia
(Zhang and Verkman, 2008b
)
provide evidence against this mechanism. We also found evidence for
extracellular space expansion in AQP4 deficiency
(Binder et al., 2004b
;
Zador et al., 2008
), in which
increased aqueous volume dilutes K+ exiting from neurons and
consequently attenuates changes in extracellular space K+
concentration. These possibilities for relating AQP4 water transport and
altered K+ dynamics, however, remain speculative.
Roles of AQP-facilitated glycerol transport by aquaglyceroporins
The functional significance of glycerol transport by aquaglyceroporins,
such
as AQP3 in skin and AQP7 in adipocytes, was for many years unclear.
We
discovered that AQP3-facilitated glycerol transport in skin
is an important
determinant of epidermal and stratum corneum
hydration
(
Fig. 2A) (reviewed by
Hara-Chikuma and Verkman,
2008c

).
Mice lacking AQP3, which is normally expressed in the
basal
layer of proliferating keratinocytes in epidermis, manifest
reduced
stratum corneum hydration and skin elasticity, and impaired
stratum corneum
biosynthesis and wound healing (Ma et al.,
2002

).
The reduced skin hydration in AQP3 deficiency is caused by
impaired
epidermal cell glycerol permeability, resulting in reduced glycerol
content
in the stratum corneum and epidermis
(Hara et al., 2002

). Topical
or
systemic glycerol administration corrected each of these defects
(Hara
and Verkman, 2003

).
A novel role of AQP3 in cell proliferation was found in several
AQP3-expressing cell types, including skin, colon and cornea. AQP3 deficient
mice manifest impaired cutaneous wound healing (Hara-Chikuma et al., 2008b),
colonic epithelial cell regeneration
(Thiagarajah et al., 2007
) and
corneal wound healing (Levin and Verkman,
2006
). In each case cell proliferation was found to be impaired. A
remarkable tumor phenotype was found in AQP3 null mice, which showed complete
resistance to the formation of skin tumors
(Hara-Chikuma and Verkman,
2008a
). AQP3-dependent epidermal cell proliferation appears to
involve reduced cellular glycerol metabolism and biosynthesis, resulting in
reduced ATP content and impaired MAP kinase signaling
(Fig. 2B). AQP3 inhibitors may
thus have utility in skin tumor prevention and therapy. Recognizing the
relationship between AQP3 expression and skin moisturization, several
companies have marketed cosmetics containing ingredients claimed to increase
AQP3 expression. However, given the relationship between AQP3 expression and
skin tumorigenesis, caution seems warranted in the use of AQP3-upregulating
cosmetics.
The aquaglyceroporin AQP7 is expressed in the plasma membrane of
adipocytes. AQP7 null mice manifest progressive increases in fat mass and
adipocyte hypertrophy as they age, with accumulation of glycerol and
triglycerides in adipocytes (Hara-Chikuma
et al., 2005
; Hibuse et al.,
2005
). Biochemical studies suggested that adipocyte hypertrophy in
AQP7 deficiency is the consequence of reduced plasma membrane glycerol
permeability, with cellular glycerol accumulation and triglyceride
biosynthesis (Fig. 2C). We
proposed that increasing adipocyte glycerol permeability, perhaps by enhancers
of AQP7 expression, might reverse this process and thus provide a novel
therapy for obesity.
AQP roles unrelated to their water and glycerol transport functions
The diverse group of physiological functions described above can be
attributed to the plasma membrane water- and/or glycerol-transporting
functions of AQPs. Various other roles of AQPs have been proposed. There is
controversial evidence that AQPs can transport certain gases, including
CO2, NO and O2 (reviewed by
Wu and Beitz, 2007
). Because
the permeability of lipid bilayers to these gases is very high, their
permeability across cell membranes is predicted to be unstirred layer limited
and thus AQP independent, as has been found experimentally for CO2
(Yang et al., 2000
;
Fang et al., 2002
;
Missner et al., 2008
). The
less membrane-permeable gas NH3 has been found to pass through AQP8
(Holm et al., 2005
), though a
study utilizing knockout mice concluded that AQP8-facilitated NH3
is not of physiological importance (Yang
et al., 2006d
). There is evidence for transport of small ions,
urea and arsenite by some AQPs, though in some cases the findings are
controversial and so far no evidence has been reported to support the
physiological importance of AQP-facilitated transport of these substances.
Evidence for AQP functioning in mitochondria in liver and brain has been
proposed (Calamita et al.,
2005
; Amiry-Moghaddam et al.,
2005
), though subsequently refuted by direct permeability
measurements (Yang et al.,
2006b
). It is unlikely that AQP-facilitated water or glycerol
transport in organellar membranes is of importance to cell functioning because
of the high surface-to-volume ratio of organelles and consequent rapid
water/solute equilibration even in the absence of AQPs. Finally, as mentioned
with regard to neuroexcitation phenomena, various AQP protein–protein
interactions have been proposed, such as AQP4–Kir4.1 interaction, though
subsequently refuted (Ruiz-Ederra et al.,
2007
). Stoichiometric interactions between AQPs and ion channels
seem unlikely because the membrane density of AQPs is 100- to 1000-fold
greater than that of ion channels. Another recently proposed non-transporting
role of AQPs is in cell–cell adhesion, including AQP4-facilitated glial
cell adhesion (Hiroake et al., 2006). However, direct measurements have
refuted the initial findings (Zhang and
Verkman, 2008a
). Together, the present evidence supports the
conclusion that AQPs are involved primarily in plasma membrane water and/or
glycerol permeability.

Aquaporin-targeted therapies
Potential clinical indications of AQP modulators
Notwithstanding some differences in human
vs mouse physiology,
the
phenotype findings in AQP-deficient mice suggest various
clinical indications
of AQP modulators. The requirement of AQPs
for the formation of a concentrated
urine suggests that AQP
inhibitors, or `AQP-aquaretics', would reduce urine
concentration,
producing a water>salt diuresis. Though inhibitors of AQP2
would
have similar aquaretic activity to existing vasopressin receptor-2
antagonists
for therapy of hyponaturemia associated with high vasopressin,
AQP1
inhibitors are predicted to have utility in diuretic-refractory
edematous
states, such as severe congestive heart failure, where
conventional
salt-blocking diuretics are of limited efficacy.
Inhibitors of AQP4 are
predicted to reduce brain swelling in
cytotoxic edema, potentially offering
neuroprotection following
brain and spinal cord injury, and ischemic stroke,
and potentially
reducing mortality in infectious meningitis and various
encephalitides.
Inhibitors of AQPs in tumor cells and microvessels are
predicted
to reduce tumor spread and angiogenesis, offering adjunctive
tumor
chemotherapy. Inhibition of AQP4-facilitated glial cell
migration is predicted
to inhibit glial scar formation following
brain and spinal cord injury,
promoting axonal regeneration
and improving long-term neurological outcome.
Topical inhibitors
of AQP1 in the eye may reduce intraocular pressure in
glaucoma,
and inhibitors of AQP3 in the skin may reduce skin cancer. Compounds
that
increase AQP function, acting by increasing AQP expression,
are predicted
to have potential efficacy in reducing fat mass
in obesity, in accelerating
brain water clearance in vasogenic
edema, in promoting wound healing and
tissue regeneration following
injury, and in inhibiting cataractogenesis.
Validation of these
predictions in humans will require the development of
AQP-specific
modulators. Challenges will include the identification of potent,
AQP
subtype-selective inhibitors, and, in the case of AQP4 inhibitors,
inhibitors
that penetrate the blood–brain barrier. Identification
of AQP
enhancers presents an even great challenge as AQPs probably
already have
maximal per-channel function that cannot be further
increased, and
identification of selective transcriptional upregulators
is without precedent
in drug discovery.
Aquaporin inhibitors
There are at present no reported AQP inhibitors that are suitable
candidates for clinical development. Though mutiple AQPs are inhibited by
sulfhydryl-reactive mercurials such as mercury and gold
(Niemietz and Tyerman, 2002
),
these metal ions are non-selective in their action and very toxic. Various
candidate blockers of AQP1 have been reported, including tetraethylammonium
(Brooks et al., 2000
),
acetazolamide (Ma et al.,
2004
) and DMSO (van Hoek et
al., 1990
); however, a careful evaluation of their inhibition
efficacy using sensitive measurement methods indicated little or no AQP1
inhibition by tetraethylammonium or acetazolamide, and apparent inhibition by
DMSO resulting from an osmotic clamp effect rather than true inhibition
(Yang et al., 2006a
). A
careful analysis in Xenopus oocytes also showed no AQP1 inhibition by
acetazolamide or tetraethylammonium
(Sogaard and Zeuthen, 2008
).
Recently, several papers from one group reported AQP4 inhibition by a series
of arylsulfonamides, antiepileptic drugs, and related molecules, with strong
inhibition at low micromolar concentrations
(Huber et al., 2007
;
Huber et al., 2008a
;
Huber et al., 2008b
); however,
these results could not be confirmed, with no inhibition activity found even
at high concentrations of any of the putative AQP4 inhibitors
(Yang et al., 2008
). The
identification of bona fide AQP inhibitors will likely require
high-throughput screening of diverse small-molecule collections, utilizing
sensitive assays of water transport function.
Screening methods for identification of AQP modulators
There are a number of possible strategies for identification of AQP
modulators by screening of large compound collections. Many methods have been
developed to measure water permeability across cell membranes, based largely
on changes in cell volume in response to osmotic gradients. Cell volume has
been measured in unlabeled cells by light scattering, phase-contrast
microscopy and interferometry, and in fluorescently labeled cells by total
internal reflection microscopy and confocal microscopy (reviewed by
Verkman, 2000
). Some of these
methods are amenable to platereader or imaging (high-content screening)
platforms. Calcein fluorescence quenching provides a simple approach to
quantify cell membrane water permeability
(Solenov et al., 2004
), in
which osmotically induced cell shrinking reduces cytoplasmic calcein
fluorescence by cytoplasmic protein-mediated quenching. A similar strategy,
following the development of second generation green fluorescent protein-based
chloride sensors (Galietta et al.,
2001
), involves measurement of cell membrane water permeability
from the time course of fluorescence in labeled cells following osmotic
challenge. Cell shrinking produces an instantaneous increase in cytoplasmic
chloride concentration and consequent reduction in sensor fluorescence.
Challenges in compound screening include the generation of stable cell lines
with appropriate AQP expression to allow accurate measurement of water
transport rates, and rapid imposition of osmotic gradients to drive cell
volume changes.
We recently devised a simple screening method to identify inhibitors of
AQP1 water permeability and UT-B urea permeability using human erythrocytes
(Levin et al., 2007
), which
was successful in identifying nanomolar potency UT-B inhibitors of
phenylsulfoxyoxozole and benzenesulfonanilide classes. Prior urea analog-based
inhibitors have millimolar potency. As shown diagrammatically in
Fig. 3, the method involves
measurement of erythrocyte lysis after imposing a large, outwardly directed
gradient of acetamide, a urea analog that is transported efficiently by UT-B.
The acetamide gradient causes cell swelling, which is limited by
UT-B-facilitated acetamide efflux. Under appropriate conditions, UT-B
inhibition slows acetamide efflux and increases cell lysis, as assayed by
near-infrared light scattering. Minor assay modification has allowed
identification of AQP1 inhibitors, in which AQP1 inhibition slows water influx
and protects against osmotic lysis. Similar lysis-based assays are potentially
suitable for studying other AQPs.

Aquaporin-based diagnostics
Antibody-based diagnostics
There is one prominent example of an AQP antibody-based diagnostic
test.
AQP4 has been implicated as a marker of the central inflammatory
demyelinating
disease neuromyelitis optica (NMO), or Devic's
disease
(Wingerchuk et al., 2007

). NMO
is a unique form of multiple
sclerosis (MS) in which inflammatory lesions are
restricted
to the optic nerve and spinal cord, causing acute ocular pain
with
loss of vision, and myelitis with symmetric paraplegia,
sensory loss and
bladder dysfunction. A serum immunoglobulin
was discovered in NMO subjects,
but not in MS or normal subjects,
which was found to target external
epitope(s) on AQP4 (Lennon
et al.,
2005

). Seropositivity for NMO-IgG is reasonably sensitive
(74%)
and specific (>90%) for NMO (Jarius et
al., 2008

),
enabling early diagnostic distinction of NMO from MS.
The characteristic
vasculocentric deposition of immunoglobulins and complement
activation
products in NMO has suggested the possibility that the AQP4
autoantibody
is involved in NMO disease pathogenesis. However, various
observations
have challenged the proposed role of AQP4 antibody in disease
pathogenesis,
such as the lack of correlation of NMO-IgG antibody titer with
disease
severity, and the restricted sites of NMO lesions compared with
the
wide distribution of AQP4. Notwithstanding the incomplete
understanding of the
origin and importance of NMO antibodies
in disease pathogenesis, the detection
of NMO-IgG has opened
a new area in the diagnosis of a neurological disease
where
alternative tests were not available. There are various other
disease
states in which AQP antibodies may be of utility for
diagnosis and possibly
involved in disease pathogenesis. As
yet untested possibilities include AQP3
autoantibodies in autoimmune
skin diseases and AQP5 autoantibodies in
Sjogren's syndrome.
Protein-based diagnostics
Assay of AQP protein content in bodily fluids and tissue specimens may have
diagnostic value. The one established example is assay of AQP2 immunoreactive
protein in urine for distinguishing among various etiologies of nephrogenic
diabetes insipidus (NDI) (Rai et al.,
1997
; Ishikawa,
2000
). The rationale for urinary AQP2 assay is the shedding, by an
exosomal mechanism, of a small amount of AQP2 protein when present at the
luminal membrane of kidney collecting duct. With suitable caveats, urinary
AQP2 protein is a marker of apical membrane AQP2 expression, being absent in
NDI caused by AQP2 deficiency or defective cellular processing. However,
diagnostic assay of urinary AQP2 has not been widely used because alternative,
reliable methods are available to evaluate NDI. The possibility of `shedding'
of other AQPs in urine, or in other bodily fluids, such as aqueous humor or
CSF, has not been explored. Another potential role for AQP protein-based
diagnostics is in evaluating AQP expression in tissue specimens. Several
studies have attempted to correlate AQP expression in tumor cells with tumor
grade (reviewed by Verkman et al.,
2008a
), and AQP expression with human epilepsy
(Lee et al., 2004
), and ocular
(reviewed by Verkman et al.,
2008b
) and skin (Olsson et
al., 2006
) diseases. Whether diagnostically useful or unique
information can be obtained by such measurements remains to be seen.

Aquaporin genetics and human disease
`Aquaporinopathies'
Though exceedingly rare, there exist loss-of-function mutations
in human
AQPs. Mutations in AQP2 produce non-X-linked NDI by
a recessive mechanism,
which involves defective mutant AQP2
protein folding/function, and by a
dominant mechanism, which
results from endoplasmic reticulum (ER)/Golgi
interactions between
wild-type and mutant AQP2 that prevent plasma membrane
targeting
of wild-type AQP2 (reviewed by
Bichet, 2006

). The incidence
of
NDI caused by AQP2 mutations is less than one in 20 million
births. For other
AQPs only a handful of subjects have been
identified with loss-of-function
mutations. The few subjects
that lack functional AQP1, which were identified
by blood group
screening, are phenotypically normal but manifest defective
urinary-concentrating
function when deprived of water
(King et al., 2001

), similar
to
findings in AQP1 null mice. Because of the rarity of AQP1-deficient
individuals,
as well as a few subjects that apparently lack functional AQP3
or
AQP7 (Roudier et al., 2002

;
Kondo et al., 2002

), and
because
of wide phenotype variations in humans, little useful information
is
available about the roles of these AQPs in humans. Mutations
in the major
intrinsic protein (MIP) of the lens cause congenital
cataracts
(Berry et al., 2000

). MIP (also
called AQP0) is homologous
to the AQPs, though its function in lens and the
relationship
between loss-of-function mutations and cataract formation are
unclear
(reviewed by Verkman et al.,
2008b

). Disease-causing mutations
of other AQPs in humans have not
been described.
The rarity of NDI caused by AQP2 mutation precludes clinical
development of
`new chemical entities' for therapy because of
the large costs involved. NDI
patients are treated primarily
by water replacement and salt restriction, and
in some cases
by drugs such as thiazides that impair urinary diluting ability.
We
have been interested in the possibility of using existing drugs
for therapy
of recessive NDI caused by defective cellular processing
of AQP2 mutants. An
emerging paradigm in molecular medicine
is the therapy of protein folding
diseases by chemical or molecular
chaperones, which facilitate folding of the
mutant protein by
direct binding and/or modulation of components of the
molecular
quality control machinery. We have focused attention on the
T126M
mutation in AQP2, one of the mutations causing recessive
NDI in humans.
Studies in mammalian cell culture models indicated
ER retention and protein
misfolding (Tamarappoo and Verkman,
1998

).
We also found that incubation of cell cultures with the
`chemical
chaperones' glycerol or trimethylamine-
N-oxide rescued
defective
AQP2-T126M cellular processing, resulting in its plasma membrane
expression
and restoration of cell membrane water permeability
(Tamarappoo
et al., 1999

).
However, chemical chaperones are not suitable
for use
in vivo because
of the high concentrations required.
For in vivo analysis, we created a mouse model of human NDI caused
by the T126M AQP2 mutation. Initially, an AQP2-T126M knock-in mouse model was
generated by targeted gene replacement using a Cre-loxP strategy in which the
targeted gene locus contained an engineered T126M mutation
(Fig. 4A)
(Yang et al., 2001
).
Unfortunately, though the homozygous mutant mice appeared normal just after
birth, they generally died in the first week of life because of
polyuria-induced renal failure (Fig.
4B, left). Immunoblot analysis of kidneys of the mutant mice
showed endoglycosidase H-sensitive, core glycosylated AQP2-T126M, indicating
ER retention (Fig. 4B, right).
As a first step in developing an AQP2-T126M `conditional knock-in' model of
NDI, we generated an inducible mouse model of AQP2 gene deletion
(`conditional knock-out' mouse) manifesting severe polyuria in adult mice
(Yang et al., 2006c
). LoxP
sequences were inserted into introns 1 and 2 in the mouse AQP2 gene.
Mating of germ-line AQP2-loxP mice with tamoxifen-inducible
Cre-expressing mice produced offspring with inducible homozygous
Cre-AQP2-loxP. Tamoxifen administration led to Cre recombinase
expression and AQP2 gene excision, resulting in severe polyuria and
an inability to concentrate their urine in response to water deprivation
(Fig. 4C,D). The adult polyuric
mice survived well. To create `conditional AQP2-T126M knock-in' mouse model,
mice heterozygous separately for floxed wild-type AQP2 and AQP2-T126M were
bred to produce hemizygous mice containing a floxed wild-type AQP2
allele and a mutant AQP2-T126M allele
(Yang et al., 2009
).
Conditional deletion of the wild-type AQP2 gene in adult mice by
tamoxifen administration produced mice expressing only the mutant AQP2-T126M
protein. The conditional knock-in adult mice showed polyuria, urinary
hypo-osmolality and ER retention of AQP2-T126M in collecting duct. Screening
of candidate protein folding `correctors' in AQP2-T126M-transfected kidney
cells showed increased AQP2-T126M plasma membrane expression with the Hsp90
inhibitor 17-allylamino-17-demethoxygeldanamycin (17-AAG), a compound
currently in clinical trials for tumor therapy. 17-AAG increased urine
osmolality in the AQP2-T126M mice (without effect in AQP2 null mice) and
partially rescued defective AQP2-T126M cellular processing. These
proof-of-concept findings suggest the possibility of using existing drugs for
therapy of some forms of NDI.
Aquaporin polymorphisms as disease markers
The possibility of functionally significant AQP polymorphisms has received
little attention, though recent data support further research into this area.
Two recent studies have investigated possible AQP4 polymorphisms. Kleffner and
colleagues (Kleffner et al.,
2008
) studied 10 AQP4 polymorphisms in 41 stroke patients with
middle cerebral artery occlusion, tentatively identifying one polymorphism
associated with increased severity of brain edema. Sorani and colleagues
(Sorani et al., 2008
)
identified 24 AQP4 variants in an ethnically diverse cohort of 188 normal
subjects, some of which altered AQP4 water permeability when expressed in cell
cultures, though the results were inconclusive because water permeability was
not normalized for plasma membrane AQP4 protein expression. In other studies,
associations were reported for single nucleotide polymorphisms in AQP1 with
priapism in sickle cell disease (Elliott
et al., 2007
) and with diabetic nephropathy
(Ewens et al., 2005
). The
significance of these observations is unclear. Single nucleotide polymorphisms
in AQP7 have also been associated with obesity and type II diabetes
(Prudente et al., 2007
).
Research in disease-related AQP polymorphisms is at a very early stage, with
its real impact to be determined. It may be worthwhile, for example, to
investigate polymorphisms in AQP4 in brain diseases such as obstructive
hydrocephalus, in AQP3 in skin diseases, and in various AQPs in cancer.

Footnotes
Support for AQP research in my lab is acknowledged from the
National
Institutes of
Health, through awards R37
DK35124, R37 EB00415,
R01
EY13574, R01 HL59198, R01
HL73856 and P30 DK72517. Deposited
in PMC
for release after 12 months.

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