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Manis AD, Hodges MR, Staruschenko A, Palygin O. Expression, localization, and functional properties of inwardly rectifying K + channels in the kidney. Am J Physiol Renal Physiol 2020; 318:F332-F337. [PMID: 31841387 PMCID: PMC7052651 DOI: 10.1152/ajprenal.00523.2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/10/2019] [Accepted: 12/10/2019] [Indexed: 12/13/2022] Open
Abstract
Inwardly rectifying K+ (Kir) channels are expressed in multiple organs and cell types and play critical roles in cellular function. Most notably, Kir channels are major determinants of the resting membrane potential and K+ homeostasis. The renal outer medullary K+ channel (Kir1.1) was the first renal Kir channel identified and cloned in the kidney over two decades ago. Since then, several additional members, including classical and ATP-regulated Kir family classes, have been identified to be expressed in the kidney and to contribute to renal ion transport. Although the ATP-regulated Kir channel class remains the most well known due to severe pathological phenotypes associated with their mutations, progress is being made in defining the properties, localization, and physiological functions of other renal Kir channels, including those localized to the basolateral epithelium. This review is primarily focused on the current knowledge of the expression and localization of renal Kir channels but will also briefly describe their proposed functions in the kidney.
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Affiliation(s)
- Anna D Manis
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Matthew R Hodges
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Neuroscience Research Center, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Alexander Staruschenko
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Oleg Palygin
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin
- Neuroscience Research Center, Medical College of Wisconsin, Milwaukee, Wisconsin
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2
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Palygin O, Pochynyuk O, Staruschenko A. Role and mechanisms of regulation of the basolateral K ir 4.1/K ir 5.1K + channels in the distal tubules. Acta Physiol (Oxf) 2017; 219:260-273. [PMID: 27129733 PMCID: PMC5086442 DOI: 10.1111/apha.12703] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 01/28/2016] [Accepted: 04/28/2016] [Indexed: 12/11/2022]
Abstract
Epithelial K+ channels are essential for maintaining electrolyte and fluid homeostasis in the kidney. It is recognized that basolateral inward-rectifying K+ (Kir ) channels play an important role in the control of resting membrane potential and transepithelial voltage, thereby modulating water and electrolyte transport in the distal part of nephron and collecting duct. Monomeric Kir 4.1 (encoded by Kcnj10 gene) and heteromeric Kir 4.1/Kir 5.1 (Kir 4.1 together with Kir 5.1 (Kcnj16)) channels are abundantly expressed at the basolateral membranes of the distal convoluted tubule and the cortical collecting duct cells. Loss-of-function mutations in KCNJ10 cause EAST/SeSAME tubulopathy in humans associated with salt wasting, hypomagnesaemia, metabolic alkalosis and hypokalaemia. In contrast, mice lacking Kir 5.1 have severe renal phenotype that, apart from hypokalaemia, is the opposite of the phenotype seen in EAST/SeSAME syndrome. Experimental advances using genetic animal models provided critical insights into the physiological role of these channels in electrolyte homeostasis and the control of kidney function. Here, we discuss current knowledge about K+ channels at the basolateral membrane of the distal tubules with specific focus on the homomeric Kir 4.1 and heteromeric Kir 4.1/Kir 5.1 channels. Recently identified molecular mechanisms regulating expression and activity of these channels, such as cell acidification, dopamine, insulin and insulin-like growth factor-1, Src family protein tyrosine kinases, as well as the role of these channels in NCC-mediated transport in the distal convoluted tubules, are also described.
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Affiliation(s)
- Oleg Palygin
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Oleh Pochynyuk
- Department of Integrative Biology and Pharmacology, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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3
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Sepúlveda FV, Pablo Cid L, Teulon J, Niemeyer MI. Molecular aspects of structure, gating, and physiology of pH-sensitive background K2P and Kir K+-transport channels. Physiol Rev 2015; 95:179-217. [PMID: 25540142 DOI: 10.1152/physrev.00016.2014] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
K(+) channels fulfill roles spanning from the control of excitability to the regulation of transepithelial transport. Here we review two groups of K(+) channels, pH-regulated K2P channels and the transport group of Kir channels. After considering advances in the molecular aspects of their gating based on structural and functional studies, we examine their participation in certain chosen physiological and pathophysiological scenarios. Crystal structures of K2P and Kir channels reveal rather unique features with important consequences for the gating mechanisms. Important tasks of these channels are discussed in kidney physiology and disease, K(+) homeostasis in the brain by Kir channel-equipped glia, and central functions in the hearing mechanism in the inner ear and in acid secretion by parietal cells in the stomach. K2P channels fulfill a crucial part in central chemoreception probably by virtue of their pH sensitivity and are central to adrenal secretion of aldosterone. Finally, some unorthodox behaviors of the selectivity filters of K2P channels might explain their normal and pathological functions. Although a great deal has been learned about structure, molecular details of gating, and physiological functions of K2P and Kir K(+)-transport channels, this has been only scratching at the surface. More molecular and animal studies are clearly needed to deepen our knowledge.
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Affiliation(s)
- Francisco V Sepúlveda
- Centro de Estudios Científicos, Valdivia, Chile; UPMC Université Paris 06, Team 3, Paris, France; and Institut National de la Santé et de la Recherche Médicale, UMR_S 1138, Paris, France
| | - L Pablo Cid
- Centro de Estudios Científicos, Valdivia, Chile; UPMC Université Paris 06, Team 3, Paris, France; and Institut National de la Santé et de la Recherche Médicale, UMR_S 1138, Paris, France
| | - Jacques Teulon
- Centro de Estudios Científicos, Valdivia, Chile; UPMC Université Paris 06, Team 3, Paris, France; and Institut National de la Santé et de la Recherche Médicale, UMR_S 1138, Paris, France
| | - María Isabel Niemeyer
- Centro de Estudios Científicos, Valdivia, Chile; UPMC Université Paris 06, Team 3, Paris, France; and Institut National de la Santé et de la Recherche Médicale, UMR_S 1138, Paris, France
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4
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Felix JP, Priest BT, Solly K, Bailey T, Brochu RM, Liu CJ, Kohler MG, Kiss L, Alonso-Galicia M, Tang H, Pasternak A, Kaczorowski GJ, Garcia ML. The Inwardly Rectifying Potassium Channel Kir1.1: Development of Functional Assays to Identify and Characterize Channel Inhibitors. Assay Drug Dev Technol 2012; 10:417-31. [DOI: 10.1089/adt.2012.462] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- John P. Felix
- Department of Ion Channels, Merck Research Laboratories, North Wales, Pennsylvania
| | - Birgit T. Priest
- Department of Ion Channels, Merck Research Laboratories, North Wales, Pennsylvania
| | - Kelli Solly
- Department of Automated Biotechnology, Merck Research Laboratories, North Wales, Pennsylvania
| | - Timothy Bailey
- Department of Ion Channels, Merck Research Laboratories, North Wales, Pennsylvania
| | - Richard M. Brochu
- Department of Ion Channels, Merck Research Laboratories, North Wales, Pennsylvania
| | - Chou J. Liu
- Department of Ion Channels, Merck Research Laboratories, North Wales, Pennsylvania
| | - Martin G. Kohler
- Department of Ion Channels, Merck Research Laboratories, North Wales, Pennsylvania
| | - Laszlo Kiss
- Department of Automated Biotechnology, Merck Research Laboratories, North Wales, Pennsylvania
| | | | - Haifeng Tang
- Department of Medicinal Chemistry, Merck Research Laboratories, Rahway, New Jersey
| | - Alexander Pasternak
- Department of Medicinal Chemistry, Merck Research Laboratories, Rahway, New Jersey
| | | | - Maria L. Garcia
- Department of Ion Channels, Merck Research Laboratories, North Wales, Pennsylvania
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5
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Ortega B, Mason AK, Welling PA. A tandem Di-hydrophobic motif mediates clathrin-dependent endocytosis via direct binding to the AP-2 ασ2 subunits. J Biol Chem 2012; 287:26867-75. [PMID: 22711530 DOI: 10.1074/jbc.m112.341990] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Select plasma membrane proteins can be marked as cargo for inclusion into clathrin-coated pits by common internalization signals (e.g. YXXΦ, dileucine motifs, NPXY) that serve as universal recognition sites for the AP-2 adaptor complex or other clathrin-associated sorting proteins. However, some surface proteins, such as the Kir2.3 potassium channel, lack canonical signals but are still targeted for clathrin-dependent endocytosis. Here, we explore the mechanism. We found an unusual endocytic signal in Kir2.3 that is based on two consecutive pairs of hydrophobic residues. Characterized by the sequence ΦΦXΦΦ (a tandem di-hydrophobic (TDH) motif, where Φ is a hydrophobic amino acid), the signal shows no resemblance to other endocytic motifs, yet it directly interacts with AP-2 to target the Kir2.3 potassium channel into the endocytic pathway. We found that the tandem di-hydrophobic motif directly binds to the ασ2 subunits of AP-2, interacting within a large hydrophobic cleft that encompasses part of the docking site for di-Leu signals, but includes additional structures. These observations expand the repertoire of clathrin-dependent internalization signals and the ways in which AP-2 can coordinate endocytosis of cargo proteins.
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Affiliation(s)
- Bernardo Ortega
- Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
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Hamilton KL, Devor DC. Basolateral membrane K+ channels in renal epithelial cells. Am J Physiol Renal Physiol 2012; 302:F1069-81. [PMID: 22338089 DOI: 10.1152/ajprenal.00646.2011] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The major function of epithelial tissues is to maintain proper ion, solute, and water homeostasis. The tubule of the renal nephron has an amazingly simple structure, lined by epithelial cells, yet the segments (i.e., proximal tubule vs. collecting duct) of the nephron have unique transport functions. The functional differences are because epithelial cells are polarized and thus possess different patterns (distributions) of membrane transport proteins in the apical and basolateral membranes of the cell. K(+) channels play critical roles in normal physiology. Over 90 different genes for K(+) channels have been identified in the human genome. Epithelial K(+) channels can be located within either or both the apical and basolateral membranes of the cell. One of the primary functions of basolateral K(+) channels is to recycle K(+) across the basolateral membrane for proper function of the Na(+)-K(+)-ATPase, among other functions. Mutations of these channels can cause significant disease. The focus of this review is to provide an overview of the basolateral K(+) channels of the nephron, providing potential physiological functions and pathophysiology of these channels, where appropriate. We have taken a "K(+) channel gene family" approach in presenting the representative basolateral K(+) channels of the nephron. The basolateral K(+) channels of the renal epithelia are represented by members of the KCNK, KCNJ, KCNQ, KCNE, and SLO gene families.
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Affiliation(s)
- Kirk L Hamilton
- Department of Physiology, Otago School of Medical Sciences, University of Otago, PO Box 913, Dunedin, New Zealand.
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7
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Mollajew R, Zocher F, Horner A, Wiesner B, Klussmann E, Pohl P. Routes of epithelial water flow: aquaporins versus cotransporters. Biophys J 2010; 99:3647-56. [PMID: 21112289 PMCID: PMC2998630 DOI: 10.1016/j.bpj.2010.10.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2010] [Revised: 10/07/2010] [Accepted: 10/14/2010] [Indexed: 11/18/2022] Open
Abstract
The routes water takes through membrane barriers is still a matter of debate. Although aquaporins only allow transmembrane water movement along an osmotic gradient, cotransporters are believed to be capable of water transport against the osmotic gradient. Here we show that the renal potassium-chloride-cotransporter (KCC1) does not pump a fixed amount of water molecules per movement of one K(+) and one Cl(-), as was reported for the analogous transporter in the choroid plexus. We monitored water and potassium fluxes through monolayers of primary cultured renal epithelial cells by detecting tiny solute concentration changes in the immediate vicinity of the monolayer. KCC1 extruded K(+) ions in the presence of a transepithelial K(+) gradient, but did not transport water. KCC1 inhibition reduced epithelial osmotic water permeability P(f) by roughly one-third, i.e., the effect of inhibitors was small in resting cells and substantial in hormonal stimulated cells that contained high concentrations of aquaporin-2 in their apical membranes. The furosemide or DIOA (dihydroindenyl-oxy-alkanoic acid)-sensitive water flux was much larger than expected when water passively followed the KCC1-mediated ion flow. The inhibitory effect of these drugs on water flux was reversed by the K(+)-H(+) exchanger nigericin, indicating that KCC1 affects water transport solely by K(+) extrusion. Intracellular K(+) retention conceivably leads to cell swelling, followed by an increased rate of endocytic AQP2 retrieval from the apical membrane.
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Affiliation(s)
- Rustam Mollajew
- Leibniz-Institut für Molekulare Pharmakologie, Berlin, Germany
| | - Florian Zocher
- Institut für Biophysik, Johannes Kepler Universität, Linz, Austria
| | - Andreas Horner
- Institut für Biophysik, Johannes Kepler Universität, Linz, Austria
| | | | - Enno Klussmann
- Leibniz-Institut für Molekulare Pharmakologie, Berlin, Germany
| | - Peter Pohl
- Leibniz-Institut für Molekulare Pharmakologie, Berlin, Germany
- Institut für Biophysik, Johannes Kepler Universität, Linz, Austria
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Hibino H, Inanobe A, Furutani K, Murakami S, Findlay I, Kurachi Y. Inwardly rectifying potassium channels: their structure, function, and physiological roles. Physiol Rev 2010; 90:291-366. [PMID: 20086079 DOI: 10.1152/physrev.00021.2009] [Citation(s) in RCA: 1074] [Impact Index Per Article: 76.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Inwardly rectifying K(+) (Kir) channels allow K(+) to move more easily into rather than out of the cell. They have diverse physiological functions depending on their type and their location. There are seven Kir channel subfamilies that can be classified into four functional groups: classical Kir channels (Kir2.x) are constitutively active, G protein-gated Kir channels (Kir3.x) are regulated by G protein-coupled receptors, ATP-sensitive K(+) channels (Kir6.x) are tightly linked to cellular metabolism, and K(+) transport channels (Kir1.x, Kir4.x, Kir5.x, and Kir7.x). Inward rectification results from pore block by intracellular substances such as Mg(2+) and polyamines. Kir channel activity can be modulated by ions, phospholipids, and binding proteins. The basic building block of a Kir channel is made up of two transmembrane helices with cytoplasmic NH(2) and COOH termini and an extracellular loop which folds back to form the pore-lining ion selectivity filter. In vivo, functional Kir channels are composed of four such subunits which are either homo- or heterotetramers. Gene targeting and genetic analysis have linked Kir channel dysfunction to diverse pathologies. The crystal structure of different Kir channels is opening the way to understanding the structure-function relationships of this simple but diverse ion channel family.
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Affiliation(s)
- Hiroshi Hibino
- Department of Pharmacology, Graduate School of Medicine and The Center for Advanced Medical Engineering and Informatics, Osaka University, Osaka 565-0871, Japan
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Lachheb S, Cluzeaud F, Bens M, Genete M, Hibino H, Lourdel S, Kurachi Y, Vandewalle A, Teulon J, Paulais M. Kir4.1/Kir5.1 channel forms the major K+ channel in the basolateral membrane of mouse renal collecting duct principal cells. Am J Physiol Renal Physiol 2008; 294:F1398-407. [PMID: 18367659 DOI: 10.1152/ajprenal.00288.2007] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
K(+) channels in the basolateral membrane of mouse cortical collecting duct (CCD) principal cells were identified with patch-clamp technique, real-time PCR, and immunohistochemistry. In cell-attached membrane patches, three K(+) channels with conductances of approximately 75, 40, and 20 pS were observed, but the K(+) channel with the intermediate conductance (40 pS) predominated. In inside-out membrane patches exposed to an Mg(2+)-free medium, the current-voltage relationship of the intermediate-conductance channel was linear with a conductance of 38 pS. Addition of 1.3 mM internal Mg(2+) had no influence on the inward conductance (G(in) = 35 pS) but reduced outward conductance (G(out)) to 13 pS, yielding a G(in)/G(out) of 3.2. The polycation spermine (6 x 10(-7) M) reduced its activity on inside-out membrane patches by 50% at a clamp potential of 60 mV. Channel activity was also dependent on intracellular pH (pH(i)): a sigmoid relationship between pH(i) and channel normalized current (NP(o)) was observed with a pK of 7.24 and a Hill coefficient of 1.7. By real-time PCR on CCD extracts, inwardly rectifying K(+) (Kir)4.1 and Kir5.1, but not Kir4.2, mRNAs were detected. Kir4.1 and Kir5.1 proteins cellularly colocalized with aquaporin 2 (AQP2), a specific marker of CCD principal cells, while AQP2-negative cells (i.e., intercalated cells) showed no staining. Dietary K(+) had no influence on the properties of the intermediate-conductance channel, but a Na(+)-depleted diet increased its open probability by approximately 25%. We conclude that the Kir4.1/Kir5.1 channel is a major component of the K(+) conductance in the basolateral membrane of mouse CCD principal cells.
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MESH Headings
- Animals
- Cell Polarity/physiology
- Cloning, Molecular
- Immunohistochemistry
- In Vitro Techniques
- Kidney Cortex/physiology
- Kidney Tubules, Collecting/cytology
- Kidney Tubules, Collecting/physiology
- Male
- Mice
- Mice, Inbred Strains
- Models, Biological
- Patch-Clamp Techniques
- Potassium Channels, Inwardly Rectifying/genetics
- Potassium Channels, Inwardly Rectifying/physiology
- Potassium, Dietary/pharmacokinetics
- RNA, Messenger/metabolism
- Sodium, Dietary/pharmacokinetics
- Kir5.1 Channel
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Affiliation(s)
- Sahran Lachheb
- Université Pierre et Marie Curie, 75720 Paris Cedex 06, France
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10
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Mason AK, Jacobs BE, Welling PA. AP-2-dependent internalization of potassium channel Kir2.3 is driven by a novel di-hydrophobic signal. J Biol Chem 2008; 283:5973-84. [PMID: 18180291 DOI: 10.1074/jbc.m709756200] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The localization and density of Kir2.3 channels are influenced by the balance between PDZ protein interaction at the cell surface and routing into the endocytic pathway. Here, we explore mechanisms by which the Kir2.3 channel is directed into the endocytic pathway. We found that Kir2.3 channels are constitutively internalized from the cell surface in a dynamin-dependent manner, indicative of vesicle-mediated endocytosis. The rate of Kir2.3 endocytosis was dramatically attenuated following RNA interference-mediated knockdown of either alpha adaptin (AP-2 clathrin adaptor) or clathrin heavy chain, revealing that Kir2.3 is internalized by an AP-2 clathrin-dependent mechanism. Structure-rationalized mutagenesis studies of a number of different potential AP-2 interaction motifs indicate that internalization of Kir2.3 is largely dependent on a non-canonical di-isoleucine motif (II413) embedded within the C terminus. Internalization assays using CD4-Kir2.3 chimeras demonstrate that the di-isoleucine signal acts in an autonomous and transplantable manner. Kir2.3 co-immunoprecipitates with alpha adaptin, and disruption of the di-isoleucine motif decreased interaction of the channel with AP-2. Replacement of the di-isoleucine motif with a canonical di-leucine internalization signal actually blocked Kir2.3 endocytosis. Moreover, in yeast three-hybrid studies, the Kir2.3 di-isoleucine motif does not bind the AP-2 alphaC-sigma2 hemicomplex in the way that has been recently observed for canonical di-leucine signals. Altogether, the results indicate that Kir2.3 channels are marked for clathrin-dependent internalization from the plasma membrane by a novel AP-2-dependent signal.
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Affiliation(s)
- Amanda K Mason
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Alewine C, Kim BY, Hegde V, Welling PA. Lin-7 targets the Kir 2.3 channel on the basolateral membrane via a L27 domain interaction with CASK. Am J Physiol Cell Physiol 2007; 293:C1733-41. [PMID: 17913842 DOI: 10.1152/ajpcell.00323.2007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Polarized expression of the Kir 2.3 channel in renal epithelial cells is influenced by the opposing activities of two different PDZ proteins. Mammalian Lin-7 (mLin-7) directly interacts with Kir 2.3 to coordinate basolateral membrane expression, whereas the tax interacting protein 1 (TIP-1), composed of a single PDZ domain, competes for interaction with mLin-7 and drives Kir 2.3 into the endocytic pathway. Here we show that the basolateral targeting function of mLin-7 depends on its L27 domain, which directs interaction with a cognate L27 domain in the basolateral membrane-anchoring protein, calcium/calmodulin-dependent serine protein kinase (CASK). In MDCK cells, the expression of an mLin-7 mutant that lacks the L27 domain displaced Kir 2.3 from the mLin-7/CASK complex and caused the channel to accumulate into large intracellular vesicles that partially colocalized with Rab-11. Conversely, transplantation of the mLin-7 L27 domain to TIP-1 conferred CASK interaction and basolateral targeting of Kir 2.3. Expression of the CASK L27 domain redistributed endogenous mLin-7 to an intracellular compartment and caused Kir 2.3 to accumulate in subapical endosomes. Taken together, these data support a model whereby mLin-7 acts as a PDZ-to-L27 adapter, mediating indirect association of Kir 2.3 with a basolateral membrane scaffold and thereby stabilizing Kir 2.3 at the basolateral membrane.
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Affiliation(s)
- Christine Alewine
- Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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