Selective inhibitors of KCl cotransport in human red cells

Pharmacology of Compounds Targeting Cation-Chloride Cotransporter Physiology

Transporters of the solute carrier family 12 (SLC12) carry inorganic cations such as Na+ and/or K+ alongside Cl across the plasma membrane of cells. These tightly coupled, electroneutral, transporters are expressed in almost all tissues/organs in the body where they fulfil many critical functions. The family includes two key transporters participating in salt reabsorption in the kidney: the Na-K-2Cl cotransporter-2 (NKCC2), expressed in the loop of Henle, and the Na-Cl cotransporter (NCC), expressed in the distal convoluted tubule. NCC and NKCC2 are the targets of thiazides and "loop" diuretics, respectively, drugs that are widely used in clinical medicine to treat hypertension and edema. Bumetanide, in addition to its effect as a loop diuretic, has recently received increasing attention as a possible therapeutic agent for neurodevelopmental disorders. This chapter also describes how over the past two decades, the pharmacology of Na+ independent transporters has expanded significantly to provide novel tools for research. This work has indeed led to the identification of compounds that are 100-fold to 1000-fold more potent than furosemide, the first described inhibitor of K-Cl cotransport, and identified compounds that possibly directly stimulate the function of the K-Cl cotransporter. Finally, the recent cryo-electron microscopy revolution has begun providing answers as to where and how pharmacological agents bind to and affect the function of the transporters.

Emerging drug targets for sickle cell disease: shedding light on new knowledge and advances at the molecular level

INTRODUCTION

In sickle cell disease (SCD), a single amino acid substitution at β6 of the hemoglobin (Hb) chain replaces glutamate with valine, forming HbS instead of the normal adult HbA. Loss of a negative charge, and the conformational change in deoxygenated HbS molecules, enables formation of HbS polymers. These not only distort red cell morphology but also have other profound effects so that this simple etiology belies a complex pathogenesis with multiple complications. Although SCD represents a common severe inherited disorder with life-long consequences, approved treatments remain inadequate. Hydroxyurea is currently the most effective, with a handful of newer treatments, but there remains a real need for novel, efficacious therapies.

AREAS COVERED

This review summarizes important early events in pathogenesis to highlight key targets for novel treatments.

EXPERT OPINION

A thorough understanding of early events in pathogenesis closely associated with the presence of HbS is the logical starting point for identification of new targets rather than concentrating on more downstream effects. We discuss ways of reducing HbS levels, reducing the impact of HbS polymers, and of membrane events perturbing cell function, and suggest using the unique permeability of sickle cells to target drugs specifically into those more severely compromised.

Cation Homeostasis in Red Cells From Patients With Sickle Cell Disease Heterologous for HbS and HbC (HbSC Genotype)

Sickle cell disease (SCD) in patients of HbSC genotype is considered similar, albeit milder, to that in homozygous HbSS individuals--but with little justification. In SCD, elevated red cell cation permeability is critical as increased solute loss causes dehydration and encourages sickling. Recently, we showed that the KCl cotransporter (KCC) activity in red cells from HbSC patients correlated significantly with disease severity, but that in HbSS patients did not. Two transporters involved in red cell dehydration, the conductive channels Psickle and the Gardos channel, behaved similarly in red cells from the two genotypes, but were significantly less active in HbSC patients. By contrast, KCC activity was quantitatively greater in HbSC red cells. Results suggest that KCC is likely to have greater involvement in red cell dehydration in HbSC patients, which could explain its association with disease severity in this genotype. This work supports the hypothesis that SCD in HbSC patients is a distinct disease entity to that in HbSS patients. Results suggest the possibility of designing specific treatments of particular benefit to HbSC patients and a rationale for the development of prognostic markers, to inform early treatment of children likely to develop more severe complications of the disease.

Swelling-induced Ca²+ influx and K+ efflux in American alligator erythrocytes

The American alligator can hibernate during winter, which may lead to osmotic imbalance because of reduced kidney function and lack of food consumption during this period. Accordingly, we hypothesized that their red blood cells would have a well-developed regulatory volume decrease (RVD) to cope with the homeostatic challenges associated with torpor. Osmotic fragility was determined optically, mean cell volume was measured by electronic sizing, and changes in intracellular Ca²+ concentration were visualized using fluorescence microscopy and fluo-4-AM. Osmotic fragility increased and the ability to regulate volume was inhibited when extracellular Na+ was replaced with K+, or when cells were exposed to the K+ channel inhibitor quinine, indicating a requirement of K+ efflux for RVD. Addition of the ionophore gramicidin to the extracellular medium decreased osmotic fragility and also potentiated volume recovery, even in the presence of quinine. In addition, hypotonic shock (0.5 x Ringer) caused an increase in cytosolic Ca²+, which resulted from Ca²+ influx because it was not observed when extracellular Ca²+ was chelated with EGTA (ethylene glycol-bis(2-aminoethylether)-N,N,N',N'-tetraacetic acid). Furthermore, cells loaded with BAPTA-AM (1,2-bis(2-aminophenoxymethyl)ethane-N,N,N',N'-tetraacetic acid tetrakis(acetoxymethyl) ester) or exposed to a low Ca²+-EGTA hypotonic Ringer had a greater osmotic fragility and also failed to recover from cell swelling, indicating that extracellular Ca²+ was needed for RVD. Gramicidin reversed the inhibitory effect of low extracellular Ca²+. Finally, and surprisingly, the Ca²+ ionophore A23187 increased osmotic fragility and inhibited volume recovery. Taken together, our results show that cell swelling activated a K+ permeable pathway via a Ca²+-dependent mechanism, and this process mediated K+ loss during RVD.

The role of potassium chloride cotransporters in murine and human sperm volume regulation

Spermatozoa need to undergo regulatory volume decrease (RVD) upon ejaculation to counteract swelling due to the hypo-osmolality of female tract fluids. Defects in sperm RVD lead to failure in both cervical mucus penetration in humans and utero-tubal junction passage in mice. The role of K/Cl cotransporters (KCCs) in RVD was investigated by incubation of spermatozoa from the murine cauda epididymidis and from human ejaculates in media mimicking female tract fluid osmolalities in the presence of KCC inhibitors. Furosemide at 100 microM or more caused swelling of murine spermatozoa as detected with a flow cytometer by increased laser forward scatter over 30 to 75 min of incubation. Bumetanide, known to have low affinity for KCCs, was effective at 1 mM, whereas 10 microM and 20 microM of the specific inhibitor DIOA (dihydroindenyl-oxy alkanoic acid) increased cell volume. These drug doses were ineffective in human spermatozoa, which, however, responded to quinine, confirming the occurrence of RVD under control conditions. The molecular identity of the murine KCC isoform involved was determined at both mRNA and protein levels. Conventional RT-PCR indicated the presence of transcripts from Slc12a4 (KCC1), Slc12a6 (KCC3), and Slc12a7 (KCC4) in the testis, whereas RT-nested PCR revealed the latter two isoforms in sperm mRNA. Of these three isoforms, only SLC12A7 (KCC4) was detected in murine sperm protein by Western blotting. Therefore, besides organic osmolyte efflux and KCl release through separate K(+) and Cl(-) ion channels, SLC12A7 also is involved in murine but not human sperm RVD mechanisms.

Role of luminal anion and pH in distal tubule potassium secretion

Potassium secretory flux (J(K)) by the distal nephron is regulated by systemic and luminal factors. In the present investigation, J(K) was measured with a double-barreled K(+) electrode during paired microperfusion of superficial segments of the rat distal nephron. We used control solutions (100 mM NaCl, pH 7.0) and experimental solutions in which Cl(-) had been replaced with a less permeant anion and/or pH had been increased to 8.0. J(K) increased when Cl(-) was replaced by either acetate ( approximately 37%), sulfate ( approximately 32%), or bicarbonate ( approximately 62%), and also when the pH of the control perfusate was increased ( approximately 26%). The majority (80%) of acetate-stimulated J(K) was Ba(2+) sensitive, but furosemide (1 mM) further reduced secretion ( approximately 10% of total), suggesting that K(+)-Cl(-) cotransport was operative. Progressive reduction in luminal Cl(-) concentration from 100 to 20 to 2 mM caused increments in J(K) that were abolished by inhibitors of K(+)-Cl(-) cortransport, i.e., furosemide and [(dihydroindenyl)oxy]alkanoic acid. Increasing the pH of the luminal perfusion fluid also increased J(K) even in the presence of Ba(2+), suggesting that this effect cannot be accounted for only by K(+) channel modulation of K(+) secretion in the distal nephron of the rat. Collectively, these data suggest a role for K(+)-Cl(-) cotransport in distal nephron K(+) secretion.

Evidence supporting a role for KCl cotransporter in the thick ascending limb of Henle's loop

BACKGROUND

A basolateral Ba(2+)-sensitive KCl cotransporter has previously been proposed as participating in basolateral K+ recycling and transepithelial NaCl reabsorption in the thick ascending limb of Henle's loop (TAL). The aim of the present study was to answer the question as to whether this cotransporter plays a role in transepithelial K+ reabsorption and whether dietary Mg(2+) deficiency, known to regulate the KCl cotransporter in erythrocytes, also regulates KCl transport in the TAL.

METHODS

The effects of a low-Mg(2+) diet were investigated on urinary and plasma K+ concentration in control mice and Mg(2+)-deficient mice. Transepithelial Na+, Cl- and K+ net fluxes (J(Na), J(Cl), J(K)), determined in isolated perfused TALs with electron probe analysis or cation-exchange high-performance liquid chromatography (HPLC) and electrophysiological parameters (V(te), R(te)), were measured in both animal groups. Expression of transcripts for the KCl cotransporter and its possible regulation by low-Mg(2+) were studied by RT-PCR in microdissected mouse cortical TAL (CTAL) and medullary TAL (MTAL) segments.

RESULTS

In isolated perfused CTALs, basolateral Ba(2+) and amiloride induced a large K+ net secretion towards the tubular lumen, paralleled by a 50% decrease in transepithelial NaCl reabsorption. KCC1 transcripts were found in the mouse CTAL and MTAL. A low-Mg(2+) diet led to diminished urinary K+ excretion, lowered plasma K+ concentration and up-regulation of KCC1 transcripts in the TAL. For low-Mg(2+) diet, this upregulation was associated with increased transepithelial K+ reabsorption in the in vitro-perfused CTAL.

CONCLUSIONS

Our study provides evidence that the KCl cotransporter, which is functionally expressed in the TAL, plays an important role in transepithelial K+ reabsorption. Direct inhibition of this transporter by Ba(2+) and its indirect inhibition by amiloride lead to a strong transepithelial K+ secretion and diminished NaCl reabsorption in the TAL. Up-regulation of KCC1 mRNA by dietary Mg(2+) restriction is associated with an increased K+ reabsorption in the in vitro perfused CTAL.

Renal potassium-chloride cotransporters

The electroneutral cotransport of potassium and chloride is mediated by potassium-chloride transporters, which are encoded by members of the gene family of cation-chloride cotransporters. A significant body of evidence argues for swelling-activated, basolateral potassium-chloride transport in the proximal tubule and thick ascending limb, with a potential role in transepithelial salt transport. However, the lack of specific inhibitors has impeded progress in this area. The cloning of the four potassium-chloride cotransporter genes has sparked new interest in this transport pathway, and promises to yield novel insights into their roles in cellular and renal physiology.

Effects of protein kinase and phosphatase inhibitors and anti-L antisera on K+ transport in LK sheep red cells

We investigated the role of protein phosphorylation in the action of anti-L on low potassium (LK) sheep red cells. Anti-L stimulated the Na/K pump by four- to fivefold, but Na/K pump activity in anti-L-stimulated or in control cells was unaffected by protein kinase/protein phosphatase (PK/PP) inhibitors. KCl co-transport activity was inhibited by anti-L (about 50%). Co-transport was stimulated by staurosporine; and inhibited by calyculin A, okadaic acid, tyrphostin B46 and genistein; with a similar pattem in both control and anti-L-treated cells. O2 sensitivity of KCl co-transport was similar in control and anti-L-treated cells. Neither control nor anti-L-stimulated Na/K pump activities were O2 sensitive. Incubation with urea stimulated KCl co-transport in both control and anti-L-treated cells. Inhibition of co-transport by anti-L was unaffected by low concentrations of urea but was reduced at higher urea concentrations. Na/K pump activity of control cells was unaffected by incubation with urea, but that in cells stimulated by anti-L was reduced, though not significantly. Under high hydrostatic pressure, KCl co-transport was stimulated, and the inhibitory effects of PP inhibition (okadaic acid), anti-L or combinations of the two were reduced. Results suggest that anti-L does not affect K+ transport in LK sheep red cells via protein phosphorylation.

Effect of dimethyl adipimidate on K+ transport and shape change in red blood cells from sickle cell patients

Dimethyl adipimidate (DMA) reduces K+ loss from, and dehydration of, red cells containing haemoglobin S (HbS cells). Three membrane transporters may contribute to these processes: the deoxygenation-induced cation-selective channel (Psickle), the Ca2+-activated K+ channel (or Gardos channel) and the K+-CI- cotransporter (KCC). We show that DMA inhibited all three pathways in deoxygenated HbS cells. The Gardos channel could be activated following Ca2+ loading. Considerable KCC activity was present in oxygenated HbS cells, showing a selective action of DMA on the transporter in deoxygenated cells. Inhibition of sickling correlated strongly with that of Psickle and moderately with that of KCC activity. We conclude that DMA does not inhibit the K+ pathways directly, but acts mainly by preventing HbS polymerisation and sickling. These findings are relevant to the development of novel chemotherapeutic agents for amelioration of sickle cell disease.

Exercise-induced stimulation of K(+) transport in human erythrocytes

The hypothesis was tested that exercise-induced changes in plasma composition stimulate unidirectional K(+) transport (J(in)K) in human red blood cells (RBCs). Ten men performed two 30-s high-intensity leg-cycling tests separated by 4 min of rest. Antecubital venous blood was sampled before exercise and at the end of the second exercise bout. RBCs were separated from true exercise plasma, (42)K was added to plasma, and RBC K(+) transport was studied in vitro at 37 degrees C. In the second part of the study, blood from nine healthy men studied in vitro at 37 degrees C was used to test the hypothesis that exercise-simulated (ES) plasma stimulates net K(+) transport and J(in)K (measured using (86)Rb) in human RBCs. The J(in)K of resting RBCs added to true exercise plasma was 1,574 +/- 200 (SE) micromol. h(-1). l(-1) vs. 1,236 +/- 256 micromol. h(-1). l(-1) in true resting plasma at 2 min (controls). In true exercise and ES plasma, J(in)K was increased through activation of the ouabain-sensitive Na(+)-K(+) pump and the bumetanide-sensitive Na(+)-K(+)-2Cl(-) cotransporter. Increases in plasma osmolality and K(+), H(+), and epinephrine concentrations independently and in combination stimulated K(+) transport into human RBCs. In a third series of experiments, in which ES plasma K(+) concentration was continuously measured during the first 5 min of incubation of RBCs, a 1.6 +/- 0.3 mmol/l decrease in plasma K(+) concentration occurred during the first 2 min. It is concluded that RBCs transport K(+) at elevated rates in response to exercise-induced changes in plasma composition.

Differential oxygen sensitivity of the K+-Cl- cotransporter in normal and sickle human red blood cells

1. K+ influx and efflux were measured in normal (HbA) and sickle (HbS) red blood cells to investigate the interaction of swelling, H+ ions and urea with O2 (0 to 150 mmHg O2) in the presence of ouabain and bumetanide (both 100 microM). 2. In HbA cells, K+-C1- cotransport was O2 dependent. At low oxygen tensions (PO2s) the transporter was inactive and refractory to low pH, swelling or urea. 3. C1--independent K+ influxes in sickle cells were elevated at low PO2s, as previously reported. C1--dependent K+ influxes were large at both high and low PO2s, whether stimulated by swelling, H+ ions or urea. In the absence of O2, C1--dependent K+ influxes were similar in magnitude to those measured at high PO2s. The minimum for C1--dependent K+ influx was observed at PO2s of about 40-70 mmHg. 4. K+ efflux from HbS cells was stimulated by the addition of urea (500 mM). The rate constants were of similar magnitude whether measured at high PO2 or in the absence of O2, and were predominantly C1- dependent under both conditions. 5. In HbS red blood cells, reduction of extracellular Ca2+, addition of 1 mM Mg2+ or nitrendipine (10 microM) to the saline had no effect. Inhibitors of K+-C1- cotransport, [(dihydroindenyl)oxy] alkanoic acid (DIOA; 100 microM) or calyculin A (0.1 microM), inhibited influxes by a similar magnitude to C1- substitution. 6. Results are significant for the pathophysiology of sickle cell disease. Low pH and urea are able to stimulate KC1 loss from sickle cells, leading to cellular dehydration, even in regions of low PO2.

Na+ and Cl- net absorption by the isolated skin of Rana esculenta

In the last five years, several measurements of 22Na+ influx (Ji) and outflux (Jo) across symmetrical parts of the isolated skin of Rana esculenta, under permanent short circuitation, were performed in our Institute. The mean value of the 22Na+ net fluxes (Ji-Jo) exceeded the mean value of the short circuit current measurements (1.14 +/- 0.04 versus 0.98 +/- 0.02 microE.cm-2.h-1, 253 experiments). Since this discrepancy could be due to a concomitant Cl- net absorption, 36Cl- unidirectional fluxes were detected under similar experimental conditions. The Cl- net flux mean value was 0.11 +/- 0.02 microE.cm-2.h-1 (316 experiments) which accounts for 70% of the discrepancy between the Na+ net flux and short circuit current. This Cl- net absorption occurred in the absence of electrochemical gradients and was very likely maintained by a Na+/K+/2Cl- cotransport located at the outermost membrane of the epithelium. In fact bumetanide challenge (10(-5) M in the external fluid) strongly inhibited 36Cl- influx and 22Na+ influx across this tissue and cleared off the discrepancy between short circuit current and sodium net flux.

The effects of furosemide and pentoxifylline on the flow properties of equine erythrocytes: in vitro studies

The effects of various concentrations of furosemide and pentoxifylline on equine RBC in vitro were evaluated to facilitate better understanding of the potential effects of these drugs on blood flow properties. Furosemide induced increased mean cell volume (MCV), increased RBC potassium concentration, increased whole blood viscosity, and decreased the RBC filtrability. These data indicate that furosemide may block the RBC membrane transport pathways resulting in potassium and water retention. The increase in size and the resultant decrease in the surface-area-to-volume ratio may have caused the impaired RBC filtrability and increased blood viscosity. Pentoxifylline improved RBC filtrability without changing the RBC size or the potassium or chloride concentrations, suggesting that pentoxifylline may increase the deformability of the RBC membrane. The study indicated that pentoxifylline has potential therapeutic applications for improving microvascular blood flow but that furosemide may have adverse effects on blood flow.

Evidence for conductive Cl- pathway in the basolateral membrane of rabbit renal proximal tubule S3 segment

The mechanism of Cl- exit was examined in the basolateral membrane of rabbit renal proximal tubule S3 segment with double-barreled, ion-selective microelectrodes. After the basolateral Cl-/HCO3- exchanger was blocked by 2'-disulfonic acid, a bath K+ step from 5 to 20 mM induced 26.6 mV depolarization and 7.7 mM increase in intracellular Cl- activities ([Cl(-)]i). K+ channel blockers, Ba2+, and quinine strongly suppressed both the response in cell membrane potentials (Vb) and in (Cl-)i to the bath K+ step, while Cl- channel blockers, A9C (1 mM) and IAA-94 (0.3 mM) inhibited only the latter response by 49 and 74%, respectively. By contrast, an inhibitor of K(+)-Cl- cotransporter, H74, had no effect on the increase in (Cl-)i to the bath K+ step. Furosemide and the removal of bath Na+ were also ineffective, suggesting that (Cl-)i are sensitive to the cell potential changes. Bath Cl- removal in the presence of quinine induced a depolarization of more than 10 mV and a decrease in (Cl-)i, and IAA-94 inhibited these responses similarly in the bath K+ step experiments. These results indicate that a significant Cl- conductance exists in the basolateral membrane of this segment and functions as a Cl- exit mechanism.

Evidence for separate Na+, K+, Cl- and K+, Cl- co-transport systems in mouse pancreatic beta-cells

The effects of H 25 and H 74 on ouabain-resistant 86Rb+ influx were tested in beta-cell-rich mouse pancreatic islets. Both H 25, which is considered to be a specific inhibitor of Na+, K+, Cl- co-transport, and H 74, a specific inhibitor of K+, Cl- co-transport, reduced the ouabain-resistant 86Rb+ influx. The specific inhibitory effects of H 25 and H 74 on 86Rb+ influx did not overlap. The data suggest that mouse pancreatic beta-cells are equipped with separate systems for Na+, K+, Cl- and K+, Cl- co-transport.

The membrane defect in hereditary stomatocytosis

Hereditary stomatocytosis and allied conditions represent a series of diseases in which abnormal movements of univalent cations across the plasma membrane play an important part in cellular disease. The primary problem lies not in the active transporters but in the basal permeability of the membrane, which is always increased, and the extent of the increase correlates with the cellular dysfunction. A number of structural abnormalities have been described in these membranes, but the most consistent and convincing is the deficiency of a hitherto uncharacterized integral membrane protein of molecular weight 31 kDa in the severe, 'overhydrated' form of the disease. The true function of this protein remains enigmatic, but its deficiency in this condition indicates that it may have a role in the regulation of cation transport.

Erythrocyte K-Cl cotransport: properties and regulation

Erythrocytes possess a Cl-dependent, Na-independent K transport system cotransporting K and Cl in a 1:1 stoichiometry that is membrane potential independent. This K-Cl cotransporter is stimulated by cell swelling, acidification, Mg depletion, and thiol modification. Cell shrinkage, elevation of cellular divalent ions, thiol alkylation, phosphatase inhibitors, and derivatives of certain loop diuretics and stilbenes are inhibitory. Thus regulation of K-Cl cotransport at the membrane and cytoplasmic levels is highly complex. Basal K-Cl cotransport decreases with cellular maturation, whereas its modes of stimulation and inhibition are variable between species. The physiological inactivation appears to be prevented in low-K animal erythrocytes. In certain human hemoglobinopathies, K-Cl cotransport may be the cause of cellular dehydration and volume decrease. K-Cl cotransport occurs also in nonerythroid cells, such as in epithelial and liver cells of other species. At the threshold of molecular characterization, this comprehensive review places our present understanding of the mechanisms modulating K-Cl cotransport physiologically and pathophysiologically into kinetic and thermodynamic perspectives.

The nature of Cl- secretion, induced by carbaryl, across the isolated skin of Rana esculenta

1. The pesticide carbaryl induces Cl- secretion through the isolated frog skin. 2. This effect is due to the activation of both processes responsible for this phenomenon: (a) Na+/K+/2Cl- cotransport on the serosal membrane; (b) Cl- selective channels on the external membrane. 3. Cl- outflux is inhibited by bumetanide (10(-5) M) on the serosal side and by diphenylamine-2-carboxylic acid (DPC) (10(-3) M) on the external side. 4. The DPC action is not mimicked by Naproxen, a specific inhibitor of cyclooxygenase. 5. A comparison with isoprenaline, demonstrates that the carbaryl action is, paradoxically, more selective than that of isoprenaline. 6. This selectivity of carbaryl action on Cl- permeability is confirmed by the fact that, unlike isoprenaline, carbaryl does not affect the permeability of Na+ and thiourea.

KCl cotransport in HbAA and HbSS red cells: activation by intracellular acidity and disappearance during maturation

Low intracellular pH was shown to be a potent activator of the KCl cotransport system in HbSS red cells, and in reticulocyte-rich fractions of HbAA red cells. Rheological experiments indicated that cell dehydration via the KCl cotransporter in response to low pH decreased the filterability of HbSS red cells. In vitro maturation experiments showed that the KCl cotransport system was rendered cryptic rapidly, in contrast to choline transport, and serine transport via system ASC, which disappeared much more slowly.