Vasopressin V2 receptor antagonists

Hyponatremia due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH) and disorders of water retention such as congestive heart failure and cirrhosis is a common problem encountered in the care of the medical patient. Thus far, available treatment modalities for disorders of excess arginine vasopressin (AVP) secretion or action have been suboptimal. The development of nonpeptide AVP V2 receptor antagonists represents a promising treatment option to directly antagonize the effects of elevated plasma AVP concentrations by increasing the water permeability of renal collecting tubules, thereby promoting excretion of retained water and normalizing hypoosmolar hyponatremia. In this review, SIADH and other water retaining disorders are briefly discussed, after which the published preclinical and clinical studies in the development of several nonpeptide AVP V2 receptor antagonists are summarized. The likely therapeutic indications and potential complications of these compounds, as well as their vascular effects, are also described.     

Vasopressin V2 receptor antagonists

Hyponatremia, whether due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH) or disorders of water retention such as congestive heart failure and cirrhosis, is a very common problem encountered in the care of medical patients. To date, available treatment modalities for disorders of excess arginine vasopressin (AVP) secretion or action have been limited and suboptimal. The recent discovery and development of nonpeptide AVP V(2) receptor antagonists represents a promising new treatment option to directly antagonize the effects of elevated plasma AVP concentrations at the level of the renal collecting ducts. By decreasing the water permeability of renal collecting tubules, excretion of retained water is promoted, thereby normalizing or improving hypo-osmolar hyponatremia. In this review, SIADH and other water retaining disorders are briefly discussed, after which the published preclinical and clinical studies of several nonpeptide AVP V(2) receptor antagonists are summarized. The likely therapeutic indications and potential complications of these compounds are also described.     

Molecular basis of quantitative factor V deficiency associated with factor V R2 haplotype

To investigate the molecular mechanisms of the quantitative factor V (FV) deficiency associated with the FV R2 haplotype, 4 missense mutations, Met385Thr, His1299Arg, Met1736Val, and Asp2194Gly, identified in the R2 haplotype allele, were analyzed by in vitro expression studies. The FV variant carrying all 4 mutations showed a markedly lower steady-state expression level than wild-type FV because of low synthesis rate and impaired secretion of the mutant protein. The Asp2194Gly mutation was found to play a key role in the impaired secretion of the mutant FV by interfering with its transport from the endoplasmic reticulum to the Golgi complex. The deleterious effect of the Asp2194Gly mutation was shown to be dominant among the 4 mutations. The Met385Thr mutation and His1299Arg mutation had no effect on steady-state expression levels, but the secretion rates of the mutant proteins were moderately decreased by these mutations. The His1299Arg mutation partially impaired glycosylation in the C-terminal part of the B-domain of the mutant FV, which was supposed to affect the secretion rate, but not the steady-state expression level. It was also suggested that the Met385Thr mutation partially impairs posttranslational modification of the mutant FV without affecting the steady-state expression level. No deleterious effect of the Met1736Val mutation was observed in terms of expression and intracellular processing. Our in vitro data strongly suggest that the naturally existing R2 haplotype mutant FV, which carries all 4 mutations, has the potential to result in quantitative FV deficiency in vivo owing to impaired expression of the mutant protein when the Asp2194Gly mutation is present.     

Ubiquitin Ligase SMURF2 Interacts with Filovirus VP40 and Promotes Egress of VP40 VLPs

Filoviruses Ebola (EBOV) and Marburg (MARV) are devastating high-priority pathogens capable of causing explosive outbreaks with high human mortality rates. The matrix proteins of EBOV and MARV, as well as eVP40 and mVP40, respectively, are the key viral proteins that drive virus assembly and egress and can bud independently from cells in the form of virus-like particles (VLPs). The matrix proteins utilize proline-rich Late (L) domain motifs (e.g., PPxY) to hijack specific host proteins that contain WW domains, such as the HECT family E3 ligases, to facilitate the last step of virus–cell separation. We identified E3 ubiquitin ligase Smad Ubiquitin Regulatory Factor 2 (SMURF2) as a novel interactor with VP40 that positively regulates VP40 VLP release. Our results show that eVP40 and mVP40 interact with the three WW domains of SMURF2 via their PPxY motifs. We provide evidence that the eVP40–SMURF2 interaction is functional as the expression of SMURF2 positively regulates VLP egress, while siRNA knockdown of endogenous SMURF2 decreases VLP budding compared to controls. In sum, our identification of novel interactor SMURF2 adds to the growing list of identified host proteins that can regulate PPxY-mediated egress of VP40 VLPs. A more comprehensive understanding of the modular interplay between filovirus VP40 and host proteins may lead to the development of new therapies to combat these deadly infections.     

Conivaptan: A Dual Receptor Vasopressin V1a/V2 Antagonist

Several fluid retentive states such as heart failure, cirrhosis of the liver, and syndrome of inappropriate antidiuretic hormone secretion are associated with inappropriate elevation in plasma levels of arginine vasopressin (AVP), a neuropeptide that is secreted by the hypothalamus and plays a critical role in the regulation of serum osmolality and in circulatory homeostasis. The actions of AVP are mediated by three receptor subtypes V_1a, V₂, and V_1b. The V_1a receptor regulates vasodilation and cellular hypertrophy while the V₂ receptor regulates free water excretion. The V_1b receptor regulates adrenocorticotropin hormone release. Conivaptan is a nonpeptide dual V_1a/V₂ AVP receptor antagonist. It binds with high affinity, competitively, and reversibly to the V_1a/V₂ receptor subtypes; its antagonistic effect is concentration dependent. It inhibits CYP3A4 liver enzyme and elevates plasma levels of other drugs metabolized by this enzyme. It is approved only for short-term intravenous use. Infusion site reaction is the most common reason for discontinuation of the drug. In animals conivaptan increased urine volume and free water clearance. In heart failure models it improved hemodynamic parameters and free water excretion. Conivaptan has been shown to correct hyponatremia in euvolemic or hypervolemic patients. Its efficacy and safety for short-term use have led to the Food and Drug Administration (FDA) approval of its intravenous form for the correction of hyponatremia in euvolemic and hypervolemic states. Despite its ability to block the action of AVP on V_1a receptors, no demonstrable benefit from this action was noted in patients with chronic compensated heart failure and it is not approved for this indication. Consideration should be given to further evaluation of its potential benefits in patients with acute decompensated heart failure.     

Clinical Significance of QS Complexes in V1 and V2 without Other Electrocardiographic Abnormality

Background: In the absence of other electrocardiographic (ECG) abnormalities, QS deflections simultaneously in both of the leads V₁–V₂ may have multiple possible causes. Despite much information in the literature indicating that this is an unlikely pattern for pure septal infarction, such an ECG diagnosis is frequently given. Methods: Ninety‐nine cases having QS deflections in both leads V₁ and V₂ but no other ECG abnormality were compared to 99 other patients with entirely normal ECGs, to whom they were matched by age, gender, and the presence or absence of septal Q waves. Retrospective analysis of medical records was performed to determine the nature of any cardiovascular disease in these two groups, and to find a possible explanation for the ECG abnormality. Results: Because of its intermittence in subjects with multiple ECGs, QS deflections in leads V₁–V₂ appeared most often to be an artifact of precordial lead placement. Prior myocardial infarction, or presence of clinical coronary disease was present in only about 20% of the cases. Neither the intermittence of Q wave in V₂ on repeated ECGs nor the absence of septal Q waves was useful in distinguishing between those with and without coronary heart disease. Conclusions: This ECG pattern is a sign of prior myocardial infarction in only a minority of cases, and in the latter, infarction limited to the interventricular septum is exceptional. This ECG finding should be interpreted as a nonspecific QRS abnormality with multiple possible causes. Clinical correlation and repeat tracings with attention to lead placement will help to clarify its significance.     

Diagnostic Significance of a Small Q Wave in Precordial Leads V2 or V3

Background: An abnormal Q wave is usually defined as an initial depression of the QRS complex having a duration of ≥40 ms and amplitude exceeding 25% of the following R wave in any contiguous leads on the 12‐lead electrocardiogram (ECG). However, much smaller Q waves are sometimes recorded on the ECG. This study investigated the diagnostic value of the small Q wave recorded in precordial leads V₂ or V₃ on the ECG. Methods: We investigated 807 consecutive patients who underwent coronary angiography. A small Q wave was defined as any negative deflection preceding the R wave in V₂ or V₃ with <40‐ms duration and <0.5‐mV amplitude, with or without a small (<0.1‐mV) slurred, spiky fragmented initial QRS deflection before the Q wave (early fragmentation). ECG and coronary angiographic findings were analyzed. Results: The small Q wave was present in 87 patients. Multiple logistic regression analysis revealed that presence of a small Q wave was a strong independent predictor of any coronary artery stenosis or left anterior descending artery (LAD) stenosis (odds ratio = 2.706, 2.902; P < 0.001, < 0.001, respectively). Conclusion: A small Q wave (<40‐ms duration and <0.5‐mV amplitude) in V₂ or V₃ with or without early fragmentation significantly predicted the presence of CAD and, especially, significant stenosis in the LAD. Ann Noninvasive Electrocardiol 2010;15(2):116–123     

Terminal notching of the QRS complex in V1 and V2 in seborrheic patients

Widening of the QRS complex by terminal notching in leads V1 and V2 was observed in 6 seborrheic patients with adequate personal hygiene. This anomaly disappeared when the presternal skin was degreased thoroughly with cationic detergent before placing the conductive paste and electrodes. We attribute these electrocardiographic alterations to variations in the apocrine secretions in the presternal region, which modified the resistance of the skin to electrical potentials.     

JAK2 V617F down-modulates MPL

Decreased expression of the thrombopoietin receptor (TPOR or MPL) on the cell surface of platelets and megakaryocytes is an established feature of and myelofibrosis; however, the exact mechanism responsible for this phenomenon has gone largely unexplained. In this issue of Blood, Pecquet and colleagues publish an excellent study revealing that MPL expression is downregulated in the context of the mutant protein, JAK2V617F.     

Attentional modulation of effective connectivity from V2 to V5/MT in humans

The nonlinear nature of integration among cortical brain areas renders the effective connectivity between them inherently dynamic and context-sensitive. One emerging architectural principle of functional brain organization, which rests explicitly on these nonlinear interactions, is that neuronal responses expressed at any level in a sensory hierarchy reflect an interaction between (i) bottom up "driving" afferents from lower cortical areas and (ii) backwards "modulatory" inputs from higher areas that mediate top-down contextual effects. A compelling example is attentional modulation of responses in functionally specialized sensory areas. The aim of this work was to demonstrate that parietal regions may mediate selective attention to motion by modulating the effective connectivity from early visual cortex to the motion-sensitive area V5/MT. Using functional magnetic resonance imaging, and an analysis of effective connectivity based on nonlinear system identification, we found that backwards modulatory influences from the posterior parietal cortex are sufficient to account for a significant component of attentional modulation of V5/MT responses to "driving" inputs from V2. By explicitly modeling interactions among inputs to V5/MT, we were able to make inferences about the influences of V2 inputs and their concomitant activity-dependent modulation by parietal afferents. The latter effects embody dynamic changes in effective connectivity that may underlie attentional mechanisms. These results speak to the context-sensitive nature of functional integration in the brain and provide empirical evidence that attentional effects may be mediated by backwards connections, of a modulatory sort, in humans.     

Mild iron overload in an African American man with SLC40A1 D270V

We report on a 46-year-old black man who resided in Alabama with normal transferrin saturation, mild hyperferritinemia, chronic hepatitis C, and 3+ iron in hepatocytes and Kupffer cells. Exome sequencing revealed heterozygosity for SLC40A1 D270V (exon 7, c.809A→T), a mutation previously reported only in 1 black patient with iron overload who resided in the Republic of South Africa. The present patient was also heterozygous for: heme transporter FLVCR1 novel allele P542S (exon 10, 1624C→T); FLVCR1 T544M (rs3207090); hemopexin (HPX) R371W (rs75307540); ferritin scavenger receptor (SCARA5) R471H (rs61737287); and transferrin receptor (TFRC) G420S (rs41295879). He had no HFE, TFR2,HJV, or HAMP mutations. D270V was not detected in 19 other African Americans with iron overload who resided in Alabama. The allele frequency of SLC40A1 D270V in 258 African American adults who participated in a health appraisal clinic was 0.0019 (95% confidence interval 0-0.0057). D270V could explain 'classical' ferroportin hemochromatosis phenotypes in some African Americans.     

Deletion of the V1/V2 region does not increase the accessibility of the V3 region of recombinant gp125

Previous analyses of HIV-1 surface glycoprotein indicate that both the V1/V2 region and the interaction of gp120 with CD4 influence the accessibility of the V3 region on gp120. In this study we investigated the accessibility of the V3 region of HIV-2 recombinant gp125 proteins using V3-specific mAbs (7C8 and 3C4) and analyzed the binding kinetics of soluble CD4 (sCD4) to recombinant HIV-1 gp120 and HIV-2 gp125 proteins by surface plasmon resonance (SPR) analysis. Our results indicated that 7C8 recognized monomers of gp125 and gp125Delta v1v2, (lacking the V1/V2 region) while 3C4 was sensitive to the conformation of gp125, recognizing only oligomers of gp125Delta v1v2. Furthermore, SPR analysis of 7C8 binding to gp125 demonstrated that the deletion of the V1/V2 region did not increase the accessibility of the V3 region in gp125Delta v1v2. Comparative SPR analyses of sCD4 binding HIV recombinant surface glycoproteins revealed a lower affinity of sCD4 to gp125 as compared to gp120. Moreover, the analyses suggest that conformational changes only occur in HIV-1 gp120 upon interaction with CD4. We hypothesize that the V3 region is accessible in HIV-2 gp125 and thus may not require interaction with CD4 to induce conformational reorientation of the V1/V2 region.     

The role of V2 vasopressin antagonists in hyponatremia

Hyponatremia is a frequent electrolyte disorder. It is often found in congestive cardiac failure, liver cirrhosis, plasma volume contraction and in SiADH. In these disorders hyponatremia is caused by nonosmotic vasopressin and sustained fluid intake. This provides a rationale for V2 vasopressin receptor antagonists in the treatment of hyponatremia. There is now convincing evidence from different animal models of congestive cardiac failure that peptide and non-peptide V2 vasopressin antagonists effectively increase renal water diuresis and plasma sodium concentration. In addition, several of the experimental studies also showed an improvement of hemodynamic changes of cardiac failure in response to V2 antagonists. Data in patients indicated that oral non-peptide V2-antagonists correct hyponatremia and may improve hemodynamic derangements in cardiac failure. In addition, experimental and clinical studies of V2 antagonists have been undertaken in liver cirrhosis and SiADH. In those studies hyponatremia was improved or corrected, too. Taken together, V2 vasopressin antagonists promise to become therapeutic agents in hyponatremic disorders.