Traumatic brain injuries (TBIs), commonly observed in military personnel and athletes, are associated with an elevated risk of premature dementia and Alzheimer’s disease
[52][99]. Numerous studies have indicated that both recurring traumatic incidents, as well as single events of moderate to severe head trauma, can result in ongoing neurodegeneration. The mechanism by which only certain individuals develop chronic traumatic encephalopathy after experiencing a similar degree of initial brain injury remains elusive
[53][100]. TBIs result in the release of β-amyloid peptide and C-tau, a proteolytic derivative of MAP-tau, which is a prominent intracellular microtubule protein in axons. Notably, C-tau, due to its vast release correlating with TBI severity, serves as a brain injury biomarker
[54][101]. A prevailing theory posits that significant surges in interstitial tau can lead to its cellular intake, initiating fibrillary aggregates. These aggregates attract more tau, fostering the formation of neurofibrillary tangles and facilitating a prion-like progression of the disease. Moreover, TBIs are connected to the development of extensive astroglial scars and the sustained activation of inherent neuroinflammation.
56. Implications of Aquaporins in Degenerative and Acute Brain Pathologies
5.1. Profiling Each Degenerative Disease (iNPH, PD, AD) and Its Associated Aquaporin Dysregulations
6.1. Profiling Each Degenerative Disease (iNPH, PD, AD) and Its Associated Aquaporin Dysregulations
56.1.1. Parkinson’s Disease
Neurodegenerative diseases impact millions globally, constituting a diverse set of disorders that specifically target certain regions of the Central Nervous System (CNS). These diseases typically result in a sustained decline in cognitive or motor functions, contingent upon the distinct type of neuronal cells undergoing selective degeneration
[55][103]. Predominantly, these pathological states are correlated with aging. Indeed, as life expectancy has risen over recent decades, the prevalence of these age-related disorders has correspondingly increased
[56][104]. Neuronal harm and oxidative stress, which are fundamental events in the onset of these conditions, precipitate an upsurge in the production of pro-apoptotic and pro-inflammatory cytokines.
56.1.2. Dopamine Regulation of AQP4 Expression
In the realm of neurodegenerative diseases, a pivotal role is played by neural stem cells. Throughout adulthood, these cells have the capability to proliferate and differentiate into either new neurons or glial cells
[57][106]. Intriguingly, studies have highlighted that adult neural stem cells display glial-associated properties in both in vivo and in vitro environments. As a testament to this, these stem cells express GFAP, a protein considered a hallmark for fully differentiated astrocytes
[58][107]. Notably, alterations in the count of GFAP-expressing cells have been implicated in neurodegenerative disorders, including Parkinson’s disease
[59][108].
Dopamine (DA), a central neurotransmitter, has been found to invigorate the proliferation of progenitor cells. This effect is observed not just in the striatum but also in the subventricular zone of mature brains. Building on this, a recent investigation led by Kueppers et al. postulates that DA orchestrates the proliferation of striatal astrocytes in culture through the mediation of Aquaporin-4
[60][109]. Their results delineate a scenario wherein DA prompts a reduction in AQP4 expression in striatal glial cells when studied in vitro.
56.1.3. Mitochondrial AQP9 in PD Brains
Within the scope of neurodegenerative disorders, a potentially significant yet conjectural association has been proposed between Aquaporin-9 (AQP9) and Parkinson’s disease
[61][113]. Within the cerebral environment, AQP9—a channel facilitating the movement of water and certain solutes—is manifested in astrocytes, brain stem catecholaminergic neurons, as well as specific subgroups of midbrain dopaminergic and hypothalamic neurons. An intriguing observation is the pronounced presence of AQP9 within the mitochondrial inner membranes, hinting at its potential role in supporting neuronal metabolism. Especially compelling is the notion that aberrations in mitochondrial AQP9 within dopaminergic neurons might be linked to the heightened susceptibility of these neurons to PD
[61][113].
56.1.4. Idiopathic Normal Pressure Hydrocephalus (iNPH)
Idiopathic normal pressure hydrocephalus (iNPH) is recognized as a distinct form of dementia, wherein intervention through cerebrospinal fluid diversion can yield favorable outcomes. Pioneering studies leveraging magnetic resonance imaging with CSF tracers have highlighted compromised CSF tracer clearance from specific cerebral regions, notably the entorhinal cortex, in iNPH patients. This compromised clearance mechanism, especially for waste solutes such as soluble amyloid-β, might be central to the neurodegenerative processes and cognitive decline characterizing iNPH.
The primary objective of the study at hand was to investigate potential alterations in the subcellular localization of aquaporin-4 water channels in relation to iNPH. Notably, AQP4 is known to play a pivotal role in modulating CSF flow and facilitating the glymphatic removal of brain metabolites. To accomplish this, cortical brain biopsy samples from 30 iNPH patients and 12 control subjects were scrutinized using AQP4 immunogold cytochemistry.
Utilizing electron microscopy, the study unveiled a markedly diminished presence of AQP4 water channels within the astrocytic endfoot membranes juxtaposed to cortical microvessels in iNPH patients, relative to the control group. Further analysis divulged a statistically significant association between AQP4 densities oriented perivascularly and those directed towards the parenchyma.
5.2. Insights into Aquaporin Behavior during Acute Cerebral Events, Such as Stroke or Traumatic Injuries
6.2. Insights into Aquaporin Behavior during Acute Cerebral Events, Such as Stroke or Traumatic Injuries
Aquaporins, water channel proteins found in the brain, have attracted substantial research attention given their potential implications in both physiological and pathological contexts
[62][117]. Among these, AQP4 has been the focal point of numerous studies, especially in relation to various brain conditions, spanning acute afflictions such as stroke and traumatic brain injury to chronic autoimmune neurodegenerative ailments. As of now, there are no targeted therapeutic interventions specifically designed to modulate the water transport activity of these channels. However, accumulating experimental data underscores the pivotal nature of AQPs, suggesting their profound relevance in future research endeavors
A predominant characteristic of many brain diseases, ranging from stroke, traumatic brain injuries, and brain tumors to inflammation, is edema. This phenomenon denotes the accumulation of water due to imbalances in brain osmotic homeostasis. A primary ramification of edema is brain swelling, which can exacerbate secondary complications, such as compromised brain perfusion. Despite its long-standing recognition in both clinical and pre-clinical realms, the molecular and cellular intricacies underpinning edema genesis and resolution remain relatively elusive. Furthermore, current therapeutic interventions fall short of effectively curbing edema onset or progression in various brain conditions.
56.2.1. Edema Build-Up Phase: Anoxic, Ionic and Vasogenic Edema
Cerebral edema, for the past four decades, has been predominantly categorized into two principal types: cytotoxic and vasogenic
[63][119]. Conventionally, cytotoxic edema denotes the accumulation of intracellular water without any disruption of the blood–brain barrier (BBB). In contrast, vasogenic edema emerges post-BBB disruption, instigating protein diffusion from the bloodstream into the tissue, subsequently leading to water buildup in the extracellular matrix. This longstanding bifurcation, however, is now considered an oversimplification, particularly in light of recent insights into the molecular shifts during edema onset and the evolving understanding of BBB properties.
Anoxic edema is typified by the immediate swelling of astrocytes and neuronal dendrites ensuing moments after a deprivation of oxygen and glucose, particularly in cerebrovascular ailments. This deficiency in essential nutrients triggers significant perturbations in cellular ionic gradients due to the non-operational energy-dependent co-transporters. Consequently, this facilitates an extensive ion influx into cells, a manifestation of which is a gradual surge in the extracellular K+ levels, leading to subsequent water entry and resultant swelling initially in astrocytes and later in neuronal dendrites
[64][121].
56.2.2. Contribution of AQPs in Edema Formation and Resolution
Aquaporins, specifically AQP1, 4, and 9, have demonstrated alterations in their expression levels in various brain disorders, as seen in both rodent models and human specimens
[65][125]. Of these, AQP4 has been the primary focus of many investigations, as its expression patterns appear to mirror the progression of edema in numerous neurological conditions
[66][126]. A significant advancement in the exploration of AQP4’s role in edema came with the creation of AQP4 knockout mice (AQP4−/−) by Dr. Verkman’s team
[67][127].
56.2.3. AQP4 and Edema Build-Up
The role of Aquaporin-4 in cerebral edema is complex, exhibiting a spectrum of expression profiles across various pathological conditions including traumatic brain injury, ischemic stroke, and subarachnoid hemorrhage. These conditions each display unique fluctuations in AQP4 expression levels
[66][68][69][124,126,129]. Specifically, in ischemic models involving transient middle cerebral artery occlusion, AQP4 is acutely up-regulated in the astrocyte endfeet adjoining blood vessels, reaching peak levels approximately 1 h post-stroke onset. This elevation in AQP4 expression is spatially and temporally correlated with the extent of cerebral edema and is most prominent in the peri-infarct region as well as the prospective lesion site
[66][70][123,126].
56.2.4. Edema Resolution in Acute Brain Disease: Role of AQP in Water Clearance
The hypothesis that Aquaporin-4 has a dual role in cerebral edema—being deleterious during edema formation while beneficial during its resolution—has gained empirical support despite the absence of conclusive evidence. Initial evidence for this comes from experiments using AQP4 knockout mice (AQP4−/−), which revealed that intracranial pressure increased significantly when a saline solution was infused into the brain parenchyma compared to wild-type mice
[6][8].
Specifically, AQP4 expression typically escalates 48 h post-insult in models of stroke, TBI, and neuroinflammatory lesions. This augmented expression is frequently localized to the astrocyte endfeet adjacent to blood vessels, as well as the astrocyte processes and glia limitans
[66][69][126,129]. Such spatial distribution of heightened AQP4 expression suggests its potential role in facilitating the clearance of edematous fluid via the subarachnoid space.
The role of other aquaporin family members, such as Aquaporin-9, in the resolution of cerebral edema warrants exploration. While AQP9 is up-regulated in reactive astrocytes seven days post-ischemic injury along the infarct border, its expression pattern does not show a strong correlation with the extent of cerebral swelling, in contrast to AQP4
[71][136].
56.2.5. Chronic Changes of Brain AQP: Relation with Water Homeostasis Dysfunction?
Aquaporins, traditionally implicated in water homeostasis both in physiological and pathological contexts, have been increasingly associated with a broader range of cellular functions, including cell migration and gas diffusion
[72][140]. Specific isoforms, such as AQP1, AQP4, and AQP9, manifest elevated expression in both brain tumors and peritumoral tissues. The augmented presence of these AQPs in astrocytes within peritumoral regions may be related to edema formation, potentially due to altered tissue homeostasis and elevated metabolic rates. Additionally, these AQPs may facilitate gas diffusion, playing a role in the clearance of excess CO
2 and the diffusion of O
2. In rodent models of spinal cord injury (SCI), an upregulation of AQP1 is observed in astrocytes as well as neurons. AQP1 expression has also been documented in neuronal processes in the dorsolateral septum at various time points following juvenile traumatic brain injury (jTBI)
[69][129]. While astrocytic expression of AQP1 may be associated with cerebrospinal fluid secretion during cyst formation, its co-localization with growth-associated protein-43 (GAP-43) in neurons suggests a role in neuroplasticity and repair after injury.
5.3. The Cascading Effects of Altered AQP Expression in Autoimmune Conditions, with a Focus on NMO
6.3. The Cascading Effects of Altered AQP Expression in Autoimmune Conditions, with a Focus on NMO
Aquaporins are not just pivotal in regulating water homeostasis; they also have roles in the immune system, specifically within both the innate and adaptive arms. In human blood leukocytes, AQP1 and AQP9 are expressed and show upregulation upon stimulation with lipopolysaccharide (LPS) either intravenously or in vitro
[73][144]. AQP9 expression is also elevated in activated polymorphonuclear leukocytes in patients suffering from systemic inflammatory response syndrome (SIRS) and infective endocarditis
[74][145].
B and T lymphocytes, key players in adaptive immunity, have been found to express AQP1, AQP3, and AQP5. Similarly, immature dendritic cells (DCs), which are integral to the innate immune system, express AQP3 and AQP5. In these immune cells, AQP expression is often correlated with their activation and proliferation. Notably, AQP9 is the most highly expressed isoform in DCs and shows further upregulation upon LPS stimulation.
Human primary blood-derived macrophages and neutrophils, critical components of the innate immune system, display high levels of AQP9, which also sees upregulation at both transcript and protein levels when stimulated with LPS
[75][147]. AQP3, another isoform, is also sensitive to LPS stimulation in monocytic THP-1 cells, a model often used to study inflammation. The inhibition or silencing of AQP3 in these cells leads to partial blockage of LPS priming and a reduction in the production of key inflammatory cytokines such as interleukin-6 (IL-6), pro-IL-1β, and tumor necrosis factor-alpha (TNF-α).
Neuromyelitis optica spectrum disorders (NMOSD) are a range of inflammatory demyelinating diseases (IDDs) that primarily affect the optic nerves and spinal cord but can also extend to the brain and, in rare instances, muscles. Brain lesions in NMOSD often localize to areas with high AQP4 expression, such as the circumventricular organs (responsible for intractable nausea and vomiting) and the diencephalon (linked to sleep disorders, endocrine imbalances, and the syndrome of inappropriate antidiuresis). Up to 10% of NMOSD patients even fulfill the Barkoff criteria for multiple sclerosis when evaluated through MRI
[76][153].
One of the hallmarks of NMOSD is the presence of autoantibodies against AQP4, known as AQP4-IgG or NMO-IgG, detected in 60–90% of NMO patients
[77][78][154,155]. AQP4 is not only found on the astrocytes in the central nervous system (CNS) but also in skeletal muscle and various epithelial cells such as those in the kidney, stomach, and exocrine glands. AQP4-IgG was initially perceived as a mere marker of the disease, possibly related to astrocyte damage. However, mounting evidence now suggests that AQP4-IgG plays a pathogenic role in NMO.
When AQP4-IgG binds to AQP4 on astrocytes, this initiates a cascade of immunological responses, primarily through complement-dependent cytotoxicity. This leads to the invasion of leukocytes into the CNS, the release of cytokines, and the disruption of the blood–brain barrier. These series of events are thought to culminate in the death of oligodendrocytes (cells responsible for myelination), resulting in myelin loss and, ultimately, neuronal death. This cascade explains the neurological deficits observed in patients with NMO.
Given the rapidly evolving knowledge on the immunobiology of AQP4 autoimmunity, there is a growing need for ongoing revisions in the diagnostic criteria for NMOSD
[76][153]. As our understanding broadens, the role of highly specific assays that can detect pathogenic AQP4-IgG targeting the extracellular domains of AQP4 becomes increasingly crucial.
The size of AQP4-IgG (autoantibodies against AQP4) presents a steric challenge when it comes to binding with AQP4, which is a tetramer consisting of four separate monomers and, by extension, four distinct water pores. This size mismatch suggests that it would be unlikely for a single AQP4 tetramer to bind with more than one AQP4-IgG molecule. Therefore, significant inhibition of water permeability by AQP4-IgG appears to be theoretically implausible.
67. Aquaporins at the Intersection of Oncology and Neurology
6.1. Unraveling the Possible Links between Aquaporin-Mediated Processes and Brain Tumorigenesis
7.1. Unraveling the Possible Links between Aquaporin-Mediated Processes and Brain Tumorigenesis
AQP1, primarily known for its role in water transport, has additional functions that are intriguing both scientifically and medically. One of these is its capability to act as a cyclic nucleotide-gated cation channel activated mainly by cGMP and, to a lesser extent, by cAMP
[79][160]. Research by Yu and colleagues suggests that the interaction of cGMP with an arginine-rich cytoplasmic Loop D in AQP1 leads to a conformational change that may mediate the gating of its central ion channel
[80][81][161,162].
The link between AQP1 and cancer progression has garnered significant attention, leading to numerous reviews on the subject. These reviews often focus on the potential of AQP inhibitors as therapeutic agents in cancer treatment
[82][83][166,167]. Given the multifaceted roles of AQP1, from water transport to ion channel gating and its association with various types of cancer, the protein appears to be a critical player in both physiology and pathophysiology, including tumorigenesis. As such, understanding its function and regulation could offer valuable insights into the development of novel therapeutic approaches for a range of diseases, including cancer (
Figure 34).
Figure 34. Overview of AQP1 in Cancer Progression-tumor development via transited molecules-emphasizing its involvement in cell migration, invasion, and angiogenesis, and its potential as a prognostic factor in various cancers.
6.2. Implications of Aquaporins in Neoplastic Cell Migration, Invasiveness, and Angiogenesis
7.2. Implications of Aquaporins in Neoplastic Cell Migration, Invasiveness, and Angiogenesis
67.2.1. AQP1-Modulated Tumor Cell Migration and Invasion
The role of AQP1 in cancer progression extends beyond its well-known function in water transport, particularly implicating it in the critical processes of tumor cell migration and invasion. Hu and Verkman found that AQP1 accelerates the migration of specific mouse melanoma and breast cancer cell lines in vitro. Notably, they observed polarized AQP1 expression at the leading edge of migrating cells. In vivo studies further revealed that AQP1 promoted cancer cell extravasation and lung metastases
[84][168].
One proposed mechanism by which AQP1 facilitates tumor cell migration involves osmotic water flow across the plasma membrane. This flow is thought to be induced by an osmotic gradient created by actin depolymerization and active solute influx at the cell’s leading edge
[85][170]. Water influx via AQP1 then increases hydrostatic pressure, leading to local expansion of the plasma membrane and actin re-polymerization to stabilize cell membrane protrusions
[4][6].
An alternative explanation focuses on AQP1’s role in changing the cell shape and volume as tumor cells navigate through confined spaces. The water flow facilitated by AQP1 helps generate the hydrostatic forces needed for this process. Actin polymerization and depolymerization as well as ionic fluxes across the membrane could support this osmotic water flow
[68][124].
Adding a more nuanced layer to these mechanisms, Stroka and colleagues proposed an “Osmotic Engine Model”, where cell migration in confined spaces is driven not just by actin and myosin interactions but also through water permeation and ion transport mediated by AQPs and Na+/H+ pumps
[86][172].
The implications of these findings are profound, as the acquisition of migratory and invasive capabilities is a key step in cancer metastasis, which accounts for the majority of cancer-related deaths. Understanding AQP1’s multifaceted role in these processes could thus offer crucial insights for the development of new therapeutic strategies targeting cancer metastasis.
These ion channels and transporters are implicated in crucial stages of tumor metastasis, such as loss of cell-to-cell contacts, invasion of the surrounding stroma, and entry into and exit from blood vessels (intra- and extra-vasation)
[87][175]. Kourghi and colleagues further deepen this narrative by showing that certain AQP1 ion channel blockers, which do not impact AQP1’s water channel activity, effectively inhibited the migration of HT29 cancer cells. The degree of inhibition was directly related to the potency of the AQP1 ion channel blockage, suggesting that the ion channel properties of AQP1 alone might be sufficient for facilitating tumor cell migration in certain cases
[88][176].
67.2.2. AQP1-Modulated Tumor Angiogenesis
Tumor angiogenesis, or the formation of new blood vessels within a tumor, serves as a lifeline for cancer cells, supplying essential nutrients and providing a pathway for metastasis
[89][179]. Ion channels and transporters, including aquaporins such as AQP1, are increasingly being recognized as key players in this process. These proteins serve various roles, including acting as enzymes, chemical and mechanical sensors, receptors, and structural scaffolds
[90][180].
A growing body of evidence further implicates AQP1 in angiogenic processes. Saadoun and colleagues found that mice lacking AQP1 and implanted with melanoma cells showed a reduced density of tumor microvessels, slower tumor growth, and increased survival
[91][181]. This supports previous work that demonstrated diminished tumor microvascular density upon inhibiting AQP1, either through RNA interference or genetic knockouts, in various animal models
[92][182].
On a cellular level, Saadoun and colleagues showed that endothelial cells deficient in AQP1 had impaired migration and abnormal vessel formation in vitro
[91][181]. Moreover, silencing AQP1 in human endothelial cells (HMEC-1) led to disorganized F-actin polarization at the cell membrane’s leading edge and a failure to establish a cord-like vascular network in culture.
67.2.3. AQP1-Modulated Tumor Proliferation
While much attention has been focused on the role of AQP1 in tumor cell migration and angiogenesis, the evidence concerning its role in tumor cell proliferation is less consistent. For instance, inhibition of AQP1 activity had no impact on the proliferation of the colon cancer cell line HT29, whereas a modest 17% reduction was observed in another colon cancer cell line, HCT-116
[93][186].
Adding another layer of complexity is the relationship between AQP1 and resistance to apoptosis. Hoque and colleagues observed that cells expressing AQP1 displayed resistance to apoptosis, possibly contributing to enhanced proliferation
[94][187]. Specifically, AQP1 transfection in PC12 cells was associated with an altered cell cycle profile
[95][188]—increased proportions of cells in the S and G2/M phases and elevated expression of cyclin D1 and E1, which are key proteins for cell cycle progression
[96][189].
6.3. Assessing the Prospects of Aquaporin-Targeted Therapies in Malignancies of the CNS
7.3. Assessing the Prospects of Aquaporin-Targeted Therapies in Malignancies of the CNS
While there is considerable excitement around the idea of aquaporin-targeted therapeutics, especially given promising data from animal studies, progress in this domain has been less than satisfactory
[97][98][99][192,193,194]. A number of factors have contributed to this state of affairs, including conflicting reports about the inhibition of AQPs by commonly used ion transport inhibitors such as loop diuretics and antiepileptic medications. The literature is also muddled by reports of small-molecule inhibitors of AQPs that later could not be replicated in follow-up studies.
Given these inconsistencies, there is a critical need for rigorous scientific approaches to evaluating AQP function and inhibitor efficacy. For instance, comprehensive functional screens involving large collections of random, drug-like small molecules could provide valuable insights into effective AQP inhibitors. Alternatively, computational chemistry could guide smaller, more focused screens to identify potent compounds. Either way, robust validation in diverse cellular contexts will be essential to confirm the efficacy of any proposed AQP-targeting compounds.
78. Conclusions
Loss-of-function mutations in aquaporins are infrequently associated with human diseases. For example, mutations in AQP2 can lead to non-X-linked nephrogenic diabetes insipidus (NDI), a condition with an extremely low incidence (~1 in 20 million births)
[100][195]. NDI results in severe symptoms such as polyuria and polydipsia that do not respond to antidiuretic hormones. The current treatment primarily involves water replacement and the use of thiazides to reduce urinary water loss. There is also ongoing research into pharmacological chaperone therapies and gene replacement or stem cell treatments as potential therapeutic avenues for NDI related to AQP2 mutations
[101][196].
In contrast to AQP2, very few individuals have been identified with loss-of-function mutations in other AQPs such as AQP1, AQP3, and AQP7. For instance, individuals with AQP1 deficiency, identified through blood-group screenings, generally appear phenotypically normal but exhibit impaired urinary concentrating abilities when water-deprived—similar to AQP1-null mice
[102][197]. Due to the rarity and variability of these conditions, there is limited information available about the roles these AQPs play in human health.
Furthermore, mutations in the major intrinsic protein (MIP, also known as AQP0) have been linked to congenital cataracts
[103][198]. However, recent studies suggest that the primary function of MIP in the lens might be related more to cell–cell adhesion and gap-junction channel regulation rather than water transport.
Overall, the rarity of AQP deficiencies and the variability of their phenotypic expression in humans make it challenging to understand their roles fully. To date, no other disease-causing mutations in AQPs have been described in the medical literature. This highlights the need for continued research to better understand the function of AQPs in human physiology and pathology.