The genetics and physiology of polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is a major, inherited disorder that is characterized by the growth of large, fluid-filled cysts from the tubules and collecting ducts of affected kidneys, and by a number of extrarenal manifestations including liver and pancreatic cysts, hypertension, heart valve defects, and cerebral and aortic aneurysms. Mutations in either of 2 different genes (PKD1 or PKD2) give rise to ADPKD. Most mutations identified in affected families appear to inactivate the PKD genes, and accumulating evidence suggests that a 2-hit mechanism, in which the normal PKD1 or PKD2 allele is also mutated, may be required for cyst growth. The protein products of the PKD genes (polycystin-1 and polycystin-2) are thought to function together as part of a multiprotein membrane-spanning complex involved in cell-cell or cell-matrix interactions. Polycystin-1 and polycystin-2 can initiate signal transduction, leading to the activation of a number of downstream effectors, including heterotrimeric G-proteins, protein kinase C, mitogen-activated protein kinases, beta-catenin, and the AP-1 transcription factor. In addition, polycystin-2 may function in mediating calcium flux. The pathogenesis of cyst formation is currently thought to involve increased cell proliferation, fluid accumulation, and basement membrane remodeling. It now appears that cyclic adenosine monophosphate (cAMP) metabolism is a central component of cyst formation, stimulating apical chloride secretion and driving the accumulation of cyst fluid. Recent evidence has shown that ADPKD cells also have an altered responsiveness to cyclic AMP. In contrast to normal kidney cells whose cell proliferation is inhibited by cyclic AMP, ADPKD cells are stimulated to proliferate. Thus, it is likely that an alteration in polycystin function transforms the normal cellular phenotype to one that responds to elevated cyclic AMP by an increased rate of cell proliferation and that the enlarging cyst expands by an increased rate of cyclic AMP-driven fluid secretion. Cyclic AMP and growth factors, including epidermal growth factor, have complementary effects to accelerate the enlargement of ADPKD cysts, and thereby to contribute to the progression of the disease. This knowledge should facilitate the discovery of inhibitors of signal transduction cascades that can be used in the treatment of ADPKD.