FLVCR2: structure, substrate transport, and emerging roles in human disease

The feline leukemia virus subgroup C receptor 2 (FLVCR2), a key member of the solute carrier (SLC) major facilitator superfamily (MFS), is a highly conserved transmembrane protein with diverse and critical functions in mammalian biology. Although once proposed as an extracellular heme importer, recent functional and structural studies strongly support FLVCR2 as a primary choline transporter, notably at the blood-brain barrier (BBB). Cryo-electron microscopy (cryo-EM) has resolved the outward-facing (OFS) and inward-facing (IFS) conformations, providing a molecular understanding of its classic MFS fold and the proposed proton-dependent rocker-switch mechanism for choline transport. This structural clarity definitively resolves the primary substrate debate. Mutations in FLVCR2 are the cause of Fowler syndrome (PVHH), resulting from severely impaired central nervous system (CNS) vascular development. Beyond this, FLVCR2 maintains systemic heme homeostasis, with its deficiency linked to exacerbation of hemolytic-induced lung injury via ferroptosis. Finally, its role in choline transport makes its upregulation in malignancies, such as acute myeloid leukemia (AML), significant, positioning FLVCR2 as a potential prognostic tumor biomarker and therapeutic target. Further research is necessary to fully exploit its clinical potential.