Endoperoxide Drug Cross-Resistance Patterns for Plasmodium falciparum Exhibiting an Artemisinin Delayed-Clearance Phenotype.

The ring-stage susceptibility assay was modified to quantify the susceptibilities of multiple strains of control and delayed-clearance phenotype (DCP) Plasmodium falciparum strains to seven endoperoxide antimalarial drugs. The susceptibility of all of the DCP lines to six of the drugs was lower than that of the controls. In contrast, DCP parasites did not show reduced susceptibility to the synthetic endoperoxide drug OZ439. These data show that it is possible to circumvent emerging artemisinin resistance with a modified endoperoxide drug.

A novel transporter, Pfcrt, confers antimalarial drug resistance.

The elucidation of the molecular details of drug resistance phenomena is a very active area of research that crosses many disciplinary boundaries. Drug resistance is due to altered drug-target interaction, and/or dysregulated signaling related to cell growth and death. Since many drugs need to rapidly diffuse into and within cells in order to find their targets, and since transmembrane ion transport is an important facet of cellular signaling, it is not surprising that membrane transport phenomena have been implicated in the evolution of drug resistance in tumor cells, bacteria, and intracellular parasites such as Plasmodium falciparum, the causative agent of the most lethal form of human malaria. The most infamous membrane transport protein involved in drug resistance is "MDR protein" or "P-glycoprotein" (Pgp),1 which was found to be overexpressed in drug-resistant tumor cells over 15 years ago, and which is representative of the ATP-binding cassette (ABC) superfamily that also includes the important cystic fibrosis transmembrane conductance regulator (CFTR) and sulfonyl urea receptor (SUR) ion channels. Availability of mouse and human Pgp cDNA rather quickly led to the identification of homologues in many species, including P. falciparum, and these were de facto assumed to be the ultimate determinants of drug resistance in these systems as well. However, research over the past 10 years has taught us that this assumption likely is wrong and that the situation is more complex. We now know that human Pgp plays a relatively minor role in clinically relevant tumor drug resistance, and that an integral membrane protein with no homology to the ABC superfamily, Pfcrt, ultimately confers chloroquine resistance in P. falciparum. Thus, the general hypothesis that membrane transport and membrane transport proteins are important in drug resistance phenomena remains correct, but at a genetic, biochemical, and physiological level we have recently witnessed a few very interesting surprises.

pH and multidrug resistance.

Most chemotherapeutic drugs in use today are hydrophobic small molecules that are also typically either weakly basic, weakly acidic or charged. Thus, changes in the electrochemical parameters of tumour cell membranes have important effects on their transmembranous diffusion and cellular retention. Changes in these parameters can also modulate the function of immunological agents, and affect the signal transduction associated with induction of apoptosis. For these reasons, it is logical to propose that many (if not most) of the characteristics of multidrug-resistant (MDR) tumour cells could be due to perturbations in cellular ion transport. Indeed, many reports of altered ion transport in MDR cells can be found in the literature. Moreover, many studies suggest that P glycoprotein (Pgp) overexpression confers this altered ion transport, however, detailed physical-chemical analysis of this phenomenon has been confused by the complexity of the model systems devised to study Pgp. To help resolve this confusion, our laboratory has focused on a detailed characterization of 'pure' and stable Pgp transfectants unadulterated by the complications of chemotherapeutic drug exposure, various yeast strains and yeast vesicle preparations, and purified, reconstituted Pgp preparations. Recent data obtained with these model systems are summarized in this paper.

Evolution of a unique Plasmodium falciparum chloroquine-resistance phenotype in association with pfcrt polymorphism in Papua New Guinea and South America.

The mechanistic basis for chloroquine resistance (CQR) in Plasmodium falciparum recently has been linked to the polymorphic gene pfcrt. Alleles associated with CQR in natural parasite isolates harbor threonine (T), as opposed to lysine (K) at amino acid 76. P. falciparum CQR strains of African and Southeast Asian origin carry pfcrt alleles encoding an amino acid haplotype of CVIET (residues 72-76), whereas most South American CQR strains studied carry an allele encoding an SVMNT haplotype; chloroquine-sensitive strains from malarious regions around the world carry a CVMNK haplotype. Upon investigating the origin of pfcrt alleles in Papua New Guinean (PNG) P. falciparum we found either the chloroquine-sensitive-associated CVMNK or CQR-associated SVMNT haplotypes previously seen in Brazilian isolates. Remarkably we did not find the CVIET haplotype observed in CQR strains from Southeast Asian regions more proximal to PNG. Further we found a previously undescribed CQR phenotype to be associated with the SVMNT haplotype from PNG and South America. This CQR phenotype is significantly less responsive to verapamil chemosensitization compared with the effect associated with the CVIET haplotype. Consistent with this, we observed that verapamil treatment of P. falciparum isolates carrying pfcrt SVMNT is associated with an attenuated increase in digestive vacuole pH relative to CVIET pfcrt-carrying isolates. These data suggest a key role for pH-dependent changes in hematin receptor concentration in the P. falciparum CQR mechanism. Our findings also suggest that P. falciparum CQR has arisen through multiple evolutionary pathways associated with pfcrt K76T.

Antimalarial drugs influence the pH dependent solubility of heme via apparent nucleation phenomena.

Recently, we measured a more acid digestive vacuolar pH for drug resistant Plasmodium falciparum [Dzekunov S, Ursos LMB, Roepe PD. Mol Biochem Parasitol 2000;in press; Ursos LMB, Dzekunov S, Roepe PD. Mol Biochem Parasitol 2000;in press]. We suggested this acidification contributes to drug resistance via the profound effects that pH has on the solubility of unpolymerized heme found in the vacuole (ferriprotoporphyrin IX mu oxo dimers). In this report, we measure how FPIX concentration, time, NaCl concentration, and several antimalarial drugs affect FPIX pH dependent solubility. Aggregation is essentially instantaneous below pH 5.3, but at vacuolar pH previously measured for HB3 parasites [Dzekunov S, Ursos LMB, Roepe PD. Mol Biochem Parasitol 2000;in press] can increase to several minutes as NaCl is lowered. As FPIX is decreased, the midpoint of the pH dependent solubility curve shifts to higher values. Addition of antimalarial drugs also increases the midpoint of the pH dependent FPIX solubility curve, with the net shift proportional to the relative affinity of the drug for FPIX. Surprisingly, however, for all drugs tested shifts of essentially identical magnitude are found at all drug: FPIX molar ratios inspected, spanning eight orders of magnitude (to as low as 0.0000001:1). This suggests that changes in pH dependent FPIX solubility by addition of antimalarial drugs is via previously unrecognized drug/FPIX nucleation phenomena. These data could have important implications for understanding the role of previously observed changes in pH(vac) [Dzekunov S, Ursos LMB, Roepe PD. Mol Biochem Parasitol 2000;in press; Ursos LMB, Dzekunov S, Roepe PD. Mol Biochem Parasitol 2000;in press] upon development of antimalarial drug resistance.

Mutations in the P. falciparum digestive vacuole transmembrane protein PfCRT and evidence for their role in chloroquine resistance.

The determinant of verapamil-reversible chloroquine resistance (CQR) in a Plasmodium falciparum genetic cross maps to a 36 kb segment of chromosome 7. This segment harbors a 13-exon gene, pfcrt, having point mutations that associate completely with CQR in parasite lines from Asia, Africa, and South America. These data, transfection results, and selection of a CQR line harboring a novel K761 mutation point to a central role for the PfCRT protein in CQR. This transmembrane protein localizes to the parasite digestive vacuole (DV), the site of CQ action, where increased compartment acidification associates with PfCRT point mutations. Mutations in PfCRT may result in altered chloroquine flux or reduced drug binding to hematin through an effect on DV pH.

Digestive vacuolar pH of intact intraerythrocytic P. falciparum either sensitive or resistant to chloroquine.

We present the first single cell-level analysis of digestive vacuolar pH for representative chloroquine resistant (strain Dd2) versus sensitive (strain HB3) malarial parasites. Human red blood cells harboring intact intraerythrocytic parasites were attached to glass substrate, continuously perfused with appropriate buffer, and pH was analyzed via single cell imaging and photometry techniques. We find that digestive vacuolar pH (pH(vac)) is near 5.6 for HB3 parasites. Surprisingly, we also find that pH(vac) of Dd2 is more acidic relative to HB3. Notably, in vitro pH titration of hematin confirms a very steep transition between soluble heme (capable of binding chloroquine) and insoluble heme (not capable of binding chloroquine, but still capable of polymerization to hemozoin) with a distinct midpoint at pH 5.6. We suggest the similarity between the hematin pH titration midpoint and the measured value of HB3 pH(vac) is not coincidental, and that decreased pH(vac) for Dd2 titrates limited initial drug target (i.e. soluble heme) to lower concentration. That is, changes in pH(vac) for drug resistant Dd2 relative to drug sensitive HB3 are consistent with lowering drug target levels, but not directly lowering vacuolar concentrations of drug via the predictions of weak base partitioning theory. Regardless, lowering either would of course decrease the efficiency of drug/target interaction and hence the net cellular accumulation of drug over time, as is typically observed for resistant parasites. These observations contrast sharply with the common expectation that decreased chloroquine accumulation in drug resistant malarial parasites is likely linked to elevated pH(vac,) but nonetheless illustrate important differences in vacuolar ion transport for drug resistant malarial parasites. In the accompanying paper (Ursos, L. et al., following paper this issue) we describe how pH(vac) is affected by exposure to chloroquine and verapamil for HB3 versus Dd2.

The effects of chloroquine and verapamil on digestive vacuolar pH of P. falciparum either sensitive or resistant to chloroquine.

In the preceding paper, we present a novel method for measuring the digestive vacuolar pH (pH(vac)) of the malarial parasite Plasmodium falciparum, and show that, surprisingly, pH(vac) is lower for chloroquine resistant (CQR) Dd2 parasites relative to chloroquine sensitive (CQS) HB3. These data may have important consequences for elucidating mechanisms of antimalarial drug resistance and for developing new antimalarial therapy. Additional issues central to a better understanding of antimalarial pharmacology and antimalarial drug resistance require detailed comparative data on the effects of key drugs and other compounds on parasite biophysical parameters such as pH(vac), measured under close-to-physiologic conditions. Since the methods we develop in the previous paper allow us to record fluorescence signals from spatially well-defined regions of the living parasite while they are under continuous perfusion, it is relatively straightforward for us to test how antimalarial drugs (e. g. chloroquine, CQ) and other compounds (e.g. the chemoreversal agent verapamil [VPL]) affect pH(vac). In this paper, we measure both short term (i.e. initial perfusion conditions) and longer-term effects of CQ and VPL for living, intraerythrocytic CQS (HB3) and CQR (Dd2) malarial parasites under constant perfusion with physiologically relevant buffers. We find that VPL normalizes pH(vac) for Dd2 to a value near that measured for HB3, but has no effect on pH(vac) for HB3. Longer term CQ exposure is found to alter pH(vac) for HB3 but not Dd2, and short-term exposure to the drug has no significant effect in either strain. The results may help resolve longstanding debate regarding the effects of CQ and VPL on parasite physiology, and further support our evolving hypothesis for the mechanism of CQ resistance.

What is the precise role of human MDR 1 protein in chemotherapeutic drug resistance?

Elucidating the molecular function of hu MDR 1 protein (also called P-glycoprotein or P-gp 1) and the precise role this protein plays in clinically relevant tumor drug resistance remains a perplexing problem. Hundreds of reports over the past decades summarize a dizzying array of observations relevant to hu MDR 1 protein function. A dominant model in the MDR literature that is used to explain many observations is the well known "drug pump" model first suggested by Keld Dano in 1973 [1]. Although this model has proved useful in conceptualizing additional experiments, it violates fundamental laws of biology and chemistry and in well over a decade of intense effort, active outward drug pumping via hu MDR 1 protein has still never been unequivocally measured. Also, in recent years it has become clear that the drug pump model cannot explain several important phenomena that are highly relevant to the cancer clinic. Thus, other models have also proved increasingly popular. One is the altered partitioning model, which does not violate fundamental laws, is consistent with the vast majority of available data, and has important predictive ability. This newer model has several novel facets that are relevant for cancer pharmacology, and that help explain phenomena not explained by the drug pump model. The basic principle of this model is that MDR proteins do not directly transport drugs, but that their altered expression leads to altered regulation of ion transport or signal transduction that is critical for setting key biophysical parameters of the cell (e.g. compartmental pH and membrane potentials) that dictate relative passive diffusion of drugs as well as important signal transduction linked to the cytotoxic actions of these drugs. Along with debate over the molecular details of hu MDR 1 function, additional controversy surrounds the precise role of hu MDR 1 in the clinic. Many investigators now debate the significance of its function (regardless of precise mechanism) with regard to "real" drug resistance phenotypes exhibited in the clinic. I believe that thorough debate on the pros and cons of various molecular models for hu MDR 1 function will help to address confusion over the clinical relevance of hu MDR1. In the current atmosphere of disappointment over the relative success of clinical trials based in large part on the logic of the drug pump model, it is important that we not lose sight of critical points. Namely, hu MDR 1 protein remains an extremely important window in on the complex pathways that lead to induced chemotherapeutic drug resistance. Exploring the rationale behind newer models for hu MDR 1 function leads to key predictions that can be tested.

Evidence for altered ion transport in Saccharomyces cerevisiae overexpressing human MDR 1 protein.

Recently [Hoffman, M. M., and Roepe, P. D. (1997) Biochemistry 36, 11153-11168] we presented evidence for a novel Na+- and Cl--dependent H+ transport process in LR73/hu MDR 1 CHO transfectants that likely explains pHi, volume, and membrane potential changes in eukaryotic cells overexpressing the hu MDR 1 protein. To further explore this process, we have overexpressed human MDR 1 protein in yeast strain 9.3 following a combination of approaches used previously [Kuchler, K., and Thorner, J. (1992) Proc. Natl. Acad. Sci. U.S.A. 89, 2302-2306; Ruetz, S., et al. (1993) Proc. Natl. Acad. Sci. U.S.A. 90, 11588-11592]. Thus, a truncated hu MDR 1 cDNA was cloned behind a tandem array of sterile 6 (Ste6) and alchohol dehydrogenase (Adh) promoters to create the yeast expression vector pFF1. Valinomycin resistance of intact cells and Western blot analysis with purified yeast plasma membranes confirmed the overexpression of full length, functional, and properly localized hu MDR 1 protein in independently isolated 9.3/pFF1 colonies. Interestingly, relative valinomycin resistance and growth of the 9.3/hu MDR 1 strains are found to strongly depend on the ionic composition of the growth medium. Atomic absorption reveals significant differences in intracellular K+ for 9.3/hu MDR 1 versus control yeast. Transport assays using [3H]tetraphenylphosphonium ([3H]TPP+) reveal perturbations in membrane potential for 9.3/hu MDR 1 yeast that are stimulated by KCl and alkaline pHex. ATPase activity of purified plasma membrane fractions from yeast strains and LR73/hu MDR 1 CHO transfectants constructed previously [Hoffman, M. M., et al. (1996) J. Gen. Physiol. 108, 295-313] was compared. MDR 1 ATPase activity exhibits a higher pH optimum and different salt dependencies, relative to yeast H+ ATPase. Inside-out plasma membrane vesicles (ISOV) fabricated from 9.3/hu MDR 1 and control strains were analyzed for formation of H+ gradients +/- verapamil. Similar pharmacologic profiles are found for verapamil stimulation of MDR 1 ATPase activity and H+ pumping in 9.3/hu MDR 1 ISOV. In sum, these experiments strongly support the notion that hu MDR 1 catalyzes H+ transport in some fashion and lowers membrane potential in yeast when K+ contributes strongly to that potential. In the accompanying paper [Santai, C. T., Fritz, F., and Roepe, P. D. (1999) Biochemistry 38, XXXX-XXXX] the effects of ion gradients on H+ transport by hu MDR 1 are examined.

Effects of ion gradients on H+ transport mediated by human MDR 1 protein.

In the previous paper we presented a variety of data consistent with significant perturbations in 9.3 yeast plasma membrane ion transport upon overexpression of the hu MDR 1 protein. Thus, in this paper, we compare formation of DeltapH for inside-out yeast plasma membrane vesicles (ISOV) prepared from control 9.3/pVT versus 9.3/hu MDR 1 yeast. Since MDR 1 ATPase activity has a broader, more alkaline pH profile relative to endogenous yeast H+ ATPase activity, we analyzed H+ pumping at pH >/= 8.0 in detail in order to selectively amplify hu MDR 1 contributions to H+ movement over those of the endogenous yeast H+ ATPase. We observed: (1) imposition of a Cl- gradient oriented outside to in enhances acidification for 9.3/pVT ISOV (as expected), but decreases acidification for 9.3/hu MDR 1 ISOV; (2) imposition of a Cl- gradient oriented inside to out decreases acidification for 9.3/pVT ISOV (as expected) but enhances acidification for 9.3/hu MDR 1 ISOV; (3) a Na+ gradient oriented in the same direction as the Cl- gradient amplifies the effects due to hu MDR 1 when both gradients are oriented inside to out, but not outside to in. The data are most easily explained by interesting Na+, Cl-, and ATP-dependent H+ transport mediated by hu MDR 1 protein as previously suggested [Hoffman and Roepe (1997) Biochemistry 36, 11153-11168]. These data may help to resolve a variety of conflicting reports in the literature regarding ion transport mediated by hu MDR 1 and have implications for the physiology of a number of polarized epithelia in which hu MDR 1 is endogenously expressed.

Intracellular pH and multidrug resistance regulate complement-mediated cytotoxicity of nucleated human cells.

In previous work (Weisburg, J. H., Curcio, M., Caron, P. C., Raghi, G., Mechetner, E. B., Roepe, P. D., and Scheinberg, D. A. (1996) J. Exp. Med. 183, 2699-2704), we showed that multidrug resistance (MDR) cells created by continuous selection with the vinca alkaloid vincristine (HL60 RV+) or by retroviral infection (K562/human MDR 1 cells) exhibited significant resistance to complement-mediated cytotoxicity (CMC). This resistance was due to the presence of overexpressed P-glycoprotein (P-GP). In this paper, we probe the molecular mechanism of this phenomenon. We test whether the significant elevated intracellular pH (pHi) that accompanies P-GP overexpression is sufficient to confer resistance to CMC and whether this resistance is related to effects on complement function in the cell membrane. Control HL60 cells not expressing P-GP, but comparably elevated in cytosolic pHi by two independent methods (CO2 "conditioning" or isotonic Cl- substitution), are tested for CMC using two different antibody-antigen systems (human IgG and murine IgM; protein and carbohydrate) and two complement sources (rabbit and human). Elevation of pHi by either of these methods or by expression of P-GP confers resistance to CMC. Resistance is not observed when the alkalinization mediated by reverse Cl-/HCO3- exchange upon Cl- substitution is blocked by treatment with dihydro-4,4'-diisothiocyanostilbene-2,2'-disulfonate. Continuous photometric monitoring of 2',7'-bis(carboxyethyl)-5, 6-carboxyfluorescein (BCECF), to assess changes in pHi or efflux of the probe through MAC pores, in single cells or cell populations, respectively, verifies changes in pHi upon CO2 conditioning and Cl- substitution and release of BCECF upon formation of MAC pores. Antibody binding and internalization kinetics are similar in both the parental and resistant cell lines as measured by radioimmunoassay, but flow cytometric data showed that net complement deposition in the cell membrane is both delayed and reduced in magnitude in the MDR cells and in the cells with increased pHi. This interpretation is supported by comparison of BCECF release data for the different cells. Dual isotopic labeling of key complement components shows no significant change in molecular stoichiometry of the MACs formed at different pHi. The results are relevant to understanding clinical implications of MDR, the physiology of P-GP, and the biochemistry of the complement cascade and further suggest that the "drug pump" model of P-GP action cannot account for all of its effects.

Are ion-exchange processes central to understanding drug-resistance phenomena?

Drug resistance in malarial parasites is arguably the greatest challenge currently facing infectious disease research. In addressing this problem, researchers have been intrigued by similarities between drug-resistant malarial parasites and tumour cells. For example, it was originally thought that the role of pfMDR (Plasmodium falciparum multidrug resistance) proteins was central in conferring antimalarial multidrug resistance. However, recent work has questioned the precise role of MDR proteins in multidrug resistance. In addition, recent ground-breaking work in identifying mutations associated with antimalarial drug resistance might have led to identification of yet another parallel between drug-resistant tumour cells and malarial parasites, namely, intriguing alterations in transmembrane ion transport, discussed here by Paul Roepe and James Martiney. This further underscores an emerging paradigm in drug-resistance research.

Analysis of ion transport perturbations caused by hu MDR 1 protein overexpression.

In previous work [Luz et al. (1994) Biochemistry 33, 7239-7249; Roepe et al. (1994) Biochemistry 33, 11008-11015] we measured changes in Cl- and HCO3--dependent pHi regulation for LR73 Chinese hamster ovary fibroblasts overexpressing mu MDR 1 protein. However, only one clonal cell line overexpressing the protein but not previously exposed to chemotherapeutic drug (i.e., a "true" transfectant) was examined, since very few MDR cell lines of this nature have been constructed. Recently [Hoffman et al. (1996) J. Gen. Physiol. 108, 295-313] we derived a series of true LR73/hu MDR 1 transfectants that are valuable for defining the MDR phenotype mediated by MDR protein alone, without the additional complexities introduced by exposing cells to chemotherapeutic drugs. Several independently derived clones from these and additional transfection experiments exhibit expression of MDR protein that is higher than that found in other true transfectants, and that is similar to the highest level of overexpression yet recorded for drug selected MDR cells. We examined altered Cl--dependent pHi regulation for these clones using improved single-cell photometry (SCP) techniques. Short-term isotonic Cl- substitution experiments performed in the presence of CO2/HCO3- reveal that mild overexpression of hu MDR 1 protein alters anion exchange (Cl-/HCO3- exchange or AE) for LR73 cells, as expected on the basis of previous work [Luz et al. (1994) Biochemistry 33, 7239-7249]. Interestingly, we now find that several independently selected high-level MDR 1 overexpressing clones acidify quite extensively upon isotonic exchange of Cl- and then rapidly alkalinize upon restoring normal [Cl-]. These data suggest that MDR protein may effectively compete against AE. The MDR protein effect is not dependent on HCO3-/CO2 or K+, is partially inhibited by verapamil, is completely inhibited by substituting K+ or N-methylglucamine (NMG+) for Na+ in the SCP perfusate but is not affected by 100 microM levels of amiloride, bumetanide, chlorothiazide, or stilbene. ATP depletion inhibits the MDR 1 effect. We are unable to restore normal AE activity for the MDR clones via manipulation of Cl- or HCO3- gradients. We thus suggest that MDR protein overexpression provides a novel Na+- and Cl--dependent pathway for transmembrane H+ transport. From analysis of ion dependency and inhibitor sensitivities, we conclude the transport is not via altered regulation of any known K+/H+, Na+/H+, or Cl-/HCO3- antiporters, Na+:K+:2Cl-, Na+:K+:2HCO3-, K+:HCO3-, or Na+:HCO3- co-transporters, or any combination of these. Thus, it appears to represent a novel ATP and Na+-dependent Cl-/H+ antiport process that (1) may be directly mediated by the MDR protein, (2) may represent the modulation of one or more currently unidentified ion transport proteins by MDR protein, (3) may be due to some combination of direct ion transport and regulation of ion transport, or (4) may represent unusual passive H+ movement in response to a novel Cl--dependent electrical perturbation that occurs during our Cl- substitution protocol. The results have important implications for understanding drug resistance mediated by MDR 1 overexpression, as well as the physiologic function of endogenously expressed MDR protein.

Human MDR 1 protein overexpression delays the apoptotic cascade in Chinese hamster ovary fibroblasts.

Several laboratories have reported that overexpression of the multidrug resistance (MDR) protein is associated with intracellular alkalinization, and several investigators have reported that cells induced to undergo programmed cell death (apoptosis) acidify quite significantly. Because it is difficult to fully explain the resistance to apoptosis-inducing chemotherapeutic drugs that is exhibited by MDR tumor cells solely via altered drug transport alone [Hoffman et al. (1996) J. Gen. Physiol. 108, 295-313], we have investigated whether overexpression of the hu MDR 1 protein alters progression of the apoptotic cascade. LR73 fibroblasts induced to undergo apoptosis either via treatment with the chemotherapeutic drug colchicine or by serum withdrawal exhibit cellular volume changes, intracellular acidification, nuclear condensation, and chromosomal digestion ("ladder formation"), characteristic of apoptosis, in a temporally well-defined pattern. However, multidrug resistant LR73/20E or LR73/27 hu MDR 1 transfectants recently created in our laboratory without selection on chemotherapeutic drug are significantly delayed in the onset of apoptosis as defined by the above criteria, regardless of whether apoptosis is induced by colchicine treatment or by serum withdrawal. Thus, the delay cannot simply be due to the well-known ability of MDR protein overexpression to lower chemotherapeutic drug accumulation in MDR cells. LR73/27V500 "selectants", exhibiting similar levels of MDR protein overexpression but higher multidrug resistance due to selection with the chemotherapeutic drug vincristine, exhibit a slightly longer delay in the progression of apoptosis. Normal apoptotic cascade kinetics are partially restored by pre-treatment of the MDR cells with the MDR protein inhibitor verapamil. Untransfected LR73 cells not expressing MDR protein but elevated in pHi via manipulation of CO2/HCO3- as described [Hoffman et al. (1996) J. Gen. Physiol. 108, 295-313] are inhibited in DNA ladder formation, similar to LR73/hu MDR 1 transfectants. These results uncover an additional mechanism whereby MDR protein overexpression may promote the survival of tumor cells and further support the notion that in some systems intracellular acidification may be either causal or permissive for proper progression of the apoptotic cascade.

Altered pHi regulation in 3T3/CFTR clones and their chemotherapeutic drug-selected derivatives.

Recently (L. Y. Wei, M. J. Stutts, M. M. Hoffman, and P. D. Roepe. Biophys. J. 69: 883-895, 1996), 3T3 cells overexpressing the cystic fibrosis transmembrane conductance regulator (CFTR) were found to exhibit chemotherapeutic drug resistance and other traits of multidrug resistant (MDR) cells. In the present work, NIH 3T3/CFTR clones were selected with either doxorubicin or vincristine in incremental fashion to generate series of stable MDR cell lines that exhibit increasing levels of drug resistance. Thus C3D6 (grown in the presence of 600 nM doxorubicin) was selected from C3D4 (grown in the presence of 400 nM doxorubicin), which was selected from C3D1 (grown in the presence of 100 nM doxorubicin), which was in turn selected from the original 3T3/CFTR clone C3 (M. J. Stutts, S. E. Gabriel, J. C. Olsen, J. T. Gatzy, T. L. O'Connell, E. M. Price, and R. C. Boucher. J. Biol. Chem. 268: 20653-20658, 1993), which was not grown in the presence of chemotherapeutic drug. A similar series was generated via selection with vincristine. In both series, as well as series derived from a different CFTR clone, initial low-level drug selection increases CFTR expression without promoting MDR 1 or multidrug resistance-associated protein expression. On continued selection at higher drug concentrations, CFTR mRNA levels decrease while MDR 1 mRNA levels concomitantly increase. At each incremental step of selection, intracellular pH (pHi) increases (e.g., pHi of C3D6 > C3D4 > C3D1 > C3). Cl-/HCO3- exchange activity is significantly reduced in the drug-selected derivatives overexpressing MDR 1 but not the parental CFTR clones. The apparent set point of Na+/H+ exchange activity is significantly lower for the non-drug-selected 3T3/CFTR clones, relative to controls, but it increases on initial selection with chemotherapeutic drug. Overexpression of MDR 1 in the higher-level selectants does not appear to further perturb apparent Na+/H+ exchange. These data further describe how CFTR and MDR proteins may affect pHi regulation.

Biophysical aspects of P-glycoprotein-mediated multidrug resistance.

In the 45 years since Burchenal's observation of chemotherapeutic drug resistance in tumor cells, many investigators have studied the molecular basis of tumor drug resistance and the phenomenon of tumor multidrug resistance (tumor MDR). Examples of MDR in microorganisms have also become topics of intensive study (e.g., Plasmodium falciparum MDR and various types of bacterial MDR) and these emerging fields have, in some cases, borrowed language, techniques, and theories from the tumor MDR field. Serendipitously, the cloning of MDR genes overexpressed in MDR tumor cells has led to elucidation of a large family of membrane proteins [the ATP-binding cassette (ABC) proteins], an important subset of which confer drug resistance in many different cells and microorganisms. In trying to decipher how ABC proteins confer various forms of drug resistance, studies on the structure and function of both murine and human MDR1 protein (also called P-glycoprotein or P-gp) have often led the way. Although various theories of P-gp function have become popular, there is still no precise molecular-level description for how P-gp overexpression lowers intracellular accumulation of chemotherapeutic drugs. In recent years, controversy has developed over whether the protein protects cells by translocating drugs directly (as some type of drug pump) or indirectly (through modulating biophysical parameters of the cell). In this ongoing debate over P-gp function, detailed consideration of biophysical issues is critical but has often been neglected in considering cell biological and pharmacological issues. In particular, P-gp overexpression also changes plasma membrane electrical potential (delta psi zero) and intracellular pH (pHi), and these changes will greatly affect the cellular flux of a large number of compounds to which P-gp overexpression confers resistance. In this chapter, we highlight these biophysical issues and describe how delta psi zero and pHi may in fact be responsible for many MDR-related phenomena that have often been hypothesized to be due to direct drug translocation (e.g., drug pumping) by P-gp.

Altered drug translocation mediated by the MDR protein: direct, indirect, or both?

Overexpression of the MDR protein, or p-glycoprotein (p-GP), in cells leads to decreased initial rates of accumulation and altered intracellular retention of chemotherapeutic drugs and a variety of other compounds. Thus, increased expression of the protein is related to increased drug resistance. Since several homologues of the MDR protein (CRP, ItpGPA, PDR5, sapABCDF) are also involved in conferring drug resistance phenomena in microorganisms, elucidating the function of the MDR protein at a molecular level will have important general applications. Although MDR protein function has been studied for nearly 20 years, interpretation of most data is complicated by the drug-selection conditions used to create model MDR cell lines. Precisely what level of resistance to particular drugs is conferred by a given amount of MDR protein, as well as a variety of other critical issues, are not yet resolved. Data from a number of laboratories has been gathered in support of at least four different models for the MDR protein. One model is that the protein uses the energy released from ATP hydrolysis to directly translocate drugs out of cells in some fashion. Another is that MDR protein overexpression perturbs electrical membrane potential (delta psi) and/or intracellular pH (pHi) and thereby indirectly alters translocation and intracellular retention of hydrophobic drugs that are cationic, weakly basic, and/or that react with intracellular targets in a pHi or delta psi-dependent manner. A third model proposes that the protein alternates between drug pump and Cl- channel (or channel regulator) conformations, implying that both direct and indirect mechanisms of altered drug translocation may be catalyzed by MDR protein. A fourth is that the protein acts as an ATP channel. Our recent work has tested predictions of these models via kinetic analysis of drug transport and single-cell photometry analysis of pHi, delta psi, and volume regulation in novel MDR and CFTR transfectants that have not been exposed to chemotherapeutic drugs prior to analysis. This paper reviews these data and previous work from other laboratories, as well as relevant transport physiology concepts, and summarizes how they either support or contradict the different models for MDR protein function.