Curis.ku.dkUniversity of Copenhagen
Acid-base transport in pancreas-new challenges
Novak, Ivana; Haanes, Kristian Agmund; Wang, Jing Published in:Frontiers in Physiology Document VersionPublisher's PDF, also known as Version of record Citation for published version (APA):Novak, I., Haanes, K. A., & Wang, J. (2013). Acid-base transport in pancreas-new challenges. Frontiers inPhysiology, 4, . DOI: 10.3389/fphys.2013.00380 Download date: 07. Oct. 2016 *, Kristian A. Haanes † and Jing Wang †
Department of Biology, University of Copenhagen, Copenhagen, Denmark Along the gastrointestinal tract a number of epithelia contribute with acid or basic Ebbe Boedtkjer, Aarhus University, secretions in order to aid digestive processes. The stomach and pancreas are the most extreme examples of acid (H+) and base (HCO−) transporters, respectively. Nevertheless, they share the same challenges of transporting acid and bases across epithelia and Martin Diener, University Giessen, effectively regulating their intracellular pH. In this review, we will make use of comparative GermanyUrsula E. Seidler, Hannover Medical physiology to enlighten the cellular mechanisms of pancreatic HCO− and fluid secretion, School, Germany which is still challenging physiologists. Some of the novel transporters to consider in pancreas are the proton pumps (H+-K+-ATPases), as well as the calcium-activated K+ and Ivana Novak, Molecular Integrative Cl− channels, such as KCa3.1 and TMEM16A/ANO1. Local regulators, such as purinergic Physiology, Department of Biology,University of Copenhagen, August signaling, fine-tune, and coordinate pancreatic secretion. Lastly, we speculate whether Krogh Building, Universitetsparken dys-regulation of acid-base transport contributes to pancreatic diseases including cystic 13, Copenhagen Ø, DK 2100, fibrosis, pancreatitis, and cancer.
Denmarke-mail: Keywords: bicarbonate transport, proton transport, H+-K+-ATPase, KCa3.1, IK, TMEM16A, ANO1, pancreatic duct
Kristian A. Haanes, Department of
Clinical Experimental Research,
Glostrup Research Institute,
Copenhagen University Hospital,
Jing Wang, National Institute for
Viral Disease Control and
Prevention, Chinese Center for
Disease Control and Prevention,
INTRODUCTION: ACID-BASE FLUXES ALONG THE
). In the intestinal phase of digestion, pancreatic ducts secrete In multicellular organisms the digestive system exhibits marked HCO−-rich fluid that contributes to alkalinization of acid chyme acid/base segmentation and gradients across the epithelia. The in duodenum. The acid generated is then transported toward most extreme examples of the acid/base transporters are the the interstitium, and one would expect an acid tide, depending stomach and the pancreas, which conduct a vectorial transport on ingested food and passage through the stomach (Rune and of acid/base to one side and base/acid to the other side of the epithelium In the stomach, the parietal cells of the From these simple considerations several questions arise. Do pyloric glands secrete H+ toward lumen (HCl), leaving HCO− the stomach and pancreas epithelia have some transport mecha- to be transported into the interstitium and blood. Thus, the nisms in common, or do they solve the task of acid-base transport phenomenon of the alkaline tide, i.e., higher blood pH in con- in different ways? nection with digestion, is well known as part of the post-prandial The molecular mechanism and regulation of stomach acid gastric phase secretion, which in humans is relatively small com- secretion is well established. In short, it involves gastric H+-K+- pared to animals that ingest large amounts of food at one time ATPases comprising of α1 and β subunits coded by ATP4A andATP4B genes. These pumps are present in tubulovesicles of pari- Abbreviations: BK, big conductance K+ channel, also named KCa1.1 and maxi-
etal cells and delivered to the luminal membranes in conjunction K+, coded by KCNMA1; CaCC, Ca2+-activated Cl− channel, e.g., TMEM16A with specific K+ (KCNQ1, KCNJ15, KCNJ10) and Cl− channels also known as ANO1; CA, carbonic anhydrase; CCK, cholecystokinin, CF, cysticfibrosis; [Ca2+]i, intracellular Ca2+ activity; CFTR, the cystic fibrosis transmem- (CFTR, CLIC-6, SCL26A9), and thereby resulting in HCl secre- brane conductace regulator; EBIO, 1-ethyl-2-benzimidazolinone; GK , conductance for K+; H+-K+-ATPases or pumps, colonic type (coded by ATP12A) and gastric ). Gastric acid secretion is regulated by neural, hormonal, types (coded by ATP4A and ATP4B); IK, intermediate conductance K+ channel, paracrine and chemical stimuli, e.g., acetylcholine, gastrin, ghre- also named KCa3.1; IRBIT, inositol 1,4,5-triphosphate (InsP3) receptor-bindingprotein released with InsP3; NBCe1 or pNBC, electrogenic Na+-HCO− trans- lin, histamine. As a protection against strong acid and pepsins, porter; NBCn1, electroneutral Na+-HCO3- transporter; NHE, Na+/H+ exchanger; the surface epithelium secretes HCO−, mucus and other fac- NKCC1, Na+-K+-2Cl− cotransporter; PKA, protein kinase A; PKC, proteins kinase tors, forming gastric diffusion barrier The validity C; SLC26A6, electrogenic Cl−-/2HCO−- exchanger; VNUT, vesicular nucleotide transporter, SLC17A9; V-H+-pump, vacuolar type H+-ATPase; ZG, zymogen of the model is confirmed by well-used drugs, including proton pump inhibitors and H2-histamine receptor blockers, to curb the
Novak et al.
Acid-base transport in pancreas the latter two, which are expressed in pancreas (see below), othercandidates remain to be explored.
Pancreatic ducts comprise 5–20% of the tissue mass, depend- ing on the species; morphologically they are different - progress-ing from flat centroacinar cells, cuboidal cells in intercalated, andsmall intralobular ducts to columnar heterogenous cells lininglarger distal ducts Bouwensand Pipeleers, ). At large, it is accepted that pancreatic ductssecrete isotonic NaHCO3 rich fluid. However, the concentrationof HCO− is not constant; it decreases with secretory rates—a pattern that is mirrored by Cl−. The HCO− excretory pat- terns are remarkably similar between various species, providingthat secretory rates are corrected for the duct mass In early studies it was proposedthat pancreatic secretion and ionic composition is a two stageprocess—primary secretion and ductal modification, the so calledadmixture hypothesis. Another, the exchange theory, also namedthe salvage mechanism, states that at lower secretory rates duc-tal transporters are presumably not saturated and therefore, are FIGURE 1 HCO− and H+ transport in gastric cells (A) and pancreatic
capable of exchanging luminal HCO− for interstitial Cl−. This duct cells (B). The models show schematically different types of epithelia
exchange phenomenon was first demonstrated on the main cat as single cells. The transport of H+ or HCO− to the bulk luminal fluid is duct . The third explanation, regarding vary- shown with large arrows. The small arrows on luminal side indicate HCO− ing HCO− concentrations, pertains H+ secretion from acini (see and H+ secretions to the mucosal buffer zone. Flux of HCO− and H+ to the above) or ducts (see below).
interstititum/blood side indicates expected alkaline or acid tides.
NOVEL ION CHANNELS AND PUMPS CONTRIBUTING TO
peptic and duodenal ulcers and reflux diseases ).
ACID-BASE TRANSPORT IN PANCREATIC DUCTS
In contrast, we do not understand the mechanism behind pan- The ion transport models for pancreatic ducts have been creatic alkaline (HCO−) secretion fully. Therefore, therapeutic described in several recent reviews Steward intervention is not possible, e.g., for cystic fibrosis patients.
and Ishiguro, ). The outline of the model is given in The PANCREATIC SECRETION—CONTRIBUTION FROM ACINI
following sections will focus on novel additions to the model.
Pancreas is composed of two main types of epithelia—secretory
acini and excretory ducts. Acini have relatively uniform mor- Ion channels and transporters proposed in the classical model phology. They secrete digestive enzymes, NaCl-rich fluid and for HCO− secretion rely on gradients created by the Na+/K+- various factors that contribute to signaling in down-stream ducts.
ATPase . However, we cannot explain formation of Studies on normal human and rodent pancreas, stimulated by high HCO− concentrations and the fact that inhibitors of NHE1, predominantly acinar agonists, e.g., cholecytokinin (CCK), result NBC (and NKCC1), and CA are relatively ineffective in blocking in neutral or weakly alkaline pancreatic juice However, a recent One solution is that a primary pump could be involved, such as study using acinar preparation and bioimaging techniques shows the vacuolar type H+-ATPase (V-H+-pump), to pump H+ out that acinar secretion is acidic due to acidic zymogen granules to interstitium and leave HCO− for the luminal transport. In (ZG) although acidity of mature ZG one study, such vacuolar H+ pump on the basolateral membrane has been discussed was proposed and detected immunohisto- ). Nevertheless, a potential acid load from acini challenging chemically Several functional studies gave proximal ducts has been considered ). One contradictory findings de possible defense mechanism could be activation of ducts by aci- Ondarza and Hootman, ). Taking an inspiration from gas- nar agonist; generally this seems not to be the case. Alternatively, tric glands, the colon and kidney distal tubules, we considered paracrine agonists such as ATP released by acini could stimulate whether pancreatic ducts express H+-K+-ATPases. Indeed, we ducts by purinergic signaling found that rodent ducts express both the gastric and non-gastric ). Lastly, pancreatic ducts might have ability to sense and (colonic) types H+-K+-ATPases Inhibition react to acid/base locally. There are a number of acid/base sen- of these with proton pump inhibitors reduced pHi recovery in sors at the single cell and whole organ level response to acid loads; more importantly, they reduced secretion in isolated pancreatic ducts. Thus, these functional studies sup- acid sensitive ASIC and TRP channels, HCO− sensitive adenylate port the theory that pancreatic ducts resemble gastric glands— cyclase, pH-sensitive K+ channels, and P2X receptors. Except for just working in reverse, expelling H+ toward the blood side
Novak et al.
Acid-base transport in pancreas FIGURE 2 Acid/base transport in pancreas. (A) The relation between
certain conditions, through Cl− channels. The luminal Cl− channels are CFTR secretory rates and HCO− concentrations in pancreatic juice of various and TMEM16A (see text). There are a number of K+ channels expressed on species. Secretions were stimulated by secretin and secretory rates were the luminal and basolateral membranes, e.g., KCa3.1, KCa1.1, KCNQ1 (see corrected for body weights. (B) The model of ion transport in a secreting
text). The luminal and basolateral H+-K+-ATPases are indicated in red and pancreatic duct cell with novel transporters, channels and luminal purinergic green, and supposedly contribute to the luminal buffer zone and the H+ efflux signaling and receptors indicated in color and discussed in the review.
to intersititum, respectively. Other ion channels and transporters, such as Intracellular HCO− is derived from CO NHE3, SLC26A3, NBC3, NKCC1, and aquaporins have a differential 2 through the action of carbonic anhydrase (CA) and from HCO− uptake via the electrogenic Na+–HCO− distribution in the duct tree and for simplicity are not included in the model.
cotransporter (pNBC, NBCe1). H+ is extruded at basolateral membrane by (C) Immunolocalization of the gastric (red) and non-gastric (green) H+-K+
the Na+/H+ exchanger (NHE1). HCO− efflux across the luminal membrane is pumps in rat pancreatic duct. The bar is 20 μm. Modified from mediated by the electrogenic Cl−/HCO− exchanger (SLC26A6), and under and leaving HCO− for the luminal transport The is—these luminal pumps are safeguarding luminal cell surface immunohistochemical study showed that the H+-K+-ATPases with acid secretions to protect against the bulk alkaline secre- (mainly colonic type) are localized to the basolateral membrane tions, which at pH >8 would be caustic to cells. Thus, pancreatic ducts would have protective buffer (and mucus) zone, which is However, H+-K+-ATPases, especially the gastric form, are reminiscent to the buffer zone in the stomach, though achieved also localized at or close to the luminal membrane by H+ rather than HCO− secretion In addition, ). It seems counterintuitive to place H+ pumps the luminal H+-K+ pumps would recirculate K+ extruded by the on the HCO− secreting luminal membrane. Nevertheless, there luminal K+ channels Lastly, luminal H+-K+ pumps are epithelia that are high HCO− secretors and yet express H+ in distal ducts would by virtue of H+ secretion have more impact pumps on the luminal membranes. For example, insect midgut on pancreatic juice composition at low flow rates and minor and marine fish intestine have functional V-H+-ATPase on the at high flow rates, thus, explaining excretory curves for HCO− luminal membranes Also other epithelia, which are not highHCO− secretors (HCO− <25 mM), express various H+ pumps Ca2+-ACTIVATED Cl− CHANNELS
on the luminal membranes. For example, airway epithelia trans- In addition to CFTR-dependent secretion, a number of studies port both base and acid, and the airway fluid layer is slightly showed that agonists acting via Ca2+-signaling stimulate Ca2+- acidic Some studies provide activated Cl− channels (CaCC) and thus, could support duct evidence for the presence of bafilomycin A sensitive V-H+ pump secretion Winpenny ); other studies show that transport is sensitive to SCH28080, The molecular identity of CaCC channels has been difficult to an inhibitor of gastric (and also non-gastric) H+-K+ pumps pinpoint [see After suggestions of CCl-2 and bestrophins, the TMEM16/ANO family was discovered (Caputo gastric, ouabain-sensitive H+-K+-pumps were also demonstrated et al., ), and especially in some studies Shan TMEM16A/ANO1 became a CaCC favorite. Recent studies show that human duct cell lines express TMEM16A, which re-localizes Coming back to the pancreatic luminal H+-K+ pumps, let from cytosol to the luminal membrane upon purinergic stimula- us speculate what their function may be. They could help to tion and gives rise to secretory potentials defend the cell against intracellular acidification, although there In human pancreatic samples immunohis- is a redundancy of acid/base transporters including several NHEs, tochemistry shows TMEM16A in centro-acinar and small ducts NBCs, and Cl−/HCO− exchangers Our proposal Novak et al.
Acid-base transport in pancreas It is relevant to ask whether TMEM16A and/or Ca2+ signal- ing pathways lead to HCO− secretion. There are a few studies in Pancreatic secretion regulated by hormonal and neural systems is support of this notion. For example, Ca2+ signaling via IRBIT stimulates NBCe1 A Paracrine regulation is less explored, but it is highly relevant as recent study on TMEM16A anion permeability shows that in it allows regulation within the gland and integration of acinar HEK293 cell expression system and mouse salivary acinar cells and ductal responses. Pancreatic ducts can be regulated by acinar the channel is directly modulated by calmodulin, which increases factors (trypsin, guanylin, ATP) as well as retrograde factors (bile its HCO− permeability This is supported by a study on ex vivo salivary glands stimulated with acetycholine, which induced production of HCO− rich pancreatic-like secre- centrate on purinergic signaling and present evidence that this tion when Cl− transport was inhibited signaling could fine-tune and coordinate pancreatic secretion on Nevertheless, it cannot be excluded that there are other molec- several fronts. Pancreatic ducts express several types of purinergic ular candidates for CaCC, or that CFTR can convey part of the receptors including members from the G-protein coupled recep- Ca2+-activated Cl− currents. The latter mechanism could involve tor families (adenosine, P2Y) and ligand-gated ion channels (P2X Ca2+ sensitive adenylate cyclases and tyrosine kinases (Src2/Pyk receptor) families that can potentially stimu- complex), both of which could alter activity of CFTR, as shown late a variety of intracellular signaling pathways for other epithelia Another effect at the CFTR level could be priming of some PKC ). These receptors regulate pancreatic isoforms that enhance CFTR activity [see duct ion transport, mucin secretion, and survival of fibrogenic )]. Lastly, it is highly unlikely that Ca2+ mediated signaling pancreatic stellate cells stands alone, rather the two major signaling pathways of Ca2+ and ATP originates from ZG where it is accumulated by the vesic- cAMP/PKA act synergistically in pancreatic ducts, e.g., via IRBIT ular nucleotide transporter VNUT regulation of CFTR and SLC26A6 ).
and in addition ATP is presumably released by nerves and ductalepithelium Burnstock K+ CHANNELS
and Novak, Various ecto-nucleotidases are expressed and The driving force for Cl− or HCO− exit is maintained by hyper- secreted, and potentially ATP/ADP and adenosine are effective polarizing membrane potential created by opening of K+ chan- regulators of ductal functions nels, and GK is both present on the basolateral and luminal ATP and UTP via P2 receptors have effects on intracellular analysis has shown that stimulation of luminal K+ channels con- Ca2+, intracellular pH, and transepithelial transport in both iso- tributes with at least with 10% to the total conductance. Modeling lated ducts and in vivo pancreas in salivary glands confirms that such ratio of luminal to basolat- ). The physiological response to nucleotides is side specific.
eral K+ channels would optimize secretion without destroying the Basolateral UTP inhibits secretion, most likely due to inhibi- transepithelial potential and transport tion of KCa1.1 channels, presumably to prevent overextension Furthermore, luminal K+ channels could of ducts. In contrast, luminal UTP/ATP application causes duct contribute to secreted K+, as pancreatic juice contains 4–8 mM secretion and activation and Cl− and K+ channels ). In particular KCa3.1 ). The molecular identity of some K+ channels in pancre- channel activation potentiates secretion (see above). It is well doc- atic ducts is known, however, the exact localization and function umented that purinergic receptor stimulation activates CFTR, remains to be verified [see )]. The Cl−/HCO− exchangers and TMEM16A on the luminal mem- KCa1.1 channels (maxi-K, BK, coded by KCNMA1) are present brane Furthermore, in pancreatic ducts ).
P2 receptors activate CaCC and CFTR interdependently and syn- The latter study proposes that these channels are expressed on the ergistically, though exact receptors and signaling pathways remain luminal membrane and activated by low concentrations of bile to be elucidated (see above). In addition, some effects can be due acids. However, earlier patch-clamp studies indicated that these to stimulation of A2A and A2B receptors, which stimulate CFTR channels were also located basolaterally Hede et al., The KCa3.1 channel (IK, SK4, coded by KCNN4) A number of processes in purinergic signaling are pH sen- was demonstrated in pancreatic ducts Jung sitive, and this must be of relevance in pancreatic duct lumen.
et al., Immunolocalization indicates For example, nucleotidase activities, CD39 and CD73 types, are that KCa3.1 is expressed on both membranes, though stronger on stimulated at alkaline pH 8–9 the luminal one Interestingly, the channel activator ), thus, favoring conversion of ATP to adenosine in duct EBIO enhanced secretion potentials Wang lumen. Furthermore, purinergic receptors are also pH sensitive.
et al., ). Recent studies on pancreatic ducts offers molecu- From other preparations we know that extracellular acidifica- lar identities of several K+ channels, including KVLQT1, HERG, tion enhanced the potency of UTP up to 10 fold on the rat EAG2; Slick, and Slack and interestingly the P2Y4 but not P2Y2 receptors ), and the pH sensor TASK-2 However, the function and P2X2 receptors was activated by acid pH regulation of these channels in pancreas physiology needs to be Extracellular alkalinization enhances activity the P2X4 and P2X7 receptors Several types Novak et al.
Acid-base transport in pancreas of these receptors are expressed in duct lumen including the Bilbao, P. S., Katz, S., and Boland, R. (2012). Interaction of purinergic recep- P2Y2 and P2X7 receptors, and these enhance pancreatic secretion tors with GPCRs, ion channels, tyrosine kinase and steroid hormone receptors and integrate acini-to-duct signaling orchestrates cell function. Purinergic Signal. 8, 91–103. doi: 10.1007/s11302-011-9260-9 Billet, A., and Hanrahan, J. W. (2013). The secret life of CFTR as a calcium-activated chloride channel. J. Physiol. 591, 5273–5278. doi: 10.1113/jphysiol.2013.261909 SUMMARY AND PERSPECTIVES
Billet, A., Luo, Y., Balghi, H., and Hanrahan, J. W. (2013). Role of tyrosine phos- The original cellular model for pancreatic HCO− secretion has phorylation in the muscarinic activation of the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR). J. Biol. Chem. 288, 21815–21823. doi: been supplemented with molecular identities for many ion trans- porters/channels. The present review challenges present concepts Bodin, P., and Burnstock, G. (2001). Purinergic signaling: ATP release. Neurochem. by including active H+ pumps in the model, and by compar- Res. 26, 959–969. doi: 10.1023/A:1012388618693 ing basic processes in pancreas and stomach. Furthermore, we Bouwens, L., and Pipeleers, D. G. (1998). Extra-insular beta cells associated with present new additions to the model—Ca2+-activated Cl− and K+ ductules are frequent in adult human pancreas. Diabetologia 41, 629–633. doi:10.1007/s001250050960 channels, and propose that they work in synergy to regulate secre- Bro-Rasmussen, F., Killmann, S. A., and Thaysen, J. H. (1956). The composition tion. On the organ level, acini, and ducts integrate their function of pancreatic juice as compared to sweat, parotid saliva and tears. Acta Physiol. in acid/base transport and regulation, the latter exemplified by Scand. 37, 97–113. doi: 10.1111/j.1748-1716.1956.tb01346.x purinergic signaling. Further challenges lay in understanding dys- Brown, D., and Wagner, C. A. (2012). Molecular mechanisms of acid-base sensing by the kidney. J. Am. Soc. Nephrol. 23, 774–780. doi: 10.1681/ASN.2012010029 regulation of acid-base transport in pancreas pathophysiology. In Burnstock, G. (2007). Purine and pyrimidine receptors. Cell Mol. Life Sci. 64, CF patients and animal models, pancreatic juice pH decreases 1471–1483. doi: 10.1007/s00018-007-6497-0 from values >8.1 to <6.6, and pancreas contributes to duode- Burnstock, G., and Novak, I. (2012). Purinergic signaling in the pancreas in health nal hyperacidity [see and disease. J. Endocrinol. 213, 123–141. doi: 10.1530/JOE-11-0434 It is not clear whether the prob- Caflisch, C. R., Solomon, S., and Galey, W. R. (1979). Exocrine ductal pCO2 in the rabbit pancreas. Pflugers Arch. 380, 121–125. doi: 10.1007/BF00582146 lem relates to ductal and/or acinar secretion. In acute pancreatitis, Caputo, A., Caci, E., Ferrera, L., Pedemonte, N., Barsanti, C., Sondo, E., which has complex etiologies, it is now appreciated that defec- et al. (2008). TMEM16A, a membrane protein associated with calcium- tive pancreatic duct secretion can be the initiating factor (Lee dependent chloride channel activity. Science 322, 590–594. doi: 10.1126/science.
and Muallem, Finally, in several cancer types, various acid-base transporters and associated ion channels, Case, R. M., and Argent, B. E. (1993). "Pancreatic duct cell secretion: control and mechanims of transport," in The Pancreas. Biology, Pathobiology, and Diseases, such as NHE1, NBCn1, CAIX, TMEM16A, Kv10.1, and KCa3.1, eds V. L. W. Go, E. P. DiMagno, J. D. Gardner, E. Lebenthal, H. A. Reber, and G.
change expression or function [see )]. Our A. Scheele (New York, NY: Raven Press), 301–350.
knowledge about the role of acid-base transporters in pancreatic Case, R. M., Harper, A. A., and Scratcherd, T. (1969). The secretion of electrolytes ductal adenocarcinoma clearly needs to be expanded, in order to and enzymes by the pancreas of the anaesthetized cat. J. Physiol. (Lond.) 201, provide potential diagnostic and therapeutic approaches.
Chu, S., and Schubert, M. L. (2012). Gastric secretion. Curr. Opin. Gastroenterol.
28, 587–593. doi: 10.1097/MOG.0b013e328358e5cc Clarke, C. E., Benham, C. D., Bridges, A., George, A. R., and Meadows, H. J.
Research projects founding basis for this review were supported (2000). Mutation of histidine 286 of the human P2X4 purinoceptor removes by The Danish Council for Independent Research Natural extracellular pH sensitivity. J. Physiol 523 (pt 3), 697–703. doi: 10.1111/j.1469-7793.2000.00697.x Sciences, The Lundbeck Foundation, The Novo Nordisk Coakley, R. D., Grubb, B. R., Paradiso, A. M., Gatzy, J. T., Johnson, L. G., Kreda, Foundation and The Carlsberg Foundation.
S. M., et al. (2003). Abnormal surface liquid pH regulation by cultured cysticfibrosis bronchial epithelium. Proc. Natl. Acad. Sci. U.S.A. 100, 16083–16088.
doi: 10.1073/pnas.2634339100 Cook, D. I., and Young, J. A. (1989). Effect of K+ channels in the apical plasma Almassy, J., Won, J. H., Begenisich, T. B., and Yule, D. I. (2012). Apical Ca2+- membrane on epithelial secretion based on secondary active Cl− transport.
activated potassium channels in mouse parotid acinar cells. J. Gen. Physiol. 139, J. Membr. Biol. 110, 139–146. doi: 10.1007/BF01869469 121–133. doi: 10.1085/jgp.201110718 DeCoursey, T. E. (2013). Voltage-gated proton channels: molecular biology, phys- Alvarez, C., Regan, J. P., Merianos, D., and Bass, B. L. (2004). Protease-activated iology, and pathophysiology of the H(V) family. Physiol. Rev. 93, 599–652. doi: receptor-2 regulates bicarbonate secretion by pancreatic duct cells in vitro.
Surgery 136, 669–676. doi: 10.1016/j.surg.2004.01.018 de Ondarza, J., and Hootman, S. R. (1997). Confocal microscopic analysis of intra- Ashizawa, N., Endoh, H., Hidaka, K., Watanabe, M., and Fukumoto, S. (1997).
cellular pH regulation in isolated guinea pig pancreatic ducts. Am. J. Physiol.
Three-dimensional structure of the rat pancreatic duct in normal and inflam- 272, G124–G134.
mated pancreas. Microsc. Res. Tech. 37, 543–556. doi: 10.1002/(SICI)1097- Duran, C., Thompson, C. H., Xiao, Q., and Hartzell, H. C. (2010). Chloride chan- nels: often enigmatic, rarely predictable. Annu. Rev. Physiol. 72, 95–121. doi: Ashley, S. W., Schwarz, M., Alvarez, C., Nguyen, T. N., Vdovenko, A., and Reber, H.
A. (1994). Pancreatic interstitial pH regulation: effects of secretory stimulation.
Fernandez-Salazar, M. P., Pascua, P., Calvo, J. J., Lopez, M. A., Case, R. M., Steward, Surgery 115, 503–509.
M. C., et al. (2004). Basolateral anion transport mechanisms underlying fluid Behrendorff, N., Floetenmeyer, M., Schwiening, C., and Thorn, P. (2010). Protons secretion by mouse, rat and guinea-pig pancreatic ducts. J. Physiol. (Lond.) 556, released during pancreatic acinar cell secretion acidify the lumen and con- 415–428. doi: 10.1113/jphysiol.2004.061762 tribute to pancreatitis in mice. Gastroenterology 139, 1711-20, 1720.e1-5. doi: Fischer, H., and Widdicombe, J. H. (2006). Mechanisms of acid and base secretion by the airway epithelium. J. Membr. Biol. 211, 139–150. doi: 10.1007/s00232- Bergmann, F., Andrulis, M., Hartwig, W., Penzel, R., Gaida, M. M., Herpel, E., et al. (2011). Discovered on gastrointestinal stromal tumor 1 (DOG1) Fong, P., Argent, B. E., Guggino, W. B., and Gray, M. A. (2003). Characterization is expressed in pancreatic centroacinar cells and in solid-pseudopapillary of vectorial chloride transport pathways in the human pancreatic duct adeno- neoplasms–novel evidence for a histogenetic relationship. Hum. Pathol. 42, carcinoma cell line, HPAF. Am. J. Physiol. Cell Physiol. 285, C433–C445. doi: 817–823. doi: 10.1016/j.humpath.2010.10.005 Novak et al.
Acid-base transport in pancreas Forte, J. G., and Zhu, L. (2010). Apical recycling of the gastric parietal cell H,K- (NTPDase1) and NTPDase2 in Pancreas and Salivary Gland. J. Histochem. ATPase. Annu. Rev. Physiol. 72, 273–296. doi: 10.1146/annurev-physiol-021909- Cytochem. 52, 861–871. doi: 10.1369/jhc.3A6167.2004 Kodama, T. (1983). A light and electron microscopic study on the pancreatic ductal Freedman, S. D., Kern, H. F., and Scheele, G. A. (2001). Pancreatic acinar cell dys- system. Acta Pathol. Jpn. 33, 297–321.
function in CFTR(-/-) mice is associated with impairments in luminal pH and Krouse, M. E., Talbott, J. F., Lee, M. M., Joo, N. S., and Wine, J. J. (2004). Acid and endocytosis. Gastroenterology 121, 950–957. doi: 10.1053/gast.2001.27992 base secretion in the Calu-3 model of human serous cells. Am. J. Physiol. Lung. Gray, M. A., Greenwell, J. R., Garton, A. J., and Argent, B. E. (1990). Regulation of Cell Mol. Physiol. 287, L1274–L1283. doi: 10.1152/ajplung.00036.2004 maxi-K+ channels on pancreatic duct cells by cyclic AMP-dependent phospho- Kulaksiz, H., Schmid, A., Honscheid, M., Eissele, R., Klempnauer, J., and rylation. J. Membr. Biol. 115, 203–215. doi: 10.1007/BF01868636 Cetin, Y. (2001). Guanylin in the human pancreas: a novel luminocrine Gray, M. A., Harris, A., Coleman, L., Greenwell, J. R., and Argent, B. E. (1989). Two regulatory pathway of electrolyte secretion via cGMP and CFTR in types of chloride channel on duct cells cultured from human fetal pancreas. Am. the ductal system. Histochem. Cell Biol. 115, 131–145. doi: 10.1007/ J. Physiol. 257, C240–C251.
Grotmol, T., Buanes, T., Bros, O., and Raeder, M. G. (1986). Lack of effect of Leal, D. B., Streher, C. A., Neu, T. N., Bittencourt, F. P., Leal, C. A., da Silva, amiloride, furosemide, bumetanide and triamterene on pancreatic NaHCO3 J. E., et al. (2005). Characterization of NTPDase (NTPDase1; ecto-apyrase; secretion in pigs. Acta Physiol. Scand. 126, 593–600. doi: 10.1111/j.1748- ecto-diphosphohydrolase; CD39; EC 184.108.40.206) activity in human lymphocytes.
Biochim. Biophys. Acta 1721, 9–15. doi: 10.1016/j.bbagen.2004.09.006 Guffey, S., Esbaugh, A., and Grosell, M. (2011). Regulation of apical H+- Lee, M. G., and Muallem, S. (2008). Pancreatitis: the neglected duct. Gut 57, ATPase activity and intestinal HCO− secretion in marine fish osmoregula- 1037–1039. doi: 10.1136/gut.2008.150961 tion. Am. J. Physiol. Regul. Integr. Comp. Physiol. 301, R1682–R1691. doi: Lee, M. G., Ohana, E., Park, H. W., Yang, D., and Muallem, S. (2012). Molecular mechanism of pancreatic and salivary gland fluid and HCO− secretion. Physiol. Haanes, K. A., and Novak, I. (2010). ATP storage and uptake by isolated pancreatic Rev. 92, 39–74. doi: 10.1152/physrev.00011.2011 zymogen granules. Biochem. J. 429, 303–311. doi: 10.1042/BJ20091337 Lenertz, L. Y., Gavala, M. L., Zhu, Y., and Bertics, P. J. (2011). Transcriptional Haanes, K. A., Schwab, A., and Novak, I. (2012). The P2X7 receptor supports both control mechanisms associated with the nucleotide receptor P2X7, a critical reg- life and death in fibrogenic pancreatic stellate cells. PLoS ONE 7:e51164. doi: ulator of immunologic, osteogenic, and neurologic functions. Immunol. Res. 50, 22–38. doi: 10.1007/s12026-011-8203-4 Hayashi, M., and Novak, I. (2013). Molecular basis of potassium channels in Liu, X., Ma, W., Surprenant, A., and Jiang, L. H. (2009). Identification of the pancreatic duct epithelial cells. Channels (Austin) 7, 1–10. doi: 10.4161/chan.
amino acid residues in the extracellular domain of rat P2X(7) receptor involved in functional inhibition by acidic pH. Br. J. Pharmacol. 156, 135–142. doi: Hayashi, M., Wang, J., Hede, S. E., and Novak, I. (2012). An intermediate- conductance Ca2+-activated K+ channel is important for secretion in pancre- Namkung, W., Lee, J. A., Ahn, W., Han, W., Kwon, S. W., Ahn, D. S., et al. (2003).
atic duct cells. Am. J. Physiol. Cell Physiol. 303, C151–C159. doi: 10.1152/ajp- Ca2+ activates cystic fibrosis transmembrane conductance regulator- and Cl− - dependent HCO3 transport in pancreatic duct cells. J. Biol. Chem. 278, 200–207.
Hede, S. E., Amstrup, J., Christoffersen, B. C., and Novak, I. (1999). Purinoceptors evoke different electrophysiological responses in pancreatic ducts. P2Y inhibits Niv, Y., and Fraser, G. M. (2002). The alkaline tide phenomenon. J. Clin. K+ conductance, and P2X stimulates cation conductance. J. Biol. Chem. 274, Gastroenterol. 35, 5–8. doi: 10.1097/00004836-200207000-00003 31784–31791. doi: 10.1074/jbc.274.45.31784 Novak, I. (2008). Purinergic receptors in the endocrine and exocrine pancreas.
Hede, S. E., Amstrup, J., Klaerke, D. A., and Novak, I. (2005). P2Y2 and P2Y4 recep- Purinergic Signal. 4, 237–253. doi: 10.1007/s11302-007-9087-6 tors regulate pancreatic Ca2+-activated K+ channels differently. Pflugers Arch.
Novak, I. (2011). Purinergic signaling in epithelial ion transport—regulation of 450, 429–436. doi: 10.1007/s00424-005-1433-3 secretion and absorption. Acta Physiologica 202, 501–522. doi: 10.1111/j.1748- Hegyi, P., Maleth, J., Venglovecz, V., and Rakonczay, Z. Jr. (2011a). Pancreatic ductal bicarbonate secretion: challenge of the acinar Acid load. Front. Physiol. 2:36. doi: Novak, I., and Greger, R. (1988). Electrophysiological study of transport systems in isolated perfused pancreatic ducts: properties of the basolateral membrane.
Hegyi, P., Pandol, S., Venglovecz, V., and Rakonczay, Z. Jr. (2011b). The acinar- Pflügers Arch. 411, 58–68. doi: 10.1007/BF00581647 ductal tango in the pathogenesis of acute pancreatitis. Gut 60, 544–552. doi: Novak, I., and Greger, R. (1991). Effect of bicarbonate on potassium conduc- tance of isolated perfused rat pancreatic ducts. Pflügers Arch. 419, 76–83. doi: Inglis, S. K., Wilson, S. M., and Olver, R. E. (2003). Secretion of acid and base equivalents by intact distal airways. Am. J. Physiol. Lung. Cell Mol. Physiol. 284, Novak, I., Hede, S. E., and Hansen, M. R. (2008). Adenosine receptors in rat L855–L862. doi: 10.1152/ajplung.00348.2002 and human pancreatic ducts stimulate chloride transport. Pflugers Arch. 456, Ishiguro, H., Naruse, S., Kitagawa, M., Hayakawa, T., Case, R. M., and Steward, 437–447. doi: 10.1007/s00424-007-0403-3 M. C. (1999). Luminal ATP stimulates fluid and HCO− secretion in guinea- Novak, I., Jans, I. M., and Wohlfahrt, L. (2010). Effect of P2X7 receptor knockout pig pancreatic duct. J. Physiol. (Lond) 519, 551–558. doi: 10.1111/j.1469- on exocrine secretion of pancreas, salivary glands and lacrimal glands. J. Physiol. (Lond) 588(pt 18), 3615–3627. doi: 10.1113/jphysiol.2010.190017 Ishiguro, H., Steward, M. C., Wilson, R. W., and Case, R. M. (1996). Bicarbonate Novak, I., Wang, J., Henriksen, K. L., Haanes, K. A., Krabbe, S., Nitschke, R., et al.
secretion in interlobular ducts from guinea-pig pancreas. J. Physiol. (Lond.) 495 (2011). Pancreatic bicarbonate secretion involves two proton pumps. J. Biol. (pt 1), 179–191.
Chem. 286, 280–289. doi: 10.1074/jbc.M110.136382 Jung, J., Nam, J. H., Park, H. W., Oh, U., Yoon, J. H., and Lee, M. G. (2013).
Novak, I., and Young, J. A. (1986). Two independent anion transport sys- Dynamic modulation of ANO1/TMEM16A. Proc. Natl. Acad. Sci. U.S.A. 110, tems in rabbit mandibular salivary glands. Pflugers Arch. 407, 649–656. doi: 360–365. doi: 10.1073/pnas.1211594110 Jung, S. R., Kim, K., Hille, B., Nguyen, T. D., and Koh, D. S. (2006). Pattern of Ca2+ Pahl, C., and Novak, I. (1993). Effect of vasoactive intestinal peptide, carbachol and increase determines the type of secretory mechanism activated in dog pancreatic other agonists on cell membrane voltage of pancreatic duct cells. Pflügers Arch.
duct epithelial cells. J. Physiol. 576, 163–178. doi: 10.1113/jphysiol.2006.114876 424, 315–320. doi: 10.1007/BF00384358 Jung, S. R., Kim, M. H., Hille, B., Nguyen, T. D., and Koh, D. S. (2004). Regulation Pallagi, P., Venglovecz, V., Rakonczay, Z. Jr., Borka, K., Korompay, A., Ozsvari, B., of exocytosis by purinergic receptors in pancreatic duct epithelial cells. Am. J. et al. (2011). Trypsin reduces pancreatic ductal bicarbonate secretion by inhibit- Physiol. Cell Physiol. 286, C573–C579. doi: 10.1152/ajpcell.00350.2003 ing CFTR Cl channels and luminal anion exchangers. Gastroenterology 141, King, B. F., Ziganshina, L. E., Pintor, J., and Burnstock, G. (1996). Full sensitiv- 2228–2239. doi: 10.1053/j.gastro.2011.08.039 ity of P2X2 purinoceptor to ATP revealed by changing extracellular pH. Br. J. Park, S., Shcheynikov, N., Hong, J. H., Zheng, C., Suh, S. H., Kawaai, K., Pharmacol. 117, 1371–1373. doi: 10.1111/j.1476-5381.1996.tb15293.x et al. (2013). Irbit mediates synergy between Ca2+ and cAMP signaling path- Kittel, A., Pelletier, J., Bigonnesse, F., Guckelberger, O., Kordas, K., Braun, N., ways during epithelial transport in mice. Gastroenterology 145, 232–241. doi: et al. (2004). Localization of Nucleoside Triphosphate Diphosphohydrolase-1 Novak et al.
Acid-base transport in pancreas Pascua, P., Garcia, M., Fernandez-Salazar, M. P., Hernandez-Lorenzo, M. P., Calvo, Ca2+-activated potassium channels in pancreatic duct epithelial cells. Gut 60, J. J., Colledge, W. H., et al. (2009). Ducts isolated from the pancreas of CFTR- 361–369. doi: 10.1136/gut.2010.214213 null mice secrete fluid. Pflugers Arch. 459, 203–214. doi: 10.1007/s00424-009- Venglovecz, V., Rakonczay, Z. Jr., Ozsvari, B., Takacs, T., Lonovics, J., Varro, A., et al.
(2008). Effects of bile acids on pancreatic ductal bicarbonate secretion in guinea Pedersen, S. F., Hoffmann, E. K., and Novak, I. (2013). Cell volume reg- pig. Gut 57, 1102–1112. doi: 10.1136/gut.2007.134361 ulation in epithelial physiology and cancer. Front. Physiol. 4, 233. doi: Villanger, O., Veel, T., and Raeder, M. G. (1995). Secretin causes H+/HCO− secretion from pig pancreatic ductules by vacuolar-type H+-adenosine triphos- Poulsen, J. H., and Machen, T. E. (1996). HCO3-dependent pHi regulation in tra- phatase. Gastroenterology 108, 850–859. doi: 10.1016/0016-5085(95)90460-3 cheal epithelial cells. Pflugers Arch. 432, 546–554. doi: 10.1007/s004240050168 Wang, J., Haanes, K. A., and Novak, I. (2013). Purinergic regulation of CFTR Roussa, E., Alper, S. L., and Thevenod, F. (2001). Immunolocalization of and Ca2+-activated Cl− channels and K+ channels in human pancreatic duct anion exchanger AE2, Na+/H+ exchangers NHE1 and NHE4, and vacuolar epithelium. Am. J. Physiol. Cell Physiol. 304, C673–C684. doi: 10.1152/ajp- type H+-ATPase in rat pancreas. J. Histochem. Cytochem. 49, 463–474. doi: Wang, J., and Novak, I. (2013). Ion transport in human pancreatic duct epithe- Rucker, B., Almeida, M. E., Libermann, T. A., Zerbini, L. F., Wink, M. R., and Sarkis, lium, Capan-1 cells, is regulated by secretin, VIP, acetylcholine, and purinergic J. J. (2008). E-NTPDases and ecto-5'-nucleotidase expression profile in rat heart receptors. Pancreas 42, 452–460. doi: 10.1097/MPA.0b013e318264c302 left ventricle and the extracellular nucleotide hydrolysis by their nerve terminal Wang, T., Busk, M., and Overgaard, J. (2001). The respiratory consequences of feed- endings. Life Sci. 82, 477–486. doi: 10.1016/j.lfs.2007.12.003 ing in amphibians and reptiles. Comp. Biochem. Physiol. A Mol. Integr. Physiol. Rune, S. J., and Lassen, N. A. (1968). Diurnal variations in the acid-base balance of 128, 535–549. doi: 10.1016/S1095-6433(00)00334-2 blood. Scand. J. Clin. Lab. Invest. 22, 151–156. doi: 10.3109/00365516809160961 Wieczorek, H., Beyenbach, K. W., Huss, M., and Vitavska, O. (2009). Vacuolar- Sachs, G., Shin, J. M., and Hunt, R. (2010). Novel approaches to inhibition of gastric type proton pumps in insect epithelia. J. Exp. Biol. 212, 1611–1619. doi: acid secretion. Curr. Gastroenterol. Rep. 12, 437–447. doi: 10.1007/s11894-010- Wildman, S. S., Unwin, R. J., and King, B. F. (2003). Extended pharmacological pro- Sachs, G., Shin, J. M., Vagin, O., Lambrecht, N., Yakubov, I., and Munson, K.
files of rat P2Y2 and rat P2Y4 receptors and their sensitivity to extracellular H+ (2007). The gastric H,K ATPase as a drug target: past, present, and future. J. Clin. and Zn2+ ions. Br. J. Pharmacol. 140, 1177–1186. doi: 10.1038/sj.bjp.0705544 Gastroenterol. 41 (Suppl. 2), S226–S242. doi: 10.1097/MCG.0b013e31803233b7 Wiley, J. S., Sluyter, R., Gu, B. J., Stokes, L., and Fuller, S. J. (2011). The human Schroeder, B. C., Cheng, T., Jan, Y. N., and Jan, L. Y. (2008). Expression cloning P2X7 receptor and its role in innate immunity. Tissue Antigens 78, 321–332. doi: of TMEM16A as a calcium-activated chloride channel subunit. Cell 134, 1019–1029. doi: 10.1016/j.cell.2008.09.003 Wilschanski, M., and Novak, I. (2013). The cystic fibrosis of exocrine pancreas. Cold Seow, K. T. F. P., Case, R. M., and Young, J. A. (1991). Pancreatic secretion by Spring Harb. Perspect. Med. 3, a009746. doi: 10.1101/cshperspect.a009746 the anaesthetized rabbit in response to secretin, cholecystokinin, and carbachol.
Winpenny, J. P., Harris, A., Hollingsworth, M. A., Argent, B. E., and Gray, M.
Pancreas 6, 385–391. doi: 10.1097/00006676-199107000-00002 A. (1998). Calcium-activated chloride conductance in a pancreatic adenocarci- Sewell, W. A., and Young, J. A. (1975). Secretion of electrolytes by the pancreas of noma cell line of ductal origin (HPAF) and in freshly isolated human pancreatic the anaesthetized rat. J. Physiol. (Lond.) 252, 379–396.
duct cells. Pflugers Arch. 435, 796–803. doi: 10.1007/s004240050586 Shan, J., Liao, J., Huang, J., Robert, R., Palmer, M. L., Fahrenkrug, S. C., et al.
Wood, C. M., Bucking, C., and Grosell, M. (2010). Acid-base responses to feed- (2012). Bicarbonate-dependent chloride transport drives fluid secretion by ing and intestinal Cl− uptake in freshwater- and seawater-acclimated killi- the human airway epithelial cell line Calu-3. J. Physiol. 590, 5273–5297. doi: fish, Fundulus heteroclitus, an agastric euryhaline teleost. J. Exp. Biol. 213, 2681–2692. doi: 10.1242/jeb.039164 Shirakabe, K., Priori, G., Yamada, H., Ando, H., Horita, S., Fujita, T., et al. (2006).
Yang, D., Shcheynikov, N., Zeng, W., Ohana, E., So, I., Ando, H., et al. (2009). IRBIT IRBIT, an inositol 1,4,5-trisphosphate receptor-binding protein, specifically coordinates epithelial fluid and HCO− secretion by stimulating the transporters binds to and activates pancreas-type Na+/HCO− cotransporter 1 (pNBC1).
pNBC1 and CFTR in the murine pancreatic duct. J. Clin. Invest. 119, 193–202.
Proc. Natl. Acad. Sci. U.S.A. 103, 9542–9547. doi: 10.1073/pnas.0602250103 doi: 10.1172/JCI36983 Smith, J. J., and Welsh, M. J. (1993). Fluid and electrolyte transport by cultured Yang, Y. D., Cho, H., Koo, J. Y., Tak, M. H., Cho, Y., Shim, W. S., et al. (2008).
human airway epithelia. J. Clin. Invest. 91, 1590–1597. doi: 10.1172/JCI116365 TMEM16A confers receptor-activated calcium-dependent chloride conduc- Sørensen, C. E., Amstrup, J., Rasmussen, H. N., Ankorina-Stark, I., and Novak, tance. Nature 455, 1210–1215. doi: 10.1038/nature07313 I. (2003). Rat pancreas secretes particulate ecto-nucleotidase CD39. J. Physiol. Yegutkin, G. G., Samburski, S. S., Jalkalen, S., and Novak, I. (2006). ATP- (Lond.) 551, 881–892. doi: 10.1113/jphysiol.2003.049411 consuming and ATP-generating enzymes secreted by pancreas. J. Biol. Chem. Sørensen, C. E., and Novak, I. (2001). Visualization of ATP release in pancreatic 281, 29441–29447. doi: 10.1074/jbc.M602480200 acini in response to cholinergic stimulus. Use of fluorescent probes and confocal You, C. H., Rominger, J. M., and Chey, W. Y. (1983). Potentiation effect of microscopy. J. Biol. Chem. 276, 32925–32932. doi: 10.1074/jbc.M103313200 cholecystokinin-octapeptide on pancreatic bicarbonate secretion stimulated by Steward, M. C., and Ishiguro, H. (2009). Molecular and cellular regulation of a physiologic dose of secretin in humans. Gastroenterology 85, 40–45.
pancreatic duct cell function. Curr. Opin. Gastroenterol. 25, 447–453. doi: Zhao, H., Star, R. A., and Muallem, S. (1994). Membrane localization of H+ and HCO− transporters in the rat pancreatic ducts. J. Gen. Physiol. 104, 57–85. doi: Steward, M. C., Ishiguro, H., and Case, R. M. (2005). Mechanisms of bicarbon- ate secretion in the pancreatic duct. Annu. Rev. Physiol. 67, 377–409. doi:10.1146/annurev.physiol.67.031103.153247 Conflict of Interest Statement: The authors declare that the research was con-
Surprenant, A., and North, R. A. (2009). Signaling at purinergic P2X recep- ducted in the absence of any commercial or financial relationships that could be tors. Annu. Rev. Physiol. 71, 333–359. doi: 10.1146/annurev.physiol.70.113006.
construed as a potential conflict of interest.
Szalmay, G., Varga, G., Kajiyama, F., Yang, X. S., Lang, T. F., Case, R. M., et al.
Received: 07 October 2013; paper pending published: 23 October 2013; accepted: 04 (2001). Bicarbonate and fluid secretion evoked by cholecystokinin, bombesin December 2013; published online: 20 December 2013. and acetylcholine in isolated guinea-pig pancreatic ducts. J. Physiol. (Lond.) 535, Citation: Novak I, Haanes KA and Wang J (2013) Acid-base transport in pancreas— 795–807. doi: 10.1111/j.1469-7793.2001.00795.x new challenges. Front. Physiol. 4:380. doi:
Tresguerres, M., Buck, J., and Levin, L. R. (2010). Physiological carbon dioxide, This article was submitted to Membrane Physiology and Membrane Biophysics, a bicarbonate, and pH sensing. Pflugers Arch. 460, 953–964. doi: 10.1007/s00424- section of the journal Frontiers in Physiology. Copyright 2013 Novak, Haanes and Wang. This is an open-access article dis- Uc, A., Stoltz, D. A., Ludwig, P., Pezzulo, A., Griffin, M., bu-El-Haija, M., et al.
tributed under the terms of the The (2011). Pancreatic and biliary secretion differ in cystic fibrosis and wild-type use, distribution or reproduction in other forums is permitted, provided the original pigs. J. Cystic Fibrosis 10, S69. doi: 10.1016/S1569-1993(11)60285-3 author(s) or licensor are credited and that the original publication in this jour- Venglovecz, V., Hegyi, P., Rakonczay, Z. Jr., Tiszlavicz, L., Nardi, A., Grunnet, nal is cited, in accordance with accepted academic practice. No use, distribution or M., et al. (2011). Pathophysiological relevance of apical large-conductance reproduction is permitted which does not comply with these terms.
Age and Ageing 2015; 44: 213–218 © The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society. This is an Open Access article distributed under the terms of the Creative Commons Attribution Published electronically 16 October 2014 Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is
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