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Am J Physiol Renal Physiol 290: F1437-F1442, 2006. First published December 27, 2005; doi:10.1152/ajprenal.00449.2005
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Molecular characterization of the mercurial sensitivity of a frog urea transporter (fUT)

Gavin S. Stewart,1 Craig P. Smith,1 and Gordon J. Cooper2

2Department of Biomedical Science, University of Sheffield, Sheffield; and 1Faculty of Life Sciences, University of Manchester, Manchester, United Kingdom

Submitted 10 November 2005 ; accepted in final form 20 December 2005


    ABSTRACT
 TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 GRANTS
 REFERENCES
 
The amphibian urea transporter (fUT) shares many properties with the mammalian urea transporters (UT) derived from UT-A and UT-B genes. The transport of urea by fUT is inhibited by the mercurial agent p-chloromercuribenzenesulfonic acid (pCMBS). We found that in oocytes expressing cRNA encoding fUT, a 5-min preincubation in 0.5 mM mercury chloride (HgCl2) also significantly reduced urea uptake. The transport of urea by fUT was rendered mercury (Hg2+) insensitive by mutating either of the residues C185 or H187, both of which lie within the M-I region (close to the hypothetical UT pore). In oocytes expressing a mixture of the C185 and H187 mutants, Hg2+ sensitivity was reestablished. The transport of urea by the mouse UTs mUT-A2 and mUT-A3 was not sensitive to Hg2+. Introducing cysteine residues analogous to that mutated in fUT into mUT-A2 or mUT-A3 did not induce Hg2+ sensitivity. Additionally, introducing the double cysteine, histidine mutations into mUT-A2 or mUT-A3 still did not induce Hg2+ sensitivity, indicating that a region outside of the M-I region also contributes to the Hg2+-induced block of fUT. Using a series of chimeras formed between UT-A3 and fUT, we found that as well as C185 and H187, residues within the COOH terminal of fUT determine Hg2+ sensitivity, and we propose that differences in the folding of this region between fUT and mUT-A2/mUT-A3 allow access of Hg2+ to the fUT channel pore.

mercury chloride; Xenopus laevis oocyte


THE ABILITY OF THE MAMMALIAN kidney to maximally concentrate urine requires the inner medullary interstitium to be hypertonic compared with plasma, with the small solute urea contributing ~50% to inner medullary hypertonicity. The transport of urea across membranes is facilitated by the urea transporter (UT) proteins. In mammals, these transporters are derived from two genes, UT-A and UT-B (reviewed in Ref. 18). The major UT-A isoforms 1–3 are expressed in the nephron. UT-A1 and UT-A3 are present in the inner medullary collecting duct (IMCD) (3, 4, 7, 19), and UT-A2 is expressed in the thin descending limb of the loop of Henle (19).

The frog urinary bladder expresses a urea transporter (fUT) that has a high identity (66% at the amino acid level) to UT-A2 and UT-B (61%). In terms of its transport properties, fUT appears to be a hybrid transporter, sharing properties of both the UT-A and UT-B proteins. Like all UTs identified to date, fUT produces a phloretin-sensitive increase in membrane urea permeability (reviewed in Ref. 16). As is the case for the UT-A family, fUT is impermeable to the urea analog thiourea, whereas UT-B is permeable to thiourea (2, 9). Thiourea reduces urea transport in oocytes expressing either UT-A or UT-B (9). Similarly, the transport of urea by fUT is sensitive to thiourea (2). Finally, like the UT-B proteins, fUT is inhibited by the organic mercurial (pCMBS) (12), whereas the transport of urea by the UT-A isoforms when expressed in Xenopus laevis oocytes is insensitive to pCMBS (9).

Very little is known about the membrane topology of the urea transporters and how they interact to produce a functional urea pore. Initial analysis of the sequence of UTs using the Kyte-Doolittle algorithm predicted proteins with intracellular NH2 and COOH termini, with 10 transmembrane spans, split by a large extracellular loop containing a N-linked glycosylation site (21). A more detailed analysis by Sands et al. (15) proposed a model with six membrane-spanning domains, split into two groups separated by a large extracellular loop (see Fig. 1). This model also predicts a short-integral membrane domain that dips into the membrane from the external face. This theoretical short-integral membrane domain, which has been designated the M-I region (15) (Fig. 1A), resembles membrane loops described for many channel proteins, such as the water channel aquaporin-1 (AQP1) (6). In the case of AQP1, the second asparagine-proline-alanine (NPA)-containing domain, which is crucial to the formation of the channel pore, would be analogous to the M-I region in the UTs. It seems feasible that the M-I loop of the UTs might fulfill a similar role and could be linked to the formation of a channel pore. The M-I region is highly conserved among UTs. The similarity between UT-A2, UT-A3, and fUT in the M-I region is on the order of 90%, and the similarity between fUT and mUT-B in this domain is 70% (Fig. 1).


Figure 1
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Fig. 1. Predicted topological structure of frog urea transporter (fUT). Top: predicted topological map for fUT based on the Sands et al. (15) model. The M-I domain is indicated by the dotted line. Bottom: table showing a comparison of the residues in the M-I region for mUT-A2, mUT-A3, hUT-B, and fUT, where m indicates mouse and h, human. Residues shown on a gray background are identical to mUT-A2, and differences are indicated by residues on a white background.

 
Like fUT and UT-B, the water channel AQP1 is inhibited by mercurial agents such as mercury chloride (HgCl2) and pCMBS (1, 13). The molecular basis of the mercurial sensitivity of AQP1 has been established and involves the cysteine residue at position 189 (14). Mutation of this cysteine to a serine residue (AQP1-C189S) renders AQP1 insensitive to mercurials. The C189 residue is close to the second NPA motif in AQP1, and in the hourglass model of AQP1 it was predicted that the C189 residue bordered the opening of the channel pore on the extracellular face of the protein (6). This prediction has been confirmed by analysis of the three-dimensional crystal structure of AQP1 (11). The mercurial-induced inhibition of human UT-B (hUT-B) has been investigated, but the basis of mercurial sensitivity was not established (8). Two individual cysteine residues were mutated (C151 and C236), but mercurial sensitivity remained intact (8). Besides these two cysteine residues, there are no immediate candidates in the region bordering the M-I loop that might account for the mercurial sensitivity of hUT-B.

We predict that residues in the M-I region confer Hg2+ sensitivity to fUT, and we have used a combination of point mutants in fUT and chimeras between fUT and mUT-A3 to test this hypothesis. We identified two residues (a cysteine and histidine), which both lie in the M-I domain, that are required to produce Hg2+-dependent inhibition of urea transport by fUT.


    METHODS
 TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 GRANTS
 REFERENCES
 
Solutions. The control amphibian Ringer solution (ND-96) contained (in mM) 96 NaCl, 2 KCl, 1.8 CaCl2, 1 MgCl2, and 5 HEPES. For the calcium-free ND-96 solution, CaCl2 was replaced by NaCl. The OR3 solution contained 6.85 g/l of Leibovitz L-15 cell culture medium (Invitrogen, Paisley, UK); 10,000 U/ml penicillin G sodium; 10,000 µg/ml streptomycin sulfate (Invitrogen); and 5 mM HEPES. The urea uptake solution contained (in mM) 1 urea, 1 KCl, 1 MgCl2, 1.8 CaCl2, 175 mannitol, and 5 HEPES. The uptake solution was supplemented with 2.67 µCi [14C]urea/ml. The stop solution contains (in mM) 10 urea, 1 KCl, 1.8 CaCl2, 1 MgCl2, 165 mannitol, and 5 HEPES. The pH of all solutions was adjusted to 7.5 using HCl, NaOH, or KOH as appropriate, and the osmolarity was adjusted to 195 ± 5 mosmol/kgH2O using NaCl, H2O, or mannitol. HgCl2 was prepared freshly as a stock solution of 100 mM in H2O and added to ND-96 to give a final concentration of 0.5 mM.

Isolation and injection of X. laevis oocytes. Mature female X. laevis were killed using a procedure approved by the University of Sheffield Field Laboratories and in accordance with current UK legislation. The ovarian lobes were removed, and oocytes were isolated as described in depth previously (1). Briefly, oocytes were isolated from lobes and agitated in calcium-free ND-96 for 60 min. This was followed by two 20-min incubations in calcium-free ND-96 containing 2 mg/ml collagenase type I (Sigma, Poole, UK), separated by a 15-min wash in calcium-free ND-96. Following the second collagenase treatment, the oocytes were washed in calcium-free ND-96 for 30 min. The isolation was completed with a 30-min wash in standard ND-96. The oocytes were transferred to OR3 media and sorted by size and stage. Stage V and stage VI oocytes were selected for injection.

Oocytes were injected with 1 ng of cRNA (50 nl of a 0.02 µg/µl cRNA solution) or an equal volume of water using a Drummond microinjector (Drummond Instruments, Broomall, PA). The oocytes were incubated at 18°C in OR3, and experiments were performed on day 3 or 4 following injection.

Urea uptake. Uptake experiments were performed in 12-well plates using a protocol based on those described previously (17). Before uptake was measured, oocytes were placed in ND-96. The ND-96 solution was removed, and the uptake solution was added. At the end of the uptake period (90 s), ice-cold stop solution was added to the halt the uptake. This was followed by three rapid washes in ice-cold stop solution. The oocytes were transferred individually to scintillation tubes and dissolved in 10% SDS. The amount of 14C in each oocyte was measured by scintillation counting. Where necessary, the oocytes were preincubated in ND-96 containing 0.5 mM HgCl2 for 5 min before the uptake phase. We found that addition of HgCl2 to the uptake solution caused a precipitate to form; therefore, the uptake measurements were carried out in the absence of HgCl2.

Preparation of cRNA. In all cases, capped cRNA was synthesized using an Ambion mMessage mMachine kit (Ambion, Huntingdon, UK). The cDNA encoding for fUT was a gift from Dr. G. Rousselet (Institut National de la Santé et de la Recherche Médicale). The gene encoding fUT had previously been subcloned into the pT7TS Xenopus expression vector (2). The plasmid was linearized using BamH1, and cRNA was prepared using T7 polymerase. The mUT-A2 and mUT-A3 clones were inserted in the pT7TS Xenopus expression vector. The plasmid was linearized with Not1, and cRNA was prepared using T7 polymerase.

Production of single- and double-point mutations. Point mutations were introduced into fUT, mUT-A2, and mUT-A3 using the QuikChange protocol (Stratagene). In fUT, the C185S mutation was created by changing TGC to AGC, and the H187Y mutation was created by changing CAC to TAC. In mUT-A2, the T184C mutation was created by changing ACC to TGC, and in the double CH mutation Y186 was mutated from TAC to CAC. In mUT-A3, T254 was mutated by changing ACA to TGC, and in the double CH mutation Y256 was altered from TAC to CAT. The mutations were confirmed by nucleotide sequencing.

Production of fUT/mUT-A3 chimeras. To facilitate the production of chimeras, between fUT and mUT-A3 restriction endonuclease sites were silently engineered into fUT and mUT-A3 using site-directed mutagenesis. The design of the restriction sites was facilitated by the SILMUT software package (11). A StuI site was produced at residues 129–131 of fUT and residues 198–200 of mUT-A3. A NheI site was engineered in fUT between residues 268 and 270. mUT-A3 already contains an Nhe1 site between residues 337 and 339. Three chimeras were formed: mUT-A3/fUTM, mUT-A3/fUTF, and mUT-A3/fUTB (see Fig. 5A for a diagrammatic representation of the composition of each chimera).


Figure 5
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Fig. 5. Effect of Hg2+ on the urea permeability of mUT-A3/fUT chimeras. A: diagrammatic representation of the components used to form each of the 3 chimeras used in this study. B and C: effect of a 5-min incubation in 0.5 mM Hg2+ on the uptake of urea in oocytes expressing the chimeras mUT-A3/fUTM (B) and mUT-A3/fUTF and mUT-A3/fUTB (C), respectively. Values are means ± SE, with the no. of observations in parentheses. *Significantly different from the paired control group as judged by ANOVA and subsequent treatment comparison, P < 0.05.

 
Statistics. Unless otherwise stated, results are presented as means ± SE. Analysis was performed using paired t-tests or ANOVA as appropriate, and significance is assumed at the 5% level. If ANOVA indicated a difference between groups, further comparison was performed using the Student-Newman-Keuls method with InStat (GraphPad Software, San Diego, CA).


    RESULTS
 TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 GRANTS
 REFERENCES
 
Effect of HgCl2 on urea uptake by oocytes expressing fUT. In initial experiments, we discovered that a 5-min preincubation in 0.5 mM HgCl2 inhibits urea transport in oocytes expressing fUT (Fig. 2A). The rat and rabbit UT-A isoforms are insensitive to mercurials (9), but this property has not been investigated for the mUT-A isoforms. A 5-min preincubation in HgCl2 had no effect on the uptake of urea in oocytes expressing mUT-A2 (Fig. 2B) or mUT-A3 (Fig. 2C).


Figure 2
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Fig. 2. Effect of cysteine mutations on urea uptake by fUT, mUT-A2, and mUT-A3. A: uptake of urea by oocytes injected with H2O or expressing cRNA encoding for fUT or its C185S mutant in the absence (open bars) or after a 5-min preincubation in 0.5 mM HgCl2 (filled bars). Values are means ± SE, with the no. of observations in parentheses. *Significantly different from the paired control group as judged by ANOVA and subsequent treatment comparison, P < 0.001. B and C: results of the same protocol performed on oocytes expressing mUT-A2 and its T184C mutant or mUT-A3 and its T254C mutant, respectively.

 
Effect of HgCl2 on uptake of urea by oocytes expressing fUT-C185S, mUT-A2-T184C, or mUT-A3-T254C mutants. The alignment in the M-I region between fUT, mUT-A2, and mUT-A3 highlights a cysteine residue at position 185 in fUT, which is absent in mUT-A2 and mUT-A3 (Fig. 1). This C185 residue in fUT was mutated to a serine. The fUT-C185S mutant transported urea (Fig. 2A), but following preincubation in HgCl2 for 5 min there was no significant reduction in urea uptake.

Cysteine residues were introduced into the equivalent positions in mUT-A2 (T184C) and mUT-A3 (T254C). Introduction of the cysteine residues into UT-A2 and UT-A3 did not effect urea transport (Fig. 2, B and C). Preincubation in HgCl2 for 5 min had no effect on urea uptake compared with paired control experiments.

Role of H187 in the sensitivity of fUT to HgCl2. The lack of effect of introducing cysteine residues into mUT-A2 and mUT-A3 suggests that there are either significant differences in structure between fUT and mUT-A2/mUT-A3 and/or other residues are involved in the inhibition of fUT by HgCl2. In fUT, close to C185 there is a histidine residue (H187) that is absent in mUT-A2 and mUT-A3 (Fig. 1). As well as being able to interact with cysteine residues, Hg2+ can also interact with histidine residues (20). The fUT-H187Y mutation was produced (tyrosine occupies the equivalent position in mUT-A2 and mUT-A3; see Fig. 1A). When expressed in oocytes, the fUT-H187Y mutant transported urea effectively (Fig. 3A), but there was no reduction in urea transport following a 5-min preincubation in HgCl2 (Fig. 3A).


Figure 3
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Fig. 3. Effect of histidine or double cysteine-histidine mutations on Hg2+-sensitive urea uptake. AC: effect of a 5-min preincubation in 0.5 mM Hg2+ on uptake of urea by oocytes injected with H2O or expressing the fUT-H187Y (A), the mUT-A2 double T184C-Y186H mutant (B), or the mUT-A3 double T254C-Y256H mutant (C). Values are means ± SE, with the no. of observations in parentheses. *Significantly different from the paired control group as judged by ANOVA and subsequent treatment comparison, P < 0.05.

 
Effect of HgCl2 on urea transport by oocytes expressing the double T184C-Y186H mUT-A2 mutant and the T254C-Y256H mUT-A3 mutant. The results indicate that both Cys185 and His187 are required for Hg2+ to exert an effect on fUT. As introducing the C184 and C254 residues in mUT-A2 and mUT-A3, respectively, by themselves were not sufficient to introduce Hg2+ sensitivity, the double mUT-A2-T184C-Y186H and mUT-A3-T254C-Y256H mutants were produced. These mutants were functional (Fig. 3, B and C); however, after a 5-min preincubation in Hg2+, there was no reduction in urea permeability compared with control.

Effect of HgCl2 on urea transport by oocytes coexpressing the fUT-C185S and fUT-H187Y mutants. C185 and H187 are required for Hg2+ to have an effect on fUT. In oocytes injected with cRNA encoding C185S or H187Y individually, Hg2+ had no effect on urea permeability (Figs. 2A and 3A). However, when oocytes were injected with a mix of cRNAs encoding for the C185S and H187Y mutants (in the ratio 1:1), Hg2+ sensitivity was reinstated and a 5-min preincubation in HgCl2 significantly reduced urea uptake (Fig. 4).


Figure 4
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Fig. 4. Effect of Hg2+ on urea uptake in oocytes injected with H2O or expressing cRNA encoding for a mixture of the fUT-C185S and fUT-H187Y mutants after a 5-min preincubation in 0.5 mM Hg2+. Values are means ± SE, with the no. of observations in parentheses. *Significantly different from the paired control group as judged by ANOVA and subsequent treatment comparison, P < 0.001.

 
Effect of HgCl2 on fUT/mUTA3 chimeras. The results from double-point mutations indicate that there is a region outside the M-I domain that contributes to the Hg2+ sensitivity of fUT. To pinpoint this region, we constructed a series of fUT/mUT-A3 chimeras (see Fig. 5A). Replacing the central region of mUT-A3 with the equivalent portion of fUT (mUT-A3/fUTM) produced a clone insensitive to Hg2+ (Fig. 5B), indicating that a region in either the NH2 or COOH terminal of the protein is required for Hg2+ sensitivity. Replacing the NH2 terminal of mUT-A3 in the mUT-A3/fUTM chimera with the equivalent sequence from fUT (mUT-A3/fUTF) did not impart Hg2+ sensitivity, indicating that the NH2 terminal of fUT is not involved (Fig. 5C). However, when we replaced the COOH terminal of mUT-A3 in mUT-A3/fUTM with the COOH-terminal region of fUT (mUT-A3/fUTB), we produced a chimera sensitive to Hg2+ (Fig. 5C). This result suggested that the additional region accounting for Hg2+ sensitivity lies in the final 121 amino acids of fUT.


    DISCUSSION
 TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 GRANTS
 REFERENCES
 
The goal of the current study was to identify the basis of mercurial-induced inhibition of urea transport in the amphibian urea transporter fUT. Couriaud et al. (2) demonstrated that fUT is inhibited by the organic mercurial pCMBS. In the current study, we show that fUT is sensitive to HgCl2 and also that mUT-A2 and mUT-A3, when expressed in X. laevis oocytes, are insensitive to Hg2+.

The overall sequence similarity among fUT, UT-A2, and UT-A3 is ~65%, but in the M-I region the homology is much higher, ~90%. Based on our assumption that the M-I region is linked to the formation of the channel pore, and the similarities between this region to pore-forming structures in aquaporins, the M-I region formed the starting point in our search for potential Hg2+ binding sites. Additionally, when the hydropathy profiles of mUT-A2 and fUT (obtained using the Kyte-Doolittle algorithm) were compared (data not shown), we found that the plots closely matched each other and it is fair to assume that the overall membrane topology of these two transporters is similar. Although there was no clear reason that Hg2+ could be interacting with this region of fUT, one difference among mUT-A2, mUT-A3, and fUT in the M-I region is the cysteine residue at position 185 in fUT. The fUT-C185S mutant is insensitive to Hg2+, suggesting that Hg2+ in some way interacts with the C185 residue and that this residue may lie close to the channel pore (as for the C189 residue in AQP1). However, introducing cysteine residues into the equivalent positions in mUT-A2 (T184C) or mUT-A3 (T254C) did not impart Hg2+ sensitivity. There are two possibilities for the lack of Hg2+ sensitivity in the mUT-A2 and mUT-A3 mutants: either more than one residue is involved in the Hg2+ binding, and/or there are differences in the protein folding that prevent Hg2+ from accessing the Hg2+-sensitive site. The inability to recreate Hg2+ sensitivity in proteins is not unusual. In the case of the mercurial-insensitive water channel AQP4, introduction of a cysteine residue into a position equivalent to the C189 residue in AQP1 did not reproduce Hg2+ sensitivity in AQP4 (5).

To address the possibility that additional residues are involved in the Hg2+ inhibition of fUT, we reexamined the sequences of fUT, mUT-A2, and mUT-A3 in the M-I region. Another difference between these three sequences is a histidine residue at position 187 in fUT. Hg2+, as well as binding to cysteine residues, is able to coordinate with histidine residues (20). In fUT, H187 was also found to be critical for the Hg2+-dependent inhibition of urea transport. However, introducing both the cysteine and histidine residues into mUT-A2 or mUT-A3 did not impart Hg2+ sensitivity. The lack of effect of Hg2+ in these double CH mutants of mUT-A2 and mUT-A3 strongly suggests that either residues lying outside of the M-I region are involved in sensitivity of urea transport to Hg2+ or that differences in the folding of mUT-A2/mUT-A3 prevent access of Hg2+ to the M-I region.

To determine whether regions of fUT outside the M-I domain contribute to Hg2+ sensitivity, we constructed a series of chimeras between mUT-A3 and fUT. The results indicate that residues in the final 121 amino acids of fUT contribute to Hg2+ sensitivity. However, a comparison of the COOH-terminal regions of mUT-A2 and mUT-A3 to fUT revealed no residues predicted to interact with mercurials, which were not present in mUT-A2 or mUT-A3. This would suggest that subtle differences in the folding of the COOH terminals of mUT-A2, mUT-A3, and fUT determine the accessibility of crucial residues within the M-I region to mercurials.

The amphibian urea transporter fUT and the mammalian isoform UT-B are sensitive to mercuricals. We have identified two residues which confer Hg2+ sensitivity within fUT. These two residues, C185 and H187, which lie in the putative integral membrane loop M-I, are absent from the UT-B family and suggest that the basis of sensitivity to Hg2+ varies between these two transporters. Interestingly, the cysteine and histidine residues responsible for Hg2+ sensitivity in fUT are preserved in the UTs from other amphibians (Bufo marinus, GenBank accession no. AB212932) and teleost fish (Takifugu rubripes, AB181946 [GenBank] ; Anguilla japonica, AB049726 [GenBank] ; Alcolapia grahami, AF278537 [GenBank] ; Danio rerio, AY788989 [GenBank] ; Opsanus beta, AF165893 [GenBank] ) but not elasmobranchs (Dasyatis sayi, AY277796 [GenBank] and AY277793 [GenBank] ; Triakis scyllium, AB094993 [GenBank] ; Squalus acanthias, AF257331 [GenBank] ). We predict that the UTs from amphibians and teleosts would also exhibit Hg2+ sensitivity, although this remains to be tested.

One surprising result was the rescue of Hg2+ sensitivity in fUT on the coexpression of the C185S and H187Y mutants. To date, there is no understanding of how the functional unit of urea transport forms. Two possibilities exist: each individual unit acts as a stand-alone urea channel, or, as has been proposed in a recent study, the functional urea channel is a dimer (10). While our results support this dimer hypothesis, without further studies it is not possible to exclude alternative explanations.

In conclusion, we have identified two residues in the M-I region that are required to confer Hg2+ sensitivity on the frog urea transporter fUT. Introducing these residues into mUT-A2 or mUT-A3 did not induce Hg2+ sensitivity in these proteins. Chimera studies indicated that addition residue(s) in the COOH terminal of fUT also contributes to Hg2+ sensitivity, although the identity of these residues still needs to be determined.


    GRANTS
 TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 GRANTS
 REFERENCES
 
The financial support of the Royal Society and Kidney Research UK is gratefully acknowledged.


    ACKNOWLEDGMENTS
 
We are grateful to Prof. A. Surprenant for helpful comments during the preparation of this manuscript. The fUT clone was a generous gift from Dr. Germain Rousselet (Institut National de la Santé et de la Recherche Médicale, France).


    FOOTNOTES
 

Address for reprint requests and other correspondence: G. J. Cooper, Dept. of Biomedical Science, Alfred Denny Bldg., Univ. of Sheffield, Sheffield S10 2TN, UK (e-mail: g.j.cooper{at}shef.ac.uk)

The costs of publication of this article were defrayed in part by the payment of page charges. The article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.


    REFERENCES
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 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 GRANTS
 REFERENCES
 

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