Comprehensive analysis of the phenotypes in the wpk rat, human tissue and cells, and experimental systems has provided a much clearer view of defects associated with MKS1 and MKS3 mutation. New cilia-related phenotypes have been identified and structural and numerical ciliary and centrosomal changes characterized, reinforcing the view that MKS is a ciliopathy. However, phenotypic differences between MKS1 and MKS3 and the lack of some characteristic ciliopathy phenotypes show the complexity of this group of disorders and provide clues to function.
A newly identified MKS defect is the lack of outer segment formation in retina of the
wpk rat. This is somewhat akin to the defect in
Bbs1M390R/M390R,
Bbs2−/−,
Bbs4−/− and
Bbs6−/− mice where the outer segment forms but degenerates as the animals age; disease thought to be due to dysfunctional intraflagella transport (IFT) in the connecting cilium (
21,
26–
29). Connecting cilia are present in the
wpk retina but the inner to outer segment interface is disorganized with no evidence of outer segment formation. It, therefore, seems that the level of ciliary dysfunction may be greater than in BBS and similar to that in the
Tg737orpk model, defective in the IFT protein IFT88 (
30). Retinal defects are commonly found in syndromic forms of PKD, including SLS, JSRD and BBS. Owing to the lethality of MKS, little is known about eye defects but MKS associated genes, including
CEP290 and
CC2D2A, have been associated with the eye diseases, Leber congenital amaurosis and retinitis pigmentosa, respectively (
31,
32). Recently, hypomorphic
MKS3 mutations were associated with a variant of JSRD (COACH syndrome) with six patients having retinal defects, including coloboma and optic-disc abnormalities (
13). Given the
wpk data, it seems that retinal defects are likely typical in MKS3.
Defects in sperm flagella were evident in the
wpk that probably explain the infertility of the males even in the BN background where they are viable to 50 days. This defect is similar to that in
Bbs1, 2, 4 and
6 null mice where flagella did not appear to form (
26–
29). However, detailed TEM analysis of
wpk sperm showed that short flagella, positive for tubulin, developed but did not elongate beyond the cell body, indicating a defect in appropriate length regulation rather than formation.
Although ciliary defects were found in many organs, lack of
situs inversus or evidence of digital defects in the
wpk indicated that nodal and limb bud cilia are not defective in this model. Polydactyly is only rarely associated with MKS3, and
situs inversus has not been described in MKS3 (
9,
17). A recently described mouse model of
Mks3 also did not develop polydactyly or
situs inversus (
20). Therefore, despite the severity of the MKS3 phenotype, it is not associated with universal loss or even functional defects of cilia in every organ, but more subtle structural and function changes in specific locations, which may be associated with expression differences.
Cystic collecting duct epithelia in the
wpk and MKS3 patients displayed longer cilia. One theory of how defective cilia result in cyst formation is related to mechano-detection of flow. The autosomal dominant PKD (ADPKD) proteins, PKD1 and PKD2 (polycystin-1 and -2), are thought to complex on cilia and form a flow-detector with a Ca
2+ influx through the polycystin-2 channel important for maintaining intracellular Ca
2+ homeostasis and epithelial cell differentiation (
33). Cilia length has been described as normal in
Pkd1−/− cells, or as slightly shorter in human PKD1 cystic epithelia (
33,
34). Cilia in the
inv model (NPHP2) appeared normal in terms of length and ability to detect flow (
35). However, mice inactivated for the KIF3A subunit of the IFT kinesin-II motor in the collecting duct developed cysts that lacked primary cilia; as did renal cysts in
Ofd1+/− females (
22,
36). The more typical finding, nonetheless, from models of PKD is a quantitative change. This manifested as: shorter cilia in biliary epithelia of
Pkhd1 mutants (
24,
25) and the
Tg737orpk model (
37); longer cilia in the
jck (
23),
Nphp3−/pcy (
38) and
Mks3 mouse models (
20); and cilia more variable in length in the
cpk model (
39). It appears that meckelin, in common with other syndromic PKD proteins, plays a role in regulating the length of the cilia/flagella. The polycystin flow complex may, therefore, function poorly on cilia of inappropriate length and cyst development result. However, it seems likely that the length defects may be symptomatic of wider problems with cargo transport in the cilium, and inappropriate positioning of protein cargos leading to cyst development; highlighting possible roles for the MKS proteins.
Studies in Chlamydomonas have identified mutants defective in regulating flagella length that result in longer or shorter flagella (
40,
41). It has been suggested that length mutants play a role in regulating IFT and that a balance between flagella assembly and disassembly determines length (
42,
43). Flagella in Chlamydomonas length mutants often also display structural abnormalities with bulbous ends containing IFT proteins (
40,
41). Similar defective ciliary structures have been found in many ciliopathies, including
Tg737orpk (
44), murine models of ARPKD (
24,
25) and
Bbs1 and
Bbs2 null mutants (
35,
37). As well as bulbous ends, these abnormal structures included branched and ‘star burst’ cilia.
In
wpk tissue, MKS1 and MKS3 cells and tissue and depleted cells, as well as length problems, ciliary defects manifested as cells with more than one cilium and over-duplicated centrosomes; extreme examples of multi-ciliated cells were seen in MKS3 tissue. Multiple cilia have been found in 12.8% of
orpk−/− kidney cysts at P14 (
45). Precise regulation of centrosome duplication to once per cell-cycle during mitosis is required to prevent the formation of multipolar spindles and genomic instability. Centrosome over-duplication is commonly found in cancer and has been proposed to be an early defect that underlies much of the aneuploidy seen in solid tumors (
46–
48). Recently, depletion of polycystin-1 was associated with centrosome amplification in cellular systems with similar phenotypes found in
Pkd1−/− cells and ADPKD cystic tissue (
49). Centrosome amplification in the cellular systems resulted in mitotic catastrophe, but ultimately stabilized clones with less extreme aneuploidy predominated. Karyotypic changes have been detected in ADPKD cyst lining cells (
50). Cell lines derived from a PKD2 transgenic mouse were also found to have centrosome amplification and genomic instability (
51). Interestingly, cells overexpressing
MKS3 often formed multinucleated cells (
15), possibly related to centrosome amplification. It is not clear to what extent genomic instability and resulting aneuploidy are associated with cyst development in MKS because both human MKS1 and MKS3 and
wpk cyst development are extremely rapid resulting in enlarged and cystic kidneys by 20 weeks gestation or by 20d post-partum, respectively. However, our data indicate that MKS joins an increasing list of forms of PKD where numerical as well as length defects to cilia are associated with cyst development.
In MKS3 mutant kidney tissue, we identified multi-ciliated cells that are not normally found in the mammalian kidney. Occasional reports of cells with multiple motile cilia have been described in patients with hypercalcemia or nephrotic syndrome (
52–
56). In zebrafish, the pronephric duct has a mixture of cells with multiple motile cilia that generate flow and those with just one primary cilium: jagged 2/Notch signaling modulates the number of multi-ciliated cells (
57,
58). Overexpression of proteins involved in regulating centriole duplication, such as Plk4 or Sas-6, can result in centriole reduplication and
de novo assembly of centrioles in acentriolar cells (
59,
60). Our data indicate a role for MKS1 and meckelin in regulating the process of centrosome duplication relative to the cell-cycle and even the formation of multi-ciliated cells. The cellular system we have developed may help to understand this process.
The process of planar cell polarity (PCP), a non-canonical branch of the Wnt signaling pathway, has been implicated in MKS because of the exencephaly and PKD phenotypes (
61,
62). The centrosomal NPHP2 protein, inversin, is thought to act as a molecular switch between the canonical and non-canonical Wnt signaling pathways (
63), and PCP has been implicated in the process of ciliogenesis (
64). Preliminary data highlighted possible defects in the PCP process of convergent extension in
mks1 depleted zebrafish;
MKS1 variants may also enhance the phenotype associated with
BBS mutations (
14). Loss of many core PCP proteins is associated with craniorachischisis, an open neural tube defect similar to an encephalocele (
65);
Bbs4 null animals also occasionally develop exencephaly (
21). Lengthening of tubules in the kidney requires coordinated cell division with the orientation of the mitotic spindle along the axis of the tubule, a process modulated by PCP (
61). Significant spindle misorientation was noted in the PCK and
Hnf1β models of PKD, potentially resulting in tubule dilatation. Our data indicate defects in the regulation of centrioles and, given their role as mitotic spindle poles, questions whether this is directly related to the cystic expansion and exencephaly through interaction of MKS1 and meckelin in the PCP pathway. An alternative explanation is that the defects found in MKS reflect problems with appropriate ciliogenesis and, therefore, disrupts the multiple pathways that require functional cilia to operate. The
wpk rat and MKS cellular systems are likely to be central to understand which mechanism predominates.