A randomized, blinded, prospective trial to compare the safety and efficacy of three bowel-cleansing solutions for colonoscopy (HSG-01*)

BACKGROUND AND STUDY AIMS

There are conflicting data regarding the optimal bowel preparation for colonoscopy. This study was carried out to compare the efficacy, safety, and tolerability of three widely used bowel lavage solutions: the standard polyethylene glycol-electrolyte solution based on the GoLytely formulation (PEG-EL1; Klean-Prep); a sulphate-free PEG-EL solution based on the NuLytely formulation (PEG-EL2, Endofalk); and a sodium phosphate preparation (NaP, Fleet Phospho-Soda).

PATIENT AND METHODS

A total of 185 consecutive patients scheduled for elective colonoscopy were prospectively randomly assigned to undergo pre-colonoscopic bowel cleansing with either 4 l of PEG-EL1 (n=64), 3 l of PEG-EL2 (n=59), or 90 ml of NaP (n=62). The quality of preparatory colonic cleansing for each segment from the rectum to the ascending colon was scored on a five-level rating scale (1, very good to 5, very poor) by endoscopists who were blinded with regard to the type of preparation used. The primary outcome measure for the comparison of treatments was the "worst" score in any of the rated bowel segments. Safety and tolerability were evaluated by means of a symptom questionnaire completed by each patient immediately before the procedure.

RESULTS

Of the 185 patients who were randomly assigned to one of the three treatments, 175 underwent colonoscopy and 173 were evaluable with regard to efficacy - 59, 54, and 60 patients treated with PEG-EL1, PEG-EL2, and NaP, respectively. The treatment groups were comparable with regard to the baseline characteristics. PEG-EL1 was statistically significantly superior to the other treatments in relation to the "worst cleansing" score ( P</=0.003). In addition, colonoscopic visualization was markedly better in each of the five bowel segments and general "very good" or "good" ratings were achieved in more than 90 % of patients treated with PEG-EL1. The percentages were consistently lower in the other two groups, particularly in the ascending colon. With the exception of the sigmoid, the differences in all segments of the large bowel were statistically significant (P</=0.04). Patient satisfaction was comparable between the treatment groups. Adverse events (mainly nausea/vomiting and abdominal pain) and deviations in laboratory values occurred more frequently in the NaP group.

CONCLUSIONS

Preparatory PEG-EL1 (Klean-Prep) was significantly superior to PEG-EL2 (Endofalk) and NaP (Fleet Phospho-Soda) in achieving effective cleansing of the entire colon prior to colonoscopy. On the basis of these data, PEG-EL1 can be regarded as the "gold standard" for bowel cleansing prior to colonoscopy.

Polarized expression of the vasopressin V2 receptor in Madin-Darby canine kidney cells

BACKGROUND

The vasopressin V2 receptor is expressed in the polarized principal cell of the renal collecting duct. Inactivating mutations of the vasopressin V2 receptor gene cause X-linked nephrogenic diabetes insipidus (NDI). Most of the mutant V2 receptors show transport defects, as analyzed in non-polarized cells, but data pertaining to polarized cells have not previously been presented.

METHODS

Madin-Darby canine kidney cell (MDCK) II clones stably expressing c-myc-tagged human V2 receptors were characterized for [3H]-arginine vasopressin (AVP)-binding and AVP-sensitive adenylyl cyclase activity. The V2 receptors were immunocytochemically localized using the tyramide signal amplification technique in conjunction with an anti-c-myc antibody.

RESULTS

The introduction of the c-myc epitope at the N- or C-terminus did not affect the functional properties of the V2 receptor expressed in MDCK II clones. However, the use of standard immunofluorescence methodology for these MDCK II clones yielded only weak signals. With the tyramide signal amplification technique, strong signals were obtained, showing the V2 receptor to be mainly localized within the lateral and, to a minor extent, apical membrane. In MDCK II clones stably expressing the c-myc-tagged V2 receptor NDI mutant L44P, fluorescent signals were found exclusively within the cell.

CONCLUSION

The wild-type V2 receptor is expressed mainly in the lateral membrane, whereas the L44P mutant is completely retained within the cell. In conjunction with tyramide signal amplification, MDCK II cells constitute a suitable model for the analysis of transport-defective mutants of the V2 receptor.

A dileucine sequence and an upstream glutamate residue in the intracellular carboxyl terminus of the vasopressin V2 receptor are essential for cell surface transport in COS.M6 cells

Little is known concerning the intracellular transport of the G protein-coupled receptors (GPCRs). Previous studies suggested a functional role for those residues immediately preceding the conserved palmitoylated cysteine residues in the intracellular carboxyl termini of some GPCRs in cell surface transport. For the human vasopressin V2 receptor, we assessed the significance of a dileucine sequence with an upstream glutamate residue (ELRSLLCC) in mediating cell surface delivery. A series of deletion and point mutants in this region were constructed, and the mutant receptors were expressed in transiently transfected COS.M6 cells. By using [3H]arginine vasopressin binding assays to intact cells and immunofluorescence studies with intact and permeabilized cells, we show that residues E335 (mutant E335Q) and L339 (mutant L339T) are obligatory for receptor transport to the plasma membrane. Residue L340 has a minor but significant influence. [3H]Arginine vasopressin binding experiments on membranes of lysed cells failed to detect any intracellular binding sites for the transport-deficient mutant receptors, suggesting that residues E335 and L339 participate in receptor folding. Studies with green fluorescent protein-tagged receptors demonstrate that the bulk of the mutant receptors E335Q and L339T are trapped in the endoplasmic reticulum. Complex glycosylation was absent in these mutant receptors, supporting this conclusion. These data demonstrate that the glutamate/dileucine motif of the vasopressin V2 receptor is critical for the escape of the receptor from the endoplasmic reticulum, most presumably by establishing a functional and transport-competent folding state. A databank analysis revealed that these residues are part of a conserved region in the GPCR family.

Folding and cell surface expression of the vasopressin V2 receptor: requirement of the intracellular C-terminus

We characterized truncations of the human vasopressin V2 receptor to determine the role of the intracellular C-terminus (comprising about 44 amino acids) in receptor function and cell surface expression. In contrast to the wild-type receptor, the naturally occurring mutant R337X failed to confer specific [3H]AVP binding to transfected cells. In addition, no vasopressin-sensitive adenylyl cyclase was detectable in membrane preparations of these cells. Laser scanning microscopy revealed that c-myc epitope- or green fluorescent protein-tagged R337X mutant receptors were retained within the endoplasmic reticulum. Increasing the number of C-terminal residues (truncations after codons 348, 354 and 356) restored G protein coupling, but revealed a length-dependent reduction of cell surface expression. Replacement of positively charged residues within the C-terminus by glutamine residues also decreased cell surface expression. A chimeric V2 receptor with the C-terminus replaced by that of the beta2-adrenergic receptor did not bind [3H]AVP and was retained within the cell. These data suggest that residues in the N-terminal part of the C-terminus are necessary for correct folding and that C-terminal residues are important for efficient cell surface expression.