Short Report

Received: March 17, 2014

Accepted: May 25, 2014
Published online: September 27, 2014

Eur Neurol 2014;72:271272

DOI: 10.1159/000364904

Aquaporin-1 Antibody in Neuromyelitis Optica

Patients
Erdem Tzn a John Tzartos c Esme Ekizolu a Christos Stergiou c
Paraskevi Zisimopoulou c Arzu oban a Erkingl Shugaiv a Recai Trkolu b
Murat Krtnc a Betl Baykan a Socrates Tzartos c
a

Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, b Department of Neurology,

Haydarpasa Numune Education and Research Hospital, Istanbul, Turkey; c Hellenic Pasteur Institute, Athens, Greece

Abstract
Background/Methods: To find out the prevalence of aquaporin-antibody (Aqp-Ab) and
characterize Aqp-Ab associated clinical features in NMO, Aqp-1 and Aqp-4-Abs were
examined using radioimmunoprecipitation
and cell-based assays, respectively. Results:
Aqp-4 and Aqp-1-Abs were detected in
20/30 and 8/30 NMO patients, respectively.
One patient was Aqp-1-Ab single-positive,
13 patients were Aqp-4-Ab single-positive, 7
patients were Aqp-4/Aqp-1-Ab double-positive and 9 patients were seronegative. All
double-positive patients had optic neuritis
during the first attack. Only 2/29 MS patients
and none of the control idiopathic intracranial hypertension patients were Aqp-1-Ab
positive. Conclusion: Aqp-1-Ab is usually detected in Aqp-4-Ab positive NMO patients
and might be involved in optic neuritis
2014 S. Karger AG, Basel
pathogenesis.

Introduction

agnostic biomarker [1]. However, in several NMO cohorts more than 40% of NMO
patients have been found Aqp-4 antibody
negative [2, 3], prompting a search for other antibodies. Aqp-1 has aroused interest as
a potential autoantigen in NMO since it is
one of the major water channels of the central nervous system (CNS), is abundantly
expressed by astrocytes and some NMO lesions might show reduced Aqp-1 expression [47]. In this study, Aqp-1 and Aqp-4
antibody measurements were conducted in
sera of NMO patients and controls.
Materials and Methods

Thirty consecutive NMO patients fulfilling Wingerchuks revised diagnostic criteria [1], 29 relapsing remitting multiple
sclerosis (MS) patients fulfilling revised
McDonald criteria [8], 29 idiopathic intracranial hypertension (IIH) patients fulfilling the modified diagnostic criteria [9] and
30 healthy individuals were included. Patients gave informed consent, which was
approved by the local medical research ethics committee. All sera were collected during an attack prior to treatment with steroids, immediately centrifuged, stored in
aliquots at 70 C.
Antibodies to the extracellular region of
Aqp-4 were measured by cell-based assay
utilizing HEK cells transfected with Aqp-4

Aquaporin-4 (Aqp-4) antibody has

long been described in neuromyelitis optica (NMO) and been utilized as a useful di-

2014 S. Karger AG, Basel

00143022/14/07260271$39.50/0
E-Mail karger@karger.com
www.karger.com/ene

DNA. Aqp-1 antibodies were detected by

radioimmunoprecepitation assay (RIPA).
All sera that were detected positive in RIPA
were further analyzed with ELISA with
Aqp-1 synthetic peptides to ensure that the
antibodies against Aqp-1 bind to the extracellular domain of the protein [4]. Only
sera with antibodies to the extracellular
side of Aqp-1 were considered positive.
Results

Aqp-4 antibody was detected in 20

NMO patients and none of the MS patients,
whereas Aqp-1 antibody was detected in 8
NMO and 2 MS patients. IIH patients and
healthy controls were seronegative for both
antibodies. Only one NMO patient was
Aqp-1 antibody single positive (Aqp-1+), 7
NMO patients were Aqp-1 and Aqp-4 antibody double positive (Aqp-1+/Aqp-4+),
13 NMO patients were Aqp-4 antibody single positive (Aqp-4+) and 9 NMO patients
were seronegative (SN) for both antibodies.
Aqp-4+ positive patients had higher
EDSS scores than Aqp-1+/Aqp-4+ and SN
patients and both Aqp-1+/Aqp-4+ and
Aqp-4+ patients had higher attack numbers than SN patients. Double-positive patients had a significantly higher rate of optic neuritis during the first attack than SN
patients. Other parameters were comparable among groups (table1). Retrospec-

Erdem Tzn, MD
Department of Neurology, Istanbul Faculty of Medicine
Istanbul University
TR34390 apa, Istanbul (Turkey)
E-Mail drerdem@yahoo.com

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Key Words
Aquaporin-1 Aquaporin-4 Neuromyelitis
optica Antibody Autoimmunity

Table 1. Comparison of demographic and clinical features of Aqp-1 and Aqp-4 antibody double-positive (Aqp-1+/Aqp-4+), Aqp-4 antibody single-positive (Aqp-4+) and seronegative (SN) NMO patients

Age, SE3
Gender, M/F4
Number of attacks, SE3
ON in 1st attack4
TM in 1st attack4
Attacks with ON+TM1,4
Positive OCB2,4
EDSS, SE5

Aqp-1+/
Aqp-4+
(n = 7)

Aqp-4+
(n = 13)

SN
(n = 9)

p values

34.3 5.2
1/6
8.1 2.0
7/7
1/7
2/7
2/7
3.6 0.6

41.0 3.4
2/11
7.0 1.1
8/13
7/13
3/13
3/13
5.0 0.5

35.0 4.1
2/7
3.8 0.6
4/9
6/9
2/9
4/9
3.3 0.5

0.152
0.729
0.371
0.083
0.105
0.594
0.590
0.045

Aqp-1+/Aqp-4+ Aqp-1+/Aqp-4+ Aqp-4+ vs. SN

vs. Aqp-4+
vs. SN
0.458
0.600
0.047
0.028
0.055
0.607
0.451
0.415

0.136
0.550
0.024
0.361
0.439
0.684
0.276
0.033

Aqp = Aquaporin; SE = standard error; ON = optic neuritis; TM = transverse myelitis; OCB = oligoclonal bands; EDSS = expanded
disability status scale.
1
Number of patients who have had simultaneous ON and TM symptoms. 2 Pattern 2 or 3 OCB positivity. Bold characters indicate
significant p values. Statistical analysis performed with 3Students t test, 4Fishers exact test and 5Mann-Whitney U, as required.

tively evaluated MRIs of NMO patients

did not reveal any distinguishing features
between antibody subgroups. Periventricular non-contrast enhancing and nonMS-like lesions (<5 per MRI examination)
were observed in MRI studies of 2 each
Aqp-1+/Aqp-4+, Aqp-4+ and SN patients
and in the Aqp-1 antibody single positive
patient.
Aqp-1 antibody-positive MS patients
had CSF oligoclonal bands; they had not
developed any optic neuritis, myelitis attacks or long, extensive spinal cord lesions.
However, both patients had short, cervical
and dorsal spinal cord and pons lesions.

Discussion

In our previous study [4] on suspected

NMO spectrum disorder patients, Aqp-1
antibodies were more frequent than Aqp-4
antibodies and most cases were single positive. Here, screening definite NMO patients, we predominantly found Aqp-1 and
Aqp-4 antibody double positive patients. A
possible explanation is that Aqp-1 antibodies are more prevalent in demyelinating
disorders that do not strictly fulfill the definite NMO criteria (e.g., opticospinal MS,
NMO spectrum disease).
Aqp-1 antibody positive MS patients
displayed spinal cord lesions, suggesting

some MS patients might share common

pathogenic mechanisms with NMO. Water
channel dysfunction has been proposed in
IIH pathogenesis. However, two previous
studies [9, 10] and the present one failed to
identify Aqp antibodies in IIH patients,
contradicting this assumption. All Aqp-1
antibody positive NMO patients had optic
neuritis during their first attacks suggesting that Aqp-1-rich optic nerve might be
the initiator of the autoimmune response.
To establish the validity of Aqp-1 Ab measurements, further antibody measurements are warranted in patients with isolated optic neuritis, myelitis and NMO
spectrum disorders.

References

272

4 Tzartos JS, Stergiou C, Kilidireas K, Zisimopoulou P, Thomaidis T, Tzartos SJ: Antiaquaporin-1 autoantibodies in patients with
neuromyelitis optica spectrum disorders.
PLoS One 2013;8:e74773.
5 Benga O, Huber VJ: Brain water channel proteins in health and disease. Mol Aspects Med
2012;33:562578.
6 Satoh J, Tabunoki H, Yamamura T, Arima K,
Konno H: Human astrocytes express aquaporin-1 and aquaporin-4 in vitro and in vivo.
Neuropathology 2007;27:245256.
7 Misu T, Hftberger R, Fujihara K, Wimmer I,
Takai Y, Nishiyama S, Nakashima I, Konno
H, Bradl M, Garzuly F, Itoyama Y, Aoki M,
Lassmann H: Presence of six different lesion
types suggests diverse mechanisms of tissue
injury in neuromyelitis optica. Acta Neuropathol 2013;125:815827.

Eur Neurol 2014;72:271272

DOI: 10.1159/000364904

8 Polman CH, Reingold SC, Banwell B, et al: Diagnostic criteria for multiple sclerosis: 2010
revisions to the McDonald criteria. Ann Neurol 2011;69:292302.
9 Ekizoglu E, Ioz S, Tuzun E, Birisik O, Kocasoy-Orhan E, Akman-Demir G, Baykan B:
Aquaporin-4 antibodies are not present in patients with idiopathic intracranial hypertension. Cephalalgia 2012;32:198202.
10 Dhungana S, Waters P, Ismail A, Woodroofe
N, Vincent A, Sharrack B: Absence of aquaporin-4 antibodies in patients with idiopathic
intracranial hypertension. J Neurol 2010;257:
12111212.

Tzn etal.

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1 Wingerchuk DM, Lennon VA, Pittock SJ,

Lucchinetti CF, Weinshenker BG: Revised
diagnostic criteria for neuromyelitis optica.
Neurology 2006;66:14851489.
2 Siritho S, Nakashima I, Takahashi T, Fujihara
K, Prayoonwiwat N: AQP4 antibody-positive
Thai cases: clinical features and diagnostic
problems. Neurology 2011;77:827834.
3 Akman-Demir G, Tzn E, Waters P, Iz S,
Krtnc M, Jarius S, Yapc Z, Mutlu M,
Yeilot N, Vincent A, Eraksoy M: Prognostic
implications of aquaporin-4 antibody status
in neuromyelitis optica patients. J Neurol
2011;258:464470.