The recurrent attacks of weakness in hypokalemic periodic paralysis (HypoPP) are caused by failure to maintain the resting potential, with paradoxical depolarization in low K+. Remarkably, 24 out of 25 HypoPP mutations are R/X substitutions in S4 segments of voltage-sensing domains of CaV1.1 (70% of cases) or NaV1.4 (10% of cases). Expression studies in oocytes and murine muscle show anomalous gating pore leakage currents (ω-pore) for six of eight CaV1.1-HypoPP mutations, with one exception being the charge-conserving R897K. The proposed consensus pathomechanism, whereby a gating pore leak predisposes to paradoxical depolarization in low K+, is now verified by continuous recording of Vm. Selective measurement of voltage-dependent Ca2+ release, in "healthy appearing" HypoPP fibers, shows only a modest decrease in the Ca2+-dependent peak fluorescence (Oregon green 488/EGTA), and supports the notion that stabilizing Vrest will be sufficient to prevent low-K+-induced loss of force. In our knockin mouse models of HypoPP (CaV1.1-R528H and NaV1.4-R669H), pretreatment with K+-channel openers protects against the loss of force with a 2 mM K+ challenge. Alternatively, gene editing offers the possibility of sustained protection from attacks of weakness, and may prevent the late-onset permanent myopathy. In a proof-of-principle study of cultured myoblasts and in vivo electroporation, we show selective editing of the mutant HypoPP allele, without compromise of the WT allele, using CRISPR/Cas-mediated indel formation to destroy the HypoPP allele or a CRISPR/Cas base editor to correct the missense mutation.
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