Fouillen, A.; Bous, J.; Couvineau, P.; Orcel, H.; Mary, C.; Pierre, T.; Mendre, C.; Gilles, N.; Schulte, G.; Granier, S.; Mouillac, B.

Antagonists of the arginine-vasopressin (AVP) V2 receptor (V2R) are key therapeutic compounds to treat hyponatremia or polycystic kidney diseases. Compounds such as Tolvaptan (TVP) and Conivaptan are marketed drugs but their mechanisms of inhibition are not known. In addition, TVP presents unwanted side effects such as serious liver injury. Conivaptan also targets AVP V1a receptor subtype and thus is not selective to V2R. To develop novel molecules with less side effects and better selectivity, rational drug design based on experimental three-dimensional G protein-coupled receptor (GPCR) structures is a powerful and successful avenue. The lack of antagonist-bound V2R structures has however impaired this strategy for this GPCR. To fill this gap of knowledge, we solved here the cryo-electron microscopy structures of the vasopressin V2R in complex with two selective antagonists, the nonpeptide TVP and the green mamba snake Mambaquaretin toxin (MQ1). Both ligands, known to be competitive, bind into the orthosteric AVP binding site but with substantial differences. The small molecule binds deeper than MQ1, and directly contacts the toggle switch residue W2846.48 in the transmembrane domain 6 (TM6), whereas the peptide Kunitz-fold toxin presents more extensive contacts with the receptor through additional interactions with extracellular and transmembrane residues. As anticipated from the pharmacological properties of TVP and MQ1, both structures represent inactive conformations of the V2R. Their comparison with those of the active AVP-bound V2R reveals the molecular mechanisms modulating receptor activity. Finally, the structure of the V2R bound to a mini-protein such as MQ1 opens a new pharmacology era in the field of water homeostasis and renal diseases.