We have sought to determine the mechanisms driving fluid secretion by the cystic epithelium in autosomal dominant polycystic kidney disease (ADPKD). We have performed in vitro experiments on intact cysts dissected from discarded ADPKD kidneys, on monolayers of cells cultured from the cystic epithelium and on microcysts clonally derived from single cultured cells. These preparations absorb fluid in the control state but secrete fluid in response to native cyst fluid, to adenylate cyclase agonists and to permeant analogues of cAMP. Measurements of short-circuit current and transepithelial voltage in the monolayers indicate that anion secretion must drive the fluid secretion. Fluid secretion by the intact cysts was inhibited by basolateral application of ouabain but not by apical application. The effect of ouabain on fluid secretion and short-circuit current in the monolayers followed the same pattern. Thus the functional Na,K-ATPase enzyme complex is located only in the basolateral membrane of the cystic cells and serves to maintain the transmembrane chemical and electrical gradients that drive anion secretion by other transport mechanisms. Fluid secretion and short-circuit current in the cultured monolayers was inhibited by the basolateral application of the Na-K-2Cl cotransporter inhibitors, bumetanide and furosemide, and by apical application of the chloride channel blocker, diphenylamine-2-carboxylate (DPC). These data suggest that chloride is the anion that is actively secreted. Preliminary experiments utilizing the monolayers and the microcysts and measuring cell chloride concentration and chloride efflux across the apical membrane support this conclusion. Other preliminary data indicate that the cystic fibrosis transmembrane conductance regulator is present in the apical membrane. Thus active chloride transport generates fluid secretion by the cystic epithelium.