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Chang CJ, Lai YJ, Tung YC, Wu LS, Hsu LA, Tseng CN, Chang GJ, Yang KC, Yeh YH. Osteopontin mediation of disturbed flow-induced endothelial mesenchymal transition through CD44 is a novel mechanism of neointimal hyperplasia in arteriovenous fistulae for hemodialysis access. Kidney Int 2023; 103:702-718. [PMID: 36646166 DOI: 10.1016/j.kint.2022.12.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 11/19/2022] [Accepted: 12/15/2022] [Indexed: 01/15/2023]
Abstract
In dysfunctional arteriovenous fistulae (AVF) for hemodialysis access, neointimal hyperplasia (NH) is prone to occur in the region exposed to disturbed flow. We hypothesized that disturbed flow contributes to NH in AVF by inducing endothelial mesenchymal transition (EndMT) through activation of the osteopontin/CD44 axis. In rats with aortocaval fistula, a rodent model of AVF, we demonstrated development of EndMT and expression of osteopontin and CD44 specifically in the vicinity of the arteriovenous junction using immunostaining. Duplex scan confirmed this region was exposed to a disturbed flow. A mixed ultrastructural phenotype of endothelium and smooth muscle cells was found in luminal endothelial cells of the arteriovenous junction by electron microscopy ascertaining the presence of EndMT. Endothelial lineage tracing using Cdh5-Cre/ERT2;ROSA26-tdTomato transgenic mice showed that EndMT was involved in NH of AVF since the early stage and that the endothelial-derived cells contributed to 24% of neointimal cells. In human umbilical vein endothelial cells (HUVECs) in culture, osteopontin treatment induced EndMT, which was suppressed by CD44 knockdown. Exposure to low oscillatory wall shear stress using a parallel-plate system induced EndMT in HUVECs, also suppressed by osteopontin or CD44 knockdown. In AVF of CD44 knockout mice, EndMT was mitigated and NH decreased by 35% compared to that in wild-type mice. In dysfunctional AVF of patients with uremia, expressions of osteopontin, CD44, and mesenchymal markers in endothelial cells overlying the neointima was also found by immunostaining. Thus, the osteopontin/CD44 axis regulates disturbed flow-induced EndMT, plays an important role in neointimal hyperplasia of AVF, and may act as a potential therapeutic target to prevent AVF dysfunction.
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Affiliation(s)
- Chi-Jen Chang
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ying-Ju Lai
- Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ying-Chang Tung
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Lung-Sheng Wu
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Lung-An Hsu
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chi-Nan Tseng
- Division of Cardiac Surgery, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Gwo-Jyh Chang
- Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Kai-Chien Yang
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan; Department and Graduate Institute of Pharmacology, National Taiwan University College of Medicine, Taipei, Taiwan; Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Division, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
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Singh M, Mahapatra HS, Pursnani L, Muthukumar B, Neeraj Anant I, Kumar A, Kaur N, Singh A, Krishnan C. Study on prediction of arterio-venous fistula maturation by flow mediated dilatation and AVF blood flow. J Vasc Access 2021; 24:443-451. [PMID: 34396827 DOI: 10.1177/11297298211033508] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The physiology and pathology of AVF maturation depends on the vessels characteristics and its ability to remodel. Outcome of AVF using flow mediated dilatation (FMD), AVF blood flow and diameter has been studied. METHODOLOGY Present observational study included single stage AVF (both Radiocephalic and Brachiocephalic) in consecutive CKD five patients (n = 158) prospectively over 1 year. Demographic and Doppler ultrasound parameters of upper limb (for vessel diameter and FMD) at baseline were recorded. Blood flow, diameter and depth of AVF were studied at 2, 6 and 12 weeks and their association with clinical maturation (usage of fistula with two needles for 75% of dialysis sessions during 15 day period) was studied (n = 129, after excluding lost to followup and expired patients; accordingly cohort was divided in matured (M) or non-matured (NM) groups. Clinical and radiological parameters between both groups were compared; receiver operator curve (ROC) and correlation of Doppler parameters were analysed. RESULTS Of 129 AVF, 67.4% were matured and 32.5% non-matured. Mean age was 40 years with male predominance75% in both the groups. The mean arterial diameter for distal (NM = 1.96 ± 0.58 and M = 2.02 ± 0.41) and proximal AVF (NM = 3.37 ± 0.82 and M = 3.36 ± 0.75) was not statistically different in both the groups. The matured fistula group had a mean FMD of 11.67 ± 4.09 as against FMD value of 9.365 ± 3.55 in the failed fistula group (p value 0.01). For maturation prediction, sensitivity and specificity of blood flow at 2 weeks were 86.2% and 59.5% and at 6 weeks 96.6% and 64.3%, respectively. In multivariate analysis predictors for AVF maturation were FMD (adjusted odds ratio (AOR) = 1.15) and blood flow (AOR = 1.67). CONCLUSION Second and Sixth week AVF blood flow was found to be predicting AVF maturation. Higher baseline FMD correlated with the AVF maturation, but not with vessel diameter.
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Affiliation(s)
- Mansi Singh
- Department of Nephrology, ABVIMS, Dr R.M.L. Hospital, New Delhi, India
| | | | - Lalit Pursnani
- Department of Nephrology, ABVIMS, Dr R.M.L. Hospital, New Delhi, India
| | - B Muthukumar
- Department of Nephrology, ABVIMS, Dr R.M.L. Hospital, New Delhi, India
| | | | - Adarsh Kumar
- Department of Nephrology, ABVIMS, Dr R.M.L. Hospital, New Delhi, India
| | - Navjot Kaur
- Department of Nephrology, ABVIMS, Dr R.M.L. Hospital, New Delhi, India
| | - Anamika Singh
- Department of Nephrology, ABVIMS, Dr R.M.L. Hospital, New Delhi, India
| | - Chandra Krishnan
- Department of Nephrology, ABVIMS, Dr R.M.L. Hospital, New Delhi, India
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Yang L, Yin A, Liu W. Variation of flow rate and angle of injected venous needle on influencing intimal hyperplasia at the venous anastomosis of the hemodialysis graft. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2017; 40:239-248. [PMID: 28168585 DOI: 10.1007/s13246-017-0526-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 01/17/2017] [Indexed: 10/20/2022]
Abstract
During hemodialysis, arteriovenous (AV) grafts tends to result in intimal hyperplasia (IH) at the venous anastomosis which leads to graft failure. It is well documented that hemodynamic factors have been implicated in IH, as well as pathogenesis of graft stenosis. In this paper, we investigate the flow rate and angle of injection of a venous needle on damaging the hemodialysis graft. Such damage is mainly caused by hemodynamics rather than the actual physical puncture of the needle. By computational fluid dynamic analysis of flow through the AV grafts, we demonstrate that slower flow rate of the needle preserve a larger region of low wall shear stress (WSS). High needle flow angle and fast flow rate tends to induce high shearing of blood against the graft wall, and therefore resulting in a concentrated region of high WSS. Despite that, the increased flow rate causes more significant change to wall shear stress gradient than the flow angle. Obviously, it is important to optimize the injection rate since a high angle can reduce the size of the injection puncture and have smaller injury for the vessel walls; but a slower injection rate may delay hemodialysis. Therefore, the ideal angle and flow rate of needle is sought in this study.
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Affiliation(s)
- Linqiang Yang
- Key Laboratory of Biological Science and Technology (Chongqing University), Ministry of Education, College of Bioengineering of Chongqing University, Shapingba, Chongqing, 400030, China.,College of Mechanical Engineering of Chongqing University, Chongqing, 400030, China
| | - Aijun Yin
- College of Mechanical Engineering of Chongqing University, Chongqing, 400030, China
| | - Wanqian Liu
- Key Laboratory of Biological Science and Technology (Chongqing University), Ministry of Education, College of Bioengineering of Chongqing University, Shapingba, Chongqing, 400030, China.
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Browne LD, Bashar K, Griffin P, Kavanagh EG, Walsh SR, Walsh MT. The Role of Shear Stress in Arteriovenous Fistula Maturation and Failure: A Systematic Review. PLoS One 2015; 10:e0145795. [PMID: 26716840 PMCID: PMC4696682 DOI: 10.1371/journal.pone.0145795] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 12/08/2015] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Non-maturation and post-maturation venous stenosis are the primary causes of failure within arteriovenous fistulae (AVFs). Although the exact mechanisms triggering failure remain unclear, abnormal hemodynamic profiles are thought to mediate vascular remodelling and can adversely impact on fistula patency. AIM The review aims to clarify the role of shear stress on outward remodelling during maturation and evaluate the evidence supporting theories related to the localisation and development of intimal hyperplasia within AVFs. METHODS A systematic review of studies comparing remodelling data with hemodynamic data obtained from computational fluid dynamics of AVFs during and after maturation was conducted. RESULTS Outward remodelling occurred to reduce or normalise the level of shear stress over time in fistulae with a large radius of curvature (curved) whereas shear stress was found to augment over time in fistulae with a small radius of curvature (straight) coinciding with minimal to no increases in lumen area. Although this review highlighted that there is a growing body of evidence suggesting low and oscillating shear stress may stimulate the initiation and development of intimal medial thickening within AVFs. Further lines of evidence are needed to support the disturbed flow theory and outward remodelling findings before surgical configurations and treatment strategies are optimised to conform to them. This review highlighted that variation between the time of analysis, classification of IH, resolution of simulations, data processing techniques and omission of various shear stress metrics prevented forming pooling of data amongst studies. CONCLUSION Standardised measurements and data processing techniques are needed to comprehensively evaluate the relationship between shear stress and intimal medial thickening. Advances in image acquisition and flow quantifications coupled with the increasing prevalence of longitudinal studies commencing from fistula creation offer viable techniques and strategies to robustly evaluate the relationship between shear stress and remodelling during maturation and thereafter.
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Affiliation(s)
- Leonard D. Browne
- Centre for Applied Biomedical Engineering Research (CABER), Department of Mechanical, Aeronautical and Biomedical Engineering, Materials and Surface Science Institute, The Health Research Institute, University of Limerick, Limerick, Ireland
| | - Khalid Bashar
- Department of Vascular Surgery, Limerick University Hospital, Dooradoyle, Limerick, Ireland
| | - Philip Griffin
- Centre for Applied Biomedical Engineering Research (CABER), Department of Mechanical, Aeronautical and Biomedical Engineering, Materials and Surface Science Institute, The Health Research Institute, University of Limerick, Limerick, Ireland
| | - Eamon G. Kavanagh
- Department of Vascular Surgery, Limerick University Hospital, Dooradoyle, Limerick, Ireland
| | - Stewart R. Walsh
- Department of Vascular Surgery, Limerick University Hospital, Dooradoyle, Limerick, Ireland
- Department of Surgery, National University of Ireland, Galway, Ireland
| | - Michael T. Walsh
- Centre for Applied Biomedical Engineering Research (CABER), Department of Mechanical, Aeronautical and Biomedical Engineering, Materials and Surface Science Institute, The Health Research Institute, University of Limerick, Limerick, Ireland
- * E-mail:
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