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Engelen MM, Verhamme P, Vanassche T. Clotting of the Extracorporeal Circuit in Hemodialysis: Beyond Contact-Activated Coagulation. Semin Nephrol 2023; 43:151473. [PMID: 38233291 DOI: 10.1016/j.semnephrol.2023.151473] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Thrombotic complications in patients with end-stage kidney disease are frequent. While being a lifesaving treatment for these patients, hemodialysis introduces a thromboinflammatory environment. Additionally, the extracorporeal hemodialysis circuit itself is prone to clotting because of an interaction between different activation mechanisms of the coagulation system, platelets, and the immune system. Anticoagulation of the patient and the machine is frequently complicated by bleeding. We discuss the factors important in this balancing act and touch on potential strategies that are on the horizon to target thromboinflammation.
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Affiliation(s)
- Matthias M Engelen
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.
| | - Peter Verhamme
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
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Li J, Sun S, Han M, Wang L, Liao R, Xiong Y, Li Y, Jiang H, Qin Z, Maharjan A, Cozzolino M, Zarbock A, Su B. The effects of citrate dialysate in hemodialysis on polymorphonuclear elastase interaction with tissue factor and its inhibitor. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:391. [PMID: 31555705 PMCID: PMC6736810 DOI: 10.21037/atm.2019.07.57] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 07/17/2019] [Indexed: 12/02/2023]
Abstract
BACKGROUND This study aimed to investigate whether hemodialysis (HD) affects tissue factor (TF), tissue factor pathway inhibitor (TFPI), and polymorphonuclear elastase (PMNE) in endstage renal disease (ESRD) patients when eliminating the effects of heparin. Also, to explore the interaction of TF, TFPI, and PMNE throughout a single HD session. METHODS We enrolled 57 ESRD patients who had undergone hemodialysis for >3 months as an experimental group. Plasma levels of TF, TFPI and PMNE were measured by ELISA in 24 ERSD patients on intermittent HD using low-molecular-weight heparin (LMWH) as anticoagulation (LMWH group) and 33 ESRD patients using citrate as anticoagulation (citrate group) at the start and at 1, 2 and 5 h of the HD session. Meanwhile,28 ESRD patients not on dialysis were enrolled as a control group and fasting venous blood samples were taken in the morning. RESULTS Compared with the control group, the plasma TFPI levels of the LMWH group and the citrate group were significantly higher (P=0.000, P=0.002, respectively) under baseline conditions as well as the plasma PMNE levels (P=0.001, P=0.02, respectively), whereas TF showed no difference (P=0.186). During HD with citrate, plasma TFPI decreased slightly (P=0.012) and PMNE increased significantly (P=0.008) at 1 h. The plasma TFPI levels of the citrate group correlate with PMNE at 2 and 5 h (P=0.001, P=0.008, respectively). CONCLUSIONS ESRD patients on HD have significantly higher TFPI and PMNE levels compared to patients not on HD under baseline conditions, while TF levels were similar between the three groups. TFPI and PMNE are differently regulated, but the plasma levels correlated during HD in the citrate group. It might be possible that PMNE plays a role in anticoagulative activity through TFPI.
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Affiliation(s)
- Jiameng Li
- Department of Nephrology, Faculty of Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Si Sun
- Department of Nephrology, Faculty of Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Mei Han
- Department of Nephrology, Faculty of Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Liya Wang
- Department of Nephrology, Faculty of Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Ruoxi Liao
- Department of Nephrology, Faculty of Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yuqin Xiong
- Department of Nephrology, Faculty of Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yupei Li
- Department of Nephrology, Faculty of Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Heng Jiang
- Department of Nephrology, Faculty of Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Zheng Qin
- Department of Nephrology, Faculty of Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Anil Maharjan
- Department of Nephrology, Faculty of Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Mario Cozzolino
- Renal Division and Laboratory of Experimental Nephrology, Department of Health Sciences, University of Milan, Milan, Italy
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, Münster, Germany
| | - Baihai Su
- Department of Nephrology, Faculty of Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
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Elevation of Platelet and Monocyte Activity Markers of Atherosclerosis in Haemodialysis Patients Compared to Peritoneal Dialysis Patients. Mediators Inflamm 2017; 2017:8506072. [PMID: 28769539 PMCID: PMC5523345 DOI: 10.1155/2017/8506072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/29/2017] [Accepted: 06/11/2017] [Indexed: 11/25/2022] Open
Abstract
Purpose The predominant cause of mortality in dialysis patients are cardiovascular events. Platelet and monocyte activity markers play an important role in cardiovascular mortality and were assessed and related to dialysis quality criteria in haemodialysis (HD) and peritoneal dialysis (PD) patients. Methods For this prospective comparative study, HD patients (n = 41) and PD patients (n = 10) were included. In whole blood samples, surface expression of CD62P and CD40L on platelets, tissue factor binding on monocytes, and platelet-monocyte aggregates were measured by flow cytometry. Plasma levels of MCP-1, IL-6, TNFα, and soluble CD40L were analysed by enzyme-linked immunosorbent assay. Results Haemodialysis patients showed a significantly higher CD62P expression on platelets (p = 0.017), significantly higher amount of platelet-monocyte aggregates (p < 0.0001), and significantly more tissue factor binding on monocytes (p < 0.0001) compared to PD patients. In PD patients, a significant correlation between Kt/V and platelet CD40L expression (r = 0.867; 0.001) and between Kt/V and platelet CD62P expression (r = 0.686; p = 0.028) was observed, while there was no significant correlation between Kt/V and tissue factor binding on monocytes and platelet-monocyte aggregates, respectively. Conclusion Platelet and monocyte activity markers are higher in HD patients in comparison with those in PD patients, possibly suggesting a higher risk of cardiovascular morbidity and mortality.
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Hasenstab D, Kirkman TR, Clowes AW, Kohler TR. Tissue Factor Activity in Dialysis Access Grafts. Ann Vasc Surg 2015; 31:179-85. [PMID: 26597243 DOI: 10.1016/j.avsg.2015.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/25/2015] [Accepted: 10/11/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intimal hyperplasia at the venous anastomosis of dialysis grafts causes early failure. We developed a sheep model of arteriovenous prosthetic grafts that fail rapidly due to intimal hyperplasia with histologic features nearly identical to human access grafts. A prominent feature of lesion development in this model is formation of luminal thrombus that becomes organized into stenosing lesions by macrophage and myofibroblast infiltration. To better understand this process, we examined the presence and activity of tissue factor (TF) in this system. This protein is the physiological initiator of coagulation in vivo and is known to contribute to development of intimal hyperplasia after vascular injury. METHODS Expanded polytetrafluorethylene (ePTFE) grafts were placed between the carotid artery and external jugular vein in sheep. Grafts were examined for luminal TF activity using a novel ex vivo assay. In a separate series of grafts, immunohistochemistry was used to localize smooth muscle cells, monocytes, and TF protein. RESULTS At 2 days, luminal TF activity already was higher in the venous and arterial end of the graft than in the adventitia. This high level of activity persisted at 8 weeks. TF activity was higher in the venous end of the grafts than in the arterial end at 2 and 8 weeks (40% and 47% increase, n = 5, n = 3, respectively, P < 0.05). Immunohistochemistry revealed TF protein localized in regions with or adjacent to fibrin accumulation and often in regions close to the lumen. CONCLUSIONS This study further examines the development of intimal hyperplasia in ePTFE dialysis access grafts. In this model, TF levels on the luminal surface were increased throughout the arteriovenous grafts and the adjacent vessels as early as 2 days after engraftment and for as long as 8 weeks thereafter. The highest levels of activity were found in the venous end of the graft, where hyperplasia is most robust. Increased activity of TF is associated with luminal thrombus, which provides a scaffolding for development of intimal hyperplasia. These findings present an opportunity to develop strategies to limit TF activity within the graft. Further studies using agents delivered locally or incorporated into the graft matrix to block the luminal activity of TF are warranted.
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Affiliation(s)
- David Hasenstab
- Department of Surgery, University of Washington, Seattle, WA
| | | | | | - Ted R Kohler
- Department of Surgery, University of Washington, Seattle, WA; Department of Surgery, Seattle VA Puget Sound Health Care System, Seattle, WA.
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Rios DRA, Carvalho MDG, Lwaleed BA, Simões e Silva AC, Borges KBG, Dusse LMS. Hemostatic changes in patients with end stage renal disease undergoing hemodialysis. Clin Chim Acta 2010; 411:135-9. [DOI: 10.1016/j.cca.2009.11.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Revised: 11/06/2009] [Accepted: 11/20/2009] [Indexed: 12/31/2022]
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Kaiser B, Hoppensteadt DA, Fareed J. Tissue factor pathway inhibitor for cardiovascular disorders. ACTA ACUST UNITED AC 2005. [DOI: 10.1517/14728214.5.1.73] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Tang SCW, Lai KN. Physiologic inhibitors of coagulation in patients on chronic hemodialysis. Hemodial Int 2003; 7:232-8. [PMID: 19379370 DOI: 10.1046/j.1492-7535.2003.00043.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients on hemodialysis are at increased risk for bleeding and thromboses. The intriguing balance between these risks is more complex than once thought, as endogenous clotting factors and their regulators come into contact with bioincompatible dialyzer membranes, in the setting of an extracorporeal circuit of blood flow, in the face of the uremic state. In this review, we summarize the current data on the interaction between the physiologic inhibitors of coagulation and hemodialysis. Data sources and study selection were obtained from research and review articles related to the endogenous anticoagulation pathway published in English on MEDLINE from 1972 to 2002. While protein C activity and protein S antigen concentrations are increased, there is no change in antithrombin III levels during hemodialysis in relation to predialysis levels. Plasma protein Z, which has only recently been studied in uremic subjects, is increased as well. In addition, hemodialysis leads to elevated tissue factor plasminogen inhibitor, thrombomodulin, tissue plasminogen activator, and plasminogen activator inhibitor-1 activities. The potential functional significance of these observations is discussed. Finally, as erythropoietin is commonly prescribed to uremic patients and is recognized to be prothrombotic, an appraisal of its interaction with the naturally occurring anticoagulants is presented. It is apparent that we are only beginning to realize the complexity of the interplay between this myriad of serum factors and hemodialysis. Further research is needed to shed light on this underexplored area of hemodialysis.
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Affiliation(s)
- Sydney C W Tang
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
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Borawski J, Naumnik B, Mysliwiec M. Tissue factor and thrombomodulin in hemodialysis patients: associations with endothelial injury, liver disease, and erythropoietin therapy. Clin Appl Thromb Hemost 2002; 8:359-67. [PMID: 12516686 DOI: 10.1177/107602960200800408] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Patients receiving maintenance hemodialysis (HD) present with hemostatic abnormalities, which may be aggravated by comorbid conditions, especially liver disease. The factors that influence plasma levels of thrombomodulin (TM), an initiator of the anticoagulant protein C pathway, and those of tissue factor (TF), which triggers the extrinsic coagulation pathway, were assessed. In 63 HD patients, TM and TF levels were higher than those in healthy controls. In bivariate analysis, TF positively correlated with TM, and both were directly associated with the presence of viral hepatitis B or C marker, serum liver enzymes, use of erythropoietin therapy, hemoglobin levels, and duration of HD therapy, and inversely correlated with body mass index. TF was also positively associated with plasma von Willebrand factor (vWF) antigen, and inversely associated with activated partial thromboplastin time. In multivariate analysis, increased vWF, alanine aminotransferase, and use of erythropoietin independently predicted both TF and TM levels. HD patients with vWF and ALT levels lower than middle, and not treated with erythropoietin had normal TF but increased TM concentrations compared with levels in healthy controls. Increased plasma levels of TM and TF in patients on maintenance HD are surrogates of vascular endothelial injury. Liver disease and use of erythropoietin treatment are also important determinants of these markers, and should be considered in further studies.
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Affiliation(s)
- Jacek Borawski
- Department of Nephrology and Internal Medicine, Medical Academy, Bialystok, Poland.
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