1
|
Xiao Y, Vazquez-Padron RI, Martinez L, Singer HA, Woltmann D, Salman LH. Role of platelet factor 4 in arteriovenous fistula maturation failure: What do we know so far? J Vasc Access 2024; 25:390-406. [PMID: 35751379 PMCID: PMC9974241 DOI: 10.1177/11297298221085458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The rate of arteriovenous fistula (AVF) maturation failure remains unacceptably high despite continuous efforts on technique improvement and careful pre-surgery planning. In fact, half of all newly created AVFs are unable to be used for hemodialysis (HD) without a salvage procedure. While vascular stenosis in the venous limb of the access is the culprit, the underlying factors leading to vascular narrowing and AVF maturation failure are yet to be determined. We have recently demonstrated that AVF non-maturation is associated with post-operative medial fibrosis and fibrotic stenosis, and post-operative intimal hyperplasia (IH) exacerbates the situation. Multiple pathological processes and signaling pathways are underlying the stenotic remodeling of the AVF. Our group has recently indicated that a pro-inflammatory cytokine platelet factor 4 (PF4/CXCL4) is upregulated in veins that fail to mature after AVF creation. Platelet factor 4 is a fibrosis marker and can be detected in vascular stenosis tissue, suggesting that it may contribute to AVF maturation failure through stimulation of fibrosis and development of fibrotic stenosis. Here, we present an overview of the how PF4-mediated fibrosis determines AVF maturation failure.
Collapse
Affiliation(s)
- Yuxuan Xiao
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY, USA
| | - Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Harold A Singer
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY, USA
| | - Daniel Woltmann
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY, USA
| | - Loay H Salman
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY, USA
- Division of Nephrology and Hypertension, Albany Medical College, Albany, NY, USA
| |
Collapse
|
2
|
Xiao Y, Martinez L, Zigmond Z, Woltmann D, Singer DV, Singer HA, Vazquez-Padron RI, Salman LH. Functions for platelet factor 4 (PF4/CXCL4) and its receptors in fibroblast-myofibroblast transition and fibrotic failure of arteriovenous fistulas (AVFs). J Vasc Access 2023:11297298231192386. [PMID: 37589266 PMCID: PMC10998683 DOI: 10.1177/11297298231192386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Over 60% of End Stage Renal Disease (ESRD) patients are relying on hemodialysis (HD) to survive, and the arteriovenous fistula (AVF) is the preferred vascular access method for HD. However approximately half of all newly created AVF fail to mature and cannot be used without a salvage procedure. We have recently demonstrated an association between AVF maturation failure and post-operative fibrosis, while our RNA-seq study also revealed that veins that ultimately failed during AVF maturation had elevated levels of platelet factor 4 (PF4/CXCL4). However, a link between these two findings was yet to be established. METHODS In this study, we investigated potential mechanisms between PF4 levels and fibrotic remodeling in veins. We compared the local expression of PF4 and fibrosis marker integrin β6 (ITGB6) in veins that successfully underwent maturation with that in veins that ultimately failed to mature. We also measured the changes of expression level of α-smooth muscle actin (αSMA/ACTA2) and collagen (Col1/COL1A1) in venous fibroblasts upon various treatments, such as PF4 pharmacological treatment, alteration of PF4 expression, and blocking of PF4 receptors. RESULTS We found that PF4 is expressed in veins and co-localizes with αSMA. In venous fibroblasts, PF4 stimulates expression of αSMA and Col1 via different pathways. The former requires integrins αvβ5 and α5β1, while chemokine receptor CXCR3 is needed for the latter. Interestingly, we also discovered that the expression of PF4 is associated with that of ITGB6, the β subunit of integrin αvβ6. This integrin is critical for the activation of the major fibrosis factor TGFβ, and overexpression of PF4 promotes activation of the TGFβ pathway. CONCLUSIONS These results indicate that upregulation of PF4 may cause venous fibrosis both directly by stimulating fibroblast differentiation and expression of extracellular matrix (ECM) molecules and indirectly by facilitating the activation of the TGFβ pathway.
Collapse
Affiliation(s)
- Yuxuan Xiao
- Department of Molecular & Cellular Physiology, Albany Medical College, Albany, NY, USA
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Zachary Zigmond
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Daniel Woltmann
- Department of Molecular & Cellular Physiology, Albany Medical College, Albany, NY, USA
| | - Diane V Singer
- Department of Molecular & Cellular Physiology, Albany Medical College, Albany, NY, USA
| | - Harold A Singer
- Department of Molecular & Cellular Physiology, Albany Medical College, Albany, NY, USA
| | - Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Loay H Salman
- Department of Molecular & Cellular Physiology, Albany Medical College, Albany, NY, USA
- Division of Nephrology & Hypertension, Albany Medical College, Albany, NY, USA
| |
Collapse
|
3
|
Martinez L, Rojas MG, Tabbara M, Pereira-Simon S, Santos Falcon N, Rauf MA, Challa A, Zigmond ZM, Griswold AJ, Duque JC, Lassance-Soares RM, Velazquez OC, Salman LH, Vazquez-Padron RI. The Transcriptomics of the Human Vein Transformation After Arteriovenous Fistula Anastomosis Uncovers Layer-Specific Remodeling and Hallmarks of Maturation Failure. Kidney Int Rep 2023; 8:837-850. [PMID: 37069981 PMCID: PMC10105062 DOI: 10.1016/j.ekir.2023.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/15/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023] Open
Abstract
Introduction The molecular transformation of the human preaccess vein after arteriovenous fistula (AVF) creation is poorly understood. This limits our ability to design efficacious therapies to improve maturation outcomes. Methods Bulk RNA sequencing (RNA-seq) followed by paired bioinformatic analyses and validation assays were performed in 76 longitudinal vascular biopsies (veins and AVFs) from 38 patients with stage 5 chronic kidney disease or end-stage kidney disease undergoing surgeries for 2-stage AVF creation (19 matured, 19 failed). Results A total of 3637 transcripts were differentially expressed between veins and AVFs independent of maturation outcomes, with 80% upregulated in fistulas. The postoperative transcriptome demonstrated transcriptional activation of basement membrane and interstitial extracellular matrix (ECM) components, including preexisting and novel collagens, proteoglycans, hemostasis factors, and angiogenesis regulators. A postoperative intramural cytokine storm involved >80 chemokines, interleukins, and growth factors. Postoperative changes in ECM expression were differentially distributed in the AVF wall, with proteoglycans and fibrillar collagens predominantly found in the intima and media, respectively. Interestingly, upregulated matrisome genes were enough to make a crude separation of AVFs that failed from those with successful maturation. We identified 102 differentially expressed genes (DEGs) in association with AVF maturation failure, including upregulation of network collagen VIII in medial smooth muscle cells (SMCs) and downregulation of endothelial-predominant transcripts and ECM regulators. Conclusion This work delineates the molecular changes that characterize venous remodeling after AVF creation and those relevant to maturation failure. We provide an essential framework to streamline translational models and our search for antistenotic therapies.
Collapse
Affiliation(s)
- Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Miguel G. Rojas
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Simone Pereira-Simon
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Nieves Santos Falcon
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Mohd Ahmar Rauf
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Akshara Challa
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | | | - Anthony J. Griswold
- John P. Hussman Institute for Human Genomics, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Juan C. Duque
- Katz Family Division of Nephrology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Roberta M. Lassance-Soares
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Omaida C. Velazquez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Loay H. Salman
- Division of Nephrology, Albany Medical College, Albany, New York, USA
| | - Roberto I. Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida, USA
- Bruce W. Carter Veterans Affairs Medical Center, Miami, Florida, USA
| |
Collapse
|
4
|
Martinez L, Perla M, Tabbara M, Duque JC, Rojas MG, Falcon NS, Pereira-Simon S, Salman LH, Vazquez-Padron RI. Systemic Profile of Cytokines in Arteriovenous Fistula Patients and Their Associations with Maturation Failure. Kidney360 2022; 3:677-686. [PMID: 35721613 PMCID: PMC9136910 DOI: 10.34067/kid.0006022021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/13/2022] [Indexed: 11/27/2022]
Abstract
Background Systemic cytokines are elevated in patients with chronic kidney disease (CKD) and on hemodialysis compared with the general population. However, whether cytokine levels interfere with vascular remodeling, increasing the risk of arteriovenous fistula (AVF) failure, remains unknown. Methods This is a case-control study of 64 patients who underwent surgery for AVF creation (32 with AVF maturation failure and 32 matching controls with successful maturation). A total of 74 cytokines, including chemokines, interferons, interleukins, and growth factors, were measured in preoperative plasma samples using multiplex assays. Sixty-two patients were included in the statistical analyses. Associations with AVF failure were assessed using paired comparisons and conditional logistic regressions accounting for paired strata. Results Seven cytokines were significantly higher in patients with AVF maturation failure than in matching controls (G-CSF, IL-6, MDC, RANTES, SDF-1α/β, TGFα, and TPO). Of these, G-CSF (odds ratio [OR]=1.71; 95% confidence interval [95% CI], 1.05 to 2.79 per 10 pg/ml), MDC (OR=1.60, 95% CI, 1.08 to 2.38 per 100 pg/ml), RANTES (OR=1.55, 95% CI, 1.10 to 2.17 per 100 pg/ml), SDF-1α/β (OR=1.18, 95% CI, 1.04 to 1.33 per 1000 pg/ml), and TGFα (OR=1.39, 95% CI 1.003, 1.92 per 1 pg/ml) showed an incremental association by logistic regression. Conclusions This study identified a profile of plasma cytokines associated with adverse maturation outcomes in AVFs. These findings may open the doors for future therapeutics and markers for risk stratification.
Collapse
Affiliation(s)
- Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Mikael Perla
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Juan C Duque
- Katz Family Division of Nephrology, Department of Medicine, University of Miami, Miami, Florida
| | - Miguel G Rojas
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Nieves Santos Falcon
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Simone Pereira-Simon
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Loay H Salman
- Division of Nephrology, Albany Medical College, Albany, New York
| | - Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida.,Bruce W. Carter VA Medical Center, Department of Veterans Affairs, Miami, Florida
| |
Collapse
|
5
|
Niyyar VD, Agarwal AK, Salman LH. Clinical Aspects of Dialysis Interventions: Physical and Sonographic Findings. Semin Intervent Radiol 2022; 39:9-13. [PMID: 35210727 PMCID: PMC8856772 DOI: 10.1055/s-0041-1740946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Physical examination (PE) of arteriovenous access remains of high clinical value and continues to be recommended by leading societies and guidelines. PE is easy to learn and perform. Once learned, examiners can provide a comprehensive arteriovenous (AV) access examination in 20 to 30 seconds. Therefore, we continue to advocate that AV access PE should be part of the training for all dialysis care providers. Similarly, ultrasound can provide important AV access evaluation and provide key information. It is relatively cheap and can be readily available at the bed side. Additionally, it is well accepted by patients, as it is not expected to be associated with pain or discomfort during the examination. We present in this review the key components of PE, signs and symptoms of AV access dysfunction, and the role of ultrasound in AV access evaluation as a complementary tool to PE.
Collapse
Affiliation(s)
- Vandana Dua Niyyar
- Division of Nephrology, Emory University School of Medicine, Atlanta, Georgia
| | - Anil K. Agarwal
- Department of Medicine, VA Central California Health Care System, Fresno, California
| | - Loay H. Salman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York,Address for correspondence Loay H. Salman, MD, MBA Division of Nephrology and Hypertension, Albany Medical CollegeAlbany, NY 12208
| |
Collapse
|
6
|
Labissiere X, Zigmond ZM, Challa A, Montoya C, Manzur-Pineda K, Abraham A, Tabbara M, Salama A, Pan Y, Salman LH, Yang X, Vazquez-Padron RI, Martinez L. Vein morphometry in end-stage kidney disease: Teasing out the contribution of age, comorbidities, and vintage to chronic wall remodeling. Front Cardiovasc Med 2022; 9:1005030. [PMID: 36419492 PMCID: PMC9676677 DOI: 10.3389/fcvm.2022.1005030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
Background Chronic kidney disease (CKD) is a highly comorbid condition with significant effects on vascular health and remodeling. Upper extremity veins are important in end-stage kidney disease (ESKD) due to their potential use to create vascular accesses. However, unlike arteries, the contribution of CKD-associated factors to the chronic remodeling of veins has been barely studied. Methods We measured morphometric parameters in 315 upper extremity veins, 131 (85% basilic) from stage 5 CKD/ESKD patients and 184 (89% basilic) from non-CKD organ donors. Associations of demographic and clinical characteristics with intimal hyperplasia (IH) and medial fibrosis were evaluated using multivariate regression models. Results The study cohort included 33% females, 30% blacks, 32% Hispanics, and 37% whites. Over 60% had hypertension, and 25% had diabetes independent of CKD status. Among kidney disease participants, 26% had stage 5 CKD, while 22 and 52% had ESKD with and without history of a previous arteriovenous fistula/graft (AVF/AVG), respectively. Intimal hyperplasia was associated with older age (β = 0.13 per year, confidence interval [CI] = 0.002-0.26), dialysis vintage > 12 months (β = 0.22, CI = 0.09-0.35), and previous AVF/AVG creation (β = 0.19, CI = 0.06-0.32). Upper quartile values of IH were significantly associated with diabetes (odds ratio [OR] = 2.02, CI = 1.08-3.80), which demonstrated an additive effect with previous AVF/AVG history and longer vintage in exacerbating IH. Medial fibrosis also increased as a function of age (β = 0.17, CI = 0.04-0.30) and among patients with diabetes (β = 0.15, CI = 0.03-0.28). Age was the predominant factor predicting upper quartile values of fibrosis (OR = 1.03 per year, CI = 1.01-1.05) independent of other comorbidities. Conclusion Age and diabetes are the most important risk factors for chronic development of venous IH and fibrosis independent of CKD status. Among kidney disease patients, longer dialysis vintage, and history of a previous AVF/AVG are strong predictors of IH.
Collapse
Affiliation(s)
- Xochilt Labissiere
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Zachary M Zigmond
- Bruce W. Carter Veterans Affairs Medical Center, Miami, FL, United States
| | - Akshara Challa
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Christopher Montoya
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Karen Manzur-Pineda
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Amalia Abraham
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Alghidak Salama
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Yue Pan
- Department of Public Health Sciences, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Loay H Salman
- Division of Nephrology, Albany Medical College, Albany, NY, United States
| | - Xiaofeng Yang
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States.,Bruce W. Carter Veterans Affairs Medical Center, Miami, FL, United States
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, United States
| |
Collapse
|
7
|
Lacson E, Argyropoulos CP, Manley HJ, Aweh G, Chin AI, Salman LH, Hsu CM, Johnson DS, Weiner DE. Immunogenicity of SARS-CoV-2 Vaccine in Dialysis. J Am Soc Nephrol 2021; 32:2735-2742. [PMID: 34348908 PMCID: PMC8806103 DOI: 10.1681/asn.2021040432] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/23/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patients receiving maintenance dialysis represent a high-risk, immune-compromised population with 15%-25% COVID-19 mortality rate who were unrepresented in clinical trials of mRNA vaccines. METHODS All patients receiving maintenance dialysis who received two doses of SARS-CoV-2 mRNA vaccines with antibody test results drawn ≥14 days after the second dose, as documented in the electronic health record through March 18, 2021, were included. Response was on the basis of levels of Ig-G against the receptor binding domain of the S1 subunit of SARS-CoV-2 spike-antigen (seropositive ≥2 U/L) using an FDA-approved semiquantitative chemiluminescent assay (ADVIA Centaur XP/XPT COV2G). RESULTS Among 186 patients on dialysis from 30 clinics in eight states tested 23±8 days after receiving two vaccine doses, there were 165 (88.7%) responders with 70% at maximum titer. There was no significant difference between BNT162b2/Pfizer (148 out of 168, 88.1%) and mRNA-1273/Moderna (17 out of 18, 94.4%), P=0.42. All 38 patients with COVID-19 history were responders, with 97% at maximum titer. Among patients without COVID-19, 127 out of 148 (85.8%) were responders, comparable between BNT162b2/Pfizer (113 out of 133) and mRNA-1273/Moderna (14 out of 15) vaccines (85.0% versus 93.3%, P=0.38). CONCLUSIONS Most patients receiving maintenance dialysis responded after two doses of BNT162b2/Pfizer or mRNA-1273/Moderna vaccine, suggesting the short-term development of antispike antibody is good, giving hope that most of these patients who are vulnerable, once immunized, will be protected from COVID-19. Longer-term evaluation is needed to determine antibody titer durability and if booster dose(s) are warranted. Further research to evaluate the approach to patients without a serologic response is needed, including benefits of additional dose(s) or administration of alternate options.
Collapse
Affiliation(s)
- Eduardo Lacson
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
- Dialysis Clinic, Inc., Nashville, Tennessee
| | | | | | | | - Andrew I. Chin
- Division of Nephrology, University of California, Sacramento, California
| | - Loay H. Salman
- Division of Nephrology, Albany Medical College, Albany, New York
| | - Caroline M. Hsu
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | | | - Daniel E. Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
8
|
Vazquez-Padron RI, Duque JC, Tabbara M, Salman LH, Martinez L. Intimal Hyperplasia and Arteriovenous Fistula Failure: Looking Beyond Size Differences. Kidney360 2021; 2:1360-1372. [PMID: 34765989 PMCID: PMC8579754 DOI: 10.34067/kid.0002022021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The development of venous intimal hyperplasia (IH) has been historically associated with failure of arteriovenous fistulas (AVF) used for hemodialysis. This long-standing assumption, based on histological observations, has been recently challenged by clinical studies indicating that the size of the intima by itself is not enough to explain stenosis or AVF maturation failure. Irrespective of this lack of association, IH is present in most native veins and fistulas, is prominent in many cases, and suggests a role in the vein that may not be reflected by its dimensions. Therefore, the contribution of IH to AVF dysfunction remains controversial. Using only clinical data and avoiding extrapolations from animal models, we critically discuss the biological significance of IH in vein remodeling, vascular access function, and the response of the venous wall to repeated trauma in hemodialysis patients. We address questions and pose new ones such as: What are the factors that contribute to IH in pre-access veins and AVFs? Do cellular phenotypes and composition of the intima influence AVF function? Are there protective roles of the venous intima? This review explores these possibilities, with hopes of rekindling a critical discussion about venous IH that goes beyond thickness and AVF outcomes.
Collapse
Affiliation(s)
- Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Juan C Duque
- Katz Family Division of Nephrology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Loay H Salman
- Division of Nephrology, Albany Medical College, Albany, New York
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| |
Collapse
|
9
|
Abstract
Neointimal cells are an elusive population with ambiguous origins, functions, and states of differentiation. Expansion of the venous intima in arteriovenous fistula (AVF) is one of the most prominent remodeling processes in the wall after access creation. However, most of the current knowledge about neointimal cells in AVFs comes from extrapolations from the arterial neointima in non-AVF systems. Understanding the origin of neointimal cells in fistulas may have important implications for the design and effective delivery of therapies aimed to decrease intimal hyperplasia (IH). In addition, a broader knowledge of cellular dynamics during postoperative remodeling of the AVF may help clarify other transformation processes in the wall that combined with IH determine the successful remodeling or failure of the access. In this review, we discuss the possible anatomical sources of neointimal cells in AVFs and their relative contribution to intimal expansion.
Collapse
Affiliation(s)
- Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Juan C Duque
- Katz Family Division of Nephrology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Loay H Salman
- Division of Nephrology, Albany Medical College, Albany, NY, USA
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| |
Collapse
|
10
|
Lacson E, Argyropoulos CP, Manley HJ, Aweh G, Chin AI, Salman LH, Hsu CM, Johnson DS, Weiner DE. Immunogenicity of SARS-CoV-2 Vaccine in Dialysis. medRxiv 2021:2021.04.08.21254779. [PMID: 33880482 PMCID: PMC8057250 DOI: 10.1101/2021.04.08.21254779] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
BACKGROUND Patients receiving maintenance dialysis represent a high risk, immune-compromised population with 15-25% COVID mortality rate who were unrepresented in clinical trials evaluated for mRNA vaccines' emergency use authorization. METHOD All patients receiving maintenance dialysis that received two doses of SARS-CoV-2 mRNA vaccines with antibody test results drawn ≥14 days after the second dose, as documented in the electronic health record through March 18, 2021 were included. We report seroresponse based on levels of immunoglobulin-G against the receptor binding domain of the S1 subunit of SARS-CoV-2 spike antigen (seropositive ≥2) using FDA-approved semi-quantitative chemiluminescent assay (ADVIA Centaur® XP/XPT COV2G). RESULTS Among 186 dialysis patients from 32 clinics in 8 states tested 23±8 days after receiving 2 vaccine doses, mean age was 68±12 years, with 47% women, 21% Black, 26% residents in long-term care facilities and 97% undergoing in-center hemodialysis. Overall seropositive rate was 165/186 (88.7%) with 70% at maximum titer and with no significant difference in seropositivity between BNT162b2/Pfizer (N=148) and mRNA-1273/Moderna (N=18) vaccines (88.1% vs. 94.4%, p=0.42). Among patients with COVID-19 history, seropositive rate was 38/38 (100%) with 97% at maximum titer. CONCLUSION Most patients receiving maintenance dialysis were seropositive after two doses of BNT162b2/Pfizer or mRNA-1273/Moderna vaccine. Early evidence suggests that vaccinated dialysis patients with prior COVID-19 develop robust antibody response. These results support an equitable and aggressive vaccination strategy for eligible dialysis patients, regardless of age, sex, race, ethnicity, or disability, to prevent the extremely high morbidity and mortality associated with COVID-19 in this high risk population. SIGNIFICANCE In this retrospective observational evaluation of SARS-CoV-2 mRNA vaccine response defined by detectable levels of immunoglobulin-G against the receptor binding domain of the S1 subunit of SARS-CoV-2 spike antigen of ≥2 in serum of patients receiving maintenance dialysis, 165/186 (88.7%) were found to be seropositive (with 70% at maximum titer) at least 14 days after completing the second dose. No significant differences were observed by race or other subgroup or by vaccine manufacturer. Therefore, an equitable and aggressive vaccination strategy for all eligible maintenance dialysis patients, regardless of age, sex, race, ethnicity, or disability, is warranted to prevent the extremely high morbidity and mortality associated with COVID-19 in this high risk population.
Collapse
|
11
|
Selman G, Martinez L, Lightle A, Aguilar A, Woltmann D, Xiao Y, Vazquez-Padron RI, Salman LH. A hyaluronan synthesis inhibitor delays the progression of diabetic kidney disease in a mouse experimental model. Kidney360 2021; 2:809-818. [PMID: 34350420 PMCID: PMC8330520 DOI: 10.34067/kid.0004642020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The role of hyaluronan (HA) in the development and progression of diabetic kidney disease (DKD), as well as the precise mechanisms and consequences of HA involvement in this pathology are still to be clarified. METHODS In this study, we assayed the effects of the HA synthesis inhibitor 4-methylumbelliferone (4-MU) on the development of DKD. Diabetic type 2 model mice (eNOS-/- C57BLKS/Jdb) were fed artificial diets containing 5% 4-MU or not for 9 weeks. Plasma glucose, glomerular filtration rate (GFR), albumin to creatinine ratio (ACR), and biomarkers of kidney function and systemic inflammation were measured at baseline and after treatment. Diabetic nephropathy was further characterized in treated and control mice by histopathology. RESULTS Treated animals consumed a daily dose of approximately 6.2 g of 4-MU per kg of body weight. At the end of the experimental period, the 4-MU supplemented diet resulted in a significant decrease in non-fasting plasma glucose (516 [interquartile range 378-1170] vs. 1149 [875.8-1287] mg/dL, P=0.050) and a trend toward lower HA kidney content (5.6 ± 1.5 vs. 8.8 ± 3.1 ng/mg of kidney weight, P=0.070) compared to the control diet, respectively. Diabetic animals treated with 4-MU showed significantly higher GFR and lower urine ACR and plasma cystatin C levels than diabetic controls. Independent histological assessment of DKD also demonstrated a significant decrease in mesangial expansion score and glomerular injury index in 4-MU-treated mice compared to controls. Plasma glucose showed a strong correlation with kidney HA levels (r=0.66, P=0.0098). Both total hyaluronan (r=0.76, P=0.0071) and low-molecular-weight hyaluronan content (r=0.64, P=0.036) in the kidneys correlated with urine ACR in mice. CONCLUSION These results show that the hyaluronan synthesis inhibitor 4-MU effectively slowed the progression of DKD and constitutes a potential new therapeutic approach to treat DKD.
Collapse
Affiliation(s)
- Guillermo Selman
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, New York
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Andrea Lightle
- Department of Pathology, Albany Medical Center, Albany, New York
| | - Alejandra Aguilar
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, New York
| | - Daniel Woltmann
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, New York
| | - Yuxuan Xiao
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, New York
| | - Roberto I. Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Loay H. Salman
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, New York,Division of Nephrology and Hypertension, Albany Medical Center, Albany, New York
| |
Collapse
|
12
|
Der Mesropian PJ, Shaikh G, Beers KH, Mehta S, Monrroy Prado MR, Hongalgi K, Mathew RO, Feustel PJ, Salman LH, Perna A, Gosmanova EO. Effect of intensive blood pressure on the progression of non-diabetic chronic kidney disease at varying degrees of proteinuria. J Investig Med 2021; 69:1035-1043. [PMID: 33542071 DOI: 10.1136/jim-2020-001702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 11/04/2022]
Abstract
The ideal blood pressure (BP) target for renoprotection is uncertain in patients with non-diabetic chronic kidney disease (CKD), especially considering the influence exerted by pre-existing proteinuria. In this pooled analysis of landmark trials, we coalesced individual data from 5001 such subjects randomized to intensive versus standard BP targets. We employed multivariable regression to evaluate the relationship between follow-up systolic blood pressure (SBP) and diastolic blood pressure (DBP) on CKD progression (defined as glomerular filtration rate decline by 50% or end-stage renal disease), focusing on the potential for effect modification by baseline proteinuria or albuminuria. The median follow-up was 3.2 years. We found that SBP rather than DBP was the primary predictor of renal outcomes. The optimal SBP target was 110-129 mm Hg. We observed a strong interaction between SBP and proteinuria such that lower SBP ranges were significantly linked with progressively lower CKD risk in grade A3 albuminuria or ≥0.5-1 g/day proteinuria (relative to SBP 110-119 mm Hg, the adjusted HR for SBP 120-129 mm Hg, 130-139 mm Hg, and 140-149 mm Hg was 1.5, 2.3, and 3.3, respectively; all p<0.05). In grade A2 microalbuminuria or proteinuria near 0.5 g/day, a non-significant but possible connection was seen between tighter BP and decreased CKD (aforementioned HRs all <2; all p>0.05), while in grade A1 albuminuria or proteinuria <0.2 g/day no significant association was apparent (HRs all <1.5; all p>0.1). We conclude that in non-diabetic CKD, stricter BP targets <130 mm Hg may help limit CKD progression as proteinuria rises.
Collapse
Affiliation(s)
- Paul J Der Mesropian
- Department of Medicine, Division of Nephrology, Albany Stratton VA Medical Center, Albany, New York, USA
| | - Gulvahid Shaikh
- Department of Medicine, Division of Nephrology, Albany Stratton VA Medical Center, Albany, New York, USA
| | - Kelly H Beers
- Department of Medicine, Division of Nephrology, Albany Medical Center, Albany, New York, USA
| | - Swati Mehta
- Department of Medicine, Division of Nephrology, Albany Medical Center, Albany, New York, USA
| | | | - Krishnakumar Hongalgi
- Department of Medicine, Division of Nephrology, Albany Medical Center, Albany, New York, USA
| | - Roy O Mathew
- Department of Medicine, Division of Nephrology, William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina, USA
| | - Paul J Feustel
- Department of Neuroscience and Experimental Therapeutics, Albany Medical Center, Albany, New York, USA
| | - Loay H Salman
- Department of Medicine, Division of Nephrology, Albany Medical Center, Albany, New York, USA
| | - Annalisa Perna
- Department of Renal Medicine, Mario Negri Institute for Pharmacological Research, Milano, Lombardia, Italy
| | - Elvira O Gosmanova
- Department of Medicine, Division of Nephrology, Albany Stratton VA Medical Center, Albany, New York, USA
| |
Collapse
|
13
|
Hernandez DR, Applewhite B, Martinez L, Laurito T, Tabbara M, Rojas MG, Wei Y, Selman G, Knysheva M, Velazquez OC, Salman LH, Andreopoulos FM, Shiu YT, Vazquez-Padron RI. Inhibition of Lysyl Oxidase with β-aminopropionitrile Improves Venous Adaptation after Arteriovenous Fistula Creation. Kidney360 2020; 2:270-278. [PMID: 34322674 PMCID: PMC8315119 DOI: 10.34067/kid.0005012020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The arteriovenous fistula (AVF) is the preferred hemodialysis access for end-stage renal disease (ESRD) patients. Yet, establishment of a functional AVF presents a challenge, even for the most experienced surgeons, since postoperative stenosis frequently occludes the AVF. Stenosis results from the loss of compliance in fibrotic areas of the fistula which turns intimal hyperplasia into an occlusive feature. Fibrotic remodeling depends on deposition and crosslinking of collagen by lysyl oxidase (LOX), an enzyme that catalyzes the deamination of lysine and hydroxylysine residues, facilitating intra/intermolecular covalent bonds. We postulate that pharmacological inhibition of lysyl oxidase (LOX) increases postoperative venous compliance and prevents stenosis in a rat AVF model. METHODS LOX gene expression and vascular localization were assayed in rat AVFs and human pre-access veins, respectively. Collagen crosslinking was measured in humans AVFs that matured or failed, and in rat AVFs treated with β-aminopropionitrile (BAPN), an irreversible LOX inhibitor. BAPN was either injected systemically or delivered locally around rat AVFs using nanofiber scaffolds. The major endpoints were AVF blood flow, wall fibrosis, collagen crosslinking, and vascular distensibility. RESULTS Non-maturation of human AVFs was associated with higher LOX deposition in pre-access veins (N=20, P=0.029), and increased trivalent crosslinks (N=18, P=0.027) in human AVF tissues. Systemic and local inhibition of LOX increased AVF distensibility, while reducing wall fibrosis and collagen crosslinking in rat fistulas. CONCLUSIONS Our results demonstrate that BAPN-mediated inhibition of LOX significantly improves vascular remodeling in experimental fistulas.
Collapse
Affiliation(s)
- Diana R. Hernandez
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Brandon Applewhite
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida,Department of Biomedical Engineering, College of Engineering, University of Miami, Coral Gables, Florida
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Tyler Laurito
- Department of Biomedical Engineering, College of Engineering, University of Miami, Coral Gables, Florida
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Miguel G. Rojas
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Yuntao Wei
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Guillermo Selman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York
| | - Marina Knysheva
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
| | - Omaida C. Velazquez
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Loay H. Salman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York
| | - Fotios M. Andreopoulos
- Department of Biomedical Engineering, College of Engineering, University of Miami, Coral Gables, Florida
| | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
| | - Roberto I. Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| |
Collapse
|
14
|
Duque JC, Martinez L, Tabbara M, Parikh P, Paez A, Selman G, Salman LH, Velazquez OC, Vazquez-Padron RI. Vascularization of the arteriovenous fistula wall and association with maturation outcomes. J Vasc Access 2020; 21:161-168. [PMID: 31608758 PMCID: PMC10970689 DOI: 10.1177/1129729819863584] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The venous vasa vasorum is the mesh of microvessels that provide oxygen and nutrients to the walls of large veins. Whether changes to the vasa vasorum have any effects on human arteriovenous fistula outcomes remains undetermined. In this study, we challenged the hypothesis that inadequate vascularization of the arteriovenous fistula wall is associated with maturation failure. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS This case-control pilot study includes pre-access veins and arteriovenous fistula venous samples (i.e. tissue pairs) from 30 patients undergoing two-stage arteriovenous fistula creation (15 matured and 15 failed to mature). Using anti-CD31 immunohistochemistry, we quantified vasa vasorum density and luminal area (vasa vasorum area) in the intima, media, and adventitia of pre-access veins and fistulas. We evaluated the association of pre-existing and postoperative arteriovenous fistula vascularization with maturation failure and with postoperative morphometry. RESULTS Vascularization of veins and arteriovenous fistulas was predominantly observed in the outer media and adventitia. Only the size of the microvasculature (vasa vasorum area), but not the number of vessels (vasa vasorum density), increased after arteriovenous fistula creation in the adventitia (median vasa vasorum area 1366 µm2/mm2 (interquartile range 495-2582) in veins versus 3077 µm2/mm2 (1812-5323) in arteriovenous fistulas, p < 0.001), while no changes were observed in the intima and media. Postoperative intimal thickness correlated with lower vascularization of the media (r 0.53, p = 0.003 for vasa vasorum density and r 0.37, p = 0.045 for vasa vasorum area). However, there were no significant differences in pre-existing, postoperative, or longitudinal change in vascularization between arteriovenous fistulas with distinct maturation outcomes. CONCLUSION The lack of change in intimal and medial vascularization after arteriovenous fistula creation argues against higher oxygen demand in the inner walls of the fistula during the vein to arteriovenous fistula transformation. Postoperative intimal hyperplasia in the arteriovenous fistula wall appears to thrive under hypoxic conditions. Vasa vasorum density and area by themselves are not predictive of maturation outcomes.
Collapse
Affiliation(s)
- Juan C Duque
- Katz Family Division of Nephrology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Punam Parikh
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Angela Paez
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | | | - Loay H Salman
- Division of Nephrology, Albany Medical College, Albany, NY, USA
| | - Omaida C Velazquez
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| |
Collapse
|
15
|
Duque JC, Martinez L, Tabbara M, Parikh P, Paez A, Selman G, Salman LH, Velazquez OC, Vazquez-Padron RI. Vascularization of the Arteriovenous Fistula Wall and Association with Maturation Outcomes. Ann Vasc Surg 2019. [DOI: 10.1016/j.avsg.2019.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
16
|
Duque JC, Martinez L, Tabbara M, Salman LH, Vazquez-Padron RI, Dejman A. Arteriovenous fistula outcomes in human immunodeficiency virus-positive patients. Saudi J Kidney Dis Transpl 2019; 29:1350-1357. [PMID: 30588966 DOI: 10.4103/1319-2442.248312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Arteriovenous fistula (AVF) remodeling is an active area of research in vascular biology given the high rates of primary failure, complications, and cost burden for the health-care system. Comorbidities such as diabetes and different types of vascular disease are known to influence AVFs outcomes. However, little is known about the effects of immunosuppression, particularly human immunodeficiency virus (HIV) infection, on AVF primary failure and patency. This retrospective study assessed the impact of HIV infection and T-cell counts on AVF outcomes. Using a retrospective cohort of 495 patients, we compared the risk of AVF primary failure and primary unassisted patency on HIV-positive and nonimmunocompromised individuals using logistic regressions and Cox proportional hazard models. Within the HIV-infected subset (n = 43), we analyzed the association between immunological parameters such as T-cell counts and primary failure. Positive predictors of primary failure were HIV infection [odds ratio (OR) = 3.09, P = 0.002] and history of a previous AVF (OR = 2.18, P = 0.003). However, there was no difference in primary unassisted patency between HIV-positive and negative individuals after excluding primary failure cases. There was no association between T-cell subset counts and AVF outcomes. Our results indicate that HIV-positive individuals have a higher risk of AVF primary failure than nonimmunocompromised patients. However, this increased susceptibility is not explained by the degree of immunosuppression.
Collapse
Affiliation(s)
- Juan C Duque
- Katz Family Division of Nephrology and Hypertension, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Loay H Salman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, NY, USA
| | - Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Adriana Dejman
- Katz Family Division of Nephrology and Hypertension, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| |
Collapse
|
17
|
Martinez L, Tabbara M, Duque JC, Selman G, Falcon NS, Paez A, Griswold AJ, Ramos-Echazabal G, Hernandez DR, Velazquez OC, Salman LH, Vazquez-Padron RI. Transcriptomics of Human Arteriovenous Fistula Failure: Genes Associated With Nonmaturation. Am J Kidney Dis 2019; 74:73-81. [PMID: 30826088 PMCID: PMC10980359 DOI: 10.1053/j.ajkd.2018.12.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 12/17/2018] [Indexed: 12/16/2022]
Abstract
RATIONALE & OBJECTIVE Improving arteriovenous fistula (AVF) outcomes requires better understanding of the biology underlying maturation or failure. Our current knowledge of maturation relies on extrapolation from other vascular pathologies, which does not incorporate unique aspects of AVF remodeling. This study compares the RNA expression of pre-access (native) veins and AVFs with distinct maturation outcomes. STUDY DESIGN Case-control study. SETTING & PARTICIPANTS 64 patients undergoing 2-stage AVF surgeries at a single center. 19 native veins and 19 AVF samples were analyzed using RNA sequencing (RNA-seq). 58 native veins were studied using real-time polymerase chain reaction; 45, using immunohistochemistry; and 19, using Western blot analysis. PREDICTOR RNA expression in native veins and AVFs. OUTCOME Anatomic nonmaturation, defined as an AVF that never achieved an internal diameter ≥ 6mm. ANALYTICAL APPROACH Pre-access native veins and AVF samples were obtained from patients undergoing 2-stage AVF creation. Veins that subsequently matured or failed after access creation were analyzed using RNA-seq to search for genes associated with maturation failure. Genes associated with nonmaturation were confirmed using real-time polymerase chain reaction, immunohistochemistry, and Western blot analysis. In addition, the association between pre-access gene expression and postoperative morphology was evaluated. RNA-seq was also performed on AVFs to search for transcriptional differences between AVFs that matured and those that failed at the time of transposition. RESULTS Pro-inflammatory genes (CSF3R, FPR1, S100A8, S100A9, and VNN2) were upregulated in pre-access veins that failed (false discovery rate < 0.05), and their expression colocalized to smooth muscle cells. Expression of S100A8 and S100A9 correlated with postoperative intimal hyperplasia and the product of medial fibrosis and intimal hyperplasia (r=0.32-0.38; P < 0.05). AVFs that matured or failed were transcriptionally similar at the time of transposition. LIMITATIONS Small sample size, analysis of only upper-arm veins and transposed fistulas. CONCLUSIONS Increased expression of proinflammatory genes in pre-access veins appears to be associated with greater risk for AVF nonmaturation.
Collapse
Affiliation(s)
- Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Juan C Duque
- Division of Nephrology and Hypertension, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Guillermo Selman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, NY
| | - Nieves Santos Falcon
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Angela Paez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Anthony J Griswold
- John P. Hussman Institute for Human Genomics, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Gioser Ramos-Echazabal
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Diana R Hernandez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Omaida C Velazquez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Loay H Salman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, NY
| | - Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL.
| |
Collapse
|
18
|
Martinez L, Duque JC, Tabbara M, Paez A, Selman G, Hernandez DR, Sundberg CA, Tey JCS, Shiu YT, Cheung AK, Allon M, Velazquez OC, Salman LH, Vazquez-Padron RI. Fibrotic Venous Remodeling and Nonmaturation of Arteriovenous Fistulas. J Am Soc Nephrol 2018; 29:1030-1040. [PMID: 29295872 DOI: 10.1681/asn.2017050559] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 10/16/2017] [Indexed: 02/03/2023] Open
Abstract
The frequency of primary failure in arteriovenous fistulas (AVFs) remains unacceptably high. This lack of improvement is due in part to a poor understanding of the pathobiology underlying AVF nonmaturation. This observational study quantified the progression of three vascular features, medial fibrosis, intimal hyperplasia (IH), and collagen fiber organization, during early AVF remodeling and evaluated the associations thereof with AVF nonmaturation. We obtained venous samples from patients undergoing two-stage upper-arm AVF surgeries at a single center, including intraoperative veins at the first-stage access creation surgery and AVFs at the second-stage transposition procedure. Paired venous samples from both stages were used to evaluate change in these vascular features after anastomosis. Anatomic nonmaturation (AVF diameter never ≥6 mm) occurred in 39 of 161 (24%) patients. Neither preexisting fibrosis nor IH predicted AVF outcomes. Postoperative medial fibrosis associated with nonmaturation (odds ratio [OR], 1.55; 95% confidence interval [95% CI], 1.05 to 2.30; P=0.03, per 10% absolute increase in fibrosis), whereas postoperative IH only associated with failure in those individuals with medial fibrosis over the population's median value (OR, 2.63; 95% CI, 1.07 to 6.46; P=0.04, per increase of 1 in the intima/media ratio). Analysis of postoperative medial collagen organization revealed that circumferential alignment of fibers around the lumen associated with AVF nonmaturation (OR, 1.38; 95% CI, 1.03 to 1.84; P=0.03, per 10° increase in angle). This study demonstrates that excessive fibrotic remodeling of the vein after AVF creation is an important risk factor for nonmaturation and that high medial fibrosis determines the stenotic potential of IH.
Collapse
Affiliation(s)
| | - Juan C Duque
- Division of Nephrology and Hypertension, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | | | - Angela Paez
- DeWitt Daughtry Family Department of Surgery and
| | - Guillermo Selman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York
| | | | - Chad A Sundberg
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
| | | | - Yan-Ting Shiu
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah.,Medical Service, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah.,Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama; and
| | | | - Loay H Salman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York
| | | |
Collapse
|
19
|
Duque JC, Tabbara M, Martinez L, Paez A, Selman G, Salman LH, Velazquez OC, Vazquez-Padron RI. Similar degree of intimal hyperplasia in surgically detected stenotic and nonstenotic arteriovenous fistula segments: a preliminary report. Surgery 2017; 163:866-869. [PMID: 29241989 DOI: 10.1016/j.surg.2017.10.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 07/26/2017] [Accepted: 10/18/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND Intimal hyperplasia has been historically associated with improper venous remodeling and stenosis after creation of an arteriovenous fistula. Recently, however, we showed that intimal hyperplasia by itself does not explain the failure of maturation of 2-stage arteriovenous fistulas. We seek to evaluate whether intimal hyperplasia plays a role in the development of focal stenosis of an arteriovenous fistula. METHODS This study compares intimal hyperplasia lesions in stenotic and nearby nonstenotic segments collected from the same arteriovenous fistula. Focal areas of stenosis were detected in the operating room in patients (n= 14) undergoing the second-stage vein transposition procedure. The entire vein was inspected, and areas of stenosis were visually located with the aid of manual palpation and hemodynamic changes in the vein peripheral and central to the narrowing. Stenotic and nonstenotic segments were documented by photography before tissue collection (14 tissue pairs). Intimal area and thickness, intima-media thickness, and intima to media area ratio were measured in hematoxylin and eosin stained cross-sections followed by pairwise statistical comparisons. RESULTS The intimal area in stenotic and nonstenotic segments ranged from 1.25 to 11.61 mm2 and 1.29 to 5.81 mm2, respectively. There was no significant difference between these 2 groups (P=.26). Maximal intimal thickness (P=.22), maximal intima-media thickness (P=.13), and intima to media area ratio (P=.73) were also similar between both types of segments. CONCLUSION This preliminary study indicates that postoperative intimal hyperplasia by itself is not associated with the development of focal venous stenosis in 2-stage fistulas.
Collapse
Affiliation(s)
- Juan C Duque
- Division of Nephrology and Hypertension, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Angela Paez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Guillermo Selman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, NY
| | - Loay H Salman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, NY
| | - Omaida C Velazquez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL.
| |
Collapse
|
20
|
Duque JC, Martinez L, Tabbara M, Dvorquez D, Mehandru SK, Asif A, Vazquez-Padron RI, Salman LH. Arteriovenous fistula maturation in patients with permanent access created prior to or after hemodialysis initiation. J Vasc Access 2017; 18:185-191. [PMID: 28218361 PMCID: PMC10949904 DOI: 10.5301/jva.5000662] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2016] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Multiple factors and comorbidities have been implicated in the ability of arteriovenous fistulas (AVF) to mature, including vessel anatomy, advanced age, and the presence of coronary artery disease or peripheral vascular disease. However, little is known about the role of uremia on AVF primary failure. In this study, we attempt to evaluate the effect of uremia on AVF maturation by comparing AVF outcomes between pre-dialysis chronic kidney disease (CKD) stage five patients and those who had their AVF created after hemodialysis (HD) initiation. METHODS We included 612 patients who underwent AVF creation between 2003 and 2015 at the University of Miami Hospital and Jackson Memorial Hospital. Effects of uremia on primary failure were evaluated using univariate statistical comparisons and multivariate logistic regression analyses. RESULTS Primary failure occurred in 28.1% and 26.3% of patients with an AVF created prior to or after HD initiation, respectively (p = 0.73). The time of HD initiation was not associated with AVF maturation in multivariate logistic regression analysis (p = 0.57). In addition, pre-operative blood urea nitrogen (p = 0.78), estimated glomerular filtration rate (p = 0.66), and serum creatinine levels (p = 0.14) were not associated with AVF primary failure in pre-dialysis patients. CONCLUSIONS Our results show that clearance of uremia with regular HD treatments prior to AVF creation does not improve the frequency of vascular access maturation.
Collapse
Affiliation(s)
- Juan C. Duque
- Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Denise Dvorquez
- Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Sushil K. Mehandru
- Department of Medicine, Division of Nephrology, Jersey Shore University Medical Center, Hackensack-Meridian Seton Hall School of Medicine, Neptune, New York - USA
| | - Arif Asif
- Department of Medicine, Division of Nephrology, Jersey Shore University Medical Center, Hackensack-Meridian Seton Hall School of Medicine, Neptune, New York - USA
| | - Roberto I. Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Loay H. Salman
- Division of Nephrology, Albany Medical College, Albany, New York - USA
| |
Collapse
|
21
|
Martinez L, Duque JC, Escobar LA, Tabbara M, Asif A, Fayad F, Vazquez-Padron RI, Salman LH. Distinct impact of three different statins on arteriovenous fistula outcomes: a retrospective analysis. J Vasc Access 2016; 17:471-476. [PMID: 27768209 PMCID: PMC10970648 DOI: 10.5301/jva.5000612] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Whether statins improve arteriovenous fistula (AVF) outcomes is still a matter of debate. Taking into consideration the existing physicochemical differences between individual drugs, this study evaluates the impact of three different statins (atorvastatin, rosuvastatin and simvastatin) on one-stage and two-stage AVF outcomes. METHODS Using a retrospective cohort of 535 patients, we analyzed the effects of each statin on primary failure and primary patency using multivariate logistic regressions and Cox proportional hazard models. RESULTS Out of the three statins analyzed, only atorvastatin improved the overall primary failure of AVF (odds ratio [OR] = 0.18, p = 0.005). Comparisons between the two AVF types demonstrated that this effect was due to a prominent reduction in primary failure of one-stage (OR = 0.03; p = 0.005), but not two-stage fistulas (OR = 0.43; p = 0.25). In contrast, primary patency of two-stage (hazards ratio [HR] = 0.51; p = 0.024), but not one-stage fistulas (HR = 0.98; p = 0.95), was improved by all statins as a group, but not by individual drugs. CONCLUSIONS Our results suggest that the potential benefit of statins on AVF outcomes is a drug-specific and not a class effect, and that such effect is also influenced by the type of fistula.
Collapse
Affiliation(s)
- Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Juan C. Duque
- Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Luis A. Escobar
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Arif Asif
- Department of Medicine, Jersey Shore University Medical Center, Hackensack-Meridian Health, Neptune, New Jersey - USA
| | - Fadi Fayad
- Section of Interventional Nephrology, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Roberto I. Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida - USA
| | - Loay H. Salman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York - USA
| |
Collapse
|
22
|
Duque JC, Tabbara M, Martinez L, Cardona J, Vazquez-Padron RI, Salman LH. Dialysis Arteriovenous Fistula Failure and Angioplasty: Intimal Hyperplasia and Other Causes of Access Failure. Am J Kidney Dis 2016; 69:147-151. [PMID: 28084215 DOI: 10.1053/j.ajkd.2016.08.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 08/02/2016] [Indexed: 12/27/2022]
Abstract
The arteriovenous fistula (AVF) is the preferred hemodialysis access type because it has better patency rates and fewer complications than other access types. However, primary failure remains a common problem impeding AVF maturation and adding to patients' morbidity and mortality. Juxta-anastomotic (or inflow) stenosis is the most common reason leading to primary failure, and percutaneous transluminal angioplasty continues to be the gold-standard treatment with excellent success rates. Intimal hyperplasia (IH) has been traditionally blamed as the main pathophysiologic culprit, but new evidence raises doubts regarding the contribution of IH alone to primary failure. We report a 64-year-old man with a 2-stage brachiobasilic AVF that was complicated by failure 4 months after creation. An angiogram showed multiple juxta-anastomotic and midfistula stenotic lesions. Percutaneous transluminal angioplasty was successful in assisting maturation and subsequently cannulating the AVF for hemodialysis treatment. We failed to identify the underlying cause of stenosis because biopsy specimens from fistula tissue obtained at the time of transposition revealed no occlusive IH. This case emphasizes the need for additional research on factors contributing to AVF failure besides IH and highlights the need for more therapeutic options to reduce AVF failure rate.
Collapse
Affiliation(s)
- Juan C Duque
- Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Jose Cardona
- Division of Nephrology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Loay H Salman
- Section of Interventional Nephrology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL.
| |
Collapse
|
23
|
Laurito T, Sueiras V, Fernandez N, Escobar LA, Martinez L, Andreopoulos F, Salman LH, Vazquez-Padron RI, Ziebarth NM. Assessment of micro-mechanical variations in experimental arteriovenous fistulae using atomic force microscopy. J Vasc Access 2016; 17:279-83. [PMID: 27032456 PMCID: PMC10949901 DOI: 10.5301/jva.5000514] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2015] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This study presents a method to quantify micro-stiffness variations in experimental arteriovenous fistulae (AVF). METHODS AVF created by anastomosing the superficial epigastric vein to the femoral artery in Sprague-Dawley rats were allowed to remodel for 21 days before being harvested and preserved in culture medium. A custom atomic force microscope was used to measure microvascular stiffness (Young's modulus) in three areas of the AVF: the inflow artery, the juxta-anastomotic area, and the outflow vein. Morphometric measurements and collagen and elastin contents were also determined. RESULTS Atomic force microscopy indentation revealed an increased stiffness in the juxta-anastomotic area of the AVF compared to the outflow vein and inflow artery. The juxta-anastomotic area was also significantly stiffer than the contralateral vein. The lack of elasticity (higher Young's modulus) of the juxta-anastomotic region was associated with a thicker vascular wall that was rich in collagen but poor in elastin. CONCLUSIONS This study demonstrates for the first time the feasibility of using atomic force microscopy to measure local stiffness variations in experimental AVF. This technique could be instrumental in advancing our understanding of how micro-spatial organization of the AVF wall determines the overall biomechanical performance of this type of vascular access.
Collapse
Affiliation(s)
- Tyler Laurito
- Department of Biomedical Engineering, University of Miami College of Engineering, Coral Gables, Florida - USA
| | - Vivian Sueiras
- Department of Biomedical Engineering, University of Miami College of Engineering, Coral Gables, Florida - USA
| | - Natasha Fernandez
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida - USA
| | - Luis A. Escobar
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida - USA
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida - USA
| | - Fotios Andreopoulos
- Department of Biomedical Engineering, University of Miami College of Engineering, Coral Gables, Florida - USA
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida - USA
| | - Loay H. Salman
- Section of Interventional Nephrology, University of Miami Miller School of Medicine, Miami, Florida - USA
| | - Roberto I. Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida - USA
| | - Noël M. Ziebarth
- Department of Biomedical Engineering, University of Miami College of Engineering, Coral Gables, Florida - USA
| |
Collapse
|
24
|
Tabbara M, Duque JC, Martinez L, Escobar LA, Wu W, Pan Y, Fernandez N, Velazquez OC, Jaimes EA, Salman LH, Vazquez-Padron RI. Pre-existing and Postoperative Intimal Hyperplasia and Arteriovenous Fistula Outcomes. Am J Kidney Dis 2016; 68:455-64. [PMID: 27012909 DOI: 10.1053/j.ajkd.2016.02.044] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 02/07/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND The contribution of intimal hyperplasia (IH) to arteriovenous fistula (AVF) failure is uncertain. This observational study assessed the relationship between pre-existing, postoperative, and change in IH over time and AVF outcomes. STUDY DESIGN Prospective cohort study with longitudinal assessment of IH at the time of AVF creation (pre-existing) and transposition (postoperative). Patients were followed up for up to 3.3 years. SETTING & PARTICIPANTS 96 patients from a single center who underwent AVF surgery initially planned as a 2-stage procedure. Veins and AVF samples were collected from 66 and 86 patients, respectively. Matched-pair tissues were available from 56 of these patients. PREDICTORS Pre-existing, postoperative, and change in IH over time. OUTCOMES Anatomic maturation failure was defined as an AVF that never reached a diameter > 6mm. Primary unassisted patency was defined as the time elapsed from the second-stage surgery to the first intervention. MEASUREMENTS Maximal intimal thickness in veins and AVFs and change in intimal thickness over time. RESULTS Pre-existing IH (>0.05mm) was present in 98% of patients. In this group, the median intimal thickness increased 4.40-fold (IQR, 2.17- to 4.94-fold) between AVF creation and transposition. However, this change was not associated with pre-existing thickness (r(2)=0.002; P=0.7). Ten of 96 (10%) AVFs never achieved maturation, whereas 70% of vascular accesses remained patent at the end of the observational period. Postoperative IH was not associated with anatomic maturation failure using univariate logistic regression. Pre-existing, postoperative, and change in IH over time had no effects on primary unassisted patency. LIMITATIONS The small number of patients from whom longitudinal tissue samples were available and low incidence of anatomic maturation failure, which decreased the statistical power to find associations between end points and IH. CONCLUSIONS Pre-existing, postoperative, and change in IH over time were not associated with 2-stage AVF outcomes.
Collapse
Affiliation(s)
- Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Juan C Duque
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Luis A Escobar
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Wensong Wu
- Department of Mathematics and Statistics, Florida International University, Miami, FL
| | - Yue Pan
- Department of Epidemiology and Public Health, University of Miami, Coral Gables, FL
| | - Natasha Fernandez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Omaida C Velazquez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Edgar A Jaimes
- Renal Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Loay H Salman
- Section of Interventional Nephrology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL.
| |
Collapse
|
25
|
Duque JC, Martinez L, Mesa A, Wei Y, Tabbara M, Salman LH, Vazquez-Padron RI. CD4(+) lymphocytes improve venous blood flow in experimental arteriovenous fistulae. Surgery 2015; 158:529-36. [PMID: 25999254 DOI: 10.1016/j.surg.2015.02.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 02/16/2015] [Accepted: 02/21/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The role of immune cells in arteriovenous fistulae (AVF) maturation is poorly understood and has received, until quite recently, little attention. This study examines the function of T lymphocytes in AVF vascular remodeling. METHODS Experimental fistulae were created in athymic rnu nude rats lacking mature T lymphocytes and euthymic control animals by anastomosing the left superior epigastric vein to the nearby femoral artery. Blood flow rates, wall morphology, and histologic changes were assessed in AVF 21 days after creation. The effect of CD4(+) lymphocytes on AVF maturation in athymic animals was analyzed by adoptive transfer of cells after fistula creation. RESULTS The absence of T lymphocytes compromised blood flow in experimental fistulae. Histopathologic inspection of AVF from athymic rats revealed that T-cell immunodeficiency negatively affected venous vascular remodeling, as evidenced by a reduced lumen, a thick muscular layer, and a low number of inflammatory cells compared with control animals. Adoptive transfer of CD4(+) lymphocytes from euthymic rats into athymic animals after fistula creation improved blood flow and reduced intima-media thickness. CONCLUSION These results point at the protective role of CD4(+) lymphocytes in the remodeling of the AVF vascular wall.
Collapse
Affiliation(s)
- Juan C Duque
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Annia Mesa
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Yuntao Wei
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Loay H Salman
- Section of Interventional Nephrology, University of Miami Miller School of Medicine, Miami, FL
| | - Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL.
| |
Collapse
|
26
|
Duque JC, Gomez C, Tabbara M, Alfonso CE, Li X, Vazquez-Padron RI, Asif A, Lenz O, Briones PL, Salman LH. The impact of arteriovenous fistulae on the myocardium: the impact of creation and ligation in the transplant era. Semin Dial 2014; 28:305-10. [PMID: 25267110 DOI: 10.1111/sdi.12313] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cardiac hypertrophy is a relatively common complication seen in patients with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD). Moreover, cardiac hypertrophy is even more frequently seen in patients with ESRD who have an arteriovenous (AV) access. There has been substantial evidence pertaining to the effects of AV access creation on the heart structure and function. Similarly, there is increasing evidence on the effects of AV access closure, flow reduction, transplantation, and immunosuppressive medication on both endpoints. In this review, we present the evidence available in the literature on these topics and open the dialog for further research in this interesting field.
Collapse
Affiliation(s)
- Juan Camilo Duque
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida; Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Affiliation(s)
- Loay H Salman
- Division of Nephrology and Hypertension, University of Miami, Miller School of Medicine, Miami, Florida
| |
Collapse
|
28
|
Skartsis N, Martinez L, Duque JC, Tabbara M, Velazquez OC, Asif A, Andreopoulos F, Salman LH, Vazquez-Padron RI. c-Kit signaling determines neointimal hyperplasia in arteriovenous fistulae. Am J Physiol Renal Physiol 2014; 307:F1095-104. [PMID: 25186298 DOI: 10.1152/ajprenal.00292.2014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Stenosis of arteriovenous (A-V) fistulae secondary to neointimal hyperplasia (NIH) compromises dialysis delivery, which worsens patients' quality of life and increases medical costs associated with the maintenance of vascular accesses. In the present study, we evaluated the role of the receptor tyrosine kinase c-Kit in A-V fistula neointima formation. Initially, c-Kit was found in the neointima and adventitia of human brachiobasilic fistulae, whereas it was barely detectable in control veins harvested at the time of access creation. Using the rat A-V fistula model to study venous vascular remodeling, we analyzed the spatial and temporal pattern of c-Kit expression in the fistula wall. Interestingly, c-Kit immunoreactivity increased with time after anastomosis, which concurred with the accumulation of cells in the venous intima. In addition, c-Kit expression in A-V fistulae was positively altered by chronic kidney failure conditions. Both blockade of c-Kit with imatinib mesylate (Gleevec) and inhibition of stem cell factor production with a specific short hairpin RNA prevented NIH in the outflow vein of experimental fistulae. In agreement with these data, impaired c-Kit activity compromised the development of NIH in A-V fistulae created in c-KitW/Wv mutant mice. These results suggest that targeting of the c-Kit signaling pathway may be an effective approach to prevent postoperative NIH in A-V fistulae.
Collapse
Affiliation(s)
- Nikolaos Skartsis
- Department of Surgery and Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Laisel Martinez
- Department of Surgery and Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Juan Camilo Duque
- Department of Surgery and Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Marwan Tabbara
- Department of Surgery and Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Omaida C Velazquez
- Department of Surgery and Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Arif Asif
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York
| | - Fotios Andreopoulos
- Biomedical Engineering Department, University of Miami, Coral Gables, Florida; and
| | - Loay H Salman
- Interventional Nephrology, University of Miami Miller School of Medicine, Miami, Florida
| | - Roberto I Vazquez-Padron
- Department of Surgery and Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, Florida;
| |
Collapse
|
29
|
Nayer A, Virmani S, Gonzalez-Suarez M, Goez-Gutierrez E, Rosenberg AE, Salman LH, Asif A. Pre-uremic calciphylaxis. Iran J Kidney Dis 2014; 8:252-256. [PMID: 24878953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 09/04/2013] [Indexed: 06/03/2023]
Abstract
Calciphylaxis is characterized by calcification and thrombosis of arteries resulting in ischemic necrosis of predominantly skin and subcutaneous tissue. Primarily affecting patients with end-stage renal disease, calciphylaxis is diagnosed rarely in the absence of renal replacement therapy. We report an elderly obese woman presented with leg pain and ulceration. She had chronic kidney disease, diabetes mellitus, hypertension, and peripheral vascular disease. Angiography revealed occlusion of the left superficial femoral, popliteal, and distal tibial arteries. Amputation was performed. Histological examination demonstrated medial calcification, intimal hyperplasia, and thrombosis of small- and medium-sized arteries in the subcutaneous tissue. This case features calciphylaxis in a patient with chronic kidney disease before the onset of uremia. Calciphylaxis and atherosclerotic peripheral vascular disease have several risk factors in common. This report calls attention to a disorder that can be masqueraded as leg ulceration due to peripheral vascular disease in the absence of renal replacement therapy.
Collapse
Affiliation(s)
- Ali Nayer
- Division of Nephrology, University of Miami, Miami, FL, USA.
| | | | | | | | | | | | | |
Collapse
|
30
|
Manning E, Skartsis N, Orta AM, Velazquez OC, Liu ZJ, Asif A, Salman LH, Vazquez-Padron RI. A new arteriovenous fistula model to study the development of neointimal hyperplasia. J Vasc Res 2012; 49:123-31. [PMID: 22249138 DOI: 10.1159/000332327] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 08/19/2011] [Indexed: 11/19/2022] Open
Abstract
This study describes an alternative arteriovenous fistula (AVF) model in the rat in which the animals develop significant neointimal hyperplasia (NIH) not only at the distal anastomotic site, but also throughout the fistula body. This aortocaval fistula was established by anastomosing the distal end of the renal vein to the abdominal aorta after unilateral nephrectomy. The increased hemodynamic stress resulting from exposing the renal vein to the arterial circulation induced venous NIH as early as 7 days after surgery. This experimental AVF was characterized by the early lack of endothelium, the accumulation of proliferating vascular smooth muscle cells and the neovascularization of the fistula adventitia. In summary, we have described an informative animal model to study the pathobiology of NIH in native AVF.
Collapse
Affiliation(s)
- Eddie Manning
- DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Fla. 33136, USA
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Skartsis N, Manning E, Wei Y, Velazquez OC, Liu ZJ, Goldschmidt-Clermont PJ, Salman LH, Asif A, Vazquez-Padron RI. Origin of neointimal cells in arteriovenous fistulae: bone marrow, artery, or the vein itself? Semin Dial 2011; 24:242-8. [PMID: 21517994 PMCID: PMC4169005 DOI: 10.1111/j.1525-139x.2011.00870.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
To elucidate the source of neointimal cells, experimental fistulas were created in Lewis wild-type (WT) and transgenic rats that constitutively expressed the green fluorescent protein (GFP) in all tissues. Arteriovenous fistula (AVFs) were created by anastomosing the left renal vein to the abdominal aorta. The contribution of bone marrow (BM)-derived cells to the AVF neointima was examined in lethally irradiated WT rats that had been rescued with GFP BM cells. Neointimal cells in these chimeric rats were mostly GFP negative indicating the non-BM origin of those cells. Then, the contribution of arterial cells to the AVF neointima was assessed in a fistula made with a GFP aorta that had been implanted orthotopically into a WT rat. Most of the neointimal cells were also GFP negative demonstrating that AVF neointimal cells are not derived from the feeding artery. Finally to study local resident cells contribution to the formation of neointimal lesions, a composite fistula was created by interposing a GFP vein between the renal vein and the aorta in a WT recipient rat. GFP neointimal cells were only found in the transplanted vein. This study suggests that neointimal cells originate from the local resident cells in the venous limb of the fistula.
Collapse
Affiliation(s)
- Nikolaos Skartsis
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Fl
| | - Eddie Manning
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Fl
| | - Yuntao Wei
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Fl
| | - Omaida C. Velazquez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Fl
| | - Zhao-Jun Liu
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Fl
| | | | - Loay H. Salman
- Section of Interventional Nephrology, University of Miami Miller School of Medicine, Miami, FL
| | - Arif Asif
- Section of Interventional Nephrology, University of Miami Miller School of Medicine, Miami, FL
| | - Roberto I. Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Fl
| |
Collapse
|