Alex A. Fu

Increased shear stress with upregulation of VEGF-A and its receptors and MMP-2, MMP-9, and TIMP-1 in venous stenosis of hemodialysis grafts

Venous injury and subsequent venous stenosis formation are responsible for hemodialysis graft failure. Our hypothesis is that these pathological changes are in part related to changes in wall shear stress (WSS) that results in the activation of matrix regulatory proteins causing subsequent venous stenosis formation. In the present study, we examined the serial changes in WSS, blood flow, and luminal vessel area that occur subsequent to the placement of a hemodialysis graft in a porcine model of chronic renal insufficiency. We then determined the corresponding histological, morphometric, and kinetic changes of several matrix regulatory proteins including VEGF-A, its receptors, matrix metalloproteinase (MMP)-2, MMP-9, tissue inhibitor of matrix metalloproteinase (TIMP)-1, and TIMP-2. WSS was estimated by obtaining blood flow and luminal vessel area by performing phase-contrast MRI with magnetic resonance angiography in 21 animals at 1 day after graft placement and prior to death on day 3 (n = 7), day 7 (n = 7), and day 14 (n = 7). At all time points, the mean WSS at the vein-to-graft anastomosis was significantly higher than that at the control vein (P < 0.05). WSS had a bimodal distribution with peaks on days 1 and 7 followed by a significant reduction in WSS by day 14 (P < 0.05 compared with day 7) and a decrease in luminal vessel area compared with control vessels. By day 3, there was a significant increase in VEGF-A and pro-MMP-9 followed by, on day 7, increased pro-MMP-2, active MMP-2, and VEGF receptor (VEGFR)-2 (P < 0.05) and, by day 14, increased VEGFR-1 and TIMP-1 (P < 0.05) at the vein-to-graft anastomosis compared with control vessels. Over time, the neointima thickened and was composed primarily of alpha-smooth muscle actin-positive cells with increased cellular proliferation. Our data suggest that hemodialysis graft placement leads to early increases in WSS, VEGF-A, and pro-MMP-9 followed by subsequent increases in pro-MMP-2, active MMP-2, VEGFR-1, VEGFR-2, and TIMP-1, which may contribute to the development of venous stenosis.

Expression of Hypoxia Inducible Factor–1α, Macrophage Migration Inhibition Factor, Matrix Metalloproteinase–2 and −9, and Their Inhibitors in Hemodialysis Grafts and Arteriovenous Fistulas

PURPOSE It is well recognized that arteriovenous fistulas (AVFs) used for hemodialysis access have better primary patency rates with less restenosis than polytetrafluoroethylene (PTFE) grafts; however, the mechanism responsible for this is not known. Recent data suggest that hypoxia inducible factor-1 alpha (HIF-1 alpha) is associated with vascular restenosis, possibly through mechanisms that increase the production of macrophage migration inhibition factor (MIF), matrix metalloproteinase-2 (MMP-2) and MMP-9, and their inhibitors (tissue inhibitor of MMPs; TIMP). The present study tested the hypothesis that there are differences in the expression patterns of HIF-1 alpha, MIF, MMP-2, MMP-9, and TIMPs in specimens removed from patients with AVFs and PTFE grafts. MATERIALS AND METHODS Whole-vessel tissue samples were obtained from the vein distal to the vein-to-PTFE graft anastomosis and the proximal outflow vein (within 6 cm of the arteriovenous anastomosis) of AVFs from 17 patients who required a surgical revision for thrombosis and stenosis. Nonstenotic veins of four patients undergoing hemodialysis vascular access placement were used as controls. PTFE grafts (n = 6), AVFs (n = 6), and control samples (n = 3) underwent Western blot analysis and zymography. A separate group of five patients with PTFE hemodialysis grafts and one control subject were used for immunohistochemical analysis. RESULTS Specimens from patients with PTFE grafts had significantly higher expression of HIF-1 alpha (P = .03), MIF (P = .02), TIMP-1 (P = .0006), pro-MMP-2 (P = .02), and pro-MMP-9 (P = .046) compared with control veins. The expression of only pro-MMP-9 was significantly higher in AVFs compared with control samples (P = .004). There was a significant increase in the expression of MIF (P = .007) and TIMP-1 (P < .0001) in PTFE graft specimens compared with AVFs. MIF and TIMP-1 were localized to the adventitia of the vein distal to the vein-to-PTFE graft anastomosis. CONCLUSIONS There were major differences in the expression patterns of hypoxia (ie, HIF-1 alpha) and proteins regulated by HIF-1?, including MIF, pro-MMP-2, pro-MMP-9, and TIMP-1, in specimens removed from patients with PTFE grafts and AVFs. Understanding the role of HIF-1 alpha and these proteins in hemodialysis access failure can help improve outcomes.

Proteomic analysis of vascular endothelial cells in response to laminar shear stress.

Isotope‐coded affinity tags (cICAT) coupled with mass spectrometric analysis is one of the leading technologies for quantitative proteomic profiling and protein quantification. We performed proteomic analysis of bovine aortic endothelial cells (BAEC) in response to laminar shear stress using cICAT labeling coupled with LC‐MS/MS. Protein expressions in BAEC under 15 dynes/cm2 of shear stress for 10 min, 3 h, and 6 h were compared with matched stationary controls. Analysis of each sample produced 1800–2400 proteins at ≥75% confidence level. We found 142, 213, and 186 candidate proteins that were up‐ or down‐regulated by at least two‐fold after 10 min, 3 h, and 6 h of shear stress, respectively. Some of these proteins have known cellular functions and they encompass many signaling pathways. The signaling pathways that respond to shear stress include those of integrins, G‐protein‐coupled receptors, glutamate receptors, PI3K/AKT, apoptosis, Notch and cAMP‐mediated signaling pathways. The validity of the mass spectrometric analysis was also confirmed by Western blot and confocal immunofluorescence microscopy. The present quantitative proteomic analysis suggests novel potential regulatory mechanisms in vascular endothelial cells in response to shear stress. These results provide preliminary footprints for further studies on the signaling mechanisms induced by shear stress.

The rat femoral arteriovenous fistula model: increased expression of matrix metalloproteinase-2 and -9 at the venous stenosis.

PURPOSE To determine whether a femoral arteriovenous (AV) fistula model in a rat was feasible and whether there is increased expression of matrix metalloproteinase (MMP)-2 and -9 and the tissue inhibitors of MMPs (TIMPs) at the venous stenosis of the fistula. MATERIALS AND METHODS Fifteen male Sprague-Harley rats weighing 353 g +/- 26 underwent creation of an AV fistula between the left femoral artery and ipsilateral femoral vein, with the contralateral femoral vessels serving as controls. The animals were euthanized at day 14 (n = 5) and day 28 (n = 10) after fistula creation. Zymography and Western blot analysis for TIMP-1 and TIMP-2 were performed at the venous stenosis and in control vessels. Hematoxylin and eosin, Verhoeff-van Gieson, Masson trichrome, and alpha-smooth muscle staining were performed at the stenosis and in controls at day 28 in four animals. The intima/media ratio was determined at day 28. RESULTS By day 14, pro-MMP-2 measurements were 8.13 +/- 1.06 at the venous stenosis and 4.1 +/- 1.33 in controls (P < .05). By day 28, they had increased to 18.95 +/- 4.8 at the stenosis and 12.11 +/- 4.84 in controls (P < .05). By day 14, active MMP-2 measurements were 7.38 +/- 1.25 at the stenosis and 2.31 +/- 1.04 in controls (P < .05). By day 28, they had increased to 12.12 +/- 3.45 at the stenosis and 9.26 +/- 3.97 in controls (P < .05). By day 28, pro-MMP-9 measurements were 11.77 +/- 4.71 at the stenosis and 7.78 +/- 3.49 in controls (P < .05), with no difference at day 14. There was no difference in expression of TIMP-1 and TIMP-2. The average intima/media ratio of the stenosis increased by 28% versus controls, and the neointima was composed of primarily alpha-smooth muscle actin-positive cells. CONCLUSIONS A rat femoral AV fistula model was created with venous stenosis formation characterized by thickened neointima composed of alpha-smooth muscle actin-positive cells compared with controls. At the venous stenosis, there was increased expression of pro-MMP-2 and active MMP-2 by days 14 and 28, with significantly increased expression of pro-MMP-9 by day 28.

Hypoxia-induced phenotypic switch of fibroblasts to myofibroblasts through a matrix metalloproteinase 2/tissue inhibitor of metalloproteinase-mediated pathway: implications for venous neointimal hyperplasia in hemodialysis access.

PURPOSE Hemodialysis grafts fail because of venous neointimal hyperplasia formation caused by adventitial fibroblasts that have become myofibroblasts (ie, alpha-smooth muscle actin [SMA]-positive cells) and migrate to the neointima. There is increased expression of hypoxia-inducible factor (HIF)-1alpha in venous neointimal hyperplasia formation in experimental animal models and clinical samples. It was hypothesized that, under hypoxic stimulus (ie, HIF-1alpha), fibroblasts will convert to myofibroblasts through a matrix metalloproteinase (MMP)-2-mediated pathway. MATERIALS AND METHODS Murine AKR-2B fibroblasts were made hypoxic or normoxic for 24, 48, and 72 hours. Protein expression for HIF-1alpha, alpha-SMA, MMP-2, MMP-9, tissue inhibitor of metalloproteinase (TIMP)-1, and TIMP-2 was performed to determine the kinetic changes of these proteins. Immunostaining for alpha-SMA, collagen, and fibronectin was performed. RESULTS At all time points, there was significantly increased expression of HIF-1alpha in the hypoxic fibroblasts compared with normoxic fibroblasts (P < .05). There was significantly increased expression of alpha-SMA at all time points, which peaked by 48 hours in hypoxic fibroblasts compared with normoxic fibroblasts (P < .05). There was a significant increase in the expression of active MMP-2 by 48-72 hours and a significant increase in TIMP-1 by 48-72 hours by hypoxic fibroblasts (P < .05). By 72 hours, there was significant increase in TIMP-2 expression (P < .05). Immunohistochemical analysis demonstrated increased expression of alpha-SMA, collagen, and fibronectin as the duration of hypoxia increased. CONCLUSIONS Under hypoxic conditions, fibroblasts will convert to myofibroblasts through an MMP-2-mediated pathway, which may provide insight into the mechanism of venous neointimal hyperplasia.

The Mouse Arteriovenous Fistula Model

PURPOSE The first aim of the present study was to create a mouse carotid artery-to-jugular vein arteriovenous (AV) fistula model. This model was used to test the hypothesis that there is increased gene expression of matrix metalloproteinase (MMP)-2 and MMP-9 at the venous stenosis. MATERIALS AND METHODS Ten male FVB/NJ mice underwent the creation of an AV fistula between the left carotid artery and ipsilateral jugular vein, with the contralateral vessels serving as controls. Two mice died 1 day after surgery and the other eight were euthanized at day 28. Reverse transcriptase polymerase chain reaction was performed in five mice, with the grafted vein and control vein tissue used to determine the expression of MMP-2, MMP-9, TIMP-1, and TIMP-2. Immunohistochemical analysis of the grafted vein and control vein was performed in three mice. RESULTS Venous stenosis formed at the outflow vein, characterized by a thickened neointima with cells staining positive for alpha-smooth muscle actin. There was increased expression of MMP-2, tissue inhibitor of metalloproteinase (TIMP)-1, and TIMP-2 by day 28 at the venous stenosis compared with control vein. CONCLUSIONS A mouse carotid artery-to-jugular vein AV fistula model was developed and used to demonstrate increased expression of several markers known to be associated with AV fistula stenosis. The model may be useful in investigating mechanisms responsible for AV fistula venous stenoses.

Increased Expression of Hypoxia-inducible Factor-1α in Venous Stenosis of Arteriovenous Polytetrafluoroethylene Grafts in a Chronic Renal Insufficiency Porcine Model

PURPOSE To create a more clinically relevant model of hemodialysis graft failure in pigs by creating chronic renal insufficiency before polytetrafluoroethylene (PTFE) hemodialysis graft placement and to determine the expression of hypoxia-inducible factor-1 alpha (HIF-1 alpha) at the vein-to-graft anastomosis (VGA). MATERIALS AND METHODS Chronic renal insufficiency was created in 14 castrated juvenile male pigs with complete embolization of the left renal artery and the partial embolization of the right renal artery by infusing 150-250-mum polyvinyl acrylide spherical particles. The efficacy of the embolization was assessed by determining the amount of polyvinyl acrylide particles used per kidney, the weight of the kidneys at sacrifice, and kidney function (blood urea nitrogen [BUN] and creatinine levels). Twenty-eight days after embolization, PTFE grafts were placed from the carotid artery to the ipsilateral jugular vein and removed 3, 7, and 14 days after graft placement. Western blot for HIF-1 alpha was performed in the VGA and control vessel. RESULTS The left kidney required two times the polyvinyl acrylide particles than did the right kidney (P < .05). The right kidney weighed nearly three times more than the left (P < .05). The BUN and creatinine levels at graft placement were significantly higher than those at baseline (P < .05). Four grafts were patent at day 3, four at day 7, and four at day 14. By day 7, the mean HIF-1 alpha at the VGA had increased significantly when compared with that of control vessels (P < .05). CONCLUSIONS A more clinically relevant porcine model of hemodialysis graft failure was created, and there was significantly increased expression of HIF-1 alpha by day 7 at the VGA.

Adventitial transplantation of blood outgrowth endothelial cells in porcine haemodialysis grafts alleviates hypoxia and decreases neointimal proliferation through a matrix metalloproteinase-9-mediated pathway—a pilot study

Purpose. We hypothesized that adventitial transplantation of blood outgrowth endothelial cells (BOEC) to the vein-to-graft anastomosis of polytetrafluoroethylene grafts will reduce neointimal hyperplasia by reducing hypoxia inducible factor-1α (HIF-1α), by increasing angiogenesis in a porcine model of chronic renal insufficiency with haemodialysis polytetrafluoroethylene grafts. Because matrix metalloproteinases (MMPs) have been shown to be involved with angiogenesis, the expression of MMPs and their inhibitors was determined. Methods. Chronic renal insufficiency was created by subtotal renal infarction and 28 days later, arteriovenous PTFE grafts were placed bilaterally from the carotid artery to the jugular vein. Autologous blood outgrowth endothelial cells labeled with Lac Z were transplanted to the adventitia of the vein-to-graft anastomosis using polyglycolic acid scaffolding and scaffolding only to other side (control). Animals were killed 14 days later and vessels were explanted from the vein-to-graft anastomosis of both sides and underwent immunohistochemical analysis, western blotting and zymography for HIF-1α, MMP-2, MMP-9, TIMP-1 and TIMP-2. BOEC were also made hypoxic and normoxic for 12, 24 and 48 h to determine protein expression for MMPs and TIMPs. Results. Under hypoxia, BOEC significantly increased the expression of pro MMP-2 by 12 h and TIMP-2 by 24 h when compared to normoxic cells (P < 0.05). Transplantation of BOEC resulted in a significant decrease in both HIF-1α and intima-to-media ratio with a significant increase in both pro and active MMP-9 when compared to control vessels (P < 0.05). MMP-9 activity was localized to the neointima of the transplanted vessels by immunohistochemistry. There was increased CD31 density with engraftment of BOEC cells into the neointima of both the transplanted vessels compared to controls (P = NS). Conclusion. Transplantation of BOEC resulted in a significant decrease in intimal hyperplasia and HIF-1α with a significant increase in both pro and active MMP-9 that was localized to the neointima of transplanted vessels. The increase in MMP-9 offers a possible mechanism for angiogenesis and the reduced intima-to-media ratio. Furthermore, we observed that BOEC had homed to the neointima of the contralateral vessels that had increased levels of HIF-1α, suggesting that hypoxia may be an important stimulus for BOEC migration.

Increased Expression of A Disintegrin and Metalloproteinase Thrombospondin–1 in Thrombosed Hemodialysis Grafts

PURPOSE To use proteomic analysis to identify upregulated and downregulated proteins in thrombosed hemodialysis graft specimens. One of these significantly upregulated proteins was a disintegrin and metalloproteinase thrombospondin-1 (ADAMTS-1), and its expression and activity were determined in thrombosed hemodialysis grafts. MATERIALS AND METHODS Hemodialysis vascular access samples (thrombosed veins, n = 8; control veins, n = 6) were obtained from patients who required surgical revision. Proteomic analysis was performed with isotope-coded affinity tag labeling with multidimensional liquid chromatography followed by tandem mass spectrometry on four thrombosed hemodialysis graft specimens with control veins. Expression of ADAMTS-1 was confirmed by performing immunoprecipitation followed by Western blot analysis. Finally, immunohistochemistry was used to localize expression in a separate group of patients with thrombosed grafts. RESULTS Thirty-nine unique proteins were common to all four patients. ADAMTS-1 was one of the only significantly upregulated protein (>38 fold). ADAMTS-1 expression was confirmed by performing immunoprecipitation and Western blot analysis and was significantly increased. ADAMTS-1 expression was localized to adventitial macrophages and neutrophils of thrombosed grafts. CONCLUSIONS ADAMTS-1 was significantly upregulated in thrombosed hemodialysis grafts by mass spectrometric analysis and Western blot analysis. Expression was localized to adventitial macrophages and leukocytes. It is hypothesized that ADAMTS-1 may be related to intimal hyperplasia in hemodialysis vascular access grafts. Future work is planned on inhibiting ADAMTS-1 expression and determining the effect on intimal hyperplasia in hemodialysis grafts.

Fetuin-A expression in early venous stenosis formation in a porcine model of hemodialysis graft failure.

PURPOSE Because fetuin-A is a cytokine with multifunctional effects on vascular smooth muscle cells and fibroblasts, the authors examined the course of its expression in early venous stenosis formation in a porcine model of chronic renal insufficiency with polytetrafluoroethylene (PTFE) arteriovenous (AV) hemodialysis grafts. MATERIALS AND METHODS Pigs had chronic renal insufficiency created by complete embolization of the left kidney and partial embolization of the right kidney. Twenty-eight days later, PTFE AV grafts were placed from the carotid artery to the ipsilateral jugular vein, and the animals were euthanized 3 days (n = 4), 7 days (n = 4), or 14 days (n = 4) later. Expression of fetuin-A was determined by Western blot analysis of the venous stenosis, control veins, and plasma. Immunohistochemical analysis of the venous stenosis and control vein was performed. Blood urea nitrogen (BUN) and creatinine were measured before embolization and at the time of graft placement. RESULTS The mean BUN and creatinine levels at graft placement were significantly higher than before embolization (P < .05). Severe venous neointimal hyperplasia occurred by day 14 and was characterized by primarily alpha-smooth muscle actin-positive cells. By day 14, fetuin-A levels had increased significantly (P < .05) at the venous stenosis compared with control veins and in the serum compared with measurements before embolization. CONCLUSIONS Significantly increased expression of fetuin-A was observed in early venous stenosis by day 14 and in serum compared with baseline measurements. Understanding the role of fetuin-A in venous neointimal hyperplasia could help in improving outcomes in patients undergoing hemodialysis.