Arteriovenous conduits for hemodialysis: how to better modulate the pathophysiological vascular response to optimize vascular access durability.

Vascular access is the lifeline for patients on hemodialysis. Arteriovenous fistulas (AVFs) are the preferred vascular access, but AVF maturation failure remains a significant clinical problem. Currently, there are no effective therapies available to prevent or treat AVF maturation failure. AVF maturation failure frequently results from venous stenosis at the AVF anastomosis, which is secondary to poor outward vascular remodeling and excessive venous intimal hyperplasia that narrows the AVF lumen. Arteriovenous grafts (AVGs) are the next preferred vascular access when an AVF creation is not possible. AVG failure is primarily the result of venous stenosis at the vein-graft anastomosis, which originates from intimal hyperplasia development. Although there has been advancement in our knowledge of the pathophysiology of AVF maturation and AVG failure, this has not translated into effective therapies for these two important clinical problems. Further work will be required to dissect out the mechanisms of AVF maturation failure and AVG failure to develop more specific therapies. This review highlights the major recent advancements in AVF and AVG biology, reviews major clinical trials, and discusses new areas for future research.

Comparison of hemodialysis arteriovenous fistula blood flow rates measured by Doppler ultrasound and phase-contrast magnetic resonance imaging.

OBJECTIVE: The objective of this study was to compare blood flow rates measured by Doppler ultrasound (DUS) and phase-contrast magnetic resonance imaging (MRI) in patients having a hemodialysis arteriovenous fistula (AVF) and to identify scenarios in which there was significant discordance between these two approaches. METHODS: Blood flow rates in the proximal artery (PA) and draining vein (DV) of newly created upper extremity AVFs were measured and compared using DUS and phase-contrast MRI at 1 day, 6 weeks, and 6 months postoperatively. RESULTS: Blood flow rates in the PA measured by DUS (1155 ± 907 mL/min, mean ± standard deviation) and by MRI (1170 ± 657 mL/min) were not statistically different (P = .812) based on 78 data pairs from 49 patients. DV DUS flow (1277 ± 995 mL/min) and MRI flow (1130 ± 655 mL/min) were also not statistically different (P = .071) based on 64 data pairs. In both PA and DV, the two methods substantially agreed with each other (Cohen κ: PA, 0.66; DV, 0.67) when flow rates were put into four clinically relevant categories (<300, 300-599, 600-1499, and ≥1500 mL/min). The Bland-Altman analyses of DUS and MRI flow identified six and four outliers for PA and DV, respectively. Seven outliers had higher DUS than MRI flow, with all DUS scan sites having a large lumen or significant local curvature; the other three had lower DUS flow, partly due to an underestimation of lumen diameter by DUS. CONCLUSIONS: DUS and MRI flow rates are generally comparable in both PA and DV. When DUS is used for flow measurements, careful attention to accurate lumen diameter measurements is needed and scan sites with marked curvature should be avoided. Our result may improve the accuracy of DUS-measured AVF blood flow rate.

Preoperative Vascular Medial Fibrosis and Arteriovenous Fistula Development.

BACKGROUND AND OBJECTIVES: Arteriovenous fistula maturation requires an increase in the diameter and blood flow of the feeding artery and the draining vein after its creation. The structural properties of the native vessels may affect the magnitude of these changes. We hypothesized that an increase in the collagen content of the vascular media (medial fibrosis) preoperatively would impair vascular dilation and thereby, limit the postoperative increase in arteriovenous fistula diameter and blood flow and clinical arteriovenous fistula maturation. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We enrolled 125 patients undergoing arteriovenous fistula creation between October of 2008 and April of 2012 and followed them prospectively. Any consenting subject was eligible. Arterial and venous specimens were sampled during arteriovenous fistula surgery. Masson's trichrome-stained samples were used to quantify medial fibrosis. Arteriovenous fistula diameter and blood flow were quantified using 6-week postoperative ultrasound. Clinical arteriovenous fistula maturation was assessed using a predefined protocol. The association of preexisting vascular medial fibrosis with arteriovenous fistula outcomes was evaluated after controlling for baseline demographics, comorbidities, and the preoperative venous diameter. RESULTS: The mean medial fibrosis was 69%±14% in the arteries and 63%±12% in the veins. Arterial medial fibrosis was associated with greater increases in arteriovenous fistula diameter (Δdiameter =0.58 mm; 95% confidence interval [95% CI], 0.27 to 0.89 mm; P<0.001) and arteriovenous fistula blood flow (Δblood flow =85 ml/min; 95% CI, 19 to 150 ml/min; P=0.01) and a lower risk of clinical arteriovenous fistula nonmaturation (odds ratio, 0.71; 95% CI, 0.51 to 0.99; P=0.04), all per 10% absolute difference in medial fibrosis. In contrast, venous medial fibrosis was not associated with the postoperative arteriovenous fistula diameter, blood flow, or clinical maturation. CONCLUSIONS: Preoperative arterial medial fibrosis was associated with greater arteriovenous fistula diameter and blood flow and a lower risk of clinical arteriovenous fistula nonmaturation. This unexpected observation suggests that medial fibrosis promotes arteriovenous fistula development by yet undefined mechanisms or alternatively, that a third factor promotes both medial fibrosis and arteriovenous fistula maturation.

The interplay of cyclic stretch and vascular endothelial growth factor in regulating the initial steps for angiogenesis.

Angiogenesis is regulated by chemical and mechanical factors in vivo. The regulatory role of mechanical factors and how chemical and mechanical angiogenic regulators work in concert remains to be explored. We investigated the effect of cyclic uniaxial stretch (20%, 1 Hz), with and without the stimulation of vascular endothelial growth factor (VEGF), on sprouting angiogenesis by employing a stretchable three-dimensional cell culture model. When compared to static controls, stretch alone significantly increased the density of endothelial sprouts, and these sprouts aligned perpendicular to the direction of stretch. The Rho-associated kinase (ROCK) inhibitor Y27632 suppressed stretch-induced sprouting angiogenesis and associated sprout alignment. While VEGF is a potent angiogenic stimulus through ROCK-dependent pathways, the combination of VEGF and stretch did not have an additive effect on angiogenesis. In the presence of VEGF stimulation, the ROCK inhibitor suppressed stretch-induced sprout alignment but did not affect stretch-induced sprout density; in contrast, the receptor tyrosine kinase (RTK) inhibitor sunitinib had no effect on stretch-induced alignment but trended toward suppressed stretch-induced sprout density. Our results suggest that the formation of sprouts and their directionality do not have completely identical regulatory pathways, and thus it is possible to separately manipulate the number and pattern of new sprouts.

Hemodynamic Shear Stress and Endothelial Dysfunction in Hemodialysis Access.

Surgically-created blood conduits used for chronic hemodialysis, including native arteriovenous fistulas (AVFs) and synthetic AV grafts (AVGs), are the lifeline for kidney failure patients. Unfortunately, each has its own limitations: AVFs often fail to mature to become useful for dialysis and AVGs often fail due to stenosis as a result of neointimal hyperplasia, which preferentially forms at the graft-venous anastomosis. No clinical therapies are currently available to significantly promote AVF maturation or prevent neointimal hyperplasia in AVGs. Central to devising strategies to solve these problems is a complete mechanistic understanding of the pathophysiological processes. The pathology of arteriovenous access problems is likely multi-factorial. This review focuses on the roles of fluid-wall shear stress (WSS) and endothelial cells (ECs). In arteriovenous access, shunting of arterial blood flow directly into the vein drastically alters the hemodynamics in the vein. These hemodynamic changes are likely major contributors to non-maturation of an AVF vein and/or formation of neointimal hyperplasia at the venous anastomosis of an AVG. ECs separate blood from other vascular wall cells and also influence the phenotype of these other cells. In arteriovenous access, the responses of ECs to aberrant WSS may subsequently lead to AVF non-maturation and/or AVG stenosis. This review provides an overview of the methods for characterizing blood flow and calculating WSS in arteriovenous access and discusses EC responses to arteriovenous hemodynamics. This review also discusses the role of WSS in the pathology of arteriovenous access, as well as confounding factors that modulate the impact of WSS.

Differential effects of cyclic stretch on bFGF- and VEGF-induced sprouting angiogenesis.

How mechanical factors affect angiogenesis and how they and chemical angiogenic factors work in concert remain not yet well-understood. This study investigated the interactive effects of cyclic uniaxial stretch and two potent proangiogenic molecules [basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF)] on angiogenesis using a stretchable three-dimensional (3-D) cell culture model. Endothelial cells seeded atop a 3-D collagen gel underwent sprouting angiogenesis while being subjected to either 10 or 20% cyclic uniaxial stretch at a frequency of either 1/12 or 1 Hz, in conjunction with an elevated concentration of bFGF or VEGF. Without the presence of additional growth factors, 10 and 20% stretch at 1 Hz induced angiogenesis and the perpendicular alignment of new sprouts, and both inductive effects were abolished by cytochalasin D (an actin polymerization inhibitor). While "10% stretch at 1 Hz," "20% stretch at 1 Hz," bFGF, and VEGF were strong angiogenesis stimulants individually, only the combination of "20% stretch at 1 Hz" and bFGF had an additive effect on inducing new sprouts. Interestingly, the combination of "20% stretch at a lower frequency (1/12 Hz)" and bFGF decreased sprouting angiogenesis, even though the level of perpendicular alignment of new sprouts was the same for both stretch frequencies. Taken together, these results demonstrate that both stretch frequency and magnitude, along with interactions with various growth factors, are essential in mediating formation of endothelial sprouts and vascular patterning. Furthermore, work in this area is warranted to elucidate synergistic or competitive signaling mechanisms.

Comparison of active and passive targeting of docetaxel for prostate cancer therapy by HPMA copolymer-RGDfK conjugates.

N-(2-Hydroxypropyl)methacrylamide (HPMA) copolymer-docetaxel-RGDfK conjugate was synthesized, characterized, and evaluated in vitro and in vivo in comparison with untargeted low and high molecular weight HPMA copolymer-docetaxel conjugates. The targeted conjugate was designed to have a hydrodynamic diameter below renal threshold to allow elimination post treatment. All conjugates demonstrated the ability to inhibit the growth of DU145 and PC3 human prostate cancer cells and the HUVEC at low nanomolar concentrations. The targeted conjugate showed active binding to α(v)ß(3) integrins in both HUVEC and DU145 cells, whereas the untargeted conjugate demonstrated no evidence of specific binding. Efficacy at two concentrations (20 mg/kg and 40 mg/kg) was evaluated in nu/nu mice bearing DU145 tumor xenografts treated with a single dose of conjugates and compared with controls. RGDfK targeted and high molecular weight nontargeted conjugates exhibited the highest antitumor efficacy as evaluated by tumor regression. These results demonstrate that α(v)ß(3) integrin targeted polymeric conjugates with improved water solubility, reduced toxicity and ease of elimination post treatment in vivo are promising candidates for prostate cancer therapy.

HPMA copolymer-aminohexylgeldanamycin conjugates targeting cell surface expressed GRP78 in prostate cancer.

PURPOSE: This study focused on the synthesis and in vitro characterization of N-(2-hydroxypropyl)methacrylamide (HPMA) copolymer conjugates for the delivery of geldanamycin to prostate cancer tumors. Conjugates were modified to incorporate WIFPWIQL peptide, which binds to cell-surface-expressed Glucose-regulated protein 78. METHODS: HPMA copolymers containing aminohexylgeldanamycin with and without WIFPWIQL peptide were synthesized and characterized, and stability in pH 7.4 and pH 5.0 buffers, complete cell culture medium, and fetal bovine serum was evaluated. The comparative cell surface expression of GRP78 in DU145 and PC3 cell lines was assessed and competitive binding to cell surface expressed GRP78 evaluated. The ability of the conjugates to inhibit cell growth was also evaluated in vitro. RESULTS: HPMA copolymer-aminohexylgeldanamycin conjugates were stable with maximal release observed in fetal bovine serum at 37°C of approximately 10% in 72 h. HPMA copolymers bearing WIFPWIQL peptide bound to cell surface expressed GRP78 with affinities comparable to free WIFPWIQL peptide and demonstrated increased cytotoxicity as compared to untargeted conjugates. CONCLUSION: HPMA copolymer aminohexylgeldanamycin conjugates bearing WIFPWIQL peptide have the ability to bind to cell-surface-expressed GRP78 and inhibit the growth of human prostate cancer cells, suggesting that the conjugates have the potential to target solid prostate cancer tumors.

HPMA copolymer-cyclic RGD conjugates for tumor targeting.

This review describes the design and development of N-(2-hydroxypropyl)-methacrylamide (HPMA) copolymer-cyclic RGD conjugates for targeting tumor angiogenesis. Relative to non-targetable systems, HPMA copolymer-RGD4C and -RGDfK conjugates have shown increased tumor accumulation in a variety of solid tumors including prostate, lung, and breast tumor xenografts. Compared to free peptides, copolymers had increased tumor accumulation and decreased uptake in non-target organs such as the liver and spleen. Clinically relevant imaging agents such as (99m)Tc, (111)In, and Gd enabled in vivo imaging of the constructs by scintigraphy and magnetic resonance techniques. Targeted delivery of (90)Y, a radiotherapeutic agent by HPMA copolymer-RGD4C conjugates resulted in tumor size reduction in mice bearing prostate tumor xenografts. Delivery of the geldanamycin derivative 17-(6-aminohexylamino)-17-demethoxygeldanamycin by HPMA copolymer-RGDfK conjugates resulted in increased tumor concentration of the free drug in a prostate xenograft model. These constructs show promise for targeted delivery of therapeutics and imaging agents to solid tumors.

Effect of gelatin on heparin regulation of cytokine release from hyaluronan-based hydrogels.

The hypothesis that incorporation of small amounts (0.3% w/w) of modified heparin in thiol-modified hyaluronan or HA and gelatin hydrogels would regulate release of cytokine growth factors (GFs) from those gels has been investigated in vitro. In addition, the physiologic response to gel implantation has been evaluated in vivo. Tests were performed with 6 GFs: basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF), angiopoietin-1 (Ang-1), keratinocyte growth factor, platelet-derived growth factor-AA (PDGF), and transforming growth factor-beta 1. Release profiles for all 6 over several weeks were well fit by first order exponential kinetics (R(2) > 0.9 for all cases). The most remarkable result of the experiment was a dramatic variation in the total mass ultimately released, which varied from as much as 90.2% of the initial load for bFGF to as little as 1.8% for PDGF, a 45-fold difference. Furthermore, gels containing either VEGF of Ang-1 produced twice the vascularization response in vivo as gels not containing a growth factor. Thus, those GFs maintained strong physiologic effectiveness.

Heparin-regulated release of growth factors in vitro and angiogenic response in vivo to implanted hyaluronan hydrogels containing VEGF and bFGF.

Controlled release of human vascular endothelial growth factor (VEGF) or basic fibroblast growth factor (bFGF) from hydrogels composed of chemically modified hyaluronan (HA) and gelatin (Gtn) was evaluated both in vitro and in vivo. We hypothesized that inclusion of small quantities of heparin (Hp) in these gels would regulate growth factor (GF) release over an extended period, while still maintaining the in vivo bioactivity of released GFs. To test this hypothesis, HA, Gtn, and Hp (15 kDa) were modified with thiol groups, then co-crosslinked with poly (ethylene glycol) diacrylate (PEGDA). Either VEGF or bFGF was incorporated into the gels before crosslinking with PEGDA. Release of these GFs in vitro could be sustained over 42 days by less than 1% Hp content, and was found to decrease monotonically with increasing Hp concentration. As little as 0.03% Hp in the gels reduced the released VEGF fraction from 30% to 21%, while 3% Hp reduced it to 19%. Since the minimum Hp concentration capable of effective controlled GF release in vitro was found to be 0.3% (w/w), this concentration was selected for subsequent in vivo experiments. To evaluate the bioactivity of released GFs in vivo, gel samples were implanted into the ear pinnas of Balb/c mice and the resulting neovascularization response measured. In the presence of Hp, vascularization was sustained over 28 days. GF release was more rapid in vitro from gels containing Gtn than from gels lacking Gtn, though unexpectedly, the in vivo neovascularization response to Gtn-containing gels was decreased. Nevertheless significant numbers of neovessels were generated. The ability to stimulate localized microvessel growth at controlled rates for extended times through the release of GFs from covalently linked, Hp-supplemented hydrogels will ultimately provide a powerful therapeutic tool.