Novel Paradigms for Dialysis Vascular Access

Abstract

SummaryVascular access dysfunction is a major cause of morbidity and mortality in hemodialysis patients. The most common cause of vascular access dysfunction is venous stenosis from neointimal hyperplasia within the perianastomotic region of an arteriovenous fistula and at the graft-vein anastomosis of an arteriovenous graft. There have been few, if any, effective treatments for vascular access dysfunction because of the limited understanding of the pathophysiology of venous neointimal hyperplasia formation. This review will (1) describe the histopathologic features of hemodialysis access stenosis; (2) discuss novel concepts in the pathogenesis of neointimal hyperplasia development, focusing on downstream vascular biology; (3) highlight future novel therapies for treating downstream biology; and (4) discuss future research areas to improve our understanding of downstream biology and neointimal hyperplasia development.

Vascular Calcification Markers and Hemodialysis Vascular Access Complications

“…The levels of fetuin-A and OPN are also associated with the production of nitric oxide [43][44][45][46]. The production of superoxide anion has been shown to be another key player in AVF dysfunction in experimental models [47]. Thus, it is possible that the associations observed were partly due to the impact of nitric oxide.…”

New Insights into Dialysis Vascular Access: Molecular Targets in Arteriovenous Fistula and Arteriovenous Graft Failure and Their Potential to Improve Vascular Access Outcomes

“…A large randomized controlled trial from the National Institutes of Health Dialysis Access Consortium study published in 2008 reported that 60% of AVFs created failed to mature for successful dialysis use at 4-5 months after creation (1). The precise mechanisms that lead to AVF maturation failure remain unclear but involve mediators that regulate outward remodeling and neointimal hyperplasia development (3,4).…”

Vascular Access Calcification and Arteriovenous Fistula Maturation

“…Furthermore, several recent publications have also demonstrated the presence of neointimal hyperplasia from patient veins and arteries collected at the time of new surgical access creation [8][9][10][11][12][13]. This suggests that the baseline vascular health of both the arteries and veins used to create new vascular accesses may play an important role in AVF maturation [1]. Vascular calcification has been demonstrated to play an important role in the cardiovascular mortality in CKD and ESRD patients [14], but with fewer published studies looking at its role in hemodialysis vascular access.…”

“…Vascular access dysfunction remains a major cause of morbidity and mortality in hemodialysis patients [1][2][3][4]. Arteriovenous fistulas (AVF) remain the preferred form of vascular access due to the lower rates of infection and maintenance procedures to treat stenosis compared to arteriovenous grafts (AVG), if the AVF successfully matures for hemodialysis.…”