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. 2023 Jan 1;18(1):72-83.
doi: 10.2215/CJN.04630422.

Association of Shear Stress with Subsequent Lumen Remodeling in Hemodialysis Arteriovenous Fistulas

Yong He  1 , Yan-Ting Shiu  2   3 , Peter B Imrey  4   5 , Milena K Radeva  4 , Gerald J Beck  4   5 , Jennifer J Gassman  4   5 , Hannah M Northrup  2 , Prabir Roy-Chaudhury  6   7 , Scott A Berceli  1   8 , Alfred K Cheung  2   3 ; Hemodialysis Fistula Maturation (HFM) Study Group*
Affiliations

Association of Shear Stress with Subsequent Lumen Remodeling in Hemodialysis Arteriovenous Fistulas

Yong He et al. Clin J Am Soc Nephrol. .

Abstract

Background: Blood flow-induced wall shear stress is a strong local regulator of vascular remodeling, but its effects on arteriovenous fistula (AVF) remodeling are unclear.

Methods: In this prospective cohort study, we used computational fluid dynamics simulations and statistical mixed-effects modeling to investigate the associations between wall shear stress and AVF remodeling in 120 participants undergoing AVF creation surgery. Postoperative magnetic resonance imaging data at 1 day, 6 weeks, and 6 months were used to derive current wall shear stress by computational fluid dynamic simulations and to quantify subsequent changes in AVF lumen cross-sectional area at 1-mm intervals along the proximal artery and AVF vein.

Results: Combining artery and vein data, prior mean wall shear stress was significantly associated with lumen area expansion. Mean wall shear stress at day 1 was significantly associated with change in lumen area from day 1 to week 6 (11% larger area per interquartile range [IQR] higher mean wall shear stress, 95% confidence interval [95% CI], 5% to 18%; n =101), and mean wall shear stress at 6 weeks was significantly associated with change in lumen area from 6 weeks to month 6 (14% larger area per IQR higher, 95% CI, 3% to 28%; n =52). The association of mean wall shear stress at day 1 with lumen area expansion from day 1 to week 6 differed significantly by diabetes ( P =0.009): 27% (95% CI, 17% to 37%) larger area per IQR higher mean wall shear stress without diabetes and 9% (95% CI, -1% to 19%) with diabetes. Oscillatory shear index at day 1 was significantly associated with change in lumen area from day 1 to week 6 (5% smaller area per IQR higher oscillatory shear index, 95% CI, 3% to 7%), and oscillatory shear index at 6 weeks was significantly associated with change in lumen from 6 weeks to month 6 (7% smaller area per IQR higher oscillatory shear index, 95% CI, 2% to 11%). Wall shear stress spatial gradient was not significantly associated with subsequent remodeling. In a joint model, wall shear stress and oscillatory shear index statistically significantly interacted in their associations with lumen area expansion in a complex nonlinear fashion.

Conclusions: Higher wall shear stress and lower oscillatory shear index were associated with greater lumen expansion after AVF creation surgery.

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Conflict of interest statement

G.J. Beck and M.K. Radeva report employment with Cleveland Clinic. S.A. Berceli reports research funding from Alucent Biomedical. A.K. Cheung reports employment with Veterans Affairs Salt Lake City Healthcare System; consultancy agreements with Boehringer-Ingelheim, Calliditas, and UptoDate; ownership interest in Merck; honoraria from Boehringer-Ingelheim and Calliditas; and royalties from UpToDate. J.J. Gassman reports employment with Cleveland Clinic, consultancy agreements with Baim Institute (formerly Harvard Clinical Research, Inc.), and honoraria from Baim Institute (Harvard Clinical Research Institute). Y. He reports research funding from Alucent Biomedical. P.B. Imrey reports employment with Cleveland Clinic Foundation; consultancy agreements with Colgate Palmolive; ownership interest in AT&T, American Electric Power, Avista, Chevron, Comcast, Constellation Energy, Duke Energy, Entergy, Exelon, Exxon Mobil, Idacorp, IBM, Kyndryl Holdings, Martin Marietta Materials, Northwest National Holding Company, Occidental Petroleum, Pacific Gas and Electric, Sempra, Southwest Gas Holdings, Teradata, Vulcan Materials, Warner Brothers Discovery, Wells Fargo, and Weyerhaeuser; and serving on the American Journal of Nephrology Editorial Board. P. Roy-Chaudhury reports employment with VAMC Salisbury, NC; consultancy agreements with Akebia, Bayer, BD-Bard, Cormedix, Humacyte, InRegen, Medtronic/Covidien, Reata, Vifor-Relypsa, and WL Gore; ownership interest as Chief Scientific Officer and Founder of Inovasc LLC; NIH small business grants as MPI or site PI with Adgero, Cylerus, Eko, and Inovasc; honoraria from Akebia, Bayer, BD-Bard, Chugai Pharmaceuticals, Cormedix, Humacyte, InRegen, Medtronic/Covidien, Reata, Vifor-Relypsa, and WL Gore; advisory or leadership roles for Akebia, ASN, Bayer, BD-Bard, Cardiorenal Society, Cormedix, Humacyte, InRegen, Medtronic/Covidien, Reata, Vascular Access Society of the America's, Vifor-Relypsa, and WL Gore; serving on the Journal of Vascular Access Editorial Board; discussions with Elucid Bio, Outset Medical, and Vasbio; and research contract while at University of Arizona with Kidney Research Institute, Seattle. Y. Shiu reports employment with VA Salt Lake City Health Care System. The remaining author has nothing to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Blood flow rates of forearm and upper-arm fistula veins at the three postoperative time points. For each fistula location and time interval, the flow rates are plotted for only those participants with usable scans at both examination times, facilitating analyses of flow rate changes. The error bars are for mean±SD.
Figure 2
Figure 2
Positive association between mean wall shear stress and lumen remodeling along forearm arteriovenous fistula vein. Plotted are the expected ratios of vein lumen cross-sectional areas at 1, 2, 3, 4, and 5 cm from the anastomosis at week 6 to those on day 1 on the y axis versus mean wall shear stress on day 1 on the x axis. The week-6 to day-1 cross-sectional area ratios result from a mixed linear regression model after log transformations of mean wall shear stress and cross-sectional area. The 10th, 25th, 50th, 75th, and 90th percentiles of mean wall shear stress are labeled. By construction, changes in location induce vertical shifts without altering basic curve shapes. The 1-cm curve is lower due to its smaller area ratio.
Figure 3
Figure 3
Positive association between mean wall shear stress and arteriovenous fistula venous lumen remodeling. Mean wall shear stress and arteriovenous fistula venous lumen remodeling: (A) forearm and (C) upper arm. Plotted are the expected ratios of vein lumen cross-sectional areas at 3 cm from the anastomosis at week 6 to those on day 1 on the y axis versus mean wall shear stress on day 1 on the x axis. The area ratios result from a mixed linear regression model after log transformations of mean wall shear stress and cross-sectional area: (B) forearm and (D) upper arm. Similarly, plotted are the expected ratios of vein lumen cross-sectional areas at 3 cm from the anastomosis at month 6 to those at week 6 on the y axis versus mean wall shear stress at week 6 on x axis. The 10th, 25th, 50th, 75th, 90th, and 95th percentiles of mean wall shear stresses are labeled in each panel.
Figure 4
Figure 4
Negative association between oscillatory shear index and arteriovenous fistula venous lumen remodeling. Oscillatory shear index and arteriovenous fistula venous lumen remodeling: (A) forearm and (C) upper arm. Plotted are the expected ratios of vein lumen cross-sectional areas at 3 cm from the anastomosis at week 6 to those on day 1 on the y axis versus day-1 oscillatory shear index on the x axis. The area ratios result from a mixed spline regression model after log transformations of oscillatory shear index and cross-sectional area: (B) forearm and (D) upper arm. Similarly, plotted are the expected ratios of vein lumen cross-sectional areas at 3 cm from the anastomosis at month 6 to those at week 6 on the y axis versus week-6 oscillatory shear index on the x axis. The area ratios result from a mixed linear regression model after log transformations of oscillatory shear index and cross-sectional area. The 25th, 50th, 75th, 90th, and 95th percentiles of oscillatory shear indies are labeled in each panel.
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Comment in

References

    1. Masengu A McDaid J Maxwell AP, et al. . Preoperative radial artery volume flow is predictive of arteriovenous fistula outcomes. J Vasc Surg. 2016;63(2):429-435. doi:10.1016/j.jvs.2015.08.106 - DOI - PubMed
    1. Woodside KJ Bell S Mukhopadhyay P, et al. . Arteriovenous fistula maturation in prevalent hemodialysis patients in the united states: a national study. Am J Kidney Dis. 2018;71(6):793-801. doi:10.1053/j.ajkd.2017.11.020 - DOI - PMC - PubMed
    1. Feldman HI Joffe M Rosas SE, et al. . Predictors of successful arteriovenous fistula maturation. Am J Kidney Dis. 2003;42(5):1000-1012. doi:10.1016/j.ajkd.2003.07.003 - DOI - PubMed
    1. Robbin ML Greene T Allon M, et al. . Prediction of arteriovenous fistula clinical maturation from postoperative ultrasound measurements: findings from the Hemodialysis Fistula Maturation study. J Am Soc Nephrol. 2018;29(11):2735-2744. doi:10.1681/asn.2017111225 - DOI - PMC - PubMed
    1. Agarwal AK Haddad NJ Vachharajani TJ, et al. . Innovations in vascular access for hemodialysis. Kidney Int. 2019;95(5):1053-1063. doi:10.1016/j.kint.2018.11.046 - DOI - PubMed