Adventitial transduction of lentivirus-shRNA-VEGF-A in arteriovenous fistula reduces venous stenosis formation

Binxia Yang, Rajiv Janardhanan, Pawan Vohra, Eddie L Greene, Santanu Bhattacharya, Sarah Withers, Bhaskar Roy, Evelyn C Nieves Torres, Jaywant Mandrekar, Edward B Leof, Debabrata Mukhopadhyay, Sanjay Misra, Binxia Yang, Rajiv Janardhanan, Pawan Vohra, Eddie L Greene, Santanu Bhattacharya, Sarah Withers, Bhaskar Roy, Evelyn C Nieves Torres, Jaywant Mandrekar, Edward B Leof, Debabrata Mukhopadhyay, Sanjay Misra

Abstract

Venous neointimal hyperplasia (VNH) causes hemodialysis vascular access failure. Here we tested whether VNH formation occurs in part due to local vessel hypoxia caused by surgical trauma to the vasa vasorum of the outflow vein at the time of arteriovenous fistula placement. Selective targeting of the adventitia of the outflow vein at the time of fistula creation was performed using a lentivirus-delivered small-hairpin RNA that inhibits VEGF-A expression. This resulted in significant increase in mean lumen vessel area, decreased media/adventitia area, and decreased constrictive remodeling with a significant increase in apoptosis (increase in caspase 3 activity and TUNEL staining) accompanied with decreased cellular proliferation and hypoxia-inducible factor-1α at the outflow vein. There was significant decrease in cells staining positive for α-smooth muscle actin (a myofibroblast marker) and VEGFR-1 expression with a decrease in MMP-2 and MMP-9. These results were confirmed in animals that were treated with humanized monoclonal antibody to VEGF-A with similar results. Since hypoxia can cause fibroblast to differentiate into myofibroblasts, we silenced VEGF-A gene expression in fibroblasts and subjected them to hypoxia. This decreased myofibroblast production, cellular proliferation, cell invasion, MMP-2 activity, and increased caspase 3. Thus, VEGF-A reduction at the time of arteriovenous fistula placement results in increased positive vascular remodeling.

Figures

Figure 1
Figure 1
Vascular endothelial growth factor-A (VEGF-A) expression is reduced in lentivirus (LV)–small hairpin RNA (shRNA)-VEGF-A-transduced and Avastin-treated vessels with decreased CD31 staining. (a, first to third columns) In situ hybridization of mRNA for VEGF-A in the LV-transduced vessels when compared with scrambled-shRNA-VEGF-A (control (C)) vessels, with arrows on cells positive for VEGF-A mRNA expression (brown). By day 3 (D3), there was a reduction of mRNA for VEGF-A being localized to the media and adventitia and by day 7 (D7), it was localized to the media and intima. In contrast, the vessels transduced with C shRNA showed increased mRNA expression of VEGF-A in the adventitia and media by day 3, and in the media and intima by day 7. (b) Pooled data for the in situ transcript levels of VEGF-A in the outflow vein of the LV-transduced vessels that was significantly reduced when compared with C vessels at day 7 (P<0.0001). (c) Upper panel shows the representative real-time PCR (RT-PCR) blots of the VEGF-A with 18S gene for loading with pooled data from the mean gene expression of VEGF-A using RT-PCR analysis. This demonstrates that there is significant reduction in the mean VEGF-A expression in the LV-transduced vessels when compared with C vessels at day 7 (P<0.0001). (d) Representative sections from VEGF-A staining at the venous stenosis of the LV and C-transduced vessels or Avastin-treated or immunoglobulin G (IgG) controls at days 14 and 28. At day 14, there is a significant reduction in the mean VEGF-A staining in the LV-transduced vessels and Avastin-treated vessels when compared with controls (P<0.0001). (e) Representative sections from CD31 staining at the venous stenosis of the LV and C-transduced vessels or Avastin-treated vessels or IgG controls at days 14 and 28. Cells staining brown are positive for CD-31. All are original magnification × 40. Bar=200 μm. *Indicates the lumen. Qualitatively, in the C tissue, when compared with the LV-transduced vessels, there is increased CD31 staining localized to the neointima/media junction by days 14 to 28 in the control tissue. Similar results in the IgG control tissues when compared with Avastin-treated vessels. (b–d) Each bar shows mean±s.e.m. of 4–6 animals per group. Two-way analysis of variance (ANOVA) followed by Student's t-test with post hoc Bonferroni's correction was performed. Significant difference from control value is indicated by #P<0.0001.
Figure 2
Figure 2
Hematoxylin and eosin (H&E) and picrosirius red staining of the lentivirus (LV)–small hairpin RNA (shRNA)–vascular endothelial growth factor-A (VEGF-A)–transduced and Avastin-treated vessels have increased lumen vessel area with decreased media and adventitia area and collagen expression. (a, first column) Representative sections after H&E at the venous stenosis of the LV-shRNA-VEGF-A (LV) and scrambled-VEGF-A (control (C))–transduced vessels or Avastin-treated vessels or immunoglobulin G (IgG) controls at day 14 showing increase in lumen vessel area. (a, second column) Representative polarized light microscopy of picrosirius red–stained venous stenosis showing decreased fibrosis (collagen fibers are bright yellow) of the LV and C-transduced vessels and Avastin-treated vessels and controls. Qualitatively, there is a reduction in collagen staining by Sirius red by days 3–21. *Indicates the lumen. Bar=200 μm. Pooled data for mean lumen vessel area LV and C groups and Avastin-treated and control vessels are shown in b. There is a significant increase in the mean lumen vessel area in the LV-transduced vessels when compared with C vessels for days 14–28 (P<0.001 for all). By day 14, there was a significant increase in the mean lumen vessel area in the Avastin-treated vessels when compared with IgG controls (P<0.001). Pooled data for mean media and adventitia area in LV and C groups and Avastin and control groups are shown in c. There is a significant decrease in the mean media and adventitia area in the LV-transduced vessels when compared with C vessels for day 14 (P<0.01). By day 28, there is a significant reduction in the mean media and adventitia area in the Avastin-treated vessels when compared with controls (P<0.001). (d) Kaplan–Meier estimates for LV-transduced vessels (red) when compared with C vessels (blue). There is improved patency in the LV-transduced vessels (red) when compared with C vessels (Log-rank test: P<0.05). (b, c) Each bar shows mean±s.e.m. of 4–6 animals per group. Two-way analysis of variance (ANOVA) followed by Student's t-test with post hoc Bonferroni's correction was performed. Significant difference from control value is indicated by **P<0.001.
Figure 3
Figure 3
(a) Representative sections from TdT-mediated dNTP nick end labeling (TUNEL) staining at the venous stenosis of the LV-shRNA-VEGF-A (LV) with scrambled-VEGF-A (control (C))–transduced control vessels or Avastin-treated with immunoglobulin G (IgG) controls at days 14 and 28. Nuclei staining brown are positive for TUNEL. Negative control is shown where the recombinant terminal deoxynucleotidyl transferase enzyme was omitted. All are original magnification × 40. Bar=200 μm. *Indicates the lumen. Pooled data for LV- and C-transduced vessels or Avastin-treated or IgG controls are shown in b. This demonstrates a significant increase in the mean TUNEL index at day 14 (P<0.0001) in the LV group when compared with C group. Similar results are seen in Avastin-treated vessels when compared with IgG controls at day 14 (P<0.0001). Pooled data for the LV- and C-transduced vessels for caspase 3 activity at days 3 (D3), 7 (D7), and 14 (D14) is shown in c. This demonstrates a significant increase in the mean caspase 3 activities at days 3 to 14 (all P<0.001). Each bar shows mean±s.e.m. of 3–6 animals per group (b, c). Two-way analysis of variance (ANOVA) followed by Student's t-test with post hoc Bonferroni's correction was performed. Significant difference from control value is indicated by **P<0.001 and #P<0.0001.
Figure 4
Figure 4
Cellular proliferation, matrix metalloproteinase 2 (MMP-2), and matrix metalloproteinase 9 (MMP-9) are decreased in lentivirus (LV)–small hairpin RNA (shRNA)–vascular endothelial growth factor-A (VEGF-A)–transduced vessels. (a, upper panel) Representative sections after Ki-67 staining at the venous stenosis of the LV-shRNA-VEGF-A (LV) and scrambled shRNA (control (C)) or Avastin-treated vessels or immunoglobulin G (IgG) controls at days 14 (D14) and 28 (D28). Nuclei staining brown are positive for Ki-67. IgG antibody staining was performed to serve as negative controls. *Indicates the lumen. All are original magnification × 40. Bar=200 μm. Pooled data for the LV and C groups or Avastin-treated vessels or IgG controls are shown in the lower panel. This demonstrates a significant decrease in the mean Ki-67 index in the LV-transduced vessels when compared with the C vessels at day 14 (P<0.01). Similar results are seen with Avastin-treated vessels when compared with controls at day 14 (P<0.01). Significant difference from control value is indicated by **P<0.001. Each bar shows mean±s.e.m. of four animals per group. Pooled data for real-time PCR (RT-PCR) analysis of (b) MMP-2 and (c) MMP-9 expression after transduction with either LV or C are shown. This demonstrates a significant reduction in the average amount of (b) MMP-2 and (c) MMP-9 in the LV-transduced vessels when compared with C vessels at day 7 (P<0.0001) with a significant increase in MMP-2 by day 28 (P<0.01). Significant difference from control value is indicated by *P<0.01 and #P<0.0001. (b, c) Each bar shows mean±s.e.m. of four animals per group. A representative zymogram for (d) MMP-2 and (e) MMP-9 is shown in the upper panel and the pooled data in the lower panels. By zymography, (d) pro-MMP-2 expression was significantly decreased in the LV-transduced vessels when compared with C vessels at day 7 (P<0.0001), and by day 14 both pro and active MMP-2 were significantly decreased (both P<0.0001). By zymography, (e) active-MMP-9 expression was significantly decreased in the LV-transduced vessels when compared with C vessels at day 14 (P<0.001). (d, e) Each bar shows mean±s.e.m. of 3–6 animals per group. Two-way analysis of variance (ANOVA) followed by Student's t-test with post hoc Bonferroni's correction was performed. Significant difference from control value is indicated by *P<0.01, **P<0.001, or #P<0.0001.
Figure 5
Figure 5
Smooth muscle cell index and vascular endothelial growth factor receptor 1 (VEGFR-1) expression are reduced in lentivirus (LV)–small hairpin RNA (shRNA)–vascular endothelial growth factor-A (VEGF-A)–transduced vessels. (a, upper panel) Representative sections after α-smooth muscle actin (α-SMA) staining at the venous stenosis of the LV-shRNA-VEGF-A (LV) and scrambled shRNA (control (C)) and Avastin treated with control vessels at days 14 and 28. Cells staining brown are positive for α-SMA. immunoglobulin G (IgG) antibody staining was performed to serve as negative control. *Indicates the lumen. All are original magnification × 40. Bar=200 μm. Pooled data for the LV and C groups and Avastin-treated and control vessels are shown in a (lower panel). This demonstrates a significant reduction in the average α-SMA index in LV-transduced vessels when compared with C vessels by day 21 (P<0.001) and day 28 (P<0.01). There is also a significant decrease in the average α-SMA index in Avastin-treated vessels when compared with controls by day 14 (P<0.001). (c) Pooled data from RT-PCR analysis for VEGFR-1 expression after transduction from the LV and C groups. A typical blot is shown in the upper panel and the pooled data in the lower panel (c). This demonstrates a significant reduction in the mean VEGFR-1 expression in the LV-transduced vessels when compared with C vessels at day 7 (P<0.001). (b, c) Each bar shows mean±s.e.m. of 4–6 animals per group. Two-way analysis of variance (ANOVA) followed by Student's t-test with post hoc Bonferroni's correction was performed. Significant difference from control value is indicated by *P<0.01, **P<0.001, or #P<0.0001.
Figure 6
Figure 6
There is decreased hypoxia-inducible factor-1α (HIF-1α) expression and staining in lentivirus (LV)–small hairpin RNA (shRNA)–vascular endothelial growth factor-A (VEGF-A)–transduced and Avastin-treated vessels. (a) Real-time PCR (RT- PCR) analysis for HIF-1α expression after transduction with LV and control shRNA (C). A typical blot is shown in the upper panel and the pooled data in the lower panel. This demonstrates a significant reduction in average HIF-1α expression in the LV-transduced vessels when compared with C vessels at days 7 (D7; P<0.001) and 14 (D14; P<0.01). (b) Representative sections after HIF-1α staining at the venous stenosis of the LV-shRNA-VEGF-A (LV) and C and Avastin- and immunoglobulin G (IgG)–treated vessels at day 14 and day 28. Brown-staining cells are positive for HIF-1α. IgG antibody staining was performed to serve as negative control. *Indicates the lumen. All are original magnification × 40. Bar=200 μm. Pooled data for the LV-transduced and C vessels and Avastin-treated and control vessels are shown in b. This demonstrates a significant reduction in the average HIF-1α index in the LV-transduced vessels when compared with C vessels at days 14 (P<0.001) and 21 (P<0.01). There is a significant reduction in the average HIF-1α index in the LV-transduced vessels when compared with C vessels at days 14 (P<0.001) and 21 (P<0.01). There is no difference in the Avastin-treated vessels compared with controls at either time point. Each bar shows mean±s.e.m. of 4–6 animals per group. Two-way analysis of variance (ANOVA) followed by Student's t-test with post hoc Bonferroni's correction was performed. Significant difference from control value is indicated by #P<0.001.
Figure 7
Figure 7
There is decreased proliferation, invasion, α-smooth muscle actin (α-SMA), and matrix metalloproteinase 2 (MMP-2) expression with increased caspase 3 activities in the lentivirus (LV)–small hairpin RNA (shRNA)–vascular endothelial growth factor-A (VEGF-A)–transduced cells subjected to hypoxia. Western blot for α-SMA after transduction LV-shRNA-VEGF-A (LV) and scrambled shRNA-VEGF-A (C) in AKR-2B fibroblasts subjected to hypoxia at 24 and 72 h. A typical western blot is shown in the upper panel and the pooled data in the lower panel (a). This demonstrates a significant reduction in the mean α-SMA expression in the LV-transduced cells when compared with C cells at 24 (P<0.0001) and 72 h (P<0.0001). (b) Staining for α-SMA (red positive cells) at 24 and 72 h. (c) Pooled data for the average intensity of cells staining positive for α-SMA, demonstrating a significant decrease in the LV-transduced cells when compared with C cells at both 24 and 72 h (both P<0.001). (d) Pooled data for proliferation using the thymidine incorporation assay for the LV-transduced cells when compared with C cells, showing a significant decrease in proliferation for the normoxic groups at 48 and 72 h (P<0.0001) and for 24 (P<0.05), 48, and 72 h (P<0.0001) of hypoxia. (e) Invasion assay for LV-transduced cells when compared with C cells for normoxia and hypoxia. (f) Pooled data for invasion of the LV-transduced cells when compared with C cells, showing a significant decrease in both the normoxic (P<0.0001) and hypoxic groups (P<0.0001). (g) Upper panel is a representative zymogram of LV-transduced cells when compared with C cells subjected to hypoxia at 24 and 72 h, and the lower panel shows pooled data demonstrating a significant reduction in both pro- and active-MMP-2 activity at 24 h for LV-transduced cells when compared with C cells (P<0.05). (h) Pooled caspase 3 activity in LV-transduced cells when compared with C cells subjected to hypoxia at 24 and 72 h, showing a significant increase in the mean caspase 3 activity in the LV-transduced cells when compared with C cells at 24 and 72 h (both P<0.0001). (c) Each bar shows mean±s.e.m. of 3–6 different experiments per group. Two-way analysis of variance (ANOVA) followed by Student's t-test with post hoc Bonferroni's correction was performed. Significant difference from control value is indicated by *P<0.05, **P<0.01, or #P<0.001.
Figure 8
Figure 8
Cartoon of proposed mechanism. Schematic showing (a) normal vein, (b) vein after arteriovenous fistula (AVF) placement, and (c) outflow vein after fistula placement with lentivirus (LV)–small hairpin RNA (shRNA)–vascular endothelial growth factor-A (VEGF-A) silencing and its different mechanisms. HIF-1α, hypoxia-inducible factor-1α.

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