Correspondence: Dr. Yasuhiko Ito, Department of Nephrology, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan. Email: pj.ca.u-ayogan.dem@otiusay

Received 2012 Mar 4; Accepted 2013 May 1.

Abstract

Peritoneal fibrosis (PF) causes ultrafiltration failure (UFF) and is a complicating factor in long-term peritoneal dialysis. Lymphatic reabsorption also may contribute to UFF, but little is known about lymphangiogenesis in patients with UFF and peritonitis. We studied the role of the lymphangiogenesis mediator vascular endothelial growth factor-C (VEGF-C) in human dialysate effluents, peritoneal tissues, and peritoneal mesothelial cells (HPMCs). Dialysate VEGF-C concentration correlated positively with the dialysate-to-plasma ratio of creatinine (D/P Cr) and the dialysate TGF-β1 concentration. Peritoneal tissue from patients with UFF expressed higher levels of VEGF-C, lymphatic endothelial hyaluronan receptor-1 (LYVE-1), and podoplanin mRNA and contained more lymphatic vessels than tissue from patients without UFF. Furthermore, mesothelial cell and macrophage expression of VEGF-C increased in the peritoneal membranes of patients with UFF and peritonitis. In cultured mesothelial cells, TGF-β1 upregulated the expression of VEGF-C mRNA and protein, and this upregulation was suppressed by a TGF-β type I receptor (TGFβR-I) inhibitor. TGF-β1–induced upregulation of VEGF-C mRNA expression in cultured HPMCs correlated with the D/P Cr of the patient from whom the HPMCs were derived (P<0.001). Moreover, treatment with a TGFβR-I inhibitor suppressed the enhanced lymphangiogenesis and VEGF-C expression associated with fibrosis in a rat model of PF. These results suggest that lymphangiogenesis associates with fibrosis through the TGF-β–VEGF-C pathway.

Abstract

The decrease in ultrafiltration capacity that is associated with the high peritoneal solute transport that is observed after prolonged peritoneal dialysis (PD) treatment is a major reason for its discontinuation.¹4 Several studies have shown that a higher peritoneal solute transport rate is associated with reduced survival of PD patients.¹25 The characteristic features of chronic peritoneal damage in PD treatment are associated with submesothelial fibrosis and neoangiogenesis.⁶7 Analyses of the surface peritoneum showed no significant changes in vessel density with duration of PD.⁶8 In addition, the vessel density in patients with ultrafiltration failure (UFF) was significantly higher than the vessel density in normal individuals or non-PD patients, but it was not higher than the vessel density in patients undergoing PD.⁶ These findings suggest that factors other than increased vascular density may be involved in disease states associated with increased transport of peritoneal membranes. In addition, the relationship between peritoneal fibrosis and UFF remains obscure.

Blood capillaries have a continuous basal lamina with tight interendothelial junctions and are supported by pericytes and smooth muscle cells. In contrast, lymphatic capillaries are thin-walled with a wide lumen and do not contain pericytes or basement membrane. The structures of lymphatic vessels are suitable for the removal of tissue fluid, cells, and macromolecules from the interstitium.⁹11 If lymphangiogenesis develops in the peritoneal membrane, absorption of the PD fluid could be increased and lead to UFF. An increase in the number of lymphatic vessels has recently been reported in several disease conditions, including tumor metastasis,¹²15 chronic respiratory inflammatory diseases,¹⁶18 wound healing,¹⁹ and renal transplant rejection.²⁰21 We recently reported that lymphangiogenesis had developed in tubulointerstitial fibrosis of human renal biopsy specimens,²² and we also reported the mechanisms of lymphangiogenesis in rat unilateral ureteral obstruction models.²³

The lymphatic absorption rate, which is measured by the rate at which intraperitoneally administered radioactive serum albumin or macromolecule dextran 70 disappears, is significantly higher in patients with UFF, and lymphatic reabsorption is considered to be one of the causes of UFF.²⁴27 However, the results from these clinical approaches have been controversial.²⁸29 In addition, little is known about the pathology and the process of lymphangiogenesis in patients with UFF and peritonitis.

In this study, we investigated lymphangiogenesis and the expression of vascular endothelial growth factor-C (VEGF-C), which is a potentially important mediator of lymphangiogenesis, in human peritoneal tissues, PD effluent, and peritoneal mesothelial cells. We also explored VEGF-C induction by TGF-β1 in the human mesothelial cell line (Met-5A) and cultured human peritoneal mesothelial cells (HPMCs) from the spent PD effluent of patients with varying rates of peritoneal transport. Finally, we explored the relationship between peritoneal fibrosis and lymphangiogenesis in rats that were administered chlorhexidine gluconate (CG) into the abdominal cavity, which provides a model of chemically induced peritoneal inflammation/fibrosis.³⁰32 This work is the first report to show that lymphangiogenesis is linked to the peritoneal fibrosis that is often associated with a high peritoneal transport rate.

Values are means ± SD. Normal renal function indicates living kidney donors with normal renal function. Predialysis uremia indicates peritoneal tissues that were taken at the time when a PD catheter was inserted because of advanced renal failure. Incident indicates that peritoneal tissues were taken when the catheter was removed because of reasons other than UFF.

D/P Cr is an index of the peritoneal transport.

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Acknowledgments

The technical assistance of Mr. Norihiko Suzuki, Ms. Keiko Higashide, Ms. Naoko Asano, and Ms. Yuriko Sawa (Department of Nephrology, Nagoya University, Nagoya, Japan) is gratefully acknowledged. We thank Drs. Isao Ito and Susumu Toda (Nagoya University Hospital, Nagoya, Japan), Drs. Midoriko Watanabe and Makoto Mizutani (Handa Municipal Hospital, Handa, Japan), Dr. Hirotake Kasuga (Nagoya Kyoritsu Hospital, Nagoya, Japan), Dr. Masanobu Horie (Daiyukai-Daiichi Hospital, Ichinomiya, Japan), and Dr. Takeyuki Hiramatsu (Kounan-Kousei Hospital, Kounan, Japan) for collecting peritoneum from the patients.

This work was supported in part by Ministry Education, Science, and Culture, Japan Grant-in-Aid for Scientific Research 20590972 (to Y.I.), a 2011 research grant from the Aichi Kidney Foundation (to H.K. and Y.I.), and the Japanese Association of Dialysis Physicians Grant 2011-13 (to Y.I.). This study was also supported in part by a Ministry of Health, Labor, and Welfare of Japan Grant-in-Aid for Progressive Renal Diseases Research, Research on Rare and Intractable Disease.

Acknowledgments

Footnotes

Published online ahead of print. Publication date available at www.jasn.org.

This article contains supplemental material online at http://jasn.asnjournals.org/lookup/suppl/doi:10.1681/ASN.2012030226/-/DCSupplemental.

Footnotes

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