Name: a large animal model for acute kidney injury by temporary bilateral renal artery occlusion
Uploaded: 2021-02-02T15:00:00
Description: Watch this Scientific Journal Video about A Large Animal Model for Acute Kidney Injury by Temporary Bilateral Renal Artery Occlusion at JoVE.com

We would like to thank Dr. Arthur Nedder for his help and guidance. This work was supported by the Richard A. and Susan F. Smith President&#39;s Innovation Award, Michael B. Klein and Family, The Sidman Family Foundation, The Michael B. Rukin Charitable Foundation, The Kenneth C. Griffin Charitable Research Fund, and The Boston Investment Council.

All in vivo studies were conducted in accordance with the National Institutes of Health&#39;s guidelines on animal care and use and were approved by the Boston Children&#39;s Hospital&#39;s Animal Care and Use Committee (Protocol 18-06-3715). All animals received humane care in compliance with the Guide for the Care and Use of Laboratory Animals. Figure 1 shows the timeline including anesthesia, surgical preparation, and timepoints for primary outcome measurements of this study.
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A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Catheter-based+induction+of+renal+ischemia/reperfusion+in+swine:+Description+of+an+experimental+model.">Catheter-based induction of renal ischemia/reperfusion in swine: Description of an experimental model.</a> Physiological Reports. 2 (9), 1-13 (2014).</li><li>Freeman, R. 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AKI is a common clinical disorder affecting up to 50% of hospitalized adult patients worldwide6,12. A clinically relevant animal model is needed to further investigate the pathophysiology of the disease and potential therapeutic targets. Although there are several murine models replicating AKI, these do not completely mimic their respective clinical scenarios and the anatomy of the human kidney. This study proposes a clinically relevant swine model to allow for t...

Acute kidney injury (AKI) is a commonly diagnosed condition among surgical patients associated with significant morbidity and mortality1,2. Available data show that AKI can affect even half of all hospitalized patients worldwide and leads to 50% mortality rate in patients in the intensive care unit1,3. Despite its high prevalence, current AKI therapy remains limited to preventive strategies, such as fluid management and dialysis. Therefore, there is an ongoing interest in exploring alternative therapies for AKI4,5,6.
AKI is typically classified into pre-renal, intrinsic, and post-renal based on its etiology4,5,6. The majority of surgical patients with AKI are associated with pre-renal causes due to hypovolemia, resulting in ischemia-reperfusion injury (IRI) of the kidneys2. Clinically, urine output decreases, and creatinine levels increase due to decreased renal function. The kidney is a high-metabolic-rate organ and susceptible to ischemia. A highly reproducible large animal model of renal IRI is necessary to obtain a better insight into the pathophysiology of AKI and its potential therapeutic approaches5.
To mimic the clinical scenario of kidney hypoperfusion peri-operatively, a model of bilateral renal artery occlusion is deemed suitable. Previously described models entailing unilateral renal artery occlusion with or without resection of the contralateral kidney do not provide sufficient clinical applicability7,8. Although these models are sufficient for causing AKI, they do not resemble real-life clinical scenarios neither in terms of type nor duration of injury.
The aim of this paper is to present a porcine model of percutaneous bilateral temporary occlusion of the renal arteries by balloon-catheter occlusion under angiography. Bilateral renal artery occlusion mimics the clinical scenario of renal hypoperfusion, followed by the subsequent removal of the balloon for reperfusion9,10. The technical steps are described, including catheterization, catheter guidance, angiography, and hemodynamic monitoring. This method not only allows for a highly controlled and replicable occlusion of the renal arteries, but the percutaneous approach minimizes the impact of the inflammatory response by limiting the amount of insult to the body compared to an open approach.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>0.9% sodium chloride injection, usp, 100 ml viaflex plastic container</td>
			<td>Baxter</td>
			<td>2B1302</td>
			<td>For animal hydration</td>
		</tr>
		<tr>
			<td>Agent contrast 100.0ml injection media btl ioversal 74%</td>
			<td>CARDINAL HEALTH</td>
			<td>133311</td>
			<td>For visualizing the vasculature</td>
		</tr>
		<tr>
			<td>Bard Bardia Closed System Urinary Drainage Bag</td>
			<td>BARD Inc</td>
			<td>802001</td>
			<td>For urine collection</td>
		</tr>
		<tr>
			<td>BD Vacutainer K2 EDTA</td>
			<td>BD</td>
			<td>367841</td>
			<td>For blood sample storage</td>
		</tr>
		<tr>
			<td>BD Vacutainer Lithium Heparin</td>
			<td>BD</td>
			<td>366667</td>
			<td>For blood sample storage</td>
		</tr>
		<tr>
			<td>Betadine</td>
			<td>Henry Schein</td>
			<td>6906950</td>
			<td>For skin disinfection</td>
		</tr>
		<tr>
			<td>Bookwalker retractor</td>
			<td>Codman</td>
			<td></td>
			<td>For skin retraction</td>
		</tr>
		<tr>
			<td>Bupivacaine 0.25%</td>
			<td>Hospira</td>
			<td></td>
			<td>Administer at incision site for analgesia</td>
		</tr>
		<tr>
			<td>Buprenorphine SR</td>
			<td>Zoo Pharm</td>
			<td></td>
			<td>10mg/ml bottle, Dose: 0.2mg/kg SC</td>
		</tr>
		<tr>
			<td>Cath angio 5.0 Fr x100.0 cm 0.038 in JR4</td>
			<td>MERIT MEDICAL SYSTEM INC</td>
			<td>7523-21</td>
			<td>For identification of the renal arteries</td>
		</tr>
		<tr>
			<td>Cuffed endotracheal tube</td>
			<td>Emdamed</td>
			<td></td>
			<td>To establish a secure airway for the duration of the operation</td>
		</tr>
		<tr>
			<td>EKG Medtronics- Physiocontrol LifePak 20 Oxygen saturation monitor</td>
			<td>GE Healthcare Madison WI</td>
			<td></td>
			<td>For oxygen saturation monitoring</td>
		</tr>
		<tr>
			<td>Encore 26 inflator</td>
			<td>BOSTON SCIENTIFIC</td>
			<td>710113</td>
			<td>For inflating the balloon catheters</td>
		</tr>
		<tr>
			<td>Ethanol 95% (Ethyl alcohol)</td>
			<td>Henry Schein</td>
			<td></td>
			<td>For skin disinfection</td>
		</tr>
		<tr>
			<td>Fentanyl patch</td>
			<td>Mylan</td>
			<td></td>
			<td>Dose: 25-50mcg/hr, TD</td>
		</tr>
		<tr>
			<td>Gold silicone coated Foley</td>
			<td>TELEFLEX MEDICAL INC</td>
			<td>180730160</td>
			<td>For urine collection</td>
		</tr>
		<tr>
			<td>Heparin sodium</td>
			<td>LEO Pharma A/S</td>
			<td></td>
			<td>Dose: 200 IU/kg IV</td>
		</tr>
		<tr>
			<td>i33 ultrasound machine</td>
			<td>Phillips</td>
			<td></td>
			<td>Use ultrasonographic guidance for femoral catherization if necessary</td>
		</tr>
		<tr>
			<td>Inqwire diagnostic guide wire - 0.035&#34; (0.89 mm) - 260 cm (102&#34;) - 1.5 mm j-tip</td>
			<td>MERIT MEDICAL SYSTEM INC</td>
			<td>6609-33</td>
			<td>For guiding the balloon catheters to the renal arteries</td>
		</tr>
		<tr>
			<td>Intravenous catheter, size 20 gauge</td>
			<td>Santa Cruz Biotechnology</td>
			<td>Inc SC-360097</td>
			<td>For fluid administration</td>
		</tr>
		<tr>
			<td>Isoflurane</td>
			<td>Patterson Veterinary Supply, Inc.</td>
			<td>21283620</td>
			<td>Dose: 3%, INH</td>
		</tr>
		<tr>
			<td>Metzenbaum blunt curved 14.5 cm - 5(3/4)&#34;</td>
			<td>Rudolf Medical</td>
			<td>RU-1311-14M</td>
			<td>For tissue dissection and cutting</td>
		</tr>
		<tr>
			<td>Neonatal disposable transducer kit with 30ml/hr flush device and double 4-way stopcocks for continuous monitoring</td>
			<td>Argon Medical</td>
			<td>041588505A</td>
			<td>For pressure measurement</td>
		</tr>
		<tr>
			<td>Powerflex pro PTA dilatation catheter 6 x 20 mm - shaft length (135cm)</td>
			<td>CARDINAL HEALTH</td>
			<td>4400602X</td>
			<td>For occlusion of the renal arteries</td>
		</tr>
		<tr>
			<td>Pressure monitoring lines mll/mll - 12&#34; clear, mll/mll</td>
			<td>Smiths Medical</td>
			<td>B1571/MX571</td>
			<td>For pressure measurement</td>
		</tr>
		<tr>
			<td>Procedure pack</td>
			<td>Molnlycke Health Care</td>
			<td>97027809</td>
			<td>Surgical drape, gauze pads, syringes, beaker etc</td>
		</tr>
		<tr>
			<td>Protamine</td>
			<td>Henry Schein</td>
			<td>1044148</td>
			<td>For heparin reversal</td>
		</tr>
		<tr>
			<td>Scalpel blade - size #10</td>
			<td>Cardinal Health (Allegiance)</td>
			<td>32295-010</td>
			<td>For the skin incisions</td>
		</tr>
		<tr>
			<td>Stopcock iv 4 way lrg bore rotg male ll adptr strl</td>
			<td>Peoplesoft</td>
			<td>1550</td>
			<td>For connecting tubings</td>
		</tr>
		<tr>
			<td>Straight lateral retractor</td>
			<td>Codman</td>
			<td></td>
			<td>For skin retraction</td>
		</tr>
		<tr>
			<td>Suture perma hnd 18in 2-0 braid silk blk</td>
			<td>CARDINAL HEALTH 1</td>
			<td>A185H</td>
			<td>For suturing incision site and securing catheters</td>
		</tr>
		<tr>
			<td>Syringe contrast injection 10ml fixed male luer red</td>
			<td>MERIT MEDICAL SYSTEM INC</td>
			<td>MSS111-R</td>
			<td>To administer the contrast agent</td>
		</tr>
		<tr>
			<td>Syringe medical 60ml ll plst strl ltx free disp</td>
			<td>CARDINAL HEALTH 1</td>
			<td>BF309653</td>
			<td>For urine collection and flushing of the angiocath</td>
		</tr>
		<tr>
			<td>Tilzolan (tiletamine/zolazepam)</td>
			<td>Patterson Veterinary Supply, Inc.</td>
			<td>07-893-1467</td>
			<td>Dose: 4-6 mg/kg, IM</td>
		</tr>
		<tr>
			<td>Xylazine</td>
			<td>Putney, INC</td>
			<td></td>
			<td>Dose: 1.1-2.2 mg/kg, IM</td>
		</tr>
	</tbody>
</table>

a large animal model for acute kidney injury by temporary bilateral renal artery occlusion

Acute kidney injury (AKI) is associated with higher risk for morbidity and mortality post-operatively. Ischemia-reperfusion injury (IRI) is the most common cause of AKI. To mimic this clinical scenario, this study presents a highly reproducible large animal model of renal IRI in swine using temporary percutaneous bilateral balloon-catheter occlusion of the renal arteries. The renal arteries are occluded for 60 min by introducing the balloon-catheters through the femoral and carotid artery and advancing them into the proximal portion of the arteries. Iodinated contrast is injected in the aorta to assess any opacification of the kidney vessels and confirm the success of the artery occlusion. This is furtherly confirmed by the flattening of the pulse waveform at the tip of the balloon catheters. The balloons are deflated and removed after 60 min of bilateral renal artery occlusion, and the animals are allowed to recover for 24 h. At the end of the study, plasma creatinine and blood urea nitrogen significantly increase, while eGFR and urine output significantly decrease. The need for iodinated contrast is minimal and does not affect renal function. Bilateral renal artery occlusion better mimics the clinical scenario of perioperative renal hypoperfusion, and the percutaneous approach minimizes the impact of the inflammatory response and the risk of infection seen with an open approach, such as a laparotomy. The ability to create and reproduce this clinically relevant swine model eases the clinical translation to humans.

Functional analysis 
The representative results of this study arise from 6 animals and the data shown are mean &#177; standard error of the mean.Renal function is assessed by determining the urine output, estimated glomerular filtration rate (eGFR), plasma creatine, and blood urea nitrogen (BUN). The biomarkers of renal function are assessed using a portable chemistry analyzer. eGFR is calculated according to the following formula: eGFR =1.879 &#215; BW1.092/PCr0.6 (...

Watch this Scientific Journal Video about A Large Animal Model for Acute Kidney Injury by Temporary Bilateral Renal Artery Occlusion at JoVE.com

A Large Animal Model for Acute Kidney Injury by Temporary Bilateral Renal Artery Occlusion

This study presents a highly reproducible large animal model of renal ischemia-reperfusion injury in swine using temporary percutaneous bilateral balloon-catheter occlusion of the renal arteries for 60 min and reperfusion for 24 h.

Acute kidney injury (AKI) is associated with higher risk for morbidity and mortality post-operatively. Ischemia-reperfusion injury (IRI) is the most ...

This study describes a reproducible large animal model of renal ischemia reperfusion injury, which can be used to study the pathophysiology of acute kidney injury, and explore potential therapeutic modalities. This method is highly reproducible and minimizes the impact of inflammatory response by limiting the amount of insult to the body compared to an open approach. This preclinical model mimics clinical scenarios, such as renal transplantation, renal hypoperfusion following cardiogenic shock, transcatheter procedures resulting in renal ischemia, and cardiovascular procedures with prolonged cardio-circulatory arrest times.To begin, disinfect the right lateral area of the neck by applying betadine and then 95%ethanol three times. Drape the animal in a sterile fashion. Perform a cutdown for the catheterization of the right carotid artery and the right jugular vein.Retract the sternocleidomastoid muscle laterally, and dissect it down to the right carotid artery and the right jugular vein. Insert a 5F angiography sheath in both the artery and the vein. Secure it with a silk 2-0 suture.Insert a 5F angiography sheath using the Seldinger technique into the left femoral artery by puncturing the artery with a hollow needle. Insert a soft-tip guide wire through the lumen and advance it into the femoral artery. Hold the guide wire secure with a hand while removing the needle.Pass the angiography sheath over the guide wire into the femoral artery and withdraw the guide wire by using ultrasound guidance if necessary. Intravenously administer 200 IU per kilogram sodium heparin to achieve systemic anticoagulation. To perform angiography, inject an iodinated contrast agent under fluoroscopy to identify the renal arteries.Identify the renal arteries and manually advance the guide wire in the guiding catheter. Position the 5F JL4 guiding catheter in the left renal artery through the right carotid artery. Position the second 5F JL4 guiding catheter in the right renal artery through the left femoral artery.Use the guide wires to direct a 5F percutaneous transluminal angioplasty, or PTA dilation catheter, in each renal artery. Position each balloon catheter in place, and connect a pressure line to each catheter. Check the presence of arterial pulse wave forms in the pressure monitor to ensure the correct positioning of the catheter.Inflate each balloon and aim for a pressure of approximately 2.5 atmospheric pressure inside the balloon. To confirm the cessation of blood flow to the kidneys, observe the flattening of the pulse waveform at the tip of the balloon catheter. Inject iodinated contrast medium in a 1:1 dilution with saline and check for any opacification of the renal vessels.After 60 minutes of occlusion, carefully deflate and remove the balloon catheters from the renal arteries. Perform an angiography using a 1:1 diluted contrast medium to confirm renal artery patency and the establishment of renal reperfusion. Remove the 5F angiography sheath from the left femoral artery.Apply from pressure at the site of catheterization for 30 minutes. Reverse the effect of heparin by the administration of three milligrams per kilogram of protamine until normalization of active clotting time. To sample urine during the post-operative period, secure a tube to the Foley catheter with a silk 2-0 suture using an interrupted stitch on the skin.For blood sampling, leave the angiography sheaths in the right carotid artery and the right jugular vein in place, and secure them with a silk 2-0 suture. administer three milligrams per kilogram of bupivacaine at the incision site to minimize pain. Continue to hydrate the animal with 0.9 sodium chloride for a total of two hours following the end of ischemia.Close the neck incision with a silk 2-0 suture using an interrupted stitch in two layers. Place a fentanyl patch of 25 to 50 micrograms per hour on the back of the animal to minimize post-operative pain, and monitor the animal on mechanical ventilation until it awakens. Collect the final blood and urine samples and calculate the urine output.Perform a midline laparotomy incision using a size-10 blade from the xiphoid down to the mid pelvis. Use a straight lateral retractor to retract the abdominal skin. Dissect the lateral peritoneal attachments of the abdominal wall to expose the right and left retroperitoneum.Identify and bluntly dissect both renal arteries and veins. Ligate both renal arteries and veins with a 2-0 silk suture and perform bilateral nephrectomies to collect whole-tissue specimens for histological and metabolic analysis. Renal function was assessed by determining the urine output, eGFR, plasma creatine, and BUN.Following 60 minutes of bilateral renal artery occlusion, urine output was significantly decreased and remained this way at six and 24 hours following reperfusion. Similarly, a significant decrease was observed in eGFR, which dropped from baseline as compared to the end of ischemia at two hours, six hours, and 24 hours of reperfusion. Plasma creatinine was significantly increased at two, six, and 24 hours of reperfusion compared to baseline.BUN was increased as compared to baseline at six and 24 hours of reperfusion. Evident necrotic and hemorrhagic areas were unevenly distributed in both kidneys at the end of the 60 minutes of bilateral renal ischemia and the 24 hours of reperfusion. Masson's trichrome staining revealed confluent coagulative necrosis, which was located at the proximal tubules of the renal cortex.Plastic-embedded sections were also assessed. All Masson's trichrome slides were evaluated for cell necrosis, loss of brush border, cast formation, and tubule dilation. Acute tubular necrosis, or ATN scoring, showed significant injury to the renal cortex and medulla.When performing this protocol, check the positioning of the balloon sites on the proximity of RC, and totally occlude the flow to the kidney. Make sure it's not kinking in that water. Following this procedure, endovascular catheter flow probes can be inserted in the renal arteries to assess renal blood flow, or renal biopsies can be performed to assess renal tissue injury.

Research

JoVE Journal

Medicine

Use of a Hanging-weight System for Isolated Renal Artery Occlusion

In hospitalized patients, over 50% of cases of acute kidney injury (AKI) are caused by renal ischemia 1-3. A recent study of hospitalized patients ...

Bilateral Common Carotid Artery Occlusion as an Adequate Preconditioning Stimulus to Induce Early Ischemic Tolerance to Focal Cerebral Ischemia

There is accumulating evidence, that ischemic preconditioning - a non-damaging ischemic challenge to the brain - confers a transient protection to a ...

Ischemia-reperfusion Model of Acute Kidney Injury and Post Injury Fibrosis in Mice

Ischemia-reperfusion induced acute kidney injury (IR-AKI) is widely used as a model of AKI in mice, but results are often quite variable with high, often ...

Renal Ischaemia Reperfusion Injury: A Mouse Model of Injury and Regeneration

Renal ischaemia reperfusion injury (IRI) is a common cause of acute kidney injury (AKI) in patients and occlusion of renal blood flow is unavoidable ...

Invasive Hemodynamic Monitoring of Aortic and Pulmonary Artery Hemodynamics in a Large Animal Model of ARDS

One of the leading causes of morbidity and mortality in patients with heart failure is right ventricular (RV) dysfunction, especially if it is due to ...

Ferric Chloride-induced Canine Carotid Artery Thrombosis: A Large Animal Model of Vascular Injury

Occlusive arterial thrombosis leading to cerebral ischemic stroke and myocardial infarction contributes to ~13 million deaths every year globally. Here, ...

Induction and Phenotyping of Acute Right Heart Failure in a Large Animal Model of Chronic Thromboembolic Pulmonary Hypertension

The development of acute right heart failure (ARHF) in the context of chronic pulmonary hypertension (PH) is associated with poor short-term outcomes. The ...

Isometric Contractility Measurement of the Mouse Mesenteric Artery Using Wire Myography

The wire myograph technique is used to assess the contractility of vascular smooth muscles in response to depolarization, GPCR agonists/inhibitors and ...

A Modified Two Kidney One Clip Mouse Model of Renin Regulation in Renal Artery Stenosis

Renal artery stenosis is a common condition in patients with coronary or peripheral vascular disease where the renin angiotensin aldosterone system (RAAS) ...

Acute Kidney Injury Model Induced by Cisplatin in Adult Zebrafish

Cisplatin is commonly used as chemotherapy. Although it has positive effects in cancer-treated individuals, cisplatin can easily accumulate in the kidney ...