Decoding the DKK1/CKAP4 signaling Axis: A novel mechanism driving Neointimal hyperplasia in arteriovenous fistulas

Autologous arteriovenous fistula (AVF) is the preferred vascular access for maintenance hemodialysis. However, its failure is frequently driven by eccentric neointimal hyperplasia (NIH) in venous outflow tracts. The mechanisms underlying NIH remain elusive. This study aimed to elucidate the role of the DKK1/CKAP4 signaling pathway in this pathological process.

Vascular tissues from 43 first-time AVF patients and 39 patients with failed AVF were analyzed. Serum DKK1 levels were measured by ELISA, while the tissue distribution and expression of DKK1/CKAP4/PI3K/Akt were assessed via immunohistochemistry, Western blotting, and RT-qPCR. In vitro, serum from patients with chronic kidney disease (CKD) was applied to rat vascular smooth muscle cells (USMCs) for functional assays and protein analysis. Furthermore, USMCs were treated with recombinant DKK1 (r-DKK1) and the PI3K inhibitor LY294002 to assess the role of this signaling pathway on cell migration and proliferation.

Clinical analysis of patient samples revealed elevated serum DKK1 levels in CKD patients, along with increased expression of DKK1 and CKAP4 in failed AVF tissues, where they were colocalized in α-SMA⁺/Vimentin⁺ VSMCs within the vascular media and NIH areas, with PI3K/Akt pathway activation. Correspondingly, in vitro experiments demonstrated that 5% CKD serum upregulates DKK1/CKAP4 and activates PI3K/Akt in USMCs, enhancing their migration and proliferation. These effects were replicated by recombinant DKK1 stimulation and abolished by the PI3K inhibitor LY294002, confirming the pathway's specific role.

The upregulation of DKK1 drives VSMC migration and proliferation via CKAP4-mediated PI3K/Akt activation, thereby exacerbating NIH and ultimately leading to the failure of AVFs.