Do medical devices contribute to sustainability? The role of innovative polymers and device design

Sustainability of a medical device has not yet become a major issue in public discussions compared to other topics with impact to material performance, clinical application, production economy and environmental pollution. Due to their unique properties, polymers (plastics) allow for multiple, flexible applications in medical device technology. Polymers are part of the majority of disposable and single use medical device and contribute with 3% to the worldwide production of plastics. The global medical polymer market size was valued 19.9 billion US-$ in 2022 and its value projection for 2023 is expected to reach 43.03 billion US-$ Here, a wider concept of related sustainability is introduced for medical devices and their polymer components. A close look on medical device specification reveals that additional properties are required to provide sustainability, such as biodegradability, quality by device design (QbD), as well as an inbuild performance service for patients, healthcare professionals and healthcare providers. The increasing global numbers for chronic and non-communicable diseases require a huge demand for single use medical devices. A careful look at polymer specification and its performance properties is needed, including possible chemical modifications and degradation processes during waste disposal. Bioengineers in charge of design and production of medical devices will only be successful when they apply a holistic and interdisciplinary approach to medical device sustainability.

Do medical devices contribute to sustainability? Environmental, societal and governance aspects

Sustainability of a product or device is currently primarily related to its environmental footprint. Here, a wider concept of sustainability is introduced for medical devices and their components in healthcare provision. Such devices sustain healthcare and patient wellbeing due to their quality specifications for material composition, product design and performance. The term quality must be intended in the most comprehensive term, including purity and biocompatibility of materials, device reliability, limited number of recalls and reduced risks as well as acceptability for patients. A close look on medical device specification shows, however, that additional parameters, such as societal, demographic and economic factors also determine medical device sustainability. The medical device life cycle, from design phase, production process to clinical application and the final disposal, also determines its impact. Recommendations for healthcare operators and managers will complete the hypothesis of this paper, that a thoroughly outlined device choice and operation together with a careful waste management of spent medical devices and their components positively affects medical device sustainability. As an example, the limited quantity of wastes and the reduced risks for adverse reaction have a positive impact on both the environmental pollution and on the costs sustained by the healthcare organisations and by the community. These factors determine both, the success of healthcare manoeuvres and the related environmental footprint.

Contrast-Enhanced Ultrasonography as a Novel Method for the Dynamic Visualization of Blood Flow and Fiber Blockage in Dialyzers: A Feasibility Study

The capillary dialyzer represents the central element of the extracorporeal blood circuit of a therapy system for hemodialysis. The aim of this study was to assess the blood-flow characteristics of dialyzers with the help of modern ultrasound techniques. Five brand-new dialyzers (FX80 classix, Fresenius Medical Care, Bad Homburg, Germany) and five dialyzers after a dialysis session were analyzed by different ultrasound techniques to detect functional and structural changes. B-mode and Doppler techniques were not suitable to describe differences in brand-new and clinically applied dialyzers. Contrast-enhanced ultrasonography, however, was able to visualize blood-flow profiles in the capillaries. Although dialyzers displayed no signs of clinical dysfunction, contrast-enhanced ultrasonography was able to detect blocked capillaries of varying degrees after a dialysis session in all five examined dialyzers. Consequently, the blood-flow velocity was higher in the remaining unblocked capillaries in comparison to the velocity in the brand-new dialyzers. This information may be helpful for improving the geometric design of dialyzers, including their capillary membranes, and optimizing anti-coagulation strategies in hemodialysis patients.

Regulatory Considerations for Hemodiafiltration in the United States

Online hemodiafiltration provides greater removal of higher molecular weight uremic retention solutes than conventional high-flux hemodialysis. However, online hemodiafiltration is used sparsely in the United States in part because of a paucity of delivery systems cleared for clinical use by the US Food and Drug Administration. Although a pathway for regulatory approval exists in the United States, concerns remain, particularly regarding online production of the large volumes of sterile, nonpyrogenic substitution fluid infused directly into the bloodstream to maintain fluid balance. Clearly defined testing protocols, acceptable to Food and Drug Administration, will be useful to show that an online hemodiafiltration system is capable of routinely achieving a sterility assurance level of 10-6 and nonpyrogenic levels of endotoxin. Large-scale clinical experience has shown that systems providing this level of performance when combined with certain design features, such as redundancy, and an appropriate quality management process can routinely and safely produce substitution fluid for online hemodiafiltration.

Hemodiafiltration to Address Unmet Medical Needs ESKD Patients

Hemodiafiltration combines diffusive and convective solute removal in a single therapy by ultrafiltering 20% or more of the blood volume processed using a high-flux hemodialyzer and maintaining fluid balance by infusing sterile nonpyrogenic replacement fluid directly into the patient's blood. In online hemodiafiltration, the large volumes of replacement fluid required are obtained by online filtration of standard dialysate through a series of bacteria- and endotoxin-retaining filters. Currently available systems for online hemodiafiltration are on the basis of conventional dialysis machines with added features to safely prepare and infuse replacement fluid and closely control fluid balance. Hemodiafiltration provides greater removal of higher molecular weight uremic retention solutes than conventional high-flux hemodialysis, and recently completed randomized, controlled clinical trials suggest better patient survival with online hemodiafiltration compared with standard high-flux hemodialysis when a high convection volume is delivered. Hemodiafiltration is also associated with improvements in other clinical outcomes, such as a reduction in intradialytic hypotension, and it is now used routinely to treat >100,000 patients, mainly in Europe and Japan.

Clinical Evaluation of a New High-Flux Cellulose Acetate Membrane

One major goal of dialysis therapy has become the removal of ß2-microglobulin (ß2-m). The interdialytic elimination of ß2-m was studied using a newly developed high-flux cellulose acetate (CA) membrane.

The results show that high-flux CA dialyzers offer better biocompatibility than classical Cuprophan or high-flux Cuprophan devices, with regard to leukopenia, C3a desarg generation, and elastase release from polymorphonuclear (PMN) leukocytes. Compared to high-flux CA membranes, high-flux PMMA membranes induce less C3a desarg formation but comparable leukopenia. High-flux PMMA membranes, however cause greater leukocyte stimulation than CA as demonstrated by more PMN elastase release during hemodialysis.

Using high-flux CA or high-flux PMMA membranes, serum ß2-m levels decreased 32% during dialysis. Serum ß2-m dropped 10% with high-flux Cuprophan membranes, but remained unchanged with conventional Cuprophan dialyzers.

Sieving coefficients for ß2-microglobulin (ß2-m) were virtually zero with classical Cuprophan and 0.66 with high-flux cellulose acetate membranes. High-flux membranes made of Cuprophan and PMMA gave coefficients of 0.25 and 0.45, respectively. This indicates the high removal capacity of the new CA-membrane for substances with high molecular weight.

This high-flux CA membrane thus appears to combine a good degree of biocompatibility with a high capacity for ß2-m removal.

Computer Aided Time-Lapse Video Analysis of Hepatocyte Morphology during Adhesion to Cellulose Membranes

An investigation was performed to demonstrate that time-lapse cinematography and computer aided video analysis of cell morphology is suitable to study and compare the characteristics of hepatocytes during the adhesion process to membranes. We chose to compare ordinary cellulose Cuprophan membranes and membranes coated with collagen or fibronectin. Striking differences between uncoated cellulose and fibronectin or collagen coating were seen in the cell count per square millimeter and adhesion behaviour. On the investigated uncoated Cuprophan the hepatocytes were found to attach but not to spread whilst on collagen coated Cuprophan most of the cells spread spherically, and on fibronectin coated membranes most of the cells flattened spherically or polygonally. Time-lapse video microscopy seems to be a valuable technique for assessing the morphologic behaviour of cells in a detailed and quantitative manner in order to improve the hepatocyte culture technique in bioreactors for hybrid systems.

Side Effects of Hybrid Liver Support Therapy: TNF-α Liberation in Pigs, Associated with Extracorporeal Bioreactors

During acute liver failure, hybrid liver support therapy could serve as a bridge to liver transplantation. In this desired temporary use, immune competent cell responses, such as the production of cytokines, might be of limiting relevance. We have investigated the Tumor Necrosis Factor-α (TNF) liberation in two models using pigs, connected with an extracorporeal bioreactor with homologous hepatocytes: TNF liberation was measured in arterial plasma during a 4 day perfusion time in untreated animals, model (i), and during short term perfusion of hepatectomized pigs in model (ii). Animals four days after catheter implantation in model (i) had TNF values of < 5 pg/ml. After connecting the system without hepatocytes, TNF rose to 9.7 ± 2 within 120 min and rose further to 32.6 ± 6 pg/ml within 4 hours after filling the system with the homologous hepatocytes. After 24 hours of continuous perfusion and during four days of perfusion, the TNF levels were lowered to baseline levels. In model (ii), TNF rose to 220 ± 130 pg/ml within 180 min and decreased to 110 ± 10 pg/ml within six hours, whereas controls without hepatocytes showed mean levels with a maximum of 120 ± 20 pg/ml. In both models, there was no correlation between TNF levels and clinical abnormalities such as fever or shock symptoms. There is evidence for an activation of blood cells during experimental extracorporeal hybrid support. No typical side effects were, however, observed. Thus, TNF mediated extracorporeal cell activation does not appear to limit the application of homologous hybrid liver support therapy.

The Influence of Different Glucose Concentrations in Haemodialysis Solutions on Metabolism and Blood Pressure Stability in Diabetic Patients

In recent years the percentage of diabetic patients on haemodialysis has increased. Considering the high frequency of intradialytic hypotensive and hypoglycaemic episodes experienced by these patients, it was the aim of the present study to evaluate the influence of different dialysate glucose concentrations (5.5 mmol/L or 11 mmol/L) on blood pressure and glycaemic regulation, using special dialysis equipment - the GENIUS® System.

This cross-over, prospective and randomised study, total duration 14 weeks, included 20 diabetic patients on maintenance haemodialysis. Group 1: 9 patients dialysed using dialysate with a glucose concentration of 5.5 mmol/L and after 7 weeks switched to dialysate with a glucose concentration of 11 mmol/L. Group 2: vice versa.

Results show a statistically higher number of patients with hypoglycaemic and hypotensive episodes using dialysate with a 5.5 mmol/L glucose concentration. Also, mean serum glucose values were higher during haemodialysis sessions with a glucose dialysate concentration of 11 mmol/L. There were no statistical differences between the groups in laboratory values, HbA1C, insulin doses or in anthropometric parameters.

Our results suggest that fewer diabetic patients undergoing haemodialysis using a higher dialysate glucose concentration of 11 mmol/L have hypoglycaemic and hypotensive episodes. Since this dialysate glucose concentration had no influence on lipid or hepatic metabolism, anthropometric parameters and especially HbA1C values in this short-term study, the long term examination of its effects is warranted.

Variables Associated with the Assessment of Systemic Tumor Necrosis Factor Alpha Levels during Hemodialysis

Conflicting results have been published concerning the systemic induction of the cytokine tumor necrosis factor alpha (TNFα) during hemodialysis (HD). We therefore evaluated in vitro TNFα production in whole blood as well as in vivo variability of TNFα levels in patients on long-term HD. Whole blood was incubated at room temperature (RT) with or without exogenously added endotoxin (ET), and plasma-TNFα was measured after 5, 30, 120, 240, and 960 min by specific enzyme immunoassay. Additionally, plasma-TNFα before and after 120 and 240 min HD was studied longitudinally once a week over a period of 4 weeks in 36 patients on Cuprophan® (CU, n=23) or polysulfone-F60 (PSu, n=13) HD. Mean plasma TNFα levels in vitro rose from (mean) 8 pg/ml after 5 min to 12 pg/ml (120′) and 32 pg/ml (960′) even without ET addition, and to 18 pg/ml (after 120′) and 88 pg/ml (after 960′) when 0.1 μg/ml ET were added. Pre-dialytic as well as intradialytic TNFα levels in patients showed high intra-individual variability. A substantial (> 100%) increase in plasma TNFα was observed during only 14 out of 84 treatments with CU and 20 out of 47 with PSu, however, the increase in TNFα was not statistically significant in either group. We conclude that the sampling procedure, if not carefully standardized, is a potential source of artifacts with regard to “systemic” TNFα levels. The high intra and inter-individual variability of plasma TNFα suggests that results of cross-sectional studies are questionable.

Detection of Charges and their Distribution on Dialysis Membranes with Cationic/Anionic Dyes Using Confocal Laser Scanning Microscopy

Methods for the detection of positive or negative charges on the surface of biomaterials/membranes and inside a membrane are important for the characterisation of such materials. We tested different dyes and optimized staining procedures. Under standardized conditions negatively charged membranes were stained with cationic triarylmethane compounds such as crystal violet and positively charged membranes with the anionic anthraquinone dye anthralan blue B. There was no staining of uncharged cellulose membranes. The applicability of these methods was demonstrated on membranes coated to varying degrees with charged compounds such as heparin, these changes in charge being detectible quantitatively by photometry. The distribution of charges inside a membrane was detected by optical sectioning across the stained (FITC labelled poly-L-lysine) membrane using confocal laser scanning microscopy (LSM). LSM offers a completely new application possibility in biomaterial and biocompatibility research.

Cellulose-Ester as Membrane Materials for Hemodialysis

The majority of dialysis membranes are fabricated from regenerated unmodified cellulose. This standard type of cellulosic membrane is frequently under attack because of its alleged lack of biocompatibility. Recent developments, however, have proven that a chemical modification of the reactive surface groups of regenerated cellulose, the hydroxylgroups, limits the complement-activating potential of these materials and thus improves its blood-compatibility. We extended the idea of modifying cellulose for improved blood-compatibility to a series of different cellulose esters. Special focus was directed towards the question whether a variation of the type of substituent and degree of substitution could influence the blood-compatibility pattern of these materials: the analysis of blood-compatibility profiles showed a direct dependency on the type of substituent and the degree of substitution (DS). As an example, it was found that the DS, necessary for a complete reduction of complement activation, decreases with increasing chain lengths of aliphatic substituents. Optimal degrees of substitution are characteristic of the type of substituents and enable us to tailor materials specifically for optimized blood compatibility.

Comparison of Hollow Fibre Membranes for Hepatocyte Immobilisation in Bioreactors

Various hollow fibre membranes of polyamide, cellulose and polypropylene were investigated as potential substrata for hepatocyte immobilisation in bioreactors for hybrid liver support systems. Membranes were subjected to a cytocompatibility test in which the attachment and morphology of primary hepatocytes were evaluated. The effect of coating with collagen and fibronectin was also studied. Adequate cell immobilisation was possible on polypropylene and polyamide membranes even without coating. The flattening process of the cells was dependent on the material and the coating. The incorporation of porous polypropylene and polyamide hollow fibres in hybrid liver cell bioreactors and their specific permeability properties could also offer means for cell oxygenation, metabolite distribution and immuno-isolation purposes.

Prediction of Cardiovascular Risk in Hemodialysis Patients by Data Mining

Objectives: The objective of this work was to contribute to the development, validation and application of data mining methods for prediction in decision support systems in medicine. The particular focus was on the prediction of cardiovascular risk factors in hemodialysis patients, specifically the interventricular septum (IVS) thickness of the heart of individual patients as an important quantitative indicator to diagnose left ventricular hypertrophy. The work was based on data from 63 long-term hemodialysis patients of the KfH Dialysis Centre in Jena, Germany.

Methods: The approach applied is based on data mining methods and involves four major steps: data based clustering, cluster based rule extraction, rulebase construction and cluster and rule based prediction. The methods employed include crisp and fuzzy algorithms. At each step, logical and medical validation of results was carried out. Different sets of randomly selected patient data were used to train, test and optimize the clusterbases and rulebases for prediction.

Results: Using the best clusterbase/rulebase combination designed, the IVS thickness cluster (‘small’ or ‘large’) was predicted correctly for 30 of the 35 patients with known IVS values in the training data set; no patient was predicted incorrectly and 5 were parity predicted. For the test data set, 4 of the 6 patients with known IVS values were predicted correctly, no patient incorrectly and 2 parity. These results did not substantially differ from those obtained using the second best clusterbase/rulebase combination which was finally recommended for use based on further performance criteria. The prediction of the IVS thickness clusters of the 22 patients with unknown IVS values also yielded good results that were (and could only be) validated by a medical individual risk assessment of these patients.

Conclusions: The approach applied proved successful for the cluster and rule based prediction of a quantitative variable, such as IVS thickness, for individual patients from other variables relevant to the problem. The results obtained demonstrate the high potential of the approach and the methods developed and validated to support decision-making in hemodialysis and other fields of medicine by individual risk prediction.

Agreement between 24-hour salt ingestion and sodium excretion in a controlled environment

Accurately collected 24-hour urine collections are presumed to be valid for estimating salt intake in individuals. We performed 2 independent ultralong-term salt balance studies lasting 105 (4 men) and 205 (6 men) days in 10 men simulating a flight to Mars. We controlled dietary intake of all constituents for months at salt intakes of 12, 9, and 6 g/d and collected all urine. The subjects' daily menus consisted of 27 279 individual servings, of which 83.0% were completely consumed, 16.5% completely rejected, and 0.5% incompletely consumed. Urinary recovery of dietary salt was 92% of recorded intake, indicating long-term steady-state sodium balance in both studies. Even at fixed salt intake, 24-hour urine collection for sodium excretion (UNaV) showed infradian rhythmicity. We defined a ±25 mmol deviation from the average difference between recorded sodium intake and UNaV as the prediction interval to accurately classify a 3-g difference in salt intake. Because of the biological variability in UNaV, only every other daily urine sample correctly classified a 3-g difference in salt intake (49%). By increasing the observations to 3 consecutive 24-hour collections and sodium intakes, classification accuracy improved to 75%. Collecting seven 24-hour urines and sodium intake samples improved classification accuracy to 92%. We conclude that single 24-hour urine collections at intakes ranging from 6 to 12 g salt per day were not suitable to detect a 3-g difference in individual salt intake. Repeated measurements of 24-hour UNaV improve precision. This knowledge could be relevant to patient care and the conduct of intervention trials.

Abstract 326: Salt Intake, Drinking Behavior, And The Body Corporate

Clinical practice and public health advice on salt consumption relies on the generally accepted notion that accurately collected 24-hour urine collections are valid estimates for salt and fluid intake. Reduced salt intake would also reduce thirst and ingestion of sugary drinks accordingly. To test these widely accepted ideas, we performed two independent ultra-long term salt balance studies lasting 105 and 205 days in 10 men simulating a flight to Mars. We fixed dietary intake of all constituents for months at salt intakes of 6, 9, and 12 grams per day and collected all urine. We controlled all environmental factors for rigorous quantitative comparison of urine volume and salt excretion with daily fluid and salt intake. In 1646 collected 24-hour urine samples, our ten subjects recovered 92% of salt they ingested. Due to infradian rhythmical renal salt excretion, only 781 out of 1646 daily urine samples correctly classified a 3 g difference in salt intake (47%). Reducing salt intake from 12 to 6 g reduced 24-hour cortisone excretion (78.3±19.6 vs. 67.2±19.3 μg/d; P<0.001) and increased water intake by 299 ml/d due to reduced glucocorticoid-driven metabolic water production. Even accurately collected 24-hour urine collections at intakes ranging from 6-12 grams salt per day provide no reliable information on individual salt intake. Reducing salt intake leads to reduced glucocorticoid levels decreased metabolic water production and a counterintuitive increase in fluid intake. Traditional views on fluid and electrolyte homeostasis may lead to misinterpretations in clinical practice, public health research, and policy-decision making.