Nanoporous biomaterials for uremic toxin adsorption in artificial kidney systems: A review

In silico screening of nanoporous materials for urea removal in hemodialysis applications

The design of miniaturized hemodialysis devices, such as wearable artificial kidneys, requires regeneration of the dialysate stream to remove uremic toxins from water. Adsorption has the potential to capture such molecules, but conventional adsorbents have low urea/water selectivity. In this work, we performed a comprehensive computational study of 560 porous crystalline adsorbents comprising mainly covalent organic frameworks (COFs), as well as some siliceous zeolites, metal organic frameworks (MOFs) and graphitic materials. An initial screening using Widom insertion method assessed the excess chemical potential at infinite dilution for water and urea at 310 K, providing information on the strength and selectivity of urea adsorption. From such analysis it was observed that urea adsorption and urea/water selectivity increased strongly with fluorine content in COFs, while other compositional or structural parameters did not correlate with material performance. Two COFs, namely COF-F6 and Tf-DHzDPr were explored further through Molecular Dynamics simulations. The results agree with those of the Widom method and allow to identify the urea binding sites, the contribution of electrostatic and van der Waals interactions, and the position of preferential urea-urea and urea-framework interactions. This study paves the way for a well-informed experimental campaign and accelerates the development of novel sorbents for urea removal, ultimately advancing on the path to achieve wearable artificial kidneys.

Modeling and Validation of an Ultra-Compact Regenerative Liver Dialysis Device

The availability of a wearable artificial liver that facilitates extracorporeal dialysis outside of medical facilities would represent a significant advancement for patients requiring dialysis. The objective of this preliminary investigation is to explore, using validated mathematical models based on in vitro data, the feasibility of developing a novel, cost-effective, and highly compact extracorporeal liver support device that can be employed as a transitional therapy to transplantation outside of clinical settings. Such an innovation would offer substantial cost savings to the national healthcare system while significantly improving the patient's quality of life. The experimental components consisted of replacing traditional adsorbent materials with albumin-functionalized silica microspheres due to their capacity to adsorb bilirubin, one of the toxins responsible for liver failure. Two configurations of the dialysis module were tested: one involved dispersing the adsorbent particles in dialysis fluid, while the other did not require dialysis fluid. The results demonstrate the superior performance of the first configuration compared to the second. Although the clinical applicability of these models remains distant from the current stage, further studies will focus on optimizing these models to develop a more compact and wearable device.

Selectively mixed matrix hemodialysis membrane for adequate clearance of p-cresol by the incorporation of imprinted zeolite

The adequacy in uremic toxin removal upon hemodialysis treatment is essential in patients with kidney failure diseases as poor removal leads to heart failure, hypertension, and stroke. The combination of adsorption and diffusion processes has become very advantageous for hemodialysis membranes. By this mechanism, water-soluble uremic toxins (WSUTs) and protein-bounded uremic toxins (PBUTs) could be removed at one time. Therefore, this study aimed to develop a novel imprinted zeolite by p-cresol (IZC) and then incorporated it into polyethersulfone (PES) and poly(vinyl pyrrolidone) (PVP) to produce hollow fiber mixed matrix membrane (HF-MMM). The IZC proved to be sensitive in attracting the adsorbate, classifying it as having a strong adsorption behavior. Accordingly, IZC is very promising to be applied as an adsorbent in the hemodialysis treatment. In this study, IZC as p-cresol's adsorbent was incorporated into a PES-based polymeric membrane with a small addition of PVP to produce HF-MMM using a dry/wet spinning process. The effect of air gap distance between the spinneret and coagulant bath and percentage loading for PES, PVP, and IZC were studied and optimized to obtain the best performance of HF-MMM. The 40 cm of air gap distance, 16 wt% of PES, 2 wt% of PVP, and 1 wt% of IZC loading were able to produce a superior hemodialysis membrane. These optimized parameters showed sufficient uremic toxin removal, i.e., 60.74% of urea, 52.35% of p-cresol in the phosphate buffer saline solution, and 66.29% of p-cresol in bovine serum albumin solution for 4 h permeation using the dialysis system. These HF-MMMs also achieved pure water flux of 67.57 L m^-2 h^-1 bar^-1 and bovine serum albumin rejection of 95.05%. Therefore, this membrane has proven to be able to clean up WSUT and PBUT through a one-step process. Moreover, as compared to the neat PES membrane, MMM was able to remove p-cresol at 186.22 times higher capability.

Evaluation and characterization of starch nanoparticles for adsorption of urea from dialysates

Starch nanoparticles (SNPs) was produced from type-A, B and C native starches (corn, potato and Trichosanthes kirilowii pulp starches respectively), via the nanoprecipitation method. The SNPs showed different amylose contents, water contact angles, surface morphologies and urea clearance performances. In this work, to examine the parameters of SNPs that may change the urea adsorption capacity, urea adsorption performance in adsorption environments with different pH values, urea concentrations, and adsorption times was examined. Thereafter, the characteristics of SNPs were tested by water contact angle measurements (WCA), transmission electron microscopy, specific surface area measurements, gel permeation chromatography, and zeta potential analysis. The results showed that the Trichosanthes kirilowii pulp (C) SNPs show better adsorption than the corn (A) and potato (B) SNPs. The hydrophobicity of SNPs promotes the urea adsorption of the SNPs. Using grey relational analysis, it was found that WCA and Mn are the critical parameter affecting the adsorption performance, with WCA and Mn within the ranges of 31-33° and 1900-2100 kDa, respectively, were found to be the conditions for optimal urea adsorption.

Removal of Uremic Solutes from Dialysate by Activated Carbon

BACKGROUND AND OBJECTIVES

Adsorption of uremic solutes to activated carbon provides a potential means to limit dialysate volumes required for new dialysis systems. The ability of activated carbon to take up uremic solutes has, however, not been adequately assessed.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Graded volumes of waste dialysate collected from clinical hemodialysis treatments were passed through activated carbon blocks. Metabolomic analysis assessed the adsorption by activated carbon of a wide range of uremic solutes. Additional experiments tested the ability of the activated carbon to increase the clearance of selected solutes at low dialysate flow rates.

RESULTS

Activated carbon initially adsorbed the majority, but not all, of 264 uremic solutes examined. Solute adsorption fell, however, as increasing volumes of dialysate were processed. Moreover, activated carbon added some uremic solutes to the dialysate, including methylguanidine. Activated carbon was particularly effective in adsorbing uremic solutes that bind to plasma proteins. In vitro dialysis experiments showed that introduction of activated carbon into the dialysate stream increased the clearance of the protein-bound solutes indoxyl sulfate and p-cresol sulfate by 77%±12% (mean±SD) and 73%±12%, respectively, at a dialysate flow rate of 200 ml/min, but had a much lesser effect on the clearance of the unbound solute phenylacetylglutamine.

CONCLUSIONS

Activated carbon adsorbs many but not all uremic solutes. Introduction of activated carbon into the dialysate stream increased the clearance of those solutes that it does adsorb.

Improving Solute Clearances by Hemodialysis

The adequacy of hemodialysis is now assessed by measuring the removal of the single-solute urea. The urea clearance provided by contemporary dialysis is a large fraction of the blood flow through the dialyzer and therefore cannot be increased much further. Other solutes however likely contribute more than urea to the residual uremic illness suffered by hemodialysis patients. We here review methods which could be employed to increase the clearance of nonurea solutes. We will separately consider the clearances of free low-molecular-mass solutes, free larger solutes, and protein-bound solutes. New clinical studies will be required to test the extent to which increasing the clearance on nonurea solutes with these various characteristics can improve patients' health.

Strategies for optimizing urea removal to enable portable kidney dialysis: A reappraisal

BACKGROUND

Portable hemodialysis has the potential to improve health outcomes and quality of life for patients with kidney failure at reduced costs. Urea removal, required for dialysate regeneration, is a central function of any existing/potential portable dialysis device. Urea in the spent dialysate coexists with non-urea uremic toxins, nutrients, and electrolytes, all of which will interfere with the urea removal efficiency, regardless of whether the underlying urea removal mechanism is based on urease conversion, direct urea adsorption, or oxidation. The aim of the current review is to identify the amount of the most prevalent chemicals being removed during a single dialysis session and evaluate the potential benefits of an urea-selective membrane for portable dialysis.

METHODS

We have performed a literature search using Web of Science and PubMed databases to find available articles reporting (or be able to calculate from blood plasma concentration) > 5 mg of individually quantified solutes removed during thrice-weekly hemodialysis sessions. If multiple reports of the same solute were available, the reported values were averaged, and the geometric mean of standard deviations was taken. Further critical literature analysis of reported dialysate regeneration methods was performed using Web of Science and PubMed databases.

RESULTS

On average, 46.0 g uremic retention solutes are removed in a single conventional dialysis session, out of which urea is only 23.6 g. For both urease- and sorbent-based urea removal mechanisms, amino acids, with 7.7 g removal per session, could potentially interfere with urea removal efficiency. Additionally for the oxidation-based urea removal system, plentiful nutrients such as glucose (24.0 g) will interfere with urea removal by competition. Using a nanofiltration membrane between dialysate and oxidation unit with a molecular weight cutoff (MWCO) of ~200 Da, 67.6 g of non-electrolyte species will be removed in a single dialysis session, out of which 44.0 g are non-urea molecules. If the membrane MWCO is further decreased to 120 Da, the mass of non-electrolyte non-urea species will drop to 9.3 g. Reverse osmosis membranes have been shown to be both effective at blocking the transport of non-urea species (creatinine for example with ~90% rejection ratio), and permissive for urea transport (~20% rejection ratio), making them a promising urea selective membrane to increase the efficiency of the oxidative urea removal system.

CONCLUSIONS

Compiled are quantified solute removal amounts greater than 5 mg per session during conventional hemodialysis treatments, to act as a guide for portable dialysis system design. Analysis shows that multiple chemical species in the dialysate interfere with all proposed portable urea removal systems. This suggests the need for an additional protective dialysate loop coupled to urea removal system and an urea-selective membrane.

Dialysis Membranes for Acute Kidney Injury

Mortality and morbidity rates among critically ill septic patients having acute kidney injury (AKI) are very high, considering the total number of deaths after their admission. Inappropriate selection of the type of continuous renal replacement therapy and inadequate therapy become the immediate causes of these issues. Dialysis is a commonly used treatment intended to prolong the life of AKI patients. Dialysis membranes, which are the core of dialysis treatment, must be properly selected to ensure fair treatment to the patients. The accumulation of certain types of molecules must be dealt with using the right membrane. Whether it is low-flux, high-flux, or adsorptive type, the dialysis membrane should be chosen depending on the condition of the patients. The selection of dialysis membranes should also be based on their effect on the treatment outcomes and well-being. All these options are needed to serve the patients of different clinical settings. The use of dialysis membranes is not restricted to conventional haemodialysis, but rather they can be employed in haemoperfusion, haemofiltration, haemodiafiltration, or a combination of any two of them. This review focuses in-depth on different types of dialysis membranes, their characteristics, and approaches in addressing the issues encountered in patients having AKI with sepsis and/or multiorgan failure in intensive care units.

Recent trends in therapeutic application of engineered blood purification materials for kidney disease

Blood purification is a commonly used method to remove excess metabolic waste in the blood in renal replacement therapy. The sufficient removal of these toxins from blood can reduce complications and improve survival lifetime in dialysis patients. However, the current biological blood purification materials in clinical practice are not ideal, where there is an unmet need for producing novel materials that have better biocompatibility, reduced toxicity, and, in particular, more efficient toxin clearance rates and a lower cost of production. Given this, this review has carefully summarized newly developed engineered different structural biomedical materials for blood purification in terms of types and structure characteristics of blood purification materials, the production process, as well as interfacial chemical adsorption properties or mechanisms. This study may provide a valuable reference for fabricating a user-friendly purification device that is more suitable for clinical blood purification applications in dialysis patients.

Improving Clearance for Renal Replacement Therapy

The adequacy of hemodialysis is now assessed by measuring the removal of a single solute, urea. The urea clearance provided by current dialysis methods is a large fraction of the blood flow through the dialyzer, and, therefore, cannot be increased much further. However, other solutes, which are less effectively cleared than urea, may contribute more to the residual uremic illness suffered by patients on hemodialysis. Here, we review a variety of methods that could be used to increase the clearance of such nonurea solutes. New clinical studies will be required to test the extent to which increasing solute clearances improves patients' health.

Blood Oxygenation Using Fluoropolymer-Based Artificial Lung Membranes

Artificial lung (AL) membranes are used for blood oxygenation for patients undergoing open-heart surgery or acute lung failures. Current AL technology employs polypropylene and polymethylpentene membranes. Although effective, these membranes suffer from low biocompatibility, leading to undesired blood coagulation and hemolysis over a long term. In this work, we propose a new generation of AL membranes based on amphiphobic fluoropolymers. We employed poly(vinylidene-co-hexafluoropropylene), or PVDF-co-HFP, to fabricate macrovoid-free membranes with an optimal pore size range of 30-50 nm. The phase inversion behavior of PVDF-co-HFP was investigated in detail for structural optimization. To improve the wetting stability of the membranes, the fabricated membranes were coated using Hyflon AD60X, a type of fluoropolymer with an extremely low surface energy. Hyflon-coated materials displayed very low protein adsorption and a high contact angle for both water and blood. In the hydrophobic spectrum, the data showed an inverse relationship between the surface free energy and protein adsorption, suggesting an appropriate direction with respect to biocompatibility for AL research. The blood oxygenation performance was assessed using animal sheep blood, and the fabricated fluoropolymer membranes showed competitive performance to that of commercial polyolefin membranes without any detectable hemolysis. The data also confirmed that the bottleneck in the blood oxygenation performance was not the membrane permeance but rather the rate of mass transfer in the blood phase, highlighting the importance of efficient module design.

Adsorption of Uremic Toxins Using Ti3C2Tx MXene for Dialysate Regeneration

The COVID-19 pandemic has become a major worldwide crisis. Although respiratory symptoms are a key feature of the disease, many people who are hospitalized with COVID-19 also suffer acute kidney injury, a condition that exacerbates patient mortality and may have to be treated through renal replacement therapy. Much of the focus on hospital capacity during the pandemic has centered on the availability of ventilators. However, supplies for dialysis treatment, including dialysate, have also run dangerously low in hospitals at the epicenter of the pandemic. Therefore, there is an urgent need to develop materials that can efficiently and rapidly regenerate dialysate, removing toxins and restoring electrolyte concentrations so that this vital resource remains readily available. In this work, Ti3C2Tx, a two-dimensional transition-metal carbide (MXene) that is known to efficiently adsorb urea, was used to remove creatinine and uric acid from an aqueous solution and dialysate, with a maximum adsorption capacity of 45.7 and 17.0 mg/g, respectively. We systematically analyzed and modeled the adsorption kinetics, isotherms, and thermodynamics, thus determining the rate-limiting step and adsorption mechanism. A fixed-bed column loaded with Ti3C2Tx was designed to further evaluate the adsorption performance under continuous fluid-flow conditions, mirroring conditions of continuous renal replacement therapy modalities. The maximum capacity and 50% breakthrough volume were calculated to further approach the practical application of Ti3C2Tx for removal of uremic toxins. Our findings suggest that Ti3C2Tx has the potential to be used as an efficient sorbent for the regeneration of dialysate, allowing for accelerated dialysate regeneration by removing filtered toxins and leading to more portable dialysis devices.

Zeolites for theranostic applications

Theranostic platforms bring about a revolution in disease management. During recent years, theranostic nanoparticles have been utilized for imaging and therapy simultaneously. Zeolites, because of their porous structure and tunable properties, which can be modified with various materials, can be used as a delivery agent. The porous structure of a zeolite enables it to be loaded and unloaded with various molecules such as therapeutic agents, photosensitizers, biological macromolecules, MRI contrast agents, radiopharmaceuticals, near-infrared (NIR) fluorophores, and microbubbles. Furthermore, theranostic zeolite nanocarriers can be further modified with targeting ligands, which is highly interesting for targeted cancer therapies.

Urea removal strategies for dialysate regeneration in a wearable artificial kidney

The availability of a wearable artificial kidney (WAK) that provides dialysis outside the hospital would be an important advancement for dialysis patients. The concept of a WAK is based on regeneration of a small volume of dialysate in a closed-loop. Removal of urea, the primary waste product of nitrogen metabolism, is the major challenge for the realization of a WAK since it is a molecule with low reactivity that is difficult to adsorb while it is the waste solute with the highest daily molar production. Currently, no efficient urea removal technology is available that allows for miniaturization of the WAK to a size and weight that is acceptable for patients to carry. Several urea removal strategies have been explored, including enzymatic hydrolysis by urease, electro-oxidation and sorbent systems. However, thus far, these methods have toxic side effects, limited removal capacity or slow removal kinetics. This review discusses different urea removal strategies for application in a wearable dialysis device, from both a chemical and a medical perspective.

Feasibility of osmotic dilution for recycling spent dialysate: Process performance, scaling, and economic evaluation

Hemodialysis is one of the therapies for patients with kidney failure. Hemodialysis requires large amounts of pure water, and is one of the most water-hungry medical procedures, and thus represents a clear opportunity where improvements should be made concerning the consumption and wastage of water. In this paper, we explored the potential of forward osmosis (FO) membrane for recycling the spent dialysate using the dialysis concentrate as the draw solution. Partially diluted dialysis concentrate could be further diluted with pure water to form dialysate for further dialysis process. Using commercial cellulose triacetate (CTA) FO membranes, the water recovery of approximately 64% was achieved and the final volume of the partially diluted dialysis concentrate was about four times the initial volume. Flux decline of the FO process was observed, mainly due to concentration of synthetic spent dialysate and dilution of dialysis concentrate, while membrane scaling had little impact on the flux decline. The urea rejection was found to be relatively low owing to the small size and electroneutral nature of the urea molecule. Obvious membrane scaling was observed after three FO cycles. The energy dispersive spectroscopy analysis of the scaling layer indicated that the scalants were phosphates and carbonates. The scaling was removed via osmotic backwash and almost completely recovery of FO flux was obtained. Economic analysis showed that the centralized treatment of spent dialysate in a dialysis center using the proposed osmotic dilution process could greatly save water resources and cost. Improving the urea rejection of FO membrane was identified as an important research focus for future research on the potential application of FO technology for recycling the spent dialysate in hemodialysis.

Preparation of Lotus Root-Type Monolithic-Activated Carbons with an Hierarchical Pore Structure from Rice Husks and Their Adsorption of Vitamin B12

Activated carbon is widely used in many fields because of its well-developed pore structure. Especially in hemoperfusion, activated carbon beads derived from macroporous resin spheres are the predominant adsorbents in hemoditoxifiers. In comparison, biomass-activated carbon attracts more extensive attention on account of its renewability and environmental protection. In this study, a lotus root-type monolithic-activated carbon with a hierarchical pore structure was made from rice husks by the injection molding process followed by carbonization and activation. The straight square channels with the side length of about 1.3 mm were designable, and these channels with adjustable lengths were favorable for the fluid flow during blood purification compared with the tightly packed carbon beads in commercialized hemoditoxifiers. Complementally, the hierarchical nano-sized pores in the walls of the big channels would contribute much to the adsorption capacity for the monolith. Specifically, the adsorption of vitamin B12, a representative of middle molecular toxins in human blood, was about 3.7 mg g^-1, which was acquired by simulated in vitro hemoperfusion tests and this demonstrated the promising application of the lotus root-type biomass-activated carbon in hemoperfusion.

Producing hybrid nanofiber-based on /PAN/Fe3 O4 /zeolite/nettle plant extract/urease and a deformed coaxial natural polymer to reduce toxicity materials in the blood of dialysis patients

On incidence of kidney failure, the concentration of urea increases and there is need for patients to visit the hospital all through the week for blood purification. However, current hemodialysis has been found to reduce only 66-75% urea in the blood of patients. The main goal of this article is to observe the effect of biocompatible and high mechanical hemodiafiltration in reducing urea and creatinine within the shortest time frame, using two methods of Nano electrospinning fiber (hybrid and coaxial). Hybrid electrospinning was made by zeolite 940-HOA(beta), Fe₃ O₄ , polyacrylonitrile as well as the addition of nettle plant's leaf extract. Dispersing solution and enzymes were added to two different syringes and was used in making hybrid nanofibers by the electrospinning process. Nessler's Reagent adsorption method was used for measuring the concentration of ammonia after urease enzyme activation. Second coaxial filter was made by the core-shell electrospinning system and cellulose acetate phthalate (CAP) as well as polyurethane (PU) were utilized. The data show hybrid hemodiafiltration with enzyme coating, decomposed urea and enzymes were activated for two days after electrospinning. The core-shell filtration can also reduce creatinine. Core-shell CAP-PU nanofiber was previously used for intravaginal drug delivery and PU was used as an artificial renal microfluidic chip. Thus, our study focused on using CAP-PU to reduce creatinine in dialysis patients. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 107A: 1736-1743, 2019.

Physicochemical evaluation and in vitro hemocompatibility study on nanoporous hydroxyapatite

Hydroxyapatite is an ideal biomaterial for bone tissue engineering due to its biocompatibility and hemocompatibility which have been widely studied by many researchers. The incorporation of nanoporosity into hydroxyapatite could transform the biomaterial into an effective adsorbent for uremic toxins removal especially in artificial kidney system. However, the effect of nanoporosity incorporation on the hemocompatibility of hydroxyapatite has yet to be answered. In this study, nanoporous hydroxyapatite was synthesized using hydrothermal technique and its hemocompatibility was determined. Non-ionic surfactants were used as soft templates to create porosity in the hydroxyapatite. The presence of pure hydroxyapatite phase in the synthesized samples is validated by X-ray diffraction analysis and Fourier transform infrared spectroscopy. The TEM images show that the hydroxyapatite formed rod-like particles with the length of 21-90 nm and diameter of 11-70 nm. The hydroxyapatite samples exhibit BET surface area of 33-45 m² g^-1 and pore volume of 0.35-0.44 cm³ g^-1. The hemocompatibility of the hydroxyapatite was determined via hemolysis test, platelet adhesion, platelet activation and blood clotting time measurement. The nanoporous hydroxyapatite shows less than 5% hemolysis, suggesting that the sample is highly hemocompatible. There is no activation and morphological change observed on the platelets adhered onto the hydroxyapatite. The blood clotting time demonstrates that the blood incubated with the hydroxyapatite did not coagulate. This study summarizes that the synthesized nanoporous hydroxyapatite is a highly hemocompatible biomaterial and could potentially be utilized in biomedical applications.

A double-lyophilization method for the preparation of CS/GO-COOH scaffold and its application in blood detoxification

The accumulation of uremic toxins in blood might induce chronic renal failure (CRF). The incidence of CRF was as high as 10%. The traditional therapy for CRF was hemodialysis, which was more effective to remove small molecules, such as urea and creatinine. However, this detoxification method ignored the tissue functional adaption due to the retention of macromolecule uremic toxins. To solve this problem, this paper developed a new kind of chitosan/carboxyl graphite oxide (CS/GO-COOH) scaffold via a double-lyophilization method. Then, this synthetic scaffold was characterized by Fourier transform infrared spectroscopy, scanning electron microscope, hydrophilic test, mechanical property, and in vitro detoxification test. Covalent bonding and hydrogen bonding were formed, indicating the strong interactions between CS and GO-COOH. There were interconnected networks in the synthesized scaffold. The mechanical test suggested that the GO-2500 scaffold had excellent mechanical strength, which was 7.41 ± 0.82 MPa with 25% shrink. What is more, GO-2500 could totally rebound within 1s, after compressed to 90% shrink. The rates of GO-2500 were 1587 ± 60 and 246 ± 10% according to the water uptake and retention data, respectively. Furthermore, the detoxification of GO-2500 to urea, creatinine, VB₁₂, and β₂-m were 67.59 ± 2.31, 39.67 ± 2.95, 31.51 ± 2.62, and 83.82 ± 7.76 mg/g, respectively. The resulting CS/GO-COOH scaffold held great potential for the detoxification of uremic toxins.