Infrared spectroscopy in hemodialysis: reagent-free monitoring of patient detoxification by infrared spectroscopy

The Potential Use of Near- and Mid-Infrared Spectroscopy in Kidney Diseases

Traditional renal biomarkers such as serum creatinine and albuminuria/proteinuria are rather insensitive since they change later in the course of the disease. In order to determine the extent and type of kidney injury, as well as to administer the proper therapy and enhance patient management, new techniques for the detection of deterioration of the kidney function are urgently needed. Infrared spectroscopy is a label-free and non-destructive technique having the potential to be a vital tool for quick and inexpensive routine clinical diagnosis of kidney disorders. The aim of this review is to provide an overview of near- and mid-infrared spectroscopy applications in patients with acute kidney injury and chronic kidney disease (e.g., diabetic nephropathy and glomerulonephritis).

The Nephrologist's Role in the Collaborative Multi-Specialist Network Taking Care of Patients with Diabetes on Maintenance Hemodialysis: An Overview

Diabetes mellitus is the leading cause of renal failure in incident dialysis patients in several countries around the world. The quality of life for patients with diabetes in maintenance hemodialysis (HD) treatment is in general poor due to disease complications. Nephrologists have to cope with all these problems because of the “total care model” and strive to improve their patients’ outcome. In this review, an updated overview of the aspects the nephrologist must face in the management of these patients is reported. The conventional marker of glycemic control, hemoglobin A1c (HbA1c), is unreliable. HD itself may be responsible for dangerous hypoglycemic events. New methods of glucose control could be used even during dialysis, such as a continuous glucose monitoring (CGM) device. The pharmacological control of diabetes is another complex topic. Because of the risk of hypoglycemia, insulin and other medications used to treat diabetes may need dose adjustment. The new class of antidiabetic drugs dipeptidyl peptidase 4 (DPP-4) inhibitors can safely be used in non-insulin-dependent end-stage renal disease (ESRD) patients. Nephrologists should take care to improve the hemodynamic tolerance to HD treatment, frequently compromised by the high level of ultrafiltration needed to counter high interdialytic weight gain. Kidney and pancreas transplantation, in selected patients with diabetes, is the best therapy and is the only approach able to free patients from both dialysis and insulin therapy.

Distinguishing active from quiescent disease in ANCA-associated vasculitis using attenuated total reflection Fourier-transform infrared spectroscopy

The current lack of a reliable biomarker of disease activity in anti-neutrophil cytoplasmic autoantibody (ANCA) associated vasculitis poses a significant clinical unmet need when determining relapsing or persisting disease. In this study, we demonstrate for the first time that attenuated total reflection Fourier-transform infrared (ATR-FTIR) spectroscopy offers a novel and functional candidate biomarker, distinguishing active from quiescent disease with a high degree of accuracy. Paired blood and urine samples were collected within a single UK centre from patients with active disease, disease remission, disease controls and healthy controls. Three key biofluids were evaluated; plasma, serum and urine, with subsequent chemometric analysis and blind predictive model validation. Spectrochemical interrogation proved plasma to be the most conducive biofluid, with excellent separation between the two categories on PC2 direction (AUC 0.901) and 100% sensitivity (F-score 92.3%) for disease remission and 85.7% specificity (F-score 92.3%) for active disease on blind predictive modelling. This was independent of organ system involvement and current ANCA status, with similar findings observed on comparative analysis following successful remission-induction therapy (AUC > 0.9, 100% sensitivity for disease remission, F-score 75%). This promising technique is clinically translatable and warrants future larger study with longitudinal data, potentially aiding earlier intervention and individualisation of treatment.

Glucose tolerance in patients with and without type 2 diabetes mellitus during hemodialysis

AIMS

The disposal of a glucose bolus was studied to identify glucose metabolism in patients with and without type 2 diabetes mellitus (T2DM) during their regular hemodialysis (HD) treatment.

METHODS

Plasma glucose, insulin, and c-peptide concentrations were measured during a 60 min observation phase following a rapid glucose infusion (0.5 g/kg dry weight). Glucose disposition and elimination rates were determined from kinetic analysis, and insulinogenic index was calculated. Insulin resistance (R_HOMA) was determined by homeostatic model assessment (HOMA).

RESULTS

35 HD patients (14 with T2DM) distinguished by a higher age (median: 70 vs. 55 y, p < 0.01) in T2DM patients were studied. Glucose kinetic data showed only small differences between patients with or without T2DM, but as R_HOMA measured in all patients increased, a larger fraction of glucose was removed by the extracorporeal system (r = 0.430, p = 0.01). One hour after glucose bolus injection the glucose level was not different from that before HD also in patients with T2DM (p = 0.115).

CONCLUSIONS

The larger glucose amount recovered in dialysate in patients with increasing R_HOMA indicates that impaired glucose disposal could be measured during HD using a non-invasive dialysis quantification approach without blood sampling. Glucose infusion during HD is safe also in patients with T2DM.

Technology Innovations in Continuous Kidney Replacement Therapy: The Clinician's Perspective

Continuous kidney replacement therapy (CKRT) has improved remarkably since its first implementation as continuous arteriovenous hemofiltration in the 1970s. However, when looking at the latest generation of CKRT machines, one could argue that clinical deployment of breakthrough innovations by device manufacturers has slowed in the last decade. Simultaneously, there has been a steady accumulation of clinical knowledge using CKRT as well as a multitude of therapeutic and diagnostic innovations in the dialysis and broader intensive care unit technology fields adaptable to CKRT. These include multiple different anticlotting measures; cloud-computing for optimized treatment prescribing and delivered therapy data collection and analysis; novel blood purification techniques aimed at improving the severe multiorgan dysfunction syndrome; and real-time sensing of blood and/or filter effluent composition. The authors present a view of how CKRT devices and programs could be reimagined incorporating these innovations to achieve specific measurable clinical outcomes with personalized care and improved simplicity, safety, and efficacy of CKRT therapy.

Innovations in CKRT: individualized therapy with fewer complications

Continuous kidney replacement therapy (CKRT) can be a lifesaving intervention for critically ill patients; however, mortality remains high. The adaptation of existing innovations, including anti-clotting measures; cloud-computing for optimized treatment prescribing and therapy monitoring; and real-time sensing of blood and/or filter effluent composition to CKRT devices has the potential to enable personalized care and improve the safety and efficacy of this therapy.

Hemodialysis monitoring using mid- and near-infrared spectroscopy with partial least squares regression

Blood constituents such as urea, glucose, lactate, phosphate and creatinine are of high relevance in monitoring the process of detoxification in ambulant dialysis treatment. In the present work, 2 different vibrational spectroscopic techniques are used to determine those molecules quantitatively in artificial dialysate solutions. The goal of the study is to compare the performance of near-infrared (NIR) and mid-infrared (MIR) spectroscopy in hyphenation with partial least squares regression (PLSR) directly by using the same sample set. The results show that MIR spectroscopy is better suited to analyze the analytes of interest. Multilevel multifactor design is used to cover the relevant concentration variations during dialysis. MIR spectroscopy coupled to a multi reflection attenuated total reflection (ATR) cell enables reliable prediction of all target analytes. In contrast, the NIR spectroscopic method does not give access to all 5 components but only to urea and glucose. For both methods, coefficients of determination greater or equal to 0.86 can be achieved in the test-set validation process for urea and glucose. Lactate, phosphate and creatinine perform well in the MIR with R²  ≥ 0.95 using test-set validation.

IR-spectroscopy of skin in vivo: Optimal skin sites and properties for non-invasive glucose measurement by photoacoustic and photothermal spectroscopy

We have reported two methods to analyze glucose in the interstitial fluid of skin based on mid-infrared excitation with a tunable quantum cascade laser and photoacoustic or photothermal detection. These methods were evaluated for optimum skin locations to obtain reproducible glucose information. The lower part of the arm, the hypothenar, the tips of the index finger and the thumb were tested. The thumb appears to be the optimal skin location, followed by the index finger. Basic requirements for an optimum site are good capillary blood perfusion, low Stratum corneum thickness and the absence of fat layers. To obtain a correlation on such a site, spectra were recorded on volunteers continuously after blood glucose manipulation. However, continuous measurements on an in vivo sample such as the skin have to cope with physiological alterations such as the formation of sweat. We have used both detection schemes to investigate the acid mantle reformation after washing during time scales similar to continuous measurements for calibration spectra. We found that reconstitution of the acid mantle of skin may be seen in less than one hour. Precleaning of the measurement site may thus be useful for intermittent, but not for long term continuous measurements.

Applications of mid-infrared spectroscopy in the clinical laboratory setting

Fourier transform mid-infrared (MIR-FTIR) spectroscopy is a nondestructive, label-free, highly sensitive and specific technique that provides complete information on the chemical composition of biological samples. The technique both can offer fundamental structural information and serve as a quantitative analysis tool. Therefore, it has many potential applications in different fields of clinical laboratory science. Although considerable technological progress has been made to promote biomedical applications of this powerful analytical technique, most clinical laboratory analyses are based on spectroscopic measurements in the visible or ultraviolet (UV) spectrum and the potential role of FTIR spectroscopy still remains unexplored. In this review, we present some general principles of FTIR spectroscopy as a useful method to study molecules in specimens by MIR radiation together with a short overview of methods to interpret spectral data. We aim at illustrating the wide range of potential applications of the proposed technique in the clinical laboratory setting with a focus on its advantages and limitations and discussing the future directions. The reviewed applications of MIR spectroscopy include (1) quantification of clinical parameters in body fluids, (2) diagnosis and monitoring of cancer and other diseases by analysis of body fluids, cells, and tissues, (3) classification of clinically relevant microorganisms, and (4) analysis of kidney stones, nails, and faecal fat.

Infrared reflectometry of skin: Analysis of backscattered light from different skin layers

We have recently reported infrared spectroscopy of human skin in vivo using quantum cascade laser excitation and photoacoustic or photothermal detection for non-invasive glucose measurement . Here, we analyze the IR light diffusely reflected from skin layers for spectral contributions of glucose. Excitation of human skin by an external cavity tunable quantum cascade laser in the spectral region from 1000 to 1245cm^-1, where glucose exhibits a fingerprint absorption, yields reflectance spectra with some contributions from glucose molecules. A simple three-layer model of skin was used to calculate the scattering intensities from the surface and from shallow and deeper layers using the Boltzmann radiation transfer equation. Backscattering of light at wavelengths around 10μm from the living skin occurs mostly from the Stratum corneum top layers and the shallow layers of the living epidermis. The analysis of the polarization of the backscattered light confirms this calculation. Polarization is essentially unchanged; only a very small fraction (<3%) is depolarized at 90° with respect to the laser polarization set at 0°. Based on these findings, we propose that the predominant part of the backscattered light is due to specular reflectance and to scattering from layers close to the surface. Diffusely reflected light from deeper layers undergoing one or more scattering processes would appear with significantly altered polarization. We thus conclude that a non-invasive glucose measurement based on backscattering of IR light from skin would have the drawback that only shallow layers containing some glucose at concentrations only weakly related to blood glucose are monitored.

Direct wide-angle measurement of a photonic band structure in a three-dimensional photonic crystal using infrared Fourier imaging spectroscopy

We propose a method to directly visualize the photonic band-structure of micrometer-sized photonic crystals using wide-angle spectroscopy. By extending Fourier imaging spectroscopy sensitivity into the infrared range, we have obtained accurate measurements of the band structures along the high-symmetry directions (X-W-K-L-U) of polymeric three-dimensional, rod-connected diamond photonic crystals. Our implementation also allows us to record single-wavelength reflectance far-field patterns showing very good agreement with simulations of the same designs. This technique is suitable for the characterization of photonic structures working in the infrared and, in particular, to obtain band-structure information of complete photonic band gap materials.

Windowless ultrasound photoacoustic cell for in vivo mid-IR spectroscopy of human epidermis: low interference by changes of air pressure, temperature, and humidity caused by skin contact opens the possibility for a non-invasive monitoring of glucose in the interstitial fluid

The application of a novel open, windowless cell for the photoacoustic infrared spectroscopy of human skin is described. This windowless cavity is tuned for optimum performance in the ultrasound range between 50 and 60 kHz. In combination with an external cavity tunable quantum cascade laser emitting in the range from ~1000 cm(-1) to 1245 cm(-1), this approach leads to high signal-to-noise-ratio (SNR) for mid-infrared spectra of human skin. This opens the possibility to measure in situ the absorption spectrum of human epidermis in the mid-infrared region at high SNR in a few (~5) seconds. Rapid measurement of skin spectra greatly reduces artifacts arising from movements. As compared to closed resonance cells, the windowless cell exhibits the advantage that the influence of air pressure variations, temperature changes, and air humidity buildup that are caused by the contact of the cell to the skin surface can be minimized. We demonstrate here that this approach can be used for continuous and non-invasive monitoring of the glucose level in human epidermis, and thus may form the basis for a non-invasive monitoring of the glucose level for diabetes patients.

In vivo noninvasive monitoring of glucose concentration in human epidermis by mid-infrared pulsed photoacoustic spectroscopy

The noninvasive determination of glucose in the interstitial layer of the human skin by mid-infrared spectroscopy is reported. The sensitivity for this measurement was obtained by combining the high pulse energy from an external cavity quantum cascade laser (EC-QCL) tunable in the infrared glucose fingerprint region (1000-1220 cm(-1)) focused on the skin, with a detection of the absorbance process by photoacoustic spectroscopy in the ultrasound region performed by a gas cell coupled to the skin. This combination facilitates a quantitative measurement for concentrations of skin glucose in the range from <50 mg/dL to >300 mg/dL, which is the relevant range for the glucose monitoring in diabetes patients. Since the interstitial fluid glucose level is representative of the blood glucose level and follows it without significant delay (<10 min), this method could be applied to establish a noninvasive, painless glucose measurement procedure that is urgently awaited by diabetes patients. We report here the design of the photoacoustic experiments, the spectroscopy of glucose in vivo, and the calibration method for the quantitative determination of glucose in skin. Finally, a preliminary test with healthy volunteers and volunteers suffering from diabetes mellitus demonstrates the viability of a noninvasive glucose monitoring for patients based on the combination of infrared QCL and photoacoustic detection.