Reconsidering adsorption in hemodialysis: is it just an epiphenomenon? A narrative review

Dialysis nanocomposite membranes based on carbon nanoforms inhibiting blood plasma protein adsorption

BACKGROUND

Protein adsorption on medical devices in contact with blood is a significant issue during renal replacement therapy. Main forces determining fouling are the electrostatic interactions between membrane and charged protein, but the dialysis membrane surface charges can be adjusted by modifying the polymer matrix to decrease the blood plasma protein adsorption.

METHODS

In this study, polysulfone membranes (PSU) were modified by incorporation of carbon nanoparticles such as: multiwall carbon nanotubes (2 wt.% MWCNT), graphene oxide (1 wt.% GO), and graphite (5 wt.% GR) during manufacturing process (nonsolvent-induced phase separation, NIPS). The PSU flat sheet membrane was the reference sample.

RESULTS

Observed morphology of nanocomposite membranes was similar (SEM imaging); all of them had finger-like pore structure with unimodal distribution of pore size and similar skin-to-support ratio (1:3). The carbon nanoadditives also influenced the surface wettability: hydrophobicity and surface free energy of membranes increased (polar components of energy were reduced, while the dispersive components were increased).

CONCLUSION

The surface charge of nanocomposite membranes increased, when the polymer matrix has been modified with CNT or GR. This significantly affects the adsorption of proteins such as chicken (CSA) and bovine serum albumin (BSA) and reduces blood clotting on the membrane.

Hemodiafiltration with endogenous reinfusion of the regenerated ultrafiltrate (HFR): towards a convective, diffusive, and adsorptive dialysis

Hemodiafiltration with endogenous reinfusion of the ultrafiltrate (HFR) is a dialysis technique characterized by a resin cartridge with adsorptive properties that combines the mechanisms of diffusion, convection, and adsorption in a single therapeutic regimen. After nearly 20 years of clinical experience with HFR, this article reviews the accumulated evidence with this technique, considering whether adsorption reduction, as a third purification mechanism, should be the next step in the treatment of hemodialysis patients. HFR, beyond producing an extensive removal of uremic toxins, has demonstrated to reduce the loss of nutrients and other physiological components during the dialysis session as compared to online hemodiafiltration, ameliorating the inflammatory state and oxidative stress in this population. In addition to its ease of use, the technique is also highly biocompatible and can be used in patients with a compromised vascular access. Based on these observations, HFR appears to be an especially useful therapy for high-comorbidity patients, including those with frailty, malnutrition, or cardiovascular disease. In this review, we, as a consensus panel of nephrologists experienced with HFR, survey existing literature and summarize our views on when to use this technique, which patients may be best suited for HFR, and how to effectively prescribe and monitor this modality of dialysis in daily clinical practice.

Biocompatibility of Surface-Modified Membranes for Chronic Hemodialysis Therapy

Hemodialysis is a life-sustaining therapy for millions of people worldwide. However, despite considerable technical and scientific improvements, results are still not fully satisfactory in terms of morbidity and mortality. The membrane contained in the hemodialyzer is undoubtedly the main determinant of the success and quality of hemodialysis therapy. Membrane properties influence solute removal and the interactions with blood components that define the membrane’s biocompatibility. Bioincompatibility is considered a potential contributor to several uremic complications. Thus, the development of more biocompatible polymers used as hemodialyzer membrane is of utmost importance for improving results and clinical patient outcomes. Many different surface-modified membranes for hemodialysis have been manufactured over recent years by varying approaches in the attempt to minimize blood incompatibility. Their main characteristics and clinical results in hemodialysis patients were reviewed in the present article.

Targeting Cytokines, Pathogen-Associated Molecular Patterns, and Damage-Associated Molecular Patterns in Sepsis via Blood Purification

Sepsis is characterized by a dysregulated immune response to infections that causes life-threatening organ dysfunction and even death. When infections occur, bacterial cell wall components (endotoxin or lipopolysaccharide), known as pathogen-associated molecular patterns, bind to pattern recognition receptors, such as toll-like receptors, to initiate an inflammatory response for pathogen elimination. However, strong activation of the immune system leads to cellular dysfunction and ultimately organ failure. Damage-associated molecular patterns (DAMPs), which are released by injured host cells, are well-recognized triggers that result in the elevation of inflammatory cytokine levels. A cytokine storm is thus amplified and sustained in this vicious cycle. Interestingly, during sepsis, neutrophils transition from powerful antimicrobial protectors into dangerous mediators of tissue injury and organ dysfunction. Thus, the concept of blood purification has evolved to include inflammatory cells and mediators. In this review, we summarize recent advances in knowledge regarding the role of lipopolysaccharides, cytokines, DAMPs, and neutrophils in the pathogenesis of sepsis. Additionally, we discuss the potential of blood purification, especially the adsorption technology, for removing immune cells and molecular mediators, thereby serving as a therapeutic strategy against sepsis. Finally, we describe the concept of our immune-modulating blood purification system.