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Janssens FV, Meijers B, François K. Avoiding Systemic Heparinization During Hemodialysis: How the Dialysis Setup Might Help. Semin Nephrol 2023; 43:151483. [PMID: 38220473 DOI: 10.1016/j.semnephrol.2023.151483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Heparin is the most widely used anticoagulant for maintaining patency of the extracorporeal blood circuit during intermittent hemodialysis. Inadvertently, this leads to systemic heparinization of the patient. Repeated intermittent heparinization during hemodialysis has been associated with increased bleeding risks and metabolic and immunologic effects. Alternative strategies for minimizing systemic anticoagulation encompass dilution methods, regional citrate anticoagulation, priming of the extracorporeal circuit, and modifications to dialyzer membranes and dialysate composition. The effectiveness of these alternatives in maintaining patency of the extracorporeal circuit varies substantially. Although most studies have focused on particular changes in the hemodialysis setup, several combined interventions for adapting the hemodialysis setup are now being studied. This narrative review aims to present an overview of the current landscape of hemodialysis setup strategies aimed at limiting or avoiding systemic anticoagulation during treatment. Additionally, this review intends to shed light on the underlying pathophysiological mechanisms that contribute to variations observed in reported outcomes.
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Affiliation(s)
- Florine V Janssens
- Department of Nephrology and Arterial Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Björn Meijers
- Laboratory of Nephrology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; Nephrology Unit, University Hospitals Leuven, Leuven, Belgium
| | - Karlien François
- Department of Nephrology and Arterial Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium.
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2
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Kawanishi H, Koremoto M, Franssen CFM, van Londen M. Clotting Propensity of Surface-Treated Membranes in a Hemodialysis Set-up That Avoids Systemic Anticoagulation. Semin Nephrol 2023; 43:151482. [PMID: 38262850 DOI: 10.1016/j.semnephrol.2023.151482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
The development of biocompatible membranes, aiming to limit the inflammatory response, oxidative stress, and coagulability during hemodialysis, has been an important step in reducing dialysis-related adverse outcomes. This includes a reduction in the risk of clotting of the extracorporeal circuit, thus enabling hemodialysis with a reduced dose or even without systemic anticoagulant drugs in patients with an increased bleeding risk. In this article, we summarize the in vitro research and clinical evidence on the antithrombotic properties of vitamin E- and heparin-coated membranes.
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Affiliation(s)
| | | | - Casper F M Franssen
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
| | - Marco van Londen
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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3
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Vanommeslaeghe F, Van Biesen W, François K. Detection and Scoring of Extracorporeal Circuit Clotting During Hemodialysis. Semin Nephrol 2023; 43:151474. [PMID: 38267348 DOI: 10.1016/j.semnephrol.2023.151474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Maintaining patency of the extracorporeal hemodialysis (HD) circuit is a prerequisite to perform HD. Unfractionated heparin and low-molecular-weight heparins are the most used anticoagulants in maintenance HD, but their administration comes with a major trade-off of bleeding complications. This narrative review article discusses technical factors impacting on HD circuit patency, such as tubings, dialyzer membranes, priming practices, and treatment settings. Strategies for monitoring extracorporeal circuit clotting during and after treatment are also reviewed, as these are essential tools for optimizing anticoagulation.
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Affiliation(s)
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, Gent, Belgium
| | - Karlien François
- Department of Nephrology and Arterial Hypertension, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
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4
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Li Y, Luo X, Yang M, Su B. Alleviation of Oxidative Stress during Hemodialysis Sessions by Hemodialysis Membrane Innovation: A Multidisciplinary Perspective. Blood Purif 2023; 52:905-916. [PMID: 37748453 DOI: 10.1159/000533656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/11/2023] [Indexed: 09/27/2023]
Abstract
Oxidative stress is prevalent in end-stage kidney disease patients receiving chronic hemodialysis and is associated with heavy cardiovascular disease burdens and increased mortality risks. Hemoincompatible hemodialysis membranes per se contribute to the activation of oxidative reactions and the generation of oxygen free radicals. Since the early 1990s, vitamin E-coated membranes have been extensively used in hemodialysis patients to reduce oxidative stress during hemodialysis sessions. However, the beneficial effects of vitamin E-coated membranes versus unmodified synthetic membranes on long-term patient-centered outcomes, such as survival, quality of life, and prevalence of cardiovascular diseases, remain controversial. Accordingly, novel antioxidant hemodialysis membranes were prepared to replace the use of vitamin E-coated membranes despite the translational research on these membranes unfortunately coming to a standstill. In this review, we first summarize the state-of-the-art on the use of vitamin E-coated membranes in hemodialysis patients to highlight their strengths and limitations. Then, we discuss the latest advances in fabricating antioxidant hemodialysis membranes and provide perspectives to bridge knowledge gaps between laboratorial investigations and clinical practice in fabricating antioxidant hemodialysis membranes.
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Affiliation(s)
- Yupei Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China,
| | - Xinyao Luo
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Mei Yang
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, China
- Department of Nephrology, The First People's Hospital of Shuangliu District, Chengdu, China
| | - Baihai Su
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
- Med-X Center for Materials, Sichuan University, Chengdu, China
- Med+ Biomaterial Institute of West China Hospital, Sichuan University, Chengdu, China
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5
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Kalugin D, Bahig J, Shoker A, Abdelrasoul A. Heparin-Immobilized Polyethersulfone for Hemocompatibility Enhancement of Dialysis Membrane: In Situ Synchrotron Imaging, Experimental, and Ex Vivo Studies. MEMBRANES 2023; 13:718. [PMID: 37623779 PMCID: PMC10456935 DOI: 10.3390/membranes13080718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/26/2023]
Abstract
The goal of the current study is to enhance the hemocompatibility of polyethersulfone (PES) membranes using heparin immobilization. Heparin was immobilized covalently and via electrostatic interaction with the positively charged PES surface (pseudo-zwitterionic (pZW) complex) to investigate the influence of each method on the membrane hemocompatibility. In situ synchrotron radiation micro-computed tomography (SR-µCT) imaging, available at the Canadian Light Source (CLS), was used to critically assess the fibrinogen adsorption to the newly synthesized membranes qualitatively and quantitatively using an innovative synchrotron-based X-ray tomography technique. The surface roughness of the synthesized membranes was tested using atomic force microscopy (AFM) analysis. The membrane hemocompatibility was examined through the ex vivo clinical interaction of the membranes with patients' blood to investigate the released inflammatory biomarkers (C5a, IL-1α, IL-1β, IL-6, vWF, and C5b-9). The presence and quantitative analysis of a stable hydration layer were assessed with DSC analysis. Surface modification resulted in reduced surface roughness of the heparin-PES membrane. Both types of heparin immobilization on the PES membrane surface resulted in a decrease in the absolute membrane surface charge from -60 mV (unmodified PES) to -13 mV for the pZW complex and -9.16 mV for the covalently attached heparin, respectively. The loss of human serum fibrinogen (FB) was investigated using UV analysis. The PES membrane modified with the heparin pseudo-ZW complex showed increased FB retention (90.5%), while the unmodified PES membrane and the heparin covalently attached PES membrane exhibited approximately the same level of FB retention (81.3% and 79.8%, respectively). A DSC analysis revealed an improvement in the content of the hydration layer (32% of non-freezable water) for the heparin-coated membranes compared to the unmodified PES membrane (2.84%). An SR-µCT analysis showed that the method of heparin immobilization significantly affects FB adsorption distribution across the membrane thickness. A quantitative analysis using SR-µCT showed that when heparin is attached covalently, FB tends to be deposited inside the membrane pores at the top (layer index 0-40) membrane regions, although its content peak distribution shifted to the membrane surface, whereas the unmodified PES membrane holds 90% of FB in the middle (layer index 40-60) of the membrane. The ex vivo hemocompatibility study indicates an improvement in reducing the von Willebrand factor (vWF) for the heparin pseudo-ZW PES membrane compared to the covalently attached heparin and the untreated PES.
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Affiliation(s)
- Denis Kalugin
- Department of Chemical and Biological Engineering, University of Saskatchewan, 57 Campus Drive, Saskatoon, SK S7N 5A9, Canada
| | - Jumanah Bahig
- Division of Biomedical Engineering, University of Saskatchewan, 57 Campus Drive, Saskatoon, SK S7N 5A9, Canada
- Kinesiology, University of Saskatchewan, 87 Campus Drive, Saskatoon, SK S7N 5B, Canada
| | - Ahmed Shoker
- Nephrology Division, College of Medicine, University of Saskatchewan, 107 Wiggins Rd, Saskatoon, SK S7N 5E5, Canada
- Saskatchewan Transplant Program, St. Paul’s Hospital, 1702 20th Street West, Saskatoon, SK S7M 0Z9, Canada
| | - Amira Abdelrasoul
- Department of Chemical and Biological Engineering, University of Saskatchewan, 57 Campus Drive, Saskatoon, SK S7N 5A9, Canada
- Division of Biomedical Engineering, University of Saskatchewan, 57 Campus Drive, Saskatoon, SK S7N 5A9, Canada
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6
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Vitamin E (Alpha-Tocopherol) Metabolism and Nutrition in Chronic Kidney Disease. Antioxidants (Basel) 2022; 11:antiox11050989. [PMID: 35624853 PMCID: PMC9137556 DOI: 10.3390/antiox11050989] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/07/2022] [Accepted: 05/10/2022] [Indexed: 01/27/2023] Open
Abstract
Vitamin E (alpha-tocopherol) is an essential micronutrient and fat-soluble antioxidant with proposed role in protecting tissues from uncontrolled lipid peroxidation. This vitamin has also important protein function and gene modulation effects. The metabolism of vitamin E depends on hepatic binding proteins that selectively retain food alpha-tocopherol for incorporation into nascent VLDL and tissue distribution together with esterified cholesterol and triglycerides. Chronic kidney disease (CKD) is a condition of oxidative stress and increased lipid peroxidation, that are associated with alterations of alpha-tocopherol metabolism and function. Specific changes have been reported for the levels of its enzymatic metabolites, including both short-chain and long-chain metabolites, the latter being endowed with regulatory functions on enzymatic and gene expression processes important for the metabolism of lipids and xenobiotics detoxification, as well as for the control of immune and inflammatory processes. Vitamin E therapy has been investigated in CKD using both oral vitamin E protocols and vitamin E-coated hemodialyzers, showing promising results in the secondary prevention of cardiovascular disease, as well as of immune and hematological complications. These therapeutic approaches are reviewed in the present article, together with a narrative excursus on the main findings indicating CKD as a condition of relative deficiency and impaired metabolism of vitamin E.
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Bonomini M, Piscitani L, Di Liberato L, Sirolli V. Biocompatibility of Surface-Modified Membranes for Chronic Hemodialysis Therapy. Biomedicines 2022; 10:biomedicines10040844. [PMID: 35453594 PMCID: PMC9025662 DOI: 10.3390/biomedicines10040844] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Mario Bonomini
- Nephrology and Dialysis Unit, Department of Medicine, G. d’Annunzio University, Chieti-Pescara, SS. Annunziata Hospital, Via dei Vestini, 66013 Chieti, Italy; (L.D.L.); (V.S.)
- Correspondence:
| | - Luca Piscitani
- Nephrology and Dialysis Unit, Department of Medicine, San Salvatore Hospital, Via Vetoio, 67100 L’Aquila, Italy;
| | - Lorenzo Di Liberato
- Nephrology and Dialysis Unit, Department of Medicine, G. d’Annunzio University, Chieti-Pescara, SS. Annunziata Hospital, Via dei Vestini, 66013 Chieti, Italy; (L.D.L.); (V.S.)
| | - Vittorio Sirolli
- Nephrology and Dialysis Unit, Department of Medicine, G. d’Annunzio University, Chieti-Pescara, SS. Annunziata Hospital, Via dei Vestini, 66013 Chieti, Italy; (L.D.L.); (V.S.)
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8
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Artificial Kidney Engineering: The Development of Dialysis Membranes for Blood Purification. MEMBRANES 2022; 12:membranes12020177. [PMID: 35207097 PMCID: PMC8876607 DOI: 10.3390/membranes12020177] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/27/2022] [Accepted: 01/30/2022] [Indexed: 11/17/2022]
Abstract
The artificial kidney, one of the greatest medical inventions in the 20th century, has saved innumerable lives with end stage renal disease. Designs of artificial kidney evolved dramatically in decades of development. A hollow-fibered membrane with well controlled blood and dialysate flow became the major design of the modern artificial kidney. Although they have been well established to prolong patients’ lives, the modern blood purification system is still imperfect. Patient’s quality of life, complications, and lack of metabolic functions are shortcomings of current blood purification treatment. The direction of future artificial kidneys is toward miniaturization, better biocompatibility, and providing metabolic functions. Studies and trials of silicon nanopore membranes, tissue engineering for renal cell bioreactors, and dialysate regeneration are all under development to overcome the shortcomings of current artificial kidneys. With all these advancements, wearable or implantable artificial kidneys will be achievable.
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9
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Chen YA, Ou SM, Lin CC. Influence of Dialysis Membranes on Clinical Outcomes: From History to Innovation. MEMBRANES 2022; 12:membranes12020152. [PMID: 35207074 PMCID: PMC8876340 DOI: 10.3390/membranes12020152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/20/2022] [Indexed: 12/18/2022]
Abstract
Dialysis membranes were traditionally classified according to their material compositions (i.e., as cellulosic or synthetic) and on the basis of the new concept of the sieving coefficient (determined by the molecular weight retention onset and molecular weight cut-off). The advantages of synthetic polymer membranes over cellulose membranes are also described on the basis of their physical, chemical, and structural properties. Innovations of dialysis membrane in recent years include the development of medium cutoff membranes; graphene oxide membranes; mixed-matrix membranes; bioartificial kidneys; and membranes modified with vitamin E, lipoic acid, and neutrophil elastase inhibitors. The current state of research on these membranes, their effects on clinical outcomes, the advantages and disadvantages of their use, and their potential for clinical use are outlined and described.
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Affiliation(s)
- Yee-An Chen
- Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan;
- Department of Medicine, Division of Nephrology, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Shuo-Ming Ou
- Department of Medicine, Division of Nephrology, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Correspondence: (S.-M.O.); (C.-C.L.); Tel.: +886-2-2875-3103 (C.-C.L.); +886-2-2871-2121 (S.-M.O.); Fax: +886-2-2875-7858 (C.-C.L.)
| | - Chih-Ching Lin
- Department of Medicine, Division of Nephrology, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Correspondence: (S.-M.O.); (C.-C.L.); Tel.: +886-2-2875-3103 (C.-C.L.); +886-2-2871-2121 (S.-M.O.); Fax: +886-2-2875-7858 (C.-C.L.)
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10
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Fisher C, Shao H, Ho CH. Improved hemocompatibility of polysulfone hemodialyzers with Endexo® surface modifying molecules. J Biomed Mater Res B Appl Biomater 2021; 110:1335-1343. [PMID: 34951744 DOI: 10.1002/jbm.b.35003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 11/19/2021] [Accepted: 12/13/2021] [Indexed: 11/09/2022]
Abstract
Anticoagulation therapy is widely used to reduce clotting during hemodialysis (HD), but may cause adverse effects in end-stage kidney disease patients. A new hemodialyzer with a membrane modified by surface modifying molecule was developed to improve hemocompatibility that aimed to reduce the need for anticoagulation during dialysis treatments. We compared membrane surface characteristics and in vitro hemocompatibility of the new hemodialyzer to the standard polysulfone (PSF) hemodialyzer membrane. Scanning electron microscopy, contact angle measurement (68° ± 3° test vs. 41.6° ± 6° control), and X-ray photoelectron spectrometry measurement for fluorine atomic % (7.4% ± 0.4% test vs. not detectable control), showed that the membrane surface was modified with surface modifying macromolecule (SMM1) but maintained membrane structure and surface hydrophilicity. Zeta potential of the blood-contacting surface showed that the absolute surface charge was reduced at neutral pH (-3.3 mV ± 1.1 mV test vs. -15.6 mV ± 1.0 mV control). Platelet count reduction was significantly less for the SMM1-modified dialyzer (40.88% ± 21.89%) compared to the standard PSF dialyzer (62.62% ± 34.13%), along with Platelet Factor 4 (1824.10 ng/ml ± 436.26 ng/ml test vs. 2479.00 ng/ml ± 852.96 ng/ml control). These studies demonstrate the successful incorporation of SMM1 into the new hemodialyzer with the expected results. Our in vitro experiments indicate that the SMM1-modified hemodialyzers could improve hemocompatibility compared to standard PSF hemodialyzers and have the potential to minimize the patient's anticoagulant requirements during HD. Additional research with SMM1 additives incorporated into the entire dialysis circuit and use in a clinical settings are required to confirm these promising findings.
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Affiliation(s)
- Colleen Fisher
- Biosciences Department, Fresenius Medical Care North America Global Research and Development, Ogden, Utah, USA
| | - Hui Shao
- Product Development Department, Fresenius Medical Care North America Global Research and Development, Ogden, Utah, USA
| | - Chih-Hu Ho
- Biosciences Department, Fresenius Medical Care North America Global Research and Development, Ogden, Utah, USA
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11
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Song X, Ji H, Li Y, Xiong Y, Qiu L, Zhong R, Tian M, Kizhakkedathu JN, Su B, Wei Q, Zhao W, Zhao C. Transient blood thinning during extracorporeal blood purification via the inactivation of coagulation factors by hydrogel microspheres. Nat Biomed Eng 2021; 5:1143-1156. [PMID: 33495638 DOI: 10.1038/s41551-020-00673-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 12/09/2020] [Indexed: 02/07/2023]
Abstract
During extracorporeal blood purification, anticoagulants are administered to prevent thrombogenesis. However, haemorrhagic complications owing to near-complete inactivation of blood coagulation and delayed recovery of haemostasis pose serious risks to patients. Here, we show in vitro and in beagle dogs that hydrogel microspheres that adsorb the coagulation factors VIII, IX and XI provide transient blood thinning when placed in the extracorporeal circuit before blood purification. The microspheres inhibited the activities of the coagulation factors by levels (~8-30%) similar to those occurring in mild haemophilia. On its reintroduction into the animal, the purified pseudo-haemophilic blood favoured faster recovery of haemostasis. The transient blood-thinning strategy may increase the safety of clinical blood-purification procedures.
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Affiliation(s)
- Xin Song
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China
| | - Haifeng Ji
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China
| | - Yupei Li
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China.,Sichuan University-the Hong Kong Polytechnic University Institute for Disaster Management and Reconstruction, Chengdu, China
| | - Yuqin Xiong
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Li Qiu
- Department of Ultrasound, West China School of Medicine/West China Hospital, Sichuan University, Chengdu, China
| | - Rui Zhong
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences, Peking Union Medical College, Chengdu, China
| | - Meng Tian
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jayachandran N Kizhakkedathu
- Department of Pathology and Laboratory Medicine, Center for Blood Research and Life Science Institute, University of British Columbia, Vancouver, British Columbia, Canada
| | - Baihai Su
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China.,Sichuan University-the Hong Kong Polytechnic University Institute for Disaster Management and Reconstruction, Chengdu, China
| | - Qiang Wei
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China.,Department of Cellular Biophysics, Max Planck Institute for Medical Research, Heidelberg, Heidelberg, Germany.,Department of Biophysical Chemistry, University of Heidelberg, Heidelberg, Germany
| | - Weifeng Zhao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China.
| | - Changsheng Zhao
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, China.
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12
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Vanommeslaeghe F, Josipovic I, Boone M, van der Tol A, Dhondt A, Van Biesen W, Eloot S. How biocompatible haemodialysers can conquer the need for systemic anticoagulation even in post-dilution haemodiafiltration: a cross-over study. Clin Kidney J 2021; 14:1752-1759. [PMID: 34548919 PMCID: PMC8447252 DOI: 10.1093/ckj/sfaa219] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 08/31/2020] [Indexed: 01/27/2023] Open
Abstract
Background While systemic anticoagulation is most widely used in haemodialysis (HD), contraindications to its use might occur in particular settings. The Solacea™ haemodialyser with an asymmetric triacetate membrane claims improved biocompatibility and has already shown promising results when used in combination with only half dose of anticoagulation. To quantify the performance of the Solacea™ when further decreasing anticoagulation to zero, fibre blocking was assessed by micro-computed tomography (micro-CT). Methods Ten maintenance HD patients underwent six dialysis sessions at midweek using a Solacea™ 19H dialyser, consecutively in pre-dilution haemodiafiltration (pre-HDF), HD and post-dilution HDF (post-HDF). After the first three sessions with only a quarter of their regular anticoagulation dose (one-quarter), the last three sessions were performed without anticoagulation (zero). Dialyser fibre blocking was quantified in the dialyser outlet potting using a 3D micro-CT scanning technique post-dialysis. Results Even in case of reduced (one-quarter) anticoagulation, the relative number of open fibres post-dialysis was almost optimal, i.e. 0.96 (0.87-0.99) with pre-HDF, 0.99 (0.97-0.99) with HD and 0.97 (0.92-0.99) with post-HDF. Fibre patency was mildly decreased for pre-HDF and HD when anticoagulation was decreased from one-quarter to zero, i.e. to 0.76 (0.61-0.85) with pre-HDF (P = 0.004) and to 0.80 (0.77-0.89) with HD (P = 0.013). Comparing the results for zero anticoagulation, post-HDF [i.e. 0.94 (0.82-0.97)] performed as well as HD and pre-HDF. Conclusions The Solacea™ dialyser provides promising results for use in conditions where systemic anticoagulation is contraindicated. Post-HDF, although inducing haemoconcentration in the dialyser, is equally effective for fibre patency in case of zero anticoagulation as pre-HDF and HD when using Solacea™.
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Affiliation(s)
| | - Iván Josipovic
- Centre for X-ray Tomography, Physics and Astronomy, Ghent University, Ghent, Belgium
| | - Matthieu Boone
- Centre for X-ray Tomography, Physics and Astronomy, Ghent University, Ghent, Belgium
| | | | - Annemie Dhondt
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Sunny Eloot
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
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13
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Locke A, Bushey MA, LaCroix C, Deardoff P, Onuigbo MAC. Timed Controlled Repeated Rotation of the CAR-170-C NXSTAGE Chronic Cartridge Hemodialysis Filter: A Novel Approach to Enabling Heparin-Free Frequent Daily Home Hemodialysis. Mayo Clin Proc Innov Qual Outcomes 2021; 5:219-224. [PMID: 33718796 PMCID: PMC7930779 DOI: 10.1016/j.mayocpiqo.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Heparin-free hemodialysis is often warranted in postoperative states, bleeding diathesis, and critically ill patients. Conventionally, this is achieved through normal saline flushes or regional citrate anticoagulation. An 87-year-old white man with end-stage renal disease and atrial fibrillation, who was taking warfarin and using maintenance home hemodialysis (HHD) with an NxStage machine, underwent laparoscopic appendicectomy. The procedure was complicated by intra-abdominal abscess, sepsis, and tamponade from a bloody pericardial effusion. He needed emergent therapeutic pericardiocentesis. Warfarin was promptly discontinued. He was discharged home with heparin-free HHD. Prior heparin anticoagulation for HHD was an initial bolus of 4000 units of heparin. He continued to clot his extracorporeal system with resultant very high venous pressures and compromised HHD. Heparin anticoagulation was still contraindicated. Flushes with 250-500 mL normal saline, delivered in aliquots every 15-30 minutes, failed to prevent the frequent clotting. The first author, our HD Senior Technician, had astutely observed that the horizontally placed hemodialysis filter exhibited early “clot” formation at the 12-o’clock position, despite the saline flushes. Through trial and error, he discovered that rotating the horizontally placed hemodialysis filter along its long axis, 60 degrees clockwise for 15 minutes, return to the neutral position for 15 minutes, rotating the filter another 60 degrees counterclockwise for 15 minutes, with this repeated cycle of rotations “did the trick.” It promptly and consistently resolved the clotting problem. The lines stopped clotting, and he has not needed saline flushes for smooth heparin-free HHD for more than 7 months. To our knowledge, this is the first such report. Further study is justified. We have hypothesized a mechanism and have named this the “Locke-Onuigbo Maneuver.”
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Affiliation(s)
- Adam Locke
- Home Dialysis Unit, University of Vermont Medical Center, Burlington, VT
| | - Margaret A. Bushey
- Home Dialysis Unit, University of Vermont Medical Center, Burlington, VT
| | - Cynthia LaCroix
- Home Dialysis Unit, University of Vermont Medical Center, Burlington, VT
| | - Patience Deardoff
- Home Dialysis Unit, University of Vermont Medical Center, Burlington, VT
| | - Macaulay Amechi Chukwukadibia Onuigbo
- Home Dialysis Unit, University of Vermont Medical Center, Burlington, VT
- The Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT
- College of Business, University of Wisconsin MBA Consortium, Eau Claire, WI
- Correspondence: Address to Macaulay Amechi Chukwukadibia Onuigbo, MD, MBA, Division of Nephrology, Department of Medicine, The Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT. UHC Campus, 1 South Prospect Street, Burlington, VT 05401. @MacO936298480
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Claudel SE, Miles LA, Murea M. Anticoagulation in hemodialysis: A narrative review. Semin Dial 2020; 34:103-115. [PMID: 33135208 DOI: 10.1111/sdi.12932] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/28/2020] [Accepted: 10/11/2020] [Indexed: 12/18/2022]
Abstract
Systemic anticoagulation in maintenance hemodialysis (HD) has historically been considered necessary to maintain the extracorporeal circuit (ECC) and preserve dialysis efficiency. Unfractionated heparin (UFH) is the most commonly used anticoagulant due to low cost and staff familiarity. Despite widespread use, there is little standardization of heparin dosing protocols in the United States. Although the complication rates with UFH are low for the general population, certain contraindications have led to exploration in alternative anticoagulants in patients with end-stage kidney disease (ESKD). Here we review the current evidence regarding heparin dosing protocols, complications associated with heparin use, and discuss alternatives to UFH including anticoagulant-free routine HD.
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Affiliation(s)
- Sophie E Claudel
- Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Lauren A Miles
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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15
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Vanommeslaeghe F, Josipovic I, Boone M, Dhondt A, Van Biesen W, Eloot S. A randomized cross-over study with objective quantification of the performance of an asymmetric triacetate and a polysulfone dialysis membrane using different anticoagulation strategies. Clin Kidney J 2019; 14:398-407. [PMID: 33564444 PMCID: PMC7857793 DOI: 10.1093/ckj/sfz163] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/02/2019] [Indexed: 02/07/2023] Open
Abstract
Background Different strategies can be used to counteract coagulation of extracorporeal systems. Systemic anticoagulation is most widely used in routine clinical practice, but can be contraindicated in specific settings. The Solacea™ dialyser, containing the asymmetric triacetate membrane, claims improved biocompatibility, which should result in decreased tendency for coagulation. We quantified the performance of the Solacea™ versus the FX800CORDIAX dialyser regarding resistance to fibre blocking as assessed by micro-computed tomography (CT). Methods This cross-over study with four arms randomized consecutively 10 maintenance haemodialysis patients to a 4-h post-dilution haemodiafiltration session at midweek, using either Solacea™ 19 H or FX800CORDIAX, with either regular or half dose of anticoagulation (EC2017/1459-NCT03820401). Dialyser fibre blocking was visualized in the dialyser outlet potting using a 3D CT scanning technique on micrometre resolution. Extraction ratios of middle molecules [myoglobin, lambda and kappa free light chains (FLCs)] were determined. Results The relative number of open fibres post-dialysis was lower in FX800CORDIAX versus Solacea™ dialyser, and this was irrespective of the anticoagulation dose used or the threshold for counting open fibres. Extraction ratios of FLCs were not different at regular anticoagulation between Solacea™ and FX800CORDIAX (21% ± 4% for kappa and 32% ± 8% for lambda with Solacea™ versus 23% ± 7% and 38% ± 6% for FX800CORDIAX), but were superior with the Solacea™ (34% ± 12% versus 22% ± 8% with FX800CORDIAX; P = 0.02) for myoglobin in case of halving anticoagulation dose. No clinically relevant albumin loss was detected. Conclusions The Solacea™ dialyser seems to be promising for use in conditions where systemic anticoagulation is contraindicated, as even under conditions of low systemic anticoagulation, virtually no signs of fibre blocking could be observed using the sensitive micro-CT scanning technique. This finding is in line with its presumed good performance in terms of biocompatibility.
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Affiliation(s)
| | - Iván Josipovic
- Centre for X-ray Tomography, Physics and Astronomy, Ghent University, Ghent, Belgium
| | - Matthieu Boone
- Centre for X-ray Tomography, Physics and Astronomy, Ghent University, Ghent, Belgium
| | - Annemie Dhondt
- Nephrology Department, Ghent University Hospital, Ghent, Belgium
| | - Wim Van Biesen
- Nephrology Department, Ghent University Hospital, Ghent, Belgium
| | - Sunny Eloot
- Nephrology Department, Ghent University Hospital, Ghent, Belgium
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16
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Vanommeslaeghe F, De Somer F, Josipovic I, Boone M, Van Biesen W, Eloot S. Evaluation of Different Dialyzers and the Impact of Predialysis Albumin Priming in Intermittent Hemodialysis With Reduced Anticoagulation. Kidney Int Rep 2019; 4:1538-1545. [PMID: 31890995 PMCID: PMC6933477 DOI: 10.1016/j.ekir.2019.07.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/08/2019] [Accepted: 07/15/2019] [Indexed: 12/15/2022] Open
Abstract
Introduction Systemic anticoagulation is widely used in routine clinical hemodialysis, but can be contraindicated in specific settings. Anticoagulant-free treatment regimens are prone to failure even in chronic intermittent hemodialysis. We quantified fiber blocking in settings of reduced anticoagulation to assess performance of different dialyzers and the potential benefit of albumin priming. Methods This crossover study included 10 patients performing 4 hours of hemodialysis at midweek in 7 different settings: that is, using Solacea 19H and FX800, both with regular and half dose of anticoagulation, Evodial 1.3 without systemic anticoagulation, and FX800 (half dose) and Evodial (no anticoagulation) when primed with a human albumin solution. Dialyzer fiber blocking was visualized in the dialyzer outlet potting using a 3-dimensional computed tomography (CT) scanning technique on micrometer resolution. Results No sessions had to be prematurely interrupted because of circuit clotting. The relative number of open fibers post dialysis was not influenced by the reduction of anticoagulation in the Solacea making this dialyzer superior in fiber patency in this setting above both the FX800 with reduced anticoagulation and the Evodial with no anticoagulation. Furthermore, no differences in relative number of open fibers were found in the FX800 and Evodial dialyzers with versus without albumin priming. Conclusion In situations in which reduced anticoagulation is indicated, the asymmetric triacetate ATA Solacea dialyzer outperforms a dialyzer with a conventional polysulfone membrane (FX800) or with the heparin-coated polyacrylonitrile membrane (Evodial). The use of human albumin to prime the dialysis circuit did not improve dialyzer patency.
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Affiliation(s)
| | - Filip De Somer
- Department of Cardiac Surgery, Ghent University Hospital, Gent, Belgium
| | - Iván Josipovic
- Centre for X-ray Tomography, Physics and Astronomy, Ghent University, Belgium
| | - Matthieu Boone
- Centre for X-ray Tomography, Physics and Astronomy, Ghent University, Belgium
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, Gent, Belgium
| | - Sunny Eloot
- Department of Nephrology, Ghent University Hospital, Gent, Belgium
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Kiaii M, Aritomi M, Nagase M, Farah M, Jung B. Clinical evaluation of performance, biocompatibility, and safety of vitamin E-bonded polysulfone membrane hemodialyzer compared to non-vitamin E-bonded hemodialyzer. J Artif Organs 2019; 22:307-315. [PMID: 31254226 PMCID: PMC6861196 DOI: 10.1007/s10047-019-01110-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 06/06/2019] [Indexed: 11/04/2022]
Abstract
The vitamin E-bonded polysulfone membrane hemodialyzer (ViE™-21) was evaluated in a clinical study for regulatory submission. Seventeen patients on hemodialysis were treated with conventional high-flux hemodialyzers for 2 weeks (Pre-ViE phase) and switched to the ViE-21 for 36 sessions (ViE phase) followed by an additional 2 weeks on conventional hemodialyzers (Post-ViE phase). Reduction ratios of urea, creatinine, beta-2-microglobulin, albumin, and ultrafiltration coefficients (KUF) were measured once during the Pre-ViE phase and twice during the ViE phase. Moreover, biocompatibility markers [leucocyte count, platelet count, and activated complement factor (C3a) levels] were evaluated pre-dialysis, 15 min after initiation, and post-dialysis. During the study, type and number of adverse events (AEs), and device malfunctions were recorded. ViE-21 reduction ratios and KUF were not noticeably different than those of conventional hemodialyzers. Fluctuations of leucocyte counts and C3a concentrations were similar using ViE-21 and conventional hemodialyzers; however, the platelet count fluctuation was lower in ViE-21 sessions. The frequency of episodes of hypotension occurring during the ViE phase was lower than that occurring during the Pre- and Post-ViE phases. In conclusion, this study provided performance and safety data of the ViE-21 for regulatory application. The data suggest that vitamin E-bonded hemodialyzers are beneficial in lowering platelet activation and frequency of intradialytic hypotension. Larger randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Mercedeh Kiaii
- St. Paul'S Hospital, 1081 Burrard Street, Vancouver, BC, Canada
| | - Masaharu Aritomi
- Asahi Kasei Medical Co., Ltd., 1-1-2 Yurakucho, Chiyoda-ku, Tokyo, 100-0006, Japan.
| | - Mitsuyo Nagase
- Asahi Kasei Medical Co., Ltd., 1-1-2 Yurakucho, Chiyoda-ku, Tokyo, 100-0006, Japan
| | - Myriam Farah
- St. Paul'S Hospital, 1081 Burrard Street, Vancouver, BC, Canada
| | - Beverly Jung
- St. Paul'S Hospital, 1081 Burrard Street, Vancouver, BC, Canada
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Reporting of "dialysis adequacy" as an outcome in randomised trials conducted in adults on haemodialysis. PLoS One 2019; 14:e0207045. [PMID: 30721242 PMCID: PMC6363141 DOI: 10.1371/journal.pone.0207045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 12/04/2018] [Indexed: 12/16/2022] Open
Abstract
Background Clinical trials are most informative for evidence-based decision-making when they consistently measure and report outcomes of relevance to stakeholders, especially patients, clinicians, and policy makers. However, sometimes terminology used is interpreted differently by different stakeholders, which might lead to confusion during shared decision making. The construct dialysis adequacy is frequently used, suggesting it is an important outcome both for health care professionals as for patients. Objective To assess the scope and consistency of the construct dialysis adequacy as reported in randomised controlled trials in hemodialysis, and evaluate whether these align to the insights and understanding of this construct by patients. Methods To assess scope and consistency of dialysis adequacy by professionals, we performed a systematic review searching the Cochrane Central Register of Controlled Trials (CENTRAL) up to July 2017. We identified all randomised controlled trails (RCT) including patients on hemodialysis and reporting dialysis adequacy, adequacy or adequacy of dialysis and extracted and classified all reported outcomes. To explore interpretation and meaning of the construct of adequacy by patients, we conducted 11 semi-structured interviews with HD patients using thematic analysis. Belgian registration number B670201731001. Findings From the 31 included trials, we extracted and classified 98 outcome measures defined by the authors as adequacy of dialysis, of which 94 (95%) were biochemical, 3 (3%) non-biochemical surrogate and 2 (2%) patient-relevant. The three most commonly reported measures were all biochemical. None of the studies defined adequacy of dialysis as a patient relevant outcome such as survival or quality of life. Patients had a substantially different understanding of the construct dialysis adequacy than the biochemical interpretation reported in the literature. Being alive, time spent while being on dialysis, fatigue and friendliness of staff were the most prominent themes that patients linked to the construct of dialysis adequacy. Conclusion Adequacy of dialysis as reported in the literature refers to biochemical outcome measures, most of which are not related with patient relevant outcomes. For patients, adequate dialysis is a dialysis that enables them to spend as much quality time in their life as possible.
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19
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Tu MM, Xu JJ, Qiu YR. Surface hemocompatible modification of polysulfone membrane via covalently grafting acrylic acid and sulfonated hydroxypropyl chitosan. RSC Adv 2019; 9:6254-6266. [PMID: 35517280 PMCID: PMC9062722 DOI: 10.1039/c8ra10573a] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 02/05/2019] [Indexed: 12/29/2022] Open
Abstract
In this study, acrylic acid (AA) and sulfonated hydroxypropyl chitosan (SHPCS) were covalently grafted on the PSf membrane surface to improve its hemocompatibility.
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Affiliation(s)
- Ming-Ming Tu
- College of Chemistry and Chemical Engineering
- Central South University
- Changsha 410083
- PR China
| | - Jing-Jie Xu
- College of Chemistry and Chemical Engineering
- Central South University
- Changsha 410083
- PR China
| | - Yun-Ren Qiu
- College of Chemistry and Chemical Engineering
- Central South University
- Changsha 410083
- PR China
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20
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Piccoli GB, Nielsen L, Gendrot L, Fois A, Cataldo E, Cabiddu G. Prescribing Hemodialysis or Hemodiafiltration: When One Size Does Not Fit All the Proposal of a Personalized Approach Based on Comorbidity and Nutritional Status. J Clin Med 2018; 7:E331. [PMID: 30297628 PMCID: PMC6210736 DOI: 10.3390/jcm7100331] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 12/14/2022] Open
Abstract
There is no simple way to prescribe hemodialysis. Changes in the dialysis population, improvements in dialysis techniques, and different attitudes towards the initiation of dialysis have influenced treatment goals and, consequently, dialysis prescription. However, in clinical practice prescription of dialysis still often follows a "one size fits all" rule, and there is no agreed distinction between treatment goals for the younger, lower-risk population, and for older, high comorbidity patients. In the younger dialysis population, efficiency is our main goal, as assessed by the demonstrated close relationship between depuration (tested by kinetic adequacy) and survival. In the ageing dialysis population, tolerance is probably a better objective: "good dialysis" should allow the patient to attain a stable metabolic balance with minimal dialysis-related morbidity. We would like therefore to open the discussion on a personalized approach to dialysis prescription, focused on efficiency in younger patients and on tolerance in older ones, based on life expectancy, comorbidity, residual kidney function, and nutritional status, with particular attention placed on elderly, high-comorbidity populations, such as the ones presently treated in most European centers. Prescription of dialysis includes reaching decisions on the following elements: dialysis modality (hemodialysis (HD) or hemodiafiltration (HDF)); type of membrane (permeability, surface); and the frequency and duration of sessions. Blood and dialysate flow, anticoagulation, and reinfusion (in HDF) are also briefly discussed. The approach described in this concept paper was developed considering the following items: nutritional markers and integrated scores (albumin, pre-albumin, cholesterol; body size, Body Mass Index (BMI), Malnutrition Inflammation Score (MIS), and Subjective Global Assessment (SGA)); life expectancy (age, comorbidity (Charlson Index), and dialysis vintage); kinetic goals (Kt/V, normalized protein catabolic rate (n-PCR), calcium phosphate, parathyroid hormone (PTH), beta-2 microglobulin); technical aspects including vascular access (fistula versus catheter, degree of functionality); residual kidney function and weight gain; and dialysis tolerance (intradialytic hypotension, post-dialysis fatigue, and subjective evaluation of the effect of dialysis on quality of life). In the era of personalized medicine, we hope the approach described in this concept paper, which requires validation but has the merit of providing innovation, may be a first step towards raising attention on this issue and will be of help in guiding dialysis choices that exploit the extraordinary potential of the present dialysis "menu".
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Affiliation(s)
- Giorgina Barbara Piccoli
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Dipartimento di Scienze Cliniche e Biologiche, University of Torino, Ospedale san Luigi, Regione Gonzole, 10100 Torino, Italy.
| | - Louise Nielsen
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Lurilyn Gendrot
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Antioco Fois
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
| | - Emanuela Cataldo
- Néphrologie Centre Hospitalier Le Mans, Avenue Roubillard 196, 72000 Le Mans, France.
- Nefrologia, Università Aldo Moro, Piazza Umberto I, 70121 Bari, Italy.
| | - Gianfranca Cabiddu
- Nefrologia Ospedale Brotzu, Piazzale Alessandro Ricchi, 1, 09134 Cagliari, Italy.
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21
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Brunot V, Serre JE, Mourad G, Klouche K, Pernin V. Heparin-free renal replacement therapy for chronic hemodialyzed patients at high risk for bleeding: a comparison of on-line predilution hemodiafiltration with conventional hemodialysis. Hemodial Int 2018; 22:463-473. [PMID: 29745004 DOI: 10.1111/hdi.12668] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/12/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND In chronic hemodialysis patients with high risk of bleeding, optimal anticoagulation of the extracorporeal circuit is challenging. Heparin-free hemodialysis (HD) with heparin-coated AN69ST dialyzer is now considered as a good option and recommended by experts. Predilutional hemodiafiltration (HDF) may represent also a feasible alternative but has been poorly investigated. In this study, our aim was to evaluate the performance of on-line automated predilution heparin-free HDF as compared to conventional heparin-free HD with a heparin-coated membrane. METHODS We prospectively studied chronic hemodialysis patients at high risk of bleeding consecutively admitted to hospital who underwent heparin-free renal replacement therapy (RRT) in our nephrology department. During 1 year, we routinely used heparin-free HD and on-line HDF in these settings. By using a propensity score, we compared HDF to HD regarding to session failure and efficiency. RESULTS One hundred and seventy-nine patients were included in the study. Clotting phenomena necessitating premature termination of RRT sessions were encountered in 19% of them. After propensity score matching, the comparison of 77 HD and 77 HDF sessions showed no significant differences in duration of the sessions and in dialyzer clotting. By multivariate analysis, a blood flow less than 250 mL/min and recent surgery were the only parameters associated with extracorporeal circuit thrombosis. CONCLUSION Heparin-free on-line predilutional HDF is a safe and effective technique for chronic hemodialysis patients with increased bleeding risk. The use of an automatic substitution volume that avoids filters hemoconcentration and of a blood flow above 250 mL/min strongly contribute to the observed performance. Further studies are, however, intended to confirm these results.
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Affiliation(s)
- Vincent Brunot
- Department of Nephrology, Dialysis, and Transplantation, Univ Montpellier, CHU Montpellier, Lapeyronie Hospital, Montpellier, France
| | - Jean-Emmanuel Serre
- Department of Nephrology, Dialysis, and Transplantation, Univ Montpellier, CHU Montpellier, Lapeyronie Hospital, Montpellier, France
| | - Georges Mourad
- Department of Nephrology, Dialysis, and Transplantation, Univ Montpellier, CHU Montpellier, Lapeyronie Hospital, Montpellier, France
| | - Kada Klouche
- Department of Intensive Care Medicine, Univ Montpellier, CHU Montpellier, Lapeyronie Hospital, Montpellier, France.,PhyMedExp, CNRS, INSERM, Univ Montpellier, Montpellier, France
| | - Vincent Pernin
- Department of Nephrology, Dialysis, and Transplantation, Univ Montpellier, CHU Montpellier, Lapeyronie Hospital, Montpellier, France
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23
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Tangvoraphonkchai K, Davenport A. Enhancing dialyser clearance-from target to development. Pediatr Nephrol 2017; 32:2225-2233. [PMID: 28401301 DOI: 10.1007/s00467-017-3647-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 03/04/2017] [Accepted: 03/08/2017] [Indexed: 01/18/2023]
Abstract
Products of metabolism accumulate in kidney failure and potentially have toxic effects. Traditionally these uraemic toxins are classified as small, middle-sized and protein-bound toxins, and clearance during dialysis is affected by diffusion, convection and adsorption. As current dialysis practice effectively clears small solutes, increasing evidence supports a toxic effect for middle-sized and protein-bound toxins. Therefore, newer approaches to standard dialysis practice are required to look beyond urea clearance. Current dialysers have been developed to effectively clear small solutes and secondly to increase middle-sized toxin clearances. However, there is no ideal dialyser which can effectively clear all uraemic toxins. Advances in nanotechnology have led to improvements in manufacturing, with the production of smoother membrane surfaces and uniformity of pore size. The introduction of haemodiafiltration has led to changes in dialyser design to improve convective clearances. Both diffusional and convectional clearances can be increased by changing dialyser designs to alter blood and dialysate flows, and novel dialyser designs using microfluidics offer more efficient solute clearances. Adjusting surface hydrophilicity and charge alter adsorptive properties, and greater clearance of protein-bound toxins can be achieved by adding carbon or other absorptive monoliths into the circuit or by developing composite dialyser membranes. Other strategies to increase protein-bound toxins clearances have centred on disrupting binding and so displacing toxins from proteins. Just as the hollow fibre design replaced the flat plate dialyser, we are now entering a new era of dialyser designs aimed to increase the spectrum of uraemic toxins which can be cleared by dialysis.
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Affiliation(s)
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London Medical School, Rowland Hill Street, London, NW3 2PF, UK.
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24
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A novel kind of polysulfone material with excellent biocompatibility modified by the sulfonated hydroxypropyl chitosan. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2017. [DOI: 10.1016/j.msec.2017.05.103] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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25
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Su T, Jin Q, Liu Z. Polyethyleneimine-treated polyacrylonitrile membrane hemofilter for critically ill patients receiving anticoagulant-free prolonged intermittent renal replacement therapy: a single-center, prospective, self-controlled pilot study. BMC Nephrol 2017; 18:208. [PMID: 28666474 PMCID: PMC5493884 DOI: 10.1186/s12882-017-0627-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 06/21/2017] [Indexed: 11/25/2022] Open
Abstract
Background Critically ill patients requiring renal replacement therapy (RRT) are at risk of disease-related bleeding. Systemic heparinization should be avoided. AN69ST, a polyethyleneimine-treated polyacrylonitrile (AN69) membrane hemofilter, can be primed with heparin, improving its local anticoagulative activity. Prolonged intermittent RRT (PI-RRT) is of shorter duration and cheaper, considered as an alternative to continuous RRT. This study was performed to compare the success rate of anticoagulant-free PI-RRT using AN69ST versus AN69 membrane hemofilter. We also evaluated risk factors for filter clotting. Methods This crossover, double-blind, randomized study included patients requiring PI-RRT but at high bleeding risk treated with AN69ST and AN69 hemo filters. The success rate of RRT, filter lifespan and severity of filter clotting were compared between the hemo filters. Factors associated with the filter clotting risk were analyzed with a Cox proportional hazards model. Results This study included 60 patients (mean age, 68.1 ± 15.8 years). Thirty-three (55.0%) patients were in the intensive care unit, 34 (56.8%) had disease-related thrombocytopenia, and 14 (23.3%) had local hemorrhagic diseases. The success rate of PI-RRT with the AN69ST and AN69 hemofilter was 51.7% and 50.9%, respectively (P > 0.05). The mean PI-RRT duration was 543.1 ± 119.0 min in the completed sessions and 387.3 ± 140.8 min in the prematurely terminated sessions, without significant difference between AN69ST and AN69 hemofilters. Cox regression analysis showed that age (odds ratio [OR], 1.023 per year), platelet count (OR, 1.07 per 10 × 109/L), hemoglobin concentration (OR, 1.035 per 1 g/L), and activated partial thromboplastin time (aPTT; OR, 0.973 per second) were associated with a hemofilter clotting risk. The AN69ST hemofilter lifespan was significantly prolonged averaging an extra 251.7 min in patients with an aPTT of <35.3 s, hemoglobin concentration of >83 g/L and platelet count of <70 × 109/L. Conclusions Anticoagulant-free PI-RRT by a heparin-primed AN69ST hemofilter reached a 51.7% success rate. The risk of premature clotting of the extracorporeal circuit remains unsatisfactory. For select patients at high risk of bleeding, the heparin-primed AN69ST hemofilter may be more appropriate for anticoagulation-free PI-RRT. Trial registration https://www.clinicaltrials.gov; study number: NCT02355873. Release Date 01/21/2015
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Affiliation(s)
- Tao Su
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, 100034, China
| | - Qizhuang Jin
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, 100034, China.
| | - Zhongyuan Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, 100034, China
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Meijers B, Metalidis C, Vanhove T, Poesen R, Kuypers D, Evenepoel P. A noninferiority trial comparing a heparin-grafted membrane plus citrate-containing dialysate versus regional citrate anticoagulation: results of the CiTED study. Nephrol Dial Transplant 2017; 32:707-714. [PMID: 28407129 DOI: 10.1093/ndt/gfw461] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/10/2016] [Indexed: 11/15/2022] Open
Abstract
Background Anticoagulation is a prerequisite for successful haemodialysis. Heparin and low-molecular weight heparins are routinely used despite increased bleeding risk. Regional citrate anticoagulation (RCA) is efficacious, but is laborious and may induce metabolic disturbances. Heparin-grafted membranes are less efficacious. It is not known whether combining citrate-containing dialysate and a heparin-grafted membrane is a valid anticoagulation strategy. Methods We performed a randomized crossover noninferiority trial, with a prespecified noninferiority threshold of 10% in maintenance dialysis patients ( n = 25). We compared the combination of citrate-containing dialysate plus a heparin-grafted membrane [CiTrate and EvoDial (CiTED) protocol] with RCA. The primary endpoint was completion of dialysis without significant clotting. Secondary endpoints included time to clotting, achieved Kt / V urea , loss of total cell volume, venous air chamber clotting score and systemic-ionized calcium concentration. Results In total, 1284 sessions were performed according to study protocol, 636 in the CiTED arm and 648 in the RCA arm. The primary outcome of preterm interruption due to clotting occurred in 36 (5.7%) of sessions in the CiTED arm, and in 40 (6.2%) sessions in the RCA arm, thereby meeting noninferiority criteria (P < 0.0001). Most of the clotting events occurred in the fourth hour of dialysis. Repetitive clotting occurred in four patients in the CiTED arm and one patient in the RCA arm. Time to preterm interruption due to clotting and achieved Kt / V urea was not significantly different. Systemic-ionized calcium levels during treatment were significantly lower in the RCA arm and clinically relevant hypocalcaemia was noted only in the RCA arm. Conclusion The combination of citrate-containing dialysate and a heparin-grafted membrane is a valid alternative to RCA.
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Affiliation(s)
- Björn Meijers
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Division of Nephrology, UZ Leuven, Leuven, Belgium
| | - Christoph Metalidis
- Division of Nephrology, UZ Leuven, Leuven, Belgium.,Nephrology Unit, ZOL, Genk, Belgium
| | - Thomas Vanhove
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Ruben Poesen
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Dirk Kuypers
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Division of Nephrology, UZ Leuven, Leuven, Belgium
| | - Pieter Evenepoel
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.,Division of Nephrology, UZ Leuven, Leuven, Belgium
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