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Zawada AM, Emal K, Förster E, Saremi S, Delinski D, Theis L, Küng F, Xie W, Werner J, Stauss-Grabo M, Faust M, Boyington S, Kennedy JP. Hydrophilic Modification of Dialysis Membranes Sustains Middle Molecule Removal and Filtration Characteristics. MEMBRANES 2024; 14:83. [PMID: 38668111 PMCID: PMC11052066 DOI: 10.3390/membranes14040083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024]
Abstract
While efficient removal of uremic toxins and accumulated water is pivotal for the well-being of dialysis patients, protein adsorption to the dialyzer membrane reduces the performance of a dialyzer. Hydrophilic membrane modification with polyvinylpyrrolidone (PVP) has been shown to reduce protein adsorption and to stabilize membrane permeability. In this study we compared middle molecule clearance and filtration performance of nine polysulfone-, polyethersulfone-, and cellulose-based dialyzers over time. Protein adsorption was simulated in recirculation experiments, while β2-microglobulin clearance as well as transmembrane pressure (TMP) and filtrate flow were determined over time. The results of this study showed that β2-microglobulin clearance (-7.2 mL/min/m2) and filtrate flow (-54.4 mL/min) decreased strongly during the first 30 min and slowly afterwards (-0.7 mL/min/m2 and -6.8 mL/min, respectively, for the next 30 min); the TMP increase (+37.2 mmHg and +8.6 mmHg, respectively) showed comparable kinetics. Across all tested dialyzers, the dialyzer with a hydrophilic modified membrane (FX CorAL) had the highest β2-microglobulin clearance after protein fouling and the most stable filtration characteristics. In conclusion, hydrophilic membrane modification with PVP stabilizes the removal capacity of middle molecules and filtration performance over time. Such dialyzers may have benefits during hemodiafiltration treatments which aim to achieve high exchange volumes.
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Affiliation(s)
- Adam M. Zawada
- Product Development, Fresenius Medical Care Deutschland GmbH, 66606 Sankt Wendel, Germany; (E.F.); (S.S.); (D.D.); (L.T.); (F.K.)
| | - Karlee Emal
- Applications Laboratory, Fresenius Medical Care, Ogden, UT 84404, USA; (K.E.); (S.B.)
| | - Eva Förster
- Product Development, Fresenius Medical Care Deutschland GmbH, 66606 Sankt Wendel, Germany; (E.F.); (S.S.); (D.D.); (L.T.); (F.K.)
| | - Saeedeh Saremi
- Product Development, Fresenius Medical Care Deutschland GmbH, 66606 Sankt Wendel, Germany; (E.F.); (S.S.); (D.D.); (L.T.); (F.K.)
- Institute for Physical Process Technology, Saarland University of Applied Sciences, 66117 Saarbrücken, Germany;
| | - Dirk Delinski
- Product Development, Fresenius Medical Care Deutschland GmbH, 66606 Sankt Wendel, Germany; (E.F.); (S.S.); (D.D.); (L.T.); (F.K.)
| | - Lukas Theis
- Product Development, Fresenius Medical Care Deutschland GmbH, 66606 Sankt Wendel, Germany; (E.F.); (S.S.); (D.D.); (L.T.); (F.K.)
| | - Florian Küng
- Product Development, Fresenius Medical Care Deutschland GmbH, 66606 Sankt Wendel, Germany; (E.F.); (S.S.); (D.D.); (L.T.); (F.K.)
| | - Wenhao Xie
- Product Development, Fresenius Medical Care, Shanghai 200233, China;
| | - Joanie Werner
- Clinical Marketing & Innovations, Fresenius Medical Care, Waltham, MA 02451, USA;
| | - Manuela Stauss-Grabo
- Global Biomedical Evidence Generation, Fresenius Medical Care Deutschland GmbH, 61352 Bad Homburg, Germany;
| | - Matthias Faust
- Institute for Physical Process Technology, Saarland University of Applied Sciences, 66117 Saarbrücken, Germany;
| | - Skyler Boyington
- Applications Laboratory, Fresenius Medical Care, Ogden, UT 84404, USA; (K.E.); (S.B.)
| | - James P. Kennedy
- Product Development, Fresenius Medical Care, Ogden, UT 84404, USA;
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Adsorption- and Displacement-Based Approaches for the Removal of Protein-Bound Uremic Toxins. Toxins (Basel) 2023; 15:toxins15020110. [PMID: 36828424 PMCID: PMC9963700 DOI: 10.3390/toxins15020110] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
End-stage renal disease (ESRD) patients rely on renal replacement therapies to survive. Hemodialysis (HD), the most widely applied treatment, is responsible for the removal of excess fluid and uremic toxins (UTs) from blood, particularly those with low molecular weight (MW < 500 Da). The development of high-flux membranes and more efficient treatment modes, such as hemodiafiltration, have resulted in improved removal rates of UTs in the middle molecular weight range. However, the concentrations of protein-bound uremic toxins (PBUTs) remain essentially untouched. Due to the high binding affinity to large proteins, such as albumin, PBUTs form large complexes (MW > 66 kDa) which are not removed during HD and their accumulation has been strongly associated with the increased morbidity and mortality of patients with ESRD. In this review, we describe adsorption- and displacement-based approaches currently being studied to enhance the removal of PBUTs. The development of mixed matrix membranes (MMMs) with selective adsorption properties, infusion of compounds capable of displacing UTs from their binding site on albumin, and competitive binding membranes show promising results, but the road to clinical application is still long, and further investigation is required.
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Hemodiafiltration: Technical and Medical Insights. Bioengineering (Basel) 2023; 10:bioengineering10020145. [PMID: 36829639 PMCID: PMC9952158 DOI: 10.3390/bioengineering10020145] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/25/2023] Open
Abstract
Despite the significant medical and technical improvements in the field of dialytic renal replacement modalities, morbidity and mortality are excessively high among patients with end-stage kidney disease, and most interventional studies yielded disappointing results. Hemodiafiltration, a dialysis method that was implemented in clinics many years ago and that combines the two main principles of hemodialysis and hemofiltration-diffusion and convection-has had a positive impact on mortality rates, especially when delivered in a high-volume mode as a surrogate for a high convective dose. The achievement of high substitution volumes during dialysis treatments does not only depend on patient characteristics but also on the dialyzer (membrane) and the adequately equipped hemodiafiltration machine. The present review article summarizes the technical aspects of online hemodiafiltration and discusses present and ongoing clinical studies with regards to hard clinical and patient-reported outcomes.
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Zaman SU, Rafiq S, Ali A, Mehdi MS, Arshad A, Rehman SU, Muhammad N, Irfan M, Khurram MS, Zaman MKU, Hanbazazah AS, Lim HR, Show PL. Recent advancement challenges with synthesis of biocompatible hemodialysis membranes. CHEMOSPHERE 2022; 307:135626. [PMID: 35863415 DOI: 10.1016/j.chemosphere.2022.135626] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/23/2022] [Accepted: 07/03/2022] [Indexed: 05/27/2023]
Abstract
The focus of this study is to enhance the protein fouling resistance, hydrophilicity, biocompatibility, hemocompatibility and ability of the membranes and to reduce health complications like chronic pulmonary disease, peripheral vascular disease, cerebrovascular disease, and cardiovascular disease after dialysis, which are the great challenges in HD applications. In the current study, the PSF-based dialysis membranes are studied broadly. Significant consideration has also been provided to membrane characteristics (e.g., flowrate coefficient, solute clearance characteristic) and also on commercially available polysulfone HD membranes. PSF has gained a significant share in the development of HD membranes, and continuous improvements are being made in the process to make high flux PSF-based dialysis membranes with enhanced biocompatibility and improved protein resistance ability as the major issue in the development of membranes for HD application is biocompatibility. There has been a great increase in the demand for novel biocompatible membranes that offer the best performances during HD therapy, for example, low oxidative stress and low change ability of blood pressure.
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Affiliation(s)
- Shafiq Uz Zaman
- Department of Chemical Engineering, Ghulam Ishaq Khan Institute of Engineering Sciences and Technology, Topi, Khyber Pakhtunkhwa, Pakistan.
| | - Sikander Rafiq
- Department of Chemical Polymer and Composite Materials Engineering, University of Engineering and Technology Lahore, New Campus, Pakistan.
| | - Abulhassan Ali
- Department of Chemical Engineering, University of Jeddah, Jeddah, Saudi Arabia.
| | - Muhammad Shozab Mehdi
- Department of Chemical Engineering, Ghulam Ishaq Khan Institute of Engineering Sciences and Technology, Topi, Khyber Pakhtunkhwa, Pakistan.
| | - Amber Arshad
- Department of Community Medicine, King Edward Medical University, Lahore, Pakistan.
| | - Saif-Ur Rehman
- Department of Chemical Engineering, COMSATS University Islamabad, Lahore Campus, Pakistan.
| | - Nawshad Muhammad
- Department of Dental Materials, Institute of Basic Medical Sciences, Khyber Medical University, Peshawar, Pakistan.
| | - Muhammad Irfan
- Centre of Environmental Sustainability and Water Security (IPASA), School of Chemical and Energy Engineering, Universiti Teknologi Malaysia, 81310, Johor Bahru, Johor, Malaysia.
| | | | | | - Abdulkader S Hanbazazah
- Department of Industrial and Systems Engineering, University of Jeddah, Jeddah, Saudi Arabia.
| | - Hooi Ren Lim
- Department of Chemical and Environmental Engineering, Faculty Science and Engineering, University of Nottingham, Malaysia, 43500, Semenyih, Selangor Darul Ehsan, Malaysia.
| | - Pau Loke Show
- Department of Chemical and Environmental Engineering, Faculty Science and Engineering, University of Nottingham, Malaysia, 43500, Semenyih, Selangor Darul Ehsan, Malaysia.
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Membranas en terapias depurativas continuas. ENFERMERIA INTENSIVA 2022. [DOI: 10.1016/j.enfi.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Bowry SK, Kircelli F, Misra M. Flummoxed by flux: the indeterminate principles of haemodialysis. Clin Kidney J 2022; 14:i32-i44. [PMID: 34987784 PMCID: PMC8711754 DOI: 10.1093/ckj/sfab182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 11/22/2022] Open
Abstract
In haemodialysis (HD), unwanted substances (uraemic retention solutes or ‘uraemic toxins’) that accumulate in uraemia are removed from blood by transport across the semipermeable membrane. Like all membrane separation processes, the transport requires driving forces to facilitate the transfer of molecules across the membrane. The magnitude of the transport is quantified by the phenomenon of ‘flux’, a finite parameter defined as the volume of fluid (or permeate) transferred per unit area of membrane surface per unit time. In HD, as transmembrane pressure is applied to facilitate fluid flow or flux across the membrane to enhance solute removal, flux is defined by the ultrafiltration coefficient (KUF; mL/h/mmHg) reflecting the hydraulic permeability of the membrane. However, in HD, the designation of flux has come to be used in a much broader sense and the term is commonly used interchangeably and erroneously with other measures of membrane separation processes, resulting in considerable confusion. Increased flux is perceived to reflect more ‘porous’ membranes having ‘larger’ pores, even though other membrane and therapy attributes determine the magnitude of flux achieved during HD. Adjectival designations of flux (low-, mid-, high-, super-, ultra-) have found indiscriminate usage in the scientific literature to qualify a parameter that influences clinical decision making and prescription of therapy modalities (low-flux or high-flux HD). Over the years the concept and definition of flux has undergone arbitrary and periodic adjustment and redefinition by authors in publications, regulatory bodies (US Food and Drug Administration) and professional association guidelines (European Renal Association, Kidney Disease Outcomes Quality Initiative), with little consensus. Industry has stretched the boundaries of flux to derive marketing advantages, justify increased reimbursement or contrive new classes of therapy modalities when in fact flux is just one of several specifications that determine membrane or dialyser performance. Membranes considered as high-flux previously are today at the lower end of the flux spectrum. Further, additional parameters unrelated to the rate of diffusive or convective transport (flux) are used in conjunction with or in place of KUF to allude to flux: clearance (mL/min, e.g. of β2-microglobulin) or sieving coefficients (dimensionless). Considering that clinical trials in nephrology, designed to make therapy recommendations and guide policy with economic repercussions, are based on the parameter flux they merit clarification—by regulatory authorities and scientists alike—to avoid further misappropriation.
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Affiliation(s)
- Sudhir K Bowry
- Dialysis-at-Crossroads (D@X) Advisory, Bad Nauheim, Germany
| | - Fatih Kircelli
- Global Medical Information and Education, Fresenius Medical Care, Bad Homburg, Germany
| | - Madhukar Misra
- Department of Medicine, Division of Nephrology, University of Missouri, Columbia, MO, USA
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Apel C, Hornig C, Maddux FW, Ketchersid T, Yeung J, Guinsburg A. Informed decision-making in delivery of dialysis: combining clinical outcomes with sustainability. Clin Kidney J 2021; 14:i98-i113. [PMID: 34987789 PMCID: PMC8711764 DOI: 10.1093/ckj/sfab193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 12/31/2022] Open
Abstract
As the prevalence of chronic kidney disease is expected to rise worldwide over the next decades, provision of renal replacement therapy (RRT), will further challenge budgets of all healthcare systems. Most patients today requiring RRT are treated with haemodialysis (HD) therapy and are elderly. This article demonstrates the interdependence of clinical and sustainability criteria that need to be considered to prepare for the future challenges of delivering dialysis to all patients in need. Newer, more sustainable models of high-value care need to be devised, whereby delivery of dialysis is based on value-based healthcare (VBHC) principles, i.e. improving patient outcomes while restricting costs. Essentially, this entails maximizing patient outcomes per amount of money spent or available. To bring such a meaningful change, revised strategies having the involvement of multiple stakeholders (i.e. patients, providers, payers and policymakers) need to be adopted. Although each stakeholder has a vested interest in the value agenda often with conflicting expectations and motivations (or motives) between each other, progress is only achieved if the multiple blocs of the delivery system are advanced as mutually reinforcing entities. Clinical considerations of delivery of dialysis need to be based on the entire patient disease pathway and evidence-based medicine, while the non-clinical sustainability criteria entail, in addition to economics, the societal and ecological implications of HD therapy. We discuss how selection of appropriate modes and features of delivery of HD (e.g. treatment modalities and schedules, selection of consumables, product life cycle assessment) could positively impact decision-making towards value-based renal care. Although the delivery of HD therapy is multifactorial and complex, applying cost-effectiveness analyses for the different HD modalities (conventional in-centre and home HD) can support in guiding payability (balance between clinical value and costs) for health systems. For a resource intensive therapy like HD, concerted and fully integrated care strategies need to be urgently implemented to cope with the global demand and burden of HD therapy.
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Affiliation(s)
- Christian Apel
- Health Economics and Market Access EMEA, Fresenius Medical Care, Bad Homburg, Germany
| | - Carsten Hornig
- Health Economics and Market Access EMEA, Fresenius Medical Care, Bad Homburg, Germany
| | - Frank W Maddux
- Global Medical Office, Fresenius Medical Care, Waltham, MA, USA
| | | | - Julianna Yeung
- Health Economics & Market Access Asia-Pacific, Fresenius Medical Care, Hong Kong
| | - Adrian Guinsburg
- Global Medical Office, Fresenius Medical Care, Buenos Aires, Argentina
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Cronin B, O'Brien EO. Intraoperative Renal Replacement Therapy: Practical Information for Anesthesiologists. J Cardiothorac Vasc Anesth 2021; 36:2656-2668. [PMID: 34750060 DOI: 10.1053/j.jvca.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 09/02/2021] [Accepted: 10/01/2021] [Indexed: 11/11/2022]
Abstract
Previous publications regarding perioperative renal replacement therapy (RRT) have focused on the general care of the RRT-dependent patient and provided a broad overview of the various RRT modalities. The goal of this review article is to provide anesthesiologists with specific practical information regarding the possible intraoperative advantages and limitations of each modality, mandatory equipment to institute intraoperative therapy, and background knowledge necessary to communicate effectively with nephrologists and/or support staff regarding the intraoperative RRT goals.
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Affiliation(s)
- Brett Cronin
- Department of Anesthesiology, University of California, San Diego, UCSD Medical Center, San Diego, CA.
| | - E Orestes O'Brien
- Department of Anesthesiology, University of California, San Diego, UCSD Medical Center, San Diego, CA.
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Kostoglou M, Karabelas AJ. Reliable fluid-mechanical characterization of haemofilters: Addressing the deficiencies of current standards and practices. Artif Organs 2021; 45:1348-1359. [PMID: 34181759 DOI: 10.1111/aor.14031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 06/16/2021] [Accepted: 06/23/2021] [Indexed: 11/30/2022]
Abstract
Facile methods for accurate fluid-mechanical characterization of haemofilters (HF) are indispensable for haemofiltration process improvements, equipment design/optimization, and reliable module specifications. Currently employed methods, implemented through specific experimental in vitro protocols, are assessed herein in detail, considering the conditions prevailing during haemofiltration. Minimum number of key parameters required to fully describe the common countercurrent flow field, in the HF active section, include membrane permeance K and friction coefficients in lumen and shell side (ff and fs ). It is shown that the countercurrent flow mode itself is incapable of yielding these parameters, based on externally measured flow rates and pressures. Similarly, the relevant ISO protocol is deficient as it can only provide rough underpredictions of permeance K. The causes of such inherent deficiencies of current standards and practices are analyzed. In contrast, a recently developed methodology, accounting for the (heretofore ignored) pressure drop in module headers and combining a mechanistic theoretical model with experimental data from 2 special haemofilter operating modes, yields an accurate determination of the key parameters (K, ff , fs ). Additionally, it permits a full description of flow field for Newtonian liquids, for both constant and axially varying viscosity in fiber-lumen due to the transmembrane flux. Development of new reliable standards is suggested, facilitated by the insights gained in this work.
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Affiliation(s)
- Margaritis Kostoglou
- Department of Chemistry, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasios J Karabelas
- Chemical Process and Energy Resources Institute, Centre for Research and Technology - Hellas, Thessaloniki, Greece
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10
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Kostoglou M, Moschona A, Karabelas AJ, Sioutopoulos DC. Implementation and validation of an innovative method for fluid mechanical characterization of haemo-catharsis modules. J Memb Sci 2021. [DOI: 10.1016/j.memsci.2021.119117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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11
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Meyer JM, Steer D, Weber LA, Zeitone AA, Thakuria M, Ho CH, Aslam S, Mullon C, Kossmann RJ. Safety of a Novel Dialyzer Containing a Fluorinated Polyurethane Surface-Modifying Macromolecule in Patients with End-Stage Kidney Disease. Blood Purif 2021; 50:959-967. [PMID: 33789265 DOI: 10.1159/000514937] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/01/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND By inhibiting the adsorption of protein and platelets, surface-modifying macromolecules (SMMs) may improve the hemocompatibility of hemodialyzers. This trial aims to assess the performance and safety of a novel dialyzer with a fluorinated polyurethane SMM, Endexo™. METHODS This prospective, sequential, multicenter, open-label study (NCT03536663) was designed to meet regulatory requirements for clinical testing of new hemodialyzers, including assessment of the in vivo ultrafiltration coefficient (Kuf). Adults prescribed thrice-weekly hemodialysis were eligible for enrollment. After completing 12 hemodialysis sessions with an Optiflux® F160NR dialyzer, patients received 38 sessions with the dialyzer with Endexo. Evaluated parameters included the in vivo Kuf of the dialyzer with Endexo extent of removal of urea, albumin, and β2-microglobulin (β2M), as well as complement activation. RESULTS Twenty-three patients received 268 hemodialysis treatments during the Optiflux period, and 18 patients received 664 hemodialysis treatments during the Endexo period. Three serious adverse events were reported, and none of them were considered device related. No overt complement activation was observed with either dialyzer. Both dialyzers were associated with comparable mean increases in serum albumin levels from pre- to posthemodialysis (Optiflux: 7.9%; Endexo: 8.0%). These increases can be viewed in the context of a mean increase in hemoglobin of approximately 5% and a mean ultrafiltration volume removed of approximately 2.2 L. The corrected mean β2M removal rate was 47% higher during the Endexo period (67.73%). Mean treatment times (208 vs. 205 min), blood flow rates (447.7 vs. 447.5 mL/min), dialysate flow rates (698.5 vs. 698.0 mL/min), urea reduction ratio (82 vs. 81%), and spKt/V (2.1 vs. 1.9) were comparable for the Endexo and Optiflux periods, respectively. The mean (SD) Kuf was 15.85 (10.33) mL/h/mm Hg during the first use of the dialyzer with Endexo (primary endpoint) and 16.36 (9.92) mL/h/mm Hg across the Endexo period. CONCLUSIONS The safety of the novel dialyzer with Endexo was generally comparable to the Optiflux dialyzer, while exhibiting a higher β2M removal rate.
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Affiliation(s)
- Jill M Meyer
- California Institute of Renal Research, Chula Vista, California, USA
| | - Dylan Steer
- California Institute of Renal Research, San Diego, California, USA
| | - Lisa A Weber
- Research Management Inc./Kansas Nephrology Research, Wichita, Kansas, USA
| | - Abeer A Zeitone
- Fresenius Medical Care North America, Renal Therapies Group, Waltham, Massachusetts, USA
| | - Mayuri Thakuria
- Fresenius Medical Care North America, Renal Therapies Group, Waltham, Massachusetts, USA
| | - Chiang-Hong Ho
- Fresenius Medical Care North America, Renal Therapies Group, Waltham, Massachusetts, USA
| | - Shakil Aslam
- Fresenius Medical Care North America, Renal Therapies Group, Waltham, Massachusetts, USA
| | - Claudy Mullon
- Fresenius Medical Care North America, Renal Therapies Group, Waltham, Massachusetts, USA
| | - Robert J Kossmann
- Fresenius Medical Care North America, Renal Therapies Group, Waltham, Massachusetts, USA
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12
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Karabelas AJ, Kostoglou M, Moschona A, Sioutopoulos DC. Method development for experimental determination οf key fluid-mechanical parameters of haemo-catharsis modules. J Memb Sci 2020. [DOI: 10.1016/j.memsci.2020.118353] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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13
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Buckberry C, Hoenich N, Komenda P, Wallace M, Milad JE. Flow balance optimization and fluid removal accuracy with the Quanta SC+ hemodialysis system. Expert Rev Med Devices 2020; 17:835-843. [PMID: 32700578 DOI: 10.1080/17434440.2020.1796634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Fluid management is integral to hemodialysis, both to correct abnormalities in a patient's plasma composition and to maintain fluid balance. Consequently, accurate net fluid removal during treatment is a critical design element of hemodialysis machines. As dialyzers have evolved, with increased ranges of ultrafiltration coefficients available, it has become more challenging for dialysis machines to minimize errors in flow balance and net fluid removal. RESEARCH DESIGN AND METHODS This paper describes the design, evaluation and experimental performance of the flow balance and ultrafiltration module of the SC+ system to deliver clinically specified fluid removal with both passive and active control measures, in laboratory conditions designed to simulate a wide range of therapies. RESULTS The use of passive and active control allows the errors to be minimized across a wider dynamic range of conditions. For the SC+ system, the average flow balance error was 1 mL/hr with an SD of 19 mL/hr and with ultrafiltration it was 13 mL/hr and an SD of 20 ml/hr across all conditions. CONCLUSIONS This paper demonstrates that the SC+ hemodialysis system, a small, simple and versatile CE marked device, operates within the limits required by international standards across a wide range of experimental conditions.
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Affiliation(s)
- Clive Buckberry
- Engineering Department, Quanta Dialysis Technologies Ltd , Alcester, UK
| | | | | | - Mark Wallace
- Engineering Department, Quanta Dialysis Technologies Ltd , Alcester, UK
| | - John E Milad
- Engineering Department, Quanta Dialysis Technologies Ltd , Alcester, UK
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14
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Ficheux A, Gayrard N, Szwarc I, Duranton F, Vetromile F, Brunet P, Servel MF, Jankowski J, Argilés À. Measuring intradialyser transmembrane and hydrostatic pressures: pitfalls and relevance in haemodialysis and haemodiafiltration. Clin Kidney J 2019; 13:580-586. [PMID: 32905251 PMCID: PMC7467581 DOI: 10.1093/ckj/sfz033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 03/01/2019] [Indexed: 11/23/2022] Open
Abstract
Background Post-dilutional haemodiafiltration (HDF) with high convection volumes (HCVs) could improve survival. HCV-HDF requires a significant pressure to be applied to the dialyser membrane. The aim of this study was to assess the pressure applied to the dialysers in HCV-HDF, evaluate the influence of transmembrane pressure (TMP) calculation methods on TMP values and check how they relate to the safety limits proposed by guidelines. Methods Nine stable dialysis patients were treated with post-dilutional HCV-HDF with three different convection volumes [including haemodialysis (HD)]. The pressures at blood inlet (Bi), blood outlet (Bo) and dialysate outlet (Do) were continuously recorded. TMP was calculated using two pressures (TMP2: Bo, Do) or three pressures (TMP3: Bo, Do, Bi). Dialysis parameters were analysed at the start of the session and at the end of treatment or at the first occurrence of a manual intervention to decrease convection due to TMP alarms. Results During HD sessions, TMP2 and TMP3 remained stable. During HCV-HDF, TMP2 remained stable while TMP3 clearly increased. For the same condition, TMP3 could be 3-fold greater than TMP2. This shows that the TMP limit of 300 mmHg as recommended by guidelines could have different effects according to the TMP calculation method. In HCV-HDF, the pressure at the Bi increased over time and exceeded the safety limits of 600 mmHg provided by the manufacturer, even when respecting TMP safety limits. Conclusions This study draws our attention to the dangers of using a two-pressure points TMP calculation, particularly when performing HCV-HDF.
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Affiliation(s)
- Alain Ficheux
- RD - Néphrologie, Montpellier, France.,BC2M, Univ Montpellier, Montpellier, France
| | - Nathalie Gayrard
- RD - Néphrologie, Montpellier, France.,BC2M, Univ Montpellier, Montpellier, France
| | - Ilan Szwarc
- Centre de dialyse de Sète, Néphrologie Dialyse St Guilhem, Sète, France
| | - Flore Duranton
- RD - Néphrologie, Montpellier, France.,BC2M, Univ Montpellier, Montpellier, France
| | | | - Philippe Brunet
- Hôpital de La Conception, Université Aix-Marseille, Service de Néphrologie, Marseille, France
| | | | - Joachim Jankowski
- Institute for Molecular Cardiovascular Research, RWTH Aachen University, Aachen, Germany
| | - Àngel Argilés
- RD - Néphrologie, Montpellier, France.,BC2M, Univ Montpellier, Montpellier, France.,Centre de dialyse de Sète, Néphrologie Dialyse St Guilhem, Sète, France
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15
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Abstract
The objectives of hemodialysis have moved from the diffusive clearance of small molecular weight uremic toxins and achieving dialyzer urea adequacy targets to emphasis on improving clinical outcomes in end stage renal failure patients by increasing larger sized uremic toxin clearance. Clinical emphasis in the last few decades has focused on increasing middle molecule weight toxin clearance by hemodiafiltration. Although long-term data is still lacking, short-term outcomes appear promising. Advancements in nanotechnology have now introduction a new generation of medium cut-off membrane dialyzers which allow diffusive clearance of similar middle molecular weight uremia toxin clearance as hemodiafiltration, without increased albumin losses. As these dialyzers have only recently been introduced into clinical practice, no long-term outcomes are available to determine the relative benefits or advantages of this approach. As dialyzers are now designed to maximize diffusive or convective clearance, or provide a combination, then clinicians can now choose dialyzers tailored to the individual patient needs depending on clinical circumstances. We review the key important features in choosing a dialyzer for patients with end stage renal failure and acute kidney injury.
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Affiliation(s)
- Sabrina Haroon
- National University Hospital, UCL department of renal medicine, London, UK
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
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16
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Gayrard N, Ficheux A, Duranton F, Guzman C, Szwarc I, Vetromile F, Cazevieille C, Brunet P, Servel MF, Argilés À, Le Quintrec M. Consequences of increasing convection onto patient care and protein removal in hemodialysis. PLoS One 2017; 12:e0171179. [PMID: 28166268 PMCID: PMC5293266 DOI: 10.1371/journal.pone.0171179] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 01/17/2017] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Recent randomised controlled trials suggest that on-line hemodiafiltration (OL-HDF) improves survival, provided that it reaches high convective volumes. However, there is scant information on the feasibility and the consequences of modifying convection volumes in clinics. METHODS Twelve stable dialysis patients were treated with high-flux 1.8 m2 polysulphone dialyzers and 4 levels of convection flows (QUF) based on GKD-UF monitoring of the system, for 1 week each. The consequences on dialysis delivery (transmembrane pressure (TMP), number of alarms, % of achieved prescribed convection) and efficacy (mass removal of low and high molecular weight compounds) were analysed. RESULTS TMP increased exponentially with QUF (p<0.001 for N >56,000 monitoring values). Beyond 21 L/session, this resulted into frequent TMP alarms requiring nursing staff interventions (mean ± SEM: 10.3 ± 2.2 alarms per session, p<0.001 compared to lower convection volumes). Optimal convection volumes as assessed by GKD-UF-max were 20.6 ± 0.4 L/session, whilst 4 supplementary litres were obtained in the maximum situation (24.5 ± 0.6 L/session) but the proportion of sessions achieving the prescribed convection volume decreased from 94% to only 33% (p<0.001). Convection increased high molecular weight compound removal and shifted the membrane cut-off towards the higher molecular weight range. CONCLUSIONS Reaching high convection volumes as recommended by the recent RCTs (> 20L) is feasible by setting an HDF system at its optimal conditions based upon the GKD-UF monitoring. Prescribing higher convection volumes resulted in instability of the system, provoked alarms, was bothersome for the nursing staff and the patients, rarely achieved the prescribed convection volumes and increased removal of high molecular weight compounds, notably albumin.
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Affiliation(s)
- Nathalie Gayrard
- RD–Néphrologie and EA7288, University of Montpellier, Montpellier, France
| | - Alain Ficheux
- RD–Néphrologie and EA7288, University of Montpellier, Montpellier, France
| | - Flore Duranton
- RD–Néphrologie and EA7288, University of Montpellier, Montpellier, France
| | - Caroline Guzman
- RD–Néphrologie and EA7288, University of Montpellier, Montpellier, France
| | - Ilan Szwarc
- Centre de dialyse Néphrologie Dialyse St Guilhem, Sète, France
| | | | | | - Philippe Brunet
- Service de Néphrologie, Hôpital de La Conception–Université Aix-Marseille, Marseille, France
- European Uraemic Toxin Working Group of ESAO, endorsed by ERA-EDTA (EUTox), Krems, Austria
| | | | - Àngel Argilés
- RD–Néphrologie and EA7288, University of Montpellier, Montpellier, France
- Centre de dialyse Néphrologie Dialyse St Guilhem, Sète, France
- European Uraemic Toxin Working Group of ESAO, endorsed by ERA-EDTA (EUTox), Krems, Austria
| | - Moglie Le Quintrec
- Service de Néphrologie et Transplantation, Hôpital Lapeyronie CHU Montpellier, Montpellier, France
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17
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Ficheux A, Gayrard N, Duranton F, Guzman C, Szwarc I, Vetromile F, Brunet P, Servel M, Argilés A. A reliable method to assess the water permeability of a dialysis system: the global ultrafiltration coefficient. Nephrol Dial Transplant 2017; 32:364-370. [PMID: 28186570 PMCID: PMC5837204 DOI: 10.1093/ndt/gfw370] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 09/12/2016] [Indexed: 12/25/2022] Open
Abstract
Background Recent randomized controlled trials suggest that sufficiently high convection post-dilutional haemodiafiltration (HC-HDF) improves survival in dialysis patients, consequently this technique is increasingly being adopted. However, when performing HC-HDF, rigorous control systems of the ultrafiltration setting are required. Assessing the global ultrafiltration coefficient of the dialysis system [GKD-UF; defined as ultrafiltration rate (QUF)/transmembrane pressure] or water permeability may be adapted to the present dialysis settings and be of value in clinics. Methods GKD-UF was determined and its reproducibility, variability and influencing factors were specifically assessed in 15 stable patients routinely treated by high-flux haemodialysis or HC-HDF in a single unit. Results GKD-UF invariably followed a parabolic function with increasing QUF in dialysis and both pre- and post-dilution HC-HDF (R2 constantly >0.96). The vertex of the parabola, GKD-UF-max and related QUF were very reproducible per patient (coefficient of variation 3.9 ± 0.6 and 3.3 ± 0.3%, respectively) and they greatly varied across patients (31–42 mL/h−1/mmHg and 82–100 mL/min, respectively). GKD-UF-max and its associated QUF decreased during dialysis treatment (P < 0.01). The GKD-UF-max decrease was related to weight loss (R2 = 0.66; P = 0.0015). Conclusions GKD-UF is a reliable and accurate method to assess the water permeability of a system in vivo. It varies according to dialysis setting and patient-related factors. It is an objective parameter evaluating the forces driving convection and identifies any diversion of the system during the treatment procedure. It is applicable to low- or high-flux dialysis as well as pre- or post-dilution HDF. Thus, it may be used to describe the characteristics of a dialysis system, is suitable for clinical use and may be of help for personalized prescription.
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Affiliation(s)
- A. Ficheux
- RD – Néphrologie and Groupe Rein et HTA, EA7288, Université de Montpellier 1, 34093 Montpellier cedex 5, France
| | - N. Gayrard
- RD – Néphrologie and Groupe Rein et HTA, EA7288, Université de Montpellier 1, 34093 Montpellier cedex 5, France
| | - F. Duranton
- RD – Néphrologie and Groupe Rein et HTA, EA7288, Université de Montpellier 1, 34093 Montpellier cedex 5, France
| | - C. Guzman
- RD – Néphrologie and Groupe Rein et HTA, EA7288, Université de Montpellier 1, 34093 Montpellier cedex 5, France
| | - I. Szwarc
- Centre de dialyse de Sète, Néphrologie Dialyse St Guilhem, 34204 Sète, France
| | - F. Vetromile
- Centre de dialyse de Sète, Néphrologie Dialyse St Guilhem, 34204 Sète, France
| | - P. Brunet
- Service de Néphrologie, Hôpital de La Conception, Université Aix-Marseille, 13005 Marseille, France
| | - M.F. Servel
- Centre de dialyse de Sète, Néphrologie Dialyse St Guilhem, 34204 Sète, France
| | - A. Argilés
- RD – Néphrologie and Groupe Rein et HTA, EA7288, Université de Montpellier 1, 34093 Montpellier cedex 5, France
- Centre de dialyse de Sète, Néphrologie Dialyse St Guilhem, 34204 Sète, France
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18
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Ficheux A, Ronco C, Brunet P, Argilés À. The ultrafiltration coefficient: this old 'grand inconnu' in dialysis. Nephrol Dial Transplant 2013; 30:204-8. [PMID: 24362905 PMCID: PMC4309188 DOI: 10.1093/ndt/gft493] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Alain Ficheux
- RD - Néphrologie and Groupe Rein et HTA, EA3127, Institut Universitaire de Recherche Clinique IURC - UM1 , Montpellier 34090, France
| | - Claudio Ronco
- Department of Nephrology Dialysis and Transplantation, International Renal Research Institute (IRRIV), San Bortolo Hospital, Vicenza 36100, Italy
| | - Philippe Brunet
- Service de Néphrologie, Hôpital de La Conception - Université Aix-Marseille, Marseille 13005, France
| | - Àngel Argilés
- RD - Néphrologie and Groupe Rein et HTA, EA3127, Institut Universitaire de Recherche Clinique IURC - UM1 , Montpellier 34090, France Centre de dialyse de Sète, Néphrologie Dialyse St Guilhem, Sète 34204, France
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19
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Schneditz D. TMP revisited: the importance of plasma colloid osmotic pressure in high-flux dialysers. Nephrol Dial Transplant 2011; 26:411-3. [DOI: 10.1093/ndt/gfq784] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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