Blood-incompatibility in haemodialysis: alleviating inflammation and effects of coagulation

Blood-incompatibility is an inevitability of all blood-contacting device applications and therapies, including haemodialysis (HD). Blood leaving the environment of blood vessels and the protection of the endothelium is confronted with several stimuli of the extracorporeal circuit (ECC), triggering the activation of blood cells and various biochemical pathways of plasma. Prevention of blood coagulation, a major obstacle that needed to be overcome to make HD possible, remains an issue to contend with. While anticoagulation (mainly with heparin) successfully prevents clotting within the ECC to allow removal of uraemic toxins across the dialysis membrane wall, it is far from ideal, triggering heparin-induced thrombocytopenia in some instances. Soluble fibrin can form even in the presence of heparin and depending on the constitution of the patient and activation of platelets, could result in physical clots within the ECC (e.g. bubble trap chamber) and, together with other plasma and coagulation proteins, result in increased adsorption of proteins on the membrane surface. The buildup of this secondary membrane layer impairs the transport properties of the membrane to reduce the clearance of uraemic toxins. Activation of complement system-dependent immune response pathways leads to leukopenia, formation of platelet–neutrophil complexes and expression of tissue factor contributing to thrombotic processes and a procoagulant state, respectively. Complement activation also promotes recruitment and activation of leukocytes resulting in oxidative burst and release of pro-inflammatory cytokines and chemokines, thereby worsening the elevated underlying inflammation and oxidative stress condition of chronic kidney disease patients. Restricting all forms of blood-incompatibility, including potential contamination of dialysis fluid with endotoxins leading to inflammation, during HD therapies is thus still a major target towards more blood-compatible and safer dialysis to improve patient outcomes. We describe the mechanisms of various activation pathways during the interaction between blood and components of the ECC and describe approaches to mitigate the effects of these adverse interactions. The opportunities to develop improved dialysis membranes as well as implementation strategies with less potential for undesired biological reactions are discussed.

Porous polymeric membranes: fabrication techniques and biomedical applications

Porous polymeric membranes have shown great potential in biological and biomedical applications such as tissue engineering, bioseparation, and biosensing, due to their structural flexibility, versatile surface chemistry, and biocompatibility. This review outlines the advantages and limitations of the fabrication techniques commonly used to produce porous polymeric membranes, with especial focus on those featuring nano/submicron scale pores, which include track etching, nanoimprinting, block-copolymer self-assembly, and electrospinning. Recent advances in membrane technology have been key to facilitate precise control of pore size, shape, density and surface properties. The review provides a critical overview of the main biological and biomedical applications of these porous polymeric membranes, especially focusing on drug delivery, tissue engineering, biosensing, and bioseparation. The effect of the membrane material and pore morphology on the role of the membranes for each specific application as well as the specific fabrication challenges, and future prospects of these membranes are thoroughly discussed.

Renal Function Replacement by Hemodialysis: Forty-Year Anniversary and a Glimpse into the Future at Hand

From its introduction in 1943 and until the late 1970s, hemodialysis (HD) has been a lengthy and cumbersome treatment administered by a few skilled physicians and technicians to a very limited number of terminal kidney patients. The technological innovations introduced over the years made HD a treatment administered and supervised by nursing personnel to a very large numbers of kidney patients, hopefully until recovery of kidney functions or kidney transplantation. In 2013, it is estimated that 2.250.00 kidney patients were treated worldwide, and their number is steadily increasing. Shortage of transplant kidneys and quality of current treatments has contributed to increasing the survival of HD patients. Today, it is not unusual to find patients who have been on HD for longer than twenty years. All this generated the feeling that performance of membranes and dialysis technology has reached its limit. Recently, the increasing economic burden of healthcare caused by people ageing and the increasing incidence of degenerative diseases (e.g. diabetes and cardiovascular diseases), and the economic crisis has pushed many governments and health insurances to cut resources for healthcare. The main consequence is that investments in research and development in HD have been significantly reduced. The question is whether there is indeed no need for innovation in HD.

In this paper, it is discussed how the paradigm of HD has changed and what possibly are now the drivers for innovation in HD. A few ideas are proposed that could be developed by adapting existing technologies to the future needs of HD.

Influence of cultivation conditions on mechanical and morphological properties of bacterial cellulose tubes

Bacterial cellulose (BC) was deposited in tubular form by fermenting Acetobacter xylinum on top of silicone tubes as an oxygenated support and by blowing different concentrations of oxygen, that is, 21% (air), 35%, 50%, and 100%. Mechanical properties such as burst pressure and tensile properties were evaluated for all tubes. The burst pressure of the tubes increased with an increase in oxygen ratio and reached a top value of 880 mmHg at 100% oxygen. The Young's modulus was approximately 5 MPa for all tubes, irrespective of the oxygen ratio. The elongation to break decreased from 30% to 10-20% when the oxygen ratio was increased. The morphology of the tubes was characterized by Scanning Electron Microscopy (SEM). All tubes had an even inner side and a more porous outer side. The cross section indicated that the tubes are composed of layers and that the amount of layers and the yield of cellulose increased with an increase in oxygen ratio. We propose that an internal vessel wall with high density is required for the tube to sustain a certain pressure. An increase in wall thickness by an increase in oxygen ratio might explain the increasing burst pressure with increasing oxygen ratio. The fermentation method used renders it possible to produce branched tubes, tubes with unlimited length and inner diameters. Endothelial cells (ECs) were grown onto the lumen of the tubes. The cells formed a confluent layer after 7 days. The tubes potential as a vascular graft is currently under investigation in a large animal model at the Centre of Vascular Engineering, Sahlgrenska University

Polymers in nephrology. Characteristics and needs

Polymers employed as biomaterials in nephrology serve for different applications: they form membranes for dialysis and plasmapheresis, are used as materials for dialyser housings and as a potting mass for capillary membranes, they make up tubing-systems for extracorporeal circuits and - in the form of beads - act as parts of adsorber columns for hemoperfusion or immunoadsorption. However, generally speaking, many polymers have not yet been designed for their final application. To date, many polymers are still taken from the chemist's shelf according to their alleged performance properties or to their sterilisability. When used in medical application, polymers must show a high purity. Uncontrolled leaching of oligomers from the polymer backbone or of additives from or during the manufacturing process must be avoided. Blood and other body fluids are extremely effective in extracting any loosely bound polymers. During long-term application, e.g. in patients suffering from chronic diseases, these effects may lead to an accumulation of these compounds in circulating blood, tissue, or joints. Consequently, polymers should show an excellent biostability and not degrade during their ageing process. The amount of extractable material should be kept low in order to avoid inflammatory reactions. Polymers must have high blood compatibility in terms of minimized cell- and complement activation. Polymers for medical application should at best be able to stand high temperatures in order to survive steam sterilisation. If this is impossible, their release kinetics for residual quantities of sterilizing agents should be fast. Finally, protein adsorption should appear under controlled conditions, otherwise a reduced performance through protein adsorption will take place. Further, the uncontrolled activation of biochemical cascades, such as the coagulation, complement or contact phase cascade, following blood/material contact must be minimized. A final aspect has been recently made responsible for adverse patients reactions, the interaction between polymers and medicinal drugs. This drug/material interaction must be low, at best zero, apart form those situations, where a controlled drug-release is wanted. The chemical variety of polymers for medical application is large. However, all typical requirements cannot be met by one single polymer. Compromises have to be found between properties and application. Polymer selection for application in nephrology has always to be made under the premise of final application.

Quo vadis dialysis membrane?

The development of dialysis membranes is closely related to the development of dialysis as a routine therapy for patients with kidney failure. Without having membranes and dialyzers available as commodity products, the treatment of more than 1 million uremic patients worldwide would be impossible. Several transition periods can be identified: a change in membrane geometry from flat sheet to capillaries, a shift in market appreciation from cellulose to synthetic polymers, and from low-flux to high-flux dialyzers. This shift is supported by the notion that convective therapies using high-flux membranes allow the removal of large-molecular-weight solutes. From a historical background, three eras of perception can be identified for both membrane and dialysis development. First, the period of survival when nephrologists had to focus on techniques for blood access and availability of membranes. Second, the period of issues dedicated to rather specific features of membranes and dialysis therapy such as dose of dialysis, reuse, sterilization, and membrane biocompatibility. And third, the period of quality tops this sequence with a complicated approach: the principal area of interest from the medical community has switched to issues such as quality of life, morbidity, mortality, therapy standards, and cost-effectiveness. New membrane developments should focus on this situation.

Enzymatic acylation of hydroxypropyl cellulose in organic media and determination of ester formation by diffuse reflectance infrared Fourier transform (DRIFT) spectroscopy

Esters were prepared by acylation of hydroxypropyl cellulose with fatty acid catalyzed by immobilized lipase from Candida antarctica in tert-butanol. The nature of the substrates used, the initial water activity of the system, and the molecular weight of the hydroxypropyl cellulose were investigated. Moreover, Fourier transform-infrared (FT-IR) spectroscopy was used for determination of ester content on hydroxypropyl cellulose. Specifically, a linear relationship was established between the peak height assigned to the absorption of the esterified carboxyl groups of the cellulose and the ester content. At optimum reaction conditions, the ester content on the hydroxypropyl cellulose was about 11%.

Surface modification of the polymers present in a polysulfone hollow fiber hemodialyser by covalent binding of heparin or endothelial cell surface heparan sulfate: flow characteristics and platelet adhesion

The present study addresses the problem of simultaneous surface modification of various polymers, i.e. polysulfone (PSU), polycarbonate (PC), and polyurethane (PU), which constitute the Ultraflux AV 600 S hollow fibre hemodialyser. An investigation was first made into six different chemical routes aimed at introducing carboxyl groups onto the surface of PSU, PC, and PU model polymers to which heparin (HE) or endothelial cell surface heparan sulfate (ESHS) was covalently bound via the reaction of residual amino groups and a coupling reagent. Carboxyl groups were introduced using three specific reactions based on their nucleophilic or electrophilic introduction into aromatic repeating units of the polymers and three non-specific carboxylation reactions, i.e. UV, heat or redoxactivation via nitrene or radical species. Concentrations of 1-20 nmol COOH groups per cm(-2) led to HE or ESHS surface concentrations corresponding to one or several layers. Two nonspecific carboxylation reactions followed by HE- or ESHS-coupling provided the lowest change in membrane pore structure according to cut off, clearance (urea, phosphate, maltose), ultrafiltration, and diafiltration assessments. In some cases the introduction of excess negatively-charged carboxyl groups and HE improved the flux properties of the modified membranes. The various methods were applied to the dialysis module. Platelet adhesion was not observed in the case of the ESHS-coating of PSU membrane at shear rates of 1050 s(-1), whereas HE and subendothelial matrix showed 56 and 100% coverage, respectively, under similar conditions. The coating of PSU or of other high-flux membranes by ESHS appears a promising method for improving membrane properties and to generate biocompatibility characteristics similar to those of natural blood vessels, i.e. inertness to platelet adhesion and no level effects for complement and intrinsic coagulation cascade activation. The ESHS coating may be used without anticoagulants.

Cellulose carbamates and derivatives as hemocompatible membrane materials for hemodialysis

Dialysis membranes made from regenerated cellulose are under dispute because of their alleged lack of hemocompatibility. The introduction of membranes from synthetically modified cellulose, like cellulose acetate or Hemophan, has proven, however, that hemocompatible membranes can be fabricated from cellulose by means of chemical surface modifications. In addition to membranes made from modified cellulose like ethers or esters, which were investigated in earlier experiments, we looked for further cellulose modifications to be assessed for their hemocompatibility. For this purpose, we synthesized a series of cellulose carbamate derivatives to profit from the excellent hemocompatibility pattern of the urethane family. In vitro investigations on membranes made from these cellulose modifications proved a direct relationship between the degree of modification and hemocompatibility. This was proven for the following 3 representative hemocompatibility parameters: complement C5a generation, thrombin-antithrombin (TAT) III formation, and platelet count (PC). As already shown for modifications made from cellulose esters, a direct dependency between improved hemocompatibility and the degree of substitution (DS) in the cellulose molecule could be found. In our experiments, a degree of substitution below a value of 0.1 led to a nearly complete suppression of complement activation for all cellulose carbamates under investigation. In contrast to data on cellulose esters, we observed that molecular weight or molecular conformation of chemical substituents exerted only a minor effect on the hemocompatibility pattern. In addition, data on cellulose carbamate esters (e.g., cellulose succinate-phenyl-carbamate) show that a simultaneous but balanced substitution with hydrophilic and hydrophobic groups at the surface of the cellulose polymer is a further prerequisite for optimal hemocompatibility. It seems that the carbamate configuration per se has a positive effect on the hemocompatibility pattern of synthetically modified cellulose membranes.

Synthetically modified cellulose: an alternative to synthetic membranes for use in haemodialysis?

Renal replacement therapy relies predominantly on the use of cellulose-based membranes. Such membranes have a biocompatibility profile which is inferior to membranes manufactured from synthetic polymers. Synthetically modified cellulose (SMC) is a new, low-flux haemodialysis membrane in which hydroxyl groups have been replaced with benzyl groups. The biocompatibility profile characterized by changes in white cell and platelet counts and the activation of complement components (C3a, C5a and C5b-9) have been studied in vivo and compared with those of cellulose acetate, unmodified cellulose (Cuprophan ) and low-flux polysulphone (Fresenius Polysulfone) in the same group of patients. For SMC, the white cell count at 15 min declined to 65.6% of pretreatment level, compared with 63.8% for the cellulose acetate, 79.6% for low-flux polysulphone and 28.1% for Cuprophan, thereafter returning to pretreatment levels. Both modified cellulose membranes were superior to unmodified cellulose (P = 0.001); the differences between the modified cellulose membranes were not significant statistically. The changes induced by all three cellulose-based membranes exceeded those for low-flux polysulphone (P = 0.001). Associated with the neutropenia was a reduction in platelet count, but this was independent of membrane type. The mean time-averaged concentrations of C3a(des Arg) over 150 min were 1168 ng ml(-1) (SMC), 1030 ng ml(-1) (cellulose acetate), 1297 ng ml(-1) (Cuprophan) and 790 ng ml(-1) (low-flux polysulphone). Equivalent values for C5a(des Arg) were 6.12 (SMC), 2.98 (cellulose acetate), 11.03 (Cuprophan) and 1.33 ng ml(-1) (low-flux polysulphone). C5b-9 values were 385 (SMC), 386 (cellulose acetate), 177 (Cuprophan) and 185 ng ml(-1) (low-flux polysulphone). For each of the complement components the differences between the membranes were significant [P = 0.0009 (C3a(des Arg)), P = 0.0001 (c5a(des Arg) and C5b-9)]. The levels of C5b-9 generated during dialysis also showed a significant positive correlation compared to C5a for all membranes considered as a single group (Pearson's correlation coefficient = 0.870, P = 0.0001). It is concluded that the modification of the cellobiosic unit is a promising approach to improve the biocompatibility profile of cellulose-based membranes. The two different methods of modification lead to similar improvements in biocompatibility compared with unmodified cellulose, but as yet do not match that of low-flux polysulphone.

In vitro evaluation of heparinized Cuprophan hemodialysis membranes

Cuprophan hemodialysis membranes can be heparinized using N,N'-carbonyldiimidazole (CDI) as a coupling agent. In this study, the characteristics of heparinized Cuprophan membranes have been evaluated. After immobilization, heparin partially retained its biologic activity. An anticoagulant activity of 12.4 +/- 4.2 mU/cm2 was measured using a thrombin inactivation assay. Immobilized heparin also displayed an anti-complement activity. After contact with human serum; heparinized Cuprophan induced no generation of significant amounts of fluid phase terminal complement complex (TCC), whereas untreated Cuprophan induced the generation of substantial amounts of TCC. Heparinization did not affect the permeability of Cuprophan for model solutes with molecular weights up to 12,000 g/mol except for sulfobromophthalein sodium salt. The permeability of Cuprophan for sulfobromophthalein sodium salt was slightly decreased after heparinization. The ultrafiltration rate of Cuprophan increased by about 30% after heparinization, probably owing to an increased swelling of the membrane in water. Heparinized Cuprophan incubated in phosphate-buffered saline at 37 degrees C showed some release of heparin. These amounts of released heparin, however, were very low as compared to the amounts of heparin which are systemically administered during clinical hemodialysis treatment. It is concluded that Cuprophan membranes heparinized by means of the CDI-activation procedure are highly promising for application in hemodialyzers to be used for the treatment of patients with reduced or without systemic administration of heparin.

Considerations on developmental aspects of biocompatible dialysis membranes

Modern strategies in developing new polymers for dialysis membranes aim to improve their blood compatibility. To achieve such a goal, two approaches have been successfully applied: existing cellulosic polymers were modified, either by introducing functional groups through ester or ether bonds, by mixing synthetic polymers with bulk additives, or by using copolymerization techniques. As a detailed example, the first synthetically modified cellulose membrane, Hemophan, was prepared by substituting some hydrogen atoms in the cellulosic glucose unit by diethyl-amino-ethyl groups with the modification having a considerable impact on the membrane's hemocompatibility. It is further known that the hemocompatibility of hydrophobic synthetic membranes is improved by rendering these materials partially hydrophilic. We tested the hypothesis, whether the hemocompatibility of a material, which is hydrophilic per se, such as unmodified cellulose, is changed after the introduction of hydrophobic substituents. For this purpose, the number and nature of substituents have been systematically varied in order to alter surface properties, and these variations have been subsequently related to blood compatibility parameters. As expected, thrombin generation as well as complement- and cell-activation depend on the number and nature of the substituents whereby some of the substituents show a very narrow optimum if their hemocompatibility is related to the degree of substitution. Changes in hemocompatibility can be followed by physical methods, such as surface angle analyses and zeta potential determinations. Data show that alterations in the lipophilic/hydrophilic balance on the polymer surface may explain substituent-related changes in polymer hemocompatibility.(ABSTRACT TRUNCATED AT 250 WORDS)