Emerging technologies in extracorporeal treatment: focus on adsorption

Effect of the oxygenic groups on activated carbon on its hemocompatibility

In this research, the effect of the oxygenic groups on activated carbon on its hemocompatibility was studied by liquid-phase oxidation to introduce oxygenic groups on its surface and subsequent heat treatment under a nitrogen environment to remove these groups. Hemocompatibility was assessed through coagulation, hemolysis, platelet adhesion, and protein adsorption using rabbit blood samples. Results showed that an increasing presence of oxygenic groups improved hemocompatibility, evidenced by enhanced coagulation, reduced hemolysis, better platelet adhesion, and decreased fetal bovine serum protein adsorption. Conversely, the removal of oxygenic groups diminished hemocompatibility, except for coagulation when groups were removed at 250 ℃ for 15 min. Therefore, this research presents a promising route to enhance the hemocompatibility of activated carbon, offering insights into surface modification for improved biomaterial design.

The early start of hemoperfusion decreases the mortality rate among severe COVID-19 patients: A preliminary study

BACKGROUND

Coronavirus disease-2019 (COVID-19)-related organ failure is partly related to a sepsis-like syndrome and extreme pro-inflammatory cytokine release, named cytokine storm. Therapeutic strategies that prevent the production of or remove the pro-inflammatory cytokines could potentially be an effective therapy in critically afflicted COVID-19 patients.

METHODS

In this clinical trial study, from April until June 2020, 68 COVID-19 patients (35 vs. 33 controls) with severe critical symptoms, and PaO₂ /FiO₂ (P/F) ratio less than 200 mmHg either received a single standard therapy or a combination of standard treatment for COVID-19 combined with hemoperfusion (hemofilter, HA330 D Javfron) for 4 h, in 3 consecutive days. The length of hospital stay and mechanical ventilation, the resolution of radiologic abnormalities, and the mortality rate were defined as the primary outcomes.

RESULTS

Demographic characteristics, the acute physiology, and chronic health evaluation score of both groups were similar (p > 0.05). Importantly, we noticed a significant mortality rate reduction in the perfused group compared with controls (37.1% vs. 63.6%, p = 0.02), this positive effect was stronger among those with a P/F ratio higher than 75 (mortality rate of 84.7% for P/F ratio < 75 vs. 15.4% for P/F ratio ≥ 75, p = 0.02).

CONCLUSIONS

The results imply that early start of hemoperfusion could be more effective and significantly reduce the mortality rate among COVID-19 patients with critical diseases.

Kinetics of Bilirubin and Ammonia Elimination during Hemadsorption Therapy in Secondary Sclerosing Cholangitis Following ECMO Therapy and Severe COVID-19

In critically ill patients, liver dysfunction often results in coagulopathy and encephalopathy and is associated with high mortality. Extracorporeal clearance of hepatotoxic metabolites, including bilirubin and ammonia, aims to attenuate further hepatocyte damage and liver injury, resulting in decreased mortality. The efficacy of hemadsorption combined with conventional hemodialysis to eliminate bilirubin and ammonia to support the liver's excretory function in acute liver injury has been described previously. However, the optimal use of liver support systems in chronic liver dysfunction due to secondary sclerosing cholangitis in critically ill patients (SSC-CIP) has not been defined yet. We herein describe the kinetics of successful bilirubin and ammonia elimination by hemadsorption in a patient with SSC-CIP after extracorporeal membrane oxygenation (ECMO) therapy for severe acute respiratory distress syndrome (ARDS) in a patient with coronavirus disease 2019 (COVID-19). During the course of the disease, the patient developed laboratory signs of liver injury during ECMO therapy before clinically detectable jaundice or elevated bilirubin levels. A diagnosis of SSC-CIP was confirmed by endoscopic retrograde cholangiopancreatography (ERCP) based on intraductal filling defects in the intrahepatic bile ducts due to biliary casts. The patient showed stable elevations of bilirubin and ammonia levels thereafter, but presented with progressive nausea, vomiting, weakness, and exhaustion. Based on these laboratory findings, hemadsorption was combined with hemodialysis treatment and successfully eliminated bilirubin and ammonia. Moreover, direct comparison revealed that ammonia is more efficiently eliminated by hemadsorption than bilirubin levels. Clinical symptoms of nausea, vomiting, weakness, and exhaustion improved. In summary, bilirubin and ammonia were successfully eliminated by hemadsorption combined with hemodialysis treatment in SSC-CIP following ECMO therapy and severe COVID-19. This observation is particularly relevant since it has been reported that a considerable subset of critically ill patients with COVID-19 suffer from liver dysfunction associated with high mortality.

Uremic Toxins and Blood Purification: A Review of Current Evidence and Future Perspectives

Accumulation of uremic toxins represents one of the major contributors to the rapid progression of chronic kidney disease (CKD), especially in patients with end-stage renal disease that are undergoing dialysis treatment. In particular, protein-bound uremic toxins (PBUTs) seem to have an important key pathophysiologic role in CKD, inducing various cardiovascular complications. The removal of uremic toxins from the blood with dialytic techniques represents a proved approach to limit the CKD-related complications. However, conventional dialysis mainly focuses on the removal of water-soluble compounds of low and middle molecular weight, whereas PBTUs are strongly protein-bound, thus not efficiently eliminated. Therefore, over the years, dialysis techniques have been adapted by improving membranes structures or using combined strategies to maximize PBTUs removal and eventually prevent CKD-related complications. Recent findings showed that adsorption-based extracorporeal techniques, in addition to conventional dialysis treatment, may effectively adsorb a significant amount of PBTUs during the course of the sessions. This review is focused on the analysis of the current state of the art for blood purification strategies in order to highlight their potentialities and limits and identify the most feasible solution to improve toxins removal effectiveness, exploring possible future strategies and applications, such as the study of a synergic approach by reducing PBTUs production and increasing their blood clearance.

Hemoperfusion as a Supportive Treatment in a COVID-19 Patient with Late Pulmonary Thromboembolism: A Case Report

In late 2019, the world encountered an unexpected new virus, resulting in a highly challenging new pandemic. The case presented here involves a 73-year-old man experiencing fever and respiratory distress, who was ultimately diagnosed with COVID-19. During the course of his hospitalization, the patient developed acute respiratory distress syndrome (ARDS), followed by being intubated due to his breathing difficulties. Because of variations in the patient’s clinical features, we decided to perform hemoperfusion to remove cytokines. Afterward, his clinical status improved significantly, and he was discharged in stable condition. However, 26 days later, fever and respiratory distress manifested again. After evaluation, pulmonary thromboembolism was confirmed through computed tomography (ie, CT scan).

Ex vivo evaluation of the blood compatibility of mixed matrix haemodialysis membranes

The patients with end stage kidney disease need haemodialysis therapies, using an artificial kidney. Nevertheless, the current therapies cannot remove a broad range of uremic toxins compared to the natural kidney. Adsorption therapies, using sorbent-based columns, can improve the clearance of uremic toxins, but the sorbent particles often require polymeric coatings to improve their haemocompatibility leading to mass transfer limitations and to lowering of their performance. Earlier, we have developed a dual layer Mixed Matrix fiber Membrane (MMM) based on polyethersulfone/polyvinylpyrrolidone (PES/PVP) polymer blends. There, the sorbent activated carbon particles are embedded in the outer membrane layer for achieving higher removal whereas the inner blood contacting selective membrane layer should achieve optimal blood compatibility. In this work, we evaluate in detail the haemocompatibility of the MMM following the norm ISO 10993-4. We study two generations of MMM having different dimensions and transport characteristics; one with low flux and no albumin leakage and another with high flux but some albumin leakage. The results are compared to those of home-made PES/PVP single layer hollow fiber and to various control fibers already applied in the clinic. Our results show that the low flux MMM successfully avoids contact of blood with the activated carbon and has good haemocompatibility, comparable to membranes currently used in the clinic. STATEMENT OF SIGNIFICANCE: Haemodialysis is a life-sustaining extracorporeal treatment for renal disease, however a broad range of uremic toxins cannot still be removed. In our previous works we showed that a double layer Mixed Matrix Membrane (MMM) composed of polyethersulfone/polyvinylpyrrolidone and activated carbon can achieve higher removal of uremic toxics compared to commercial haemodialysers. In this work we evaluate the haemocompatibility profile of the MMM in order to facilitate its clinical implementation. The lumen particle-free layer of the MMM successfully avoids the contact of blood with the poorly blood-compatible activated carbon. Moreover, thanks to the high amount of polyvinylpyrrolidone and to the smoothness of the lumen layer, the MMM has very good haemocompatibility, comparable to membranes currently used in the clinic.

Hemocompatible hemoadsorbent for effective removal of protein-bound toxin in serum

Resin hemoperfusion is a life-saving treatment for drug intoxication or hepatic failure of patients. However, current resin adsorbents exhibit a limited hemocompatibility or low adsorption efficiency, representing a major roadblock to successful clinical applications. In this work, we developed a hemocompatible and effective hemoadsorbent based on polystyrene resin (H103) microparticles encapsulated in anti-biofouling zwitterionic poly(carboxybetaine) (PCB) hydrogels. Apart from a strong mechanical stability, this PCB-based adsorbent (PCB-H103) exhibited excellent hemocompatibility (hemolysis ratio was ∼0.64%), which was attributed to the anti-biofouling property of PCB hydrogel. In addition, it can efficiently adsorb both small and middle molecular weight molecules in phosphate-buffered saline, and the efficiencies were significantly higher than poly(ethylene glycol) methacrylate-based and poly(2-hydroxyethyl methacrylate)-based adsorbent counterparts, indicating the favorable permeability of PCB hydrogel coating. More importantly, PCB-H103 could effectively remove protein-bound toxins including phenol red and bilirubin in bovine serum albumin solution or even in 100% fetal bovine serum (FBS). In 100% FBS, the adsorption capacity of PCB-H103 towards bilirubin was 8.3 times higher than that of pristine clinical-scale resin beads. Findings in this work may provide a new strategy for the development of modern resin hemoperfusion technology.

Bead-type polystyrene/nano-CaCO3 (PS/nCaCO3) composite: a high-performance adsorbent for the removal of interleukin-6

A novel nano-CaCO₃ (nCaCO₃) particle composite-derived polystyrene (PS) resin was successfully synthesized by a suspension polymerization method. The nCaCO₃ reinforced PS material (PS/nCaCO₃) possessed a structure with abundant mesopores of high porosity, high specific surface area (828.3 m² g^-1) and large pore volume (1.83 cm³ g^-1). It was revealed that the incorporation of nCaCO₃ into the PS matrix enhanced both the mechanical strength which can prevent the fragmentation and its adsorption capacity for interleukin-6 (IL-6, M_W = 24.0 kDa) from human plasma. The adsorption isotherm could be described by the Langmuir model and classified as S-3 type, showing an IL-6 uptake of up to 25.6 ng g^-1 at an equilibrium concentration of about 500 ng L^-1. The adsorption capacity for IL-6 of PS/nCaCO₃ is not only significantly higher than that of PS (without nCaCO₃), but also superior to those of currently available adsorbents that are under clinical studies (e.g., CytoSorb™ towards cytokines). In addition, the PS/nCaCO₃ adsorbent also had good hemocompatibility and showed no leakage of nCaCO₃ in the plasma in a flowing model system. Therefore, the synthesized PS/nCaCO₃ nano-composite has a great potential to be used as an efficient adsorbent for the removal of interleukin-6 (IL-6) from blood of inflammatory and auto-immune disease patients through hemoperfusion.

Surface-Engineered Blood Adsorption Device for Hyperphosphatemia Treatment

Correspondence: Melanie S. Joy, PharmD, PhD, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Pharmaceutical Sciences, Mail Stop C238, Room V20-4108, 12850 East Montview Blvd, Aurora, CO 80045. Email: Melanie.Joy@ucdenver.edu The research employed surface engineering methods to develop, optimize, and characterize a novel textile-based hemoadsorption device for hyperphosphatemia in hemodialysis-dependent end-stage kidney disease. Phosphate adsorbent fabrics (PAFs) were prepared by thermopressing alumina powders to polyester filtration fabrics and treatment with trimesic acid (TMA). For static experiments, phosphate adsorption capacity in buffer solution, plasma, and blood were evaluated by submersing the PAFs in 100 ml. For dynamic experiments, PAFs were equipped in a device prototype and incorporated in a pump-driven circuit. Phosphates were determined by a colorimetric assay and an Ortho Clinical Diagnostics Vitros 5600 Integrated analyzer. The maximum loading amount of TMA-alumina on PAFs was approximately 35 g/m under 260°C processing temperature. Phosphate adsorption capacity increased with initial concentration. Adsorption isotherms from buffer demonstrated a maximum phosphate adsorption capacity of approximately 893 mg/m at 37.5°C, pH 7.4, with similar results from plasma and whole blood. Measured phosphate concentrations during simulations demonstrated a 42% reduction, confirming the high capacity of the PAFs for removing phosphate from whole blood. Results from the current study indicated that an alumina-TMA treated PAF can dramatically reduce phosphate concentrations from biological samples. The technology could potentially be used as a tunable adsorbent for managing hyperphosphatemia in kidney disease.

Nanoporous biomaterials for uremic toxin adsorption in artificial kidney systems: A review

Hemodialysis, one of the earliest artificial kidney systems, removes uremic toxins via diffusion through a semipermeable porous membrane into the dialysate fluid. Miniaturization of the present hemodialysis system into a portable and wearable device to maintain continuous removal of uremic toxins would require that the amount of dialysate used within a closed-system is greatly reduced. Diffused uremic toxins within a closed-system dialysate need to be removed to maintain the optimum concentration gradient for continuous uremic toxin removal by the dialyzer. In this dialysate regenerative system, adsorption of uremic toxins by nanoporous biomaterials is essential. Throughout the years of artificial kidney development, activated carbon has been identified as a potential adsorbent for uremic toxins. Adsorption of uremic toxins necessitates nanoporous biomaterials, especially activated carbon. Nanoporous biomaterials are also utilized in hemoperfusion for uremic toxin removal. Further miniaturization of artificial kidney system and improvements on uremic toxin adsorption capacity would require high performance nanoporous biomaterials which possess not only higher surface area, controlled pore size, but also designed architecture or structure and surface functional groups. This article reviews on various nanoporous biomaterials used in current artificial kidney systems and several emerging nanoporous biomaterials. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 1232-1240, 2017.

Adsorption properties of an activated carbon for 18 cytokines and HMGB1 from inflammatory model plasma

The ability of an activated carbon (AC) to adsorb 18 different cytokines with molecular weights ranging from 8 kDa to 70 kDa and high mobility group box-1 (HMGB1) from inflammatory model plasma at 310 K and the mechanisms of adsorption were examined. Porosity analysis using N2 gas adsorption at 77K showed that the AC had micropores with diameters of 1-2 nm and mesopores with diameters of 5-20 nm. All 18 cytokines and HMGB1 were adsorbed on the AC; however, the shapes of the adsorption isotherms changed depending on the molecular weight. The adsorption isotherms for molecules of 8-10 kDa, 10-20 kDa, 20-30 kDa, and higher molecular weights were classified as H-2, L-3, S-3, and S-1 types, respectively. These results suggested that the adsorption mechanism for the cytokines and HMGB1 in the mesopores and on the surface of the AC differed as a function of the molecular weight. On the basis of these results, it can be concluded that AC should be efficient for cytokine adsorption.

Pore Size – a Key Property for Selective Toxin Removal in Blood Purification

Purpose

Extracorporeal blood purification systems based on combined membrane/adsorption technologies are used in acute liver failure to replace detoxification as well as to remove inflammatory mediators in sepsis patients. In addition to coating and chemical modification of the surface, pore size significantly controls the selectivity of adsorption materials.

Methods

This study addresses the adsorption of albumin bound liver toxins, cytokines, and representative plasma compounds on three adsorbents which differ only in pore size distribution. All three adsorbents are based on hydrophobic poly(styrene-divinylbenzene) copolymer matrices and have mean pore sizes of 15, 30, and 100 nm.

Results

The pores of adsorbents act as molecular sieves and prevent the entry of molecules that are larger than their molecular cut-off. The results of this study reveal that adsorbents based on styrene-divinylbenzene polymers with 15 nm pores are suitable for cytokine removal, and the same adsorbents with 30-40 nm pores are the best choice for the removal of albumin-bound toxins in the case of liver failure. Adsorbents with very large pores lack selectivity which leads to uncontrolled adsorption of all plasma proteins. Therefore, hydrophobic adsorbents with large pores offer inadequate plasma compatibility and do not fulfill the requirements for blood purification.

Conclusions

Biocompatibility and efficiency of adsorbents used for blood purification can improved by fine tuning of adsorbent surface pore distributions.

Recrudescent digoxin toxicity treated with plasma exchange: a case report and review of literature

A 53-year-old woman presented with digitalis toxicity caused by acute overdose that manifested as atrial tachycardia with block, sinus pauses, and competing AV junctional rhythm with atrial fibrillation. Patient admitted to overdosing with digoxin 15-20 h before presentation with intent to commit suicide. Serum digoxin level was 35.6 ng/ml and renal function was normal. Patient was treated with 1,040 mg of digoxin-specific antibody Fab fragment with prompt resolution of arrhythmias and restoration of sinus rhythm. Four hours after digoxin antibody administration, serum digoxin level declined to 0.2 ng/ml. Eighteen hours after treatment with Fab fragment, patient developed premature ventricular complexes, atrial tachycardia with and without atrioventricular block, and non-sustained ventricular tachycardia followed by ventricular fibrillation from which she was successfully resuscitated. Electrocardiogram showed no evidence of acute myocardial infarction, and emergent coronary angiogram did not reveal significant coronary artery disease. Repeat digoxin level was 20.4 ng/ml. A diagnosis of recrudescent digoxin toxicity was made and the patient was treated with one session of plasma exchange with resolution of arrhythmias. Immediately after plasma exchange, digoxin level decreased to 10.4 ng/ml, and after 10 h, the level further decreased to 6.6 ng/ml. The following day, digoxin level had decreased to 2.9 ng/ml. Our experience with this case would suggest that plasma exchange should be considered as a treatment modality for recrudescent digoxin toxicity.

Dynamics of elimination of bacterial endotoxins and cytokines from the blood of tumor patients with sepsis in hemoperfusion using carbon adsorbents

We studied the effects of carbon adsorbent hemoperfusion on the dynamics of LPS and cytokine concentrations in the blood of cancer patients with sepsis and septic shock. In addition, hemadsorbent washout fluid specimens after hemoperfusion were analyzed. A significant (3-fold) reduction of blood LPS levels after hemoperfusion was found, while shifts in free cytokine levels in the sera were negligible. At the same time, hemadsorbents used in the study effectively eliminated some free cytokines (IL-6, -8, -12, IFN-γ, TNF-α) from the blood.

Possibility of microorganism elimination from the blood using modified coal hemosorbents

We studied the possibility of using coal hemosorbents for elimination gram-positive and gram-negative microorganisms from the blood. After hemosorption, the number of S. aureus and K. pneumoniae pneumoniae colony-forming units significantly decreased. The obtained results indicate that coal sorbents can bind and probably eliminate gram-positive and gram-negative bacteria from the blood.

Activation-dependent adsorption of cytokines and toxins related to liver failure to carbon beads

In the course of severe pathological conditions, such as acute liver failure and sepsis, toxic metabolites and mediators of inflammation are released into the patient's circulation. One option for the supportive treatment of these conditions is plasmapheresis, in which plasma, after being separated from the cellular components of the blood, is cleansed by adsorption of harmful molecules on polymers or activated carbon. In this work, the adsorption characteristics of activated carbon beads with levels of activation ranging from 0 to 86% were assessed for both hydrophobic compounds accumulating in liver failure (bilirubin, cholic acid, phenol and tryptophan) and cytokines (tumor necrosis factor α and interleukin-6). Progressive activation resulted in significant gradual reduction of both bulk density and mean particle size, in an increase in the specific surface area, and to changes in pore size distribution with progressive broadening of micropores. These structural changes went hand in hand with enhanced adsorption of small adsorbates, such as IL-6 and cholic acid and, to a lesser extent, also of large molecules, such as TNF-α.

Microscopic Perspective on the Adsorption Isotherm of a Heterogeneous Surface

Adsorption of dissolved molecules onto solid surfaces can be extremely sensitive to the atomic-scale properties of the solute and surface, causing difficulties for the design of fluidic systems in industrial, medical and technological applications. In this communication, we show that the Langmuir isotherm for adsorption of a small molecule to a realistic, heterogeneous surface can be predicted from atomic structures of the molecule and surface through molecular dynamics (MD) simulations. We highlight the method by studying the adsorption of dimethyl-methylphosphonate (DMMP) to amorphous silica substrates and show that subtle differences in the atomic-scale surface properties can have drastic effects on the Langmuir isotherm. The sensitivity of the method presented is sufficient to permit the optimization of fluidic devices and to determine fundamental design rules for controlling adsorption at the nanoscale.

Mesoporous carbide-derived carbon with porosity tuned for efficient adsorption of cytokines

Porous carbons can be used for the purification of various bio-fluids, including the cleansing blood of inflammatory mediators in conditions such as sepsis or auto-immune diseases. Here we show that the control of pore size in carbons is a key factor to achieving efficient removal of cytokines. In particular, the surface area accessible by the protein governs the rate and effectiveness of the adsorption process. We demonstrate that novel mesoporous carbon materials synthesized from ternary MAX-phase carbides can be optimized for efficient adsorption of large inflammatory proteins. The synthesized carbons, having tunable pore size with a large volume of slit-shaped mesopores, outperformed all other materials or methods in terms of efficiency of TNF-alpha removal and the results are comparable only with highly specific antibody-antigen interactions.

Assessing the in vitro biocompatibility of a novel carbon device for the treatment of sepsis

The aim of the present study was to conduct a preliminary investigation into the blood biocompatibility of a novel, uncoated carbon for use in a filtration/adsorption device for the treatment of sepsis. Carbon well prototypes were manufactured from phenol-formaldehyde-aniline-based pyrolysed carbons using monolithic polymer technology. Inflammatory blood cell and plasma protein mediation of the inflammatory response were evaluated using the novel carbon prototypes and compared with dialyser membrane and tissue culture plate controls. Assays determining monocyte and granulocyte adhesion, platelet adhesion and activation, granulocyte activation and complement activation were performed. Preliminary findings suggest an adsorptive but passivating carbon surface. Moderate levels of monocyte and granulocytes adhesion were seen in conjunction with adsorption of plasma proteins to the carbon surface. Activation of granulocyte and adherent platelets was not detected and the complement cascade was not activated by the carbons, indicating a surface compatible with blood contact. The results support the further development of the proposed carbon-based device for the treatment of sepsis.

Development and Characterization of a New Stationary Phase for an Immunoadsorption Wall

This study introduces a newly developed method for the formation of a stationary phase superficially embedded with immunoadsorbent, that is partially incomplete two-stage polymerization of acrylamide. Preliminary experimental studies show that binding activity of the immunoadsorbent was satisfactorily maintained after immobilization. With an appropriate configuration of selected immunoadsorption matrices and immunoisolation barriers, it is hoped that this stationary phase could be used to resolve some difficult problems arising from the accumulation of certain middle molecular weight toxins not removed by other blood purification procedures.