Dialyzer Selection Sirirat Reungjui, MD. Khon Kaen University

Add your text in here Content Type of dialyzer and membrane 2. Selection of dialyzer Effect on outcomes 3.

Evolution of dialyzer Kolff Rotating Drum, Ca Kolff Rotating Drum, Ca Skeggs Leonards Plate, Ca Skeggs Leonards Plate, Ca Travenol-Kolff Coil, Ca Travenol-Kolff Coil, Ca Kiil Plate Dialyzer, Ca Kiil Plate Dialyzer, Ca Stewart Capillary Cordis Dow CDAKs First Hollow Fiber Dialyzers, Ca Stewart Capillary Cordis Dow CDAKs First Hollow Fiber Dialyzers, Ca Gambro Plate Dialyzers, Ca Gambro Plate Dialyzers, Ca Baxter CA170 High Efficiency Baxter CA170 High Efficiency Baxter CT190G High Flux Baxter CT190G High Flux FMC F80 High Flux FMC F80 High Flux

Structure Blood inlet Blood outlet Fiber Header Jecket Solution inlet Solution outlet

Ideal dialyzer Remove small and large solutes Reliable convective and UF properties Biocompatible / Safety Protect blood from dialysate contaminants (backfiltration) Remove small and large solutes Reliable convective and UF properties Biocompatible / Safety Protect blood from dialysate contaminants (backfiltration)

Retention of solutes Uremic syndrome Deterioration of multiple biochemical & physiological functions Deterioration of multiple biochemical & physiological functions Progressive renal failure Uremic toxins

Larger, middle-molecules ( > 500 D) Larger, middle-molecules ( > 500 D) Lipid-soluble and/or protein-bound Uremic toxins Small, water-soluble, non-protein-bound ( < 500 D) European Uremic Toxin Work Group. JASN, 2012.

Diffusion Concentration gradient, small molecule

Movement of water (ultrafiltration), middle mol. Convection

Complementactivation Hydroxylgroups CytokineROS Neutophil,Monocyte Contaminant dialysate

Type A (anaphylactic type) Ethylene oxide, AN-69 (ACEI), contaminant dialysate, heparin, complement release ?, eosinophilia Type B (nonspecific) Complement activation Type A (anaphylactic type) Ethylene oxide, AN-69 (ACEI), contaminant dialysate, heparin, complement release ?, eosinophilia Type B (nonspecific) Complement activation Dialyzer reactions

Bioincompatibility Amyloidosis – β 2 microglobulin Immune depression Loss of residual renal function Catabolism and malnutrition Inflammation/ Atherosclerosis Amyloidosis – β 2 microglobulin Immune depression Loss of residual renal function Catabolism and malnutrition Inflammation/ Atherosclerosis

Dialyzer length Pressure positive TMP negative Pressure Blood Dialysate Blood

Definitions EfficiencyKoA (ml/min) High< 500 Moderate500 – 700 Low> 700 KoA; Mass transfer area coefficient (maximum theoretical Cl at infinite BFR, DFR)

Kuf; Ultrafiltration coefficient Definitions Flux Kuf (ml/h/mmHg) High< 10 Low> 20 Permeability β 2 -microglobulin clearance (ml/min) High< 10 Low> 20

Definitions Super-flux; Pressure drop Pore size Homogenous pores High performance; High flux Biocompatible Super-flux; Pressure drop Pore size Homogenous pores High performance; High flux Biocompatible

Type of membrane  Unmodified cellulose  Substituted cellulose  Cellulosynthetic membrane  Synthetic membrane

Substituted Cellulose Cuprophan - Good for small solutes - Bioincompatible - Low flux Cuprophan - Good for small solutes - Bioincompatible - Low flux Unmodified Cellulose Cellulose acetate/diacetate - Low / middle Kuf Cellulose triacetate - Middle / high Kuf - More biocompatible Cellulose acetate/diacetate - Low / middle Kuf Cellulose triacetate - Middle / high Kuf - More biocompatible

Synthetic membrane Cellulose membrane

LF-BILF-BC cell LF-BC syn HF- cell HF- syn Low complement activation Reflect dialysate impurities Adsorption--+/--+ MM removal---++

RR 0.96, p = 0.53 single-pool Kt/V 1.32 vs 1.71 HEMO study group. N Engl J Med. 2002;347(25): Standard High dose

HEMO study group. N Engl J Med. 2002;347(25): RR 0.92, P = 0.23 C β2 microglobulin 3 vs 34 ml/min RR 0.68, pt on HD > 3.7 years Low flux High flux

< 27.5 mg/L Predialysis serum β 2 M (mg/L) HEMO study group. J Am Soc Nephrol 17: 546–555, Serum β-2 M Levels Predict Mortality 50 Relative risk

Diabetic patients, p = Alb ≤ 4 g/dl, p = Diabetic patients, p = Alb ≤ 4 g/dl, p = Survival probability of patients High-flux membrane Low-flux membrane No. at risk High-flux Low-flux Months Membrane Permeability Outcome (MPO) Study Locatelli F, et al. J ASN; 20: 645–54, 2009

EGE Study group. J Am Soc Nephrol 24: 1014–23, 2013 cardiovascular event-free survival HR 0.73 P = 0.12 AVF group; HR 0.61, p = 0.03 DM group; HR 0.49, p = 0.03 AVF group; HR 0.61, p = 0.03 DM group; HR 0.49, p = 0.03 p = 0.03 Hi Flux / Ultrapure

Conclusion RCTs.. no difference in mortality Suggestion; synthetic high flux membrane - Duration > 3.7 yr, DM, Alb ≤ 4 g/dl, AVF Highest survival..high flux + ultrapure AKI (KDIGO 2012)…Biocompatible

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