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Dialyzer Selection. Sirirat Reungjui , MD. Khon Kaen University. Content. Type of dialyzer and membrane . 1. 2. Selection of dialyzer. Effect on outcomes. 3. Add your text in here. Evolution of dialyzer. Stewart Capillary Cordis Dow CDAKs First Hollow Fiber Dialyzers, - PowerPoint PPT Presentation
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Dialyzer SelectionSirirat Reungjui, MD.Khon Kaen University
Add your text in here
Content
1. Type of dialyzer and membrane
2. Selection of dialyzer
Effect on outcomes3.
Evolution of dialyzer
Kolff Rotating Drum,
Ca. 1943
Skeggs Leonards Plate,
Ca. 1948
Travenol-Kolff Coil,
Ca. 1956
Kiil Plate Dialyzer,Ca. 1960
Stewart Capillary Cordis Dow CDAKs
First Hollow Fiber Dialyzers,Ca. 1964 - 1967
Gambro Plate Dialyzers,Ca. 1967 - 1979
Baxter CA170High Efficiency
Baxter CT190GHigh Flux
FMC F80High Flux
StructureBlood inlet
Blood outlet
Fiber
Header
JecketSolution inlet
Solution outlet
Ideal dialyzer• Remove small and large solutes• Reliable convective and UF properties• Biocompatible / Safety• Protect blood from dialysate contaminants (backfiltration)
Retention of solutes
Uremic syndromeDeterioration of multiple biochemical
& physiological functions
Progressive renal failure
Uremic toxins
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
Hydroxyl groups
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
Dialyzer reactions
Bioincompatibility• Amyloidosis – β 2 microglobulin• Immune depression• Loss of residual renal function• Catabolism and malnutrition• Inflammation/ Atherosclerosis
Dialyzer lengthPr
essu
re positive
TMP
negativePres
sure
BloodDialysate
DialysateBlood
Definitions
Efficiency KoA (ml/min)
High < 500Moderate 500 – 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 < 10Low > 20
Permeability β 2 -microglobulin
clearance (ml/min)
High < 10Low > 20
Definitions
• 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
Unmodified Cellulose
• Cellulose acetate/diacetate
- Low / middle Kuf• Cellulose triacetate - Middle / high Kuf - More biocompatible
Synthetic membraneCellulose membrane
LF-BI
LF-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):2010-9.
Standard
High dose
HEMO study group. N Engl J Med. 2002;347(25):2010-9.
RR 0.92, P = 0.23
Cβ2 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, 2006.
Serum β-2 M Levels Predict Mortality
< 27.5 27.5-35 35-42.5 42.5-50 > 50
Rela
tive
ris
k
Diabetic patients, p = 0.039
Alb ≤ 4 g/dl, p = 0.032
Surv
ival
pro
babi
lity
of p
atie
nts
High-flux membraneLow-flux membrane
No. at riskHigh-flux 83 67 55 46 27 14 7 3 Low-flux 74 59 40 29 19 11 3 0
0 12 24 36 48 60 72 84 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 0.73P = 0.12
AVF group; HR 0.61, p = 0.03DM group; HR 0.49, p = 0.03p = 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
Thank you!
Contact Address: Prof. Somchai Doe Tel:Email: www.kku.ac.th