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Dialyzer Selection

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,

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Dialyzer Selection

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  1. Dialyzer Selection SiriratReungjui, MD. KhonKaen University

  2. Content Type of dialyzer and membrane 1. 2. Selection of dialyzer Effect on outcomes 3. Add your text in here

  3. Evolution of dialyzer Stewart Capillary Cordis Dow CDAKs First Hollow Fiber Dialyzers, Ca. 1964 - 1967 Kolff Rotating Drum, Ca. 1943 SkeggsLeonards Plate, Ca. 1948 Travenol-Kolff Coil, Ca. 1956 Kiil Plate Dialyzer, Ca. 1960 Gambro Plate Dialyzers, Ca. 1967 - 1979 Baxter CA170 High Efficiency Baxter CT190G High Flux FMC F80 High Flux

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

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

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

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

  8. Diffusion Concentration gradient, small molecule

  9. Convection Movement of water (ultrafiltration), middle mol.

  10. Hydroxyl groups Complement activation Cytokine ROS Neutophil, Monocyte Contaminant dialysate

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

  12. Bioincompatibility • Amyloidosis – β2microglobulin • Immune depression • Loss of residual renal function • Catabolism and malnutrition • Inflammation/ Atherosclerosis

  13. TMP Dialysate Blood positive Blood Dialysate Pressure Pressure negative Dialyzer length

  14. Definitions KoA; Mass transfer area coefficient (maximum theoretical Cl at infinite BFR, DFR)

  15. Definitions Kuf; Ultrafiltrationcoefficient

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

  17. Type of membrane • Unmodified cellulose • Substituted cellulose • Cellulosynthetic membrane • Synthetic membrane

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

  19. Synthetic membrane Cellulose membrane

  20. single-pool Kt/V 1.32 vs 1.71 High dose RR 0.96 , p = 0.53 Standard HEMO study group. N Engl J Med. 2002;347(25):2010-9.

  21. Cβ2 microglobulin 3vs 34 ml/min RR 0.68 , pt on HD > 3.7 years High flux RR 0.92, P = 0.23 Low flux HEMO study group. N Engl J Med. 2002;347(25):2010-9.

  22. Serum β-2 M Levels Predict Mortality < 27.5 mg/L Relative risk Predialysis serum β2 M (mg/L) HEMO study group. J Am Soc Nephrol 17: 546–555, 2006. < 27.5 27.5-35 35-42.5 42.5-50 > 50

  23. Membrane Permeability Outcome (MPO) Study Diabetic patients, p= 0.039 Alb ≤4 g/dl, p = 0.032 High-flux membrane Low-flux membrane Survival probability of patients 0 12 24 36 48 60 72 84 Months No. at risk High-flux 83 67 55 46 27 14 7 3 Low-flux 74 59 40 29 19 11 3 0 Locatelli F, et al. J ASN; 20: 645–54, 2009

  24. cardiovascular event-free survival Hi Flux / Ultrapure AVF group; HR 0.61, p = 0.03 DM group; HR 0.49, p = 0.03 HR 0.73 P = 0.12 p = 0.03 EGE Study group. J Am Soc Nephrol24: 1014–23, 2013

  25. 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

  26. Thank you! Contact Address: Prof. Somchai Doe Tel: Email: www.kku.ac.th

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