High

Report
Dialyzer Selection
Sirirat Reungjui, MD.
Khon Kaen University
Content
1.
Type of dialyzer and
membrane
2.
Selection of dialyzer
3.
Effect on outcomes
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Evolution of dialyzer
Stewart Capillary Cordis Dow CDAKs
Travenol-Kolff
Coil, Fiber
Kiil
Plate
Dialyzer,
First
Hollow
Dialyzers,
Kolff Rotating
Drum,
Skeggs
Leonards
Plate,
Gambro
Plate
Dialyzers,
BaxterCa.
CA170
Baxter
CT190G
FMC F80
1956
1960
Ca. 1943 Ca. 1964 - 1967Ca. 1948
1979
High Efficiency Ca. 1967
High- Flux
High Flux
Structure
Blood inlet
Header
Solution outlet
Fiber
Jecket
Solution inlet
Blood outlet
Ideal dialyzer
• Remove small and large solutes
• Reliable convective and UF properties
• Biocompatible / Safety
• Protect blood from dialysate
contaminants (backfiltration)
Progressive renal failure
Uremic
toxins
Retention
of solutes
Uremic syndrome
Deterioration of multiple biochemical
& physiological functions
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
Diffusion
Concentration gradient, small molecule
Convection
Movement of water (ultrafiltration), middle mol.
Hydroxyl
groups
Contaminant
dialysate
Complement
activation
Cytokine
ROS
Neutophil,
Monocyte
Dialyzer reactions
• Type A (anaphylactic type)
• Ethylene oxide, AN-69 (ACEI),
contaminant dialysate, heparin,
complement release ?, eosinophilia
• Type B (nonspecific)
• Complement activation
Bioincompatibility
• Amyloidosis – β 2 microglobulin
• Immune depression
• Loss of residual renal function
• Catabolism and malnutrition
• Inflammation/ Atherosclerosis
TMP
Dialysate
Pressure
Blood
Dialysate
Pressure
Blood
positive
negative
Dialyzer length
Definitions
Efficiency
High
Moderate
Low
KoA (ml/min)
< 500
500 – 700
> 700
KoA; Mass transfer area coefficient
(maximum theoretical Cl at infinite BFR, DFR)
Definitions
Flux
Kuf (ml/h/mmHg)
High
Low
< 10
> 20
Kuf; Ultrafiltration
coefficient
β 2 -microglobulin
Permeability
clearance (ml/min)
High
Low
< 10
> 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
Unmodified
Cuprophan
- Good for small solutes
- Bioincompatible
Low
flux
• Cellulose acetate/diacetate
- Low / middle Kuf
• Cellulose triacetate
- Middle / high Kuf
- More biocompatible
Cellulose
membrane
Synthetic membrane
LF-BI LF-BC LF-BC HFcell
syn
cell
Low
complement
activation
Reflect
dialysate
impurities
Adsorption
MM removal
HFsyn
-
++
++
++
+++
-
-
++
-
++
-
-
+/-
++
+
++
single-pool Kt/V 1.32 vs 1.71
High dose
Standard
RR 0.96 , p = 0.53
HEMO study group. N Engl J Med. 2002;347(25):2010-9.
Cβ2 microglobulin 3 vs 34 ml/min
RR 0.68 , pt on HD > 3.7 years
High flux
Low flux
RR 0.92, P = 0.23
HEMO study group. N Engl J Med. 2002;347(25):2010-9.
Relative risk
Serum β-2 M Levels Predict Mortality
< 27.5 mg/L
< 27.5 27.5-35 35-42.5 42.5-50 > 50
Predialysis serum β 2 M (mg/L)
HEMO study group. J Am Soc Nephrol 17: 546–555, 2006.
Membrane Permeability Outcome (MPO) Study
Survival probability of patients
Diabetic patients, p = 0.039
Alb ≤ 4 g/dl, p = 0.032
No. at risk
High-flux
Low-flux
High-flux membrane
Low-flux membrane
0
12
24
36 48 60
Months
83
74
67
59
55
40
46
29
27
19
14
11
72
84
7
3
3
0
Locatelli F, et al. J ASN; 20: 645–54, 2009
cardiovascular event-free survival
Hi Flux / Ultrapure
HRgroup;
0.73 HR 0.61, p = 0.03
AVF
p
=
0.03
P
=
0.12 HR 0.49, p = 0.03
DM group;
EGE Study group. J Am Soc Nephrol 24: 1014–23, 2013
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

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