Wearable artificial kidney: problems, progress and prospects

Surveillance and prevention of infection in clinical xenotransplantation

SUMMARYXenotransplantation, the transplantation of living organs, tissues, or cells between species, carries the potential to address the global shortage of human organs for patients with end-stage organ failure. Recent advances in genetic engineering have improved prospects for clinical xenotransplantation by reducing immune and inflammatory responses to grafts, controlling coagulation on endothelial surfaces, and modifying viral risks, including the porcine endogenous retrovirus (PERV). Management of infectious risks posed by clinical xenotransplantation requires meticulous attention to the biosecure breeding and microbiological surveillance of source animals and recipients and consideration of novel infection control requirements. Infectious risks in xenotransplantation stem from both known human pathogens in immunosuppressed transplant recipients and from porcine organisms for which the clinical manifestations, microbial assays, and therapies are generally limited. Both known and unknown zoonoses may be transmitted from pigs to humans. Some pig-specific pathogens do not infect human cells but have systemic manifestations when active within the xenograft, including porcine cytomegalovirus/porcine roseolovirus (PCMV/PRV), which contributes to graft rejection and consumptive coagulopathy. The role of porcine endogenous retrovirus (PERV) in humans remains uncertain despite the absence of documented transmissions and the availability of swine with inactivated genomic PERV. New technologies, such as metagenomic sequencing and multi-omics approaches, will be essential for detection of novel infections and for understanding interactions between the xenograft, the host's immune system, and potential pathogens. These approaches will allow development of infection control protocols, pathogen surveillance requirements, and tailored antimicrobial therapies to enhance the safety and success of clinical xenotransplantation.

Antifouling Zwitterionic Polymer Coatings for Blood-Bearing Medical Devices

Blood-bearing medical devices are essential for the delivery of critical care medicine and are often required to function for weeks to months. However, thrombus formation on their surfaces can lead to reduced device function and failure and expose patients to systemic thrombosis risks. While clinical anticoagulants reduce device related thrombosis, they also increase patient bleeding risk. The root cause of device thrombosis and inflammation is protein adsorption on the biomaterial surfaces of these devices. Protein adsorption activates the coagulation cascade and complement, and this, in turn, activates platelets and white blood cells. Surface modifications with zwitterionic polymers are particularly effective at reducing protein adsorption as well as conformational changes in proteins due to their hydrophilicity. Multiple coating strategies have been developed using carboxybetaine (CB), sulfobetaine (SB), and 2-methacryloyloxyethyl phosphorylcholine (MPC) zwitterionic polymers applied to the metals and hydrophobic polymers that make up the bulk of blood-bearing medical devices. These coatings have been highly successful at creating large reductions in protein adsorption and platelet adhesion during studies on the order of hours on flat surfaces and at reducing thrombus formation for up to a few days in full medical devices. Future work needs to focus on their ability to limit inflammation, particularly during hemodialysis, and in providing anticoagulation on the order of weeks, particularly in artificial lungs.

Thermal Vapor Deposition of a Hydrophobic and Gas-Permeable Membrane on Zirconium Phosphate Cation Exchanger: An Oral Sorbent for the Urea Removal of Kidney Failure

An oral sorbent with high capacity for NH4+ is desirable in lowering the blood urea level and mitigating the dialysis burden for end-stage kidney disease (ESKD) patients. Zirconium phosphate (ZrP) is an amorphous cation ion exchanger with high NH4+ binding capacity as a sorbent material, but its selectivity to remove NH4+ is limited in the presence of other competing ions in water solution. We previously have developed a gas-permeable and hydrophobic perfluorocarbon coating on ZrP, which improves ZrP's NH4+ selectivity. However, the coating preparation procedure, a wet chemistry approach, is complicated and time-consuming, and more importantly, the large amount of usage of acetone poses a concern for the application of ZrP as an oral sorbent. In this study, we developed a solventless coating protocol that effectively coats ZrP with tetraethyl orthosilicate (TEOS) and 1H,1H,2H,2H-perfluorooctyltriethoxysilane (FOTS) via thermal vapor deposition (TVD) in a simplified manner. X-ray photoelectron spectroscopy (XPS) and contact angle measurements verify the two coatings are successfully deposited on the ZrP surface, and the coating condition was optimized based on an in vitro static binding study. The dynamic binding study of competing ions on Na-loaded ZrP with TVD coatings yields a maximum NH4+ removal (∼3.2 mequiv/g), which can be improved to ∼4.7 mequiv/g if H-loaded ZrP under the same coating condition is used in basic stock solutions. More importantly, both materials barely remove Ca2+ and show excellent acid resistance. The significant improvement in the NH4+ binding capacity and selectivity reported here establishes a highly promising surface modification approach to optimize oral sorbents for ESKD patients.

Immobilized Urease Vector System Based on the Dynamic Defect Regeneration Strategy for Efficient Urea Removal

The clearance of urea poses a formidable challenge, and its excessive accumulation can cause various renal diseases. Urease demonstrates remarkable efficacy in eliminating urea, but cannot be reused. This study aimed to develop a composite vector system comprising microcrystalline cellulose (MCC) immobilized with urease and metal-organic framework (MOF) UiO-66-NH2, denoted as MCC@UiO/U, through the dynamic defect generation strategy. By utilizing competitive coordination, effective immobilization of urease into MCC@UiO was achieved for efficient urea removal. Within 2 h, the urea removal efficiency could reach up to 1500 mg/g, surpassing an 80% clearance rate. Furthermore, an 80% clearance rate can also be attained in peritoneal dialyzate from patients. MCC@UiO/U also exhibits an exceptional bioactivity even after undergoing 5 cycles of perfusion, demonstrating remarkable stability and biocompatibility. This innovative approach and methodology provide a novel avenue and a wide range of immobilized enzyme vectors for clinical urea removal and treatment of kidney diseases, presenting immense potential for future clinical applications.

Artificial kidney: Challenges and opportunities

This review aims to present the developments occurring in the field of artificial organs and particularly focuses on the presentation of developments in artificial kidneys. The challenges for biomedical engineering involved in overcoming the potential difficulties are showcased, as well as the importance of interdisciplinary collaboration in this marriage of medicine and technology. In this review, modern artificial kidneys and the research efforts trying to provide and promise artificial kidneys are presented. But what are the problems faced by each technology and to what extent is the effort enough to date?

Cell-inspired selective potassium removal towards hyperkalemia therapy by microphase-isolated core-shell microspheres

Hyperkalemia is a common metabolic problem in patients with chronic kidney disease. Although oral medications and hemodialysis are clinically applied for lowering serum potassium, the intrinsic limitations encourage alternative therapy in the trend of adsorbent-based miniaturized blood purification devices. Cells serve as the biological K⁺ storage units that accumulate K⁺ through multiple mechanisms. Inspired by cells, our strategy aims at favorable permeation and enrichment of K⁺ in the microsphere. We incorporate cation-affinitive groups into core-shell structures with submicron-sized phase separation. These nano-spaced side-groups cooperate to form interlinked clusters, where crown ethers with Angstrom-scale ring for size-matched complexation, while ionic sulfonic acid groups for hydrophilicity and charge-buffering. The unique structure with such non-covalent interactions facilitates K⁺ for permeation across the shell and binding to the core while also ensuring mechanical strength and anti-swelling durability in biofluids. The microspheres exhibit high selectivity ratios of K⁺ (S_K/Na, S_K/Ca, S_K/Mg up to 9.8, 21.6, and 17.7). As column adsorbents for hemoperfusion simulation, they effectively lower elevated K⁺ levels to the normal range (clearance rates up to 44.4%/45.3% for hyperkalemic human serum/blood). Blood compatibility tests show low protein adsorption, preferable hemocyte compatibility, and anticoagulation property in vitro. This promising strategy has clinical potential for hyperkalemia in high-risk patients. STATEMENT OF SIGNIFICANCE: Hyperkalemia (serum potassium >5 mmol/L) is a common complication in chronic renal failure patients. The limitations of existing treatments prompt a shift to wearable artificial kidney technology for clinical convenience and efficacy. Existing treatments have limitations, and we turn to adsorbent-based miniaturized blood purification devices in the prospect of wearable artificial kidney technology. There exists a lack of ion-specific adsorbents applied in extracorporeal circuits to redress electrolyte imbalances like hyperkalemia. Inspired by cells, we aim at the favorable permeation and enrichment of K⁺ by microspheres. The microspheres have a microphase-isolated core-shell structure, whose nano-spaced groups form cation-affinitive clusters. Selective K⁺ removal and blood compatibility are achieved. We expect this strategy to enlighten alternative hyperkalemia therapy for these high-risk patients.

Strategies for optimizing urea removal to enable portable kidney dialysis: A reappraisal

BACKGROUND

Portable hemodialysis has the potential to improve health outcomes and quality of life for patients with kidney failure at reduced costs. Urea removal, required for dialysate regeneration, is a central function of any existing/potential portable dialysis device. Urea in the spent dialysate coexists with non-urea uremic toxins, nutrients, and electrolytes, all of which will interfere with the urea removal efficiency, regardless of whether the underlying urea removal mechanism is based on urease conversion, direct urea adsorption, or oxidation. The aim of the current review is to identify the amount of the most prevalent chemicals being removed during a single dialysis session and evaluate the potential benefits of an urea-selective membrane for portable dialysis.

METHODS

We have performed a literature search using Web of Science and PubMed databases to find available articles reporting (or be able to calculate from blood plasma concentration) > 5 mg of individually quantified solutes removed during thrice-weekly hemodialysis sessions. If multiple reports of the same solute were available, the reported values were averaged, and the geometric mean of standard deviations was taken. Further critical literature analysis of reported dialysate regeneration methods was performed using Web of Science and PubMed databases.

RESULTS

On average, 46.0 g uremic retention solutes are removed in a single conventional dialysis session, out of which urea is only 23.6 g. For both urease- and sorbent-based urea removal mechanisms, amino acids, with 7.7 g removal per session, could potentially interfere with urea removal efficiency. Additionally for the oxidation-based urea removal system, plentiful nutrients such as glucose (24.0 g) will interfere with urea removal by competition. Using a nanofiltration membrane between dialysate and oxidation unit with a molecular weight cutoff (MWCO) of ~200 Da, 67.6 g of non-electrolyte species will be removed in a single dialysis session, out of which 44.0 g are non-urea molecules. If the membrane MWCO is further decreased to 120 Da, the mass of non-electrolyte non-urea species will drop to 9.3 g. Reverse osmosis membranes have been shown to be both effective at blocking the transport of non-urea species (creatinine for example with ~90% rejection ratio), and permissive for urea transport (~20% rejection ratio), making them a promising urea selective membrane to increase the efficiency of the oxidative urea removal system.

CONCLUSIONS

Compiled are quantified solute removal amounts greater than 5 mg per session during conventional hemodialysis treatments, to act as a guide for portable dialysis system design. Analysis shows that multiple chemical species in the dialysate interfere with all proposed portable urea removal systems. This suggests the need for an additional protective dialysate loop coupled to urea removal system and an urea-selective membrane.

Artificial Kidney Engineering: The Development of Dialysis Membranes for Blood Purification

The artificial kidney, one of the greatest medical inventions in the 20th century, has saved innumerable lives with end stage renal disease. Designs of artificial kidney evolved dramatically in decades of development. A hollow-fibered membrane with well controlled blood and dialysate flow became the major design of the modern artificial kidney. Although they have been well established to prolong patients’ lives, the modern blood purification system is still imperfect. Patient’s quality of life, complications, and lack of metabolic functions are shortcomings of current blood purification treatment. The direction of future artificial kidneys is toward miniaturization, better biocompatibility, and providing metabolic functions. Studies and trials of silicon nanopore membranes, tissue engineering for renal cell bioreactors, and dialysate regeneration are all under development to overcome the shortcomings of current artificial kidneys. With all these advancements, wearable or implantable artificial kidneys will be achievable.

OUP accepted manuscript

The world faces a dramatic man-made ecologic disaster and healthcare is a crucial part of this problem. Compared with other therapeutic areas, nephrology care, and especially dialysis, creates an excessive burden via water consumption, greenhouse gas emission and waste production. In this advocacy article from the European Kidney Health Alliance we describe the mutual impact of climate change on kidney health and kidney care on ecology. We propose an array of measures as potential solutions related to the prevention of kidney disease, kidney transplantation and green dialysis. For dialysis, several proactive suggestions are made, especially by lowering water consumption, implementing energy-neutral policies, waste triage and recycling of materials. These include original proposals such as dialysate regeneration, dialysate flow reduction, water distillation systems for dialysate production, heat pumps for unit climatization, heat exchangers for dialysate warming, biodegradable and bio-based polymers, alternative power sources, repurposing of plastic waste (e.g. incorporation in concrete), registration systems of ecologic burden and platforms to exchange ecologic best practices. We also discuss how the European Green Deal offers real potential for supporting and galvanizing these urgent environmental changes. Finally, we formulate recommendations to professionals, manufacturers, providers and policymakers on how this correction can be achieved.

Surface Engineering Strategies to Enhance the In Situ Performance of Medical Devices Including Atomic Scale Engineering

Decades of intense scientific research investigations clearly suggest that only a subset of a large number of metals, ceramics, polymers, composites, and nanomaterials are suitable as biomaterials for a growing number of biomedical devices and biomedical uses. However, biomaterials are prone to microbial infection due to Escherichia coli (E. coli), Staphylococcus aureus (S. aureus), Staphylococcus epidermidis (S. epidermidis), hepatitis, tuberculosis, human immunodeficiency virus (HIV), and many more. Hence, a range of surface engineering strategies are devised in order to achieve desired biocompatibility and antimicrobial performance in situ. Surface engineering strategies are a group of techniques that alter or modify the surface properties of the material in order to obtain a product with desired functionalities. There are two categories of surface engineering methods: conventional surface engineering methods (such as coating, bioactive coating, plasma spray coating, hydrothermal, lithography, shot peening, and electrophoretic deposition) and emerging surface engineering methods (laser treatment, robot laser treatment, electrospinning, electrospray, additive manufacturing, and radio frequency magnetron sputtering technique). Atomic-scale engineering, such as chemical vapor deposition, atomic layer etching, plasma immersion ion deposition, and atomic layer deposition, is a subsection of emerging technology that has demonstrated improved control and flexibility at finer length scales than compared to the conventional methods. With the advancements in technologies and the demand for even better control of biomaterial surfaces, research efforts in recent years are aimed at the atomic scale and molecular scale while incorporating functional agents in order to elicit optimal in situ performance. The functional agents include synthetic materials (monolithic ZnO, quaternary ammonium salts, silver nano-clusters, titanium dioxide, and graphene) and natural materials (chitosan, totarol, botanical extracts, and nisin). This review highlights the various strategies of surface engineering of biomaterial including their functional mechanism, applications, and shortcomings. Additionally, this review article emphasizes atomic scale engineering of biomaterials for fabricating antimicrobial biomaterials and explores their challenges.

Characterization of the cylindrical electrospun nanofibrous polysulfone membrane for hemodialysis with modelling approach

Electrospun nanofibrous membrane (ENM) is a membrane fabricated using electrospinning technique which has considerable characteristics such as high porosity, nanometer pore size, and simple process. Although ENMs are being evaluated in various medical applications, the effectiveness for hemodialysis (HD) has not been evaluated carefully. Thus, in this study, the cylindrical electrospun nanofibrous polysulfone (CENP) membrane was fabricated and its performance in the dialysis adequacy in HD patients was evaluated.The CENP membrane was fabricated in a tabular shape. The physical characteristics of the membrane are examined using scanning electron microscope (SEM) images and the permporometry technique. Then, its efficiency in urea and creatinine removal from the blood serum of 21 HD patients was evaluated at a low blood flow rate (BFR) of 200 ml min^-1 and dialysate fluid rate (DFR) of 300 ml min^-1. Afterwards, the results were modeled and optimized using artificial neural network (ANN) and genetic algorithm (GA), respectively. Finally, sensitive analysis was performed via Spearman's rank correlation coefficient. The highest dialysis adequacy was observed in membranes with an inner diameter of 3 mm. The CENP membrane belongs to the super high-flux membrane and it could be replaced with existing commercial hollow fiber membranes.

The Roles of Membrane Technology in Artificial Organs: Current Challenges and Perspectives

The recent outbreak of the COVID-19 pandemic in 2020 reasserted the necessity of artificial lung membrane technology to treat patients with acute lung failure. In addition, the aging world population inevitably leads to higher demand for better artificial organ (AO) devices. Membrane technology is the central component in many of the AO devices including lung, kidney, liver and pancreas. Although AO technology has improved significantly in the past few decades, the quality of life of organ failure patients is still poor and the technology must be improved further. Most of the current AO literature focuses on the treatment and the clinical use of AO, while the research on the membrane development aspect of AO is relatively scarce. One of the speculated reasons is the wide interdisciplinary spectrum of AO technology, ranging from biotechnology to polymer chemistry and process engineering. In this review, in order to facilitate the membrane aspects of the AO research, the roles of membrane technology in the AO devices, along with the current challenges, are summarized. This review shows that there is a clear need for better membranes in terms of biocompatibility, permselectivity, module design, and process configuration.

Shedding Light on Miniaturized Dialysis Using MXene 2D Materials: A Computational Chemistry Approach

Materials science can pave the way toward developing novel devices at the service of human life. In recent years, computational materials engineering has been promising in predicting material performance prior to the experiments. Herein, this capability has been carefully employed to tackle severe problems associated with kidney diseases through proposing novel nanolayers to adsorb urea and accordingly causing the wearable artificial kidney (WAK) to be viable. The two-dimensional metal carbide and nitride (MXene) nanosheets can leverage the performance of various devices since they are highly tunable along with fascinating surface chemistry properties. In this study, molecular dynamics (MD) simulations were exploited to investigate the interactions between urea and different MXene nanosheets. To this end, detailed analyses were performed that clarify the suitability of these nanostructures in urea adsorption. The atomistic simulations were carried out on Mn₂C, Cd₂C, Cu₂C, Ti₂C, W₂C, Ta₂C, and urea to determine the most appropriate urea-removing adsorbent. It was found that Cd₂C was more efficient followed by Mn₂C, which can be effectively exploited in WAK devices at the service of human health.