Carbon Adsorbents With Dual Porosity for Efficient Removal of Uremic Toxins and Cytokines from Human Plasma

Displacing the Burden: A Review of Protein-Bound Uremic Toxin Clearance Strategies in Chronic Kidney Disease

Uremic toxins (UTs), particularly protein-bound uremic toxins (PBUTs), accumulate in chronic kidney disease (CKD) patients, causing significant health complications like uremic syndrome, cardiovascular disease, and immune dysfunction. The binding of PBUTs to plasma proteins such as albumin presents a formidable challenge for clearance, as conventional dialysis is often insufficient. With advancements in the classification and understanding of UTs, spearheaded by the European Uremic Toxins (EUTox) working group, over 120 molecules have been identified, prompting the development of alternative therapeutic strategies. Innovations such as online hemodiafiltration aim to enhance the removal process, while novel adsorptive therapies offer a means to address the high affinity of PBUTs to plasma proteins. Furthermore, the exploration of molecular displacers, designed to increase the free fraction of PBUTs, represents a cutting-edge approach to facilitate their dialytic clearance. Despite these advancements, the clinical application of displacers requires more research to confirm their efficacy and safety. The pursuit of such innovative treatments is crucial for improving the management of uremic toxicity and the overall prognosis of CKD patients, emphasizing the need for ongoing research and clinical trials.

Adsorption Dynamics of Uremic Toxins to Novel Modified Magnetic Nanoparticles

Kidney dysfunction leads to the retention of metabolites in the blood compartment, some of which reach toxic levels. Uremic toxins are associated with the progression of kidney disease and other symptoms of kidney failure (i.e., nausea, itchiness, and hypertension). Toxin removal ameliorates symptoms and reduces further organ damage, but membrane-based methods are inadequate for this purpose. Engineered adsorbents may facilitate enhanced removal of retained toxins, especially those bound strongly by proteins. Poly 2-(methacryloyloxy)ethyl phosphorylcholine-co-β-cyclodextrin (p(MPC-co-PMβCD)) coated magnetic nanoparticles are synthesized, characterized for their physicochemical properties (Fourier-transform infrared spectroscopy (FTIR), nuclear magnetic resonance (NMR), thermogravimetric analysis(TGA), gel permeation chromatography (GPC), and transmission electron microscope (TEM), and evaluated toxin adsorption from a complex solution for the first time to quantify the effects of film chemistry and incubation time on the adsorbed toxinome (the collection of toxins). Uremic toxins are bound by even "low-fouling" polymer films themselves; providing further insight into how small molecule interactions with "low-fouling" films may affect protein-surface interactions. These results suggest a dynamic interaction between toxins and surfaces that is not driven by solution concentration alone. This knowledge will help advance the design of novel adsorbent films for clearing uremic toxins.

Hemocompatibility of β-Cyclodextrin-Modified (Methacryloyloxy)ethyl Phosphorylcholine Coated Magnetic Nanoparticles

Adsorbing toxins from the blood to augment membrane-based hemodialysis is an active area of research. Films composed of β-cyclodextrin-co-(methacryloyloxy)ethyl phosphorylcholine (p(PMβCD-co-MPC)) with various monomer ratios were formed on magnetic nanoparticles and characterized. Surface chemistry effects on protein denaturation were evaluated and indicated that unmodified magnetic nanoparticles greatly perturbed the structure of proteins compared to coated particles. Plasma clotting assays were conducted to investigate the stability of plasma in the presence of particles, where a 2:2 monomer ratio yielded the best results for a given total surface area of particles. Total protein adsorption results revealed that modified surfaces exhibited reduced protein adsorption compared to bare particles, and pure MPC showed the lowest adsorption. Immunoblot results showed that fibrinogen, α1-antitrypsin, vitronectin, prekallikrein, antithrombin, albumin, and C3 correlated with film composition. Hemocompatibility testing with whole blood illustrated that the 1:3 ratio of CD to MPC had a negative impact on platelets, as evidenced by the increased activation, reduced response to an agonist, and reduced platelet count. Other formulations had statistically significant effects on platelet activation, but no formulation yielded apparent adverse effects on hemostasis. For the first time, p(PMβCD-co-MPC)-coated MNP were synthesized and their general hemocompatibility assessed.

Synthesis of an IRMOF-1@SiO2 Core-Shell and Amino-Functionalization with APTES for the Adsorption of Urea and Creatinine Using a Fixed-Bed Column Study

Kidney dysfunction is a clinical disease that disables the kidneys to remove the waste products and uremic toxins from the circulation and may lead to fatal kidney failure. Hemodialysis is advantageous in this circumstance since it prevents the accumulation of waste products in the body and facilitates the removal of uremic toxins. However, hemodialysis cannot entirely remove some uremic toxins, such as urea and creatinine. In this paper, a high-performance fixed-bed column for urea and creatinine removal was offered. As a result, a MOF layer was built on SiO₂, which was then amino-functionalized using APTES. Numerous assays were used to characterize the final adsorbent. The adsorption of urea and creatinine was evaluated in batch and continuous conditions. Thus, it was demonstrated that the adsorption behavior of A(0.2)-IRMOF-1@SiO₂ followed the Langmuir isotherm, and it exhibited the maximum adsorption capacity. The batch experiment determined that urea and creatinine had an adsorption capacity of 1325.73 and 625.00 mg·g^-1, respectively. The adsorption capacity was increased, which was due to the presence of amino groups (APTES) on the MOF surface. The continuous operation was evaluated using the A(0.2)-IRMOF-1@SiO₂ fixed-bed column. Thomas and Nelson's models were examined to achieve a better understanding of the adsorption behaviors. The A(0.2)-IRMOF-1@SiO₂ fixed-bed column successfully removed 92.57% of urea and 80.47% of creatinine. The separation factor for urea in comparison to creatinine was 2.40 in the A(0.2)-IRMOF-1@SiO₂ fixed-bed column.

Assembly of chemically modified protein nanocages into 3D materials for the adsorption of uremic toxins

Hemodialysis fails to remove protein-bound uremic toxins that are attributed with high cardiovascular risk. Application of adsorption materials is a viable strategy, but suitable biocompatible adsorbents are still not available. Here, we demonstrate that adsorbents based on the bottom-up assembly of the intrinsically biocompatible protein cage ferritin are applicable for toxin adsorption. Due to the size-exclusion effect of its pores, only small molecules such as uremic toxins can enter the protein cage. Protein redesign techniques that target selectively the inner surface were used to introduce anchor sites for chemical modification. Porous crystalline adsorbents were fabricated by bottom-up assembly of the protein cage. Linkage of up to 96 phenylic or aliphatic molecules per container was verified by ESI-MS. Materials based on unmodified ferritin cages can already adsorb the uremic toxins. The adsorption capacity could be increased by about 50% through functionalization with hydrophobic molecules reaching 458 μg g^-1 for indoxyl sulfate. The biohybrid materials show no contamination with endotoxins and do not activate blood platelets. These findings demonstrate the great potential of protein-based adsorbents for the clearance of uremic toxins: modifications enhance toxin adsorption without diminishing the biocompatibility of the final protein-based material.

Effectively Decontaminating Protein-Bound Uremic Toxins in Human Serum Albumin Using Cationic Metal-Organic Frameworks

In the field of replacement of conventional dialysis treatment, searching superior materials for removal of protein-bound uremic toxins is a challenge on account of strong interactions between proteins and uremic toxins. Herein, we first adopted cationic metal-organic frameworks (MOFs), ZJU-X6 and ZJU-X7, as sorbents to decontaminate uremic toxins (p-cresyl sulfate and indoxyl sulfate). ZJU-X6 and ZJU-X7 exhibited innate advantage for sequestration of uremic toxins by utilizing a positive charge framework with exchangeable anions. Especially, ZJU-X6 showed a higher sorption capacity and faster sorption kinetics than those of most reported materials. Moreover, the cationic MOF materials could selectively remove uremic toxins even if in the presence of competitive chloride ions and proteins. Meanwhile, pair distribution function (PDF) and density functional theory (DFT) were employed to elucidate the sorption mechanism between uremic toxins and sorbents. This work suggests an attractive avenue for constructing new types of sorbents to eliminate uremic toxins for uremia treatment.

Hierarchically structural layered double oxides with stretchable nanopores for highly effective removal of protein-bound uremic toxins

The global outbreak and prevalence of coronavirus disease 2019 (COVID-19) has triggered an urgent demand for family hemodialysis equipment. It is particularly vital to design and apply superior adsorbents to adsorb toxins for reducing the usage of dialysate. In this work, hierarchically structural MgAl layered double oxides (LDO) with stretchable nanopores were exploited through a facile one-pot trisodium citrate (TSC) assistant hydrothermal reaction followed by calcination treatment for effectively adsorbing protein-bound uremic toxins such as hippuric acid (HA) or indoxyl sulfate (IS). The optimized MgAl LDO possessed flower-like spherical morphology, ultrahigh specific surface area (187.3 m²/g) and uniquely stretchable nanopores, which were more conducive to incorporating anions due to their unique memory effect endowing them with promising adsorption capacities for HA or IS. And the adsorption data could be better conformed to pseudo-second-order kinetic model and Langmuir isotherm determining that the maximum adsorption capacity of HA and IS was 129.8 mg/g and 63.1 mg/g, respectively. Furthermore, the computation of molecular size paired with the analysis of adsorption mechanism accurately revealed that high-efficiency toxin capture was mainly attributed to electrostatic interaction for internal intercalation and surface adsorption. Therefore, the application of such delicate LDO as new premium adsorbent would facilitate the development and popularization of family hemodialysis equipment.

The Dual Roles of Protein-Bound Solutes as Toxins and Signaling Molecules in Uremia

In patients with severe kidney disease, renal clearance is compromised, resulting in the accumulation of a plethora of endogenous waste molecules that cannot be removed by current dialysis techniques, the most often applied treatment. These uremic retention solutes, also named uremic toxins, are a heterogeneous group of organic compounds of which many are too large to be filtered and/or are protein-bound. Their renal excretion depends largely on renal tubular secretion, by which the binding is shifted towards the free fraction that can be eliminated. To facilitate this process, kidney proximal tubule cells are equipped with a range of transport proteins that cooperate in cellular uptake and urinary excretion. In recent years, innovations in dialysis techniques to advance uremic toxin removal, as well as treatments with drugs and/or dietary supplements that limit uremic toxin production, have provided some clinical improvements or are still in progress. This review gives an overview of these developments. Furthermore, the role protein-bound uremic toxins play in inter-organ communication, in particular between the gut (the side where toxins are produced) and the kidney (the side of their removal), is discussed.

Research progress on the relationship between IS and kidney disease and its complications

Indoxyl sulphate (IS) a representative uraemic toxin in the blood of patients with chronic kidney disease (CKD). Its accumulation may be closely related to CKD and the increasing morbidity and mortality of the disease's related complications. Timely and effective detection of the IS level and efficient clearance of IS may effectively prevent the progression of CKD and its related complications. Therefore, this article summarizes the research progress of IS related, including IS in CKD and its associated complications including chronic kidney disease, chronic kidney disease with cardiovascular disease, renal anemia, bone mineral metabolic disease and neuropsychiatric disorders, looking for IS accurate rapid detection methods, and explore the efficient treatment to reduce blood levels of indole phenol sulphate.

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.

Nanodiamond as a Cytokine Sponge in Infectious Diseases

Cytokine release syndrome (CRS) is a systemic inflammatory response resulting in overexpression of cytokines in serum and tissues, which leads to multiple-organ failure. Due to rapid aggravation of symptoms, timely intervention is paramount; however, current therapies are limited in their capacity to address CRS. Here, we find that the intravenous injection of highly purified detonation-synthesized nanodiamonds (DND) can act as a therapeutic agent for treating CRS by adsorbing inflammatory cytokines. Highly purified DNDs successfully inactivated various key cytokines in plasma from CRS patients with pneumonia, septic shock, and coronavirus disease 2019 pandemic (COVID-19). The intravenous injection of the DND samples in a mouse sepsis model by cecal ligation and puncture significantly improved survival rates and prevented tissue damage by reducing the circulating inflammatory cytokines. The results of this study suggest that the clinical application of highly purified DND can provide survival benefits for CRS patients by adsorbing inflammatory cytokines.

Increased clearance of indoxyl sulphate in renal failure rats with the addition of water-soluble poly-β-cyclodextrin to the dialysate

AIM

Indoxyl sulphate (IS), a protein-bound uremic toxin that dramatically increases in the sera of patients with end-stage renal disease (ESRD), is poorly removed by conventional haemodialysis (HD). The purpose of this study was to explore whether the addition of water-soluble sorbent poly-β-cyclodextrins (PCDs) to dialysate can increase the clearance of IS in uremic rats in vivo.

METHODS

Male SD rats (450-550 g, n = 18) with nephrectomy plus IS injection (10-mg/kg) were randomly divided into three groups: 1. The HD group (n = 6): conventional HD for 4 h; 2. the 2% PCD group: 2% PCD added to the dialysate, HD for 4 h; and 3. the 4% PCD group: 4% PCD added to the dialysate, HD for 4 h. The serum IS levels in model rats were similar to those of ESRD patients. A stable and safe rat HD treatment mode was established by adjusting the vascular access, blood flow rate, dialysate flow rate, dialysis pipe, dialysate configuration, temperature, treatment environment, and other aspects.

RESULTS

Our study found that adding 2% PCD to dialysate significantly improved the clearance of IS approximately twofold compared with conventional HD. Further increasing the PCD concentration to 4% did not increase IS clearance.

CONCLUSION

Therefore, our study showed that adding water-soluble sorbent PCDs to dialysate significantly improved the clearance of IS in uremic rats in vivo.

Mixed Matrix Membranes Adsorbers (MMMAs) for the Removal of Uremic Toxins from Dialysate

We developed Mixed Matrix Membrane Adsorbers (MMMAs) formed by cellulose acetate and various sorbent particles (activated carbon, zeolites ZSM-5 and clinoptilolite) for the removal of urea, creatinine and uric acid from aqueous solutions, to be used in the regeneration of spent dialysate water from Hemodialysis (HD). This process would allow reducing the disproportionate amount of water consumed and permits the development of closed-loop HD devices, such as wearable artificial kidneys. The strategy of MMMAs is to combine the high permeability of porous membranes with the toxin-capturing ability of embedded particles. The water permeability of the MMMAs ranges between 600 and 1500 L/(h m² bar). The adsorption of urea, the limiting toxin, can be improved of about nine times with respect to the pure cellulose acetate membrane. Flow experiments demonstrate the feasibility of the process in a real HD therapy session.

Classification of Uremic Toxins and Their Role in Kidney Failure

Advances in our understanding of uremic retention solutes, and improvements in hemodialysis membranes and other techniques designed to remove uremic retention solutes, offer opportunities to readdress the definition and classification of uremic toxins. A consensus conference was held to develop recommendations for an updated definition and classification scheme on the basis of a holistic approach that incorporates physicochemical characteristics and dialytic removal patterns of uremic retention solutes and their linkage to clinical symptoms and outcomes. The major focus is on the removal of uremic retention solutes by hemodialysis. The identification of representative biomarkers for different classes of uremic retention solutes and their correlation to clinical symptoms and outcomes may facilitate personalized and targeted dialysis prescriptions to improve quality of life, morbidity, and mortality. Recommendations for areas of future research were also formulated, aimed at improving understanding of uremic solutes and improving outcomes in patients with CKD.

Recent advances in dialysis membranes

PURPOSE OF REVIEW

Improvement in hemodialysis treatment and membrane technology are focused on two aims: the first one is to achieve a better control of circulating uremic solutes by enhancing removal capacity and by broadening molecular weight spectrum of solutes cleared; the second one is to prevent inflammation by improving hemocompatibility of the global dialysis system.

RECENT FINDINGS

Despite impressive progresses in polymers chemistry few hazards are still remaining associated with leaching or sensitization to polymer additives. Research has focused on developing more stable polymers by means of additives or processes aiming to minimize such risks. Membrane engineering manufacturing with support of nanocontrolled spinning technology has opened up membrane to middle and large molecular weight substances, while preserving albumin losses. Combination of diffusive and enhanced convective fluxes in the same hemodialyzer module, namely hemodiafiltration, provides today the highest solute removal capacity over a broad spectrum of solutes.

SUMMARY

Dialysis membrane is a crucial component of the hemodialysis system to optimize solute removal efficacy and to minimize blood membrane biological reactions. Hemodialyzer is much more than a membrane. Dialysis membrane and hemodialyzer choice are parts of a treatment chain that should be operated in optimized conditions and adjusted to patient needs and tolerance, to improve patient outcomes.

In Search of Effective UiO-66 Metal-Organic Frameworks for Artificial Kidney Application

The removal of uremic toxins from patients with acute kidney injury is a key issue in improving the quality of life for people requiring peritoneal dialysis. The currently utilized method for the removal of uremic toxins from the human organism is hemodialysis, performed on semipermeable membranes where the uremic toxins, along with small molecules, are separated from proteins and blood cells. In this study, we describe a mixed-linker modulated synthesis of zirconium-based metal-organic frameworks for efficient removal of uremic toxins. We determined that the efficient adsorption of uremic toxins is achieved by optimizing the ratio between -amino functionalization of the UiO-66 structure with 75% of -NH2 groups within organic linker structure. The maximum adsorption of hippuric acid and 3-indoloacetic acid was achieved by UiO-66-NH2 (75%) and by UiO-66-NH2 (75%) 12.5% HCl prepared by modulated synthesis. Furthermore, UiO-66-NH2 (75%) almost completely adsorbs 3-indoloacetic acid bound to bovine serum albumin, which was used as a model protein to which uremic toxins bind in the human body. The high adsorption capacity was confirmed in recyclability test, which showed almost 80% removal of 3-indoloacetic acid after the third adsorption cycle. Furthermore, in vitro cytotoxicity tests as well as hemolytic activity assay have proven that the UiO-66-based materials can be considered as potentially safe for hemodialytic purposes in living organisms.

Sponge-like Chitosan Based Porous Monolith for Uraemic Toxins Sorption

More than three million patients are treated for kidney failure world-wide. Haemodialysis, the most commonly used treatment, requires large amounts of water and generates mountains of non-recyclable plastic waste. To improve the environmental footprint, dialysis treatments need to develop absorbents to regenerate the waste dialysate. Whereas conventional dialysis clears water-soluble toxins, it is not so effective in clearing protein-bound uraemic toxins (PBUTs), such as indoxyl sulfate (IS). Thus, developing absorption devices to remove both water-soluble toxins and PBUTs would be advantageous. Vapour induced phase separation (VIPS) has been used in this work to produce polycaprolactone/chitosan (PCL/CS) composite symmetric porous monoliths with extra porous carbon additives to increase creatinine and albumin-bound IS absorption. Moreover, these easy-to-fabricate porous monoliths can be formed into the required geometry. The PCL/CS porous monoliths absorbed 436 μg/g of albumin-bound IS and 2865 μg/g of creatinine in a single-pass perfusion model within 1 h. This porous PCL/CS monolith could potentially be used to absorb uraemic toxins, including PBUTs, and thus allow the regeneration of waste dialysate and the development of a new generation of environmentally sustainable dialysis treatments, including wearable devices.

Synthesis and Characterisation of Activated Carbon Obtained from Marula (Sclerocarya birrea) Nutshell

Globally, a ninth of people use polluted water sources because an estimated 300–400 Mt of waste and 90% of sewage are discharged into water bodies from industries and developing countries, respectively. The utilisation of indigenous fruit pits in producing novel adsorbents will greatly benefit in wastewater treatment. In most underdeveloped countries, activated carbon (AC) is imported at a high cost. The study was aimed at synthesising and characterisation of AC obtained from Marula nutshell. Carbonization of organic matter from Marula nutshell was carried out at 200°C, 400°C, 500°C, and 600°C. Sulphuric (H2SO4) and phosphoric (H3PO4) acids were used as activating agents at concentrations of 20–60% ( $v/v$ ). Physicochemical characteristics of the AC, such as bulk density, moisture, ash, pH, and iodine number, were analyzed using standard methods. Functional groups and total carbon content were determined using the FTIR spectroscopy and Nitrogen Carbon Sulphur (NCS) analyzer, respectively. The values of carbon yield and total carbon in activated samples with H2SO4 and H3PO4 were 32.2–93.2%, 26.9–95.8%, and 46–79%, 20.8–69.8%, respectively. The pH, ash, moisture, and bulk density of activated high carbon samples with H2SO4 ranged from 2.4–6.1, 0.65–3.49%, 1.3–8.4%, and 0.42–0.62 gcm−3, respectively. Activated high carbon samples with H3PO4 had 2.7–3.2, 11.3–29.8%, 4.7–14.6%, and 0.39–0.54 gcm−3 pH, ash, moisture, and bulk density, respectively. The synthesised AC samples with 40% H3PO4 at 500°C had the highest iodine value of 1075.7 mg/g. FTIR results showed the presence of aliphatic carboxylic acid salt, inorganic nitrate (NO3−), and phosphate groups in the synthesised AC and were not significantly different ( $p<0.05$ ) from commercial AC. The untreated Marula nutshell had some aliphatic hydrocarbon (alkanes), inorganic phosphate ( ${\text{PO}}_4^{3-}$ ), aliphatic ester (–COO), and aliphatic carboxylic acid salt (–C(=O)O–) groups. A novel adsorbent, AC was produced from Marula nutshell with the potential to be used in water treatment.

Indolic Structure Metabolites as Potential Biomarkers of Non-infectious Diseases

Interest in indolic structure metabolites, including a number of products of microbial biotransformation of the aromatic amino acid tryptophan, is increasingly growing. The review prepared by a team of authors is based on in-depthscrutiny of data available in PubMed, Scopus, Cyberleninka, Clinical Trials, and Cochrane Library, eventually narrowing the search to a set of keywords such as tryptophan metabolites; plasma metabolomics profiling; metabolomics fingerprinting; gas-, liquid chromatography mass spectrometry; serotonin; melatonin; tryptamine; indoxyl sulfate; indole-3-acetic acid; indole-3-propionic acid; 5-hydroxyindole-3-acetic acid; gut microbiota and microbial metabolites. It provides a summary that outlines the pattern of changes in the level of indolic structure metabolites in a number of diseases and deals with the data from the field of human microbiota metabolites. In modern experimental studies, including the use of gnotobiological (germ-free) animals, it has been convincingly proved that the formation of tryptophan metabolites such as indole-3-acetic acid, indole-3-propionic acid, tryptamine, and indoxyl sulfate is associated with gut bacteria. Attention to some concentration changes of indolic compounds is due to the fact that pronounced deviations and a significant decrease of these metabolites in the blood were found in a number of serious cardiovascular, brain or gastrointestinal diseases. The literature-based analysis allowed the authors to conclude that a constant (normal) level of the main metabolites of the indolic structure in the human body is maintained by a few strict anaerobic bacteria from the gut of a healthy body belonging to the species of Clostridium, Bacteroides, Peptostreptococcus, Eubacteria, etc. The authors focus on several metabolites of the indolic structure that can be called clinically significant in certain diseases, such as schizophrenia, depression, atherosclerosis, colorectal cancer, etc. Determining the level of indole metabolites in the blood can be used to diagnose and monitor the effectiveness of a comprehensive treatment approach.

A Uremic Goat Model Created by Subtotal Renal Artery Embolization and Gentamicin

A large animal model of (end-stage) kidney disease (ESKD) is needed for the preclinical testing of novel renal replacement therapies. This study aimed to create stable uremia via subtotal renal artery embolization in goats and induce a temporary further decline in kidney function by administration of gentamicin. Renal artery embolization was performed in five Dutch white goats by infusing polyvinyl alcohol particles in branches of the renal artery, aiming for the embolization of ~80% of one kidney and complete embolization of the contralateral kidney. Gentamicin was administered to temporarily further increase the plasma concentrations of uremic toxins. After initial acute kidney injury, urea and creatinine plasma concentrations stabilized 1.5 ± 0.7 months post-embolization and remained elevated (12 ± 1.4 vs. 5.6 ± 0.8 mmol/L and 174 ± 45 vs. 65 ± 5.6 µmol/L, resp.) during follow-up (16 ± 6 months). Gentamicin induced temporary acute-on-chronic kidney injury with a variable increase in plasma concentrations of small solutes (urea 29 ± 15 mmol/L, creatinine 841 ± 584 µmol/L, phosphate 2.2 ± 0.3 mmol/L and potassium 5.0 ± 0.6 mmol/L) and protein-bound uremic toxins representative of patients with ESKD. A uremic goat model characterized by stable moderate uremia was established via subtotal renal artery embolization with the induction of temporary severe acute-on-chronic kidney injury by the administration of gentamicin, allowing preclinical in vivo validation of novel renal replacement technologies.

Uremic Toxins and Blood Purification: A Review of Current Evidence and Future Perspectives

Accumulation of uremic toxins represents one of the major contributors to the rapid progression of chronic kidney disease (CKD), especially in patients with end-stage renal disease that are undergoing dialysis treatment. In particular, protein-bound uremic toxins (PBUTs) seem to have an important key pathophysiologic role in CKD, inducing various cardiovascular complications. The removal of uremic toxins from the blood with dialytic techniques represents a proved approach to limit the CKD-related complications. However, conventional dialysis mainly focuses on the removal of water-soluble compounds of low and middle molecular weight, whereas PBTUs are strongly protein-bound, thus not efficiently eliminated. Therefore, over the years, dialysis techniques have been adapted by improving membranes structures or using combined strategies to maximize PBTUs removal and eventually prevent CKD-related complications. Recent findings showed that adsorption-based extracorporeal techniques, in addition to conventional dialysis treatment, may effectively adsorb a significant amount of PBTUs during the course of the sessions. This review is focused on the analysis of the current state of the art for blood purification strategies in order to highlight their potentialities and limits and identify the most feasible solution to improve toxins removal effectiveness, exploring possible future strategies and applications, such as the study of a synergic approach by reducing PBTUs production and increasing their blood clearance.

Linoleic acid-modified liposomes for the removal of protein-bound toxins: An in vitro study

INTRODUCTION

Protein-bound uremic toxins (PBUTs) and liver failure-related cholestatic solutes are associated with adverse outcomes in patients with chronic kidney disease (CKD) and liver failure, respectively, and are not easily removed by traditional dialysis therapies. We constructed linoleic acid-modified liposomes (LA-liposomes) as indirect adsorbent in the dialysate, and evaluated their effects on the clearance of the representative PBUTs and cholestatic solutes.

METHODS

The LA-liposomes were prepared by the thin-film hydration method. The binding rates of liposomes and protein-bound solutes were detected by the ultrafiltration column. The in vitro dialysis experiments were performed using both non-current and current devices to assay the clearing efficiency of the dialysate supported by LA-liposomes.

RESULTS

The LA-liposomes exhibited good binding properties to the PBUTs, bilirubin and bile acids. The LA-liposome dialysate showed higher solute reduction rates of the representative PBUTs and cholestatic solutes than the traditional dialysate or dialysate supported by the unmodified plain liposomes. Also, albumin binding of the PBUTs was significantly inhibited by the addition of linoleic acid (LA), and the removal efficiency of PBUTs was greatly enhanced by the combination of indirect adsorbent LA-liposomes and LA as the competitive displacer.

CONCLUSION

LA-liposomes were efficient in the clearance of the representative PBUTs and liver failure-related solutes. Moreover, the combination of indirect adsorbent LA-liposomes and competitive displacer suggested a potential application for the extremely highly-bound solutes.

Ex vivo evaluation of the blood compatibility of mixed matrix haemodialysis membranes

The patients with end stage kidney disease need haemodialysis therapies, using an artificial kidney. Nevertheless, the current therapies cannot remove a broad range of uremic toxins compared to the natural kidney. Adsorption therapies, using sorbent-based columns, can improve the clearance of uremic toxins, but the sorbent particles often require polymeric coatings to improve their haemocompatibility leading to mass transfer limitations and to lowering of their performance. Earlier, we have developed a dual layer Mixed Matrix fiber Membrane (MMM) based on polyethersulfone/polyvinylpyrrolidone (PES/PVP) polymer blends. There, the sorbent activated carbon particles are embedded in the outer membrane layer for achieving higher removal whereas the inner blood contacting selective membrane layer should achieve optimal blood compatibility. In this work, we evaluate in detail the haemocompatibility of the MMM following the norm ISO 10993-4. We study two generations of MMM having different dimensions and transport characteristics; one with low flux and no albumin leakage and another with high flux but some albumin leakage. The results are compared to those of home-made PES/PVP single layer hollow fiber and to various control fibers already applied in the clinic. Our results show that the low flux MMM successfully avoids contact of blood with the activated carbon and has good haemocompatibility, comparable to membranes currently used in the clinic. STATEMENT OF SIGNIFICANCE: Haemodialysis is a life-sustaining extracorporeal treatment for renal disease, however a broad range of uremic toxins cannot still be removed. In our previous works we showed that a double layer Mixed Matrix Membrane (MMM) composed of polyethersulfone/polyvinylpyrrolidone and activated carbon can achieve higher removal of uremic toxics compared to commercial haemodialysers. In this work we evaluate the haemocompatibility profile of the MMM in order to facilitate its clinical implementation. The lumen particle-free layer of the MMM successfully avoids the contact of blood with the poorly blood-compatible activated carbon. Moreover, thanks to the high amount of polyvinylpyrrolidone and to the smoothness of the lumen layer, the MMM has very good haemocompatibility, comparable to membranes currently used in the clinic.

Cardiorenal syndrome: Multi-organ dysfunction involving the heart, kidney and vasculature

Cardiorenal syndrome (CRS) is a multi-organ disease, encompassing heart, kidney and vascular system dysfunction. CRS is a worldwide problem, with high morbidity, mortality, and inflicts a significant burden on the health care system. The pathophysiology is complex, involving interactions between neurohormones, inflammatory processes, oxidative stress and metabolic derangements. Therapies remain inadequate, mainly comprising symptomatic care with minimal prospect of full recovery. Challenges include limiting the contradictory effects of multi-organ targeted drug prescriptions and continuous monitoring of volume overload. Novel strategies such as multi-organ transplantation and innovative dialysis modalities have been considered but lack evidence in the CRS context. The adjunct use of pharmaceuticals targeting alternative pathways showing positive results in preclinical models also warrants further validation in the clinic. In recent years, studies have identified the involvement of gut dysbiosis, uraemic toxin accumulation, sphingolipid imbalance and other unconventional contributors, which has encouraged a shift in the paradigm of CRS therapy.

Efficacy of Divinylbenzenic Resin in Removing Indoxyl Sulfate and P-Cresol Sulfate in Hemodialysis Patients: Results From an In Vitro Study and An In Vivo Pilot Trial (xuanro4-Nature 3.2)

High serum levels of microbiota-derived uremic toxins, indoxyl sulfate (IS) and p-cresyl sulfate (PCS), are associated with chronic kidney disease (CKD) progression and cardiovascular complications. IS and PCS cannot be efficiently removed by conventional hemodialysis (HD), due to their high binding affinity for albumin. This study evaluates the efficacy of a divinylbenzene-polyvinylpyrrolidone (DVB-PVP) cartridge and a synbiotic to reduce uremic toxins in HD patients. First, the in vitro efficacy of DVB-PVP in adsorbing IS and PCS was evaluated. Second, a randomized, placebo-controlled pilot study in HD patients was carried out to establish whether the administration of a synbiotic, either individually and in association with DVB-PVP-HD, could reduce the production of uremic toxins. In vitro data showed that DVB-PVP resin removed a mean of 56% PCS and around 54% IS, after 6 h of perfusion. While, in the in vivo study, the DVB-PVP cartridge showed its adsorbing efficacy only for IS plasma levels. The combination of synbiotic treatment with DVB-PVP HD decreased IS and PCS both at pre- and post-dialysis levels. In conclusion, this study provides the first line of evidence on the synergistic action of gut microbiota modulation and an innovative absorption-based approach in HD patients, aimed at reducing plasma levels of IS and PCS.

A Review of Chemicals to Produce Activated Carbon from Agricultural Waste Biomass

The choice of activating agent for the thermochemical production of high-grade activated carbon (AC) from agricultural residues and wastes, such as feedstock, requires innovative methods. Overcoming energy losses, and using the best techniques to minimise secondary contamination and improve adsorptivity, are critical. Here, we review the importance and influence of activating agents on agricultural waste: how they react and compare conventional and microwave processes. In particular, adsorbent pore characteristics, surface chemistry interactions and production modes were compared with traditional methods. It was concluded that there are no best activating agents; rather, each agent reacts uniquely with a precursor, and the optimum choice depends on the target adsorbent. Natural chemicals can also be as effective as inorganic activating agents, and offer the advantages that they are usually safe, and readily available. The use of a microwave, as an innovative pyrolysis approach, can enhance the activation process within a duration of 1–4 h and temperature of 500–1200 °C, after which the yield and efficiency decline rapidly due to molecular breakdown. This study also examines the biomass milling process requirements; the influence of the dielectric properties, along with the effect of washing; and experimental setup challenges. The microwave setup system, biomass feed rate, product delivery, inert gas flow rate, reactor design and recovery lines are all important factors in the microwave activation process, and contribute to the overall efficiency of AC preparation. However, a major issue is a lack of large-scale industrial demonstration units for microwave technology.

A Bifunctional Adsorber Particle for the Removal of Hydrophobic Uremic Toxins from Whole Blood of Renal Failure Patients

Hydrophobic uremic toxins accumulate in patients with chronic kidney disease, contributing to a highly increased cardiovascular risk. The clearance of these uremic toxins using current hemodialysis techniques is limited due to their hydrophobicity and their high binding affinity to plasma proteins. Adsorber techniques may be an appropriate alternative to increase hydrophobic uremic toxin removal. We developed an extracorporeal, whole-blood bifunctional adsorber particle consisting of a porous, activated charcoal core with a hydrophilic polyvinylpyrrolidone surface coating. The adsorption capacity was quantified using analytical chromatography after perfusion of the particles with an albumin solution or blood, each containing mixtures of hydrophobic uremic toxins. A time-dependent increase in hydrophobic uremic toxin adsorption was depicted and all toxins showed a high binding affinity to the adsorber particles. Further, the particle showed a sufficient hemocompatibility without significant effects on complement component 5a, thrombin-antithrombin III complex, or thrombocyte concentration in blood in vitro, although leukocyte counts were slightly reduced. In conclusion, the bifunctional adsorber particle with cross-linked polyvinylpyrrolidone coating showed a high adsorption capacity without adverse effects on hemocompatibility in vitro. Thus, it may be an interesting candidate for further in vivo studies with the aim to increase the efficiency of conventional dialysis techniques.

In vitro assessment of mixed matrix hemodialysis membrane for achieving endotoxin-free dialysate combined with high removal of uremic toxins from human plasma

For a single hemodialysis session nearly 500 L of water are consumed for obtaining pyrogen-free dialysis fluid. However, many efforts are required to avoid biofilm formation in the system and risk of contamination can persist. Water scarcity and inadequate water purification facilities worsen contamination risk in developing countries. Here, we investigated the application of an activated carbon (AC)/polyethersulfone/polyvinylpyrrolidone mixed matrix membrane (MMM) for achieving for the first time endotoxin-free dialysate and high removal of uremic toxins from human plasma with a single membrane. The MMM, thanks to sorbent AC, can remove approximately 10 times more endotoxins from dialysis fluid compared to commercial fibers. Pyrogens transport through the MMM was investigated analyzing inflammation in THP-1 monocytes incubated with samples from the dialysis circuit, revealing safety-barrier properties of the MMM. Importantly, endotoxins from dialysate and protein-bound toxins from human plasma can be removed simultaneously without compromising AC adsorption capacity. We estimated that only 0.15 m² of MMM is needed to totally remove the daily production of the protein-bound toxins indoxyl sulfate and hippuric acid and to completely remove endotoxins in a wearable artificial kidney (WAK) device. Our results could open up new possibilities for dialysis therapy with low water consumption including WAK and where purity and scarcity of water are limiting factors for hemodialysis treatment. STATEMENT OF SIGNIFICANCE: Hemodialysis is a life-sustaining extracorporeal treatment for renal disease, however the production of pyrogen-free dialysate is very costly and water demanding. Biofilm formation in the system worsens bacteria contamination risk. Pyrogens could be transferred into the patients' blood and trigger inflammation. Here, we show for the first time that a mixed matrix membrane composed of polyethersulfone/polyvinylpyrrolidone and activated carbon can achieve simultaneous complete removal of endotoxins from dialysate and high removal of uremic toxins from human plasma without compromising activated carbon adsorption capacity. The mixed matrix membrane could find future applications for simultaneous blood purification and dialysate depyrogenation thus lowering water consumption as for wearable artificial kidney devices and where purity and scarcity of water hamper hemodialysis treatment.

Zirconium-Based Metal-Organic Frameworks for the Removal of Protein-Bound Uremic Toxin from Human Serum Albumin

Uremic toxins often accumulate in patients with compromised kidney function, like those with chronic kidney disease (CKD), leading to major clinical complications including serious illness and death. Sufficient removal of these toxins from the blood increases the efficacy of hemodialysis, as well as the survival rate, in CKD patients. Understanding the interactions between an adsorbent and the uremic toxins is critical for designing effective materials to remove these toxic compounds. Herein, we study the adsorption behavior of the uremic toxins, p-cresyl sulfate, indoxyl sulfate, and hippuric acid, in a series of zirconium-based metal-organic frameworks (MOFs). The pyrene-based MOF, NU-1000, offers the highest toxin removal efficiency of all the MOFs in this study. Other Zr-based MOFs possessing comparable surface areas and pore sizes to NU-1000 while lacking an extended aromatic system have much lower toxin removal efficiency. From single-crystal X-ray diffraction analyses assisted by density functional theory calculations, we determined that the high adsorption capacity of NU-1000 can be attributed to the highly hydrophobic adsorption sites sandwiched by two pyrene linkers and the hydroxyls and water molecules on the Zr₆ nodes, which are capable of hydrogen bonding with polar functional groups of guest molecules. Further, NU-1000 almost completely removes p-cresyl sulfate from human serum albumin, a protein that these uremic toxins bind to in the body. These results offer design principles for potential MOFs candidates for uremic toxin removal.

Bioengineering Organs for Blood Detoxification

For patients with severe kidney or liver failure the best solution is currently organ transplantation. However, not all patients are eligible for transplantation and due to limited organ availability, most patients are currently treated with therapies using artificial kidney and artificial liver devices. These therapies, despite their relative success in preserving the patients' life, have important limitations since they can only replace part of the natural kidney or liver functions. As blood detoxification (and other functions) in these highly perfused organs is achieved by specialized cells, it seems relevant to review the approaches leading to bioengineered organs fulfilling most of the native organ functions. There, the culture of cells of specific phenotypes on adapted scaffolds that can be perfused takes place. In this review paper, first the functions of kidney and liver organs are briefly described. Then artificial kidney/liver devices, bioartificial kidney devices, and bioartificial liver devices are focused on, as well as biohybrid constructs obtained by decellularization and recellularization of animal organs. For all organs, a thorough overview of the literature is given and the perspectives for their application in the clinic are discussed.