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Afsar B, Afsar RE. Hypersensitive Reactions During Hemodialysis Treatment: What Do We Need to Know? Semin Dial 2024; 37:189-199. [PMID: 38433728 DOI: 10.1111/sdi.13197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/30/2024] [Indexed: 03/05/2024]
Abstract
Kidney replacement therapies (KRTs) including hemodialysis (HD) are one of the treatment options for most of the patients with end-stage kidney disease. Although HD is vital for these patients, it is not hundred percent physiological, and various adverse events including hypersensitivity reactions may occur. Fortunately, these reactions are rare in total and less when compared to previous decades, but it is still very important for at least two reasons: First, the number of patients receiving kidney replacement treatment is increasing globally; and the cumulative number of these reactions may be substantial. Second, although most of these reactions are mild, some of them may be very severe and even lead to mortality. Thus, it is very important to have basic knowledge and skills to diagnose and treat these reactions. Hypersensitivity reactions can occur at any component of dialysis machinery (access, extracorporeal circuit, medications, etc.). The most important preventive measure is to avoid the allergen. However, even with very specific test, sometimes the allergen cannot be found. In mild conditions, HD can be contained with non-specific treatment (topical creams, antihistaminics, corticosteroids). In more severe conditions, treatment must be stopped immediately, blood should not be returned to patient, drugs must be stopped, and rules of general emergency treatment must be followed.
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Affiliation(s)
- Baris Afsar
- Department of Nephrology, School of Medicine, Suleyman Demirel University, Isparta, Turkey
| | - Rengin Elsurer Afsar
- Department of Nephrology, School of Medicine, Suleyman Demirel University, Isparta, Turkey
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Pethő Á, Schnabel K, Dézsi L. Complement-mediated dialysis reaction during regular hemodialysis treatment: a case report. J Med Case Rep 2024; 18:46. [PMID: 38326856 PMCID: PMC10851616 DOI: 10.1186/s13256-024-04365-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/05/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Hemodialysis reactions (HDRs) are similar to complement activation-related pseudo allergy (CARPA), a hypersensitivity reaction that occurs when administering certain (nano)drugs intravenously. The pathomechanism of CARPA was described based on animal experiments. Typical CARPA-like dialysis reactions, which occur at the start of hemodialysis, have been reported using polysulfone dialyzers. However, to our knowledge, this is the first dialysis reaction that occurred towards the end of hemodialysis treatment. CASE PRESENTATION This report describes a 52-year-old Caucasian male patient who had been receiving chronic hemodialysis for 3 years and exhibited a CARPA reaction during his third hour of treatment. Upon activation of the microbubble alarm, the extracorporeal system recirculated for five minutes. Following reconnection, the patient exhibited a drop in systemic blood pressure, chest pain, and dyspnea after five minutes. Symptoms disappeared spontaneously after reducing the speed of the blood pump, placing the patient in a Trendelenburg position, and administering a bolus infusion from the dialysis machine. The remaining dialysis treatment was uneventful. CONCLUSION Numerous case reports about reactions occurring with modern high-efficiency polysulfone dialyzers have been published. However, due to changes in the material structure by the manufacturers, we have not encountered such cases lately. The recently reported increase in thromboxane-B2 and pulmonary arterial pressure and complement activation upon re-infusion of extracorporeal blood following dialysis may explain the reaction observed here.
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Affiliation(s)
- Ákos Pethő
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Korányi S. U. 2/a, 1083, Budapest, Hungary.
| | - Karolina Schnabel
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Korányi S. U. 2/a, 1083, Budapest, Hungary
| | - László Dézsi
- SeroScience Ltd., Budapest, Hungary
- Nanomedicine Research and Education Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
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Davenport A. Why is Intradialytic Hypotension the Commonest Complication of Outpatient Dialysis Treatments? Kidney Int Rep 2023; 8:405-418. [PMID: 36938081 PMCID: PMC10014354 DOI: 10.1016/j.ekir.2022.10.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 11/11/2022] Open
Abstract
Intradialytic hypotension (IDH) is the most frequent complication of hemodialysis (HD) treatments with a frequency of 10% to 12% for patients with chronic kidney disease attending for outpatient treatments and is associated with both temporary ischemic stress to vital organs, including the heart and brain, and increased patient mortality. Although there have been many different definitions of IDH over the years, an absolute nadir systolic blood pressure (SBP) has the strongest association with patient outcomes. The unifying pathophysiology is one of reduced effective blood volume, resulting in lower plasma tonicity, and if this cannot be adequately compensated for by activation of neurohumeral systems, then arteriolar tone and blood pressure fall. The risk factors for developing IDH are numerous, ranging from patient-related factors, including age and comorbidity with reduced cardiac reserve, to patient compliance with dietary and lifestyle advice, to reactions with the extracorporeal circuit and medications, choice of dialysate composition and temperature, setting of postdialysis target weight, ultrafiltration rate, and profiling. Advances in dialysis machine technology by providing real time estimates of the effective circulating volume and adjusting dialysate composition to maintain vascular tonicity are being developed, but currently require more sophisticated biofeedback loops to be clinically effective in preventing IDH. While awaiting advances in artificial intelligence, the clinician continues to rely on patient education to limit interdialytic weight gains, frequent assessment of the postdialysis target weight, adjusting dialysate composition and temperature, introducing convective therapies to increase thermal losses, and altering dialysis session duration and frequency to reduce ultrafiltration rate requirements.
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Affiliation(s)
- Andrew Davenport
- Department of Renal Medicine, Royal Free Hospital, Faculty of Medical Sciences, University College London, London, UK
- Correspondence: Andrew Davenport, UCL Department of Nephrology, Royal Free Hospital, University College London, Rowland Hill Street, London NW3 2PF, UK.
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Rodríguez-Sanz A, Sánchez-Villanueva R, Domínguez-Ortega J, Álvarez L, Fiandor A, Nozal P, Sanz P, Pizarro-Sánchez MS, Andrés E, Cabezas A, Pérez-Alba A, Bajo MA, Selgas R, Bellón T. Characterization of hypersensitivity reactions to polysulfone hemodialysis membranes. Ann Allergy Asthma Immunol 2022; 128:713-720.e2. [PMID: 35288272 DOI: 10.1016/j.anai.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND In recent years, cases have been reported in which unexpected systemic hypersensitivity reactions occurred in patients dialyzed with polysulfone- or polyethersulfone-biocompatible membranes in the absence of other risk factors. The pathomechanisms involved in these reactions are largely unknown. OBJECTIVE To characterize hypersensitivity reactions to polysulfone hemodialysis using clinical and laboratory data and to identify biomarkers suitable for endotype identification and diagnosis. METHODS We prospectively collected data from 29 patients with suspected hypersensitivity reactions to polysulfone hemodialysis membranes. Clinical laboratory parameters such as tryptase, blood cell counts, and complement levels were recorded. Acute samples were obtained from 18 cases for the ex vivo assessment of basophil activation by flow cytometry analysis of CD63, CD203, and FcεRI cell membrane expression. Serum cytokines and anaphylatoxin concentrations were evaluated in 16 cases by Luminex and cytometric bead array analysis. RESULTS Tryptase was elevated during the acute reaction in 4 cases. Evidence of basophil activation was obtained in 10 patients. Complement activation was found in only 2 cases. However, C5a serum levels tended to increase during the acute reaction in those patients with hypoxemia. Significantly higher serum levels of interleukin-6 were observed during the acute reactions to polysulfone hemodialysis (P = .0103). CONCLUSION Based on biomarker analysis, various endotypes were identified, including type I-like (with the involvement of mast cells or basophils), complement, and cytokine (interleukin-6) release-related reactions, with some patients showing mixed reactions. Further research is needed to unravel the exact mechanisms involved in the activation of these cellular and molecular pathways.
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Affiliation(s)
- Aranzazu Rodríguez-Sanz
- Drug Hypersensitivity Laboratory, Institute for Health Research Hospital Universitario La Paz-IdiPAZ, Madrid, Spain; Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Javier Domínguez-Ortega
- Drug Hypersensitivity Laboratory, Institute for Health Research Hospital Universitario La Paz-IdiPAZ, Madrid, Spain; Allergy Service, Hospital Universitario La Paz, Madrid, Spain
| | - Laura Álvarez
- Nephrology Service, Hospital Universitario La Paz, Madrid, Spain
| | - Ana Fiandor
- Allergy Service, Hospital Universitario La Paz, Madrid, Spain
| | - Pilar Nozal
- Immunology Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Paloma Sanz
- Nephrology Service, Hospital Quirón Ruber Juan Bravo, Madrid, Spain
| | | | - Elena Andrés
- Nephrology Service, Hospital General Universitario de Albacete, Albacete, Spain
| | - Antonio Cabezas
- Nephrology Service, Hospital Universitario de Torrevieja, Torrevieja, Alicante, Spain
| | - Alejandro Pérez-Alba
- Nephrology Service, Hospital General Universitario de Castellón, Castellón, Spain
| | - M Auxiliadora Bajo
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain; Nephrology Service, Hospital Universitario La Paz, Madrid, Spain
| | - Rafael Selgas
- Red de Investigación Renal (REDINREN), Instituto de Salud Carlos III, Madrid, Spain; Nephrology Service, Hospital Universitario La Paz, Madrid, Spain
| | - Teresa Bellón
- Drug Hypersensitivity Laboratory, Institute for Health Research Hospital Universitario La Paz-IdiPAZ, Madrid, Spain.
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Pethő Á, Piecha D, Mészáros T, Urbanics R, Moore C, Canaud B, Rosivall L, Mollnes TE, Steppan S, Szénási G, Szebeni J, Dézsi L. A porcine model of hemodialyzer reactions: roles of complement activation and rinsing back of extracorporeal blood. Ren Fail 2021; 43:1609-1620. [PMID: 34882053 PMCID: PMC8667923 DOI: 10.1080/0886022x.2021.2007127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Hemodialysis reactions (HDRs) resemble complement-activation-related pseudoallergy (CARPA) to certain i.v. drugs, for which pigs provide a sensitive model. On this basis, to better understand the mechanism of human HDRs, we subjected pigs to hemodialysis using polysulfone (FX CorDiax 40, Fresenius) or cellulose triacetate (SureFlux-15UX, Nipro) dialyzers, or Dialysis exchange-set without membranes, as control. Experimental endpoints included typical biomarkers of porcine CARPA; pulmonary arterial pressure (PAP), blood cell counts, plasma sC5b-9 and thromboxane-B2 levels. Hemodialysis (60 min) was followed by reinfusion of extracorporeal blood into the circulation, and finally, an intravenous bolus injection of the complement activator zymosan. The data indicated low-extent steady rise of sC5b-9 along with transient leukopenia, secondary leukocytosis and thrombocytopenia in the two dialyzer groups, consistent with moderate complement activation. Surprisingly, small changes in baseline PAP and plasma thromboxane-B2 levels during hemodialysis switched into 30%-70% sharp rises in all three groups resulting in synchronous spikes within minutes after blood reinfusion. These observations suggest limited complement activation by dialyzer membranes, on which a membrane-independent second immune stimulus was superimposed, and caused pathophysiological changes also characteristic of HDRs. Thus, the porcine CARPA model raises the hypothesis that a second "hit" on anaphylatoxin-sensitized immune cells may be a key contributor to HDRs.
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Affiliation(s)
- Ákos Pethő
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Dorothea Piecha
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | | | | | - Christoph Moore
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Bernard Canaud
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany.,School of Medicine, Montpellier University, Montpellier, France
| | - László Rosivall
- International Nephrology Research and Training Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Tom Eirik Mollnes
- Department of Immunology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Research Laboratory, Nordland Hospital Bodø and Faculty of Health Sciences and TREC, University of Tromsø, Tromsø, Norway.,Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sonja Steppan
- Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany
| | - Gábor Szénási
- International Nephrology Research and Training Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - János Szebeni
- SeroScience Ltd, Budapest, Hungary.,Nanomedicine Research and Education Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
| | - László Dézsi
- SeroScience Ltd, Budapest, Hungary.,Nanomedicine Research and Education Center, Institute of Translational Medicine, Semmelweis University, Budapest, Hungary
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Abstract
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.
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Affiliation(s)
- Bernard Canaud
- Global Medical Office, FMC Deutschland, Bad Homburg, Germany
- University of Montpellier, UFR of Medicine, Montpellier, France
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Beige J, Rüssmann D, Wendt R, Ringel KP. A new immune-toxicological test for polysulfone hypersensitivity in hemodialysis patients. Int J Artif Organs 2020; 44:25-29. [PMID: 32400289 DOI: 10.1177/0391398820922240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Incompatibility of dialysis procedure due to hypersensitivity against dialyzer material, currently mainly based on polysulfone and derivatives, cannot be assessed by routine laboratory tests. Although the frequency of such symptoms is suspected to be lower than 2%, it resembles an important clinical problem because dialysis procedures are frequently accompanied by symptoms of non-tolerability with reasons not being entirely clear. To enlighten the role of polysulfone hypersensitivity, we adapted known standardized material immune-toxicological tests (lymphocyte transformation test, basophil degranulation test) to the specific conditions of dialysis and polysulfone material sensitivity. We developed a method of polysulfone micronisation and measured humoral immune response of isolated patient's lymphocytes when incubated with polysulfone dispersion. Thirty-nine samples from 103 patients with suspected polysulfone hypersensitivity within the dialysis population of a nation-wide dialysis provider (n = 15.761 patients) showed positive results for type 1 (n = 19), type 4 (n = 18) or both type (n = 2) reactions. This is the first methodological report showing plausible in-vitro results of patients' samples concerning polysulfone intolerance. Further clinical and laboratory research is needed to define true polysulfone hypersensitivity and to enlighten the field of hypothetic subclinical material incompatibility in patients with impaired dialysis tolerability.
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Affiliation(s)
- Joachim Beige
- Department of Nephrology, Hospital St. Georg, Leipzig, Germany.,Kuratorium for Dialysis and Transplantation (KfH), Leipzig and Neu-Isenburg, Germany.,Martin-Luther-University Halle/Wittenberg, Halle, Germany
| | - Despina Rüssmann
- Kuratorium for Dialysis and Transplantation (KfH), Leipzig and Neu-Isenburg, Germany
| | - Ralph Wendt
- Department of Nephrology, Hospital St. Georg, Leipzig, Germany
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Kerboua KE, Djenouhat K. Semi-solid phase assay for the alternative complement pathway activity assessment (AP 100). J Immunoassay Immunochem 2019; 41:144-151. [PMID: 31771421 DOI: 10.1080/15321819.2019.1696819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Since the introduction of the most expensive drug in the world (Eculizumab) in the therapeutic arsenal of many diseases involving the alternative complement pathway (ACP) in their pathophysiology, the unmet need to perform simple ACP assays affordable for all countries has become one of the major challenges of the contemporary medicine. The assay currently used is AH50, despite it still challenging for several laboratories. This educational chapter consists of a detail protocol of standardized hemolytic assay AP100 and aims to help clinical laboratories over the world and especially those of the developing and low income countries to perform it. The procedure is essentially the same as for the timed lysis assay and dilution methods (AP50) except the concentration of ACP buffer and the chicken erythrocyte density used to make the gels. In clinical field, AP100 has at least nine applications in disease diagnosis and follow-up. AP100 has many advantages over the AH50 as it is more reliable for the Eculizumab monitoring and more practical with a purpose to be stored and transported for several weeks. AP100 is a portable and easy to use device both at the bedside and in the companion medical care.
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Affiliation(s)
- Kheir Eddine Kerboua
- Laboratory of Immunology, Faculty of Medicine, University of Kasdi Merbah Ouargla, Algeria
| | - Kamal Djenouhat
- Laboratory of Immunology, Faculty of Medicine, University of Algiers I, Algeria
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Poppelaars F, Gaya da Costa M, Faria B, Berger SP, Assa S, Daha MR, Medina Pestana JO, van Son WJ, Franssen CFM, Seelen MA. Intradialytic Complement Activation Precedes the Development of Cardiovascular Events in Hemodialysis Patients. Front Immunol 2018; 9:2070. [PMID: 30271407 PMCID: PMC6146103 DOI: 10.3389/fimmu.2018.02070] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/21/2018] [Indexed: 12/13/2022] Open
Abstract
Background: Hemodialysis (HD) is a life-saving treatment for patients with end stage renal disease. However, HD patients have markedly increased rates of cardiovascular morbidity and mortality. Previously, a link between the complement system and cardiovascular events (CV-events) has been reported. In HD, systemic complement activation occurs due to blood-to-membrane interaction. We hypothesize that HD-induced complement activation together with inflammation and thrombosis are involved in the development of CV-events in these patients. Methods: HD patients were followed for the occurrence of CV-events during a maximum follow-up of 45 months. Plasma samples were collected from 55 patients at different time points during one HD session prior to follow-up. Plasma levels of mannose-binding lectin, properdin and C3d/C3 ratios were assessed by ELISA. In addition, levels of von Willebrand factor, TNF-α and IL-6/IL-10 ratios were determined. An ex-vivo model of HD was used to assess the effect of complement inhibition. Results: During median follow-up of 32 months, 17 participants developed CV-events. In the CV-event group, the C3d/C3-ratio sharply increased 30 min after the start of the HD session, while in the event-free group the ratio did not increase. In accordance, HD patients that developed a CV-event also had a sustained higher IL-6/IL-10-ratio during the first 60 min of the HD session, followed by a greater rise in TNF-α levels and von Willebrand factor at the end of the session. In the ex-vivo HD model, we found that complement activation contributed to the induction of TNF-α levels, IL-6/IL-10-ratio and levels of von Willebrand factor. Conclusions: In conclusion, these findings suggest that early intradialytic complement activation predominantly occurred in HD patients who develop a CV-event during follow-up. In addition, in these patients complement activation was accompanied by a pro-inflammatory and pro-thrombotic response. Experimental complement inhibition revealed that this reaction is secondary to complement activation. Therefore, our data suggests that HD-induced complement, inflammation and coagulation are involved in the increased CV risk of HD patients.
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Affiliation(s)
- Felix Poppelaars
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Mariana Gaya da Costa
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Bernardo Faria
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- Nephrology and Infecciology Group, INEB/I3S, University of Porto, Porto, Portugal
- Department of Nephrology, Hospital Braga, Braga, Portugal
| | - Stefan P. Berger
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Solmaz Assa
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Mohamed R. Daha
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- Department of Nephrology, University of Leiden, Leiden University Medical Center, Leiden, Netherlands
| | | | - Willem J. van Son
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Casper F. M. Franssen
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Marc A. Seelen
- Division of Nephrology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Abstract
In this Editor's Review, articles published in 2017 are organized by category and summarized. We provide a brief reflection of the research and progress in artificial organs intended to advance and better human life while providing insight for continued application of these technologies and methods. Artificial Organs continues in the original mission of its founders "to foster communications in the field of artificial organs on an international level." Artificial Organs continues to publish developments and clinical applications of artificial organ technologies in this broad and expanding field of organ Replacement, Recovery, and Regeneration from all over the world. Peer-reviewed Special Issues this year included contributions from the 12th International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion edited by Dr. Akif Undar, Artificial Oxygen Carriers edited by Drs. Akira Kawaguchi and Jan Simoni, the 24th Congress of the International Society for Mechanical Circulatory Support edited by Dr. Toru Masuzawa, Challenges in the Field of Biomedical Devices: A Multidisciplinary Perspective edited by Dr. Vincenzo Piemonte and colleagues and Functional Electrical Stimulation edited by Dr. Winfried Mayr and colleagues. We take this time also to express our gratitude to our authors for offering their work to this journal. We offer our very special thanks to our reviewers who give so generously of time and expertise to review, critique, and especially provide meaningful suggestions to the author's work whether eventually accepted or rejected. Without these excellent and dedicated reviewers the quality expected from such a journal could not be possible. We also express our special thanks to our Publisher, John Wiley & Sons for their expert attention and support in the production and marketing of Artificial Organs. We look forward to reporting further advances in the coming years.
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