Outside-In Hemofiltration for Prolonged Operation without Clogging

Hemofiltration (HF) is used extensively for continuous renal replacement therapy, but long-term treatment is limited by thrombosis leading to fiber clogging. Maximum filter life is typically less than 20 hours. We have achieved for the first time continuous and consistent hemofiltration for more than 100 hours using outside-in hemofiltration with the blood flow into the inter-fiber space (IFS). Although thrombi do deposit in the IFS, they have minimal affect on the blood flow and filtrate flux due to the three-dimensional system of interconnected hydrodynamic flow channels in the IFS. Microscopic examination of sections of the fiber bundle showed that deposited thrombi have dimensions about the size of the gaps between the hollow fibers and remain isolated from each other. A simple mathematical model is developed to describe the effect of thrombus deposition on the fluid flow that accounts for the enhanced performance arising from the interconnected flow. The hydrodynamic advantage of outside-in HF decreases at low anticoagulant concentration due to the instability in the blood and the very high volume fraction of thrombi that deposit in the entrance zone of the filter. These results clearly demonstrate the significant potential advantages of using outside-in hemofiltration for long-term renal replacement therapy.

First level prevention instead of third level intervention-review of research to improve biocompatibility and performance of capillary membrane apheresis in critically ill patients

In intensive care medicine, convection-based apheresis is of growing interest. Applying extracorporeal systems in the critically ill patient can cause severe complications like nosocomial infections and bleeding, which can be worsened or even initialized by the anticoagulation protocol used. Furthermore, the filter modules (hemo- and plasmafilters) often tend to a fast blockage. A decrease in sieving performance due to membrane fouling may be tolerable for some time, but the complete blockage of high percentages of hollow fibers, which is named "clotting," often requires the immediate exchange of the filter. Extracorporeal detoxification and high clearance renal replacement regimes both require high blood flow and filtration rates. As a consequence, filter clotting and anticoagulation-associated bleeding are the most sensitive aspects in these applications. We were interested in the paradox phenomenon of the parallel occurrence of intra vitam bleeding and filter clotting in critically ill patients. Through stepwise investigations based on in vitro and animal experiments, we identified a stasis of blood flow followed by blood cell sedimentation and aggregation ("clogging") as the main factor of hollow fiber blockage in hemo- and plasma filters. As a result, various aspects which increase the risk of stasis inside the hollow fibers were investigated, for example, patient's hemorheology, configuration of an extracorporeal treatment system including interaction of catheter features with the filtration procedure, and basic therapeutic approaches such as colloidal volume substitutes and tolerated acidosis. Finally, an etiological triad for the blockage of hollow fibers due to filter clogging and consecutive filter failure was formed.

Thermography as potential real-time technique to assess changes in flow distribution in hemofiltration

Flow distributions are critical determinants in the function of hemofilters. Despite their importance, however, flow distributions cannot currently be measured in filters during experimental or clinical applications. Here, we demonstrate that the thermal conduction properties of extracorporeal circuits may provide a tool to overcome this limitation. More specifically, we show that thermography provides an indirect approach to visualize differences in regional perfusion rates through temperature profiles on the filter surface. Thermograms were recorded using a TVS700 system (Ca. Goratec) during recirculating in vitro hemofiltration of porcine blood. Different test protocols were executed to characterize the contribution of thermal conduction and convection to the measurable changes in the temperature at the surface of the filter housing. For comparison and validation, these experiments were supplemented by computer tomography (CT) of filters after dye injection. Thermography enabled real-time visualization of the flow distributions in a hemofilter. Moreover, 'point' trends taken from different regions of the filter provided quantitative information about changes of flow distributions in response to changing experimental conditions. Our preliminary data suggest that thermography is a promising new approach for assessing the principles and time-related changes in flow distributions in hemofiltration. As expected, resolution is lower than that in CT measurements and further studies will be necessary to determine the smallest temperature gradient that still identifies differences in regional perfusion rates. Given its potential to develop into an inexpensive tool for the 'bedside' level monitoring of flow distributions during clinical studies, further investigation of thermography is highly desirable.

HYDROXYETHYL STARCH 130 KD/0.4 AND ALBUMIN IMPROVE CVVH BIOCOMPATIBILITY WHEREAS GELATIN AND HYDROXYETHYL STARCH 200 KD/0.5 LEAD TO ADVERSE SIDE EFFECTS OF CVVH IN ANESTHETIZED PIGS

Both fluid management and renal replacement therapies play a fundamental role in the treatment of critically ill patients. In a recent in vitro study, we have shown specific interactions of different colloids and the hemocompatibility of hemofilters. The present study was performed to compare the five most common fluids for volume resuscitation, i.e., normal saline (SAL), hydroxyethyl starch 130 kd/0.4 (HES130), hydroxyethyl starch 200 kd/0.5 (HES200), albumin (ALB), and gelatin (GEL) with respect to their interaction with continuous venovenous hemofiltration (CVVH) in anesthetized domestic pigs.

METHODS

Animals (n = 63) were allocated randomly to the fluid type and the respective subgroups, which were divided into control and CVVH groups (n = 6 ndash; 7 per group). Bolus infusion of group specific fluid was followed by a bolus of heparin and the initiation of hemofiltration in CVVH groups. Thereafter, fluids were infused at constant rates, and heparin application was adjusted to keep the activated clotting time at 200 to 250 s. Hemodynamics, airway pressures, pulmonary gas exchange, diuresis, creatinine clearance, and blood cell counts were investigated during the entire procedure (10 ndash; 12 hours).

RESULTS

Basics of in vivo effects of SAL, HES130, and ALB were not altered during CVVH. HES130 and ALB enabled stable hemocompatibility, diuresis, and hemodynamics in the respective groups. In contrast, organ functions were significantly different between control and CVVH groups when animals were treated with GEL or HES200. In particular, during CVVH, HES200 led to reduced platelet counts, deteriorated hemodynamics, and increasing airway pressures during CVVH. GEL led to increasing airway pressures, a decrease in pulmonary gas exchange, deteriorated hemodynamics, altered renal histomorphology, reduced platelet counts, and reduced hemoglobin.

CONCLUSIONS

Direct in vivo effects of colloids in anaesthetized and ventilated pigs are not predictable for their effects during CVVH. Interaction between CVVH and every volume substitute occur in a highly specific manner. This observation could be helpful to explain contradictory study results and should be considered for future study designs.

Relation of haemofilter type to venous catheter resistance is crucial for filtration performance and haemocompatibility in CVVH--an in vitro study

BACKGROUND

Main factors for the overall performance of haemofilters (HF) are membrane features and filter durability without clogging/clotting of capillaries. However, the venous line resistance (Pv) is a powerful force for net filtrate flux resulting in haemoconcentration and thus is enhancing the phenomenon of membrane clogging. Therefore, we hypothesized that catheter type, as it is associated with Pv-levels, contributes to the extent in which filter longevity and filtration performance are restricted due to blocked hollow fibres.

METHODS

Heparinized porcine blood (5 IU/ml) was circulated in an in vitro system for haemofiltration (FH6S-filters were used, Ca. Gambro). Three different sizes of catheters for peripheral vein access (Vygonuele V, Ca. Vygon) were alternately inserted into the circuit for blood return from the filter to the reservoir. To produce Pv-levels lower than commonly induced by Shaldon catheters, a 14G-vygonuele was used. Pv-levels standard for 11-12 French catheters were provided by using a 16G-vygonuele. To produce Pv-levels common for low-French or tri-lumen catheters, a shortened 18G-vygonuele was used. The respective Pv-levels attained were compared with respect to the overall filtration performance (system pressures, haemocompatibility and sieving coefficients).

RESULTS

Catheters of 14 and 16G enabled transiently maximal blood flow (Qb)/filtration rates (Qf) of 300/60 ml/min and continuous filtration with Qb/Qf of 200/40 ml/min. The shortened 18G catheter reduced maximal flow rates down to Qb/Qf of 200/40 ml/min, and continuous flow rates down to Qb/Qf of 125/25 ml/min. At the end, median values for blocked hollow fibres were, 35% in the 14G-group, 40% in the 18G-group and 70% in the 16G-group. Haemocompatibility appeared to be higher in the 14G-group with respect to various parameters when compared with the other groups.

CONCLUSIONS

The flow resistance by the catheter chosen for haemofiltration clearly influenced the filtration performance. Thus, investigations focused on compatibility of catheter type as it related to Pv-levels with the particular method of renal replacement therapy that should be performed. This point could be crucial in reducing filter clogging and haemostasis during CVVH.

Albumin and hydroxyethyl starch 130 kDa/0.4 improve filter clearance and haemocompatibility in haemo- and plasmafiltration—an in vitro study

BACKGROUND

Apart from their standard applications, haemofiltration (HF) and plasmafiltration (PF) may provide helpful therapy for sepsis, multiple organ- and acute liver-failure. Some colloids cause either decreases or increases in blood cell agglomeration. We hypothesized that solutions which reduce cell aggregability may lead to both improved filter clearance and better haemocompatibility due to decreasing rates of clogged hollow fibres.

METHODS

Heparinized porcine blood (5 IU/ml) was used in an in vitro circuit. The filter types tested were from GAMBRO: HF66D (effective membrane surface: 0.6 m2) and PF1000N (effective membrane surface: 0.15 m2). Albumin (ALB), hydroxyethyl starch (HES) 200/0.5, HES 130/0.4, gelatin (GEL) or normal saline (0.9%) were added to the blood (n = 6/group). Recirculation systems were run for 2 h. Spontaneous haemolysis and filter resistance >420 mmHg were selected as indications of maximal flow rates. Sieving coefficients were determined for 17 parameters at the lowest and highest blood flows and filtration rate.

RESULTS

Based on the filter types used, supplementation of ALB and HES130/0.4 led to an improved filter clearance without increasing the number of clogged capillary membranes or causing impaired haemocompatibility. Sieving coefficients for most solutes were independent of volume substitute and flow rate. Haemocompatibility and filter clearance deteriorated after addition of HES200 or GEL to the blood.

CONCLUSIONS

Under standardized in vitro conditions, we found that colloids which reduce cell aggregability cause improved HF- and PF-performance. This phenomenon may provide new options for higher clearances and may lead to new concepts in low dose anticoagulation.

Impact of Inverse Plasma Filtration on Complement Activation in Porcine Blood

During extracorporeal circulation, activation of the complement system as a bioincompatibility reaction upon contact with artificial surfaces is well known. This may induce adverse effects for the patient as well as for the bioreactor when using a hybrid liver support system. At present, the achievable clearance rates in hybrid liver support systems are restricted by the limitations of blood flow through the capillaries of the plasma filter. In order to enhance clearance rates it is desirable to develop a high-flow plasma separation unit in which the activation of the complement system is as low as possible. Conventional plasma filters operating in normal and in inverse (blood flow around the capillaries and the capillary lumen serving as plasma compartment) modes were investigated applying an in vitro circuit (n = 4 in each group). For this purpose heparinized porcine blood was used. Complement activation was measured as generation of the soluble membrane attack complex, SC5b-9. With a normal flow mode the maximum achievable filtration rates varied from 25 to 40 mL/min, whereas the maximal filtration rates with an inverse flow mode varied from 40 to 100 mL/min. While these values were significantly higher than those with regularly operating plasma filters, there was no significant difference between normal and inverse mode in the production of SC5b-9. We conclude that the outer surface of the investigated conventional plasma filtration membranes is suitable for an inverse mode and does not lead to an excessive activation of the complement system upon dynamic blood contact. Thus, the inversion of the blood and the plasma compartments may be a possible way forward in the development of a high-flow plasma separation filter.

Influence of different heparin concentrations on the results of in vitro investigations in plasmaseparation technology using capillary membrane filters

Capillary membrane filters are devices commonly used for plasmapheresis and recirculating detoxification systems, including plasmaseparation units. Besides clinical trials and case reports, research on plasmafiltration techniques is carried out using in vitro systems. Notably, such hemoperfused in vitro systems require anticoagulation protocols suitable for investigating the clearance performance and hemocompatibility of a plasmafilter. This study analyzes how different heparin concentrations affect filtration performance and the hemocompatibility under conditions typically employed during in vitro experiments. Porcine blood from healthy slaughtered animals was used in an in vitro circuit. The blood collecting system was primed with heparin. Depending on the study group, blood was anticoagulated with either 2.5 IU/ml or 5 IU/ml heparin. The filters were n=10 PF1000N (effective membrane surface: 0.15 m2). For each experiment, the maximal permissible flow rate was established by determining the point where spontaneous hemolysis occurred and/or pressure values exceeded the highest limit of the pressure units on the apheresis monitor. Sieving coefficients of ten parameters, platelet counts, and coagulation patterns were determined at the lowest and highest blood flow (Qb) and filtration rates (Qf). Except for the activated clotting time (ACT), both anticoagulation protocols caused the blood to respond to its exposition to the plasmafilters concerning the activation and inhibition of the coagulation system. A significant decrease in platelet counts did not occur. There were sporadic differences in sieving properties between the groups. However, heparinization with 2.5 IU/ml resulted in unreproducible flow rate profiles, and pressure levels were higher than in the group with 5 IU/ml heparin. Compared to heparinization at 2.5 IU/ml, higher levels of heparinization stabilize rheological properties of the blood, and thereby increase the reliability of data obtained from plasmafiltration experiments carried out in vitro.