University of Padova – Chair of Nephrology
Department of Nephrology Dialysis and Transplantation
International Renal Research Institute
St. Bortolo Hospital, Vicenza - Italy
Claudio Ronco
Renal Glomerular Filtration System
A size- (and charge-)selective blood-to-urine barrier
Glomerular capillary wall Glomerular filtration slit
S. Bowry
Dialysis Membranes: Classification
• Composition and structure (Biomaterial / Process)• Cellulosic vs Synthetic: Polymer Composition
• Pore size, Pore size distribution, thickness
• Performance characteristics:• Permeability / Efficiency / Flux / Cut-off / Adsorption
• Surface modification (functionalization):• Hydrophilic / hydrophobic
• Roughness
• Electrical charges
• Additives
New Spinning Technologies
Change of the spinning conditions:
• More homogeneous polymer solution mixing
• Refined precipitation conditions
• Improved design of spinning nozzles
Results in :
• Defined Pore structure of thin inner ‘skin’ region
• The fibre dimensions (ID + wall thickness)
• Optimised fibre structure (“wavy” fibres)
• Geometry & distribution of the pores of the innermost
surface controlled at nano-scale level
Conventional pores: ragged, tortuous below surface
Nanocontrolled pores: smooth, cylindrical: less resistance
Basis of the nanostructure of membrane pores
Outer membrane
Skin layer
Dead end pore
Stenotic pore
Old Synthetic Membranes
Standardized pore structure
Nanocontrolled Membrane
Improved Synthetic Membr
Mix of small and large pores
Membrane Surface
S. Bowry
Computer Image Analysis (CIA) of Transmission Electron Micrographs
1. Thin, separating layer.
2. High local porosity - and decreasing polymer concentration.
A B
C D
X 20.000
X 80.000
1 µm
100 µm 250 nm
X 20.000
X 80.000
1 µm
100 µm 250 nm
X 20.000
X 80.000
1 µm
100 µm 250 nm
X 20.000
X 80.000
1 µm
100 µm 250 nm
Surface Microdomains may limit Interactions with Proteins and Cells
IMPORTANCE OF HYDROPHILIC SURFACES OF PORES
Can pore size distribution
be precisely controlled ?
High Cut-Off (HCO) vs High-Flux Membranes
High Cut-Off
HighFlux
0
0,2
0,4
0,6
0,8
1
100 1000 10000 100000
Molecular Weight [Dalton]
Siev
ing
Co
effi
cien
t
Creatinine(113)
Vit. B12(1355)
Inulin(5200)
2-M(11.800)
Albumin(68.000)
Low-Flux
High-Flux S
Helixone
HPS
High-Flux LS
High Flux
Low Flux
High Flux
Mod Cell
Mod Surf
NCS Mod
High Cut off
Membranes and Therapies
Protein bound solutes
Mediators of inflammation
Erythropoiesis inhibitors
Smart Cut off
Figure 10
A B C
D
Blood In Blood Out
Dial. InUF or Effluent
Diffusable Solutes
membrane
Non diffusable solutes
Proteins
Cells
K = QF/S (S= [UF]/ [Pw]
Effluent equals K when S=1
S≠ [UF]/ [Pw] when
[UF] < [Pw]1 (membrane)
[Pw]2 < [Pw]1
Post Dilution
[Pw]1
Pre Dilution
> [Pw]2
Creatinine Sieving Coefficient over time
The Membrane as an active component
Endotoxins or proinflammatory mediators can be adsorbed
S. Bowry
Dialysis Membranes: Classification
• Composition and structure (Biomaterial + Process)– Cellulosic vs Synthetic: Polymer Composition
– Pore size, Pore size distribution, thickness
• Performance characteristics:– Permeability / Efficiency / Flux / Cut-off / Adsorption
• Surface modification (functionalization):– Hydrophilic / hydrophobic
– Roughness
– Electrical charges
– Additives
Effects of Surface Modification
Ultra-thin Layer
Biocompatibility, Permeability, Non-fouling effect
Highly Adsorbitive MembranesProteins
Polymer chain
Ionic
interactions
Van der Waals
forces
AdsorptionHydrophobic
domain
Hydrophobic
interactions
MatrixWeak
Medium
Strong
AN69 ST* and Heparin Adsorption
Polyethyleneimine
Hep.
Heparin
oXiris Membrane - Material
Free amine groups of PEI → endotoxin adsorption
CH2CH C
-
CH2
CH2
CH3
CN
SO3 Na-- --+
Bioactivity
AN69
N
NH
N
NH
NH2
NH NH
Polyethylene-imine
-
-
-
-
heparin
Available
active sites
for AT link
PS PMMA AN69
asymmetric structure
microporous membranes
symmetric structure
microporous membranes
symmetric structure
hydrogel membrane
Effective surface accessible for protein adsorptionProteins
Polymer chain
scanning electron microscopy
AN69 based membrane
Acrylonitrile Sodium Methallyl Sulfonate
Hydrophilic
Negative charge
−CH2−CH
CN n
CH2− C −
CH2
CH3
SO3 Na
m
- +
AN69 hydrogel membrane
(社内資料)
Hydrogel structure
TNF-α IL-1β IL-6 IL-8 IL-10 HMGB1
Cytokine clearance
(CHDF at 3 hour)
0
20
40
60
Clearance
(mL/min)
57.1±46.0
(n=15)
(n=19)
(n=32)
(n=23)
(n=25)
(n=13)
:AN69ST-CHDF trial
Data were used when blood cytokine levels before treatment were above the following cut-off values;
TNF-α: 10 pg/mL, IL-1β: 10pg/mL, IL-6: 100 pg/mL, IL-8:100 pg/mL, IL-10: 8 pg/mL, HMGB1: 10 ng/mL
amino group(positive)
sulfonate group
(negative)HH
HN
O
O
O
O O
O
O
OS
S
S
+-
Membrane nature allows ionic binding for targeted removal
Adsorptive β2-Microglobulin Removal
by AN69 vs Cellulose TriacetateClark et al, Kidney Int 1995
AN69
CTA
Β2M Adsorption Isotherms Clark et al, Kidney Int 1994
Porous AN69
Non-porous AN69
HMGB-1 (High Mobility Group 1 protein) is secreted by immune cells
(macrophages & monocytes) as a cytokine mediator of Inflammation.
Oxiris®: animal data
Oxiris®: animal data
- P. Aeruginosa porcine model of septic shock
- 2 × 10 pigs : 6 h of HF with oxiris versus 6 h of HF with a standard mb
- Arterial and Swan-Ganz catheters to assess hemodynamics
- MAP and PCWP maintained stable with crystalloids, colloids and epinephrine infusion
Endotoxin Removal – AN69 oXiris
Rimmele T et al., NDT 2009;24:354-357
Rimmelé, Peng, Kellum. unpublished data
oxiris ®
Hemoperfusion
Sham
Oxiris®: animal data (10 rats per group)
Cytokine Removal During Conventional CRRTDe Vriese et Al
Time (hours) T
NF
-α
IL-1
β
IL-6
TN
F-α
IL-1
β
IL-6
TN
F-α
IL-1
β
IL-6
TN
F-α
IL-1
β
IL-6
TN
F-α
IL-1
β
IL-6
TN
F-α
IL-1
β
IL-6
% t
ota
l re
moval 40
30
20
10
0
t=1 t=6 t=12 t=13 t=18 t=24
% AD% UF
*
**
*
*
*
*
Total amount of cytokine removed is expressed as a percentage of the amount in present in prefilter plasma
Hemofilter:AN69
In AKI, there is an imbalance between pro- and anti-oxidant factorsleading to potential tissue damage
In CRRT, blood membrane interaction may lead to production of reactive oxidant species contributing to damage
Vit E-coated membranes In addition to antioxidant therapy
Strategy
Direct scavenging on the membrane surface is preferable. Gastrointestinalabsorption of oral supplements can be affected by many factors, patients may notbe compliant, and oral supplements can be cleared by the dialysis process.
Taking advantage of new membrane manufacturing processes andmembrane surface modification/functionalization we can perform a
The effect on ROS is exerted in situ on blood cells without release of the vitamin E
This results in improved biocompatibility, with less activation of leukocytes and productionof inflammatory cytokines, as well as decreased endothelial cell activation due toscavenging of ROS products from vitamin E.
OxidativeSTRESS
The Role of Vitamin E- Coated Membrane
0
50.000
100.000
150.000
200.000
250.000
300.000
350.000
400.000
t0MPO t2MPO t24MPO
Filter E Filter NE
CRRT in Acute Kidney Injury Comparison activity MOPpg/m
l
Time from Tx beginning
n.16
MicroMacro Nano
mmcm nm
S. Bowry
Functionalization allows a new dimension in
dialysis membranes