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Dialyzer Selection Sirirat Reungjui, MD. Khon Kaen University Content 1. Type of dialyzer and membrane 2. Selection of dialyzer 3. Effect on outcomes Add your text in here Evolution of dialyzer Stewart Capillary Cordis Dow CDAKs Travenol-Kolff Coil, Fiber Kiil Plate Dialyzer, First Hollow Dialyzers, Kolff Rotating Drum, Skeggs Leonards Plate, Gambro Plate Dialyzers, BaxterCa. CA170 Baxter CT190G FMC F80 1956 1960 Ca. 1943 Ca. 1964 - 1967Ca. 1948 1979 High Efficiency Ca. 1967 High- Flux High Flux Structure Blood inlet Header Solution outlet Fiber Jecket Solution inlet Blood outlet Ideal dialyzer • Remove small and large solutes • Reliable convective and UF properties • Biocompatible / Safety • Protect blood from dialysate contaminants (backfiltration) Progressive renal failure Uremic toxins Retention of solutes Uremic syndrome Deterioration of multiple biochemical & physiological functions Uremic toxins European Uremic Toxin Work Group. JASN, 2012. Small, water-soluble, non-protein-bound ( < 500 D) Larger, middle-molecules ( > 500 D) Lipid-soluble and/or protein-bound Diffusion Concentration gradient, small molecule Convection Movement of water (ultrafiltration), middle mol. Hydroxyl groups Contaminant dialysate Complement activation Cytokine ROS Neutophil, Monocyte Dialyzer reactions • Type A (anaphylactic type) • Ethylene oxide, AN-69 (ACEI), contaminant dialysate, heparin, complement release ?, eosinophilia • Type B (nonspecific) • Complement activation Bioincompatibility • Amyloidosis – β 2 microglobulin • Immune depression • Loss of residual renal function • Catabolism and malnutrition • Inflammation/ Atherosclerosis TMP Dialysate Pressure Blood Dialysate Pressure Blood positive negative Dialyzer length Definitions Efficiency High Moderate Low KoA (ml/min) < 500 500 – 700 > 700 KoA; Mass transfer area coefficient (maximum theoretical Cl at infinite BFR, DFR) Definitions Flux Kuf (ml/h/mmHg) High Low < 10 > 20 Kuf; Ultrafiltration coefficient β 2 -microglobulin Permeability clearance (ml/min) High Low < 10 > 20 Definitions • Super-flux; Pressure drop Pore size Homogenous pores • High performance; High flux Biocompatible Type of membrane Unmodified cellulose Substituted cellulose Cellulosynthetic membrane Synthetic membrane Substituted Cellulose Unmodified Cuprophan - Good for small solutes - Bioincompatible Low flux • Cellulose acetate/diacetate - Low / middle Kuf • Cellulose triacetate - Middle / high Kuf - More biocompatible Cellulose membrane Synthetic membrane LF-BI LF-BC LF-BC HFcell syn cell Low complement activation Reflect dialysate impurities Adsorption MM removal HFsyn - ++ ++ ++ +++ - - ++ - ++ - - +/- ++ + ++ single-pool Kt/V 1.32 vs 1.71 High dose Standard RR 0.96 , p = 0.53 HEMO study group. N Engl J Med. 2002;347(25):2010-9. Cβ2 microglobulin 3 vs 34 ml/min RR 0.68 , pt on HD > 3.7 years High flux Low flux RR 0.92, P = 0.23 HEMO study group. N Engl J Med. 2002;347(25):2010-9. Relative risk Serum β-2 M Levels Predict Mortality < 27.5 mg/L < 27.5 27.5-35 35-42.5 42.5-50 > 50 Predialysis serum β 2 M (mg/L) HEMO study group. J Am Soc Nephrol 17: 546–555, 2006. Membrane Permeability Outcome (MPO) Study Survival probability of patients Diabetic patients, p = 0.039 Alb ≤ 4 g/dl, p = 0.032 No. at risk High-flux Low-flux High-flux membrane Low-flux membrane 0 12 24 36 48 60 Months 83 74 67 59 55 40 46 29 27 19 14 11 72 84 7 3 3 0 Locatelli F, et al. J ASN; 20: 645–54, 2009 cardiovascular event-free survival Hi Flux / Ultrapure HRgroup; 0.73 HR 0.61, p = 0.03 AVF p = 0.03 P = 0.12 HR 0.49, p = 0.03 DM group; EGE Study group. J Am Soc Nephrol 24: 1014–23, 2013 Conclusion • RCTs .. no difference in mortality • Suggestion; synthetic high flux membrane - Duration > 3.7 yr, DM, Alb ≤ 4 g/dl, AVF • Highest survival..high flux + ultrapure • AKI (KDIGO 2012)…Biocompatible Thank you! Contact Address: Prof. Somchai Doe Tel: Email: www.kku.ac.th