1. Dialyzer Selection Sirirat Reungjui, MD. Khon Kaen University

2. Add your text in here Content 1. 1. Type of dialyzer and membrane 2. Selection of dialyzer Effect on outcomes 3.

3. Evolution of dialyzer Kolff Rotating Drum, Ca. 1943 Kolff Rotating Drum, Ca. 1943 Skeggs Leonards Plate, Ca. 1948 Skeggs Leonards Plate, Ca. 1948 Travenol-Kolff Coil, Ca. 1956 Travenol-Kolff Coil, Ca. 1956 Kiil Plate Dialyzer, Ca. 1960 Kiil Plate Dialyzer, Ca. 1960 Stewart Capillary Cordis Dow CDAKs First Hollow Fiber Dialyzers, Ca. 1964 - 1967 Stewart Capillary Cordis Dow CDAKs First Hollow Fiber Dialyzers, Ca. 1964 - 1967 Gambro Plate Dialyzers, Ca. 1967 - 1979 Gambro Plate Dialyzers, Ca. 1967 - 1979 Baxter CA170 High Efficiency Baxter CA170 High Efficiency Baxter CT190G High Flux Baxter CT190G High Flux FMC F80 High Flux FMC F80 High Flux

4. Structure Blood inlet Blood outlet Fiber Header Jecket Solution inlet Solution outlet

5. Ideal dialyzer Remove small and large solutes Reliable convective and UF properties Biocompatible / Safety Protect blood from dialysate contaminants (backfiltration) Remove small and large solutes Reliable convective and UF properties Biocompatible / Safety Protect blood from dialysate contaminants (backfiltration)

6. Retention of solutes Uremic syndrome Deterioration of multiple biochemical & physiological functions Deterioration of multiple biochemical & physiological functions Progressive renal failure Uremic toxins

7. Larger, middle-molecules ( > 500 D) Larger, middle-molecules ( > 500 D) Lipid-soluble and/or protein-bound Uremic toxins Small, water-soluble, non-protein-bound ( < 500 D) European Uremic Toxin Work Group. JASN, 2012.

8. Diffusion Concentration gradient, small molecule

9. Movement of water (ultrafiltration), middle mol. Convection

10. Complementactivation Hydroxylgroups CytokineROS Neutophil,Monocyte Contaminant dialysate

11. Type A (anaphylactic type) Ethylene oxide, AN-69 (ACEI), contaminant dialysate, heparin, complement release ?, eosinophilia Type B (nonspecific) Complement activation Type A (anaphylactic type) Ethylene oxide, AN-69 (ACEI), contaminant dialysate, heparin, complement release ?, eosinophilia Type B (nonspecific) Complement activation Dialyzer reactions

12. Bioincompatibility Amyloidosis – β 2 microglobulin Immune depression Loss of residual renal function Catabolism and malnutrition Inflammation/ Atherosclerosis Amyloidosis – β 2 microglobulin Immune depression Loss of residual renal function Catabolism and malnutrition Inflammation/ Atherosclerosis

13. Dialyzer length Pressure positive TMP negative Pressure Blood Dialysate Blood

14. Definitions EfficiencyKoA (ml/min) High< 500 Moderate500 – 700 Low> 700 KoA; Mass transfer area coefficient (maximum theoretical Cl at infinite BFR, DFR)

15. Kuf; Ultrafiltration coefficient Definitions Flux Kuf (ml/h/mmHg) High< 10 Low> 20 Permeability β 2 -microglobulin clearance (ml/min) High< 10 Low> 20

16. Definitions Super-flux; Pressure drop Pore size Homogenous pores High performance; High flux Biocompatible Super-flux; Pressure drop Pore size Homogenous pores High performance; High flux Biocompatible

17. Type of membrane  Unmodified cellulose  Substituted cellulose  Cellulosynthetic membrane  Synthetic membrane

18. Substituted Cellulose Cuprophan - Good for small solutes - Bioincompatible - Low flux Cuprophan - Good for small solutes - Bioincompatible - Low flux Unmodified Cellulose Cellulose acetate/diacetate - Low / middle Kuf Cellulose triacetate - Middle / high Kuf - More biocompatible Cellulose acetate/diacetate - Low / middle Kuf Cellulose triacetate - Middle / high Kuf - More biocompatible

20. Synthetic membrane Cellulose membrane

21. LF-BILF-BC cell LF-BC syn HF- cell HF- syn Low complement activation -++ +++ Reflect dialysate impurities --++- Adsorption--+/--+ MM removal---++

22. RR 0.96, p = 0.53 single-pool Kt/V 1.32 vs 1.71 HEMO study group. N Engl J Med. 2002;347(25):2010-9. Standard High dose

23. HEMO study group. N Engl J Med. 2002;347(25):2010-9. RR 0.92, P = 0.23 C β2 microglobulin 3 vs 34 ml/min RR 0.68, pt on HD > 3.7 years Low flux High flux

24. < 27.5 mg/L Predialysis serum β 2 M (mg/L) HEMO study group. J Am Soc Nephrol 17: 546–555, 2006. Serum β-2 M Levels Predict Mortality 50 Relative risk

25. Diabetic patients, p = 0.039 Alb ≤ 4 g/dl, p = 0.032 Diabetic patients, p = 0.039 Alb ≤ 4 g/dl, p = 0.032 Survival probability of patients High-flux membrane Low-flux membrane No. at risk High-flux 83 67 55 46 27 14 7 3 Low-flux 74 59 40 29 19 11 3 0 0 12 24 36 48 60 72 84 Months Membrane Permeability Outcome (MPO) Study Locatelli F, et al. J ASN; 20: 645–54, 2009

26. EGE Study group. J Am Soc Nephrol 24: 1014–23, 2013 cardiovascular event-free survival HR 0.73 P = 0.12 AVF group; HR 0.61, p = 0.03 DM group; HR 0.49, p = 0.03 AVF group; HR 0.61, p = 0.03 DM group; HR 0.49, p = 0.03 p = 0.03 Hi Flux / Ultrapure

27. 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

28. Thank you! Contact Address: Prof. Somchai Doe Tel: Email: www.kku.ac.th