Advanced in vitro hemocompatibility assessment of biomaterials using a new flow incubation system.

Physiologically relevant in vitro hemocompatibility assessment of biomaterials remains challenging. We present a new setup that enables standardized whole blood incubation of biomedical materials under flow. A blood volume of 2 mL is recirculated over test surfaces in a custom-made parallel plate incubation system to determine the activation of hemostasis and inflammation. Controlled physiological shear rates between 125 s-1 and 1250 s-1 and minimized contact to air are combined with a natural-like pumping process. A unique feature of this setup allows tracing adhesion of blood cells to test surfaces microscopically in situ. Validation testing was performed in comparison to previously applied whole blood incubation methodologies. Experiments with the newly developed setup showed that even small obstacles to blood flow activate blood (independent of materials-induced blood activation levels); that adhesion of blood cells to biomaterials equilibrates within 5 to 10 min; that high shear rates (1250 compared to 375 s-1) induce platelet activation; and that hemolysis, platelet factor 4 (PF4) release and platelet loss - but not thrombin formation - depend on shear rate (within the range investigated, 125 to 1250 s-1).

Hemocompatibility tuning of an innovative glutaraldehyde-free preparation strategy using riboflavin/UV crosslinking and electron irradiation of bovine pericardium for cardiac substitutes.

Hemocompatibility tuning was adopted to explore and refine an innovative, GA-free preparation strategy combining decellularization, riboflavin/UV crosslinking, and low-energy electron irradiation (SULEEI) procedure. A SULEEI-protocol was established to avoid GA-dependent deterioration that results in insufficient long-term aortic valve bioprosthesis durability. Final SULEEI-pericardium, intermediate steps and GA-fixed reference pericardium were exposed in vitro to fresh human whole blood to elucidate effects of preparation parameters on coagulation and inflammation activation and tissue histology. The riboflavin/UV crosslinking step showed to be less efficient in inactivating extracellular matrix (ECM) protein activity than the GA fixation, leading to tissue-factor mediated blood clotting. Intensifying the riboflavin/UV crosslinking with elevated riboflavin concentration and dextran caused an enhanced activation of the complement system. Yet activation processes induced by the previous protocol steps were quenched with the final electron beam treatment step. An optimized SULEEI protocol was developed using an intense and extended, trypsin-containing decellularization step to inactivate tissue factor and a dextran-free, low riboflavin, high UV crosslinking step. The innovative and improved GA-free SULEEI-preparation protocol results in low coagulant and low inflammatory bovine pericardium for surgical application.

Discovery of hemocompatible bacterial biofilm-resistant copolymers.

Blood-contacting medical devices play an important role within healthcare and are required to be biocompatible, hemocompatible and resistant to microbial colonization. Here we describe a high throughput screen for copolymers with these specific properties. A series of weakly amphiphilic monomers are combinatorially polymerized with acrylate glycol monomers of varying chain lengths to create a library of 645 multi-functional candidate materials containing multiple chemical moieties that impart anti-biofilm, hemo- and immuno-compatible properties. These materials are screened in over 15,000 individual biological assays, targeting two bacterial species, one Gram negative (Pseudomonas aeruginosa) and one Gram positive (Staphylococcus aureus) commonly associated with central venous catheter infections, using 5 different measures of hemocompatibility and 6 measures of immunocompatibililty. Selected copolymers reduce platelet activation, platelet loss and leukocyte activation compared with the standard comparator PTFE as well as reducing bacterial biofilm formation in vitro by more than 82% compared with silicone. Poly(isobornyl acrylate-co-triethylene glycol methacrylate) (75:25) is identified as the optimal material across all these measures reducing P. aeruginosa biofilm formation by up to 86% in vivo in a murine foreign body infection model compared with uncoated silicone.

The blood compatibility challenge. Part 3: Material associated activation of blood cascades and cells.

Following protein adsorption/activation which is the first step after the contact of material surfaces and whole blood (part 2), fibrinogen is converted to fibrin and platelets become activated and assembled in the form of a thrombus. This thrombus formation is the key feature that needs to be minimized in the creation of materials with low thrombogenicity. Further aspects of blood compatibility that are important on their own are complement and leukocyte activation which are also important drivers of thrombus formation. Hence this review summarizes the state of knowledge on all of these cascades and cells and their interactions. For each cascade or cell type, the chapter distinguishes statements which are in widespread agreement from statements where there is less of a consensus. STATEMENT OF SIGNIFICANCE: This paper is part 3 of a series of 4 reviews discussing the problem of biomaterial associated thrombogenicity. The objective was to highlight features of broad agreement and provide commentary on those aspects of the problem that were subject to dispute. We hope that future investigators will update these reviews as new scholarship resolves the uncertainties of today.

The blood compatibility challenge. Part 4: Surface modification for hemocompatible materials: Passive and active approaches to guide blood-material interactions.

Biomedical devices in the blood flow disturb the fine-tuned balance of pro- and anti-coagulant factors in blood and vessel wall. Numerous technologies have been suggested to reduce coagulant and inflammatory responses of the body towards the device material, ranging from camouflage effects to permanent activity and further to a responsive interaction with the host systems. However, not all types of modification are suitable for all types of medical products. This review has a focus on application-oriented considerations of hemocompatible surface fittings. Thus, passive versus bioactive modifications are discussed along with the control of protein adsorption, stability of the immobilization, and the type of bioactive substance, biological or synthetic. Further considerations are related to the target system, whether enzymes or cells should be addressed in arterial or venous system, or whether the blood vessel wall is addressed. Recent developments like feedback controlled or self-renewing systems for drug release or addressing cellular regulation pathways of blood platelets and endothelial cells are paradigms for a generation of blood contacting devices, which are hemocompatible by cooperation with the host system. STATEMENT OF SIGNIFICANCE: This paper is part 4 of a series of 4 reviews discussing the problem of biomaterial associated thrombogenicity. The objective was to highlight features of broad agreement and provide commentary on those aspects of the problem that were subject to dispute. We hope that future investigators will update these reviews as new scholarship resolves the uncertainties of today.

Influence of Charge on Hemocompatibility and Immunoreactivity of Polymeric Nanoparticles.

The benefits of nanomedicine may be restricted by hemocompatibility and immunoreactivity problems arising from administration of exogenous materials into the bloodstream. To understand how surface charge influences the interaction of polymeric nanoparticles with blood components, we synthesized three well-defined, charge-varied hyperbranched polymers (HBPs) of similar size and analyzed both hemocompatibility and immunoreactivity of these methacrylate-based HBPs ex vivo using primary human blood cell assays and image analyses following intravenous injection into mice. The results show that, regardless of charge, endotoxin-free HBPs had minimal effects on coagulation, platelet, complement, or T cell activation. However, high concentrations (100 µg mL-1) of cationic HBPs led to significant dendritic cell activation, suggesting the potential application of these nanoparticles as vaccine adjuvants to aid efficient antigen presentation. Biodistribution studies showed that intravenously administered charge-neutral HBPs had a longer retention time in the circulation than cationic or anionic HBPs; whereas these neutral HBPs were eventually cleared in the urine, charged HBPs mainly accumulated in liver and spleen. Overall, these results demonstrate that, regardless of surface charge, HBPs display a high level of hemocompatibility. In contrast, immunoreactivity and biodistribution are significantly influenced by charge. Manipulation of surface charge may thus be a useful method by which nanomaterials such as HBPs can be tailored to different clinical applications.

A Positively Charged Surface Triggers Coagulation Activation Through Factor VII Activating Protease (FSAP).

Contact between biomedical materials and blood often initiates undesirable pro-coagulant and pro-inflammatory processes. On negatively charged materials, blood coagulation is known to be triggered through autoactivation of Factor XII, while activation on cationic surfaces follows a distinct and so far enigmatic mechanism. Because Factor VII activating protease (FSAP) is known to be activated on positively and on negatively charged macromolecules in plasma, we have investigated its interaction with charged biomaterials and its consequences for coagulation. Several activation processes in blood and plasma were characterized after contact with material surfaces with varied charge. FSAP was found to be exclusively activated by the positively charged surfaces polyethylenimine (PEI) and poly-l-lysine (PLL), not by the negatively charged glass or self-assembled monolayer with carboxyl group termination (SAM-COOH), as well as uncharged (Teflon AF) surfaces. Whole blood incubation on PEI showed that this activation was concomitant with coagulation as determined by thrombin and fibrin formation, which was high for glass (F1+2, 138 nM) and PEI (F1+2, 44 nM) but low for Teflon AF (F1+2, 3.3 nM) and SAM COOH (F1+2, 5.8 nM). Contact phase inhibitor diminished coagulation to background levels for all surfaces except PEI (F1+2: ^PEI 43 to 25 nM; glass, 58 to 1.5 nM) indicating that coagulation activation is not dependent on FXII activation on the PEI surface. A decisive role of endogenous FSAP for coagulation however was confirmed with the use of FSAP inhibitory antibodies which showed no influence on Teflon AF, glass and SAM COOH but diminished F1+2 on PEI to less than 50%. We propose that FSAP activation could be a novel mechanism of surface-driven coagulation. An inhibition of this protease might improve hemocompatibility of cationic surfaces and therefore facilitate the application of polycationic surfaces in blood.

Biocompatibility assessment of silk nanoparticles: hemocompatibility and internalization by human blood cells.

Many nanoparticles are designed for use as potential nanomedicines for parenteral administration. However, emerging evidence suggests that hemocompatibility is important, but is highly particle- and test-bed dependent. Thus, knowledge of bulk material properties does not predict the hemocompatibility of uncharacterized nanoparticles, including silk nanoparticles. This study compares the hemocompatibility of silk versus silica nanoparticles, using whole human blood under quasi-static and flow conditions. Substantial hemocompatibility differences are noted for some nanoparticles in quasi-static versus dynamic studies; i.e., the inflammatory response to silk nanoparticles is significantly lower under flow versus quasi-static conditions. Silk nanoparticles also have very low coagulant properties - an observation that scales from the macro- to the nano-level. These nanoparticle hemocompatibility studies are complemented by preliminary live cell measurements to evaluate the endocytosis and trafficking of nanoparticles in human blood cells. Overall, this study demonstrates that nanoparticle hemocompatibility is affected by several factors, including the test bed design.

Neutrophil extracellular trap formation upon exposure of hydrophobic materials to human whole blood causes thrombogenic reactions.

Neutrophil extracellular trap (NET) formation, a reaction of the innate immune system to fight pathogens, was shown to be involved in thrombus formation. In the present study blood-contacting biomaterials with graded surface characteristics were investigated as a potential cause of NET formation on medical devices. Surface properties are known to govern protein adsorption, cell adhesion and ultimately the activation of several other host defense pathways - potentially also the formation of NETs. Model materials of defined hydrophilic or hydrophobic properties (glass, and thin films of poly(ethylene-alt-maleic anhydride), self-assembled monolayers of methyl terminated alkanethiols, and Teflon AF™) were incubated either with isolated human granulocytes after pre-adsorption with plasma proteins or with human whole blood. NET formation - detected as extracellular DNA, citrullinated histones, elastase and reactive oxygen species (ROS) - was observed on hydrophobic surfaces. Furthermore, NET formation on the hydrophobic surface Teflon AF™ resulted in elevated thrombin generation in hirudin-anticoagulated whole blood, but not in heparinized whole blood. Disintegration of surface-bound NETs by DNase treatment resulted in significantly lower pro-coagulant effects. Thus, NET formation can contribute to the thrombogenicity of clinically applied hydrophobic materials, suggesting NETosis as well as NET surface anchorage as new targets of anticoagulation strategies.

Adaptive release of heparin from anticoagulant hydrogels triggered by different blood coagulation factors.

Feedback-controlled anticoagulant hydrogels were formed by crosslinking the anticoagulant heparin with star-shaped poly(ethylene glycol) using peptide linkers, which are selectively cleaved by different activated blood coagulation factors acting as proteolytic enzymes. Various cleavable peptide units, differing either in their thrombin turnover rates or in their responsiveness to factors activated earlier in the course of blood coagulation, were used for the formation of the biohybrid materials. Release triggered by the early coagulation factors Xa (FXa) or FXIIa/kallikrein was shown to enhance the efficiency of the released anticoagulant. Furthermore, FXa-cleavable gels enabled a faster release of heparin, which was attributed to the lower affinity of the factor for heparin. Combining early and fast responses, FXa-cleavable gels were shown to provide anticoagulant protection of biomaterial surfaces at low levels of released heparin in human whole-blood incubation experiments. The results demonstrate the potential for employing biomolecular circuits in the design of functional biomaterials to tailor the adaptive delivery of bioactive molecules.

The effect of octadecyl chain immobilization on the hemocompatibility of poly (2-hydroxyethyl methacrylate).

Albumin-scavenging surfaces decorated with n-alkyl chains represent an established strategy for blood-contacting applications. To evaluate this concept, a set of poly (2-hydroxyethyl methacrylate) (pHEMA) films modified with different amounts of octadecyl isocyanate (C18) was investigated in an in vitro hemocompatibility assay using freshly drawn human whole blood. In addition, the hydrogel materials were thoroughly characterized with respect to changes in wettability and elasticity, which accompanied the gradual chemical modification of pHEMA. An increase of the surface C18 content induced enhanced hydrophobicity and stiffness. Immobilization of C18 chains was found to substantially reduce the coagulation activation and the complement activation by the pHEMA films. Platelet adhesion and degranulation (PF4 release) were similar on the modified and the unmodified pHEMA. Platelet adhesion to pHEMA hydrogels was lower than the polytetrafluoroethylene reference. We conclude that the immobilization of octadecyl chains improved the hemocompatibility of pHEMA materials under conditions that might be encountered in low shear blood flow.

Immobilization of the irreversible thrombin inhibitor D-Phe-Pro-Arg-chloromethylketone: a concept for hemocompatible surfaces?

The irreversible thrombin inhibitor D-Phe-Pro-Arg-chloromethylketone (PPACK) was covalently immobilized to PEGylated polymer thin films at its primary alpha-amino group. Activity assays and capture of radioconjugated thrombin reveal that the PPACK-decorated surfaces could bind thrombin forming up to 30% of a monolayer density. Back-calculation of this high thrombin-inhibiting capacity indicated that the surface immobilization of the inhibitor was still associated with more than two orders of magnitude of loss of activity; increasing activity was observed at higher surface densities. PPACK-containing polymer films almost duplicated the plasma coagulation time when compared with the reference substrate without inhibitor. In whole blood, however, the anticoagulant properties were below those previously found for benzamidine-type reversible thrombin inhibitors; in addition, the surface exhibited inflammatory properties. It is concluded that immobilized reversible thrombin inhibitors are more effective by passivating higher amounts of thrombin in a cooperative action with antithrombin III.

The ability of surface characteristics of materials to trigger leukocyte tissue factor expression.

Biomaterial-induced thrombosis is usually attributed to blood coagulation initiated by contact phase and platelet-related reactions. Considering the major role of extrinsic initiation in blood coagulation in vivo, we studied the material related-induction of this pathway by investigating the relevance of surface properties for the expression of Tissue Factor (TF), a critical initiator of the extrinsic pathway of coagulation. We incubated materials with self-assembled monolayers of alkylthiols (SAMs) displaying various ratios of -CH(3), -OH, and -COOH terminations with fresh heparinized whole human blood in vitro. The transcription of TF-mRNA in leukocytes showed clear differences in relation to surface properties and increased over time. In addition, a positive correlation between TF transcription and its presence on leukocytes, granulocyte activation, and complement activation was found. Cells displaying the highest TF expression after material contact had significantly lower intracellular TF, pointing to previous TF release. Yet under the conditions of our whole blood incubation set-up within the limited time frame the observed initiation of the extrinsic pathway did not trigger blood coagulation.

Synergistic effect of hydrophobic and anionic surface groups triggers blood coagulation in vitro.

Biomaterial induced coagulation encompasses plasmatic and cellular processes. The functional loss of biomedical devices possibly resulting from these thrombotic reactions motivates the need for a better understanding of processes occurring at blood-biomaterial interfaces. Well defined model surfaces providing specific chemical-physical properties (self assembled monolayers (SAMs)) displaying hydrophobic or/and acidic terminal groups were used to uncover initial mechanisms of biomaterial induced coagulation. We investigated the influence of electrical charge and wettability on platelet- and contact activation, the two main actors of blood coagulation, which are often considered as separate mechanisms in biomaterials research. Our results show a dependence of contact activation on acidic surface groups and a correlation of platelet adhesion to surface hydrophobicity. Clot formation resulting from the interplay of blood platelets and contact activation was only found on surfaces combining both acidic and hydrophobic surface groups but not on monolayers displaying extreme hydrophobic/acidic properties.

Blood coagulation on biomaterials requires the combination of distinct activation processes.

The rational design of hemocompatible materials requires a mechanistic understanding of activation processes induced at the blood-material interface. Binary self-assembled monolayers of alkyl thiols (SAMs) with various ratios of -CH3 and -COOH terminations were used to study the relevance of hydrophobic and negatively charged surfaces for the initiation of blood coagulation. Platelet adhesion and activation of the intrinsic coagulation pathway scaled with the surface composition: the numbers of adherent platelets were highest on the 100%-CH3 surface whereas the greatest contact activation was seen on 100%-COOH surfaces. In vitro whole blood incubation assays showed, however, that the surfaces exposing either -CH3 or -COOH groups induced comparably low levels of thrombin formation while the surfaces with intermediate contents of both terminating groups had significantly higher values. These results reveal that contact activation and platelet adhesion have a strong synergistic effect on coagulation on blood-contacting materials even though these events in isolation are not sufficient to induce substantial thrombin formation. Successful surface design strategies for hemocompatible materials therefore need to carefully consider the interplay of both processes.

Surface endotoxin contamination and hemocompatibility evaluation of materials.

To evaluate the blood compatibility of new materials, a clear distinction between properties of the materials and effects due to surface contamination by adsorbed endotoxins is essential. This study compares direct contact approaches and elution methods with water, organic solvents, nonionic, and zwitterionic detergents for determination of surface-adsorbed endotoxin by the limulus amoebocyte lysate (LAL) test and determines the blood compatibility of various surfaces with controlled endotoxin contamination in vitro. The LAL test in direct contact with an endotoxin-contaminated surface was concluded to be not practicable for most devices and its sensitivity showed a high dependence on surface characteristics. Among the elution methods, 0.2% Tween-20 showed most stable elution characteristics and appears therefore preferable. Biological reactions at in vitro blood exposure were found to be only minimally influenced by adsorbed endotoxin during the time window of 2 h, allowing for a straightforward discrimination between materials and endotoxin-dependent reactions.

In vitro blood reactivity to hydroxylated and non-hydroxylated polymer surfaces.

Complement activation on hydroxyl-group-bearing surfaces is regarded as the main reason for granulocyte activation in applications of blood-contacting medical devices such as extracorporeal blood purification. However, the factors inducing the cell adhesion so far remained ambiguous. For a dedicated research, whole blood was incubated with a set of structurally similar polymer coatings on glass with either hydroxy or ether functionalities. By co-incubation of an activating with a non-activating surface, the reaction of granulocytes activated by complement fragments on non-activating surfaces could be evaluated. As expected, hydroxyl-terminated polymer layers induced much higher levels of complement activation than those with ether functionalities. Leukocyte activation, as measured by the expression of CD11b, correlated closely with the presence of free complement fragment C5a. However, adhesion of leukocytes was rather associated with the adsorption of activated fragments of C3 than with the activation level of the cells. Moreover, it was found that adsorbed quantities of fibrin and fibrinogen had little influence on leukocyte adhesion. It is concluded that the activation of leukocytes is triggered by soluble complement factors such as C5a while their adhesion on hydroxy-bearing surfaces is mainly triggered by the presence of surface-bound complement fragment C3b.

Sulfated glycopolymer thin films - preparation, characterization, and biological activity.

The impact of heparinoid characteristics on model surfaces obtained from immobilization of sole sulfate groups as well as sulfated glycosides, sulfated cellulose, and definite heparin has been investigated. The obtained layers were physico-chemically characterized regarding film thickness, chemical composition, wettability, and surface morphology. Antithrombin adsorption, studied by fluorescence labeling, revealed a strong dependence on the presence of glycosidic structures and on the molecular weight of the grafted saccharide. On contact with whole blood, the coatings resulted in a diminished plasmatic and cellular coagulation in vitro, which did not reflect well the antithrombin binding. Therefore, more complex activating pathways are discussed.

Benzamidine-based coatings: Implication of inhibitor structure on the inhibition of coagulation enzymes in solution and in vitro hemocompatibility assessment.

Synthetic inhibitors of trypsin-like serine proteases were covalently immobilized to polymeric materials to passivate coagulation enzymes during blood contact. The inhibitory potency of a structurally simple and larger, more complex amidine derivatives was assessed against thrombin and factor Xa. After adsorption of serum albumin, the polymer films decorated with either one of the inhibitors were found to scavenge thrombin-with a higher affinity in the case of the larger inhibitor-but not factor Xa. Both inhibitor-containing coatings showed a significantly reduced thrombogenicity, coagulation activation, as well as complement activation when incubated with freshly drawn human whole blood in vitro. The authors conclude that the introduced principle offers a promising approach for hemocompatible materials for short term applications. Even rather simple inhibitors can be successfully employed for that purpose.