Development of a multifunctional detoxifying unit for liver failure patients.

BACKGROUND/AIMS: Extracorporeal blood detoxification strategies aimed at supporting impaired liver function have been explored because of the imbalance between donor organs and waiting patients. A limited number of artificial devices are now available clinically, and these are characterized by the use of multistage adsorption procedures in conjunction with hemodialysis, but these features simultaneously increase system complexity and treatment costs. METHODS: The authors developed a simpler strategy for liver dialysis based on the use of a multifunctional filter, which enables plasma separation and perfusion in a single unit. RESULTS: Liver dialysis treatments were successfully performed using the devised unit when bovine blood containing uremic and hepatic toxins was circulated. Removal of the solutes under investigation was significant, and reduction ratios of 78% for urea, 98% for creatinine and 91% for bilirubin were achieved. Plasma free hemoglobin levels were reasonably maintained despite prolonged blood recirculation for 5 h, and platelet, hematocrit and hemoglobin levels remained uniform throughout liver dialysis sessions. CONCLUSION: The devised liver support unit may offer a straightforward and efficient means of cleansing blood for patients with hepatic failure.

Evaluation of a new method for pulse push/pull hemodialysis: comparison with conventional hemodialysis.

The repetition of forward and backward filtration during hemodialysis (HD) increases convective mass transfer, and thus, the authors devised a method of achieving cyclic repletion of ultrafiltration and backfiltration. Hemodialytic efficiencies of the developed unit are described. The devised method, named pulse push/pull hemodialysis (PPPHD), is based on the utilization of dual pulsation in a dialysate stream. Clearances of solutes with different molecular weights were determined, and in vivo hemodialytic performance was investigated in a canine renal failure model. Urea and creatinine reduction and albumin (ALB) loss were monitored, and the results obtained were compared with those of a conventional high-flux hemodialysis (CHD). Dialysis sessions were repeated eight times for PPPHD and six times for CHD by alternating PPPHD and CHD sessions in a single animal, which remained stable throughout the experiments. Urea and creatinine reductions for the PPPHD unit were 49.2 ± 2% and 44.3 ± 3.3%, respectively, which were slightly higher than those obtained for the CHD. Total protein and ALB levels were preserved by both methods. However, in vitro results revealed that PPPHD achieved significantly greater inulin clearance than CHD. The developed PPPHD unit facilitates repetitive filtration and improves convective mass transfer during HD, without the need for external replacement infusion.

A dual-chambered hemodialyzer for convection-enhanced hemodialysis.

Convective clearance during hemodialysis (HD) improves dialysis outcomes in kidney failure patients, and, thus, trials have been undertaken to increase convective mass transfer, which is directly related to internal filtration rates. The authors designed a new hemodialyzer to increase the internal filtration rates, and here describe the hemodialytic efficacy of the devised unit. The developed dual-chambered hemodialyzer (DCH) contains two separate chambers for dialysate flow within a single housing. By placing a flow restrictor on the dialysate stream between these two chambers, dialysate pressures are regulated independently. Dialysate is maintained at a higher pressure than blood pressure in one chamber, and at a lower pressure in the other chamber. The dialysis performance of the DCH was investigated using an acute canine renal failure model. Urea and creatinine reductions and albumin loss were monitored, and forward and backward filtration rates were measured. No procedurally related malfunction was encountered, and animals remained stable without any complications. Urea and creatinine reductions after 4-h dialysis treatments were 75.2 ± 6.5% and 67.7 ± 8.9%, respectively. Post-treatment total protein and albumin levels remained at pretreatment values. Total filtration volume was 4.98 ± 0.5 L over 4 h, whereas the corresponding backfiltration (BF) volume was 4.77 ± 0.6 L. The developed dual-chamber dialyzer has the benefit of providing independent control of forward filtration and BF rates. HD using this dialyzer provides a straightforward means of increasing the internal filtration and convective dose.

Effects of arterial port design on blood flow distribution in hemodialyzers.

BACKGROUND/AIMS: Blood flow profiles in fiber bundles depend on the design of the arterial port and affects the biocompatibility of the hemodialyzer. We analyzed the effects of arterial port design on blood flow distribution in fiber bundles using nonintrusive imaging techniques. METHODS: The velocity fields in arterial ports and the hemodynamics in fiber bundles were analyzed for hemodialyzers with different configurations using particle image velocimetry and perfusion computed tomography. RESULTS: In a hemodialyzer with standard arterial ports, high blood flow profiles in the central and peripheral regions and low blood profiles in the middle region were developed due to jet flow and vortices around the jet. In a hemodialyzer with spiral arterial ports, higher flow profiles were developed due to the central vortices that decrease perfusion into the fiber bundles. CONCLUSION: The arterial port design of hemodialyzers should be optimized such that jet flow and vortices do not impair dialysis efficiency and biocompatibility.

Development of a cold dialysate regeneration system for home hemodialysis.

BACKGROUND/AIMS: Because longer and/or more frequent dialysis has potential clinical benefits, home hemodialysis (HHD) systems should provide flexible renal replacement therapies. We propose a new cold dialysate regeneration system that requires 10 l per treatment for HHD. METHODS: We designed a dialysate regeneration system using cold dialysate and 2 activated carbon columns alternatively switched between adsorption and desorption. Urea adsorption ratios were compared in three different conditions; cold dialysate (5.7 degrees C), normal dialysate (36.8 degrees C), and cold dialysate with washing. In vivo tests (n = 8) were conducted to validate this system. RESULTS: The urea removal ratios were 20.0 +/- 1.7% in cold dialysate, 36.0 +/- 1.7% in normal dialysate, and 82.5 +/- 1.2% in cold dialysate with washing. In animal experiments, the urea reduction ratio was 60.9 +/- 6.3%, Kt/V was 1.0 +/- 0.2, and serum electrolytes remained stable. CONCLUSION: The proposed cold dialysate regeneration system using a small volume of dialysate will be useful for HHD.

Quantitative analysis of pulsatile flow contribution to ultrafiltration.

We evaluated the quantitative contribution of pulsatile flow to ultrafiltration (UF) in terms of fluid power, membrane stretch, and reduction of membrane layering. An in vitro comparison of the UF rate using pulsatile and roller pumps was performed with distilled water and bovine whole blood. The mean transmembrane pressure (TMPm) and UF rate were higher with the pulsatile pump for the same mean flow rate: 6.6 mm Hg and 21.1 mL/min higher on average for distilled water and 34.2 mm Hg and 31.4 mL/min higher on average for blood. The average UF rate was 8.4 mL/min higher with the pulsatile pump for the same TMPm with bovine blood. However, the relationship between the UF rate and the TMPm was independent of the flow configuration for distilled water. We showed that the higher UF rate in the pulsatile pump is mainly due to greater fluid power and reduction of membrane layering, while the membrane stretch was not an important factor.

Pulse push/pull hemodialysis in a canine renal failure model.

A new dialysis modality was devised to increase convective mass transfer. Blood and dialysate are circulated by a pulsatile pump, but with pulsatile flow patterns that are 180 degrees out of phase, which causes blood-to-dialysate pressure gradients to oscillate between positive and negative. In the present study, hemodialytic performance of the devised modality was investigated using a canine renal failure model. Membrane hydraulic permeabilities (K(uf)) and fiber bundle volumes (FBV) were measured after each dialysis session. Postdialysis K(uf) and FBV were then compared with those with conventional high-flux hemodialysis. No complications concerning animals or technical problems with the devised modality were encountered. Urea and creatinine reductions were satisfactory. Postdialysis K(uf) and FBV values were significantly reduced after hemodialysis sessions, but were higher for the new modality. The devised modality incorporated with blood and dialysate pulsation offers a simple but safe means new mode of hemodialysis.

Comparison of a pulsatile blood pump and a peristaltic roller pump during hemoperfusion treatment in a canine model of paraquat poisoning.

This study examined the treatment efficacy and the damage to the blood during hemoperfusion for treating paraquat poisoning using two blood pump mechanisms. Paraquat-poisoned animal models were prepared. A conventional hemodialysis machine, AK90, with a peristaltic roller pump and a cardiopulmonary support system, T-PLS, with a pulsatile blood pump were used during the animal experiments. A total of 12 dogs were treated with hemoperfusion using a charcoal column. Six dogs were treated with hemoperfusion and T-PLS, and the other six were treated with AK90. A paraquat dose of 30 mg/kg was administrated by an intravenous injection. Both pumps maintained blood flow rates of 125 mL/min measured by an ultrasonic flowmeter. For anticoagulation, heparin was administrated by an initial bolus (250 IU/kg) and a continuous injection (100 IU/kg/h). During the experiments, T-PLS and AK90 showed a similar toxin removal efficacy. Both devices decreased the plasma paraquat concentration to 10% of the initial dose within 4-h hemoperfusion. The two pumps showed similar hemolysis properties with acceptable levels. Although T-PLS was developed as a cardiopulmonary bypass system, it can also be used as a hemoperfusion treatment device.

Application of an elastic biodegradable poly(L-lactide-co-epsilon-caprolactone) scaffold for cartilage tissue regeneration.

In cartilage tissue regeneration, it is important that an implant inserted into a defect site can maintain its mechanical integrity and endure stress loads from the body, in addition to being biocompatible and able to induce tissue growth. These factors are crucial in the design of scaffolds for cartilage tissue engineering. We developed an elastic biodegradable scaffold from poly(L-lactideco-epsilon-caprolactone) (PLCL) for application in cartilage treatment. Biodegradable PLCL co-polymer was synthesized from L-lactide and epsilon-caprolactone in the presence of stannous octoate as a catalyst. A highly elastic PLCL scaffold was fabricated by a gel-pressing method with 80% porosity and 300-500 microm pore size. The tensile mechanical and recovery tests were performed in order to examine mechanical and elastic properties of the PLCL scaffold. They could be easily twisted and bent and exhibited almost complete (over 94%) recoverable extension up to breaking point. For examining cartilaginous tissue formation, rabbit chondrocytes were seeded on scaffolds. They were then cultured in vitro for 5 weeks or implanted in nude mice subcutaneously. From in vitro and in vivo tests, the accumulation of extracellular matrix on the constructs showed that chondrogenic differentiation was sustained onto PLCL scaffolds. Histological analysis showed that cells onto PLCL scaffolds formed mature and well-developed cartilaginous tissue, as evidenced by chondrocytes within lacunae. From these results, we are confident that elastic PLCL scaffolds exhibit biocompatibility and as such would provide an environment where cartilage tissue growth is enhanced and facilitated.

Pulse push/pull hemodialysis: in vitro study on new dialysis modality with higher convective efficiency.

Midsize molecule retention is related with renal-failure-associated mortality. Here, the authors describe a new dialysis modality, pulse push/pull hemodialysis (PPPHD), which increases convective clearance. Blood and dialysate are circulated by a pulsatile pump, but with pulsatile flow patterns that are 180 degrees out of phase. This causes blood-to-dialysate pressure gradients that oscillate between positive and negative, and which cause consecutive periods of ultrafiltration and backfiltration. The devised PPPHD was compared with conventional high-flux hemodialysis (CHFHD) in terms of solute clearances, albumin loss, and total protein levels. Human plasma containing dissolved uremic marker molecules was used as a blood substitute, and clearances were investigated for blood urea nitrogen, creatinine, vitamin B12, and inulin. Observed clearances were found to be significantly higher for PPPHD by approximately 3-14% for low-molecular-weight solutes, by 47-48% for vitamin B12, and by 38-49% for inulin than for CHFHD. No albumin loss was observed in either of these two study groups. The authors conclude that PPPHD offers a simple straightforward means of enhancing uremic molecule removal by increasing total ultrafiltration volume without the need to infuse replacement fluid.

Hemodialysis using a valveless pulsatile blood pump.

Research on pulsatile blood pumps for extracorporeal life support has been widely performed because of the proven advantageous effects of blood pulsation. However, studies on the use of pulsatile blood pumps for hemodialysis are limited, although available evidence demonstrates that pulsatile blood flow has a positive influence on dialysis outcome. Therefore, the authors designed a new pulsatile pump, which is characterized by minimal-occlusion of blood-containing tubing, no requirement for valves, and no blood flow regurgitation. In-vitro hemolysis tests were conducted using fresh bovine blood, and the normalized index of hemolysis was adopted to compare blood traumas induced by the devised pulsatile pump and a conventional roller pump. In addition, experimental hemodialyses with a canine renal failure model were performed using the devised pump. Normalized index of hemolysis levels obtained was much smaller for the devised pulse pump (45 +/- 21 mg/100 L) than for the roller pump (103 +/- 10 mg/100 L), and no technical problems were encountered during dialysis sessions. Blood and dialysate flow rates were maintained at predetermined values and molecular removal was satisfactory. Postdialysis urea and creatinine reduction ratios were 61.8% +/- 10.6% and 57.4% +/- 9.0%, respectively. Pulsatile flow has usually been generated using pulsatile devices containing valves, but the valves cause concern in terms of the clinical applications of these devices. However, the described pulsatile pump does not require valves, and yet no blood flow regurgitation was observed.

Comparison of hemolytic properties of different shapes of occlusion of blood sac in occlusive-type pulsatile blood pump.

The occlusive-type pulsatile extracorporeal blood pump (T-PLS, Seoul National University, Seoul, Korea) received the Communauté Européenne mark of the European Directives (2003) and Korea Food and Drug Administration approval (2004) for short-term application as an extracorporeal life support system. The pump system was recently upgraded in the ameliorated actuator head for reducing hemolysis, rather than in the existing actuator head. In this study, the hemolytic performance of the new pump system (assessed as the degree of occlusiveness of the blood sac) was compared with the existing one. A roller pump, the Stockert S3 (Stockert Instrumente GmbH, Munchen, Germany), was selected as a control device. Five tests were conducted for each pump, with each of these tests lasting for 6 h. A pump flow of 3 L/min with 50 beats per minute was included in the hemolytic test conditions. The lowest hemolytic results were obtained by the new pump system yielding a normalized index of hemolysis of less than 0.005 g/100 L, and this result was one-fourth that of the roller pump, Stockert S3.

Cartilaginous tissue formation using a mechano-active scaffold and dynamic compressive stimulation.

It is known that complex loading is involved in the development and maintenance of articular cartilage in the body. It means the compressive mechanical stimulation is a very important factor for formation of articular cartilage using a tissue-engineering technique. The objective of this study is to engineer cartilaginous constructs with mechano-active scaffolds and to evaluate the effect of dynamic compression for regeneration of cartilage. The mechano-active scaffolds were prepared from a very elastic poly(L-lactide-co-epsilon-caprolactone) (PLCL) with 85% porosity and 300-500 mum pore size using a gel-pressing method. The scaffold was seeded with 2 x 10(6) chondrocytes and the continuous compressive deformation of 5% strain was applied with 0.1 Hz for 10 days and 24 days, respectively. Then, the chondrocytes-seeded constructs were implanted subcutaneously into nude mice. Mechano-active scaffolds with complete rubber-like elasticity showed almost complete (over 97%) recovery at an applied strain of up to 500%. The amount of chondral extracellular matrix was increased significantly by mechanical stimulation on the highly elastic mechano-active scaffolds. Histological analysis showed the mechanically stimulated implants formed mature and well-developed cartilaginous tissue, as evidenced by the chondrocytes within lacunae and the abundant accumulation of sulfated GAGs. However, unhealthy lacunae shapes and hypertrophy forms were observed in the implants stimulated mechanically for 24 days, compared with those stimulated for 10 days. In conclusion, the proper periodical application of dynamic compression can encourage chondrocytes to maintain their phenotypes and enhance the production of GAGs, which would improve the quality of cartilaginous tissue formed both in vitro and in vivo.

Computational dose predictions for combined treatment of hemofiltration with weekly hemodialysis.

Hemodialysis (HD) has sufficient efficacy as a conventional diffusive treatment for removing small molecules, whereas hemofiltration (HF), which is a convective treatment, has an improved the clearance of intermediate-sized molecules. This paper reports a combined treatment (CT) which combines the diffusive and convective efficacies of HF several times weekly with HD weekly. CT modalities with various schedules and prescriptions are described mathematically using a variable-volume two-compartment kinetics model, and the kinetic parameters were obtained from previous clinical reports and a hemodialysis-related database. The blood concentration profiles of the three waste molecules for 52 weeks were calculated in order to compare the capability of removing small and intermediate-sized molecules to those of other renal treatments. The results by a computer simulation show that CT can reduce the frequency of sessions and the volume of replacement fluid compared with daily convective treatment, and achieve the adequate treatment efficiency with both small and intermediate-sized molecules for chronic renal failure patients.

Durability improvement of polymer chamber of pulsatile extracorporeal life support system in terms of mechanical change.

Twin Pulse Life Support, T-PLS has received the CE mark (2003) and Korea Food and Drug Administration (KFDA) approval (2004) for short-term application as an Extracorporeal Life Support system (ECLS). T-PLS's original intention was to apply for not only short-term but also long-term application such as Extracorporeal ventricular assist device (VAD). Hence, a long-term durability test was conducted. The 1-year reliability of the systems tested in this study did not meet the STS/ASAIO standard of 80% reliability with 60% confidence for a 1-year mission life. However, without the disposable units, which are only designed to operate for 6 h, the 1-year reliability exceeded the STS/ASAIO standard of 80% reliability with 60% confidence. In this study, by using the existing analysis methods and analyzing the root cause of the failure used by a numerical analysis. As eliminating or mitigating of the root cause of the failure, we improved the durability of blood chamber and evaluated the performance of the modified system via the hemolysis test.

Convection-enhanced high-flux hemodialysis.

Internal filtration contributes to convective clearance in high-flux hemodialysis but its contribution is limited by low pressure gradients. Therefore, a modification using a conventional dialyzer was conceived to enhance internal filtration and backfiltration (BF) rates. The modified dialyzer includes two longitudinal independent regions for blood flow, which were created by redesigning dialyzer caps. Blood pressures remained higher than dialysate pressures in one region and lower in the other region, allowing continuous internal filtration and BF in these respective regions. Modified and conventional dialyzers were compared in terms of pressure gradients and solute clearances. Thus, our experiments involved two groups: the modified dialyzer group and the conventional dialyzer group. A renal failure model was established using a dog weighing 25-30 kg by renal artery and vein ligation. With the exception of the dialyzers, experimental conditions were identical in the two groups. The pressure gradients between blood and dialysate were much higher for the modified dialyzer than for the conventional dialyzer. No significant differences were observed with respect to small solute clearances between the two groups, but mid-range solute clearances were significantly higher in the modified group. More optimization is required before the devised unit can be used clinically. However, the devised unit offers a straightforward means of regulating internal filtration and BF rates.

Probe classification of on-off type DNA microarray images with a nonlinear matching measure.

We propose a nonlinear matching measure, called counting measure, as a signal detection measure that is defined as the number of on pixels in the spot area. It is applied to classify probes for an on-off type DNA microarray, where each probe spot is classified as hybridized or not. The counting measure also incorporates the maximum response search method, where the expected signal is obtained by taking the maximum among the measured responses of the various positions and sizes of the spot template. The counting measure was compared to existing signal detection measures such as the normalized covariance and the median for 2390 patient samples tested on the human papillomavirus (HPV) DNA chip. The counting measure performed the best regardless of whether or not the maximum response search method was used. The experimental results showed that the counting measure combined with the positional search was the most preferable.

Differentiation, engraftment and functional effects of pre-treated mesenchymal stem cells in a rat myocardial infarct model.

BACKGROUND: Mesenchymal stem cells (MSCs) offer a novel therapeutic option in the treatment of acute myocardial infarction. MSCs are able to differentiate into myogenic cells after 5-azacytitdine treatment. However, 5-azacytidine might have genotoxic effects. Recently, it was reported that combined treatment with bone morphogenetic protein-2(BMP-2) and fibroblast growth factor-4(FGF-4) caused cardiac differentiation in non-precardiac mesoderm explants. Therefore, we investigated whether MSCs treated with combined BMP-2 and FGF-4 showed evidence of myogenic differentiation in vitro, and whether these cells resulted in sustained engraftment, myogenic differentiation, and improved cardiac function after implantation in infarcted myocardium. METHODS AND RESULTS: In vitro study: MSCs were treated with BMP-2 + FGF-4 (GF-MSCs) and myogenic phenotype was evaluated immunohistochemically. Cell growth curve was used to compare MSC proliferative capacity between the growth factors and 5-azacytidine treatments. In vivo study: two weeks after coronary artery occlusion, GF-MSCs (n=15), MSCs (n=5) labelled with PKH26 were injected into infarcted myocardium. Control animals (n=5) received a culture medium into the infarcted myocardium. Two weeks after implantation, some engrafted GF-MSCs or MSCs expressed sarcomeric-alpha-actinin and cardiac myosin heavy chain, as was observed in culture. Echocardiography showed that the GF-MSC group had a better (p < 0.05) left ventricular performance than the other groups. CONCLUSION: GF-MSCs induced myogenic differentiation in vitro. Moreover, GF-MSCs engrafted into the infarcted myocardium increased myogenic differentiation, prevented dilation of the infarcted region, and eventually improved heart function.

Computerized scheme for assessing ultrasonographic features of breast masses.

RATIONALE AND OBJECTIVE: To evaluate the ultrasonographic features of breast masses using a computerized scheme and to correlate the feature values with radiologists' grading. MATERIALS AND METHODS: One hundred and seventy-five breast ultrasound images (one to five images per subject) from 61 women (age 17-89 years, mean 43 years) were studied. Thirty-eight of the 157 images were from 11 women with malignant lesions, and the remaining 137 were from 50 patients with benign lesions. Two breast imaging radiologists participated in an observer performance study and were asked to grade, on a scale of 3, shape (1: regular, 3: very irregular), border (1: sharp, 3: ill-defined), internal texture (1: homogeneous, 3: very heterogeneous), width/depth ratio (1: flat, 3: tall), posterior enhancement (1: strong, 3: none), and lateral shadowing (1: strong, 3: none). The computerized scheme analyzed the breast region within a region of interest that was placed by a radiologist and quantified the following parameters: shape (jag count, disperse, convex hull depth, and lobulation count), border (acutance, average maximum ascending gradient, and sigmoid curve fitting), texture (edge density, co-occurrence matrix, and fractal dimension), width-depth ratio, posterior enhancement, and lateral shadowing. Correlations between the radiologists and the computerized scheme for assessing parameters in corresponding categories were computed. RESULTS: Good agreement was seen in posterior enhancement (P < .001, r = 0.45), lateral shadowing (P < .001, r = 0.38), width-depth ratio (P < .001, r = 0.33), and shape features (all P < .001): jag count (r = 0.38), disperseness (r = 0.55), and convex hull depth (r = 0.44). The remaining parameters demonstrated a poor or weak correlation (r < 0.30). CONCLUSION: The radiologists and the computerized scheme correlated best in analysis of shape features and posterior enhancement. We have yet to determine the significance of these features for the implementation of a computer-aided diagnosis program for characterizing breast ultrasound masses.