Evaluación clínica y económica del uso de ultrafiltración en pacientes con insuficiencia cardíaca aguda / Clinical and economic evaluation of the use of ultrafiltration in patients with acute heart failure

ANTECEDENTES: La ICA es la mayor causa de hospitalizaciones en personas de ≥65 años, y está asociada a una tasa de mortalidad y reingreso elevada. La ICA se puede presentar como una primera manifestación de la IC (de novo) o, más frecuentemente, como consecuencia de una descompensación aguda de la IC crónica. Los diuréticos son la base del tratamiento de la ICA con sobrecarga de volumen y congestión. Los más utilizados son los diuréticos de asa. En ciertos pacientes, puede existir una resistencia a estos fármacos, por lo que, para resolver la congestión, se ha empleado la ultrafiltración. La ultrafiltración se refiere a la eliminación mecánica y ajustable de agua plasmática isotónica de la sangre a través de una membrana semipermeable (hemofiltro), mediada por la aplicación de un gradiente de presión hidrostática generado por una bomba. OBJETIVO: Evaluar la eficacia, seguridad y costo-efectividad del uso de ultrafiltración en pacientes con insuficiencia cardiaca aguda. MÉTODOS: Se realizó una búsqueda sistemática y exhaustiva de toda la evidencia disponible en Pubmed, BVS y Cochrane library, obteniendo una revisión sistemática con metaanálisis de confianza alta, de acuerdo a AMSTAR-2, la cual fue utilizada para el análisis cualitativo. RESULTADOS: Se identificaron un total de 780 estudios, de los cuales, 59 estudios fueron revisados a texto completo, obteniendo 4 revisiones sistemáticas, en donde, 3 no cumplieron con criterios de calidad metodológica, consiguiendo una confianza críticamente baja. La revisión sistemática incluida en nuestro análisis, demostró un efecto estadístico nulo en todos los desenlaces evaluados (mortalidad, rehospitalización, mejoría clínica, efectos adversos), a excepción de la rehospitalización por insuficiencia cardiaca a largo plazo, donde el efecto favoreció a la intervención de análisis (ultrafiltración). CONCLUSIÓN: De los datos obtenidos de la evaluación clínica, se identifica que la UF podría reducir la rehospitalización por insuficiencia cardiaca, la cual, es la causa de los mayores gastos por insuficiencia cardiaca aguda en los sistemas de salud. Debido a la certeza limitada de los hallazgos, se debe mantener en vigilancia estrecha a las nuevas publicaciones del tema, para confirmar o modificar la dirección del efecto de los distintos desenlaces.

Economic model for obtaining cyclodextrins from commercial cgtase

A repetitive batch process was employed followed by membrane ultrafiltration system to produce low-cost cyclodextrins (CDs) using commercial enzymes Toruzyme® cyclomaltodextrin glucanotransferase (CGTase) and its kinetic parameters were determined. The ultrafiltration system enabled the removalof inhibitory products from the reaction medium, allowing the enzyme to be recovered for reuse. A 10 kDa membrane was used to separate the different CDs produced by the CGTase. The substrates evaluated were maltodextrin, corn starch and cassava starch at 5, 10 and 15% (w/V), in the presence and absence of 10% (V/V) ethanol. After reaction for 132 h, 10% (w/V) cassava starch in the presence of ethanol provided the best results with 32.1 mg/mL of ß-CD. Maximum production occurred after 72 h of reaction, with a yield of 87.4% of ß-CD and an α-CD, ß-CD and γ-CD production ratio of 1:1:0.08 g, respectively. When eight repetitive batches of 72 h followed by ultrafiltration and crystallization of ß-CD were performed, 2.1 g of precipitate was obtained with a purity of 67.6% ß-CD. The supernatant from the crystallization process was lyophilized and resulted in 35.3% α-CD. The developed model can be used industrially for the production of low cost CDs from easily obtained raw material

Evaluation of Membrane Ultrafiltration and Residual Chlorination as a Decentralized Water Treatment Strategy for Ten Rural Healthcare Facilities in Rwanda.

There is a critical need for safe water in healthcare facilities (HCF) in low-income countries. HCF rely on water supplies that may require additional on-site treatment, and need sustainable technologies that can deliver sufficient quantities of water. Water treatment systems (WTS) that utilize ultrafiltration membranes for water treatment can be a useful technology in low-income countries, but studies have not systematically examined the feasibility of this technology in low-income settings. We monitored 22 months of operation of 10 WTS, including pre-filtration, membrane ultrafiltration, and chlorine residual disinfection that were donated to and operated by rural HCF in Rwanda. The systems were fully operational for 74% of the observation period. The most frequent reasons for interruption were water shortage (8%) and failure of the chlorination mechanism (7%). When systems were operational, 98% of water samples collected from the HCF taps met World Health Organization (WHO) guidelines for microbiological water quality. Water quality deteriorated during treatment interruptions and when water was stored in containers. Sustained performance of the systems depended primarily on organizational factors: the ability of the HCF technician to perform routine servicing and repairs, and environmental factors: water and power availability and procurement of materials, including chlorine and replacement parts in Rwanda.

A novel configuration for an anaerobic submerged membrane bioreactor (AnSMBR). Long-term treatment of municipal wastewater under psychrophilic conditions.

A novel design for a pilot scale anaerobic submerged membrane bioreactor (AnSMBR) equipped with an ultrafiltration unit, treating municipal wastewater at 18 ± 2°C, and inoculated with a mesophilic inoculum without acclimation, was implemented and evaluated over 3 years of stable operation. The AnSMBR operated with a volumetric loading rate between 1.6 to 2.0 kg COD/m(3)UASBd, 12.8 to 14.2h hydraulic retention time, and reached a tCOD removal efficiency of around 90%. Biosolid production was between 0.05 and 0.083 g VS/g CODremoved. Dissolved methane oversaturation in the effluent was observed, reaching average values of 19.1 ± 0.84 mg CH4/L. The permeate flow rate ranged from 10 to 14L/m(2)h with trans-membrane pressure (TMP) values of 400-550 mbar, using cycles of 30s backwash, 7.5 min filtration, and continuous biogas sparging (9-16 m/h). During the three years of continuous operation, the membrane was not physically or chemically cleaned.

Assessment of biological trickling filter systems with various packing materials for improved wastewater treatment.

Attached growth processes for wastewater treatment have significantly been improved during recent years. Their application can be extended to sustainable municipal wastewater treatment in remote locations and in developing countries for the purpose of organic matter (biochemical oxygen demand, BOD) removal and pathogenic decontamination. The aim of this study is to assess selected packing media for biological trickling filters (BTFs) and to develop a simplified model for describing the capacity of BOD removal in BTFs. In this work, BTFs with four different media viz., rubber, polystyrene, plastic and stone have been investigated at two temperature ranges of 5-15°C and 25-35°C. The average removal of both chemical oxygen demand and BOD was higher than 80 and 90% at temperature ranges of 5-15 and 25-35°C, respectively. The geometric mean of faecal coliforms in BTF using polystyrene, plastic, rubber and stone as filter media was reduced by 4.3, 4.0, 5.8 and 5.4 log10, respectively, at a low temperature range of 5-15°C. At a higher temperature range of 25-35°C, the faecal coliform count was reduced by 3.97, 5.34, 5.36 and 4.37 log10 from polystyrene, plastic, rubber and stone media BTF, respectively. Simplified model was developed and used to estimate the optimal BOD loading rates (Bvd) for designing robust BTF systems, with appropriate filter media. It has been concluded that highly efficient BTFs can be designed using various filter media, which may be capable of treating organic loading rates of more than 3 kg BOD/m3 day. These types of BTFs can be applied for the BOD and microbial contaminants removal of wastewater for potential reuse in developing countries.

Accuracy assessment on the analysis of unbound drug in plasma by comparing traditional centrifugal ultrafiltration with hollow fiber centrifugal ultrafiltration and application in pharmacokinetic study.

In present study, accuracy assessment on the analysis of unbound drug in plasma was made by comparing traditional centrifugal ultrafiltration (CF-UF) with hollow fiber centrifugal ultrafiltration (HFCF-UF). We used metformin (MET) as a model drug and studied the influence of centrifugal time, plasma condition and freeze-thaw circle times on the ultrafiltrate volume and related effect on the measurement of MET. Our results demonstrated that ultrafiltrate volume was a crucial factor which influenced measurement accuracy of unbound drug in plasma. For traditional CF-UF, the ultrafiltrate volume cannot be well-controlled due to a series of factors. Compared with traditional CF-UF, the ultrafiltrate volume by HFCF-UF can be easily controlled by the inner capacity of the U-shaped hollow fiber inserted into the sample under enough centrifugal force and centrifugal time, which contributes to a more accurate measurement. Moreover, the developed HFCF-UF method achieved a successful application in real plasma samples and exhibited several advantages including high precision, extremely low detection limit and perfect recovery. The HFCF-UF method offers the advantage of highly satisfactory performance in addition to being simple and fast in pretreatment, with these characteristics being consistent with the practicability requirements in current scientific research.

Wastewater polishing using membrane technology: a review of existing installations.

The use of membrane technology for municipal wastewater reuse is growing in importance worldwide as water becomes increasingly scarce. A review of nine membrane technology-based water reuse plants from across the world has been conducted to provide an insight into the trends in design and operation of these plants, and elucidate the impact of key water quality and other determinants. Data reveal a number of common elements, such as the design flux for the reverse osmosis membrane, as well as a number of other trends. The microfiltration/ultrafiltration (MF/UF) backwash interval appears to correlate better with feed water temperature than turbidity or total suspended solids, whereas chemical cleaning requirements are more dependent on plant operating parameters and water quality. There is some indication that the MF/UF pore size influences the filtrate turbidity (and silt density index) and so downstream reverse osmosis fouling and cleaning. Finally, specific energy demand (SED) values vary widely, from 0.8 to 2.3 kWh m(-3) permeate. Whilst the SED for the MF/UF process follows the flux, the overall energy demand shows no apparent dependence on the dissolved solids concentration or other feed water quality determinants. This range of energy demand amounts to 25-70% of the energy demand for seawater desalination.

Styrene process condensate treatment with a combination process of UF and NF for reuse.

Aiming at reusing the SPC to save water resource and heat energy, a combination treatment process of UF/NF was applied to remove inorganic irons, suspended particles and little amount of organic contaminants in this article. To achieve the indexes of CODM≤5.00 mg L(-1), oil≤2.00 mg L(-1), conductivity≤10.00 µs cm(-1), pH of 6.0-8.0, the NF membrane process was adopted. It was necessary to employ a pretreatment process to reduce NF membrane fouling. Hence UF membrane as an efficient pretreatment unit was proposed to remove the inorganic particles, such as iron oxide catalyst, to meet the influent demands of NF. The effluent of UF, which was less than 0.02 mg L(-1) of total iron, went into a security filter and then was pumped into the NF process unit. High removal efficiencies of CODM, oil and conductivity were achieved by using NF process. The ABS grafting copolymerization experiment showed that the effluent of the combination process met the criteria of ABS production process, meanwhile the process could alleviate the environment pollution. It was shown that this combination process concept was feasible and successful in treating the SPC.

The path to wearable ultrafiltration and dialysis devices.

Wearable blood processing devices offer an attractive solution to problems inherent in clinic-based, intermittent end-stage renal disease therapies. What is involved in transitioning even a part of the current clinic-based population to ambulatory therapy has not been clearly enumerated. This paper addresses what a first-generation wearable device might accomplish, how issues of safety will need to be addressed, and what will make the device attractive to, and manageable by, the patient. Medical, technological, and economic issues are identified.

The future of the artificial kidney: moving towards wearable and miniaturized devices.

New directions in dialysis research include cheaper treatments, home based therapies and simpler methods of blood purification. These objectives may be probably obtained with innovations in the field of artificial kidney through the utilization of new disciplines such as miniaturization, microfluidics, nanotechnology. This research may lead to a new era of dialysis in which the new challenges are transportability, wearability and why not the possibility to develop implantable devices. Although we are not there yet, a new series of papers have recently been published disclosing interesting and promising results on the application of wearable ultrafiltration systems (WUF) and wearable artificial kidneys (WAK). Some of them use extracorporeal blood cleansing as a method of blood purification while others use peritoneal dialysis as a treatment modality (ViWAK and AWAK.) A special mention deserves the wearable/portable ultrafiltration system for the therapy of overhydration and congestive heart failure (WAKMAN). This system will allow dehospitalization and treatment of patients with less comorbidity and improved tolerance. On the way to the wearable artificial kidney, new discoveries have been made such as a complete system for hemofiltration in newborns (CARPEDIEM). The neonate in fact is the typical patient who may benefit from miniaturization of the dialysis circuit. This review analyzes the rationale for such endeavour and the challenges to overcome in order to make possible a true ambulatory dialysis treatment. Some initial results with these new devices are presented. We would like to stimulate a collaborative effort to make a quantum leap in technology making the wearable artificial kidney a reality rather than a dream. 

Integrated downstream processing of lactoperoxidase from milk whey involving aqueous two-phase extraction and ultrasound-assisted ultrafiltration.

The present work involves the adoption of an integrated approach for the purification of lactoperoxidase from milk whey by coupling aqueous two-phase extraction (ATPE) with ultrasound-assisted ultrafiltration. The effect of system parameters of ATPE such as type of phase system, polyethylene glycol (PEG) molecular mass, system pH, tie line length and phase volume ratio was evaluated so as to obtain differential partitioning of contaminant proteins and lactoperoxidase in top and bottom phases, respectively. PEG 6000-potassium phosphate system was found to be suitable for the maximum activity recovery of lactoperoxidase 150.70% leading to 2.31-fold purity. Further, concentration and purification of enzyme was attempted using ultrafiltration. The activity recovery and purification factor achieved after ultrafiltration were 149.85% and 3.53-fold, respectively. To optimise productivity and cost-effectiveness of integrated process, influence of ultrasound for the enhancement of permeate flux during ultrafiltration was also investigated. Intermittent use of ultrasound along with stirring (2 min acoustic and 2 min stirring) resulted in increased permeate flux from 0.94 to 2.18 l/m(2) h in comparison to the ultrafiltration without ultrasound. The use of ultrasound during ultrafiltration resulted in increase in flux, but there was no significant change in activity recovery and purification factor. The integrated approach involving ATPE and ultrafiltration may prove to be a feasible method for the downstream processing of lactoperoxidase from milk whey.

The substitution of sand filtration by immersed-UF for surface water treatment: pilot-scale studies.

The newly issued National Drinking Water Standard required that turbidity should be lower than 1 NTU, and the substitution of sand filtration by immersed ultrafiltration (immersed-UF) is feasible to achieve the standard. This study aimed to optimise the operational processes (i.e. aeration, backwashing) through pilot scale studies, to control membrane fouling while treating the sedimentation effluent. Results indicated that the immersed-UF was promising to treat the sedimentation effluent. The turbidity was below 0.10 NTU, bacteria and E. coli were not detected in the permeate water. The intermittent filtration with aeration is beneficial to inhibit membrane fouling. The critical aeration intensity is observed to be 60.0 m(3) m(-2) h(-1). At this aeration intensity, the decline rate of permeate flux in one period of backwashing was 1.94% and 7.03% for intermittent filtration and sustained filtration respectively. The different membrane backwashing methods (i.e. aeration 1.5 min, synchronous aeration and water backwashing 2 min, water backwashing 1.5 min; synchronous aeration and water backwashing 3 min, water backwashing 2 min; aeration 3 min, single water backwashing 2 min; synchronous aeration and water backwashing 5 min; single water backwashing 5 min) on the recovery of permeate flux were compared, indicating that the synchronous aeration and water backwashing exhibited best potential for permeate flux recovery. The optimal intensity of water backwashing is shown to be 90.0 L m(-2) h(-1). When the actual water intensity was below or exceeded the value, the recovery rate of permeate flux would be reduced. Additionally, the average operating cost for the immersed UF membrane, including the power, the chemical cleaning reagents, and membrane modules replacement, was about 0.31 RMB/m(3).

Reclamation of the wastewater from an industrial park using hollow-fibre and spiral-wound membranes: 50 m3 d(-1) pilot testing and cost evaluation.

The feasibility of reclaiming effluent from industrial park wastewater treatment plants through a membrane process was evaluated in three phases. In phase 1 we selected nine wastewater treatment plants (WWTPs), each with a design capacity exceeding 10,000 m3 d(-1), and analyzed the corresponding effluent composition. 'Potential recycling percentage', R, ranged from 50% to 80% for the industrial park WWTPs, indicating a high feasibility for the reuse of effluent. In phase 2, a 50 m3 d(-1) pilot plant was installed in one of the selected WWTPs and underwent testing for one year. The quality of the reclaimed water was suitable for general-purpose industrial use. In the two ultrafiltration (UF) modules tested, the hydrophilic polyethersulfone hollow-fibre module was more tolerant to variable properties, and had higher recycling percentages than those of backwashable hydrophobic polyvinylidene difluoride spiral-wound module. Using the spiral-wound UF module helped reduce the cost for producing 1 m3 of reclaimed water (US$0.80) compared with a hollow-fibre module (US$0.88). In phase 3, we evaluated the negative effects of refluxing the reverse osmosis retentate, containing high total dissolved solids and non-biodegradable organics, with the biological treatment unit of the upstream WWTP. Biological compactibility tests showed that the refluxed retentate ratio should be reduced to maintain the conductivity of mixed liquor in the aeration tank at less than 110% of the original value.

Cost-effective dialysis for the developing world.

INTRODUCTION: Dialysis is an effective treatment for end-stage renal disease, but it is available to only approximately half of those who need it in the world. METHODS: Two prototype passive-flow dialysate delivery systems were constructed. RESULTS: Each dialysate delivery system provided a flow of dialysate in the range of 200-300 mL/minute. In one example, flow regulation was good, but ultrafiltration could not be monitored. The second prototype could monitor and regulate ultrafiltration but required repeated manual adjustment to maintain nearly constant dialysate flow. Approaches to the remaining obstacles to a fully passive dialysis system are outlined, but these will require further work to prove feasibility. CONCLUSION: In principle, costs of providing hemodialysis could be reduced and equipment created to function without electricity by exploiting passive-flow techniques.

Laboratory assessment of a gravity-fed ultrafiltration water treatment device designed for household use in low-income settings.

Interventions to improve water quality, particularly when deployed at the household level, are an effective means of preventing endemic diarrheal disease, a leading cause of mortality and morbidity in the developing world. We assessed the microbiologic performance of a novel water treatment device designed for household use in low-income settings. The device employs a backwashable hollow fiber ultrafiltration cartridge and is designed to mechanically remove enteric pathogenic bacteria, viruses, and protozoan cysts from drinking water without water pressure or electric power. In laboratory testing through 20,000 L (approximately 110% of design life) at moderate turbidity (15 nephelometric turbidity unit [NTU]), the device achieved log(10) reduction values of 6.9 for Escherichia coli, 4.7 for MS2 coliphage (proxy for enteric pathogenic viruses), and 3.6 for Cryptosporidium oocysts, thus exceeding levels established for microbiological water purifiers. With periodic cleaning and backwashing, the device produced treated water at an average rate of 143 mL/min (8.6 L/hour) (range 293 to 80 mL/min) over the course of the evaluation. If these results are validated in field trials, the deployment of the unit on a wide scale among vulnerable populations may make an important contribution to public health efforts to control intractable waterborne diseases.

A practical guide for ultrafiltration in acute decompensated heart failure.

Acute decompensated heart failure is the most common reason for inpatient hospital admission. Most patients admitted for decompensated heart failure are by definition diuretic-resistant. The therapeutic objective for these patients is volume and sodium removal and restoration of diuretic sensitivity. In a significant proportion of patients, this objective is not met, subjecting patients to readmission for recurrent heart failure decompensation. Ultrafiltration therapy offers the potential of greater volume and sodium removal as compared with conventional therapies in a more expeditious manner. Ultrafiltration can be safely and effectively accomplished in a non-intensive care setting but relies on earlier discharge with reduced readmission rates to be economically feasible. This paper reviews the current data regarding ultrafiltration therapy and provides a practical guide to patient selection, implementation and management of this therapy.

Biofiltration methods for the removal of phenolic residues.

Industrial effluents from the pharmaceutical industry often contain high concentrations of phenolic compounds. The presence of "anthropogenic" organic compounds in the environment is a serious problem for human health; therefore, it merits special attention by the competent public agencies. Different methods have been proposed in the last two decades for the treatment of this kind of industrial residues, the most important of which are those utilizing absorption columns, vaporization and extraction, and biotechnological methods. Biofiltration is a method for the removal of contaminants present in liquid or gaseous effluents by the use of aerobic microorganisms, which are immobilized on solid or porous supports. Although several bacteria can utilize aromatic compounds as carbon and energy source, only a few of them are able to make this biodegradation effectively and with satisfactory rate. For this reason, more investigation is needed to ensure an efficient control of process parameters as well as to select the suited reactor configuration. The aim of this work is to provide an overview on the main aspects of biofiltration for the treatment of different industrial effluents, with particular concern to those coming from pharmaceutical industry and laboratories for the production of galenicals.

Ultrafiltration for acute decompensated heart failure.

For the 13th consecutive year, acute decompensated heart failure is the most common reason for admission to American hospitals. Most patients admitted for decompensated heart failure are by definition, diuretic resistant. The therapeutic objective in these patients is volume and sodium removal, and the restoration of diuretic sensitivity. In a significant proportion of patients, this objective is not met, subjecting patients to readmission for recurrent (or continued) heart failure decompensation. Ultrafiltration therapy offers the potential of greater volume and sodium removal as compared with conventional therapies in a more expeditious manner. Ultrafiltration can be accomplished safely, quickly and on a regular telemetry ward in extremely ill patients, but relies on earlier discharge with reduced readmission rates to be economically feasible.

Membrane bio-reactor for textile wastewater treatment plant upgrading.

Textile industries carry out several fiber treatments using variable quantities of water, from five to forty times the fiber weight, and consequently generate large volumes of wastewater to be disposed of. Membrane Bio-reactors (MBRs) combine membrane technology with biological reactors for the treatment of wastewater: micro or ultrafiltration membranes are used for solid-liquid separation replacing the secondary settling of the traditional activated sludge system. This paper deals with the possibility of realizing a new section of one existing WWTP (activated sludge + clariflocculation + ozonation) for the treatment of treating textile wastewater to be recycled, equipped with an MBR (76 l/s as design capacity) and running in parallel with the existing one. During a 4-month experimental period, a pilot-scale MBR proved to be very effective for wastewater reclamation. On average, removal efficiency of the pilot plant (93% for COD, and over 99% for total suspended solids) was higher than the WWTP ones. Color was removed as in the WWTP. Anionic surfactants removal of pilot plant was lower than that of the WWTP (90.5 and 93.2% respectively), while the BiAS removal was higher in the pilot plant (98.2 vs. 97.1). At the end cost analysis of the proposed upgrade is reported.