Effects of dialysate flow configurations in continuous renal replacement therapy on solute removal: computational modeling.

BACKGROUND/AIMS: Continuous renal replacement therapy (CRRT) is commonly used for critically ill patients with acute kidney injury. During treatment, a slow dialysate flow rate can be applied to enhance diffusive solute removal. However, due to the lack of the rationale of the dialysate flow configuration (countercurrent or concurrent to blood flow), in clinical practice, the connection settings of a hemodiafilter are done depending on nurse preference or at random. METHODS: In this study, we investigated the effects of flow configurations in a hemodiafilter during continuous venovenous hemodialysis on solute removal and fluid transport using computational fluid dynamic modeling. We solved the momentum equation coupling solute transport to predict quantitative diffusion and convection phenomena in a simplified hemodiafilter model. RESULTS: Computational modeling results showed superior solute removal (clearance of urea: 67.8 vs. 45.1 ml/min) and convection (filtration volume: 29.0 vs. 25.7 ml/min) performances for the countercurrent flow configuration. Countercurrent flow configuration enhances convection and diffusion compared to concurrent flow configuration by increasing filtration volume and equilibrium concentration in the proximal part of a hemodiafilter and backfiltration of pure dialysate in the distal part. In clinical practice, the countercurrent dialysate flow configuration of a hemodiafilter could increase solute removal in CRRT. Nevertheless, while this configuration may become mandatory for high-efficiency treatments, the impact of differences in solute removal observed in slow continuous therapies may be less important. Under these circumstances, if continuous therapies are prescribed, some of the advantages of the concurrent configuration in terms of simpler circuit layout and simpler machine design may overcome the advantages in terms of solute clearance. CONCLUSION: Different dialysate flow configurations influence solute clearance and change major solute removal mechanisms in the proximal and distal parts of a hemodiafilter. Advantages of each configuration should be balanced against the overall performance of the treatment and its simplicity in terms of treatment delivery and circuit handling procedures.

Enhancement of solute removal in a hollow-fiber hemodialyzer by mechanical vibration.

Better solute clearance, particularly of middle-molecular-weight solutes, has been associated with improved patient outcomes. However, blood-membrane interaction during dialysis results in the development of secondary mass transfer resistances on the dialyzer membrane surface. We discuss the potential effects of mechanical vibration on the diffusion, convection and adsorption of uremic solutes during dialysis. For sinusoidal and triangular vibratory motions, we conceptualized the hemodynamic changes inside the membrane and consequent effects on membrane morphology. Longitudinal vibration generates reverse flow by relative membrane motion, and transverse vibration generates a symmetric swirling flow inside the hollow fiber, which enhances wall shear stress and flow mixing. Moreover, the impulse induced by triangle wave vibration could provide higher absorption capacity to middle-molecular-weight solutes. Mechanical vibration could enhance solute removal by minimizing membrane morphology changes resulting from blood-membrane interaction during hemodialysis. These effects of mechanical vibration can be helpful in extracorporeal blood purification therapies including continuous, portable and wearable systems.

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.

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.

Computational modeling of effects of mechanical shaking on hemodynamics in hollow fibers.

INTRODUCTION: Blood-membrane interaction during hemodialysis develops a secondary protein layer on the dialysis membrane surface, resulting in reduction of hemodialyzer performance. Wall shear stress at the surface of the hollow-fiber membrane is one of the determinant factors able to influence dialysis efficiency. Shaking of hemodialyzer during treatment could increase the wall shear stress of the membrane, which could enhance hemodialyzer performance. METHODS: In this study, hemodynamic changes in hollow fibers were analyzed using computational fluid dynamics software for various shaking conditions of hemodialyzer (longitudinal, transverse, rotational motions). RESULTS: Longitudinal motion induced reverse flow, while transverse motion induced symmetric swirling inside the hollow fiber. During rotational motions, nonuniform vortices were developed according to the rotational radius of the hollow fiber. These changes in flow pathlines induced by different shaking profiles increased the relative motion of blood, transmembrane pressure, and wall shear stress on dialysis membrane surfaces. Both longitudinal and transverse shaking profiles showed a linear relationship between shaking velocity (the product of amplitude and frequency) and wall shear stress. CONCLUSION: Performance of hemodialyzer can be enhanced with simple mechanical shaking motions, and optimal shaking profiles for clinical application can be investigated and predicted with the computational fluid dynamics model proposed in this study.

A wearable artificial kidney: technical requirements and potential solutions.

Recently, new approaches for miniaturization and transportability of medical devices have been developed, paving the way for wearability and the possibility of implantation, for renal replacement therapies. A wearable artificial kidney (WAK) is a medical device that supports renal function during ambulation or social activities out of hospital. With the aim of improving dialysis patients' quality of life, WAK systems have been developed for several decades. However, at present there are a lot of technical issues confronting the attempt to apply WAK systems in clinical practice. This article focuses on technical requirements and potential solutions for WAKs and reviews up-to-date approaches related to dialysis membrane, dialysate regeneration, vascular access, patient-monitoring systems and power sources for WAKs.