Patent Grant
9675745
The present invention relates generally to medical treatments. More specifically, the present invention relates to medical fluid treatments, such as the treatment of renal failure and fluid removal for congestive heart failure.
Hemodialysis (“HD”) in general uses diffusion to remove waste products from a patient's blood. A diffusive gradient that occurs across the semi-permeable dialyzer between the blood and an electrolyte solution called dialysate causes diffusion. Hemofiltration (“HF”) is an alternative renal replacement therapy that relies on a convective transport of toxins from the patient's blood. This therapy is accomplished by adding substitution or replacement fluid to the extracorporeal circuit during treatment (typically ten to ninety liters of such fluid). That substitution fluid and the fluid accumulated by the patient in between treatments is ultrafiltered over the course of the HF treatment, providing a convective transport mechanism that is particularly beneficial in removing middle and large molecules (in hemodialysis there is a small amount of waste removed along with the fluid gained between dialysis sessions, however, the solute drag from the removal of that ultrafiltrate is not enough to provide convective clearance).
Hemodiafiltration (“HDF”) is a treatment modality that combines convective and diffusive clearances. HDF uses dialysate to flow through a dialyzer, similar to standard hemodialysis, providing diffusive clearance. In addition, substitution solution is provided directly to the extracorporeal circuit, providing convective clearance.
Home hemodialysis (“HHD”) has declined in the last twenty years even though the clinical outcomes of this modality are more attractive than conventional hemodialysis. One of the drawbacks of home hemodialysis is the need for a dedicated water treatment, which includes equipment, water connection and drainage. Installing and using those components is a difficult and cumbersome task that can require a patient's home to be modified. Nevertheless, there are benefits to daily hemodialysis treatments versus bi- or tri-weekly visits to a treatment center. In particular, a patient receiving more frequent treatments removes more toxins and waste products than a patient receiving less frequent but perhaps longer treatments.
The present invention provides a system, method and apparatus that performs a daily renal replacement therapy, which combines both diffusion and convection transport from the patient. In hemodialysis, high flux membranes can in some cases backfilter fluid from the dialysate to the blood even though, on balance, net fluid flow is from the patient. That backfiltration is due to a pressure differential between the inlet/outlet of the blood and inlet/outlet of dialysate in specific areas of the dialyzer. The present invention capitalizes on that phenomenon.
In one embodiment, two small high flux dialyzers are connected fluidly to the cassette in series. Dialysate and blood flow in a countercurrent manner through the dialyzers and extracorporeal circuit. In one embodiment, however, the dialysate flow through the dialyzers can alternatively be co-current or in the same direction as the flow of blood through the blood circuit. A restriction is placed between the two dialyzers in the dialysate flow path. The restriction is variable and adjustable in one preferred embodiment to account for different treatment conditions or to be adjusted during a single treatment. The restriction is alternatively a simple fixed restriction, such as an orifice plate with a smaller orifice. Due to the restriction between the filters, a positive pressure is built in the venous dialyzer, causing a high degree of intentional backfiltration. Depending on the size of the restriction between the dialyzers, that backfiltration causes a significant flow of dialysate through the high flux venous membrane directly into the blood. That backfiltered solution is subsequently ultrafiltered from the patient from the arterial dialyzer. The movement of dialysate into the blood in the venous filter and removal of dialysate from the arterial dialyzer causes a convective transport of toxins from the patient. Additionally, the dialysate that does not move directly into the patient but instead flows across the membranes of both dialyzers provides a diffusive clearance of waste products.
The system therefore acts as a hemodiafiltration system providing both convective and diffusive clearances. The system in one embodiment is configured for home use, wherein at least a portion of the dialysate and extracorporeal flow paths is sterilized and provided in a disposable cassette, which is loaded into a home pumping apparatus. For example, the system can be a portable device that uses an integrated disposable fluid management system or cassette and a sterile, prepackaged solution to perform a hemodialysis therapy. The system in one embodiment is particularly suited for home use because of its compact size, ease of therapy setup, and lack of need for a water treatment and dialysate proportioning system.
Unlike current hemodialysis machines, the patient does not have to manage complicated tubing sets. The patient simply places the cassette into the renal failure therapy machine, connects solution bags to the machine and starts an automated priming sequence. When the priming is complete, the patient connects the bloodlines to the patient's body and starts the dialysis therapy. At the end of treatment the patient's blood is returned to the patient's body. The patient merely discards the ultrafiltrate (“UF”) waste and the therapy ends without the patient having to perform a complicated disinfection procedure.
In one embodiment, the cassette-based system operates as follows. A blood pump pulls blood from the patient, pushes it through both hemodialyzers and returns the blood to the patient. Dialysate solution is drawn from a dialysate source and heated to a desired patient temperature. Infusion pumps pump fresh dialysate from the bag into the venous dialyzer. The restriction is placed in the dialysate flow path between the two dialyzers to facilitate the backfiltration of dialysate into the bloodline via venous dialyzer. The restriction is preferably variable but alternatively fixed.
The flow out of the infusion pumps pushes fluid at the restriction creating a positive pressure in the venous hemodialyzer. Using a high flux membrane, the backpressure forces a portion of the dialysate, e.g., fifty percent or more, into the patient's bloodline. The rest of the dialysate flows through to the arterial dialyzer. Drain pumps remove from the flow paths an equivalent amount of fluid as delivered by the infusion pumps as well as any fluid loss that the patient has gained in the interdialytic period. The spent fluid and ultrafiltrate are then put into a drain bag or dumped to an external drain.
The cassette-based dialysate pumps are controlled to balance the dialysate flow to the venous dialyzer with the dialysate flow from the arterial dialyzer so that the patient fluid status is maintained. Due to that balancing capability an identical amount of fluid is ultrafiltered from the patient in the arterial hemodialyzer as is backfiltered into the extracorporeal circuit in the venous dialyzer. Ultrafiltering this fluid from the blood creates a solute drag effect providing a convective transport of toxins similar to hemofiltration. Since some dialysate flows along the fiber in the venous to arterial dialyzer there is also diffusive transport of toxins from the blood.
Air bubble detectors, heating elements, pressure sensors, temperature sensors, etc., are also integrated into the cassette for both the dialysate management and extracorporeal blood sides as necessary to allow for a safe treatment for the patient and reliable operation of the system.
Recently published studies show that ultrapure dialysate produces better outcomes when compared to standard dialysate. The prepackaged, sterilized dialysate used in one embodiment of the present invention may produce outcomes that are as good as, if not better than, ultrapure dialysate. It should be appreciated however that the present invention is not limited to the use of prepackaged dialysate bags, but instead, may use dialysate prepared on-line or at home. The advantage of the online system to the patient is to eliminate the solution bags and the space they consume. The dialysate, whether supplied from a sterilized bag or made online, may also be recirculated in one or more loops using one or more charcoal or sorbent cartridge.
One preferred at home generation system is described herein. That system uses a reservoir, such as a five liter bag of sterile dialysate installed in a rigid container. A shunt is placed across the dialyzers at start-up for rinsing and priming. During treatment, a sorbent cartridge that operates using an urea exchange or a binding urea is placed in the post dialyzer or ultrafilter (“UF”) loop. The sorbents may remove other substances, such as beta 2 microglobulin or phosphate, etc. A series of infusion pumps simultaneously pull dialysate from the sterile bag, through a heater, through an ultrafilter and through the shunt to the sorbent cartridge. If necessary, an infusate such as a gamma sterilized infusate that includes calcium, magnesium, and potassium is added to the dialysate reservoir.
After the solution is heated and ready for treatment, the blood treatment machine prompts the user to install the cassette. The blood circuit can be primed with a saline bag hooked via the arterial bloodline or by backfiltering dialysate through the blood treatment venous filter. Air bubble detectors, heating elements, pressure sensors, temperature sensors, etc., are integrated into the cassette for both the dialysate and extracorporeal blood circuits as necessary to enable a safe treatment for the patient and a system that operates reliably.
The patient is then hooked to the arterial and venous needles and the treatment begins. For short therapies, the dialysate flow can be relatively high, for example, three hundred ml/min for three hours or one hundred ml/min for up to eight hours. The dialysate/UF flow control pumps control the flow to and from the dialyzers. By increasing the frequency of the pumps that pull the effluent dialysate from the arterial dialyzer, the fluid accumulated in the patient in the interdialytic period is removed. Portions of the dialysate/UF flow control pumps are integrated into the cassette along with a portion of the blood pump in one embodiment or are alternately provided separate from the cassette and integrated into the machine.
Due to the impracticality of hanging and storing bags, solution-bag based systems are limited to a total practical amount of dialysate per treatment. The sorbent-based fluid regeneration system enables a therapy that uses more dialysate and thereby provides enhanced waste clearance. Providing an increased amount of dialysate beneficially enhances the clearance of waste products from the renal patient. For example, the sorbent cartridge could be used for a four hour treatment at two hundred to two hundred fifty ml/min dialysate flow or about fifty liters of dialysate over the entire treatment, which would provide an increased volume of dialysate and better waste clearance over other hemofiltration systems. The sorbent system is also applicable to the hemofiltration systems described herein, making even predilution HF possible. For hemofiltration, an additional reusable ultrafilter is provided to maintain redundancy of bacteria and endotoxin removal.
The sorbent-based regeneration system is particularly suited for home use because it eliminates the need to store numerous solution bags, eases therapy setup and does not require a connection to the patient's water tap. Also, the patient does not have to connect a tubing set. The patient instead places the cassette into the machine, adds an initial five liter bag of sterile dialysate to the reservoir and starts the automated priming sequence. When the priming is complete, the patient connects himself/herself to the blood circuit and starts the dialysis therapy.
The portable device, the use of prepackaged solutions or an on-line fluid generation system and the use of a disposable set each provide dialysis patients with the flexibility and freedom that previously has only been available to peritoneal dialysis patients. Because there is no dedicated water hookup and the present machines are small, it is possible for a patient using the present systems to travel and perform blood therapy dialysis sessions on the road. Many of the systems and methods described herein can be adapted to work with in-center solutions, and many of the aspects of the present invention are not limited to home use.
High convection hemodialysis is believed to be more effective than conventional hemofiltration because it has convective clearance in addition to the diffusive transport of toxins. The therapy is expected to provide good waste clearance of small, middle and large molecules from even end-stage renal patients.
The device is well-suited for use in hospitals for acute patients for situations in which a required water supply and dialysis proportioning system are unavailable. The present device is easier to set up and use in an intermittent acute setting.
The present invention provides multiple methods and apparatuses for not only controlling the amount of dialysate or substitution fluid that is delivered to the extracorporeal circuit or dialyzer but also for accurately controlling the amount of ultrafiltrate removed from the patient. The various alternatives can be divided into three main types. One type of control used is a pneumatic control based on Boyle's Law. Here, the fluid pumps are placed in fluid communication with a known volume of air. The system uses Boyle's Law to place into an equation a series of known or measured values to calculate accurately the amount of fluid (e.g., versus air) from a pump chamber pumped to the patient. The method and apparatus use fluid and air pressure signals generated and converted to numbers that are placed into an equation. The equation yields the fluid volume pumped per cycle or stroke of the pump. The Boyle's law system in one embodiment provides accurate information on an end stroke or pump cycle basis but not necessarily on a real time basis. The present invention also includes a system and method based on Boyle's Law that generates flow rate data on a real time basis.
A second large category of volumetric control includes the use of a balancing device. Many embodiments for employing such balancing device are discussed below. The balancing device embodiments may be parsed into two main sub-groups. One sub-group uses a single balancing device. Another sub-group includes dual balancing devices.
The present invention also teaches and discloses a plurality of different types of balancing devices. In one embodiment, the system employs one or two balancing chambers. In another embodiment, the system employs one or two balancing tubes. The balancing tubes include a tubular housing with a piston or ball-like separator within the housing. The separator acts similarly to the membrane or diaphragm of the balance chamber.
A third type of balancing device is one or more tortuous path. The tortuous path is defined in one embodiment by a disposable cassette as an elongated channel. The diameter or cross-sectional area of the channel is configured so that bulk movement of fresh or effluent dialysate can efficiently move an existing bulk of fluid within the tortuous path. That is, fresh dialysate in bulk moves a bulk of spent or effluent dialysate currently residing in the path to drain. In the next cycle, spent or effluent dialysate in bulk pushes the bulk of fresh fluid just introduced into the tortuous path to the patient or dialyzer. The cross-section and the length of the path are configured to minimize an amount of mixing of the fresh and spent fluids at the ends of the bulks of fluid.
The various volumetric balancing devices can be used with many different types of pumps, such as a peristaltic pumps, membrane pumps, gear pumps or a combination thereof. A single pump may be used with the balancing devices. Separate fresh and spent dialysate pumps may be used alternatively. Further, a separate ultrafiltrate pump is also contemplated and discussed, which enables the main pump(s) to be dedicated to pumping an equal volume of fluid to and from the patient.
The third major type of fluid management uses a scale to measure the amount of fluid delivered to the patient and the amount of fluid removed from the patient. In an embodiment illustrated below, fluid bags are placed on a stand, which is coupled to a shaft. At one end, the shaft couples to a rolling diaphragm. The rolling diaphragm, in combination with other apparatus, defines a closed but variable volume. As the weight in the fluid bags fluctuates, a pressure within the volume also fluctuates. A pressure sensor senses the pressure and the controller or processor of the machine processes the signal from the pressure sensor to develop a corresponding weight signal. The weight signal is then used to determine how much fluid has been delivered and or removed from the patient. In one embodiment, fresh and spent fluid bags are measured by the same weight sensing device, so that the system expects to see a net overall weight gain over time due to the ultrafiltrate removed from the patient. A load cell could also be used for this application.
As illustrated in detail below, the present invention provides multiple embodiments for other components of the systems and methods of the present invention, such as the fluid heater, the balancing devices, the disposable cassette, bag positioning and other important features of the present invention. For example, the present invention includes an access disconnection sensor (“ADS”), which can detect when either the arterial or venous needle has been removed inadvertently from the patient during treatment. Further, various pressure relief schemes, integrity tests, etc., are discussed herein, which are important especially for a home-use machine, which the patient may be use while sleeping.
It is therefore an advantage of the present invention to provide a hemodialysis, hemofiltration or hemodiafiltration system usable in a home or clinic setting.
It is another advantage of the present invention to provide a cassette-based hemofiltration/hemodiafiltration system, which enables a patient at home to easily set up a sterile blood therapy system.
It is another advantage of the present invention to improve the effectiveness of renal failure blood treatment therapy.
Moreover, it is an advantage of the present invention to provide a renal failure blood therapy that employs convective and diffusive modes of clearance.
Still further, it is an advantage of the present invention to provide a renal failure blood therapy in which both diffusive and convective clearance modes are provided and wherein the percentage use of either mode can be varied.
Further still, it is an advantage of the present invention to provide a cassette-based blood therapy that is configurable in the field to perform either hemodialysis, enhanced convection hemodialysis, hemofiltration or hemodiafiltration.
Yet further, it is an advantage of the present invention to provide a blood therapy system with one or more therapy fluid circulation loops that optimize the consumption of fresh dialysate.
Still another advantage of the present invention is to provide a home renal failure blood treatment therapy that is configurable to operate with multiple different types of therapy fluid sources, such as solution bags, solution preparation units or on-line dialysate generation systems.
It is yet a further advantage of the present invention to provide a home renal failure therapy system operable with many types of systems that control accurately the amount of fluid exchanges and the amount of fluid or ultrafiltrate removed from the patient.
Still further, it is an advantage of the present invention to provide improved fluid volume control devices.
Additional features and advantages of the present invention are described in, and will be apparent from, the following Detailed Description of the Invention and the figures.
Additional features and advantages are described herein, and will be apparent from the following Detailed Description and the figures.
The present invention provides various apparatuses and methods for a home hemodialysis (“HHD”) treatment that increases and enhances the amount of backfiltration during treatment. It is important to note that even though this system is designed for the home, it is also suitable for use in a clinic, acute renal treatment center or self-care center. The system uses a disposable fluid management system, which may include a disposable set having a disposable cassette or tubing organizer (referred to herein collectively as cassette). The cassette houses at least a portion of at least one of the dialysate and extracorporeal flow paths. In one embodiment, two small high flux dialyzers are connected fluidly and in series to the cassette. In one embodiment, dialysate and blood flow in a countercurrent manner through the dialyzers with respect to each other. A restriction is placed between the two dialyzers in the dialysate flow path. The restriction is variable and adjustable in one embodiment to account for different treatment conditions or to be adjusted during a single treatment. The restriction is alternatively fixed, such as an orifice plate with a restricting orifice.
Due to the restriction between the filters, a positive pressure is built in the venous dialyzer (first dialyzer to receive dialysate but second dialyzer to receive blood in countercurrent arrangement), intentionally causing a relatively high degree of backfiltration. Depending on the size of the restriction between the dialyzers, that backfiltration causes a significant flow (e.g., 10 to 70 percent of total dialysate flow) of dialysate through the high flux venous membranes and into the blood circuit. The backfiltered solution provides convective clearance. In one embodiment, ultrafiltrate is removed from the patient via the arterial dialyzer (first dialyzer to receive blood but second dialyzer to receive dialysate in countercurrent arrangement).
The diffusion of dialysate into the venous dialyzer and removal of dialysate from the arterial dialyzer causes a convective transport of toxins from the patient. Additionally, the dialysate that does not move directly into the extracorporeal circuit (e.g., the other percentage of the dialysate) but instead flows across the membranes of both dialyzers, providing a diffusive clearance of waste products. This system, referred to herein as an enhanced convection hemodialysis (“ECHD”) system, is similar to a hemodiafiltration system, which provides both convective and diffusive clearances. The system in one embodiment is configured for home use, wherein at least a portion of the dialysate and extracorporeal flow paths is sterilized and provided in a disposable set, which is loaded into a machine having multiple pumps, a heater, valve actuators and the like.
Referring now to the drawings and in particular to
As discussed above, hemodialyzers 20 and 30 cause backfiltration in the venous dialyzer 20 of a relatively large portion of the fresh dialysate. The backfiltered dialysate and the fluid accumulated during the interdialytic period is ultrafiltered or removed from the patient 42 via the arterial dialyzer 30. The fluid not backfiltered flows across the semi-permeable membrane in the arterial 30 and venous 20 dialyzers, enabling system 10 to provide both diffusive and convective removal of waste from the patient's blood.
In one home use and in-center embodiment shown in
It should be appreciated that the present invention is not limited to capacitive fluid volume measuring but can use instead other suitable types of volume measuring. Moreover, the present invention is not limited to volume measuring but instead can employ balancing devices that ensure a set amount of dialysate is pumped to the dialyzers, from the dialyzers and from the patient 42. Further alternatively, fluid pump management can be accomplished on a mass basis, via one or more scale. Still further, flowrate and volume pumped can be calculated based on a number of pump strokes, such as a number of peristaltic pump revolutions based on a number of steps of a stepper motor, based on a sensed amount of movement of a linear or rotating pump actuator or via a device that operates according to Boyle's Law. All of those measuring alternatives are included in the term “volume measuring device.” Control using the volume measuring device can be closed loop, where the actual amount of fluid delivered is monitored, or open loop, where the scheme relies on the inherent accuracy of the pump and perhaps motion control feedback, such as a monitoring of number of step pulses sent to drive the motor, linear encoder feedback or rotary encoder feedback, etc.
Pump Set 1 inputs fresh dialysate from bags 14 to 18 to the system 10 and Pump Set 2 removes a volumetric equivalent of the fluid pumped by Pump Set 1 and any fluid removed from patient 42 during the course of the treatment. As illustrated, fresh dialysate is pumped via pumps 22 and 24 from sources 14, 16 and 18 to the venous dialyzer 20. A restriction 40 is located between venous dialyzer 20 and arterial dialyzer 30. Restriction 40 builds pressure in venous dialyzer 20, so that a relatively large amount of fresh dialysate entering venous dialyzer 20 is forced through the walls of the membranes inside venous dialyzer 20 and into the extracorporeal or blood circuit 50. The other portion of the fresh dialysate entering venous dialyzer 20 flows across the membranes inside venous dialyzer 20, through restriction 40 and into arterial dialyzer 30.
Convective clearance occurs when a volumetric equivalent of the fluid backfiltered through venous dialyzer 20 is removed from the arterial dialyzer 30. Also, a diffusive transport of toxins occurs across both dialyzers 20 and 30 due to a diffusive gradient that exists between blood circuit 50 and the flow of dialysate. Over the total therapy, the total amount of fluid removed from the arterial dialyzer 30 is greater than the total amount of dialysate supplied to the venous dialyzer 20, accounting for an amount of UF removal prescribed for the therapy.
The following example further illustrates one preferred therapy for the present invention. In the example, pumps 22 and 24 of Pump Set 1 infuse eighteen liters of dialysate from sources 14, 16 and 18 over two hours. Of that volume, one hundred ml/min of dialysate is backfiltered into the patient's blood circuit 50 through the membrane walls of venous dialyzer 20. Fifty ml/min of dialysate passes through the venous dialyzer 20, restriction 40 and into venous dialyzer 30. Pumps 26 and 28 of Pump Set 2 remove the total of eighteen liters of dialysate from bags 14, 16 and 18 plus any desired amount of fluid from the patient. Over two hours, twelve liters (100 ml/min multiplied by 120 minutes) of dialysate is backfiltered into the patient's blood through the venous dialyzer 20. Pumps 26 and 28 of Pump Set 2 remove that twelve liters, the six liters of dialysate that is not backfiltered into blood circuit 50 plus any fluid ultrafiltered from the patient.
The addition and removal of the twelve liters of dialysate from blood circuit 50 over the two hour therapy yields an overall convective removal according to the equation HF stdKt/V of ˜2, which has been reported to be a suitable daily amount (see Jaber B T, Zimmerman D L, Leypoldt J K. Adequacy of Daily Hemofiltration: Clinical Evaluation of Standard Kt/V (stdKt/V), Abstract Hemodialysis International Volume 7, number 1, p 80, 2003. Additionally, over the course of two hours, six liters of dialysate was used for diffusive clearance via the dialysate gradient across the membranes of dialyzers 20 and 30. Note that the dialysate flow rates and percent convective versus diffusive could be higher or lower than those used in the example.
Referring additionally to
In one preferred embodiment, disposable cassette 100a and associated attached tubing are gamma sterilized and sealed prior to use. Alternatively, sterilization via ethylene oxide or ebeam is employed. The patient or operator opens the seal just prior to use, inserts cassette 100a into the therapy machine for a single use and then discards the cassette 100a and associated tubing. While cassette 100a and flow paths 50 and 60 are intended for a single use in one embodiment, cassette 100a and flow paths 50 and 60 could be reused with suitable disinfection and/or sterilization.
Referring to
Blood pump 48 is peristaltic pump 48 in one embodiment and is located between pressure sensor PT1 and a drip chamber 52a with integral pressure transducer 46, labeled PT2. The drip chambers 52a to 52c remove air from the fluids passing through the drip chambers. One, a multiple of or all the drip chambers 52a to 52c in an alternative embodiment includes an associated level sensor 68a to 68c. Those sensors are connected to or integrated into the associated drip chambers. Level sensors 68a to 68c sense and indicate the level or height of dialysate or therapy fluid in the dialyzer. Blood pump 48 is alternatively a volumetric pumping device other than a peristaltic pump, such as a diaphragm pump or centrifugal pump. Blood pump 48 can also be bidirectional for system priming as discussed below. Pressure sensor PT246 is alternatively not associated with a drip chamber, where for example pressure transducers are used instead. Pressure sensors PT1 and PT2, drip chamber 52a as well as the tubing 102 for peristaltic pump 48 are all connected to cassette 100a.
After drip chamber 52a, blood flows out of the housing 104 of cassette 100a into a the relatively small, high flux dialyzer arterial dialyzer 30. As seen in
An air bubble detector 54 labeled ABD is located downstream from drip chamber 52b in blood line 50. A venous line clamp or valve 56, labeled V1, which may be cassette-based or provided external to cassette 100a, and which shuts down blood flow if air is detected in line 50 by detector 54, is located between the air detector 54 and arterial access 44b, which returns blood to patient 42. An air level sensor (not illustrated) on drip chamber 52b is used alternatively or in addition to ABD 54. To detect air in the blood, a level detect scheme is alternatively or additionally provided with drip chamber 52b or pressure transmitter 46, labeled PT3. For example, an ultrasonic sensor can be placed on opposite sides of the drip chamber. The sensor generates a signal that depends upon the percentage of air in the blood that passes between a transmitting and receiving positions of the sensor. Under normal operation, when no air is present, the blood within drip chamber 52b resides at a relatively steady level, although level fluctuations do occur due to changes in pressure, amount of blood pumped, etc. A threshold level of blood in chamber 52b does exist below which the blood should not drop. When air in the blood lines is present, the blood level in the chamber 52b is lower than a threshold level, triggering an alarm from the alternative air/blood detector. It is important to note that an air detector and line clamp may be used on line 44a, if required by rinse, prime or blood rinseback.
Dialysate flow path 60 is also located primarily in the housing of organizer or cassette 100a. The dialysate is supplied initially in dialysate or therapy fluid supply bags 14, 16 and 18. In alternative embodiments shown below in connection with
Dialysate or therapy solution flows from one of sources 14 to 18 to the volumetric diaphragm pumps 22 and 24 of set 1. The volumetric accuracy of the pumps is confirmed by monitoring. As discussed above, it is desirable to use two alternating solution delivery pumps 22 and 24 to limit the amount of pulsatile flow. As a safety measure, the diaphragms of each of the pumps 22 to 28 are configured so that if they leak, the can only leak externally. Any leaks collected externally from pumps 22 to 28 is then diverted towards a moisture sensor built into the cassette 100a, machine and/or cassette/machine interface, which senses such leak and signals: (i) an alarm; (ii) to shut down pumps 22 to 28 and 48; and (iii) to take any other appropriate action.
Suitable pneumatically and mechanically driven medical fluid pumps and diaphragms therefore are described in commonly owned U.S. Pat. No. 7,238,164, entitled Systems, Methods And Apparatuses For Pumping Cassette-Based Therapies, filed Dec. 31, 2002, the teachings of which are incorporated herein by reference. The pumps and pumping technology currently used in the HomeChoice® series of APD devices, as embodied in U.S. Pat. No. 5,431,626 and its associated family of patents, the teachings of each of which are incorporated herein by reference, are also suitable, as are various pumping technologies described in commonly owned U.S. Pat. No. 6,814,547, entitled “Medical Fluid Pump”, filed May 24, 2002, the teachings of each of which are incorporated herein by reference.
As discussed above, each of the pumps 22 to 28 operates individually with a volume measuring device 32 to 38. In one preferred embodiment, volume measuring devices 32 to 38 are capacitance fluid volume sensors, indicated in
Generally, the capacitance C between two capacitor plates changes according to the function C=k×(S/d), wherein k is the dielectric constant, S is the surface area of the individual plates and d is the distance between the plates. The capacitance between the plates changes proportionally according to the function 1/(R×V), wherein R is a known resistance and V is the voltage measured across the capacitor plates.
The dielectric constant k of medical fluid or dialysate is much higher than that of air, which typically fills a pump chamber (such as pump chambers 122, 124, 126 and 128 in
As at least one flexible membrane positioned within chambers 122 to 128 expands and fills with medical fluid, the overall capacitance changes, i.e., increases, creating a high impedance potential across the capacitor plates, one of which is grounded, the other of which is active. That high impedance potential is indicative of an amount of fluid in the chambers 122 to 128. If the sensed potential does not change, or does not change enough, when it is expected to change, the system controller recognizes such lack of change as air that has become trapped in the dialysis fluid and commands appropriate actions.
A capacitance sensing circuit is provided, which amplifies the high impedance signal to produce a low impedance potential. The low impedance is fed back to the capacitance plates 32 to 38 and is used to protect the sensitive generated capacitance signal from being effected by outside electrical influences. The amplified potential is also converted to a digital signal and fed to a the system controller, where it is filtered and or summed. A video monitor having a graphical user interface can then be used to visually provide a volume and/or a flowrate indication to a patient or operator based on the digital signal. Additionally, the controller uses the flowrate and volume information to ensure that Pump Set 2 (pumps 26 and 28) withdraws the appropriate amount of fluid from arterial dialyzer 30, namely, the amount of dialysate pumped from Pump Set 1 (pumps 22 and 24) plus the prescribed amount of UF removed from the patient.
An additional use for capacitance plates or volume measuring devices 32 to 38 is to detect a leak across pump valves V3 and V5, V2 and V4, V15 and V16 and/or V17 and V18. Those valves cycle and alternate during the pump-in and pump-out strokes of pumps 22, 24, 26 and 28, respectively and are opening and closing much more often than other valves in system 10, such as fluid container valves V8 to V14. The pump valves are therefore more susceptible to leakage than are other valves and are relatively critical to the operation of system 10.
The pump valves operate in alternating pairs. For instance, to deliver fluid into pump 22, valve V3 is opened while valve V5 is closed. Conversely, to push fluid from pump 22, valve V3 is closed while valve V5 is opened. If both valves are either opened or closed while a pump stroke takes place, volumetric error occurs. The present invention contemplates a method and apparatus for testing valves V3 and V5, using volume measuring devices 32 to 38.
The valve test in one embodiment utilizes the fact that the pump has flexible fluid membranes that are crimped between a fixed volume pump chamber. When a pump-in stroke takes place, the membranes fill with fluid expanding the membrane. The corresponding pump inlet valve (e.g., valve V3) is then closed, trapping fluid within the flexible pump chamber membranes. A partial pump-out stroke is attempted either via a mechanical piston or positive/negative pneumatic pressure. The pressure exerted is not enough to damage the pump components but is enough so that if either inlet or outlet valves (e.g., V3 and V5) is faulty or leaking, fluid would flow, creating a volume change that would be sensed by volume measuring devices 32 to 36.
If the valves close properly, and assuming dialysate to be incompressible, the small pressure exerted should move no fluid and produce no detectable volume change. If a leak is present, a volume change occurs and is detected, causing the controller to issue an alarm condition or take other appropriate action. The above-described test can be performed at the start of therapy and/or intermittently and periodically throughout therapy, e.g., every five minutes or every one thousand strokes. The test, it should be appreciated, can at least detect which set of pump valves V3 and V5, V2 and V4, V15 and V16 or V17 and V18 is leaking. The test is applicable to all types of medical fluid systems, including blood therapy systems, congestive heart failure systems and peritoneal dialyzer systems.
The chambers 122 to 128 and housing 104 of cassette 100a form a first portion of a clamshell, the second portion being formed by the renal therapy machine. The first and second portions house at least one flexible membrane and the dialysate when dialysate is present. The portions are rigid and form a fixed volume in one preferred embodiment. The portions form the shape of and also house the capacitor plates 32 to 38. That is, one of the capacitor plates is housed in cassette 100a, while the other is housed inside the therapy machine. Alternatively, both plates are housed in the therapy machine, one on either side of the cassette. As stated above, either the cassette or machine (whichever houses the active rather than the ground capacitor plate) houses an additional guard or shield plate that provides noise protection for the high impedance signal transmitted from the active capacitor plate.
As an alternative to the capacitance volume sensor described above, the volume or mass of dialysate fluid flowing through the pumps 22 to 28 can be determined using other methods, such as through an electronic scale or balance. In other alternative embodiments, the mass or volume of dialysate flowed in any of the systems described herein can be sensed using various types of medical grade flowmeters, orifice plates, mass flow meters or other devices employing Boyle's Law. Further, the Fluid Management System (“FMS”) technology used in HomeChoice®, as embodied in U.S. Pat. No. 5,431,626 and its associated family of patents, the teachings of each of which are incorporated herein by reference, is also suitable for use in the present invention. A pneumatically controlled system employing this technology is discussed in more detail below. Conductivity sensors may also check for conductive and nonconductive states across the valves, detection of valve leaks is easy with this method.
Still further alternatively, fluid balancing chambers or match flow equalizers may be used, such as those described in U.S. Pat. No. 5,486,286, assigned to the assignee of the present invention, incorporated herein by reference, which are also employed in the System 1000™ produced by the assignee of the present invention. The balancing chambers or flow equalizers are integrated in the cassette in one embodiment and require a separate pump or pressurization source. The chambers or equalizers would manage fresh dialysate on one side of a diaphragm and the spent dialysate on the other side of the diaphragm, matching the volume flow of fresh and spent dialysate. A separate pump is then used to ultrafiltrate fluid from patient 42 accumulated between patient sessions. Peristaltic pumps may also be used to pump dialysate to dialyzers 20 and 30 or to any of the blood filtering devices described herein, pump an equal amount of fluid from such devices, control and pump out a prescribed amount of ultrafiltrate from the patient. One suitable peristaltic pump arrangement is illustrated below in connection with
Referring still to
Valve 56 labeled V6 provides a bypass that enables solution at too high or too low a temperature to be diverted to a point upstream of pumps 22 and 24 to prevent solution at too high/low a temperature from reaching the dialyzers 20 and 30 and ultimately blood circuit 50. To that end, temperature sensor 62 labeled T2 senses and provides feedback to the controller of system 10 indicating the temperature of dialysate leaving heater 58. The temperature sensor 62 could be a thermocouple or IR sensor or thermistor, which is housed inside, integral with or directly adjacent to a conductivity sensor probe 63. Conductivity sensing is temperature dependent, so it is logical to locate the two sensors 62 and 63 together or directly adjacent to each other.
A suitable location for the temperature sensor/conducting sensor is, for example, at sensor location T2, T3 which senses the conductivity of the fluid prior to the fluid reaching dialyzers 20 and 30. Conductivity sensor 63 may be used to test the electrolyte composition of the solution. Conductivity sensor or electrolyte sensor 63 is particularly useful when using a dual chamber version of containers 14, 16 and 18, which have multiple solution components that are mixed just prior to use.
A pressure sensor 46 labeled PT4 measures the pressure of the fluid flowing to venous dialyzer 20 and in one embodiment is provided in association with an additional drip chamber 52c that purges air through vent 64c and vent valve 56 labeled V19. Sensor PT4 and chamber 52c are located alternatively prior to volumetric diaphragm pumps 22 and 24.
The dialysate next flows into venous dialyzer 20. The membranes housed inside venous dialyzer are high flux membranes as discussed above. The dialysate flow path connects to the venous 20 and arterial 30 dialyzers via the restriction 40. Restriction 40 provides backpressure that drives a significant amount of the dialysate through the high flux membranes of the venous dialyzer 20 and directly into the blood flowing through the membranes inside venous dialyzer 20. Restriction 40 can be set to backpressure ten to ninety percent of the dialysate entering venous dialyzer 20 into the bloodline. As discussed above, restriction 40 can be set or variable. If a fixed restriction is desired, it is possible to use a single dialyzer rather than the two dialyzers 20 and 30 shown in
As alluded to above, it is desirable for a number of reasons that restriction 40 be a variable restriction. For one reason, different patients may respond to a therapy that is more convective or more diffusive. From a cost and manufacturing standpoint, it is desirable to have a unit that can be adjusted for any patient rather than “custom” units fitted with the necessary flow restriction. Second, it is very possible that the patient and doctor will not know initially what the optimal percentage convective clearance versus diffusive clearance breakdown is, requiring some period of experimentation and optimization. Moreover, it may be desirable for a patient to perform a first treatment using a first percentage convective clearance versus diffusive clearance and later in the week, the next day or later in the same day perform a second treatment using a different percentage convective clearance versus diffusive clearance.
Still further, system 10 has the capability of varying the percentage convective clearance versus diffusive clearance over a single therapy session or treatment, for example in step increments or continuously. Such changes can be made as gradually or quickly as desired and span as great a range as desired, e.g., starting with 90 percent convective and ending with 90 percent diffusive. It may be determined that it is desirable to clear molecules of a particular size or range of sizes or molecules of a particular type during a certain point in the therapy, e.g., at the beginning or end. Variable restriction 40 also makes it possible to repeat certain settings or patterns of settings during a single treatment.
The present invention contemplates at least three levels of variability for restriction 40. The first level can be referred to as “semi-fixed”. Here, the restriction could use a fixed orifice restriction plate, but wherein restriction 40 is configured and arranged so that the plate can be swapped out for a plate having a different sized orifice. Such swapping out would occur, however, between therapies. A second level of variability can be referred to as “manual-on-the-fly”. Restriction 40 in this instance could be a backpressure regulator or variable orifice valve with a manual adjustment that enables the patient or operator to adjust the backpressure and thus the convective versus diffusive clearance percentage. The manual adjustment could be made during a current therapy or between therapies. The third level of variability is automatic, which could be effected for example via a pneumatically operated backpressure regulator or variable orifice valve. Such pneumatically operated device receives a pneumatic signal at a controlled pressure, which sets the backpressure accordingly. The controller could be configured to output for example an analog signal, e.g., a 0-5 VDC or 4-20 mA signal, which is converted via an I/P converter to a pressure signal at a corresponding pressure. The automatic adjustment could be made during a current therapy or between therapies.
Referring still to
The waste dialysate and a volumetric equivalent to the patient's fluid gained in the interdialytic period flows from arterial dialyzer 30, through valves 56 labeled V16 and V18, through pumps 26 and 28, through valves 56 labeled V15 and V17, through a blood leak detector 66 and to one of the drain bags 12 to 16, which as discussed above are opened selectively via valves 56 labeled V9 to V14. Valves 56, detector 66 and fluid contacting portions of pumps 26 and 28 are each in one embodiment located in the housing portion 104 of cassette 100a. The waste and a volumetric equivalent to the patient's UF may alternatively be routed after BLD 66 to a long tube placed in an acceptable drain. This alternative will not work with balance scale systems.
Blood leak detector 66 includes in one embodiment a light source and a photo sensor. Blood components that are not meant to be filtered through dialyzers 20 and 30 lower the light reaching the photo sensor of detector 66 if such components do travel through the membrane walls of the dialyzers into the therapy solution flow path. The controller of system 10 continuously monitors the photo sensor. Detection of a blood leak triggers an audio and/or visual alarm, stops blood pump 48 and closes venous line valve V1. A blood sensor, such as detector 66, is alternatively or additionally placed in the venous line running from venous dialyzer 30 to pumps 26 and 28.
In special modes, infusion pumps 22 and 24 of Pump Set 1 can infuse more solution than is removed to drain by pumps 26 and 28 of Pump Set 2. For example, during priming, during blood rinseback or for bolus infusion, infusion pumps 22 and 24 can infuse a volume that is greater than the volume removed by pumps 26 and 28. The special modes enable the system to fill with fluid, enable blood in line 50 at the end of therapy to rinseback to the patient 42 or for the patient 42 to receive a bolus of solution via the venous dialyzer into the post dialyzer portion of circuit 50 and through venous access 44b to patient 42.
During priming, the arterial and venous needles 44a and 44b are connected together as seen in
In one embodiment, blood is returned to the body by reversing the flow direction of blood pump 48, which would require an additional air/blood detector and clamp, such as ABD 54 and clamp V1 placed in line 44a, between pump 48 and patient 42. Blood pump 48 would run in reverse until the additional air blood sensor detected an absence of blood in line 44a. Pump 48 would be reversed again to flow fluid in the normal direction, which would return filtered dialysate and blood to patient 42 until the absence of blood is sensed in the venous line 44b. Alternatively, this same method of blood rinseback may be employed but the air blood sensor would only be used to confirm the absence of blood, but the rinse controlled by pre-set dialysate and/or saline volume.
Referring now to
System 110 differs from system 10 in that system 110 does not use solution bags 14 to 18 and drain bag 12, instead, system 110 operates with and connects to a separate fluid preparation module 112. System 110 is advantageous because patient 42 is not required to store, connect to, disconnect from and discard multiple solution bags as described above. As seen by comparing systems 10 and 110, system 110 eliminates multiple valves 56 (V9, V10 and V12 to V14) by using an on-line dialysate generation source 112.
One suitable fluid preparation module 112 suitable for home use is commercially available from PrisMedical, however, other systems having a water purification pack and electrolyte cartridge to prepare the dialysate could be used. System 110 alternatively uses a large, e.g., about 120 liters, fill bag or fill container (not illustrated), which receives dialysate or therapy fluid from the preparation module 112. System 110 is also compatible with an in-center environment, wherein a single-patient or central fluid preparation module 112 supplies a single or multiple systems 110. The single patient or central proportioning module could prepare dialysate or substitution fluid using a proportioning system. For an in-center use, it is contemplated not to use cassette 100a but instead provide a machine that can be sterilized and re-used. In any of the above-described embodiments for system 110, the system pumps waste dialysate and UF to a waste dialysate bag, waste container, drain or waste area 114.
Referring now to
Regeneration loop 212 includes an additional pump 214, which operates with an associated volumetric measuring device 216. Any of the embodiments described above for pumping, measuring flow and controlling flow may be employed for pump 214 and measuring device 216. Additional inlet and outlet valves 56, labeled V22, V23 and V26 are provided to allow or disallow flow of spent dialysate/UF from arterial dialyzer 30 to be pumped to pump 214. As illustrated, pump 214 can pump to the recirculation sorbent cartridge 222 or to drain. Additional outlet valves 56, labeled V24 and V25, are connected fluidly to UF pumps 26 and 28, so that those pumps can pump selectively to drain or to the recirculation sorbent cartridge 222. In short, any combination of pumps 26 and 28 can be used repeatedly or at different times during therapy for recirculation or ultrafiltration.
As illustrated, pump 214 is configured to pump spent dialysate/UF back to the inlet of arterial dialyzer 30 via line 220. Line 220 alternatively runs to the inlet of venous dialyzer 20, wherein the regenerated fluid is reintroduced into that dialyzer. Moreover, regenerated fluid could be pumped to both of the inlets of venous dialyzer 20 and arterial dialyzer 30. Still further, it is possible to regenerate fluid exiting venous dialyzer 20 alternatively or additionally to the regeneration of fluid exiting arterial dialyzer 30.
In system 210, the total amount pumped through UF pumps changes due to the additional recirculation pump 214. In the example given above, pumps 26 and 28 of Pump Set 2 were said to remove eighteen liters of dialysate added over the course of the therapy (wherein twelve liters was used for convective clearance, while six liters of dialysate was used for diffusive clearance) plus any fluid ultrafiltered from the patient.
Applying the eighteen liters used in the above Example to system 210, and assuming twelve liters is used to produce convective clearance, the remaining six liters plus the volume of fluid that is recirculated through recirculation loop 212 is then used to produce diffusive clearance. If pumps 26, 28 and 214 are configured so that one-third of all fluid exiting arterial dialyzer 30 is recirculated, then 225 ml/min is pulled from arterial dialyzer 30, 75 ml is passed through recirculation loop 212 and 150 ml is discharged to the drain bags 12, 14 and 16. The diffusive clearance is calculated to be the six liters of single pass dialysate plus 75 ml/min of recirculation loop 212 dialysate for 120 minutes, or six liters plus nine liters, totaling fifteen liters of diffusive clearance. If pumps 26, 28 and 214 are each operated at 100 ml/min, one-half of all fluid exiting arterial dialyzer 30 is recirculated through recirculation loop 212 and the diffusive clearance increases to six liters plus 150 ml/min for 120 minutes or six liters plus eighteen liters, totaling twenty-four liters of total diffusive clearance.
The trade-off for the increased clearance is that a sorbent cartridge 222 is required in recirculation loop 212 to clean or regenerate the spent dialysate/UF pulled exiting arterial dialyzer 30. Depending on quantity and quality needed for the regenerated fluid, cartridge 222 may be as simple as a carbon cartridge but is alternatively a multilayer cartridge with Urease (similar to the cartridges described in U.S. Pat. Nos. 3,669,880 and 3,669,878, the teachings of which are incorporated herein by reference). Other suitable cartridges and materials therefore are discussed in commonly owned U.S. patent application Ser. No. 10/624,150, entitled, “Systems And Methods For Performing Peritoneal Dialysis” and commonly owned U.S. Pat. No. 7,208,092, entitled, “Systems And Methods For Peritoneal Dialysis”, the teachings of each of which are incorporated herein by reference. Depending on the type of sorbent used in cartridge 222, system 210 as well as any other system described herein that uses sorbents may require a sterile infusate additive 616 on line 220 to replace electrolytes lost in the sorbent cartridge and a conductivity temperature sensor 62, 63 to measure the electrolytes independently of the infusion.
In general, the cleaning cartridges remove waste products from the spent fluid and improve the efficiency of same for causing diffusive transport of toxins. Sorbent cartridge or cleaning cartridge 22, can employ one or more different types of cleaners or exchangers, such as an activated charcoal filter, a sorbent exchange, a chemical cleaner, a chemical exchange, a biological cleanser, a binding adsorption agent, an enzomatic reaction agent, a mechanical cleaner and any combination thereof.
Referring now to
The remainder of system 310 is configured by disconnecting the line 314 (shown in
A check valve 326 is placed in line 314 to prevent blood from backing up into pumps 22 and 24. A similar check valve 326 can be used in an analogous location in any hemofiltration or HDF embodiment described herein, e.g.,
System 310 as illustrated is a postdilution hemofiltration device, wherein fluid from infusion pumps 22 and 24 is injected directly into the postdilution bloodline 316, which is located downstream of hemofilter 312. In an alternative embodiment, fluid from infusion pumps 22 and 24 is injected directly into the predilution bloodline 318, which is located upstream of hemofilter 312. In such a case, the fluid in one preferred embodiment is injected at or upstream of drip chamber 52a to prevent air from entering filter 312. Predilution and postdilution both have particular advantages over one another.
Postdilution provides better clearance per liter of substitution solution than does the predilution clearance mode. Postdilution clearance per liter of substitution fluid can, for example, be twice as effective as predilution clearance. Postdilution blood flow rate limitations, however, restrict the total amount of substitution fluid due to the risk of hemoconcentration. Predilution allows for higher clearance rates because the volume of substitution fluid is not limited by hemoconcentration. Therefore, the overall clearance over a given time can be, albeit less efficiently, greater using predilution therapy than for postdilution therapy.
A second line 322 extends from the output of predilution pump 24 to the drip chamber 52a placed just in front of predilution line 318, which extends to the input of hemofilter 312. Check valves 326 are placed in both lines 320 and 322 to prevent blood from backing up into pumps 22 and 24, respectively. The embodiments discussed in
The dialysate flow path 460 is configured somewhat differently than dialysate or therapy solution flow path 60 described above. As illustrated, heater 58 is moved in front of Pump Set 1, namely, postdilution pump 22 and predilution pump 24. Drip chamber 52c likewise has been moved to be in front of infusion pumps 22 and 24 of Pump Set 1. Drip chamber 52c is provided with two temperature sensors, labeled T1 and T2, as illustrated. Drip chamber 52c also operates with vent 64c as described above. Heated fluid leaving heater 58 enters postdilution and predilution pumps 22 and 24.
Fluid exiting postdilution pump 22 flows via line 320 to postdilution line 316, where that fluid enters alternative blood circuit 350 to perform convective clearance. Fluid pumped from predilution pump 24 flows via predilution line 322 to drip chamber 52a, wherein the dialysate or therapy fluid is mixed in drip chamber 52a with blood pumped via pump 48. The blood and dialysate or therapy fluid thereafter flow to hemofilter 312.
Assuming pumps 22 and 24 pump about the same amount of fluid over a given period of time, fifty percent of the dialysate or therapy fluid is used for postdilution clearance, while the other fifty percent, approximately, is used for predilution clearance. It is important to note that this ratio can be varied by changing the frequency of pumps 22 and 24. The postdilution dialysate enters the patient 42 before flowing through hemofilter 312. The predilution dialysate or therapy fluid on the other hand flows through hemofilter 312 before reaching patient 42.
Any of the embodiments described herein for providing dialysate, either prepackaged or prepared on-line, is applicable to system 310 and 410 of
Referring now to
The dialysate or therapy fluid flow path 560 of hemodiafiltration unit 510 is a hybrid of the flow path 460 of system 410 described in connection with
Like
Hemodiafiltration system 510 operates in a similar manner to the system 10, 110 and 210 described above. That is, both systems provide convective and diffusive clearance modes. In system 510, the convective clearance occurs because lines 320 and 322 from the infusion pumps convey dialysate or therapy fluid directly into the blood circuit 350. Check valves 326 are placed in both lines 320 and 322 to prevent blood from backing up into pumps 22 and 24, respectively. Diffusive clearance also occurs because dialysate is additionally moved across the membranes inside dialyzer 20, 30.
At least a portion of many of the sensors, the pump chambers, the fluid heating pathway, the fluid flow portions of valves 56 as well as many other components of system 510 are provided in whole or in part on a cassette, such as cassette 100a. Cassette 100a is then loaded into a hemodiafiltration machine for a single use and then discarded. System 510 is thereby well suited for home use.
The systems described previously require a fluid source, such as, sterile dialysate from bags, e.g., as in
Referring now to
In the system 610 of
Heater 58 heats the solution leaving reservoir 612. After the solution is heated, system 610 prompts the user or patient 42 to install a disposable, sterile cassette, such as cassette 100a described above. At least a portion of the air bubble detectors 54, heating elements of heater 58, pressure sensors 46, temperature sensors 62, etc., are integrated into the cassette in both the dialysate and extracorporeal blood flow paths as necessary to allow for a safe treatment for the patient and reliable operation of system 610. The blood circuit 50 is primed with a saline bag connected to the arterial bloodline or via backfiltering dialysate or saline through venous dialyzer 20.
The patient is connected to the arterial and venous access lines 44a and 44b respectively, and treatment begins. For short therapies, the dialysate flow can be relatively high, such as three hundred ml/min for three hours or one hundred ml/min for up to eight hours. Dialysate pumps 22 and 24 and UF pumps 26 and 28 control flow to and from dialyzers 20 and 30. By increasing the pumping rate of pumps 26 and 28 that remove the effluent dialysate from arterial dialyzer 30, the fluid accumulated in the patient in the interdialytic period is removed. The fluid flow portions of dialysate/UF pumps 22 to 28 are integrated into the cassette along with the extracorporeal circuit in one embodiment. Alternatively, those components are maintained separately from the cassette and are integrated into the machine.
Fresh dialysate flows initially to venous hemodialyzer 20. A restriction 40 placed between dialyzers 20 and 30 builds backpressure in dialyzer 20, so that a relatively large amount of the dialysate is backfiltered into blood circuit 50, with the remaining portion of the dialysate flowing to arterial dialyzer 30. System 610 in that manner provides diffusive as well as convective clearance as has been described herein.
Used dialysate and UF pulled from arterial dialyzer 30 is then circulated through the sorbent cartridge 222. Cartridge 222 removes waste products from the spent dialysate/UF fluid. The cleaned fluid is pumped to reservoir/bag 612, where infusate 616 is added to replace the electrolytes removed by the sorbent cartridge 222.
The majority of dialysate flow path 620 is located within the cassette. The cassette is single use in one embodiment but is alternatively reusable with suitable disinfection and/or sterilization. Most all components of the extracorporeal circuit 50 may be integrated into the cassette except, e.g., the tubing extending to and from the patient. The extracorporeal circuit 50 of system 610 is similar to the circuit 50 described above in systems 10, 110 and 210.
The dialysate/infusate is heated as it exits reservoir 612 and flows past a temperature/conductivity sensor 62. If the solution is too hot, too cold or otherwise outside of a defined physiological range, a bypass valve 56 provided with ultrafilter 626 is closed and a purge valve 56 in bypass line 628 is opened to bypass dialyzers 20 and 30. During that bypass, both the infusate and UF pumps 22 to 28 may be stopped. To facilitate the bypass and a smooth, steady flow of fluid to/from reservoir 612, a second circulation pump 624b may be employed.
When the solution is within the defined temperature/physiological range, the solution passes through reusable ultrafilter 626, which employs a molecular weight cutoff that filters bacteria. Ultrafilter 626 also filters and absorbs endotoxin. The filtration of system 610, including ultrafilter 626, is intended to provide dialysate in as pure a form as possible. Ultrafilter 626 may also be a microfilter, if the microfilter can remove acceptable amounts of bacteria and pyrogens.
From ultrafilter 626 the dialysate or therapy solution is pumped to infusion pumps 22 and 24. Flow measuring devices 32 to 38 monitor the volume of the fluid pumped by pumps 22 to 28. Pumps 22 to 28 are configured as described above to leak to an external point. Any leaks are diverted into a moisture sensor built into the cassette and/or cassette/machine interface, so that corrective action is taken upon detection of a leak.
Fluid flows from infusion pumps 22 and 24 through a small 0.2 micron microfilter 630 in one embodiment. Filter 630 is integrated into the cassette and provides additional filtration of bacteria and endotoxin. The dialysate flows from filter 630 to venous dialyzer 20, which employs high flux membranes. The dialysate flow path 620 connects the venous and arterial dialyzers via a restriction 40 between the two dialyzers. Restriction 40 provides backpressure to drive a significant amount of the dialysate directly into the blood circuit 50 inside venous dialyzer 20. The remainder of the dialysate flows to arterial dialyzer 30.
UF pumps 26 and 28 are provided on the exit side of the arterial dialyzer 30. Those pumps are normally configured to pump at the rate of the fresh dialysate plus an additional amount to remove the fluid accumulated in the patient between treatment sessions. The used dialysate fluid and UF fluid is then circulated to the sorbent cartridge 222 and cleaned before returning to reservoir 612 and receiving an infusate 616 of e.g., calcium chloride, magnesium chloride, potassium chloride and possibly sodium acetate. As described above in connection with system 10, pumps 22 to 28 may operate differently for priming, for bolus infusion or for blood rinseback.
Systems 610 and 710 include a number of alternative embodiments. Ultrafilters 626 and/or microfilter 630 may or may not be reusable. Pumps 22 to 28 and flow measuring devices 32 to 38 include any of the alternatives described above in connection with system 10, such as the matched flow equalizers such as in the System 1000™, produced by the assignee of the present invention. Any of the alternatives may be at least partially integrated with the cassette or provided elsewhere in the dialysis machine. A further alternative method is to use other volumetric pumping technology, such as piston pumps (with some piston pumps, depending upon if the piston exposes the solution to air, the ultrafilter needs to be placed after the pumps in the fresh dialysate loop to prevent the solution from becoming contaminated). Still further, flow monitoring could be employed instead of the volumetric pumps. Here, flow sensors measure flow and provide flowrate feedback to one or more pumps located upstream and/or downstream of the dialyzers 20, 30 or hemofilter 312.
Referring now to systems 810 and 910 of
System 810 of
Valves 56a to 56h are configured and arranged to enable either peristaltic pump 820 or peristaltic pump 830 to perform either of the fluid infusion or fluid removal tasks, namely, to infuse fluid into venous dialyzer 20 or to pull ultrafiltrate from arterial dialyzer 30. Peristaltic pumps are inherently less accurate than the volumetric diaphragm pumps described above as well as other types of pumps or volumetric devices, such as fluid balancing chambers. Due to this inaccuracy, peristaltic pumps may have to be combined with a balance scale or another balancing method. Peristaltic pumps are, however, easy to sterilize and maintain in an injectable quality state, the pumps are generally hearty, robust and also provide built-in clamping when the pump stops pumping because the pump head pinches closed the tubing wrapped around the head. The pumps are also well accepted by the dialysis community. The valve arrangement of valves 56a to 56h and the use of the peristaltic pumps is advantageous for the above reasons.
The inaccuracy inherent in peristaltic pumps is repeatable especially when the pumps are rotated in the same direction. Systems 810 and 910 provide dual pumps 820 and 830 and valves 56a to 56h that are opened and closed to enable the same pump 820 and 830 to be rotated in the same direction for the same number of pump-in strokes and pump-out strokes. That feature cancels most error associated with the pumps. The pumps then perform additional pump out strokes to remove the desired amount of ultrafiltrate.
It should be appreciated that the above canceling can also be achieved by running one pump in one direction for the appropriate number of strokes and alternating the valves to sequentially pump-in and pump-out with the single peristaltic pump. Such an arrangement creates pulsatile flow, however, which is less desirable than a steady flow from dual pumps 820 and 830. Therapy time is reduced as are the chances of hemoconcentrating the patient.
Valves 56a and 56b enable dialysate heated by heater 58 to flow to either peristaltic pump 820 or 830. Valves 56c and 56d in turn enable fluid to flow from either pump 820 or 830 to venous dialyzer 20. Valves 56e and 56f enable ultrafiltrate to be pulled from arterial dialyzer 30 to either peristaltic pump 820 or 830, respectively. In turn, valves 56g and 56h enable the ultrafiltrate pulled from dialyzer 30 to be pumped via either valve 820 or 830, respectively, to drain bag 12, 14 or 16.
The operation of dialyzers 20 and 30 in combination with restriction 40 does not change in system 810 from their operation described above in connection with system 10 of
Flow or volume measuring devices 840 and 850 are each provided to operate with a respective pump 820 or 830, respectively. Devices 840 and 850 can provide tachometer feedback, for example, measuring the speed of rotation of the peristaltic pump head in one example. In another example, measuring devices 840 and 850 count to the number of strokes made by the head of peristaltic pumps 820 and 830. In a further alternative embodiment, ultrasonic, mass flow, vortex shedding, or other type of flow measurement technique is used to measure the amount of fluid entering or exiting pumps 820 and 830. Various embodiments showing peristaltic pumps in combination with one or more balancing chamber or volumetric control device are illustrated in detail below.
System 910 of
Any of the alternative embodiments for providing a sterile solution or for regenerating used solution described above are applicable to systems 810 and 910. Further, each of the components described above, such as valves 56, drip chambers 52 (collectively referring to drip chambers 52a, 52b and 52c), heater 58, etc., or those portions thereof that contact the fluids used in the systems, can be provided in a disposable cassette in systems 810 and 910. In particular, shown below are machines that house the flow devices as well as the disposable cassette. Those machines show that a majority of the peristaltic blood pump is located within the machine, with the peristaltic pump head located outside of the machine. Such arrangement is applicable to systems 810 and 910, which use multiple peristaltic pumps. The cassette can have multiple tubing portions that the patient or operator wraps around the externally located peristaltic pump heads for use.
Referring now to system 950 of
System 950 operates in a similar manner to system 10 of
Co-current flow of dialysate via line 952 of system 950 is beneficial in one respect because, as with predilution hemofiltration, dialysate is introduced into arterial dialyzer 30 at the start of the blood filtration portion of blood circuit 50, and may, therefore, help to prevent hemoconcentration of the patient's blood. Variable restriction 40 operates to backfilter therapy fluid inside arterial dialyzer 30 into extracorporeal circuit 50. Afterwards, blood and therapy fluid flow into venous dialyzer 20 via bloodline 50 and are subjected to diffusive clearance via the non-backfiltered dialysate that flows from arterial dialyzer 30 into venous dialyzer 20 through restriction 40. The roles of dialyzers 20 and 30 are reversed in system 950 with respect to system 10 of
Operation of system 950 is otherwise substantially similar to that described above in connection with system 10 of
Referring now to
Reference reservoirs 256 and 258 have a constant and known volume. In the equations shown below the volumes of reservoirs 256 and 258 are designated as V1 reservoir and V2 reservoir. In the example, the volumes of pressure sensors that measure V1 reservoir and V2 reservoir are 20 ml. The blood therapy treatment unit also has pressure sensors that measure the pressure inside reference reservoirs 256 and 258. In
The cassette is also configured such that a pressure sensor housed within the blood therapy unit measures the initial and final air fluid pressures, inside pumps 22 and 24. In the equations shown below, the fluid pressure inside pump 22 is designated as P1 chamber. The fluid pressure inside pump 24 is designated as P2 chamber. The fluid pressures vary from an initial pressure to a final pressure. Likewise, the pressures P1 and P2 within reservoirs 256 and 258 designated as P1 and P2 reservoir, respectively, vary from an initial pressure to a final pressure.
The volume of air within either one of the pumps 22 or 24 (volume V1 for pump 22 which is supposed to be full is shown for example) is calculated via Equation 1 as follows:
The volume of air for an empty chamber for either one of the pumps 22 or 24 (shown in this example for pump 24 or V2) is calculated according to Equation 2 as follows:
Each of the pressures for each of the pumps 22 and 24 shown in Equation 1 is measured via a suitably placed transducer. The final air pressure within the reservoirs 256 and 258 is also measured. The final pressure of air within the chambers, which should equal the final reservoir pressure can be double checked. The measured pressures satisfy the numerators and denominators in Equations 1 and 2. As discussed above, the volumes of the reservoirs V1 and V2 are constant and known.
For each pump then, Equation 3 calculates the volume pumped for a stroke as follows:
The fluid volume pumped for a stroke of a pump is equal to the volume of air when that pump chamber is empty or void of fluid less the volume of air in that pump chamber when the chamber is expected to be full of fluid. It should be appreciated that the Equations 1 to 3 that are derived from Boyle's law compensate for air bubbles that may be present in the dialysate and for instances where membranes 252 and 254 may not travel fully to one side or the other of the pump chambers of pumps 22 and 24, respectively.
The above-described method provides an accurate, after-the-fact, measurement of the volume of fluid that has been moved by either one of the pumps 22 and 24. By using the volumetrically controlled pumps, an exact amount of fluid can be exchanged with the patient and an exact amount of ultrafiltrate can be removed from the patient by setting the fluid removal pumps, e.g., pumps 26 and 28, to pump faster or more volume than the fluid inlet pumps 22 and 24 (see for example, in
It should be appreciated that Equations 1 to 3 described above could be used in a machine that mechanically moves membranes 252 and 254. In such case, positive and negative pressure tanks 268 and 270 would not be needed, however, separate reference reservoirs 256 and 258 as well as a test pressure tank 272 are needed. Test pressure tank 272 may be employed even in the present embodiment so that pressure tanks 268 and 270 may be operated independent from the volume control.
Calculating the volume of fluid pumped according to Equations 1 to 3 provides information on how much volume has been moved per pump stroke. The equations do not provide real time information of actual fluid flow. That is the valve opening and closing, sequence in
If fluid flow stops or occurs at a flow rate that is greater than a desired flow rate, the pneumatic system may not detect this until after the undesired fluid flow rate has occurred. In blood therapy systems, such as dialysis, hemofiltration or hemodiafiltration, if the withdrawal of the fluid from circulating blood exceeds about thirty percent of the blood flow rate, the blood thickens and may clog the dialyzer or hemofilter fibers. If the dialyzer or filter becomes clogged, therapy may have to be terminated and the patient may lose an amount of blood trapped in the extracorporeal circuit.
The apparatus shown in
In the following equations, the total initial volume in pump 22 and the respective pressure chamber is V1 total, initial=V1 chamber, initial plus Vpos/neg tank. The total volume in pump 24 and the respective pressure chamber is V2 total, intial=V2 chamber, initial plus Vpos/neg tank. The pressure of the pump 22 system as measured at the positive or negative tank is initially Ppos/neg, tank, initial. The pressure of the pump 24 system as measured at the positive or negative tank is initially Ppos/neg tank, initial. The pressure of either system at any time T is Ppos/neg tank, time T. The volume in either pump at time T is therefore as follows:
The fluid moved by either pump at time T is therefore as follows:
Vfluid moved by pump 1 or 2=V1 or V2 total,time T−V1 or V2 total,initial EQUATION 5
Knowing the time T and the volume of fluid moved by pump 22 or 24 at time T, the flow rate on a real time basis may be calculated, displayed and used to control the renal failure therapy systems of the present invention.
Each of the systems 10, 110, 210, 310, 410, 510, 610, 710 and 950 that employ membrane pumps, such as pumps 22, 24, 26 and 28 are capable of metering out precise amounts of fluid, which can be controlled as described above for example via Boyle's Law. For manufacturing and cost reasons, however, it may be desirable to use a different type of pump to move spent and effluent dialysate. For example, peristaltic pumps, such as the blood pump 48 described above, may more easily integrate into a disposable cassette or tubing set because the disposable part of a peristaltic pump is essentially a loop of tubing. The accuracy of peristaltic pumps, however, may not alone be precise enough for pumping dialysate in systems, such as hemofiltration, hemodialysis and hemodiafiltration, in which a prescribed amount of ultrafiltrate or effluent dialysate needs to be removed from the patient.
Patient 42 between dialysis or hemofiltration treatments gains water depending on the extent of kidney loss and fluid intake. Many people suffering kidney failure do not have the ability to urinate. Over the time between dialysis treatments, those patients accumulate fluid. The patient's total fluid weight gain can vary over different treatments based on the amount of fluid the patient has consumed between treatments and the amount of time between treatments. Therefore, the systems and methods of the present invention need to have a controllable and accurate way of removing whatever amount of fluid is needed to be taken from the patient during the home treatment. Because home patients can treat themselves more often, the amount of fluid that needs to be removed will be typically less than that for in-center treatments. Nevertheless, the home dialysis machine needs to be able to remove the amount of fluid gained between treatments.
Referring now to
Balancing chamber 340 provides the level of volumetric accuracy provided by the membrane pumps discussed above. The majority of systems 300 use peristaltic pump 370 to drive the dialysate, while balancing chamber 340 meters a precise amount of dialysate to the dialyzer, hemofiltration line, etc. Balance chamber 340 in turn meters a pressurized amount of ultrafiltrate from the dialyzer or hemofilter. System 300f of
One primary difference between systems 300a to 300d is the modality or type of therapy with which balance chamber 340 and peristaltic dialysate pump 370 are used. System 300a of
System 300d of
Viewing any of the systems 300, effluent or spent dialysate flows from a dialyzer 20, 30 or hemofilter 312 through effluent line 328 and valve V5 to peristaltic dialysate pump 370. While pump 370 in one preferred embodiment is a peristaltic pump, pump 370 can alternatively be of any desired variety, such as a piston-driven diaphragm pump, a pneumatic pump or a gear pump. The output of fluid from pump 370 flows via valve V4 to a spent side 342 of the balance chamber 340. Similar to the flexible membrane in the membrane pump, balance chamber 340 is separated into a spent compartment 342 and a fresh compartment 344 via a flexible membrane 346. As discussed herein, valves 56, such as valve V4, may be any suitable type of valve, such as a standard solenoid valve or a volcano-type valve formed partially in the cassette, which is the same or similar to that used in a HomeChoice® system.
Balance chamber 340 is a passive volumetric metering device. The same or substantially the same amount of fluid is pushed out of balance chamber 340 as is received into balance chamber 340. Pumping effluent dialysate into spent compartment 342 in turn pushes membrane 346, which forces an equal amount of fresh dialysate to exit fresh compartment 344 and travel through valve V1 in line 314 and into dialyzer 20, 30 or into venous line 44b depending on the modality used.
In an alternative embodiment, dialysate pump 370 is placed upstream of heater 58. In such case, pressure relief 332 can extend from the inlet of dialysate pump 370 to fresh dialysate inlet line 334 upstream of valve V3. In yet another alternative embodiment, pressure relief 332 incorporates sterile dialysate bags or substitution bags 14 to 18. That configuration is desirable because it prevents inline heater 58 from overheating fluid when idle, e.g., during an ultrafiltration stroke.
A cycle in which effluent fluid is removed from the dialyzer or hemofilter and fresh fluid is sent to the patient or dialyzer has been described. A next cycle sends fluid to drain. Here, heated and fresh dialysate from one of supplies 14, 16 or 18 flows through valve V6, dialysate pump 370, valve V3 and into dialysate compartment 344 of balance chamber 340. Valves V1, V4 and V5 are closed. The receipt of fresh dialysate into compartment 344 pushes flexible membrane 346, causing an equal amount of spent or effluent dialysate to drain via valve V2 and drain line 338. Depending on the point in time in the therapy in which this drain cycle takes place, spent effluent can be sent to drain bag 12 or one of the used supply bags 14 or 16. Once all of the spent dialysate in chamber 342 is emptied through valve V2 and drain line 338, all valves V1 to V6 are shut off. The fill with spent fluid and pump to patient cycle may then be repeated via the cycle described above.
It should be appreciated that the two cycles just described ensure that an equal amount of fluid is sent to the patient and taken from the patient. A UF sequence is described below in which fluid is taken from the patient but not sent to the patient. Calculating the total volume of ultrafiltrate moved is readily done in the illustrated systems 300. The cumulative volume of the UF cycles is added to determine the total amount of fluid removed from the patient.
In one embodiment, pump 370 is run at a slower speed when fresh dialysate is pumped to the dialyzer or patient than when dialysate is pumped from the patient. The difference in speed increases the time that fresh dialysate is flowing to the dialyzer. For hemodialysis, the speed difference increases the diffusion time by increasing the time that dialysate is flowing along the hollow fibers within the dialyzer. The increased time also benefits HF, HDF and ECHD by producing a more gradual ultrafiltration of the patient. The gradual ultrafiltration reduces the risk of hemoconcentration.
To remove ultrafiltrate, system 300 begins from an all valves closed position and opens valves V2, V3 and V5. Pump 370 causes effluent dialysate to fill the fresh compartment 344 with spent dialysate. That action moves membrane 346 and forces an equal amount of spent fluid previously removed from the patient in spent chamber 342 to be pushed through valve V2 and line 338 to one of the drain bags. Because the source of fluid used to push this amount of fluid to drain is used dialysate, the amount of used dialysate pumped into fresh compartment 344 is also removed from the patient as ultrafiltrate. That is, there is a small net loss of fluid from the patient during this cycle. In one embodiment, the ultrafiltrate cycle just described is timed to occur every so often during the previously described pump to patient and pump to drain cycles, so as to remove an overall net amount of ultrafiltrate that has collected in the patient between treatments. That net amount is entered into the machine at the start of therapy.
One potential drawback of the single balance chamber 340 and single dialysate pump 370 approach is that when spent dialysate is pulled from the dialyzer or hemofilter through line 328 and line 336 via pump 370 into the spent chamber or compartment 342, a small amount of fresh dialysate is also pushed into spent compartment 342. That small amount of fresh dialysate is the amount that remains in the tubing leading from valve V6, bending around peristaltic pump 370, and extending further along line 328 towards valves V3 and V4. While the single pump and single balance chamber system is desirable from the standpoint of having a cassette that is simple and relatively inexpensive, it may not be desirable to lose fresh dialysate especially if bagged sterilized dialysate is used. It should be appreciated, however, that if the dialysate is made online, the drawback is less of a concern.
Referring now to
In the alternative pump arrangement of system 300e, pump 390 pumps spent fluid through line 328, valve V4 and into the spent compartment 342 of single balance chamber 340. That action causes membrane 346 to move and push an equal amount of fresh dialysate from fresh chamber 344 through valve V1, line 314 and into the dialyzer or patient. At the end of the pump to patient cycle, all valves shut off. Afterwards, valves V2 and V3 open allowing fresh dialysate pump 370 to pull fresh, heated dialysate from one of the supplies, through line 330, through valve V3 and into fresh compartment 344. That action moves membrane 346 to push spent dialysate from spent compartment 342 through valve V2 and line 338, to one of the drain bags.
Each of the alternative configurations for the placement of pressure relief 332 is equally applicable to the dual dialysate pump system 300e. In a further alternative embodiment (see
To remove ultrafiltrate from the patient via the dual dialysate pump system 300e, with the spent compartment 342 full of effluent dialysate, valves V2, V3 and V5 are opened. Spent fluid pump 390 pumps effluent fluid through line 328, valve V5, line 348 and valve V3 into fresh compartment 344. Such action causes membrane 346 to move and push effluent fluid from compartment 342 through valve V2, line 338 and into one of the drain bags. Because the source of matching fluid for the balance chamber is used dialysate, that amount of matching fluid is removed from the patient as ultrafiltrate.
It should be appreciated that after the ultrafiltrate stroke, the next action is to again pump spent fluid from the dialyzer or hemofilter through valve V4 into spent chamber 342. That action causes membrane 346 to move and in turn pump one balance chamber volume worth of spent fluid from fresh compartment 344 (used previously to push the volume of ultrafiltrate) through line 314 to either the dialyzer or the patient. The spent dialysate still provides a clearance benefit to the patient, especially with respect to larger molecules, such as β2M. This action also extends the life of a certain amount of the dialysate, which is beneficial especially in the case of a home treatment using sterilized and bagged fluid.
Referring now to
As with the other systems, system 300f is operable with any of the modalities discussed herein and is illustrated only for convenience in combination with a single dialyzer 20, 30. The advantage of system 300f is that there is no mixing of fresh and spent dialysate at the balancing chamber. It should be appreciated that even in
It is necessary in renal replacement therapies, such as hemodialysis to provide a bolus of fresh solution to the patient for various reasons. For instance, the patient may need a bolus or volume of fluid if the patient becomes hypovolemic (abnormally low volume of circulating blood) or hypotensive (low blood pressure). To provide a bolus of solution for system 300f, fresh dialysate pump 22, 24 expels a predetermined amount of fluid, while valves V3 and V4 are opened and all other valves are closed. The fresh dialysate travels through line 330, valve V3 and into fresh compartment 344 of balance chamber 340. That action causes membrane 346 to move and push fluid back through line 328 and valve 324 into effluent dialysate pump 26, 28. Afterwards, all valves are closed. Then, valves V1 and V4 are opened and effluent dialysate pump 26, 28 pushes used dialysate into spent chamber 342 of balancing chamber 340. That action causes membrane 346 to move, pushing fresh solution from fresh chamber 344 into the dialyzer. Since no ultrafiltration is removed in this cycle, the amount of fluid sent to the dialyzer represents a net gain or bolus of fluid for the patient. This process can be repeated as many times as necessary to provide a patient with an overall net gain in fluid, if needed.
Previous
In an alternative embodiment, system 300e of
A number of alternative embodiments may be used with systems 300a to 300f. Any of the dialyzers discussed herein, such as the single filter disclosed in U.S. Pat. No. 5,730,712, assigned to the assignee of the present invention, may be used. Furthermore, the single dialyzer discussed below in connection with
Systems 300a to 300f also include electrodes or contacts 354 and 356, which are used with an access disconnection sensor (“ADS”). ADS contacts 354 and 356 are incorporated respectively in arterial line 44a and venous line 44b. If one of the arterial or venous lines becomes disconnected from the patient, an electrical impedance is changed. The break of the loop is sensed, blood pump 48 is shut down and corresponding clamps are closed. An alternative mechanism for the detection of accidental needle disconnection is the use of a conductive blanket underneath the patient's access. Any spillage of blood changes the conductivity of the blanket, setting off an alarm and stopping the pumping of blood and dialysate.
The principles described above in
System 400 of
Valves V1 and V4 are opened, while valves V2, V3, V5 and V6 are closed for the pump to dialyzer or patient cycle in system 400. Spent dialysate pump 390 pumps effluent dialysate through line 328 and valve V4 into the spent side 364 of balance tube 360. That action causes separator 366 to move towards the fresh side 362 of balance tube 360 and push a like amount of fluid out through line 314 and valve V1 into dialyzer 20, 30 or directly to the patient (as before, system 400 of
In the pump to drain cycle, valves V2 and V3 are opened, while valves V1, V4, V5 and V6 are closed. Fresh dialysate pump 370 pumps fresh fluid through line 330 and valve V3 into the fresh side 362 of balance tube 360. That action causes separator 366 to move towards the spent side 364 of balance tube 360. A like amount of fluid is forced out of spent side 364, through drain line 338 and valve V2 to one of the drain bags.
For the ultrafiltration cycle of system 400, valves V2, V3 and V5 are opened, while valves V1, V4 and V6 are closed. Prior to this cycle, effluent dialysate resides within balance tube 360 and separator 366 is pushed all the way to the fresh side 362 of the balance tube 360. Next, spent dialysate pump 390 pulls effluent dialysate from the dialyzer or hemofilter through line 328, through ultrafiltrate line 348 and valve V5, through fill line 330 and valve V3 into the fresh side 362 of balance tube 360. That action causes separator 366 to move towards spent side 364, pushing an equal volume of fluid out through valve V2 and drain line 338 to one of the drain bags. Because the fluid sent to drain is matched with effluent dialysate from the dialyzer or ultrafilter, the fluid sent to drain constitutes fluid removed or ultrafiltered from the patient.
For a bolus of fluid to the patient, valves V3 and V6 are opened, while valves V1, V2, V4 and V5 are closed. In essence, no fluid can be drawn from the dialyzer or hemofilter. Instead, fresh dialysate pump 370 pumps fresh dialysate through line 330, through valve V3 and into the fresh dialysate side 362 of balance tube 360. Such action causes separator 366 to move towards side 364 of balance tube 360. A like volume of fluid is pushed from balance tube 360, through bolus line 352 and valve V6, through fill line 314 into dialyzer 20, 30 or directly into the venous line 44b. Because the fluid delivered to the dialyzer or patient is not matched with an amount of fluid removed from the dialyzer or hemofilter, the fluid delivered to the dialyzer or patient constitutes a net fluid gain or bolus for the patient. Such procedure is repeated as necessary until the patient receives a needed amount of fluid. Any of the alternative bolus embodiments described above in connection with
Referring now to
The primary difference between system 450 and the previous single balance device systems is the use of a tortuous path 470 as opposed to a confined volume that is divided by a separator, such as a membrane or moving ball or piston. The advantage of system 450 is that to place tortuous path 470 in a cassette is relatively simple compared with either the volumetric membrane pumps or the balance chambers and tubes described above, which each require a flexible sheeting or membrane to be sonically welded, chemically adhered or otherwise fused to a rigid plastic cassette.
Tortuous path 470 as seen in
A drawback of tortuous path 470 of system 450 is the potential for fresh dialysate and spent dialysate to mix within the tortuous path as opposed to moving as bulk fluids. The configuration of the path is refined so that such mixing is minimized and occurs as much as possible only at the interface between the fresh and used dialysate, leaving the middle of the bulk of either fluid relatively unmixed and consistent. To this end, measures may be taken to maintain the flow of both fluids in either a laminar or turbulent state as desired to minimize mixing. For the online systems described herein especially, tortuous path 470 offers a viable solution, wherein the cost and complexity of a cassette or volumetric control system is reduced.
To perform the fill to dialyzer or patient cycle in system 450, fresh dialysate is pumped via dialysate pump 370 through line 330 and valve V2 up to closed valves V7 and V9. Next, valves V5 and V9 are opened, while valves V2 and V7 are closed. Spent dialysate pump 390 pulls effluent dialysate from arterial dialyzer 30 through line 328, valve V5, tortuous path line 328, 330 and up to valve V9. That bulk transport of fluid pushes the fresh dialysate residing within tortuous path line 328, 330 through valve V9, through fill line 314 and into venous dialyzer 20 or venous line 44b.
After the fill cycle takes place, tortuous path line 328, 330 is filled with effluent or spent dialysate. The drain cycle may then take place. Here, valves V5 and V9 are closed, while valves V2 and V7 are opened. Fresh dialysate pump 370 pumps fresh, heated dialysate through valve V2, line 330, through tortuous path line 328, 330 and up to the point of valve V9 or V7. That bulk transport of fluid in turn pushes spent dialysate through drain line 338 and valve V7 into one of the drain bags.
The ultrafiltrate cycle takes place as follows. With the tortuous path line 328, 330 filled with ultrafiltrate, valves V5 and V7 are opened, while valves V2 and V9 are closed. Spent dialysate pump 390 pulls fluid from arterial dialyzer 30 through line 328, valve V5 to fill tortuous path line 328, 330. That amount of fluid is then moved through valve V7, line 338, to drain. Because the amount of fluid moved to drain is matched at least substantially by effluent or spent dialysate, the patient experiences a net loss or ultrafiltration of fluid.
To provide a bolus of fluid to the patient, with the tortuous path line 328, 330 full of fresh or effluent fluid, valves V5 and V7 are closed, while valves V2 and V9 are opened. Fresh dialysate pump 370 pumps fresh dialysate through line 330 and fills tortuous path line 328, 330. A same volume or substantially the same volume of fluid flows through valve V9, fill line 314 and into venous dialyzer 20. Because the patient or dialyzer has received an amount of fluid without a corresponding amount of fluid being withdrawn from arterial dialyzer 30, patient 42 experiences a net gain or bolus of fluid.
One potential problem with the single balancing device embodiments just previously described is pulsatile flow. The single balancing device systems can compensate the pulsatile nature of the flow somewhat by slowing the flowrate of fresh fluid to the dialyzer relative to the flowrate of fluid from the dialyzer. Other solutions are provided by system 500 of
System 500 includes first and second balance chambers 340a and 340b, which are each the same in one embodiment as balance chamber 340 described above in connection with
In the illustrated embodiment, dialysate pumps 370 and 390 are peristaltic pumps. They may alternatively be membrane pumps or other types of pumps described herein. Fresh dialysate pump 370 is shown upstream of heater 58, which is different from the single balance device configurations. Either configuration is possible for either of the single and double balance device systems. Further, each of the valves used in system 500 may be configured in a cassette or be any type of valve as discussed herein.
In a first exchange cycle, one of the balance chambers 340a or 340b fills with fresh solution and at the same time delivers an equal volume of spent dialysate to drain. In that same first cycle, the other balance chamber 340a or 340b fills with effluent dialysate and at the same time pushes a like volume of fresh dialysate to the dialyzer 20 or the patient according to the modality. Then, in a second cycle, the balance chambers 340a and 340b alternate functions so that the balance chamber that previously delivered fresh dialysate to the patient now delivers spent dialysate to drain, while the balance chamber that previously delivered spent dialysate to drain now delivers fresh dialysate to the dialyzer or patient.
Based on the foregoing description of the operation of balance chamber 340 in connection with
The flow equalizer or balance chambers 340a and 340b are used differently than in other systems employing a flow equalizer from the standpoint that there is not a separate UF removal device in system 500. That is, in other systems employing a flow equalizer or dual balance chambers, the balance chambers are dedicated to removing an amount of fluid from the dialyzer, while at the same time filling the dialyzer with a like amount of fluid. System 500, on the other hand, uses balance chambers 340a and 340b for that purpose and also to remove a net amount of fluid or ultrafiltrate from patient 42. The valve operation for removing a net loss or ultrafiltration of fluid from the patient includes opening valves V1, V2, V6, V7, and V9, while closing valves V3, V4, V5, V8 and V10. This valve configuration pushes effluent dialysate to drain by pushing the fresh dialysate from balance chamber 340b to balance chamber 340a.
The systems herein including system 500 having dual balancing chambers 340a and 340b enable an ultrafiltrate removal rate to vary over time, which is sometimes referred to as an ultrafiltrate profile. For example, if an ultrafiltrate cycle is typically performed after each five exchange cycles, one could change the rate at which ultrafiltrate is removed from the patient by increasing or decreasing the frequency of cycles. This could result, for example, in more fluid being removed during a first part of therapy than a second. In the present invention, the processor of the renal failure therapy machine may be configured to run an algorithm, which enables the patient to select a profile, a treatment time and an overall volume to be removed. The algorithm automatically calculates an ultrafiltrate frequency profile that achieves, according to the profile, an entered net cumulative ultrafiltrate volume over an entered treatment time. Those parameters may be entered through a patient data card or through a secure data connection.
System 500 can also provide a bolus of solution to the patient when needed. Valves V2, V3, V7, V8 and V10 are opened and valves V1, V4, V5, V6 and V9 are closed. Pump 370 is run forcing one balance chamber bolus of dialysate and/or substitution fluid to the dialyzer or patient.
In any of the embodiments described herein, it is important that the valves of the systems are checked to ensure that they open and close properly. In one embodiment, the valves are checked periodically throughout treatment using conductive sensing. That is, if fluid escapes from the system via a faulty valve or tear in a cassette membrane, conductive sensors that measure a flow of electricity across a liquid can send an alarm and trigger appropriate action. Further, with a cassette, temperature sensing may be employed, for example, by applying a thermistor, IR sensor or thermocouple on one side of the sheeting of the cassette. Here, the temperature sensor is attached to the blood therapy instrument and, for example, contacts the sheeting membrane so as to obtain a quick reading of the temperature of the dialysate.
Referring now to
In the next step of this first priming method of the present invention, blood pump 48 runs in its operational direction until half the volume of the drip chamber is moved. Then, blood pump 48 runs in the reverse direction again until drip chamber 52 is again filled and vented. The pump then runs again in the normal operation direction enough to move half a drip chamber volume worth of fluid in the normal operating direction. In each cycle, dialysate or substitution fluid is back-filtered through dialyzer 20, 30 (or different filter for a different modality), adding to the total volume of fluid in the extracorporeal circuit over each cycle period. This first priming method cycles back and forth as described until the extracorporeal circuit is completely filled with dialysate or substitution fluid. It should be appreciated that this priming method applies to any of the modalities described herein, any of the pumping arrangements described herein and any of the volumetric control methods described herein.
In a second priming method, a separate saline or priming fluid bag 368 is connected to the extracorporeal circuit via saline line 372. In the illustrated embodiment, saline line 372 tees into the extracorporeal circuit at two places, upstream and downstream of blood pump 48. Valves V11 and V12 are positioned in saline line 372 so as to allow saline to flow selectively to one of or both of the teed connections upstream and downstream of blood pump 48. Arterial access line 44a is again connected to venous access line 44b via connection 358.
In the operation of the second priming method of the present invention, valve V11 located downstream of pump 48 is opened, enabling blood pump 48 to run in reverse and pump saline from bag 368, through saline line 372, through valve V11 through access line 44a, through connection 358, through access line 44b, and into drip chamber 52. Blood pump 48 pumps saline until drip chamber 52 is full and air is purged via vent 64. Next, valve V11 and air detector clamp 53 are closed and valve V12 is opened, enabling blood pump 48 to pull saline from bag 368 and push that volume of fluid in the normal operating direction downstream of pump 48, venting air through vent 64. This cycle continues until the extracorporeal circuit is fully primed. It should be appreciated that this second priming method is equally applicable to any of the modalities, pumping regimes, and volumetric control methods discussed herein.
Modifications to either of the first and second priming methods can also be made to provide a blood rinseback to patient 42. This is done at the end of therapy to return any blood in the extracorporeal line to the patient. The primary difference for blood rinseback is that access lines 44a and 44b are connected to patient 42 instead of to each other via connection 358. For example, using saline 368 or other suitable source, valve V11 is opened and pump 48 runs in reverse to rinseback blood to the pre-pump portion of arterial line 44a. An air detector 54 in that portion of arterial line 44a detects any air in the blood or saline and clamps the circuits if such air is detected. Pump 48 runs for an appropriate amount of time to ensure that blood has been fully rinsed back to the patient through the pre-pump portion of arterial line 44a.
Next, valve V11 closes and valve V12 opens, enabling pump 48 to pull saline from supply 368 and operate in the normal direction. Pump 48 pumps saline or other suitable fluid from source 368 through the remaining portion of arterial line 44a, through dialyzer 20, 30 (depending on modality) and through venous line 44b including drip chamber 52. The rinseback returns blood from those portions of the extracorporeal circuit to patient 42. In an embodiment, saline sensors on the arterial and venous lines 44a and 44b, respectably, cause an alarm if the extracorporeal circuit is not clear or transparent after a preset amount of rinseback. After blood is fully rinsed back to the patient, the patient is instructed to disconnect from the renal failure therapy system of the present invention.
The first priming method described above may also be adapted for blood rinseback. Here either dialysate or saline is back-filtered through the dialyzer or other modality filter. Blood pump 48 is run in the reverse and forward cycles described above in connection with the first priming method. Pump 48 may be run at a slower speed for blood rinseback so as to limit an amount of mixing between saline and blood. The saline or other solution needed to fully rinseback the blood to the patient is thereby minimized.
In an alternative method for priming system 500 or rinsing back blood to the patient, one of the line clamps 54 in the extracorporeal circuit is closed and saline or dialysate is pumped via one or both dialysate pumps 370 and 390 into the extracorporeal circuit until drip chamber 52 fills to a preset level, such as ¾ full. After the drip chamber 52 is filled to the preset level, the dialysate or saline infusion is stopped, and pumps 370 and 390 no longer pump fluid into the extracorporeal circuit. Then, line clamp 54 is opened. Blood pump 48 circulates the dialysate through the extracorporeal circuit. If needed, line clamp 54 may be clamped again to repeat the process.
In a further alternative prime or rinseback embodiment, saline bag 368, dialysate from a supply or drain bag, saline line 372, valve V12 and the portion of line 372 leading to the extracorporeal circuit between clamp 54 and blood pump 48 are used. Here, valve V11 in
It should be appreciated that each of the forgoing methods of prime and rinseback may be used in any of the forgoing modalities, pump configurations and volumetric control schemes. Further, those of skill in the art may be able to determine additional valving operations to achieve an effective prime and rinseback using the apparatuses and methods of the present invention.
While the present invention sets forth multiple embodiments for balancing devices, it is believed that the balancing tubes provide a good trade-off between ease of manufacturing, cost and effectiveness. The balancing chambers shown previously for example in
The tortuous path embodiment, while perhaps involving the simplest cassette, may not be as desirable with respect to efficient use of fresh dialysate (due to the tendency of the fresh and effluent dialysates to mix). Again, this potential drawback is not as much of a concern when dialysate is made online. The balance tubes may offer the best solution however for home use with fresh dialysate bags.
Referring to
The cycle shown in
At the same time spent dialysate pump 330 pushes effluent dialysate from a dialyzer or hemofilter through manifold 328, line 328a, valve V4 and into the spent portion 364a of balance tube 360a. The force of fluid entering spent portion 364a of balance tube 360a causes separator 366a to move towards the fresh portion 362 of balance tube 360a. In turn, fresh dialysate is pushed through valve V1, line 314a, manifold 314 and valve V10 to a dialyzer or the extracorporeal circuit, depending on the modality used. It should be appreciated from the valving description of
Referring now to
After the cycle of
Referring now to
This ultrafiltrate cycle may be varied in frequency relative to the fluid exchange cycles to vary the rate of ultrafiltrate removal over time. It should be appreciated that a bolus of fluid may be given to the patient in a similar manner, with incoming fresh dialysate pushing effluent dialysate via a separator from one balance tube to the other, forcing the separator in the other balance tube to push fresh solution towards the dialyzer or extracorporeal circuit depending on modality. The patient or dialyzer gains fluid without a corresponding loss of fluid from the patient, resulting in a bolus of fluid.
Referring now to
Referring now to
In one preferred embodiment, the tortuous paths 470a and 470b are alternated so that one path delivers dialysate to the dialyzer during one cycle and the other tortuous path delivers dialysate to the dialyzer during the same cycle. The roles of paths 470a and 470b are then reversed. While one path is delivering dialysate to the dialyzer, the other is filling with fresh solution and delivering spent dialysate to drain. Each of the tortuous paths 470a and 470b is built to have a length and diameter that attempts to minimize the amount of mixing between fresh and spent fluids, so that the fluids tend to move in bulk to their desired destination.
To remove ultrafiltrate, fresh fluid from one line 328a, 330a or 328b, 330b can be moved to in turn displace spent fluid from the other line to drain. For example, valves V1 and V4 of tortuous path 470a may be opened so that spent dialysate enters line 328a, 330a and displaces fresh dialysate through open valve V7 into line 328b, 330b of tortuous path 470b. Valve V6 is opened and spent dialysate is moved through line 572 to drain. If needed, a valve may be added after dialysate pump 390 so that spent fluid does not flow back into pump 390 during the ultrafiltrate cycle.
As illustrated, a separate ultrafiltrate pump 570 may be added to system 550 or to any of the forgoing systems. Ultrafiltrate pump 570 enables tortuous paths 470a and 470b to operate continuously to send fluid to and take equal amounts of fluid from the dialyzer or hemofilter. The ultrafiltrate pump 570 removes dialysate through ultrafiltrate line 572 to one of the drain bags. It is believed that removing the ultrafiltrate function from the tortuous paths 470a and 470b may reduce mixing of the fresh and spent fluids. The additional ultrafiltrate pump 570 can also be run in reverse with pump 390 to provide a bolus of fluid to a patient in need same.
It should appreciated that any of the dual balancing device systems described herein can employ the ADS contacts 354 and 356 and associated electronics to detect when one of the access lines 44a or 44b is inadvertently disconnected from the patient during treatment. Further, any system can employ one of more of the various pressure reliefs 332 shown in
Referring now to
The import of
A seat 164 seals one end of a rolling diaphragm 168 between the seat and cap 154. A housing 176 coupled to foot 152 and the machine frame seals the other end of rolling diaphragm 168 between housing 176 and the frame of machine 140. Housing 176, rolling diaphragm 168 and seat 164 form a closed volume chamber. The rolling diaphragm enables the volume to remain closed and also enables shaft 146 to fluctuate up and down due to the varying weight within the supply end drain bags. The rolling diaphragm 168 may be made of any suitable deformable but impermeable material, such as rubber or plastic sheeting. The volume of air within the closed volume chamber pressurizes due to the weight of the bags 14 to 18 and supporting apparatus. The amount of pressure indicates or varies with the amount of liquid in bags 14 to 18.
A pressure sensor, which may be any suitable type of sensor (not illustrated), is provided for example within opening 178 defined by seat 164. The pressure sensor senses the amount of pressure within the closed volume chamber. The sensor sends a signal to a processor or a controller within machine 140, which processes that signal and determines the corresponding weight in bags 14 to 18.
The weight control system is desirable because it removes the need for the volumetric control devices described above. The cassette for machine 140 is much simpler, including mainly valve flow paths. One disadvantage of the weight system is that it requires the patient to load the bags properly onto stand 144. The stand and assembly described in connection with
Referring now to
Filter 600 includes a housing 602 corresponding to venous dialyzer 20 and a housing 602 corresponding to arterial dialyzer 30. Housing 602 may be made of any suitable material, such as a cylindrical, rigid plastic. Fibrous, semi-permeable membranes are loaded within the venous section 20 and the arterial section 30. Those membranes are potted at the outside ends of housings 602 via a potting 604 according to any method known to those of skill in the art. The membranes are potted at the inside ends of each of the venous 20 and arterial 30 sections of filter 600 via a potting 606.
A blood entry cap 608 is fixed in a sealed manner to housing 602 so that blood may enter cap 608 via a blood tube, be dispersed within the cap and enter the inside of the hollow semi-permeable fiber membranes of arterial section 30. At the same time, blood is blocked from entering housing 602 on the outside of hollow fiber membranes via potting 604.
Blood travels through filter 600 via the arrow shown in
Blood then enters the second set of hollow semi-permeable membranes housed within venous portion 20 of filter 600. The blood enters those fibers and is prevented from entering housing 602 of venous portion 20 outside the fibers via internal potting 606 at the internal end of housing 602 of venous portion 20. Blood flows through the venous portion of the membranes, through an outer potting 604 and into a blood exit cap 632. Blood exit cap 632 in turn couples sealingly to a tube that carries the blood away from filter 600 within the extracorporeal circuit.
Housing 602 of venous portion 20 includes a dialysate entry port 634 and a dialysate exit port 636. Likewise, housing 602 of arterial portion 30 includes a dialysate inlet port 638 and a dialysate exit and ultrafiltrate port 640. Ports 634, 636, 638 and 640 may be of any suitable type for mating sealingly with a medical fluid tubing. Port 634 receives dialysate from the dialysate supply. Port 640 enables dialysate and ultrafiltrate from the patient to be pulled out of filter 600. The effluent dialysate stream exists filter 600 via port 640.
Variable restriction 40 is placed in fluid communication with ports 636 and 638. The restriction may be made more or less restrictive so as to backfilter greater or lesser amounts of fresh dialysate into the hollow fiber membranes located in housing 602 of venous portion 20. As described above, the clearance of filter 600 is convective and diffusive. Filter 600 achieves one desired goal of the present invention, namely, to provide an overall effective treatment of small, middle and large molecules of a patient's waste via both convective and diffusive clearance modes. Housings 602, caps 632, 608, the potting material, the porous fibers and the ports may be made of any suitable materials.
Referring now to
A tube section 962 shown also in
Importantly, stepper motor 954 is accurate and repeatable. That is, stepper motor 954 can be commanded to rotate lever arm 956 to virtually the same position time and time again. Because tube section 962 is held in the same position via bracket 964 relative to lever arm 956 and fixed surface 960, lever arm 956 accurately and repeatedly creates the same amount of restriction through line 962 when the arm 956 travels to the same commanded position. The programmable nature of stepper motor 954 also enables restriction 40 to have virtually any desired restriction profile that varies over the duration of therapy as desired by the patient, physician or other operator. Such variable restriction profiles are described above and can be stored as programs within a memory device of the controller of the systems described herein, such that one of the variable restriction profiles can be called upon and implemented as desired.
Referring now to
For reference, drain container 12 and solution bags 14 to 18 are shown in one possible proximal position to cassette 100a in
Referring now to
Machine 150 includes a graphical user interface 160 that enables the patient 42, nurse or other operator, to begin therapy, monitor therapy, receive status messages from the therapy, as well as collect data for post-therapy analysis of the patient's treatment and status. Graphical user interface (“GUI”) 160 allows patient 42 or other operator to select the desired therapy and to adjust the desired or necessary fluid loss or UF volume for each treatment. GUI 160 receives prescription entries via the packetized or checked data packets via memory card, flash memory, modem, internet connection, or other suitable local area or wide area mode of data communication. The electronic and software architecture running GUI 160 is redundant in one preferred embodiment, so that monitoring and controlling any critical function is executed through separate hardware and software.
GUI 160 in one embodiment includes a touch screen that enables the patient 42 or operator to enter desired parameters. In an alternative embodiment, GUI 160 uses electromechanical devices, membrane switches, voice activation, memory cards, or any combination of the above-described input devices. In one embodiment, GUI 160 is run via multiple processors, such as a supervisory/delegate processor system. A separate processor is provided for monitoring and checking that the critical functions of the machine are being performed correctly. That is, while one processor is dedicated to controlling the flow devices of the system to achieve the desired therapy, another processor is provided to check that the hardware processor and the associated flow devices are operating properly.
Referring now to
Machine 180 of
Referring now to
Referring now to
Cassettes 100b and 100c both include linear tubing portions 184 shown above in
Cassette 100c of
Referring now to
As seen in
Regarding inline heater 58b, fluid flows via a dialysate pump through a tube (not illustrated) connected sealingly to inlet port 82. Fluid flows out of heater 58b to the disposable cassette through a tube (not illustrated) connected sealingly to outlet port 84 and a similar port located on the main body of the disposable cassette.
Heaters 58a and 58b each include a heating element or inductive coil 80. Heater element 80 is inserted into each of the fluid flow channels 74a and 74b. In an embodiment, heater element 80 is substantially cylindrical and when placed within the substantially cylindrical housings 72a and 72b, respectively, creates an annular fluid flow path that flows longitudinally down the outside of heater element 80 and up the inside of heater element 80 before leaving heater 58a or 58b. Heater elements 80 can be corrugated or otherwise have fin-like structures to increase the surface area of the heating element with respect to the fluid flowing through heaters 58a and 58b.
In an embodiment, heater element 80 is a or acts as a shorted secondary coil of a transformer. The closed or looped element does not allow energy to dissipate electrically, instead is converted to heat. A transformer located in the machine includes a primary coil. The primary coil can be powered by an AC high frequency supplier.
The fluid heaters 58a and 58b incorporate one or more temperature sensors located so that the temperature of the liquid flowing through the heater can be monitored. The temperature sensors in one embodiment are infrared temperature sensors. Heater element 80 in an embodiment is made of a non-corrosive metal, such as stainless steel.
In operation, cold or room temperature dialysate is pumped into the induction heaters 58a or 58b along the outside of heater element 80, around the bottom of heater element 80 and then along the inside of heater element 80, finally exiting the heater. In an embodiment, the disposable cassette, such as cassette 100 is inserted such that the heating cavity defined by housing 72a is as positioned directly on the primary coil located within the renal therapy machine. When energized, the primary coil magnetically induces a current into the shorted coil 80, causing the element 80 and surrounding fluid to heat. The primary coil serves a secondary purpose of centering and steadying the cassette within the renal failure therapy machine.
In one implementation, the surface area of the element 80 may be around or less than ten square inches to heat dialysate from five degrees Celsius to thirty-seven degrees Celsius at a flow rate of approximate 150 milliliters per minute. The heater may have a dimension of about 1 inch (25.4 mm) in diameter by 1.5 inches (38.1 mm). Other sizes, shapes and/or multiple coils 80 may be used alternatively.
Referring now to
The sheeting 346 is welded or bonded to one half 96 or 98. Excess sheeting is trimmed. The two portions 96 and 98 are then bonded at a mating interface between the portions. This captures the sheeting 346 between portions 96 and 98. Portions 96 and 98 are configured so that the welding of sheeting 346 is constrained between portions 96 and 98. Portions 96 and 98 thereby sandwich the flexible membrane or diaphragm 346 of the cassette.
Using the same nomenclature from
When balance chamber 340 is full of fresh fluid, a valve located upstream of the balance chamber and fresh fluid path 334 is closed. To push dialysate to the patient or dialyzer, a valve communicating with inlet effluent line 336 is opened as is a valve communicating with fresh dialysate delivery line 314. That valve configuration enables pressurized effluent fluid to push membrane or diaphragm 346 away from the opening of effluent inlet 336 and towards the top of chamber 340, thereby dispelling fresh dialysate within chamber 340 to a dialyzer or patient.
Balance chamber 340 may be oriented horizontally as shown or vertically. If vertically, the inlets are preferably located below the outlets to better enable air to escape from the fluid. Also, the ports may be combined to a single port for each chamber, similar to the alternative valve configuration of
In another embodiment (not illustrated) the portion of cassette 100 that provides a balance chamber does not include upper and lower rigid portions 96 and 98. Instead that portion of cassette 100 includes three-ply or three separate flexible membranes. When the cassette is loaded into the renal failure therapy machine, the machine pulls a vacuum on the two outer membranes, causing the outer membranes to be sucked against the machine walls defining the balance chamber. This configuration reduces the amount of rigid plastic needed and is believed to be simpler and cheaper to produce. In an alternative configuration, the pressures in the balance chamber cavities push the sheeting to conform to the cavities, negating the need for a vacuum. The outer plies may have ports formed integrally with or connected sealingly to the plies to mate with inlet and outlet dialysate lines.
Referring now to
In an embodiment, cylindrical tube 382 is translucent or transparent, so that an optical sensor can detect if ball or separator 366 has properly reached the end of travel. Ultrasonic or other types of sensors may be used alternatively. The assembly could be made of two pieces of injection molded plastic that mate in the center of the tubes with the separator 366 installed prior to mating. Mating may be done by solvent bond, ultrasound or other techniques known to one of skill in the art. Tube 382 may also be a simple extrusion with molded end caps applied by a secondary operation.
Ball or separator 366 is sized to fit snuggly but smoothly within the interior of cylinder 382. A small amount of mixing between fresh and effluent fluid may occur without substantially affecting the performance of the system. In an alternative embodiment, a cylindrical piston type separator is provided. In either case, separator 366 may have additional sealing apparatus, such as wipers or deformable flanges that help to enhance the sliding or rolling seal as the case may be.
Each of the components shown in
It should be understood that various changes and modifications to the presently preferred embodiments described herein will be apparent to those skilled in the art. Such changes and modifications can be made without departing from the spirit and scope of the present invention and without diminishing its intended advantages. It is therefore intended that such changes and modifications be covered by the appended claims.
This application claims priority to and the benefit as a continuation application of U.S. patent application Ser. No. 15/163,128, entitled “Systems, and Methods For Priming Hemodialysis Using Dialysis Fluid”, filed May 24, 2016, which in turn claims priority to and the benefit of U.S. patent application Ser. No. 13/749,309, entitled, “Systems and Methods for Priming Sorbent-Based Hemodialysis Using Dialysis Fluid”, filed Jan. 24, 2013, issued as U.S. Pat. No. 9,364,602, which in turn claims priority to and the benefit of U.S. patent application Ser. No. 13/222,622, entitled, “Systems And Methods for Priming Sorbent-Based Hemodialysis”, filed Aug. 31, 2011, now U.S. Pat. No. 9,072,830, which in turn claims priority to and the benefit of U.S. patent application Ser. No. 10/982,170, entitled, “High Convection Home Hemodialysis/Hemofiltration and Sorbent System”, filed Nov. 4, 2004, now U.S. Pat. No. 8,029,454, which in turn claims priority to and the benefit of U.S. Provisional Patent Application No. 60/517,730, filed Nov. 5, 2003, entitled, “High Convection Home Hemodialysis/Hemofiltration and Sorbent System”, the entire contents of each of which are hereby incorporated by reference and relied upon.
| Number | Name | Date | Kind |
|---|---|---|---|
| 3268441 | Lindstrom | Aug 1966 | A |
| 3327115 | Bartlett | Jun 1967 | A |
| 3375716 | Hersch | Apr 1968 | A |
| 3388803 | Scott | Jun 1968 | A |
| 3428828 | Korzekwa et al. | Feb 1969 | A |
| 3485245 | Lahr et al. | Dec 1969 | A |
| 3507708 | Vignaud | Apr 1970 | A |
| 3617545 | Dubois et al. | Nov 1971 | A |
| 3619423 | Galletti et al. | Nov 1971 | A |
| 3626670 | Pecker | Dec 1971 | A |
| 3656873 | Schiff | Apr 1972 | A |
| 3667612 | Leonard | Jun 1972 | A |
| 3669880 | Marantz et al. | Jun 1972 | A |
| 3689204 | Prisk | Sep 1972 | A |
| 3703959 | Raymond | Nov 1972 | A |
| 3707967 | Kitrilakis et al. | Jan 1973 | A |
| 3709222 | DeVries | Jan 1973 | A |
| 3727612 | Sayers et al. | Apr 1973 | A |
| 3730183 | Goldsmith et al. | May 1973 | A |
| 3774762 | Lichtenstein | Nov 1973 | A |
| 3792643 | Scheafer | Feb 1974 | A |
| 3799873 | Brown | Mar 1974 | A |
| 3809241 | Alvine | May 1974 | A |
| 3820661 | Pages | Jun 1974 | A |
| 3823724 | Davis | Jul 1974 | A |
| 3825493 | Brown et al. | Jul 1974 | A |
| 3839200 | Gigou | Oct 1974 | A |
| 3882899 | Ginsberg | May 1975 | A |
| 3884808 | Scott | May 1975 | A |
| 3902490 | Jacobsen | Sep 1975 | A |
| 3903478 | Stuart | Sep 1975 | A |
| 3926797 | Gigou | Dec 1975 | A |
| 3929314 | Stratynski | Dec 1975 | A |
| 3939069 | Granger | Feb 1976 | A |
| 3955901 | Hamilton | May 1976 | A |
| 3966358 | Heimes et al. | Jun 1976 | A |
| 3967809 | Skantar | Jul 1976 | A |
| 3976574 | White | Aug 1976 | A |
| 3979284 | Granger | Sep 1976 | A |
| 4008712 | Nyboer et al. | Feb 1977 | A |
| 4016868 | Allison et al. | Apr 1977 | A |
| 4071040 | Moriarty | Jan 1978 | A |
| 4079007 | Hutchisson | Mar 1978 | A |
| 4083777 | Hutchisson | Apr 1978 | A |
| 4086653 | Gernes | Apr 1978 | A |
| 4096059 | Pinkerton | Jun 1978 | A |
| 4096859 | Agarwal et al. | Jun 1978 | A |
| 4118314 | Yoshida | Oct 1978 | A |
| 4126132 | Portner et al. | Nov 1978 | A |
| 4142524 | Jassawalla et al. | Mar 1979 | A |
| 4158530 | Bernstein | Jun 1979 | A |
| 4161264 | Malmgren et al. | Jul 1979 | A |
| 4180460 | Calari | Dec 1979 | A |
| 4181245 | Garrett et al. | Jan 1980 | A |
| 4190047 | Jacobsen et al. | Feb 1980 | A |
| 4190536 | Grimsrud | Feb 1980 | A |
| 4191646 | Larsson et al. | Mar 1980 | A |
| 4192748 | Hyden | Mar 1980 | A |
| 4194536 | Stine et al. | Mar 1980 | A |
| 4199307 | Jassawalla | Apr 1980 | A |
| 4204545 | Yamakoshi | May 1980 | A |
| 4209391 | Lipps et al. | Jun 1980 | A |
| 4212738 | Henne | Jul 1980 | A |
| 4235231 | Schindler et al. | Nov 1980 | A |
| 4236880 | Archibald | Dec 1980 | A |
| 4240408 | Schael | Dec 1980 | A |
| 4244816 | Vogler et al. | Jan 1981 | A |
| 4252115 | Schael | Feb 1981 | A |
| 4252651 | Soderstrom | Feb 1981 | A |
| 4265601 | Mandoian | May 1981 | A |
| 4267040 | Schael | May 1981 | A |
| 4269708 | Bonomini et al. | May 1981 | A |
| 4273121 | Jassawalla | Jun 1981 | A |
| 4276175 | Bower | Jun 1981 | A |
| 4277226 | Archibald | Jul 1981 | A |
| 4293762 | Ogawa | Oct 1981 | A |
| 4301879 | Dubow | Nov 1981 | A |
| 4303376 | Siekmann | Dec 1981 | A |
| 4310141 | Tamura | Jan 1982 | A |
| 4318447 | Northcutt | Mar 1982 | A |
| 4338190 | Kraus et al. | Jul 1982 | A |
| 4351333 | Lazarus et al. | Sep 1982 | A |
| 4366061 | Papanek et al. | Dec 1982 | A |
| 4370983 | Lichtenstein | Feb 1983 | A |
| 4375346 | Kraus et al. | Mar 1983 | A |
| 4381003 | Buoncristiani | Apr 1983 | A |
| 4381005 | Bujan | Apr 1983 | A |
| 4386634 | Stasz et al. | Jun 1983 | A |
| 4391600 | Archibald | Jul 1983 | A |
| 4396382 | Goldhaber | Aug 1983 | A |
| 4413988 | Handt et al. | Nov 1983 | A |
| 4430048 | Fritsch | Feb 1984 | A |
| 4456218 | Kawabata et al. | Jun 1984 | A |
| 4464172 | Lichtenstein | Aug 1984 | A |
| 4464563 | Jewett | Aug 1984 | A |
| 4468222 | Lundquist | Aug 1984 | A |
| 4468329 | Shaldon et al. | Aug 1984 | A |
| 4475900 | Popovich et al. | Oct 1984 | A |
| 4476005 | Tokinaga et al. | Oct 1984 | A |
| 4477342 | Allan et al. | Oct 1984 | A |
| 4479760 | Bilstad et al. | Oct 1984 | A |
| 4479761 | Bilstad et al. | Oct 1984 | A |
| 4479762 | Bilstad et al. | Oct 1984 | A |
| 4482584 | Hess et al. | Nov 1984 | A |
| 4488961 | Spencer | Dec 1984 | A |
| 4498900 | Buoncristiani | Feb 1985 | A |
| 4504038 | King | Mar 1985 | A |
| 4530759 | Schal | Jul 1985 | A |
| 4532414 | Shah et al. | Jul 1985 | A |
| 4552552 | Polaschegg et al. | Nov 1985 | A |
| 4559036 | Wunsch | Dec 1985 | A |
| 4559044 | Robinson et al. | Dec 1985 | A |
| 4560472 | Granmzow et al. | Dec 1985 | A |
| 4574876 | Aid | Mar 1986 | A |
| 4579642 | Niiyama et al. | Apr 1986 | A |
| 4584061 | Shelton | Apr 1986 | A |
| 4586920 | Peabody | May 1986 | A |
| 4613327 | Tegrarian et al. | Sep 1986 | A |
| 4614590 | Rath et al. | Sep 1986 | A |
| 4618343 | Polaschegg | Oct 1986 | A |
| 4620846 | Goldberg et al. | Nov 1986 | A |
| RE32303 | Lasker et al. | Dec 1986 | E |
| 4629015 | Fried et al. | Dec 1986 | A |
| 4634430 | Polaschegg | Jan 1987 | A |
| 4639245 | Pastrone et al. | Jan 1987 | A |
| 4642098 | Lundquist | Feb 1987 | A |
| 4648810 | Schippers et al. | Mar 1987 | A |
| 4650458 | Dahlberg et al. | Mar 1987 | A |
| 4655753 | Bellotti et al. | Apr 1987 | A |
| 4657490 | Abbott | Apr 1987 | A |
| 4661246 | Ash | Apr 1987 | A |
| 4678460 | Rosner | Jul 1987 | A |
| 4680445 | Ogawa | Jul 1987 | A |
| 4694848 | Jorgensen et al. | Sep 1987 | A |
| 4696671 | Epstein et al. | Sep 1987 | A |
| 4702829 | Polaschegg et al. | Oct 1987 | A |
| 4703773 | Hansen et al. | Nov 1987 | A |
| 4708802 | Rath et al. | Nov 1987 | A |
| 4710166 | Thompson et al. | Dec 1987 | A |
| 4711715 | Polaschegg | Dec 1987 | A |
| 4715959 | Allan et al. | Dec 1987 | A |
| 4717117 | Cook | Jan 1988 | A |
| 4718890 | Peabody | Jan 1988 | A |
| 4735609 | Comeau et al. | Apr 1988 | A |
| 4742870 | Darone et al. | May 1988 | A |
| 4747822 | Peabody | May 1988 | A |
| 4747828 | Tseo | May 1988 | A |
| 4747950 | Guinn | May 1988 | A |
| 4756706 | Kerns et al. | Jul 1988 | A |
| 4765907 | Scott | Aug 1988 | A |
| 4767399 | Bollish | Aug 1988 | A |
| 4769134 | Allan et al. | Sep 1988 | A |
| 4769151 | Shouldice | Sep 1988 | A |
| 4770769 | Schael | Sep 1988 | A |
| 4778356 | Hicks | Oct 1988 | A |
| 4778451 | Kamen | Oct 1988 | A |
| 4784576 | Bloom et al. | Nov 1988 | A |
| 4794942 | Yasuda et al. | Jan 1989 | A |
| 4798580 | DeMeo et al. | Jan 1989 | A |
| 4804360 | Kamen | Feb 1989 | A |
| 4804474 | Blum | Feb 1989 | A |
| 4804950 | Moon et al. | Feb 1989 | A |
| 4808161 | Kamen | Feb 1989 | A |
| 4816019 | Kamen | Mar 1989 | A |
| 4818186 | Pastrone et al. | Apr 1989 | A |
| 4818190 | Pelmulder et al. | Apr 1989 | A |
| 4823552 | Ezell et al. | Apr 1989 | A |
| 4826482 | Kamen | May 1989 | A |
| 4828543 | Weiss et al. | May 1989 | A |
| 4828545 | Epstein et al. | May 1989 | A |
| 4830586 | Herter et al. | May 1989 | A |
| 4834888 | Polaschegg | May 1989 | A |
| 4838865 | Flank et al. | Jun 1989 | A |
| 4842584 | Pastrone | Jun 1989 | A |
| 4844074 | Kurucz | Jul 1989 | A |
| 4847470 | Bakke | Jul 1989 | A |
| 4848722 | Webster | Jul 1989 | A |
| 4850805 | Madsen et al. | Jul 1989 | A |
| 4852851 | Webster | Aug 1989 | A |
| 4857199 | Cortial | Aug 1989 | A |
| 4858883 | Webster | Aug 1989 | A |
| 4859319 | Borsari | Aug 1989 | A |
| 4865584 | Epstein et al. | Sep 1989 | A |
| 4869286 | Williams et al. | Sep 1989 | A |
| 4872813 | Gorton et al. | Oct 1989 | A |
| 4873623 | Lane et al. | Oct 1989 | A |
| 4886432 | Kimberlin | Dec 1989 | A |
| 4889812 | Guinn et al. | Dec 1989 | A |
| 4895657 | Polaschegg | Jan 1990 | A |
| 4898578 | Rubalcaba et al. | Feb 1990 | A |
| 4906816 | Van Leerdam | Mar 1990 | A |
| 4914624 | Dunthorn | Apr 1990 | A |
| 4915688 | Bischof et al. | Apr 1990 | A |
| 4916441 | Gombrich | Apr 1990 | A |
| 4918019 | Guinn | Apr 1990 | A |
| 4923598 | Schal | May 1990 | A |
| 4925152 | Huber | May 1990 | A |
| 4927411 | Pastrone et al. | May 1990 | A |
| 4935125 | Era et al. | Jun 1990 | A |
| 4941519 | Sestak et al. | Jul 1990 | A |
| 4942735 | Mushika et al. | Jul 1990 | A |
| 4956996 | Morris | Sep 1990 | A |
| 4971700 | Tsuji et al. | Nov 1990 | A |
| 4976162 | Kamen | Dec 1990 | A |
| 4976683 | Gauthier et al. | Dec 1990 | A |
| 4990054 | Janocko | Feb 1991 | A |
| 4997570 | Polaschegg | Mar 1991 | A |
| 5000664 | Lawless et al. | Mar 1991 | A |
| 5002471 | Perlov | Mar 1991 | A |
| 5004459 | Peabody et al. | Apr 1991 | A |
| 5006050 | Cooke et al. | Apr 1991 | A |
| 5006997 | Reich | Apr 1991 | A |
| 5019140 | Bowser et al. | May 1991 | A |
| 5037385 | O'Byrne | Aug 1991 | A |
| 5043201 | Cote | Aug 1991 | A |
| 5053003 | Dadson et al. | Oct 1991 | A |
| 5056059 | Tivig et al. | Oct 1991 | A |
| 5062774 | Kramer et al. | Nov 1991 | A |
| 5063937 | Ezenwa et al. | Nov 1991 | A |
| 5073167 | Carr et al. | Dec 1991 | A |
| 5083872 | Farling et al. | Jan 1992 | A |
| 5088515 | Kamen | Feb 1992 | A |
| 5091094 | Veech | Feb 1992 | A |
| 5098262 | Wecker et al. | Mar 1992 | A |
| 5106366 | Steppe | Apr 1992 | A |
| 5108367 | Epstein et al. | Apr 1992 | A |
| 5114580 | Ahmad et al. | May 1992 | A |
| 5116203 | Natwick et al. | May 1992 | A |
| 5125069 | O'Boyle | Jun 1992 | A |
| 5127907 | Courtre et al. | Jul 1992 | A |
| 5135485 | Cohen et al. | Aug 1992 | A |
| 5141492 | Dadson et al. | Aug 1992 | A |
| 5141493 | Jacobsen et al. | Aug 1992 | A |
| 5151082 | Gorsuch et al. | Sep 1992 | A |
| 5152671 | Harant | Oct 1992 | A |
| 5152743 | Gorsuch et al. | Oct 1992 | A |
| 5163900 | Wortrich | Nov 1992 | A |
| 5173125 | Felding | Dec 1992 | A |
| 5176956 | Jevne et al. | Jan 1993 | A |
| 5178182 | Kamen | Jan 1993 | A |
| 5180896 | Gibby et al. | Jan 1993 | A |
| 5194157 | Ghezzi et al. | Mar 1993 | A |
| 5211849 | Kitaevich et al. | May 1993 | A |
| 5215312 | Knappe et al. | Jun 1993 | A |
| 5240614 | Ofsthun et al. | Aug 1993 | A |
| 5245693 | Ford et al. | Sep 1993 | A |
| 5247434 | Peterson et al. | Sep 1993 | A |
| 5252044 | Raines et al. | Oct 1993 | A |
| 5261876 | Popovich et al. | Nov 1993 | A |
| 5277820 | Ash | Jan 1994 | A |
| 5282783 | Lindsay | Feb 1994 | A |
| 5284470 | Beltz | Feb 1994 | A |
| 5292306 | Wynkoop et al. | Mar 1994 | A |
| 5295964 | Gauthier | Mar 1994 | A |
| 5302093 | Owens et al. | Apr 1994 | A |
| 5307263 | Brown | Apr 1994 | A |
| 5311899 | Isayama et al. | May 1994 | A |
| 5316452 | Bogen et al. | May 1994 | A |
| 5324422 | Colleran et al. | Jun 1994 | A |
| 5326476 | Grogan et al. | Jul 1994 | A |
| 5332372 | Reynolds | Jul 1994 | A |
| 5334139 | Jeppsson et al. | Aug 1994 | A |
| 5338293 | Jeppsson et al. | Aug 1994 | A |
| 5344292 | Rabenau et al. | Sep 1994 | A |
| 5344392 | Senniger et al. | Sep 1994 | A |
| 5350357 | Kamen et al. | Sep 1994 | A |
| 5352364 | Kruger et al. | Oct 1994 | A |
| 5364342 | Beuchat et al. | Nov 1994 | A |
| 5370674 | Farrell | Dec 1994 | A |
| 5374813 | Shipp | Dec 1994 | A |
| 5376263 | Fischel | Dec 1994 | A |
| 5378126 | Abrahamson et al. | Jan 1995 | A |
| 5381510 | Ford et al. | Jan 1995 | A |
| 5385540 | Abbott et al. | Jan 1995 | A |
| 5389243 | Kaplan | Feb 1995 | A |
| 5401238 | Pirazzoli | Mar 1995 | A |
| 5408576 | Bishop | Apr 1995 | A |
| 5409355 | Brooke | Apr 1995 | A |
| 5415528 | Ogden et al. | May 1995 | A |
| 5420962 | Bakke | May 1995 | A |
| 5421208 | Packard et al. | Jun 1995 | A |
| 5421823 | Kamen et al. | Jun 1995 | A |
| 5429485 | Dodge | Jul 1995 | A |
| 5431626 | Bryant et al. | Jul 1995 | A |
| 5438510 | Bryant et al. | Aug 1995 | A |
| 5439587 | Stankowski et al. | Aug 1995 | A |
| 5441606 | Schlesinger et al. | Aug 1995 | A |
| 5449000 | Libke et al. | Sep 1995 | A |
| 5458468 | Ye et al. | Oct 1995 | A |
| 5470483 | Bene et al. | Nov 1995 | A |
| 5474683 | Bryant et al. | Dec 1995 | A |
| 5476368 | Rabenau et al. | Dec 1995 | A |
| 5482438 | Anderson et al. | Jan 1996 | A |
| 5482440 | Dennhey et al. | Jan 1996 | A |
| 5487649 | Dorsey, III et al. | Jan 1996 | A |
| 5508912 | Schneiderman | Apr 1996 | A |
| 5522769 | DeGuiseppi | Jun 1996 | A |
| 5522998 | Polaschegg | Jun 1996 | A |
| 5536412 | Ash | Jul 1996 | A |
| 5540265 | Polaschegg et al. | Jul 1996 | A |
| 5540568 | Rosen et al. | Jul 1996 | A |
| 5542919 | Simon et al. | Aug 1996 | A |
| 5554013 | Owens et al. | Sep 1996 | A |
| 5556263 | Jacobsen et al. | Sep 1996 | A |
| 5563584 | Rader et al. | Oct 1996 | A |
| 5572992 | Kankkuen et al. | Nov 1996 | A |
| 5578223 | Bene et al. | Nov 1996 | A |
| 5580460 | Polaschegg | Dec 1996 | A |
| 5582732 | Mao et al. | Dec 1996 | A |
| 5583948 | Shibayama | Dec 1996 | A |
| 5586868 | Lawless et al. | Dec 1996 | A |
| 5588816 | Abbott et al. | Dec 1996 | A |
| 5601420 | Warner et al. | Feb 1997 | A |
| 5603354 | Jacobsen et al. | Feb 1997 | A |
| 5608193 | Almogaibil | Mar 1997 | A |
| 5609572 | Lang | Mar 1997 | A |
| 5614677 | Wamsiedler et al. | Mar 1997 | A |
| 5620312 | Hyman et al. | Apr 1997 | A |
| 5628908 | Kamen et al. | May 1997 | A |
| 5632606 | Jacobsen et al. | May 1997 | A |
| 5634896 | Bryant et al. | Jun 1997 | A |
| 5636653 | Titus | Jun 1997 | A |
| 5641405 | Keshaviah et al. | Jun 1997 | A |
| 5643201 | Peabody et al. | Jul 1997 | A |
| 5645734 | Kenley et al. | Jul 1997 | A |
| 5654537 | Prater | Aug 1997 | A |
| 5660722 | Nederlof | Aug 1997 | A |
| 5669764 | Behringer et al. | Sep 1997 | A |
| 5670057 | Chen et al. | Sep 1997 | A |
| 5671362 | Cowe et al. | Sep 1997 | A |
| 5676530 | Nazarifar | Oct 1997 | A |
| 5683381 | Carr et al. | Nov 1997 | A |
| 5685988 | Malchesky | Nov 1997 | A |
| 5690160 | Sutton et al. | Nov 1997 | A |
| 5690614 | Carr et al. | Nov 1997 | A |
| 5698083 | Glass | Dec 1997 | A |
| 5698090 | Bene et al. | Dec 1997 | A |
| 5702597 | Chevallet et al. | Dec 1997 | A |
| 5718569 | Holst | Feb 1998 | A |
| 5720313 | Grobbel | Feb 1998 | A |
| 5722947 | Jeppsson et al. | Mar 1998 | A |
| 5724478 | Thweatt | Mar 1998 | A |
| 5725775 | Bene et al. | Mar 1998 | A |
| 5729653 | Magliochetti et al. | Mar 1998 | A |
| 5730712 | Falkvall et al. | Mar 1998 | A |
| 5732401 | Conway | Mar 1998 | A |
| 5735284 | Tsoglin et al. | Apr 1998 | A |
| 5752234 | Withers | May 1998 | A |
| 5758563 | Robinson | Jun 1998 | A |
| 5776345 | Truitt et al. | Jul 1998 | A |
| 5778643 | Tacchini | Jul 1998 | A |
| 5783085 | Fischel | Jul 1998 | A |
| 5788846 | Sternby | Aug 1998 | A |
| 5788851 | Kenley et al. | Aug 1998 | A |
| 5790752 | Anglin et al. | Aug 1998 | A |
| 5792367 | Mattisson et al. | Aug 1998 | A |
| 5800397 | Wilson et al. | Sep 1998 | A |
| 5807075 | Jacobsen et al. | Sep 1998 | A |
| 5816779 | Lawless et al. | Oct 1998 | A |
| 5843474 | Williams | Dec 1998 | A |
| 5846419 | Nederlof | Dec 1998 | A |
| 5858186 | Glass | Jan 1999 | A |
| 5858238 | McRea et al. | Jan 1999 | A |
| 5863421 | Peter, Jr. et al. | Jan 1999 | A |
| 5867821 | Ballantyne et al. | Feb 1999 | A |
| 5871566 | Rutz | Feb 1999 | A |
| 5875282 | Jordan et al. | Feb 1999 | A |
| 5910252 | Truitt et al. | Jun 1999 | A |
| 5912818 | McGrady et al. | Jun 1999 | A |
| 5919154 | Toavs et al. | Jul 1999 | A |
| 5919369 | Ash | Jul 1999 | A |
| 5921951 | Morris | Jul 1999 | A |
| 5924975 | Goldowsky | Jul 1999 | A |
| 5925011 | Faict et al. | Jul 1999 | A |
| 5925014 | Teeple, Jr. | Jul 1999 | A |
| 5928196 | Johnson et al. | Jul 1999 | A |
| 5931647 | Jacobsen et al. | Aug 1999 | A |
| 5938634 | Packard | Aug 1999 | A |
| 5944495 | Jacobsen et al. | Aug 1999 | A |
| 5944684 | Roberts et al. | Aug 1999 | A |
| 5945831 | Sargent et al. | Aug 1999 | A |
| 5951863 | Kruger et al. | Sep 1999 | A |
| 5960160 | Clark et al. | Sep 1999 | A |
| 5965433 | Gardetto et al. | Oct 1999 | A |
| 5980481 | Gorsuch | Nov 1999 | A |
| 5989238 | Ginsburg | Nov 1999 | A |
| 5989423 | Kamen et al. | Nov 1999 | A |
| 5997502 | Reilly et al. | Dec 1999 | A |
| 6007310 | Jacobsen et al. | Dec 1999 | A |
| 6017194 | North, Jr. | Jan 2000 | A |
| 6017198 | Traylor et al. | Jan 2000 | A |
| 6017318 | Gauthier et al. | Jan 2000 | A |
| 6036668 | Mathis | Mar 2000 | A |
| 6041801 | Gray et al. | Mar 2000 | A |
| 6065941 | Gray et al. | May 2000 | A |
| 6069343 | Kolowich | May 2000 | A |
| 6077443 | Goldau | Jun 2000 | A |
| 6109254 | Reinke et al. | Aug 2000 | A |
| 6110384 | Goux et al. | Aug 2000 | A |
| 6110617 | Feres | Aug 2000 | A |
| 6122972 | Crider | Sep 2000 | A |
| 6126403 | Yamada | Oct 2000 | A |
| 6126831 | Goldau et al. | Oct 2000 | A |
| 6129699 | Haight et al. | Oct 2000 | A |
| 6133547 | Maynard | Oct 2000 | A |
| 6139528 | Kistner et al. | Oct 2000 | A |
| 6139748 | Ericson et al. | Oct 2000 | A |
| 6142974 | Kistner et al. | Nov 2000 | A |
| 6146359 | Carr et al. | Nov 2000 | A |
| 6165154 | Gray et al. | Dec 2000 | A |
| 6175688 | Cassidy et al. | Jan 2001 | B1 |
| 6208107 | Maske et al. | Mar 2001 | B1 |
| 6223130 | Gray et al. | Apr 2001 | B1 |
| 6228033 | Kööbi et al. | May 2001 | B1 |
| 6228047 | Dadson | May 2001 | B1 |
| 6229957 | Baker | May 2001 | B1 |
| 6231320 | Lawless et al. | May 2001 | B1 |
| 6234991 | Gorsuch | May 2001 | B1 |
| 6234992 | Haight et al. | May 2001 | B1 |
| 6236809 | Cassidy et al. | May 2001 | B1 |
| 6246831 | Seitz et al. | Jun 2001 | B1 |
| 6246894 | Steuer et al. | Jun 2001 | B1 |
| 6248093 | Moberg | Jun 2001 | B1 |
| 6257265 | Brunner et al. | Jul 2001 | B1 |
| 6259074 | Brunner et al. | Jul 2001 | B1 |
| 6260715 | Simard et al. | Jul 2001 | B1 |
| 6261261 | Gordon | Jul 2001 | B1 |
| 6270673 | Belt et al. | Aug 2001 | B1 |
| 6278084 | Maynard | Aug 2001 | B1 |
| 6280632 | Polaschegg | Aug 2001 | B1 |
| 6283719 | Frantz et al. | Sep 2001 | B1 |
| 6287516 | Matson et al. | Sep 2001 | B1 |
| 6293921 | Shinmoto et al. | Sep 2001 | B1 |
| 6293926 | Sorensen et al. | Sep 2001 | B1 |
| 6302653 | Bryant et al. | Oct 2001 | B1 |
| 6343614 | Gray et al. | Feb 2002 | B1 |
| 6364857 | Gray et al. | Apr 2002 | B1 |
| 6385593 | Linberg | May 2002 | B2 |
| 6416293 | Bouchard et al. | Jul 2002 | B1 |
| 6447491 | Lord | Sep 2002 | B1 |
| 6463394 | Von Bahr | Oct 2002 | B1 |
| 6471855 | Odak et al. | Oct 2002 | B1 |
| 6484383 | Herklotz | Nov 2002 | B1 |
| 6491656 | Morris | Dec 2002 | B1 |
| 6495366 | Briggs | Dec 2002 | B1 |
| 6572576 | Brugger et al. | Jun 2003 | B2 |
| 6572641 | Brugger et al. | Jun 2003 | B2 |
| 6582385 | Burbank et al. | Jun 2003 | B2 |
| 6589482 | Burbank et al. | Jul 2003 | B1 |
| 6595948 | Suzuki et al. | Jul 2003 | B2 |
| 6607669 | Schick | Aug 2003 | B2 |
| 6615077 | Zhu et al. | Sep 2003 | B1 |
| 6620120 | Landry et al. | Sep 2003 | B2 |
| 6638477 | Treu et al. | Oct 2003 | B1 |
| 6638478 | Treu et al. | Oct 2003 | B1 |
| 6649063 | Brugger et al. | Nov 2003 | B2 |
| 6672841 | Herklotz et al. | Jan 2004 | B1 |
| 6673314 | Burbank et al. | Jan 2004 | B1 |
| 6676621 | Menninger | Jan 2004 | B1 |
| 6685831 | Dönig et al. | Feb 2004 | B2 |
| 6702561 | Stillig et al. | Mar 2004 | B2 |
| 6743201 | Doenig et al. | Jun 2004 | B1 |
| 6746606 | Pfeil et al. | Jun 2004 | B2 |
| 6752172 | Lauer | Jun 2004 | B2 |
| 6752928 | Pfeil et al. | Jun 2004 | B2 |
| 6764761 | Eu et al. | Jul 2004 | B2 |
| 6780322 | Bissler et al. | Aug 2004 | B1 |
| 6814547 | Childers et al. | Nov 2004 | B2 |
| 6821441 | Pedrini et al. | Nov 2004 | B2 |
| 6830553 | Burbank et al. | Dec 2004 | B1 |
| 6835175 | Porumbescu | Dec 2004 | B1 |
| 6843779 | Andrysiak et al. | Jan 2005 | B1 |
| 6852090 | Burbank et al. | Feb 2005 | B2 |
| 6869538 | Yu et al. | Mar 2005 | B2 |
| 6881344 | Vasta et al. | Apr 2005 | B2 |
| 6882982 | McMenimen et al. | Apr 2005 | B2 |
| 6890157 | Pfeil et al. | May 2005 | B2 |
| 6918886 | Baurmeister | Jul 2005 | B1 |
| 6925447 | McMenimen et al. | Aug 2005 | B2 |
| 6929751 | Bowman, Jr. et al. | Aug 2005 | B2 |
| 6939111 | Huitt et al. | Sep 2005 | B2 |
| 6948918 | Hansen | Sep 2005 | B2 |
| 6953323 | Childers et al. | Oct 2005 | B2 |
| 6955655 | Burbank et al. | Oct 2005 | B2 |
| 6979309 | Burbank et al. | Dec 2005 | B2 |
| 7008403 | Mallett | Mar 2006 | B1 |
| 7029456 | Ware et al. | Apr 2006 | B2 |
| 7033539 | Krensky et al. | Apr 2006 | B2 |
| 7074332 | Summerton et al. | Jul 2006 | B2 |
| 7076303 | Linberg | Jul 2006 | B2 |
| 7087036 | Busby et al. | Aug 2006 | B2 |
| 7112273 | Weigel et al. | Sep 2006 | B2 |
| 7115228 | Lundtveit et al. | Oct 2006 | B2 |
| 7142118 | Hamilton et al. | Nov 2006 | B2 |
| 7153286 | Busby et al. | Dec 2006 | B2 |
| 7175606 | Bowman, Jr. et al. | Feb 2007 | B2 |
| 7208092 | Micheli | Apr 2007 | B2 |
| 7214210 | Kamen et al. | May 2007 | B2 |
| 7228170 | Zhu et al. | Jun 2007 | B2 |
| 7230521 | Terenna | Jun 2007 | B2 |
| 7252230 | Sheikh et al. | Aug 2007 | B1 |
| 9050411 | Kelly | Jun 2015 | B2 |
| 20010018937 | Nemoto | Sep 2001 | A1 |
| 20010032818 | Nikaido et al. | Oct 2001 | A1 |
| 20010034502 | Moberg et al. | Oct 2001 | A1 |
| 20010035378 | Nikaido | Nov 2001 | A1 |
| 20010045395 | Kitaevich et al. | Nov 2001 | A1 |
| 20020017489 | Utterberg | Feb 2002 | A1 |
| 20020041825 | Scheunert et al. | Apr 2002 | A1 |
| 20020045851 | Suzuki et al. | Apr 2002 | A1 |
| 20020062109 | Lauer | May 2002 | A1 |
| 20020077598 | Yap et al. | Jun 2002 | A1 |
| 20020081109 | Mitsunaga et al. | Jun 2002 | A1 |
| 20020103453 | Burbank et al. | Aug 2002 | A1 |
| 20020112609 | Wong | Aug 2002 | A1 |
| 20020147423 | Burbank et al. | Oct 2002 | A1 |
| 20030017073 | Eckhardt et al. | Jan 2003 | A1 |
| 20030036719 | Giacomelli et al. | Feb 2003 | A1 |
| 20030105424 | Karoor et al. | Jun 2003 | A1 |
| 20030208113 | Mault et al. | Nov 2003 | A1 |
| 20030220598 | Busby et al. | Nov 2003 | A1 |
| 20040019313 | Childers et al. | Jan 2004 | A1 |
| 20040092841 | Singer | May 2004 | A1 |
| 20040111293 | Firanek et al. | Jun 2004 | A1 |
| 20040111294 | McNally et al. | Jun 2004 | A1 |
| 20040122705 | Sabol | Jun 2004 | A1 |
| 20040158189 | Tonelli et al. | Aug 2004 | A1 |
| 20040181528 | Tirinato et al. | Sep 2004 | A1 |
| 20040243048 | Brugger et al. | Dec 2004 | A1 |
| 20040243049 | Brugger et al. | Dec 2004 | A1 |
| 20040243050 | Treu et al. | Dec 2004 | A1 |
| 20040245161 | Treu et al. | Dec 2004 | A1 |
| 20040249331 | Burbank et al. | Dec 2004 | A1 |
| 20040267184 | Burbank et al. | Dec 2004 | A1 |
| 20040267185 | Weaver et al. | Dec 2004 | A1 |
| 20050000868 | Weigel et al. | Jan 2005 | A1 |
| 20050004502 | O'Mahoney et al. | Jan 2005 | A1 |
| 20050010158 | Brugger et al. | Jan 2005 | A1 |
| 20050011823 | Delnevo et al. | Jan 2005 | A1 |
| 20050020958 | Paolini et al. | Jan 2005 | A1 |
| 20050020959 | Brugger et al. | Jan 2005 | A1 |
| 20050020960 | Brugger | Jan 2005 | A1 |
| 20050055242 | Bello et al. | Mar 2005 | A1 |
| 20050131332 | Kelly et al. | Jun 2005 | A1 |
| 20050256745 | Dalton | Nov 2005 | A1 |
| 20060113249 | Childers et al. | Jun 2006 | A1 |
| 20060138049 | Kim et al. | Jun 2006 | A1 |
| 20070007208 | Brugger et al. | Jan 2007 | A1 |
| 20070038191 | Burbank et al. | Feb 2007 | A1 |
| 20070228068 | Schneider et al. | Oct 2007 | A1 |
| 20080015493 | Childers et al. | Jan 2008 | A1 |
| 20080125693 | Gavin et al. | May 2008 | A1 |
| 20080161751 | Plahey et al. | Jul 2008 | A1 |
| 20080296226 | Gotch | Dec 2008 | A1 |
| 20090275881 | Lo et al. | Nov 2009 | A1 |
| 20110004351 | Kelly et al. | Jan 2011 | A1 |
| 20130150780 | Childers et al. | Jun 2013 | A1 |
| Number | Date | Country |
|---|---|---|
| 1121738 | Apr 1982 | CA |
| 2002033 | Aug 1970 | DE |
| 2901628 | Jul 1980 | DE |
| 3122756 | Jun 1982 | DE |
| 210425 | Jun 1984 | DE |
| 3307830 | Jun 1984 | DE |
| 4003452 | Aug 1991 | DE |
| 4208054 | Oct 1992 | DE |
| 4122754 | Jan 1993 | DE |
| 19830928 | May 1999 | DE |
| 19814695 | Oct 1999 | DE |
| 19854338 | Jun 2000 | DE |
| 10011208 | Sep 2001 | DE |
| 1010146 | Jul 2002 | DE |
| 10100146 | Jul 2002 | DE |
| 0165751 | Jun 1985 | EP |
| 0165751 | Dec 1985 | EP |
| 0166920 | Jan 1986 | EP |
| 0 204 260 | Dec 1986 | EP |
| 0306241 | Mar 1989 | EP |
| 0 319 272 | Jun 1989 | EP |
| 0403294 | Dec 1990 | EP |
| 0222709 | May 1991 | EP |
| 0451429 | Oct 1991 | EP |
| 0490212 | Jun 1992 | EP |
| 0611228 | Aug 1994 | EP |
| 0623357 | Nov 1994 | EP |
| 0722744 | Jul 1996 | EP |
| 0796998 | Sep 1997 | EP |
| 0659091 | Dec 2000 | EP |
| 1097724 | May 2001 | EP |
| 1 205 144 | May 2002 | EP |
| 1235614 | Sep 2002 | EP |
| 1535576 | Jun 2005 | EP |
| 1 938 849 | Feb 2008 | EP |
| 2 368 588 | Sep 2011 | EP |
| 2246718 | Feb 1992 | GB |
| 50-72494 | Jun 1975 | JP |
| S5115360 | May 1976 | JP |
| S61-8057 | Jan 1986 | JP |
| 63-95063 | Apr 1988 | JP |
| H02336268 | Aug 1990 | JP |
| 04-212631 | Apr 1992 | JP |
| 04-212631 | Aug 1992 | JP |
| 07-035413 | Feb 1995 | JP |
| H7-313590 | Dec 1995 | JP |
| H09327511 | Dec 1997 | JP |
| 11-506962 | Jun 1999 | JP |
| H11226120 | Aug 1999 | JP |
| 2000-84071 | Mar 2000 | JP |
| 2000-107283 | Apr 2000 | JP |
| 2002-217908 | Aug 2000 | JP |
| 2002119585 | Apr 2002 | JP |
| 2004205146 | Jul 2004 | JP |
| 2004209103 | Jul 2004 | JP |
| 2006500968 | Jan 2006 | JP |
| 2006512138 | Apr 2006 | JP |
| 1001945 | Mar 1983 | RU |
| 1821222 | Jun 1993 | RU |
| 9014850 | Dec 1990 | WO |
| WO 9424929 | Nov 1994 | WO |
| WO9424929 | Nov 1994 | WO |
| WO 9625214 | Aug 1996 | WO |
| 9640320 | Dec 1996 | WO |
| 9832477 | Jul 1998 | WO |
| 9835747 | Aug 1998 | WO |
| WO 9835747 | Aug 1998 | WO |
| WO 9906082 | Feb 1999 | WO |
| 9942150 | Aug 1999 | WO |
| WO 9946657 | Sep 1999 | WO |
| WO9946657 | Sep 1999 | WO |
| WO 9952025 | Oct 1999 | WO |
| WO9952025 | Oct 1999 | WO |
| 0009182 | Feb 2000 | WO |
| 0031967 | Jun 2000 | WO |
| 0057925 | Oct 2000 | WO |
| 0057926 | Oct 2000 | WO |
| 0057927 | Oct 2000 | WO |
| 0064510 | Nov 2000 | WO |
| 0124849 | Apr 2001 | WO |
| 0137786 | May 2001 | WO |
| 0137894 | May 2001 | WO |
| 0137895 | May 2001 | WO |
| 0137900 | May 2001 | WO |
| 0137895 | May 2001 | WO |
| WO 0137786 | May 2001 | WO |
| 0141831 | Jun 2001 | WO |
| 0141832 | Jun 2001 | WO |
| 0142758 | Jun 2001 | WO |
| 0145769 | Jun 2001 | WO |
| 0141833 | Jun 2001 | WO |
| WO 0141831 | Jun 2001 | WO |
| 0147576 | Jul 2001 | WO |
| 0147581 | Jul 2001 | WO |
| 02070042 | Sep 2002 | WO |
| 03041764 | May 2003 | WO |
| WO03041764 | May 2003 | WO |
| WO 03061740 | Jul 2003 | WO |
| 03011376 | Dec 2003 | WO |
| WO 2004006776 | Jan 2004 | WO |
| 2005042065 | May 2005 | WO |
| 2005044339 | May 2005 | WO |
| 2007074425 | Jul 2007 | WO |
| Entry |
|---|
| Mexican Office Action issued on May 19, 2016 in corresponding Mexican application No. MX/a/2011/010561 (4 pages). |
| European Extended Search Report—Appl. No. 16164103.0-1651 dated Jul. 8, 2016—9 pages. |
| Notice of Opposition to a European Patent EP 2 368 588 (Appl. No. 11075130.2) mailed May 13, 2016—6 pages. |
| Opposition against European Patent EP 2 368 588 (Appl. No. 11075130.2) mailed May 13, 2016—30 pages. |
| Wang, Samuel J. et al., User-Definable Medical Favorites for an Outpatient Electronic Medical Record Syste, Proc AMIA Symp. 2001:1055. |
| Japanese Office Action mailed Sep. 11, 2012 corresponding to Japanese Application No. 2009-527618 (with English translation) 5 pages. |
| European Office Action dated Apr. 18, 2013, corresponding to European Patent Application No. 11075127.8. 5 pages. |
| Manns et al., “The acu-menTM: A new device for continuous renal replacement therapy in acute renal failure,” Kidney International, 1998, vol. 54, pp. 268-274. |
| Opposition brief filed by Fresenius Medical Care in European Patent Application No. 1 235 614 mailed on May 14, 2014. |
| Machine translation of Opposition brief filed by Fresenius Medical Care in European Patent Application No. 1 235 614 mailed on May 14, 2014. |
| NxStage Response to the Oppositions filed by Fresenius Medical Care and Baxter in European Patent Application No. 1 235 614 mailed Jan. 8, 2014. |
| U.S. Appl. No. 12/170,204, filed Jul. 9, 2008. |
| U.S. Appl. No. 13/024,990, filed Feb. 10, 2011. |
| U.S. Appl. No. 13/679,525, filed Nov. 16, 2012. |
| U.S. Appl. No. 13/828,900, filed Mar. 14, 2013. |
| U.S. Appl. No. 13/947,771, filed Jul. 22, 2013. |
| Japanese Office Action issued Sep. 29, 2014 in corresponding Japanese Application No. 2011-163710. |
| European Office Action issued Oct. 6, 2014 in corresponding European Application No. 11185090.5. 6 pages. |
| Japanese Office Action mailed Jul. 2, 2014, corresponding to Japanese Patent Application No. 2013-169818. |
| European Office Action dated Aug. 20, 2013, corresponding to European Patent Application No. 11075128.6. |
| European Office Action mailed Sep. 26, 2013, corresponding to European Patent Application No. 11185090.5. |
| Japanese Office Action mailed Jan. 10, 2014, corresponding to Japanese Patent Application No. 2013-000322. |
| European Office Action mailed Sep. 30, 2013, corresponding to European Patent Application No. 11185112.7. |
| European Office Action mailed Sep. 26, 2013, corresponding to European Patent Application No. 11075129.4. |
| European Office Action mailed Sep. 30, 2013, corresponding to European Patent Application No. 11075130.2. |
| Japanese Office Action mailed Jan. 30, 2014, corresponding to Japanese Patent Application No. 2011-163710. |
| European Office Action issued Jun. 6, 2013 for related European Appln. No. 11075125.2. |
| European Office Action mailed Mar. 18, 2013, corresponding to European Patent Application No. 11075126.0. |
| Japanese Office Action mailed Dec. 20, 2012, corresponding to Japanese Application No. 2010-514907. |
| European Office Action mailed Feb. 12, 2013, corresponding to European Patent Application No. 11075124.5. |
| European Office Action dated Apr. 18, 2013, corresponding to European Patent Application No. 11075127.8. |
| Japanese Office Action mailed Sep. 11, 2012 corresponding to Japanese Application No. 2009-527618. |
| European Search Report issued Mar. 26, 2012, corresponding to European Appln. No. 11075125.2. |
| European Search Report for Application No. EP 11 07 5130 mailed on Mar. 15, 2012. |
| Office Action issued in corresponding Japanese Patent Application No. 2014-223121 mailed May 20, 2016. |
| Hemodialysis machine/Operating instructions Software 4008 H Version 4.2 12th Edition, Jun. 2001—364 pages. |
| Japanese Office Action issued Sep. 30, 2015 for corresponding Japanese Appln. No. 2014-223121 (8 pages). |
| Japanese Office Action mailed Sep. 14, 2015 for corresponding Japanese Appln. No. 12014-21619 (5 pages). |
| Japanese Office Action mailed Jan. 10, 2014 for related Japanese Application No. 2013-000322. |
| Japanese Office Action mailed Jan. 30, 2014 for related Japanese Application No. 2011-163710. |
| Japanese Office Action issued Apr. 10, 2015 in corresponding Japanese Application No. 2013-169818. |
| Japanese Office Action for corresponding Japanese Application No. 2009-527618. |
| European Office Action issued Mar. 14, 2013 for corresponding European Application No. 11075126.0. |
| European Office Action issued Nov. 10, 2014 for corresponding European Application No. 111185112.7 (5 pages). |
| European Office Action issued Jan. 21, 2016 for corresponding European Application No, 11075128.6 (6 pages). |
| European Office Action issued Jun. 6, 2013 for related European Application No. 11075125.2. |
| European Office Action dated Feb. 12, 2013 for related European Application No. 11075124.5. |
| European Office Action issued Aug. 20, 2013 for related European Application No. 11075128.6. |
| European Office Action for related European Application No. 11075129.4. |
| European Search Report for corresponding European Application No. 15156422.6 (8 pages). |
| European Search Report for European Application No. 11 07 5124 mailed on Mar. 16, 2012. |
| European Search Report for European Application No. 11 07 5125 mailed on Mar. 26, 2012. |
| European Search Report for European Application No. 11 07 5126 mailed on Mar. 22, 2012. |
| European Search Report for European Application No. 11 07 5127 mailed on Mar. 28, 2012. |
| European Search Report for European Application No. 11 07 5128 mailed on Apr. 3, 2012. |
| European Search Report for European Application No. 11 07 5129 mailed on Mar. 29, 2012. |
| Mexican Office Action for Application No. PA/a/2006/005045 mailed May 17, 2012. |
| Extended European Search Report for European Application No. 11185112.7 mailed Dec. 20, 2011. |
| Extended European Search Report for European Application No. 11185090.5 mailed Dec. 22, 2011. |
| European Office Action mailed Aug. 7, 2014 for related European Appln. No. 11075128.6 (5 pages). |
| International Search Report and the Written Opinion for International Application No. PCT/US2008/064086 mailed on Jan. 27, 2009. |
| Manns et al., The acu-menTM: A new device for continuous renal replacement therapy in actue renal failure, Kidney International, 1998, pp. 268-274, vol. 54. |
| U.S. Appl. No. 14/708,614, filed May 11, 2015, Ying-Cheng Lo et al. |
| U.S. Appl. No. 14/754,856, filed Jun. 30, 2015, Kelly et al. |
| U.S. Appl. No. 14/976,773, filed Dec. 21, 2015, Kelly et al. |
| U.S. Appl. No. 15/090,084, filed 4, 2016, Kelly et al. |
| U.S. Appl. No. 15/163,128, filed May 24, 2016, Kelly et al. |
| U.S. Appl. No. 15/205,268, filed Jul. 8, 2016, Kelly et al. |
| U.S. Appl. No. 15/291,806, filed Oct. 12, 2016, Kelly et al. |
| Baxter Renalsoft Patient Management Software Suite description [online] [retrieved Aug. 21, 2008, available prior to Jul. 9, 2008]. Retrieved from the Internet at <URL: http://www.baxter.com/products/renal/software/renalsoft.html>. Publication Date Unknown. |
| Brochure entitled Fresenius Delivers 90/2 Peritoneal Therapy Cycler (Apr. 2001). |
| CMS 08—Handbook, published by Fresenius AG, 4 Edition 1988. |
| European Search Report issued Jan. 12, 2009, for corresponding International Application No. PCT/US2009/050062. |
| Fresenius 90/2 Brochure (Apr. 2001). |
| Fresenius 90/2 Cycler Software, Version 3.96 (Jan. 24, 1992). |
| Fresenius 90/2 Peritoneal Therapy Cycler (on information and belief, on sale in United States by 1991). |
| Fresenius 90/2 Peritoneal Therapy Cycler Operator's Instructions, dated 2000. |
| Fresenius Freedom Cycler Operating Instructions. |
| Fresenius Medical Care Acute Dialysis Machine Operating Instructions for acu-men, Software Version 1.0. |
| Fresenius Medical Care Operating Instructions for sleep-safeTM, Software Version 1.0, Part No. 677 805 1. |
| Fresenius Medical Care Slide Presentation for sleep-safeTM. |
| Fresenius Medical Care Technical Manual for sleep-safeTM, Part No. 677 807 1. |
| Gambro Laboratoriesvar APD written by Gambro Lundia AB, Lundia AB, Lund, Sweden, Jan. 1999, printed by Elanders Skogs Grafiska AB, Rev. 2, May 2001. |
| Gambro PDC—Personal Dialysis Capacity [online] [retrieved Nov. 10, 2006]. Retrieved from the Internet at <URL: http://www.em.gambro.com/Pages/InfoPage.aspx?id=4788.html>. Publication Date Unknown. |
| Gambro PDC Measuting in APD Patient Manual written by Gambro Lundia AB, Lund, Sweden, Oct. 1998, printed by Elanders Skogs Grafiska AB, Rev. 3, Jan. 2001. |
| International Preliminary Report on Patentability for International Application No. PCT/US2009/050062 mailed on Oct. 5, 2010. |
| Operating Instructions, Peritoneal Dialyser PD700, for Ser. No. 300. |
| Operator's Instructions, Fresenius 90/2 Peritoneal Therapy Cycler (Rev. C. copyright 1991-2000). |
| PD700 Peritoneal Dialyser Users Hand-book, Dec. 1977. |
| Peritoneal Dialyser PD700 Instruction Manual. |
| Peritoneal Dialyser PD700 Service Manual, Jun. 1977. |
| Notice of Opposition to a European Patent EP 2 368 588 (Appl. No. 11075130.2) mailed Jun. 14, 2016—5 pages. |
| Opposition against European Patent EP 2 368 588 (Appl. No. 11075130.2) May 13, 2016—30 pages. |
| Notice of Opposition to a European Patent EP 1 235 614 (Application No. 00992532.2) May 8, 2013—5 pages. |
| Opposition Statement European Patent No. 1 235 614 B (Application No. 00992532.2)—May 8, 2013—45 pages. |
| Fourtounas et al. “Telemedicine technology and applications for home hemodialysis”,—Int J. Artif Organs, Oct. 22, 1999 (10):679-83—3 pages (Exhibit E1). |
| Carson , E. et al., A system methodology for the development and evaluation of a telematic homehaemodialysis service, Annual Int. Conf. of the IEEE Engineering in Medicine and Biology Society; Oct. 1997, 907-910 IEEE; 1997 Publication Date—5 pages (Exhibit E2). |
| Tsavdaris, H., et al., “Monitoring and Supporting Home Haemodialysis using Telematic Services”, Decision Support Systems Laboratory, National Technical University of Athens, Wire Communications Laboratory, University of Patras—6 pages. |
| Agroyannis, N. ,et al. “Telemedicine technology and applications for home hemodialysis”, The Int Journal of Artificial Organs, vol. 22, No. 10, 1999, pp. 679-683. |
| Carson et al., “A Systems Metholodology for the Development and Evaluation of a Telematic Home Haemodialysis Service”, Proceedings—19th International Conference—IEEE/EMBS Oct. 30-Nov. 2, 1997 Chicago, Il USA—4 pages. |
| Decision—Facts and Submssions—EP Patent Appl. No. 00992532.2—dated Jul. 30, 2015—20 pages. |
| Office Action issued in related Japanese Patent Application No. 2016-37500 on Jan. 18, 2017. |
| Office Action (along with English translation) issued in related Japanese Patent Application No. 2016-37501 on Jan. 25, 2017. |
| Office Action issued in related Japanese Patent Application No. 2014-223121 on Feb. 1, 2017. |
| Number | Date | Country | |
|---|---|---|---|
| 20170065761 A1 | Mar 2017 | US |
| Number | Date | Country | |
|---|---|---|---|
| 60517730 | Nov 2003 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 15163128 | May 2016 | US |
| Child | 15355590 | US | |
| Parent | 13749309 | Jan 2013 | US |
| Child | 15163128 | US | |
| Parent | 13222622 | Aug 2011 | US |
| Child | 13749309 | US | |
| Parent | 10982170 | Nov 2004 | US |
| Child | 13222622 | US |
