Hemocompatibility of medical devices
Transcript of Hemocompatibility of medical devices
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Hemocompatibility of medical devices
biomateria
l
Prof. Dr. Carsten Werner Dr. Claudia Sperling Dr. Manfred Maitz
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basics – blood – blood reactions on biomaterial surfaces – hemocompatibility
our research – in vitro blood incubation – initiation of blood activation on biomaterial surfaces
functionalization strategies – passivation – active interface
outline
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basics – blood – blood reactions on biomaterial surfaces – hemocompatibility
our research – in vitro blood incubation – initiation of blood activation on biomaterial surfaces
functionalization strategies – passivation – active interface
part 2
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Why hemocompatibility?
• immediate exposure to all host defense mechanisms • incompatibility reactions affect remote and vital organs
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Blood reaction cascades Primary aim: minimizing blood coagulation
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Surface functionalization for hemocompatibility
passivation - active inhibition permanent - renewable
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Surface functionalization for hemocompatibility
passivation - active inhibition permanent - renewable
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protein adsorption
‚translates‘ the presence of a foreign surface into the ‚language‘ of the living organism
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repetition - protein adsorption
• albumin and fibrinogen show competitive behaviour – albumin/fibrinogen ratio frequently used for a first rating of
hemocompatibility – in vitro dependent from the salt concentration and buffer system
• different behaviour of free and adsorbed fibrinogen – free fibrinogen without effect on blood platelets – adsorbed and denatured fibrinogen activates blood platelets
• threshold surface fibrinogen concentration for platelet activation at polymer surfaces
– 30 ng/cm2
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hydrophilic surfaces • ionized surfaces (acidic – alkaline) • polar chemical groups
– Ester R-COOR – Ether -C-O-C- – Alcohols C-OH
• zwitterionic materials • pure metals (free electrons)
hydrophobic hydrophilic
hydrophobic surfaces • aliphatic groups –CH2-CH3
• aromatic groups • inorganic carbon • fluorine groups (Teflon) –(C2F4)-
10
hydrophilicity
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hydrophilic surfaces • adsorbed water makes them
more or less invisible for biosystems
⇨ lower protein adsorption ⇨ less conformation changes of
proteins • effect is enhanced by flexible
hydrophilic chains on the surface
O H H O H H O H H O H H O H H
O H H O H H
O H H
O H H
11
strategy 1: hydrophilicity
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hydrophilic brushes • Arrangement of water
molecules at flexible hydrophilic chains
• Polyethylenglycol
• Jeffamine®
• Hydrogels
HO
OHn
H3CO
ONH2
CH3
yx
Hemostasis
TAT or PF4 [arb. U]
0 1 2 3 4 5 6
PP-MA
PTFE
Albumin
JeffamineTATPF4
12
hydrophilicity
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hydrophilic brushes prevent surface-protein interaction
protein
Poly(ethylen- glycole) PEG
Jeffamine
Poly(vinylpyrroli- done) PVP
Poly(ethyl- oxazoline) PEOx
Zwitterion P122
PTFE TPU-B TPU-F PVP PEG PEOx P122 0
3000
6000
9000
12000
F1+2
[pm
ol/l
PTFE TPU-B TPU-F PVP PEG PEOx P1220
2
4
6
8
10
C5a
[µg/
l]
protein
Coagulation
Inflammation
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strategy 2: omniphobicity
D.C. Leslie, et al. A bioinspired omniphobic surface coating on medical devices prevents thrombosis and biofouling, Nature Biotechnology (2014).
cardioperfusion tubing + porcine blood for 2 min.
http://www.sarracenia.com/photos/nepenthes/nepenhyb02001.jpg
SLIPS: slippery, liquid-infused, porous surface nepenthes
TP: tethered perfluorocarbon LP: mobile layer of an LP (perfluorodecalin)
labelled fibrin(ogen)
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strategy 2: omniphobicity
D.C. Leslie, et al. A bioinspired omniphobic surface coating on medical devices prevents thrombosis and biofouling, Nature Biotechnology (2014).
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strategy 2: omniphobicity
D.C. Leslie, et al. A bioinspired omniphobic surface coating on medical devices prevents thrombosis and biofouling, Nature Biotechnology (2014).
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strategy 3: antifouling polymer brushes
A. de Los Santos Pereira, et al. Antifouling polymer brushes displaying antithrombogenic surface properties. Biomacromolecules 17, (2016)
polymerbrushes on polycarbonate surfaces: pronounced resistance to protein adsorption and marked reduction in thrombogenicity in relation to control substrate underlying principle: dependency on chain length and brush density determines mobility and resulting steric compulsion
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strategy 3: antifouling polymer brushes
X.L. Liu, L. Yuan, D. Li, Z.C. Tang, Y.W. Wang, G.J. Chen, H. Chen, J.L. Brash, Blood compatible materials: state of the art, Journal of Materials Chemistry B 2(35) (2014) 5718-5738.
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strategy 4: surface modifying additives
M.L. Lopez-Donaire, J.P. Santerre, Surface modifying oligomers used to functionalize polymeric surfaces: Consideration of blood contact applications, Journal of Applied Polymer Science 131(14) (2014)
www.interfacebiologics.com
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strategy 4: surface modifying additives
http://www.interfacebiologics.com/endexo.htm
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Surface functionalization for hemocompatibility
passivation - active inhibition permanent - renewable
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albumin
alkyl-grafted hydrogels for self-renewing albuminization
albumin
M. Fischer, C.P. Baptista, I.C. Goncalves, B.D. Ratner, C. Sperling, C. Werner, C.L. Martins, M.A. Barbosa, The effect of octadecyl chain immobilization on the hemocompatibility of poly (2-hydroxyethyl methacrylate), Biomaterials 33(31) (2012) 7677-85.
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Alkyl-grafted hydrogels for self-renewing albuminization
pHEMA 2.5%C18 5%C18 10%C18
0
5
10
15
20
**
*
Plas
ma
C5a
[µg/
l]
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• coagulation cascade, blood platelets and inflammation must be considered at the same time
• translation of effective surface characteristics into
STABLE real world materials
challenges of passive modifications
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Surface functionalization for hemocompatibility
passivation - active inhibition permanent - renewable
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http://nsf.gov/
passive • “appropriate” wettability
− no protein adsorption • smooth • barrier against surrounding
tissue
active (constant or regulated) • anticoagulants
− heparan sulfate − tissue factor pathway inhibitor (TFPI) − thrombomodulin
• anti platelet action − nitric oxide
• stimulated fibrinolysis − tissue plasminogen activator (tPA)
model surface: endothelium
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coatings to promote endothelialization • direct seeding of endothelial cells (EC) (ex vivo) • surface modification:
• positive charge • immobilization of cell recognition sites • immobilization of ECM derived proteins / peptides • employment of growth factors (VEGF)
• in vivo endothelialization • EC migration to (modified) surfaces • capture of EPCs (endothelial progenitor cells)
• via monoclonal antibodies • aptamers
No sufficiently reliable strategy with success in a clinical study found yet.
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inhibition sites
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thrombin inhibition coatings based on natural substances • thrombomodulin (complex formation with thrombin) • heparin (activation of antithrombin AT) • hirudin (direct thrombin inhibition)
coatings based on synthetic inhibitors • small molecule synthetic inhibitors
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Vessel wall protein thrombomodulin Different functions within one molecule:
• Binds thrombin and changes its substrate specifity from fibrinogen to protein C
Inhibits coagulant thrombin activity Activates anticoagulant protein C
pathway − Inactivates Factor V and VIII − Antiinflammatory properties
Leading anticoagulant and antiinflammatory molecule in the endothelium cell membrane
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Vessel wall protein thrombomodulin Immobilization in physiological orientation on model substrates
Coagulation
Glass
PTFE
Jeffa
mine
Thrombo
moduli
n
Thro
mbi
n-An
tithr
ombi
n C
ompl
ex(T
AT) [
ng/m
L]
0
200
400
600
800Inflammation
Glass
PTFE
Jeffa
mine
Thrombo
moduli
n
Surfa
ce C
3c [a
rb. U
]
0
1
2
3
4
5
6
CD
11b
Expr
essi
on [R
FU]
0
200
400
600
800
1000
1200
1400C3bCD11b
Less coagulation and inflammation than the controls PTFE or jeffamine.
Reduced leukocyte adhesion with thrombomodulin
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thrombin inhibition coatings based on natural substances • thrombomodulin (complex formation with thrombin) • heparin (activation of antithrombin AT) • hirudin (direct thrombin inhibition)
coatings based on synthetic inhibitors • small molecule synthetic inhibitors
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• linear polysaccharide • 5-40 kDa • highly O and N sulfated and carboxylated • biomacromolecule with highest (negative) charge
density • interaction with anion binding sites of proteins
heparin
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• AT III adsorbs • sticks at the
pentasaccharide sequence
AT
AT T
AT T
Thrombin slides
Irreversible thrombin-antithrombin (TAT) complex assembles: coagulation effect of thrombin is neutralized
AT T
TAT complex dissociates, heparin „active sequence“ remains
Heparin can catalyse next inhibition cycle
AT
T
Thrombin adsorbs
AT
heparin – mode of action
AT antithrombin heparin T thrombin
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CBAS™ EN ISO 9001/EN 46001 CERTIFIED carmeda bioactive surface works for
Vascular Grafts & Coronary Stents
Cardiopulmonary Bypass Circuits Ventricular Assist Devices Central Venous Catheters Intravascular Blood Gas Sensors
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• surface-bound heparin leaches • low stability upon sterilization and in vivo… • dependence on antithrombin • limited safety (animal product) • risk of HIT-II (heparin induced thrombocytopenia)
robust synthetic molecules
mimicking inhibitor functions
challenges of heparin coatings
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thrombin inhibition coatings based on natural substances • thrombomodulin (complex formation with thrombin) • heparin (activation of antithrombin AT) • hirudin (direct thrombin inhibition)
coatings based on synthetic inhibitors • small molecule synthetic inhibitors
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Hirudin inhibits thrombin, the key enzyme of the blood coagulation cascade
hirudo medicinalis
Hydrophobic Interactions
Strong Hydrophobic Interactions
Salt Bridge
Synthetic inhibitors, e.g. NAPAP, can mimic this function
C. Lin, M. Tseng, Surface characterization and platelet adhesion studies on polyethylene surface with hirudin immobilization, Journal of Materials Science: Materials in Medicine 12 (2001) 827-832.
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Challenges of bioactive protein immobilization
• high expenses • immobilization without loss of activity • stability upon shelf storage, sterilization, in
vivo degradation • safety (source of the product)
Look for more stable structures
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thrombin inhibition coatings based on natural substances • thrombomodulin (complex formation with thrombin) • heparin (activation of antithrombin AT) • hirudin (direct thrombin inhibition)
coatings based on synthetic inhibitors • small molecule synthetic inhibitors
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COAGULATION PLATELET ACTIVATION
Activation parameters after incubation in human whole blood (2 h)
Covalently immobilized benzamidine layers minimize coagulation
DE 103 30 900; DE 103 29 296; Biointerphases 2006, 1, 1559; Acta Biomaterialia 2005, 1, 441; Biomaterials 2005, 26, 6547
b.i. PPMA BzI 0
20 40 60 80
800
1000
TAT
[µg/
l]
b.i. PPMA BzI 0
50
100
150
200
PF4
[IU/m
l]
PPMA copolymer BzI = PPMA +
PEG spacer + benzamidine
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inhibition sites
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inhibition of contact activation immobilization of corn trypsin inhibitor
J.W. Yau, A.R. Stafford, P. Liao, J.C. Fredenburgh, R. Roberts, J.L. Brash, J.I. Weitz, Corn trypsin inhibitor coating attenuates the prothrombotic properties of catheters in vitro and in vivo, Acta Biomaterialia 8(11) (2012) 4092-100.
adsorption of 125I- fXII or fibrinogen onto unmodified or modified PCI catheters in plasma.
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inhibition of contact activation
J.W. Yau, A.R. Stafford, P. Liao, J.C. Fredenburgh, R. Roberts, J.L. Brash, J.I. Weitz, Corn trypsin inhibitor coating attenuates the prothrombotic properties of catheters in vitro and in vivo, Acta Biomaterialia 8(11) (2012) 4092-100.
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inhibition sites
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inhibition of platelet activation and aggregation • dipyridamol • prostaglandin PGE1 • nitric oxide
resting platelet
activated platelet
aggregated platelets
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thrombus formation (red) and bacterial infection (green) on surface of intravascular catheters
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E.J. Brisbois, T.C. Major, M.J. Goudie, M.E. Meyerhoff, R.H. Bartlett, H. Handa, Attenuation of thrombosis and bacterial infection using dual function nitric oxide releasing central venous catheters in a 9 day rabbit model, Acta Biomaterialia 44 (2016) 304-312.
nitric oxide releasing surfaces NO: versatile regulator: inhibition of SMCs, platelets and leukocyte chemotaxis, antibacterial
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E.J. Brisbois, T.C. Major, M.J. Goudie, M.E. Meyerhoff, R.H. Bartlett, H. Handa, Attenuation of thrombosis and bacterial infection using dual function nitric oxide releasing central venous catheters in a 9 day rabbit model, Acta Biomaterialia 44 (2016) 304-312.
NO flux
(A) NO-releasing (B) control catheters
implantation in rabbit veins for 9 days
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nitric oxide releasing surfaces
NO donor substrates limited amount released release of carcinogenic nitrosamines catalytic agents: agents capable of synthesizing NO using physiologic sources cystein modified polymers doping of surfaces with Cu+
Clinical validation not yet successful
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inhibition sites
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activation of fibrinolysis
Schematic representation of the lysine-based clot lysing surface plasmin degrades insoluble fibrin clots to generate soluble fibrin fragments D. Li, H. Chen, J.L. Brash, Mimicking the fibrinolytic system on material surfaces, Colloids and Surfaces B: Biointerfaces 86(1) (2011) 1-6.
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activation of fibrinolysis surface modification substances
direct immobilization • plasminogen activators (t-PA, u-PA) • recombinant compounds (alteplase, reteplase, …)
lysine-functionalization • captures plasmatic t-PA
D. Li, H. Chen, J.L. Brash, Mimicking the fibrinolytic system on material surfaces, Colloids and Surfaces B: Biointerfaces 86(1) (2011) 1-6.
fast reaction is necessary: detachment of complete thrombus – embolization possible! no successful clinical trials yet
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• dosage invariant and limited by surface area of device
• restricted accessibility of active component in layered material
• other activation pathways remain active
challenges of direct inhibitors
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Surface functionalization for hemocompatibility
passivation - active inhibition permanent - renewable
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Modular polymer networks based on heparin and 4-armed, end-functionalized polyethylene glycol (starPEG)…
starPEG
heparin
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(with/without incorporation of peptides)
covalent bond
cleavable peptides
‚directly linked‘ gels
protease cleavable gels
Thrombin cleavable peptide sequence NH2-Gly-Gly-(D)Phe-Pip-Arg-Ser-Trp-Gly-Cys-Gly-CONH2
Crosslinking principles of the hydrogel
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Similarity with endothelial cogulation control
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Similarity with endothelial cogulation control
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Similarity with endothelial cogulation control
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Similarity with endothelial cogulation control
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Similarity with endothelial cogulation control
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Heparin release
time [h]
0 2 4 6 8 10 12
cum
ulat
ive re
leas
e [µ
g/cm
2 ]
0
20
40
60
80
100
120
low crosslink
medium crosslink
high crosslink
45 nM Thrombin
15 nM Thrombin
5 nM Thrombin
1.67 nM Thrombin
Variation of • Crosslinking degree • Thrombin concentration
Gel degradation in thrombin solution
cumulative release [µg/cm2]0 20 40 60 80
Thro
mbi
n
45nM
15nM
5nM
2nM
cumulative release [IU/cm2](not corrected to activity loss)
0 2 4 6 8 10 12 14
low crosslinkmedium crosslinkhigh crosslink
• linear release kinetics • release scales with
crosslinking degree and thrombin level
Heparin release
time [h]
0 2 4 6 8 10 12
cum
ulat
ive re
leas
e [µ
g/cm
2 ]
0
20
40
60
80
100
120
low crosslink
medium crosslink
high crosslink
45 nM Thrombin
15 nM Thrombin
5 nM Thrombin
1.67 nM Thrombin
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Thrombin cleavable gels suppress coagulation of external activators
Whole blood incubation: co-incubation with pro- coagulant surfaces
co-incubation stable vs. thrombin-cleavable gels
Coagulant stress-test
COOH content20% 50% 80%
F1+2
[nm
ol/l]
02468
1012146080
100
non responsiveThr. responsive
Hydrogel
SAM with graded activation
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Incubation with non-anticoagulated whole blood F1
+2 P
eptid
e [n
mol
/l]
1
10
100
1000
1h
F1+2
Pep
tide
[nm
ol/l]
1
10
100
1000
1h1h+1h
PTFE/ePTFE hydrogel bare heparin
grafted non-
responsive responsive
thrombin responsive hydrogel outperforms references including non-responsive gels and endpoint heparinized ePTFE enhanced anticoagulant effect of responsive gel upon repeated incubation with fresh blood only responsive hydrogel prevents clotting
M.F. Maitz, U. Freudenberg, M.V. Tsurkan, M. Fischer, T. Beyrich, C. Werner, Bio-responsive polymer hydrogels homeostatically regulate blood coagulation, Nat Commun 4 (2013) 2168.
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Thrombin as hydrogel-degrading protease
• High plasma concentration − High gel degradation promised
• High affinity to heparin and accumulation at the hydrogel − Increased activity?
• Very late protease in congulation process − Would earlier heparin release be more efficient?
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Different triggers for heparin release
XIIa
XI XIa
IX IXa
X
Xa
II IIa
I Ia
Kal
VIIa
Faster reaction by hydrogels with response to other coagulation factors
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Different triggers for heparin release
XIIa
XI XIa
IX IXa
X
Xa
II IIa
I Ia
Kal
VIIa
• FXIIa/Kallikrein – Contact phase activation – Very early activation – Low inhibition by heparin
• FXa – Low plasma concentration – In prothrombinase complex
no heparin affinity – Peak concentration after
thrombin
• Thrombin – High concentration – Heparin affinity – Rapid fibrin formation
Faster reaction by hydrogels with response to other coagulation factors
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Whole blood incubation
Hydrogel
SAM 80% COOH
Improved performance by optimized design Inhibitor release upon early coagulation factor FXa: less drug release has same biological effect
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Limitations of heparin dependence
• side effects • indirect anticoagulant: requires antithrombin • Structure- and effective molecule in the
hydrogel: Independent optimization not possible
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Responsive PEG hydrogels for delivery of synthetic inhibitors - PPACK (Peptide) - HD1 (DNA-Aptamer)
PPACK HD1
Thrombin
PDB: 4DIH
PPACK HD1
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blank PPACK HD1
Thr a
ctiv
ity d
ecay
(%)
0
10
20
30
40
50stable
PPACK HD1
Thrombin
PDB: 4DIH
Thrombin (60min incubation)
blank PPACK HD1
Thr a
ctiv
ity d
ecay
(%)
0
10
20
30
40
50stable Thr cleavable
Substrate-pNA (no color)
Substrate + pNA (yellow)
Thrombin
Measurement at 405nm
Responsive PEG hydrogels for delivery of synthetic inhibitors - Function in buffer
Direct thrombin inhibitors linked to hydrogels are active
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PPACK HD1
Thrombin
PDB: 4DIH
Responsive PEG hydrogels for delivery of synthetic inhibitors - Function in whole blood
PEG-Hep blank PPACK HD1
F1+2
(pM
)
0
500
1000
1500
2000
2500
3000stable
PEG-Hep blank PPACK HD1
F1+2
(pM
)
0
500
1000
1500
2000
2500
3000stableThr cleavable
no d
ata
hydrogel
Pro-coagulant SAM (80% COOH)
Anticoagulant activity of hydrogels with direct inhibitors –so far– is limited
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• optimization of physicochemical surface properties can be effective – but hardly sufficient
• immobilization of (e.g. coagulation) inhibitors is powerful – but difficult to dose
• activation-controlled delivery systems for inhibitors may create new opportunities for safety solutions with extended durability
summary & perspective: surface modification for hemocompatible materials
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passive hemocompatibility active hemocompatibility
Mode of action: Mainly low interaction with blood proteins and cells
Selective interaction with activating or inhibitory systems
Smart principles of cell/protein activation may be addressed Usually low cost Frequently expensive Usually lower efficiency High efficiency
Sterilization and shelf stability usually not critical
Sterilization and shelf stability have to be considered
Frequently long lasting biological effect
Time limited effect due to saturation or bio-degradation
summary: comparison
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78
summary: strategies for material coatings for passive antithrombogenicity
1. hydrophilicity 2. hydrophobicity / omniphobicity 3. antifouling polymer brushes 4. surface modifying additives
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active interference of surfaces with blood
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80
summary: targets and substances for material coatings for active antithrombogenicity 1. thrombin inhibition coatings based on natural substances • thrombomodulin (complex formation with thrombin) • heparin (activation of antithrombin AT) • hirudin (direct thrombin inhibition)
coatings based on synthetic inhibitors • small molecule synthetic inhibitors
3. inhibition of platelet activation and aggregation dipyridamol nitric oxide
4. activaton of fibrinolysis tissue-type plasminogen activator
2. inhibition of FXIIa corn trypsin inhibitor
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Further reading
http://www.ipfdd.de/2879.0.html Passwort: surface
C. Sperling, M.F. Maitz, C. Werner, Test methods for hemocompatibility of biomaterials pp. 77-104 M. Fischer, M. Maitz, C. Werner, Coatings for biomaterials to improve hemocompatibility pp. 163-190 in: C.A. Siedlecki (Ed.), Hemocompatibility of Biomaterials for Clinical Applications, Elsevier, Amsterdam, 2017.
ISBN: 978-0-08-100497-5 (print) ISBN: 978-0-08-100499-9 (online)
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the hemocomp group in IPF Claudia Sperling, Manfred Maitz, Sandra Schulz, Tina Helmecke, Steffi Hänsel, Martina Franke, students
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Thank you for your attention!