Role of contact system activation in hemodialyzer-induced thrombogenicity

Background. The contact system is generally believed to be the main trigger of the coagulation cascade during extracorporeal circulation. However, the extent of contact activation, its role for intradialytic thrombin generati on as well as the influence of different dialyzer membranes have not been w ell established. Methods. In a novel full-scale ex vivo recirculation dialysis model, we inv estigated the thrombogenicity of three widely used hemodialyzers (Cuprophan Renak RA 15-U, Polysulfone F6HPS and AN69XT Nephral 200). The activation o f the contact system was evaluated using a newly developed ELISA for factor XIIA- CI-inhibitor complexes. Additionally. we determined free FXIIa (ELIS A), thrombin-antithrombin (TAT) complexes, platelet factor 4 (PF4), complem ent activation (C5a), granulocyte elastase and blood cell counts. The findi ngs in blood from normal volunteers were compared with factor XII-deficient blood. Results. With normal blood AN69 exhibited the highest thrombogenicity in co mparison to Cuprophan and Polysulfone, as assessed by TAT generation and pl atelet consumption. AN69 caused a rapid increase of the FXIIa-C1-inhibitor complexes and of free FXIIa. Despite significant TAT generation with Cuprop han and Polysulfone free FXIIa remained unchanged and the FXIIa-C1-inhibito r complexes stayed below the detection limit. With factor XII-deficient blo od Polysulfone exhibited the same TAT generation, whereas the thrombogenici ty of AN69 was greatly reduced. Conclusions. Our data challenge the common assumption that activation of th e contact system with generation of FXIIa is the main trigger for coagulati on and thrombus formation in hemodialysis. Only the negatively charged AN69 membrane with enhanced thrombogenicity strongly induced contact activation .