ADVOS Questions and Answers
“ADVOS” is the abbreviation for ADVanced Organ Support.
“ADVOS multi” is the name of the machine used to provide this organ support, with “multi” referring to the fact that the machine can simultaneously support multiple organs (lungs, liver, kidneys).
Use of the device, and the device’s treatment settings, are always based on the primarily affected organ, but due to the way the procedure works, the other organs are always supported as well.
The indication for use of the ADVOS multi is based on the organ that is primarily affected; the other organs are also supported according to the treatment parameters that are set. If, in the context of multiple organ failure, further organs fail, the treatment parameters can be adjusted to provide additional and improved support without needing to set up the machine again or even replace it. This is what we mean by scalable support.
It is possible to deduct kidney dialysis with an additional fee and to deduct liver dialysis with an additional fee that is agreed individually with a hospital.
The costs of the device depend on multiple factors, for example whether the equipment is bought, leased or provided by ADVITOS, in each case with or without firmly agreed purchase of consumables. Our field service will be happy to provide details.
The procedure can also be used in dialysis centres.
The devices are also rented out where there is a corresponding agreement with the clinic, medical practice or service provider. Our field service will be happy to provide details.
The ADVOS multi is intended for combination with ADVOS fluids for patients with acute, chronic, or acute-to-chronic liver failure or kidney failure.
The aims of treatment are:
- Removing water-soluble and protein-bound toxic substances.
- Normalising and improving blood composition in cases of electrolyte imbalance or acid-base imbalance.
- Removing fluids in cases of overhydration.
There are no known contraindications.
The haemodialysis device is not intended for:
- Breast-feeding mothers
- Pregnant persons
- Patients with prion diseases, e.g. Creutzfeldt–Jakob disease
The ADVOS multi circulation takes place inside the machine with two specially designed filters.
The first innovative feature is the method, which combines the benefits of human serum albumin dialysis (efficient detoxification of protein-bound substances) with further benefits (low consumption of human serum albumin, high flow of dialysate, low flow of blood).
In addition, the procedure’s scalability is innovative, i.e. the possibility of specifically supporting the lungs, liver, kidneys and acid-base balance with just one machine – something that so far is only possible with the ADVOS multi.
The procedure can be used for as long as the treating physician considers necessary, although the machine must be disinfected every 24 hours. Uninterrupted treatment is therefore possible with two machines.
Treatment typically lasts up to 24 hours, depending on the aim of treatment. In the case of lung support, for example, 24 hours of continuous treatment makes sense, whereas for liver or kidney dialysis, 8 hours of treatment are possible, depending on the indication.
In principle, however, the duration of organ support is up to the treating physician; the only restriction on the method side is that the machine needs to be disinfected every 24 hours. Uninterrupted treatment is possible if two machines are used.
We are currently developing further options for organ support, both in specifically designed devices and as additions within the ADVOS multi.
The number of treatments depends on the clinical picture; typically, patients are treated three to ten times, but some patients have been successfully treated as many as 100 times.
Acid and alkaline concentrates are used to reduce and raise (respectively) the pH value in the two separate ADVOS regeneration circuits, in order to filter out toxins.
The added acid and base are converted into water and common salt in the ADVOS reservoir after the separate purification circuits: HCl + NaOH => H₂O + NaCl and are then disposed of through the dialysis circuit’s filtrate.
The filtrate is disposed of by the ADVOS multi fluid management, by means of the container system, and into the clinic’s/practice’s disposal drain.
The acid and base and the canister must be disposed of as hazardous waste. Note the following:
- Once treatment is complete, seal the canister with the canister lid.
- Contact the local authorities for information on regional regulations concerning disposal.
- Dispose of uncleaned packaging in accordance with official regulations.
- Dispose of acid concentrate separately from the alkaline concentrate (base).
- Prevent these from entering the public sewage system.
Two dialysers are used in the purification circuits within the ADVOS multi circuit (one in the acid circuit and one in the base circuit). Two other dialysers are needed in the blood circulation to ensure effective purification by the human serum albumin dialysate, given the large surface area.
For method-specific reasons and for reasons of regulatory approval, only dialysers from the ADVOS multi treatment set may be used. If dialysers that have not been approved by ADVITOS are used, no liability is assumed and the user in question bears sole responsibility for any complications or side effects in the patient undergoing treatment.
ADVOS multi offers the following benefits compared to competitors:
- Simultaneous support for all three excretory organs: lungs, liver and kidneys
- Possible to focus on a leading organ
- Lung support without the need for large-lumen vascular access and high flow rates
- Progressive treatment of kidney failure by removing water-soluble and also protein-bound nephrotoxins
- Bicarbonate-independent treatment of severe metabolic and respiratory acidosis
- Acidosis therapy by means of adjusting the pH and bicarbonate to the specific patient during treatment
- Low consumption of human serum albumin
- Continuous and intermittent treatment possible
As the method is still very new, there are only a limited number of studies in animal and test subjects available, which we will be happy to send to you. Further studies are currently underway or in preparation. Our field service will be happy to provide details.
Data available to date from the EMOS register attests to good treatment results. For details, our Literature Service would be happy to help or we can refer you to experienced users.
Unlike all other combined dialysis devices, the ADVOS multi does not require a gas exchanger for CO₂ removal, using a chemical process instead: Physiologically, CO₂ +H₂O (carbon dioxide and water) are in constant equilibrium with H⁺ + HCO₃⁻ (proton and bicarbonate), according to what is known as the Henderson-Hasselbalch equation:
CO₂ + H₂O <-> H₂CO₃ <-> H⁺ + HCO₃⁻
If you remove the proton (H⁺) and bicarbonate (HCO₃⁻) from the right side of the equation, the body recreates it from carbon dioxide (CO₂) and water (H₂O), thus reducing the CO₂ on the left side of the equation.
If you increase the pH value in the ADVOS dialysate while simultaneously reducing the bicarbonate content, the concentration gradient causes both protons (H⁺) and bicarbonate (HCO₃⁻) to move from the blood through the dialyser to the dialysate, thereby lowering the CO₂ content in the blood.
See also “What are the indications for ADVOS multi?”
In the ADVOS multi circulation, the human serum albumin dialysate is separated into two independent circuits, to which acid or base concentrate is added, respectively, in order to lower or increase the pH value. In the acid circuit, positively charged substances (such as copper and CO₂) are removed from the dialysate, while in the base circuit, negatively charged substances (such as bilirubin and bile acid) are removed. Next, the retreated dialysate is merged in order to pass through the dialysis filters again.
All anticoagulants that are taken for kidney dialysis can also be used with the ADVOS multi.
- Calcium citrate
- Epoprostenol (Flolan)
- Thrombin inhibitors (Argatroban)
For the recommended dosing, refer to our brief guide or the clinic’s own standards. We do not recommend operating the ADVOS multi without any anticoagulation.
We recommend a standard disinfection method as is always required after treatment. When changing patients, we recommend a subsequent Citro disinfection.
Both the permeate and the filtrate are stored in the container, allowing treatment without the need for osmosis water connections.
The ADVOS multi can also be used for out-patient treatment like conventional kidney dialysis.
The recommended anticoagulation method is citrate anticoagulation. We recommend using standard chemical laboratory monitoring measures and, in the case of patients with liver failure, paying particular attention to citrate accumulation.
Citrate and calcium should be administered in accordance with the clinic’s internal guidelines. For more details, refer also to the ADVOS best practice guide.
The ADVOS multi normally works with blood flow rates of 100 ml/min to 500 ml/min and dialysate flow rates of up to 96 l/h. The flow rates can be varied, depending on the detoxification performance that is desired and the indications.
Human serum albumin (200 ml 20%) is not provided by ADVITOS and must be requested separately from the relevant hospital pharmacy.
The medication needed for anticoagulation (e.g. citrate, heparin) must also be provided by the clinic.
No, the patient is not cooled down. A hose heater ensures a stable body temperature. The medication needed for anticoagulation (e.g. citrate, heparin) must also be provided by the clinic.
If the patient loses heat, the blood is heated up in the blood circulation by a hose heater downstream of the dialyser.
No, there is no need for an additional heated blanket.
Yes, the ADVOS multi can also be used with citrate anticoagulation. In fact, citrate is the method most commonly employed by users. We recommend using standard chemical laboratory monitoring measures and, in the case of patients with liver failure, paying particular attention to citrate accumulation.
Balancing takes place by means of the weighing equipment built into the container support.
The ADVOS multi is currently used in both intensive care units and at peripheral dialysis stations. On request, we will be happy to provide you with the relevant reference addresses.
ADVOS treatment fluids differ from conventional dialysis fluids in that human serum albumin is added, although significantly less of the expensive human serum albumin is needed than in competitor products. The bicarbonate concentration can be chosen according to the aim of treatment.
It takes about 30 to 45 minutes to set up the device, depending on the user’s level of experience.
New users are supervised and instructed on site by our experienced application consultants during the initial treatments. After this time, you can contact us at any time on our 24/7 hotline: Germany: 0800 43 72 92 74 / Austria: 0800 44 77 07
You can reach us any time on our 24/7 hotline regarding questions and possible problems: Germany: 0800 43 72 92 74 / Austria: 0800 44 77 07
The ADVOS procedure is currently used in many leading (university) clinics. We would be happy to provide you with contact addresses on request.
ADVITOS GmbH (formerly Hepa Wash GmbH) was founded in 2004 by the nephrologist PD Dr. med. Bernhard Kreymann with the intention of developing effective multiple organ support.
After numerous in vitro tests, preclinical and clinical trials, the method was approved in Europe in 2011, receiving a strong, positive response from clinical users.
The company is certified in accordance with ISO 13485:2016 & MDD 93/42 EEC Annex II.3, and, as a full-service provider, it covers the entire process of development, production and quality assurance of medical equipment and the necessary treatment concentrates on the premises.