CONCENTRATE FOR MEDICAL SOLUTION AND USE THEREOF

Abstract: A concentrate for use in preparation of a medical solution for hemodialysis, hemodiafiltration, hemofiltration or peritoneal dialysis or an infusion solution. The concentrate comprises gluconic acid and glucose. The concentrate is extremely concentrated in a degree of concentration of at least 1:150. The concentrate is d iluted and mixed with a second solution comprising sodium bicarbonate, whereby the gluconic acid is used to adjust the medical solution to a physiological pH value of between 7.1 and 7.4. The gl uconic acid thus replaces the conventionally used acetic acid. T he invention also relates to the use of a concentrate comprising glucose and gluconic acid. The gluconic acid can be obtained by dissolving glucono-lactone in powder form in water.

Description: TITLE CONCENTRATE FOR MEDICAL SOLUTION AND USE THEREOF TECHNICAL FIELD The present invention relates to a concentrate for preparing a medical solution, such as a dialysis solution intended for hemodialysis, hemodifiltration, hemofiltration or peritoneal dialysis. The invention particularly relates to a concentrate comprising glucose and an acid. BACKGROUND OF THE INVENTION A concentrate may be a solution in water of one or several substances, which solution is intended to be diluted with water in a certain ratio, such as 1:35. A concentrate may alternatively be in powder form, for example comprising sodium bicarbonate in powder form, which concentrate is intended to be dissolved in water, and then diluted. The dissolution may take place in a separated process so that all powder is dissolved before dilution. The dissolution may also take place on-line by passing water through a bed of powder to produce a solution to be diluted. The powder can be a single component, like sodium bicarbonate or sodium chloride, or a mixture of components, like sodium chloride, pottasium chloride, magnesium chloride, calcium chloride etc. It is conventional during hemodialysis to prepare the dialysis solution in situ by mixing one or several concentrates with water in a dialysis machine. The dialysis machine controls the mixing so that the correct composition of the prepared dialysis solution is attained. A dialysis machine is described in EP-B1-278100 for the preparation of a dialysis solution starting from one or more concentrates in powder form and one or more concentrates in liquid form. The concentrates are diluted with pure water obtained from a water purifier, such as an RO-unit (reverse osmosis unit) . The dialysis machine prepares a dialysis solution comprising sodium-, bicarbonate,- potassium-, calcium-, magnesium-, chloride- and acetate ions in suitable concentrations, as well as possibly glucose and other ions, all being dissolved in water. The concentrations of the ions in the dialysis solution are generally mirror images of the corresponding concentrations in blood, where the mirror line is the normal concentration in blood of the ions. Thus, if an ion concentration is increased in the blood over the normal concentration, the ion concentration in the dialysis solution is decreased in relation to the normal concentration. The pH of the solution is adjusted to about 7.1-7.4. A typical composition of the dialysis solution is the following: sodium ions 130-150 mM bicarbonate ions 20-40 mM potassium ions 2-5 mM calcium ions 0-5 mM magnesium ions 0-5 mM glucose 0-0,2% acetate ions 3-4 mM (as well as chloride ions) As is apparent from the above table, in addition to pure water, there are two substances which are present in the prepared dislysis solution in large quantities, namely sodium ions and bicarbonate ions. In the above-mentioned publication, EP-B1-280100, at least one of these bulk substances is provided by the machine, starting from powder concentrate provided in one or several columns. The remaining substances are supplied via a fluid concentrate which comprises primarily potassium, calcium and magnesium ions and possibly glucose. This concentrate further comprises an acid to balance the pH value for the bicarbonate so that the final dialysis solution has a physiological pH value of about 7.1-7.4. Normally, acetic acid (acetate ions) is used. Since these substances are present m relatively small quantities, the solution can be very concentrated. A concentrate is described in EP-613688 having a degree of concentration of between 1:120 and 1:250, i.e. it is intended to be diluted with water in said ratio. It is said to comprise sodium chloride, potassium chloride, calcium chloride, magnesium chloride, hydrochloric/acetic acid and glucose. The concentrate is to be combined with a basic concentrate which comprises the two substances which are present in large quantities, namely sodium and bicarbonate ions derived from sodium chloriαe, and sodium bicarbonate. Moreover, the basic concentrate comprises sodium acetate. Soαium acetate is described as oemg mixed m the basic concentrate because the addition of sodium acetate prevents precipitation of bicaroonate by complex formation between acetate and bicarbonate ions. The highly concentrated concentrate is used as a treatment mdividualisation concentrate. This is possible and suitable since the concentrate is used m small quantities, normally less than one litre per treatment. Many different compositions of the mdividualisation concentrate can be stored in a limited storage space. The highly concentrated concentrate has a very high salt concentration (ionic strengtn) and is viscous. During experimentation witn a highly concentrated concentrate having a degree of concentration of 1:400, comprising, among other things, glucose and 1200 mM (mmole/litre) acetic acid (undiluted) , we discovered that, after one week's storage, the acetate ion concentration was reduced markedly, by more than 5%. Accordingly, the concentrate did not comply with the information on the label that it contained 3 mM (mmol/1) acetate after dilution m the ratio of 1:400 and with a margin of error of +; 5%. In addition, the reduction the acetic concentration indicated that some other substance had formed, probably by reaction with, or through decomposition of, glucose. Such substance may influence upon the patient who is undergoing dialysis . During continued experiments, it appeared that there is probably an interaction or reaction between acetic acid and glucose causing said reduction of acetate concentration and also of glucose concentration. Accordingly, the concentration of acid was reduced during storage, which may result in raising the pH value of the final prepared solution to an unacceptable level. The concentration values which are present in the concentrate are about 1.2 M acetic acid (or another acid) and about 2.2 - 4.4 M glucose at a concentration of 1:400, which results in 3mM acetic acid and 0.1-0.2% glucose in the finally prepared dialysis solution. SUMMARY OF INVENTION A first object of the invention is to provide a concentrate for dilution to a medical solution, in which the acid concentration is not reduced during storage. During experimentation with other acids, we found surprisingly that the above-mentioned reduction of the acetic acid and glucose concentrations does not occur if gluconic acid is used instead of acetic acid. More or less the same effect also occurs with other saccharic acids such as glycuronic acid, glucaric acid, etc. The same effect can also be attained from sodium gluconate together with hydrochloric acid, due to the fact that gluconic acid is formed by reaction of sodium gluconate and hydrochloric acid. Gluconic acid (C 6 Hι 2 0 7 ) can also be obtained by dissolving gluconolactone (C 5 Hι 0 θ6) in water, as described further below. Another object of the invention is to provide a concentrate for a medical solution which lacks acetate ions, since a great number of patients have developed intolerance for acetate ions. In accordance with the invention, by replacing the conventionally used acetic acid, which contains acetate ions, with gluconic acid, even patients with acetate ion intolerance can be treated with a medical solution obtained according to this invention. Gluconic acid has previously been used in connection with peritoneal dialysis, see EP 612528, as an osmotic agent, i.e. as (partial) replacement for glucose. In said document, it is disclosed that gluconic acid can totally or partially replace glucose, i.e. mixtures of gluconic acid and glucose are used. Those concentrations which are mentioned are between 75 and 250 mM of the added or combined concentrations of gluconic acid and glucose . In the present invention, the demonstrated effect of reduction of the acetic acid and glucose concentrations arises at considerably higher concentrations. At a degree of concentration of 1:400, the combined concentrations of glucose and gluconic acid are 3.4 - 5.6 M. At 250 mM, the effect according to the present invention is hardly detectable. Nowhere in EP 612528 is it mentioned that gluconic acid should have any favourable effect on the stability of glucose. A further object of the invention is to provide a concentrate for a medical solution, comprising a physiologicaly aceptable acid replacing the conventionally used acetic acid. Gluconic acid is a substance which is present in the body and may be decomposed in the body. Accordingly, it should not cause any damage or be accumulated in the body. Gluconic acid is a somewhat stronger acid than acetic acid. In order to have the same effect as 3mM acetic acid, referred to the diluted dialysis solution, a somewhat higher concentration of gluconic acid is however necessary, such as 4-5 mM, probably primarily due to formation of lactones which are reformed to gluconic acid at an acceptable speed only when the pH value reaches about 9. Accordingly, there is provided, according to the invention, a concentrate for use in preparation of an infusion solution or a medical solution for hemodialysis, hemodiafiltra- tion, hemofiltration or peritoneal dialysis, comprising gluconic acid. The concentrate may further comprise glucose. Gluconic acid may replace the conventional use of acetic acid, which means that a concentrate could be produced which lacks acetate ions . The concentrate is intended to be diluted with water or a water solution in a ratio of at least 1:150 and comprises at least 150g/l glucose and at least 600 mmol/1 gluconic acid. The invention also comprises use of a concentrate comprising gluconic acid and glucose for the preparation of a medical infusion solution, whereby the solution is diluted with water in a ratio of at least 1:150. According to another aspect of the invention, it comprises use of a concentrate comprising gluconic acid and possibly glucose for preparation of a medical solution intended for hemodialysis, hemodifiltration, he ofiltration or peritoneal dialysis, whereby the concentrate is diluted with water and mixed with a solution comprising sodium bicarbonate and in which gluconic acid is used to adjust the medical solution to a physiological pH value of between 7.1 and 7.4. The invention will be described in more detail below with reference to preferred embodiments of the invention with reference to the attached drawings. Further objects, features and advantages of the invention will be apparent from the following description. BRIEF DESCRIPTION OF THE DRAWINGS Fig. 1 is a diagram where the reduction in concentration is shown as a function of time for different degrees of concentration and at different temperatures. Fig. 2-7 are diagrams which show the concentration of gluconic acid as a function of time for different degrees of concentration and with and without glucose. DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS Fig. 1 is a diagram summarising Experiments 1 - 10. EXPERIMENTS 1, 2 AND 3 We have analyzed previously manufactured concentrates of a normal composition for hemodialysis and having the following intended composition after dilution: sodium 140 mM potassium 2 mM calcium 1.75 mM magnesium 0.5 mM glucose 0.1% or 0.2% acetate ions 3 or 4 mM In the absence of any indications to the contrary, all given concentration values refer to the concentration values in the finally diluted solution. The concentration values in the above disclosed concentrate are thus 35 times greater than the given values. In this manner, it is easier to compare concentrates with different degrees of concentration which are intended to result in the same concentration in the final solution. The mentioned concentrates had been stored for 3.5 years and were analyzed for concentration of acetic acid. The measurement points in the diagram are marked with a solid triangle for Experiment 1: 0.1% glucose, 3 mM HAc, a hollow triangle for Experiment 2: 0.2% glucose, 3 mM HAc and a hollow square for Experiment 3: 0.2% glucose, 4 mM HAc. As is apparent from the diagram, the concentration of acetic acid is unchanged at 0.1% glucose and reduced at 0.2% glucose, just under 2% at the maximum. These measured values lie within the tolerance limits for such concentrates and may be caused by differences during manufacture. We were unable to test these concentrates for shorter storage periods. However, we surmise that the deviations from the initial values would be less if the concentrates were stored for a shorter period. EXPERIMENTS 4 AND 5 We have also analyzed liquid concentrates with the above- given composition, but without the sodium chloride, in the case where sodium chloride is produced by the dialysis machine starting from a powder concentrate. We have tested two different degrees of concentration, namely 1:175 in Experiment 4 and 1:350 in Experiment 5. The concentrates had the following composition, multiplied by 175 and 350, respectively: potassium 2 mM calcium 1 .75 mM magnesium 0. .5 mM glucose 0. .1% acetate ions 3 mM The 1:175 and 1:350 concentrates were tested after 2 years storage and the result is illustrated in Fig. 1, using a diamond for Experiment 4, 1:175, and a hollow dotted square for Experiment 5, 1:350. As is clearly apparent, the reduction of the acetic acid concentration for the concentration 1:175 is about 3%, which is within the tolerance limits. For the double concentration 1:350, there is a reduction of about 9%, which is outside of the tolerance limits. EXPERIMENTS 6, 7, 8 AND 9 We have performed a test series with concentrates having concentration degrees of 1:200 and 1:400 which were manufactured and continuously monitored during a period of just over one year. The concentrates had the same composition as for experiments 4 and 5, however multiplied with the given degrees of concentration. The 1:200 concentrate in Experiment 6, denoted on Fig. 1 by solid diamonds, has a continuous reduction of the acetic acid concentration that seems to level out at a reduction of just below 4%. The same applies for two experiments, Experiment 7 indicated by hollow small squares and Experiment 8 indicated by filled small squares, with the same composition but aged in a climatic chamber at 40°C. As is apparent from Fig. 1, Experiments 7 and 8 reach equilibrium at a reduction of about 4% after about 2 months. The curve of Experiment 7 was obtained via titration and the curve of Experiment 8 was obtained by HPLC chromatography. The differences lie within the error tolerances of the methods. We have also manufactured a concentrate with a concentration degree of 1:400, Experiment 9 indicated by hollow squares with a dot, which was followed for slightly more than one year. Here the situation, as illustrated in Fig. 1, is quite clear, namely that the acetic acid concentration reduces rapidly during the first weeks and then levels out at a reduction of about 10,5%. EXPERIMENT 10 We have also performed experiments with concentrates without glucose having the degree of concentration of 1:400. As is apparent from Fig. 1, where Experiment 10 is indicated by crosses, no marked reduction of acetic acid concentration is detected. The combined observations from the various experiments is quite clear. The acetic acid concentration reduces in all concentrates. The reduction is dependent on the degree of concentration of the solution. This effect has not been observed in the literature. We have also been able to determine that the glucose concentration reduces in proportion to the reduction of the acetic acid concentration. This causes us to assume that the acetic acid reacts with glucose and forms a reaction product. We have unexpectedly discovered that if the acetic acid is replaced by gluconic acid, the above reduction of the acid concentration and the glucose concentration is not observed, see the following experiments. Figs. 2 - 8 are diagrams of the concentration of gluconic acid and the pH values, respectively, for concentrates with the following composition: potassium 2 mM calcium 1.75 mM magnesium 0.5 mM glucose 0% or 0.1% gluconic acid 4 mM EXPERIMENTS 11 AND 12 In experiments 11 and 12, Fig. 2 and 3, a concentrate with a degree of concentration of 1:35, i.e. a "conventional" concentrate, was used. The concentrate further comprises sodium chloride with a concentration of 140 mM (times 35) . Experiment 11 is without glucose and experiment 12 is with 0.1% glucose. Two parallel trial series are run, one in which the concentrates are stored at 25°C and the other in which the concentrates are stored at 40°C. Since aging takes place more quickly at higher temperatures, a difference between the two concentrates should quickly arise if any reaction takes place. As is seen from Figs. 2 and 3, no differences are observed. The concentration of the gluconic acid was measured via titration (square and diamond denoted by M/25C and M40C in Figs. 2 and 3) and via measurement of the pH value (triangle and cross denoted by pH/25C and pH/40C in Figs. 2 and 3). As is apparent from Figs. 2 and 3, the concentration of gluconic acid is constant at about 0.105 M. Furthermore, the pH value is relatively constant at pH=1.6. The variations which are apparent in Figs. 2 and 3, and also from the following diagrams, are believed to be due to calibration of the pH meter. EXPERIMENTS 13 AND 14 As illustrated in Figs. 4 and 5, the same experiments were performed as in experiments 11 and 12, with a degree of concentration of 1:200 and without sodium chloride. It is apparent from the diagrams that no change occurs in the concentration of gluconic acid which is constant at 0.6 M. The pH values are also relatively constant. EXPERIMENTS 15 AND 16 As illustrated in Figs. 6 and 7, the same experiments wre performed as in experiments 13 and 14, with a degree of concentration of 1:400. Again, it is apparent from the diagrams that substantially no change occurs in the concentration of gluconic acid which is constant at 1.2 M (undiluted). The pH values are also relatively constant . It is to be noted that the pH value in Fig. 7 where glucose is added is clearly lower than in Fig. 6 without glucose. We believe that this difference is not an actual difference but instead is due to glucose affecting the pH electrode. As is apparent, the titrated concentration (M) is constant and of the same magnitude in Figs. 6 and 7. Our measurements over a long period and documented in Experiments 11 - 16 show that the gluconic acid retains a stable concentration and does not seem to react with glucose. Accordingly, both the acid concentration and the glucose concentration are retained. It should be noted that a somewhat greater quantity of gluconic acid is required compared to acetic acid to obtain the same effect when mixing a dialysis solution starting from concentrates. We have not been able to find any reason to suspect that any unidentifed substance is produced which may have potentially damaging effect on a patient who is treated using this concentrate (after dilution) during dialysis or infusion. Gluconic acid can be obtained on the market in the form of 50% solution. However, we prefer to use glucono-delta-lactone (C 6 Hι 0 O 6 ) which can be obtained in powder form and in pure form. When dissolved in water, gluconolactone is substantially immediately hydrolysed to gluconic acid. Gluconic acid is naturally occurring in the body. We have been unable to evidence any damaging effect on the body during use of gluconic acid during dialysis. According to the invention, the conventionally used acetic acid is replaced by gluconic acid. The gluconic acid, or more precisely gluconate, can also act as a buffer, and thus replace lactate during peritoneal dialysis. Gluconic acid can also be produced in situ by mixing sodium gluconate with hydrochloric acid, whereby gluconic acid is formed. It is also possible to use other salts comprising gluconate, such as pottasium gluconate, calcium gluconate and magnesium gluconate, since these cations, pottasium, calcium and magnesium ions, normally are included in a dilaysis solution. In other types of solutions, other salts may be used. The invention has been described above with reference to experiments and embodiments of solutions of differing compositions. The principle of the invention is, however, generally applicable and is not restricted to the above given examples, but is restricted only by the appended claims.

Claims: CLAIMS 1. Concentrate for use in preparation of an infusion solution or a medical solution for hemodialysis, hemodiafiltration, hemofiltration or peritoneal dialysis, characterized in that it comprises gluconic acid. 2. Concentrate according to claim 1, characterized in that it further comprises glucose. 3. Concentrate according to claim 1 or 2, characterized in that it lacks acetate ions. 4. Concentrate according to claim 2 or 3, characterized in that it is intended to be diluted with water or a water solution in a ratio of at least 1:150 and comprises at least 150g/l glucose and at least 600 mmol/1 gluconic acid. 5. Concentrate according to claim 2 or 3, characterized in that it is intended to be diluted in a ratio of at least 1:200 and comprises at least 200g/l glucose and at least 800 mmol/1 gluconic acid. 6. Concentrate according to claim 2 or 3, characterized in that it is intended to be diluted in a ratio of at least 1:400 and comprises at least 400g/l glucose and at least 1600 mmol/1 gluconic acid. 7. Use of a concentrate according to claim 2 or 3 comprising gluconic acid and glucose for the preparation of a medical infusion solution, whereby the solution is diluted with water in a ratio of at least 1:150. 8. Use of a concentrate according to claim 1 or 3 comprising gluconic acid for preparation of a medical solution intended for hemodialysis, hemodifiltration, hemofiltration or peritoneal dialysis, whereby the concentrate is diluted with water and mixed with a solution comprising sodium bicarbonate and in which gluconic acid is used to adjust the medical solution to a physiological pH value of between 7.1 and 7.4. 9. Use according to claim 8, in which the dilution occurs in a ratio greater than 1:200. 10. Use of a concentrate according to claim 2 or 3 comprising gluconic acid and glucose for preparation of a medical solution intended for hemodialysis, hemodifiltration, hemofiltration or peritoneal dialysis, whereby the concentrate is diluted with water and mixed with a solution comprising sodium bicarbonate and in which the gluconic acid is used to adjust the medical solution to a physiological pH value of between 7.1 and 7.4. 11. Use according to claim 10, in which the dilution occurs in a ratio greater than 1:200. 12. Use of glucono lactone in powder form for preparation of a concentration according to any one of claims 1 - 6 by dissolving glucono-lactone powder in water.

Inventors: JOENSSON LENNART, KNUTSSON STEFAN, LINDEN TORBJOERN, PICARD ROBERT, JOENSSON, LENNART, KNUTSSON, STEFAN, LINDEN, TORBJOERN, PICARD, ROBERT
Applicants: GAMBRO AB, JOENSSON LENNART, KNUTSSON STEFAN, LINDEN TORBJOERN, PICARD ROBERT, JOENSSON, LENNART, KNUTSSON, STEFAN, LINDEN, TORBJOERN, PICARD, ROBERT
Application year: 1998
Main classification: A61K31
IPC codes: A61K9, A61K31, A61K33, A61M1, A61P7