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Maintaining water quality for hemodialysis

Nicholas Hoenich, PhD
Richard A Ward, PhD
Section Editor
Steve J Schwab, MD
Deputy Editor
Alice M Sheridan, MD


Water is required for hemodialysis. Hemodialysis patients are vulnerable to contaminants in the water used to prepare concentrate and dialysis fluid or in water used for reprocessing dialyzers. This vulnerability is due to the following:

Hemodialysis patients are exposed to extremely large volumes of water. The estimated water intake of a healthy individual is 2 L per day or 14 L per week. By comparison, during a single dialysis treatment lasting four hours, performed at a dialysis fluid flow rate of 800 mL/min, a hemodialysis patient is exposed to 192 L of water or to 576 L per week, if treated three times weekly.

Hemodialysis patients have inadequate barriers to waterborne contaminants. In healthy individuals who are not on dialysis, the gastrointestinal tract separates blood from contaminants in the water. By comparison, the barrier between blood and water in hemodialysis patients is the membrane within the hemodialyzer through which transfer of contaminants is limited only by the size of the contaminant.

Hemodialysis patients are unable to renally excrete any contaminants taken up from the dialysate.

No municipal water can be considered safe for use in hemodialysis applications in the absence of a treatment system. All dialysis facilities therefore require an appropriately designed and correctly maintained water treatment system to safeguard patients [1].


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Literature review current through: Sep 2016. | This topic last updated: Jul 14, 2016.
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  1. Martin K, Laydet E, Canaud B. Design and technical adjustment of a water treatment system: 15 years of experience. Adv Ren Replace Ther 2003; 10:122.
  2. Association for the Advancement of Medical Instrumentation. Guidance for the preparation and quality management of fluids for hemodialysis and related therapies, ANSI/AAMI/ISO 23500:2011, Association for the Advancement of Medical Instrumentation, Arlington, VA 2011.
  3. Penne EL, Visser L, van den Dorpel MA, et al. Microbiological quality and quality control of purified water and ultrapure dialysis fluids for online hemodiafiltration in routine clinical practice. Kidney Int 2009; 76:665.
  4. Tsai YP, Pai TY, Hsin JY, Wan TJ. Biofilm bacteria inactivation by citric acid and resuspension evaluations for drinking water production systems. Water Sci Technol 2003; 48:463.
  5. Sakuma K, Uchiumi N, Sato S, et al. Experience of using heat citric acid disinfection method in central dialysis fluid delivery system. J Artif Organs 2010; 13:145.
  6. Hanna-Attisha M, LaChance J, Sadler RC, Champney Schnepp A. Elevated Blood Lead Levels in Children Associated With the Flint Drinking Water Crisis: A Spatial Analysis of Risk and Public Health Response. Am J Public Health 2016; 106:283.
  7. Newbigging N, Peel W, Bell E, Isles C. Unexpected cyanosis in a haemodialysis patient-did someone add hydrogen peroxide to the dialysis water? NDT Plus 2009; 2:158.
  8. Bek MJ, Laule S, Reichert-Jünger C, et al. Methemoglobinemia in critically ill patients during extended hemodialysis and simultaneous disinfection of the hospital water supply. Crit Care 2009; 13:R162.
  9. NHS National Patient Safety Agency. Risks to hemodialysis patients from water supply (hydrogen peroxide). NPSA/2008/RRR007. https://www.cas.dh.gov.uk/ViewandAcknowledgment/ViewAttachment.aspx?Attachment_id=50485 (Accessed on April 01, 2009).
  10. Hoenich NA. Disinfection of the hospital water supply: a hidden risk to dialysis patients. Crit Care 2009; 13:1007.
  11. Mackler BA, Merkle JC. Current knowledge on groundwater microbial pathogens and their control. Hydrogeol J 2000; 8:29.
  12. Standard Methods for the Examination of Water and Wastewater, 22nd Edition. American Public Health Association (APHA), Washington, DC 2012.
  13. Association for the Advancement of Medical Instrumentation. Guidance for the preparation and quality management of fluids for hemodialysis and related therapies. ANSI/AAMI 23500:2014, Arlington, VA 2014.
  14. National Patient Safety Agency: Haemodialysis patients: risks associated with water supply (hydrogen peroxide). Central Alert System reference NPSA/2008/RRR007 2008. http://www.nrls.npsa.nhs.uk/resources/?entryid45=59893 (Accessed on April 11, 2016).
  15. Davidovits M, Barak A, Cleper R, et al. Methaemoglobinaemia and haemolysis associated with hydrogen peroxide in a paediatric haemodialysis centre: a warning note. Nephrol Dial Transplant 2003; 18:2354.
  16. Bova G, Sharpe P, Keane T. Evaluation of Chlorine Dioxide in Potable Water Systems for Legionella Control in an Acute Care Hospital Environment. Proc. 65th International Water Conference, Pittsburgh, PA, 2004. http://www.legionellae.org/HopkinsResearchPaperIWCOct04.pdf (Accessed on April 11, 2016).
  17. Jiang ZL, Zhang BM, Liang AH. A new sensitive and selective fluorescence method for determination of chlorine dioxide in water using rhodamine S. Talanta 2005; 66:783.
  18. Association for the Advancement of Medical Instrumentation. Water for hemodialysis and related therapies. ANSI/AAMI 13959: 2014 Association for the Advancement of Medical Instrumentation, Arlington, VA, 2014.
  19. Tao X, Hoenich N, Handelman SK, et al. Transfer of low-molecular weight single-stranded DNA through the membrane of a high-flux dialyzer. Int J Artif Organs 2014; 37:529.
  20. Schindler R, Beck W, Deppisch R, et al. Short bacterial DNA fragments: detection in dialysate and induction of cytokines. J Am Soc Nephrol 2004; 15:3207.
  21. Hasegawa T, Nakai S, Masakane I, et al. Dialysis fluid endotoxin level and mortality in maintenance hemodialysis: a nationwide cohort study. Am J Kidney Dis 2015; 65:899.
  22. Bommer J, Jaber BL. Ultrapure dialysate: facts and myths. Semin Dial 2006; 19:115.
  23. Section IV. Dialysis fluid purity. Nephrol Dial Transplant 2002; 17 Suppl 7:45.
  24. Ledebo I. Ultrapure dialysis fluid--how pure is it and do we need it? Nephrol Dial Transplant 2007; 22:20.
  25. EDTNA/ERCA guidelines: technical section. EDTNA ERCA J 2002; 28:107.
  26. Ray J. Microbiological monitoring of dialysis water systems--which culture method? J Ren Care 2007; 33:66.
  27. van der Linde K, Lim BT, Rondeel JM, et al. Improved bacteriological surveillance of haemodialysis fluids: a comparison between Tryptic soy agar and Reasoner's 2A media. Nephrol Dial Transplant 1999; 14:2433.
  28. Pass T, Wright R, Sharp B, Harding GB. Culture of dialysis fluids on nutrient-rich media for short periods at elevated temperatures underestimate microbial contamination. Blood Purif 1996; 14:136.
  29. Bolasco P, Contu A, Meloni P, et al. Microbiological surveillance and state of the art technological strategies for the prevention of dialysis water pollution. Int J Environ Res Public Health 2012; 9:2758.
  30. International Organization for Standardization. Water for hemodialysis and related therapies. ISO 13959. 2014 International Organization for Standardization, Geneva, 2014.
  31. Smeets E, Kooman J, van der Sande F, et al. Prevention of biofilm formation in dialysis water treatment systems. Kidney Int 2003; 63:1574.