Maintaining water quality for hemodialysis
- Nicholas Hoenich, PhD
Nicholas Hoenich, PhD
- Honorary Lecturer
- Institute of Cellular Medicine, Newcastle University
- Richard A Ward, PhD
Richard A Ward, PhD
- Professor of Medicine
- University of Louisville
INTRODUCTION AND BACKGROUND
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 a properly designed and maintained water treatment system to safeguard patients .
- 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.
- 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.
- Water System Flow Diagram/Critical Water and Dialysate Requirements: Two-page summary of the ANSI/AAMI RD 62 water and dialysate requirements and a diagram of a typical water system (Version 1.2). https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Dialysis.html (Accessed on April 23, 2014).
- Dunsmore BC, Jacobsen A, Hall-Stoodley L, et al. The influence of fluid shear on the structure and material properties of sulphate-reducing bacterial biofilms. J Ind Microbiol Biotechnol 2002; 29:347.
- Soini SM, Koskinen KT, Vilenius MJ, Puhakka JA. Effects of fluid-flow velocity and water quality on planktonic and sessile microbial growth in water hydraulic system. Water Res 2002; 36:3812.
- Libman V. Use of Reynolds number as a criteria for design of high-purity water systems. Ultrapure water 2006; 23:26.
- 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.
- 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.
- 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.
- 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.
- 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).
- Hoenich NA. Disinfection of the hospital water supply: a hidden risk to dialysis patients. Crit Care 2009; 13:1007.
- Association for the Advancement of Medical Instrumentation. Water for hemodialysis and related therapies. ANSI/AAMI/ISO 13959: 2009 Association for the Advancement of Medical Instrumentation, Arlington, VA, 2011.
- Bommer J, Jaber BL. Ultrapure dialysate: facts and myths. Semin Dial 2006; 19:115.
- Section IV. Dialysis fluid purity. Nephrol Dial Transplant 2002; 17 Suppl 7:45.
- Ledebo I. Ultrapure dialysis fluid--how pure is it and do we need it? Nephrol Dial Transplant 2007; 22:20.
- EDTNA/ERCA guidelines: technical section. EDTNA ERCA J 2002; 28:107.
- Ray J. Microbiological monitoring of dialysis water systems--which culture method? J Ren Care 2007; 33:66.
- 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.
- 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.
- 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.
- Smeets E, Kooman J, van der Sande F, et al. Prevention of biofilm formation in dialysis water treatment systems. Kidney Int 2003; 63:1574.
- INTRODUCTION AND BACKGROUND
- COMPONENTS OF QUALITY MANAGEMENT PROGRAM
- MAINTENANCE PRACTICES
- DISINFECTION OF WATER DISTRIBUTION PIPING
- Methods of monitoring water quality
- - On-line measurements
- - Off-line measurements
- Carbon media
- Reverse osmosis
- CHEMICAL CONTAMINANT LEVEL MEASUREMENTS
- Chlorine and chloramine
- MICROBIAL CONTAMINANT LEVEL MEASUREMENTS
- Sample collection
- Analytical methods
- - Sample plating
- Membrane filtration
- Spread plate technique
- Pour plate technique
- - Sample culture
- ACTION IN RESPONSE TO DETECTED PROBLEMS
- MAINTENANCE AND MONITORING SCHEDULES AND DOCUMENTAION
- MAINTAINING WATER QUALITY IN NONDIALYSIS UNIT SETTINGS
- SUMMARY AND RECOMMENDATIONS