Water purification systems in 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
The different water purification systems used in hemodialysis are reviewed here. Discussions concerning the waterborne contaminants to which hemodialysis patients are exposed and the methods of monitoring water purification systems used in hemodialysis are presented separately. (See "Contaminants in water used for hemodialysis" and "Maintaining water quality for hemodialysis".)
RATIONALE FOR WATER PURIFICATION SYSTEMS
All dialysis facilities require a properly designed and maintained water treatment system to safeguard patients . No municipal water can be considered safe for use in hemodialysis applications in the absence of a treatment system since some of the most toxic contaminants arise from municipal water treatment practices.
Hemodialysis patients are particularly vulnerable to contaminants in the water used to prepare concentrate and dialysis fluid, or in water used for reprocessing dialyzers (see "Reuse of dialyzers", section on 'Reprocessing techniques'). This vulnerability is due to the following:
●Since water is the major constituent of dialysis fluid, compared with individuals who are not on hemodialysis, 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 such 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 molecular or particulate size of the contaminant.
- 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.
- International Organization for Standardization. Water Treatment Equipment for Hemodialysis and Related Therapies, ISO 26722:2009, International Organization for Standardization, Geneva 2009 http://www.iso.org/iso/home/store/catalogue_tc/catalogue_detail.htm?csnumber=43700 (Accessed on February 09, 2014).
- Association for the Advancement of Medical Instrumentation, Water Treatment Equipment for Hemodialysis and Related Therapies, ANSI/AAMI/ISO 26722:2009, Association for the Advancement of Medical Instrumentation, Arlington, VA 2011 http://my.aami.org/store/detail.aspx?id=26722 (Accessed on February 09, 2014).
- International Organization for Standardization. Water for Hemodialysis and Related Therapies, ISO 13959:2009, International Organization for Standardization, Geneva 2009. http://www.iso.org/iso/home/store/catalogue_ics/catalogue_detail_ics.htm?csnumber=43699 (Accessed on February 09, 2014).
- 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. http://my.aami.org/store/detail.aspx?id=13959 (Accessed on February 09, 2014).
- European best practice guidelines for haemodialysis (Part 1). Nephrol Dial Transplant 2002; 17(Suppl 7):50.
- Kawanishi H, Masakane I, Tomo T. The new standard of fluids for hemodialysis in Japan. Blood Purif 2009; 27 Suppl 1:5.
- Tokars JI, Miller ER, Alter MJ, Arduino MJ. National surveillance of dialysis associated diseases in the United States, 1995. ASAIO J 1998; 44:98.
- Arnow PM, Bland LA, Garcia-Houchins S, et al. An outbreak of fatal fluoride intoxication in a long-term hemodialysis unit. Ann Intern Med 1994; 121:339.
- Pérez-García R, Rodríguez-Benítez P. Chloramine, a sneaky contaminant of dialysate. Nephrol Dial Transplant 1999; 14:2579.
- Calderaro RV, Heller L. [Outbreak of hemolytic reactions associated with chlorine and chloramine residuals in hemodialysis water]. Rev Saude Publica 2001; 35:481.
- Junglee NA, Rahman SU, Wild M, et al. When pure is not so pure: chloramine-related hemolytic anemia in home hemodialysis patients. Hemodial Int 2010; 14:327.
- Meyer MA, Klein E. Granular activated carbon usage in chloramine removal from dialysis water. Artif Organs 1983; 7:484.
- Farmer RW, Kovacic SL. Catalytic activated carbon offers breakthrough for dialysis water treatment. Dial Transplant 1997; 26:771.
- 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.
- 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.
- RATIONALE FOR WATER PURIFICATION SYSTEMS
- CHOOSING A WATER TREATMENT SYSTEM
- WATER PURIFICATION PROCESSES
- Reverse osmosis
- Carbon filtration
- Other purification processes
- - Softeners
- - Filters
- WATER STORAGE AND DISTRIBUTION
- ASSEMBLING A WATER TREATMENT SYSTEM
- WATER TREATMENT FOR HOSPITAL BEDSIDE DIALYSIS MACHINES
- SUMMARY AND RECOMMENDATIONS