The importance of pure water in Dialysis

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The importance of pure water in Dialysis
Joey Smith Universitas Renal Unit
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Introduction

• During the early days of dialysis the need to
  purify water was not recognized
• Early seventies it was discovered that
  bacterimia or pyrogenic reactions in HD were
  associated with high bacterial count
• Since then the increase pt survival revealed
  many acute and chronic toxic consequences of
  inadequate treated water
• Dialysis practices require particularly clean
  dialysis water
• Tap water is generally not of sufficient quality
  for HD
• Water quality for HD must be more stringent than
  for drinking water

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Introduction (cont.)

• Regulations and standards for drinking water
  calculated on water intake of 14 liters per week
• HD pts are exposed to approximately 360 liters
  per week
• Contaminants in dialysis fluid must only
  penetrate the non-selective semi-permeable
  dialyser membrane
• A healthy person excretes toxic substances by
  the kidney but this is not so for the end-stage
  renal failure patient
• Strict microbiological and chemical standards
  specifically for dialysis water are demanded
  today.

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Clinical consequences of poor water

• Poor water have clinical consequences for the
  dialysis pt
• Common contaminants classified as chemical or
  microbial
• Chemicals interfere with the maintenance of the
  body and
• can be toxic
• Low concentrations of some electrolytes can be
  physiologically
• unsafe
• Contaminants can be devided into 2 groups
• 1 - Ions
• 2 - Trace elements

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Clinical consequences of poor water(cont.)
Ions
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Clinical consequences of poor water (cont.)
Trace elements
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Water treatment systems

• Pre-treatment consisting of filters, softener,
  activated carbon
• filter and micro filters.
• Primary treatment involving one or more reverse
  osmosis
• devices and optionally a de-ioniser.
• Post treatment of dialysis water and fluid with
  a storage tank,
• submicronic filters, ultraviolet treatment and
  ultrafiltration.

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Water treatment systems (cont.)

• Filters remove particles particle size exclusion
  at a porous
• medium or membrane
• Softening is necessary to avoid hard water
  syndrome
• Chlorine added to water to prevent bacterial
  contamination
• This must be removed by passing water through
• granulated active carbon filters
• An activated carbon filter is good breeding
  ground for bacteria
• Reverse osmosis is a separation process
• Pressure is applied to the water to force it
  through a semi-permeable membrane
• Pre-treated water which passed through a RO
  filter is safe for dialysis use.

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Conclusion

• The chronic HD patient exposed to nearly 400 l
  per week
• Studies performed reveal that water is often
  contaminated
• with bacteria and their products
• Chemical contamination - agricultural processes,
  industrial
• pollution, supplements added
• Naturally occurring, water-borne fungi, yeast,
  bacteria and
• products thereof pollute hemodialysis water
• Most commonly found microorganisms are
  gram-negative
• bacteria - pseudomonas group

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Conclusion (cont.)

• Clinical consequences of contamination depend on
  the quantity and quality
• Mild symptoms to chronic diseases up to death
• The function and quality of water in the
  treatment system
• must be tested regularly
• Chemical contamination can be avoided with
  appropriate
• devices and a stringent quality control
• The quality of water used has been recognized as
  a major issue in Good Dialysis Practice.

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Thank you for you time