National kidney foundation report on dialyzer reuse

Abstract

The Council on Dialysis of the National Kidney Foundation convened an expert panel to evaluate the current practice and literature related to the reuse of hemodialyzers. The panel reviewed and evaluated literature related to reuse since the last report of the National Kidney Foundation recommendations on reuse was published in 1988. The group sought to develop a consensus concerning the effect of reuse of hemodialyzers on mortality; the efficiency of delivered hemodialysis when reused hemodialyzers are used in the clinical setting; the clinical effects of reused dialyzers as compared with dialyzers not reused on intradialytic symptoms; infections in patients using reused dialyzers; and the effect of reused dialyzers on complement activation, cytokine production, and β 2-microglobulin metabolism and clearance. In addition, the panel reviewed the literature on the potential toxicity of germicides used in the processing of dialyzers for reuse as well as recent changes in federally mandated regulations concerning labeling of dialyzers for reuse, the monitoring of the reuse process, and the effectiveness of reused dialyzers to achieve a prescribed delivered clearance as estimated by urea kinetic modeling or by percent urea reduction. The National Kidney Foundation takes no position for or against dialyzer reuse. The principal reason for the practice of reuse is economical. In view of the uncertainties related to the safety and biological impact of reuse procedures, the task force recommends that a full discussion of the issue of reuse and its potential beneficial and detrimental effects be undertaken with each patient. There is no conclusive evidence to substantiate the notion that either morbidity or mortality associated with single use or reuse is different. Microbial contamination of the water used for dialyzer reprocessing increases patient morbidity. The chemical quality of water used for dialyzer reprocessing should, at least, fall within the same standards as those recommended for product water intended for hemodialysis. Dialyzers should not be reprocessed from patients who have tested positive for hepatitis B surface antigen. The effects of reprocessing high-flux dialyzers on β 2-microglobulin clearance are dependent on the reprocessing technique, the number of reuses, and the nature of the dialyzer membrane used. There are insufficient data on the effects of reuse on β 2-microglobulin behavior to make uniform recommendations. Untoward effects of reused dialyzers may still occur in spite of rigorous adherence to the AAMI guidelines. For example, use of the total cell volume method for assessing changes in small molecule clearances will not show the loss of performance attributable to dialysate shunting. For this reason, the measurement of Kt/V for urea as recommended by the AAMI or the determination of the urea reduction ratio (URR) is strongly recommended at least monthly to gauge the adequacy of the dialysis procedure. Given the significant fall in dialyzer efficiency for urea removal that can occur after repeated uses of a dialyzer, dialysis prescriptions in units practicing reuse should be designed to deliver a Kt/V or URR value that exceeds the dose used for patients treated with single-use dialyzers to make allowance for any possible reuse-induced reduction in dialyzer efficiency. Technicians and other personnel responsible for the reprocessing of dialyzers should receive proper training. These health care providers should be certified in reprocessing by an examining body so that professional competency can be assured.