Central Dialysis Fluid Delivery System Research Articles

Effect of Central Dialysis Fluid Delivery System (CDDS) using high flux dialyzer versus Regular Water Treatment Stations on Endotoxemia and Inflammatory Markers among Prevalent Patients on Regular Hemodialysis

Abstract Background and Objectives Translocated endotoxins derived either from intestinal bacteria or backfiltration, have a wide range of adverse effects on patients. Most end stage renal disease (ESRD) patients have systemic inflammation which increases the risk of morbidity and mortality. The central dialysis fluid delivery system (CDDS) has been used exclusively in Japan since 1960s, and now is being used in Ain Shams University. Our aim of the study is to evaluate the effect of (CDDS) versus single patient dialysis fluid delivery system (SPDDS) on endotoxemia and inflammatory markers among prevalent patients on regular hemodialysis (HD). Methods Eighty Patients were randomly selected from HD units, then divided into two groups, (group I) doing HD using CDDS water purification system at El Demerdash Hospital, (group II) using regular water purification system at Ain Shams University Specialized Hospital. Pre- dialysis and post-dialysis serum samples were obtained to measure endotoxin levels of both groups, as well as postdialysis serum samples were obtained to measure interleukin 6 (IL6) level and highly sensitive Creactive protein (Hs CRP). Results Circulating endotoxemia was most notable in group II, The mean predialysis endotoxin level in group I was 0.07 ± 0.05 Eu/mL, while in group II was 0.20 ± 0.07 Eu/mL and mean of post-dialysis endotoxin level in group I was 0.04 ± 0.02 Eu/mL, while in group II was 0.15 ± 0.03 Eu/mL. IL6 as well as Hs CRP levels were higher in group II in comparison to group I. Conclusion Our data showed significant reduction in circulating endotoxins in CDDS group.

Effect of central dialysis fluid delivery system using high flux dialyzer versus regular water treatment stations on endotoxemia and inflammatory markers among prevalent patients on regular hemodialysis

Effect of central dialysis fluid delivery system using high flux dialyzer versus regular water treatment stations on endotoxemia and inflammatory markers among prevalent patients on regular hemodialysis

Purification of central dialysis fluid delivery system for hemodialysis: practical training on the east kyushu medical valley project

Purification of central dialysis fluid delivery system for hemodialysis: practical training on the east kyushu medical valley project

Impact of Dialysis Fluid Delivery System on Anemia in Hemodialysis Patients

Background Patients on standard dialysis, in particular those on high-flux and high-efficiency dialysis, are exposed to hundreds of liters of dialysis-water per week. The quality of dialysis-water is a factor responsible for inflammation which is a potent trigger of atherosclerosis and a pathogenic factor in anemia, increasing mortality and morbidity in these patients. Current systems for water treatment do not completely eliminate bacteria and endotoxins. Our study tests if improved dialysiswater purity by using Central dialysis Fluid Delivery System (CDDS) can reduce inflammation and ameliorate hemoglobin levels. Aim of the Work The aim of this work is to compare between the effect of using Central Dialysis Fluid Delivery System (CDDS) and Single Dialysis Fluid Delivery System (SDDS) on Anemia in prevalent Hemodialysis Patients Patients and Methods This prospective observational cohort study was conducted between May 2019 and July 2019 and was conducted on 100 prevalent Hemodialysis Patient divided into 2 groups, each group included 50 patients, one group receiving Hemodialysis treatment using the central dialysis fluid delivery system (CDDS), while the other group receiving Hemodialysis treatment using the single-patient dialysis fluid delivery system (SPPDS). Results Endotoxin level in the dialysate fluid was found to be markedly lower in the CDDS group (0.05 EU/ml) compared to the SPDDS group (0.11 EU/ml). Baseline CRP level didn’t differ significantly between both groups (P-value: 0.88), however throughout the follow up period patients who were on dialysis using the CDDS showed a sustained significant decrease in CRP level compared to those using the SPDDS (P-value: <0.001 for the 3m follow up period), denoting improvement of their chronic inflammatory status. Baseline hemoglobin level didn’t differ significantly between both groups (P-value: 0.52), however throughout the follow up period patients who received dialysis using CDDS showed a sustained significant increase in their hemoglobin level, while those receiving dialysis using SPDDS showed no significant change in their hemoglobin level, also hemoglobin level in the CDDS Group was higher than in the SPDDS group at 1st, 2nd and 3rd months. (P-value: 0.008, <0.001 and <0.001 for the follow up month 1, 2 and 3 respectively). Using URR as an indicator for efficiency of the HD session, there was no statistically significant difference between both groups among three months of follow-up. Conclusion Ultrapure dialysis fluid (UPD) produced by the Central dialysis

Impact of Water Treatment on Anemia in Hemodialysis Patients.

The microbiological quality of water in the dialysate used in hemodialysis has been suggested as a contributor to inflammation, and a link between dialysate purity, inflammation, and responsiveness to erythropoietin therapy has been suggested in many studies. The level of endotoxin might induce inflammation and resistance to erythropoietin therapy in dialysis patients. We aimed to compare the effect of using the central dialysis fluid delivery system (CDDS) versus the single-patient dialysis fluid delivery system (SPDDS) on anemia in prevalent hemodialysis patients. In a prospective cohort study, 100 adult prevalent hemodialysis patients with T-SAT ≥20% were divided into two equal groups: CDDS and SPDDS. Endotoxin in water sample and routine investigations (hemoglobin, serum Ca+, serum Po4-, PTH, and urea level) were done. CRP, erythropoietin resistivity index (ERI), and erythropoietin stimulating agents (ESAs) doses were assessed repeatedly to assess inflammatory and anemia states. Endotoxin level in the dialysis fluid of the CDDS group was significantly lower compared to the SPDDS group (0.05 vs. 0.11 EU/ml, P = 0.001). CRP level decreased significantly after 3 months in the CDDS group (P < 0.001) compared to the SPDDS group (P = 0.54), with significant improvement in the hemoglobin level and ERI at 3 months in the CDDS group and decrease in ESA requirements. Improvement in dialysis liquid purity reduces inflammatory markers in prevalent hemodialysis patients, improves ERI, and decreases ESA requirements in renal anemia.

Effectiveness of combination of heat water disinfection, continuous water circulation, and minimalized dead space for dialysis piping in maintaining ultrapure dialysis fluid and preventing biofilm formation in a central dialysis fluid delivery system.

Various benefits have been attached to purifying the dialysis fluid used for hemodialysis therapy. The central dialysis fluid delivery system can treat approximately 50 dialysis patients simultaneously and is convenient to operate. In contrast, the dialysis fluid supply piping is complicated, and bacterial growth can cause biofilms. This study aimed to develop sustainable cleaning strategies to solve the complicated dialysis fluid piping, which is a weakness of the central dialysis fluid delivery system, and provide ultrapure dialysis fluid for a long term. Combination of heat water disinfection, continuous water circulation, and minimalized dead space in the dialysis piping were designed for a central dialysis fluid delivery system and used in a clinic for 6years. As an index of water purification, endotoxin concentrations and microbial colony counts in reverse osmosis water and dialysis fluid were measured. In addition, we performed scanning electron microscopy of the silicon tube surface that had been used for 5years to confirm the presence or absence of biofilm formation. For 6years, endotoxin concentrations and microbial colonies were not detected in reverse osmosis water and dialysis fluid using the multiple-patient dialysis fluid supply equipment. The purity of the dialysis fluid was maintained. No biofilm formation was observed by scanning electron microscopy. Combination of heat water disinfection, continuous water circulation, and minimalized dead space designs for dialysis piping can supply ultrapure dialysis fluid with minimal biofilm formation in the piping in the long term.

Effect of Central Dialysis Fluid Delivery System (CDDS) on IL6 &amp; CRP Levels in Prevalent Haemodialysis Patients

Abstract Background Dialysis is a chronic inflammatory state due to both decreased renal clearance and increased production of procytokines, moreover extracorporeal factors, such as impurities in dialysis water,etc. The central dialysis fluid delivery system (CDDS) is a cost-effective, laborsaving, time-tested system with good microbial safety, which has been used for 45 years in many countries &amp; this study, studies the effect of (CDDS) on IL6 &amp; hs-CRP levels in prevalent hemodialysis patients. Aim of the Work To compare the effect of central dialysis fluid delivery system (CDDS) versus single-patient dialysis fluid delivery system (SPDDS) in purification of water that used in dialysate and its effect on inflammatory markers (hs-CRP &amp; IL-6) levels in prevalent hemodialysis patients. Patients and Methods A Case control study that was conducted on 100 patients of end-stage renal disease on hemodialysis in a university-affiliated hospital. Patients were classified into two groups, each included 50 patients; group (1) receiving regular dialysis by central dialysis fluid delivery system (CDDS), while group (2) receiving regular dialysis by single patient dialysis fluid delivery system (SPDDS) . Patients underwent full clinical assessment including thorough history taking, clinical examination, routine investigation, IL-6 and hsCRP testing to all patients. Results One hundred prevalent hemodialysis patients were included in this study. In this study, the levels of IL-6 and hs-CRP were found to be significantly higher in group 2 (SPDS) as compared to group 1 (CDDS). Conclusion In conclusion, central dialysis fluid delivery system (CDDS) seems to have a better effect on systemic inflammation (IL-6 and hsCRP) as compared with single-patient dialysis fluid delivery system (SPDDS). There is a statistically negative correlation between serum IL-6 and hsCRP levels with dry weight, Hemoglobin level, serum creatinine level &amp; serum albumin level for group (1) (CDDS). However, there is a statistically positive correlation between serum IL-6 and hsCRP levels with Total Leuckocytic Count (TLC), serum ferritin level, serum potassium level, weight gain and duration of dialysis for group (2) (SPDS).

Assessment of an Automatic Hot Water Sterilizing System-Equipped Dialysis Supply Device's Circuit Degradation, 7 Years Postinstallment.

At most dialysis clinics in Japan, a central dialysis fluid delivery system (CDDS) is used primarily to provide consistent treatment to patients. We incorporated hot water disinfection to a CDDS over a 7 year period, after which we assessed the dialysis purification levels. We observed that adequate levels had been maintained. We rated the internal circuits of the device at the 7 year mark, comparing the insides of both the used and unused new Synflex tubing, silicone blades, Teflon tubing, silicone rubber tubing, and stainless steel parts. No bacteria or contamination (such as endotoxins) was detected, and no degradation or damage were observed. Even after the auto-hot water disinfection system was installed, no internal tubing degradation due to hot water or mechanical issues have occurred, and the system's dialysis fluid purification levels have been maintained.

Purification for dialysis fluid in Central Dialysis fluid Delivery System

Purification for dialysis fluid in Central Dialysis fluid Delivery System

MON-099 Particulates mixed in dialysate

When foreign bodies that cannot be metabolized enter the systemic circulation, they remain in the body and are often difficult to remove. Therefore, each country’s pharmacopoeia measures insoluble particulates that are unintentionally mixed into injections and manages quality control by the predetermined permissible range of insoluble particulates. However, the present Standard of Fluids for Hemodialysis and Related Therapies only stipulates the water quality standard for biological and chemical contaminants, but there is no standard for insoluble particulates in dialysate. We measured insoluble particulates in online prepared substitution fluid prepared from dialysate and substitution fluid for hemofiltration and evaluated the insoluble particulates using scanning electron microscopy/energy dispersive spectroscopy. We measured insoluble particulates in online prepared substitution fluid prepared by filtering dialysate using an endotoxin retentive filter installed in the central dialysis fluid delivery system and commercially-available substitution fluid for hemofiltration. We used the Light Obscuration Particle Count Test for measurement, as stipulated by Japanese pharmacopoeia. We evaluated the constituent elements of insoluble particulates using scanning electron microscopy/energy dispersive spectroscopy. We also measured silicon contained in reverse osmosis water used to prepare dialysate in the central dialysis fluid delivery system and substitution fluid for hemofiltration. The mean number of particles of ≥ 10 μm contained in the online prepared substitution fluid was 0.1–1 /mL and 0–0.1 /mL for particles of ≥ 25 μm. Insoluble particulate elements included carbon, oxygen, calcium, magnesium, and silicon. The silicon content of reverse osmosis water was 0.5 mg/L. The mean number of particles of ≥ 10 μm contained in substitution fluid for hemofiltration was 0.5 /mL, with no particles ≥ 25 μm. These insoluble particulates were composed of carbon and oxygen. The silicon content was 0.1 mg/L. Japanese pharmacopoeia stipulates that the number of insoluble particulates in 1 mL of injection fluid must be 25 or fewer for particles of ≥ 10 μm and 3 or fewer for particles of ≥ 25 μm. The numbers of insoluble particles in online prepared substitution fluid and substitution fluid for hemofiltration were within permissible ranges, as stipulated by Japanese pharmacopoeia. We presume that insoluble particulates in online prepared substitution fluid were calcium and magnesium precipitated from dialysate and silicon precipitated from reverse osmosis water. The insoluble particulates in the substitution fluid for hemofiltration were carbon and oxygen, which were presumed to be components of glucose based on the composition of hemofiltration substitution fluid.

A Perspective on the Current Status of Home Hemodialysis.

Most hemodialysis (HD) in Japan is based on the central dialysis fluid delivery system (CDDS). With CDDS, there is an improvement in work efficiency, reduction in cost, and a reduction in regional and institutional differences in dialysis conditions. This has resulted in an improvement in the survival rate throughout Japan. However, as the number of cases with various complications increases, it is necessary to select the optimal dialysis prescription (including hours and frequency) for each individual in order to further improve survival rates. To perform intensive HD, home HD is essential, and various prescriptions have been tried. However, several challenges remain before widespread implementation of home HD can occur.

Preparation and Quality Management of Fluids for Hemodialysis.

In 2008, the Japanese Society for Dialysis Therapy (JSDT) proposed a standard for the quality of fluids for hemodialysis. The standard was geared toward Japan, where the central dialysis fluid delivery system is routinely used. After establishment of the standard, dialysis fluid quality was markedly improved in facilities across the country. Moreover, the number of on-line hemodiafiltration patients dramatically increased. However, the 2008 standard specifies only microbiological qualities and does not cover toxic chemicals. The basis of toxic chemical management depends on the source water and water treatment equipment for hemodialysis, but no standard applies to water treatment equipment as a medical device. Specifications for the equipment were, for the most part, entrusted to individual manufacturers. Key Messages: The JSDT is investigating revision of its standard for dialysis fluid quality for hemodialysis to add control standards for toxic chemicals and water treatment equipment, with the aim of achieving quality of dialysis water superior to that of terminal dialysis fluid.

The central dialysis fluid delivery system (CDDS): is it specialty in Japan?

The central dialysis fluid delivery system (CDDS) simplifies the maintenance and supervision involved by enabling the combined management of dialysis fluid for multiple persons, preparation of cleaning and antiseptic solutions, and delivery of these to each patient monitor. The CDDS has been used exclusively in Japan since 1960s. Approximately 88 % of dialysis machines are patient monitors with CDDS. It is a cost-effective, laborsaving, time-tested system with good microbial safety, which has been used for 45 years. In many countries, especially in Asia, the number of end-stage renal disease (ESRD) patients is increasing. The CDDS will contribute to such emerging situations with its easy handling and economic advantages.

Current topics of purification and constitutions of dialysis fluid.

Dialysis fluid is a fundamental component of hemodialysis treatment, and its roles include the correction of electrolyte levels, pH, and osmolality, as well as the removal of uremic solutes from the blood of patients with renal failure. In recent years, purification of dialysis fluid has become essential due to the use of high-flux membrane dialyzers. Therefore, rigorous standards have been established for the purification of dialysis fluid, which is becoming widely practiced in Japan. The effects of dialysis fluid purification include the prevention of micro-inflammation, preservation of residual renal function, improvement of nutritional status, and resolution of resistance to erythropoiesis-stimulating agents. When purifying the dialysis fluid used in the central dialysis fluid delivery system, validation of the system is also important. Dialysis fluid that does not contain acetate has become available, and there have been reports of decreased micro-inflammation, etc., with this innovation. In addition, dialysis fluid containing a higher concentration of bicarbonate than is conventionally employed has become available. Although correction of acidosis remains important, excess alkalosis may reportedly worsen the survival prognosis of hemodialysis patients. Sufficient attention should be paid to these issues.

Dialysate Purification After Introduction of Automated Hot Water Disinfection System to Central Dialysis Fluid Delivery System

Most dialysis clinics in Japan have mainly adopted the central dialysis fluid delivery system (CDDS) to provide constant treatment to many patients. Chemical disinfection is the major maintenance method of the CDDS. Our clinic introduced an automated hot water disinfection system that used the heat conduction effect to disinfect a reverse osmosis (RO) device and dialysis fluid supply equipment. Endotoxin level and the amount of viable bacteria often showed abnormal values before introduction of this system. After its introduction, weekly disinfection resulted in endotoxin levels and the amount of viable bacteria lower than measurement sensitivity. In hot water disinfection, water heated to 90°C in the RO tank flows into the dialysis fluid supply equipment. The maximum temperature inside the tank of the supply equipment is 86.3°C. (We confirmed that the temperature was maintained at 80°C or more for 10 minutes or more during the monitoring.) Dialysate purification was maintained even after introduction of the automated hot water disinfection system and the dialysate could be supplied stably by the CDDS. Therefore, this disinfection system might be very useful in terms of both cost and safety, and can be used for dialysis treatment of multiple patients.

Experience of using heat citric acid disinfection method in central dialysis fluid delivery system

We applied the heat citric acid disinfection method in the main part of the central dialysis fluid delivery system (MPCDDS), which consists of a multiple-patient dialysis fluid supply unit, dialysis console units, and dialysis fluid piping. This disinfection method has been used for single-patient dialysis machines, but this is the first trial in the MPCDDS. We examined, by points of safety and disinfection effect, whether this disinfection method is comparable to conventional disinfection methods in Japan. The conventional disinfection method is a combination of two disinfectants, sodium hypochlorite and acetic acid, used separately for protein removal and decalcification. Consequently, total microbial counts and endotoxin concentrations fully satisfied the microbiological requirements for standard dialysis fluid of ISO 11663. From our results and discussion, this heat citric acid disinfection method is proved to be safe and reliable for MPCDDS. However, to satisfy the microbiological requirements for ultrapure dialysis fluid, further consideration for this method in MPCDDS including the reverse osmosis device composition and piping is necessary.