Dialysis Water Research Articles

The Effect of Bacterial DNA and Hemodialysis Therapy Conditions on Interleukin 6 Levels Variation in End-stage Renal Disease Patients

Hemodialysis (HD) is the most common therapy to treat end-stage renal disease (ESRD) patients. That is used to clear blood from metabolism end products and maintain water and electrolyte balance in patients’ body when failed kidneys unable to do that. Patient’s blood contact via dialysis filter (dialyzer) about 400 L of dialysis fluid that is mainly form of water and some electrolyte, this quantity of fluid contact can stimulate the production of pre-inflammatory markers due to carrying pathogens such as bacterial DNA fragments even in small quantity that can pass all filters to bloodstream stimulating production of IL-6. A total of 90 blood samples were collected from 45 patients under hemodialysis therapy in Baghdad Teaching Hospital, Gazy Alhariry general hospital, Al-khayal private hospital and Al-Muayad private hospital before and after 3 hours of HD therapy to detect IL-6 by ELISA technique. And from the same centers dialysis fluid and water samples were collected to detect bacterial DNA fragments. PCR technique using 16s universal bacterial primer showed presence of bacterial DNA fragments in dialysis fluid and water used to prepare it.The ELISA readings showed a variety in IL-6 levels higher in patients with low ultrafiltration UF rate than its level in patients with high UF and generally, the level of IL-6 in patients treated in centers with DF preparation direct water distribution system were lower than its level in patients treated in centers with indirect water distribution systems.

Determination of aluminum concentrations in biological specimens: application in the clinical laboratory.

Aluminum enters the body primarily through diet or occupational exposure, and is cleared through urine. However, this trace element may accumulate and cause toxicity in subjects with renal insufficiency, and even in dialysis patients. The mechanism of aluminum toxicity is related to increased oxidative and inflammatory stress, iron and calcium dyshomeostasis, or cholinergic dysregulation, among other. A review was conducted on the specimens and analytical methods used to determine aluminum in biological specimens and dialysis water. This paper describes the most relevant aspects related to quality assurance. This is a practical guideline for the development and implementation of a reliable method for determination of aluminum in the clinical laboratory. Serum aluminum is the main biomarker of toxicity. For cases of chronic exposure, urine testing is recommended. At present, inductively coupled plasma mass spectrometry (ICP-MS) is the gold-standard determination method, since it has been proven to have the best quantification limits, selectivity and robustness. Clear recommendations are provided in relation to the specimens used for aluminum determination. Relevant pre-analytical, analytical, and post-analytical considerations are also presented.

Dialysis Water Quality and Its Impact on Maintenance for the Hemodialysis Community

The quality of water for hemodialysis (HD) is a concern for all dialysis centers because of its impact on the health of HD patients. There are guidelines by the Association for the Advancement of Medical Instrumentation (AAMI) for maximum limits for chemical contaminants, bacterial colony-forming units, and endotoxin limits. But some of the contaminants like fungus and algae are still missing from guidelines. Impurities in dialysis water can lead to many health issues among the HD community and it can increase the mortality rate as well. The present paper focuses on the different contaminants in dialysis water and their health impacts on the HD community.

Particulates formed in online prepared substitution fluid-Effect of acetic acid cleaning on endotoxin retentive filters.

There is no standard for insoluble particulate matters in dialysate. We evaluated the insoluble particulate matters in online prepared substitution fluid. We evaluated particle diameters and constituent elements of particles in online prepared substitution fluid and the final endotoxin retentive filter (ETRF). The measurement results with particles in the online prepared substitution fluid and particles attached to the final ETRF revealed that Ca-containing particles accounted for 11 particles and Si-containing particles accounted for 19 particles of 30 particles detected in the online prepared substitution fluid and the final ETRF. We presume that insoluble particulates in online prepared substitution fluid were Ca and Mg precipitated from dialysate and Si precipitated from dialysis water. Even if two ETRFs were connected in series, these particles were formed in the final ETRF.

Quality of dialysis water and dialysate in haemodialysis centres: Highlight for occurrence of non-fermenting gram-negative bacilli.

To evaluate the physicochemical and microbiological quality of dialysis water and dialysate samples from haemodialysis centres. Samples were fortnightly collected from three haemodialysis centres in Bauru City, Brazil, between July 2017 and June 2018, at the stages of post-reverse osmosis, reuse and dialysate. Analyses included determination of conductivity, fluoride, nitrate and sulphate; test for total coliform bacteria; count of heterotrophic bacteria; count and identification of non-fermenting gram-negative bacilli (NFGNB); drug susceptibility test; biofilm formation capacity; and genetic similarity among some isolated NFGNB. Of the analysed samples, only 4/72 (5.6%) had conductivity values ≥10 mS/cm, 4/216 (1.9%) presented total coliforms and 1/216 (0.5%) had heterotrophic bacteria count >100CFU/ml. NFGNB were isolated from 99/216 (45.8%) samples, and the major identified micro-organisms included Herbaspirillum aquaticum/huttiense, Brevundimonas aurantiaca, Cupriavidus metallidurans, Pseudomonas aeruginosa and Ralstonia insidiosa. Isolates of P. aeruginosa and Burkholderia cepacia complex were sensitive to most antimicrobials and, together with isolates of Ralstonia insidiosa and Ralstonia pickettii, showed strong biofilm formation capacity. Some isolates expressed the same electrophoretic profile on pulsed-field gel electrophoresis, indicating the persistence of bacterial clones in the systems over time. NFGNB were observed in several dialysis water and dialysate samples from all investigated centres, which may represent a risk to the health of patients. Regular inclusion of actions for NFGNB control and monitoring in haemodialysis fluids are suggested for greater safety of the dialytic process.

Basic prerequisites for on-line, high-volume hemodiafiltration.

High-volume hemodiafiltration involves filtration of >23 L/treatment and its replacement by sterile non-pyrogenic substitution fluid, while maintaining the patient's fluid balance. That volume of substitution fluid precludes the use of prepackaged sterile fluid. Instead, substitution fluid must be prepared on-line using machines that incorporate a series of bacteria- and endotoxin-retentive filters. The sterilizing ultrafilters are validated to deliver sterile, non-pyrogenic fluid to the patient when operated according to the machine manufacturer's instructions and in compliance with international standards and regulatory oversight. A successful hemodiafiltration program also places important responsibilities on the user. Specifically, the user is responsible for ensuring that the dialysis water or dialysis fluid delivered to the sterilizing filters of the hemodiafiltration machine meets the machine manufacturer's specifications and is consistent with the quality used in the sterilization validation process. The user is also responsible for ensuring that the treatment prescription allows a filtration volume >23 L/treatment to be achieved by careful selection of a dialyzer, blood flow rate and treatment time. Questions related to assurance that the substitution fluid will routinely be sterile and non-pyrogenic have limited the uptake of on-line hemodiafiltration as a therapeutic option in some countries, such as the United States.

Mixed Matrix Membranes Adsorbers (MMMAs) for the Removal of Uremic Toxins from Dialysate.

We developed Mixed Matrix Membrane Adsorbers (MMMAs) formed by cellulose acetate and various sorbent particles (activated carbon, zeolites ZSM-5 and clinoptilolite) for the removal of urea, creatinine and uric acid from aqueous solutions, to be used in the regeneration of spent dialysate water from Hemodialysis (HD). This process would allow reducing the disproportionate amount of water consumed and permits the development of closed-loop HD devices, such as wearable artificial kidneys. The strategy of MMMAs is to combine the high permeability of porous membranes with the toxin-capturing ability of embedded particles. The water permeability of the MMMAs ranges between 600 and 1500 L/(h m2 bar). The adsorption of urea, the limiting toxin, can be improved of about nine times with respect to the pure cellulose acetate membrane. Flow experiments demonstrate the feasibility of the process in a real HD therapy session.

Waterborne Outbreaks in Hemodialysis Patients and Infection Prevention.

Individuals treated with dialysis are at high risk for healthcare-associated infections. We conducted a literature review of outbreaks associated with water in hemodialysis during years 2011–2021 to understand the role of water as a source of infections for patients receiving hemodialysis with a focus on the risks associated with dialysis water and dialysate. For dialysis patients, water and dialysate have been a source of healthcare-associated pathogens, including nontuberculous mycobacteria and gram-negative bacilli as well as systemic reactions due to gram-negative bacilli–associated endotoxin. Lapses in infection prevention practices and dialysis water management were primarily involved in waterborne outbreaks. Dialysis clinics should adhere to recommendations regarding monitoring and levels of bacteria and endotoxin in hemodialysis water and dialysate. Since hemodialysis patients are at increased risk of healthcare-associated infections, it is important for healthcare personnel to adhere to infection prevention guidelines in hemodialysis patient care, especially hand hygiene, aseptic technique, cleaning/disinfection, and water management.

Accessibility and quality of haemodialysis services in an urban setting in South India: a qualitative multiperspective study

ObjectiveTo explore the accessibility and quality of existing haemodialysis services in an urban setting.SettingThe study was conducted in Bangalore city, India.ParticipantsA total of 28 stakeholders including 2 nephrologists, 7 duty...

Water treatment for hemodialysis in Baghdad medical city, Iraq

AbstractWater quality for dialysis fluid is an important consideration for dialysis patients. As a result, strict monitoring of water quality is required to avoid complications and ensure the safety and health of patients. The current study aimed to determine the water quality used in hemodialysis treatment centers. Twenty water samples were collected and analyzed from three hospitals in Baghdad's medical city over four seasons. Counts of bacteria and chemical contaminants were determined in raw and dialysis water from each of four dialysis centers. After collecting samples, bacteriological and chemical analyses were performed in the laboratory. Results show that the quality of dialysis water fluctuates, making it unacceptable when compared to international standards. Bacterial counts were above the maximum value of 100 CFU/ml in 50% of the samples tested. Chemical analysis showed that the dialysis water quality suffers from elevated free chlorine concentrations in some dialysis centers. Also, there were no significant differences between the measured parameters in the dialysis water at four treatment centers during the study period at p < 0.05. Hemodialysis centers require constant monitoring, maintenance, and the development of water treatment systems to ensure optimum water quality. Additional disinfection is essential in order to prevent bacterial growth and biofilm formation.

MANAGEMENT OF WATER QUALITY IN SOME DIALYSIS CENTRES IN GIZA GOVERNORATE HOSPITALS, EGYPT

Dialysis patients are exposed to more than 40 times more water per week than healthy individuals drink. Therefore, this study aims at how to prevent risk factors that may be in the dialysis water by water quality monitoring to develop a Dialysis Water Safety Plan (DWSP) appropriate for the water source quality and conditions of each dialysis unit to prevent morbidity and mortality associated with dialysis water contaminants. 204 samples were taken from hospitals drinking water before treatment and 342 samples after treatment from 24 dialysis units from 17 hospitals that are fed from surface or underground sources in Giza from April 2020 to March 2021 monthly. Chemical and microbiological analysis were performed according to the American standard methods for the examination of water and wastewater. Visiting the treatment units once a month to monitor any change or inefficiency in any part of the unit. The findings showed that drinking water results were applicable to Egyptian limits except 2.45% for ammonia, iron (9.3%), manganese (6.86%), Total Coliform (2.9%), Escherichia coli (1.96%) and heterotrophic plate count in 1.96%. Hemodialysis water were not applicable for residual chlorine (0.87%), ammonia (1.46%), nitrites (2.6%), sodium(0.58%), potassium (0.29%), calcium (2.05%), magnesium (1.46%), total dissolved solids (1.46%), aluminium (0.58%). Total Coliform (2.6%), and E.coli in (1.46%), Pseudomonas (5.3%) and Streptococcus in (2.6%), and heterotrophic plate count (4.1%). But after the corrective actions according to DWSP, all samples became applicable. Thus, it is clear that DWSP should be implemented by developing an understanding of the system and its ability to provide safe dialysis water

Membrane filtration enhanced by ultrasound for reducing endotoxin in dialysis water

Membrane filtration enhanced by ultrasound for reducing endotoxin in dialysis water

Reflection about the hemodialysis water microbiological quality in Brazil

Dialysis has been widely used in the treatment of patients with chronic kidney diseases and is considered a global public health issue. This treatment, which has changed the prognosis and quality of life in patients with chronic renal failure, can lead to complications that are often fatal. For this reason, there is a need for validation of alternative tests that favor the monitoring of treated water for dialysis in real-time to promote and prevent injuries to patients submitted to this procedure.

Efficacy of Supra-HFR in Removing FGF23 and Cytokines: A Single Session Analysis.

Supra hemodiafiltration with reinfusion of the endogenous ultrafiltrate (Supra-HFR) is a dialysis technique used to improve uremic toxin removal in the range of the middle molecular weight molecules. Supra-HFR does not require the preparation and online infusion of high-purity dialysis water because it allows the production of an endogenous ultrafiltrate that undergoes detoxification through an adsorbing resin. We investigated the ability of Supra-HFR to remove fibroblast growth factor 23 (FGF23), interleukin 6 (IL-6), tumor necrosis factor alpha (TNF-alpha), interleukin 8 (IL-8), and transforming growth factor alpha (TGF-alpha) after a single session dialysis in nine patients affected by end stage renal disease (ESRD). The same patients underwent a single session of online hemodiafiltration (OL-HDF) to evaluate possible differences in FGF23 and IL-6 levels. A significant reduction in FGF23 was observed with both Supra-HFR (p=0.001) and OL-HDF. As for TNF-alpha and TGF-alpha, which were measured using Supra-HFR only, their percentage values were significantly lower at the end of dialysis than at the start (p=0.0028 and p=0.03, respectively). This did not change with post-dialysis rebound. Supra-HFR was found to have no effect on IL-6 and IL-8. Interestingly, the removal rate for FGF23 and IL-6 was similar to that observed with OL-HDF. Supra-HFR was not superior to OL-HDF, with suboptimal convective volume in the removal of the molecules tested, especially FGF23, which is considered a large middle molecular weight uremic toxin.

Variation in physico-chemical and bacteriological characteristics of dialysis water: a case study of eight hemodialysis centers

Variation in physico-chemical and bacteriological characteristics of dialysis water: a case study of eight hemodialysis centers

Effect of Central Dialysis Fluid Delivery System (CDDS) on IL6 & 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 & this study, studies the effect of (CDDS) on IL6 & 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 & 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 & 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).

Fungi in dialysis water and dialysate: occurrence, susceptibility to antifungal agents and biofilm production capacity.

The aim of this study was to investigate the occurrence of fungi in dialysis water and dialysate, in addition to evaluating the susceptibility to antifungals and the biofilm production capacity of isolated microorganisms. The samples were collected in three hemodialysis units in Bauru (Brazil), every 15 days (July 2017-June 2018) at post-reverse osmosis, reuse, and dialysate points. The fungi were isolated by spread plate on Sabouraud dextrose agar. Filamentous fungi were phenotypically identified and yeasts were subjected to molecular evaluation of the ITS region. Susceptibility test to antifungals was carried out by the broth microdilution method and biofilm production capacity was evaluated in microtiter plates using crystal violet staining. Fungi were isolated in 52/216 (24.1%) samples, with an average count of 16.3 (10-40) CFU/mL. Overall, 61 microorganisms were identified, with 54 (88.5%) filamentous fungi and 7 (11.5%) yeasts. The main genera included were Penicillium, Cladosporium, Scedosporium, Rhinocladiella, Fusarium, and Emmonsia. Most isolates showed high values of minimum inhibitory concentration for 5-flucytosine and fluconazole and 35/45 (77.8%) isolates were classified as strong producers of biofilm. In order to increase the safety of the dialysis process, the adoption of control measures and monitoring of fungi in hemodialysis fluids is suggested.

Evaluation of Physicochemical and Microbial Quality Control of Hemodialysis Machines Water in Hospitals

Abstract Background and Objectives: Water quality is important for preparation of dialysis solution due to its direct relationship with blood of patients with renal failure. The aim of this study was to evaluate the chemical and microbial quality of inlet and outlet water of dialysis devices in hospitals of East Azerbaijan province. Material and Methods: This study was a descriptive-analytical study in which the water of dialysis ward of three hospitals affiliated to East Azerbaijan University of Medical Sciences was investigated. The results of physicochemical (45 cases) and microbial (163 cases) of dialysis water were extracted from the relevant archives in two stages before and after reverse osmosis treatment during 2014-2016. Independent t-test and one-way ANOVA were used for statistical analysis while extracting descriptive statistical parameters. Data analysis was done using Excel and SPSS 23 software. Results: Evaluation of the efficiency of reverse osmosis system showed that there was a significant difference between water quality, before and after the system. Except for calcium, magnesium, fluoride and nitrate, the concentrations of other cations and anions in 100% of samples were lower than the European Pharmacopoeia standard. Incoming water samples to dialysis machine in 4.9% of cases had total coliform contamination and there was no fecal coliform in any of the samples. The frequency and frequency of tests in hospitals are not observed and despite the risk of heavy metals, heavy metals tests are not performed on dialysis water for the health of dialysis patients. Conclusion: The need to develop a national standard for controlling dialysis water, testing all quality parameters of dialysis water according to standards in regular times and timeframes, informing hospital managers and environmental health experts about the importance of dialysis water quality in health and increasing life expectancy of dialysis patients is felt.

Water Treatment for Hemodialysis in Benghazi Medical Center (BMC)

Background: A single 4-hour dialysis treatment can require up to 400 liters of water per week for dialysis patients compare that with healthy person who drinks less than 15 liters of water per week. Therefore, it is clearly important to know and monitor the chemical and microbiological purity of the dialysis water.
 Aims: Determine the physicochemical and bacteriological characteristics of water used by hemodialysis services Isolate and identify fungi present in water systems of hemodialysis units in Benghazi Medical center (BMC) in Benghazi, Libya.
 Methods: Analysis study carried out in hemodialysis unit in BMC collected samples from each places (A & B) sections.
 Results: Six samples that target to chemical analysis and 32 samples for microbiological test, Chemical parameters of study area A and B for drinking and dialysis water were within international standards, but there was a minute of Calcium elevation in area B that was 3.3mg/l. No contamination with bacteria observed in all samples in section (A), the counts of yeasts and filamentous fungi investigated in the tap water, in the treated water, and dialysis machine in section B and Penicillium spp was the most frequent fungi.
 Conclusions: Our study demonstrated that the tap and dialysis water success to meet the all-chemical and microbiological requirements in (A) area inside hospital of Benghazi center. In generally to prevent the risk of contaminants for hemodialysis patients need to a high water quality management program and development of water treatment system in hemodialysis centers.

Quality Assurance and Preventing Serious Adverse Events in the Home Hemodialysis Setting.

Patient safety is of the utmost importance in home hemodialysis (HHD). Recognizing that there are risks related to vascular access (both infectious and noninfectious events), dialysis water quality, and procedural-related adverse events (including arteriovenous fistula needle dislodgement or air embolism), there is a need for systematic identification and management. Although adverse events are relatively infrequent in HHD, the potential consequences of these events may include significant morbidity, HHD treatment failure, or death. Therefore, having a systematic framework to review each event, audit and retrain patient technique, disclose and discuss events with patients, home unit staff and device companies (if relevant) and determine preventative measures to avoid future adverse events, is crucial. In this review, we will describe the literature around the types and relative frequency of serious adverse events in the HHD setting and we will outline a quality assurance framework for capturing, managing, and avoiding serious adverse events. Finally, we will describe some of the novel existing approaches to preventing or addressing serious adverse events and critical knowledge gaps that should be evaluated in future study.