Hemodialysis Water Research Articles

Potentially pathogenic culturable bacteria in hemodialysis waters

BackgroundHemodialysis patients are at risk of acquiring healthcare-related infections due to using non-sterile water to prepare hemodialysis fluid. Therefore, microbiological control and monitoring of used water are of crucial importance.Materials and methodsIn this work, we identified bacterial populations occupying a hemodialysis water distribution system for almost a 6-month period in Ahvaz city, southwest of Iran. A total of 18 samples from three points were collected. We found high colony counts of bacteria on R2A agar. 31 bacteria with different morphological and biochemical characteristics were identified by molecular-genetic methods based on 16 S rRNA gene sequencing. Endotoxin concentrations were measured, using Endosafe® Rapid LAL Single-Test Vials.ResultsA diverse bacterial community was identified, containing predominantly Gram-negative bacilli. The most frequently isolated genus was Sphingomonas. Five species including M. fortuitum, M. lentiflavum, M.szulgai, M. barrassiae, and M. gordonae was identified .Despite the presence of Gram-negative bacteria the endotoxin analysis of all samples revealed that their endotoxin values were below the detection limit.ConclusionThe members of Sphingomonas genus along with Bosea and mycobacteria could be regarded as pioneers in surface colonization and biofilm creation. These bacteria with others like Pelomonas, Bradyrhizobium, staphylococcus, and Microbacterium may represent a potential health risk to patients under hemodialysis treatment.

Filamentous fungi in water used in hemodialysis treatment: a persistence challenge for health surveillance

Introduction: Fungi usually are resistant to disinfection and has pathogenic potential; however, they are not legally controlled in hemodialysis water (HW). Objective: Filamentous fungi (FF) were evaluated in HW from a tertiary hospital in southeast of São Paulo state (Brazil) and is a reference medical center providing service to millions of people every year. Method: A total of 84 water samples were collected in seven hydraulic system points during a period of one year and FF was identified by macroscopic and microscopic features. Results: FF were detected in all points ranging from 1 to 334 CFU/100 mL. Nine genera along the hydraulic system were identified, including Acremonium, Alternaria, Aspergillus, Beltrania, Bipolaris, Cladosporium, Exophiala, Fusarium, and Penicillium. Conclusions: Most fungi are ubiquitous and some cause human infection and mycotoxins producers. The various genera found reveal possible failures in treatment and distribution system, either through inadequate hygiene practices or infusion of these microorganisms into the pipes. FF detection is needed bearing mind immunological vulnerability of patients under hemodialysis treatment requiring continuous health surveillance actions.

TECHNOLOGIES WITH OZONE IN HEMODIALYSIS

This study aimed to verifying the impacts of technologies with ozone in water treatment and disinfection of hemodialysis water systems, replacing the conventional chemical processes. Through scientific research developed on the subject, the study conducted a comparative analysis between the conventional technologies and technologies using ozone, in order to evaluate positive aspects and fragilities; and demonstrate it’s contribution to the practice of sustainability in economic, social and environmental aspects. The results of these analyzes demonstrated that the technologies with ozone are a safe and effective method, which results in the improvement of hemodialysis; giving quality and sustainability to the process.

Mycobacterium detection method combining filtration, immunomagnetic separation, and electrochemical readout in a portable biosensing device

This study addresses a straightforward and highly sensitive approach for detecting Mycobacterium fortuitum. The method involves a combination of filtration and direct immunomagnetic separation to isolate the bacteria retained on filters for further electrochemical magneto immunosensing in a handheld device. Unlike conventional methods involving pre-enrichment by culturing, this approach employs a simplified preconcentration technique, which includes filtration of large water samples, up to 100 mL, followed by a one-step process of immunomagnetic separation and labeling. After a 60-min, during which the filter with the retained bacteria and all the reagents (including modified magnetic particles and enzymatic conjugates) are incubated, the resulting product is directly drop into a cartridge, capable of performing magnetic actuation and washing. The electrochemical readout is carried out on a portable battery-operated device within 30 seconds. Remarkably, the immunosensor demonstrates an outstanding limit of detection of 5 CFU mL−1 in hemodialysis water processing 100 mL of sample. This achievement is remarkable considering the short and simplified analytical procedure, compared to the traditional isolation and culturing of mycobacteria, which typically takes 2 weeks.

Water and dialysis fluid purity for contemporary hemodialysis.

The purity of water and dialysis fluids is of utmost importance in ensuring the safe and effective administration of hemodialysis treatment to patients with chronic kidney disease. It is crucial to enforce compliance with international standards for dialysis water and fluids, as this is mandatory in reducing chemical hazards, mitigating the adverse effects of bioincompatibility resulting from contaminated water and ultimately enhancing long-term patient outcomes. Within this comprehensive review, we highlight the presence of water contaminants and thoroughly assess the existing international standards for dialysis water and fluids, spanning from pure to ultrapure. Additionally, we delve into the fundamental components of water purification and present a comprehensive range of water treatment options, encompassing pre-treatment, primary treatment (reverse osmosis), and tertiary water treatment. Furthermore, we outline recommended monitoring and maintenance procedures, ensuring the consistent delivery of high-quality water and dialysis fluids at the point of care. WATER PURIFICATION AND MONITORING SUSTAINABILITY AND FUTURE CHALLENGES: Importantly, we raise concerns regarding the sustainability and conservation of water resources in hemodialysis treatment. It is imperative that these concerns be addressed in the future to avert the potential shortage of this essential resource. In conclusion, the contemporary landscape of hemodialysis conditions has engendered an urgent necessity for advanced water treatment systems and optimized delivery of dialysis fluids. This review serves as a comprehensive update on the latest technological advancements aimed at meeting these critical demands. Dialysis water and fluids must adhere to increasingly stringent purity constraints, encompassing both biochemical and microbiological perspectives.

Reverse osmosis water purification and brine valorization in a Tunisian hemodialysis center

ABSTRACT The technical–economic analysis of the hemodialysis water purification process, which uses reverse osmosis with sand, softeners, and granular-activated carbon as pretreatment steps, shows that the permeate conductivity exceeds 25 µS cm−1 at 25°C due to softeners failure and that the cost of cubic meter of water produced is 2.4 €. The purification unit generated brine with a conductivity above 5 mS.cm−1 and it is discharged into the sewer. Several brine valorizations are proposed; brine recycling and simulation with IMS design software reveal that it is possible to recycle 0.2 m3.h−1 of brine and achieve 83% conversion rate with a good quality of permeate. The residual of the first reverse osmosis brine is diluted by the second reverse osmosis permeate and is to be used for toilet flushing, landscape irrigation, and sterilization steam production.

Water quality and adverse health effects on the hemodialysis patients: An overview.

Hemodialysis is considered a treatment of choice for patients with renal failure worldwide, allowing the replacement of some kidney functions by diffusion and ultrafiltration processes. Over 4 million people require some form of renal replacement therapy, with hemodialysis being the most common. During the procedure, contaminants in the water and the resulting dialysate may pass into the patient's blood and lead to toxicity. Thus, the quality of the associated dialysis solutions is a critical issue. Accordingly, the discussion of the importance of a dialysis water delivery system controlled by current standards and recommendations, with efficient monitoring methods, disinfection systems, and chemical and microbiological analysis, is crucial for improving the health outcomes of these patients. The importance of treatment, monitoring, and regulation is emphasized by presenting several case studies concerning the contamination of hemodialysis water and the adverse effects on the respective patients.

#4059 MICROBIOLOGICAL ANALYSIS OF HEMODIALYSIS WATER AT THE DOUALA GENERAL HOSPITAL, CAMEROON

Abstract Background and Aims Rigorous control of the microbiological quality of water in hemodialysis services is important because the immune system of patients with chronic renal failure is weakened. The aims of this study was to determine the microbiological quality of water for hemodialysis in Nephrology Unit of the Douala Général Hospital in order to improve the disinfection strategy. Method Twelve water samples were collected each month at different sites of the hemodialysis circuits A (inlet of filters), B (Outlet of filters / inlet of Reverse Osmosis (RO) device) and C (outlet of the RO device / close to the generator) between November 2015 and February 2016 to be analyzed. The bacteria were isolated after filtration of 100 ml of water at each site through nitrocellulose membrane with 0.45 µm microporosity deposited on the surface of the Tryptone Glucose Extract Agar (TGEA) and then incubated at room temperature (20 to 22°C) for 7 days. After transplanting to different environments, pure bacterial isolates were identified by their cultural characters and marketed biochemical galleries. Results The colony count was well above the required international standards (˃100 CFU / ml), for the hemodialysis water with a percentage of 50% of non-compliance. Among the bacteria identified, seven (07) were Gram-negative bacilli including Pseudomonas fluorescens, and Klebsiella pneumoniae subsp ozaenae, three (03) Gram-positive bacilli all Bacillus sp and three (03) Gram-positive cocci all of coagulase-negative staphylococci. The most frequently isolated bacterial genera were Pseudomonas sp (38,5%), Staphylococcus sp (23%), Bacillus sp (23%) and Klebsiella sp (15,5%). Conclusion The high bacteriological contamination of the hemodialysis water with the detection of a variety of bacteria shows that the disinfection procedure of the distribution loop is not efficient and cannot prevent the development of a biofilm. A higher frequency of disinfection (almost every week), an increase of the concentration and time of contact of the chlorine disinfection product or the use of peracetic acid and a regular monitoring can contribute to improve the quality of the hemodialysis water at the Douala General Hospital to ensure a better quality of life for patients undergoing this treatment.

Microbiological analysis of hemodialysis water at the Douala General Hospital, Cameroon

Rigorous control of the microbiological quality of water in hemodialysis services is important because the immune system of patients with chronic renal failure is weakened. The objective of this study was to determine the microbiological quality of water for hemodialysis in the hemodialysis department of the hemodialysis center of Douala General Hospital in order to improve the disinfection strategy. Twelve water samples were collected each month at different sites of the hemodialysis circuits A (inlet of filters), B (Outlet of filters / inlet of Reverse Osmosis (RO) device) and C (outlet of the RO device / close to the generator) between November 2015 and February 2016 to be analyzed. The bacteria were isolated after filtration of 100 ml of water at each site through nitrocellulose membrane with 0.45 µm microporosity deposited on the surface of the Tryptone Glucose Extract Agar (TGEA) and then incubated at room temperature (20 to 22ºC) for 7 days. After transplanting to different environments, pure bacterial isolates were identified by their cultural characters and marketed biochemical galleries. The colony count was well above the required international standards (˃100 CFU / ml), for the hemodialysis water with a percentage of 50% (6/12) of non-compliance. Among the bacteria identified, nine (07) were Gram-negative bacilli including Pseudomonas fluorescens and Klebsiella pneumoniae subsp ozaenae, three (03) Gram-positive bacilli all Bacillus sp and three (03) Gram-positive cocci all of coagulase-negative staphylococci. The most frequently isolated bacterial genera were Pseudomonas (38.5%), Klebsiella (15, 5%), Bacillus (23%) and Staphylococcus (23%). The detection of a variety of bacteria in the hemodialysis water in this study indicates the need for regular and appropriate monitoring of water for hemodialysis by the hemodialysis center of Douala General Hospital to ensure a better quality of life for patients undergoing this treatment.

Transfer of Leachable Substances from Cross-Linked Peroxide Polyethylene (PEX-a) into Hemodialysis Water

Transfer of Leachable Substances from Cross-Linked Peroxide Polyethylene (PEX-a) into Hemodialysis Water

Observations from the Field Concerning Water and Dialysate for Hemodialysis

Observations from the Field Concerning Water and Dialysate for Hemodialysis

Acute Neurotoxicity and Hyperlactatemia Due to Hemodialysis Water System Contamination: A New Relationship

Acute Neurotoxicity and Hyperlactatemia Due to Hemodialysis Water System Contamination: A New Relationship

Electrochemical treatment of hemodialysis wastewater including pharmaceutical products

Hemodialysis is an extracorporeal kidney replacement procedure to remove impurities or waste products from the blood that is used in the treatment of kidney failure. During this process, large amounts of water are used, which, lacking control, end up in sewage systems, potentially flushing high levels of organic and inorganic contaminants into the receiver's aqua biota. This research considered the treatment of synthetic hemodialysis water under acid and basic conditions. To better simulate the presence of organic compounds, 10 mg L−1 of amoxicillin, an antibiotic commonly present in wastewater from clinics and hospitals, was added. Laboratory and pilot tests were performed using coupled electrocoagulation and electro-oxidation. During electrocoagulation, the use of stainless steel and aluminum, as sacrificial anodes, were compared in acidic and basic pH. The stainless steel rod anode and a titanium mesh cathode were used during electrocoagulation in acidic conditions at a field strength of 3.0 V which was applied for 60 min. After electrocoagulation, the solution obtained was filtered to separate precipitates. The supernatant was then treated with electro-oxidation using an IrO2-Ta2O5|Ti anode and the titanium mesh cathode while applying 10 mA for 120 min. Wear of the stainless steel anode was identified by scanning electron microscopy and microanalysis. Removal of organic compounds including amoxicillin was significant. These results were confirmed by decreased contaminant concentration found by diode coupled chromatography detection. In the final analysis this coupled treatment system completely eliminated amoxicillin and significantly reduced entrained salts.

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.

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.

Identification and assessment of antimicrobial resistance bacteria in a hemodialysis water treatment system.

The water treatment process is a vital factor for hemodialysis (HD) patients. This study aimed to assess the degree of contamination of HD water by bacteria at the HD center of Mohammedia, Morocco, in addition to evaluating the antimicrobial resistance of isolated bacteria. Fifty-four water samples were taken, the appropriate cultures were used to isolate the pathogenic bacteria, which were identified biochemically and molecularly by 16S RNA sequencing. Their susceptibility to antimicrobial drugs was determined by the disk diffusion method. Approximately 5.5% of water samples were above the norm. The isolated bacteria that colonized the HD systems were mostly Gram-negative bacilli, such as Stenotrophomonas maltophilia, Pseudomonas spp., and Burkholderia cepacian. Results of the antibiotics test showed remarkable resistance levels. Among Pseudomonas spp. and S. maltophilia, 10 strains were classified as multidrug-resistant (MDR), and 4 as extensively drug-resistant (XDR). The diversity of bacterial strains isolated in the water used for HD treatments, and their worrying resistance levels pose a significant risk to patients. For these reasons, an urgent need for periodic microbiological monitoring of water after each treatment step must be applied, and the treatment process should also be optimized.

Evaluation of Some Chemical Parameters of Hemodialysis Water: A Case Study in Iran.

One of the most common diseases in the world is kidney failure, which can lead to the death of patients. Hemodialysis is a treatment for patients whose kidneys are failing. The water used to perform dialysis must be healthy, safe, and clean. This study aimed to investigate the concentration of heavy metals in hemodialysis water in one of the Hospitals in Iran and compare it with European Pharmacopeia (EPH) and Association for the Advancement of Medical Instrumentation (AAMI) standards. The present study is a descriptive-analytical study conducted on the inlet water of hemodialysis machines in hospital. The samples were collected for 3 months from June to September 2021, Which was examined in terms of free residual chlorine, electrical conductivity, pH, and calcium, magnesium, sodium, aluminum, zinc, copper, and lead concentration. Metals concentration in hemodialysis water was measured by Inductively Coupled Plasma Mass Spectrometry (ICP-MS) technique. The average value of parameters such as electrical conductivity, pH, residual free chlorine, sodium, calcium, magnesium, zinc, copper and lead in the hemodialysis water was less than the AAMI and EPH standards limits. There was a significant difference at the 95% confidence level with the standard limits, but the aluminum concentration was higher than the standard limits. Also, by examining the medical files of dialysis patients, the most observed problems were anemia and bone diseases, which are probably caused by exposure to high concentrations of aluminum in hemodialysis water. In present study the aluminum concentration is higher than the standard limits. Considering that the higher aluminum concentration can cause diseases such as anemia, bone diseases, nervous deterioration, and death in hemodialysis patients, therefore, it is recommended to continuously evaluate and monitor the quality of hemodialysis water and the performance of its treatment system.

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

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.

NO WATER, NO PROBLEM: USING CRRT FOR HEMODIALYSIS PATIENTS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Each dialysis session uses approximately 150 to 200 L of water [1]. While this was an issue discussed by policymakers and environmentalists, the winter storm that swept across the southwest United States in February 2021 made the bedside physician keenly aware of the problem. The region saw an unprecedented disruption of water and power supplies which put end-stage renal disease (ESRD) patients in jeopardy. Intermittent hemodialysis (IHD) could not be performed due to lack of running water, low water pressures, and unsanitary water conditions. We present 4 cases when continuous renal replacement therapy (CRRT) was utilized to provide urgent hemodialysis in hemodynamically stable, non-critically ill ESRD patients during this time of water supply crisis. CASE PRESENTATION: Our patients were between the ages 47-62 years old, mostly male. All patients were ESRD patients on IHD three days per week. Shortness of breath was the presenting complaint in 3 of 4 patients, each of whom had missed their last scheduled HD session due to inclement weather. 1 of 4 patients presented with altered mental status. Indications for hemodialysis included volume overload with pulmonary edema and respiratory distress, hypertensive crisis, refractory hyperkalemia, and uremic encephalopathy. The CRRT equipment used included the PRISMAX system for CRRT with M150 filters. Renal replacement solution containing 32 mEq/L bicarbonate, 4 mEq/L potassium, and 2.5 mEq/L calcium was used as dialysate fluid. Continuous veno-venous hemodialysis (CVVHD) more was used with a dialysate flow rate of 6L /hour and a blood flow rate of 200/per hour with calculated urea clearance of 100 ml/min. The duration of treatment was 8 hours to achieve the target Kt/V of 1.15, comparable to the recommended 1.2 provided by IHD. 9-10 bags of dialysate were used per each session. Fluid removal ranged from 150-500 ml/hr. 1 patient required a repeat session on a subsequent day due to incomplete treatment due to filter clotting. All patients tolerated the procedure well with the resolution of their acute conditions and normalization of blood pressure and electrolytes. 1 patient developed brief hypotension which resolved with fluid administration. No other adverse events were seen. DISCUSSION: CRRT has typically been used for renal replacement therapy in critically ill patients. It requires specialized equipment and a higher nurse: patient ratio as compared to IHD but can be used to manage volume overload and electrolyte derangements in ESRD patients without the substantial water requirements of IHD. CONCLUSIONS: We demonstrate limited CRRT as an alternative to safely manage ESRD patients needing urgent hemodialysis in the scenario of a natural disaster resulting in a water outage. REFERENCE #1: Hoenich NA, Levin R, Ronco C: Water for haemodialysis and related therapies: recent standards and emerging issues. Blood Purif 2010;29:81–8 DISCLOSURES: No relevant relationships by Sukhmani Boparai, source=Web Response Scientific Medical Advisor relationship with ALung Technologies, Inc. Please note: $5001 - $20000 by Steven Conrad, source=Web Response, value=Consulting fee No relevant relationships by Rajkamal Hansra, source=Web Response No relevant relationships by Prathik Krishnan, source=Web Response No relevant relationships by Audrey Netzel, source=Web Response