RENAL RESEARCH INSTITUTE SYMPOSIUM: The Implications of Water Quality in Hemodialysis

Water used in dialysis requires additional treatment to minimize patient exposure to potential contaminants that may be present in drinking water. Although standards for the chemical purity of water are in existence and have eliminated many of the problems seen in renal units in the 1970s, some problems remain, and the importance of newer contaminants arising from changes in water treatment at the municipal level are being recognized. Despite this, recent surveys have indicated considerable shortcomings in compliance with chemical standards. The water quality used in the preparation of dialysis fluid also requires minimal bacterial content. Staff working in renal units are frequently unaware of the level of microbiologic contamination in their dialysis fluid arising from the presence of biofilm in the dialysis machines and the water distribution network. Bacterial fragments generated by such biofilms are able to cross the dialysis membrane and stimulate an inflammatory response in the patient. Such inflammation has been implicated in the mortality and morbidity associated with dialysis. The desire to improve treatment outcomes has led to the application of more stringent standards for the microbiologic purity of dialysis fluid and to the introduction of ultraclean dialysis fluid into clinical practice.

[1]  D. Kerr.  Clinical and pathophysiologic changes in patients on chronic dialysis: the central nervous system. , 1980, Advances in nephrology from the Necker Hospital.

[2]  D. Kerr,et al.  Dialysis encephalopathy, bone disease and anaemia: the aluminum intoxication syndrome during regular haemodialysis. , 1981, Journal of clinical pathology.

[3]  V. Tesar,et al.  Trace elements in end-stage renal disease. 1. Methodological aspects and the influence of water treatment and dialysis equipment. , 1999, Blood purification.

[4]  K. Berend,et al.  Acute aluminum encephalopathy in a dialysis center caused by a cement mortar water distribution pipe. , 2001, Kidney international.

[5]  N. Gupta,et al.  Toxins and bioactive compounds from cyanobacteria and their implications on human health. , 2002, Journal of environmental biology.

[6]  A. Bergner,et al.  Dialysate related cytokine induction and response to recombinant human erythropoietin in haemodialysis patients. , 2000, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[7]  B. Canaud,et al.  Microbiologic Purity of Dialysate:Rationale and Te chnical Aspects , 2000, Blood Purification.

[8]  J. Cannata-Andía.  Reconsidering the Importance of Long‐Term Low‐Level Aluminum Exposure in Renal Failure Patients , 2001, Seminars in dialysis.

[9]  C. Tetta,et al.  Pyrogen retention by highly permeable synthetic membranes during in vitro dialysis. , 2001, Artificial organs.

[10]  Wiseman Kc.  Use of ascorbic acid to remove chloramine from dialysate water. , 1997 .

[11]  W. Mckane,et al.  Chloramine-induced haemolysis presenting as erythropoietin resistance. , 1999, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[12]  Y. Yawata,et al.  Abnormal red cell metabolism causing hemolysis in uremia. A defect potentiated by tap water hemodialysis. , 1973, Annals of internal medicine.

[13]  S. McAllister,et al.  A prospective study of pyrogenic reactions in hemodialysis patients using bicarbonate dialysis fluids filtered to remove bacteria and endotoxin. , 1992, Journal of the American Society of Nephrology : JASN.

[14]  P. Frederik,et al.  Does ultrapure dialysate prevent the development of biofilm in dialysis therapy? , 2001, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[15]  R. Guerrant,et al.  Cryptosporidiosis: an update. , 2001, The Lancet. Infectious diseases.

[16]  V. Tesar,et al.  Trace elements in end-stage renal disease. 2. Clinical implication of trace elements. , 1999, Blood purification.

[17]  Soo‐Hun Cho,et al.  An Outbreak of Heinz Body Positive Hemolytic Anemia in Chronic Hemodialysis Patients1 , 1993, The Korean journal of internal medicine.

[18]  Y. Berland,et al.  Using Ultrapure Water in Hemodialysis Delays Carpal Tunnel Syndrome , 1991, The International journal of artificial organs.

[19]  L. Bland,et al.  An Outbreak of Fatal Fluoride Intoxication in a Long-Term Hemodialysis Unit , 1994, Annals of Internal Medicine.

[20]  C. Caramelo,et al.  Mechanisms of aluminum-induced microcytosis: lessons from accidental aluminum intoxication. , 1995, Kidney international.

[21]  H. Leclerc,et al.  Microbial Agents Associated with Waterborne Diseases , 2002, Critical reviews in microbiology.

[22]  M. Ballestri,et al.  Biofilms Invade Nephrology: Effects in Hemodialysis , 2000, Blood Purification.

[23]  K. Kalantar-Zadeh,et al.  Relative contributions of nutrition and inflammation to clinical outcome in dialysis patients. , 2001, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[24]  R. Calderaro,et al.  [Outbreak of hemolytic reactions associated with chlorine and chloramine residuals in hemodialysis water]. , 2001, Revista de saude publica.

[25]  R. Pérez-García,et al.  Chloramine, a sneaky contaminant of dialysate. , 1999, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[26]  S. Lapierre,et al.  Quality of hemodialysis water: a 7-year multicenter study. , 1995, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[27]  M. Nieuwenhuijsen,et al.  Chlorination disinfection byproducts in water and their association with adverse reproductive outcomes: a review , 2000, Occupational and environmental medicine.

[28]  W. J. Johnson,et al.  Exposure to excessive fluoride during hemodialysis. , 1974, Kidney international.

[29]  M. Torres,et al.  Chloramines, an aggravating factor in the anemia of patients on regular dialysis treatment. , 1977, Proceedings of the European Dialysis and Transplant Association. European Dialysis and Transplant Association.

[30]  J. Eaton,et al.  Chlorinated Urban Water: A Cause of Dialysis-Induced Hemolytic Anemia , 1973, Science.

[31]  R. Ward,et al.  Ultrapure Dialysate: A Desirable and Achievable Goal for Routine Hemodialysis , 2000, Seminars in dialysis.

[32]  P. Stenvinkel,et al.  Anaemia, rHuEPO resistance, and cardiovascular disease in end-stage renal failure; links to inflammation and oxidative stress. , 2002, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[33]  M. D. de Broe,et al.  Adequacy of dialysis: trace elements in dialysis fluids. , 1996, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[34]  A. Canteros,et al.  Aluminum exposure in chronic renal failure in iberoamerica at the end of the 1990s: overview and perspectives. , 2000, The American journal of the medical sciences.

[35]  E. Lowrie.  Chronic inflammation and clinical outcome in adult hemodialysis patients. , 2002, Kidney international. Supplement.

[36]  W. Carmichael,et al.  Human intoxication by microcystins during renal dialysis treatment in Caruaru-Brazil. , 2002, Toxicology.

[37]  Kerr Dn.  Clinical and pathophysiologic changes in patients on chronic dialysis: the central nervous system. , 1980 .

[38]  C. Bartlett,et al.  Erythropoietin resistance due to dialysate chloramine: the two-way traffic of solutes in haemodialysis. , 1999, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[39]  F Vorbeck,et al.  Quality of water used for haemodialysis: bacteriological and chemical parameters. , 1999, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[40]  A. Alfrey.  Dialysis encephalopathy syndrome. , 1978, Annual review of medicine.

[41]  R. Hamilton,et al.  Impact of Oral Bases on Aluminum Absorption , 2001, American journal of therapeutics.

[42]  D. Ward.  Chloramine removal from water used in hemodialysis. , 1996, Advances in renal replacement therapy.

[43]  Eaton Jw,et al.  Prevention of chloramine-induced hemolysis in dialyzed patients. , 1978 .

[44]  B. Han,et al.  Estimation of potential lifetime cancer risks for trihalomethanes from consuming chlorinated drinking water in Taiwan. , 2001, Environmental research.

[45]  K. Wiseman.  Use of ascorbic acid to remove chloramine from dialysate water. , 1997, ANNA journal.

[46]  K. Sugimura,et al.  Response of peripheral blood mononuclear cells in hemodialyzed patients against endotoxin and muramyldipeptide. , 2002, International journal of molecular medicine.

[47]  P. Vaillant,et al.  Evidence of bacterial biofilm in tubing from hydraulic pathway of hemodialysis system. , 1998, Artificial organs.

[48]  W. Kleophas,et al.  Long-term experience with an ultrapure individual dialysis fluid with a batch type machine. , 1998, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[49]  K. Hung,et al.  Trace Metals' abnormalities in hemodialysis patients: relationship with medications. , 2000, Artificial organs.

[50]  M. Arvanitidou,et al.  Endotoxin concentration in treated water of all hemodialysis units in Greece and inquisition of influencing factors. , 1999, Journal of nephrology.

[51]  G. Lonnemann.  Chronic Inflammation in Hemodialysis: The Role of Contaminated Dialysate , 2000, Blood Purification.

[52]  V. Tesar,et al.  Trace Elements in End-Stage Renal Disease , 1999, Blood Purification.

[53]  W. D. Kaehny,et al.  The dialysis encephalopathy syndrome. Possible aluminum intoxication. , 1976, The New England journal of medicine.

[54]  J. Mahony,et al.  Heinz‐body haemolysis in haemodialysed patients caused by chloramines in Sydney tap water , 1982, The Medical journal of Australia.