2023 Guide Of  The Importance of Dialysis Water Treatment Plants in Renal Health

The importance of water treatment for dialysis patients cannot be overstated, as it plays a pivotal role in ensuring their safety and well-being during treatments. Dialysis patients are exposed to a significant amount of water, approximately 120-200 liters, during each treatment, making them particularly vulnerable to small molecular weight contaminants in the water used to prepare concentrates and dialysis fluid. These contaminants can enter the bloodstream unimpeded and accumulate in the body, as the patient’s compromised kidneys are unable to remove them.

Water treatment systems are therefore essential in all dialysis facilities to safeguard patients from harmful contaminants such as aluminum, chlorine, fluoride, and various inorganic and organic chemicals. Providing clean, purified water that meets or exceeds the American National Standards Institute (ANSI),

Association for the Advancement of Medical Instrumentation (AAMI), and International Standards Organization (ISO) guidelines are crucial for driving positive patient outcomes. Utilizing reverse osmosis (RO) systems for water purification not only ensures patients receive safe, clean water but also reduces energy usage and operating costs for clinics. In summary, water treatment for dialysis patients is a vital aspect of their care, as it helps maintain health and prevent complications resulting from exposure to water contaminants. [

Harmful Water Contaminants for Dialysis Patients

Dialysis patients are at a greater risk of being exposed to harmful contaminants present in the water used for their treatment. These small molecular weight contaminants easily enter the bloodstream and accumulate in the body, since kidney removal is compromised. Some hazardous contaminants found in the water include aluminum, chloramines, fluoride, copper, and bacteria.

Aluminum, added by many water systems as a flocculating agent, becomes sequestered in the bone, causing osteomalacia and encephalopathy. Chloramines, added to prevent bacterial proliferation, can lead to hemolysis (blood cell rupture). Fluoride, used to reduce tooth decay, is linked to renal osteodystrophy and muscle weakness when ingested in large quantities. Copper, which can leach from metal pipes and fittings, is another cause of hemolytic anemia.

Additionally, bacterial contaminants, such as endotoxins or bacterial fragments, can cause pyrogenic or fever-inducing reactions when they cross the dialyzer membrane and enter the bloodstream. To ensure patient safety, dialysis facilities need to have properly designed and maintained water treatment systems in place.

3. Water Quality Requirements for Dialysis Treatment

Ensuring the quality of water used for dialysis treatment is essential for the health and safety of patients. Water, which is primarily used in the form of dialysate, plays a crucial role in the dialysis process. As patients undergoing hemodialysis are exposed to large volumes of water – between 300-600 liters per week – it is vital that this water meets specific quality requirements.

Several organizations, including the Association for the Advancement of Medical Instrumentation (AAMI) and the Centers for Disease Control and Prevention (CDC), have established guidelines for water quality in dialysis treatments. These guidelines address the required equipment and processes used to purify and store water, as well as allowable and action threshold levels of chemical and microbiological contaminants, bacterial cell counts, and endotoxins.

By adhering to the water quality guidelines set forth by these organizations, dialysis centers can help prevent the risk of chemical, bacterial, and endotoxin contamination, which has been linked to adverse patient outcomes. Regular monitoring of water quality and timely intervention is vital to ensure that patients receive safe and effective dialysis treatment.

Dialysis water quality is critical for the health and safety of those undergoing hemodialysis treatment. To ensure the safety and effectiveness of the procedure, specific standards for bacterial and endotoxin concentrations in dialysis water have been established. The Association for the Advancement of Medical Instrumentation (AAMI), in conjunction with the International Standards Organization (ISO), has set guidelines addressing chemical and microbiological standards for the water used in dialysis procedures.

According to the AAMI standards, the acceptable total viable count (TVC) for water used in dialysis is 100 colony-forming units per milliliter (CFU/mL), and the action level is 50 CFU/mL. For endotoxins, the allowable limit is 0.25 endotoxin units per milliliter (EU/mL), and the action level is set at 0.125 EU/mL. Regular testing and monitoring, ideally once a month and during any outbreaks, is crucial to maintaining proper water quality and ensuring the safety of dialysis patients.

It must be noted that adherence to these standards is not only strongly supported by well-designed scientific studies, but is also a requirement in many jurisdictions. Ensuring compliance with these guidelines helps to prevent infections and other adverse outcomes associated with hemodialysis treatment.

5. Methods of Water Purification for Dialysis

The process of water purification for dialysis involves multiple filtration steps to ensure that the water is of high quality and free of contaminants such as particles, trace elements, chemicals, organic matter, bacteria, and bacterial fragments. There are five key stages in the water purification process:

1. Preliminary treatment: This step involves blending hot and cold water to a constant temperature, preliminary filtration, water softening, and adsorption with activated carbon. In some cases, hydrochloric acid may be injected to correct pH levels.

2. Water softening: This stage involves using a water softener to exchange calcium and magnesium ions in hard water for sodium ions. This process helps to prolong the life of the reverse osmosis (RO) membrane.

3. Activated carbon filtration: In this step, activated carbon filters are used to remove chlorine, chloramines, and other dissolved organic contaminants from the water. Two carbon beds are often employed to ensure the complete removal of these substances.

4. Reverse osmosis (RO): This is the primary method for water purification in dialysis units. RO uses hydrostatic pressure to force water across a semipermeable membrane, removing over 90% of contaminants, including ionic substances, bacteria, and endotoxins.

5. Deionization (DI): This process removes ionic contaminants by exchanging cations for H ions. DI is usually employed as a backup in cases of RO membrane failure or as an additional purification step. However, DI systems can promote bacterial growth, necessitating the use of bacterial control filters after purification. Continuous monitoring of conductivity is also required for DI systems.

Overall, these methods help to produce ultrapure water, which is essential for safe and effective dialysis treatment.

6. Pre-Treatment and Softening of Water

Before being used in a dialysis unit, the water needs to undergo a pre-treatment process to ensure the purity and safety of the treatment. This process involves blending hot and cold water to maintain a constant temperature, preliminary filtration, softening, and adsorption with activated carbon. Temperature mixing valves are typically installed to regulate the water feed at 77 degrees Fahrenheit, promoting the efficiency of the reverse osmosis membrane system.

The softening process is crucial for the protection and life extension of the reverse osmosis membranes. This involves the use of ion exchange to remove positively charged ions such as calcium, magnesium, and heavy metals from the water supply, replacing them with sodium ions.

Water softeners play a significant role in areas with ‘hard water,’ reducing the accumulation of calcium and magnesium salts that can damage the reverse osmosis membrane.

In a dialysis water purification system, single and duplex softeners are commonly used for effective results. By implementing proper pre-treatment and softening processes, dialysis units can ensure the adequacy of water quality for safe and efficient treatment.

7. Carbon Adsorption and Filtration

Within the water purification process for hemodialysis units, carbon adsorption and filtration play a vital role in ensuring the delivery of clean, safe water to patients. Carbon adsorption is a method whereby activated carbon is utilized for the effective removal of contaminants such as chlorine, chloramines, and other dissolved organic compounds from the water. These compounds, if not removed, can pose a significant risk to the health of patients undergoing hemodialysis treatments.

The carbon adsorption process typically comprises two activated carbon beds to guarantee the complete removal of contaminants. Filtration is an additional step that is carried out using a filter installed just before the reverse osmosis membrane to catch any residual carbon particles and resin beads that may have been inadvertently released from the pre-treatment system. This combination of carbon adsorption and filtration enhances the effectiveness and safety of water purification systems for hemodialysis units.

By incorporating these critical steps in water treatment plants for dialysis units, healthcare providers can ensure the delivery of high-quality medical water, minimizing the risk of complications and enhancing patient outcomes. Ultimately, carbon adsorption and filtration contribute significantly to improving human health and well-being for those dependent on hemodialysis. [13][14]

Reverse Osmosis and Deionization for Dialysis Water

Reverse Osmosis (RO) and Deionization (DI) are essential methods of water purification for hemodialysis treatments. These processes play a crucial role in producing high-quality purified water, as patients with kidney problems undergoing dialysis are exposed to large amounts of dialysis solution and can be highly vulnerable to contaminants in water.

RO is a widely-used technique in dialysis water purification. It relies on hydrostatic pressure to push water through a semipermeable membrane, effectively removing more than 90% of contaminants, including ionic impurities, bacteria, and endotoxin. This method helps ensure the water is safe and of appropriate quality for dialysis.

On the other hand, DI is typically employed either when the RO membrane fails or as an additional purification process. It involves exchanging cations for H ions and removing ionic contaminants from the water. One major concern with DI systems is their tendency to promote bacterial growth. Therefore, bacterial control filters are necessary after DI purification to keep the water safe for patients.

In conclusion, Reverse Osmosis and Deionization have key roles in maintaining the quality of water used for dialysis treatments. A well-designed and maintained water treatment system incorporating these methods helps protect patients and ensure their treatments are safe and effective.

The use of ultrapure water in hemodialysis units has become increasingly important as it offers numerous benefits to patients undergoing chronic hemodialysis treatments. Patients undergoing chronic hemodialysis are exposed to a high volume of water, between 360 and 576 liters weekly, depending on their dialysate blood flow. Contamination of this water by microorganisms or toxic chemicals poses a significant risk to a patient’s health, making it crucial to achieve the highest level of water purity possible.

The adoption of ultrapure water in hemodialysis units has been found to enhance the overall efficiency and safety of  dialysis treatment. As a result, more centers worldwide, particularly in Europe and Japan, are transitioning to the use of ultrapure fluids in dialysis treatments. Studies have shown that the use of ultrapure dialysis fluid is associated with a reduced risk of inflammation, infection, and other complications in patients undergoing chronic hemodialysis.

Moreover, the cost of implementing ultrapure water systems in low and middle-income countries is lower than in high-income countries, making it a feasible option for improving the quality of care in these regions. In summary, the use of ultrapure water in hemodialysis units is vital for enhancing patient safety, reducing complications, and improving overall treatment outcomes.

Risks Associated with Inadequate Water Treatment for Dialysis Patients

Hemodialysis patients are at  high risk for healthcare-associated infections due to their exposure to large volumes of water and dialysate during treatment. According to PMC, over 383,900 individuals in the U.S. undergo maintenance hemodialysis, highlighting the importance of maintaining water quality for patient safety. Inadequate water treatment can lead to the presence of chemical, bacterial, and endotoxin contaminants in the water used for dialysis.

These contaminants have been linked to several outbreaks since the 1960s, resulting in at least 592 cases and 16 deaths in the U.S. Oxford Academic further emphasizes that lapses in infection prevention practices and dialysis water management contribute to waterborne outbreaks involving nontuberculous mycobacteria, gram-negative bacilli, and systemic reactions due to gram-negative bacilli-associated endotoxin.

Therefore, dialysis clinics must adhere to recommendations regarding the monitoring and levels of bacteria and endotoxin in hemodialysis water and dialysate. Ensuring proper water treatment and compliance with infection prevention guidelines can minimize the risks associated with inadequate water treatment for dialysis patients. [19][20]

ETCH2O Dialysis Water Treatment Solution is a state-of-the-art system designed to ensure the safety and well-being of patients undergoing hemodialysis treatments. Given that patients are exposed to 120-200 liters of dialysis solution during each treatment, the water used in preparing concentrates and dialysis fluid must be free from contaminants that can accumulate in the body and cause harm.

This cutting-edge solution employs a three-step purification process, adhering to stringent industry guidelines set by the American National Standards Institute (ANSI), the Association for the Advancement of Medical Instrumentation (AAMI), and International Standards Organization (ISO). The ETCH2O system effectively removes small molecular weight contaminants, including aluminum, chlorine, fluorides, copper, and other harmful substances, while minimizing bacterial and endotoxin levels.

By utilizing the ETCH2O Dialysis Water Treatment Solution, dialysis centers can provide high-quality, ultra-pure water for patients, ensuring better health outcomes and reducing the risk of complications. With its advanced technology and commitment to patient safety, the ETCH2O system is quickly becoming the gold standard for dialysis water treatment in both home-based and center-based settings.