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1. DIALYSIS WATER AND DIALYSATE Presenter Dr Manoj Aryal DM-Resident Department of Nephrology NAMS (2081-02-29)

2. PRODUCT WATER During each hemodialysis treatment, patients with end-stage kidney disease(ESKD) are exposed to 120-200 L of dialysis It is crucial to ensure the purity of the dialysate, as any contaminants in it can enter the patient's bloodstream and cause harm. Dialysis solution is prepared from purified water and concentrates .

3. WATER CONTAMINANTS Municipal water can cause injury to renal failure patients if these substances are allowed to remain in the water used for dialysis. Municipal water supplies assumed to contain substances harmful to dialysis patients . A ll dialysis facilities require a system for purifying municipal water.

4. FLUID QUALITY W ater used to prepare dialysis solution should contain <100 colony-forming units (CFU)/mL of bacteria and <0.25 endotoxin units (EU)/mL of endotoxin The maximum levels for the final dialysis solution are 100 CFU/mL and 0.5 EU/mL, respectively

5. ULTRAPURE DIALYSIS SOLUTION R educed plasma levels of C-reactive protein I nterleukin-6 I mproved response of anemia to erythropoietin therapy better nutrition R educed plasma levels of β2-macroglobulin. S lower loss of residual renal function L ower cardiovascular morbidity In observational studies, the use of so-called ultrapure dialysis solution, which is characterized by a bacteria level below 0.1 CFU/mL and endotoxin level below 0.03 EU/mL

6. METHODS OF PURIFYING WATER FOR HAEMODIALYSIS Pretreatment Primary purification Distribution of purified water

7. Water Pretreatment system.

8. PRETREATMENT: I nclude a valve to blend hot and cold water to a constant temperature preliminary filtration, softening, and filtration through activated carbon Correction of pH

9. Carbon : R emove chlorine and chloramine which are not removed by RO R emoves other small organic compounds that may be in the water The kinetics of the reaction through which carbon removes chloramine from water are slower than those for the removal of chlorine

10. Carbon: Because of the critical need to remove chloramine and related organics, the water stream is run through two carbon beds in series. The upstream worke r carbon bed will become exhausted first. The downstream or polishe r carbon bed is used as a backup.

11. Carbon: Although the levels of chlorine and chloramine can be determined separately, it is simpler to measure total chlorine. E xhausted carbon beds needs to be replaced based on that measurement. If the municipal water contains chloramine, the total chlorine level in the water exiting the primary worker carbon bed needs to be checked before each dialysis shift.

12. Carbon: If breakthrough is noted, the total chlorine level should be checked downstream of the polisher bed If no breakthrough is noted at that point, treatments can be continued while closely monitoring the outflow from the downstream polisher carbon bed. If total chlorine breakthrough is noted downstream of the polisher bed, treatments must cease immediately.

13. Carbon: Optimal removal of chloramine by carbon may require adjustment of the pH of the feed water. Even with pH adjustment, carbon may provide inadequate removal of chloramine if the water contains corrosion inhibitors or other substances that prevent chloramine molecules from reaching the surface of the carbon. In those situations it may be necessary to use alternative methods of chloramine removal such as injection of sodium bisulfite

14. WATER SOFTENER

15. WATER SOFTENER R emove calcium and magnesium from water by exchange for sodium bound ionically to a resin bed. The resin exchanges Na+ ions for Ca++ and Mg++ as well as for other cations such as iron and manganese. P rotects the downstream RO membrane from scaling by calcium and magnesium in the source water.

16. Water Softener: Water softener resins need to be backwashed and regenerated frequently on a routine basis using a concentrated sodium chloride solution (brine) During backwash, water is drawn into the softener in a reverse direction to wash and fluff the resin, and then the brine solution is introduced to regenerate the resin, replacing the recently bound Ca++ and Mg++ ions with Na+ ions.

17. Primary purification process : The primary purification process is almost always RO. A filter is normally placed just upstream of the RO membrane to catch any carbon particles and resin beads that may have been inadvertently released from the pretreatment system.

18. Reverse osmosis :

19. Reverse osmosis : This is achieved by high pressure filtration of water through a semipermeable membrane that will hold back dissolved solutes R emove more than 95% of ionic contaminants and nonionic contaminants as small as glucose E ffective barrier against bacteria and endotoxins

20. Deionization : M ay be used as an alternative to RO F requently used to further purify water following processing by RO Deionizers do not remove nonionic contaminants, bacteria or endotoxins A solid-phase deionizer contains both cationic and anionic resins

21. Deionization: These can be configured as either two beds or as a single bed containing a mixture of both resins Cationic resins contain sulfuric groups and these exchange hydrogen ions for other cations such as sodium, calcium, and aluminum

22. Anionic resins contain ammonium groups, which exchange hydroxyl ions for other anions such as chloride, phosphate, and fluoride The hydrogen and hydroxyl ions released during the exchange process then combine to become water, resulting in a product water that contains very few residual ions.

23. Deionizer: Deionizer function is monitored by checking the conductivity of the outflow water When the resins in a deionizer tank have exchanged all their available hydrogen and hydroxyl ions for cations and anions from the water, its capacity to remove ions is “exhausted.”

24. The conductivity of the outflow water increases following exhaustion, signaling that the tank needs to be replaced An “exhausted” deionizer resin is not inactive, but will rapidly release the ions that are most weakly bound to the resin

25. Deionizer: All ion exchange tanks are required to be fitted with online monitors that continuously monitor the conductivity of the outflow water and divert that water away from the patients should it exceed 1 mS /cm (a resistivity of 1 MΩ-cm ) S ome tanks also have a light that is normally off, and then turns on when the outflow conductivity increases, or a light that is normally on, and which turns off when conductivity monitoring fails

26. Deionizer: The resin of deionizers presents a large surface area for bacterial proliferation Since all bacteriostatic substances such as chlorine and chloramine will have been removed the level of bacterial contamination of the water flowing through deionizer tanks is subject to increase

27. For this reason, an ultrafilter usually is placed downstream to the deionizer to remove any bacteria or endotoxin that may have accumulated from the deionizer tanks Some centers also prefer to destroy bacteria (whether in a vegetative or a sporulated state) with ultraviolet radiation However, the UV process can increase the lipopolysaccharide and peptidoglycan content of the treated water due to bacterial death.

28. Distribution of purified water : Purified water intended for the preparation of dialysis solution must be distributed to the individual dialysis machines to produce dialysis solution that remains free of contaminants Chemical contaminants are avoided by using inert materials, such as plastics, for all components that contact the purified water and dialysis solution

29. Microbiologic contamination is avoided by using appropriately designed and constructed piping systems in combination with regular disinfection The water distribution system is configured in a loop without multiple branches or dead ends If the distribution system includes a storage tank (ideally, the use of a storage tank should be avoided), the tank is of the minimum required size, has a tight-fitting lid, and is designed for ease of disinfection

30. Distribution of purified water : Water storage and distribution systems are disinfected on a regular schedule to prevent bacterial colonization of the system and minimize the formation of biofilm When chemical germicides are used, disinfection is generally performed at least monthly The disinfection schedule should be designed to minimize biofilm formation in the storage and distribution system, not to eliminate biofilm after it has formed

31. Distribution of purified water Distribution systems are now available that can be disinfected with hot water or ozone These systems allow more frequent disinfection because there is no need to rinse the system free of residual germicide Water and dialysis solution cultures and endotoxin tests are performed to demonstrate the adequacy of the disinfection schedule

32. Raw Water tank

33. VFD BOOST PUMP

34. BRINE TANK

35. Multimedia Carbon tank Water softner

36. RO UNIT

37. UV treatment

38. Composition of a Standard Hemodialysis Solution

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