Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad

- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html

1. Mohammed Abdel Gawad MD/PhD Neph, ESENeph
Nephrology Unit, School of Medicine, NewGiza University
Nephrology Consultant, Alexandria
Founder of NephroTube.com
Chair of AFRAN Web/Media Committee
ISN Education SoMe Team Member
Chapter 3
Dialysis Water Unit
You can get this book free from www.NephroTube.com

2. Watch the video recording of this lecture
on NephroTube YouTube channel
www.YouTube.com/NephroTube

3. Visit
www.NephroTube.com
to get more Nephrology lectures
(pdf and video recordings)

4. Chapter 3
Dialysis Water Unit
•During each hemodialysis treatment, patients with end-stage kidney
disease (ESKD) are exposed to 120-200 L of dialysate.
•It is crucial to ensure the purity of the dialysate, as any contaminants
in it can enter the patient’s bloodstream and cause harm.
City tap water is used as the water
source for dialysis

5. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

6. Talk Outline: Chapter 3
Dialysis Water Unit
•Tap water purification by dialysis water unit
•Water piping (distribution) system
•Water storage tank and piping system disinfection
•Standards of treated pure water (product water or permeate)
•Frequency of water unit quality monitoring
•Green Dialysis (Green nephrology)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

7. Talk Outline: Chapter 3
Dialysis Water Unit
•Tap water purification by dialysis water unit
•Water piping (distribution) system
•Water storage tank and piping system disinfection
•Standards of treated pure water (product water or permeate)
•Frequency of water unit quality monitoring
•Green Dialysis (Green nephrology)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

8. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Multi
media
filter
Water pump
Handbook of Dialysis Therapy (Sixth Edition)
2023, Pages 80-92

9. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Multi
media
filter
Carbon
filter
Water pump
Handbook of Dialysis Therapy (Sixth Edition)
2023, Pages 80-92

10. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Multi
media
filter
Carbon
filter
Water pump
Softener
Brine
tank

11. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Multi
media
filter
Carbon
filter
Softener
Brine
tank
Handbook of Dialysis Therapy (Sixth Edition)
2023, Pages 80-92

12. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Multi
media
filter
Carbon
filter
Water pump
Softener
Brine
tank
Pre-RO
microfilter
5 μm
Feed water
(pretreated
water)
Step 2:
Water
treatment
(purification)
system

13. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Multi
media
filter
Carbon
filter
Water pump
Softener
Brine
tank
Pre-RO
microfilter
5 μm
Feed water
(pretreated
water)
Step 2:
Water
treatment
(purification)
systemMicrofilter
25 μm
Microfilter
10 μm

14. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Multi
media
filter
Carbon
filter
Water pump
Softener
Brine
tank
Pre-RO
microfilter
5 μm
Feed water
(pretreated
water)
Step 2:
Water
treatment
(purification)
systemMicrofilter
25 μm
Microfilter
10 μm

15. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Brine
tank
Multi
media
filter
Carbon
filter
Softener
Microfilter
25 μm
Microfilter
10 μm
Pre-RO
microfilter
5 μm
Water pump
Pressure gauges
Step 2:
Water
treatment
(purification)
system
Feed water
(pretreated
water)

16. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Brine
tank
Multi
media
filter
Carbon
filter
Softener
Microfilter
25 μm
Microfilter
10 μm
Pre-RO
microfilter
5 μm
Water pump
Pressure gauges
Step 2:
Water
treatment
(purification)
system
Feed water
(pretreated
water)
Filters should be backwashed daily when no patients are connected to
the hemodialysis machines.

17. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Brine
tank
Multi
media
filter
Carbon
filter
Softener
Microfilter
25 μm
Microfilter
10 μm
Pre-RO
microfilter
5 μm
Water pump
Pressure gauges
Step 2:
Water
treatment
(purification)
system
Feed water
(pretreated
water)
Filters should be backwashed daily when no patients are connected to
the hemodialysis machines.

18. Talk Outline: Chapter 3
Dialysis Water Unit
•Tap water purification by dialysis water unit
•Water piping (distribution) system
•Water storage tank and piping system disinfection
•Standards of treated pure water (product water or permeate)
•Frequency of water unit quality monitoring
•Green Dialysis (Green nephrology)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

19. Talk Outline: Chapter 3
Dialysis Water Unit
•Tap water purification by dialysis water unit
•Water piping (distribution) system
•Water storage tank and piping system disinfection
•Standards of treated pure water (product water or permeate)
•Frequency of water unit quality monitoring
•Green Dialysis (Green nephrology)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Components of the water treatment system are reverse osmosis (RO)
and deionization (DI).

20. Talk Outline: Chapter 3
Dialysis Water Unit
•Tap water purification by dialysis water unit
•Water piping (distribution) system
•Water storage tank and piping system disinfection
•Standards of treated pure water (product water or permeate)
•Frequency of water unit quality monitoring
•Green Dialysis (Green nephrology)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Components of the water treatment system are reverse osmosis (RO)
and deionization (DI).

21. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Feed water
(pretreated
water) from
pretreatment
system (step 1)
Water containing
ions, bacteria,
and endotoxin
excluded back
High pressure causes
water movement
through semipermeable
membrane
Product water
or permeate
Product water to
HD machines
Rejected water
to drain
RO

22. Monitoring RO membrane efficacy can be
done by one of two methods
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Percent rejection Percent recovery
[(feed water TDS – product water TDS) ÷
feed water TDS] × 100.
[product water flow rate ÷ (product water
flow rate + rejected water flow rate)] × 100.
Percent rejection value below 90%
indicates the need to clean the
membranes or change the membrane
module.
Percent recovery value below 90% indicates
the need to clean the membranes or change
the membrane module.

23. Monitoring RO membrane efficacy can be
done by one of two methods
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Percent rejection Percent recovery
[(feed water TDS – product water TDS) ÷
feed water TDS] × 100.
[product water flow rate ÷ (product water
flow rate + rejected water flow rate)] × 100.
Percent rejection value below 90%
indicates the need to clean the
membranes or change the membrane
module.
Percent recovery value below 90% indicates
the need to clean the membranes or change
the membrane module.

24. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
1- RO indirect feed system
(product/permeate storage tank)
2- RO direct feed system

25. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
1- RO indirect feed system
(product/permeate storage tank)
2- RO direct feed system

26. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Product
water
storage tank
UV irradiation
Distribution
closed loop
or
Ultrafilter
Submicron
filters
Water pump
Non used water by
machines returns
to storage tank
Ultrafilter or
submicron filter

27. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
1- RO indirect feed system
(product/permeate storage tank)
2- RO direct feed system

28. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Distribution
closed loop
Submicron
filters
Non used water by
machines returns
to join feed water

29. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Distribution
closed loop
Submicron
filters
Non used water by
machines returns
to join feed water
UV irradiation
or
Ultrafilter
Ultrafilter or
submicron filter

30. Talk Outline: Chapter 3
Dialysis Water Unit
•Tap water purification by dialysis water unit
•Water piping (distribution) system
•Water storage tank and piping system disinfection
•Standards of treated pure water (product water or permeate)
•Frequency of water unit quality monitoring
•Green Dialysis (Green nephrology)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Components of the water treatment system are reverse osmosis (RO)
and deionization (DI).

31. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
Ultrafilter
(bacteria- and endotoxin-
retentive filter)
Feed water
(pretreated
water) from
pretreatment
system (step 1)
H
+
H
+
H
+
H
+
H
+
H
+
OH
−
OH
−
OH
−
OH
−
OH
−
OH
−
Na
+
, Ca
++
, Mg
++
, etc.
Cl
-, Fl
-, NO3
-, etc.
Rejected
water to drain
RO
Product water to
HD machines
Deionization
Monitoring DI efficacy: The
acceptable level of pure
water resistivity from the DI
system is ≥ 1MΩ/cm.

32. DI connection with hemodialysis machines
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

33. Talk Outline: Chapter 3
Dialysis Water Unit
•Tap water purification by dialysis water unit
•Water piping (distribution) system
•Water storage tank and piping system disinfection
•Standards of treated pure water (product water or permeate)
•Frequency of water unit quality monitoring
•Green Dialysis (Green nephrology)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

34. Talk Outline: Chapter 3
Dialysis Water Unit
•Tap water purification by dialysis water unit
•Water piping (distribution) system
•Water storage tank and piping system disinfection
•Standards of treated pure water (product water or permeate)
•Frequency of water unit quality monitoring
•Green Dialysis (Green nephrology)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

35. Water piping (distribution) system:
Configuration
•Loop circuit without any branches, dead ends, or areas of stagnation.
•If valves are required, they should be placed on lateral arms whose
length does not exceed the diameter of the principal circuit.
•Continuous water circulation is necessary to prevent water
stagnation, bacterial growth, and biofilm formation.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

36. Water piping (distribution) system:
Pipes
•Smooth and polished inner surface.
•Inert materials to avoid chemical contaminants.
•Stainless steel is ideal, but high cost.
•High-grade synthetic polymer materials, such as PVC, PEX, PVDF, and
PTFE, are commonly used because of their lower cost and ease of
handling.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

37. Talk Outline: Chapter 3
Dialysis Water Unit
•Tap water purification by dialysis water unit
•Water piping (distribution) system
•Water storage tank and piping system disinfection
•Standards of treated pure water (product water or permeate)
•Frequency of water unit quality monitoring
•Green Dialysis (Green nephrology)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

38. Water storage tank and piping system
disinfection
•Regularly disinfection.
•The presence of biofilm, once established, can be challenging to
remove and may require the replacement of the piping system.
•Methods of disinfection:
•Chemical germicides: Generally performed at least monthly.
•Hot water or ozone: These systems can provide more frequent
disinfection.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

39. Talk Outline: Chapter 3
Dialysis Water Unit
•Tap water purification by dialysis water unit
•Water piping (distribution) system
•Water storage tank and piping system disinfection
•Standards of treated pure water (product water or permeate)
•Frequency of water unit quality monitoring
•Green Dialysis (Green nephrology)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

40. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

41. Nephrol Nurs J. 2013 Sep-Oct;40(5):383-404, 465

42. Talk Outline: Chapter 3
Dialysis Water Unit
•Tap water purification by dialysis water unit
•Water piping (distribution) system
•Water storage tank and piping system disinfection
•Standards of treated pure water (product water or permeate)
•Frequency of water unit quality monitoring
•Green Dialysis (Green nephrology)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

43. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

44. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

45. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

46. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

47. NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com
When there is a suspicion of contamination, increasing the frequency of
monitoring is essential.

48. Talk Outline: Chapter 3
Dialysis Water Unit
•Tap water purification by dialysis water unit
•Water piping (distribution) system
•Water storage tank and piping system disinfection
•Standards of treated pure water (product water or permeate)
•Frequency of water unit quality monitoring
•Green Dialysis (Green nephrology)
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

49. Green Dialysis (Green nephrology)
•Repurposing of rejected water of RO.
•Decrease water consumption.
•Utilize renewable energy.
•Less than one-third of the non-infectious garbage was possibly recyclable.
•Use recycled paper and monitor paper usage.
NephroTube Synopsis of Conventional Hemodialysis, First Edition, 2024
You can get this book free from www.NephroTube.com

50. Thank You