The production of on-line dialysis water for extracorporeal dialysis: proposals for an increased safety upgrade: a viewpoint

Abstract

Introduction At the start of the 2000s, the progressive diffusion of high-flux extracorporeal dialysis and membranes saw an increased use of high infusion volumes injected into the patient’s blood circuit following the advent of on-line water production plants. Methodology Our 15-year experience with on-line extracorporeal methodologies using very high infusion volumes has led to the detection of errors and weaknesses, thus allowing us to correct and provide for the implementation of appropriate technology in dialysis water production plants with the aim of ensuring a higher chemical-physical, bacteriological and endotoxin quality. The initial procedures had already been outlined in the 2005 Italian Guidelines, although still today Health Technicians and Nephrologists operating in the field are unable to take on board specific integrations for on-line methods due to a lack of upgrading of documentation in both European and non-European Guidelines. Results After more than 17 years’ experience, and in view of the technological implementations developed since 2005, we wish to put forward a series of suggestions in an attempt to improve the safety of on-line water, with uses ranging from drinking water, pre-treatment, osmosis, distribution circuit, hemodialysis monitors up to the most recent update of microbiological cultures. Discussion Additional, more stringent measures are required to prevent the occurrence of acute accidents during dialysis sessions and to reduce chronic inflammation-oxidation deriving from the use of not totally ultra-pure/sterile dialysis fluids. Conclusion Our point of view based on our long-standing experience, the proposals made relate to procedures to be applied in technological maintenance, which the consultant nephrologist and other relevant personnel such as microbiologists, biologists, and technical operators should adhere to rigorously to ensure that the production of dialysis water on-line is viewed on a par with a pharmacological administration.

Panorama da qualidade biológica da água destinada ao tratamento dialítico em pacientes sob cuidados críticos em Unidades de Terapia Intensiva

“…Por fim, o elevado índice de resultados satisfatórios observados na unidade hospitalar I, com relação ao ensaio de contagem de bactérias heterotróficas para as soluções de dialisato, pode ser inferido à possibilidade de utilização de máquinas com a presença de módulos de ultrafiltração para retenção bacteriana do fluído de diálise (dialisato). Este equipamento, localizado imediatamente antes da entrada no dialisador, proporciona a redução de valores de contagens de bactérias heterotróficas provenientes da água tratada destinada à preparação do fluído de diálise e, desta forma, pode minimizar os efeitos prejudiciais à saúde do paciente exposto à terapia renal 32,33,[36][37][38] .…”

“…Resultados semelhantes aos obtidos na presente pesquisa para a qualidade da solução de dialisato foram descritos na literatura 33,37,38 . No entanto, outros autores alcançaram conclusões discordantes em relação a este estudo, visto que a solução de dialisato pode ser suscetível à contaminação microbiana, com possível formação de biofilme ao longo das tubulações do sistema de produção do fluído de diálise, comprometimento da membrana do processo de osmose reversa, interferência na qualidade da manufatura da água e elevação dos níveis de contaminação acima do valor máximo permitido em legislação para contagem de bactérias heterotróficas 19,36,38 .…”

Management of Chronic Heart Failure in Dialysis Patients: A Challenging but Rewarding Path

“…However, some studies have concluded that this dialysis modality is not significantly different from other modalities [ 226 ]. The effects of different dilution modes, dilution ratios and flow rates [ 227 ] during dialysis with OL-HDF on solute clearance [ 228 , 229 ] and dialysate quality [ 230 ] in HF in dialysis patients requires further investigation. Home HD [ 231 ] is a potential therapeutic option with potential benefits in terms of improved LVH, stabilization of blood pressure, increased rates of urinary toxin excretion, improved patient quality of life and reduced medication burden for the patient, which may be associated with a slower ultrafiltration rate and increased frequency of dialysis.…”

Clinical relevance of abstruse transport phenomena in haemodialysis

“…The assay used most is the limulus amoebocyte lysate (LAL) test, either manual (gel-clot) or based on kinetic turbidimetric principles using chromogenic substrates. For either, it is crucial for proper sterile sample collection procedures to be followed and testing carried out rapidly (within the specified time interval) by laboratories well-versed with microbial testing methodologies [ 104 ].…”