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Fluid Quality at Home Haemodialysis Installations. Gareth Murcutt Royal Free Hospital London. Why does water quality matter?. An average patient dialyses for 4 hrs 3 times per week against a fluid rate of 0.6 l min -1

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fluid quality at home haemodialysis installations

Fluid Quality at Home Haemodialysis Installations

Gareth Murcutt

Royal Free Hospital

London

why does water quality matter
Why does water quality matter?

An average patient dialyses for 4 hrs 3 times per week against a fluid rate of 0.6 l min-1

Annually an HD patient will be exposed to over 22,000 litres of water

ro hhd vs hospital
RO: HHD vs Hospital

Can this………………replace this?

hhd fluid testing program
HHD: Fluid Testing Program

Business case prepared / accepted / partially funded

6 monthly chemical RO water analysis at all home patients

6 monthly TVC & endotoxin: water / d/fluid analysis at all home patients

Samples taken during service visits and collected by courier

Results are emailed and posted

Results recorded / actioned

hhd water contamination
HHD Water Contamination
  • Chemical Contamination
  • Microbiological contamination
hhd water contamination10
HHD Water Contamination
  • Chemical Contamination
  • Microbiological Contamination
how pure is tap water

Chemical Contamination

How pure is tap water?

2,4-D, Bentazone, Clopyralid, Dicamba, Dichlorprop, Fluroxypyr, MCPA, MCPB, Mecoprop, Carbendazim, Glyphosate, Copper, Lead, Zinc, Dichlobenil, Propyzamide, Triallate, Benzo 3,4 Pyrene, Total PAHs, Total Pesticide, Atrazine, Simazine, Trietazine, Carbetamide, Chlorotoluron, Cyanazine, Diuron, Isoproturon, Linuron, Tetrachloroethene, Tetrachloromethane, Total Trihalomethanes, Trichloroethene, Odour Intensity,Manganese,Ammonium, Hydrogen IonAluminium, Odour, Odour Intensity, Taste Intensity, Taste, Electrical Conductivity, Colour, Aluminium, Iron as Fe, Temperature, Nitrate, Nitrite, Hydrogen Ion, Turbidity, Alkalinity as HCO3, Free Cyanide, Fluoride, Mercury, Selenium, Antimony, Arsenic, Barium, Boron, Cadmium, Calcium, Chromium, Magnesium, Nickel, Potassium, Silver, Sodium, Phosphorus, Chloride, Sulphate, Total Hardness, Oxidizability, Surfactants, Dry residue, Total Organic Carbon, Total Chlorine.

hhd stable chemicals results

Chemical Contamination

HHD Stable chemicals: results

Total of 51 samples taken from 23 HHD installations

the special case of nitrates

Chemical Contamination

The special case of nitrates

Nitrate Vunerable Zones

AAMI limit = < 2 mg l-1 (as NO3 -N )

EPh limit = < 2 mg l-1 (as nitrate: NO3)

1 mole of N = 14g

1 mole of NO3 = 62g

To convert (NO3 -N) to (NO3) the result

must be multiplied by 62/14 (~ 4.5)Action level of 4 mg l-1 agreed

carbon hhd vs hospital

Chemical Contamination

Carbon: HHD vs Hospital

Can this………………replace this?

testing for residuals

Chemical Contamination

Testing for Residuals

A standard test for chlorine in water is the DPD method. Free chlorine reacts with diethyl-p-phenylene diamine (DPD) tablets in buffered solution to produce a pink colour.Our testing shows that the filters used still adequately remove chlorine and chloramines after 6 months at an HHD site.

Reaction of free chlorine with DPD.

+ 1/2 Cl2

+ H+ Cl-

Clear

Red

hhd water contamination18
HHD Water Contamination
  • Chemical Contamination
  • Microbiological Contamination
discussion hhd chemistry

Carbon

filter

RO

HHDm/c

Discussion: HHD Chemistry

This simple set-up is capable of providing water for dialysis of an acceptable chemical composition

Planned maintenance and analysis must be done to ensure correct operation

discussion hhd microbiology
Discussion: HHD Microbiology

Carbon

filter

RO

HHDm/c

Biofilm

TVC / Eu

This set-up is probably NOT capable of providing water for dialysis of an acceptable microbiological standard

  • Long periods of stagnation
  • Difficulty of disinfection
achieving compliance
Achieving compliance

An example of a system that should be capable of providing chemically and microbiologically acceptable dialysis fluid

Integrateddisinfection

planning for hhd fluid quality
Planning for HHD fluid quality

Contact with water suppliers

System design

Chlorine/chloramine

Adequate carbon filtration

Chlorine testing

Good quality RO membrane

Water Analysis

Integrated disinfection

HHD machine

Robust disinfection regime

Ultrafilter

D/fluid analysis

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