Fluid quality at home haemodialysis installations
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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 l.jpg

Fluid Quality at Home Haemodialysis Installations

Gareth Murcutt

Royal Free Hospital

London


Why does water quality matter l.jpg
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



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RO: HHD vs Hospital

Can this………………replace this?




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Where is water used for dialysis?

Hospital Site

Home Site


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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


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HHD Water Contamination

  • Chemical Contamination

  • Microbiological contamination


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HHD Water Contamination

  • Chemical Contamination

  • Microbiological Contamination


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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.


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Chemical Contamination

Comparison of chemical limits


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Chemical Contamination

FT30 membrane % rejections


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Chemical Contamination

HHD Stable chemicals: results

Total of 51 samples taken from 23 HHD installations


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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


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Chemical Contamination

Carbon: HHD vs Hospital

Can this………………replace this?


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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


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HHD Water Contamination

  • Chemical Contamination

  • Microbiological Contamination


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Microbiological Contamination

Microbiological Standards


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Microbiological Contamination

Endotoxin Results: Oct 2003


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Microbiological Contamination

TVC Results: Oct 2003


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Microbiological Contamination

TVC Results Analysis


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Microbiological Contamination

Standard vs Ultrafiltered d/f


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Microbiological Contamination

TVC results: Standard d/f


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Microbiological Contamination

Cut-away RO pure water


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Microbiological Contamination

Biofilm in RO pure water output


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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


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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


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Achieving compliance

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

Integrateddisinfection


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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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