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8 Water Treatment for Contemporary Hemodialysis

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8 Water Treatment for Contemporary Hemodialysis 8 WATER TREATMENT FOR CONTEMPORARY HEMODIALYSIS BERNARD J.M. CANAUD and CHARLES M. MION Rationale for water treatment in iiemodialysis 231 Water and dialysate distribution system 246 Water contaminants 232 Final filtration 246 Water treatment devices 234 Water treatment system maintenance and Activated carbon filters 234 hygiene of dialysis 247 Distillation 236 Disinfection 247 Softening 237 Filter and resin changes 247 Filtration 238 Biofilm synthesis and destruction 247 Ultrafiltration 239 Water treatment quality control 249 Reverse osmosis (RO) 239 Chemical purity 249 Deionization 240 Microbiological purity 250 Ultraviolet radiation treatment 242 Water standards for contemporary dialysis 250 Water treatment system concept 242 Conclusions 251 Water pre-treatment and purification systems 243 References 251 Water storage 245 RATIONALE FOR WATER TREATMENT IN has introduced new risks directly related to the quality HEMODIALYSIS and purity of water used in dialysis (8-11). Hemodialy­ sis using highly permeable membrane and ultrafiltration Maintenance hemodialysis is an accepted life support sys­ controller is responsible for backfiltration and/or backdif- tem ensuring long term survival of half a million end stage fusion from dialysate (12-17). On the one hand, such an renal failure patients worldwide. Hemodialysis patients unapparent convective transport phenomenon is capable are regularly exposed to 300-400 liters of hemodialy­ of transferring toxic and/or pyrogenic substances from sis fluids per week during dialysis. The quality of water dialysate to blood resulting in febrile reaction (18-21). used to dilute the concentrated dialysate fluid is important On the other hand, dialysate contaminants may contribute because of the nature of the contact between dialysate and to the activation of various protein systems, enzymes and the patient's blood. The end stage renal failure patient is cells circulating in the blood compartment (22, 23). In­ the last link of a complex chain leading to the hemodialy­ line production of substitution fluid used in some dialysis sis process, where patient's blood is exposed to dialysate. modalities (e.g., in-line hemofiltration, HF or hemodi- One can look at the hemodialysis system as the end point afiltration, HDF) infuse a large fraction of dialysate fluid of an hydraulic circuit where city water is changed in dhectly into the patient's blood stream enhancing risks water for HD through municipal water supply, water treat­ for direct toxicity and/or pyrogenicity (24, 25). Dialyz­ ment system, distribution system and delivering dialysate er reconditioning using water from the dialysis unit is through the artificial kidney (Figure 1). associated with hazards of introducing pyrogenic materi­ From the early days of dialysis it is known that water al and/or bacteria within the lumen of the dialyzer fibers used for hemodialysis must be purified in order to prevent (26-35). Water treatment system therefore must provide clinical side effects due to contamination of water (1-4). the dialysis facility and the hemodialysis machine with a Water for dialysis must be considered as a pharmaceuti­ pure water which has been cleared from all contaminants cal product exposed to patient's blood system requiring a (36-38), specific and more stringent purification approach (5-7). Water purity requirements have changed over the past Drinking regulation standards for water are based on a three decades. Hemodialysis has been used routinely as weekly exposure of 14 liters with a selective gut barri­ maintenance therapy in end stage renal disease patients for er. Hemodialysis patients are exposed to 300-400 liters thirty years. Schematically, water purity has considerably per week through a non-selective artificial dialyzer mem­ improved according to a three stage periods. brane. Furthermore, dialysis patients having non urinary The first decade (1960-1970) was a pioneering period. excretion capacity are exposed to higher risk of toxic The objectives were essentially the development of dialy­ substances accumulation particularly for those who are sis program in order to ensure survival of end stage renal bound to protein and/or tissue. Contemporary dialysis failure patients. Water treatment system used during this 232 Bernard J.M. Canaud and Charles M. Mion 1. Water supply Municipal water supply Charcoal r-Pm-treatmmt Fllteriii|»SoftenerMJ|. jj^^^ Ji-iMcrofliter 2. Water L Primary Reverse treatment treatment Ultrafllter Delontzer ' osmosis Sabmicronic L. PosMreatment storage tank filter charged* 3. Distribution system 4. Dialfsate w H li IP delivery Hemodialysis tacility Figure 1. Schematic representation of the different steps of the water purification system, starting from the municipal water supply and ending at the dialysate delivery system. period was basically designed to remove colloid particu­ hypothesis was the starting point of a new research area in lates, calcium, magnesium, chlorine and toxic substances water and dialysate purity leading to the use of ultrapure in order to prevent mainly 'haxd water syndrome' and water and dialysate in hemodialysis (22), also to prevent pyrogenic reactions. Indeed, from the ear­ In this chapter, the various water puriication options ly Seattle experience, it was shown that the bacteriologic available to the dialysis practionner will be described. contamination of the dialysis iuid was a potential risk for Details will be provided concerning the nature of water the hemodialysis patient (39). treatment systems, the physical principles involved, and The second decade (1970^1980) revealed the hazards the monitoring approach necessary to optimize water of various substances added to city water to control tur­ treatment production for hemodialysis. The quality stan­ bidity (aluminium sulfate) or bacteriologic contamination dards required to satisfy contemporary dialysis needs and (chlorine, chloramine). Aluminium intoxication revealed to ensure patient's safety on a long term basis will also be by the epidemic occurrence of 'dialysis dementia' was discussed. particularly stressed (40-44), Water treatment system improvement consisted in generalizing the use of reverse osmosis system and/or the deionizers (mixed beds) to WATER CONTAMINAHTS prevent the rislc of aluminium intoxication, and activat­ ed charcoal to remove chlorine and chloramine from city There are three major groups of water contaminants: par­ water (45-49). ticulates, dissolved substances and microorganisms which The third decade (1980-1990) was characterized by the are presented in Figure 2. introduction of major changes in hemodialysis technolo­ Depending on the source, water will contain varying gy. Bicarbonate dialysis, highly permeable membranes, amounts of particulates, TTiese particulates are responsible ultrafiltration controllers were soon identified as new haz­ for water turbidity: they include minerals (clay, sand, iron) ards requiring a higher degree of water purity with reduced or coUoids (silica soluble or polymerised). bacteriologic and endotoxin contamination (8). In this Dissolved substances are inorganics or organics, context, water became a component of the complex prob­ microorganisms and pyrogens. lem hemodialysis hemocompatibility. The Interleukin-i 8: Water Treatment for Hemodialysis 233 Water contaminants Reteitale Permeate Heyerse osmosis yitiBliltraliOtt Submicronic MIcroiltratlon M'daftons fiifration i.45jinti 0.22 - 0.04|jiii Figure 2. Water contaminants. Efficacy of several water purification devices cuirently used in water treatment system. The main inorganic species are represented by ions, salts, Ca, Fe, Zn. Among the organic substances, the Table 1. Contaminants of water and tlieir toxic effects as docu­ main commoa species are by-product from natural sub­ mented in hemodialysis patients stances (tannin, lignine) or from agricultural (pesticide, insecticide, fertilizer) or industrial (oil, mining, munici­ Contaminants Toxic effects pal dumps) processes. Contaminants of water which have Aluminium Dialysis encephalopathy, bone documented toxicity in hemodialysis have been listed in disease, microcytic anemia Table 1. Calcium-Magnesium Hard water syndrome: nausea, Microorganisms are mainly represented by bacte­ vomiting, muscular wealcness. ria, although fungi, yinises, protozoan are occasionally headache, hypertension, malaise encountered. Bacteria contamination with living organ­ Chloramines Hemolysis, anemia. isms lead also to release of degradation products (endo­ methemoglobinemia toxin, peptidoglycanes) (50, 51). The main microorgan­ Copper Mausea, chills, headaclie, severe isms observed in city and/or dialysis water are listed in hemolysis, hepatitis Table 2. Fluoride Bone disease: osteomalacia Water treatment options should take into account the Nitrate Methemoglobinemia, cyanosis, degree of contamination of the incoming water and hypotension, nausea requirements for purity grade of the final water prod­ Sodium Hypertension, pulmonary oedema. uct. Furthermore, it must be emphasized that municipal confusion, headache, thirst, water supplies may have seasonal yaiiations (52). Chem­ tachycardia, seizures, coma ical substances, such as aluminum, chlorine, chloramine, Sulfate Nausea, vomiting, metabolic iuoride, that are added by municipal authorhies to clear acidosis or to make water safe for drinking make unsafe the water Zinc Anemia, nausea, vomiting, fever for hemodialysis (53-74). In addition, the distribution Microbial Chills, fever, nausea, septicemia piping system may itself
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