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Zhang J, Qi H, Wu JJ, Mao X, Zhang H, Amin N, Xu F, Dong C, Wang C, Wang P, Zheng L. Disposable Peptidoglycan-Specific Biosensor for Noninvasive Real-Time Detection of Broad-Spectrum Gram-Positive Bacteria in Exhaled Breath Condensates. Anal Chem 2024; 96:9817-9825. [PMID: 38730304 DOI: 10.1021/acs.analchem.4c00059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
Rapidly identifying and quantifying Gram-positive bacteria are crucial to diagnosing and treating bacterial lower respiratory tract infections (LRTIs). This work presents a field-deployable biosensor for detecting Gram-positive bacteria from exhaled breath condensates (EBCs) based on peptidoglycan recognition using an aptamer. Dielectrophoretic force is employed to enrich the bacteria in 10 s without additional equipment or steps. Concurrently, the measurement of the sensor's interfacial capacitance is coupled to quantify the bacteria during the enrichment process. By incorporation of a semiconductor condenser, the whole detection process, including EBC collection, takes about 3 min. This biosensor has a detection limit of 10 CFU/mL, a linear range of up to 105 CFU/mL and a selectivity of 1479:1. It is cost-effective and disposable due to its low cost. The sensor provides a nonstaining, culture-free and PCR-independent solution for noninvasive and real-time diagnosis of Gram-positive bacterial LRTIs.
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Affiliation(s)
- Jian Zhang
- College of Electrical and Electronic Engineering, Wenzhou University, Wenzhou 325035, China
- School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, China
- State Key Laboratory of Transducer Technology, Shanghai Institute of Microsystem and Information Technology, Chinese Academy of Sciences, Shanghai 200050, China
| | - Haochen Qi
- College of Electrical and Electronic Engineering, Wenzhou University, Wenzhou 325035, China
- Department of Electrical Engineering and Computer Science, the University of Tennessee, Knoxville, Tennessee 37996, United States
| | - Jie Jayne Wu
- Department of Electrical Engineering and Computer Science, the University of Tennessee, Knoxville, Tennessee 37996, United States
| | - Xuanjiao Mao
- Clinical Laboratory, The People's Hospital of Pingyang, Wenzhou 325400, China
| | - Hailin Zhang
- Department of Children's Respiratory Medicine, the Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou 325027, China
| | - Niloufar Amin
- Department of Electrical Engineering and Computer Science, the University of Tennessee, Knoxville, Tennessee 37996, United States
| | - Feng Xu
- Department of Gastroenterology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450001, China
| | - Changkun Dong
- College of Electrical and Electronic Engineering, Wenzhou University, Wenzhou 325035, China
| | - Chunchang Wang
- Laboratory of Dielectric Functional Materials, School of Materials Science & Engineering, Anhui University, Hefei 230601, China
| | - Pengjun Wang
- College of Electrical and Electronic Engineering, Wenzhou University, Wenzhou 325035, China
| | - Lei Zheng
- School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, China
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Lévesque R, Savard P, Canaud B. Pseudo-outbreak of haemodiafiltration dialysis fluid contamination: results of a detailed epidemiologic investigation. Infect Prev Pract 2023; 5:100292. [PMID: 37692534 PMCID: PMC10485658 DOI: 10.1016/j.infpip.2023.100292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/29/2023] [Indexed: 09/12/2023] Open
Abstract
Background Compliance with dialysis fluid ultrapurity standards is a paramount for online modalities. More than 200 dialysis fluid samples have been analyzed monthly for years in our two dialysis units, with compliant microbiological results until mid-2020. Aim In mid-2020, an unusual occurrence (30%) of contaminated dialysis fluids in dialysis units led us to investigate to determine the source. Methods Microbiological methods for aquaphilic bacteria culturing and endotoxin detection in dialysis fluids were routinely performed on a monthly basis for all dialysis machines. As the contamination appeared randomly and almost simultaneously in our two units without any routine change or febrile syndrome, we searched for a common cause. Supplier's sampling kits as well as microbiological laboratory procedures were scrupulously investigated. Findings 21 out of 30 sampling bags filled with sterile water brought back numerous fungi and bacteria. Laboratory's investigation, through the negative control tests performed routinely, exonerated the lab. All batches of bags analyzed later showed variable levels of contamination according to their transport/storage mode or date of manufacturing. Analyses performed by the supplier - methods complying with the medical device's standards but different from those recommended for dialysis fluids purity - remained negative. Conclusion Our investigation revealed that the contamination of our sampling kits came presumably from the manufacturer's supplying chain. Such false-positive results findings, created serious safety issues and disturbed clinical activities since positive machines were quarantined. Furthermore, it raised a serious concern about manufacturing, microbiological checking and shipping methods for the medical device industry that deserve further attention.
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Affiliation(s)
- Renée Lévesque
- Department of Medicine, Division of Nephrology, Centre Hospitalier de l’Université de Montréal, University of Montreal, Montreal, Canada
| | - Patrice Savard
- Department of Medicine, Division of Infectious Disease, Centre Hospitalier de l’Université de Montréal, University of Montreal, Montreal, Canada
- Department of Clinical Laboratories, Division of Microbiology, Centre Hospitalier de l’Université de Montréal, University of Montreal, Montreal, Canada
| | - Bernard Canaud
- MTX Consulting International SAS, Montpellier, France
- University of Montpellier, Montpellier, France
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Imai M, Yamamoto M, Togo K, Yamashita AC. Particulates formed in dialysis fluid: effect of silica in tap water. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00433-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
A fluid commonly used for dialysis in Japan is prepared from two dialysate concentrates and dialysis water. Silicon (Si) from tap water is reported in dialysis water as suspended insoluble particulate matters. We aimed to examine the source of insoluble particulate matters in the online prepared substitution fluid and to examine effects of the silica (SiO2) of tap water on the SiO2 of dialysis water.
Method
Based on the number of particles and particle size distribution in online prepared substitution fluid, we evaluated particle diameters and constituent elements of particles in online prepared substitution fluid. To identify sources of insoluble particulate matters in the online prepared substitution fluid, we measured particle diameters and constituent elements of particles adhering to the surface of hollow fiber of the final endotoxin-retentive filter (ETRF) and to the inner surface of the housing of the final ETRF and measured SiO2 in tap water, dialysis water, and commercial sterile substitution fluid.
Results
Si-containing particles accounted for 83% of 30 particles detected in the final ETRF (the hollow fibers and the housing) and the online prepared substitution fluid sampled from the final ETRF. The large variability in the SiO2 in tap water depending on the geographic regions. The SiO2 in dialysis water was 0.4–0.7 mg/L. Si was not detected in particles in the commercial sterilized substitution fluid, and the commercial sterile substitution fluids contained SiO2 at 0.1 mg/L.
Conclusion
We presume that insoluble particulates in online prepared substitution fluid were calcium and magnesium precipitated from dialysate and Si precipitated from dialysis water. Moreover, variation in the SiO2 in tap water is a factor affecting the SiO2 level in dialysis water. If the formation of silicates in the online prepared substitution fluid is considered and the target SiO2 in dialysis water is to be set ≤ 0.1 mg/L, SiO2 in tap water available in hospitals and dialysis centers should be known before specifications of instruments for dialysis fluid preparation are determined.
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Imai M, Yamamoto M, Togo K, Yamashita AC. Particulates formed in online prepared substitution fluid- Effect of acetic acid cleaning on endotoxin retentive filters. Ther Apher Dial 2022; 26:1193-1201. [PMID: 35415877 DOI: 10.1111/1744-9987.13851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/21/2022] [Accepted: 04/09/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION There is no standard for insoluble particulate matters in dialysate. We evaluated the insoluble particulate matters in online prepared substitution fluid. METHODS We evaluated particle diameters and constituent elements of particles in online prepared substitution fluid and the final endotoxin retentive filter (ETRF). RESULTS The measurement results with particles in the online prepared substitution fluid and particles attached to the final ETRF revealed that Ca-containing particles accounted for 11 particles and Si-containing particles accounted for 19 particles of 30 particles detected in the online prepared substitution fluid and the final ETRF. CONCLUSION We presume that insoluble particulates in online prepared substitution fluid were Ca and Mg precipitated from dialysate and Si precipitated from dialysis water. Even if two ETRFs were connected in series, these particles were formed in the final ETRF.
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Affiliation(s)
- Motoyuki Imai
- Department of Applied Chemistry, Graduate School of Science and Engineering, Hosei University, Tokyo, Japan.,Department of Electrical Engineering, Faculty of Engineering, Tokyo University of Science, Tokyo, Japan
| | - Masahito Yamamoto
- Department of Applied Chemistry, Graduate School of Science and Engineering, Hosei University, Tokyo, Japan
| | - Konomi Togo
- Medical Engineering Course, Department of Medical Course, Faculty of Health and Medical Science, Teikyo Heisei University, Tokyo, Japan
| | - Akihiro C Yamashita
- Department of Applied Chemistry, Graduate School of Science and Engineering, Hosei University, Tokyo, Japan
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García-Lorenzo B, Fernández-Barceló C, Maduell F, Sampietro-Colom L. Health Technology Assessment of a new water quality monitoring technology: Impact of automation, digitalization and remoteness in dialysis units. PLoS One 2021; 16:e0247450. [PMID: 33630930 PMCID: PMC7906308 DOI: 10.1371/journal.pone.0247450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 02/06/2021] [Indexed: 11/18/2022] Open
Abstract
Background Water quality monitoring at the dialysis units (DU) is essential to ensure an appropriate dialysis fluid quality and guarantee an optimal and safe dialysis treatment to patients. This paper aims to evaluate the effectiveness, economic and organizational impact of automation, digitalization and remote water quality monitoring, through a New Water Technology (NWT) at a hospital DU to produce dialysis water, compared to a Conventional Water Technology (CWT). Methods A before-and-after study was carried out at the Hospital Clínic Barcelona. Data on CWT was collected during 1-year (control) and 7-month for the NWT (case). Data on water quality, resource use and unit cost were retrospective and prospectively collected. A comparative effectiveness analysis on the compliance rate of quality water parameters with the international guidelines between the NWT and the CWT was conducted. This was followed by a cost-minimization analysis and an organizational impact from the hospital perspective. An extensive deterministic sensitivity analysis was also performed. Results The NWT compared to the CWT showed no differences on effectiveness measured as the compliance rate on international requirements on water quality (100% vs. 100%), but the NWT yielded savings of 3,599 EUR/year compared to the CWT. The NWT offered more data accuracy (daily measures: 6 vs. 1 and missing data: 0 vs. 20 days/year), optimization of the DU employees’ workload (attendance to DU: 4 vs. 19 days/month) and workflow, through the remote and continuous monitoring, reliability of data and process regarding audits for quality control. Conclusions While the compliance of international recommendations on continuous monitoring was performed with the CWT, the NWT was efficient compared to the CWT, mainly due to the travel time needed by the technical operator to attend the DU. These results were scalable to other economic contexts. Nonetheless, they should be taken with caution either when the NWT equipment/maintenance cost are largely increased, or the workforce involvement is diminished.
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Affiliation(s)
- Borja García-Lorenzo
- Assessment of Innovations and New Technologies Unit, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
- * E-mail:
| | - Carla Fernández-Barceló
- Assessment of Innovations and New Technologies Unit, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
| | - Francisco Maduell
- Department of Nephrology and Renal Transplantation, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
| | - Laura Sampietro-Colom
- Assessment of Innovations and New Technologies Unit, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
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Abbass AA, El-Koraie AF, Hazzah WA, Omran EA, Mahgoub MA. Microbiological monitoring of ultrapure dialysis fluid in a hemodialysis center in Alexandria, Egypt. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2018.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Affiliation(s)
- Aleya A. Abbass
- Microbiology Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Ahmed F. El-Koraie
- Nephrology Unit, Internal Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Walaa A. Hazzah
- Microbiology Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Eman A. Omran
- Microbiology Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Mohammed A. Mahgoub
- Microbiology Department, High Institute of Public Health, Alexandria University, Alexandria, Egypt
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Bengtsson D, Westerberg M, Nielsen S, Ridell M, Jönsson B. Mycobacterium chimaera in heater-cooler units used during cardiac surgery - growth and decontamination. Infect Dis (Lond) 2018; 50:736-742. [PMID: 29688098 DOI: 10.1080/23744235.2018.1464204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Previous studies have identified patients infected with Mycobacterium chimaera (M. chimaera) subsequent to cardiac surgery. Water tanks in heater-cooler units (HCUs) used cardiac heart surgery was traced as source. The aim was to investigate occurrence of M. chimaera and other microorganisms in HCUs and evaluate the silver-ion cleaning routine. METHOD Five HCUs were disinfected with silver-ions and examined for mycobacteria directly (15 min) after the disinfection procedures and later on three occasions (3, 6, 10 weeks). One HCU was selected for additional investigation of the presence of other microorganisms. In addition, tap water from five sinks in the surgical department was examined for the presence of mycobacteria and other microorganisms. RESULTS M. chimaera grew in all the HCU water tanks and in 35 of the 40 HCU samples. Three of the samples also contained Mycobacterium gordonae. When the selected HCU tanks were analysed directly after the disinfection procedure bacteria and fungi were found but no non-fermenting Gram-negative rods. These HCU samples contained a doubled to 3 fold amount of bacteria compared to initial tap water samples. No mycobacteria were found in any sample from the five water taps. CONCLUSION The silver-ion cleaning routine was insufficient and M. chimaera was found in all HCUs. However, no mycobacteria were found in any sample from the five water taps suggesting another source of colonization. It is probable that residual water and biofilm are of importance. Our results emphasize the need for improved disinfection procedures and improved construction of the HCUs.
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Affiliation(s)
- Daniel Bengtsson
- a Department of Cardiothoracic Surgery , Sahlgrenska University Hospital , Göteborg , Sweden
| | - Martin Westerberg
- a Department of Cardiothoracic Surgery , Sahlgrenska University Hospital , Göteborg , Sweden
| | - Susanne Nielsen
- b Department of Molecular and Clinical Medicine , Sahlgrenska Academy, Göteborg University , Göteborg , Sweden
| | - Malin Ridell
- c Department of Microbiology and Immunology , Institute of Biomedicine, University of Gothenburg , Göteborg , Sweden
| | - Bodil Jönsson
- d Department of Infectious Medicine , Institute of Biomedicine, University of Gothenburg , Göteborg , Sweden.,e Clinical Microbiology Laboratories , Sahlgrenska University Hospital , Gothenburg , Sweden
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8
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Maltais JAB, Meyer KB, Foster MC. Comparison of techniques for culture of dialysis water and fluid. Hemodial Int 2016; 21:197-205. [DOI: 10.1111/hdi.12477] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 07/17/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | - Klemens B. Meyer
- William B. Schwartz Division of Nephrology; Tufts Medical Center; Boston Massachusetts USA
| | - Meredith C. Foster
- William B. Schwartz Division of Nephrology; Tufts Medical Center; Boston Massachusetts USA
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Nagata T, Yasuda Y, Ando M, Abe T, Katsuno T, Kato S, Tsuboi N, Matsuo S, Maruyama S. Clinical impact of kidney function on presepsin levels. PLoS One 2015; 10:e0129159. [PMID: 26030716 PMCID: PMC4451771 DOI: 10.1371/journal.pone.0129159] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 05/05/2015] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Presepsin is highlighted as a diagnostic and prognostic marker of sepsis. Little information is available regarding the accurate association between presepsin levels and the degree of kidney function. We analyzed presepsin levels in patients with a glomerular filtration rate (GFR) in the categories G1 to G5, evaluated via inulin renal clearance test, and receiving hemodialysis (HD). METHODS Patients who were not receiving HD were included if they had undergone inulin renal clearance measurements for the accurate measurement of GFR (measured GFR), and patients who were receiving hemodialysis (HD) were included if they had anuria. Exclusion criteria were infection, cancer, liver disease, autoimmune disorders, or steroid or immunosuppressant use. GFR category was defined as follows; G1: GFR ≥ 90 ml/min/1.73 m2, G2: GFR = 60 to 90 ml/min/1.73 m2, G3: GFR = 30 to 60 ml/min/1.73 m2, G4: GFR = 15 to 30 ml/min/1.73 m2, G5: GFR ≤ 15 ml/min/1.73 m2. RESULTS Seventy-one patients were included. The median (IQR) presepsin values of patients in each GFR category were as follows: G1 + G2: 69.8 (60.8-85.9) pg/ml; G3: 107.0 (68.7-150.0) pg/ml; G4: 171.0 (117.0-200.0) pg/ml; G5: 251.0 (213.0-297.5) pg/ml; and HD: 1160.0 (1070.0-1400.0) pg/ml. The log-transformed presepsin values, excluding patients receiving HD, inversely correlated with the measured GFR (Pearson's correlation coefficient = -0.687, P < 0.001). The multivariate analysis revealed that measured GFR and hemoglobin levels significantly correlated with elevated presepsin levels. CONCLUSION Presepsin levels were markedly high in patients receiving HD, similar to values seen in patients with severe sepsis or septic shock. In patients who were not receiving HD, presepsin levels increased as GFR decreased. Thus, the evaluation of presepsin levels in patients with chronic kidney disease requires further consideration, and a different cutoff value is needed for diagnosing sepsis in such patients.
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Affiliation(s)
- Takanobu Nagata
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshinari Yasuda
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Tomoko Abe
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takayuki Katsuno
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Sawako Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naotake Tsuboi
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Seiichi Matsuo
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Hasegawa T, Nakai S, Masakane I, Watanabe Y, Iseki K, Tsubakihara Y, Akizawa T. Dialysis fluid endotoxin level and mortality in maintenance hemodialysis: a nationwide cohort study. Am J Kidney Dis 2015; 65:899-904. [PMID: 25641063 DOI: 10.1053/j.ajkd.2014.12.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 12/03/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND The quality of dialysis fluid water might play an important role in hemodialysis patient outcomes. Although targeted endotoxin levels of dialysis fluid vary among countries, evidence of the contribution of these levels to mortality in hemodialysis patients is lacking. STUDY DESIGN Retrospective cohort study using data from the Japan Renal Data Registry, a nationwide annual survey. SETTING & PARTICIPANTS 130,781 patients receiving thrice-weekly in-center hemodialysis for more than 6 months were enrolled at 2,746 facilities in Japan at the end of 2006. None of the patients changed facility or treatment modality during 2007. PREDICTOR Highest endotoxin level in dialysis fluid reported by each facility during 2006. Patients were categorized by facility endotoxin level into the following groups: <0.001, 0.001 to <0.01, 0.01 to <0.05, 0.05 to <0.1, and ≥0.1EU/mL. Age, sex, dialysis vintage, diabetes mellitus as a primary cause of end-stage renal disease, Kt/V, normalized protein catabolic rate, dialysis session duration, serum albumin, and hemoglobin were measured as potential confounders. OUTCOME All-cause mortality, censored by transplantation; withdrawal from dialysis treatment; or end of follow-up. RESULTS Of 130,781 hemodialysis patients, 91.2% had facility endotoxin levels below the limit set for dialysis fluid in Japan (<0.05EU/mL). During a 1-year follow-up, 8,978 (6.9%) patients died of all causes. The rate of all-cause mortality at 1 year was highest in the ≥0.1-EU/mL category (88.0 deaths/1,000 person-years). Patients in the ≥0.1-EU/mL group exhibited an increased risk of all-cause mortality of 28% (95% CI, 10%-48%) compared to the <0.001-EU/mL group. LIMITATIONS Endotoxin level in dialysis fluid is reported as categorical data. No information about variation in endotoxin levels in dialysis fluid over time. CONCLUSIONS Higher facility endotoxin levels in dialysis fluid may be related to increased risk for all-cause mortality among hemodialysis patients. Correcting this modifiable facility water management practice might improve the outcome of hemodialysis patients.
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Affiliation(s)
- Takeshi Hasegawa
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, Japan; Division of Nephrology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan; Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan.
| | - Shigeru Nakai
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Fujita Health University, Toyoake, Japan
| | - Ikuto Masakane
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Yabuki Hospital, Yamagata, Japan
| | - Yuzo Watanabe
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Kasugai Municipal Hospital, Kasugai, Japan
| | - Kunitoshi Iseki
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Faculty of Medicine, University of Ryukyus, Okinawa, Japan
| | - Yoshiharu Tsubakihara
- Committee of Renal Data Registry, the Japanese Society for Dialysis Therapy, Tokyo, Japan; Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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Abstract
Chronic unexplained inflammation remains a prevalent and clinically significant problem for patients with end-stage kidney disease (ESKD), especially in the dialysis population. The causes of persistent inflammation are likely to be multifactorial, but the underlying mechanisms remain to be elucidated. Endotoxins are reported to play a significant role in the pathogenesis of inflammation in patients with ESKD. However, blood endotoxin measurement with the Limulus amoebocyte lysate (LAL) assay is difficult with current detection systems. The reported degree and prevalence of endotoxemia varies in the literature. There are questions as to whether endotoxemia is truly present; whether the varied findings are due to methodological issues with the LAL assay and whether any endotoxemia that might be present plays a role in chronic inflammation frequently observed in ESKD patients. This review will discuss the challenges of accurate blood endotoxin detection, the potential source of blood endotoxins, and the significance of endotoxemia to patient with ESKD.
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Affiliation(s)
- Jonathan Wong
- Department of Renal Medicine, Lister Hospital, Stevenage, Hertfordshire, UK; Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, Hertfordshire, UK
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van der Weerd NC, Den Hoedt CH, Blankestijn PJ, Bots ML, van den Dorpel MA, Lévesque R, Mazairac AHA, Nubé MJ, Penne EL, ter Wee PM, Grooteman MPC. Resistance to erythropoiesis stimulating agents in patients treated with online hemodiafiltration and ultrapure low-flux hemodialysis: results from a randomized controlled trial (CONTRAST). PLoS One 2014; 9:e94434. [PMID: 24743493 PMCID: PMC3990567 DOI: 10.1371/journal.pone.0094434] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 03/14/2014] [Indexed: 12/17/2022] Open
Abstract
Resistance to erythropoiesis stimulating agents (ESA) is common in patients undergoing chronic hemodialysis (HD) treatment. ESA responsiveness might be improved by enhanced clearance of uremic toxins of middle molecular weight, as can be obtained by hemodiafiltration (HDF). In this analysis of the randomized controlled CONvective TRAnsport STudy (CONTRAST; NCT00205556), the effect of online HDF on ESA resistance and iron parameters was studied. This was a pre-specified secondary endpoint of the main trial. A 12 months' analysis of 714 patients randomized to either treatment with online post-dilution HDF or continuation of low-flux HD was performed. Both groups were treated with ultrapure dialysis fluids. ESA resistance, measured every three months, was expressed as the ESA index (weight adjusted weekly ESA dose in daily defined doses [DDD]/hematocrit). The mean ESA index during 12 months was not different between patients treated with HDF or HD (mean difference HDF versus HD over time 0.029 DDD/kg/Hct/week [−0.024 to 0.081]; P = 0.29). Mean transferrin saturation ratio and ferritin levels during the study tended to be lower in patients treated with HDF (−2.52% [−4.72 to −0.31]; P = 0.02 and −49 ng/mL [−103 to 4]; P = 0.06 respectively), although there was a trend for those patients to receive slightly more iron supplementation (7.1 mg/week [−0.4 to 14.5]; P = 0.06). In conclusion, compared to low-flux HD with ultrapure dialysis fluid, treatment with online HDF did not result in a decrease in ESA resistance. Trial Registration ClinicalTrials.gov NCT00205556
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Affiliation(s)
- Neelke C. van der Weerd
- Department of Nephrology, Academic Medical Center, Amsterdam, The Netherlands
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | - Claire H. Den Hoedt
- Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Internal Medicine, Maasstad Hospital, Rotterdam, The Netherlands
| | - Peter J. Blankestijn
- Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel L. Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Renée Lévesque
- Department of Nephrology, Centre Hospitalier de l'Université de Montréal, St-Luc Hospital, Québec, Canada
| | - Albert H. A. Mazairac
- Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Menso J. Nubé
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
- Institute for Cardiovascular Research VU Medical Center (ICaR-VU), VU Medical Center, Amsterdam, The Netherlands
| | - E. Lars Penne
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
- Department of Internal Medicine, Medical Center Alkmaar, Alkmaar, The Netherlands
| | - Pieter M. ter Wee
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
- Institute for Cardiovascular Research VU Medical Center (ICaR-VU), VU Medical Center, Amsterdam, The Netherlands
| | - Muriel P. C. Grooteman
- Department of Nephrology, VU Medical Center, Amsterdam, The Netherlands
- Institute for Cardiovascular Research VU Medical Center (ICaR-VU), VU Medical Center, Amsterdam, The Netherlands
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Abstract
Over 383,900 individuals in the U.S. undergo maintenance hemodialysis that exposes them to water, primarily in the form of dialysate. The quality of water and associated dialysis solutions have been implicated in adverse patient outcomes and is therefore critical. The Association for the Advancement of Medical Instrumentation has published both standards and recommended practices that address both water and the dialyzing solutions. Some of these recommendations have been adopted into Federal Regulations by the Centers for Medicare and Medicaid Services as part of the Conditions for Coverage, which includes limits on specific contaminants within water used for dialysis, dialysate, and substitution fluids. Chemical, bacterial, and endotoxin contaminants are health threats to dialysis patients, as shown by the continued episodic nature of outbreaks since the 1960s causing at least 592 cases and 16 deaths in the U.S. The importance of the dialysis water distribution system, current standards and recommendations, acceptable monitoring methods, a review of chemical, bacterial, and endotoxin outbreaks, and infection control programs are discussed.
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Masakane I, Kawanishi H, Mineshima M, Takemoto Y, Uchino J, Hoshino T, Igoshi T, Hirakata H, Akizawa T. 2011 JSDT Standard on the Management of Endotoxin Retentive Filter for Dialysis and Related Therapies. Ther Apher Dial 2013; 17:229-40. [DOI: 10.1111/1744-9987.12031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Ikuto Masakane
- Working Group on the Development of the ETRF Management Standard; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Hideki Kawanishi
- Working Group on the Development of the ETRF Management Standard; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Michio Mineshima
- Working Group on the Development of the ETRF Management Standard; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Yoshiaki Takemoto
- Working Group on the Development of the ETRF Management Standard; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Junji Uchino
- Working Group on the Development of the ETRF Management Standard; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Taketoshi Hoshino
- Working Group on the Development of the ETRF Management Standard; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Tadaaki Igoshi
- Working Group on the Development of the ETRF Management Standard; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Hideki Hirakata
- Chairperson of the Committee of Scientific Academy; The Japanese Society for Dialysis Therapy; Tokyo; Japan
| | - Tadao Akizawa
- President of the Japanese Society for Dialysis Therapy; The Japanese Society for Dialysis Therapy; Tokyo; Japan
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Corradi V, Cruz D, Vázquez-Rangel A, Furlan F, Grillone R, Bonaccorsi A, Cazzavillan S, de Cal M, Frisone P, Morea A, Brendolan A, Rassu M, Ronco C. Purity and stability of online-prepared hemodiafiltration fluid after storage. Blood Purif 2013; 35:112-8. [PMID: 23343555 DOI: 10.1159/000346095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Previous studies have suggested that online hemodiafiltration (OL-HDF) fluid can be used as dialysate for continuous renal replacement therapies, and thus HDF costs can be reduced. The aims of this study were to determine the purity of OL-HDF fluid and to verify the stability of the electrolyte composition and acid-base balance during its storage. METHODS OL-HDF fluid was collected in 70 individual bags and stored for up to 7 days. The following tests were performed daily in 10 bags: natural visible precipitation (macrocrystallization), sample collection for chemical analysis and fluid culture, limulus amebocyte lysate endotoxin test, standard culture of NALGENE® filters after passing of the fluid, and molecular analysis of bacterial DNA. RESULTS The values of pH and pCO(2) showed a significant change starting at 24 h (p < 0.001); after 72 h, their values were beyond the measurable range. Coefficient of variation for pCO(2) was as high as 25.7%. Electrolyte composition (Na(+), K(+), Cl(-), Ca(2+) and glucose) showed a statistically significant difference over time (p < 0.05); however, their coefficients of variation were low (1.7, 1.4, 0.6, 2.3 and 0.9%, respectively), which might not be considered clinically significant. Negative results were obtained at all points by fluid and filter cultures, endotoxin test and molecular analysis. No macrocrystallization was observed at any time point. CONCLUSIONS We demonstrate the microbiological purity of OL-HDF fluid stored for up to 7 days. The electrolyte composition was stable, except for a relevant change in pCO(2) and consequently in pH (first noted at 24 h), emphasizing the need to reassess the acid-base balance in multilayer plastic bags in future studies.
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Affiliation(s)
- V Corradi
- Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
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Susantitaphong P, Riella C, Jaber BL. Effect of ultrapure dialysate on markers of inflammation, oxidative stress, nutrition and anemia parameters: a meta-analysis. Nephrol Dial Transplant 2013; 28:438-46. [PMID: 23291370 DOI: 10.1093/ndt/gfs514] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Markers of inflammation are linked to malnutrition and confer an increased mortality risk in hemodialysis patients. Ultrapure dialysate might have a beneficial effect on markers of inflammation. We conducted a meta-analysis that examined the effect of ultrapure versus standard dialysate on markers of inflammation, oxidative stress, nutrition and anemia parameters. METHODS We performed a literature search using MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and scientific abstracts. Single-arm studies, nonrandomized and randomized controlled trials were included. We conducted random effects model meta-analyses to assess changes in the aforementioned outcomes. RESULTS We identified 16 single-arm studies, 2 crossover and 3 parallel-arm nonrandomized controlled trials and 5 crossover and 5 parallel-arm randomized controlled trials. In an analysis of 23 study arms or cohorts (n = 2221), ultrapure dialysate resulted in a significant decrease in C-reactive protein (-3.2 mg/L; 95% CI -4.6, -1.8; P < 0.001). Other markers of inflammation and oxidative stress displayed similar significant improvements. Ultrapure dialysate also resulted in a significant increase in serum albumin (0.11 g/dL; 95% CI 0.02, 0.19; P = 0.011) and hemoglobin (0.40 g/dL; 95% CI 0.06, 0.75; P = 0.022), and a decrease in the weekly erythropoietin dose (-273 units; 95% CI -420, -126; P < 0.001). The results remained significant in analyses restricted to controlled trials. CONCLUSIONS Use of ultrapure dialysate in hemodialysis patients results in a decrease in markers of inflammation and oxidative stress, an increase in serum albumin and hemoglobin and a decrease in erythropoietin requirement. Although improvement in these surrogate endpoints might confer a cardiovascular benefit, a large trial with hard clinical endpoints is required.
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Affiliation(s)
- Paweena Susantitaphong
- Department of Medicine, Division of Nephrology, Kidney and Dialysis Research Laboratory, St Elizabeth's Medical Center, Boston, MA, USA
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Elkabbaj D, Bahadi A, Cherrah Y, Errasfa M, Eljaoudi R. Impact of improving quality of dialysis fluid on oxidative stress and lipid profile in hemodialysis patients. ISRN NEPHROLOGY 2012; 2013:717849. [PMID: 24967229 PMCID: PMC4045418 DOI: 10.5402/2013/717849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 11/17/2012] [Indexed: 12/03/2022]
Abstract
The aim of this study was to evaluate the levels of malondialdehyde as an oxidative stress marker in the same hemodialysis patients after changing the quality of dialysate with ultrapure dialysis fluid. Methods. This prospective study concerns hemodialysis patients; all patients were in the first step treated with conventional dialysate, and in the second step (three months later) the same patients were treated with online produced ultrapure dialysis fluid. The malondialdehyde, C-reactive protein, total cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein, fibrinogen, and albumin were quantified before the two steps. Results. Thirty-seven patients completed the study. Ultrapure dialysis fluid reduced but not significantly the malondialdehyde concentrations. Both dialysis fluids were associated with improvement in the malondialdehyde level before and after the hemodialysis session. In lipid parameters, there was a significant decrease with conventional dialysis fluid versus ultrapure dialysis fluid of triglycerides, total cholesterol, and high-density lipoprotein in patients' blood. Instead, the level of low-density lipoprotein, fibrinogen, albumin, and C-reactive protein does not change significantly. Conclusion. The lipid parameters were improved for triglycerides and total cholesterol. Malondialdehyde increases following the hemodialysis session, and the conventional dialysate increased malondialdehyde levels more than the ultrapure dialysis but the differences were not statistically significant.
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Affiliation(s)
- Driss Elkabbaj
- Nephrology Department, Military Hospital Mohammed V, 10000 Rabat, Morocco
| | - Abdelali Bahadi
- Nephrology Department, Military Hospital Mohammed V, 10000 Rabat, Morocco
| | - Yahia Cherrah
- Pharmacology and Toxicology Department, Faculty of Medicine and Pharmacy, 10000 Rabat, Morocco
| | - Mourad Errasfa
- Pharmacology Department, Faculty of Medicine and Pharmacy, 30000 Fes, Morocco
| | - Rachid Eljaoudi
- Pharmacology and Toxicology Department, Faculty of Medicine and Pharmacy, 10000 Rabat, Morocco
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Fendley DA, Ward RA. Dialysate Quality: New Standards Require a New Approach to Compliance. Semin Dial 2012; 25:510-5. [PMID: 22994601 DOI: 10.1111/sdi.12007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- David A Fendley
- Department of Medicine, University of Louisville, Louisville, Kentucky 40202-1718, USA
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Canaud B, Lertdumrongluk P. Ultrapure dialysis fluid: a new standard for contemporary hemodialysis. Nephrourol Mon 2012; 4:519-23. [PMID: 23573478 PMCID: PMC3614300 DOI: 10.5812/numonthly.3060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 12/15/2011] [Accepted: 01/09/2012] [Indexed: 12/18/2022] Open
Affiliation(s)
- Bernard Canaud
- Nephrology, Dialysis and Intensive Care Unit, Montpellier, France
- Corresponding author: Bernard Canaud, Nephrology, Dialysis and Intensive Care Unit, Lapeyronie University Hospital & Institut de Recherche et Formation en Dialyse, 375, Avenue du Doyen Giraud, 34295 Montpellier, France. Tel.: +334-67338495, Fax: +334-67603783, E-mail:
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Canaud B. Rapid assessment of microbiological purity of dialysis water: the promise of solid-phase cytometry assessment and the epifluorescence microscopy method. Nephrol Dial Transplant 2011; 26:3426-8. [PMID: 22039011 DOI: 10.1093/ndt/gfr601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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21
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Canaud B, Granger-Vallée A. Should ultrapure dialysate be part of standard therapy in hemodialysis? Semin Dial 2011; 24:426-7. [DOI: 10.1111/j.1525-139x.2011.00947.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bacelar Marques ID, Pinheiro KF, de Freitas do Carmo LP, Costa MC, Abensur H. Anaphylactic reaction induced by a polysulfone/polyvinylpyrrolidone membrane in the 10th session of hemodialysis with the same dialyzer. Hemodial Int 2011; 15:399-403. [PMID: 21624039 DOI: 10.1111/j.1542-4758.2011.00553.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The majority of severe hypersensitivity reactions in hemodialysis patients have occurred due to sensitization to ethylene oxide or to nonbiocompatible membrane dialyzers. The use of polysulfone dialyzers rarely causes hypersensitivity reactions. In the present study, we describe a case of severe life-threatening reactions induced by polysulfone dialyzers (from different manufacturers subjected to a variety of sterilization methods), which occurred after 9 sessions of hemodialysis with the same prescription, exemplifying the complexity of such reactions.
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Movilli E, Camerini C, Gaggia P, Poiatti P, Pola A, Viola BF, Zubani R, Jeannin G, Cancarini G. Effect of post-dilutional on-line haemodiafiltration on serum calcium, phosphate and parathyroid hormone concentrations in uraemic patients. Nephrol Dial Transplant 2011; 26:4032-7. [DOI: 10.1093/ndt/gfr179] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Mactier R, Hoenich N, Breen C. Renal Association Clinical Practice Guideline on haemodialysis. Nephron Clin Pract 2011; 118 Suppl 1:c241-86. [PMID: 21555899 DOI: 10.1159/000328072] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Accepted: 12/01/2009] [Indexed: 11/19/2022] Open
Affiliation(s)
- Robert Mactier
- Renal Services, NHS Greater Glasgow and Clyde and NHS Forth Valley.
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Lodi CA, Vasta A, Hegbrant MA, Bosch JP, Paolini F, Garzotto F, Ronco C. Multidisciplinary evaluation for severity of hazards applied to hemodialysis devices: an original risk analysis method. Clin J Am Soc Nephrol 2010; 5:2004-17. [PMID: 20813858 DOI: 10.2215/cjn.01740210] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Risk analysis for medical devices is a crucial process to grant adequate levels of safety. Identification of device exposure-related hazards is one of the main objectives. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Hazard analysis for hemodialysis devices has been performed by a multidisciplinary team involving engineers and clinical experts. A potential harm list was identified from clinical and technical experience, postproduction information, and literature. Various hazardous situations (circumstances when the use of the dialysis device may lead to described harms) were described. Such hazardous situations were correlated to the extent of the deviation of a specific device parameter from expected ranges. The clinical severity that was relevant to any specific harm was categorized for each hazardous situation using a descriptive and numerical scale with five levels (from negligible [i.e., discomfort only] to catastrophic [i.e., potentially lethal]). RESULTS Harms in which the deviation of a parameter strictly coincides with the clinically measured effect on the patient are defined as "direct." Otherwise, when another clinical parameter must be involved to quantify severity, the related harm is considered "indirect." Two complete examples of multidisciplinary evaluation for severity of hazards (MESH) are given for a direct harm (air embolism) and for an indirect harm (hypothermia). For other harms, the maximum value of severity involved is provided. CONCLUSIONS MESH represents a possible example of risk management for dialysis equipment in which, although the manufacturer is directly responsible, a multidisciplinary task force may contribute to a better link between engineering and clinical perspectives.
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Penne EL, van der Weerd NC, van den Dorpel MA, Grooteman MP, Lévesque R, Nubé MJ, Bots ML, Blankestijn PJ, ter Wee PM. Short-term Effects of Online Hemodiafiltration on Phosphate Control: A Result From the Randomized Controlled Convective Transport Study (CONTRAST). Am J Kidney Dis 2010; 55:77-87. [PMID: 19962805 DOI: 10.1053/j.ajkd.2009.09.023] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Accepted: 09/24/2009] [Indexed: 12/21/2022]
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Ledebo I, Blankestijn PJ. Haemodiafiltration-optimal efficiency and safety. NDT Plus 2009; 3:8-16. [PMID: 20090878 PMCID: PMC2808132 DOI: 10.1093/ndtplus/sfp149] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Accepted: 09/25/2009] [Indexed: 11/13/2022] Open
Abstract
Haemodiafiltration (HDF) is the blood purification therapy of choice for those who want significant removal of uraemic solutes beyond the traditional range of small molecules. Combining diffusive and convective solute transport, a HDF treatment comprises the largest number of variables among blood purification therapies, and it is important to understand how they interact in order to optimize the therapy. This review discusses the parameters that determine the efficiency of HDF and how they can be controlled in the different forms of HDF and ‘HDF-like’ therapies practised today. The key to safe and effective HDF therapy is to have access to large volumes of high-quality fluids. Starting with ultrapure dialysis fluid, on-line preparation of a sterile, non-pyrogenic substitution solution can be made an integral part of the treatment, and we describe the necessary conditions for this. On-line HDF can provide the largest removal of the widest range of solutes among available dialysis therapies, and the potential clinical benefits of this are within practical reach for the increasing number of patients dialysed with high-flux membranes and ultrapure dialysis fluid.
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Nystrand R. Official recommendations for quality of fluids in dialysis -the need for standardisation. J Ren Care 2009; 35:74-81. [PMID: 19432852 DOI: 10.1111/j.1755-6686.2009.00091.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Recommendations/guidelines regarding the microbiological and chemical quality of fluids in dialysis are increasing in numbers, both nationally and internationally. As dialysis is a worldwide issue, with many elements being similar regardless of geographical area, it is logical to have the same quality requirements on fluids used in dialysis. At present, there are large differences between the different documents. This situation makes studies where several nations participate more difficult to interpret as the fluids used in dialysis are crucial for the dialysis session. A special situation applies for substitution fluid produced 'On-Line' for haemodiafiltration (HDF) and haemofiltration (HF), where some recommendations are questionable from a scientific standpoint. The International Organisation for Standardisation (ISO) is in the process of finishing a collection of standards including guideline for fluids in dialysis (water, concentrates, dialysis fluid, substitution fluid) and equipment used for water preparation. To have the same quality for reference worldwide will facilitate the interpretation of international studies as well as give dialysis patients treatments based on the same quality baseline.
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Kawanishi H, Akiba T, Masakane I, Tomo T, Mineshima M, Kawasaki T, Hirakata H, Akizawa T. Standard on microbiological management of fluids for hemodialysis and related therapies by the Japanese Society for Dialysis Therapy 2008. Ther Apher Dial 2009; 13:161-6. [PMID: 19379157 DOI: 10.1111/j.1744-9987.2009.00674.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The Committee of Scientific Academy of the Japanese Society for Dialysis Therapy (JSDT) proposes a new standard on microbiological management of fluids for hemodialysis and related therapies. This standard is within the scope of the International Organization for Standardization (ISO), which is currently under revision. This standard is to be applied to the central dialysis fluid delivery systems (CDDS), which are widely used in Japan. In this standard, microbiological qualities for dialysis water and dialysis fluids are clearly defined by endotoxin level and bacterial count. The qualities of dialysis fluids were classified into three levels: standard, ultrapure, and online prepared substitution fluid. In addition, the therapeutic application of each dialysis fluid is clarified. Since high-performance dialyzers are frequently used in Japan, the standard recommends that ultrapure dialysis fluid be used for all dialysis modalities at all dialysis facilities. It also recommends that the dialysis equipment safety management committee at each facility should validate the microbiological qualities of online prepared substitution fluid.
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Affiliation(s)
- Hideki Kawanishi
- Committee of Scientific Academy, Japanese Society for Dialysis Therapy, Tokyo, Japan.
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Microbiological quality and quality control of purified water and ultrapure dialysis fluids for online hemodiafiltration in routine clinical practice. Kidney Int 2009; 76:665-72. [PMID: 19606080 DOI: 10.1038/ki.2009.245] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
During online hemodiafiltration, patients are directly infused with sterile substitution solutions to maintain fluid balance. Adequate water treatment and a well-organized quality control process are essential to provide non-pyrogenic fluids with consistent optimal quality. We sought to assess water quality, the water treatment system, and the methods for surveillance of microbiological water quality in 10 Dutch dialysis centers that routinely treat patients with hemodiafiltration. Microbiological monitoring results (micro-organisms and endotoxins) were collected over a 1-year period representing 11,258 hemodiafiltration sessions covering 97 patients. In all centers, water purification was based on a reverse osmosis module in combination with a second reverse osmosis and/or an electrodeionizer. All centers regularly and routinely monitored the microbiological purity of the dialysis water with adequate analytical methods but with variable monitoring frequency. Microbiological assessments were compliant with reference quality levels in 3923 of 3961 samples. Our study suggests that non-pyrogenic substitution fluids can be produced online for a prolonged period of time. It is likely that the current Dutch Quality of Care Guideline has contributed to high-quality water treatment and a well-organized control process.
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Masakane I, Tsubakihara Y, Akiba T, Watanabe Y, Iseki K. Bacteriological Qualities of Dialysis Fluid in Japan as of 31 December 2006. Ther Apher Dial 2008; 12:457-63. [DOI: 10.1111/j.1744-9987.2008.00635.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
AIMS To examine the diversity of cultivable 0.2 micron filtrate biofilm forming bacteria from drinking water systems. METHODS AND RESULTS Potable chlorinated drinking water hosts phylogenetically diverse ultramicrocells (UMC) (0.2 and 0.1 microm filterable). UMC (starved or dwarf bacteria) were isolated by cultivation on minimal medium from a flow system wall model with polyvinyl chloride (PVC) pipes. All cultivated cells (25 different isolates) did not maintain their ultra-size after passages on rich media. Cultured UMC were identified by their 16S ribosomal DNA sequences. The results showed that they were closely related to uncultured and cultured members of the Proteobacteria, Actinobacteria and Firmicutes. The isolates of phylum Actinobacteria included representatives of a diverse set of Actinobacterial families: Micrococcaceae, Microbacteriaceae, Dermabacteraceae, Nocardiaceae and Nocardioidaceae. CONCLUSIONS This study is the first to show an abundance of cultivable UMC of various phyla in drinking water system, including a high frequency of bacteria known to be involved in opportunistic infections, such as Stenotrophomonas maltophilia, Microbacterium sp., Pandoraea sp. and Afipia strains. SIGNIFICANCE AND IMPACT OF THE STUDY Chlorinated tap water filtrate (0.2 and 0.1 microm) still harbours opportunistic micro-organisms that can pose some health threat.
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Affiliation(s)
- F S Silbaq
- Mar Elias Educational Institutions and Mar Elias Campus, Ibillin, Galilee, Israel.
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Abstract
In hemodialysis, huge amounts of water are used for diluting the concentrates to produce dialysis fluid. The water is produced on site by reverse osmosis units. The chemical and microbiological quality of the water is essential for dialysis patients. Reverse osmosis units produce water of acceptable chemical quality that can be kept throughout the water system. The microbiological water quality, on the other hand, does not depend on the reverse osmosis unit but on the maintenance of the whole water system. All over the world, dialysis units take water samples and send them to laboratories for cultivation and endotoxin tests. Depending on the method of microbiological analysis, the water may be judged to be very good even if in reality it is much worse and outside of standard recommendations. When standardizing the methods with adequate cultivation of water samples, the accuracy of the tests will be better, and as a result, dialysis units can use their resources for keeping the water systems in good shape, i.e. disinfect preventively and frequently and use less effort in collecting samples. This will benefit patients, who will receive a high-quality dialysis fluid, thus eliminating the effects of microbiological impacts such as increased levels of inflammation markers (e.g. C-reactive protein). In the situation of performing hemodiafiltration by producing the substitution fluid "on-line", it is even more important to have a sensitive method of microbiological verification to follow-up the hygienic quality.
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Affiliation(s)
- Rolf Nystrand
- Bio-TeQ Nystrand Consulting, gullbackengatan, Malmö, Sweden.
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Abstract
The fluids used in dialysis are all water based. Water, which is necessary for life, is also a good environment for micro-organisms. The result of this is quite simply that microbial growth, i.e., increased numbers of micro-organisms, results in the presence of endotoxins and the formation of metabolites. The situation is not favorable for dialysis and needs to be understood and corrected. In order to act in the right way we must analyze and synthesize the available information, which will lead us to decide what actions and precautions are necessary. The possible negative effects of a too-high microbiological content in dialysis fluid and the importance of hygiene have been well-documented. This chain of events depends on ensuring that the information and thus the understanding we get from that information is accurate. If it is not accurate, any actions taken may be inadequate and result in a situation we can no longer control. The patient will be in contact with the dialysis fluid in every session of dialysis due to the phenomenon of backfiltration, which means that anywhere from 100 ml to multiple liters of dialysis fluid is filtered over the dialyzer membrane and into the blood. The problems that may occur when contaminated dialysis fluid is used range from the acute pyrogenic reaction to chronic reactions over time where no acute symptoms are identified. The immune defense system is, however, constantly tested by the presence of body foreign components in the dialysis fluid. This paper will discuss the microflora (the micro-organisms present in the microbial community) that occur in systems of fluids in dialysis, limits, and methods of cultivation and disinfection. Results presented are original data examples out of some 350 investigations of fluid systems in dialysis units around the world, using analytic methods.
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Shimakita T, Yamamoto H, Naramura T, Fujimori A, Ide T, Tashiro Y, Saito M, Matsuoka H. Rapid count of microbial cells in dialysate. Ther Apher Dial 2007; 11:363-9. [PMID: 17845395 DOI: 10.1111/j.1744-9987.2007.00500.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
An apparatus for the non-culture method (NCM) of microbial cell count was formerly developed and named a bioplorer. The bioplorer NCM is based on the double staining of cells with 4', 6-diamidino-2-phenylindole (DAPI) and propidium iodide (PI) and the automatic analysis of their fluorescent microscopic images. Viable cells can be stained with DAPI, while dead cells can be stained with DAPI and PI. In this study, the bioplorer NCM has been applied to the dialysate. The viable and dead cells in dialysate could be counted within 20 min. The detection limit expressed by log(10)[cells/100 mL] was 2.0. When cell-spiked dialysate samples containing prescribed number of Bacillus subtilis cells were assayed, the numbers of cells determined by the bioplorer NCM (N(VIA)(NCM)) and a conventional culture method (CM) on R2A medium (N(VIA)(R2A-CM)) were similar in the range of 2.6-4.6 within the 95% confidence interval (NCM-CM equivalent range). When test solutions sampled from a practical facility in a hospital were assayed, N(VIA)(NCM) was greater than, but comparable to, N(VIA)(R2A-CM). The endotoxin (ET) in the test samples were assayed as well using a test kit for limulus amoebocyte lysate assay. The results of microbial cells and ET concentration indicated that the dialysate supplying line was clean and well maintained. The bioplorer NCM can determine if the microbial contamination of dialysate supplying facilities is greater than 2.6 (398 cells/100 mL).
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Affiliation(s)
- Tomonori Shimakita
- Biosensing Business Project, Matsushita Ecology Systems Co. Ltd., Kasugai, Aichi, Japan
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Abstract
Use of ultrapure dialysate (bacteria < 0.1 CFU/mL and endotoxin < 0.03 EU/mL) is associated with a reduction in inflammation and morbidity in patients treated with conventional thrice-weekly dialysis. The improved outcomes obtained with more frequent dialysis schedules have reawakened interest in home hemodialysis. More frequent dialysis also appears to reduce inflammation, and whether combining more frequent dialysis with use of ultrapure dialysate will have an additive effect on inflammation and its consequences remains unclear. Routinely producing ultrapure dialysate in a home environment with a conventional hemodialysis machine poses technical challenges related to the design of the equipment and the intermittent nature of hemodialysis. Solutions to these problems include use of a system in which the water-treatment equipment is fully integrated with the dialysis machine, use of dry-powder cartridges or sterile prepackaged liquids for bicarbonate concentrate, and use of a bacteria-retentive and endotoxin-retentive filter for final purification of the dialysate immediately before it enters the dialyzer. Alternatively, ultrapure dialysate may be achieved with newer machines designed specifically for home hemodialysis that use a new batch of dialysate for each treatment. The volume of dialysate available with these machines, however, currently limits their use to short-daily dialysis.
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Affiliation(s)
- Rosemary Ouseph
- Department of Medicine, University of Louisville, Louisville, KY 40202-1718, USA
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KJELLSTRAND CM, KJELLSTRAND P. Beyond ultrapure hemodialysis: A necessary and achievable goal. Hemodial Int 2007. [DOI: 10.1111/j.1542-4758.2007.00145.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kawanishi H. On-line continuous hemodiafiltration in sepsis. Transfus Apher Sci 2006; 35:265-9. [PMID: 17140852 DOI: 10.1016/j.transci.2006.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Accepted: 06/14/2006] [Indexed: 11/21/2022]
Abstract
On-line products of substitution fluid by bicarbonate buffered dialysate permits virtually unlimited fluid volume exchange during continuous hemodiafiltration (CHDF) to critical care. In on-line hemodiafiltration (HDF), endotoxin free dialysate obtained using pyrogen cut filters is infused into the blood circuit, and HDF is automatically performed using the close-loop balancing system of the dialysis machine. On-line CHDF is the application of this on-line HDF to continuous renal replacement therapy in the critical care field. We performed on-line CHDF of the totally in 123 septic shock patients during a 5-year period and the mean survival rate was 54%. We concluded that on-line CHDF system is safe and effective at maintaining acute kidney injury with sepsis.
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Affiliation(s)
- Hideki Kawanishi
- Akane Foundation, Tsuchiya General Hospital 3-30, Nakajima-cho, Naka-ku, Hiroshima 730-8655, Japan
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Abstract
Online hemodiafiltration (HDF) is an extracorporeal technique for solute removal in renal failure, which takes advantage of an enhancement of convective treatment by the large amount of ultrapure nonpyrogen dialysate being used for substitution of the ultrafiltered volume. It offers many advantages aside from its safe inflammatory profile, which is attributable to the use of ultrapure dialysate and highly biocompatible dialysis membranes. Due to an improved convective clearance, significantly increased removal of large or protein-bound uremic retention solutes can be achieved, with a potential benefit on cardiovascular morbidity and mortality. Recent observational data indicate that online HDF offers a survival advantage even after adjustment for comorbidity and dialysis efficiency. Research has been ongoing to maximize further the effectiveness of the technique by new technical innovations such as transmembrane-pressure feedback control or mid-dilution online HDF.
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Affiliation(s)
- Steven Van Laecke
- Nephrology Section of Department of Internal Medicine, University of Ghent, De Pintelaan 185, Ghent, Belgium
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Abstract
It has generally been accepted that biological contamination of dialysate deteriorates the biocompatibility of dialysis therapy and accelerates dialysis-related complications such as dialysis-related amyloidosis (DRA) and malnutrition-inflammation-atherosclerosis (MIA) syndrome. During the past decade several studies have clarified that very slight amounts of contamination can lead to inflammatory response, and we could not confirm biological dialysate quality only by measuring endotoxin levels despite of measuring viable cell counts or biofilms. To achieve this, the European Renal Association/European Dialysis Transplantation Association and the American National Standardization Institute/Association for the Advancement of Medical Instrumentation published new standards for dialysate, in which very strict control levels were recommended with regard to viable bacterial cell counts. In 2004 JSDT raised the required standard of the levels of endotoxin, and began to develop a standard for bacterial cell counts. In Japan, many chronic kidney disease patients are treated with centralized dialysate supply systems which have weak spots in disinfecting the system. This causes some difficulties in making a standard for viable bacterial cell counts. In the present paper, we summarize evidences of clinical usefulness of ultrapure dialysate and perspectives of the standard for dialysate in Japan.
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Affiliation(s)
- Ikuto Masakane
- Kidney and Dialysis Center, Yabuki Hospital, Yamagata, Japan.
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Lamas JM, Alonso M, Sastre F, García-Trío G, Saavedra J, Palomares L. Ultrapure dialysate and inflammatory response in haemodialysis evaluated by darbepoetin requirements—a randomized study. Nephrol Dial Transplant 2006; 21:2851-8. [PMID: 16822792 DOI: 10.1093/ndt/gfl322] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Dialysate quality has been suggested to influence inflammation status in patients subject to haemodialysis (HD). The aim of this study was to compare ultrapure dialysate (UPD) vs conventional dialysate (CD) with respect to darbepoetin requirements and other inflammation markers. METHODS A controlled prospective randomized study was carried out on 78 patients from two HD units who were treated with low-flux polyamide dialysers. Patients were assigned to two groups by using different sized blocks per unit and dialysis session. One group received CD treatment while the other was treated with UPD over 12 months. From the groups, 37 patients started treatment with CD and 41 with UPD while 31 patients ended with CD and 30 with UPD. The main variables analysed were haemoglobin (Hb) and darbepoetin dose; other variables studied were C-reactive protein (CRP), albumin, interleukin-6 (IL-6) and interleukin-1 receptor antagonist (IL-1Ra). RESULTS No significant differences were observed between the two groups for the variables analysed. At the beginning of the study the following values of CD and UPD were assessed: Hb 11.3 and 11.3 (g/dl); darbepoetin dose: 0.49 and 0.44 (microg/kg/week); CRP: 13 and 24 (mg/l); albumin: 3.8 and 3.7 (g/dl); IL-6: 5.94 and 4.18; and IL-1Ra: 345 and 420 (ng/l), respectively. At the end of the study the values of CD and UPD were: Hb 12 and 11.9 (g/dl); darbepoetin dose: 0.47 and 0.48 (microg/kg/week); CRP: 14 and 14 (mg/l); albumin: 3.8 and 3.7 (g/dl); IL-6: 14.03 and 12.93 and IL-1Ra: 322 and 340 (ng/l). CONCLUSIONS UPD does not improve the inflammatory status evaluated by darbepoetin requirements in conventional HD patients treated with low-flux polyamide dialyser. Further controlled studies are required to evaluate the clinical influence of UPD in HD with other low- and high-flux membranes.
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Affiliation(s)
- José M Lamas
- Hospital Meixoeiro, Complejo Hospitalario Universitario de Vigo unidad de Nefrología, Alto de Puxeiros s/n, 36200 Vigo, Pontevedra, Spain.
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Abstract
Biofilm/bioslime is a complex, dynamically interactive multicellular community protected within a heterogeneous exopolysaccharide matrix. Its formation results in the genesis or perpetuation of infection, enhancement of inflammation, and tissue damage or death. Industrial financial losses result from biofilm/bioslime formation; however, the consequences in the medical realm are equally devastating. The relation of biofilm to patients with chronic kidney disease is often covert and extends beyond the colonization of hemodialysis circuits and vascular accesses. Urinary tract device- and vascular access-related biofilms may also increase the burden of cardiovascular risk borne by chronic kidney disease patients, synergizing with the chronic inflammatory state already incurred by these individuals. Current anti-infective strategies are aimed at rapidly killing planktonic forms of microorganisms without specifically targeting the sessile forms that perpetuate their planktonic brethren. Future treatments of infections must ultimately target these reservoirs of infection aiming for their complete eradication. Presently, included among these novel weapons of microdestruction are molecular blockading techniques, electrical enhancement of anti-infectives, and bacterial interference. Nonetheless, the best approach against biofilm formation remains the prevention of microbial colonization, which can be largely by sterile handling of patient-related devices, the most well-established biofilm reservoirs.
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Affiliation(s)
- Gino Tapia
- Department of Medicine, Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI 48202, USA
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Abstract
Many terms have been used to describe the collection of signs and symptoms triggered by the initial use of dialyzers. These reactions can be divided into Type A (hypersensitivity reactions, with the incidence of 4/100,000) and Type B (nonspecific reactions, incidence 3-5/100). Many different mechanisms have been postulated, including complement activation, pulmonary leukostasis, hypersensitivity to ethylene oxide, interaction between the AN69 membrane and angiotensin-converting enzyme inhibitors, and dialysate contamination. An unusual case of dialyzer reactions is presented here, involving a patient who had to discontinue peritoneal dialysis when she was admitted with fungal peritonitis. Upon initiation of hemodialysis, she experienced dyspnea and burning sensation and demonstrated significant leukopenia, thrombocytopenia, and oxygen desaturation. These reactions persisted despite double-rinsing of the dialyzers and the use of several different dialyzers with synthetic membranes (polysulfone and AN69), and a variety of sterilization methods (electron beam and gamma radiation). In the end, a simple measure was found to be effective in preventing further dialyzer reactions in this fascinating case.
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Affiliation(s)
- Robert C Yang
- Division of Nephrology, University of Western Ontario, London, Ontario, Canada.
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Marion-Ferey K, Leid JG, Bouvier G, Pasmore M, Husson G, Vilagines R. Endotoxin Level Measurement in Hemodialysis Biofilm Using "The Whole Blood Assay". Artif Organs 2005; 29:475-81. [PMID: 15926985 DOI: 10.1111/j.1525-1594.2005.29081.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Biofilms have been found on the inner surface of silicone tubing inside dialysis machines. Endotoxin releasing from those biofilms increases the bioincompatibility of dialysis liquids and leads to long-term inflammatory complications among dialysis patients. Endotoxin measurement is recommended for the control of dialysis liquids. This article describes the use of a new method, the Whole Blood Assay (WBA), for endotoxin quantification in dialysis biofilms. Biofilms were suspended in sterile water by scraping the tubing samples. Diluted blood samples from healthy donors were stimulated overnight with the contaminated suspension. Stimulated mononuclear cells released IL-1beta in response to endotoxins. IL-1beta level was then measured using an ultrasensitive ELISA method. We demonstrated a semilogarithmic model in which the optical densities measured after the ELISA assay increases linearly with the levels of endotoxin. This model allowed the determination of the amount of endotoxins in biofilm samples with a detection limit of 0.032 EU/mL. Most of the time, the amounts of endotoxin measured by the WBA were higher than those measured by the Limulus Amoebocyte Lysate (LAL) assay. This study suggested the presence of "endotoxin-like" compounds different from the lipopolysaccharides that are not detected by the LAL assay. We concluded that the LAL is necessary but insufficient to have a representative quantification of endotoxins that could be hazardous to patient health.
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Ledebo I. Ultrapure Dialysis Fluid – Direct and Indirect Benefits in Dialysis Therapy. Blood Purif 2005; 22 Suppl 2:20-5. [PMID: 15655318 DOI: 10.1159/000081869] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The fluid quality description 'ultrapure' means practically free from bacteria and endotoxin. In quantitative terms it is defined as <0.1 CFU/ml and <0.03 EU/ml. The requirements on endotoxin as well as bacteria should be fulfilled, because these two entities are not strictly correlated. Ultrapure dialysis fluid can be prepared from standard quality fluid by a single step of controlled ultrafiltration. Recent clinical studies demonstrate that the use of ultrapure dialysis fluid in hemodialysis is associated with patient benefits indicating a less inflammatory state compared to hemodialysis with standard fluid. By applying one additional step of controlled ultrafiltration, ultrapure dialysis fluid can be further purified to such high microbiological quality that it can be used for infusion. This opens up the possibility for convective therapies, hemodiafiltration and hemofiltration, for which large volumes of sterile infusion solution are needed. With optimal application of these therapies, solute removal is enhanced, qualitatively as well as quantitatively, and fluid management is facilitated through improved hemodynamic stability.
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Koda Y. Internal filtration-enhanced hemodialysis is a cost-effective treatment in view of solute removal. Blood Purif 2005; 22 Suppl 2:36-9. [PMID: 15655322 DOI: 10.1159/000081873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
By modifying dialyzer module design, internal filtration (IF) within a dialyzer is enhanced to increase convective solute transport. Thus, it can be an alternative to hemodiafiltration with no requirement of substitution fluid or additional complex machines. Cost-effective analysis was conducted in three modes of therapy: high-flux hemodialysis, on-line hemodiafiltration and IF-enhanced hemodialysis. In IF-enhanced hemodialysis, cost-effectiveness of small solute removal is comparable with high-flux hemodialysis and that of beta(2)-microglobulin removal is the best. It is concluded that IF-enhanced hemodialysis is the most cost-effective therapy mode in comprehensive overall solute removal.
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Affiliation(s)
- Yutaka Koda
- Koda Medical and Dialysis Clinic, Niigata, Japan.
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Affiliation(s)
- Francisco Maduell
- Department of Nephrology, Hospital General de Castellón, Avenue Benicasim s/n, 12004 Castellón, Spain.
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Abstract
To prevent pyrogenic reactions during hemodialysis, it is recommended that bacteria and endotoxin in dialysate not exceed 100-200 colony forming units (CFU)/ml and 0.25-2 endotoxin units (EU)/ml, respectively. While these limits are adequate to prevent acute pyrogenic reactions, data are accumulating to suggest they may not prevent stimulation of chronic inflammation in hemodialysis patients. Fragments of endotoxin and other bacterial products capable of stimulating immune cells cross low-flux and high-flux membranes in vitro. In clinical studies, use of ultrapure dialysate (bacteria < 0.1 CFU/ml and endotoxin < 0.03 EU/ml) is associated with lower concentrations of inflammatory markers and acute phase reactants than are observed with dialysate meeting current quality recommendations. Moreover, observational studies suggest a link between clinical outcomes and dialysate purity. Treatment of patients with ultrapure dialysate is reported to improve nutritional status, increase responsiveness to erythropoietin, slow the decline in residual renal function, lessen cardiovascular morbidity, and decrease the incidence of beta(2)-microglobulin amyloidosis. To date, however, none of these studies has shown a cause-and-effect relationship between dialysate purity and outcome. Further, there are no data defining the concentration dependence of outcomes on dialysate purity and the relative importance of dialysate purity as a trigger of inflammation remains unclear. While the technology exists to routinely provide ultrapure dialysate, controlled clinical trials are still needed to answer the question of whether or not introducing ultrapure dialysate into routine clinical practice represents an efficient use of limited resources in terms of decreasing inflammation and improving outcomes in hemodialysis patients.
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Affiliation(s)
- Richard A Ward
- Kidney Disease Program, Department of Medicine, University of Louisville, 615 S. Preston Street, Louisville, KY 40202-1718, USA.
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