UNRESOLVED ISSUES IN DIALYSIS: Dialyzer Best Practice: Single Use or Reuse?

Reprocessing and reuse of dialyzers: A technological solution for balancing cost and quality in lower and middle-income countries

Hemodialysis is the commonest kidney replacement therapy (KRT) globally and rapidly growing in developing countries, while in developed countries it is reaching a plateau. The penetration of hemodialysis (HD) varies widely among countries and is largely influenced by socioeconomics, healthcare financing, particularly by government, local infrastructure, healthcare workforce, health system characteristics, and affordability of the population. Biomedical equipment, consumables, disposables, and labor are major cost drivers of KRT. Implementing strategies to balance cost and quality of care is an arduous task for health care planning, delivery, and patient care in low- and middle-income countries. In this context, the cost of dialyzers which form a significant component of the recurring cost of HD can be reduced by reuse after appropriate reprocessing. But this practice is largely abandoned in developed countries because of concerns of safety. However, the evidence against the reuse of modern dialyzers is not robust and certainly not based on well-designed randomized trials. The industrialization of dialysis delivery, the interests of equipment manufacturers and the nature of dialysis delivery have propelled single use of dialyzers. In this context, developing countries needing to expand HD services access at low cost are caught at crossroads. Process improvements are needed to standardize reprocessing that prioritizes safety while maintaining effectiveness. Recent advances in mobile and internet technologies could make this an achievable reality. We propose such an approach that would ensure treatment effectiveness, patient and healthcare provider safety, efficient resource utilization, and cost control.

Long-Term Sustainability of Using Hemodialyzers to Inexpensively Provide Pathogen-Free Water to Remote Villages Lacking Electricity

The provision of clean water to remote communities is a major goal of both the World Health Organization and the United Nations. We report on the long-term sustainability of filter-sterilizing polluted water in remote villages in Ghana that lack electricity. Contaminated water pumped several times a week via a gasoline pump into a 1000 L elevated tank is filtered through polysulfone hemodialyzers on demand. The 3 nm fiber pore size rejects all bacteria, parasites, and viruses. Villagers flush organic matter from the dialyzers thrice daily to maintain a flow of up to 250 L/hour. Having previously reported a 73% reduction in diarrheal episodes, we now address system sustainability. After passing through the hemodialyzer filters, a fecally polluted water source remains consistently free of pathogens even after the system has been in place for >1 year in most villages. Filters are easily replaced when needed. Daily cost for unlimited clean water is less than USD 2.22 per village over five years. Villagers have continued to independently fill the tank and flush the system, because they appreciate the clean water and health benefits. We demonstrate that over 2–6 years this system providing pathogen-free drinking water can be maintained independently by villagers for long-term sustainability. It does not require electricity nor disinfectants to be added to the product water and is ready for far broader application in similarly remote settings.

Understanding Development of Malnutrition in Hemodialysis Patients: A Narrative Review

Hemodialysis (HD) majorly represents the global treatment option for patients with chronic kidney disease stage 5, and, despite advances in dialysis technology, these patients face a high risk of morbidity and mortality from malnutrition. We aimed to provide a novel view that malnutrition susceptibility in the global HD community is either or both of iatrogenic and of non-iatrogenic origins. This categorization of malnutrition origin clearly describes the role of each factor in contributing to malnutrition. Low dialysis adequacy resulting in uremia and metabolic acidosis and dialysis membranes and techniques, which incur greater amino-acid losses, are identified modifiable iatrogenic factors of malnutrition. Dietary inadequacy as per suboptimal energy and protein intakes due to poor appetite status, low diet quality, high diet monotony index, and/or psychosocial and financial barriers are modifiable non-iatrogenic factors implicated in malnutrition in these patients. These factors should be included in a comprehensive nutritional assessment for malnutrition risk. Leveraging the point of origin of malnutrition in dialysis patients is crucial for healthcare practitioners to enable personalized patient care, as well as determine country-specific malnutrition treatment strategies.

Medical problems in patients with chronic kidney disease undergoing hemodialysis and their therapy

Background It was reported that hemodialysis (HD) with either a new or reused dialyzer raises medical problems that require therapeutic regimens. This study aimed to investigate the medical problems and their management in patients undergoing HD. Methods This study was conducted by prospectively observing patients with chronic kidney disease undergoing HD. The incidence of medical problems and the treatment given were recorded. Results Among 351 cases of HD, medical problems occurred in 15.7% of cases, including hypotension as the most dominant, followed by muscle cramps, shivering, headache, asphyxia, fever, chest pain, and pruritus. Hypotension was ameliorated with intravenous 40% dextrose and normal saline. Muscle cramps were overcome with 40% dextrose, normal saline, methampyrone, and calcium gluconate. Shivering was managed by warming the patients followed by intravenous methampyrone, 40% dextrose, and normal saline. Meanwhile, headache was reduced by paracetamol or intravenous methampyrone and 40% dextrose. Fever was treated by intravenous methampyrone or oral paracetamol. Pruritus was managed by intravenous dexamethasone and diphenhydramine. Conclusions Medical problems occurring during HD are prevalent and need immediate therapy. Pharmacists and clinicians should work in collaboration to improve the patients' quality of life.

A call-to-action for sustainability in dialysis in Brazil

Human-induced climate change has been an increasing concern in recent years. Nephrology, especially in the dialysis setting, has significant negative environmental impact worldwide, as it uses large amounts of water and energy and generates thousands of tons of waste. While our activities make us responsible agents, there are also several opportunities to change the game, both individually and as a society. This call-to-action intends to raise awareness about environmentally sustainable practices in dialysis and encourages this important discussion in Brazil.

Clinical and microbiological effects of dialyzers reuse in hemodialysis patients

Introduction:

Chronic kidney disease (CKD) has a high prevalence and is a worldwide public health problem. Reuse of dialyzers is a cost reduction strategy used in many countries. There is controversy over its effects on clinical parameters and microbiological safety.

Methods:

In this clinical crossover study, 10 patients performed consecutive hemodialysis (HD) sessions divided in two phases: "single use" sessions (N = 10 HD sessions) followed by "dialyzer reuse" sessions (N = 30 HD sessions). Clinical, laboratory, and microbiological parameters were collected in the following time points: "single use", 1^st, 6^th, and 12^th sessions with reuse of dialyzers, including bacterial cultures, endotoxins quantification in serum and dialyzer blood chamber, and detection of hemoglobin and protein residues in dialyzers.

Results:

Mean age of the sample was 37 ± 16 years, 6 (60%) were men, and 5 (50%) were white. CKD and HD vintage were 169 ± 108 and 47 (23-111) months, respectively. Serum C-reactive protein (CRP) [4.9 (2.1) mg/mL], ferritin (454 ± 223 ng/mL), and endotoxin levels [0.76 (0.61-0.91) EU/mL] were high at baseline. Comparison of pre- and post-HD variations of serum levels of CRP and endotoxins in the "single use" versus "reuse" phases did not result in differences (p = 0.8 and 0.4, respectively). Samples of liquid in the dialyzer inner chamber were negative for the growth of bacteria or endotoxins. There was no significant clinical manifestation within and between the phases.

Conclusion:

Dialyzers reuse was safe from a clinical, microbiological, and inflammatory point of view. The dialyzer performance remained adequate until the 12^th reuse.

Measurement accuracy of total cell volume by automated dialyzer reprocessing: A prospective cohort study

INTRODUCTION

Dialyzer reprocessing machines have replaced human labor in preparing re-usable dialyzers. It also made the process of total cell volume (TCV) measurement become faster. Nevertheless, there has been a lack of data on efficacy of weight evaluation on TCV by machine compared to volume evaluation by the conventional method. The aim of this study was to evaluate the efficacy of TCV measurement performed by Kidney-Kleen® reprocessing machine, produced by MEDITOP Company in Thailand, compared to that of the conventional method.

METHODS

This prospective cohort study was performed during September 2014 to December 2015.The low-flux (N = 101) and high-flux dialyzers (N = 100) were included for TCV evaluation. Reused times were up to 5 in the low-flux and 20 in the high-flux dialyzers. The Bland Altman analysis was used to evaluate value measured by different methods.

RESULTS

The values measured by weight evaluation (by machine) were higher than those obtained by volumetric evaluation of the conventional method in the low-flux (0.81 ± 0.20%) and high-flux (1.32 ± 0.39%) dialyzers. The correlation of TCV values of the two methods were r = 0.98, p < 0.001 and r = 0.71, p < 0.001 for the low- and high-flux dialyzers. Moreover, there was robust association and agreement between the two methods, confirmed by the Bland-Altman Analysis, which suggested that the values acquired by machine were within the limits of agreement, indicating acceptable accuracy of equipment.

CONCLUSION

The approach of measurement differed from that of the conventional method (weight evaluation was used instead of volumetric evaluation), the reprocessing machine could offer accurate results.

Reuse and Biocompatibility of Hemodialysis Membranes: Clinically Relevant?

The practice of reprocessing dialyzers for reuse, once predominant in the United States, has been steadily declining over the last 20 years. The professed roles of reuse in improving dialyzer membrane biocompatibility and lowering the risk of first-use syndrome have lost relevance with the advent of biocompatible dialyzer membranes and favorable sterilization techniques. The potential for cost-savings from reuse is also called into question by the easy availability of comparatively cheaper dialyzers and rising regulatory demands and operational cost of reprocessing systems. While the environmental concerns from additional dialyzer-related solid waste from rising single-use practice remains pertinent and requires development of safer dialyzer disposable system technologies, there is no meaningful medical rationale for the continued practice of dialyzer reuse in the twenty-first century.

Hemodialyzer Reuse and Gram-Negative Bloodstream Infections

BACKGROUND

Clusters of bloodstream infections caused by Burkholderia cepacia and Stenotrophomonas maltophilia are uncommon, but have been previously identified in hemodialysis centers that reprocessed dialyzers for reuse on patients. We investigated an outbreak of bloodstream infections caused by B cepacia and S maltophilia among hemodialysis patients in clinics of a dialysis organization.

STUDY DESIGN

Outbreak investigation, including matched case-control study.

SETTING & PARTICIPANTS

Hemodialysis patients treated in multiple outpatient clinics owned by a dialysis organization.

PREDICTORS

Main predictors were dialyzer reuse, dialyzer model, and dialyzer reprocessing practice.

OUTCOMES

Case patients had a bloodstream infection caused by B cepacia or S maltophilia; controls were patients without infection dialyzed at the same clinic on the same day as a case; results of environmental cultures and organism typing.

RESULTS

17 cases (9 B cepacia and 8 S maltophilia bloodstream infections) occurred in 5 clinics owned by the same dialysis organization. Case patients were more likely to have received hemodialysis with a dialyzer that had been used more than 6 times (matched OR, 7.03; 95% CI, 1.38-69.76) and to have been dialyzed with a specific reusable dialyzer (Model R) with sealed ends (OR, 22.87; 95% CI, 4.49-∞). No major lapses during dialyzer reprocessing were identified that could explain the outbreak. B cepacia was isolated from samples collected from a dialyzer header-cleaning machine from a clinic with cases and was indistinguishable from a patient isolate collected from the same clinic, by pulsed-field gel electrophoresis. Gram-negative bacteria were isolated from 2 reused Model R dialyzers that had undergone the facility's reprocessing procedure.

LIMITATIONS

Limited statistical power and overmatching; few patient isolates and dialyzers available for testing.

CONCLUSIONS

This outbreak was likely caused by contamination during reprocessing of reused dialyzers. Results of this and previous investigations demonstrate that exposing patients to reused dialyzers increases the risk for bloodstream infections. To reduce infection risk, providers should consider implementing single dialyzer use whenever possible.

A new spectrophotometric method to detect residual amounts of peroxide after reprocessing hemodialysis filters

OBJECTIVE

Reuse of hemodialysis filters is a standard practice and the sterilizing chemical most often employed is peracetic acid. Before starting the dialysis session, filters and lines are checked for residual levels of peracetic acid by means of a non-quantitative colorimetric test that is visually interpreted. The objective of this study was to investigate a new quantitative spectrophotometric test for detection of peracetic acid residues.

METHODS

Peracetic acid solutions were prepared in concentrations ranging from 0.01 to 10 ppm. A reagent (potassium-titanium oxide + sulfuric acid) was added to each sample in proportions varying from 0.08 to 2.00 drops/mL of solution. Optical densities were determined in a spectrophotometer using a 405-nm filter and subjected to visual qualitative test by different observers.

RESULTS

A relation between peroxide concentrations and respective optical densities was observed and it was linear with R2 > 0.90 for all reagent/substrate proportions. The peak optical densities were obtained with the reagent/substrate ratio of 0.33 drops/mL, which was later standardized for all further experiments. Both qualitative and quantitative tests yielded a specificity of 100%. The quantitative test was more sensitive than the qualitative test and resulted in higher positive and negative predictive values. There was a difference between observers in the qualitative test and some samples with significant amounts of peroxide were not detected.

CONCLUSION

A quantitative spectrophotometric test may improve detection of residues of peracetic acid when compared to the standard visual qualitative test. This innovation may contribute to the development of safer standards for reuse of hemodialysis filters.

Green dialysis: the environmental challenges ahead

The US Environmental Protection Agency Resource Conservation website begins: "Natural resource and energy conservation is achieved by managing materials more efficiently--reduce, reuse, recycle," yet healthcare agencies have been slow to heed and practice this simple message. In dialysis practice, notable for a recurrent, per capita resource consumption and waste generation profile second to none in healthcare, efforts to: (1) minimize water use and wastage; (2) consider strategies to reduce power consumption and/or use alternative power options; (3) develop optimal waste management and reusable material recycling programs; (4) design smart buildings that work with and for their environment; (5) establish research programs that explore environmental practice; all have been largely ignored by mainstream nephrology. Some countries are doing far better than others. In the United Kingdom and some European jurisdictions, exceptional recent progress has been made to develop, adopt, and coordinate eco-practice within dialysis programs. These programs set an example for others to follow. Elsewhere, progress has been piecemeal, at best. This review explores the current extent of "green" or eco-dialysis practices. While noting where progress has been made, it also suggests potential new research avenues to develop and follow. One thing seems certain: as global efforts to combat climate change and carbon generation accelerate, the environmental impact of dialysis practice will come under increasing regulatory focus. It is far preferable for the sector to take proactive steps, rather than to await the heavy hand of government or administration to force reluctant and costly compliance on the un-prepared.

Outbreak of bloodstream infections associated with multiuse dialyzers containing O-rings

This report details an outbreak investigation conducted by the Los Angeles County Department of Public Health of 3 cases of bacterial infection among patients receiving hemodialysis who were treated at the same dialysis center in 2011. Improper disinfection of reusable dialyzers was hypothesized as the source of transmission.

Patient and facility safety in hemodialysis: opportunities and strategies to develop a culture of safety

Patient safety is the foundation of high-quality health care. More than 350,000 patients receive dialysis in the United States, and the safety of their care is ultimately the responsibility of the facility medical director. The medical director must establish a culture of safety in the dialysis unit and lead the quality assessment and performance improvement process. Several lines of investigation, including surveys of patients and dialysis professionals, have helped to identify important areas of safety risk in dialysis facilities. Among these are lapses in communication, medication errors, patient falls, errors in machine and membrane preparation, failure to follow established policies, and lapses in infection control. The quality assessment and performance improvement process should include a dedicated safety team to focus on specifically identified areas of risk and to establish outcome goals guided by best practices and agreed-upon measures of success. A safety questionnaire can be given to patients and staff and the responses evaluated to improve understanding of the prevailing attitudes and concerns about safety. By sharing these results, openly acknowledging the challenges, and using a blame-free root cause process to identify action plans, the facility can begin to establish a culture of safety.

Dialyzer reuse and mortality risk in patients with end-stage renal disease: a systematic review

BACKGROUND AND AIM

Robust evidence about dialyzer reuse effects on mortality is not available. Our aim was to summarize the evidence for the effectiveness of dialyzer reuse compared to single use in patients with end-stage renal disease.

METHODS

We searched MEDLINE, Embase, CINAHL, SciELO, LILACS, USRDS ADR, universities' theses databases and annals of congress from major nephrology societies. Reviewers performed the study selection and data extraction independently. We used the GRADE approach to assess the quality of the evidence. Mortality was the primary outcome.

RESULTS

A total of 1,190 studies were retrieved, and 14 were included in the review (n = 956,807 patients). The disinfectants used on dialyzer reprocessing were hypochlorite, formaldehyde, glutaraldehyde, and peracetic acid. The evidence available from the studies was of very low quality. Most studies found no differences between groups. In studies with statistically significant differences, these differences were not observed in all groups and they varied by the type of disinfectant, time of observation and treatment unit.

CONCLUSIONS

No significant differences were identified for the superiority or inferiority of dialyzer reuse versus single use when assessing the mortality of patients with end-stage renal disease. Studies of higher quality, including randomized clinical trials, are required to provide conclusive evidence regarding the effectiveness and safety of dialyzer reuse.

Renal replacement therapy review: past, present and future

Support of renal function in modern times encompasses a wide array of methods and clinical scenarios, from the ambulatory patient to the critically ill. The ability to safely and routinely deliver ongoing organ support in the outpatient setting has until recently separated renal replacement therapy from other organ support. Renal replacement therapy (RRT) can be applied intermittently or continuously using extracorporeal (hemodialysis) or paracorporeal (peritoneal dialysis) methods. The purpose of this article is to familiarize the reader with the history, physiology, mode, dose, equipment and future of renal replacement therapy and not to detail the technical methods employed for blood purification.

Abandoning peracetic acid-based dialyzer reuse is associated with improved survival

BACKGROUND AND OBJECTIVES

Higher mortality risk reported with reuse versus single use of dialyzers is potentially related to reuse reagents that modify membrane surface characteristics and the blood-membrane interface. A key mechanism may involve stimulation of an inflammatory response.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In a prospective crossover design, laboratory markers and mortality from 23 hemodialysis facilities abandoning reuse with peracetic acid mixture were tracked. C-reactive protein (CRP), white blood cell (WBC) count, albumin, and prealbumin were measured for 2 consecutive months before abandoning reuse and subsequently within 3 and 6 months on single use. Survival models were utilized to compare the 6-month period before abandoning reuse (baseline) and the 6-month period on single use of dialyzers after a 3-month "washout period."

RESULTS

Patients from baseline and single-use periods had a mean age of approximately 63 years; 44% were female, 54% were diabetic, 60% were white, and the mean vintage was approximately 3.2 years. The unadjusted hazard ratio for death was 0.70 and after case-mix adjustment was 0.74 for single use compared with reuse. Patients with CRP≥5 mg/L during reuse (mean CRP=26.6 mg/ml in April) declined on single use to 20.2 mg/L by August and 20.4 mg/L by November. WBC count declined slightly during single use, but nutritional markers were unchanged.

CONCLUSIONS

Abandonment of peracetic-acid-based reuse was associated with improved survival and lower levels of inflammatory but not nutritional markers. Further study is needed to evaluate a potential link between dialyzer reuse, inflammation, and mortality.

Single-UseversusReusable Dialyzers: The Known Unknowns

The practice of reusing dialyzers has been widespread in the United States for decades, with single use showing signs of resurgence in recent years. Reprocessing of dialyzers has traditionally been acknowledged to improve blood-membrane biocompatibility and prevent first-use syndromes. These proposed advantages of reuse have been offset by the introduction of more biocompatible membranes and favorable sterilization techniques. Moreover, reuse is associated with increased health hazard from germicide exposure and disposal. Some observational studies have also pointed to an increased mortality risk with dialyzer reuse, and the potential for legal liability is another concern. The desire to save cost is the major driving force behind the continued practice of dialyzer reuse in the United States. It is imperative that future research focus on the environmental consequences of dialysis, including the need for more optimal management of disinfectant-related waste with reuse, and solid waste with single use. The dialysis community has a responsibility to explore ways to mitigate environmental consequences before single-use and a more frequent dialysis regimen becomes a standard practice in the United States.