Quantitative microbiological monitoring of hemodialysis fluids: evaluation of methods and demonstration of lack of test relevance in single-pass hemodialysis machines with automatic dialysate proportioning with reverse osmosis-treated tap water

Water quality in conventional and home haemodialysis

Dialysis water can be contaminated by chemical and microbiological factors, all of which are potentially hazardous to patients on haemodialysis. The quality of dialysis water has seen incremental improvements over the years, with advances in water preparation, monitoring and disinfection methods, and high standards are now readily achievable in clinical practice. Advances in dialysis membrane technology have refocused attention on water quality and its potential role in the bioincompatibility of haemodialysis circuits and adverse patient outcomes. The role of ultrapure dialysate is increasingly being advocated, given its proposed clinical benefits and relative ease of production as a result of the widespread use of reverse osmosis and ultrafiltration. Many of the issues pertaining to water quality in hospital-based dialysis units are also pertinent to haemodialysis in the home. Furthermore, an increased awareness of the environmental and financial consequences of home haemodialysis has resulted in the development of automated and more efficient dialysis machines. These new machines have an increased emphasis on water conservation and recycling along with a decreased need for a complex infrastructure for water purification and maintenance.

Bacterial colonization and endotoxin content of a new renal dialysis water system composed of acrylonitrile butadiene styrene

We measured endotoxin and bacterial levels in tap water, in water purified by reverse osmosis, and in dialysate samples over a 4-month period in a new 10-bed renal dialysis unit. Water treated by reverse osmosis is conducted to the 10 stations through 111 m of piping composed of acrylonitrile butadiene styrene (ABS). All determinations were made prior to the opening of the unit and after the system was purged for 35 h with all bedside station taps open. Formaldehyde disinfection of the piping system was attempted with a recommended protocol after 11 weeks by feeding 2.5 liters of 37% formaldehyde (0.85%, vol/vol) into the delivery system. Prior to water purging, 24 ng of endotoxin per ml was detected. This level decreased to 2.0 ng of endotoxin after the purging. Levels of endotoxin remained below 1.0 ng of endotoxin per ml throughout the duration of the study. In contrast, the level of viable microorganisms recovered from the treated water was approximately 3.5 X 10(4) CFU/100 ml. Even after disinfection of the system, there was no significant decrease in culturable bacteria from the water even though endotoxin levels were lower. Species isolated from the renal dialysis system were predominately pseudomonads, whereas species isolated from the tap water were Bacillus and Flavobacterium species. ABS provides a surface suitable for long-term colonization and growth of bacteria. Currently recommended decontamination protocols are ineffective in removing potentially pathogenic bacteria from ABS pipes and thus constitute an increased risk to patients undergoing dialysis.