GM ART2k3 final3

Fluid Quality at Home Haemodialysis Installations: 

Fluid Quality at Home Haemodialysis Installations Gareth Murcutt Royal Free Hospital London

Why does water quality matter?: 

Why does water quality matter? An average patient dialyses for 4 hrs 3 times per week against a fluid rate of 0.6 l min-1 Annually an HD patient will be exposed to over 22,000 litres of water

Adverse Incidents: 

Adverse Incidents

RO: HHD vs Hospital: 

RO: HHD vs Hospital Can this………………replace this?

Where is water used for dialysis? : 

Where is water used for dialysis?

Where is water used for dialysis? : 

Where is water used for dialysis?

Where is water used for dialysis? : 

Where is water used for dialysis? Hospital Site Home Site

HHD: Fluid Testing Program: 

HHD: Fluid Testing Program Business case prepared / accepted / partially funded 6 monthly chemical RO water analysis at all home patients 6 monthly TVC & endotoxin: water / d/fluid analysis at all home patients Samples taken during service visits and collected by courier Results are emailed and posted Results recorded / actioned

HHD Water Contamination: 

HHD Water Contamination Chemical Contamination Microbiological contamination

HHD Water Contamination: 

HHD Water Contamination Chemical Contamination Microbiological Contamination

How pure is tap water?: 

How pure is tap water? 2,4-D, Bentazone, Clopyralid, Dicamba, Dichlorprop, Fluroxypyr, MCPA, MCPB, Mecoprop, Carbendazim, Glyphosate, Copper, Lead, Zinc, Dichlobenil, Propyzamide, Triallate, Benzo 3,4 Pyrene, Total PAHs, Total Pesticide, Atrazine, Simazine, Trietazine, Carbetamide, Chlorotoluron, Cyanazine, Diuron, Isoproturon, Linuron, Tetrachloroethene, Tetrachloromethane, Total Trihalomethanes, Trichloroethene, Odour Intensity, Manganese, Ammonium, Hydrogen Ion Aluminium, Odour, Odour Intensity, Taste Intensity, Taste, Electrical Conductivity, Colour, Aluminium, Iron as Fe, Temperature, Nitrate, Nitrite, Hydrogen Ion, Turbidity, Alkalinity as HCO3, Free Cyanide, Fluoride, Mercury, Selenium, Antimony, Arsenic, Barium, Boron, Cadmium, Calcium, Chromium, Magnesium, Nickel, Potassium, Silver, Sodium, Phosphorus, Chloride, Sulphate, Total Hardness, Oxidizability, Surfactants, Dry residue, Total Organic Carbon, Total Chlorine. Chemical Contamination

Comparison of chemical limits: 

Comparison of chemical limits Chemical Contamination

FT30 membrane % rejections: 

FT30 membrane % rejections Chemical Contamination

HHD Stable chemicals: results: 

HHD Stable chemicals: results Total of 51 samples taken from 23 HHD installations Chemical Contamination

The special case of nitrates: 

AAMI limit = < 2 mg l-1 (as NO3 -N ) EPh limit = < 2 mg l-1 (as nitrate: NO3) 1 mole of N = 14g 1 mole of NO3 = 62g To convert (NO3 -N) to (NO3) the result must be multiplied by 62/14 (~ 4.5) Action level of 4 mg l-1 agreed The special case of nitrates Nitrate Vunerable Zones Chemical Contamination

Carbon: HHD vs Hospital: 

Carbon: HHD vs Hospital Can this………………replace this? Chemical Contamination

Testing for Residuals: 

Testing for Residuals A standard test for chlorine in water is the DPD method. Free chlorine reacts with diethyl-p-phenylene diamine (DPD) tablets in buffered solution to produce a pink colour. Our testing shows that the filters used still adequately remove chlorine and chloramines after 6 months at an HHD site. Reaction of free chlorine with DPD. + 1/2 Cl2 + H+ Cl- Clear Red Chemical Contamination

HHD Water Contamination: 

HHD Water Contamination Microbiological Contamination Chemical Contamination

Microbiological Standards: 

Microbiological Standards Microbiological Contamination

Endotoxin Results: Oct 2003: 

Endotoxin Results: Oct 2003 Microbiological Contamination

TVC Results: Oct 2003: 

TVC Results: Oct 2003 Microbiological Contamination

TVC Results Analysis : 

TVC Results Analysis Microbiological Contamination

Standard vs Ultrafiltered d/f: 

Standard vs Ultrafiltered d/f Microbiological Contamination

TVC results: Standard d/f: 

TVC results: Standard d/f Microbiological Contamination

Cut-away RO pure water: 

Cut-away RO pure water Microbiological Contamination

Biofilm in RO pure water output: 

Biofilm in RO pure water output Microbiological Contamination

Discussion: HHD Chemistry: 

Discussion: HHD Chemistry This simple set-up is capable of providing water for dialysis of an acceptable chemical composition Planned maintenance and analysis must be done to ensure correct operation

Discussion: HHD Microbiology: 

Discussion: HHD Microbiology Carbon filter RO HHD m/c Biofilm This set-up is probably NOT capable of providing water for dialysis of an acceptable microbiological standard Long periods of stagnation Difficulty of disinfection TVC / Eu

Achieving compliance: 

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

Planning for HHD fluid quality: 

Planning for HHD fluid quality Contact with water suppliers Adequate carbon filtration Good quality RO membrane HHD machine Chlorine testing Water Analysis Ultrafilter System design D/fluid analysis Chlorine/chloramine Integrated disinfection Robust disinfection regime