Water treatment for hemodialysis, including the latest AAMI standards

The AAMI Standard (1998, 2001) has established maximum allowable levels for chlorine
of 0.5 mg/L and 0.1 mg/L for chloramine. A test for total chlorine, which tests for both "free"
chlorine and "combined" chlorine or chloramine, should be performed on fresh effluent exiting
the first tank a minimum of once a day (AAMI, 2001). The safest practice is to test before every
patient shift. If breakthrough is detected from the first tank, a test after the second tank should be
done. Assuming the second test is negative, patient runs can be initiated if the first tank is
replaced within a reasonable time, for instance 24 hours. In addition, hourly testing for total
chlorine should be performed on the second tank.

Bypass valves placed on the piping to carbon tanks that allow the feed water to
completely bypass the carbon tanks without being carbon filtered are unsafe and not
recommended.

With a standard DPD (N, N-diethyl-p-phenylenediamine) test, the difference between the
"free" chlorine and "total chlorine" is considered the chloramine content, since there is no test
that isolates chloramine. When total chlorine tests are used as a single analysis (e.g., test strips),
the maximum level for both chlorine and chloramine should not exceed 0.1 mg/L. Since there is
no distinction between chlorine and chloramine, this safely assumes that all chlorine present is
chloramine (AAMI, 2001).

Even if chloramines are not normally present in the water supply, chloramines can form
naturally from chlorine combining with ammonia from decomposing vegetation. Chloramine
may also be added unexpectedly to the source water, especially those municipal suppliers using
surface water. Therefore, always test for total chlorine and never just free chlorine alone.

Channeling of the GAC is a common problem because water tends to flow in the path of
least resistance. Carbon will also filter debris from the water, and compaction of the carbon will
create smaller carbon fines. Biological fouling is another inherent problem with GAC because it
is an organic medium, and with the chlorine and chloramine removed from the water, bacteria
grow. These phenomena cause the carbon surface area to be underused. Therefore, carbon tanks
are backwashed on a routine basis to "fluff" the bed, clean the debris out, and expose unused
sides of the carbon. Backwashing does not regenerate the carbon when it is exhausted, it simply
exposes unused sides of the carbon. If the carbon tank cannot be backwashed, the carbon media
should be changed on a more frequent basis.

Monitor the pre and post GAC tank pressures and check the setting of the control head
clock and record daily. Testing the effluent for chlorine/chloramine break-through must be done
at minimum daily, but before every patient shift is safest. Document when the tanks have been
exchanged or re-bedded, and include the grade of carbon used and rinse time of the tank
performed.

Reverse Osmosis (RO) Systems

Prefilter. Prefilters are particulate filters positioned after all the pretreatment and
immediately before the RO pump and RO membrane. Carbon fines, resin beads, and other debris
exiting the pretreatment destroy the pump and foul the RO membrane. Typically, prefilters range
in pore size from 3-5 microns. Two gauges monitor the inlet versus the outlet pressures across
the filter. If the delta pressure increases by eight over new filter pressure differential, the filter is
clogged and needs replacement. Prefilters are inexpensive insurance against damaging more
expensive items downstream in the system. Therefore, changing them on a routine basis before
the pressure differential indicates is good practice. Inspect the filter's center tube for soiling. If
dirt is present, the prefilter was overburdened and should have been replaced sooner. AAMI
(2001) standards dictate that the housing of the pre filter should be opaque to deter algae growth.