WATER TREATMENT

FOR DIALYSIS

Adhilakshmi. T
Bsc dialysis technology.
 Water treatment for Hemodialysis

Water is a complex and incompletely understood chemical compound.

 The purest form of water is freshly formed rain as it leaves the cloud.

 7.1 Steps in Water treatment
 Filtration
 Softner
 Carbon filter
 Deionizer
 Reverse osmosis
 UV Radiation
 Test
 Filtration:
 Two types of filtration:
 Surface
 Depth
Surface filtration:
 Removes particular matter by filtering through rigid structure
 Made of cotton fibers wound around plastic frames
 Pores range from 30 microns – 0.2 microns
 Discarded when plugged with particles and replaced.
Depth filtration
 Multimedia depth filter removes suspended particulate matters
 Filters passing through layers of sand
 Typical sand fibers can employ fine sand or a non hydrous silicate sand
 Sediment filter can be back flushed and therefore regenerated
Slit density index
 SDI is an indicator of the colloidal and suspended particulate matter in tap water.
 Measured as pressure drop against time as tap water crosses 0.45 µm membrane
filters.
 An SDI of less than 5.0 is required of fluid water for most reverse osmosis
systems.

Softner:
 A water softner is an ion exchange device which exchanges calcium and
magnesium ions for sodium ions.
 Calcium and magnesium ions constitute of dialysate and excessive amounts are
determental to patients.
 Calcium from calcium chloride being exchange for sodium which forms sodium
chloride
Process
 Removes hardness from water
 Resin heads in the softner tank are saturated with sodium
 These heads are regenerated on site by means of timers and brine tank
filled with tank salts.
 Brine (water with a high concentration of sodium) is pulled from the
brine tank into resin tanks
 The high concentration of sodium in this solution replaces the calcium
and magnesium from the heads.
 The brine is the flushed to the drain
 Water softner has ability to remove other positively charged ions such as
aluminum if which is not can cause bone disease and dialysate dementia.
Monitoring of the softner is done by measuring calcium carbonate also
known as hardness
Carbon filtration:

 Carbon filtration is commonly used to remove chloride, undesirable organic

contaminants, taste, color, and odor from water.
 Carbon material is made from coal, wood, animal bone, nut shell, or pulp waste.
 In dialysis carbon is primarily used for the removal of chlorine and chloramines.
 Carbon tank must be in two service
First tank as working tank
Second tank as polishing tank
 Carbon tanks should be sized to maintain an empty bed contact time of ten minutes.
 The carbon tanks should be rotated with fresh virgin carbon.
 Chlorine breaks through is detected, working tank.
 The polishing tank has relatively low than through it and all the chlorine is removed in
the working tank creating potential bacterial growth.
Reverse osmosis:
 The most effective means of treating water for dialysis is reverse osmosis.
 The particular advantage of reverse osmosis is that bacterial endotoxin and
bacteria are removed from water supply.
 Dissolved solids will remain on the bed side of the membrane.
 Pure water will form on the product side of the membrane.
 The hydraulic pressure overcomes the osmotic pressure hence the name is
called reverse osmosis.
 The quality of reverse osmosis water is measured by conductivity.
 UV radiation;
 Removes bacteria, invisible naked eyes
 Wave length used between 180-390 nm.
 Effective at 254 nm of wavelength
•Destroys bacteria by penetrating the cell wall
•Acts on DNA of bacteriaCannot remove
endotoxins
•Cannot remove endotoxins
•Uv radiation is not active against some
organism.
Hemodialysis water quality
 Hemodialysis patients are exposed to more water in three years than most people are exposed to in their
life.
 Hemodialysis patient’s blood is directly exposed to any toxic contaminants in the water.
 Hemodialysis patient have diminished renal function so they cannot excrete the toxic substance in
urine.
 In organic substances in water are sodium, chloride, iron , aluminum, nitrates, manganese, copper, zinc,
iodide, and fluoride are common ionic constituents.
 Presence of nitrates in dialysis water cause meth hemoglobinemia, copper cause hemolysis, fluoride
aggrevates uremic bone disease, zinc cause GI Upset and Aluminium cause dialysis dementia,
osteodystrophy and amemia.

Frequency of Testing for Bacteria and Endotoxin levels

 Testing should be performed monthly. If standards are exceeded, testing should be performed weekly
until the problem is resolved.
Sample Collection:
The sample ports used to collect the samples must be rinsed for at least one minute at
normal pressure and flow rate before drawing the samples.
 Samples should be collected using a “clean catch” technique to minimize potential
contamination of the sample, leading to false positive results.
 Sample ports should not be disinfected.
 If a facility insists on disinfecting the ports, alcohol should be used and allowed to
completely dry before the sample is drawn.
 Bleach or other disinfectants should not be used.
Sample collection sites:
 The sample should be taken from the product water distribution piping at the following
locations:
Site 1:
 At the point where the water leaves the RO machine, before it enters the holding tank (Indirect
System), or before it goes to the treatment room to provide water for dialysis machines (Direct
System).
Site 2:
 If an RO water holding tank is present, a sample should be taken at the point where the water
leaves the tank.
Site 3:
 At the end of the return line of the RO water distribution loop, whether it is returning to the
RO or a water holding tank.
Site 4:
 At the point where water enters into the dialyzer reprocessing system, whether it is a manual
or automated system.
Site 5:
 At a point where water enters equipment used to prepare bicarbonate concentrate.
Site 6:
 At the point where the dialysis machine is connected to the product water loop
Site 7:
 Hemodialysis machine dialysate sample port

Testing Methodology
Samples for bacteriological testing should be processed within 1-2 hours or refrigerated
and processed within 24 hours.
 The AAMI standard recommends culturing samples of 0.5 to 1.0 cc for 48 hours at 35
C, using tryptic soy agar as the culture medium.
 The testing of endotoxin is performed by the Limulus Amebocyte Lysate (LAL) test.
Corrective action
 Corrective action should be undertaken in the area of the suspected cause for
exceeding the action level. Corrective action may include:
 Cleaning and disinfection of RO machine membranes.

 Disinfection of the product water tank and distribution loop should be

done.
 The installation of an endotoxin filter system in the RO water distribution
system and/or increasing the frequency of disinfection of existing bacteria
filter(s).
 Make sure that the water hose on the machine is being disinfected.
AAMI standards
No Inorganic Contaminants Max. Concentration Mg/l

1 Aluminum 0.01
2 Arsenic 0.005
3 Barium 0.1
4 Cadmium 0.001
5 Calcium 2
6 Chloramines 0.1
7 Free chloride 0.5
8 Chromium 0.14
9 Copper 0.1
10 Fluoride 0.2
11 Lead 0.005
12 Magnesium 4
13 Mercury 0.0002
14 Nitrate 2
15 Potassium 8
16 Selenium 0.097
17 Silver 0.005
18 Sodium 70
N Microbiological contaminants Max concentration
o

1 Bacteria <200 cfu/l

2 Bacterial action level <50 cfu/l

3 Endotoxin <2 eu/l

4 Endotoxin action level <0.2 eu/l

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