Analysis of hemodialysis water quality from 2008 to 2016 in Minas Gerais, Brazil / Análise da qualidade da água de hemodiálise durante o período de 2008 a 2016 em Minas Gerais, Brasil

Water quality requirements for hemodialysis are crucial for preventing health risks for renal patients. The objective of this study was to assess the quality of the water used for hemodialysis treatments in the state of Minas Gerais. The analytical results for 25 parameters in 1056 hemodialysis water samples from 89 renal dialysis units were analyzed. Data were obtained through the Minas Gerais Hemodialysis Unit Quality Monitoring Programme between July 2008 and December 2016. The effects of the Programme on patient health protection were assessed by evaluating compliance with legal limits and the efficacy of implementing inspections from 2012. Considering the 1056 samples analyzed, 264 (25%) presented at least one parameter in disagreement with current legislation. Conductivity (9.8%), endotoxin (6.9%), fluoride (4.2%) and heterotrophic bacteria (2.2%) were the most critical parameters. Nevertheless, the concentrations of all these parameters (except fluoride) decreased after implementing inspections. The average levels of 15 parameters decreased throughout the study period. The annual percentage of non-compliance decreased from 44% in 2008 to 23% in 2016. It was verified the relevance of the implementation of the Program in the prevention of possible disorders to the patients’ health, indicating the importance of its continuity.

Os requisitos de qualidade da água para a hemodiálise são cruciais para prevenir riscos à saúde de pacientes renais. O objetivo foi avaliar a qualidade da água utilizada nos tratamentos de hemodiálise em Minas Gerais. Os dados foram obtidos por meio do Programa de Monitoramento da Qualidade dos Serviços de Hemodiálise do Estado entre julho de 2008 e dezembro de 2016. Os resultados analíticos para 25 parâmetros em 1056 amostras de água em hemodiálise de 89 unidades renais foram analisados. Os efeitos do Programa na saúde dos pacientes foram avaliados através da conformidade dos limites legais e da eficácia da implementação de inspeções a partir de 2012. Considerando-se as 1056 amostras analisadas, 264 (25%) apresentaram pelo menos um parâmetro em desacordo com a legislação vigente. Condutividade, endotoxina, fluoreto e bactérias heterotróficas foram os parâmetros mais críticos. No entanto, as concentrações de todos esses parâmetros (exceto flúor) diminuíram após a implementação das inspeções. Os níveis médios de 15 parâmetros diminuíram ao longo do período do estudo. O percentual anual de não conformidade diminuiu de 44% (2008) para 23% (2016). Verificou-se a relevância da implantação do Programa na prevenção de possíveis transtornos à saúde dos pacientes, indicando a importância de sua continuidade.

Analysis of hemodialysis water quality from 2008 to 2016 in Minas Gerais, Brazil / Análise da qualidade da água de hemodiálise durante o período de 2008 a 2016 em Minas Gerais, Brasil

Water quality requirements for hemodialysis are crucial for preventing health risks for renal patients. The objective of this study was to assess the quality of the water used for hemodialysis treatments in the state of Minas Gerais. The analytical results for 25 parameters in 1056 hemodialysis water samples from 89 renal dialysis units were analyzed. Data were obtained through the Minas Gerais Hemodialysis Unit Quality Monitoring Programme between July 2008 and December 2016. The effects of the Programme on patient health protection were assessed by evaluating compliance with legal limits and the efficacy of implementing inspections from 2012. Considering the 1056 samples analyzed, 264 (25%) presented at least one parameter in disagreement with current legislation. Conductivity (9.8%), endotoxin (6.9%), fluoride (4.2%) and heterotrophic bacteria (2.2%) were the most critical parameters. Nevertheless, the concentrations of all these parameters (except fluoride) decreased after implementing inspections. The average levels of 15 parameters decreased throughout the study period. The annual percentage of non-compliance decreased from 44% in 2008 to 23% in 2016. It was verified the relevance of the implementation of the Program in the prevention of possible disorders to the patients health, indicating the importance of its continuity.(AU)

Os requisitos de qualidade da água para a hemodiálise são cruciais para prevenir riscos à saúde de pacientes renais. O objetivo foi avaliar a qualidade da água utilizada nos tratamentos de hemodiálise em Minas Gerais. Os dados foram obtidos por meio do Programa de Monitoramento da Qualidade dos Serviços de Hemodiálise do Estado entre julho de 2008 e dezembro de 2016. Os resultados analíticos para 25 parâmetros em 1056 amostras de água em hemodiálise de 89 unidades renais foram analisados. Os efeitos do Programa na saúde dos pacientes foram avaliados através da conformidade dos limites legais e da eficácia da implementação de inspeções a partir de 2012. Considerando-se as 1056 amostras analisadas, 264 (25%) apresentaram pelo menos um parâmetro em desacordo com a legislação vigente. Condutividade, endotoxina, fluoreto e bactérias heterotróficas foram os parâmetros mais críticos. No entanto, as concentrações de todos esses parâmetros (exceto flúor) diminuíram após a implementação das inspeções. Os níveis médios de 15 parâmetros diminuíram ao longo do período do estudo. O percentual anual de não conformidade diminuiu de 44% (2008) para 23% (2016). Verificou-se a relevância da implantação do Programa na prevenção de possíveis transtornos à saúde dos pacientes, indicando a importância de sua continuidade.(AU)

Acute kidney failure following severe viper envenomation: clinical, biological and ultrasonographic aspects

Acute kidney injury (AKI) is a frequent complication of snakebite envenomation, which is still little known in sub-Saharan Africa. This study aims to describe the clinical, biological and ultrasonographic aspects of AKI following severe snakebite envenomation managed in the intensive care unit. Method: A prospective observational survey was performed in Benin over a period of 18 months. All patients suffering severe snakebite envenomation (SBE) were included. The diagnosis of AKI was made using the KDIGO criteria. Kidney ultrasound exam was performed in all patients to assess internal bleeding and morphological and structural abnormalities of the kidneys. Results: Fifty-one cases of severe SBE were included. All patients presented inflammatory syndrome and showed abnormal WBCT whereas bleeding was found in 46 of them (90%). The median time to hospital presentation was three days. The majority of patients were male (M/F sex ratio = 1.55) and the median age was 26. Sixteen patients (31%) showed AKI according to the KDIGO criteria. Severe AKI (KDIGO stage 2 and 3) was observed in three patients, including one stage 2 and two stage 3. Kidney ultrasound revealed three cases of kidney capsular hematoma (6%), two cases of kidney hypertrophy (3%), three cases of kidney injury (4%), two stage 1 KDIGO and one stage 2 KDIGO. Only one patient benefited from hemodialysis. All patients showing AKI recovered without sequels. The median duration of hospital stays was four days. Seven patients died (14%) including four among the 16 AKI patients. Antivenom has been administered to 41 patients (80%). The comparison between patients without and with AKI did not show any significant difference except gender (p = 10-2). Conclusion: AKI is a common complication of severe snakebite envenomation. Resulting from inflammatory and hemorrhagic disorders, AKI may prove to be a short-term life-threatening factor.(AU)

Acute kidney failure following severe viper envenomation: clinical, biological and ultrasonographic aspects

Acute kidney injury (AKI) is a frequent complication of snakebite envenomation, which is still little known in sub-Saharan Africa. This study aims to describe the clinical, biological and ultrasonographic aspects of AKI following severe snakebite envenomation managed in the intensive care unit. Method: A prospective observational survey was performed in Benin over a period of 18 months. All patients suffering severe snakebite envenomation (SBE) were included. The diagnosis of AKI was made using the KDIGO criteria. Kidney ultrasound exam was performed in all patients to assess internal bleeding and morphological and structural abnormalities of the kidneys. Results: Fifty-one cases of severe SBE were included. All patients presented inflammatory syndrome and showed abnormal WBCT whereas bleeding was found in 46 of them (90%). The median time to hospital presentation was three days. The majority of patients were male (M/F sex ratio = 1.55) and the median age was 26. Sixteen patients (31%) showed AKI according to the KDIGO criteria. Severe AKI (KDIGO stage 2 and 3) was observed in three patients, including one stage 2 and two stage 3. Kidney ultrasound revealed three cases of kidney capsular hematoma (6%), two cases of kidney hypertrophy (3%), three cases of kidney injury (4%), two stage 1 KDIGO and one stage 2 KDIGO. Only one patient benefited from hemodialysis. All patients showing AKI recovered without sequels. The median duration of hospital stays was four days. Seven patients died (14%) including four among the 16 AKI patients. Antivenom has been administered to 41 patients (80%). The comparison between patients without and with AKI did not show any significant difference except gender (p = 10-2). Conclusion: AKI is a common complication of severe snakebite envenomation. Resulting from inflammatory and hemorrhagic disorders, AKI may prove to be a short-term life-threatening factor.(AU)

Microbiological analyses of water from hemodialysis services in São Luís, Maranhão, Brazil

Rigorous control of water quality in hemodialysis services is extremely important in order to guarantee a better quality of life of the patients submitted to this treatment. The lack of adequate water monitoring has caused the death of various patients in the past. The objective of the present study was to determine the physicochemical and bacteriological characteristics of water used by hemodialysis services in hospitals of the city of São Luís, Maranhão, Brazil. Bacteriological analyses included the membrane filter method for the determination of total coliform bacteria, the Cult-Dipcombi-TTC-agar method for heterotrophic bacteria and the limulus amebocyte lysate method for the determination of endotoxins. Eighteen water samples obtained from three hospital units, six samples per hemodialysis service, collected directly at the pre- and post-treatment points, were analyzed. Microorganisms were detected in the water used by the hemodialysis services in two of the three hospital units (B and C) studied. No contamination with heterotrophic bacteria was observed in pretreatment samples, while endotoxin production was detected in 100% of the samples. In post-treatment samples, heterotrophic bacteria were detected in 66.6% of the samples and endotoxins in 33.3%. The microorganisms identified in unit B were Burkholderia cepacia, Alcaligenes xylosoxidans,Pseudomonas aeruginosa and Stenotrophomonas maltophilia In unit C Flavimonas oryzihabitans,Ralstonia pickettii and Burkholderia cepacia were identified. A significant correlation was observed between the presence of endotoxins and the physicochemical characteristics of water such as turbidity and conductivity. These data indicate that two of the three hospital units studied should revise the control of their hemodialysis water system.

A necessidade de um controle rigoroso no serviço de hemodiálise tornou-se algo de extrema importância para garantir uma melhor qualidade de vida aos pacientes submetidos a este tratamento, uma vez que, a falta de controle de qualidade da água, tem levado a óbito vários pacientes. Este estudo teve como objetivo avaliar as características físico-químicas e bacteriológicas da água utilizada pelos serviços de hemodiálise em hospitais da cidade de São Luís. A metodologia utilizada para as análises bacteriológicas foi: método da membrana filtrante para determinação de coliformes totais, método Cult-Dipcombi-ttc-ágar para bactérias heterotróficas e método limulus amebocyte lysate para endotoxinas. Foram analisadas dezoito amostras de água em três unidades hospitalares, sendo seis amostras provenientes de cada serviço de hemodiálise, colhidas diretamente dos pontos pré e pós-tratamento. Quanto à presença de microrganismos na água utilizada pelos serviços de hemodiálise, observou-se positividade nas unidades hospitalares B e C. Não foi encontrada contaminação por bactérias heterotróficas nas amostras examinadas no pré-tratamento, entretanto a contaminação por endotoxinas foi em 100% das amostras. Nas amostras pós-tratamento encontrou-se para bactérias heterotróficas 66,6% e endotoxinas 33,3%. Os microrganismos identificados na unidade hospitalar B foram: Burkholderia cepacia, Alcalígenes xilosoxidans, Pseudomonas aeruginosa e Stenotrophomonas maltophilia. Na unidade C, foram identificados: Flavimonas oryzihabitans, Ralstônia pickettii e Burkholderia cepacia. Houve uma correlação significativa entre a presença de endotoxinas e características físico-químicas da água tais como: turbidez e condutividade. Estes dados revelaram que duas das três unidades hospitalares avaliadas necessitam rever o controle do sistema de água de hemodiálise.

The relevance of the program for monitoring dialysis water quality for the patient safety / A importância de programas de monitoramento da qualidade da água para diálise na segurança dos pacientes

Considering the relevance of the quality of treated water in dialysis units to prevent the risks for patients with chronic kidney diseases, a Monitoring Program has been established in order to evaluate the quality of treated water used in the dialysis units of the state of São Paulo, based on the parameters established by Resolution RDC / 154/2004. The effectiveness of the sanitary surveillance activities was evidenced because the consistent water quality has been improved on several analyzed parameters, which indicates the importance of keeping up the treated water-monitoring program at hemodialysis units in order to guarantee the patients safety.

Considerando a importância da qualidade da água tratada nos serviços de diálise para prevenção de riscos de infecção aos pacientes com insuficiência renal crônica, foi estabelecido o programa de monitoramento nos serviços de diálise do Estado de São Paulo, com base nos parâmetros estabelecidos pela Resolução RDC nº 154/2004. Foi atestada a efetividade das ações de vigilância sanitária que tem resultado em aumento dos níveis de qualidade da água tratada em vários dos parâmetros analisados, o que indica a importância da continuidade dos programas de monitoramento com intuito de garantir a segurança dos pacientes.