Pre-emptive replacement of water treatment components improves responsiveness to erythropoiesis-stimulating agents in maintenance haemodialysis patients: a quality improvement report.

Hypo-responsiveness to erythropoiesis-stimulating agents (ESAs) has been associated with increased mortality. We examined the effect of water treatment component replacement on declining ESA responsiveness in the absence of chemical or microbiological standards failure. Pre-emptive renewal of the water treatment system supplying 802 standard-flux haemodialysis patients resulted in a significant rise in haemoglobin from (mean ± SD) 12.1 ± 1.2 to 12.3 ± 1.0 g/dl (p < 0.0001), accompanied by a significant decrease in prescribed dose of darbepoetin alfa from 47.9 ± 27.3 to 44.7 ± 27.6 µg/week (p < 0.0001). ESA responsiveness improved significantly from 0.060 ± 0.041 to 0.055 ± 0.040 µg/kg/g · dl(-1) (p < 0.0001) and the number of patients no longer requiring ESA therapy increased threefold. These benefits were derived in the absence of haemolysis or significant changes in water quality. Renewal of water system components should be conducted even in the absence of proven microbiological and chemical failure.

Água para hemodiálise no estado do Rio de Janeiro: uma avaliação dos dados gerados pelo programa de monitoramento da qualidade nos anos de 2006-2007 / Hemodialysis water in the state of Rio de Janeiro: an evaluation of data generated by the program for monitoring quality in the years 2006-2007

No presente estudo, avaliamos a distribuição percentual dos resultados de análises fiscais da água em relação ao perfil das unidades e ao cumprimento das exigências de controle e manutenção dos sistemas de tratamento.

[Field 7. Safety practice for renal-replacement therapies. French-speaking Society of Intensive Care. French Society of Anesthesia and Resuscitation]. / Champ 7. Sécurisation des procédures d'épuration extrarénale. SRLF. SFAR.

Renal-replacement therapies are among the most invasive techniques used in the intensive-care units. An increased security of these methods can be expected from interventions on several areas. Teaching and training are probably the more important due to the complexity of both techniques and devices. The interest and the limits of the monitoring techniques need to be known as well as the guidelines for an optimal ordering. As often, a set of written procedures must ideally be constructed by the ICU team then learned and periodically revised.

Review: Clinical usefulness of ultrapure dialysate--recent evidence and perspectives.

It has generally been accepted that biological contamination of dialysate deteriorates the biocompatibility of dialysis therapy and accelerates dialysis-related complications such as dialysis-related amyloidosis (DRA) and malnutrition-inflammation-atherosclerosis (MIA) syndrome. During the past decade several studies have clarified that very slight amounts of contamination can lead to inflammatory response, and we could not confirm biological dialysate quality only by measuring endotoxin levels despite of measuring viable cell counts or biofilms. To achieve this, the European Renal Association/European Dialysis Transplantation Association and the American National Standardization Institute/Association for the Advancement of Medical Instrumentation published new standards for dialysate, in which very strict control levels were recommended with regard to viable bacterial cell counts. In 2004 JSDT raised the required standard of the levels of endotoxin, and began to develop a standard for bacterial cell counts. In Japan, many chronic kidney disease patients are treated with centralized dialysate supply systems which have weak spots in disinfecting the system. This causes some difficulties in making a standard for viable bacterial cell counts. In the present paper, we summarize evidences of clinical usefulness of ultrapure dialysate and perspectives of the standard for dialysate in Japan.

Aluminum determination in biological fluids and dialysis concentrates via chelation with 8-hydroxyquinoline and solvent extraction/fluorimetry.

We describe a simple, rapid, and sensitive fluorescence method for measurement of aluminum (Al) in human biological fluids, in dialysis solutions, and in tap water, which uses 8-hydroxyquinoline for ion chelation. The fluorescence intensity of the toluene-extracted metal chelate (excitation wavelength, 380 nm; emission wavelength, 504 nm) remains unchanged for over 48 h at room temperature. Fluorescence intensity is a linear function of the concentration of Al in the 2-1000 microg/L range with detection limits of 0.7-2 microg/L. A large excess of other ions normally found in biological fluids does not interfere in Al determination. The method developed was successfully used in assaying Al in serum and urine of reference subjects, in serum samples from patients undergoing long-term dialysis, and in dialysis solutions. Al concentrations, measured by this fluorimetric procedure, were compared with those obtained by Zeeman graphite-furnace atomic absorption spectrometry. A correlation coefficient of 0.98 was obtained. The proposed method could be used for routine analysis in clinical laboratories for accurate determination of aluminum in aqueous or biological fluids.

Ultrapure dialysate reduces plasma levels of beta2-microglobulin and pentosidine in hemodialysis patients.

BACKGROUND: beta2-Microglobulin (beta2MG) and carbonyl stress are reported to contribute to the development of dialysis-related amyloidosis. The aim of this study was to determine whether the purity of dialysate affects plasma levels of beta2MG and pentosidine (a surrogate marker of carbonyl stress) in hemodialysis patients. METHODS: Sixteen patients on hemodialysis with a polysulfone membrane participated in this study. We switched the dialysate from conventional dialysate (endotoxin level 0.055-0.066 endotoxin units (EU)/ml) to ultrapure dialysate (endotoxin level <0.001 EU/ml), followed patients for 6 months, and then switched back to conventional dialysate once again. Plasma levels of beta2MG, pentosidine, CRP and interleukin-6 (IL-6) were determined before the switch to ultrapure dialysate, 1 and 6 months after the switch to ultrapure dialysate, and 1 month after the switch back to conventional dialysate. RESULTS: The switch from conventional to ultrapure dialysate significantly decreased plasma levels of beta2MG, from 30.1 +/- 1.4 to 27.1 +/- 1.4 mg/dl (p < 0.05) and pentosidine, from 1,535.8 +/- 107.5 to 1,267.6 +/- 102.9 nmol/l (p < 0.01) after 1 month of use. The change of dialysate also significantly decreased plasma levels of CRP, from 0.28 +/- 0.09 to 0.14 +/- 0.05 mg/dl (p < 0.05) and IL-6, from 9.4 +/- 2.7 to 3.5 +/- 0.8 pg/ml (p < 0.01) over the 1-month period. These changes in plasma levels of beta2MG, pentosidine, CRP and IL-6 were maintained over 6 months after switching to ultrapure dialysate and returned to basal levels by switching back to a conventional dialysate. CONCLUSIONS: Ultrapure dialysate decreases plasma levels of beta2MG, pentosidine and inflammatory markers in hemodialysis patients. The use of ultrapure dialysate might be useful in preventing and/or treating complications of dialysis, such as dialysis-related amyloidosis, atherosclerosis and malnutrition.

Water treatment for hemodialysis--updated to include the latest AAMI standards for dialysate (RD52: 2004) continuing.

While nurses may not routinely service the water treatment system or mix the dialysate, they are responsible for understanding all the clinical ramifications of water and dialysate for HD and helping to piece together the entire treatment picture. Although historically the water treatment system has been in the technicians' domain, knowing the technical aspects is important in order for the entire team to work together toward the patients' ultimate well being. This article describes the composition of water treatment systems for hemodialysis as well as the monitoring and testing necessary to assure that both water and dialysate are safe for patient use.

[Guidelines for quality management of dialysis solutions]. / Guías de gestión de calidad del líquido de diálisis (LD).

A Best Practice Guideline about Dialysis fluid purity has been developed under the leadership of the Spanish Society of Nephrology. The Guideline has established recommendations for standards for preparing dialysate: water, concentrates and hemodialysis proportioning systems. The Guideline was based on the European pharmacopoeia, the Real Farmacopea Española, the AAMI Standards and Recommended Practices, European Best Practice Guidelines for Haemodialysis (Section IV), literature reviews, according to their level of evidence, and the opinion of the expert spanish group. Two levels of quality of water were defined: purified water and high purified water (Ultra pure) and for dialysate: standard dialysate and ultra pure dialysate. Regular use of ultra pure dialysate is necessary for hemofiltration and hemodiafiltration on-line and desirable for high-flux hemodialysis to prevent and delay the occurrence of complications: inflammation, malnutrition, anemia and amyloidosis. Water, concentrates and dialysate quality requirements are defined as maximum allowable contaminant levels: chemicals (1.1.2), microbial and endotoxins: [table: see text] Monitoring frequency, maintenance and corrective actions were specified. Methods of sampling and analysis were described in appendix (Anexos). For microbiological monitoring, TSA or R2A medium are recommended, incubated during 5 days at a temperature of 30-35 degrees C. The dialysate quality assurance process involves all dialysis staff members and requires strict protocols. The physician in charge of hemodialysis has the ultimate responsibility for dialysate quality. All suggestions and questions about this Guideline are wellcome to www.senefro.org

Ultrapure dialysate: a desirable and achievable goal for routine hemodialysis.

United States standards for the microbiologic quality of dialysate are not very stringent and have remained unchanged for more than 20 years, despite significant changes in the patient population and in the technology of hemodialysis. Numerous studies have demonstrated that bacterial products can cross dialysis membranes and stimulate an inflammatory response in the patient. Inflammation has been implicated in several complications associated with long-term hemodialysis therapy, and the use of ultrapure dialysate has been shown to reduce the incidence of one of these complications, beta2-microglobulin amyloidosis. Since technological innovations in water treatment and improvements in dialysis machine design allow the routine production of ultrapure dialysate, its use should now become standard.