Validation and applicability of an alternative method for dialysis water and dialysate quality analysis / Validação e aplicabilidade de um método alternativo para análise da qualidade da água e do dialisato em diálise

ABSTRACT Introduction: In hemodialysis, patients are exposed to a large volume of water, which may lead to fatal risks if not meeting quality standards. This study aimed to validate an alternative method for monitoring microbiological quality of treated water and assess its applicability in dialysis and dialysate analysis, to allow corrective actions in real-time. Methods: Validation and applicability were analyzed by conventional and alternative methods. For validation, E. coli standard endotoxin was diluted with apyrogenic water in five concentrations. For the applicability analysis, treated water for dialysis was collected from different points in the treatment system (reverse osmosis, drainage canalization at the storage tank bottom, reuse, and loop), and dialysate was collected from four machines located in different rooms in the hemodialysis sector. Results: The validation results were in accordance with the Brazilian Pharmacopoeia acceptance criteria, except for the last two concentrations analyzed. In addition, the ruggedness criterion performed under the US Pharmacopoeia was in agreement with the results. Discussion: A limiting factor in the applicability analysis was the absence of the endotoxin maximum permitted level in dialysate by the Brazilian legislation. When comparing the analysis time, the alternative method was more time-consuming than the conventional one. This suggests that the alternative method is effective in the case of few analyses, that is, real-time analyses, favoring corrective actions promptly. On the other hand, it does not support the implementation of the alternative method in a laboratory routine due to the high demand for analyses.

RESUMO Introdução: Na hemodiálise, os pacientes são expostos a um grande volume de água, o que pode levar a riscos fatais se não cumprir com padrões de qualidade. Este estudo teve como objetivo validar um método alternativo para monitorar a qualidade microbiológica da água tratada e avaliar sua aplicabilidade em análises de diálise e dialisato, para permitir ações corretivas em tempo real. Métodos: A validação e aplicabilidade foram analisadas por métodos convencionais e alternativos. Para validação, a endotoxina padrão de E. coli foi diluída com água apirogênica em cinco concentrações. Para a análise de aplicabilidade, a água tratada para diálise foi coletada em diferentes pontos do sistema de tratamento (osmose reversa, canalização de drenagem no fundo do tanque de armazenamento, reutilização e circuito) e o dialisato foi coletado em quatro máquinas localizadas em diferentes salas do setor de hemodiálise. Resultados: Os resultados da validação obedeceram aos critérios de aceitação da Farmacopeia Brasileira, com exceção das duas últimas concentrações analisadas. Além disso, o critério de robustez realizado sob a Farmacopeia dos EUA estava de acordo com os resultados. Discussão: Um fator limitante na análise de aplicabilidade foi a ausência do nível máximo permitido de endotoxina no dialisato pela legislação brasileira. Ao comparar o tempo de análise, o método alternativo consumiu mais tempo que o convencional. Isso sugere que o método alternativo é eficaz no caso de poucas análises, ou seja, análises em tempo real, favorecendo ações corretivas imediatamente. Por outro lado, não suporta a implementação do método alternativo em uma rotina de laboratório devido à alta demanda por análises.

Validation and applicability of an alternative method for dialysis water and dialysate quality analysis.

INTRODUCTION: In hemodialysis, patients are exposed to a large volume of water, which may lead to fatal risks if not meeting quality standards. This study aimed to validate an alternative method for monitoring microbiological quality of treated water and assess its applicability in dialysis and dialysate analysis, to allow corrective actions in real-time. METHODS: Validation and applicability were analyzed by conventional and alternative methods. For validation, E. coli standard endotoxin was diluted with apyrogenic water in five concentrations. For the applicability analysis, treated water for dialysis was collected from different points in the treatment system (reverse osmosis, drainage canalization at the storage tank bottom, reuse, and loop), and dialysate was collected from four machines located in different rooms in the hemodialysis sector. RESULTS: The validation results were in accordance with the Brazilian Pharmacopoeia acceptance criteria, except for the last two concentrations analyzed. In addition, the ruggedness criterion performed under the US Pharmacopoeia was in agreement with the results. DISCUSSION: A limiting factor in the applicability analysis was the absence of the endotoxin maximum permitted level in dialysate by the Brazilian legislation. When comparing the analysis time, the alternative method was more time-consuming than the conventional one. This suggests that the alternative method is effective in the case of few analyses, that is, real-time analyses, favoring corrective actions promptly. On the other hand, it does not support the implementation of the alternative method in a laboratory routine due to the high demand for analyses.

Cálculo da estimativa da incerteza de medição associada ao ensaio de contagem de bactérias heterotróficas em matriz água purificada através da técnica de detecção por fluorescência / Measurement uncertainty calculation associated with heterotrophic bacterial count in purified water matrix using the fluorescence detection technique

A incerteza de medição representa o nível de confiança no resultado. Para a estimativa da incerteza de medição foi empregado o cálculo do desvio padrão da reprodutibilidade intralaboratorial de 48 ensaios de contagem de bactérias heterotróficas pela técnica da membrana filtrante com detecção por fluorescência pelo uso de substrato fluorogênico em amostras de água purificada contaminadas artificialmente entre 10 e 100 UFC/mL. O valor obtido, 1,3 x 10-3 (log10), indica que a técnica utilizada pode ser uma alternativa para a estimativa da incerteza de medição em ensaios microbiológicos quantitativos de contagem de bactérias heterotróficas em amostras de água purificada. (AU)

Measurement uncertainty represents the confidence level in the result. To estimate the expanded measurement uncertainty, the standard deviation of intra-laboratory reproducibility of 48 heterotrophic bacterial count assays by fluorescence detection by the use of fluorogenic substrate on artificially contaminated purified water samples between 10 and 100 CFU/mL was used. The value obtained, 1.3 x 10-3 (log10), indicates that the technique used can be an alternative to estimate measurement uncertainty in quantitative microbiological heterotrophic bacterial count assays in purified water samples using fluorogenic substrate. (AU)

Cálculo da estimativa da incerteza de medição associada ao ensaio de contagem de bactérias heterotróficas em matriz água purificada através da técnica de detecção por fluorescência / Measurement uncertainty calculation associated with heterotrophic bacterial count in purified water matrix using the fluorescence detection technique

A incerteza de medição representa o nível de confiança no resultado. Para a estimativa da incerteza de medição foi empregado o cálculo do desvio padrão da reprodutibilidade intralaboratorial de 48 ensaios de contagem de bactérias heterotróficas pela técnica da membrana filtrante com detecção por fluorescência pelo uso de substrato fluorogênico em amostras de água purificada contaminadas artificialmente entre 10 e 100 UFC/mL. O valor obtido, 1,3 x 10-3 (log10), indica que a técnica utilizada pode ser uma alternativa para a estimativa da incerteza de medição em ensaios microbiológicos quantitativos de contagem de bactérias heterotróficas em amostras de água purificada.

Measurement uncertainty represents the confidence level in the result. To estimate the expanded measurement uncertainty, the standard deviation of intra-laboratory reproducibility of 48 heterotrophic bacterial count assays by fluorescence detection by the use of fluorogenic substrate on artificially contaminated purified water samples between 10 and 100 CFU/mL was used. The value obtained, 1.3 x 10-3 (log10), indicates that the technique used can be an alternative to estimate measurement uncertainty in quantitative microbiological heterotrophic bacterial count assays in purified water samples using fluorogenic substrate.

Is dialysis water a safe component for hemodialysis treatment in São Paulo State, Brazil?

Failure on the water treatment poses hemodialysis patients at risk of injury and death. Identifying if the patients are exposed to water quality related microbiological risks is an important objective to reduce the mortality for chronic renal patients and is the main issue of this study. We evaluated the microbiological water quality used by 205 dialysis services in São Paulo State, Brazil between 2010 to 2016. The study included heterotrophic bacteria count, total coliforms research, and bacterial endotoxin determination in 1366 dialysis water samples. The number of unsatisfactory clinics for at least one microbiological parameter decreased 16.0% between 2010 to 2015 but increased 57.2% in 2016. In 2010, the most frequent unsatisfactory parameter was related to heterotrophic bacteria count (54.8%) followed by endotoxin determination (45.2%). However, in 2013 an opposite situation was observed: endotoxin determination as the parameter of the higher incidence of nonconformities. Total coliform was verified at a lower frequency. We highlighted the importance of regular monitoring of dialysis water quality to prevent infections caused by dialytic procedures and to ensure that the water is a safe component of the treatment.

Is dialysis water a safe component for hemodialysis treatment in São Paulo State, Brazil?

Failure on the water treatment poses hemodialysis patients at risk of injury and death. Identifying if the patients are exposed to water quality related microbiological risks is an important objective to reduce the mortality for chronic renal patients and is the main issue of this study. We evaluated the microbiological water quality used by 205 dialysis services in São Paulo State, Brazil between 2010 to 2016. The study included heterotrophic bacteria count, total coliforms research, and bacterial endotoxin determination in 1366 dialysis water samples. The number of unsatisfactory clinics for at least one microbiological parameter decreased 16.0% between 2010 to 2015 but increased 57.2% in 2016. In 2010, the most frequent unsatisfactory parameter was related to heterotrophic bacteria count (54.8%) followed by endotoxin determination (45.2%). However, in 2013 an opposite situation was observed: endotoxin determination as the parameter of the higher incidence of nonconformities. Total coliform was verified at a lower frequency. We highlighted the importance of regular monitoring of dialysis water quality to prevent infections caused by dialytic procedures and to ensure that the water is a safe component of the treatment.

Effectiveness of the monitoring program for ensuring the quality of water treated for dialysis in the state of São Paulo / Efetividade do programa de monitoramento da qualidade da água tratada para diálise no estado de São Paulo

ABSTRACT Introduction: Chronic kidney failure is a disease that affects the functions of the kidneys and can cause irreversible kidney failure over time. Among the main factors that cause this disease are hypertension and diabetes mellitus. The number of patients presenting this clinical condition has been increasing in Brazil, leading to an increase in renal replacement therapy, such as hemodialysis. Material and methods: In the state of São Paulo, a joint action between the Adolfo Lutz Institute, the Sanitary Surveillance Center, and the Sanitary Surveillance Groups have promoted the State Program for the Monitoring of Water Treated for Dialysis since 2007 to evaluate the chemical and microbiological quality of the water used in dialysis in compliance with the current legislation. Objective: This study aimed to evaluate the monitoring program developed between 2010 and 2016 as a tool for corrective action when unsatisfactory results are observed. Results: The level of satisfactory results during the period varied from 85.8 to 98.0%, indicating an increase in the adequacy of the dialysis services in producing water with adequate quality for patient health. Conclusion: The design adopted in the state monitoring program is highly effective based on new collections after the joint actions of the Sanitary Surveillance System and the State Dialysis Services.

RESUMO Introdução: A Insuficiência Renal Crônica caracteriza-se como uma doença que afeta as funções dos rins, podendo causar a falência irreversível dos órgãos ao longo do tempo. Dentre os principais fatores que podem causar a doença, destacam-se a hipertensão arterial e o diabetes mellitus. O número de pacientes com esse quadro clínico - que precisam submeter-se a procedimentos de tratamentos renais substitutivos, como a hemodiálise - vem aumentando no país. Materiais e métodos: No estado de São Paulo, uma ação conjunta entre o Instituto Adolfo Lutz, o Centro de Vigilância Sanitária e Grupos de Vigilância Sanitária vem promovendo, desde 2007, o Programa Estadual de Monitoramento de Água Tratada para Diálise para avaliar a qualidade química e microbiológica da água utilizada em tratamentos dialíticos, em atendimento à legislação vigente. Objetivo: O presente estudo teve como objetivo avaliar o Programa de Monitoramento desenvolvido entre 2010 a 2016, como ferramenta para tomadas de ações corretivas quando resultados insatisfatórios foram observados. Resultados: O nível de resultados satisfatórios no período variou de 85,8% a 98,0%, indicando aumento de adequação dos Serviços de Diálise na produção de água com qualidade necessária à preservação da saúde dos pacientes. Conclusão: Os resultados indicaram que o delineamento adotado no programa estadual de monitoramento, com novas colheitas após tomadas de ações conjuntas entre os órgãos do Sistema de Vigilância Sanitária e as equipes dos Serviços de Diálise do estado, apresenta alta efetividade.

Effectiveness of the monitoring program for ensuring the quality of water treated for dialysis in the state of São Paulo.

INTRODUCTION: Chronic kidney failure is a disease that affects the functions of the kidneys and can cause irreversible kidney failure over time. Among the main factors that cause this disease are hypertension and diabetes mellitus. The number of patients presenting this clinical condition has been increasing in Brazil, leading to an increase in renal replacement therapy, such as hemodialysis. MATERIAL AND METHODS: In the state of São Paulo, a joint action between the Adolfo Lutz Institute, the Sanitary Surveillance Center, and the Sanitary Surveillance Groups have promoted the State Program for the Monitoring of Water Treated for Dialysis since 2007 to evaluate the chemical and microbiological quality of the water used in dialysis in compliance with the current legislation. OBJECTIVE: This study aimed to evaluate the monitoring program developed between 2010 and 2016 as a tool for corrective action when unsatisfactory results are observed. RESULTS: The level of satisfactory results during the period varied from 85.8 to 98.0%, indicating an increase in the adequacy of the dialysis services in producing water with adequate quality for patient health. CONCLUSION: The design adopted in the state monitoring program is highly effective based on new collections after the joint actions of the Sanitary Surveillance System and the State Dialysis Services.

Qualificação do transporte de amostras para o monitoramento da qualidade de água tratada para uso em diálise / Qualification of the sample transport for monitoring the quality of water for dialysis purpose

As condições de coleta e o transporte das amostras de água tratada para uso em diálise são etapas críticas para garantir a qualidade dos resultados analíticos. A temperatura no transporte de amostras deve assegurar a manutenção das características físicas e biológicas desde a coleta até o recebimento pelo laboratório analítico. O objetivo deste estudo foi de qualificar o transporte de amostras de água tratada para diálise desde os Serviços de Diálise do estado de São Paulo até o Instituto Adolfo Lutz, realizado durante a execução do Programa Estadual de Monitoramento. Os resultados obtidos indicaram que o sistema adotado, utilizando-se caixas isotérmicas e gelo reutilizável, é capaz de garantir as condições adequadas de temperatura durante o transporte do ponto de coleta das amostras até o laboratório analítico.

The conditions for collecting and transporting the dialysis water samples are the critical steps to assure the quality of the analytical results. The temperature during the water samples transport should ensure the maintenance of the physical and biological characteristics of samples from their collections to the analytical laboratory. The objective of this study was to qualify the transport of the dialysis water samples from the Dialysis Services of the state of São Paulo to the Adolfo Lutz Institute, during the performance of the State Monitoring Program. By using the isothermal boxes and the reusable ices, the obtained results indicated that the adopted system were able to guarantee the adequate temperature conditions during the transport from the sample collection point to the analytical laboratory.

Validação de metodologia analítica para determinação de endotoxina bacteriana em água para diálise por meio de método cromogênico cinético / Analytical methodology validation for determining the bacterial endotoxin in the dialysis water by means of kinetic chromogenic technique

O nível de endotoxina presente na água tratada para hemodiálise é um importante indicador de qualidade, uma vez que altas concentrações de endotoxina atuam como a principal fonte de inflamação crônica em pacientes submetidos à diálise. Este estudo visa validar o método analítico para determinar quantitativamente a endotoxina bacteriana em amostras de água de hemodiálise pelo método cromogênico cinético e de comparar com o método de coagulação em gel. Os ensaios pelo método de coagulação em gel foram realizados de acordo com a Farmacopeia Brasileira em três amostras de água de hemodiálise. A validação do método cromogênico cinético foi realizada utilizando-se as mesmas amostras por meio de sistema de teste portátil. As médias geométricas das concentrações dos pontos finais obtidos nos testes de confirmação de sensibilidade LAL e de interferência por método de coagulação em gel apresentaram resultado de 0,125 UE/mL. Os resultados obtidos pelo método cromogênico para a recuperação do controle positivo do produto variaram de 89 a 186% e o coeficiente de variação de 2,5 a 18,2%, demonstrando que as amostras não apresentaram interferência. Foram obtidos resultados equivalentes em ambos os métodos, o que permite a implementação do método em laboratórios de saúde pública.

The occurrence of endotoxin in the treated water for hemodialysis is an important indicator of quality, since high concentrations of endotoxin constitute the main source for causing chronic inflammation in patients undergoing dialysis. This study aims at validating the analytical method for determining quantitatively the bacterial endotoxin in hemodialysis water samples. The data from the kinetic chromogenic method were compared with the results obtained from the gel coagulation technique. The gel coagulation assays were performed in three samples of hemodialysis water, according to the Brazilian Pharmacopoeia. The validation of the kinetic chromogenic method was performed using the same samples through the portable test system. The geometric means of the concentrations of the endpoints obtained from the tests for confirming the LAL sensitivity and the interference by gel coagulation method showed a result of 0.125 EU/mL. The results obtained by the chromogenic method for recovering the product positive control varied from 89 to 186% and the coefficient of variation from 2.5 to 18.2%, demonstrating that the samples did not show interference. Equivalent results were obtained in both methods, therefore being viable the implementation of this methodology in the public health laboratories.