Worldwide water standards for hemodialysis

Ward, Richard A.

doi:10.1111/j.1542-4758.2007.00142.x

Cited by 31 publications

(21 citation statements)

References 13 publications

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“…However, it should be noted that mean level of endotoxin was 0.1560.22 EU/ml in the standard dialysate group, which is much lower than recommended levels for endotoxin by many national authorities until quite recently. 21 Therefore, it is possible that relatively good quality of standard dialysate in the current study might blunt the demonstration of a beneficial effect of ultrapure dialysate.…”

Section: Discussionmentioning

confidence: 99%

The Impact of Membrane Permeability and Dialysate Purity on Cardiovascular Outcomes

Aşçı

Töz

Özkahya

et al. 2013

Journal of the American Society of Nephrology

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The effects of high-flux dialysis and ultrapure dialysate on survival of hemodialysis patients are incompletely understood. We conducted a randomized controlled trial to investigate the effects of both membrane permeability and dialysate purity on cardiovascular outcomes. We randomly assigned 704 patients on three times per week hemodialysis to either high-or low-flux dialyzers and either ultrapure or standard dialysate using a two-by-two factorial design. The primary outcome was a composite of fatal and nonfatal cardiovascular events during a minimum 3 years follow-up. We did not detect statistically significant differences in the primary outcome between high-and low-flux (HR=0.73, 95% CI=0.49 to 1.08, P=0.12) and between ultrapure and standard dialysate (HR=0.90, 95% CI=0.61 to 1.32, P=0.60). Posthoc analyses suggested that cardiovascular event-free survival was significantly better in the high-flux group compared with the low-flux group for the subgroup with arteriovenous fistulas, which constituted 82% of the study population (adjusted HR=0.61, 95% CI=0.38 to 0.97, P=0.03). Furthermore, high-flux dialysis associated with a lower risk for cardiovascular events among diabetic subjects (adjusted HR=0.49, 95% CI=0.25 to 0.94, P=0.03), and ultrapure dialysate associated with a lower risk for cardiovascular events among subjects with more than 3 years of dialysis (adjusted HR=0.55, 95% CI=0.31 to 0.97, P=0.04). In conclusion, this trial did not detect a difference in cardiovascular event-free survival between flux and dialysate groups. Posthoc analyses suggest that high-flux hemodialysis may benefit patients with an arteriovenous fistula and patients with diabetes and that ultrapure dialysate may benefit patients with longer dialysis vintage.

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Section: Discussionmentioning

confidence: 99%

The Impact of Membrane Permeability and Dialysate Purity on Cardiovascular Outcomes

Aşçı

Töz

Özkahya

et al. 2013

Journal of the American Society of Nephrology

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“…HD patients are at risk for injury from chemical and microbiological contaminants in the dialysate, and the water and concentrates used to produce dialysate, as well as the dialysate itself, are required to meet well-established quality standards (80). There are considerable differences between standards regarding the maximum allowable levels of microbiological contaminants and the methods to be used for measuring them.…”

Section: Purity Of Dialysate and Dialysis Watermentioning

confidence: 99%

Did 20 Years of Technological Innovations in Hemodialysis Contribute to Better Patient Outcomes?

Lameire¹,

Biesen²,

Vanholder³

2009

Clinical Journal of the American Society of Nephrology

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During the past two decades, impressive technological innovations have been introduced in the field of hemodialysis. This review analyzes whether these have been translated into better patient survival. The potential impacts of an increase in dialysis dosage, the preference of high-flux versus low-flux membranes, the choice between convection and diffusion as dialysis strategy, the chemical composition and biologic purity of dialysate, the effect of sodium, potassium, volume profiling, and the intradialytic volume monitoring aiming at improving hemodynamic stability are explored. Studies in which the dialysis dosage was increased were not associated with increased patient survival, whereas the superiority of high-flux over low-flux membranes is not convincingly demonstrated. Although strict evidence is lacking, observational data suggest an advantage of convective over pure diffusive strategies. Longer duration of the dialysis sessions and/or higher frequency of dialysis is probably beneficial, but the results of powerful randomized, controlled trials should be awaited. Sodium profiling has more disadvantages than advantages, whereas potassium profiling mainly in arrhythmia-prone patients with ventricular hypertrophy should be considered. Intradialytic blood volume monitoring has reduced intradialytic hypotension episodes, but hard evidence for improving patient survival is lacking. Overall, the major technological advances in dialysis have not yet been translated into longer patient survival. Optimal predialysis care in preventing the cardiovascular damage that accumulates before the start of dialysis and timely creation of an arteriovenous fistula as vascular access is a more effective and more economic strategy in the long-term outcome of the dialysis patient.

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“…These include the European Pharmacopoeia, the Japanese Society for Dialysis Therapy, the Canadian Standards Association and the American National Standards Institute/Association for the Advancement of Medical Instrumentation (AAMI). Within these standards, there is general agreement concerning the maximum allowable levels of inorganic chemicals with documented toxicity in haemodialysis patients such as aluminium, chloramines, copper, fluoride, lead, nitrate, sulphate and zinc, although minor differences between the standards exist [6] .…”

Section: Standards For Chemical and Microbiological Purity Of Water Amentioning

confidence: 99%

Water for Haemodialysis and Related Therapies: Recent Standards and Emerging Issues

2010

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Dialysis is a well-established and widely used procedure. For a number of years, the focus has been on ensuring that water used in the preparation of dialysis fluid meets the required chemical and microbiological quality and complies with national or international standards which have recently been updated. Continued vigilance is required, in particular when new chemicals such as silver-stabilized hydrogen peroxide and chlorine dioxide are used to prevent growth of Legionella bacteria in hospital water systems, since residues are harmful to patients receiving dialysis. To achieve the required quality, large volumes of water are processed, and a substantial portion is sent to waste via the municipal sewer systems with little attempt to reuse such water on site. In view of concern about global warming and climate change, there is a need to adopt a more environmentally conscious attitude requiring dialysis providers to focus on this aspect of water usage.

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Worldwide water standards for hemodialysis

Cited by 31 publications

References 13 publications

The Impact of Membrane Permeability and Dialysate Purity on Cardiovascular Outcomes

The Impact of Membrane Permeability and Dialysate Purity on Cardiovascular Outcomes

Did 20 Years of Technological Innovations in Hemodialysis Contribute to Better Patient Outcomes?

Water for Haemodialysis and Related Therapies: Recent Standards and Emerging Issues

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