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Fluid Quality at Home Haemodialysis Installations

Fluid Quality at Home Haemodialysis Installations. Gareth Murcutt Royal Free Hospital London. Why does water quality matter?. An average patient dialyses for 4 hrs 3 times per week against a fluid rate of 0.6 l min -1

EllenMixel
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Fluid Quality at Home Haemodialysis Installations

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  1. Fluid Quality at Home Haemodialysis Installations Gareth Murcutt Royal Free Hospital London

  2. Why does water quality matter? An average patient dialyses for 4 hrs 3 times per week against a fluid rate of 0.6 l min-1 Annually an HD patient will be exposed to over 22,000 litres of water

  3. Adverse Incidents

  4. RO: HHD vs Hospital Can this………………replace this?

  5. Where is water used for dialysis?

  6. Where is water used for dialysis?

  7. Where is water used for dialysis? Hospital Site Home Site

  8. HHD: Fluid Testing Program Business case prepared / accepted / partially funded 6 monthly chemical RO water analysis at all home patients 6 monthly TVC & endotoxin: water / d/fluid analysis at all home patients Samples taken during service visits and collected by courier Results are emailed and posted Results recorded / actioned

  9. HHD Water Contamination • Chemical Contamination • Microbiological contamination

  10. HHD Water Contamination • Chemical Contamination • Microbiological Contamination

  11. Chemical Contamination How pure is tap water? 2,4-D, Bentazone, Clopyralid, Dicamba, Dichlorprop, Fluroxypyr, MCPA, MCPB, Mecoprop, Carbendazim, Glyphosate, Copper, Lead, Zinc, Dichlobenil, Propyzamide, Triallate, Benzo 3,4 Pyrene, Total PAHs, Total Pesticide, Atrazine, Simazine, Trietazine, Carbetamide, Chlorotoluron, Cyanazine, Diuron, Isoproturon, Linuron, Tetrachloroethene, Tetrachloromethane, Total Trihalomethanes, Trichloroethene, Odour Intensity,Manganese,Ammonium, Hydrogen IonAluminium, Odour, Odour Intensity, Taste Intensity, Taste, Electrical Conductivity, Colour, Aluminium, Iron as Fe, Temperature, Nitrate, Nitrite, Hydrogen Ion, Turbidity, Alkalinity as HCO3, Free Cyanide, Fluoride, Mercury, Selenium, Antimony, Arsenic, Barium, Boron, Cadmium, Calcium, Chromium, Magnesium, Nickel, Potassium, Silver, Sodium, Phosphorus, Chloride, Sulphate, Total Hardness, Oxidizability, Surfactants, Dry residue, Total Organic Carbon, Total Chlorine.

  12. Chemical Contamination Comparison of chemical limits

  13. Chemical Contamination FT30 membrane % rejections

  14. Chemical Contamination HHD Stable chemicals: results Total of 51 samples taken from 23 HHD installations

  15. Chemical Contamination The special case of nitrates Nitrate Vunerable Zones AAMI limit = < 2 mg l-1 (as NO3 -N ) EPh limit = < 2 mg l-1 (as nitrate: NO3) 1 mole of N = 14g 1 mole of NO3 = 62g To convert (NO3 -N) to (NO3) the result must be multiplied by 62/14 (~ 4.5)Action level of 4 mg l-1 agreed

  16. Chemical Contamination Carbon: HHD vs Hospital Can this………………replace this?

  17. Chemical Contamination Testing for Residuals A standard test for chlorine in water is the DPD method. Free chlorine reacts with diethyl-p-phenylene diamine (DPD) tablets in buffered solution to produce a pink colour.Our testing shows that the filters used still adequately remove chlorine and chloramines after 6 months at an HHD site. Reaction of free chlorine with DPD. + 1/2 Cl2 + H+ Cl- Clear Red

  18. HHD Water Contamination • Chemical Contamination • Microbiological Contamination

  19. Microbiological Contamination Microbiological Standards

  20. Microbiological Contamination Endotoxin Results: Oct 2003

  21. Microbiological Contamination TVC Results: Oct 2003

  22. Microbiological Contamination TVC Results Analysis

  23. Microbiological Contamination Standard vs Ultrafiltered d/f

  24. Microbiological Contamination TVC results: Standard d/f

  25. Microbiological Contamination Cut-away RO pure water

  26. Microbiological Contamination Biofilm in RO pure water output

  27. Carbon filter RO HHDm/c Discussion: HHD Chemistry This simple set-up is capable of providing water for dialysis of an acceptable chemical composition Planned maintenance and analysis must be done to ensure correct operation

  28. Discussion: HHD Microbiology Carbon filter RO HHDm/c Biofilm TVC / Eu This set-up is probably NOT capable of providing water for dialysis of an acceptable microbiological standard • Long periods of stagnation • Difficulty of disinfection

  29. Achieving compliance An example of a system that should be capable of providing chemically and microbiologically acceptable dialysis fluid Integrateddisinfection

  30. Planning for HHD fluid quality Contact with water suppliers System design Chlorine/chloramine Adequate carbon filtration Chlorine testing Good quality RO membrane Water Analysis Integrated disinfection HHD machine Robust disinfection regime Ultrafilter D/fluid analysis

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