Water treatment for hemodialysis, including

the latest AAMI standards

Nephrology Nursing Journal, Dec, 2001 by Rebecca L. Amato
Many documented hemodialysis (HD) patient injuries and deaths are associated with
inadequately purified water for the HD treatment. Table 1 describes potential clinical symptoms
of using inadequately purified water. It is estimated that many more incidences go unreported
because the chronic symptoms, like bone disease, can be insidious and relegated to problems
secondary to ESRD unless a patient exhibits an acute or subacute reaction. Nurses may not be
servicing the water treatment system, but nurses are responsible for understanding all the clinical
ramifications of water treatment for hemodialysis and piecing together the entire picture.
Although historically the water treatment system is the technicians' domain, knowing the
technical aspects in order to work together is best for the patients' ultimate well-being.
More than 90% of dialysate is water. The more pure the water, the more accurate the dialysate
prescription delivered. Companies who sell water purification devices are regulated by the Food
and Drug Administration (FDA). Water treatment systems, dialysis machines, and ancillary
devices are mandated as Class II medical devices by the FDA. Class I encompasses loosely
regulated items such as band-aids and tongue depressors; Class III stringently regulates devices
like high-flux hemodialyzers and implantable items such as pace makers.

Water Supply
There are two sources of municipal water: surface water and ground water. Surface water comes
from lakes, ponds, rivers, and other surface type reservoirs. It is generally more contaminated
with organisms and microbes, industrial wastes, fertilizers, and sewage. Ground water comes
from underground chambers such as wells and springs and is generally lower in organic materials
but contains higher inorganic ions such as iron, calcium, magnesium, and sulfate.
Public water systems process both types of water. They add chemicals depending on the quality
of the supply water. By law, strict guidelines must be adhered to as stated in the Safe Drinking
Water Act. This law pertains to the maximum allowable level of contaminants in potable water.
Public water systems are regulated by the Environmental Protection Agency (EPA).

Municipal water suppliers use processed waste water from sewage and industry for drinking
water. For example, waste from the manufacturing process is metered into the waste water drain
in compliance with EPA and other regulations. The waste water is distributed to a waste water
plant where it is run into large settling ponds and is treated with chemicals and flocculants to
remove the contaminants. After the waste settles to the bottom, the top layer of water is fed into a
river or reservoir that feeds the municipal potable water facility. At the municipality, the water is
further treated with flocculants, such as aluminum sulfate (alum), to remove nonfilterable
suspended particles (colloidal matter); depth filtration to remove filterable solids;
chlorination/chloramination for disinfection; and fluoridation to prevent cavities. Ironically, most
chemical additives have unenforceable contaminant level goals; in other words, no citations are
given when a desired level is violated. Table 2 gives maximum allowable levels of contaminants
in water by the Association for the Advancement of Medical Instrumentation (AAMI) and the
EPA.
Water supply companies are mandated by the EPA to monitor and test the water on a periodic
basis. Water can change from season to season and even day to day. It has been reported that up
to 48 of our 50 states have been out of compliance with the EPA Standards at any given time
(Carpenter, 1991). This places an extra burden on the nephrology professionals to deliver the
purest water feasible to persons on HD.

Why Water Purity is Important During HD

By the time water arrives at our faucets, it is deemed acceptable to drink by the municipality and
the EPA; however, not acceptable to perform HD. The average person drinks approximately two
liters of water a day, whereas a dialysis patient is exposed to anywhere from 90 to 192 liters of
water per treatment. In healthy individuals, the contaminants in water are mainly excreted
through the kidneys and gastrointestinal (GI) system. HD patients on the other hand, do not have
functioning kidneys to excrete the waste products from this massive water (as dialysate)
exposure. The blood is separated from the water by a semipermeable membrane, the dialyzer, that
is selective as far as size of molecule but not contaminant specific.
This article reviews technical information sectioned into Feed Water Components, Pretreatment
Components, Reverse Osmosis (RO) System, Posttreatment Components and Distribution
System. Typically, not all the components mentioned are on a water treatment system for
hemodialysis. From facility to facility, components will vary dependent upon incoming water
quality and philosophy of the staff.

Feed Water Components

The AAMI recommends and the FDA and Health Care Financing Administration (HCFA) dictate
that all water treatment devices be labeled with: (a) the type of device; (b) the manufacturer name
and address with phone number; (c) appropriate warnings for use; and (d) identifications to
prevent improper connections. Flow schematics and diagrams should be displayed in the water
treatment room and updated as necessary.

Back-flow preventer. All water treatment systems require a form of back-flow prevention device.
A back-flow preventer prohibits the water in the water treatment components from flowing back
into the potable drinking water lines. This protects the drinking water from contamination with
disinfectants and cleaners that are used in the water treatment system. Many other devices, like
air conditioners connected to the drinking water supply, require back-flow prevention in order to
prevent back-syphoning of anti-freeze and other toxins.

Local plumbing codes dictate the type of back-flow preventer that can be used and varies from
area to area. A device that creates an air gap, such as break tank is considered a back-flow
prevention device and is sometimes used on small portable RO machines. Back-flow preventers
must be installed by a licensed plumber, and validated annually by a state authorized licensed
inspector.

Temperature blending valve. The temperature blending valve mixes hot and cold water to a RO
membrane industry standard temperature of around 77 [degrees] F (25 [degrees] C). These valves
are widely used on large central RO systems that tend to have cold incoming water. The colder
the source water, the less purified water the RO membrane will produce. Per 1 [degrees] F
temperature drop, the RO membrane produces 1.5% less purified water (1 [degrees] C drop
equals a 3% decrease). For instance, an incoming temperature of 50 [degrees] F would result in
an approximate loss of 40% (product water flow).

An alternative to temperature blending when not practical, as in single patient portable RO

machines, is the use of larger or more RO membranes. The larger membrane surface area
produces more permeate water. If blending hot and cold water together from a sink faucet, a
temperature gauge must be in place with an audible alarm. Most RO membranes are heat
intolerant and can be destroyed with temperatures above the manufacturer's recommendations.

A temperature gauge with an audible and visual alarm should follow temperature blending
valves. Temperature readings should be compared to an independent meter and recorded at least
daily.

Booster pump. The RO system requires a constant supply of water flow and pressure in order to
operate successfully. Dialysis facilities experience fluctuating or decreased incoming water
pressure and flow, especially since back flow preventers and temperature blending valves
substantially lower pressure. In order to compensate, a booster pump may be placed after these
devices. Booster pumps should be followed by a pressure gauge that is read and recorded daily.