Water for Dialysis Part 1: Components Danilo B. Concepcion, CBNT, CHT-A, FNKF danilo.concepcion@stjoe.org (714)771-8944 The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of St. Joseph Hospital
Safety of Water and Dialysis Delivery: The highly-technical nature of dialysis treatments place the patients at significant risk if there is isolated or systemic failure to follow precise procedures.
Anemia Bone Disease Fever, Chills Hemolysis Hypotension Hypertension Muscle Weakness Metabolic Acidosis Methemoglobinemia with cyanosis Nausea & Vomiting Neurological Deterioration
Why Water Must be Treated Average Person Drinks 14 liters of water/week GI tract more selective Functioning kidney 10-14 Liters Person on Hemodialysis Blood is exposed to 360 + liters of water/ week Dialyzer membrane is thin, non-selective Nonfunctioning kidney Can experience harm or death from untreated water 350-450 Liters 5
The Role of Water in Hemodialysis Preparation of dialysate Reprocessing of hemodialyzers 6
How Water is Treated The municipal or public water supply is made safe for dialysis by use of a water treatment system. 7
Sources of Water Ground Water Surface Water Municipal Water 8
Types of Contaminants Microorganisms Organic Contaminants Inorganic Contaminants 9
Water Treatment Standards AAMI: Association for the Advancement of Medical Instrumentation CMS: FDA: State: Facility: Centers for Medicare & Medicaid Services (Formerly HCFA) Federal Drug Administration Each state sets it s own standards Policies and Procedures 10
AAMI STANDARDS CHEMICAL mg/l Fluoride 0.20 Chloramine 0.10 Free Chlorine 0.50 Sulfate 100.00 CHEMICAL mg/l Nitrate 2.00 Zinc 0.10 Copper 0.10 Aluminum 0.01 11
AAMI STANDARDS (cont.) CHEMICAL mg/l Barium 0.100 Selenium 0.090 Chromium 0.014 Lead 0.005 Silver 0.005 Thallium 0.002 CHEMICAL mg/l Cadmium 0.0010 Mercury 0.0002 Arsenic 0.0050 Beryllium 0.0004 Antimony 0.0060 12
AAMI STANDARDS (cont.) CHEMICAL mg/l Calcium 2.0 Magnesium 4.0 Sodium 70.0 Potassium 8.0 13
The Water Treatment System Components Backflow Preventer Temperature Blending Valve Booster Pump Sediment, Depth, or Multimedia Filter Water Softener Carbon Tanks Micron Filters Reverse Osmosis (R.O.) Deionization Tanks (D.I.) Storage Tank Ultrafilters Flowpath, Pipes, and Gauges 14
The Water Treatment System Components Backflow Preventer Prevents water and/or disinfectants from flowing backward from the dialysis unit into the municipal (public) water supply 15
Backflow Preventer Prevents reverse flow of water and or contaminants through the valve, which would contaminate the potable drinking water supply. Installed, tested by licensed plumber
The Water Treatment System Components Temperature Blending Valve Mixes incoming cold water with water from the hot water heater 18
The Water Treatment System Components Booster Pump Boosts water pressure from 40 psi to 60-80 psi (pounds per square inch) 19
Sediment Filter
The Water Treatment System Sediment, Depth, or Multimedia Filter Designed to catch large suspended particles such as algae, rust, and sand Components 21
Sediment Filter What is it and What does it do? Tank containing several layers of different media designed to filter sediment particles from city water supply How do we Monitor it? Sediment filter is monitored on daily basis for: Pressure drop across filters Backwash timer heads set to correct time of day Re-generated or backwashed during hours of non-operation in order to clean the media
Sediment Filter What do we do if it fails? Depending on facility s Silt Density Index, RO may handle short term bypass of this device What is the adverse impact on the patient if it fails? Failure of this equipment may not effect operation at all, depending on city feed water quality
The Water Treatment System Components Water Softener Removes calcium and magnesium 24
Softener Resin Bead Na+ Na+ Na+ Na+ Na+ Na+ Na+ Ca++ Ca++ Na+ Ca++ Ca++ Ca+ Ca++ 2Na+ 2Na+ 2Na+ Na+ Cl- 2Na+ 2Na+ 2Na+ Cl- Cl- Cl-
Softeners & Exchange Tanks For the removal of water hardness (calcium, magnesium) in exchange for sodium NaCl solution
Softeners and Exchange Tanks Monitoring Record pressure pre and post softener At least daily Check hardness post softener In a.m. and p.m. <2 grains hardness (<35 mg/l)
Softeners Shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration shall be interlocked. Shall be measured at the end of each treatment day.
Water Softener What do we do if it fails? Softeners may be temporarily bypassed Running RO without a softener for prolonged amount of time could cause permanent damage to RO membranes What is the adverse impact on the patient if it fails? Prolonged failure of water softener can cause failure of RO membranes, and can also cause further patient complications
The Water Treatment System Components Carbon Tanks Used to remove chlorine and chloramine Two Carbon tanks are used in sequence, a Worker and a Polisher 30
SA = 1000 m 2 /gm or 3280 f 2 /0.002 pounds
Carbon Tanks Iodine number of 900 or higher Acid washing removes manufacturing debris Tanks are sized for Empty Bed Contact Time (EBCT). 10 minutes EBCT for chloramine removal V=(Q x EBCT)/7.48 1.2 gal/min EBCT 10 min./7.48 = 1.6ft 3 Two tanks in series for total EBCT, worker and polisher
Carbon Tanks Monitoring Check total chlorine post first tank Before every shift Every four hours Pre and post pressure
Carbon Tanks What do we do if it fails? If breakthrough is noted on primary tank, total chloramine level should immediately be checked after secondary tank If there is no breakthrough noted after secondary tank, treatments can continue with increased frequency (at least hourly) of total chloramine monitoring with Medical Director approval for up to 72 hrs If breakthrough is noted after secondary GAC tank, treatment must be stopped immediately Both tanks must be re-bedded within 72 hrs
Carbon Tanks What is the adverse impact on the patient if it fails? Failure of GAC tanks may result in elevated level of chlorine and chloramine in pre-treated water Chlorine and chloramine will cause permanent damage to most RO membranes Chlorine and chloramine in product water can lead to hemolysis or death
The Water Treatment System Components Micron Filters Micron filters remove small particulate matter 36
Prefilters Head Outlet Flow O-ring Filter Cartridge Flow Final Barrier against particles or debris that can damage RO pumps and membranes Shell
Prefilters Considerations/Concerns Disposable cartridge with a 3 to 5 micron filter size Change prefilter when 8-10 PSI higher than clean pressure loss Or on a routine schedule Disinfect bowl and head to remove biofilm AAMI standards require housing to be opaque
Membrane Element Permeate Flow Concentrate Permeate Feed Solution Collection Tube
Monitors and Controls Indicators of water quality (conductivity, TDS, resistivity) Local Remote % Rejection (Input - Product / Input) x 100 (V200) Include a means to prevent patient exposure to unsafe product water, such as diversion of the product water to drain Disinfection lock-out
V199 V201 R.O. 5.2.7 a means to prevent patient exposure to unsafe product water, such as diversion of the product water to drain V200 IG: In the absence of an automatic divert to drain valve for the RO, facility staff must demonstrate knowledge of the requirement to manually stop water flow to the dialysis machines 6.2.7 chemical analysis Installation, membrane replacement, seasonal variations, <90% rejection
Post Treatment Components U.V. Light Sub-micron/Ultra-filters
Ultraviolet Irradiator Kills or alters DNA of bacteria as water passes through UV Quartz Sleeve UV Lamp O Ring Quartz Nipple Pilot Light Power Supply Lamp Harness Assembly Washer Plug
Ultraviolet Irradiator UV is a mercury vapor lamp enclosed in a fused quartz sleeve Endotoxins may be produced as it kills bacteria Ultrafilter recommended after UV for endotoxin control UF may be placed at points of use Check LAL
Ultraviolet Irradiator UV Maintenance Routine cleaning REQUIRED to retain efficiency Lamp replacement Once per year, not when burns out
Submicron and Ultra Filters Sub micron filter 0.1 through 1.0 microns UF filters/membranes rated by pore size Generally.001 through 0.05 microns
Ultrafiltration (UF) Prevents patient from being final filter Removes Bacteria and endotoxin Validated medical filter (absolute rating) Rated in nominal MWCO Problem with decrease in pressure and flow which affects velocity Place at points of use: Dialyzer reprocessing equipment Bicarbonate filling station Dialysis machine on dialysate