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contamination should be done regularly. lt ls recommended that dialysis water or dialysate should be sent on weekly basis or at least monthly. Samples can be tested for bacterial culture, endotoxin detection or endotoxin effects7.

For culture, water samples from multiple sites should be tested. Water for bacteriological analysis should be sampled at distinct points in the water distribution system(i) main water supply, (ii) water distal to the decalci-fication column, (iii) water distal to the activated charcoal cartridge,

(iv) water distal to the reverse osmosis, (v) water of some of the lines supplying the dialysing machines, selected on a rotating basis, and (vi) samples of the dialysis fluid proximal to the dialyser taken from all dialysis machines. The samples must be collected meticulously: a site of direct access to the

centre setting, the water distribution pipelines are heat disinfected (- 90°C) three times per week; this process is driven by a hot feed installed downstream the RO membrane.

The HD machines are also included in the circuit covered by

this heat disinfection procedure. In addition, a chemical disinfection of each HD machine is performed after each session, while after 100 treatments, the ultrafilters, used for ET and bacteria retention, are replaced followed by a chemical disinfection.

Disinfection of the RO membrane itself is only performed by the manufacturer, and onlywhen the circuit has been opened for maintenance purposes or if, during monitoring, the alert

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Touma! of Renal Nutrition and Metabolism Vol 2 No 2 April- Tune 2016 Endotoxins 20


levels or standard values of ET and/or bacterial culture (BC) are exceeded.

Although storage tanks should be avoided because of the risk of biofilm formation, it might be unavoidable to use them in some unitslO. In which case, they can be subjected to UV irradiation, which is, however, only effective to kill planktonic micro­ organisms. In addition, they should be frequently drained and adequately disinfected 11.

The management requires coordinated efforts by clinicians, nurses, cleaning personnels andhospital administration.

References

  1. Hoenich NA, Ronco C, Levin R. The importance of water quality and haemodialysis fluid composition. Blood Purif 2006;24:ll-8.

  2. Bommer J, Jabert BL. Ultrapure dialysate: facts and myths.Semin Dial2006;19{2) :115-9.

  3. Schindler R, Beck W, Deppisch R, Aussieker M, Wilde A,Gohl H, et al. Short bacterial DNA fragments: detection in dialysate and induction of cytokines. J Am SocNephrol2004;15:3207-l4.

  4. Handelman GJ, Megdal PA, Handelman SK. Bacterial DNA in water and dialysate: detection and significance for patient outcomes. Blood Purif 2009;27:81-5.


  5. Bergstro"m J, Heimbu"rger 0,Lindholm B, Qureshi AR. C­ reactive protein as predictor for serum albumin and mortality in hemodialysis. J Am SocNephrol 1995; 6: 573

  6. Pannichi V, Migliosi M, de Pietro S et al. Plasma C-reactive protein inhemodialysis patients. Blood Purification, inpress

  7. Hardind GB, Pass T, Wright R. Bacteriology of hemodialysis fluids: Are current methodologies meaningful? Artif Organs 1992;16:448-456

  8. Caroff M, Karibian D, Cavaillon JM,et al. Structural and functional analyses of bacterial lipopolysaccharides. Microbes Infect 2002;4:915-926.

  9. Lonnemann G. Assessment of the quality of dialysate. NephrolDial Transplant 1998; 13 [Suppl 5]: 17-20

  10. Patterson MK, Husted GR, Rutkowski B, Mayette DC. Bacteria: isolation, identification and microscopic properties of biofilms in high-purity water distribution systems. Ultrapure Water 1991; 8: 18-24

  11. Glorieux G, Neirynck N, Nie Veys N , Vanholder R. Dialysis water and fluid purity: more than endotoxin. Nephrol. Dial. Transplant. (2012) 27 (11): 4010-4021.