Is dialysis water a safe component for hemodialysis treatment in São Paulo State, Brazil?

Failure on the water treatment poses hemodialysis patients at risk of injury and death. Identifying if the patients are exposed to water quality related microbiological risks is an important objective to reduce the mortality for chronic renal patients and is the main issue of this study. We evaluated the microbiological water quality used by 205 dialysis services in São Paulo State, Brazil between 2010 to 2016. The study included heterotrophic bacteria count, total coliforms research, and bacterial endotoxin determination in 1366 dialysis water samples. The number of unsatisfactory clinics for at least one microbiological parameter decreased 16.0% between 2010 to 2015 but increased 57.2% in 2016. In 2010, the most frequent unsatisfactory parameter was related to heterotrophic bacteria count (54.8%) followed by endotoxin determination (45.2%). However, in 2013 an opposite situation was observed: endotoxin determination as the parameter of the higher incidence of nonconformities. Total coliform was verified at a lower frequency. We highlighted the importance of regular monitoring of dialysis water quality to prevent infections caused by dialytic procedures and to ensure that the water is a safe component of the treatment.

Importancia sanitaria de Pseudomonas aeruginosa en agua de hemodiálisis y su desinfección / Health importance of Pseudomonas aeruginosa in hemodyalisis water and its disinfection

Introducción: la contaminación microbiológica de los sistemas de tratamiento de agua para hemodiálisis es un problema actual, sobre todo, por la persistencia de determinados microorganismos en la formación del biofilm, entre ellos Pseudomonas aeruginosa. Objetivo: actualizar los conocimientos sobre la importancia sanitaria de Pseudomonas aeruginosa y su desinfección en agua de hemodiálisis, que aporten criterios para la toma de decisiones adecuadas. Métodos: los datos se obtuvieron de organismos internacionales como son la Asociación para el Avance de Instrumentos Médicos y la Organización Internacional de Normalización, de criterios de expertos y de resultados de laboratorio y guías de trabajo. Síntesis de la información: existen diferentes manera de actuar sobre la contaminación bacteriana, uno de ellos es evitarla, que se puede lograr si ciertos elementos del sistema son mejorados para crear finalmente un flujo turbulento y evitar la presencia de biofilm, también puede lograrse con calor o con productos químicos desinfectantes que deben estar validados. Sin embargo, para evitar la presencia de Pseudomonas aeruginosa y otros microorganismos, hay que poner énfasis en la limpieza y desinfección de forma regular y preventiva de todas las partes de los sistemas de tratamiento y de distribución de agua y de las máquinas de hemodiálisis. Conclusiones: el proceso de desinfección en el caso de contaminación por Pseudomonas aeruginosa en una planta de tratamiento es casuístico, teniendo en cuenta la diversidad de sistemas de tratamiento de agua, sistemas de distribución, su tiempo de explotación y la necesidad de tomar medidas puntuales para cada una de estos(AU)

Introduction: microbiological contamination of the hemodialysis water treatment is a present problem mainly because of the persistence of certain microorganisms in the biofilm formation, such as the case of Pseudomonas aeruginosa. Objective: to update the knowledge on the health importance of Pseudomonas aeruginosa and their disinfection in hemodialysis water for adequate decision-making. Methods: data were taken from international bodies such as the Association for the Advancement of Medical Instruments, the International Standardization Organization, expert criteria and lab results as well as work guidelines. Information synthesis: there are different ways of acting upon the bacterial contamination; one of them is to prevent it. This can be accomplished if certain elements of the system are improved to create a turbulent flow that prevents the presence of biofilm; it may also be attained by using heat or disinfectant chemical products that should be validated. However, for the purpose of preventing the presence of Pseudomonas aeruginosa and other microorganisms, emphasis must be made on regular and preventive cleaning and disinfection of all the parts of the water treatment and distribution systems and of the hemodialysis equipment. Conclusions: the process of disinfection of Pseudomonas aeruginosa in a water treatment plant is casuistic, taking into account the diversity of water treatment systems, distribution systems, operating time and need of taking point measures aimed at each of them(AU)

Evidência adicional de que uso de água ultrapura diminui inflamação em hemodiálise / Further evidence that ultrapure water decreases inflammation in hemodialysis

Introdução: Uso de membranas não bio- compatíveis e exposição a água imprópria para hemodiálise (HD) podem aumentar os níveis de Proteína- Creativa (PCR). Esse estudo, acompanhando um grupo de indivíduos em HD, avaliou padrões de inflamação antes e após a introdução de água ultrapura (AUP). Métodos: PCR foi determinada nos mesmos 31 pacientes antes e depois da introdução da AUP para HD. Episódios de calafrios (não associados com infecção detectada) e transfusões de sangue foram mensurados nos três meses precedendo as determinações laboratoriais. Dialisadores de polissulfona foram utilizados. Análise estatística: teste t para amostras pareadas, Wilcoxon- ranked signed test, qui- quadrado e odds- ratio. Resultados:A comparação entre os períodos de 3 meses antes e 3 meses após a implantação da AUP permitiu observar diferenças nos parâmetros: incidência decalafrios (42 episódios versus dois episódios em 1178 sessões, p< 0.0001); número de transfusões (0,193 versus 0,096 unidades/paciente/mês, p<0,0001); Hemoglobina (Hgb) média, (aumentou de 9.6±1.8 para 10.4±1.6 g/dL, p< 0.007); e PCR média (diminuiu de 1.05±0.74 para 0.43±0.23 mg/dL, p< 0.001). Conclusões: Significativa redução nos níveis de PCR, com marcada diminuição dos episódios de calafrios ocorreu, apontando para diminuição dos níveisinflamatórios após uso de AUP. O aumento de Hgb refletiu-se na diminuição da necessidade de transfusões, sugerindo que a AUP diminuiu a inflamaçãodos pacientes em HD.

Background: Use of non-biocompatible membranes and exposure to inappropriately treated hemodialysis (HD) water may increase C- reactive protein (CRP). This study, following a single group of HD individuals, evaluated signs of inflammation before and after using ultrapure water (UPW) for HD.Methods: CRP levels were measured in the same 31 patients before and after UPW implementation in HD. Episodes of chills (not associated with detectableinfections) and blood transfusions, were compared in the three months periods preceding the laboratory determinations. Polysulfone dialyzers were used. Statistical analysis was accomplished using paired t test, Wilcoxon signed-rank test, chi-square test and odds-ratio. Results: The comparison between the3 months period preceding and following UPW implementation disclosed differences in the following parameters: incidence of chills (42 versus 2 episodesin 1178 HD sessions, p<0.001); number of blood transfusions ( 0.193 versus 0.096 units/patient/ month, p<0.0001). Mean Hemoglobin (increased from9.6±1.8 to 10.4±1.6 g/dL, p=0.01); and mean CRP (dropped from 1.05±0.74 to 0.48±0.23 mg/dL, p<0.001). Conclusions: A significant reduction in CRP levels occurred with marked decrease in the episodes of chills pointing to a diminished inflammatory process with the use of UPW. The increase in Hgblevels was reflected in the decrease of blood transfusion requirements, suggesting that the use of UPW reduces the inflammatory status of hemodialysispatients.