Academic journal article Iranian Journal of Public Health

Evaluation of Bacteriological and Chemical Quality of Dialysis Water and Fluid in Isfahan, Central Iran

Academic journal article Iranian Journal of Public Health

Evaluation of Bacteriological and Chemical Quality of Dialysis Water and Fluid in Isfahan, Central Iran

Article excerpt


Patients receiving hemodialysis are exposed to a large volume of dialysis fluid (approximately 120 l) in a single dialysis treatment (1). The presence of a nonselective semipermeable membrane, which acts as a barrier between blood and dialysis fluid, provides a direct route for transformation of contaminants into the blood stream. Consequently, many of permitted levels of chemical substances in drinking water are potentially dangerous for dialysis patients (2). Some of these chemicals such as calcium, nitrate, sulfate and chloramines cause well-defined acute or chronic poisoning syndromes for these patients (3). High calcium and magnesium levels for instance, cause cardiac problems. Aluminum overload may also lead to encephalopathy, bone disease and anemia in dialysis patients (4). To minimize patient exposure to potential contaminants of drinking water therefore, additional purification treatment is necessary for water used in dialysis. A series of purification processes such as deionization, carbon filtration and reverse osmosis (RO) are generally used to remove chemical pollutants from water used in hemodialysis. These processes are also an effective barrier against microbiological contaminants (5).

In addition, tubing system (hydraulic circuit) of the dialysis machines could promote bacterial growth and biofilm formation. Biofilm acts as a source of bacterial fragments such as DNA and endotoxin which are released into the water and potentially able to penetrate dialysis membranes (1, 6). Endotoxin can induce the production of proinflammatory cytokines. Cytokine induction causes acute symptoms and has been incriminated in the various dialysis-related complications of patients such as dialysis-related amyloidosis, malnutrition inflammation and atherosclerosis syndrome (7, 8). Therefore, the quality of dialysis fluid is a critical factor in the overall care received by dialysis patients and bacteriological quality particularly, has a strong effect on the patient health and outcome (4, 7). To prevent patients from risks of water contaminants a number of standards for quality of dialysis water and fluid have been proposed (2). The Association for the Advancement of Medical Instrumentation (AAMI) standards have represented the most widely standards for the chemical and microbial quality of dialysis water (2, 3).

Over the last decade, a number of studies aimed at evaluating the quality of dialysis water and fluid, especially microbial quality, have been performed in developed countries (3, 5, 9). Vorbeck-Meister et al. performed a survey on microbiological and chemical quality of the dialysis water in seven dialysis wards in Vienna, Austria. They observed an increase in endotoxin levels after the water had passed through the tubing system of dialysis machines. They reported that a satisfactory chemical water quality for dialysis could be obtained only by the combination of ion exchange and reverse osmosis (9). A study in 2 dialysis facilities showed viable cell counts of dialysis fluids were less than 10 CFU/ml but colonies were not formed after passing the endotoxin retentive filters (1). Microbiological results from the central plant and piping ring of 5 dialysis units have led to an improvement in microbiological quality of water subsequent to changes made in the use of materials and procedures. Besides, these changes have a positive impact on the microbiological quality of dialysis patients over a 15-yr period (5).

Based on these premises, the present study was undertaken to investigate the chemical and bacteriological quality of dialysis water and fluid in dialysis centers of five hospitals in Isfahan, Iran. Since, identification of bacteria could be important for assessment of health risks associated with the presence of pathogens and opportunistic bacteria in dialysis fluid (10); the identification of predominant bacteria was also performed.

Materials and Methods

In a cross-sectional study, the bacteriological and chemical quality of the water used in dialysis centers of five hospitals in Isfahan, Iran was analyzed over a 5-month period in 2011-2012. …

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