Water Quality Through Proper

Material Selection

NIPRO CORPORATION, JAPAN

Mahendra Gunatilake
Regional Technical Manager,
Nipro Asia Pte Ltd, Singapore

04 September 2019, Surabaya

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 World ESRD requirements
• Dialysis patient's population is increasing globally

• Variety of treatment methods are introduced.

• To achieve target result in stable condition, Healthcare professionals

are continuously improving treatment techniques providing better
quality and safety for renal patients

NIPRO is continuously improving solutions to provide

quality and safe treatment

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Nutshell of dialysis treatment

➢Uremic Toxins
➢Optimisation of treatment
➢Treatment techniques
➢Nipro dialysis machine

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Uremic toxins

Dr. Lemke at ExcorLab, Germany

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 Options and variables
Technology
 Low Flux dialysis
 High Flux dialysis
 Single use dialyzer
 Length of dialysis
 Frequency of dialysis
 Dialysis Dose (Kt/V)
 Intradialytic length
 Ultrafiltration rate
 Dialysis membrane – dialyzer
 Purification of dialysate (ultrapure dialysate)
 High volume online HDF

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 Water

 Natural product
 Most important life supporting substance
 Drinking water is the most important food
 Drinking water is a precious resource

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 Drinking Water

• Ground water
mostly with a good quality, to use without any preparation
for drinking

• Surface water
river bank filtrate from rivers or artificial lakes, storage
reservoir

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 Water pollution
Vegetable material
Inorganic
Type of pollution
Na+ Cl-
Mg ++
Ions Colloids
+ Organic
+ - + +
+ - -+
- - -
+- - + +- - + R-COOH
- - - - -+
+ - + +
+ +

• Organic pollutants
particles, colloids, bacteria, pyrogens, chloramines, pesticides

• Inorganic pollutants
monovalent/ polyvalent ions, especially calcium, sodium,
magnesium, nitrate, copper, aluminium etc

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 Type of pollution

Inorganic

Na+ Cl-
Mg ++ Vegetable material
Organic
Ions
R-COOH

Particles

Colloids
+ +
+ - + + - -+
- - - Microorganisms
+- - + +- - +
- - - - -+
+ - + +
+ +

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 Why is water so important?

• Healthy Individual ±2 L/day 14 L/week

• Hemodialysis Patient 150 L/day

• Healthy individuals
Gastrointestinal tract separates blood from contaminants in the water

• Hemodialysis patients
Dialyzer membrane forms a barrier, limited only for some molecular or
particulate size of contaminant

No water No Treatment

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Objective when designing a water treatment system

• Clean water
• Reliable water
• Cost effective water

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Dialysis water – Microbiological contaminants

Maximum allowable level – ISO13959:2014

Contaminant RO water Dialysis Fluid Ultrapure

dialysis fluid
TVC < 100 CFU/ml < 100 CFU/ml < 0.1 CFU/ml
Endotoxin < 0.25EU/ml < 0.5 EU/ml < 0.03 EU/ml

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 Dialysis water – Microbiological contaminants
Maximum allowable level – ISO13959:2014

Contaminant Toxic chemical

concentration mg/l
Aluminum 0.01
Total Chlorine 0.1
Copper 0.1
Fluoride 0.2
Lead 0.005
Nitrate (as N) 2
Sulfate 100
Zinc 0.1

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 Dialysis water – Microbiological contaminants
Maximum allowable level – ISO13959:2014

Contaminant Other elements concentration

mg/l
Antimony 0.006
Arsenic 0.005
Barium 0.1
Beryllium 0.0004
Cadmium 0.001
Chromium 0.014
Mercury 0.0002
Selenium 0.09
Silver 0.005
Thallium 0.002
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Dialysis water – Microbiological contaminants

Contaminant Hazard due to chemical

contaminants
Aluminum Brain damage
Copper Hemolysis, Liver Damage
Fluoride Bone disease
Lead Neurological Damage
Nitrate Methemoglobinemia
Sulfate Metabolic Acidosis
Zink Anemia
Chromium Hemolysis

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Dialysis water – Microbiological contaminants
Dialysate ET level and HR of death (JSDT data)

Hasegawa T, ＡＪＫＤ2015 ;65(6):899-904

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Objective when designing water treatment system
RO System
- Right Dimension
- Easy Installation/Maintenance
- Cost of Intervention
- Choice of material Single/Double RO
- Full output in failure mode

Loop Selection
- Choice of material
- Design

Disinfection method
- Heat/Chemical
- Frequency

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From water work to dialysis center

• Communication with water works

• Water quality & stability with the help of
hospital
• Chlorine
• Additives from Silicate
• Water analysis

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 Material selection

•Correct design of pre-treatment

Provided by the
Nipro Pure Water
customer

Inlet water tank with Sand filter/ Soft water monitoring

free inlet Media filter system Carbon filter
Water alarm with
Backflushing water motor valve
filter
Pre-filter 25µm
Booster pump Softener Pre-filter 5 - 10µm

230V, 16A 230V, 16A

Ball valve

Flow direction

Drain HT50

Leak sensor
Reverse osmosis

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Selection of piping material

•Chemical resistance
•Mechanical property
•Hydrophobic property
•Rougness

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 Selection of loop design
➢ Avoid stagnant water

➢ Maintain flow velocity

➢ Avoid Aluminium, copper, Lead and Zinc fittings

Long term cumulative toxity

➢ Avoid biofilm formation possibilitis

PVC pipe connections

➢ Shortest path, avoid multiple branches, minimum fittings, dead leg

free design

➢ Multi-loop design

Hemodialysis is a long term chronic treatment modality. This facts

should be considred selecting suitable materials for construction.

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 Selection of loop design

Single loop Multi loop

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 Selection of RO

•Right dimention
•Easy to install
•Easy to maintain
•Cost of intervention
•Choice of material
•Single / Double stage RO
•Full output in failure mode

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 NIPRO dialysis machine and RO
system portfolio

SURDIAL55Plus Nipro ROMEDICAL Nipro Phoenix One DS

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Hygiene & disinfection
Endotoxin Filter

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Hygiene & disinfection
Bicarbonate Cartridge

• cartridge change in all phases of

operation .

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 Disinfection

Disinfectant:
• Hot Citric acid (39 min)
• Sodium hypochlorite (41 min)

Features:
• Weekly disinfection program
• In-line heat
• Disinfection history
• Low disinfectant consumption

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 Conclusion

❑ Think quality as priority

❑ If possible

–Select proper raw water source

–Avoid PVC in favor of PEX or PVDF
–Use multiploop design
–Select a system that assures water supply no matter
what

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 TERIMA KASIH
for your kind attention!

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