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Module 1: Introduction of Water Treatment Systems

Global Technical Service

Aquaboss_std_Module 1_Introduction of Water Treatment Systems_ Presentation_Rev
1.00_2018-01-24
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Introduction Pre-treatment RO Systems

Introduction

During hemodialysis treatment patients

are exposed to large quantities of dialysis
fluid, which is used to remove waste
products from the patient’s blood. As
more than 95% of the dialysis fluid is
water and as it is only separated from the
patient’s blood by a nonselective dialyzer
membrane, which is permeable to many
contaminants (harmful substances) found
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Water Supply
The are two types of water sources: ground water and
surface water.
Ground water comes from wells and springs. It is
often higher in ions (eg iron, calcium, magnesium) but
lower in microorganisms (bacteria, viruses,
endotoxin).
Surface water comes from lakes, rivers and
reservoirs. It may be high in contaminants such as
pesticides, industrial waste, sewage and
microorganisms.
Both types of water (source and ground water) are
often treated by the municipal water supplier, in order
to make it drinkable. Sometimes even processed
waste water from sewage and industry is processed
as drinking water.
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Introduction Pre-treatment RO Systems

Treatment of Drinking Water

Municipal water suppliers often process the water with:

 Flocculants (e.g. aluminum sulfate): to remove non-

filterable suspended particles (colloidal matter)
 Depth filtration: to remove filterable solids Chlorine
and chloramines: for disinfection (to kill off harmful
bacteria)
 Fluoride: to prevent tooth decay due to cavities pH
raising substances (e.g. sodium hydroxide): to
minimize leaching (dissolving) of metals from the
pipes

Ironically, most of the chemicals added by the water

supplier to make the water drinkable, are either harmful
for the dialysis patient or can affect the performance of
the water treatment system. Due to this the incoming
water supply has go through further treatment to
remove these potentially harmful additives.
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Introduction Pre-treatment RO Systems

Pre-Treatment

Pre treatment is necessary to remove substances from the raw water that can pass (e.g.
Aluminium, Chloramines) or block / destroy the RO membrane
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Pre-Treatment Water Tank

Ideally the water treatment system has a direct feed system without a pre-treatment water
tank involved, as any kind of tank increases the risk of bacterial contamination. However,
some countries have a legal requirement of pre-treatment storage tanks. There are also
some advantages to have a small tank:
 can be used for disinfection of the pre-treatment part of the water system
 used in case of a fluctuating water supply

Due to its large volume, internal surface area and water which can be standing still during
non-operating times, the risk of bacterial contamination is high. Therefore regular checks of
the tank should include:
 adequate water level according to the minimum and maximum levels
 close fitting lid is securely in place
 algal and bacterial contamination is cleaned regularly
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Introduction Pre-treatment RO Systems

Sediment or Multimedia Filter

Multimedia filters are used to remove particulate matter in size from 500 to 50
microns. These large particles, such as dirt, silt and colloidal matter, cause the
incoming water to be turgid and unless removed will clog the resins of the
softener and carbon filters, damage the RO pump and foul the RO
membranes.
The degree of ‘contamination’ of the incoming water is measured using the silt
density index (SDI). An SDI higher than 3 usually require a sand filters and
cartridge filters as part of the pre-treatment filter range.
While sand filters use a single grade of sand media to remove particulates
(suspended solids) larger than 50 microns, multimedia filters consist of
multiple layers of different sized media, such as sand of different grain sizes
and gravel. The density of the media and different characteristics of each layer
improve particulate filtration. In a typical sand filter with one grade of grain
size, 90% of all filtration takes place in the top 8-10cm. In a multimedia filter,
filtration takes place in each layer.
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Multimedia Sediment Filter

Using a multimedia filter (as shown on the right) improves

the overall filtration of sediment from the incoming water.
The larger sized media is at the top of the tank, with the
grade of material becoming finer towards the bottom.

Incoming water flows from the top to the bottom, trapping Free
Area

sediment as water moves through the tank .At the bottom  Gravel

of the tank, water is transported back via a tube to the pre- (3,16 –
5, 6

treatment pipe to continue onto the next filtration stage. 

mm)
Gravel

Sediment filters have to be backwashed routinely as the (2,0 –

3,2 mm)

trapped sediment has to be cleaned from the tank.  Gravel

Backwashing is done by redirecting the water flow from (0,4 –

0,8 mm)

the bottom to the top of the filter. This lifts the tightly
compressed media layers releasing the sediment and
flushing it to the drain.
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Cartridge Sediment Filters

A 5 micron cartridge filter is commonly used along with the

multimedia filter to further improve the removal of sediment
from the incoming water. However, in areas where the water
has a very low SDI, cartridge filters can be used alone, without
the need for a sand or multimedia filter. The filter is changed on
a routine basis, usually monthly. Is changed on a routine basis
from 4 to 8 weeks.

The filter is made of a fibre wound is a specific pattern to

create hundreds of identical, tapered, spiral passageways and
tunnels (pores). The pores get smaller from the outside
towards the core. Finer particles are progressively trapped as
the water travels into the centre of the filter. Thus filtration tales
place throughout the filter, not just at the surface.
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Biological and microbiological contamination of the sediment filter

Being the first main filter in the line of the pre-treatment
filters, and having chlorinated water entering, the
sand/sediment filter can serve as an ideal growth
medium for worms, protozoas and bacteria. Especially
if the quality of the incoming water is poor (surface
water). This is due to its large surface area, low water
flow, porosity of the media used and because the water
stays in the tank overnight when dialysis has finished.
So what can be done to reduce this risk?
If the incoming water has very little chlorination, and/or
high contamination count then pre-dosing of the in-
coming water can be undertaken to kill off bacterial
contamination. Though this need to be done with care
to prevent chlorine breakthrough in the carbon filter.
 Regular pre-treatment disinfection
 Routine exchange of the media bed
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What checks do I need to make on the sediment filter?

Pre-post pressure gauge: The pressures across these two
gauges should be checked and documented daily. There
should be a pressure gauge before and after the filter. Any
drop in the pressure difference between the two could be an
indication that the sand in the filter tank is either blocked with
sediment, or over time the sand has become compacted.
Either way, the effectiveness of the filter will be reduced and
action needs to be taken. First check that the filter has been
backwashing correctly. Next try to wash through the filter
with HCl of 1%, to solve carbonates and other deposits like
iron. If this does not help then the media has become
compacted and will probably need to be changed.
Back-wash Timers: The filters are back washed on a
regular basis to recharge the media and flush out the
sediment collected in the filter and to prevent bacteria
colonization. The clock timer needs to be checked each day
to ensure that the time is correct. If a sediment filter goes
into backwash during a dialysis session is very inconvenient!
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Water Softener
The water softener is a crucial part of the pre-treatment
system. Its main purpose is to “soften” the water by
removing calcium (Ca++) and magnesium ions (Mg++), in
order to protect the RO membrane from fouling and
blocking. Calcium and magnesium ions degrade the RO
membrane performance by forming mineral deposits on it.
As a consequence membrane life-time of the RO is
shortened and the risk of hard water getting to the patient
(due to high Ca++ and Mg++ levels) increases.
The softener is filled with resin beads which attract and
bind the polyvalent magnesium and calcium ions and
instead release monovalent sodium ions, which can be
easily removed by the RO membrane and rejected to
drain. Softeners are also capable of removing other
polyvalent cations such as iron and manganese, however
being somewhat limited in this regard.
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Water Softener Regenaration

In order to restore the resin beads capacity for trading

sodium ions with polyvalent cations, the softener needs
to be regenerated regularly with concentrated sodium
chloride solution (brine). Before the regeneration the
resin is backwashed briefly to loosen the media and
remove any particulate matter. Thereafter, the brine
solution is drawn from the brine tank (a tank filled with
salt pellets and water) into the tank for regeneration. Due
to the high concentration of sodium ions, the resin
releases calcium and magnesium and other positively
charged ions and exchange them with sodium ions. At
the end of the process the excess salt solution is rinsed
out. To produce the saturated sodium chloride solution
only refined pellet shaped salt should be used.
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Water Softener – What should I be monitoring

Water hardness: Different areas have different levels of

water hardness, but all water treatment plants are
designed to produce water of <4ppm water hardness.
The water hardness should be checked each morning
before the first dialysis session as a minimum. If there
are any problems with the result then consideration
should be given before allowing dialysis to continue.
Pre-post pressure gauge: The pressures across these
two gauges should be checked and documented daily.
There should be a pressure gauge before and after the
water softener. Any drop in the pressure difference
between the two could be an indication that the resin in
the softener tank is either blocked with sediment, or over
time the resin has become compacted. Either way, the
effectiveness of the softener will be reduced and action
needs to be taken. First check that the softener has
been backwashing correctly. If this is OK then the resin
will probably need be changed.
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Water Softener – What should I be monitoring

Back-wash Timers: It is recommended to design the
softeners to back wash daily, to recharge the resin and to
prevent poliferation of bacteria. This can either be done via
a clock timer or is based upon the volume of water that is
used. If a clock timer is used, this needs to checked each
day to ensure that the time is correct. If a softener goes
into backwash during a dialysis session is very
inconvenient! The amount of sodium released during the
backwash could affect the conductivity of the RO causing
multiple alarms and interruptions to the water supply to the
dialysis machines.
Brine Tank: Check the brine tank each day to ensure that
there is a regular salt consuption day by day and enough
salt to allow an effective back wash when required. If there
is too little salt in the brine tank then the resin will not be
recharged fully, and the softener will probably fail part way
through the day.
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Bacterial contamination of the water softener

The water softener and brine can act as common source of
bacterial contamination of the pre-treatment water system. The
brine tank is not a fully closed system because of the need to
refill the tank on a regular basis. Because of this bacterial
contamination of the saturated salt solution is a real possibility.
Moreover, the saturated salt solution acts as an optimal growth
medium. When the water softener is regenerated then the
contained salt solution is drawn into the softener tank
contaminating the resin.
So what can you do to reduce this risk?
Simple precautions can go a long way in preventing
contamination of the system:
 Only use food grade pellet shaped salt.
 Keep the lid of the brine tank closed at all times.
 Clean the brine tank regularly according to the manufacturers
instructions
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What happens if the softener fails?

If the softener fails then hard water will pass through the pre-treatment system to the RO.
The RO membranes will remove the calcium and magnesium from the water, preventing
the patients from dialysing against ‘hard water’. However, over time the RO membranes
will become ‘calcified’ with calcium layers over the membrane itself. This will reduce
efficiency of the RO and the permeate flow will fall. Most RO’s can cope for about a day
on hard water before causing major problems, depending on the how hard the incoming
water actually is. However, the technician should always be contacted immediately for
advice.
There is always a theoretical risk the membranes will fail and the patients will be dialysed
with hard water which contains high concentrations of calcium and magnesium. These
ions will then pass the dialyser membrane into the patients’ blood stream resulting in
hypercalcaemia:
 hypertension
 headache
 nausea and vomiting
 fitting and possible death
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Disinfection of drinking water

Municipal water suppliers are required to ensure that

drinking water does not contain any concentration of
pathogens that would threaten public health (European
Directive 98/83/EC). However, during distribution of
water there is always the risk of contamination, and the
maintenance of disinfection within the pipes is a primary
concern. Water companies have used chlorine as the
main disinfection agent since the early 1900s.
However, it is well established that when chlorine is
injected into water with naturally occurring humic acids,
fulvic acids or other natural material, it can react with
these organic materials and form harmful DBPs such as
trihalomethane (THM) compounds (WHO 2004).
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Disinfection of drinking water

Because of this risk water companies also use

monochloramine as a disinfectant, and it can be more
effective at controlling biofilm growth in distribution
systems. The use of chloramines reduces the
formation of THMs by as much as 40-80% (WHO
2004). Although using chloramines reduces THM
levels, the formation of other by products such a
haloketones, aldehydes and chlorophenols have been
reported (Krasner et al, 1989).
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Carbon Filter

The carbon filter used to remove chlorine and chloramine

from the incoming water because of the potential risk to
the dialysis. In addition, RO membranes are not very
effective at removing chlorine and chloramine from the
dialysis water, and the membranes can be damaged by
chlorine and chloramine.
Carbon filtration will remove chlorine and chloramines by
means of a chemical process termed adsorption. As the
input water flows down through the granular activated
carbon (GAC), solutes diffuse from the water into the
pores of the carbon and become attached to the structure.
As a side benefit, a wide variety of naturally occurring and
synthetic organic compounds such as herbicides,
pesticides and industrial solvents will be adsorbed too
(AAMI, 2004; Luehmann et al, 1989).
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What is granular activated carbon?

GAC is a type of carbon that is appropriate for HD and can be

made of many different organic materials such as bituminous
coal, coconut shells, peach pits, wood, bone and lignite that
have been exposed to excessive temperatures (pyrolysis).
GAC is then acid washed to remove the ash and etch the
carbon to increase the porosity and thereby the adsorbency of
the GAC. All GAC used for dialysis should be acid washed,
especially carbon derived from bone, wood or coal as these
tend to leach metals, such as aluminum, when they are not
acid washed and exposed to water.
Regenerated carbon that is reburnt and reused by the
manufacturer, shall not be used for dialysis, it must be virgin
carbon. Carbon is used in many, more toxic applications than
dialysis and when reprocessed, can retain impurities that may
be toxic to patients (AAMI, 2004, EDTA 2002).
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Adsorption
Adsorption is the adhesion of molecules of gas, liquid, or dissolved solids to a
surface.This process creates a film of the adsorbate (the molecules or atoms being
accumulated) on the surface of the adsorbent. It differs from absorption, in which a fluid
permeates or is dissolved by a liquid or solid.
Similar to surface tension, adsorption is a consequence of surface energy. In a bulk
material, all the bonding requirements (be they ionic, covalent, or metallic) of the
constituent atoms of the material are filled by other atoms in the material. However, atoms
on the surface of the adsorbent are not wholly surrounded by other adsorbent atoms and
therefore can attract adsorbates. The exact nature of the bonding depends on the details of
the species involved, but the adsorption process is generally classified as physisorption
(characteristic of weak van der Waals forces) or chemisorption (characteristic of covalent
bonding).
Adsorption is present in many natural physical, biological, and chemical systems, and is
widely used in industrial applications such as activated charcoal, and water purification.
Adsorption, ion exchange, and chromatography are sorption processes in which certain
adsorbates are selectively transferred from the fluid phase to the surface of insoluble, rigid
particles suspended in a vessel or packed in a column.
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Placement of the Carbon Filter

Opinions are divided on the best placement of

the carbon filter in relation to the softener.
Softeners provide an ideal bacterial growth
medium, so placing the carbon bed after the
softener allows chlorine in the incoming water
to reduce bacterial growth. However, the ion-
exchange resin used in the softener can be
degraded by an average of 5-15% per year.
This loss causes a reduction in the functional
resin capacity, requiring the resin to be replaced
sooner than if the softener was placed after the
carbon filter. In most installations the carbon
filter is installed after the softener as it is
thought that the costs will be higher if the
softener becomes contaminated with bacterial
growth.
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Empty bed contact time

The size of the carbon filter is dependent upon the maximum water flow required to meet
the needs of the clinical room. Therefore the carbon filters, and by definition the volume of
carbon used, have to be able to ensure that water is in contact with the carbon for a
minimum period of 10 minutes, but still provide adequate water to the RO and
subsequently the dialysis machines. This is known as the “Empty Bed Contact Time”. This
can be calculated using the following formula.
EBCT= V/Q
Where V = volume of carbon in litres and Q = water flow rate in litres per minute.

Example Calculation
Dialysis machines in use at peak times 20
Peak water consumption during disinfection (Q) 1200 l/hr = 20 l/min
Minimum EBCT 12 minutes
Volume of carbon needed [V=(QxEBCT)] 240 litres
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Chlorine breakthrough

Chlorine and chloramines react with the body fluids

and liberates hypochloric acid, hypochlorite and free
oxygen radicals. They are capable of modifying
cellular proteins and lips and causing protein
denaturation and haemolysis. In dialysis patients the
most obvious clinical manifestation of chlorine
breakthrough is haemolytic anaemia. The
haemoglobin molecule is altered to form
methaemoglobin, which is unable to transport oxygen
or carbon diaoxide.
When the chloramine concentration is low (0.1-0.2
ppm) the half-life of the red blood cells is reduced,
requiring larger doses of EPO to maintain the patients
Hb (Perez-Garcia & Rodriguez-Benitez, 1999). Higher
concentrations of chlorine and chloramine will have
increasing effects on the patient – see the case study
in next page.
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Case Study

A serious incident that required the

temporary closure of a satellite dialysis
unit occured in 2009. A two to three fold
increase in chlorine levels following a
switch in water supply overwhelmed the
charcoal filters at a Satellite Renal
Dialysis Unit. This resulted in
haemolysis and anaemia in almost all
the 28 patients treated in the unit.
Although the high chlorine levels were
identified through the regular monitoring
of chlorine by staff in the unit but, in the
absence of a formal policy and
adequate, staff continued to dialyse
patients and did not contact technical
services or the medical staff.
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Case Study

A patient was admitted with a HB of 5.8 mg/dl and subsequent analysis of blood tests on
the patients showed an almost universal (91%) drop in their Hb levels compared to
previous tests in December 2008, with an average fall in haemoglobin of 2mg/dl between
November 2008 and January 2009.

A proportion of patients also complained of increased symptoms of tiredness or

breathlessness in December 2008 or January 2009. These symptoms could reasonably
be attributed to the haemolysis that patients experienced.
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What do I need to monitor?

Chlorine and Chloramine Levels: The water
post-carbon filter and before the RO needs to be
checked for chlorine and chloramine breakthrough
before each patient shift. The safe monitoring
levels are currently set at <0.5ppm for free chlorine
and <0.1ppm for chloramine. If the first test
provides a result above these levels, then a fresh
water sample needs to be taken and tested. If the
levels remain elevated then a decision has to be
made if it is safe to continue with dialysis, and
technical support is required to identify the
problem.
Back-wash Timers: The filters are back washed
on a regular basis to recharge the media and flush
out the sediment collected in the filter. The clock
timer needs to checked each day to ensure that
the time is correct. If a carbon filter goes into
backwash during a dialysis session is very
inconvenient!
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Introduction Pre-treatment RO Systems

What else should I monitor?

Pre-post pressure gauge: The pressures across
these two gauges should be checked and
documented daily. There should be a pressure
gauge before and after the water softener. Any drop
in the pressure difference between the two could be
an indication that the carbon in the filter tank is
either blocked with sediment, or over time the
carbon has become compacted. Either way, the
effectiveness of the filter will be reduced and action
needs to be taken. First check that the filter has
been backwashing correctly. If this is OK then the
carbon will probably need changing.
Carbon bed exchange: Document when the carbon
bed has been changed or re-bedded. This should
also include reference to the type of carbon used,
and the length of time the new carbon was rinsed. If
it not rinsed fully before use, residue form the new
carbon can damage the RO membranes.
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Reverse Osmosis (RO) Treatment

The RO is the core of the water treatment system

and remove the majority of metals and chemicals
present in the incoming water ensuring that the
dialysis water is safe before the patient is exposed
to it during dialysis.
The RO system is made up from the following
components (we shall look at each briefly)
 Cartridge pre-filter
 RO pump
 RO membranes
 Gauges and meters, e.g. temperature, pressure,
conductivity, water flow
 Main board and display
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RO Cartridge Pre-filter

Most RO systems have a cartridge filter placed before the

RO to protect it from any sediment from the incoming water
e.g. carbon from the carbon bed, or sediment from other
sources. The pore size is usually 5 micron, but can be
smaller.
This filter is usually replaced monthly, but may require more
frequent changes if the pressure drop results in a reduced
water flow to the RO. The pressure differences across this
filter should be checked daily.
It is important that the filter is changed under clean
conditions to avoid possible bacterial contamination of the
RO membranes, so gloves should be worn and the filter
handled as little as possible.
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Reverse Osmosis Concept

Osmosis Balanced System Reverse Osmosis

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RO Membranes

The RO membranes are the heart of the

system, and are responsible for the final
purification of the incoming water (more
on this in the next page). The purified
water is called the permeate or product
water, and is used for dialysis. The
unfiltered water is called the reject or
concentrate as it is full of the
contaminants removed form the
incoming water. Some of this reject
water is passed to the drain, and some
of it mixed again with the pre-treated
water and “recycled”.
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How does reverse osmosis work?

Reverse osmosis, as the name suggests is the opposite to osmosis. In reverse osmosis
the incoming water is forced to flow in the opposite, or unnatural direction across a semi-
permeable membrane by means of high pressure. Natural osmotic flow is overcome, and
pure water passes through the membrane, leaving the dissolved solids (slats, metals
ect.) and other constituents (or waste) on the other side.

g water
Incomin
Perforated collection tube

Spacer

te Membrane
Permea

trate
Concen
Permeate collection material

Membrane

Spacer

Outer wrap
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How does reverse osmosis work?

RO membranes reject dissolved inorganic elements such as ions of metals, salts,
chemicals and organics including bacteria, endotoxin and viruses. Rejection of charged
ionic particles ranges from 95-99%.

Chlorine and chloramines will damage the RO membranes, hence the need for the
carbon filter before the RO. Scales deposits such as calcium, magnesium, organics and
dirt will accumulate on and eventually block the RO membrane. therefore regular
cleaning is required.
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Filter Effectiveness
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Importance of a fully functioning

RO system

The RO system is the last defence in

protecting the patient from contaminants in
the dialysis water. The RO is responsible for
removing metals and salts that could cause
suffering for your patients, and even death.
The only substances that the RO cannot
remove are chlorine and chloramines, hence
the need for the carbon filter. It is therefore
imperative that this is working correctly. The
next two pages outline some of the
conditions that patients can suffer if the RO
is functioning poorly.
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Patient Conditions and Symptoms

Contaminant Symptom
Aluminium Encephalopathy, bone disease, anaemia, myocardial infarction
Calcium, Magnesium Hard water syndrome, hypertension, headache, nausea and vomiting
Fluoride Bone disease
Nitrate Methemoglobinaemia and haemolysis, hypotension, nausea and vomiting
Copper Acute haemolytic anaemia, fever, hepatic damage, nausea and vomiting
Zinc Anaemia
Sodium Hypertension
Potassium Cardiac arrhythmias
Cadmium, Bone disease
Manganese
Chloramines Anaemia, haemolysis
Sulfates Metabolic acidosis, nausea and vomiting
Seleneium Neuropathy, anaemia
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What do I need to monitor?

Conductivity: Record this daily to identify any
trends in the performance of the RO. This should be <
50 µs/cm. If it is above this limit then the RO filters
may need replacing. If this is increasing over time
seek advise from the local technical support
team. The conductivity level should be
<10µS/cm. If the RO conductivity is greater >10
µS/cm but < 50 µS/cm a detailed chemical
analysis should prove permeate quality complies
with limits of substances.
RO Filters – 5micron: Check the difference in
pressure for the RO filters. The reading is taken
off the RO panel, or pressure gauges, and the
difference should be less than 0.5 bar/10 psi.
RO Rejection Rate: This should be >95%. If it is
less, it might indicate that the RO Plant needs
cleaning.
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Rejection Rate

The rejection rate is the percentage of total dissolved solids which are rejected (filtered
out) by the RO membrane, and can be calculated if you know the input and output
conductivity of the RO. The conductivity is the level of total dissolved solids in the water in
terms of parts per million (ppm) or MicroSiemens (µS/cm). So for example, if the input
conductivity is 100 and the output conductivity is 5, the rejection rate is 95%.
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Recovery Rate

The recovery rate is the amount of permeate produced in relation to the amount of pre-
treated water fed into the RO system.

For example if 1000l water enter the RO system and 700l leave the system as permeate
the recovery rate is 70%. Recovery rates for modern RO systems for dialysis range from
70-85% depending upon the quality of the incoming water and temperature. RO
membranes reduce their efficiency if the incoming water is very cold.
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Endotoxin monitoring
It is recommended to take a sample every 3 months from the end of
the water loop to test for endotoxin concentrations. The current
limits are < 0.25 eu/ml to indicate pure water and < 0.03 eu/ml for
ultrapure water. If the minimum amount of < 0.25 eu/ml is exceed
then high flux dialysis must be discontinued and remedial actions
taken to reduce the count.
Endotoxins are part of the outer membrane of the cell wall of Gram-
negative bacteria. Endotoxin is invariably associated with Gram-
negative bacteria whether the organisms are pathogenic or not,
such as Escherichia coli, Salmonella, Shigella, Pseudomonas,
Neisseria, Haemophilus influenzae, Bordetella pertussis and Vibrio
cholerae.
Endotoxins are small enough to pass across the membranes of high
flux dialysers into the patients blood stream. This can set of an
immune reaction, sever if the endotoxin levels are high. But even in
small concentrations their effect can result in a low grade immune
reaction in the pateint, resulting in increased beto2-microglobumin
production and other long tem complications in dialysis
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Bacterial monitoring of the water loop

Bacteriological testing of the product water

should be conducted monthly form the end of
the water loop. The results should not exceed
100cfu/ml, with an action level of 50cfu/ml.
Above these levels remedial action must be
taken immediately to reduce the contamination
by disinfection of the Ro and loop. The system
should then be retested to assess the
effectiveness of the disinfection.
Regular maintenance of the RO and water loop
will reduce the risk of bacterial contamination
and build-up of biofilm. Once biofilm has become
established in the water loop it can be very
difficult to remove, and will result in continuously
raised bacterial and endotoxin levels.
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Effects of bacterial and endotoxin contamination

of the dialysis water

Contaminant Symptom
Bacteria Nausea, vomiting, fever, headache, chills, myalgia,
hypotension, septicaemia
Endotoxins Nausea, vomiting, fever, headache, chills, myalgia,
hypotension, shock, catabolism, β2-microglobulin amyloidosis,
osteopenia, EPO resistance
Esotoxins and other Nausea, vomiting, fever, hypotension, hepatitis, catabolism,
derived microbial β2-microglobulin amyloidosis, osteopenia, EPO resistance
products
Training Center

Introduction Pre-treatment RO Systems

Conclusion

Regular daily and monthly checks of the

water treatment plant are very important
for the safety of the patient receiving
dialysis in the BBraun Dialysis Centre. It is
too easy to cause patient suffering or even
death through he provision of poor water
quality. It is therefore important that these
checks are made, and that staff are aware
of the limits and action that need to be
taken.
Although it has not been possible to cover
all aspects of water treatment in great
detail, it is hoped that you will use this as a
platform to explore the subject further.
Training Center

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