STATEWIDE RENAL NETWORKHaemodialysis Water Sampling Handbook Version 2 Statewide Renal Network Haemodialysis Water Sampling Handbook ©The State of Queensland (Queensland Health) 2009. The Queensland Government supports and encourages the dissemination and exchange of information. However, copyright protects this material. The State of Queensland has no objection to this material being reproduced, made available online or electronically, provided it is for your personal, non-commercial use or use within your organisation, this material remains unaltered and the State of Queensland (Queensland Health) is recognised as the owner. Inquiries for commercial use or to adapt this material, should be addressed by email to:
[email protected] or by mail to: The IP Officer, Purchasing and Logistics Unit, Queensland Health, GPO Box 48, BRISBANE 4001. 2 Version 2 Produced: September 2009 Statewide Renal Network – Haemodialysis Water Sampling Handbook, dated September 2009. Scheduled review date September 2011. Version 1 Produced: November 2007 Southern Area Health Service – Haemodialysis Water Sampling Handbook, November 2009. Versions 1 & 2 published by Production Services Health Information Services Darling Downs – West Moreton Health Service District Situated Toowoomba Statewide Renal Network Haemodialysis Water Sampling Handbook Handbook This Handbook has been created as part of the Statewide Renal Network Water Standardisation for Haemodialysis Units Project. It is for use for Haemodialysis Unit staff to assist them in Haemodialysis Water Sampling Procedures. This handbook updated September 2009 with funding from the Statewide Renal Network. For rural and remote areas please see the Remote Area Water Sampling Guidelines booklet. Competencies Two competencies are associated with this Handbook – Water Sampling and Water Result Analysis. These can be accessed within the Haemodialysis Unit. 3 Statewide Renal Network Handbook Author • Robyn Bailey, Project Officer, Statewide Renal Network Acknowledgements • Queensland Nephrology Nurses Network, Southern Area Health Service – Renal Network • Ms Judy March, Project Sponsor and Executive Director of Nursing and Midwifery Services at Darling Downs – West Moreton Health Service District (Toowoomba & Darling Downs) • Mr David Lawrie, Renal Technician Darling Downs – West Moreton Health Service District (Toowoomba & Darling Downs) • Mr Lionel Thring, Renal Technician, Princess Alexandra Hospital • Ms Janine Jeffries, NUM Home Haemodialysis, Princess Alexandra Hospital • A/Professor James Petrie, Nephrologist, Princess Alexandra Hospital • Mr Henry Olszowy, Supervisor – Inorganic Chemistry, QHFSS • Mr Bruce Gray, Supervising Scientist Public Health Microbiology, QHFSS • Ms Teresa Galos, Manager Central Sample Receival QHFF • Ms Mary Hodge, Supervisor Organic Chemistry, QHFSS • Statewide Renal Network staff • Production Services, Health Information Services, Darling Downs – West Moreton Health Service District (Toowoomba & Darling Downs) 4 Haemodialysis Water Sampling Handbook Reviewers • Ms Jenny Best, Pre-dialysis Educator, Princess Alexandra Hospital • Ms Jennifer Boys, Renal Educator, Royal Brisbane Hospital • Ms Kylie Dunbar-Reid, Renal Nurse Educator, Cairns Base Hospital • A/Professor Carmel Hawley, Nephrologist, Princess Alexandra Hospital • Ms Angela Henson, Renal Nurse Educator, Princess Alexandra Hospital • Mr Roger Lawrence, Manager Statewide Dialysis Services Biomedical Technological Services, Queensland Health • Ms Paula McLeister, Renal Nurse Educator, Gold Coast Hospital • Ms Josie Skewes, Renal Nurse Educator, Darling Downs – West Moreton Health Service District (Toowoomba & Darling Downs) Final Reviewers • A/Professor James Petrie • A/Professor Carmel Hawley • Janine Jeffries • Lionel Thring Update July 2009 • Keri-Lu Equinox, Project Officer, Statewide Renal Clinical Network Statewide Renal Network Haemodialysis Water Sampling Handbook History of Water Treatment in Dialysis by A/Professor James Petrie If the water used for dialysis is not correctly treated, serious problems can result. In 1969 an outbreak of copper poisoning was reported. The dialysis water was deionised. Exhaustion of part of the deionization bed led to the water becoming strongly acidic. This leeched copper out of the piping used in the dialysis circuit, leading to haemolytic anaemia and the death of at least one patient1. Water authorities routinely add chlorine and ammonia to drinking water to minimalise bacterial growth. The chloramines formed can be removed by carbon filtration, but as chlorine and chloramines are dissolved gases they cannot be removed by reverse osmosis. Chloramines, like copper can cause haemolytic anaemia. Kjellstrand et al demonstrated adding ascorbic acid to the dialysis concentrate neutralised the chloramines, allowing dialysis to proceed2. In the late 1970’s, two complications appeared – fracturing osteodystrophy and dialysis dementia. Both proved to be due to aluminium in the dialysis water. Aluminium is added to the water as a flocculating agent. It causes small particles to precipitate, clarifying the water3. Aluminium however is protein bound. It will dialyse into a patient, bind to transferrin, and not dialyse out again. It can be highly toxic to bone (causing osteodystrophy) and to brain (causing dementia). It is effectively removed by reverse osmosis. Perhaps the most dramatic example of aluminium toxicity occurred in Eindhoven in Holland in 1976. A dialysis unit in that town did not use reverse osmosis. The dialysis fluid was prepared insitu and warmed to blood heat with an electric heater. The anode of this heater was made of aluminium, and over time it dissolved almost completely, releasing the aluminium into the dialysate. A major outbreak of dialysis dementia ensued4. The most recent major toxic event due to dialysis water impurities occurred in Caruaru in Brazil in 1996. Two dialysis units received water from a local reservoir. This water was heavily contaminated by blue green algae or cyanobacteria. One unit treated the feed water fully, with filtration, chlorination and reverse osmosis. No problems occurred at this unit. No effective water treatment occurred at the second unit. 76% of the patients in this unit died of liver failure. This liver failure was caused by the microcystins produced by the cyanobacteria5. Water used for dialysis tends not to be sterile. Most guidelines allow for the use of water containing one or two hundred colony forming organisms per ml. This seldom produced adverse effects in the short term. Water containing even small numbers of bacteria exposes patients to endotoxins and leads to a chronic inflammatory state. The use of sterile endotoxin free water is associated in many studies with improved patient outcomes. 5 .W.Dial. and Linderman. G. Trans. 1976. 4 5 Jochimsen. Carmichael.D... Easton. Artif. Aluminium intoxication – the cause of dialysis dementia? Proc. Lethal copper intoxication in hemodialysis. J. J. Nephron 1974 13 427.M. Y.G.H. Am. J. Jruis. W.. Med 1998.. A. Mishel.. J.A.M.W. C. 338 873-878. Psiminos. Syndrome of dyspraxia and multiple seizures associated with chronic hemodialysis. N..Eur. J. 3 Alfrey. Liver failure and death after exposure to microcystins at a hemodialysis centre in Brazil. B. Intern. Cardo. Yawawata. R.Statewide Renal Network REFERENCES 1 Matter.Transplant Assoc.M.. Eng. J.. Am. H. Trans. 15 309. Organs 1969.M. Organs 1972: 18 257. Burks. Intern. et al. 2 Kjellstrand.C. Haemolysis in dialysed patients caused by chloramines. Pederson. Artif.J. E. D. 13 355.. et al. 6 Haemodialysis Water Sampling Handbook Flendrig. et al. ...................................................... 45 Machine Testing ............................................. 12 Sampling Frequency ............................................... 47 References/Information Sources/Suggested Readings .............................................................................................................. 42 Standard Water Testing ................................................................................. 15 Endotoxin Testing ....... 40 Heavy Metal Testing ....................................................................... 8 Haemodialysis Water Guidelines ............................................................................................................................................................................................................................ 10 Water Testing Schedule ........................................................................................ 37 Mercury Testing ........................................................................... 13 In Home/Community Haemodialysis Frequency ......Statewide Renal Network Haemodialysis Water Sampling Handbook Contents Water Treatment Plant ... 19 Pesticide Testing ................................................... 13 Haemodialysis Unit Frequency .......................................... 26 Trihalomethane Testing ................................ 33 Calcium and Magnesium Testing ............... 14 Bacterial Testing .............................. 8 Initial Testing .................................. 23 Chlorine and Chloramine Testing ............................................................................................................................... 48 7 ... Initial testing Initial water testing of the source water should include the following tests: • Bacteria and Endotoxin • Pesticide • Mercury • Lead • Trihalomethanes • Standard Water • Calcium & Magnesium • Anions & Cations / Heavy Metals / pH & Conductivity 8 Haemodialysis Water Sampling Handbook On return of the water tests (which can take up to six weeks in the case of pesticides depending on the testing facility used) the water treatment plant can be designed. It is recommended that the distribution loop is a continuous loop. . however second daily and three times per week can achieve guidelines results. If guidelines are not being met then an increase in the disinfection routine is required7. The routine most commonly used is daily. has no dead ends. Council supply) it will already meet drinking water guidelines for Australia as per the NHMRC Australian Drinking Water Guidelines1. It is necessary to plan and design a pre-treatment plant that will remove or reduce the contaminants in the water to an acceptable level for haemodialysis. It is necessary to know the quality of the water that will be supplied to the unit to identify the type of treatment plant that will be required. Disinfection of the loop is required to decrease the risk of bacterial or endotoxin contamination affecting the haemodialysis patients. Refer to Table 2 -Drinking Water Guidelines and Haemodialysis Water Guidelines Comparison . decreases stagnant areas by limiting the use of branches5. It is suggested that the routine of heat disinfection to be utilised is at the time period that ensures achievement of adopted guideline.g.Statewide Renal Network Water treatment Plant The first step of installation of a water treatment plant for haemodialysis commences with the sampling of water from the site where it is expected the water treatment plant will go. While it is important to ensure bacterial and endotoxin contamination does not occur it is also necessary to ensure water usage is kept to a minimum. Heat disinfection is a relatively inexpensive and practical method of disinfecting the water plant and distribution loop although it will not remove biofilm1.American Association of Medical Instrumentation2 (AAMI) European Guidelines (EP)3 and 2006 Draft International Standards Organisation (ISO) Fluids for Haemodialysis and Related Therapies Guidelines4. When planning the haemodialysis water treatment plant and distribution loop there are many specifications to take into consideration.6 and the loop conserves water where able5. If water is supplied from a municipal water supply (e. All aspects need to be taken into consideration including possible seasonal changes or contamination due to human intervention. brass and aluminium5. Bleach Peracetic Hot Water (Sodium Hypochlorite) Acid Polyvinylchloride (PVC) Cross-linked Polyethylene(PEX) Stainless Steel Polypropylene Polyethylene Table 1. Common disinfectants and piping materials compatibility.Statewide Renal Network Haemodialysis Water Sampling Handbook Refer to the manufacturers recommendations regarding disinfection techniques although generally the water temperature used should be greater than 85°C8 and disinfection should run for a period of thirty minutes5 at the desired temperature. It is necessary to ensure that trained personnel undertake repairs or changes to the distribution loop or water treatment plant.1 International Standards Organisation Draft Guidelines 2006. Flow or scrubbing velocities of the distribution loop also needs to meet criteria to ensure the risk of biofilm adherence inside the loop piping is decreased. Permeate should travel through the distribution loop at approximately one metre per 2. PEX is able to withstand high temperatures and has a smooth inner surface9 and PVC is used throughout the United States due to cost limiting factors of other materials5. lead.9 are two of the common and preferred materials for haemodialysis water treatment with stainless steel and titanium blend used in distribution loop systems. zinc. These toxic materials include copper. Polyvinyl chloride (PVC)5 and Polyethylene (PEX)5. Adapted from Table B. 9 . PVC is not as tolerant to high temperatures as some of the other piping such as PEX. Soldering can also adversely affect the haemodialysis water treatment plant by dropping flux into the inner aspect of the piping causing contamination of the water supply. Fluids for Haemodialysis and related therapies.3 seconds. It is important to ensure that no piping is used that is made from toxic Material materials in haemodialysis water plants or distribution loops due to the ability of the purified water to affect these materials and thus contaminate the water. improved response to erythropoetic agents and reduce catabolic nutritional state’ 11. ‘Ultrapure water may reduce longterm risk of accelerated vascular damage. Although the CARI group has made no guidelines it has made suggestions for clinical care. While the AAMI and EP guidelines are not Australian they have been adopted by most Australian haemodialysis units. The CARI group have recommended: 1. Note some of the limitations to accurate chemical and microbial testing. 10 Haemodialysis Water Sampling Handbook 2. . ‘Infusion fluid for haemodiafiltration or haemofiltration must be produced with strict observance of the manufacturer’s validated process. ‘European guidelines should be the basis for optimal dialysate production’ 11. ‘Ensure regular testing and auditing of water treatment system and quality of water produced for dialysis. Final filtration must ensure 7 log reduction in bacterial count of ultrapure fluid’ 11. Be familiar with local practice in municipal water treatment and testing procedures’ 11. 3. In Australia the Caring for Australians with Renal Impairment (CARI) guidelines have not made recommendations as AAMI and EP have. 4.Statewide Renal Network Haemodialysis Water Guidelines Water Guidelines have been designed to ensure quality haemodialysis water is delivered to dialysis machines no matter where patients dialyse. The reason for this is that Level I or II evidence for water quality haemodialysis standards is lacking. 05 2.0002 2.014 0.005 0.008 0.0 0.0 0.10 0.7 0.002 0.50 0.Statewide Renal Network Haemodialysis Water Sampling Handbook CONTAMINANT AAMI2 Maximum limits (mg/L) European3 Maximum limits (mg/L) *Australian Drinking Water Guidelines1 mg/L Aluminium Ammonium Antimony Arsenic Barium Beryllium Cadmium Calcium Chloramines Chloride Free Chlorine Total Chlorine Chromium Copper Fluoride Heavy Metals Lead Magnesium Mercury Nitrate pH Potassium Selenium Silver Sodium Sulphate Thallium Trihalomethanes Zinc 0.0 0.0004 0.01 0.00 0.1 0.1 180 500 0.00 0.5 0.002 200 50 0.005 0.001 2.09 0.006 0.001 50 6.20 0.1 0.0010 2.00 ` 8 0.007 0.20 0.10 1.0 1. 11 .00 0.005 4.09 0.10 0.25 3 Table 2.002 < 0.005 2.0 0.014 0.2 0.005 50 50 0.005 70 100.5 0.0004 0.5-8.10 5.00 2.20 0.10 0.01 0.0010 2 0.006 0.1 0.01 0. Guideline Comparison.003 0. limits limits Japan Society for Dialysis Therapy Max. 12 After the initial validation of the water plant has occurred ongoing routine testing should occur at least monthly5. Dialysate 3.2.24. .Statewide Renal Network CONTAMINANT Haemodialysis Water Sampling Handbook AAMI European Singapore12 Maximum Pharmacopoeia Maximum limits Max.27. Bacterial and Endotoxin testing continues monthly both post Reverse Osmosis water and dialysate.25EU/ml 5 EU/ml 0. Water Testing Schedule Once a water treatment plant is commissioned it is necessary to routinely test the water prior to commencement of any haemodialysis occurring and in an ongoing routine.28 for a three month period and then move to every three months. Ongoing water sampling is then required to reduce the risk to haemodialysis patients a sampling frequency regime has been adopted. For at least the first three months when commissioning a new water plant bacterial and endotoxin testing should occur weekly from multiple points throughout the system: 1.12. limits EDTNA/ERCA Maximum limits ISO 2006 Draft4 Bacteria 200 cfu/ml 100 cfu/ml 200 cfu/ml 100cfu/ml 100 cfu/ml 100 cfu/ml Endotoxins 2EU/ml 0.4. Post reverse osmosis unit 2.25 EU/ml Fungi and Yeast 10 cfu/ml Table 3. It should be remembered that water testing results will not be available immediately (can take up to 14 days for return of results) and this time delay should be considered before booking patients for haemodialysis when commissioning a haemodialysis water plant.25 EU/ml 0. End of distribution loop If bacterial and endotoxin levels exceed the recommended level then a thorough chemical disinfection of the water plant and distribution loop is necessary.25 EU/ml 0. Bacterial and Endotoxin Comparison Table for Haemodialysis product water (permate)1. It may also be necessary to increase the points where water tests are taken to pin point the area of possible contamination.3. Changes will occur over time. Water hardness can be tested using: • Yes/No tables • Testing strips When using hardness or chlorine testing methods refer to manufacturers information sheets provided for testing method. A Chlorine testing should also occur before each dialysis or dialysis shift. Haemodialysis Unit Sampling Timetable.Statewide Renal Network Haemodialysis Water Sampling Handbook Sampling Frequency The Sampling Frequency section has been compiled using current knowledge and acceptability and incorporates the needs of rural and metropolitan centres and those that have a blending of both.g. 13 . Chlorine testing can occur using: • DPD 4 tablets • Combination DPD 1 and 3 tablets • Chlorometer or Photometer B Water Hardness testing should occur before each dialysis or dialysis shift. Validation of chlorine and hardness tests needs to occur routinely using an independent testing centre. Frequency may need to be changed due to seasonal and environmental variations of the specific area e. cotton industry increases aerial spraying from September to November requiring increased sampling for pesticides during this period. HAEMODIALYSIS UNIT FREQUENCY Legend for Table 4 Haemodialysis Unit Frequency for water sampling. Collection Point/Sample Bacteria Counts Endotoxins Pesticides* Chlorine & Chloramine THM’s Calcium & Magnesium Auslab Codes HPC - DWPEST DCLNH THM DCAMG Feedwater Post Carbon Post dialysis machine Collection Frequency Bacterial Counts Endotoxins Pesticides* DHMSA (feed) HGFW (feed) DPROW (post RO) HGRO (post RO) Standard Water Analysis DSWA pH/Cond THM’s Calcium & Magnesium Heavy Metals Mercury Standard Water Analysis B 3 Monthly (4 x year) 6 Monthly (2 x year) Chlorine & Chloramine A Predialysis Monthly Mercury Post Softener Post RO Heavy Metals Annually (1 x year) Rural Metro Table 4. Harvesting can also cause materials to become air-borne increasing pesticide contamination of the surface water. C Chlorine testing should also occur before each dialysis or dialysis shift. 14 Mercury Post Softener Post RO Heavy Metals F .Statewide Renal Network Haemodialysis Water Sampling Handbook IN HOME/COMMUNITY HAEMODIALYSIS FREQUENCY Legend for Table 5 In Home/Community Haemodialysis Unit Frequency for water sampling. Validation of chlorine and hardness tests needs to occur routinely using an independent testing centre. E Rural areas F Metropolitan Areas G Where resources allow H Minimum Collection Point/Sample Bacteria Counts Endotoxins Pesticides* Chlorine & Chloramine THM’s Calcium & Magnesium Auslab Codes HPC - DWPEST DCLNH THM DCAMG Feedwater Post Carbon Post dialysis machine Collection Frequency Bacterial Counts Endotoxins Pesticides* Chlorine & Chloramine THM’s C Predialysis DHMSA (feed) HGFW (feed) DPROW (post RO) HGRO (post RO) Standard Water Analysis DSWA pH/Cond G G 3 Monthly (4 x year) H H 1st 3 mths 6 Monthly (2 x year) E Annually (1 x year) F Calcium & Magnesium Heavy Metals Mercury Standard Water Analysis D Monthly 1st 3 mths E E F Table 5. Chlorine testing can occur using: • DPD 4 tablets • Combination DPD 1 and 3 tablets • Chlorometer or Photometer D Water Hardness testing should occur before each dialysis or dialysis shift. Water hardness can be tested using: • Yes/No tables • Testing strips When using hardness or chlorine testing methods refer to manufacturers information sheets provided for testing method used. In home/community haemodialysis sampling timetable. 16. Haemodialysis Water Sampling Handbook Samples to be collected and tested at points expected to have the highest bacterial load1 or lowest water flow. Guidelines for Bacterial counts are designed to ensure quality haemodialysis water is delivered to dialysis machines. Water sampling is used as a validation tool for the disinfection process. End of loop 8. These testing points should be: 1. Microbiological testing should occur at least once per month testing both reverse osmosis water and dialysate for in-centre units and monthly to three monthly for home/community haemodialysis (dependant upon resources). Post carbon (Water) 3. dialysate bottles and inside dialysate machines15. This is significant in the planning and designing of haemodialysis units and associated plumbing as biofilm can adhere to surfaces such as piping. Post RO 5. Bacterial testing Bacteria occur naturally in water sources but can also be introduced or occur due to reduced water flow.Statewide Renal Network SAMPLING Sampling methodology may change over time as new equipment and procedures change please refer to Queensland Health Scientific Services (or independent testing facility) to ensure containers listed are current. 15 . Feed supply water tap (Water) 2. Maximum microbial contamination of Haemodialysis Permeate should be <100 cfu/ml and maximum microbial contamination of dialysate should be <25 cfu/ml with a suggested action level of 50 cfu/ml5. Dialysate Once testing has occurred and results are available they will need to be reported to the appropriate personnel. If the results are greater than the guidelines then disinfection and increased monitoring may be required. Feedwater 2. Random outlets on loop 7. hoses. To ensure the correct machine disinfection process occurs water sampling is required. Post machine 9. Post pre-treatment (softener and carbons) 3. Post UV irradiation (if applicable) 4. Post RO (Permeate) 4. Start of distribution loop 6. Post dialysis machine (Dialysate) If routine sampling points identify an elevated result then increased testing is required using the following testing points: 1. Note: Bacterial samples should be taken after testing for heavy metals and pesticides as the ethanol spray (used for bacterial and endotoxin testing) can adversely effect the other water sample results. Should a tap be used for sample collection – the tap will require disinfection prior to the collection of the water sample. Once collection occurs ensure the label on the container is completed with as much information as appropriate. At least two litres of water should be run through tap at a high flow before taking mid stream water samples from the disinfected tap. . where possible.Statewide Renal Network Sampling The bacterial samples should be collected in a 120ml container with sodium thiosulphate already added. The tap. The test carried out is called the heterotrophic plate count (HPC). 16 Haemodialysis Water Sampling Handbook Sampling procedure Step 1. Ensure the correct testing point is chosen with the correct preparation of port or collecting point. Samples for bacterial counts are inoculated onto agar plates and incubated @ 360C for 40 to 48 hours before being counted and then reported in colony forming units. should be soaked in a 70-90% ethanol solution. These containers can be supplied by the testing centre. Sample: UR number generated by unit and inputted by pathology department. where it is collected from. Label example: Should the dialysate connector (Hansen connectors) be used for sampling – the connectors will require disinfection using 70-90% ethanol solution in a spray container. Date: Date sample collected in dd. Wait a minimum of two to three minutes before taking the required sample. The dialysate should be run through the connectors by initiating dialysate flow.yy format Number: Batch number of samples sent. Source: The source of the sample i. Ensure the label on the container is completed with as much information as is appropriate.mm.Statewide Renal Network Should a port be used – the port will require disinfection using 70-90% ethanol solution in a spray container. Time: Time sample taken using 24 hour clock Example: 2100hrs (9pm). This waiting period allows the ethanol solution to evaporate otherwise the ethanol will falsely affect the test results.e.07 Number: TWH 126 Time: 0630hrs 17 .05. Allow at least 200mls to flow through connectors prior to taking a mid stream sample. BACTERIOLOGICAL WATER SAMPLES Sender: Toowoomba Renal Unit Source: Toowoomba Town Supply Sample: RENTW… Date: 10. Haemodialysis Water Sampling Handbook Step 2. Sender: This is the unit sending the sample. No : (Insert Batch number) G.C. 18 .No : (Bottle ID Number) RN Smith RN Smith 10/05/07 0630 hrs Inserting information such as collector name and phone number can be helpful to the testing centre as they can feedback any problems with testing the sample or if further information is required prior to testing the sample provided. This information can help reduce the number of samples discarded and not tested.B.Statewide Renal Network Haemodialysis Water Sampling Handbook Step 3.L. Form example: Toowoomba Renal Unit (07) 4616 6167 RN Smith RN Smith 10/05/07 6167 P.ID. Ensure the form is completed with as much information as is appropriate. aeromonas.Statewide Renal Network Step 4. Post dialysis machine Note: Endotoxin testing is not performed by CaSS. Endotoxins can be Haemodialysis Water Sampling Handbook present in source water or can occur during the bacterial breakdown process that occurs post disinfection or post ultraviolet radiation. To validate correct machine disinfection processes occur water sampling is required.25EU/ml for permeate and < 0. An agreement for endotoxin testing needs to occur between the individual unit and the testing facility. Bacterial results are reported as Heterotrophic Colony Count in Colony Forming Units per mL at 360C.03 for dialysate3. Endotoxin testing should occur at least once per month testing both reverse osmosis water and dialysate and monthly to three monthly for home/ community haemodialysis (dependant upon resources).e. Do not freeze samples. achromobacter. Bacterial samples need to reach the testing point within 12 hours (as per the International Standard) with the sample being kept between 2 and 80C during transportation (i. Report Results will be reported into Auslab by the testing facility or communicated to the unit by the process which has been previously determined. flavobacterium. Results should be within adopted guidelines < 0. Refer to your own units disinfection processes. Post RO 2. 19 . ensuring it is stored and transported under the correct conditions.0 shows possible actions of Bacterial or Endotoxin tests that are above adopted guidelines. Endotoxin testing Endotoxin is the toxic byproduct of gram negative bacteria including pseudomonas. with ice bricks). Samples to be collected and tested at points expected to have the highest bacterial load1 or lowest water flow. serratia. Action required after result received will depend on if the result is within or outside the Guideline. enterobacter. Ensure the sample is forwarded to the testing centre within the correct time period. Guidelines for endotoxin counts are designed to ensure quality haemodialysis water is delivered to dialysis machines. moraxella and alcaligenes 15. Flowchart 1.16 which have adapted to survive in water15. Routine testing points should be: 1. Random outlets on loop 7. Dialysate Contamination point identified Machine identified Outside machine identified Disinfect machine using different disinfection technique Change disinfection loop or reverse osmosis membrane using different or alternate method of disinfection Retest Retest positive Retest positive? Retest positive? Yes No Check and change as appropriate: 1.positive result received Positive Endotoxin/Bacterial Test noted Identify where possible contamination is by increasing sampling points. Hoses 2.0 Problem Solving Flow Chart for Positive Bacterial/Endotoxin Test Routine samples taken . Ultrafilter 3. Work from pre-treatment to machine or machine to end of loop depending on where contamination has been highest. Start of distribution loop 6. End of loop 8. Post reverse osmosis 5. Feedwater (bacterial only) 2. Post UV irradiation (if applicable) 4. Dialysate delivery lines Change disinfection routine for machine utilising varied or alternate method disinfection techniques 20 Yes No Review and alter (as appropriate) chemical disinfection technique and dwell times Change disinfection routine for loop or reverse osmosis membrane utilising varied or alternate method disinfection techniques . Increased sampling points include: 1. Post pre-treatment (softener and carbons) 3.Statewide Renal Network Haemodialysis Water Sampling Handbook Flowchat 1. Post machine 9. This is dependant on the first sampling point. Post RO 3. The LAL gel clot method gives a positive or negative reading to a particular endotoxin sensitivity in endotoxin units (EU) per ml.Statewide Renal Network If routine sampling points identify an elevated result then increased testing is required using the following testing points: 1. Haemodialysis Water Sampling Handbook Testing Technique The sample is tested by Limulus Amebocyte Lysate (LAL) Testing techniques. Polypropylene containers are not recommended as endotoxins are known to stick to the polypropylene material. 21 . If the same test is positive the report would state the result is > 0. The test requires three to tens mls of water post reverse osmosis unit or dialysate to be tested13. Once collection occurs ensure the label on the container is completed with as much information as appropriate. Borosilicate glass tubes are the gold standard. Dialysate If the results are greater than the guidelines then disinfection and increased monitoring may be required.a local arrangement needs to occur between the testing facility and haemodialysis unit. Random outlets on loop 5. LAL Testing includes Gel clot. Post UV irradiation (if applicable) 2. Kinetic Chromogenic or Chromogenic and endpointturbidimetric technique13. End of loop 6. Sampling The endotoxin samples should be collected in a yellow capped sterile polystyrene specimen container or a glass container depending on testing centres requirements. LAL gel clot comes with product control (PPC) to be tested with each batch to validate the methodology of testing13. Start of distribution loop 4. The single test vial is marked with its endotoxin sensitivity.25 EU/ml and the test is negative the result is reported as < 0. Post machine 7. For example if the LAL tubes endotoxin sensitivity is 0.25 EU/ml13.25 EU/ml. Refer to your testing facility for the container they require. The endotoxin samples are not available through QHSS . Specimen: The sample type Sender: This is the unit sending the sample. Step 2.07 Time 0630 hrs DOB No. Form example: Toowoomba Renal Unit (07) 4616 6167 RN Smith RN 10/05/07 Post RO EU 6167 P.05. Ensure the form is completed with as much information as is appropriate.yy format Time: Time sample taken using 24 hour clock Example: 2100hrs (9pm). Step 3.e.C. port or Hansen connectors. Date: Date sample collected in dd.Statewide Renal Network Haemodialysis Water Sampling Handbook Sampling procedure See for Step 1 Bacterial sampling for preparation of tap. Label example: SPECIMEN CONTAINER Name Post RO Specimen Permeate Sender Toowoomba Hospital Renal Unit Date 10.L.No : (Insert Batch number) G.mm.B.No : (Bottle ID Number) 22 RN Smith 10/05/07 RN 0630 hrs . Ensure the label on the container is completed with as much information as is appropriate. Number: Auslab number allocated to this source. DOB: Not required for this sample. Name: The source of the sample i. where it is collected from.ID. nematicides. No pesticides or herbicides should be present in haemodialysis permeate. Pesticide overexposure is linked to symptoms of headache.Statewide Renal Network Step 4. rodenticides and miticides1 and occur in water due to rural or metropolitan pesticide usage. 23 . Do not freeze the sample. The samples should be collected in a 1000ml (one litre) amber coloured glass solvent washed bottle (pictured). Report Results will be reported onto Auslab by the testing facility or communicated to the unit by the process which has been previously determined. Endotoxin samples need to reach the testing point within 24 hours with the sample being kept at 40C during transportation (i. Once collection occurs ensure the label on the container is completed with as much information as appropriate. Endotoxin results are reported as Endotoxin Units (EU) per ml. Pesticide Testing Pesticides include herbicides. liver irritation and death15 while exposure to herbicides have been noted as twitching. convulsions. Action required after result received will depend on if the result is within or outside the Guideline. This sample requires no additive. Refer to your own units disinfection processes. heart muscle irritation. ensuring it is stored and transported at correct conditions. Haemodialysis Water Sampling Handbook Pesticides can be removed from the haemodialysis water by activated carbon and the intact reverse osmosis membrane.0 shows possible actions of Bacterial or Endotoxin tests that are above adopted guidelines. Sampling When testing for pesticides and herbicides water testing from the following sample points and sample types are required on a 6 monthly basis: • Water from the Feed supply • Permeate from post reverse Osmosis Unit Please note season variations will dictate more frequent sampling requirements. muscle paralysis and loss of sexual function15. Flowchart 1. insecticides. on ice). dizziness.e. Ensure the sample is forwarded to the testing centre within the correct time period. S.H. Identification Number: Local Authority: Toowoomba Town Supply Sample Point: Feedwater Owner/Address: Toowoomba Hospital Renal Unit 24 R.yy format By: Samplers name Q.Statewide Renal Network Haemodialysis Water Sampling Handbook Sampling procedure Step 1.S. Smith .H. Batch Number: By: 1524 Q.S.S. Ensure the label on the container is completed with as much information as is appropriate.mm.S.H.S. Preservatives Added: Nil required for Pesticide testing Preservative Batch Numbers: Not applicable Analysis Required: Test required for this sample Date Sealed: Date sample collected in dd. Ensure the correct testing point is chosen and container is filled without overflowing.H.07 Q.S. Unique Sample Identification Number: Unit identification number set up with Auslab.WASHED Unique Sample Identification Number: RENTW Preservatives Added: Nil Preservative Batch Numbers: Not applicable Analysis Required: Pesticide screen Date Sealed: 10. Step 2.S.05.N. Identification Number: Number allocated by QHSS when sample received at their testing facility Local Authority: Council that supplies water for unit or machine Sample Point: Site where water sample from Owner/Address: Renal Unit or Home address Label example: SOLVENT . Batch Number: Number of batch Q. Report Results will be reported onto Auslab by the testing facility or communicated to the unit by the process which has been previously determined.B.No : (Bottle ID Number) RN Smith 10/05/07 RN 0630 hrs Step 4.No : (Insert Batch number) G. There should be no pesticides or herbicides present in haemodialysis product water (permeate).L. Ensure the sample is forwarded to the testing centre within the correct time period.Statewide Renal Network Haemodialysis Water Sampling Handbook Step 3. Ensure the form is completed with as much information as is appropriate. Do not freeze. (Guideline and Health values compared to reporting limits). Form example: Toowoomba Renal Unit (07) 4616 6167 RN Smith RN 10/05/07 6167 P. ensuring it is stored and transported at correct conditions. Pesticide results will be reported as μg/L.ID.C. 25 . Keep sample chilled (on ice) post collection and during transportation. Patients may exhibit symptoms of shortness of breath. While Heinz bodies are an indicator of chloramine water contamination they are not present for long in the patients’ blood stream due to the actions of the spleen. This gas when mixed with water creates strong biocidal properties1. Methemoglobin also leads to the formation of Heinz bodies 17.14.14. headache. This has been estimated at a minimum requirement of six minutes for free chlorine and ten minutes for chloramines14. Ascorbic acid added to the dialysate has also been known to absorb chloramines20. The formation of methemoglobin means that the transport of oxygen or carbon dioxide cannot occur causing cyanosis and hypoxic symptoms for the patient. This ammonia and chlorine interaction causes the formation of chloramines to occur and as such councils have a longer term bacterial measure. The importance of careful testing for chlorine and chloramines cannot be stressed enough. They will be present in the blood stream longer for patients with splenic dysfunction. haemolysis followed by 26 Haemodialysis Water Sampling Handbook anaemia.20. This usually occurs when the local Council treats the drinking water supply with chlorine in gas form. Although chlorine has these biocidal properties the effect does diminish over time. Chlorine is easily absorbed by carbon filters while a longer contact time is required to remove chloramines from the water.18. Chloramine levels don’t dissipate in the water and as such need to be effectively removed from the haemodialysis dialysis water supply1. The amount of chlorine added to the water varies on individual council requirements. While chlorine and chloramines may be good disinfectants for use in water treatment it is damaging to the red blood cells should it come into contact with a haemodialysis patients’ blood. .Statewide Renal Network Chlorine and Chloramine testing Bacterial contamination of water is a large concern for all Councils and Haemodialysis Units. Contaminants such as chlorine can compromise the integrity of the reverse osmosis membrane causing the delivery of chloramines and other contaminants to the client. This decrease in the level of chlorine in the water therefore increases the risk of bacterial growth occurring. Refer to WPI 000014 for Ascorbic Acid Additive to Neutralise Dialysate Chlorine.15. Chlorine and chloramines are removed from the haemodialysis water by carbon filters.17. palpitations. To combat the diminishing effects of chlorine councils also add ammonia to the water. If chlorine or chloramines are in the dialysate a dark blood appearance can be seen in the blood lines leading away from the dialyser. methemoglobinemia and possibly death 5. Bacterial levels are decreased in water supply by adding chlorine as a disinfectant. vomiting.19.21 Since these are dissolved gases they are not removed by reverse osmosis. e. Permeate levels of Total Chlorine should not exceed 0.11. minimum ten minutes Haemodialysis Water Sampling Handbook EBCT for two vessels) at the maximum product water flow rate. The use of carbon filters that have backwashing capabilities is recommended. 2. Carbon filter clogging or related problems: * Exhaustion or adsorption rate of the carbon media.Statewide Renal Network Chlorine levels should be checked before each patient dialysis. The carbon media size required is that which successfully adsorbs chlorine and chloramines from the feed water supply without compromising water quality with bacterial growth by over sizing the carbon vessels. Each adsorption bed will require an Empty Bed Contact Time (EBCT) of minium 5 minutes (i. * Filter is in bypass * Channelling of carbon filter has occurred * Nitrified bacteria present within the carbon filter * Contact time not sufficient to reduce chlorine/chloramine (can be due to the demand being greater and reducing the contact time the water has with each filter) 27 . Testing for chlorine and chlorines is done within the dialysis unit using: • DPD4 tables • A combination of DPD 1 and 3 • Chlorometer/Photometer (Highly Recommended and preferred method). To ensure adequate removal at least two carbon adsorption beds/vessels (with a sampling tap between) installed in a series configuration is recommended. or if incentre. Chlorine/chloramine reading may be elevated post Reverse Osmosis Unit if: 1.3. Feed supply water chlorine/ chloramine level is elevated – this can occur if the Council has increased the dosing of chlorine due to bacterial problems with the water. No patients should dialyse on PERMEATE from REVERSE OSMOSIS UNIT reading 0. For accuracy of the reading the pre treatment will have needed to be running for at least fifteen minutes prior to test being taken. Ascorbic acid can be added to dialysate as an interim measure to help with chlorine breakthrough. The carbon minimum iodine rating of 900 is required. before each patient shift post carbon filters.1 mg/L. It will depend on the configuration of the pre-treatment to which carbon filter this should be taken from – preferable post worker carbon or carbons (pre-polisher carbon).4. To effectively remove chlorine and chloramines from haemodialysis water activated carbon filters are required. Larger carbon vessels have been linked to bacterial growth in some facilities while smaller carbon vessels can encourage channelling of the carbon media.1mg/L or higher2. Diagnosis: This problem is diagnosed by observation of the taps on the piping between or above the carbon filters. Extensive discussions would be required with the Director of the unit. Diagnosis: This problem is diagnosed by daily testing of the effectiveness of the carbon media. 2. Increased chlorine level of feed supply It is recommended for the Haemodialysis Unit to have a good relationship with the local Council as well as a reporting method where the local Council can notify the haemodialysis staff of any irregularities in the water supply. . The backwashing process “fluffs” up the carbon decreasing clumping of the carbon fibres and increasing the surface area available. These fines need to be stopped before progressing to the RO membrane with the use of smaller micron filters post carbon and pre reverse osmosis unit.Statewide Renal Network 1. Note: The polisher or last carbon filter should never have the capability of being bypassed. This would allow forward notification of elevated chlorine levels noted from the water as it leaves the Council reservoir. 28 Haemodialysis Water Sampling Handbook Procedure: These filters are backwashed one at a time when dialysis has been completed for the day. This reservoir method tends to work if chlorine gas is elevated as it allows the dissipation of this gas. engineers and pre-treatment service providers. the facility plumbers. Backwashing can cause problems post carbon filter as fines can be released into the water once the carbon filters have completed backwashing. This method will have bacterial contamination risks and will need careful planning and decision making as specific tank sizes will be required and the type of chlorine contamination will affect this. b) Filter is in bypass – ensure the appropriate carbon filters are not bypassed. a) Exhaustion or absorption rate of the carbon media. Carbon filter clogging or related problems. Daily testing using DPD tablets or chlorimeter/photometer. Procedure: The taps should be opened to ensure the appropriate carbon filters are being utilised. If elevation of chlorine or chloramines occurs after backwashing has occurred then the carbon media may be exhausted and require rotation and replacement of the carbon media. As chlorine dissipates with time a reservoir positioned before the pretreatment may allow for the chlorine levels to drop prior to the water being treated by the haemodialysis units. e. At a flow of 2 litres/min (maximum expected for a portable RO and a dialysis machine running at 500 ml/ min).through an 0. chlorine breakthrough. Procedure: Empty Bed Contact Time (EBCT) needs to be re-evaluated. d) Nitrified bacteria present within the carbon filter. Procedure: Backwashing of the filter is required as per Exhaustion or adsorption rate of the carbon media. Procedure: The carbon vessel will need to be emptied and disinfected with the appropriate solution. Diagnosis: This problem is diagnosed by daily testing of the effectiveness of the carbon media. for a total of 10 minutes. EMCT Calculation = (7. Diagnosis: Water samples to be taken post carbon filters for total organic carbon (TOC) or dissolved organic carbon (DOC . Discussion will then need to occur about the type and amount of carbon that will need to fill the vessel to decrease the chance of reoccurrence. this gives an EBCT of 5 minutes per cylinder. Re-evaluation of particle filtration method would be required in this instance.Statewide Renal Network c) Channelling of carbon filter has occurred. which are each part filled (to allow for backwashing) with 10 litres of carbon.45 micron filter). Haemodialysis Water Sampling Handbook e) Contact time not sufficient to reduce chlorine/chloramine (can be due to the demand being greater and reducing the contact time the water has with each filter) Diagnosis: Ongoing and increasing chlorine levels post carbon filters i. Daily testing using DPD tablets or chlorimeter/photometer. 29 .48 x V) Q V = Volume of particles in the bed (ft3) and Q = flow rate of water through the filter (gal/min) Easy guide to EBCT is: Volume of carbon (in litres) flow (in litres/min) eg: The BTS portable water trolleys use two 14 litre capacity cylinders. Review number of carbon filters.0 Action for Elevated Chlorine/Chloramine Levels Elevated Chlorine/Chloramines noted Identify problem Increased chlorine/chloramine level in feed water Discussions with Council re: chlorine/ chloramine increase in water supplied to haemodialysis unit Discussions required re: pre-treatment requirements to cope with increase in feedwater chlorine/chloramine levels should this be an ongoing problem Carbon clogging or related problems Identify problem Nitrified bacteria Filter bypassed Carbon filter to have carbon removed and appropriate disinfection. 30 Ensure regular backwashing procedure during unit downtime . Review carbon material type.Statewide Renal Network Haemodialysis Water Sampling Handbook Flowchat 2. Review empty bed contact time. saturation or channelling Backwashing required No Improvement? Discussions required Yes Review of particle filtration method required Discussions required Review carbon change protocol. Ensure filter online Carbon exhaustion. New carbon required. S.H.S. Sampling procedure Step 1.S.N. Ensure the correct testing point is chosen.S. Label example: DETERGENT . The third fill will be the sample collection.Statewide Renal Network Haemodialysis Water Sampling Handbook Sampling When testing for chlorine or chloramines water testing from the following sample points and sample types is required on a 3 monthly basis: • Water from the Feed supply • Water post carbons (or a specific carbon number depending on unit design) The samples should be collected in a 250ml detergent washed bottle (pictured). Once collection occurs ensure the label on the container is completed with as much information as appropriate. Ensure the label on the container is completed with as much information as is appropriate. Details required on this label are the same as the Pesticides label. Ensure container is filled but not overflowing.H. Smith 0794 Q.WASHED Unique Sample Identification Number: RENTW Preservatives Added: Nil Preservative Batch Numbers: Not applicable Analysis Required: Total Chlorine and Chloramine level Date Sealed: 10. Fill container again to the top with water from testing point and discard. Step 2. Batch Number: By: R. Collect sample by filling the container half full with water from testing point and discard. Step 3. This sample should be kept out of sunlight in a well sealed bottle.07 Q.05. Identification Number: Local Authority: Toowoomba Town Supply Sample Point: Feedwater Owner/Address: Toowoomba Hospital Renal Unit 31 . Keep out of sunlight. If organic matter is in the water the chlorine and chloramine testing needs to occur immediately. Report Results will be reported onto Auslab by the testing facility or communicated to the unit by the process which has been previously determined.B.No : (Insert Batch number) G. . Keep sample chilled (on ice) post collection and during transportation. Do not freeze. Form example: Toowoomba Renal Unit (07) 4616 6167 RN Smith RN 10/05/07 6167 P. Ensure the form is completed with as much information as is appropriate. ensuring it is stored and transported at correct conditions.ID.C.L. Ensure the sample is forwarded to the testing centre within the correct time period.No : (Bottle ID Number) RN Smith 10/05/07 RN 0630 hrs Step 5. Note: Analysis to occur within 48 hours of sample collection with 6 hours being ideal where possible. Chlorine and Chloramine results will be reported as mg per litre. 32 Organic matter can be identified by running 60mls of the water from sampling point through a 0. Elevated bacterial levels also indicate the presence of organic matter.Statewide Renal Network Haemodialysis Water Sampling Handbook Step 4.45micron filter. Bromodichloromethane and Dibromochloromethane. Elevated THM levels indicate exhaustion or saturation of the carbon vessels. 33 . THM Guidelines1.08mg/L < 8μg/L Table 6. Haemodialysis Water post carbon filter should be Trihalomethane free. Chlorine gas added to water creates hypochlorous acid which takes electrons from organic materials creating a carcinogenic by-product called Trihalomethane (THM)1. When testing for Total Trihalomethane (TTHM) the sample is tested for the four components of TTHM – Trichloromethane (chloroform).25mg/L 80μg/L 0. CONTAMINANT Australian Drinking Water Guidelines1 US EPA Drinking Water Guidelines22 Haemodialysis Guideline2 Trihalomethanes 250μg/L 0.22. Trihalomethane levels for dialysis patients should be less than one tenth of drinking water specifications using US EPA drinking water standards2. The monitoring of Trihalomethane (THM) levels in haemodialysis water is required to ensure the effectiveness of the carbon filters. Tribromemethan (Bromoform).2.Statewide Renal Network Haemodialysis Water Sampling Handbook Trihalomethane testing Haemodialysis water should be free from carcinogenic by-products. THM levels should not exceed 8μg/L2. 34 Haemodialysis Water Sampling Handbook Sampling procedure Step 1. Each adsorption bed will require an Empty Bed Contact Time (EBCT) of minium 5 minutes (i. Once collection occurs ensure the label on the container is completed with as much information as appropriate.e. The carbon minimum iodine rating of 900 is required. minimum ten minutes EBCT for two vessels) at the maximum product water flow rate.Statewide Renal Network To effectively remove THM’s from haemodialysis water activated carbon filters are required. . EBCT and water flow rate will successfully remove THM’s. Monitoring of THM levels in haemodialysis water alerts the user to a possible Chloramine breakthrough/ exhaustion of carbon tank. To ensure adequate removal of THM at least two carbon adsorption beds/vessels (with a sampling tap between) installed in a series configuration is recommended. Sampling When testing for Trihalomethane water testing from the following sample points and sample types is required on a 3 monthly basis: • Water from the Feed supply • Water post carbons (or a specific carbon number depending on unit design) The samples should be collected in a 200ml amber glass container with ammonium chloride preservative (pictured). Ensure the correct testing point is chosen and the sample is taken as per sampling procedure. This carbon configuration. Ensure the label on the container is completed with as much information as is appropriate. Smith 1464 Q.N. The ammonium chloride preservative should be added to the amber glass bottle (the preservative converts free chlorine to a combined chlorine residual ensuring no further byproduct formation occurs before analysis).S. When sampling from a tap remove any aerator and run the tap for 3 to 5 minutes (running allows the water temperature to stabilise as well as clearing any stagnant water prior to THM sample collection).WASHED Unique Sample Identification Number: RENTW Preservatives Added: Ammonium Chloride Preservative Batch Numbers: 1464 Analysis Required: Trihalomethanes Date Sealed: 10. Agitate the bottle by hand for 1 minute to dissolve the preservative.05. 4. Do not rinse the collection container with the sample water and do not overfill.H. Details required on this label are the same as the Pesticides label in different order.S. Seal the bottle once the sample has been collected with the white screw cap ensuring the Teflon liner is in place.S.Statewide Renal Network Haemodialysis Water Sampling Handbook Sampling Procedure for Trihalomethanes23 To ensure collection of a representative sample the following technique should be observed: 1. Identification Number: 35 .07 Q.S. 3. Batch Number: By: R. Fill the container to the top.H. 2. Ensure no air bubbles pass through the sample and take care to ensure the preservative is not flushed out. Step 2. Label example: Local Authority: Toowoomba Town Supply Sample Point: Post carbon 4 Owner/Address: Toowoomba Hospital Renal Unit SOLVENT . 5. ensuring it is stored and transported at correct conditions.No : (Insert Batch number) G.C. Keep out of sunlight. Form example: Toowoomba Renal Unit (07) 4616 6167 RN Smith RN 10/05/07 6167 P.No : (Bottle ID Number) RN Smith 10/05/07 RN 0630 hrs Step 4. . Do not freeze.Statewide Renal Network Haemodialysis Water Sampling Handbook Step 3. Ensure the form is completed with as much information as is appropriate. 36 Report Results will be reported onto Auslab by the testing facility or communicated to the unit by the process which has been previously determined. Do not shake the sample23.L. Trihalomethane results will be reported as levels of Trichloromethane (chloroform). Ensure the sample is forwarded to the testing centre within the correct time period.ID. Keep sample chilled (on ice) post collection and during transportation. Bromodichloromethane and Dibromochloromethane (and total Trihalomethanes) in μg/L.B. Tribromomethane (Bromoform). Haemodialysis Water Sampling Handbook Sampling When testing for calcium and magnesium sampling from the following sample points and sample types is required on a 3 monthly basis: • Water post water softener Calcium and Magnesium levels in haemodialysis permeate should be less than 2. Calcium and magnesium can coat or scale the reverse osmosis membrane decreasing it efficiency. To remove calcium and magnesium from the water a water softener is used where calcium and magnesium ions are exchanged for sodium ions. The water softener uses a negatively charged resin (cation resin) to attract the positively charged calcium and magnesium ions (cations) and releases sodium ions during this exchange14.25. vomiting. When calcium and magnesium are present in the water the water is known as “hard” water and once calcium and magnesium are removed the water is termed “soft”. The samples should be collected in a 250ml detergent washed bottle (pictured). This sample should be kept out of sunlight in a well sealed bottle. hypertension. cardiac symptoms and neurological disturbances that may lead the clinician to believe that the patient has dialysed against hard water5. The removal of calcium and magnesium is often termed as softening the water. headache. muscle weakness.21.Statewide Renal Network Calcium and Magnesium testing Calcium and magnesium may also be present in water at the source. malaise.0 mg/L5. Once collection occurs ensure the label on the container is completed with as much information as appropriate. 37 . Patients may have symptoms of nausea. Identification Number: Local Authority: Toowoomba Town Supply Sample Point: Feedwater Owner/Address: Toowoomba Hospital Renal Unit 38 R.H. Fill container again to the top with water from testing point and discard.H. Label example: DETERGENT .S.S. Step 3. Ensure the label on the container is completed with as much information as is appropriate. Details required on this label are the same as the Pesticides label.N.07 Q. Smith . Collect sample by filling the container half full with water from testing point and discard. Ensure container is filled but not overflowing.S.05.S. Batch Number: By: 0794 Q.WASHED Unique Sample Identification Number: RENTW Preservatives Added: Nil Preservative Batch Numbers: Not applicable Analysis Required: Total Chlorine and Chloramine level Date Sealed: 10.Statewide Renal Network Haemodialysis Water Sampling Handbook Sampling procedure Step 1. Step 2. Ensure the correct testing point is chosen. The third fill will be the sample collection. Form example: Toowoomba Renal Unit (07) 4616 6167 RN Smith RN 10/05/07 6167 P. Ensure the sample is forwarded to the testing centre.L. Calcium and Magnesium results will be reported as mg/L.C. Ensure the form is completed with as much information as is appropriate. Report Results will be reported onto Auslab by the testing facility or communicated to the unit by the process which has been previously determined.Statewide Renal Network Haemodialysis Water Sampling Handbook Step 4.ID. No particular instructions are available for storage or transportation. 39 .B.No : (Bottle ID Number) RN Smith 10/05/07 RN 0630 hrs Step 5.No : (Insert Batch number) G. Mercury levels in haemodialysis permeate should be less than 0. • The third fill will be the sample collection. Sampling procedure • Fill container half full with water from testing point and discard. . Add the nitric acid preservative (liquid form) and potassium dichromate then top up the sample until the container is full. Container required is a 200ml glass acid washed with additive 70% nitric acid and potassium dichromate 50mg/ ml (4mls). Mercury is known to be reduced in water by carbon filtration and reverse osmosis10. 40 Haemodialysis Water Sampling Handbook Once collection occurs ensure the label on the container is completed with as much information as appropriate. Toxicity when ingested orally has also resulted in haemorrhagic gastritis and colitis26.0002 mg/L2. The most significant damage occurs to the kidneys in the form of tubular necrosis. • Fill container again to the top with water from testing point and discard. but not overflowing. Mercury is known to have toxic effects when ingested orally.Statewide Renal Network Mercury testing When testing for mercury sampling from the following sample points and sample types is required on an annual basis: • Water from feed source • Permeate Post RO Mercury test can also be taken as part of a standard water test but may be required at some stage as a separate sampling procedure. proteinuria and hypoalbuminaemia26. 05.S.C.B.S.L. Form example: Toowoomba Renal Unit (07) 4616 6167 RN Smith RN 10/05/07 6167 P.S.No : (Insert Batch number) G.H.S.Statewide Renal Network Haemodialysis Water Sampling Handbook Label example: NITRIC ACID . Identification Number: Local Authority: Toowoomba Town Supply Sample Point: Post RO Owner/Address: Toowoomba Hospital Renal Unit Step 4.H.No : (Bottle ID Number) RN Smith 10/05/07 RN 0630 hrs 41 .07 Q. Ensure the form is completed with as much information as is appropriate. Smith 1464 Q.N.ID.WASHED Unique Sample Identification Number: RENTW Preservatives Added: 70% nitric acid and potassium dichromate 50mg/ml Preservative Batch Numbers: 0624 Analysis Required: Mercury Date Sealed: 10. Batch Number: By: R. iron.Statewide Renal Network Haemodialysis Water Sampling Handbook Step 5. molybdenum. No particular instructions are available for storage or transportation. manganese. 42 Post RO collection needs: 1 litre detergent washed bottle. Copper. Heavy Metal testing Heavy metal test includes levels of : Silver. + .5ml) additive. nickel. selenium. Beryllium. Barium. Cobalt.5ml) additive. vanadium and aluminium. Mercury results will be reported as mg/L. chromium. Sampling When testing for heavy metals sampling from the following sample points and sample types is required on a 3 monthly basis in rural areas and 6 monthly otherwise: • Water from feed supply • Permeate post RO Feed water collection needs: . Lead.250ml Plastic acid washed container with 70% nitric acid (2. Boron. Cadmium. No preservative. Chromium. Plus the above 250ml Plastic acid washed container with 70% nitric acid (2. zinc. Ensure container is filled without overflowing Report Results will be reported onto Auslab by the testing facility or communicated to the unit by the process which has been previously determined. Arsenic. Lead sampling can also occur separately if welding or changes to the piping in the unit occurs. Ensure the sample is forwarded to the testing centre. Identification Number: Local Authority: Toowoomba Town Supply Sample Point: Post RO Owner/Address: Toowoomba Hospital Renal Unit 43 . Label example: NITRIC ACID WASHED Unique Sample Identification Number: RENTW Preservatives Added: 70% nitric acid (2.S. Smith 1464 Q.S.H.5ml) additive Preservative Batch Numbers: 1324 Analysis Required: Heavy metals Date Sealed: 10. Batch Number: By: R.05.S. • Fill container again to the top with water from testing point and discard. Add the nitric acid preservative (liquid form) and then top up the sample until the container is full.S.H. but not overflowing.Statewide Renal Network Haemodialysis Water Sampling Handbook Once collection occurs ensure the label on the container is completed with as much information as appropriate.07 Q. Sampling procedure • Fill container half full with water from testing point and discard.N. • The third fill will be the sample collection. Barium.No : (Insert Batch number) G.No : (Bottle ID Number) RN Smith 10/05/07 RN 0630 hrs Step 5. molybdenum. Ensure container is filled without overflowing 44 Report Results will be reported onto Auslab by the testing facility or communicated to the unit by the process which has been previously determined.L. vanadium and aluminium in mg/L. Boron. selenium.ID. Heavy metal results will be reported as levels of Silver.C. Ensure the sample is forwarded to the testing centre. Chromium. iron.B. zinc. manganese.Statewide Renal Network Haemodialysis Water Sampling Handbook Step 4. . Lead. Arsenic. Copper. Form example: Toowoomba Renal Unit (07) 4616 6167 RN Smith RN 10/05/07 6167 P. Ensure the form is completed with as much information as is appropriate. nickel. chromium. Cadmium. No particular instructions are available for storage or transportation. Beryllium. Cobalt. Colour. Once collection occurs ensure the label on the container is completed with as much information as appropriate. Hydroxide. Ensure the correct testing point is chosen.Iron. No preservative. Step 3. Alkalinity. Lead sampling can also occur separately if welding or changes to the piping in the unit occurs. Details required on this label are the same as the Pesticides label. Turbidity and Cations: . Aluminium. Magnesium and Hydrogen and Anions: . Ensure the label on the container is completed with as much information as is appropriate. Fluoride. 45 . Step 2.Bicarbonate. Potassium. Fill container again to the top with water from testing point and discard. pH.Sodium. Total Dissolved Solids (TDS). Sampling When testing for standard water sampling from the following sample points and sample types is required on a 3 monthly basis: • Water from feed supply Haemodialysis Water Sampling Handbook 1 litre detergent washed bottle. Calcium. Boron and Copper. Chloride. Collect sample by filling the container half full with water from testing point and discard. Zinc. The third fill will be the sample collection. Silica. Nitrate and Sulphate plus other Dissolved Elements: . Carbonate.Statewide Renal Network Standard Water Testing A standard water test includes testing of: Conductivity. Manganese. Sampling procedure Step 1. Ensure container is filled but not overflowing. Hardness. S. Form example: Toowoomba Renal Unit (07) 4616 6167 RN Smith RN 10/05/07 6167 P. Ensure the form is completed with as much information as is appropriate.L.No : (Insert Batch number) G. Smith 1464 Q.S. Batch Number: By: R. Identification Number: Local Authority: Toowoomba Town Supply Sample Point: Post RO Owner/Address: Toowoomba Hospital Renal Unit Step 4.No : (Bottle ID Number) 46 RN Smith 10/05/07 RN 0630 hrs .Statewide Renal Network Haemodialysis Water Sampling Handbook Label example: DETERGENT .H.05.H.B.N.ID.07 Q.S.WASHED Unique Sample Identification Number: RENTW Preservatives Added: Nil Preservative Batch Numbers: Not applicable Analysis Required: Standard water analysis Date Sealed: 10.C.S. This is significant in the planning and designing of haemodialysis units and associated plumbing as biofilm can adhere to surfaces such as piping. Fluoride. Carbonate. Hardness. Ensure the sample is forwarded to the testing centre. Manganese. Hydroxide. Ensure container is filled without overflowing Report Results will be reported onto Auslab by the testing facility or communicated to the unit by the process which has been previously determined. Chloride. Magnesium. It is recommended that 30% of all machines on the haemodialysis floor should be tested monthly with every machine being tested at least once every three months in the in-centre haemodialysis unit.Statewide Renal Network Step 5. Standard water analysis results will be reported as levels of Conductivity. Sodium. Aluminium. Boron and Copper. Alkalinity. 47 . pH. Total Dissolved Solids (TDS). hoses. Hydrogen. Calcium. Each individual unit will have specific guidelines for machine disinfection including differing methods of disinfection. Nitrate. Zinc. Sulphate. Iron. Potassium. Turbidity. Colour. dialysate bottles and inside dialysate machines15.16. Silica. Haemodialysis Water Sampling Handbook Machine Testing Biofilm can adhere inside haemodialysis machinery and as such machinery should be correctly and adequately disinfected. Bacteria occur naturally in water sources but can also be introduced or occur due to reduced water flow. Bicarbonate.0. Refer to Flowchart 1. No particular instructions are available for storage or transportation. Be aware of your own units guidelines and regime for this. It is recommended that in home machines should be tested three monthly. pp 82. Vol. 2007. 2 Association for the Advancement of Medical Instrumentation. Department of Health and Human Services. Keshaviah. 12 Ministry of Health Singapore. Kidney Dialysis Facilities and Plumbing Systems. Policy on Limulus Amebocyte Lysate (LAL) Test. 8 Biomedical/Clinical Engineering Association of Ireland. and Thomas. 1999. Accessed from www. 11. 6 Luehmann. 2007.Statewide Renal Network REFERENCES/INFORMATION SOURCES/ SUGGESTED READINGS 1 National Health and Medical Research Council & Agriculture and Resource Management Council Of Australia and New Zealand. Draft International Standard ISO/DIS 23500. No.gov.moh-ela. Company for Educational Advancement. 2001. Princess Alexandra Hospital. R.org/waterindial. 9. org. 11 Caring for Australians with Renal Impairment. Nephrology Nursing Journal. . 48 Haemodialysis Water Sampling Handbook 9 Brown. 13 Australian Pesticides and Veterinary Medicines Authority.gov. 15 Curtis. 2005. Oct 2005. ANSI/AAMI. and Varughese. 2001. 16 Charles River.S. 5 Amato. 2005. Core Curriculum for the Dialysis Technician: Module 8 – Water Treatment. Guidelines for Renal Dialysis Centres.2. L. Klein. Accessed at www.au in February. 1989. Australian Drinking Water Guidelines.sg on 19 April. Water Treatment for Hemodialysis – Updated to Include the Latest AAMI Standards for Dialysate (RD52:2004). Accessed from www. 14 Byrne. Hemodialysis International. U. 3 European Pharmacopeia. 2005. Contaminant Removal Information Sheet. Vol. 7 Ahmed. D. A Manual on Water Treatment for Hemodialysis. Bacterial Growth and Pyrogenic Reactions. Water quality for Haemodialysis. 2001.html in February. 2007. 8.pdf on 17 April. Ward.. J. Accessed from http://www. LAL Times. 2006. 1996.au/guidelines/ limulus_amebocyte_lysate.cari. 2005. pp 127-134.. Amgen Inc. P.. 1. Water Treatment Equipment for Haemodialysis Applications. 2006. 10 Thring. American National Standard. P. Water Training for Hemodialysis Volume 1– CD.apvma. 32. E. 2002. European Guidelines for Haemodialysis. S. A. Vol. Essentials of water treatment in hemodialysis. beai. No. Wes. 10. J. Water in Dialysis. PM Engineer. 2007. R. 4 International Organization for Standardisation. lafayette. Accessed at http://ndt. P. Glenda. 18 Heonich. oxfordjournals. A. 17. ChloraminesThe City of Lafayette Water Works Answers Your Questions About Chloramines.org in February. and Levin. First Addendum to 3rd Edition. 24 European Renal Association – European Dialysis and Transplant Association.. N. 2006. A. Seminars in Dialysis. Hemodialysis Horizons accessed From www. Guidelines for Drinking-water Quality. & Rodriguez-Benites.renal. Accessed 27. 49 . 28 Mactier. 22 Environmental Protection Agency. No.epa. N.07 at www. a sneaky contaminant of dialysate. 9. R.2007.gov/safewater/mdbp/qrg_ st1. 16..pdf in February. R. 2006.org/cgi/content/ full/14/11/2579 on 10/07/2005 20 City of Lafayette.. Stage 1 Disinfectants and Disinfection Byproducts Rule: A Quick Reference Guide. S. World Health Organisation.aami.. Accessed from www. Accessed from http:// www. 2007. Suppl 7. The Implications of Water Quality on Hemodialysis. 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